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Jl Psoriasis (from Nature). ° A PRACTICAL TREATISE ON DISEASES OF THE SKIN BY JOHN V. ^HOEMAKER, M. D., LL. D. Professor of Skin and Venereal Diseases in the Medico- Chirurgical College and Hospital of Philadelphia Physician to the Philadelphia Hospital for Diseases of the Skin Member of the American Medical Association of the Pennsylvania and Minnesota State Medical Societies of the American Academy of Medicine, and of the British Medical Association Fellow of the Medical Society of London THIRD EDITION, REVISED AND ENLARGED WITH CHROMOGRAVURE PLATES AND OTHER ILLUSTRATIONS LIBRARY SURGEON GEWSfiACS OFFICE SEP.-1M-1899 NEW YORK D. APPLETON AND COMPANY 1898 WR ma Copyright, 1888, 1892, 1897, By D. APPLETON AND COMPANY. PREFACE TO THE THIRD EDITION. In preparing a third edition the author has followed the same principles which have guided him from the first. Diseases of the skin have received so much attention during recent years that the current literature upon the subject has become very voluminous. From these various contributions the author has carefully gathered the additions to our knowledge, especially in relation to the symp- tomatology, diagnosis, etiology, and treatment of the maladies de- scribed. The conclusions reached by the latest investigators of the bacteriology and pathology of various affections have also been in- corporated. Kew methods of treatment appearing of good promise are brought to the notice of the reader. A number of new medici- nal preparations have within the last five years been introduced and recommended as of value in this department of medicine. The most important of these remedies and those whose worth has been most thoroughly tested are noticed in these pages. The rapid progress of dermatology has led to a more thorough comprehension of disease processes. The former conceptions of pathology and relationship of a number of diseases have required considerable modification. The assiduous observations of special workers have resulted in the recognition of several diseases which had previously been overlooked. Those which have been most accurately studied, or which are of somewhat frequent occurrence, have been briefly described in the present edition. A short account has also been given of mycosis fungoides and actinomycosis. By a condensation of the text the new material has been intro- duced without increasing the size of the volume. J. V. S. iii PREFACE TO THE SECOND EDITION. A second edition of this work being demanded, the author has taken the opportunity of incorporating in it various newr points relative to etiology, pathology, and treatment which have been brought forward since the first edition was issued. Many memoirs and valuable text-books have appeared within that time, and their pages have been carefully consulted with the view of making this volume useful to the reader and a faithful representation of the present knowledge of dermatology. Interesting facts pertaining to the clinical history of different affections have been added, and the object has ever been kept in view to describe the maladies of the skin in their relation to the general state of the economy. The results of the cultivation of bacteriology have, in several instances, given precision to our views concerning etiology. Brief descrip- tions have been given of those micro-organisms which have been demonstrated to be exciting causes of certain cutaneous maladies. The effect of local antisepsis is briefly discussed in the introductory chapter upon treatment in Part I. The most efficient bactericides and their influence in various morbid conditions are described in the same portion of the book, Avhile the details of their application are given in the consideration of the various diseases in which they are applicable. A special section has been added upon electricity, in which the value of this agent is discussed in the treatment of many diseases of the skin. The effect of diet in the production and treatment of cutaneous affections is also alluded to at some length. Attention is given to improved methods in the treatment of the eruptive fevers. Many additions have been made to the chapter on syphilis. A sufficiently full account has been given of the various methods of hypodermic medication that have been v vi PREFACE TO THE SECOND EDITION. advocated in this disease, together with an estimate of their advan- tages and defects. A section has been added descriptive of the various changes wliich the nails undergo in consequence of local or general disease. The recent literature upon the subject of lep- rosy has been surveyed, and the opposing doctrines concerning its contagious and hereditary character have been patiently considered. Upon these subjects, however, the writer has seen no reason for changing the opinions advanced in the first edition. The consti- tutional effects of carcinoma are briefly described. An account has been given of the recent literature upon the etiology of cancer in connection with the views advanced by Darier and others upon the subject of cutaneous psorospermosis. The pathogenesis of lupus vulgaris and its relation to other forms of cutaneous tuber- culosis receive due attention. The results of the treatment of lupus by tuberculine are described in accordance with the experi- ence of the author in the use of this remedy. A number of additional valuable formulas have been embodied in the work, illustrative of the therapeutic methods of various authorities at home and abroad. The recent treatise of Leloir and Vidal (unfortunately incom- plete at this date) upon pathology, and that by Brocq on treatment; the excellent works of Fox, Piffard, Morrow, and Taylor; together with innumerable memoirs appearing in the journals of our own and foreign countries, with the personal experience of the author during the last four years, form the basis of the additions made to the original text. The author wishes to thank his colleagues, Prof. Frank Wood- bury, Dr. George Hewitt, and Dr. E. S. Gans, for kind assistance during the preparation of this edition for the press. John V. Shoemaker. No. 1519 Walnut Street, Philadelphia, July, 1892. PREFACE TO THE FIRST EDITION. Association during the past few years with many students and physicians, at the Medico-Chirurgical College and at the Philadelphia Hospital for Skin Diseases, having taught me as a teacher the de- sirability of conciseness in the treatment of any subject, in this work will be found but little reference to the extensive literature of the affections of which it treats. The limits in size to which a work of its intention should be circumscribed having been rigorously imposed upon it and adhered to, it has been my constant aim within those limits to present brief, although clear, descriptions of numerous affections of the skin. I have also in the preparation of the work purposely omitted many cumbrous technical words and phrases which often confuse and mislead the student, and in their stead have substituted words and phrases well understood and fully con- veying their meaning. All that I claim in it as especially original is a statement of the relative effects and values of numerous agents tested in my own many years of clinical experience in the treatment of skin-diseases. The pictures representing the normal skin and the pictures pro- duced by photo-micrograph have been contributed by Dr. Morris Longstreth, assisted by Dr. Martin Rively. To Dr. Richard J. Dunglison my thanks are due for the execution of the complete index that accompanies the work. The drawings for the woodcuts were executed by Mr. William Earl Smith, and are for the most part from cases of my own in the Philadelphia Hospital for Skin Diseases. In conclusion, I would merely add that the whole work has been written from the standpoint of an active general practitioner, and, vii viii PREFACE TO THE FIRST EDITION. as I think it reasonable to believe, can hardly fail to bear that im- press ; and if I am right in so thinking, knowing as I do that that standpoint has been inclusive of special opportunities and study within the department of skin-diseases, I cannot but hope that the work will fulfil in some measure its intention of supplying the needs of the medical student and of the busy physician. John V. Shoemaker. No. 1519 Walnut Street, Philadelphia, January, 1888. CONTENTS. PART I. GENERAL CONSIDERATIONS. PAGE Anatomy of the Skin............1 Epidermis..............3 Corium...............6 Subcutaneous Connective Tissue.........8 Sweat-Glands.............9 Sebaceous Glands............12 Hairs...............14 Hair-Follicles.............17 Muscles of the Skin............20 Blood-Vessels of the Skin..........21 Lymphatics of the Skin...........22 Nerves of the Skin............23 Pacinian Corpuscles............23 Tactile Corpuscles............24 Non-medullated Nerves...........24 Physiology of the Skin...........25 Regulation of the Temperature of the Body......25 Respiratory Function of the Skin.........27 Sensation..............28 Absorption..............30 Secretion and Excretion...........33 Sebum...............33 Perspiration..............33 Electric Currents of the Skin.........36 Odor of the Skin............37 Symptomatology ............. 38 Diagnosis..............48 Pathology..............52 Etiology..............58 Treatment..............65 PART II. CLASSIFICATION. Class I. Disorders of Secretion and Excretion (Anomaliaa Secretionis et Ex- cretionis)............122 Class II. Hyperemias (Hyperaeraiae).........122 ix X CONTENTS. PAGE Class III. Haemqrrhages (Haemorrhagiae).......122 Class IV. Exudations (Exudationes)........1-2 Class V. Hypertrophies (Hypertrophiac).......122 Class VI. Atrophies (Atrophia)).........122 €Jass VII. Tumors (Neoplasmata).........122 Class VIII. Neuroses (Neuroses)..........123 Class IX. Parasites (Parasitae)..........123 Class I. DISORDERS OF SECRETION AND EXCRETION. Seborrhoea..............123 Comedo...............132 Milium................135 Sebaceous Cyst.............136 Hyperidrosis..............137 Anidrosis..............141 Bromidrosis..............142 Chromidrosis.............144 Sudamina..............146 Hydrocystoma.............146 Hydradenitis destruens suppurativa.........147 Class II. HYPEREMIAS. Erythema simplex............150 Erythema Intertrigo............152 Class III. HEMORRHAGES. Purpura...............154 Haemophilia..............161 Haematidrosis.............161 Class IV. EXUDATIONS. Rubeola..............162 Rotheln..............I67 Scarlatina..............168 Variola...............180 Varicella..............191 Vaccinia..............I93 Erysipelas..............198 Chancroid..............207 Syphilis...............214 Erythema Multiforme............266 Erythema Nodosum............268 CONTEXTS. x| PAGE Urticaria..............271 Lichen Planus.............282 Lichen Scrofulosus............285 Prurigo..............287 Herpes...............290 Miliaria...............300 Pemphigus..............303 Hydroa...............311 Pompholyx..............313 Acne...............314 Rosacea..............330 Sycosis...............339 Impetigo.............. 344 Impetigo Contagiosa............347 Ecthyma..............348 Pityriasis Rubra.............351 Furunculus..............355 Carbunculus..............359 Anthrax..............362 Equinia..............364 Delhi Boil............. .365 Abscessus..............366 Wounds and Contusions...........367 Dissecting Wounds............367 Poisoned Wounds............368 Ulcers...............369 Eczema............• 373 Dermatitis..............450 Combustio..............468 Congelatio..............473 Class V. HYPERTROPHIES. Lentigo . ..........477 Chloasma..............478 Nanus Pigmentosus............483 Callositas ..............484 Clavus...............485 (\>rnu Cutaneum.............487 Keratosis Pilaris.............489 Psoriasis..............490 Lichen Ruber.............509 Verruca..............512 Ichthyosis..............516 Scleroderma..............521 Sclerema Neonatorum ............ 526 Morphcoa..............528 Elephantiasis.............531 Dennatolysis.............537 Hypertrophy of the Hair...........538 Hypertrophy of the Nails...........542 Xli CONTENTS. Class VI. ATROPHIES. page Albinismus..............546 Vitiligo...............547 Canities..............550 Atrophia Cutis.............555 Xeroderma Pigmentosum...........556 Senile Atrophy.............558 Striae et Macula? Atrophica?...........559 Alopecia..............560 Alopecia Circumscripta........... 570 Atrophy of the Hair............576 Atrophy of the Nails............579 Class VII. TUMORS. Rhinoscleroma.............584 Lupus Erythematosus............587 Lupus Vulgaris......'.......592 Scrofuloderma.............611 Molluscum Epitheliale............619 Lepra...............621 Epithelioma..............650 Sarcoma Cutis.............661 Carcinoma Cutis.............665 Keloid...............667 Molluscum Fibrosum............674 Xanthoma..............676 Lipoma..............679 Angioma..............680 Lymphangioma.............688 Neuroma..............689 Myoma...............690 Ainhum..............690 Mycosis Fungoides............692 Class VIII. NEUROSES. Hyperasthesia.............694 Anaesthesia............._ 694 Dermatalgia..............694 Paraesthesia..............696 Class IX. PARASITES. Scabies............... 705 Pediculosis.............. 714 Cimex Lectularius............721 CONTENTS. xiH PAGE Pulex Irritans.............700 Pulex Penetrans.............722 Demodex FoUiculorum...........722 Leptus...............723 Cysticercus Cellulosae............724 Filaria Medinensis............724 ffistrus...............725 Culex...............726 Ixodes...............726 Tinea Versicolor.............727 Tinea Favosa .............734 Tinea Tricophytina............741 Tinea Tonsurans.............741 Tinea Sycosis.............752 Tinea Circinata.............755 Trichomycosis Nodosa............760 Actinomycosis.............761 Metric System of Weights and Measures.......*763 Formulary..............765 Index...............871 ..s* LIST OF ILLTTSTKATIONS. PLATE PAGE I. Psoriasis (from Nature).......Frontispiece II. Papillary Syphilide (from Nature)......facing 223 III. Gummatous Syphilide, with ulceration and necrosis of the frontal bone (from Nature).........facing 233 IV. Pemphigus (from Nature)........" 304 V. Acne Indurata (from Nature)......." 316 VI. Dermatitis Venenata (from Nature)......" 450 VII. Ichthyosis (from Nature)........" 516 VIIL Alopecia Circumscripta (from Nature)....." 570 IX. Lupus Vulgaris (from Nature)......." 592 X. Lupus Vulgaris (from Nature)......." 596 XI. Tubercular Leprosy (from Nature)......'• 623 XII. Mycosis Fungoides (from Nature)......" 692 1. Anatomy of the skin...........2 2. Section of skin magnified seventy-five diameters......3 3. Sweat-gland.............10 4. Magnified hair............15 5. Human hair magnified...........16 6. Transverse section through hairs magnified seventy-five diameters . . 17 7. Section through end of finger of a child.......'20 8. The author's woven gum bandage........112 9. Dermatological case...........113 10. Dermatome, or needle-knife..........113 11. Tubercular syphilide...........231 12. Cutaneous horns............488 13. Vitiligo..............548 14. Atrophy of hair-root...........577 15. Atrophy of hair-substance..........577 16. Epithelioma magnified seventy-five diameters......653 17. Keloid tumor.............668 18.. Keloid in negro............669 19. Section of keloid magnified seventy-five diameters.....669 20. Acarus scabiei and egg...........708 21. Pediculus capitis............715 22. Pediculus corporis............716 23. Pediculus pubis............717 24. Demodex folliculorum...........723 25. Spores in epidermis of the chest.........730 26. Achorion Schonleinii...........737 \ DISEASES OF THE SKIN. PART I. GENERAL CONSIDERATIONS. ANATOMY OF THE SKIN. TnE skin is a firm, fibro-elastic membrane which covers the exter- nal surface of the body, and is continuous at the natural orifices with the mucous membrane lining the interior ; is varied in function and complex in organization ; adapts itself by its elasticity to the move- ments of the underlying structures, and protects them from external irritation or injury ; binds the muscles and fascia together, gives shape and color to the body, and prevents the too rapid escape of fluid from the tissues. It is also of the utmost importance as an organ of sensation, absorption, secretion, and excretion. The skin is grooved by a network of minute furrows which corre- spond to the depressions between its papillae and cross each other in all directions. These furrows are especially noticeable on the back of the hand, where they divide the surface into a multitude of irregular triangular and quadrilateral spaces. Larger ones, in conformity with the folds of the skin, are found on the face and neck, and near the joints. The surface of the skin is pierced by millions of minute openings—the orifices of the hair-follicles, and of the sebaceous and sudoriparous ducts. Hairs, coarse or fine, are found on every region of the body except the clitoris, the glans penis, the inner surface of the prepuce and labia majora, the palms of the hands, the soles of the feet, and the dorsal surfaces of the last phalanges. The color of the skin depends upon the amount of pigmentary matter it contains. The characteristic racial differences, as well as the variations of complexion of individuals of the same race, are due to a more or less abundant sup- ply of this material. In the Caucasian race it is usually deposited in the greatest quantity in the scrotum and labia, and in the aureolas of the nipples. The skin varies in thickness in different parts of the body. It is thinnest on the eyelids and prepuce, and thickest on the back, but- tocks, palms, and soles. Its attachment to the structures beneath it varies with the density of the areolar tissue and the amount of adi- l 2 DISEASES OF THE SKIN. pose matter present. In those portions of the body where the areolar tissue is compact, or where there is an abundance of fat, as on the pubes, perineum, and back, the connection is firm and close. Where great mobility is desirable, as around the joints and on the eyelids, the areolar tissue is loose, and contains little or no fat. In these regions the attachment is comparatively slight, and the soft and pliant skin can easily be raised into folds between the fingers. Turner and other writers of the eighteenth century record the case of a Spaniard whose skin was so loose and elastic on the right side, that it could be drawn out from his body for twelve inches in any direction. An analogous case is that of Herr Elaag, a native of Nuremberg, who has recently been on exhibition in the cities of Europe and the United States as "the India-rubber-skin man." This abnormality is only explicable on the supposition that there is a large increase of elastic tissue in the corium, and an absence of any connecting fibres between it and the deeper structures. Fig. 1.—A. Epidermis. B. Corium. C. Subcutaneous connective tissue. 1. Corneous laver 2. Stratum lueidum. 3. Granular layer. 4. Mucous layer. 5. Papilla. 6. Tactile corpuscle. 7. Capillary in the papilla. 8. Hair-shaft. 9. Excretory duct of sudoripa- rous gland. 10. Sudoriparous or sweat gland forming the coil. 11. Pacinian corpuscle 12. Papilla of the hair. 13. Sebaceous or sebiparous gland. 14. Erector-pili muscle' 15. Adipose tissue. A knowledge of the minute anatomy, as well as of the general structure of the skin, is necessary for a proper appreciation of the ANATOMY OF THE SKIN. 3 changes produced by disease. It is also of importance as a basis for the rational application of therapeutic measures. Some morbid con- ditions involve the skin in its entirety ; others manifest no tendency to spread beyond the part in which they first appear. The skin is composed of three layers : the epidermis, the corium, and the subcutaneous connective tissue, each of which is formed by the aggregation of a number of primary layers. The line of demarca- tion between the epidermis and the corium is sharply defined. They can be detached from each other by maceration, and are separated by various morbid processes. The corium and subcutaneous connective tissue, however, merge imperceptibly into each other, the boundary- line between them being merely an imaginary one. The skin is abun- dantly supplied with blood-vessels, lymphatics, nerves, and muscles, and is also provided with certain special appendages necessary for the per- formance of its functions, viz., sudoriparous and sebaceous glands, hair-follicles, hairs, and nails. (See Fig. 1.) The Epidermis.—The epidermis, cuticle, or scarf-skin, is the most superficial portion of the skin. It is a laminated, slightly elastic membrane, composed en- tirely of epithelial cells and scales. It contains no blood-vessels, and is but scantily supplied with nerves, only a few filaments having been traced to its deeper lay- ers. It covers the cori- um closely everywhere, and serves to protect that structure from external irritation or injury. It is pierced by the hair- follicles and the ducts of the sudoriparous and se- baceous glands, and is marked by a network of minute furrows which represent the depressions between the papillae of the corium. The larger furrows found on the face and the neck, and in the vicinity 01 tne joints, correspond to the folds of the skin when not in motion. The epidermis consists of four separate layers : 1. Stratum corneum. 2. Stratum lucidum. 3. Stratum granulosum. 4. Stratum mucosum. The first two layers are frequently considered as one, denominated the Fig. 2.—Photo-micrograph. Section of skin, magnified seventy-five diameters, a. Corneous layer of epider- mis, b. Mucous layer of epidermis, c. Hair in its sheath, d. Sweat-gland, from which the larger draw- ing of sweat-gland in this book was taken, e. Hair in sheath cut irregularly. /, /. Subcutaneous fat. 4 DISEASE* OF TnE SKIN. horny layer; and the latter two likewise, as one, and styled the mucous layer. This classification is, however, erroneous, and should be dis- carded. There are four layers, whether viewed from a pathological or a histological point of view. The epidermis varies in thickness in accordance with the develop- ment of its various layers. It is thinnest about the lips and on the face, and thickest upon the palms and soles. The coloring-matter of the epidermis is almost exclusively found in the stratum mucosum. Steatum Coeneum (Coeneous Layer).—This is the external or superficial layer of the epidermis. It is composed of several strata of flattened, transparent cells of various shapes and sizes. The cells of the deeper are polygonal or spindle-shaped in form, and are larger and more distinct than those above them. Some present traces of a nucleus, and can be stained faintly with carmine. The superficial strata consist of flat, polymorphous scales, which become more and more shrivelled in appearance and curved upon themselves as the sur- face is approached. They do not contain any nuclei. The stratum corneum varies in different portions of the body. It is thinnest on the lips and face, and thickest on the palms and soles. Its thickness does not depend on the development of the other layers of the epidermis. Steatum Lucidum.—The stratum lucidum, called also the stra- tum of Oehl, after its first discoverer, is the narrow, transparent layer of compressed cells found immediately beneath the stratum corneum. According to Unna* it contains from four to six rows of cells that in fresh, unstained sections, attract attention by reason of their ex- treme transparency. They are derived from the cells of the granular layer by the loss of that material and the increase in transparency of the rest of the cell-substance. Each cell contains a staff-shaped or flattened nucleus. Unna believes that this layer is merely a portion of the stratum corneum, and suggests that the title of stratum lucidum be abandoned, as incorrect and misleading. Steatum Gbanulosum.—The granular layer, or layer of Lan- gerhaus, consists of two or three rows of flattened, nucleated cells, which are situated immediately beneath the stratum lucidum. They were at one time supposed to be true connective-tissue corpuscles, be- cause of their spindle-shaped appearance when a vertical section of this layer is made. Their long diameter is parallel to the surface of the epidermis. They are characterized by the presence around their nuclei of a number of minute granules of a substance known as eleidin which, according to Eanvier, is a material intermediate in nature be- tween protoplasm and keratin. It is most abundant near the nuclei of the cells, and diminishes or disappears as the periphery is ap- proached. Unna regards the presence and formation of the granules * " The Anatomy and Development of the Skin," in Ziemssen's Handbook of Dis- eases of the Skin. ANATOMY OF THE SKIN. of this layer as a necessary step in the process of the development of the stratum lucidum and the stratum corneum. He believes that the color of the skin in the white race is also dependent upon the presence of these granules. They refract the light very strongly, and therefore appear white in a reflected light. Prior to their formation the epidermis of the foetus is so transparent that the blood-vessels of the corium can be seen distinctly beneath it. Stratum Mucosum; Stratum Malpighii ; Rete Mucosum; Rete Malpighii.—The stratum mucosum, or mucous layer, called also the layer of Malpighi, is that portion of the epidermis which lies immediately above the corium ; it is separated from it by a thin basement membrane. It adapts itself closely to the upper surface of the corium by means of its interpapillary processes, which fit into the depressions between the papillae. It is composed of several layers of nucleated cells, which vary in size and shape. Those of the deepest layer are small and columnar, with oval nuclei, and are arranged with their long axes perpendicular to the surface of the corium. They are composed of granular protoplasm surrounding the nuclei, and have no distinct cell-wall. According to Biesiadecki and Heule, the out- lines of the individual cells of this layer are obliterated occasionally, so that the surface of the corium appears to be covered with a mass of protoplasm containing a number of nuclei. The cells of the next two or three rows are larger and cubiform, or more or less polygonal, and the nuclei are spherical, well defined, and homogeneous in struct- ure, are inclosed in a cell-wall or membrane, and contain granular and pigmentary matter. The cells of the superficial strata are still larger and more granular in appearance, but become flattened as they approach the surface, so that their long axes finally become parallel to the general surface of the skin. All the cells of the stratum mucosum, except the columnar of the internal row, are connected with each other by means of a series of minute fibrils of protoplasm. Schultz, who was the first to discover these connecting filaments, believed they were formed by the union of projecting processes from adjacent cells. In accordance with his view, this layer is spoken of as the prickle layer, and the filaments are referred to as the prickles of Max Schultz. These prickles or fila- ments vary in size in different parts of the body. Robinson says they are most distinct where the development of the mucous layer is perfect, and they are thicker and longer in the upper than in the lower strata. They are also found in the stratum granulosum, but are not present in the stratum lucidum. They are true connecting fila- ments, and, as asserted by Unna, are to be regarded as a system of protoplasmic fibrils which permit the free circulation of nutritive ma- terial through their interspaces, and effect a firm, but not unalterable connection between adjacent cells. 6 DISEASES OF THE SKIN. Wandering cells, or lymphoid corpuscles, are occasionally found in this layer, especially in the lower and middle strata. Their number is small, however, in the normal healthy state, but they are considerably increased in various pathological conditions. They are of an irregular or stellate form, and are known as Lan- gerhans's cells. By some they are regarded as colorless pigment cells, and by others as connective-tissue corpuscles. The stratum mucosum in color ranges from yellowish white to brown or black, dependent on race and the region of the skin. This is due to differences in the amount of pigmentary material present in the cells of this layer. When the skin is only slightly colored, the pigment matter is absent from all but the most internal strata of cells. Darker shades are produced by its deposition and diffusion among two, three, or more strata. The Corium.—The corium, derma, cutis, or cutis vera, is the most important and most highly organized portion of the skin. It is com- posed of a dense network of bundles of white fibrous tissue with which muscular elements and yellow elastic fibrillae are closely interwoven. The interstitial spaces, which are much smaller than those of the sub- cutaneous connective tissue, diminish in size as the surface is ap- proached. They contain lymphoid corpuscles as well as true con- nective-tissue cells. Fat-globules are also present. This layer varies in thickness in different individuals and in dif- ferent parts of the body. It is thinnest on the eyelids, the glans penis, clitoris, prepuce, and inner surface of the labia majora, where ft ranges from 0-27 to 0-56 mm. On the face, the scrotum, and the areola of the nipples, it varies from O68 to 1-13 mm. On the forehead it is 1*50 mm. Its average depth on the general surface of the body is between 1-69 and 2-26 mm. It attains its greatest thickness on the sole of the foot, the back, and the nates, where its continuity is broken by the projection of a number of columns of fat, which extend from the sub- cutaneous connective tissue to the base of the follicles of the lanugo. In these regions it is frequently 5 5 mm. deep. The projecting columns of fat are of importance in supplying nutrition to the fine hairs. They also increase the flexibility of the integument, furnish a channel for the passage of the vessels, and serve as an outlet for various morbid products in disease. The corium is richly supplied with arteries, veins, lymphatics, nerves, and muscular tissue. It is traversed by the folli- cles of the deep-seated hairs and the ducts of the sudoriparous glands. The sebaceous glands and the follicles of the finer hairs are embedded in its middle third. The corium is divided for facility of description into the upper or papillary layer, and the lower or reticular layer. This division is, however, mainly an arbitrary one, and is based principally upon the greater size of the connective-tissue bundles in the lower strata and the ANATOMY OF THE SKIN. * consequent looseness of the network. The superficial portion is sepa- rated from the epidermis by a thin basement membrane, but the deep- er one merges imperceptibly into the subcutaneous connective tissue. Pahs Reticulaeis.—The reticular layer is the lower portion of the corium. It is composed mainly of bundles of white fibrous tissue, which decussate at first without division. The largest meshes are filled with fatty tissue, and contain blood-vessels, lymphatics, and nerves. They also give passage to the deep-seated hair-follicles and the sudorip- arous ducts. The smaller interspaces contain connective-tissue cor- puscles and wandering cells. The bundles of connective tissue cross each other obliquely, divide and subdivide as they proceed upward until they reach the papillary layer, which is formed by the interlace- ment of numbers of single fibrillae. The manner in which these bundles intersect accounts for what has been called the " cleavage " of the skin. Different parts of the skin may be mapped out in tracts in which the connective-tissue bundles exhibit a definite parallel arrangement. This structural peculiarity has much to do with the extensibility of the skin. Pars Papillaeis.—The papillary layer is the superficial or external portion. It is distinguishable from the reticular layer only by the great- er density of its structure. Its fibres are intricately bound together, and its interfascicular spaces are so minute that in many places it presents a perfectly homogeneous appearance. Its upper surface is roughened by the projection of millions of small but distinct prominences, termed the papillae, from which this layer derives its name. They contain the ter- minal expansions of the cutaneous vessels and nerves, and are the most important constituents of the corium. They are ordinarily cylindrical or conical, but vary in size and shape, and also in number, in various regions. Occasionally they are club-shaped, or square and flattened. Those that arise from a separate base are termed simple papillae, in con- tradistinction to the tufts of five or six which spring from a common trunk, and are called compound papillae. They may be again divided into vascular and nervous papillae. The former are provided with an af- ferent arteriole or capillary plexus and an efferent vein. The latter con- tain medullated nerve-fibres and one or more tactile corpuscles. In rare cases a papilla has been observed to contain both nerves and blood-ves- sels. This anomaly is supposed to be due to fusion of two distinct papillae. The papillae are most numerous and perfectly developed on the palms, the tips of the fingers, and the soles, where they are arranged in a series of circular or elliptical ridges. Meissner observed four liundred upon a square line of the end of the finger, and AVeber found one hundred and fifty to two hundred single, and eighty- one compound papillae upon a square line of the palm of the hand. They are also present in great numbers upon the nipple, the clitoris, the glans penis, the labia minora, and also on the pro- 8 DISEASES OF THE SKIN. labium. The smallest papillae are found on the face, especially upon the eyelids, brows, nose, cheeks, and chin. Those on the general sur- face of the body'are also small in size. The total number of the pa- pillae is very great. Sappey says that there are over sixty thousand to the square inch in many regions of the body. An estimate, based on this statement, would make the number on the whole surface of the body vary between one hundred and fifty and two hundred mill- ions. The Subcutaneous Connective Tissue.—This portion of the skin is composed principally of bundles of fibrous connective tissue, which rise obliquely from the periosteum or from the superficial fascia, and merge imperceptibly into the substance of the corium. These bundles vary in size, but are cylindrical in form, and interweave with each other, form- ing a series of networks with well-defined interfascicular spaces. Adi- pose tissue is found in more or less quantity in these spaces, consti- tuting the panniculus adiposus, upon which the plumpness of the body depends. According to Biesiadecki,* the individual fat-globules are composed of minute drops of oil, each of which is inclosed in a deli- cate membrane. They are sometimes round or oval in form, but more frequently polyhedral from pressure. The membrane or cell-wall is so distended by its contents that it is not discernible until they have been extracted by alcohol or ether. The fat-globules are aggregated into masses or lobules of varying size. Each lobule is provided with an afferent artery, a capillary plexus, and one or more efferent veins. Several lobules at times unite to form an acinous-like structure which is surrounded by a sheath of connective tissue. Large quantities of fat are found beneath the skin of the palms and soles, the back, the buttocks, and the mammary glands. Warren f has shown that in the thickest portions of the skin, columns or pillars of fat extend from this layer in an oblique direction through the lower two-thirds of the corium, and terminate at the base of the follicles of the lanugo. These columns are almost continuous in direction with the erector- pili muscles, to which they are also attached. They convey blood- vessels and lymphatics to the corium, and occasionally contain sudo- riparous glands. Their function has not been definitely ascertained. Warren believes that they furnish flexibility to the otherwise dense and unyielding integument, and that they assist in the action of the erector-pili muscles, and are essential to the nutrition of the lanugo. In health they furnish a channel for the blood-vessels and lymphatics, and in disease they provide an outlet for various morbid products. The quantity of fat in the subcutaneous connective tissue varies * " The Section of the Skin," by Professor Alfred Biesiadecki, in Strieker's Manual of Histology. \ Loc. at. ANATOMY OF THE SKIN. 9 greatly. It is usually found in larger proportion in women and chil- dren than in men, and lessens with advancing age. In cases of star- vation, and in all diseases attended with waste of tissue, the contents of the fat-globules disappear ; but the cell-walls remain, and are rap- idly refilled when health returns. Obesity consists in an over-produc- tion and abnormal deposition of fat. Some portions of the body, as the eyelids, penis, scrotum, and labia minora, are destitute of fat. The interfascicular spaces of the subcutaneous connective tissue in these regions are traversed by fine connective-tissue bands or single fibrillae. The interstices between the fibrillae and the primary bands vary in size under different circum- stances, and in proportion to the amount of fluid in the tissues. In some pathological conditions they are almost obliterated, while in others they are greatly increased in size. The cells of this layer consist of fixed or true connective-tissue cells, and lymphoid corpuscles or wandering cells which have migrated from the blood-vessels. The former are more or less spindle-shaped, and send processes between the primitive bundles of white fibrous tissue. These processes gradually develop into yellow elastic fibrillae. The lymphoid corpuscles are most abundant in the vicinity of the blood-vessels and glands, where they are similar in size and appear- ance to the white corpuscles of the blood. As they wander further into the tissues, they lose their circular form, and become somewhat spindle-shaped also. The sudoriparous glands and the bases of the deep-seated hair-fol- icles are imbedded in the subcutaneous connective tissue. It also contains lymphatics, nerves, and blood-vessels. Some of the nerves terminate in Pacinian corpuscles. The larger lymphatic vessels have a markedly transverse muscular structure, and are surrounded by a minute vascular network. The blood-vessels are of large size, and after supplying the hair-follicles, sudoriparous glands, and fat-lobules, send a number of branches to the corium. The Sweat Glands.—The sudoriparous or sweat glands are small, round or oval-shaped bodies, which are imbedded in the subcutane- ous connective tissue, and open on the surface of the epidermis by means of the sudoriparous ducts. They are yellowish or yellowish- red in color, and vary in size in different parts of the body. They are smallest on the eyelids, the nose, and the pinna of the ear; where they range from -gfo to y^ of an inch in diameter; and largest on the aureola of the nipple, the base of the scrotum, and in the axilla, where they sometimes attain a diameter of one-tenth of an inch. A sudoriparous gland consists essentially of a number of convolutions of a minute tube, which commences with a blind extremity, and is coiled upon itself several times to form a more or less globular mass which is the body of the gland. The tube then ascends in a perpendicular or 10 DISEASES OF THE SKIN oblique direction to the free surface of the epidermis, and becomes the duct or excretory canal of the gland. It passes through the lower portion of the corium in a direct or slightly flexuous manner, and, emerging between two papillae, pursues a more or less tortuous course through the layers of the epidermis, and finally terminates in a funnel- shaped opening or pore. Where the epidermis is thick, as on the palm of the hand and the sole of the foot, the tor- tuosity of the ducts is marked, and the pores are large in size. Kolliker's investiga- tions lead him to believe that the sudoriparous glands first appear in the fifth month of em- bryonic life as perfectly solid processes of the stratum Malpighii which gradually elongate, and, penetrating the deeper structures, begin to coil upon themselves. They are therefore to be re- garded as simple invo- lutions of this layer, which, by a continual process of cell-multiplica- tion, grow deeper and deeper into the corium and subcutaneous con- nective tissue, become convoluted, and divide into the glands proper and their ducts, while at the same time, either by a process of lique- faction of their central cells or by the excretion of a fluid between the cells, a lumen or cavity is formed. Klein has observed that both the gland and its duct are lined with a delicate cuticle which is especially marked in the duct and in the commencement of the coiled tube. In the epidermis the lumen bordered by this cuticle is all that is present of the sudoriparous duct. Unna insists that the duct ends in reality at the surface of the corium, and that the tortuous canal which ap- pears to be its continuation through the epidermis does not belong to it alone, but is also the receptacle for the exudations from the inter- stices of the epidermis. The duct proper has two other coats—the external one, or limit- ing membrana propria, which is continuous with the basement mem- brane of the surface of the corium, and the middle or epithelial coat, which is continuous with the deeper layers of the stratum Mal- Fio. 3.—Sweat-gland. Drawn from a speciuien beneath the microscope magnified 450 diameters. The section is cut right through the gland, a. Connective tissue supporting gland, b. Gland, c. Gland cut transverse- ly, d. Duct going off. ANATOMY OF THE SKIN. 11 pighii, and is composed of two or three rows of nucleated polyhedral cells. The proximal portion of the coiled tube which forms the body of the gland is identical in size and structure with the sudoriparous duct, with which it is directly continuous. The remaining or distal portion is much larger in diameter, and differs, according to Klein and Kolli- ker, in these essential respects, that its middle or epithelial lining con- sists of but one layer of transparent columnar cells, and that there exists between it and the limiting membrana propria a layer of non- striped muscle-cells which are arranged parallel with the long axis of the tube. This distal portion of the tube is of great length in the glands of the palms and soles, the scrotum, the nipple, the scalp, the axilla, and other regions of the body, and its epithelial cells contain a considerable number of granules. Each sudoriparous gland is surrounded by an investing sheath of connective tissue, interspersed with fat-cells, which supports the vessels that supply the gland, and binds the convolutions of the tubes closely to each other. Connective-tissue fibres with numerous cells accom- pany the duct, running parallel to it through the corium, and as a rule there are also two accompanying small blood-vessels (Biesiadecki). The nervous supply of the sudoriparous system has not yet been dem- onstrated. Langerhaus, however, claimed, years ago, to have found traces of a nervous structure in the inter-epithelial spaces of the outer coat of the duct. Sudoriparous glands are found in great numbers in every portion of the body except the glans penis, the clitoris, and the red border of the lips. Their distribution varies widely, however, in different re- gions of the body. In the axilla they form a continuous layer beneath the corium. Krause states that there are 2,736 in a square line on the palm of the hand, 2,685 in the same space on the sole of the foot, 1,490 on the back of the hand, 1,258 on the forehead, 1,136 on the chest and abdomen, 1,123 on the inside of the arm, 566 on the inside of the thigh, 548 on the cheeks, and 417 on the neck, back, and but- tocks in every square inch. The same observer estimated the total number of these glands on the body of an adult of average size to be 2,381,248. As the length of an untwisted tube is about one-fourth of an inch, the total length of the tubing through which the perspiratory function is carried on is almost fifty thousand feet, or over nine miles. The secretion of the sudoriparous glands varies in quality and quan- tity according to their size and situation, and a number of other nor- mal and abnormal circumstances. The small glands secrete a clear, watery fluid without any granular matter. The larger glands, especially those of the axilla, secrete a thicker fluid containing numerous fat- cells, and granules with free nuclei, which are derived from the epi- thelial cells lining the interior of the gland. This fact led Meissner 12 DISEASES OF THE SKIN. to believe that the real function of the sweat-glands was to furnish a material for the oiling of the skin. This view was not accepted then. Unna has again revived it, and claims that the secretion of the seba- ceous glands is only sufficient to lubricate the interior of the hair- follicles, and that the sweat-glands exist solely for the purpose of pro- viding an oily material for the surface of the skin. He also believes that the perspiratory fluid, generally supposed to be secreted by the sweat-glands, is in reality an exudation from the interstices of the epidermis. Therefore they should be entitled " coil-glands " in future. Further research will, however, probably show that they are necessary for the proper performance of both functions. Anbert, on the basis of experiments which he has made, maintains that insensible perspiration is due to evaporation from the skin gener- ally, and not to the action of the sudoriparous glands. The ceruminous glands of the ear are similar in appearance and structure, and allied in function to the glands of the sudoriparous sys- tem. They do not exist in the whole external auditory meatus, but only in the cartilaginous portion, between the lining membrane of the ear and the cartilage. They form a continuous yellowish-brown layer, occasionally visible to the naked eye. Their secretion is a modification of that of the sudoriparous glands. The cerumen or wax of the ear is a combination of the secretions of the ceruminous glands with that of sebaceous glands of the auditory meatus. The circum-anal glands of Gay, which form a zone around the verge of the anus, are to be regarded as a part of the sudoriparous system. They are identical in structure with the coil-glands of the other por- tions of the body, and differ from them in size only. The Sebaceous Glands.—The sebaceous or sebiparous glands, called also the glands of the hair-follicles, are simple or compound racemose glands, found in every portion of the skin except on the clitoris, the glans penis, the palms, the soles, and the dorsal surfaces of the last phalanges of the fingers and toes. They are invariably situated in the upper or middle part of the corium, and do not extend to the subcuta- neous connective tissue. They are most abundant upon the hairy por- tions of the body, and are connected as a rule with the hair-follicles into which their secretion is discharged. According to Sappey, they may be divided into three groups. The first group comprises the glands of the scalp, the beard, the axilla, the pubes, the labia majora, and the scro- tum. The hairs in these regions are coarse and fully developed, and each follicle is provided with two, three, or more sebaceous glands, which may properly be regarded as appendages of the hair-follicles. The glands of the second group are larger in size and more com- plex in structure, and are connected with the lanugo. The duct of the gland is, however, so much wider than the lanugo-follicle that the relation may be reversed, and the hair considered to be an append- ANATOMY OF THE SKIN. 13 age of the gland. The glands of this group are found mainly upon the forehead, nose, cheeks and aureola of the nipples. A few are also present upon the genitalia, and various portions of the chest, the ab- domen, and the upper and lower extremities. Piffard says that acne is almost exclusively an affection of this class of glands. The third group is small in number, and comprises those which open directly upon the surface of the skin, and are not connected in any way with the hair-follicles. They are found only on the internal surface of the prepuce and behind the corona glandis in the male, and upon the surface of the nipple, the vestibule, and the labia minora in the female. The sebaceous glands are whitish in color, and vary in size in dif- ferent portions of the skin. The largest are found on the eyelids (Meibomian glands), the mons veneris, the scrotum, the labia majora, in the axillary and anal regions and on the aureola of the female nip- ple (glands of Montgomery), where they frequently attain an enormous size. Those of the scalp are smaller in size, but greater in number. AV. Krause has estimated that there are over eighty thousand hair-fol- licles on the average adult head, each of which is provided with two or more of these glands. Some of the coarse hairs on the genitalia are surrounded by a labyrinth of glands ; seven or eight being fre- quently connected with each hair-follicle. Each gland is composed of from two to twenty acini or lobules, and may be divided into a body or gland proper, and an excretory duct. In structure it con- sists of an external membrana propria and an internal epithelial lin- ing of several layers of nucleated cells, which is practically a con- tinuation of the outer root-sheath of the hair-follicle. The external membrana propria is identical and continuous with the basement membrane of the surface of the corium, and is surrounded by an in- vestment of connective tissue containing blood-vessels, lymphatics, and nerves. The cells of the epithelial lining of the gland proper are almost identical in size and arrangement with those of the stratum Malpighii. Those of the first layer are imbedded in the basement membrane, and are small, granular, and columnar, with spherical or oval nuclei. Next to this, and filling the entire space of the acini, are large polyhedral cells with spherical nuclei, containing a variable amount of fat and fat-globules. The cells nearest the centre of the alveoli are the largest in size, but become shrivelled as they ap- proach the beginning of the duct. The cavity, or centre of the gland, contains a grumous pulp formed of free fat, fat-globules, and epi- thelial debris floating in a watery fluid. This is termed sebum. The duct is similar in structure to the body or gland proper. It is com- posed of an external basement membrane, an internal epithelial lining, and a central cavity or lumen through which the sebum is discharged. It opens into the hair-follicle at an acute angle at its upper third ; the 14 DISEASES OF THE SKIN. gland proper lies in the corium nearly on a level with the middle third of the follicle. The ducts of the glands that open directly upon the surface of the skin receive an additional layer of cells from the stratum corneum of the epidermis. The sebaceous glands begin to be developed at the end of the fourth month of foetal life as small solid projections from the outer root-sheath of the hair-follicles. They gradually attain their definite size and shape by a process of cell-multiplication ; and an internal cavity or lumen is finally formed by the fatty metamorphosis of the central layer of cells. The Hairs.—Hairs are slender cylindrical structures composed of modified epithelial tissue. They are imbedded in depressions of the skin known as the hair-follicles or sheaths, and are developed from a minute papilla which projects from the base of each follicle. They are found upon every portion of the skin except the upper eyelids, the lips, the palms and soles, the clitoris, the glans penis, and the dorsal surfaces of the last phalanges of the fingers and toes. They vary in length and thickness in different regions of the body, and may be divided into four groups. Those of the first group are long and soft, and are found only on the scalp. Those of the second group are long and coarse, and are found in the beard and whiskers, and in the axil- lary and pubic regions. The third group comprises the short coarse hairs of the eyebrows, eyelashes, the nostrils, and the external audi- tory meatus. The fourth group consists of the delicate lanugo, which are present on the face, trunk, and other portions of the body. The size of the hairs is further influenced by age and sex. They are thicker in general in adult age than in childhood, and in the female than in the male. Their number varies considerably, dependent upon the region of the skin and the individual. According to Whitoff, there are 293 in a quarter of a square inch on the scalp, 39 in the same space on the chin, 34 on the pubes, 23 on the forearm, and 19 in the same space on the front of the thigh. AVilson estimated the total number on the scalp to be 120,000, but Krause and other observers say there are only 80,000. This discrepancy may be due in part to the color of the hair which was the subject of calculation. Light hairs are placed more closely together, and are more abundant, as a rule, than dark ones. They vary in color both in race and individual. The different shades depend upon the amount of pigment material which is present in the cells of the hair, and in the interstitial cement substance which binds them together. In the dark there is an abundance of the interstitial pigment-granules. In the red the pigment material is confined to the substance of the hair-cells. White hairs are destitute of all pig- ment. Gray contain bubbles of air in their superficial layers. The color of the hair gradually becomes darker from childhood to adult life. It ANATOMY OF THE SKIN. has been estimated that the hair of light-complexioned male children darkens from 55 per cent, during the first five years of life to 33 per cent. at forty-five years. This change is much less marked in females. The hairs are so elastic that they can be stretched to nearly a third more than their natural length, and if the tension be not too long con- tinued they will contract to very near their normal size. Owing to their fibrous structure they are very strong, and will bear a weight of from one to three pounds without breaking. They absorb moisture readily, and part with it freely. They are therefore either dry and brittle, or moist and soft, in accordance with the amount of fluid secreted by the skin and the amount of moisture present in the atmosphere. They are identical in structure with the horny layer of the epidermis, and like it they contain neither blood-vessels nor nerves. Their nourishment is derived from the cells of the papillae at the base of the hair-follicles. Their rate of growth varies from five to seven inches or more in a year. Each hair has a certain limit, after attaining which it remains stationary for a while, and then becomes detached from its papilla and expelled from the follicle. Those of the scalp when left uncut fre- quently reach a length of six feet before this process of degeneration and extrusion occurs. A complete living hair consists of a free portion or shaft, which extends beyond the surface of the skin; an inclosed portion or root, which is contained within the fol- licle ; and an expanded portion or bulb, which rests upon the hair-pa- pilla at the base of the follicle. The hair-papilla is a small, pear- shaped or oval body, which arises from the base and projects into the cavity of the hair-follicle. It is about twice as long as it is broad, and is composed of connective-tis- sue fibres, between which are found ^ numbers of round nuclei and spher- Fig. 4.—Magnified hair: a. Internal root- ical nucleated cells. It is identical S^KS°I nSSmde Si^ in structure with the Other papillae ly torn in places, d. Where blood-vessel ,. enters hair-bulb. e. Hair showing mter- of the corium, and is continuous at nai and fibrous structure. its origin with the fibres of the outer layer of the hair-follicle. Its upper surface is covered by a thin basement membrane, which is reflected from the inner layer of the fol- licle, and which separates it from the hair-bulb. It contains two arter- ies (Biesiadecki), two or more veins, and some medullated nerve-fibres. 16 DISEASES OF THE SKIN. The hair-bulb is the terminal expansion of the root of the hair. It surrounds the papilla, and completely fills the lower part of the fol- licle. It is composed of several layers of polyhedral nucleated cells, which resemble the cells of the rete Malpighii. They are united to each other by cement substance, and are continuous with the cells of the outer root-sheath. The layer which is situated on the basement membrane immediately above the papilla is composed entirely of short columnar cells. According to Klein, the cells of this layer are in an active state of multiplication and proliferation, reproducing them- selves continually. As this process goes on, the cells of the other layers of the hair-bulb are gradually forced upward into the cavity of the follicle, where they form the cells of the root of the hair. They also change in shape, becoming flattened and fusiform, constituting the cells of the hair-substance, except in the centre, where they remain polyhedral as those of the medulla of the hair. The peripheral cells which compose the inner root-sheath retain more or less of their original form. The hair-root proper consists of the medulla of the hair, the hair- substance, and the cuticle of the hair. The medulla i» composed of several rows of polyhedral cells which occupy the centre of the hair, and extend from the bulb to very nearly the point of the shaft. Kol- liker states that they contain neither fat nor pigment granules, but derive their color from the presence of a variable number of minute vesicles which are filled with air. The lanugo and immature hairs have no medullary cells whatever. The hair-substance, or cortical substance, is com- posed of several layers of flat, elongated fibres, which form the greater part of the hair and give it shape and consistency; they vary in length and breadth, and are held together by an albuminous cement; they are longitudinally striated, and contain a varia- showing cortical ble amount of pigment matter. Each fibre consists substance and « , n 11 t -..i t i ■, , ■ ■, medulla. 0T- two or more flattened epithelial scales, which present a remnant of a nucleus, but are so closely united one to the other that they can only be separated by strong acids or alkalies. Air-bubbles are present in considerable quantity in the spaces between the hair-fibres. The cuticle of the hair is a thin, transparent membrane, which completely invests the hair, and is intimately united with the hair-substance on the inside and the cuti- cle of the inner root-sheath on the outside. It arises from the neck of the papilla, and extends from the bulb along the entire length of the hair. It is composed of a single layer of non-nucleated hyaline scales, which are frequently round or columnar in the portion sur- rounding the bulb, but become elongated and fusiform in the root and shaft. They are arranged transversely, and overlap each other ANATOMY OF THE SKIN. 17 Fig. 6.—(Photo-micrograph.) Transverse section through hairs magnified 75 diameters, a. Hair. b. Internal root-sheath, c. External root-sheath, d. Hair-follicle. like the tiles on a house or the scales on a fish. The cuticle presents more or less marked projections or serrations, according to the degree in which its scales over- lap. The shaft of the hair, or the part pro- jecting beyond the sur- face of the skin, is iden- tical in structure with the root of the hair. The Hair - Follicles. —The hair-follicles, or hair - sacs, are flask- shaped depressions of the epidermis and cori- um which closely envel- op the roots of the hairs. Each follicle commences on the ex- ternal surface of the Bkin by a funnel-shaped opening or mouth, and passes in an oblique or slightly curved direction through the corium into the subcutaneous connective tissue. It terminates in a bulbous expansion which is in- vaginated over the papilla of the hair. The narrowest portion of the follicle is called its neck, and is situated just below the upper surface of the papillary layer of the corium. The ducts of one or more sebaceous glands empty into the follicle at this point. The follicles of the lanugo do not penetrate as deeply into the subcuta- neous connective tissue as do those of the coarser hairs, and fre- quently do not extend below the deeper portions of the corium. The hair-follicles vary considerably in diameter, and also in number, in the different regions of the body, but agree in their general structure. Each follicle consists of an external, fibrous, vascular portion or hair-follicle proper, and an internal epithelial portion, which imme- diately surrounds the root, and is therefore usually termed the root- sheath. The external portion, or hair-follicle proper, is composed of an ex- ternal, a middle, and an internal layer. The external layer (the external fibrous sheath of Kolliker) is the thickest and most important portion of the follicle. It consists of compact connective-tissue fibres which run parallel with the long axis of the follicle, and which are intimately united with the fibres of the corium above. It merges externally into the surrounding fibrous tis- 18 DISEASES OF THE SKIN. sue, and terminates below in an intricate network which envelops the papilla of the hair. It contains a minute artery and vein (Biesiadecki), and also some nerve-fibres, which divide dichotomously. The middle layer (the internal fibrous sheath of Kolliker) is com- posed of a single layer of transversely or circularly arranged spindle- shaped cells with long, narrow nuclei; they resemble, and are gener- ally considered to be, smooth muscle-cells. They line the whole inte- rior of the body of the follicle, but do not extend above its neck. Kolliker says that this layer contains neither blood-vessels nor nerves. The internal layer is also called the hyaline membrane and glassy or vitreous membrane. It consists of a delicate, transparent membrane, which lines the whole interior of the follicle, and is reflected over the surface of the hair-papilla. It is a direct continuation of the base- ment membrane of the corium, and contains neither vessels nor nerves. The root-sheath, or the internal portion of the hair-follicle, is con- tinuous with the lower strata of the epidermis, and is made up of an outer and an inner layer. The outer root-sheath is a prolongation of the stratum Malpighii, with which it is identical in structure and ar- rangement. It is composed of an external layer of columnar cells, next to which are found several rows of polyhedral cells. Its inner wall is formed by one or more rows of flattened, nucleated scales. It extends along the entire inner surface of the follicle, but is thinner at the neck than in the body, and becomes continuous at the base with the cells of the hair-bulb. There are no blood-vessels in the outer root-sheath ; but, according to Langerhaus, it contains a few nerve- fibres similar to those which are found elsewhere in the stratum Mal- pighii. The inner root-sheath is a delicate membrane which is closely con- nected externally with the outer root-sheath and internally with the cuticle of the hair. It arises from the neck of the papilla at the base of the hair-follicle, and is composed of an outer, or Henle's layer, which is a single layer of elongated cells without nuclei; an inner, or Huxley's layer, consisting of one or two strata of polygonal nucleated cells ; and an internal, delicate cuticle. Biesiadecki remarks that the internal root-sheath is developed from the cells of the root of the hair. It terminates at the neck of the follicle, and contains neither blood- vessels nor nerves. Each hair-follicle is supplied with one or more muscles, the ar- rectores pili, which are composed of several bundles of non-striated fibres. They arise by a series of digitations from the upper portion of the corium just beneath the basement membrane, and, passing ob- liquely downward, encircle the sebaceous gland, and become inserted in the lower portion of the hair-follicle. They are invariably found on the inner side of the follicle, with which they form an acute angle. Their attachment to the hair-follicles is to be regarded as a relatively ANATOMY OF THE SKIN. 19 fixed point, and that to the corium as a relatively movable one. (Tomser.) When these muscles contract they depress the papillary layer at various points along the periphery, draw the hair-follicle from an ob- lique into a vertical position, and, by elevating the hair-follicle and hair above the surrounding surface, produce the condition known as cutis anserina. The hair is at the same time compelled to assume a more upright position, or, as is commonly said, " to stand on end." They also, by contracting, compress the sebaceous gland, and as- sist in the discharge of its secretion. The hairs begin to develop in the third month of foetal life, as small, solid, cylindrical projections from the under surface of the stratum Malpighii, which fit into the depressions in the corium. As multiplication and cell-proliferation continue, they penetrate deeper and deeper into the substance of the corium, which becomes con- densed around them, and forms the hair-follicle proper, and at its fundus forms the papilla upon which the Malpighian cells are invagi- nated. The cells around the papilla proliferate rapidly and create the hair-bulb from which the hair proper and the inner root-sheath are gradually developed. The new hair does not penetrate the stratum corneum of the epidermis at once, but burrows its way into that layer in an oblique direction for some time before reaching the surface. The first hairs are always of the lanugo type. When a hair has reached its limit of existence it undergoes de- generation, becomes separated from its papilla, which atrophies, and a new papilla and a new hair are formed in connection with the old follicle. According to Klein, the lower part of the follicle including the hair-bulb degenerates also, and is gradually absorbed. There is then left only the upper part of the follicle and the hair-root, the fibres of which become fringed at the distal end and lost among the cells of the outer root-sheath, constituting the hair-knob of Henle. After a time a cylindrical outgrowth of epithelial cells projects down- ward from the outer root-sheath and becomes invaginated over a new papilla. Multiplication and cell-proliferation ensue, and a new hair- bulb and hair are formed, and the old hair is gradually pushed out of the follicle as the new one makes its way to the surface. The Nails.—The nails are dense, horny, translucent structures which are implanted in the skin of the dorsal surfaces of the terminal phalanges of the fingers and toes. They are quadrilateral in shape, and flattened anteriorly and posteriorly, but curved from side to side. Their anterior border is free ; their posterior and lateral borders are inserted in a fold of the skin called the nail-groove. The nail-groove is shallow at its commencement at the tip of the finger, but deepens as it extends posteriorly. That portion of the nail which is inclosed in the groove is called the root of the nail, the remainder constitutes 20 DISEASES OF THE SKIN. the body of the nail. The nail-bed is that part of the skin upon which the body of the nail is imbedded. It is composed of stratum Mal- pighii, corium, and subcutaneous cellular tissue. The matrix is the posterior portion of the nail-bed, and is situated immediately beneath the root of the nail. The white line at the base of the nail is called the lunula, and represents the anterior termination of the matrix. The corium of the nail-bed is firmly united by bands of fibrous tissue to the underlying periosteum. It is richly supplied with blood-ves- sels and nerves, but contains no fat. The subcutaneous cellular tis- sue is also destitute of The nails grow more rapidly in summer than in winter, and in childhood than in old age. They grow continually if cut, but when left uncut they only attain a certain length, after which their development ceases. They begin to form in the third month of foetal life, and are fully developed by the end of the eighth month. The authority just quoted says they are produced by a rapid multiplication of the cells of the stratum Malpighii, and the conversion of its superficial cells into the scales of the stratum lucidum. The nail is covered by the stratum corneum at this stage, but at the end of the fifth month its margins break through, and by the end of the seventh the greater part has become clear. Muscles of the Skin.—The skin contains both striated and non- striated muscular fibres. The former are found only in the forehead, nose, cheeks, and neck, where they arise from the subcutaneous cellu- lar tissue, or from the fascia of the superficial layer of muscles, and ANATOMY OF THE SKIN. 21 passing obliquely upward are inserted into the corium between the hair-follicles and the sebaceous glands. The non-striated muscles are more numerous, and are present in every portion of the skin either as compound fibres which run horizontally to the surface and form anas- tomosing networks, or as bundles of fasciculi which run obliquely up- ward. According to Unna, they may be divided into the muscular membranes, the arrectores pili, and the proper diagonal muscles of the corium. The muscular membranes are found in the skin of the scro- tum, the penis, the mammary aureola, and the nipple. They are com- posed of a network of bundles of muscular fibres, which are deposited in layers in the corium, and run parallel to its surface. They are especially well developed in the aureola of the female nipple, where they are arranged in a delicate circular layer which becomes thicker as it approaches the base of the nipple. Kolliker states that this layer is occasionally visible to the naked eye. The muscular fibres of the nipple run in various directions, and form an exceedingly close network which surrounds the lacteal ducts, and constitutes their sphincter. The arrectores pili are the muscles of the hair-follicles. The proper diagonal muscles of the corium (Unna) are similar in structure and size to the arrectores pili, but have no connection with the hair-follicles. They arise from the upper portion of the papillary layer of the corium, and running obliquely downward are inserted into its lower portion, or into the reticular layer. AVhen they contract they produce a general condensation of the tissues of the corium. As a result of this action, the blood-vessels are subjected to increased pressure, the blood is driven from the periphery toward the centre, and the papillary layer becomes pale and bloodless. At the same time the sebaceous and sudoriparous glands are compressed, and their con- tents forced outward along their ducts. The cold sweat of fear is thus produced. The number of muscular fibres varies in different portions of the skin. They are most abundant in the scrotum, where they form a continuous layer—the dartos. They are also present in great numbers in the prepuce and the skin of the penis. Neumann observes that they are less developed on the flexor than on the extensor surfaces, and occur with diminishing frequency on the perineum, scalp, fore- arm, thighs, shoulders, forehead, abdomen, axilla, legs, face, the palmar and plantar and dorsal surfaces of the hands and feet. The Blood-Vessels of the Skin.—There are no blood-vessels in the epidermis, but the corium and subcutaneous connective tissue are abundantly supplied with arteries, capillaries, and veins The arteries of the subcutaneous connective tissue are of large size and anastomose freelv, forming a plexus from which small branches pass off in all directions to the fat-lobules, sweat-glands, hair-follicles, and muscles 22 DISEASES OF THE SKIN. of the skin. Other and larger branches proceed directly or obliquely upward to the superficial layers of the corium, and, after sending small branches to the sebaceous glands and the upper part of the hair-folli- cles, form a second plexus, which is situated directly beneath the base of the papillae. Millions of minute capillaries arise from this super- ficial plexus and project into the substance of the vascular papillae. Each papilla is supplied with a single arterial capillary, which, after pursuing a tortuous course toward the apex, bends over and passes down and out as a venous capillary. These venous capillaries unite in the upper layer of the corium to form a network of minute veins, from which larger ones arise, and passing downward empty into those of the subcutaneous connective tissue. There are no capillaries, as a rule, in the papillae which contain nerve-fibres or tactile corpuscles. All the arteries and veins in the upper portion of the corium con- sist only of a single layer of endothelial cells, which is re-enforced as they approach the subcutaneous connective tissue by a rudimentary media and adventitia (Unna). Hoyer says that many of the cutane- ous arteries in the nail-bed and in the skin of the terminal phalanges of the fingers and toes empty directly into the veins of those parts without the intervention of capillaries. The fat-lobules, the sebaceous and sudoriparous glands, the hair- follicles, and the cutaneous muscles, are surrounded by a dense net- work of capillary vessels which terminate in one or more efferent veins. The larger arteries are richly supplied with nerve-fibres. The Lymphatics of the Skin.—The lymphatic system of the skin is composed of lymphatic vessels proper and lymph - spaces. The former are well-defined circular canals inclosed by their own distinct walls; the latter are interstices in the substance of the skin between the capillaries and lymphatic vessels, and contain a variable amount of fluid. They have no distinct wall, and freely communicate with each other. They are the principal seat of the effusion in all exuda- tive diseases. Lymphatic vessels are found in every portion of the skin, but they are most abundant in those regions where its attachment to the sub- jacent tissues is comparatively loose, as on the eyelids and scrotum. They present a distinct lumen, which is bounded by a single layer of elongated, flattened endothelial cells. Those of the subcutaneous cel- lular tissue have a rudimentary muscular coat in addition, and contain one or more valves. They are arranged in a series of plexuses, which ramify horizontally in the corium and subcutaneous connective tissue. Those of the superficial layer begin with a blind extremity in the upper portion of the papillae, and unite to form an exceedingly close network of minute vessels, which become larger in calibre as they de- scend in the substance of the corium. They finally empty by a few ANATOMY OF THE SKIN. 23 large trunks along with those of the deeper layers into the lymphatics of the subcutaneous cellular tissue. The lymph-spaces of the corium and subcutaneous tissue are iden- tical with the interfascicular spaces, and communicate with the lym- phatic vessels of those parts by means of a multitude of small stomata. There are none of these vessels in the stratum Malpighii. The cir- culation there is carried on entirely through the lymph-spaces, which are the interstices between the so-called prickle-cells. The fat tissue, the sudoriparous and sebaceous glands, and the hair-follicles are sup- plied with separate lymphatic vessels, and honeycombed with lym- phatic clefts and sinuses. The Nerves of the Skin.—The stratum Malpighii, the corium, and the subcutaneous connective tissue are richly supplied with nerves, but none have yet been discovered in the stratum corneum. The nerves of the subcutaneous connective tissue are large in size, and are directly continuous with the large nerve-trunks of the subjacent structures. They send horizontal branches to the large arteries and Pacinian corpuscles, and then pass obliquely upward to the under sur- face of the corium, where they divide into a number of minute branches which ramify through the substance of the corium, and are composed of both medullated and non-medullated fibres. The medullated terminate in the Pacinian and tactile corpus- cles, and are consequently most numerous in the regions where those structures are most abundantly developed. The non-medullated arc present in every portion of the skin. The Pacinian Corpuscles.—The Pacinian corpuscles, or corpuscles of Vater, are small, firm, compact, semi-transparent bodies, which are found in large numbers in the subcutaneous connective tissue of the corpora cavernosa, the palms of the hand, and the soles of the feet. They are especially abundant and well developed on the inner surfaces of the terminal phalanges of the fingers and toes. Their total number on each hand and foot varies from 600 to 1,400. They are more or less elliptical or ovoid in form, and are plainly visible to the naked eye. They are composed of from twenty to sixty lamellae, or capsules, which are arranged concentrically around a cylindrical or elongated central cavity. The capsules consist of an internal layer of nucle- ated endothelial cells and an external layer of hyaline ground-sub- stance, in which fine bundles of connective-tissue fibres are im- bedded. Each Pacinian corpuscle is pierced at its base by a single medullated nerve-fibre, which gradually loses its neurilemma as it passes through the capsular layers, and enters the central cavity as a simple axis-cylinder, which finally divides into two or more branches, terminating in pear-shaped enlargements in the distal portion of the central cavity. This cavity is lined by agranular albuminous substance containing 24 DISEASES OF THE SKIN. traces of cell-structure, which has been supposed to be identical with the medullary substance of the nerve. The lamellae are developed from, and are directly continuous with, the external layers of the neurilemma. According to Biesiadecki, a large artery enters the cor- puscle near its base, and forms a network of capillaries that ramify between its outer lamellae. The Tactile Corpuscles.—The tactile corpuscles, called also touch- corpuscles, corpuscles of Meissner, and corpuscles of AYagner, are small round or oval bodies, which are present in the sensory papillae of the corium. They vary in number in different regions of the body. Meiss- ner has estimated that there are 108 in a square line on the flexor sur- faces of the terminal phalanges of the fingers, but only forty in the same space on the second, fifteen on the first, and eight in the palm of the hand. They exist in considerable numbers on the lips and nip- ples, and are more or less scattered in other portions of the body. They occupy the greater portion of the papillae in which they are found, and present a transversely striated appearance on section. They are composed of large, flat connective-tissue cells, which are held closely together by a network of delicate fibres, and are surrounded by an investment of fibrous tissue. Each corpuscle is penetrated by a single medullated nerve. Klein states that the nerve first pursues a winding course around the corpuscle, during which its neurilemma becomes fused with the fibrous sheath of the corpuscles. It then loses its medullary substance, and penetrates into the interior of the cor- puscle as a simple axis-cylinder. This axis-cylinder further divides into a number of minute branches, which ascend spirally through the substance of the corpuscle and terminate in small pear-shaped or cylindrical enlargements, known as the touch-cells of Merkel. The genital corpuscles of Krause, or the end-bulbs of Krause, are similar in structure and arrangement to the tactile corpuscles, and are found immediately beneath the epithelium of the penis, clitoris, and vagina. The Non-Medullated Nerves.—The non-medullated nerves give off branches in the lower portion of the corium to the blood-vessels, the hair-follicles, and the sebaceous and sudoriparous glands. They then ascend obliquely to the superficial layer of the corium, where they form a dense plexus around the papillary vessels. From this plexus numerous elementary fibrils ramify in various directions. Some pass downward into the tissues of the corium, but the greater number pierce the basement-membrane, and, passing through the stratum Mal- pighii, form another plexus there, from which other fibrils pass upward into the stratum granulosum. It was formerly believed, that they ended in this layer as minute expansions between the granular cells • Unna, however, states as a result of the most recent investigations that they penetrate the protoplasm of the cells and terminate in a minute PHYSIOLOGY OF THE SKIN. 25 bulb, which is closely applied to the nucleus of the cells. They some- times wind around the nucleus, but do not penetrate it. Their manner of termination is, therefore, typically intracellular. PHYSIOLOGY OF THE SKIN. Its functions are more numerous and varied than those of any other organ. It forms a protective covering for underlying structures, prevents too rapid evaporation of the water of the tissues, and assists in maintaining the temperature at the normal standard. It is of the utmost importance as an organ of sensation, secretion, excretion, and absorption. It also serves as an accessory organ of respiration. The cushion-like formation of the subcutaneous connective tissue, and the elasticity and firmness of the corium, modify the effect of ex- ternal injuries, and protect the internal organs to a more or less extent from shock. The comparative impermeability of the horny layer of the epidermis prevents too rapid transudation and evaporation of the fluids. If it were not for the barrier thus interposed, the escape and evapora- tion of the water would be so continuous and excessive that the tissues would become dried up and death ensue. The horny layer is also a protection to a considerable extent against the action of caustic or irri- tant substances, and the effects of high or low temperature. The hair of the head and face is an additional protection against injuries, as well as excessive heat and cold. The mustache and beard debar foreign matter from entering the air-passages, the eyebrows prevent the per- spiration from running over the eyelids, the eyelashes prevent particles of irritants from settling on the conjunctiva, and the short, stiff hairs at the openings of the ears and nostrils obstruct the entrance of in- sects into those passages. Professor Exner points out that upon folds of the skin which come in contact, as in the axilla, and between the scrotum or labia majora and the thigh, the hairs serve as rollers, and facilitate the gliding upon each other of opposed surfaces. Regulation of the Temperature of the Body.—One of the most im- portant functions of the skin is that of maintaining the temperature of the body at the normal standard. An increase of ten degrees above, or a decrease of fifteen degrees below that standard, is incompatible with life. Owing, however, to the power which the skin possesses of resisting or accommodating itself to changes in the external tempera- ture, much greater variations are every day endured with impunity. The skin and its appendages are imperfect conductors of heat. 26 DISEASES OF THE SKIN. They protect the body against the effects of cold by retaining within the tissues a considerable proportion of the heat which is produced there. This action is further assisted by the involuntary contraction of the cutaneous muscles, by which the blood is driven from the pe- riphery toward the centre, the general cutaneous surface lessened in extent, and the radiation of heat proportionately diminished. They also form a mechanical protection against the action of moder- ate external heat. The processes by which the human body is enabled to resist a continuously high temperature are more intricate. The prob- lem in this case is to prevent the temperature of the body from rising above the normal at a time when it is not only producing a super- abundance of heat within itself, but is also surrounded by a still hotter atmosphere from which it is constantly receiving accessions. The chief means by which this result is attained is by a large increase of the cutaneous transpiration. In consequence of the impression made by a warm or hot atmosphere on the vaso-motor nerves of the skin, the cutaneous muscles become relaxed, the blood-vessels dilated, and the general superficies of the skin increased. A much greater surface is thus exposed for radiation and transudation, the skin becomes bathed with perspiration, by the evaporation of which active heat is converted into latent heat, and the temperature of the evaporating surface correspondingly diminished. This effect in re- ducing the temperature of the body or preventing an abnormal rise is greatest when the air is dry as well as warm. The amount of perspi- ration secreted under these circumstances is sometimes very great, amounting to from one to four pounds in an hour. The degree of heat that can be endured as long as perspiration and evaporation are not interfered with is astonishing. Drs. Blagden and Banks ascer- tained that a temperature of 211° could be borne without much incon- venience for a limited time in dry air. During one of their experi- ments the temperature was raised to 260°, and kept at that point for eight minutes. At the end of that time the clothes and furniture in the room were very hot, but the temperature of the body remained about normal. Tillet mentions the case of a girl who remained in an oven for several minutes without any ill effect while the temperature was 324"5°. The workmen of Sir F. Chantrey became habituated to entering the oven where their moulds were dried while the ther- mometer stood at 350°, and those employed by M. Magnus were ac- customed to entering his oven when the temperature was over 400°. Chabert, the fire-king, is said to have entered ovens which were heated to 400° and 600°. In all these cases the atmosphere was perfectly dry, and the bodily temperature was kept down by the production and evaporation of a profuse amount of perspiration. When, however, the air is moist, as well as hot, evaporation is ef- fected with more difficulty ; the temperature of the body rises rapidly, PHYSIOLOGY OF THE SKIN'. 27 and the degree of heat that can be endured is much less. C. James, an English observer, was overcome by a temperature of 112° in the vapor-baths of Xero; but in the caves of Testaccio, in which the air is dry, he suffered very little inconvenience, although the temperature was 176°. In the former evaporation from the skin was an impossi- bility, while in the latter it was abundant. Being exposed to so many vicissitudes, it is not surprising that the temperature of the skin itself should be neither as elevated nor as constant as that of the interior of the body. Differences are observable, also, in different regions of the integument. It is evident to the touch, for instance, that the habitual temperature of the forehead is greater than that of the feet. A series of interesting experiments upon the subject of local temperatures has been conducted by A. J. Kunkel.* This investigator finds, notwith- standing considerable fluctuations due to various causes, that the skin tends to approximate a constant degree, which he terms the optimum, and that a marked deviation from this optimum is productive of pain. In a well-clad individual, sitting in a room of ordinary temperature, the optimum varied from 33-8° to 34-8° 0. (92-8° to 94-6° F.). The normal temperature of the parts of the body habitually covered by clothing averages from 34-2° to 34-6° C. (93-5° to 94-5° F.). Local variations, however, result from anatomical and physiological causes. The heat of the skin is increased by activity of tissue-change in under- lying parts or organs. In regions situated near the axis of the body, over bulky muscular masses, and over the cranium, maximum tempera- tures are obtained. High temperatures are observed over great vessels. The face is generally half a degree warmer than the covered parts of the body. When prolonged exposure to cold has depressed the tempera- ture of a large area to 32° 0. (89-6° F.) or lower, discomfort is pro- duced. Kunkel states, however, that under highly unfavorable cir- cumstances the surface temperature of the person experimented upon never sank below 31*6° C. (88*9° F.). Upon the face the tempera- ture seldom fell below 26-27° C. (79-4° F.). This temperature, though unpleasant, was not actually painful. When the temperature of the hands was reduced to 25° C. (77° F.), a sensation of pain was experienced. After remaining in a very hot room, the highest temperature (35-5° C. = 9.V9° F.) was always found in the face. A sensation of disagreeable heat was present, but no visible perspiration. The result of these inquiries is to show that in spite of the fre- quent and extreme fluctuations to which it is exposed, the temperature of the human skin is nearly constant. Local refrigeration is soon counterbalanced by increased local circulation. The Respiratory Function of the Skin.—The respiratory function of the skin is analogous to that of the lungs. Oxygen is absorbed, and carbonic acid is exhaled. The quantity of either which passes through * " Monatshefte fur Praktische Dermatologie." 28 DISEASES OF THE SKIN. the-skin is only a fractional part, however, of that which is taken up or given off by the lungs. Gerlach states that the lungs absorb one hundred and thirty-seven times as much oxygen as the skin. Scharling endeavored to make an estimate of the extent of the cuta- neous respiration as compared with the pulmonary by a calculation based on the quantity of carbonic acid given off through each during the twenty-four hours. From his observations, he estimates that the skin performs from one fiftieth to one fortieth of the entire respira- tory process. It is probable, however, that this result is too high. A great deal of the carbonic acid which is given off is eliminated through its function as a medium of excretion, and is not connected with the process of respiration. Sensation.—The skin is the organ of the sense of touch, by means of which external impressions are recognized and localized. Tactile sensibility is an exaltation of the sensory power, by means of which the shape, size, and other properties of various objects are recognized. The sense of temperature is a variety of common sensation which ena- bles us to differentiate between heat and cold. According to Schiff and Brown-Sequard, each of these'impressions is transmitted to the brain by a different set of nerve-fibres. All parts of the skin are endowed with common sensation, but some regions are more sensitive than others. In those regions of the body where the epidermis is thin, as on the face, neck, breasts, and inner surfaces of the arms and thighs, the susceptibility to external impres- sions is marked. Where the epidermis is thick, as on the heel, the back, and the outer surfaces of the limbs, the sensitiveness is much less. If the epidermis be removed, and the corium exposed, the sen- sation of contact is transformed into pain. The tactile sensibility of the skin varies in accordance with the number of the nervous papillae in the corium, and the presence or ab- sence of *the tactile and Pacinian corpuscles. Impressions made upon the epidermis are transmitted to the papillae, and through them to the peripheral nerve-endings. The tactile and Pacinian corpuscles prob- ably act mechanically by furnishing a support for the terminal expan- sions of the tactile nerves, and by presenting a hard surface against which the delicate nerve-filaments can be pressed. They are not essen- tial for the exercise of common sensation, but wherever they exist the power of appreciating delicate impressions is much increased. Meissner remarks that the tactile corpuscles are most abundant on the- tips of the fingers, where he counted one hundred and eight in the space of a fiftieth of an inch. Consequently tactile sensibility is most highly developed there, the delicacy of touch of the fingers being proverbial. It can be further increased by education and practice, and by its acute- ness frequently compensates in a great degree for. the loss of other powers. In this manner the blind become able to read sentences in PHYSIOLOGY OF THE SKIN. 29 raised letters, to recognize individuals by the contour of their faces, and even to distinguish various shades of color through some inde- scribable difference of surface. The relative tactile sensibility of different parts of the skin has been ascertained by an ingenious method devised by E. Weber in 1829. This method is based upon the power of recognizing and isolating two distinct impressions made upon the surface at the same time, and at a minimum distance apart. It consists in the application to the skin of two fine points placed at a known distance apart. If two impressions are felt, the distance between the points is to be gradually decreased until the limit of their perception as two points is reached. This is termed the limit of confusion. If the points be brought still nearer together, their double effect will be felt as only one impression. AVe learn from the experiments made by AVeber, and confirmed since by other observers, that tactile sensibility is most acute on the end of the third finger and the tip of the tongue If the eyes be closed, and the points of an aesthesiometer be applied to either the tip of the tongue or the end of the third finger, a double impression is distinctly perceived when the points are only one twenty-fourth of an inch apart; while, for the recognition of two impressions on the palmar sur- face of the thumb, the points must be separated one twelfth of an inch ; on the red surface of the lip, one sixth of an inch; tip of the nose, one fourth of an inch ; middle of the dorsal surface of the tongue, one third of an inch; the eyelids and palm of the hand, five twelfths of an inch ; back of the fingers, seven twelfths of an inch; forehead and cheeks, five sixths of an inch; back of the hand, one and one sixth of an inch; crown of the head, one and one fourth of an inch; patella and lower portion of the thigh, one and one third of an inch; leg and dorsum of foot, one and a half inch; back of neck, two inches; sacral region, one and a half inch; sternal region, one and twro thirds of an inch ; lumbar and upper dorsal vertebral region, two inches; and, finally, over the middle cervical and middle dorsal ver- tebrae, and middle of the thigh and forearm, the points are not per- ceived as two until they are separated two and a half inches. It will thus be seen that this faculty is sixty times greater in some regions of the skin than it is in others. This difference depends upon the num- ber of primitive nerve-fibres present, and therefore indirectly upon the number of papillae in the part. If the primitive nerve-fibres are few in number, it is possible that several contiguous impressions may be conveyed to the same nerve-fibre, and consequently produce but one impression on the sensorium. Each nerve-fibre ends in a tuft of deli- cate filaments which supply an oval or circular area of the skin of about one four-hundredth of an inch in diameter, but the filaments of contiguous fibres interlace with each other, so that, the more numer- ous and closer the nerve-fibres, the greater the probability that two 30 DISEASES OF THE SKIN.- simultaneous impressions made upon the surface will be transmitted to different nerve-filaments, and recognized by the sensorium as sepa- rate impressions. The sensibility of the skin to changes in temperature varies in dif- ferent individuals and in different parts of the body. It is most acute in those portions of the surface where the epidermis is thin. ATari- ations of even one half a degree can be distinguished with the tip of the tongue. The face and the fingers and the elbow are also capable of appreciating very slight changes in temperature. Leegaard has de- vised an instrument by which he has been able to study the sensibility of the skin to variations of temperature. He found that in healthy persons three fourths of a degree either below or above 82° F. was the range of indifferent temperature—that is, which might be pro- nounced either hot or cold by healthy people, the eyes being closed during application of the test. He made many observations on dif- ferent portions of the body, and determined that from one to one degree and a half is the smallest measure of difference which could be detected by the skin in health. As a result of his experiments, he be- lieves that the temperature sense is very equally distributed over dif- ferent parts of the body, the variation in this respect being much less than had been taught by Xothnagel. He found a great difference in individuals as regards their ability to distinguish variations of tem- perature. AVeber's experiments have shown that sensations of heat and cold are modified by the extent of the surface exposed to the impression; the greater the extent of surface exposed, the more intense will be the sensation produced. The whole hand dipped in water of a certain temperature may feel it too hot to be borne, while to a single finger it may be only comfortably warm. The sense of temperature is distinct from that of touch, and may remain unimpaired when all other sensation is lost. It is well known that paralyzed limbs, which are insensible to pressure and the contact of the aasthesiometer, are capable of recognizing the difference be- tween heat and cold. This may be explained by the existence of a special set of nerves for the reception and conveyance of thermal im- pressions, or the occurrence of degenerative changes in the cord or in the cerebrum. Absorption.—It was formally supposed that the horny layer of the epidermis presented an insuperable obstacle to the passage of any sub- stance through the skin into the blood. So much evidence, however, has been accumulated to the contrary, that the importance of the skin as an organ of absorption is now universally recognized. Under ordi- nary circumstances this function is limited to the absorption of oxygen and watery vapor, but it may be utilized for the administration of various medicinal preparations. Experience has shown that their ac- PHYSIOLOGY OF THE SKIN. 31 tion when introduced into the system in this manner is almost as prompt and effcacious as when they are taken into the alimentary canal. The absorption of oxygen by the skin is undoubted, and constitutes an essential part of the general respiratory process. The absorption of watery vapor is well shown by the rapid recovery of the weight which has been lost by excessive perspiration. Persons after taking a hot bath, during which they lose one or two pounds in weight, almost invariably regain their former weight in a couple of hours, although they neither eat nor drink in the mean time. Part of this increase is elTeeted by pulmonary absorption, but a considerable part of it is due to cutaneous absorption. It has also been observed that the sensation of thirst is diminished in a moist atmosphere, and that it may be fur- ther lessened by immersing the clothes or the whole body in water. Shipwrecked sailors have relieved their thirst in this way and pre- served their lives, long after their supply of drinking-water became exhausted. This happy result is in part due to a diminution of the evaporation of the fluids of the tissues, but is also due in part to the direct absorption of a large quantity of water. In reference to this point, Captain Kennedy says, in the narrative of his shipwreck, which he addressed to the Royal Philosophical Society: " I can not conclude without making mention of the great advantage I derived from soak- ing my clothes twice a day in sea-water, and putting them on with- out wringing. . . . There is one very remarkable circumstance, and worthy of notice, which was that we daily made the same quantity of urine as if we had drunk moderately of any liquid, which must be owing to a body of water absorbed through the pores of the skin. . . . So very great advantage did we derive from this practice that the vio- lent drought went off, the parched tongue was cured in a few minutes after bathing and washing our clothes; at the same time we found ourselves as much refreshed as if we had received some actual nour- ishment." Experimental observations have shown that when the temperature of a bath is higher than that of the body, more water is lost by perspi- ration and pulmonary exhalation than is absorbed, and there is conse- quently a loss in weight. In a bath of 90° the processes of exhalation and absorption are equal, but in tepid and cold bathing the gain by absorption exceeds the loss by exhalation, and the body-weight is slightly increased. Various medicinal substances may be introduced into the system through the medium of the bath, and can be afterward detected in the urine. The benefit derived from a residence at the different springs of Europe or America is due in a considerable de- gree to the absorption through the skin of the sulphur, the alkaline, or the chalvbeate ingredients of the water in which the daily bath is taken. 32 DISEASES OF THE SKIN. The rate of cutaneous absorption depends upon the solubility and diffusibility of the substance which may be placed in contact with the skin. Insoluble substances can not be absorbed at all, while oxygen, hydrogen, chlorine, and other gases, and chloroform, turpentine, ether, and similar volatile substances, diffuse into the blood with great rapid- ity. Alcoholic 'solutions are not well absorbed, but chloroformic solu- tions of the various alkaloids, when applied to the surface, produce their characteristic systemic effects in a very short time. Prof. X. A. Khrjonshtchevsky, of Kiev, has investigated this subject anew in a series of experiments upon dogs, cats, and boys. The subjects 'were immersed in a specially constructed bath. Dogs and cats were killed, through the cutaneous absorption, by aqueous solutions of strychnine in two and a half or three hours; by alcoholic ones in one or one and a half; by nicotine solutions in two and a half; by conium in one or one and a half ; by veratrin in nine or ten hours; by cyanide of potas- sium at 25° C. (77° F.) in one or one and a quarter hour; at 42° C. (107,6° F.) in thirteen to fifteen minutes. Indigo-carmine could be detected in an animal's urine in three hours. When a solution of ferrocyanide of potassium was injected into an animal's veins and the animal placed in a bath of lactate of iron (or vice versa), there could be seen in about two or two and a half hours a blue discoloration of its cutaneous blood-vessels from the formation of ferrocyanide of iron. Prof. Baelz, of Tokio, Japan, has made many experiments in order to determine whether w7atery solutions of salts are absorbed by the skin. He found that salicylic acid solution 1:1,000 is readily absorbed in baths of 40° to 45° C. (104° to 113° F.), but that salicylate of sodium is not absorbed. Baelz concludes that there is no general law governing ab- sorption or non-absorption through the skin, but that in this respect every substance must be individually tried.* The absorption of soluble but non-volatile substances is effected more slowly, but may be facilitated by friction, by which their particles are forced into the orifices of the glands, where they are dissolved by the secretions and carried into the system through the interstices of the stratum lucidum. It is in this manner that mercurial ointments produce their specific effect in syphilis. The poisonous effects of lead and arsenic are developed in the same way in those whose occupations compel them to handle these minerals, or who use them for any length of time as cosmetics. The various oils and fats, and substances dissolved or held in sus- pension by them, are readily absorbed by the skin. Baths or inunc- tions of cod-liver oil form an invaluable resource in the treatment of phthisis, marasmus, and other wasting diseases. Medicinal substances applied to the surface of the corium after the epidermis has been removed are absorbed with great rapidity. * " Satellite," September, 1889. PHYSIOLOGY OF THE SKIN. 33 Secretion and Excretion.—The importance of the skin as an organ of secretion and excretion can not be overestimated. Any disturbance of its functions in this respect is liable to be followed by the most serious consequences, and their complete suspension is certain to result in death. Instances of recovery after the urinary secretion has been suppressed for several days are recorded, but if the elimination of effete material by the skin be completely prevented, a fatal result will ensue in a few hours. Burns involving more than one third of the general surface are invariably fatal, not because of the pain or the shock to the nervous system, but because the excretory surface of the skin is lessened one third. As a consequence of this sudden diminu- tion of the eliminating process, death frequently occurs from cerebral effusion in an hour or two after the injury. In the majority of cases, however, the kidneys and lungs endeavor to compensate by increased work for the lessened excretion by the skin, but the over-excitation of these organs generally results in inflammation in a few days, and the patient dies from pneumonia or nephritis. The skin secretes sebaceous matter and the perspiration or sweat, excretes carbonic acid and water, and, probably, certain other volatile principles which have thus far escaped observation. The elimination of carbonic acid by the skin is an essential part of the respiratory pro- cess. If an animal be covered with varnish, impermeable by water or gases, it will die in from six to twelve hours. The cause of this has not been definitely ascertained. All that is known is that complete suppression of the functions of the skin in this manner is followed by a rapid fall of temperature and death. The fatal result is perhaps due in part to the retention of carbonic acid and in part to the retention of some undiscovered morbific cutaneous products. The Sebum.—The sebaceous matter, or sebum, is a semi-fluid mate- rial secreted by the sebaceous glands. It is composed of free fat, fat- cells, and epithelial debris. It contains about thirty-five per cent. of water, forty per cent, of olein and palmatin, thirteen per cent, of casein, eight per cent, of gelatin, traces of albumen and various odor- ous principles, and a small quantity of the chloride, phosphate, and sulphate of sodium. The function of the sebaceous glands is carried on under the influence of the nervous system. The uses of this secretion are manifold. It preserves the normal softness and pliability of the skin, and acts as a protection to parts of the body exposed to atmospheric changes. It prevents the maceration of the epidermis that would otherwise follow profuse perspiration, less- ens friction between contiguous surfaces, and protects the skin around the outlets of the body from the contact of irritating excretions. It gives lustre and pliability to the hairs, and probably contributes to their growth and nutrition. The Perspiration.—The perspiratory function of the skin is of the 3 34 DISEASES OF THE SKIN. utmost importance, as a means by which effete materials are removed, and the temperature prevented from rising above the normal. It was formerly supposed that perspiration was the product of the sudo- riparous glands alone; it is now known that it is composed in large pai't of the water which is diffused outward from the interstices of the deeper layers of the epidermis, and becomes intermingled with the secretions of the glands. Perspiration in health is a colorless fluid, saltish in taste, and slightly acid in reaction. It is composed of nine hundred and ninety parts of water and ten parts of organic and inorganic solids. The in- organic materials consist mainly of the chlorides of sodium and potas- sium, with some traces of iron and the earthy phosphates. The organic constituents consist chiefly of urea, fat, and fatty acids. The reaction, according to Heuss, is normally acid during rest, but becomes neutral or even alkaline when an excessive amount of fluid is secreted. Gaube has found albumen in the perspiration, together with diastasic fer- ments. The quantity of urea contained in perspiration under ordinary circumstances is not large, but it is enormously increased when the functions of the kidneys are suppressed, as in certain forms of Bright's disease. The odor of perspiration is partly due to the various fatty acids, and partly perhaps to some volatile odorous substances which have not ye£ been isolated. The mutual relation existing between the skin and kidneys as organs of elimination is shown by the well-known fact that when the perspiration is diminished, as in cold weather, the quantity of urine is increased, while during warm weather, when the perspiration is more abundant, a smaller amount of urine is secreted. The production, of perspiration is controlled by a special system of nerves, analogous to those which regulate the secretion of saliva, and is stimulated under normal circumstances by the presence of an in- creased quantity of blood in the capillaries of the skin. It may, how- ever, be increased or diminished by the action of certain medicinal agents without regard to the condition of the cutaneous circulation. Atropine, as is well known, will check the most profuse perspiration, although it may, and frequently does, produce at the same time an intense hypersemia of the whole surface. Opium, pilocarpine, ipecac, and other diaphoretic agents induce free perspiration, during which the skin remains pale and cool. The cold sweats of phthisis, of syn- cope, and of fear also occur while the surface is pale. It is not im- probable, however, that these abnormal perspirations are due to a paresis of the nerves and a relaxation of the vessels, and should conse- quently be regarded as an exudation rather than a secretion. The amount of perspiration in health varies in different indi- viduals and under different circumstances. It is decreased by cold and increased by heat. It is increased by exercise and by taking food PHYSIOLOGY OF THE SKIN. 33 or drink, by breathing in a confined space, by putting on additional clothing, and by all circumstances that produce an increased flow of blood through the capillaries of the skin. Peiper has demonstrated that the perspiration is more abundant upon the right side of the body, that the palm of the hand perspires four times more than that of the skin of the chest, and the cheeks one and a half times as much. The secretion slowly increases in the afternoon, especially from eight o'clock to mid- night, after which there is a diminution. Food has but little influence upon the perspiration. The quantity is generally less in infants than in adults, while the weight of the body and sex are without marked influence. The effect of woolen underclothing upon the perspiration has been investigated by Lasarew, who kept a number of healthy sol- diers under observation for a period of thirty days. While such under- clothing wras worn the amount of all substances excreted by the lungs and skin was increased and the quantity of urine decreased. The sur- face temperature was raised several tenths of a degree. The general temperature, pulse, and respiration remained unaltered. When linen underclothing was worn the urine was increased, and excretion from the lungs and skin diminished.* According to the observations of Seguin, Lavoisier, and others, the average daily amount of water re- moved from the body by perspiration is thirty ounces. More than this quantity may, however, be lost in an hour when the body is ex- posed to a very high temperature. It is by the evaporation of this large amount of water that the surface heat is lowered, and the tem- perature of the blood prevented from being raised to a point incompati- ble with life. The influence of the perspiration upon the constitution of the gastric juice and urine has been studied by Yiktorin S. Gruzdeff, who experimented upon seven persons in Prof. V. A. Manassein's clinic. The loss of weight after sweating varied in different observations from 120 to 1,020 grammes (3 oz. 412 grains to 32 oz. 391 grains). Free perspiration reduced the acidity, digestive power, and total quantity of the gastric juice as well as the proportion of freet hydrochloric acid which it should contain. The proportion of pepsin appeared to remain unchanged. These alterations were less marked in healthy persons than in those suffering from chronic gastric catarrh. The more pro- fuse the perspiration the more considerable was the decrease of acidity. The longer the interval between the sweating and secretion of the gas- tric juice the greater the decrease. The alterations in the juice may last from several hours to two days. The acidity of the urine remained unchanged. A remarkable case of post-mortem sweating has been placed upon record by Mr. John A. Cones. A man, forty-two years of age, the subject of albuminuria, was suddenly seized, ten days before death, with uremic coma and left hemiplegia. The temperature was normal * " 3Ionatsheft. fiir praktische Dermatologie," No. 6, 1889. 38 DISEASES OF THE SKIN. until within the last few days, when it ranged from 102° to 104° six hours before death, when it began to sink. It was found difficult to excite perspiration. Pilocarpine was given hypodermically in gradu- ally increasing doses. The last injection, three days before death, pro- duced a fair amount of sweating for about twenty minutes, but, as it gave rise to excessive bronchial secretion, was not repeated. Forty- eight hours before death, however, the patient began to perspire pro- fusely, and this continued without interruption to the very end, even when the surface temperature was decidedly subnormal. The body was washed, and four hours later laid upon a bier, nothing unusual being noticed at the time of removal or before ; but sixteen hours after death the sheets and pillows were found absolutely saturated with sweat, and the skin felt moist and clammy. This state continued for at least eight hours. The strange features of the case are the considerable time that must have elapsed after death before the secretion was poured out, at all events to any extent, and the great quantity of the fluid. The writer suggests, in explanation of the phenomenon, that as the patient had been sweating freely to the time of his death, the glands and lymph-spaces surrounding them were probably engorged with fluid, and that with the beginning of rigor mortis the contents of these glands and lymph-spaces had been mechanically expressed.* The perspiration emanating from the axilla, the genital regions, and between the toes has a peculiar odor, which at times becomes ex- cessively offensive, constituting the affection known as bromidrosis. It is always distinctly alkaline. Donne states that the alkalinity, as well as the odor, is due to the intermingling and decomposition of the secretions of the follicles other than those of the sudoriparous glands. Electric Currents.—M. Tarchanoff has studied the production of electric cutaneous currents in man by means of a very sensitive gal- vanometer, together with a special device for preventing spontane- ous movements. The electrodes being in position, the production of cutaneous currents was determined under the influence of the most various excitations, a call in a loud voice, a shock, etc. The psychical sensations of heat and cold suggested to the subject determined ex- tremely delicate reactions of the galvanometer. When the left hand was in contact with the electrodes, and it was suggested to the subject that his right hand was warm and commencing to perspire, no effect was observed; but when the left hand was spoken of, a considerable de- viation of the needle of the instrument at once occurred. Here was an electric discharge of purely psychical origin which might to a cer- tain extent be compared to the discharge of a torpedo. In prosecuting these experiments it wras necessary to choose regions rich in sudoriparous glands. These glands play a notable part in the production of the cutaneous currents. A person in a state of expectant attention causes * The " Lancet," May 25, 1889, p. 1027. PHYSIOLOGY OF THE SKIN. 37 the needle to oscillate incessantly. It is necessary, before beginning the experiments, to secure the utmost tranquillity in the subject, in order to determine the zero of the galvanometer. Another example forcibly demonstrates the effect of mental effort. An easy act of mul- tiplication produces no result; but if a person is asked to perform a difficult problem of the same kind, the needle is deflected in proportion to the difficulty. Muscular movements give rise to deviations which must be attributed not merely to the acts themselves—for the effect is disproportionate—but to the effort of will which they necessitate. The deviation is, in fact, greater when the subject looks at the tip of his nose than when he raises his arm, even if some degree of force be used. Fatigued persons produce no reaction. M. Tarchanoff thinks that the sudoriparous glands exercise a regulative influence upon the produc- tion of these cutaneous currents. He considers it a thermic regula- tion, favoring cutaneous evaporation and disassimilation in the course of cerebral acts and dependent upon them.* Odor.—A perceptible odor is sometimes emitted by the skin of healthy individuals. This is more distinct in some races than in others; the negro, for instance, being characterized by a strong, un- pleasant odor. But apart from the smell dependent upon uncleanli- ness, a distinct and fragrant scent is exhaled by the bodies of some persons. In some instances the perfume has been likened to that of violets. Curious examples have been from time to time reported of individuals whose sense - of smell was so acute that they were able to distinguish between men and women, young and old, by the sense of olfaction. *"Le Progres Medical," July 6,1889; "Medical Bulletin," November, 1889, p. 355. 38 DISEASES OF THE SKIN. SYMPTOMATOLOGY. Diseases of the skin manifest themselves by local and consti- tutional symptoms. The constitutional vary in gravity in accord- ance with the amount of nutritive or functional disturbances present. In some cases they may be so slight as scarcely to attract attention, while in others they may be so serious that energetic treatment is necessary for their relief. Disorders of digestion are the most frequent constitutional symptoms of skin diseases. Disorders of menstruation are often present. Functional disturbances of the urinary and other organs may also occur, and if not remedied may lead to serious struct- ural changes. Fever is present at times, and some forms of skin diseases are accompanied by increasing debility and progressive ema- ciation. The local symptoms of cutaneous diseases are subjective and ob- jective. Subjective Symptoms.—The subjective symptoms of cutaneous dis- eases are those which can be recognized by the patient alone. They consist of alterations or anomalies in the sensation of a portion of the surface, and may be conveniently considered as pain, hyperaesthesia, anaesthesia, and pruritus, or itching. They vary in degree in differ-, ent diseases, and are sometimes entirely absent. The pain may be hot or burning, as in the "various inflammatory af- fections of the skin, or it may be sharp and neuralgic in character, as in herpes zoster, neuroma, and carcinoma. Hyperaesthesia, or an in- creased sensitiveness of the cutaneous surface, is a prominent symptom of both functional and organic derangements of the nervous centres. At times it appears to be purely idiopathic, as in dermatalgia. Anaes- thesia, or a diminished sensitiveness of the skin, is sometimes sympto- matic of diseases of the nerve-centres, and sometimes due to local causes. It is present to a marked degree in leprosy, and is found occa- sionally in connection with syphilis. Pruritus, or itching, is the most frequent and most prominent of the subjective symptoms of cutaneous disease. It occurs in varying degree in a great number of affections. It may be due to the irritation of parasites, or to the reflex action of internal causes, as in jaundice, or, as is more commonly the case, to the direct action of inflammatory or other morbid processes upon the ter- minal filaments of the cutaneous nerves. The sensation of itching has been carefully studied by Dr. E. B. Bronson, who has made it the sub- ject of a paper read before the New York Neurological Association, October 7, 1890. This author believes that there is sufficient evidence to locate the essential seat of pruritus in the epiderm. The sensation may be excited by pathological changes in the epidermis or by certain condi- tions of the nerve-centres. Dr. Bronson called attention to the etymo- SYMPTOMATOLOGY. 39 logical relation between pruritus and prurience»and remarked that the impulse to scratch was closely akin to a lustful feeling, and one that sometimes made scratching an actual sensual indulgence. A disposi- tion is not infrequently excited to attack the itching surface with a vehemence that amounts to a passion. This is particularly the case in pruritus of the genitalia, and serves to explain the sexual excitement or depravity associated with that condition. Such sensations, however, are not confined to genital pruritus, but may attend itching in almost any sensation. The writer concluded that in pruritus it is the sense of contact that is disturbed; that it primarily concerns simple cuta- neous nerves or nerve-endings situated superficially and probably in the epidermis; that in pruritus the disturbance is of the nature of a dysaesthesia; and that the voluptuous sensations which may attend pruritus are a manifestation of a generalized aphrodisiac sense, and represent a phase of common sensation which has its source in the sense of contact. Objective Symptoms.—The objective symptoms of skin diseases are the structural lesions which become manifest upon the surface of the skin, and can be recognized by the physician as well as by the patient. They are the result of the various pathological processes which occur in the skin, and by their number and character indicate the nature and intensity of the morbid process. They consist of primary and secondary lesions. The primary are those which are due to the direct action of various morbid processes or to the deposition of morbid products in the skin. The secondary are those which follow the primary, and are due to the softening and breaking down, or to the organization and metamorphosis of the prod- ucts of disease. The primary lesions are : 1. Macula?, macules, spots; 2. Erythema, hyperaemia, redness; 3. Pomphi, wheals; 4. Papulae, papules, pimples ; 5. Tubercula, lumps, tubercles ; 6. Tumores,tumors; 7. Vesiculae,vesi- cles ; 8. Bullae, blebs; 9. Pustulse, pustules. The secondary lesions are: 1. Excoriationes, excoriations; 2. Squamae, scales; 3. Crustre, crusts, scabs; 4. Khagades, cracks, fis- sures ; 5. Ulcera, ulcers; 6. Cicatrices, scars; 7. Pigmentation. Primary Leisons. Maculae, Macules, Spots.—Macules are small, circumscribed alter- ations in the color of the skin, unaccompanied by any marked eleva- tion or depression of the surface. They are usually oval or circular, but vary in form as well as in size. They vary in color also in accord- ance with the morbid processes of which they are the result. Those which are due to simple hyperasmia of a portion of the papillary layer of the corium are red or rose-colored, and disappear under pressure. They are termed roseola, and are met with in a number of cutaneous 40 DISEASES OF THE SKIN. and systemic affections. Those which are accompanied by inflamma- tion and slight exudation are more persistent, and can not be effaced so easily by pressure. The hyperaemic or inflammatory area that en- circles a cutaneous lesion is termed an areola. Macules which are caused by haemorrhages into the skin vary in color from dark-red to purple and black, and are termed purpura. If the haemorrhagic spots are minute, they are known as petechiae. Linear hyperaemias or extravasations are called vibrices. The discoloration produced by a large effusion of blood into the subcutaneous connective tissue is termed an ecchymosis. Those which are caused by an abnormal development and dilata- tion of the blood-vessels of the corium may be either congenital or acquired. When they are congenital, they are termed naevi; when they appear after birth, they are known as telangiectases. They vary in color from scarlet to violet, and do not disappear under pressure. If due to an excessive amount of pigment in the skin they are yel- low, brown, or black in color, as in lentigo, chloasma, and naevus pig- mentosus. The latter is sometimes congenital, as in the so-called " mother's marks," but lentigo and chloasma are invariably acquired. AThen produced by a deficiency of pigment they are white in color, and constitute the disease known as leucoderma. Congenital deficiency of pigment is known as albinism. Macules produced by the microsporon furfur, a vegetable parasite, are yellow or yellowish-red in color, and are characteristic of the dis- ease called tinea versicolor. If due to the action of heat, or various chemical substances, they present all shades of colors. If the alteration in color is uniform, and involves all or a large por- tion of the skin, it is termed a discoloration. This pathological con- dition is the prominent symptom in jaundice, chlorosis, morbus ceru- leus, and argyria. It is also present in chronic malaria, leprosy, carcinoma, and in some forms of ovarian and uterine diseases. Erythema, Hyperemia, Redness.—Erythema is a diffused redness of a portion of the surface of the skin produced by an active conges- tion of the capillary plexuses of the corium. It differs from roseola in size, and in the greater intensity of its exciting cause. The congestion in roseola is frequently passive, and is manifested at isolated points on the surface. The congestion in erythema is invariably active, and involves one or more groups of contiguous vessels. It is also accom- panied by more or less heat, swelling, and pain. Erythema may be produced by external causes, as by exposure to heat, or by friction or other irritation. At other times it is due to in- ternal causes alone. It is always a prominent symptom in the diseases with which it is associated, and is frequently so severe as to demand special treatment. Sometimes it appears to be the only lesion, and constitutes the disease itself. SYMPTOMATOLOGY. 41 Passive congestion, due to venous obstruction or a weak heart, can readily be distinguished from erythema, by the contrast between the coldness and dull, blue color of the skin in the former, and the heat and fiery redness of the surface in the latter. Pomphi, Urticae, Wheals.—AVheals are flattened, oval, or circular elevations of the skin, rapid in formation, evanescent in character, and attended by intense itching. They vary from a few lines to an inch or more in diameter. They are usually white or pale-red in color. Fre- quently they are pale in the centre and red at the periphery. They may appear singly, but generally several are developed simultaneously. Those that are adjacent to each other manifest a tendency to coalesce and form a large patch of irregular shape. Occasionally gyrate figures result from disappearance of the centre, together with increase at the periphery and coalescence with a neigh- boring wheal. They are attended by a sensation, of heat or tingling. Scratching or rubbing only serves to increase and enlarge them. The distinctive peculiarities of wheals are their extremely rapid development, the brief period during which, in many instances, they remain upon the surface, and the sudden manner in which they generally disappear. They are caused by a dilatation of the capillaries and an exudation of serum into the interstices of the corium and rete mucosum, fol- lowed by a spasmodic contraction of the tissues around the periphery of the exudation. As soon as the spasm subsides the exudation is ab- sorbed, and the wheal vanishes almost as suddenly as it was formed. Sometimes a little blood may be found mingled with the serum. Oc- casionally the amount of exudation is so great as to form a bulla, as in urticaria, bullosum, or a node, as in urticaria nodosum. Papulae, Papules, Pimples.—Papules are small, solid elevations of the skin of new formation, ranging in size from a mustard-seed to a split pea. They may be of any color from red to black, and are either round, flat, or conical in form. They occur in a great many diseases, and are due to a number of different pathological processes. Papules are usually accompanied by more or less desquamation. Sometimes they are due- to an excessive growth and accumulation of epidermic cells around the orifices of the hair-follicles, as in keratosis pilaris. At other times they are caused by retention of sebum, as in milium and comedo. They may also be due to an abnormal development of the papillae of the corium, as in verruca and ichthyosis, or to a hyper- plasia of the rete mucosum, as in psoriasis and cornu cutaneum. The most common variety of papules are those which occur in acne and eczema, and are due to inflammation and plastic exudation into the skin. Papules may also be produced by cell-infiltration, as in syphilis, or by a new cell-growth, as in lupus and carcinoma. Occasionally they are due to haemorrhage, as in purpura papulosa. Those which are the result of the inflammatory process are usually attended by more or less itch- 42 DISEASES OF THE SKIN. ing, and frequently become converted into vesicles or pustules. As they recede in size and elevation their color gradually fades, but spots of varied tints are generally present for a considerable period, indi- cating the former location of papules. The papule is one of the most important of the primary lesions since it is of so common occurrence, due to so many causes, and may be transformed into other primary and secondary lesions. Papules contain no fluid, but are due to an aggregation of cells. They are slightly compressible. The color of papules varies according to the dis- ease of which they are a manifestation, and according to the stage of the disease. Their hue is generally bright in acne, eczema, and psori- asis ; violet in lichen planus; copper-colored in syphilis; while in urti- caria and prurigo they present the normal color of the skin. In some instances they develop rapidly, and the surface is soon covered; in others they make their appearance gradually and in successive crops. Papules may occur upon any portion of the body, but in certain dis- eases they exhibit a predilection for certain regions. Thus, in acne, they are most often seen upon the face. The papules of eczema attack the flexor surfaces of the limbs, the trunk, and the face; while those of psoriasis invade the extensor surfaces of the limbs and regions in which the epidermis is thick. The distribution of this lesion is varied, though a certain symmetry of arrangement can usually be traced. Tubercula, Tubercles.—Tubercles are solid elevations of the skin of new formation, varying in size from a split pea to a hazelnut. They are of different colors, but are usually reddish or flesh-colored. They are generally circular or oval, but may be flattened or irregular in outline. They are caused by an intensification of the same morbid processes which are concerned in the production of papules, and differ from them only in their greater size. In fact, the line of distinction is mainly an arbitrary one. Many of the tubercles met with in disease begin as papules, and by involving deeper tissues and a greater extent of surface develop into tubercles. Syphilis, leprosy, lupus, and carci- noma present typical examples of this metamorphosis. Tubercles undergo various changes after the acme of their develop- ment has been reached. Those which are purely inflammatory may proceed to complete involution by absorption of their contents and desquamation of their epidermic covering. If due to the retention of sebum, they may become indurated by calcification of their contents, or they may soften and suppurate. Syphilitic tubercles usually termi- nate in ulceration. Tubercles due to neoplastic growths generally end in ulceration, but occasionally they manifest a disposition to remain without undergoing any change whatever. Tumores, Tumors.—Tumors are large, solid elevations of the skin, of all sizes from a hazelnut to a cocoanut, or even larger. They are generally spherical or hemispherical in form, but may be cylindrical SYMPTOMATOLOGY. 43 or flattened. They are usually flesh-colored, but at times are brown or black. They arise from the corium or the subcutaneous connective tissue, and by their outward development raise the epidermis to a con- siderable degree above the surrounding surface. They are due to a number of pathological processes. Among the more frequent exciting causes are new growths in the corium and degeneration of the seba- ceous glands, with exudation and extravasation into the surrounding tissues. Large tumors are sometimes formed by retention of sebum, and the gradual distention and hypertrophy of the sebaceous glands. Vesiculae, Vesicles.—Vesicles are small, round, or conical elevations of the epidermis, in dimension from a mustard-seed to a split pea, and contain serum, or a sero-purulent or bloody liquid. They vary in color in accordance with their contents. The typical vesicle is transparent, and contains pure serum unmixed with either pus or blood. Those that contain lymph or pus-corpuscles are white or opaque, and those in which blood is present are dark or dark red in color. Their walls are tense when they are completely filled with fluid, and flaccid when they are only partially filled. They may be superficial or deep-seated. Those that are superficial are situated be- tween the horny and mucous layers of the epidermis. The others are formed between the strata of the rete mucosum. The superficial rup- ture easily. Those which are developed in the rete mucosum are sur- rounded by thicker walls, and consequently are more tenacious. Vesicles are of inflammatory origin as a rule, and are due to an ex- udation of fluid from the vessels of the papillary layer of the corium. As the exudation is poured out, it passes through and distends the intercellular spaces of the mucous layer of the epidermis, and forms a vesicle by elevating the stratum corneum, or the upper layer of the stratum mucosum. Occasionally they are produced by simple reten- tion of perspiration, as in sudamina. They may be either simple or compound. The former consist of one chamber, as in eczema ; the latter are composed of two or more, as in varicella. Vesicles seldom occur singly; they are generally developed in considerable numbers, and are met with in a variety of diseases and on all parts of the body. They may be arranged in groups, as in herpes, or irregularly distrib- uted, as in eczema. They are brief in duration, and end by rupture of their walls and escape of their contents, or by absorption of the fluid and desquamation of their roof ; or else they become tilled with pus-cells, and transformed into pustules. Bullae, Blebs.—Blebs are large oval or spherical elevations of the epidermis, in size from a split pea to a small cocoanut, and contain a serous, sero-purulent, or bloody fluid. Bullae may be regarded as enlarged vesicles. Their color depends upon the character of their contents, and varies from clear or light- yellow, in those that contain only serum, to dark red or black in those 44 DISEASES OF THE SKIN. in which an extravasation of blood has taken place. In consequence of their rapid formation their walls are usually distended at first, but as absorption begins they soon become flaccid. Bullae consist as a rule of but one chamber; compound bullas, which are occasionally met with, contain two or more chambers, and are due to the coalition and enlargement of a group of adjacent vesicles. Like vesicles, they are situated between the horny and mucous layers of the epidermis, and are produced by a sudden and overwhelming exudation from the ves- sels of the corium. Ordinarily they do not rupture as easily as vesicles, but in pemphigus foliaceus they burst before they are fully formed. Sometimes they are attended by marked itching or burning sensa- tions ; at other times they are not accompanied by any subjective symptoms whatever. Bullae are met with in pemphigus and pemphi- goid eruptions, syphilis, leprosy, herpes iris, and in some cases of ery- sipelas and acute dermatitis. They are sometimes surrounded by an inflammatory areola, but frequently rise abruptly from the surface of apparently healthy skin. Pustulae, Pustules.—Pustules are round, flat, or conical elevations of the epidermis, varying in size from a mustard-seed to a cherry, and containing pus. They are inflammatory in origin, and are produced by the migration and proliferation of lymphoid corpuscles from the vessels of the corium. They are usually yellow or yellowish-white in color, but are occasionally dark from haemorrhagic exudation. They have been divided into primary and secondary. The secondary are those which are developed from pre-existing papules or vesicles. The primary are those in which the preceding stages of congestion and exudation are so brief that they escape notice until suppuration is complete, and the resulting pustule appears to be the original le- sion. Pustules may originate in the sebaceous glands, as in acne ; or in the hair-follicles, as in sycosis; or in the papillary layer of the corium, as in ecthyma and eczema pustulosum. They may also de- velop in the horny and mucous layers of the epidermis, as in variola, or deep in the corium and subcutaneous connective tissue, as in furun- cle and anthrax. They are usually encircled by an inflammatory area, and are occasionally attended by marked itching or burning sensations. Sometimes they are extremely painful, but generally they are not ac- companied by any marked subjective symptoms. They may be simple, as in acne, or compound, as in variola, where they contain two or more chambers. Pustules are of comparatively brief duration, and end by absorption, or rupture of their walls and discharge of their contents. If the suppurating process has been limited to the epidermis, no de- formity will result; but, if a considerable portion of the corium has been destroyed, permanent scarring or pitting may ensue, as in variola, syphilis, and severe cases of acne. Pustules are encountered in acne, sycosis, ecthyma, impetigo, variola, scabies, syphilis, and eczema. They SYMPTOMATOLOGY. 45 may also be produced by traumatism, and by the application of croton oil, tartar emetic, and other irritating substances. Secondary Lesions. Excoriationes, Excoriations.—Excoriations are losses of substance from the superficial layers of the skin resulting from traumatic causes. They vary in size and shape, but generally consist of torn points or linear furrows from which minute particles of blood and serum are oozing, or which have dried up and formed a crust over the lesions. Ordinarily they do not extend beneath the mucous layer of the epi- dermis, although at times they may involve the upper portion of the corium. They usually heal rapidly without the formation of a cicatrix. Excoriations are occasionally produced by superficial incised wounds or by accidental lacerations or abrasions of the surface, but in the great majority of cases they are the direct result of excessive scratch- ing caused by the itching and irritation of a cutaneous affection. As itching is a prominent symptom of a number of skin diseases, excori- ations are frequently observed, and at times render important assist- ance in establishing a diagnosis. They occur most abundantly in pru- rigo, pruritus, eczema, scabies, and pediculosis. Squamae, Scales.—Scales are masses of dead epidermis which have been completely or partially separated by disease from the underlying strata. They arc usually white or gray in color, but may be yellow or brown. They differ in form and size and also in number, in accord- ance with the situation and intensity of their exciting cause. When the morbid process which produces them is superficial, they are small and scanty ; when it is deep-seated, they are larger and more abun- dant. They are met with in various parasitic and inflammatory af- fections, and in diseases due to perverted nutrition of the epidermis. They are thin, fine, and branny in pityriasis, seborrhoea sicca, and some forms of eczema. In psoriasis they form large masses of a white pearly color, while in ichthyosis they form thick plates. In scarlatina, and other diseases, the epidermis is sometimes cast off in large parch- ment-like masses several inches in diameter. This extensive exfoli- ation is termed desquamation in mass, in contradistinction to the pro- cess of formation and detachment of fine branny scales, which is known as furfuraceous desquamation. Crustae, Crusts, Scabs. — Crusts or scabs are solid masses formed by the drying up of exuded or extravasated fluids, or by the collection on the surface of sebaceous matter or fungous elements. They vary in color as well as in size and form. Those which are formed by the drying up of a serous exudation, as in vesicular eczema, are thin and yellow or light-colored, and have no definite form. Those which re- sult from the drying up of pus are thick and green, or dark yellow in color, and are of the same form as the ulcer or broken-down pustule 4b' DISEASES OF THE SKIN. upon which they are seated. When blood is mixed with the exuda- tion, the crust will be reddish or black. Syphilitic crusts are thick and hard and dark green or black in color, and usually present a lamel- lated appearance. Crusts formed by the drying up of sebaceous ma- terial vary in color from light to dark yellow, and can be recognized at once by their greasy appearance. The crusts produced by the favus parasite are cup-shaped, yellow, or sulphur-colored, and exceedingly friable. Rhagades, Cracks, Fissures.—Cracks or fissures are linear wounds of the skin produced by muscular action. They are usually limited to the horny and mucous layers of the epidermis, but may extend a short distance into the corium. They are caused by muscular con- traction acting on a portion of the skin, which from inflammatory in- filtration or abnormal dryness has become inelastic or brittle, and rupt- ures instead of yielding. They may occur on any part of the surface which is exposed to tension, but are observed most frequently on the knuckles, the palms of the hands, the soles of the feet, the knees and elbows, and at the angles of the mouth. They are of different lengths, and may run in a straight or irregular direction. Deep fissures bleed readily, and are accompanied by more or less pain, which is aggra- vated by motion. Fissures are present in psoriasis, eczema, lichen ruber, scleroderma, and syphilis. They may also be produced by the use of strong soaps, or the action of cold and other irritants. Ulcera, Ulcers.—Ulcers are inflammatory breaches of continuity due to suppurative destruction of the superficial tissues. They are usually seated in the upper portion of the corium, but may extend into the subcutaneous connective tissue. They vary much in size and shape. Small ulcers are usually circular; large ulcers may be round or oval, but are often serpiginous or irregular in outline. The walls of an ulcer are either perpendicular or sloping, and are fre- quently undermined. The base may be smooth, but is generally un- even, and is covered by a more or less copious secretion of pus. Ulcers may occur on any part of the body, but they are found most fre- quently on the lower extremities. They vary in color from light-red to dark-purple, according to the intensity and character of the inflam- mation of which they are' the result. They are surrounded by a zone of congestion, and manifest a tendency to enlarge in breadth rather than in depth. Ulcers occur in syphilis, lupus, leprosy, carcinoma, anthrax, furuncle, scrofula, and several other diseases. They may also be produced by any local cause which seriously interferes with the circulation. They are always secondary to other lesions, and may run an acute or chronic course. They heal by granulation and the forma- tion of a cicatrix, which sometimes remains permanently. Ulcers are attended by more or less pain. SYMPTOMATOLOGY. 47 Cicatrices, Scars.—Scars are new formations of connective tissue which occupy the place of lost normal tissue. They are covered by a thin layer of epidermis, and are supplied with blood-vessels and lymphatics, but do not contain any hair-follicles or glands. They arc of a pale-red color at first, but generally become white. Large cica- trices range in color from gray to brown. Superficial cicatrices are smooth, soft, and freely movable; those which are deeper seated are hard, uneven, and immovable. Those which are raised above the surrounding surface are termed hyper- trophic cicatrices; those on a level with it are called normal cicatrices; those which are depressed beneath it are known as atrophic cicatrices. Cicatrices are not characteristic of any one morbid process; but are the result of extensive destruction of the corium. They are met with in all the ulcerative diseases, and may follow severe burns, wounds, and other injuries. Their size and form depend upon the nature and extent of the preceding ulcerative or traumatic lesions. They are gen- erally permanent, although occasionally they may be slowly obliterated. They are not supplied with nerves, and in consequence are generally devoid of sensation; but in some rare instances they are the seat of excruciating pain. This is due, however, to pressure of the contract- ing new tissue on a nerve-fibre which has been accidentally inclosed in it. Atrophic cicatrices that are multiple, and bean or kidney shaped, are generally the result of syphilis. Pigmentation.—Pigmentation is an augmentation in color of a con- siderable portion of the skin. It may be of brief duration, or may remain permanently. It may be due to chronic inflammation or long- continued congestion. Sometimes it is caused by the formation of neoplasms in the skin, and at other times it appears to depend upon trophic disturbances. Typical instances of pigmentation are presented in Addison's disease, and as a result of excessive scratching and con- tinuous hyperaemia in pediculosis. Bronzing of the skin has been ob- served in certain cases of diabetes, described originally by MM. Hanot and Chauffard. The discoloration is most marked upon the face, limbs, and genital organs. Pigmentation occurs during pregnancy, and is usually limited to the face and the vertical median line of the abdo- men. The deposit may be more unequally and irregularly distributed over the chest, abdomen, and thighs. Kaposi expresses the belief that, though haemoglobin is in many cases the source of the pigment, yet in others the color is due to a pigment-forming function of other protoplasmic bodies, particularly to the lowest layer of the rete mucosum. This opinion receives support from investigations upon trout and frogs. The changes of color mani- fested in these animals under different circumstances depend upon alterations in the form and activity of the pigment-cells, the changes being under the influence of the sympathetic nervous system. 48 DISEASES OF THE SKIN. DIAGNOSIS. The importance of making a correct diagnosis in all cases of cu- taneous affections can not be overestimated. No satisfactory plan of treatment can be formulated unless the disease be definitely recog- nized, and an endeavor made to ascertain its cause. The diagnosis of skin-diseases is not difficult as a rule. The most essential requisite for success in this respect is a thorough knowledge of the cause and mode of development and termination of the various diseases of this class, and of the significance of the lesions that oc- cur in the progress of each. Valuable assistance may also be derived from a careful consideration of the patient's personal and family history. In order to elicit all the information possible in reference to each case, a systematic method of examination should be adopted. Light.—Abundant daylight is indispensable for the proper exami- nation of the diseased cutaneous surface. Many of the macular erup- tions, which can readily be perceived then, appear indistinct or may escape recognition in the twilight, or in an imperfectly lighted room. Artificial light, no matter how brilliant or from what source it may be derived, should be avoided, as it always gives an unnatural color to the skin, and adds to the difficulty of making a correct diagnosis. Temperature of the Room.—The temperature of the room should be maintained at about 70°. Variations above and below this point modify the color of the skin, change the appearance of the eruption, and may be uncomfortable or injurious to the patient. Inspection.—In order to make a correct diagnosis, every portion of the affected surface should be examined. Some diseases present so many points of resemblance that the differentiation between them can not be made without a critical and comprehensive observation of all their features. There is a natural reluctance on the part of many pa- tients to permit an examination of certain parts of the body, but this difficulty can be overcome by the exercise of a little tact. If the eruption be diffused, and the patient be a man or a child, the clothing should be removed, and the entire surface exposed to view. All deviations from the normal color or appearance of the skin should be carefully noted. In some diseases the surface is dry and scaly, while in others it presents an extremely greasy and glossy appearance. It should be observed whether the natural lines and furrows of the skin are lessened or exaggerated in size ; whether the orifices of the sebaceous ducts are closed or patulous ; whether the growth of hair is more or less abundant than normal, and whether the individual hairs present a healthy or an unhealthy appearance. It should also be ob- served whether the sebaceous and sudoriparous secretions are profuse ! DIAGNOSIS. 49 or scanty. The degree of muscular development and the amount of adipose tissue present should also be taken into consideration. Palpation.—The information obtained by palpation is of the utmost importance, and is frequently indispensable to the formation of a cor- rect diagnosis. By it we can recognize whether the skin is cold or hot, dry or moist; whether it is smooth and soft, or rough and hard ; and whether it is abnormally loose and thin, or thickened and infiltrated. By palpation we are also enabled to determine whether the abnormal rednos of the skin which is present in many affections is due to sim- ple capillary congestion or to haemorrhagic extravasation ; and whether the various exudative collections are fluid or solid in character. We can also ascertain by it whether the hairs are brittle and loose, or strong and resisting, and firmly imbedded in their follicles. Odor.—Valuable information is sometimes afforded by the sense of smell. The offensive odor of bromidrosis, the ammoniacal odor of uridrosis, and the peculiar odor of favus and small-pox, are so charac- teristic that a diagnosis can often be made in these diseases by the smell alone. Constitutional Symptoms.—The majority of skin-diseases are not accompanied by severe constitutional symptoms. Disorders of the ali- mentary canal are frequently met with, and pain is a prominent feat- ure of herpes zoster and several other cutaneous affections, but high fever and general malaise rarely occur except in connection with the exanthemata. It must be remembered, however, that the eruption of secondary syphilis is sometimes preceded by marked pyrexia, and that severe forms of eczema, pemphigus, urticaria, erythema nodosum. pityriasis rubra, and lichen ruber, may be attended by violent con- stitutional disturbances. Anthrax, furuncles, and erysipelas are also accompanied by more or less fever and, pain. Ag"e.—The age of the patient is an important factor in making a diagnosis. Some diseases are most frequently met with during infan- tile life, some occur only at the age of puberty and in young adults, while others are found only in advanced age. Acne, for instanoe, rarely occurs before puberty, psoriasis has never been observed in an infant, while epithelioma seldom occurs before the thirtieth year, and is most frequent from the fiftieth to the seventieth. Sex.—The sex of the patient should also be taken into considera- tion. Owing to the differences in habit and modes of life and con- stitutional peculiarities of the two sexes, some diseases are found more frequently in males, others in females. Sycosis is found only in men. Temperament.—The temperament or natural constitution of the patient should be carefully observed, as it is well known that some diseases manifest a predisposition to attack persons of a certain tem- perament in preference to those of a different type. Psoriasis, erythe- 4 50 DISEASES OF THE SKIN. ma nodosum, and chronic eczema generally occur in those of a gouty or rheumatic diathesis. Intertrigo, impetigo, and pustular eczema are more commonly met with in lymphatic patients, while diseases of the sebaceous glands are more frequent in those of a nervous temper- ament. General Condition.—The general condition of the patient's health should be carefully ascertained. This can only be done properly by thoroughly investigating the manner in which the functions of the organs of digestion, assimilation, secretion, and excretion are dis- charged. The tongue should be examined, and the condition of the mouth and breath observed. Attention should then be directed to the stomach, and any disturbance of its functions noted. Inquiry should finally be made as to the present and usual state of the bow- els. Irregularities of the menstrual function should be noted. Im- portant assistance may sometimes be derived from information ob- tained by making an examination of the urine. Habits.—The habits of the patient should be carefully inquired into. Many a doubtful point may be cleared up by ascertaining whether the patient is an inveterate smoker, or indulges in alcoholic or sexual excesses, or is accustomed to use cosmetics. Occupation.—The occupation of the patient sometimes points di- rectly to the diagnosis. Blacksmiths, brick-layers, cooks, and grocers frequently suffer from erythema and eczema. Butchers, hide-dealers, and wool-sorters are especially liable to be attacked by boils and car- buncles. Acne is common among persons who lead a sedentary life. Various forms of dermatitis occur among workers in dye-stuffs and other chemicals. Peculiar forms of eruption have also been noticed in those who are employed in oil-refineries and tar-distilleries. Subjective Symptoms. The subjective symptoms are of the utmost importance, and fre- quently render valuable assistance in making a diagnosis. Inflamma- tory diseases, as a rule, are attended by more or less pain and itching. Syphilitic eruptions, on the contrary, may be free from both. Herpes zoster and some other diseases are characterized by intense pain. Anaesthesia and hyperaesthesia are symptomatic of disorders of inner- vation. Objective Symptoms. General Appearance of the Disease.—The general appearance of a cutaneous affection is almost invariably characteristic of that affection alone. In some diseases the eruption is uniformly macular, in others it is papular, in others again it is purely vesicular or pustular, while in some, two or more varieties of lesions may be noticed at the same time. By careful study, however, of the origin and manner of devel- opment of the various diseases, the difficulties of the subject will dis- DIAGNOSIS. 51 appear, and such proficiency will be obtained that a diagnosis can be made in the majority of cases from the objective symptoms alone. Duration.—The duration of the eruption is a matter of consider- able importance. Some diseases, as lupus, are essentially chronic in character; others, as roseola and erythema, tend to disappear within a comparatively short time. Inquiry should also be made as to whether the eruption ever occurred before, and, if so, how often. Color.—The color of the eruption is a valuable aid in making a diagnosis. The raw-ham or copper color of syphilitic eruptions is characteristic. Patches of chloasma vary from dark yellow to brown. Xanthoma is yellow in color. Tinea versicolor varies from light yellow to reddish brown. Arrangement.—The form and arrangement of the lesions should be carefully observed. Those of lichen planus, herpes zoster, herpes iris, and the various forms of tinea, are characteristic in both respects. Location and Extent,—The location and extent of the lesions often point unerringly to the diagnosis. Some diseases are confined to cer- tain regions of the body, while others involve the whole surface. Individual Lesions.—The size, shape, and mode of evolution of the individual lesions should be carefully observed, but too much impor- tance should not be attached to trifling irregularities in their appear- ance or development. A correct diagnosis can be made only by a comprehensive review of the whole eruption and its accompanying symptoms. Microscopic Examination.—Important assistance may be obtained in many doubtful cases by making a microscopic examination of a sec- tion of the affected skin. The various parasitic diseases may be recog- nized in this way, and a distinction made between lupus exedens and epithelioma. 52 DISEASES OF THE SKIN. PATHOLOGY. The skin is subject to the same morbid processes by which other portions of the body are affected, and consequently presents a variety of pathological changes, the most important of which are anaemia, hyperaemia, inflammation, haemorrhage, hypertrophy, atrophy, and the formation of new growths. All three layers of the skin may be involved in these changes, but the corium is usually primarily and principally affected by them because of its abundant nervous and vas- cular supply. The skin is also attacked by numerous animal and vege- table parasites, and is sometimes the seat of various neurotic disturb- ances. Functional disorders of the sebaceous and sudoriparous glands frequently occur, and structural alterations of the glands and their ducts are often observed. The hair-follicles, the hairs, and the nails are also subject to various pathological changes, which may be idiopathic in character or second- ary to those which affect the adjacent cutaneous surface. Anaemia.—Anaemia of the skin is symptomatic of a deficient amount of blood in the cutaneous capillaries. It may be the result of disease, or may be due to excessive loss of blood from the general system by haemorrhage. It is charcterized by unnatural pallor, which may be succeeded by a yellowish or greenish hue involving all or a great por- tion of the skin. It is usually attended by a decrease in the surface temperature, and may be accompanied by profuse perspiration. In many cases of general cutaneous anaemia the normal sensibility of the skin is altered, being usually diminished. The changes of color de- pend upon the loss of haemoglobin since Preger has shown by his spectroscopic experiments that a concentrated solution of haemoglobin transmits only the red rays, while weak solutions transmit the yellow and green rays. A partial cutaneous anaemia may occur in any portion of the body under the influence of various agencies capable of exciting constriction of the capillary vessels. The effect may be direct, through reflex mechanism or by impairment of nutrition. Among the causes of partial anaemia of the skin may be mentioned cold, local anaesthesia, injury, and certain trophic disorders. Hyperaemia.—Hyperaemia of the skin is caused by congestion of the blood-vessels of the corium. It is usually active in character, but may be passive. Active hyperaemia may be produced by internal causes, or by the action of heat, cold, or other external irritating in- fluences. It is characterized by a more or less diffused bright-red color of the skin, which can be effaced by pressure, but returns as soon as the pressure is removed. It is accompanied by a sensation of tin- gling or burning, and at times by considerable elevation of the temper- PATHOLOGY. 53 ature of the surface of the affected part. Active hyperaemia is of comparatively brief duration. The excess of blood is usually diverted into other channels, the congestion subsides, and the skin regains its normal appearance without the occurrence of either desquamation or pig- mentation. If the congestion remain for any length of time, exudation is apt to occur, and the hyperaemic process passes into inflammation. Passive hyperaemia may be due to simple relaxation of the capilla- ries, or to any local or systemic interference with the venous circula- tion. It may be frequently observed on the lower extremities, and is often followed by permanent pigmentation. Inflammation.—The minute phenomena of cutaneous inflammation are identical in character with those which accompany inflammation of any other organ. There is a preliminary stage of active congestion during which the arterioles of the affected part are dilated, and the flow of blood through them is accelerated. This stage is of varying duration, but is always present. It is succeeded by retardation of the blood-current, and softening or relaxation of the walls of the capil- laries. Exudation of the liquor sanguinis then occurs, followed by migration of the white and red corpuscles, and complete stasis of the circulation The inflammatory process varies, however, in accordance with the diathesis of the patient and the nature and intensity of the exciting cause, and may be interrupted or modified at any period of its development. In some diseases, as herpes and vesicular eczema, the effusion is a serous fluid composed almost entirely of liquor san- guinis, and contains very few corpuscles. In diseases characterized by the formation of papules and tubercles it is semi-solid, and composed almost altogether of cells, while in pustular diseases it consists largely of pus-corpuscles and liquor puris. Cutaneous inflammations always originate in the corium or sub- cutaneous connective tissue, and involve the epidermis secondarily. Thev are accompanied by more or less discoloration, heat, swelling, and pain. They terminate by absorption and resolution, or by sup- puration and discharge of the effused material, or by its organization and conversion into new tissue. They may be either acute or chronic in character. Haemorrhage.—Cutaneous haemorrhage may occur by diapedesis, but in the great majority of cases it is the result of rupture of the cap- illaries of the corium. In some rare instances the escaped blood oozes out upon the surface of the skin, but usually it is extravasated into the substance of the corium or the subcutaneous connective tissue. The amount of the haemorrhage is influenced by the condition of the vessels, the plasticity of the blood, and the intensity of the exciting cause. In some cases it is limited to a few drops, in others it may be so large that one or more aggregations of several ounces each may be formed. The minute extravasations are usually circular, but are oc- 54 DISEASES OF THE SKIN. casionally linear in form; the large extravasations are of all shapes and sizes. AVhen a considerable quantity of blood is effused, the epi- dermis may be elevated by it, and haemorrhagic papules, vesicles, and tubercles formed, but in the majority of cases the haemorrhagic spots are not raised above the surface of the surrounding skin. They can readily be distinguished from pigmentary deposits by the suddenness of their appearance, and, unlike the discolorations pro- duced by capillary congestion, they can not be effaced by pressure. They vary in color from dark red to purple at first, but change to black, yellow, green, or brown, before they disappear. They are usu- ally of comparatively brief duration, and are entirely removed by ab- sorption in a few weeks. Sometimes a slight permanent discoloration may remain, but this is of rare occurrence. Hypertrophy.—Hypertrophy consists of an abnormal increase in size of the normal tissues. It may be produced by an excessive devel- opment of the pre-existing elements, or by the formation of new ele- ments of the same tissues. It may be limited to one of the layers of the skin, or occur simultaneously in all three layers. In callosities, the epidermis alone is involved. In ichthyosis, clavus, cornu cuta- neum, and verruca, hypertrophy of both the epidermis and the corium occurs. Lentigo, chloasma, and naevus pigmentosus are caused by an increase in the amount of pigment in the rete mucosum. The epi- dermis, the corium, and the subcutaneous connective tissue are all involved in elephantiasis arabum, while in scleroderma the morbid process is limited to the corium and subcutaneous connective tissue. Hypertrophy of the substance of the hair and nails occurs under vari- ous circumstances. Atrophy.—Atrophy is a decrease in either the size or number of the elements of a tissue. AATien it affects only the size of the tissues, it is termed simple atrophy; when their number is lessened, it is known as numerical atrophy. It may involve the greater portion of the surface, as in senile atrophy ; or it may be limited to a few spots, as in vitiligo. It is most frequently observed in connection with the appendages of the skin, as in canities and alopecia, and in atrophy of the nails. It is probably due to a disturbance of the trophic system. New Formations.—New formations are produced by the deposition of new material and the development of new tissues in the substance of an organized structure. They may be composed of simple connect- ive tissue, like the part in which they are developed, or they may con- sist entirely of cellular material. The former are found in xanthoma, keloid, and molluscum fibrosum and cicatrices, and are benign in char- acter. The latter occur in lupus, leprosy, carcinoma, sarcoma, syphilis, and rhinoscleroma, and are malignant in the majority of cases. The lymphatics, blood-vessels, and nerves are sometimes invaded by new formations, as in lymphangioma, angioma, and neuroma. PATHOLOGY. 55 Parasites.—The skin is infested at times by animal and vegetable parasites, which prey upon its structures and produce more or less an- noyance and inflammation by their presence and habits. The animal parasites which are most frequently met with are the Pediculus, or louse, and the Sarcoptes scabiei, or itch-mite. The Cimex lectularius, or bed-bug; the Pulex irritans, or common flea; the Pulex penetrans, or sand-flea, and various other insects, also attack the skin and produce considerable irritation. The vegetable parasites are microscopic fungi which attach them- selves to the skin, and continue to develop on its surface. They rarely penetrate between the layers of the epidermis, but they frequently in- vade the hair-follicles and attack the hairs. They sometimes attack the nails also. Three varieties of vegetable parasites have been recognized. They are the Microsporon furfur, which produces the disease known as tinea versicolor; the Aclwrion Sclwnleinii, the fungus of tinea favosa; and the Trichophyton, the fungus of tinea circinata, tinea sycosis, and tinea tonsurans. They act in varying degree as irritants to the skin. Tinea versicolor is a trivial affection, but tinea sycosis and tinea tonsurans may produce extensive inflammation and suppuration. Tinea favosa may be followed by permanent loss of hair. The development of bacteriological research has inevitably modified and enlarged our conceptions of the etiology and pathogenesis of dis- eases of the skin. It has been already clearly demonstrated that many are, either directly or indirectly, the results of infectious processes. It is reasonable to assume that the list of infectious dermatoses will be ex- tended considerably from the investigations constantly being carried on by numerous and independent observers. Clinical facts had already assured us that cutaneous manifestations were in many instances ex- cited by the presence in the blood of products of tissue change. Being retained within the organism, these substances have the power of excit- ing disease in the integument as well as in other tissues. The erup- tion, consequently, is but a part of a general disorder, such as gout, rheumatism, diabetes, syphilis, scrofula, or tuberculosis. These dis- eases are engendered by chemical compounds elaborated within the body, and not necessarily or always of microphytic origin. In another class of cases the cutaneous malady seems to depend upon the direct action of micro-organisms which have lodged upon the skin, and there found a fitting soil for development. It is probable that here as else- where the two causes are often conjoined, and that, as a rule, the skin only proves a fitting soil when its vitality has been previously impaired by causes acting from within the organism. External agencies, also, such as heat, cold, clothing, etc., have their share of influence in pre- paring a field upon which parasitic organisms may flourish. In some instances, therefore, disease of the skin is but one of the 56 DISEASES OF THE SKIN. many consequences of a systemic infection, and, though valuable in itself as a diagnostic sign, is generally of less importance than the de- rangement of more important organs. Such is the case in the eruptive fevers, syphilis, tuberculosis, and leprosy. On the other hand, in cer- tain forms of eczema, in acne, furuncle, carbuncle, acute abscess, in some forms of ulceration, and, possibly, carcinoma in its early stage, we see the direct effects of pathogenic bacteria. In either case, in that of systemic or that of local infection, the malady is due to the action of poisonous products which the parasite has elaborated at the expense of the tissue in which it is lodged. These chemical substances, of definite though often complicated composition, act as direct irritants to the skin, whether originally deposited in or upon that tissue or brought to it by the blood. In their effects upon the skin, therefore, they may be compared to the action of those drugs which have the power of ex- citing eruptions when applied to the integument or when ingested. In those cutaneous disorders attended by the formation of pus the pyogenic bacteria have often been detected in the lesions. Three dis- tinct organisms have been recognized as the most frequent exciting causes of suppuration, viz., the staphylococcus pyogenes aureus, the staphylococcus pyogenes albus, and the streptococcus pyogenes. Of these, the first-named has been most frequently found. This appears in the form of small, roundish cells which are so aggregated as to bear a resemblance to a bunch of grapes, and hence the name which has been bestowed upon it, from o-rafaXr], a grape. Sporulation has never been observed in this species, which thrives at the ordinary temperature of living-rooms. When cultivated it produces an orange-yellow color. The staphylococcus albus differs from the foregoing species only in not producing the yellow pigment. It appears, likewise, to be somewhat less virulent in its action. The streptococcus pyogenes, though some- times associated with staphylococci, is more frequently observed alone in purulent collections. It can not satisfactorily be distinguished either in form or behavior from the streptococcus of erysipelas described by Fehleisen. Certain or all of these micro-organisms have been discov- ered in the lesions of acne, impetigo, ecthyma, furuncle, carbuncle, and abscess. Prof. Leloir has plausibly suggested that the ulceration of lupous nodules is due to the activity of pyogenic bacteria, though the tubercle itself depends upon the presence of the tubercle bacillus. The pustules of variola contain the ordinary microbes of suppuration, though the specific exciting cause of the eruptive fever has not yet been isolated. Anthrax, or malignant pustule, depends upon the growth of a specific bacillus of marked infective properties. Fehleisen has demonstrated that the specific cause of erysipelas is an organism developing in the form of small, globular cells which manifest a de- cided tendency to link themselves together and produce the appear- ance of extended chains. This characteristic arrangement is per- PATHOLOGY. 57 ceived when the organism is studied either in artificial cultures or dis- eased tissues. Gibier asserts his belief that he has detected specific parasites in the lesions of pemphigus and hydroa. Pityriasis rubra is probably of microphytic origin, though an organism has not yet been isolated. Owing to the presence of the bacillus tuberculosis in the nodules of lupus, that disease is now generally looked upon as a peculiar form of tuberculosis of the skin. Though its clinical manifestations differ in decided respects from other forms of cutaneous tuberculosis, yet the present tendency is to consider the several varieties as falling under one and the same category. A fuller discussion of this subject will be given in connection with the account of the pathology and eti- ology of-lupus in the body of this work. Leprosy has been proved to depend upon the activity of a certain bacillus, which is described with sufficient detail for the purposes of this book in the section on leprosy. That syphilitic infection is due to bacterial agency seems in entire ac- cordance with the nature and course of the disease. The hypothesis, however, is as yet very far from having been demonstrated. Lust- garten has detected in syphilitic lesions an organism which he con- siders to be the material cause of the disease. According to his description, the cells resemble the tubercle bacilli in form, though they may be distinguished from the latter by the fact that they are more curved and that they are marked by nodose swellings. It has been claimed, however, that his methods of preparation are com- plicated and unsatisfactory, and that many competent observers have failed to confirm his discovery. AVe must, therefore, regard ourselves as still in the dark concerning the origin of the syphilitic virus. Many facts in its natural history suggest that cancer should be classed among the diseases of parasitic origin. The investigations of Darier relative to the pathogenesis of Paget's disease of the nipple, those of Albarran, Wickham, Cornil, and others respecting carcinoma, render it probable that, at least in some cases, the multiplication and activity of protozoa give rise to carcinomatous formations. The lesions of molluscum epitheliale, likewise, have been thought to depend upon the same ex- citing cause. The interpretation of these observations has been denied by Torok, Piffard, and other writers. From a study of the effect of polarized light upon the supposed protozoa, Piffard has concluded that, as regards molluscum epitheliale, and probably the other affections, the supposed protozoa are merely rete cells undergoing a species of horny degenera- tion. The occurrence of a micro-organism in the newly formed tissue of rhinoscleroma was first announced by Frisch and subsequently con- firmed by other authorities, though it still remains uncertain whether the microbe should be regarded as the specific exciting cause of the disease. Some forms of eczema seem to depend upon the development of bacteria, wdiile bacilli and micrococci have been found by several observers in the blood of subjects suffering from purpura. 58 * ' DISEASES OF THE SKIN. ETIOLOGY. Diseases of the skin are produced by a variety of causes. A great number are secondary to morbid changes or functional disturbances in other organs or tissues, but many are the result of processes affecting the skin alone. The former are termed symptomatic or sympathetic affections, and are illustrated by urticaria, erythema nodosum, and the various exanthemata. The latter are known as idiopathic diseases, and may be produced by either internal or external causes. They are typi- cally represented by the erythemas of heat and cold, and a number of the local hypertrophies. The relation between the skin and the other organs of the body is so intimate, however, that the distinction be- tween these two classes can not always be made. In some cases the local causes predominate, but in others the constitutional changes are the most important. A correct appreciation of the etiological value of each can be obtained only by a comprehensive review of the origin and development of the eruption. The causes concerned in the production of diseases of the skin may be conveniently divided into predisposing and exciting. Predisposing Causes. The predisposing causes are those which produce certain alterations or conditions of the general system or the cutaneous surface, by which the individual liability to the development of certain diseases is in- creased. They do not produce disease, but render liability to it greater. The most important of the predisposing causes of cutaneous diseases are age, sex, diathesis, occupation, seasons, climate, plethora, debility, and heredity. Age.—Many cutaneous diseases occur only during certain periods of life. Thus, tinea versicolor is a disease of adult age, while tinea tonsurans is more common in childhood. Ichthyosis, sclerema neo- natorum, and the congenital syphilodermata appear at birth, or with- in a short time afterward. Strophulus is an affection of the first week of infantile life. Erythema, urticaria, and eczema capitis are fre- quently observed during dentition. Acne, seborrhoea, and psoriasis rarely appear before the age of puberty. Carcinoma, epithelioma, and the majority of cases of pruritus are maladies of advanced life. Impe- tigo and intertrigo are affections of early childhood. Rhinoscleroma, morphoea, scleroderma, and acne rosacea are diseases of adult age. Sex.—Some cutaneous diseases occur more frequently, or exclu- sively, in the male sex, Avhile others are more often observed in females. Sycosis, for instance, is found only in man. Chloasma and lupus erythematosus occur more frequently in woman, epithelioma and her- pes in man. ETIOLOGY. 59 Diathesis.—Psoriasis, eczema, and erythema nodosum can fre- quently be traced to a rheumatic or a gouty diathesis. Persons of a lymphatic temperament are liable to recurrent attacks of intertrigo, impetigo, and pustular acne and eczema. Eczema, lupus, and scrofu- loderma are common in those of a strumous diathesis. Occupation.—Various occupations are prolific predisposing causes of cutaneous diseases. Stone-cutters, shoemakers, carpenters, machin- ists, and other artisans, present more or less hypertrophy of the palmar epidermis. Blacksmiths, cooks, brick-layers, and firemen are frequent sufferers from erythema, eczema, and dermatitis. Fissured eczema of the hands from the use of strong soaps is often observed among washer- women. Eczema of the hands is very common among bartenders. Plasterers and stone-masons are also subject to the same affection. Hackmen are particularly prone to suffer from rosacea. Confection- ers are liable to a form of onychia produced by the action of sugar, acids, and heat. Eczema occurs in grocers and sugar warehousemen from handling raw sugar which generally contains an acarus closely resembling the acarus scabiei. Butrh-ers, tanners,.and wool-sorters are liable to ecthyma and anthrax. AVorkers in aniline manufactories, oil-refineries, and tar-distilleries are often attacked by violent der- matitis. Seasons.—Many cutaneous diseases occur more frequently or are aggravated in intensity during particular seasons of the year. Inter- trigo and miliaria are rarely encountered except in warm weather. Erythema multiforme and furuncles are more frequently observed in the spring and autumn months. Pruritus is usually most severe in the winter. Eczema and psoriasis have been frequently noticed to dis- appear in summer, only to reappear with the first week of cold weather. Seborrhoea and ichthyosis are also wrorse during the winter. Climate.—The influences exerted by climate in the development of cutaneous diseases is analogous to that of the various seasons of the year. Some diseases are peculiar to cold climates, others occur more frequently in the temperate zone, and some are almost exclusively lim- ited to the tropical regions. The relative dryness or humidity of the atmosphere is also an important factor, and the clothing, diet, hygiene, and habits of the people in the different climatic regions must also be taken into consideration as exercising more or less influence upon the origin and progress of the prevalent diseases. Plethora.—Plethoric patients are peculiarly liable to be attacked by the superficial inflammations of the skin. Intertrigo, erythema, and eczema develop in them upon the slightest cause, or frequently without any apparent cause, and in many cases prove rebellious to treatment. Pruritus and hyperidrosis are also observed in this class of patients. Debility.—Debility is the essential predisposing cause of a great 60 DISEASES OF THE SKIX. number of skin-diseases. Impetigo, ecthyma, and pemphigus rarely occur except in the weak and ill-nourished. Furuncles and carbuncles are generally more severe in the debilitated than the robust. Sebor- rhoea and comedo usually accompany a weak and relaxed condition of the system. Heredity.—Heredity exercises an important influence in the pro- duction of many cutaneous diseases. The peculiar liability of some persons to be attacked by a variety of skin-diseases, while enjoying good health in every other respect, can be most satisfactorily explained by the supposition that they inherited a weak or susceptible skin. Among the diseases which are directly transmitted from parents to children are scrofula, syphilis, leprosy, and ichthyosis. Psoriasis and eczema frequently appear to be hereditary also. Exciting Causes. The exciting causes of diseases of the skin are those which di- rectly or indirectly produce the disease. They may be divided into internal and external. INTERNAL EXCITING CAUSES. The internal exciting causes are those that act from within the body. They are varied and numerous, and at times are so obscure as to escape recognition. They may be seated in the affected portion of the surface, but more frequently they are to be found in disorders of distant organs and tissues, or in derangements of the general system. The most prominent of the internal causes of diseases of the skin are the systemic disturbances produced by pregnancy, dentition, vaccina- tion, and certain medicinal substances; dietetic errors, neurotic dis- turbances, constitutional diseases, and disorders of internal organs. Pregnancy.—Many women suffer during the latter months of preg- nancy from herpes, eczema, or pruritus, for which no other cause can be observed than the physiological alterations which occur at that period in the blood and other tissues. Patches of chloasma are also frequently developed at the same time. The treatment in these cases should be merely palliative in character, as all the symptoms usually disappear spontaneously as soon as the pregnancy is ended. It is a curious fact that psoriasis and other chronic affections fre- quently disappear during pregnancy, or are lessened in extent and severity. Lactation also exerts considerable influence on the progress of psoriasis, eczema, acne, and other disorders of the sebaceous glands. In some cases these affections are aggravated by lactation, but in the great majority of cases marked improvement is perceptible. Dentition,—The systemic irritation produced by dentition is fre- quently the only observable cause of urticaria, erythema, eczema capi- tis, and other cutaneous diseases, but its importance must not be ex- ETIOLOGY. 61 aggerated. Close investigation will often result in the discovery of other and more important disorders. Vaccination.—Vaccination is occasionally followed by extensive erythematous or inflammatory eruptions. They are usually benign in character, and disappear in a few days. Sometimes, however, owing to the use of impure lymph, or to the depraved state of the patient's con- stitution, deep-seated erysipelatous inflammation may be developed, and run a tedious course, during which much destruction of tissue may occur. Medicines.—Various cutaneous disorders have been observed to fol- low the use of certain medicinal substances. An obstinate form of acne is produced by the prolonged administration of either the bromide or iodide of potash. Antipyrin, copaiba, cubeb, and santonine fre- quently give rise to an urticarial eruption. Turpentine, quinine, chloral, opium, and belladonna sometimes produce an extensive ery- thema resembling the eruption of scarlet fever. Dietetic Errors.—A great number of cutaneous diseases are pro- duced by errors of diet. In some cases the food habitually partaken of is too rich or too highly seasoned ; in others it is too poor in quality and insufficient in quantity. In many persons cutaneous eruptions are invariably produced by special articles of food. Urticaria is frequently developed after a meal during which fish, oysters, or strawberries have been eaten. Obstinate pruritus, erythema, and eczema are known to be frequently due to a diet of oatmeal or buckwheat. Acne and urti- caria are often produced or aggravated by fish, cheese, pastry, ale, and beer. These affections may be caused by chronic constipation and consequent auto-intoxication. In this connection it may be noted that a warm-water enema will occasionally give rise to a scarlatiniform rash. Neurotic Disturbances.—Neurotic disturbances are the principal factors in the production of a great many cutaneous diseases. In some cases the morbid process is seated in the central nervous system, but in others it involves only the peripheral terminations of the nerves to the affected part. Prominent among the affections which are due to disturbances of innervation are urticaria, herpes, dermatalgia, pruritus, and a number of hypertrophies, atrophies, and new formations. As indicative of the nervous origin of a skin-disease Mr. Jonathan Hutch- inson points to the corymbiform or branched disposition of the lesions as corresponding to the distribution of cutaneous nerve-fibrils. More- over, a neurotic affection does not propagate itself by direct extension or infection of adjacent parts, and the malady likewise develops itself fully in the first instance. Erythema, eczema, pemphigus, ecthyma, scleroderma, vitiligo, and other affections may also be the result of alterations of the nervous system. From the same cause the glands and the appendages of the skin may become diseased. Hyperidrosis, anidrosis, grayness, baldness, and loss of deformity of the nails not 62 DISEASES OF THE SKIN. infrequently depend upon lesion of some portion of the nervous system. Functional nervous disorders, reflex excitation, and strong emotion often occasion eruptions upon the skin. Under the title of " gero- morphism," A. Souques and J. B. Charcot have described a case, be- ginning after severe fright, in which a series of papules recurred and in a few weeks rendered the countenance unrecognizable. Ten years later, at the age of twenty-one, the patient looked like an old woman. Constitutional Diseases.—Among constitutional diseases which pro- duce cutaneous disorders are pyaemia, syphilis, scrofula, scurvy, malaria, chlorosis, Addison's disease, and the exanthemata. In a few instances gonorrhoea has been known to occasion an eruption resembling that of measles or scarlatina, and followed by desquamation. Disturbances of Internal Organs.—Functional and organic disturb- ances of internal organs are exciting causes of a number of eruptions. Pruritus and eczema are frequently due to cardiac degeneration or valvular disease. Diabetes is a cause of pruritus and furuncles. Acne, eczema, and urticaria often depend upon some genito-urinary disorder. Bright's disease and other affections of the kidneys are frequently the direct exciting cause of erythema and eczema. Uridrosis is the result of complete suppression of the urinary secretion. An eruption of bright red, itching macules and papules, followed by desquamation, in- crustation, or suppuration, has been witnessed in the latter stage of chronic interstitial nephritis. Acne, eczema, and erythema nodosum are produced by disorders of the liver. The menstrual periods are sometimes marked by the development of erythema or other eruption. Derangements of the alimentary canal, however, are the most frequent causes of all cutaneous diseases of an erythematous or inflammatory type. The external exciting causes of diseases of the skin are varied and numerous. The most important are improper clothing, extremes of heat and cold, mechanical and chemical irritants, personal habits, scratching, parasites, and contagion. Improper Clothing.—Improper clothing is a common cause of cuta- neous diseases. Erythema, eczema, pruritus, and miliaria are often devel- oped by the use of flannel under-clothing. Colored stockings frequently produce severe and extensive cutaneous inflammations. Silk underwear has been known to set up a dermatosis. Tight garters may give rise to varicose veins, chilblains, or eczema. Irritation of corsets or friction of under-clothing may induce a circumscribed scleroderma. According to Hutchinson, the irritation of a new woolen vest may bring out an erup- tion upon the trunk in a syphilitic subject. A non-specific eruption resembling syphilis may be produced by like cause. Dr. Hobein has investigated the receptivity of various kinds of underwear for micro- organisms. These "bodies are caught in the interstices of the cloth or ad- here to its surface. The looser the woof the more readily are microbes retained. Smooth and fine woven linen and cotton materials retain ETIOLOGY. 63 fewer organisms and can be most thoroughly cleansed by boiling. Under ordinary circumstances the germs do not develop and multiply in the clothing.* Heat and Cold.—Heat and cold are also important factors in the production of cutaneous diseases. Exposure to intense heat, whether artificial or that of the sun, is a frequent cause of erythema, derma- titis, eczema, and miliaria. A variety of fissured eczema, ordinarily known as " chapping of the hands," is a common result of exposure to cold. If the cold be intense it may be followed by the development of chilblains, or the death of the exposed part. Mechanical and Chemical Irritants.—Many cutaneous diseases are the result of mechanical irritation. Tight shoes or stockings produce corns and various excoriations or ulcerations of the feet. Tight gar- ters often give rise to an eczematous condition of the lower extremities. Extensive erythemas and eczemas are sometimes caused by ill-fitting under-clothing. Various callosities and other hypertrophies are de- veloped in carpenters, stone-cutters, shoemakers, and other artisans, by the pressure and friction to which certain portions of the integument are constantly subjected during working-hours. Intertrigo is produced and aggravated by the pressure and friction of the apposing surfaces. Chemical irritation is a more frequent and more serious cause of cutaneous diseases. Severe inflammations may result from the use of arsenical cosmetics or depilatories Artificial-flower makers, manu- facturers of wall-paper, and workers in acids, alkalies, aniline dyes, and other chemicals, are subject to various eruptions which are the result of the irritating action of these materials on the skin. Bakers and workmen in sugar refineries are subject to eczema of the fingers and hands, spinners to eczema and a peculiar form of dermatitis. Dr. Paul Fabre, in his studies of diseases of miners, describes, among others, miliary eruptions, erythema, furuncles, and prurigo.f Dermatitis of the legs is not infrequently produced by colored stockings. Severe cutaneous inflammation may also be caused by the incau- tious application of any of the ordinary rubefacients or epispastics, or by contact with various poisonous plants. Various eruptions may like- wise result from the external use of arnica or the sulphur and mer- curial preparations. Personal Habits.—The habits of the individual are often important factors in the production of cutaneous diseases. Eczema and acne rosacea are frequently the result of alcoholic indulgence. Acne may be due to excessive smoking. Personal uncleanliness is also a cause of cutaneous disease in some cases; but, on the other hand, too much attention may be given to cleanliness, and the integument injured by the frequent use of strong soaps. * " Weekly Medical Review," February 28, 1891. f "Le Progrcs Medical," June 15, 1889. 64 DISEASES OF THE SKIX. Scratching.—Many cutaneous lesions are produced, and all pre- existing eruptions are intensified, by scratching. In urticaria it in- creases the size and number of the wheals, and in eczema it augments the inflammation and exudation. Scabies, prurigo, and pediculosis are increased in severity by it, and an insignificant pruritus may be converted by it into an extensive inflammatory disease. In protracted cases it may produce considerable pigmentation and thickening of the skin. Parasites.—A number of cutaneous diseases are produced by animal and vegetable parasites. The hair and nails also suffer from their ravages. Those organisms which are the best known and most com- mon exciting causes of disease of the integument have been enumer- ated on page 55, under the section upon general Pathology. They need not, therefore, be repeated in this place. Numerous microphytes are constantly present upon the general surface. Of these, some spe- cies are probably incapable of thriving upon the human skin; others are pathogenic under favorable circumstances. AVhen the proper con- ditions are lacking they are unable to multiply, and remain innocuous. Contagion.—Contagion is a prolific source of cutaneous diseases. Impetigo contagiosa, small-pox, measles, scarlet-fever, equinia, and erysipelas are frequently communicated by direct contact. Many of the cutaneous lesions of syphilis are contagious; likewise the parasitic diseases, but some are more readily transmitted than others. Indi- vidual susceptibility is an important factor in the propagation of all diseases of this nature. Some persons are readily affected by the poi- sonous germs or spores, while others may be exposed to them with im- punity. Many diseases of the skin are brought to this country by immigrants. Cases of parasitic disorders are readily contracted on ship-board. To prevent the spread of these the persons and clothing should be scrupulously cleansed upon arrival. Diseases of uncommon occurrence in this country are also not infrequently imported. TREATMENT. 65 TREATMENT. The adaptation of the proper treatment to diseases of the skin requires on the part of the physician a thorough knowledge of general medicine. The previous history—including any idiosyncrasies which the patient may have, the present constitutional and local condition, the nature of the affection and its cause, if apparent—should all be looked into from the standpoint of general medicine, and rational de- ductions drawn from these considerations as to the proper method of treatment. As a rule, the deductions, after careful inquiry into all the circumstances just briefly recounted, will lead the physician in the majority of cases to employ both constitutional and local remedies. The most decided, rapid, and certain results are generally obtained from constitutional treatment, which assists frequently the action of the topical remedies which may be employed. In some affections it alone may be demanded, or simple local treatment will suffice, while in still others it becomes necessary to employ both at the same time. Again, constitutional and local in conjunction may be necessary at one stage of the disease, and should only be used singly at another. Further, the remedy or remedies employed, whether for systemic or local action, may be proper at one period and useless or harmful at another. Great care must, therefore, be exercised to be able to know from a general knowledge of medicine just what to do at the proper time. Constitutional Treatment. The general health should be carefully examined, and, if impaired or deranged in the least, should be corrected by suitable constitutional treatment. It may be necessary to administer acids, or one of the va- rious tonics, or alkalies—particularly the natural alkaline waters—al- teratives, anodynes, or hypnotics, or various other remedies, to make a thorough impression and relieve or cure the eruption. It often be- comes necessary likewise to use diaphoretics, or to increase the action of organs of the body by the employment of aperients, cathartics, and diuretics, particularly in inflammatory diseases in which there may be imperfect or defective secretion and excretion. The principal means employed may be referred to as follows : Hygiene.*—The observance of the commonly accepted hygienic laws in diseases of the skin is all-important, especially after the eruption is developed, or has become chronic. The first and most essential measures which should receive attention are ventilation and bathing. The latter will be found in some acute affections to be contra-indi- * See paper by author on "Hygiene of the Skin in Health and Disease," in " Journal of Cutaneous and Genito-Urinary Diseases," 1889, vol. vi, pp. 373 and 416. 5 GG DISEASES OF THE SKIX. cated, while in others, especially those of a subacute or chronic nature, it may be followed by the most happy effect. Dress for all parts of the body, but more particularly for those which come in contact with the affected surface, requires just what may be suitable to the case under consideration. Clothing has an influence upon the health of the integument. That worn during the day should be entirely removed before retiring to rest, and each piece hung up separately, in order that the absorbed perspiration may evaporate and the garments be ventilated. Cutaneous disease is apt to be occasioned by dyed hosiery or underwear. Next in importance to dress are rest and exercise, the former being very frequently necessary in some of the inflammatory diseases, espe- cially in their beginning, and the latter, judiciously and properly used in later stages, or in the chronic forms. Outdoor exercise, with plenty of good fresh air and sunlight, should be taken, if possible; or, if not, passive exercise, or massage, may be resorted to, if necessary. A change of climate will often in some of the more obstinate diseases, es- pecially those due to impairment of the nervous system, be followed by beneficial results. Climate has an undoubted influence upon the well-being of the skin. The customary temperature of the atmosphere, joined with the modifications of dress, diet, and general habits of life which it creates, establish a predisposition to certain forms of disease. The skin cer- tainly requires somewhat different treatment, both in health and dis- ease, according to whether the climate be cold and dry or moist and warm. The health of the hair is promoted by the use, in winter, of soft hats pierced with numerous holes or, in summer, of light straw hats of open structure. Sleep is also a hygienic measure which concerns the skin no less than the nerve-centres. Cheerfulness should be cultivated, since cuta- neous disturbances of sensibility or of circulation are often the out- come of long-continued mental strain. Frequent ablutions are neces- sary to the health and beauty of the skin. Diet.—Attention to diet is often more important than the admin- istration of remedies. The quality and quantity of the food must be regulated according to the disease and the condition of the patient. A diet restricted to certain articles of food may be demanded, or a special dietetic course be necessary. Each case requires to be carefully looked into by the physician, and the amount and character of food * regulated as may seem suitable and judicious. Imperfect digestion is, either directly or indirectly, an important factor in the etiology of many diseases of the skin. The nutritive condition of the skin is, in- * See paper on " Food in Health and Disease," " The Medical Bulletin," Janu- ary, 1891. TREATMENT. 67 deed, an index to that of the organism generally, and a characteristic appearance of the integument is produced by any grave perversion of general nutrition, as, for instance, chlorosis, amyloid degeneration, chronic malaria, leukaemia, jaundice, Addison's disease, purpura, scurvy, cancer, or pyaemia. Cutaneous maladies are common in scrof- ula and diabetes mellitus. In syphilis and the exanthemata a diagnos- tic importance attaches to the cutaneous lesions. x\ less severe sys- temic intoxication results from the retention in the blood of excre- .mentitious products, the results of faulty elaboration of food. When these are produced in excess the excretory glands are unable to elimi- nate them completely, and their presence excites disease in various organs and tissues, including the skin. The* secerning glands eventually be- come involved, when diminished elimination adds to the effect of in- creased production. The habitual ingestion of excessive quantities of nitrogenous food and the constant consumption of alcoholic beverages are productive of many disorders of the integument. Functional or organic disease of the stomach, liver, pancreas, or intestinal mucous membrane generates a host of cutaneous maladies. The imperfect digestion of starchy and fatty substances leads to consequences scarcely less deleterious. There appears to be no direct relation between partic- ular affections of the alimentary canal and disease of the skin notwith- standing the fact that many of the latter appear under modified forms upon the mucous membrane of the gastro-intestinal tract. Catarrh of the stomach or bowel is not necessarily represented upon the skin by eczema, but may give rise to urticaria or other lesion. The beneficial effect of an appropriate and regulated diet upon dis- eases of the skin is not always justly appreciated. Unless the general health is obviously impaired, close inquiry concerning the state of the digestive functions is apt to be neglected. Great care should be en- joined as to the use of articles which, like animal food, may embarrass the liver or those which, like fatty, amylaceous, or saccharine materials, readily undergo fermentative changes in the alimentary canal. Alco- holic liquors, as a rule, should be forbidden. In the lithic-acid diath- esis a highly nitrogenized diet is inadvisable. In acute eczema, espe- cially wrhen a large extent of surface is involved and when the patient is young, the condition may approach, in severity and constitutional reaction, that of an essential fever. In this case a bland, unirritating, and easily digestible diet is indicated, such as milk, milk toast, boiled or baked potatoes, tapioca, arrowroot, etc. AATien eczema occurs in a gouty subject, meats should be sparingly given and alcohol prohibited. The diet should be composed chiefly of vegetables and fruit with bread and butter. In rheumatic eczema, articles which readily undergo fer- mentation should be eliminated as far as possible from the food. A scrofulous patient requires liberal sustenance. Fat in some form or other should be as freely supplied as the state of the digestive organs 68 DISEASES OF THE SKIN. will permit. Meat (except the more indigestible kinds, as veal), soups, broths, eggs, custards, milk, and vegetables should form the dietary. I regard cod-liver oil, so universally given in any scrofulous manifestation, as a true food, and it is noteworthy that strumous pa- tients, even children, will often take the oil without repugnance. Milk is doubtless the most general pabulum in all the protean varie- ties of eczema. Unfortunately, however, patients will often tire of a rigidly monotonous milk diet. AVe may often, however, vary the reg- imen by the use of puddings prepared with milk, as bread, apple, or, tapioca pudding, custard, or by ice cream. AVhen eczema is produced by diabetes mellitus, it is evident that its relief must depend upon the success of our treatment, chiefly dietetic, of the underlying condition. Affections of the glandular system of the skin generally require food of a supporting character as an important adjunct in their treatment. Their internal medication often resolves itself into the effort to improve digestion and assimilation. In seborrhoea the food must be sufficient, nutritious, and digestible. Beef, mutton, eggs, poultry, rabbit, soups, pigeon, sweetbread, venison, oysters, fresh fish, and the more digestible vegetables are especially valuable. The subjects of acne generally pre- sent evidences of impaired nutrition in the form of anaemia, chlorosis, general debility induced by genital defects, or suffer from some consti- tutional taint, notably scrofula. The dietary in this disease should be constructed upon the same plan as that already outlined for seborrhoea. Hyperidrosis and anidrosis usually occur in debilitated individuals, whose diet, therefore, should be of a supporting nature. Kosacea gen- erally depends upon long-continued irritation of the walls of minute blood-vessels by waste products, the result of incomplete digestion or upon the presence of alcohol in the blood. The food should there- fore be simple and substantial, and alcoholic beverages should, in most cases, be interdicted. In purpura, which is preceded or accompanied by considerable or even grave prostration, an abundant supply of nu- trient material, such as milk, soups, broths, and oysters, is demanded. Lichen planus is often due to impaired digestion, and recovery is accel- erated by a liberal diet, consisting of animal food, eggs, milk, poultry, fruit, and vegetables. Lichen ruber is benefited by a similar regimen. Herpes zoster calls for an abundant supply of fatty articles of food, as milk, cream, butter, eggs, animal fats, vegetable oils, cocoa, etc., not forgetting cod-liver oil. In pemphigus and hydroa the bill of fare should be composed of soups, poultry, the more digestible meats and vegetables, eggs, and milk. Nutritious food should be an essential part of any plan of treatment in sycosis. In the pustular affections, impetigo, impetigo contagiosa, and ecthyma the bill of fare should be constructed upon the same plan as that recommended for pemphigus. Pityriasis rubra demands vigorous alimentation. The digestible meats the fat as well as the lean, strong soups, milk, cream, eggs, and vegeta- TREATMENT. 69 bles should be given as freely as the digestive powers of the patient will admit. If furuncles occur in the course of diabetes mellitus the reg- imen suitable to that disease is required; if in a rheumatic, gouty, scrofulous, or tuberculous condition of the system, the diet should be arranged in reference to the underlying diathesis. Boils may be the expression of malnutrition arising from dyspepsia, in which case a selection of foods should be made in accordance with the form which the indigestion assumes. The necessity of a generous diet is even more urgent in carbuncle, which calls imperatively for animal broths, with the addition, as a rule, of alcoholic stimulation. Alimentary principles are demanded in the management of the hypertrophic skin- diseases. In psoriasis a great deal depends upon attention to the gas- trointestinal tract, and the effect of any medicinal measures is greatly enhanced when digestive failures are first corrected. In recent cases it is wise to limit the quantity of nitrogenous substances consumed, and depend for support rather upon the carbohydrates, supplemented by bread and butter, fruits, and vegetables. Ichthyosis is essentially incurable, but in addition to local treatment, which is our main de- pendence, it seems advisable that the diet should be rich in fats, in the hope of aiding the nutritive effects of the unguents applied exter- nally. Scleroderma may also be favorably modified by the use of fatty articles of food. Begulation of diet should enter into our treatment of alopecia, especially of alopecia circumscripta. In scrofuloderma, lupus erythematosus, and lupus vulgaris the food should consist of the sub- stances already mentioned as appropriate to eczema. Even in such fatal diseases as lepra, epithelioma, and sarcoma the use of suitable food is not entirely without advantage. In lepra the diet should be bland and nutritious; in epithelioma and in sarcoma bread, milk, eggs, vegetables, and fruits may be allowed^but it is advisable to limit the consumption of animal food. In the more severe forms of the exanthemata so great is the febrile reaction that gastric intolerance is a prominent symptom. Milk, or milk and lime-water, is often all that will be borne. Fortu- nately, in scarlatina the fever is of brief duration, and in view of the frequent occurrence of nephritis as a sequela, no article is better adapted to the disease than milk. After the subsidence of the fever, however, beef soup, mutton broth, or milk toast may be added. Kubeola and rotheln generally require less scrupulous attention, but in malignant or black measles the same sustaining diet is necessary as in any other virulent specific fever. Coniluent and malignant small-pox demand systematic nourishment from the beginning of the attack. In erysipe- las, vitality must be supported by the same nutritious and assimilable diet demanded in variola, typhoid and typhus fevers, and diphtheria. The neuroses of the skin are not infrequently due to chronic indiges- tion. AA'hatever may be the origin, it is nearly always of such a nature as to indicate a generous diet, rich in fatty foods. 70 DISEASES OF THE SKIN. In diseases of the skin alimentation is, indeed, but another mode of medication. The mineral substances contained in foods are identical with those demanded for the composition of the blood and tissues. As far as they are absorbed from the food, to that extent are drugs to be looked upon as merely supplementary. Cod-liver Oil.—In diseases of the skin, cod-liver oil is both a good food and a valuable remedy. It is the remedy above all to employ in those cases in which the health has become affected through faulty as- similation, as in eczema, scrofuloderma, and syphilis. It is also ser- viceable in many of the chronic forms of skin-diseases. It may be ad- ministered in from one fluid drachm to half an ounce, either alone or as an emulsion. A few drops of ether to the dose may overcome any unpleasant effect from it, and assist its absorption. If the oil can neither be retained nor assimilated, it may be given* hypodermatically, one or two drachms being injected into the loose cellular tissue of the back. I have recommended and demonstrated the utility of employ- ing it in this manner in scrofuloderma, paraesthesia, and other cuta- neous diseases depending upon a lack of nutrition of the system. If a large-sized hypodermic syringe be used, and the oil deposited deep into the cellular tissue, it usually disappears in from twelve to twen- ty-four hours without any unfavorable results. That the oil is ab- sorbed and assimilated can be demonstrated by injecting the same quantity of castor-oil, its viscidity being lessened with an equal amount of almond oil, and the result will generally be a satisfactory laxative action within one or two hours' time. Phosphorus and its Preparations.—Phosphorus is known to have a special action in cutaneous diseases depending upon nerve-debility. It has been followed by benefit in psoriasis, eczema, lupus, herpes zos- ter, and pemphigus, due to the above condition. Piffard recommends it in large doses to promote the rash in exanthematous diseases. The dose of phosphorus is from one twelfth to one one-hundredth of a grain dissolved in almond- or sweet-oil, or given as a pill. Instead of phosphorus, the phosphide of zinc is frequently prescribed in form of pill in one thirtieth to one fiftieth of a grain. The best preparations of phosphorus are the sirup of the lacto-phosphate of lime, compound sirup of the phosphates, and the sirup of the hypophosphites. These compounds are especially serviceable in eczema of children depending upon malnutrition, and in boils, carbuncles, and some cases of papu- lar and pustular acne. Iron and its Preparations.—The preparations of iron are invaluable in a number of skin-diseases. They are indicated in all eruptions, as eczema, psoriasis, sycosis, syphilis, and scrofula, which are due to a * " The Treatment of Disease by the Hypodermatic Injection of Oil." Read by the author before the Section of Practical Medicine, at the meeting of the American Medical Association, June, 1885. TREATMENT. 71 depraved state of the system. The iodide of iron or the sirup ex- ercises at times a beneficial effect over pustular eczema, and in chron- ic cases of syphilis. Many cutaneous eruptions due to anaemia and chlorosis are favorably influenced by one of the preparations of iron. The tincture of the chloride in large doses, one half to two drachms every two or three hours, certainly assists in arresting erysipelas. Iron may be advantageously combined with strychnia, arsenic, qui- nine, and other remedies, or administered in the form of a chalybeate water. Quinine.—Quinine, by its action upon various inflammatory diseases of the skin, is one of the most valuable agents at our disposal. In erysipelas it is a remedy of great utility. In variola, scarlatina, ty- phoid fever, and rubeola, it can be used with advantage in reducing excessive fever. It is an appropriate remedy to employ in diseases arising from malaria, or from an impoverished state of the system, as in impetigo, impetigo contagiosa, ecthyma, boils, and sycosis. Affec- tions depending upon a derangement of the nervous system may also be benefited by it. Arsenic*—Arsenic is ureful in some affections of the skin, and useless in others. It is also valuable in some stages of eruptions, and absolutely injurious in others. The disease, as well as the stage of the eruption, must be carefully considered before it is employed. It has been shown to possess an action upon the epidermis, and is especially beneficial in diseases involving that part of the skin. Administered to animals, especially the horse, it improves nutrition and power, and gives a sleek and glossy appearance to the coat. Gubler,f in speaking of this effect, says Tschudy, in his account of the arsenic-eaters of Lower Austria, remarks that it improves their appearance and gives them additional power: "They acquire great strength, have remarkable agility, climbing the steepest mountain- sides ; . . . the young girls, veritable rosebuds, as colored as ripened apples ; they acquire flesh even ; and, as fine skin is never seen in their people, over bones thinly covered, their skin becomes clearer and trans- parent." Arsenic, the same author states, will not always give such admirable results, and, when its habitues come to require considerable doses, serious effects may ensue. From what has been recounted, the wonderful power will be observed that this metal possesses of modify- ing and changing the epidermis. Administered for its effect upon the skin, the action of arsenic is usually slow, often requiring some time before a given result is ob- * " The Useful Administration of Arsenic in Diseases of the Skin," by Edward L. Keyes, M. D. Journal of Cutaneous and Venereal Diseases, August, 1886. New York. " The Question of the Value of Arsenic in Diseases of the Skin," by W. A. Hardaway, M. D. Ibid. f Gublcr's Therapeutics, page 278. 72 DISEASES OF THE SKIN. tained. When an impression has resulted from its use, it should be persistently continued, but in smaller doses, for a time after all symptoms of the eruption have vanished. It is contra-indicated in the inflammatory or acute stage of all eruptions, and if em- ployed then may be followed by injurious effects from its stimulating action on the epidermis. In other words, it should not be given in active cell-proliferation, but during the stage of decline or chronic period of eruption, in which the affection is situated in the super- ficial portion of the skin. It is a useful remedy in psoriasis and eczema, after the inflammatory period of these diseases. It often acts happily in obstinate and chronic cases of papular eczema, pem- phigus, lichen ruber, and at times in secondary syphilis. It can be taken by most persons, or administered hypodermatically for a very long time, without injury to the health. Some persons are at times quickly and easily affected by small doses; others, who have some ali- mentary disorders, will not tolerate its internal administration. Its success, therefore, often depends upon a judicious manner of admin- istration so as to overcome these objections and permit it to be accept- ably received by the tissues. If the subject has a peculiar idiosyn- crasy, beginning with a minimum dose, or combining with it either opium, bromide of potassium, quinine, pepper, etc., or a bitter, or an aperient, will often cause it to be better borne, and at times enhance its therapeutic value. If arsenic is not tolerated by the alimentary canal, the same result may be reached by the hypodermatic method of administration. It may therefore be employed according to the indications in each case, either given by the stomach or hypodermatically, to produce its sys- temic effects. The preparations of arsenic usually employed are arsenious acid, the arseniate of sodium, and the solution of arsenite of potassium (Fowler's solution), or the solution of arseniate of so- dium (Pearson's solution). In the majority of cases I prefer using the arsenious acid or the arseniate of sodium to any one of the solu- tions of arsenic. My reason for this preference is, that arsenic solu- tions are often uncertain, being poorly or improperly prepared, or, if kept on hand too long, a chemical change may take place, which lessens their activity. Arsenic preparations are often thus given by the most skilful without producing any decided effect. If the physician is certain beyond all doubt that the solution is fresh and properly prepared, it will be equally elective with the arsenious acid or the arseniate of sodium. The advantage, however, in giving ' the latter is that their effectiveness, if arsenic will have any over the disease, is certain beyond all doubt. AVhile I have employed the iodide of arsenic, and the solutions of the arseniate of sodium, and the iodide of arsenic and mercury (Donovan's solution), I have not had as good results from their use as from the other preparations TREATMENT. 73 already named. Arsenious acid and the arseniate of sodium are not only preferable for their therapeutic effect, but they are likewise a ready and convenient form of administering arsenic either alone or combined. They can be prescribed to begin with in a very minimum dose, from one one-hundredth to one tenth of a grain, given as pills three times daily, which can be carried around and readily taken by patients without the least trouble. It is best to administer the pills immediately after a meal, when, according to the views of Ein- ger, the arsenic becomes absorbed by the lacteals, and through them mixed with the blood; while, if the stomach is empty, it is absorbed by the veins, and, passing into the liver, is separated with the bile. The dose of arsenious acid or its salt can be increased, given in the above manner, until it reaches the limit of toleration, which may be recognized by the metallic taste, increased flow of saliva, itching and swelling of the eyelids, and an unpleasant sensation over the epigas- trium. The patient during the period that arsenic is being adminis- tered should have all the secretions kept in an active condition, and should be under the constant observation of a physician. In the event that the medicine shows the slightest evidence of producing its constitutional effect, the dose should be decreased, or the remedy withdrawn, and one of the bitter tonics substituted for a time until it can again be safely resumed. If these precautions be observed, no unexpected or violent action need result from its administration. I have had numerous cases in which arsenic in one of these forms has been given for a very long time with great tolerance and without the least injurious effect. I believe that, in many instances in which it has suddenly given rise to toxic effects, the accident has been due to subjects pursuing an arsenic course of treatment without being under the constant observation of the physician. The prescription ordered two, three, or four weeks previously has been renewed time and again, the patient requesting advice only when some unexpected symptom appears. In using the solutions of arsenic for their systemic effect, the best and most serviceable are the solutions of the arsenite of potassium (Fowler's) or the arseniate of sodium (Pearson's), from one to twenty drop doses after meals, either administered alone or given with an aromatic water, or simple bitters. It is well, in order to avoid any idiosyncrasy that the patient may have, to begin always with the minimum dose, viz., from one to three drops. Some practitioners prefer, in giving arsenic in a solution, to use the arseniate of sodium, which it is said is better and more easily ab- sorbed than that of the arsenite of potassium. The solutions of ar- senic, for the same reason that has been mentioned when speaking of arsenious acid and the arseniate of sodium, should always be given 74 DISEASES OF THE SKIN. after a meal. If they agree with the patient, the dose can be gradu- ally increased, drop by drop, until a decided effect is apparent on the eruption. The solutions of arsenic, like the solid preparations, can often be advantageously combined with other drugs, which generally enhance their value and render them easily borne. They can be prescribed with the tinctures of cinchona and serpentaria, the bromide of potas- sium, etc. In cases in which the use of arsenic produces disfiguring acne-spots, the addition of the bromide of potassium to the prescrip- tion will either prevent or lessen their development. Dr. T. N. Mc- Laughlin, of AA^ashington, D. C, has derived advantage from the ad- ministration of realgar or bisulphide of arsenic in psoriasis, chronic eczema, and scrofuloderma. He also prescribes it in suppurative affec- tions, as acne and furunculus, in which he considers it to fulfill the same purposes as sulphide of calcium. I will now pass to the consideration of the systemic effect occa- sioned by the introduction of arsenic beneath the skin into the sub- cutaneous areolar tissue. By this method the same physiological and therapeutic effects occur as when the metal is given by the stomach. This fact was fully demonstrated by Dr. C. B. Radcliffe,* who injected for the first time on January 12, 1866, the solution of the arsenite of potassium under the skin of a patient suffering from chorea, with good results. Later, M. Lippf injected arsenious acid in psoriasis and chronic eczema, which he reported as successful. Since that time the same method has been used and commended in various parts of the world. It is, however, to be regretted that this ready means of intro- ducing arsenic rapidly and beneficially into the system is so little used by physicians. I regard it as being the very best manner for producing a speedy, powerful, and effective impression upon the diseased skin. The arsenic is not altered, changed, or lessened in its action, as by a diseased stomach, the presence of food, the condition of the fluids, the veins, the nerves, and the liver, and consequently its therapeutic effects are produced to the fullest degree. This method is especially adapted to the treatment of obstinate cases of psoriasis and eczema. It is also of value in sarcoma and lichen planus. It spares the digestive organs, and abridges very much the duration of treatment. I first tested this excellent method in 1876, and after some years of experience have found that I can often arrest and cure some obstinate cases which resist arsenic given by the stomach. Mercury adminis- tered by the stomach for syphilis will sometimes prove ineffective, but when used hypodermatically, cures often follow; so also arsenic given hypodermatically will in some instances produce more marked sys- temic effects. I began by using the solution of the arsenite of potas- * Reynolds's " System of Medicine," vol. i. p. 712. f " Archiv fiir Dermatologie und Syphil.,'; No. 3, 1869. TREATMENT. 75 sium diluted; later, a weak solution of arsenious acid; and now I gen- erally administer either the arsenious acid or the arsenate of sodium in solution. Some regard the latter preparation as the most accept- able, as it is a higher oxide than the arsenate of potassium, is less irri- tant in its local action, and not so liable to be followed by toxic symp- toms. I usually have the arsenate of sodium made into pellets of various strengths, beginning with one tenth of a grain, one of which is dissolved in ordinary water (distilled water, however, as a medium is always the best), and deposited daily into the areolar tissue over some part of the back. In the course of a few days the dose is gradually increased, until some evidence of the action of the metal is observed either upon the disease or by its constitutional effect. I have in this manner given as high as from one quarter to a half and in one instance one grain daily, without injurious results. The effect is usually very speedy; in some individuals it was observed in two weeks, in others from six to eight weeks. As soon as the systemic or local action of arsenic is noticed, the dose should be decreased to the minimum amount. In case the disease persists, it can again be gradually in- creased. It is proper to bear in mind that in exceptional cases arsenic gives rise to cutaneous manifestations. These may occur irrespective of any signs of systemic intoxication. A diffuse, more or less general, erythema is sometimes produced by a few doses. This rash may or may not attack the face. Prof. James Stewart * met with a patient in whom wart-like excrescences formed upon the dorsal surfaces of the hands and fingers. In a similar case involving the palms and soles, observed by Dr. Pringle, there was a universal thickening of the epi- dermis of the affected parts with well-marked hyperidrosis. A brown pigmentation occasionally develops in consequence of an arsenical course. The discoloration may appear on any portion of the body. It may exist as disseminated patches or may be so generalized as to pre- sent the appearance characteristic of Addison's disease. This pigmen- tation gradually disappears after the remedy has been suspended. Mr. Jonathan Hutchinson supposes that a course of arsenic prolonged for years is capable of producing epithelioma. The evidence upon which he founds this belief seems inconclusive, and the result, if really due to the drug, must be of very rare occurrence. Antimony.—Tartar emetic, a well-known and useful drug, fell, owing to its constitutional effects in many cutaneous diseases, into dis- use until recently, when excellent results were reported from its admin- istration by Morris, of London. It is quickly diffused into the circula- tion, which it lessens, and assists in eliminating the waste products by the alimentary canal, the kidneys, and the skin. In most of the in- flammatory affections, with elevation of temperature, it will be found to exercise a beneficial influence in reducing the exudation and the * " Canada Medical and Surgical Journal," April, 1888. 76 DISEASES OF THE SKIN. temperature. It is of undoubted value in eruptive fevers and acute eczema and psoriasis by allaying the irritation and congestion of the skin. It often acts well in chronic eczema, psoriasis, scrofuloderma, syphilis, and other cutaneous eruptions. Mr. Morris believes that anti- mony is likely to be of special value in cases dependent upon func- tional nervous disorder. Antimony is best given as the tartrate of antimony and potassium in from one twentieth to one tenth of a grain dose every four to six hours; or the wine of antimony, in from five drops to half a drachm, repeated in the same manner. Turpentine.—Clinical experience has demonstrated that turpentine is a valuable remedy both in its direct and indirect action. In moder- ate doses it stimulates the vaso-motor nervous system, leading to an increase, followed by a diminution, of the capillary circulation. This important action of turpentine renders it one of the most useful drugs in lessening inflammation in psoriasis and eczema, attended with much dilatation of the arterioles and thickening of the skin. Crocker * re- ports very good results from its employment in the diseases just named. He recommends the oil of turpentine in from ten to forty minims three times daily after meals. Barley-water, usually about a quart a day, is recommended from the beginning of the treatment, to avoid irritation of the urinary organs; the Chian turpentine in from five to fifteen grains was followed by improvement in pityriasis rubra. Gould also reported through Crocker good results from the latter preparation in a case of epithelioma and scirrhus; the pain in both was lessened and the growth retarded. Benefit has resulted in my experience in chronic psoriasis, eczema, and purpura from the use of both the oil and the Venice turpentine. Mercury and its Preparations.—Mercury is an effective antiphlo- gistic agent. In small doses it improves the quality of the blood, es- pecially increasing the red corpuscles. By this action it forms a pow- erful agent for combating and treating syphilis. It can be employed with advantage in minute doses in the treatment of eczema accom- panied with severe inflammatory symptoms, particularly in children having the pustular variety. It is also of value in small doses in the treatment of many other inflammatory affections of the integument, among which may be mentioned lupus, sycosis, chronic eczema, psoria- sis, and scrofuloderma. Mercury may be introduced into the system by inunction, fumigation, the hypodermatic method, or by the stomach. In the treatment of obstinate and chronic forms of syphilis, the hypo- dermatic method is to be preferred. It is cleanly, more economical, and more rapid in its action in arresting the disease. If mercury is administered by the mouth, the corrosive chloride, the mild chloride, blue pill, mercury with chalk, the protiodide, and the biniodide are * " On the Internal Administration of ^Turpentine in Cutaneous Diseases." Read before the Hunterian Society, London, January 14, 1886. TREATMENT. 77 the preparations ordinarily used. The drug should usually be given in the beginning in very small doses, and its effect watched in order to pre- vent ptyalism. A minute quantity, as the one twentieth to the one sixtieth, for instance, of the corrosive chloride, or the mild chloride, well rubbed up with sugar, or triturated, as recommended by Piffard,* and given in frequently repeated doses, acts more decidedly than larger doses at longer intervals. Mercury may be administered alone or given in combination with other substances; the best example of which is the liquor arsenici et hydrargyri iodidi, which in from five to fifteen drop doses is of utility in syphilis, sycosis, and in the various forms of cancer. Chlorate of Potassium.f—This powerful but valuable remedy is useful in the treatment of all diseases depending upon suboxidation or defective nutrition, secretion, excretion, aeration, and molecular metamorphosis. In small doses it increases the appetite, and in large or excessive doses it may, like any other potent but valuable remedy, produce an injurious or poisonous action. Given in small or mod- erate portions, it is a most effective remedy for abating and often cur- ing many pustular diseases. It is beneficial in ecthyma in debilitated subjects. In boils, carbuncles, sties, pustular acne, pustular eczema, and sycosis it diminishes the tendency to suppuration, and if the latter stage has been reached, will assist largely in arresting it. A happy effect from the drug will frequently be experienced from its employ- ment in scrofulous subjects suffering from enlarged and suppurating glands, unhealthy ulcers, papules, pustules, and other lesions arising from this peculiar state of the system, and accompanied with more or less constitutional impairment. In many such typical cases, and some even less so, the continued use of the drug in moderate doses will tone up the digestive organs, increase the appetite, and lessen the forma- tion of pus. It will, by thus adding tone and vigor to a previously weakened system, prepare the patient for the use of other measures, such as good, nourishing food, exercise, fresh air, and perhaps tonics, all of which are so necessary for thoroughly eradicating scrofula. Purpuric and broken-down syphilitic patients are often benefited by chlorate of potassium. It will also increase the quantity of urine, and may be discovered in that secretion. The dose of the drug is usually from one half to thirty grains, freely diluted with water, every three or four hours. The dose will have to be graded according to the condi- tion of the patient; the pale, weak, and enfeebled bear much larger doses than the apparently vigorous. Iodine and its Preparations.—The preparations of iodine have a * " A Treatise on the Materia Medica and Therapeutics of the Skin," pp. 61-63, New York, William Wood & Co., 1881. f See paper by the author, " Th% Therapeutic Action of Potassium Chlorate." Transactions of the American Medical Association, vol. xxxiii., pp. 131-149. 7S . DISEASES OF THE SKIN. large range of usefulness in affections of the skin. They are said to influence the elimination of waste products from the system. Iodine is effective in small doses in the treatment of scrofula and lupus. The iodide of potassium or the iodide of sodium, but preferably the former salt, is one of the most effective remedies in the treatment of the ter- tiary stage of syphilis. As iodine and its preparations may produce a variety of cutaneous eruptions, they should be cautiously used. The usual dose of the tincture of iodine is from one to five drops, and of the iodide of potassium or sodium from five to sixty grains. In the tertiary form of syphilis, particularly if attended with ulceration, large doses should be administered, in order to produce a decided effect. To avoid the gastric disturbance which not infrequently results from the prolonged administration of iodine or its salts, we are now provided with an admirable remedy in the sirup of hydriodic acid. One fluid ounce of this preparation contains about six and a half grains of iodine, and the dose is from half a fluid drachm to half a fluid ounce. It is relatively more powerful than iodide of potassium, since nascent iodine is liberated in the stomach. The sirup of hydriodic acid * is valuable in syphilis, especially in the latter stages of the disease, and is tol- erated when the stomach has become rebellious to the iodide. It is of great efficacy in the eczema of feeble or scrofulous children. In scrofuloderma and lupus vulgaris it is likewise of service. Dr. Hugh AYoods, of Highgate, has introduced another substitute for the iodides in the hypiodite of potassium (liquor potassae iodinatae). Each ounce of the solution contains about twenty-eight grains of iodine in a loose combination, and nascent iodine is set free by the action of the gastric juice. It is given in doses of five to ten minims. When shaken up with an equal quantity of olive-oil, it forms a soapy liniment which is a useful antiseptic remedy for external use.f Sulphur X and Calx Sulphurata.—Sulphur given internally in from one grain to two drachms in sirup, honey, or milk, may produce ex- cellent results in alopecia, diseases of the nails, glandular affections, eczema, and psoriasis. The most elegant and useful preparation of sulphur is calx sulphurata. It will, in from one-quarter to one-grain doses, three or four times daily, prove a useful remedy in acne, and in boils and abscesses. It will lessen the formation of pus. A nat- ural sulphur-water, as the Blue Lick water, of Kentucky, can be pre- scribed with advantage in the same class of affections. Tar, Carbolic Acid, and Creasote.—These remedies are sometimes serviceable given internally. Tar, or one of its products, may in some cases lessen cutaneous irritation, but in others increase it. Chronic * " Hydriodic Acid," by the author, " The Medical Bulletin," August, 1889. f " British Medical Journal," April 26, 1890. X See paper by author on " The Physiological and Therapeutic Action of Sul- phur." " Transactions of the Pennsylvania State Medical Society," 1890. TREATMENT. 79 eczema, psoriasis, lichen, and prurigo may be influenced favorably by the administration of either tar, carbolic acid, or creasote in small doses. Dr. Augagneur speaks particularly of the good effects of the internal administration of carbolic acid in alleviating the troublesome itching which often accompanies eczema and psoriasis. Local Treatment. The external means which are employed for relieving or curing cutaneous diseases are innumerable. Some have value, while others are useless and hardly worth describing. Among those that have been found effective are the following: Baths.—Baths are essential for the preservation of health, as well as to prevent and assist in eradicating disease, by draining from the system effete products which are often the active factors in many affections of the skin. They not only have this general effect, but by their local action they remove from the skin all abnormal products, such as irritating discharges, scales, crusts, and all extraneous matter. They soften the hardened integument, lessen vascular excitement, relax muscular tension, soothe, astringe, or stimulate the organ, relieve irritation and inflammation, and assist the action of both the constitu- tional and additional local treatment to be employed. Among the various forms of baths that are serviceable are the water, the medicated water, the hot-air, the vapor, simple and medicated, and the electro-vapor bath. Brief reference will be made to those just mentioned, and some others, as follows: The water-bath should be composed of soft or rain water, procured from tubs, tanks, or cisterns in which it is caught, or from creeks, rivers, and most springs. Hard water, if possible, should always be avoided, or made soft by adding potash or soda in the proportion of one liundred grains of either to the gallon of water, as, owing to the presence especially of lime sulphate in it, the skin, particularly if sen- sitive, may be irritated or inflamed. The water-bath, if properly used, either cold, tepid, warm, or hot, is often'of great value in the in- flammatory and hypertrophic affections, as in eczema, psoriasis, pity- riasis, dermatitis, and ichthyosis. Hot water baths restore the function of the glands in acne, relieve the abnormal sensibility of dermatalgia and panvsthesia, are beneficial in pityriasis, prurigo, pediculosis, and scabies. AY arm baths are of service in ecthyma and syphilis. The continuous water-bath, recommended by Hebra, so arranged that patients can remain in it for a long time, is useful in the treat- ment of pemphigus, chronic eczema, psoriasis, and burns. Medicated Water-Baths.—These baths generally consist of from twenty to thirty gallons of water, which may be of any temperature, but usually about 9.')° Fahr. The following are the principal varieties and the formula employed in their preparation: 80 DISEASES OF THE SKIN. Acid Baths.—Hydrochloric, nitric, or one of the mineral acids, one ounce. Serviceable in prurigo, lichen, and chronic scrofuloderma and syphilis. Alkaline Baths: •— Bicarbonate of sodium or borax, two to ten ounces, but generally about six ounces. Useful in very many varieties of cutaneous diseases attended with irritation of the part, especially in eczema, dermatitis, psoriasis, paraesthesia, erythema, urticaria, lichen, and prurigo. Astringent Baths.—Alum, from four to six ounces, or a decoction made with half a pound of white-oak bark, added to the usual quan- tity of water. Used in chronic eruptions, especially in eczema and in purpura. Bromine and Iodine Baths.—The former is prepared by using twenty to forty drops of bromine with two to four ounces of iodide of potassium, and the latter by adding one half to one drachm of iodine to one or two ounces of liquor potassa and the required quantity of water. Employed in scrofuloderma, syphilis, elephantiasis Arabum, vitiligo, and in excess of pigment. Emollient Baths.—Potato-starch, gelatine, linseed, or marsh-mallow^ from one to four pounds. They often allay active irritation and in- flammation, and can be used in conjunction with the alkaline bath with decided effect. Of value in erythema, eczema, urticaria, derma- titis, herpes, and psoriasis. Mercurial Baths.—One or two drachms of the corrosive chloride of mercury with a drachm of hydrochloric acid. Potassium Sulphuret Baths. —From one to six ounces of the above salt to each bath. The Hot-Air Bath, as constructed in the Hospital for Diseases of the Skin, in Philadelphia, consists of a closed chamber, six feet square by eight feet in height, provided with ventilators. The heat is car- ried to it by flues which surround all sides, and thus radiates from all parts of the chamber. The temperature is indicated by a thermometer fixed in the room, which can be watched by an attendant from the out- side, and is usually maintained at from 130° to 140° Fahr. It may be inconvenient for patients at times to leave their homes to visit an in- stitution for this form of bath. For those so situated the bath can be constructed as follows : The patient is placed in a nude condition on a perforated or cane-bottom chair, and the body from the neck is enveloped in a blanket. A lighted spirit-lamp of good size is then placed beneath the chair, and, care being exercised to retain as much as possible of the heated air in contact with the body, free perspira- tion soon follows, the procedure being continued for from ten to twenty minutes, after which the patient is rubbed dry and placed be- tween warm blankets or sheets. This form of bath is of value in ecze- ma, psoriasis, pityriasis, ichthyosis, and paraesthesia. It makes the su- TREATMENT. 81 doriparous and sebaceous glands active, equalizes capillary circulation, and cleanses the skin of all abnormal products. The Vapor-Bath, Simple and Medicated, is arranged in a sim- ilar manner to the hot-air bath; the vapor being conveyed by a series of pipes instead of hot-air flues. The temperature is indicated in the same way, and is maintained at from 115° to 140° Fahr. Given at home, the patient is prepared in the same manner as for the hot-air bath. An ordinary tin pan, or any vessel containing boiling water, is first placed under the chair, and a brick or good- sized stone, previously heated red hot, is next carefully deposited in the water, a portion of it being left uncovered by the fluid, if it is desired to sprinkle over the surface a drug with which to medicate the bath. The vapor quickly ascends, causing copious perspiration, which may be continued from ten to thirty minutes, and the patient is afterward treated as in the hot-air bath. If the medicinal sub- stance employed to impregnate the bath is difficult to volatilize, it may be better accomplished by placing a small tray and spirit-lamp beneath the chair, as the drug may be dissolved in water and after- ward evaporated by the lamp. The following medicinal agents can be volatilized and used in the quantities named : Mercury and its salts, more particularly calomel or the red sulphuret of mercury, from one half to a drachm ; tar, naphthol, the balsams, especially Peruvian bal- sam, one to four drachms ; carbolic acid, and the essential oils, five to thirty drops ; sulphur, from one half to tAvo ounces. The simple vapor-bath is similar in action to the hot-air bath, with the addition of slightly stimulating and making the skin more soft and pliable. It is beneficial in acne, eczema, and prurigo, and in all diseases accom- panied by heat, dryness, and irritability of the skin. Of the medi- cated vapor-baths, the mercurial is invaluable in syphilitic eruptions, especially when mercury is not well borne by the alimentary canal; the tar and others, in chronic eruptions, particularly in eczema and psoriasis. The sulphur vapor-bath is useful in soothing the irritated surface in obstinate and chronic cases of scabies. Finally, during a vapor-bath, electricity may be brought in contact with the skin, either as the galvanic or faradic current. The so-called electro-vapor bath may give good results in hypertrophies of the skin and in the neuroses, especially in paraesthesia. As it has been shown that the fluid and the medicinal substances contained in baths are absorbed by the skin, some benefit may re- sult from their direct s; temic action. The principal value of baths, however, is in their direct effect upon the skin and their indirect impression upon the system. They should always be used, however, with caution, and never given or persisted in if contra- indicated by any constitutional weakness or disease. With the aged and the very young they should be used carefully. Baths 6 82 DISEASES OF THE SKTN. should never be given upon a full stomach ; the period for con- tinuing in the bath should usually be short, and the bather should be guided by the temperature of the medium in relation to the heat of the body. The various baths, if used judiciously, are im- portant and useful auxiliaries in the treatment of diseases of the skin. Soaps.—Soaps * are useful in assisting to maintain the skin and the body in a healthy condition, and are frequently valuable aids in the treatment of diseases of the integument. They can be employed either as the potash or soft, or the soda or hard. Soft Soap.—Potash soap, sapo mollis, sapo viridis, brown soap, black soap, soft soap. Potash soap, which contains a certain excess of alkali, is made with either an animal fat or a vegetable oil; olive-oil with potash being often employed. When well and prop- erly made, it should be of the consistence of jelly, and should not flow out if the vessel containing it is inverted. It ought to be of a brownish, greenish, or olive-green color, soft and perfectly homo- geneous, with a strong, caustic odor, and an acrid, alkaline taste. It should contain no particles of sand, and readily dissolve in alco- hol with little or no residue. These characteristics will, of course, vary much according to the manner in which the soap is made. The best potash soap. which has a definite strength is imported from Europe, and obtained from either Duvernois, of Stuttgart, or from Bassermann and Herschel, Mannheim, Germany. Potash soap, when applied to the skin, softens and macerates the epidermis, or even destroys it—the effect on the cutaneous surface varying according to its application lightly or with great friction, as well as to the length of time it is left in contact with the parts. The variable and uncer- tain effect that occasionally follows its use, denuding the epidermis at one spot and making no impression whatever at another, is due to the soap being neither properly nor well prepared. Potash soap may be used alone or dissolved in alcohol, as recommended by Hebra, in the proportion of two parts of soap to one of alcohol, which will remove its unpleasant smell. To make it more elegant, and free from any particles of sand that may be present, the solution is allowed to settle, or filtered and scented with the spiritus lavandulae, and it is then known as spiritus saponatus kalinus, or Hebra's spirit of soap. Mollin, \ which is a modified soft soap, lias recently been highly ex- * The brief description of soaps is abstracted from my paper " On Soaps, especially Medicated, in Diseases of the Skin." For a detailed account, see Transactions of the Medical Society of Pennsylvania, vol. xvii., pp. 190-205. f "Mollin," Jackson adds, in the New York Medical Journal, November 6, 1886 " is prepared from the best and freshest kidney-fat and suet and the finest Cochin cocoa- nut-oil. The fat is saponified cold with potash and some soda, so that to one hundred parts of fat there are forty parts of lye. Into the mass thirty per cent of glycerine is TREATMENT. 83 tolled in Germany as a useful vehicle for applying various substances to the skin. Soda or hard soap, which contains soda as the base, and is gen- erally a nearly neutral soap, may also be made with either an animal or mineral fat or a vegetable oil. From the investigations of Dr. B. H. Paul* we learn that a perfectly neutral soda soap made with ordinary fat consisting principally of oleic and stearic acids contains about eleven parts of soda for every one hundred parts of fatty acid. But a neutral soda soap made with cocoa-nut oil, in which palmitic acid preponder- ates, contains a larger proportion of alkali. According to the same writer, the proportions of soda and potash given in the formula for Unna's super-fatted soap suffice for the complete saponification of the fat though it has been supposed that this preparation contained four per cent of unsaponified fat. It differs from the potash soap in being hard, or comparatively so, and in having a less stimulating or destructive action on the skin. If soap is needed, either to cleanse the surface or for its local effect, it is often best to employ first the soda and then subsequently, if necessary, the potash soap. The field of usefulness of both may be rendered more extensive and effective by medicating them with such agents as alum, arnica, boro-glyceride, camphor, carbolic acid, chamomile, eucalyptol, naphthol, salicylic acid, mercury, sulphur, and tar. In making these med- icated soaps, chemical requirements must be carefully observed or useless preparations result. It has been stated that soap containing free iodine remains unaltered but a short time. Resorcin can be preserved only in a neutral soap, while in a neutral or alkaline soap hydroxylamine under- goes progressive decomposition, evidenced by the continual evolution of gas. Chrysarobin is not soluble in a neutral but readily soluble in an alkaline soap. A toilet soap should not contain free alkali, which removes too much of the cutaneous fat and causes premature exfoliation of the corneous epidermic cells. It should be neutral in reaction, and P. J. Eichhoff points out that a few drops of a hot solu- tion of mercuric chloride let fall upon the soap will develop a yellow- ish discoloration if any free alkali be present. Eichhoff describes four methods in which medicated soaps may be used in the treatment of disease : by simple washing; by allowing the lather to remain upon the skin for a short time and then rubbing it off with a dry cloth; by permitting the lather to dry upon the surface; and, finally, which he worked, and the whole carefully heated. When properly made, mollin has a pale- white color with a slightly yellow tint, and an agreeable, smooth, soft consistence. It is not essentially affected by exposure to changes of temperature or by being kept in open vessels. It is superior to an ointment in being perfectly clean, not soiling the under-clothing and not becoming rancid, and in being readily removed from the skin by warm or cold water, leaving it soft and smooth." * " Toilet Soap considered from a Chemical Point of View," British Journal of Dermatology, March, 1890. S4 DISEASES OF THE SKIN. considers the most effective, by covering the dry lather with an im- pervious layer of rubber cloth or tissue. He states that resorcin soap may be preserved by the addition of salicylic acid, and incorporates three parts of each substance in ninety-four parts of soap to form resorcin-salicylic-acid soap. This preparation he finds advantageous in parasitic skin-diseases, especially those in which epithelial hyperplasia is a marked feature, as seborrhceic eczema, psoriasis, and ichthyosis. A salicylic-acid-resorcin-sulphur soap contains three parts each of sali- cylic acid and resorcin, and ten parts of precipitated sulphur to eighty- four parts of soap. Acne, rosacea, psoriasis, ichthyosis, ringworm, and favus are benefited by this application. The addition of five parts of tar to the preceding soap constitutes his salicylic-acid-resorcin-sulphur- tar soap, which is deleterious in acute inflammations but useful in para- sitic affections, squamous eczema, and psoriasis. Three per cent, of qui- nine added to soap is recommended for chromophytosis, used morning and evening and the lather allowed to remain. A soap containing three per cent, of hydroxylamine is serviceable in psoriasis, seborrhoeal ec- zema, and tinea sycosis. A five-per-cent. iodoform soap may be used in cleansing common and syphilitic ulcers. One containing five per cent, of creolin is efficacious in scabies, impetigo contagiosa, intertrigo, hyperidrosis, and bromidrosis. Eichhoff employs an ergotin soap of the same strength in the treatment of varicose ulcers, frost-bite, and rosacea. A preparation in which three parts of iodine and 1-5 part of iodide of potassium are present is employed to reduce enlarged scrofu- lous glands, and is of avail in psoriasis. A salicylic-acid-creasote soap into which enter five per cent, of salicylic acid and two per cent, of pure creasote is of value in lupus, ring-wrorm, and seborrhceic eczema. Oils.—The oils employed locally in the treatment of cutaneous dis- eases are either bland or stimulating. Among the former are olive- oil, linseed-oil, oil of sweet almonds, cotton-seed oil, and cod-liver oil. They are valuable for softening and removing scales, crusts, and extra- neous matter from the surface. They are also useful for protecting and soothing the irritated and inflamed skin in the eruptive fevers. The tar-oils, as the oil of cade, the oil of juniper, the oil of ergot, and chlorinated oil, are examples of the stimulating variety. They are particularly serviceable in many affections of the skin. Chlori- nated oil, as I have demonstrated, often acts well in animal parasitic diseases, especially scabies. The oil of ergot * is also a valuable remedy in seborrhoea of the scalp and loss of hair. Poultices or Cataplasms.—Various substances which retain heat and moisture can be used as poultices, such as bread, flaxseed-meal, potato-starch, etc. AArater, milk, or some other boiling fluid, should * See paper by the author, " New Kennedies in the Treatment of Skin Diseases," Transactions of the Medical Society of the State of Pennsylvania, vol. xiii., part 1, p. 85. TREATMENT. 85 always be used in preparing poultices. They should be applied as hot as comfort will permit, and should be covered, if possible, with oiled silk to retain the heat and moisture. Cloths dipped in boiling water, partially wrung out, at once applied and covered with oiled silk, make an excellent poultice. The most soothing and most effective of all poultices in cutaneous diseases is composed of starch. It is important, however, that this poultice should be properly made. In the first place, enough tepid water should be mixed with the starch to form a paste. Boiling water should then be added, the mixture left on the fire for about a minute, being briskly stirred to make it homogeneous. It should then be spread upon tarlatan previously deprived of its stiff- ening. Poultices act very often in a happy manner in dilating vessels, relaxing the muscular tension, and assisting in removing the hard, tense, high inflammation and the sensitive condition of the nerves of the part. In infiltrated and dormant conditions of the integument they soften and soothe the parts, arouse the absorbents, and assist the action of other local remedies. Poultices relieve pain and promote suppuration in deep inflammation of the integument. They are also of great utility in many affections, particularly for removing scales, crusts, and extraneous matter. Dusting-Powders.^Dusting-powders are employed to protect the skin; and, at times, to produce a soothing, stimulating, or astringent action. The most useful are starch, wheaten and buckwheat flour, corn- starch, orris-root, arrow-root, carbonate of magnesia, carbonate of lead, the impure carbonate of zinc, carbonate of zinc, oxide of zinc, subnitrate of bismuth, lycopodium, boric acid, salicylic acid, alum, French chalk, talc, red cinchona powder, oleate of zinc, and prepared earth. The latter two are especially valuable; the oleate of zinc being particularly effective in many inflammatory cutaneous diseases. Prepared earth—so long and favorably employed by the late Dr. Addinell Hewson in the treatment of old ulcers, epithelioma, small-pox, and other diseases of the skin— has a beneficial effect, not only in relieving but often in absolutely curing the eruption to which it has been applied. Dusting-powders should be carefully prepared. They must be thoroughly ground, and afterward sifted through fine bolting-cloth. It is important that they should be smooth and free from grit. A powder brought into notice by Dr. Allan Jamieson is known as emol-keleet. It is an impalpable, emollient powder, described as containing a considerable proportion of steatite, with silica, alumina, traces of calcium salts, and some ferrous oxide. Emol-keleet is of a light flesh-color, a good absorbent and anti- pruritic, and is said to have the property of softening horny thicken- ing of the integument. Dusting-powders, by protecting the skin from the air and all irri- tating substances which may come in contact with it, and by absorb- ing the exudation, are of great value in certain stages of erythema, 86 DISEASES OF THE SKIN. eczema, herpes, herpes zoster, pemphigus, and the various disorders of secretion. Lotions.—Lotions are liquid preparations for external application, best adapted for use upon diseases involving a large surface, and where other applications are contraindicated. They constitute a cleanly and economical method of medicating the skin. Lotions may be prepared with water, alcohol, spirits, glycerin, oils, and other fluid substances, and may be divided into those which are sedative, astringent, and stimulating. Sir James Sawyer advocates the use of ether as the best menstruum for the solution of many reme- dies for local action through the skin. It is a good solvent-for the active principles of many drugs, and also for the fatty constituents of the sebum. Sedative lotions diminish or relieve irritability. They are employed in inflammatory diseases and the neurotic and parasitic affections. Among the most valuable are lead-water and laudanum, elder-flower water, camphor-water, black- and yellow-wash, glycerin and rose- water, glycerin and lime-water, glycerole of lead, weak solutions of the alkalies, of boric, hydrocyanic, and carbolic acids, and thymol. Astringent lotions contract the tissues to which they are applied, lessen or arrest discharge and moderate or control inflammation. They can be made with one of the fluids already named, and may contain tannic or gallic acid, catechu, ergot, kino, rhatany; the various acids, the preparations of lead, alum, iron, and other drugs, having a similar action. They are used largely in certain varieties of eczema, purpura, seborrhoea oleosa, the disorders of secretion, and in many chronic forms of cutaneous diseases. Stimulating lotions are irritant in character and arouse the torpid integument to activity. They are prepared with one or more of the following drugs in varying proportions: tar and its products, stimu- lating oils, alkalies, the preparations of ammonia, benzoic acid, chrysa- robin, arnica, rosemary, menthol, thymol, camphor, boro-glyceride, sul- phur and its preparations, and similar drugs. They are most effective in chronic eczema, psoriasis, acne, rosacea, and seborrhoea. Ointments.—Ointments may be made from various fatty substances, but lard, butter, suet, lanolin, and petroleum-jelly are usually employed. An ointment may be simple, consisting of only one of the above materials, or it may be medicated by the addition of various remedies. Simple and medicated ointments are among the most effective means of making an impression upon diseased skin. They are especially useful in chronic disorders and those accompanied by incrustations. In reference to the proper base to employ for ointments, I repeat what is briefly stated in my small book on the oleates : The fatty vehicles intended for ointment bases are a matter of choice according to the indications of the case. TREATMENT. S7 While, no doubt, the most elegant preparations can be made with the petroleum fats, they form, in my opinion and in that of others, the least desirable substances for such use.* In my paper, read be- fore the Medical Society of the State of Pennsylvania,! I stated that I considered the petroleum products as objectionable for such a purpose; and Dr. Robson, of England, has made a similar observation on the use of vaseline as a surgical dressing. I also consider them to possess a feebler penetrative power, if any at all, than animal fats, which have more affinity for the integument. They usually contain some irritating constituent, which lessens or destroys their emollient action, and con- stitutes a great source of hindrance to their use as external remedies in active inflammation. The investigations of Liebreich confirm the conclusions which I came to some years ago. I place them side by side, for comparison: LiebreicK's Investigations on the Action of Mineral Fats. "Quite apart from the fact that the absorption of medicaments, when mixed with pure fat is but imperfectly effected, fat-ointments are subjected to decomposition, which may lead to irri- tation of the skin. It is true that vase- line does not decompose, but it prevents the entrance of medicaments' into the skin, so that even poisonous substances, when mixed with vaseline and rubbed into the skin, produce neither local nor constitutional symptoms of poi- soning." \ My own Investigations on the Action of Mineral Fats, reported in 1882, 1884, and 1885. '' Petroleum products, vaseline, cos- moline, etc., possess feebler power to penetrate the skin, if any at all, than animal fats, which have more affinity for the integument. Their absorptive power for penetrative action into the skin is so feeble as almost to cause them to be excluded as such. Irritant oint- ments of veratria and other substances which I had made respectively of vase- line, cosmoline, and of simple cerate, manifested themselves in the former two preparations as almost inert; while the activity of those made with simple cerate very soon became evident. Fur- ther, the petroleum products retain some stimulating constituent left after their manufacture." From Liebreich's experiments and conclusions, and my own, the substance to employ as a basis for ointments should possess the power of penetrating the integument and not irritating it. Lard, suet, and lanolin are all animal fats, which are therefore best adapted for this purpose. Lard is the most economical and the most commonly used; * See an article on the " Irritation of the Skin following the Application of Vaseline," in the London Lancet, of November 8, 1884. t Transactions of the Medical Society of the State of Pennsylvania, vol. xiv., p. 129. X " An Address on Lanolin; a Hew Basis for Ointments," British Medical Jour- nal, January 16, 188G. 88 DISEASES OF THE SKIN. the objection against its becoming rancid quickly can be overcome by prescribing a sufficient quantity to last but a few days, and it rarely undergoes change before it is utilized; or the addition of benzoin or a small quantity of /?-naphthol will prevent it from becoming rancid for a long time. Digestion with freshly bruised poplar-buds will also ac- complish the same purpose. It is sometimes of advantage to stiffen the lard by the addition of white wax or spermaceti. The latter substance, however, is prone to become rancid. Suet also forms a valuable oint- ment, and a serviceable vehicle for the application of many medicinal substances to the skin. Lanolin,* or wool-fat, a new basis for oint- ments, introduced by Liebreich in 1886,f is one of the most desirable vehicles for limited applications. I quote from investigations which I made some years ago, and published in a paper on lanolin,J as follows: " Lanolin possesses great absorptive action, and through its neutrality, its own decomposition is out of the question, and consequently it will not irritate the skin." Liebreich states that it has its origin in keratinous tissue, and is manufactured chiefly from wool by " transforming the wool-fat into a milk and then subjecting it to a centrifugal action." By this process, he further adds," a thin milk and cream are obtained, just as when milk is subjected to centrifugal action, and the cream contains lanolin in a pure condition. More than one hundred per cent, of water can be kneaded with it, the result being a yellow, very plastic ointment." It is neutral in reaction, and has the consistency of ordinary citrine oint- ment, which it very much resembles, and is soft, smooth, and slightly tenacious. In order to overcome this stickiness, Mr. II. Helbing has suggested a mixture of sixty-five parts of anhydrous lanolin, thirty parts of liquid paraffine, and five parts of cerasin. Prof. P. D. Keyser, of this city, with the same object in view, combines one part of ben- zoated lard with three parts of lanolin. We may in some cases take advantage of the tenacious consistence of lanolin to render certain ointments stiffer and more adhesive by the addition of about twenty per cent. On applying it to the skin with slight frict ion it rapidly disappears. It is decomposed, it is claimed, with great difficulty, and it readily combines with other fats, oils, and glycerine, forming many excellent ointments and liniments. Paschkis recommends what he terms " lanolin milk " as an excellent application to dry, harsh skins, and useful, moreover, as covering the skin with a thin layer of fatty material, to which dusting-powders will readily adhere. Lanolin milk * The best lanolin is manufactured at Lanolin Works, Martinikenfelde, Ger- many. Burroughs, Welcome & Co., Snow Hill Bui1' :ngs, London, are the agents, and have placed before the profession some elegant preparations of this fatty substance. f See Liebreich's paper read before the Section of Therapeutics of the British Medical Association, August. 1886, with discussion by the author, in British Medi- cal Journal, October 23, 1886. X The Medical and Surgical Reporter, Philadelphia, April 3, 1886. TREATMENT. 89 is made by rubbing up seventy-five grains of lanolin with about a fluid ounce of water, gently warming and adding to the mixture four grammes neutral soap dissolved in an ounce of water. This is again rubbed up, enough warm water added to make about twelve fluid ounces, and the whole thoroughly agitated. If desirable, a little tincture of benzoin or borax dissolved in a small quantity of warm water may be added. The mixture needs to be strained. As used in medicine, lanolin contains from twenty-five to thirty per cent, of water, not, however, in a state of chemical combination. Made according to the latest improved processes, the odor is almost entirely overcome and the substance is of a whitish color. Lanolin serves a double purpose as an excipient for mercury. The metal is readily incorporated, and the prolonged manip- ulations formerly necessary in the preparation of mercurial ointment are now succeeded by a more rapid and easy process. Again, the ab- sorbability of lanolin promotes the efficiency of the mercury which it may contain. On account of the miscibility of lanolin with water, an aqueous solution of any drug may be intimately united with the fat* Lanolin is impermeable to micro-organisms, and is consequently an aseptic material. By virtue of this property, it is well adapted for use in burns, scalds, frost-bites, and erysipelas. Gottstein has taken advan- tage of its power for absorbing water to incorporate with it aqueous solutions of corrosive sublimate. It thus constitutes an admirable dis- infectant application to wounds and ulcers. In the same way it may be impregnated with other medicinal substances. According to Lassar, lanolin promotes or intensifies the action of chrysarobin. Lanolin is a valuable unguent in senile atrophy of the skin, ichthyosis, scleroderma, psoriasis, anidrosis, chronic eczema, and impetigo contagiosa. Its pene- trative quality renders it an excellent vehicle for germicides in the treat- ment of tinea trichophytina and for mercury when inunction is prac- ticed for syphilis. Lanolin is useful in improving depressed nutrition of the hair and nails. This substance has lately been produced in the form of a powder by the following procedure : The lanolin is dissolved in ether, alcohol, chloroform, or acetone; the solution mixed with mag- nesia and dried. The mixture is additionally pulverized, and starch can be added in any proportion. Oxide of zinc, talc, alum, or bismuth may be used instead of magnesia. The preparation may be serviceably employed as a dusting-powder. Hallopeau regards lanolin, with a solu- tion of gutta-percha in benzol, as the best plaster constituent which we possess. According to Unna, fats, glycerin, lanolin, and vaseline diminish evaporation of water from the skin. Caoutchouc and gutta-percha have the same effect. As a result of diminished transpiration a corre- sponding quantity of water is driven to the kidneys. * See Ointments and Oleates, especially in Diseases of the Skin, by John V. Shoe- maker, A. M., M. D., second edition, Philadelphia, 1890, F. A. Davis, p. 14 et seq. 90 PHYSIOLOGY OF THE SKIN. Whenever ointments are prescribed, it is essential that the ingredi- ents should be thoroughly triturated and intimately mixed with the excipient. Exact directions, moreover, should be given to the patient as to the mode of application. If used at all, it should be in a proper manner. Otherwise, an appropriate preparation may work injury in- stead of benefit. An ointment generally needs to be kept in constant contact with the affected surface as long as the indications are the same which suggested its employment in the first place. As a rule, an abun- ) dance of material should be applied, spread thickly upon the woolly side of the lint, which will not absorb the medicament and leave the integu- ment almost or entirely unmedicated. The dressing is then held in position by a bandage. Again, in reference to the strength of oint- ments, it is obvious that no absolute rule can be formulated. The skin of individuals differs normally in sensibility, and the difference becomes more marked when the integument is the seat of disease. If the offici- nal ointments are used, it will frequently be found that some are too strong, while others are too weak. In beginning the treatment of a case, therefore, it is advisable to use mild preparations, which can be gradually strengthened if necessary. Ointments, like lotions, may be sedative, astringent, and stimu- lating. Sedative Ointments.—Simple ointment, suet, lanolin, unsalted but- ter, ordinary cerates, spermaceti, cacao-butter, lead, zinc, and cucum- ber ointments, are examples of this class. They are employed for their bland action in protecting the surfaces, and in soothing and allaying irritation and inflammation in many cutaneous diseases. The rose-water ointment or cold cream is bland, elegant, and effi- cient. In certain cases, as Bulkley points out,* when the skin is too dry, a portion of the water which it contains may be serviceably re- placed by glycerine. Astrinyent Ointments.—Ointments of this class are employed for the purpose of contracting the integument to which they are applied, lessening discharge, and arresting or modifying inflammation. They are composed of lead, bismuth, tannic acid, kino, ergot, and various other astringent substances mixed with a fatty base. Stimulatiny Ointments.—Ointments containing a stimulating ingre- dient are to be used in the conditions already alluded to in speaking of stimulating lotions. They are most essential, especially in the subacute and chronic stages of many eruptions. Tar, naphthol, carbolic acid, cre- asote, thymol, sulphur, the mercurials, chrysarobin and pyrogallic acid, are among some of the most valuable agents which can be used alone or combined for their stimulating action upon the skin. Great precau- tions must be exercised in employing chrysarobin and pyrogallic acid over a large surface, as severe constitutional symptoms may follow from * Therapeutic Gazette, August 15,1891. TREATMENT. 91 the application of the latter, especially after extensive use. Biesner and others have reported marked toxic action from its application. Chrysarobin ointment must not be brought into contact with healthy skin, as it may occasion a severe dermatitis. The ointment of pyrogal- lic acid, if made too strong, may also produce sloughing of tissue, and it should never be spread upon an extensive area of surface. The petroleum-fats also can be employed for stimulating purposes, providing penetrative action is not desired for any substance which may be mixed with them. Several new preparations have been recently introduced with the object of superseding ointments or, in certain particulars, improving the effects of those preparations. Bassorin Paste.—The use of bassorin was first suggested by Dr. Ferdinand Lascar. It is a constituent of various vegetable substances, but that obtained from gum tragacanth was found the most satisfactory in practice. Bassorin is demulcent, tasteless, and odorless. The paste is made by soaking one part of pure bassorin in fifteen parts of water and adding twenty-five per cent, of white dextrin and ten per cent. of glycerin. The paste is of neutral reaction, light yellow in color, smooth, homogeneous, and dries quickly upon the skin. It keeps well, does not stain, is readily removed by water, and adapts itself perfectly to the affected surface. Bassorin paste is rendered too liquid by mix- ture with fluid preparations, while alcoholic solutions cause it to be- come hard and brittle. In this country it has been much employed by Dr. George T. Eliot, of New York. Almost any solid substance except tannates and iron compounds can be incorporated with the mass. Bassorin paste is regarded as especially useful when combined with zinc oxide. Unyuentum Caseini (Caseine Ointment).—This is an unguent base proposed by Unna. It is a mixture of two parts of caseine, carefully freed from butter-fat, with one part of glycerine and three parts of vaseline. The solution of the caseine is effected by potash or soda, three per cent, of the weight of the caseine in the fixed alkalies being sufficient to make a permanent emulsion of neutral reaction. Acids which coagulate milk can not be used in caseine ointment, but slightly acid medicaments may be incorporated. Pulverulent neutral drugs can be added to the paste. The unguent soon dries smoothly when applied, and can be removed at any moment by_ washing with warm water. Caseine ointment is recommended by Unna as a useful appli- cation in the pruriginous eczema of childhood, paraesthesia, urticaria, rosacea, acne, and other affections. It is also useful as a protective covering to the skin. Epiderm in.—This name is given to a base prepared by Dr. S. Kohn by melting half an ounce of white wax and triturating it in a warm mortar with an equal quantity of powdered gum-arabic until a homo- 92 DISEASES OF THE SKIN. geneous paste is produced. To this mass is then added a boiling mix- ture of half an ounce each of water and glycerin, and the whole is stirred together until cold. Epidermin is a semi-fluid, creamy sub- stance which soon dries upon the skin, forming a tenacious and elastic coating. Oleates.*—The history and origin of this class of remedies, which were first pointed out by Attfield and Marshall, together with their process of manufacture, their physiological action, and their therapeu- tic effect, are fully considered in my little work devoted to this sub- ject. I do not, however, and never did claim, as has been unjustly charged by some uninformed writers, that the oleates were original with me. An examination of the various papers I have written, as well as the book just referred to, will clearly show that I make no such pretensions. I do, however, claim that my physiological and therapeutic investigations are original, as set forth in the contribu- tions referred to. The oleates, particularly those of arsenic, copper, lead, mercury, and zinc, are most valuable remedies, and the professed lack of faith in and condemnation of them by a few are due entirely to the fact that they have been used improperly and hastily, and erroneous conclusions drawn from imperfect experience with them. The following alphabetical arrangement of the oleates, with descrip- tion of their therapeutic action, has been extracted from my book: Aconitine Oleate.—Aconitine oleate has a slight local action, its effect is, however, very feeble ; it can be used in mild cases of neu- ralgia, where a weak anaesthetic impression is desired. Atropine Oleate.—Atropine oleate has a mild action upon the in- tegument, the toxic effect of the drug being almost impossible, unless it be applied freely over a large surface. Aluminium Oleate.—Aluminium oleate, melted with an equal pro- portion of lard and some fatty substance, represents the ointment of aluminium oleate. It is serviceable in checking the muco-purulent discharges that occur in dermatitis and in eczema. In hyperidrosis it lessens and frequently removes the excessive secretion, while in bromidrosis the fetid discharge will either be entirely overcome by its use, or very much diminished. It is beneficial as a dressing in foul ulcers, abscesses, sinuses, chilblains, and burns. Arsenicum Oleate.—Arsenicum oleate, melted in the proportion of one part to nine parts of lard as an unguent base, or one part in four, according to the strength desired, forms the ointment of arsenic oleate. * Transactions of the Medical Society of the State of Pennsylvania, vol. xii., p. 707. See papers on oleates with discussion, read before the Section of Pharmacology and Thera- peutics, at the Fifty-second Annual Meeting of the British Medical Association, in the British Medical Journal, October 18, 1864, pp. 749-754. "The Oleates," by J. V. Shoe- maker, A. M., M. D., Philadelphia, F. A. Davis, 1885. "Elements of Pharmacy, Materia Medica, and Therapeutics," by William Whitla, M. D., Belfast, 1885, pp. 309, 310. TREATMENT. 93 It is both a valuable alterative and an escharotic, but should always be used with caution. Applied to the normal skin, little or no change is produced, but when used moderately strong on abrasions, wounds, and ulcerating and granulating surfaces, it acts as an escharotic, ex- citing active inflammation, and destroying the tissue to some depth. In ulcerating epithelioma it is one of the very best remedies, by reason of its being better borne for a longer period in its application than any other form of arsenic. In lupus it is especially serviceable, destroying, by its constant use, cell-infiltration in a comparatively mild and painless manner. In old ulcers, especially those of a scrofu- lous nature, it is of great utility. Bismuth Oleate.—The ointment of bismuth oleate, a pearl-gray, soft, bland substance, possesses an emollient and slightly astringent action,-and is useful in soothing and relieving cutaneous irritation. It is a valuable remedy in all pustular eruptions. It allays and often overcomes the high inflammation in erysipelas and sunburn. In acne and rosacea it soothes the hyperasmic skin, and relieves the engorge- ment of the glands, frequently subduing some of the most intractable cases. Cadmium Oleate.—The ointment of cadmium oleate has had as yet but little practical use. It is a very strong stimulant, having an almost caustic action upon the denuded integument, resembling in this respect very much the action of the ointment of nickel oleate. It has been used with some advantage in enlarged glands. It has also been serviceable at times in cases of chronic eczema, with great infil- tration, and in exuberant granulations, and old ulcers. Cocaine Oleate.—Cocaine oleate (six per cent, alkaloid) has a slight anaesthetic action upon the integument. The decided effect, how- ever, that has been claimed by some from its application to the skin has not been observed in my experience, even after repeated experiments with it in operations on warts, corns, horns, cancer, lupus, and the removal of superfluous hairs. Copper Oleate.—Copper oleate, melted with either four or nine parts of fat or lard, gives respectively a twenty or ten per cent, oint- ment. Applied to the unbroken skin, it has no visible effect on the surface, but penetrates deeply into the follicles, causing slight stimu- lation. If brought in contact with the broken skin it has both an astringent and stimulating effect, and an insoluble albuminate is formed which coats over the surface, thus supplying the place of the abraded skin. It condenses the tissues, constringes the blood- vessels, and thus lessens the determination of blood to the part. It acts as an irritant to any delicate surface, causing inflammation and pain. It is a most effective application to arrest bleeding, par- ticularly in irritable sores and indolent ulcers; obstinate granula- tions will often yield to it. It is an excellent antiseptic, as well as 94 DISEASES OF THE SKIN. an antiparasitic agent. The most successful results, however, have followed its use upon vegetable parasitic affections, both in my owrn ex- perience, and in that of Sawyer, Harries,* Startin,f and Alder Smith. In tinea versicolor, or chromophytosis, it acts in a decided man- ner, rapidly removing the parasite from the surface, as well as from the follicles. It is equally effective in favus, which often yields quickly to its application. In all vegetable parasitic affections to which it is applied, care should be taken to avoid the use of water to the parts, which may prevent the copper oleate from penetrating to the lowest depth of the follicle, and thus interfere with its action on the fungus. Copper oleate, melted and spread as plaster, will relieve, and very often cure, hard and horny warts, corns, bunions, and thickened con- ditions of the epidermis to which it is applied. The ointment of cop- per oleate is a useful remedy for freckles and other yellowish-brown or blackish patches of the skin. Iron Oleate.—Iron oleate is readily soluble in fats. It is a valu- able styptic and astringent. In the inflammatory form of eczema, in which the surface has become denuded, red, raw, and bleeding, the application of a weak ointment of iron oleate, or the oleate itself used in other soothing and slightly astringent combinations, will prove of the greatest vake, its styptic and astringent action having a very happy effect upon the parts. It has a marked action in pustular eczema, sycosis, furuncles, and in scrofulous ulcers and sinuses. The first and second stages of acne rosacea are promptly benefited and often entirely relieved by its application. The lesions that result from arsenical poisoning, especially the pustules and ulcers, are more bene- fited by this ointment than- by any other remedy that I have used in such conditions. Lead Oleate.—Lead oleate, melted with equal parts of lard or lard- oil, gives a cream-colored, semi-solid ointment of the consistence of simple cerate. It is more easily and cheaply prepared than either Goulard's cerate, or Hebra's litharge-ointment, or any of the later modifications; it is more readily absorbed, and is superior to all of them. The ointment of lead oleate, when applied to the denuded skin, has both an astringent and sedative action, arresting morbid discharges and allaying irritation. It soothes effectually the intense irritation that is often present in papular eczema; it is equally beneficial in fissured eczema of the palmar and plantar surfaces. It is a useful remedy in hard and indurated papular acne of the face, neck, and back, and in rosacea. * British Medical Journal, November 28, 1885. f See an interesting paper on " Oleate of Copper in Ringworm," by James Startin, Burgeon, of England, read before the Will an Society, December, 1884. TREATMENT. 95 Mercuric Oleate.—The ointment of mercuric oleate is a yellowish chemical combination having a fatty smell, and an unctuous consist- ence. It has a stimulating, resolvent, and alterative action on the integument, especially upon tumors, glandular enlargements, indura- tions, and thickening of the skin. In some old cases of eczema, in which the skin has become greatly infiltrated, the twofold action of the ointment of mercuric oleate is often attended with happy effects. It is an acceptable and, at the same time, beneficial agent in obstinate ulcers and indolent papules, tubercles, and in infiltration attendant upon abscesses, in inflammation of the hair-follicles of the beard, and scrofuloderma. It can be used with success in excess and deficiency of pigment. It is a useful remedy in both the animal and vegetable parasitic affections. In all varieties of vegetable parasites, it is not only effective on the surface, but possesses the power of penetrating into the hairs, the follicles, and sebaceous glands, and thus killing the fungus that has passed into these parts. Mercurous Oleate.—The ointment of mercurous oleate is yerj much stronger in mercury than that of mercuric oleate—in the ratio of 41*6 to 26 "2, or about one and a half time as strong. It has marked stimu- lating action bordering on congestion of the integument, and has a decided resolvent and alterative effect. It is, therefore, applicable to the same class of affections in which the ointment of mercuric oleate is used, particularly if it is desirable to make a more decided impres- sion. Morphine Oleate.—Morphine oleate has, like all the alkaloidal ole- ates, a feeble action, and only upon the part to which it is applied. It can be employed in all irritable conditions of the integument, but many other stronger sedatives are preferable. Nickel Oleate.—Nickel oleate mixed with a fatty base, in the pro- portion of from one to sixty grains to the ounce, has a very decided astringent action, almost bordering upon that of a caustic on abraded surfaces. The ointment of nickel oleate of a weak strength, from five to twenty grains to the ounce of lard, acts at times very well in epi- thelial ulcerations. It is often useful in exuberant granulations and in old callous ulcers. Quinine Oleate.—Quinine oleate, both from physiological experi- ments and from repeated clinical experience, has proved with me of little, if any, service. Silver Oleate.—Silver oleate, applied in its natural form to the abraded skin or sores, combines with the albumen and fibrin of the parts, forming a coat and thus excluding the air. It likewise causes a powerful contraction of the blood-vessels, and condenses and super- ficially destroys the tissue. Silver oleate sprinkled over ulcers, bed- sores, and exuberant granulations, will set up a healthier action of the surface. When previously dissolved with an equal amount of oleic 96 DISEASES OF THE SKIN. acid, and then mixed with lard in the proportion of from five to sixty grains to the ounce, it forms a dark-brown, soft, and pliable ointment. The ointment of this oleate is a safe and efficacious remedy applied over the inflamed surface of erysipelas, or around the margins, to pre- vent the disease from spreading. Strychnine Oleate.—Strychnine oleate can be applied to the integu- ment in large quantities and for some time without producing any sys- temic action. Its local impression is weak, and it is a remedy of but little value. Tin Oleate.—Tin oleate, mixed with lard or a fatty base, in the proportion of from ten to sixty grains of the former to one ounce of the latter, forms a grayish-brown ointment, possessing an astringent action. It renders good service in papular and fissured eczema. The ointment of tin oleate is of great utility in diseases of the nails. It assists in such cases in overcoming the brittle, split, and soft conditions that result from injury to the parts, or that follow certain affections of the skin. This ointment, especially when com- bined with a little carmine, forms an elegant article of toilet ijor the nails and surrounding parts, giving them a beautiful lustre. Agnail, or the ragged and attenuated skin at the base of the nail, that is so frequently observed from neglecting these appendages, can be relieved or checked by it. Veratrine Oleate.—Veratrine oleate has a valuable action as a coun- ter-irritant when used upon the integument. Zinc Oleate.—Zinc oleate occurs as a fine, pearl-colored powder, with a soft, soapy feel, very much like powdered French chalk. It has both an astringent and stimulating action. In hyperidrosis and osmi- drosis, or excessive sweating, fetid or otherwise, it is one of the very best remedies for topical use. It is especially applicable to those who suffer from an increased flow of sweat around the axillae, genitalia, and palmar and plantar surfaces. Dr. William Murrell, in the "London Medical Record," of November 15, 1883, also calls attention to its value in local sweating. He reports that when mixed with thymol (1 in 500), and used as a dusting-powder, it forms an excellent applica- tion in many varieties of local sweating. In acute vesicular eczema, in which the parts become covered with small vesicles, swollen, hot, inflamed or raw, weeping, and attended with intense itching, the combined protecting, astringent, and stimu- lating action of the zinc oleate will usually cause all the inflammatory symptoms to abate, the discharge to dry up, and the swollen skin to resume its normal condition. Dr. McCall Anderson has referred to its utility in eczema, especially of the nares, in an article published in the "Journal of Cutaneous and Venereal Diseases." The great advantage and value of the zinc oleate among the same class of cutaneous affec- tions have been referred to by Dr. James Sawyer, in a communication TREATMENT. 97 to the " British Medical Journal," of February 10, 1883, and also in another to the " Birmingham Medical Review," published a year later. It forms an excellent and useful toilet powder for ladies who are troubled with shining faces or seborrhoea oleosa, dusted over the parts either alone or mixed with an equal quantity of arrow-root, bismuth subnitrate, or lead carbonate, and scented with the oil of verbena or rose. It likewise acts in an efficacious manner on an inflamed surface that is hot and tumid; in cases of erythema about the groins and ax- illae ; and is also beneficial in herpes and herpes zoster. One part of the powdered zinc oleate melted with four parts of a fatty vehicle yields the ointment which can be used in the same class of affections just enumerated, in acne, rosacea, subacute and chronic forms of eczema. Sulpholeate of Sodium.—Br. Fox, of New York, has called attention to this substance as a local remedy. Sulpholeic acid is obtained by slowly mixing without the aid of heat sulphuric acid with any fixed oil or fat. The result is a thick and viscid mass of a brownish color and strongly acid reaction. By slowly adding a solution of carbonate of sodium to this mass and constantly stirring, the sulpholeate of sodium is formed. The combination has a nearly neutral reaction, is a bland, oily fluid, and contains about thirty per cent, water, which is easily expelled by evaporation. It is very miscible with water, is rapidly absorbed by the skin, and is an excellent solvent for many drugs. It dissolves at least two per cent, of sulphur or chrysarobin. This com- pound may be applied to the skin as a liniment or, mixed with gelatine and spread upon muslin, as a plaster. If its water is driven off, its appearance and consistency are similar to those of vaseline and it may be employed as an ointment basis. Anaesthetics.—Applications can be made to the skin for the purpose of benumbing or suspending the action of the sensory nerves, either to allay great local irritation from disease, or to avoid pain in minor oper- ations. Rhigolene has been specially recommended by Richardson for its local anaesthetic action. In burns he relieved rapidly the pain by applying on cotton-wool a combination consisting of camphor and spermaceti, each one drachm, mixed in two ounces of rhigolene. The rhigolene spray may be successfully used prior to opening abscesses, boils, carbuncles, and in operations upon in-growing nails. Chloro- form and ether applied to the skin act as local anaesthetics. The for- mer can be brushed over the surface with lint, and often relieves the intolerable itching of some of the neuroses, as, for instance, in paraes- thesia ; and it is also useful for the same effect in urticaria. Ether is better emplo}Ted with a spray, and is applicable in operations on the in- tegument. Ice applied for some time to the skin, or cold lotions, wrill produce an anaesthetic action similar to ether; veratrine ointment, thirty to sixty grains to the ounce of lard, often benumbs the sensibility of the skin. 7 98 DISEASES OF THE SKIN. Another valuable local anaesthetic is cocaine hydrochlorate, in the form of a lotion or injected under the integument; upon the unbroken skin it produces little or no impression, but upon a denuded surface, in from a two to a five per cent, solution, it often has a good effect. In most cases the injection of a cocaine solution into, instead of be- neath, the skin causes local anassthesia with less danger of systemic effects. This mode of application has been developed by Schleich, who has demonstrated that anaesthesia may be produced by quantities far less than had been hitherto employed. The fluid should be of a low temperature. The anaesthesia depends upon the local anaemia and compression occasioned. The entrance of the fluid causes a local code- ma, and when this is complete anaesthesia begins. According to the painfulness of the part, Schleich employs a fluid containing from one sixth grain to three grains of cocaine hydrochlorate, one twelfth to one half grain of morphine hydrochlorate, and three grains of sodium chlo- ride to three ounces of distilled water. Of this dilute solution a num- ber of injections are made along the line of incision. It has been found that ten syringefuls suffice for most operations, which is much less than that required by the subcutaneous administration. Schleich's method has been amply tested and proved efficient. In place of cocaine other similar compounds, as eucaine and holocaine, have been used for the purpose of producing local anaesthesia. Carbolic acid and creasote in weak solutions are also pronounced anaesthetics. The injection beneath or into the skin of three fourths of a grain of guaiacol dissolved in olive-oil produces complete local anaesthesia. Alcohol, menthol, tincture of aconite, and the ointment of aconitine are useful; the latter should be applied with caution. Plasters.—The use of plasters is a desirable means of keeping medicinal substances in continuous contact with the skin. They are particularly adapted to chronic and localized forms of skin diseases. They fulfil the triple purpose of protection, compression, and medical application; are cleanly, and can be used upon regions where it is almost impossible to secure the continuous application of ointments. In fissured eczema of the lips, palms, and soles, common adhesive, opium, belladonna, lead, and salicylic-acid plasters are useful. Aconite, aconite and belladonna, Peruvian balsam, bryonia, and soap plasters are serviceable in frost-bites. Mercurial and copper plasters act hap- pily in local spots of syphilis, scrofula, keloid, warts, burns, corns, and callosities. Witch-hazel, hemlock, and ammoniac and mercurial plas- ters are useful in chronic eczema and psoriasis. Ergot, iron, lead, arnica, asafoetida, and phytolacca plasters are beneficial in ulcers and bed-sores. Opium and arnica, opium and belladonna, and soap plasters often prove valuable in boils and carbuncles. Opium and iodine plas- ter frequently assists in removing deep spots of infiltration, especially in syphilitic subjects. TREATMENT. 99 Antiparasitics.—This class of remedies destroys both animal and vegetable parasites of the skin. The mercurials are, no doubt, the most potent of all medicines in their effective action on all forms of parasitic life. The best prepara- tion of mercury to employ is, perhaps, the ointment of mercuric oleate. The corrosive chloride, the mild chloride, the ammoniated, the red sulphuret, the yellow oxide, and the yellow sulphuret of mercury are also useful. Chlorinated oil, or olive-oil saturated with chlorine, is serviceable in scabies, acting without irritating the skin. Peruvian balsam, sty- rax, and sulphur are valuable for scabies, and cocculus Indicus and staphisagria for pediculosis. Copper, in the form of the sulphate, or better the oleate, is a good remedy for exterminating vegetable para- sites, especially ringworm, favus, and tinea versicolor. Boric acid and alcohol also hold a high place in the treatment of the latter class of diseases. Among the many other antiparasitic remedies which may likewise be employed are sulphur, sulphite of sodium, hyposulphite of sodium, sulphuret of potassium or lime, salicylic acid, naphthol, thy- mol, chrysarobin, Goa powder, creasote, carbolic acid, tar, croton-oil, cantharides, and iodine. Caustics or Escharotics.—These are agents which destroy the tissue with which they come in contact, mainly by abstracting moisture from it. The mineral acids, particularly nitric, hydrochloric, and sulphuric, are generally used, and are very certain in their action on venereal sores, warts, and indolent ulcers. The acid nitrate of mercury is espe- cially valuable for application to all venereal growths. The painful effect of nitric acid is said to be lessened by saturating a small quan- tity of it with hydrochlorate of cocaine preparatory to applying it to the skin. Chromic acid is also a caustic which has a mild but useful action in growths on mucous surfaces, and is serviceable in ulcerations of the tongue, the buccal cavity, and other mucous outlets. Lactic and glacial acetic acids have recently been employed with good result in epithelioma and like morbid growths. Probably one of the most effective of all caustics used at this time is ethylate of sodium. It has a deep and penetrating action, abstracting rapidly the water from the tissues, especially if the surface to which it is applied has been denuded. It is beneficial in lupus, epithelioma, naevi, and in various ulcers. Caustic potash in the solid form, or as a solution, is endowed with powerful destructive action, and should be applied with caution. It can be used either alone or in combination with lime or other sub- stances. The chloride of zinc and arsenic are two effective escharotics which may be employed alone or mixed with other remedies to form many of the caustic pastes. They are both very painful applied in lupus, the various forms of cancer, and in old ulcers. The great ad- vantage of arsenic, however—which can be used either as a powder or 100 DISEASES OF THE SKIN. added to some fatty base—is its property of acting upon morbid in preference to healthy tissue. It has the disadvantage of sometimes act- ing slowly. There are a number of agents which are to be recommended for superficial caustic effect, such as sapo viridis, the mercurials, espe- cially the corrosive chloride, acetate and sulphate of zinc, acetic acid, collodion, iodine, and carbolic acid. The external layer of the skin, the epidermis, when necessary, may be destroyed by one or the other of the last-named remedies. The following have also been shown to have some special local ac- tion in diseases of the skin : Hydrastine Hydrochlorate.*—This salt combines well with water, alcohol, or fats, and I have experienced good results from it in hyperi- drosis, seborrhoea, acne, eczema, and in ulcers. Ten to thirty grains of hydrastine hydrochlorate in five ounces of water or distilled extract of witch-hazel have a beneficial action on excessive secretion about the axillary or inguinal regions and on the palmar and plantar surfaces. This solution likewise removes the offensive odor of bromidrosis. Weak alcoholic or aqueous solutions of it also act well in seborrhoea sicca and acne. From five to thirty grains of the salt incorporated in an ounce of fatty substance is a good application in chronic eczema and in scrofulous and varicose ulcers, and allays the fetor of phage- daenic and malignant ulcers. Hydrastine ointment may also be bene- ficially applied to fissured nipples and chancroids. Erythroxylon Coca.f—The fluid extract and the extract of ery- throxylon coca, I have found, after a thorough trial, will produce a sedative action upon irritable conditions of the integument. The fluid extract can be used alone or combined with oil, glycerine, or water; one to three drachms to the ounce of either will be useful in acute ec- zsma, dermatitis, herpes, rosacea, and urticaria. The extract is best employed mixed with some fatty substance in the proportion of one half to two or more drachms to the ounce. It is applicable to the same class of affections referred to above, and also in neuroses of the skin, particularly paraesthesia. The active principle, cocaine, in the form of cocaine hydrochlorate, is an admirable local application to burns, erysipelas, fissured eczema, herpes zoster, irritable ulcers, and is useful in allaying the pain of ul- cerated epithelioma. It may be employed in aqueous solution or as an ointment, rubbed up with lanolin or other suitable excipient. Naphthol.J—Naphthol is probably the most effective topical remedy * See paper by the author on " Hydrastis and Hydrastine Hydrochlorate in Diseases of the Skin," Drugs and Medicines of North America, Cincinnati, Septem- ber, 1885. f The Medical Bulletin, December, 1884, Philadelphia. X See paper by the author on " Naphthol; its Medicinal Use and Value," in Journal of the American Medical Association, November 3, 1883. TREATMENT. 101 of all substances recently introduced. It is a deodorant, and has a stimulating, followed by some anaesthetic action upon the skin. This effect can easily be demonstrated by rubbing the sensitive ends of the fingers through a quantity of naphthol for a few moments, when a numb feeling will soon be experienced. It also possesses useful de- tergent and deodorant properties. Scabies, pediculosis, and all animal parasitic diseases are not only relieved by application of lotions or ointments of naphthol, but they are frequently cured. It is for these affections the most certain of all the remedies which we possess. Naphthol* is likewise efficacious in the different forms of tinea. It relieves itching in urticaria, paraesthesia, pemphigus, and prurigo, and is of value in the treatment of acne, sycosis, alopecia circumscripta, and both forms of lupus. To wounds, ulcers, chancres, and chancroids this substance is a beneficial application. The fetor of cancer is sup- pressed by the use of naphthol. It may be used in the form of pow- der, solution, or ointment according to the nature of the case. Naph- thol is practically insoluble in water, but dissolves freely in alcohol, ether, chloroform, and fixed oils. Camphorated naphthol, a creamy fluid made by rubbing together one part of naphthol and two parts of camphor, is a good antiseptic dressing for wounds and ulcers. Naph- thol used in the form of a five or twenty per cent, ointment lessens the infiltration and itching of chronic eczema. It produces equally good results in chronic psoriasis. It can also be employed combined with talc, starch, or other powders, in excessive sweating or foetid perspira- tion in all parts of the body, with the most-happy effect. Naphthol can be added to ointments in the proportion of one to ten grains to the ounce for the purpose of simply preserving them—as it will for a very long time—from decomposition. Toxic effects will not follow, as I have shown, from either the internal or external use of properly pre- pared naphthol. A compound of /?-naphthol and mercury has been recommended as an ideal antiseptic, though it does not seem to have made its way into general use. This substance occurs in the form of lemon-yellow crys- tals or powder, is neutral and odorless, insoluble in the usual solvents. It contains 30-8 per cent, of mercury, and may be applied as an oint- ment or, rubbed up with white of egg and water, as an emulsion. Naphthol-mercury is an excellent stimulant to chronic ulcers, abscesses, sinuses, etc. Favorable reports have been made concerning its internal administration in syphilis. Ichthyol. f—Ichthyol, which is a substance having the appearance of tar, with an odor of gas, was brought to the notice of the profession * See paper by the author, Therapeutic Gazette, October 15, 1889. f Ichthyol is also useful sometimes administered internally in chronic eczema, psoriasis, and other cutaneous diseases. The dose is from two to ten drops three times a day. 102 DISEASES OF THE SKIN. through Unna, of Hamburg. It is procured from a bituminous rock in the Tyrol, which is said to contain decomposed animal material. It contains, according to Schmidt,* carbon, 55*05; hydrogen, 6-06; sulphur, 15-27 ; sodium, 7'78; oxygen, 15-83; and combines well with alcohol, ether, and all fatty substances. It has a similar effect to that of both sulphur and tar, with often even a more decided and beneficial action. Unna states that it will not produce ordinarily in chronic skin affections, in which it is a useful remedy, any irritating action. But this assertion requires qualification, for I have, not infrequently, seen it irritate the integument. Nor is it, in general, well absorbed according to my experience. In from a five to a thirty per cent. ointment it is serviceable in psoriasis, eczema, rosacea, furunculus, lichen, keloid, and ichthyosis. Ichthyol is serviceable in that stage of acne which demands stimu- lation, and has been used with advantage in frost-bite, burns, and ulcers. This remedy will sometimes ameliorate urticaria and paraesthesia and may be a good dressing in erysipelas. In the last-named affection it may be used as an ointment or dissolved in a mixture of ether and glycerine or ether and collodion. Sinclair reports a deep stupor following its application in an infant; this case, however, recovered. Thiol, a substance of similar chemical composition to ichthyol, has been introduced as a substitute for the latter substance. Thiol is a mixt- ure of sulphuretted hydrocarbons rendered soluble in water by treatment with sulphuric acid. It is estimated to contain about twelve per cent. of sulphur. As made by Riedel, it occurs in the form of a soft gray pow- der or as a watery solution, of the consistence of a thick sirup. The powder is obtained by evaporating the liquid. The compound is de- void of odor, and can easily be removed from the skin or clothing. The powder is an excellent absorbent for use in moist eczema, erythema multiforme, erysipelas, burns, and pemphigus. Prof. Schwimmer ob- tained especially good results in dermatitis herpetiformis and herpes zoster from a ten-per-cent. solution painted twice daily upon the affected parts. The liquid is likewise serviceable in papular and pustular eczema. In acne and rosacea good results have attended the use of the same remedy. Thio-resorcin, a sulphur substitution-compound of resorcin, an amber-yellow crystalline body, without odor, has been used as a substi- tute for iodoform in the dressing of wounds. This substance js insolu- ble in water and only partially soluble in alcohol and ether. Tumenol.—A substance bearing this title has recently been discov- ered by Spiegel, and has been closely studied by Neisser, who recom- mends it as of value in certain affections of the skin. Tumenol is allied to ichthyol, and, like the latter, is obtained from mineral oils, to * The Therapeutic Gazette, June 15, 1886. TREATMENT. 103 which circumstance it owes its name, an amalgamation of bitumen and oleum. The impure mother substance occurs among the unsaturated hydrocarbons of the oils, and is separated by the addition of sulphuric acid, a process of sulphonation taking place with the production of a compound which contains tumenol sulphon and tumenol sulphonic acid. These are separated by processes unnecessary to repeat here, and it is the aqueous solution of the latter substance with which Neisser has experimented. He has used it in the form of solution in sul- phuric ether and alcohol, as a powder, ointment, or plaster, and has found it beneficial in acute eczema accompanied by weeping, erythem- atous and bullous burns, paraesthesia, and superficial or deep ulcera- tion. Jequirity.*—This vegetable bean, when properly prepared, has a powerful action upon morbid conditions of the skin. I herewith give my method : Two hundred grains of the bean are decorticated by being slightly bruised and cracked in a mortar; the red hulls are then care- fully picked from the cotyledons, placed in a bottle, and covered with water. They are thus macerated for twenty-four hours, after which they are again transferred to a mortar and thoroughly triturated until they are reduced to a smooth paste, when sufficient water is added to make the whole weigh eight hundred grains. Prepared in this man- ner, the product has the appearance of an emulsion, and can be easily applied to the diseased surface. It is painless on application, but very soon sets up irritation and severe local inflammation, and at times some systemic symptoms, as headache, pains through the body, ele- vated temperature, and high pulse. In from twelve to forty-eight hours the inflammatory action becomes most abundant. A cuirass- like crust soon forms, followed by a free flow of pus. In the course of five or six days the discharge lessens, the crusts may become gradu- ally detached, or can be removed by suitable dressings, exposing a sur- face studded with healthy granulations which before the application may have been the seat of exuberant ones. The virtue of the remedy is in its power to destroy the latter. I have therefore found it to be of the utmost value in specific ulcerations, indolent, scrofulous, and epithelial ulcers, and in ulcerating lupus. In truth, it is a powerful remedy in unhealthy and granulating surfaces, on which it exercises a destructive change, and favors the development rapidly of healthy tis- sue. It should, owing to the erysipelatous inflammation and constitu- tional symptoms which it may occasion, be applied with caution in weak and irritable patients. Gelatine.—The use of white gelatine dissolved in twice its weight of water, by means of a water-bath, and spread upon diseased parts of the skin, has been recommended by Pick, of Prague. The solution * "Jequirity; its Use in Diseases of the Skin," by the author. See Transactions of the Medical"Society of the State of Pennsylvania, vol. xvi., pp. 259-2G7. 104 DISEASES OF THE SKIN. is a useful vehicle for suspending chrysarobin, mercury, naphthol, and other remedies. It is valuable in limited chronic affections, especially in psoriasis and eczema—the medicated gelatine solution forming not only a protection for the skin, but at the same time having valuable action upon it. Unna states that thin layers of gelatine or collodion augment perspiration. He considers the application of gelatine useful in fever. Gelatine preparations are largely used by Unna. For a gen- eral basis he employs zinc gelatine, which may be made harder or softer by varying the proportions of its ingredients. His usual formula calls for fifteen parts each of zinc oxide and gelatine, twenty-five parts of glycerine,, and forty-five parts of water. Other substances may be added to the mixture, according to indications. For eczema with ex- cessive itching, the incorporation of two per cent, of ichthyol or five per cent, of extract of cannabis Indica is recommended; for pruritus, the addition of cannabis Indica, chloral hydrate, carbolic acid, cam- phor, salicylic acid, etc. He recommends particularly a preparation which he terms "gelanthum," a combination of equal parts of gela- tine and tragacanth. Gelanthum dries rapidly with a smooth surface, allows a uniform suspension of medicaments, incorporates larger doses of drugs than the older preparations of the same class. An additional advantage is that incompatible substances remain in gelanthum with- out any mutual action. Pastes.—These preparations are similar to ointments, but of firmer consistence, owing to the larger proportion of powder which they con- tain. Both mineral and vegetable substances are used in making pastes. Among minerals the oxide of zinc, carbonate of calcium or magnesium, and talc are most frequently employed, while those derived from the vegetable kingdom are starch and lycopodium. Pastes protect the sur- face from atmospheric contact, and have the advantage of absorbing the secretions of the diseased part. They should be gently rubbed with the finger upon the affected area, and spread upon the epiderm in a moderately thick layer. This class of remedies is particularly adapted to the treatment of certain forms of eczema. Unna * has lately com- pounded a number of pastes having as a basis bassorin, casein, castor- oil mixed with shellac, collodion, or lead, etc. WTith these mixtures may be incorporated various medicaments, such as oxide of zinc, sul- phur, salicylic acid, resorcin, chrysarobin, etc. Formulae for some of these pastes are given in the body of this book. Gutta-Percha.—Auspitz recommended one part of gutta-percha with ten of chloroform as a permanent application in the same class of affections as mentioned in the paragraph on gelatine. The solution so prepared is known as traumaticin, and various drugs may be mixed with it and applied to the skin. * Therapeutische Monatshefte, November, 1891. TREATMENT. 105 Resorcin.—This drug is frequently of utility in benefiting the skin or leading to a cure of many of its diseases. It can be employed either in the form of a powder, solution, or ointment. Good effect may follow from the application of the powder to ulcers, epithelioma, the open lesions of syphilis, and sloughing wounds. Cases of complete cicatrization of epithelioma by resorcin have been reported by Luciani, Antonio, and Chasseaud. Resorcin destroys the offensive odor of carcinoma, and is a serviceable local remedy in variola, erysipelas, anthrax, psoriasis, and lupus erythematosus. Dr. M. Ihle,* of Leipsic, reports that it is espe- cially a good remedy as a disinfectant, by destroying the germs of dis- ease. He has used it effectively in herpes tonsurans, in parasitic sycosis, and in wounds and ulcers. He prefers to use it in the form of a paste, which I have modified, as follows: R, Resorcini puri......................3 ijss (10*0). Ungt. simplicis.....................3 xiij (50-0). Zinci oxidat., Amyli...........................aa 3 vj (aa 25-0). M. Ft. pasta. He also suggests the following, made of resorcin, and recommends it spread on a piece of flannel and used in alopecia areata and sebor- rhoea, attended with falling of the hair: 5 Resorcini puri...........gr. lxxvij-cliv (5-0-10-0). 01. ricini.......................f 3 xjss (45-0). Spirit, vini...............,.....f § iv (150-0). Bals. Peruvian..................gr. viij (0-5). M. Resorcin is also useful in tinea versicolor and in eczema margi- natum. Pointed condylomata may be removed by a salve contain- ing fifty to eighty per cent, of the drug, applied daily. Resorcin may be irritating to the healthy surrounding tissue, which should be protected on its application to the diseased part. When pure it is white in color; impure, it assumes a yellow appearance and is useless for application. Hamamelis. f—Witch-hazel is a valuable remedy to employ either in the form of the tincture, the fluid extract, or the extract. It can be used alone, diluted with water, or the extract can be combined with some fatty vehicle. Hamamelis has both an astringent and a sedative * Monatsch. f. pr. Dei-mat., 13, 1886. Medical and Surgical Reporter, April 17, 1886, p. 501. f Hamamelis often acts with good effect given internally—in acute and sub- acute eczema, erysipelas, psoriasis, and varicose ulcers. See papers by the author, on " Hamamelis," read before the Section of Therapeutics, British Medical Associa- tion, Brighton, August, 1886. " Hamamelis in the Treatment of Diseases of the Skin," read before the Section of Dermatology at the meeting of the Association of German Naturalists and Physicians, held in Berlin, September, 1886. The Med- ical Bulletin, December, 1886. 106 DISEASES OF THE SKIN. effect, and lessens inflammatory action. It is of much value in eczema, erysipelas, rosacea, seborrhoea, and varicose ulcers. An ointment of hamamelis is a useful dressing to burns. The diluted fluid extract is of value in hyperidrosis, carbuncle, and chancroid. Chrysarobin.—This substance is of an orange-yellow color, free from odor, insoluble in water and alcohol, soluble in ether and alkaline solutions. Chrysarobin ointment is decidedly irritant, and communi- cates a stain to skin and clothing. Chrysarobin excites conjunctivitis if brought into contact with the eye. It is principally employed in psoriasis, in which it is one of our most efficient local remedies. The official ointment is too strong for general use. Chrysarobin is useful in chronic eczema, lupus vulgaris, rosacea, and tinea trichophytosis. Anthrarobin.—A compound related to chrysarobin and known as anthrarobin has been introduced as a substitute for the former sub- stance. Anthrarobin has been used locally with success in psoriasis, chronic eczema, tinea versicolor, and tinea tonsurans in the form of a ten-per-cent. ointment or solution in alcohol. Salicylic Acid.—This substance is valuable from its antiseptic and germicidal properties and power of softening the epiderm. It likewise allays pruritus. Salicylic acid is serviceable in chronic eczema, psoriasis, bromidrosis, sloughing wounds or ulcers, and in open cancer. In tinea versicolor and tinea trichophytina it may be applied with benefit. Sali- cylic acid removes freckles and is sometimes of benefit in lupus vulgaris. It may be used as a powder, ointment, dissolved in collodion or mixed with gelatine and glycerin. The powder requires, as a rule, to be diluted with rice, chalk, talc, or other inert substance. The ointmeut may be made to contain from five to sixty grains to the ounce. Salol is likewise an excellent application to chancroids, chancres, ulcers, wounds, burns, impetigo, and eczema pustulosum. It is gener- ally employed as a dusting-powder diluted with starch. Menthol relieves pain and itching. In ointment, oleaginous, alco- holic, or ethereal solution it is a good application in herpes zoster, dermatalgia, eczema, parassthesia, and urticaria. Tar.—In many subacute and chronic cases tar is valuable. The offi- cial ointment requires to be diluted. The strength can be gradually in- creased. Tar may be used in tinea, scabies, pemphigus, sycosis, comedo, lichen, lupus erythematosus and vulgaris, prurigo, and paraesthesia. Losophan.—This substance occurs as white needles, soluble in ether, chloroform, and fixed oils. It has been used with success in parasitic, pruriginous, and chronic inflammatory diseases as a one-per-cent. solu- tion in alcohol and water and a one- to three-per-cent. ointment. Dermatol.—Bismuth subgallate or dermatol, a yellow powder, insolu- ble in water, alcohol, and ether, is astringent, antiseptic, and anaesthetic. Dermatol is a serviceable application to wounds, burns, ulcers, eczema, pemphigus, herpes zoster, chancroids, chancres, and cutaneous abscesses. TREATMENT. 107 Iodoform.—The antiseptic and anaesthetic properties of iodoform render it a very valuable application in many diseases of the skin. This substance is efficient, not by destroying the micro-organisms of disease, but by rendering the tissue upon which it is spread an unfav- orable soil for bacterial development. It is probably also able to coun- teract the effect of microbian products. Iodoform is a decidedly beneficial topical remedy in various inflam- matory conditions, especially after suppuration or ulceration has oc- curred. In chancroidal bubo or in scrofulous adenitis it may prevent the formation of pus or degenerative tissue changes. It may be lightly powdered over the affected surface, spread upon the integument in the form of an ointment or, mixed with oil or glycerine, be injected into the focus of inflammation. If tissue has been destroyed the granula- tions are stimulated and sterilized by a covering of iodoform. Ulcer- ated bubo, chronic ulcers of the leg, scrofuloderma, and bed-sores are markedly improved by the use of this agent. In abscess, ecthyma, furuncle, and carbuncle it is of no less service. Iodoform has been ex- tensively and successfully employed in the treatment of venereal ulcers. This substance is one of the best applications to chancroids and is of particular efficacy in phagedaena. Syphilitic lesions also are amenable to its influence. Open chancres, moist papules, ulcerated tubercles, and the ulcers of the tertiary form are very advantageously treated by means of the compound under consideration. It is likewise a valuable remedy in burns. The exposed surface is protected from the attacks of micro-organisms, while at the same time the dressing acts as a local anaesthetic and reduces suffering. To the open lesions of lupus vul- garis iodoform is a beneficial application. The pain of ulcerated car- cinoma is appreciably assuaged by means of this agent. The applica- tion of iodoform is at times attended by satisfactory results in chronic eczema, and has been advised in prurigo. The forms in which iodoform has been used as a local remedy have been already mentioned. The particular methods according to which it is employed in the various affections to which I have alluded will be detailed in the sections on the treatment of those diseases. Notwithstanding the undeniable efficacy of this substance in a variety of conditions, two serious drawbacks attend its use. The first consists in its peculiar, penetrating, and offensive odor. Many expe- dients have been devised for the purpose of overcoming this character- istic property. The combinations which have proved most successful are enumerated upon a subsequent page. A more grave objection is the toxicity of iodoform. Its absorption may be followed by prostra- tion, headache, faintness, elevation of temperature, delirium, suicidal mania, or death. In cases ending fatally the kidneys, liver, heart, and voluntary muscles have been found in a state of fatty degeneration. 108 DISEASES OF THE SKIN Circumspection, therefore, should always be observed in the employ- ment of this potent drug. Iodol.—This compound, which contains about ninety per cent, of iodine, was introduced as a substitute for iodoform. Iodol is almost insoluble in water, soluble in chloroform, ether, and fatty oils. It is destitute of odor, slowly absorbed but rapidly eliminated, and is much less apt than iodoform to produce toxic effects. It has been given with advantage internally in doses from one quarter to five grains for the manifestations of scrofula and tertiary syphilis. Iodol has chiefly been used, however, as a topical remedy. This substance is destructive to microphytes, and is therefore efficacious in diseases attended by sup- puration as well as in those which depend upon the growth of a vegeta- ble parasite. Venereal, syphilitic, or common ulcers, lupus, impetigo, furuncle, and carbuncle are benefited by the application of iodol. In variola it moderates the intensity of the eruption, is an excellent dress- ing to enlarged or degenerated glands, and is of service in psoriasis. Iodol has been employed with success in tinea tonsurans. Iodol may be used as a dusting-powder, an ointment, or in solution. One part of iodol dissolved in sixteen of alcohol and thirty-four of glycerine constitutes an excellent preparation for local use. Aristol.—In this substance we have another excellent antiseptic and germicide, which has already proved itself a valuable addition to our therapeutical resources. Discovered in 1889 by Messinger and Vort- mann, of Aix-la-Chapelle, it was first employed clinically by Eichhoff, of Elberfeld. Aristol is a compound of iodine and thymol, containing 45-8 per cent, of the former substance. It is a soft, fawn-colored pow- der, having a faint and not unpleasant odor. It is insoluble in water and glycerine, but readily soluble in ether,- chloroform, fixed oils, and liquid petroleum. It adheres readily to the surface of the skin, wound, or ulcer, is a mild stimulant but not a decided irritant, and possesses some local anaesthetic power. It stimulates the absorbent vessels, though it is not itself absorbed by skin, mucous membranes, or raw surfaces, and therefore exerts no toxic action. Aristol promotes the absorption of inflammatory exudates, and is a useful application in thickened conditions of the integument. It is of special service in the treatment of varicose-leg ulcers and the ulcers of late syphilis. In ulcerated lupus, likewise, it is of decided benefit, but is useless while the skin is still unbroken. Spread upon chancres and ulcerated buboes, it hastens cicatrization. It not infrequently causes retrocession of enlarged lymphatic glands, and promotes absorption after degeneration has occurred. Aristol is efficacious in ulcerated epithelioma. This remedy is of avail also in the treatment of burns, scalds, frost bite, squamous and seborrhceic eczema. In psoriasis it is of equal value to chrysarobin, though less rapid in its action. Its germicidal property renders it useful in tinea trichophytina. Aristol TREATMENT. 109 is also productive of benefit in hyperidrosis and bromidrosis, in acne, and rosacea. This substance may be employed as a dusting-powder either alone or combined with the impure carbonate of zinc or subnitrate of bis- muth, or as an ointment, ten per cent, or more being rubbed up with any suitable excipient. Hydrogen Dioxide.—This compound, in the fifteen-volume solu- tion as prepared by Charles Marchand, of New York, is a very effi- cient oxidizing and antiseptic agent. Its special value consists in its power of decomposing pus. When placed in contact with pus it causes a frothing, the cessation of this action indicating that the pathological product has been destroyed. This fluid is a simple, cleanly, and efficacious application to ulcer- ated surfaces. In the management of many diseases of the skin at- tended by suppuration and destruction of tissue, lotions of hydrogen peroxide are of decided service, as in the suppurative stage of acne, in impetigo, ecthyma, furuncle, carbuncle, and lupus. Properly diluted it may be used to disinfect the surface in confluent small-pox. It has been found beneficial in acute eczema, although, to be grateful to the inflamed surface, the solution needs to be considerably weakened. Applied by means of a camel's-hair brush, it has given good results in chloasma. Disinfection of the throat and nose is accomplished in scarlatina by means of a spray of hydrogen peroxide. In that most distressing affection, paraesthesia of the female genital organs, this agent is advantageously employed in the form of a vaginal injection consisting of one part to three of water. A spray has been found a remarkably beneficial application to the surface stung by a hornet. Unna has found it useful in the treatment of comedones. Antiseptics.—The therapeutical resources of dermatology have been greatly enlarged by the introduction of many substances belonging to this class, which have the power either of destroying the specific micro- organisms of disease or of neutralizing their effects. In addition to those diseases which were long ago demonstrated to be due to the presence of a parasite, we have more lately learned much concerning the part played by microbes in the production of numerous other cutaneous maladies. The micro-organisms of suppuration have been found in acne, impetigo, ecthyma, boils, carbuncles, abscesses, sycosis, and in the pus of variola. Another class of diseases, such as lupus, scrofuloderma, onychia maligna, and the other varieties of local tuber- culosis, we now know to depend upon the development of Koch's bacillus. Strong reasons exist for the belief that at least certain forms of eczema, purpura in some cases, psoriasis, the exanthemata, and syphilis, originate in the same manner. Abraded, excoriated, blistered, or burned surfaces furnish an excellent soil for the growth of many forms of bacteria. The problem of topical medication, therefore, is to 110 DISEASES OF THE SKIN. destroy the bacteria in situ, or at least inhibit their further develop- ment and prevent the absorption of their poisonous products. These objects are more effectively accomplished when the presence of an open surface allows our remedies to be brought into immediate contact with the pathogenic organisms than when these are protected by an intact epithelium. As, however, in nearly all cases the processes inaugurated by the organized germs lead to the destruction of tissue, we are often able to shorten the duration of the case by anticipating the course of na- ture, by the removal of crusts, the erosion of neoplastic deposits, or by the injection of an antiseptic agent into the substance of the lesion. In lupus vulgaris an effective plan consists in destroying the nodules and sprinkling the surface of the artificial ulcer with aristol, naphthol, or iodoform, or the same substances in ointment form, or the appli- cation of camphorated naphthol or lysol. Prior to softening of the nodule, injections of iodoform or the introduction of iodine have been found of advantage. Iodoform in the form of a five-per-cent. solu- tion in oleic acid has an excellent effect in preventing the degeneration of enlarged lymphatic glands. The injection of camphorated naphthol has also been followed by good results. Lupous ulcers are benefited, moreover, by the application of salicylated camphor, iodol, iodosul- phate of cinchonine, and other antiseptic substances, which are men- tioned in detail in the section relating to the treatment of that disease. The same substances are available in the management of scrofuloderma. Carbolic acid, salicylic acid, pyoktanin, etc., are frequently successful in aborting the progress of a boil. Carbolic acid has been the most widely employed for this purpose. It has been made use of in the form of a spray, of compresses soaked in a solution of suitable strength and kept in constant contact with the inflamed area, and by injection into the interior of the boil. Similar procedures have been advan- tageous in the case of carbuncle, carbolic acid or tincture of iodine being injected into the cribriform openings and pyoktanin, campho- phenique, or iodol laid upon the surface. Subcutaneous injections of an antiseptic solution promise well in malignant pustule. The local treatment of erysipelas has been revolutionized. Whereas, a few years since, external remedies were generally looked upon as of slight avail, great stress is now laid upon the use of certain agents, which have shown themselves remarkably efficacious in limiting the extent and severity of the disease. The most valuable of these substances are resorcin, carbolic acid, creasote, creolin, alcohol, corrosive sublimate, salicylic acid, and salol. The methods in which they are used are described in the section relating to the treatment of erysipelas. It is of the utmost importance that the surfaces of burns and ulcers should be covered by dressings impregnated with substances able to prevent the activity of microphytes. The local therapy of the pustular diseases of the skin is to be conducted upon analogous principles. The TREATMENT. Ill adoption of antiseptic precautions in performing the trifling operation of vaccination has reduced to a remarkable extent the occurrence of those accidents which have sometimes brought undeserved discredit upon the most valuable prophylactic measure yet known to medical science. In small-pox decided benefit is obtained by the use of parasiti- cides in the form of lotions, powders, ointments, or pastes. Suppura- tion is lessened, the virus weakened or destroyed, fever diminished, and pitting reduced. The severity of scarlatina may be mitigated and its extension restrained by the sedulous adoption of antiseptic measures. As the technique of disinfectant applications will be described separately in the treatment of the individual disorders of the skin, it is unnecessary to dwell at length upon the subject in this place. For further information, therefore, the reader is referred to the body of the work. CONSTITUTIONAL AND LOCAL TREATMENT. The following mechanical remedies, the consideration of which I have largely extracted from one of my papers * treating of them, can be employed either for their systemic or local action, or both, or as an assistant to topical medication. I shall speak of these remedies under the following headings, and for a more detailed description of them will refer to my paper read before the American Medical Association, June, 1883. Massage.—As a general remedy, massage has been long and favor- ably known, but has been seldom employed as a method of treating diseases of the skin. In certain morbid states of the integument, it is, when properly used, attended with a most beneficial effect, and often results in restoring the surface to its natural condition. The func- tions of the skin are roused into full activity. The volume and rapidity of the cutaneous circulation are increased. The secretions of the skin are augmented and cutaneous respiration is promoted. From the sen- sory and tactile end-organs a beneficial effect is produced upon the central nervous system. A simultaneous or successive conduction of influence from many parts of the surface, affecting many centres, di- rectly contributes to the restoration of exhausted energy. The practice of massage increases muscular strength. Manipulation of the abdomen, properly performed, exalts the functions of the viscera contained within its cavity. It excites peristalsis, stimulates the menstrual function, and, in man, invigorates the testes. The appetite and digestion are im- proved. The urine is increased in quantity and variously altered. Mas- sage not only acts directly on the part, but by its indirect effect, when employed over the general surface, will impart tone and vigor \o the * Extracted from a paper read by the author before the Section of Dermatology and Syphilis, at the meeting of the International Medical Congress at Copenhagen, Denmark, August 12, 1884. 112 DISEASES OF THE SKIN. entire system. This direct as well as indirect action of massage renders it available both for its local and constitutional effect in many diseases of the skin. Massage is a most important and valuable adju- vant in promoting and increasing oxidation in psoriasis and scrofulo- derma. In these and other similar pathological conditions the skin is rendered more active by its use, the effete products are removed, and the red corpuscles of the blood are increased. It is especially advan- tageous for its effect in neuralgia, in perverted sensibility, and trophic disturbances of the skin. In these neuroses it relieves pain by its sedative and counter-irritant effects, and has a tonic action upon the nervous system. In some of the subacute forms of eczema, in which the integument is covered with groups of papules somewhat thickened and dry, the application of massage will often arouse the activity of the absorbents, increase the circulation, lessen or arrest the itching, and restore the skin to its natural condition. It is, however, in the chronic form of eczema that massage has been, according to my ex- perience, both effective and curative. In chronic cases of eczema, where the integument is deeply infiltrated, rough, thickened even to a leathery state, hard and dry, upon which medication has been used without any result, the application of massage breaks up the exudation, stimulates the absorbents, removes the inflammatory products from the parts, and restores them to their natural condi- tion. It is equally efficacious in the same disease when the integu- ment is covered with confluent patches of papules, and more or less infiltration with dryness of the surface, and attended with an intense and persistent itching. The abnormal and pent-up products are gen- erally speedily removed, the massage having a sedative action on the parts as well as on the entire body, a pleasant state of repose following. Massage is a useful and beneficial application in the dry form of sebor- rhoea and in thinning and loss of hair; the sluggish circulation being augmented, the absorbents made active, and tone and vigor being im- parted to the glands and hair-follicles. It is like- wise a valuable agent in indurated acne, in glandu- lar swelling, and in excessive and deficient pig- mentation of the skin ; the choked-up absorbents are aroused to activity, and the parts are soon re- stored to their normal condition. Massage not only acts in this local manner, but it is an important remedy applied over the general surface in curing or assisting to remove many functional derange- ments, such as gastric and intestinal disorders, with or without constipation, which are insidious factors io. 8.—The author's • _ > j • woven gum band- in many cutaneous diseases. age, used in apply- Compression.—Compression, which is very use- ing compression to « , . , „ , - „ . the extremities. tul in the treatment of diseases of the skm, can be TREATMENT. 113 applied by means of any substance that will afford rest and support to the affected parts. In many affections of the skin it will either prove curative or assist medication in overcoming the morbid state of the tis- sue, which often resists for a long time the action of drugs. Compres- Fio. 9.—Dermatological case, used by the author, showing a lens, probes, knives, forceps, scissors, spoon, curette, hypodermic syringe and needle, holder and needles. sion is a valuable means to use in eczema, especially that form which involves the abdomen, the nates, and the genital regions. It serves in these affections to protect the parts, prevents friction with the ad- joining portion of the integuments, and limits the spread of disease. It relieves the congestion in such cases, and arrests the effusion. It is also very effective in acute and subacute eczema by soothing muscular irritation, toning up the dilated capilla- ries, and preventing the escape of serum. Com- pression is an important adjuvant in the treatment of certain eruptive fevers, for oedema after erysipe- las, as well as in eczema, furuncular and glandular affections, herpes, herpes zoster, and urticaria. It can be employed with muslin, gum, or woven band- ages—the latter being especially serviceable—or with simple or medicated plasters. Blood-letting'.—The abstraction of blood is bene- ficial in diseases of the skin, both for its general and local effect. It is a powerful antiphlogistic remedy, and acts in a speedy manner in relieving and in arresting morbid changes of the skin. Blood-letting is not onlj valuable as an adjuvant in treating certain obstinate cutaneous dis- Fig. 10.—1. The der- matome or needle- knife, with spoon . upon one end. 2. The dermatome oi needle - knife with curette upon the ex- tremity. 114 DISEASES OF THE SKIN. eases, but it is also useful in chronic affections, after medication has been exhausted without having any effect upon the parts. Blood may be abstracted either topically, as from the capillaries of the integu- ment, or generally from a vein or artery. Local depletion is a com- mon and useful form of abstracting blood for the treatment of diseases of the skin, general blood-letting only being used in a very few in- stances. Topical blood-letting may be performed by puncturing, scarification, or leeching. Puncturing.—The integument can be depleted either by a bistoury, a tenotome, or a short pointed needle ; the one which I use in my practice I have termed the "dermatome." (See Fig. 10.) Punctur- ing the skin relieves the congestion and stagnation of the blood in the vessels, by equalizing the circulation, stimulating the action of the absorbents, and thus removing all deposits from the tissue. It is de- cidedly effective in chronic eczema, acne, scrofuloderma, carbuncles, erysipelas, excess of pigment, and in the neuroses. Scarification.—Scarification, although not as frequently employed as puncturing in the treatment of diseases of the skin, is nevertheless an im- portant means to use over an inflamed surface, the relief brought to the parts from dividing the engorged blood-vessels being often most decided. Leeching.—Leeching, while inferior to puncturing and scarifica- tion for the abstraction of blood, can be resorted to in nervous per- sons, who fear the use of the knife or the needle. Venesection.—Venesection will bring a decided relief in certain cutaneous eruptions, especially in strong, robust subjects bearing every evidence of a plethoric state of the system. I have employed it with success in general eczema and psoriasis. Incisions.—Incisions are made upon the integument for the pur- pose of exposing, dividing, or removing the parts. They are valu- able in sebaceous cysts, lymphatic enlargements, in local inflamma- tory patches, to relieve the tension of the integument, to divide sensitive nerves, and to give a free exit to pent-up inflammatory products. Incisions are employed with advantage in sycosis, rosacea, erysipelas, boils, and carbuncles. Excision.—Excision, or the removal of a part, can be accomplished by either incision with the knife, by ligature, or by crushing benign and malignant tumors of the skin as well as warts. It is also useful for the removal of horns and moles. Enucleation.—Enucleation is employed to rapidly peel out diseased structures, especially after the skin and capsules have been divided over morbid growths. Scooping.—Scooping is a form of enucleation. It is usually per- formed with a smooth, sharp spoon, and is an efficient method for removing broken-down products and pent-up secretions, especially in cutaneous abscesses, sinuses, and strumous glands. TREATMENT. 115 Scraping.—Scraping is but a modification of scooping, and can be performed with almost any rough substance. The curette is, how- ever, the instrument generally used. Morbid products can be re- moved by scraping, as in lupus, cancers, etc., thus facilitating the application or assisting the action of local remedies. Cauterization.—Cauterization can be performed by the use of a metallic substance heated to a high degree of temperature, or through the action of the solar rays and a lens, or by the galvano-cautery, as well as by any of the various caustic medicinal agents. The mechani- cal cautery, as usually employed, consists of variously shaped pieces of iron, needles, pins, or any metallic substance heated to either a white or dull-red heat and applied to the affected integument. The success of the actual cautery in morbid growths of the skin, especially in lupus and cancerous affections, is already well known to every practitioner, and simply needs to be mentioned in referring to the great value of this useful mechanical agent. t The mechanical remedies that I have thus briefly enumerated can be used alone or combined. They will be found to be invaluable adjuvants, and often powerful agents in arresting and removing some of the most obstinate diseases of the skin after medicines have entirely failed. Electricity.—In the treatment of diseases of the skin, electricity* has an extensive and interesting field of application ; and all the usual forms in which this agent is used in general medicine f and surgery have been utilized, to a greater or less extent, in dermatology. The faradic or induced currents are more frequently employed than the currents of high potential from the static apparatus, but the most use- ful of all forms is the galvanic or voltaic current, the cell current, which is of comparatively low potential but of large volume. The current from the storage battery, or the Edison dynamo, may be substituted for the galvanic or cell current in connection with the current controller and milliamperemetre for all purposes to which the former is applicable, and is coming more and more into use by phy- sicians in their offices. The moist structures of the human body are as a- rule good con- ductors of electricity; but the dry skin, on the contrary, is a very poor conductor, and offers the principal obstacle to the medical employment of this force. Since the dry skin exhibits such decided resistance, it is customary to moisten the part to which electricity is to be applied, and this is accomplished best by having the electrodes ■ in the form of sponges set on handles, or, what is better, moistened cotton may be * See paper by author, on " Electricity in Skin and Venereal Diseases," the Medical Bulletin, October, 18S9. f See paper by author, on " The Therapeutic Uses of Electricity," Journal of the Americal Medical Association, August 17, 1889. 116 DISEASES OF THE SKIN. used instead of the sponge. Saline solutions being much better con- ductors than pure water, it is considered advisable to employ salt water for this purpose when it is desired to have electricity penetrate the skin. Where the effect is especially intended for the epidermic struct- ures, or where the cutaneous nerves and capillaries are principally to be impressed, dry metallic electrodes may be used. These may be had of different sizes and shapes; one in the form of a sphere, half an inch or more in diameter, made of steel which may be nickel-plated, is useful in dermatology for applying electricity to the various diseases of the skin. The roller electrode of Dr. Butler is employed for general electriza- tion of a portion of the surface to improve the nutrition of the skin, or the wire brush may be used, which is very stimulating, being agreeable to some and rather painful to others. In electrolytic work the needle- holder is convenient, not only for epilation, but also in the treatment of hypertrophied scars, and for obliterating the dilated vessels in rosacea. For galvano-cautery applications to naevi and malignant growths in the skin, the ordinary forms of instruments are employed. Electricity not only acts, when properly applied, as a nervous stim- ulant, and to some extent as a vital energizer of growing cells, but also as an alterative where cell-action is abnormal. That during life there are physiological electrical currents generated in the human body is now generally conceded, and these currents undoubtedly play an im- portant part in carrying on the functions of cells and organs. Clinical experience shows that the passage of electricity through the body by including portions of organs in the circuit, when currents of a certain strength are used, has a decided effect upon the blood-supply and the nerve force, as manifested by physiological and therapeutic effects upon the parts thus included betwreen the electrodes. The discovery of electro-capillary phenomena and the effects of so-called currents of polarization, within recent years, has shown the identity of the electri- cal phenomena occurring normally in the human organism, and those induced by the passage of the current. According to Becquerel, Dujardin-Beaumetz, and other well-known clinical authorities, the muscles and nerves have electrical currents of their own, and when these have been altered by disease, the clinical application of faradism and galvanism may restore lost function in nerve or muscle. This is probably true also of the skin, which in some disorders is deficient in its blood-supply and sensation, both of Avhich are notably increased by electrical stimulation. Not only are motor and sensory nerves stim- ulated, but the trophic nerves and vaso-motor fibres have their functions likewise increased, so that in atrophic affections and disorders of the sensation (paraesthesia, etc.) electricity is frequently of advantage. As regards the forms of currents to use, according to Dujardin-Beaumetz :* * Clinical Therapeutics, Dujardin-Beaumetz, translated by E. P. Hurd. George S. Davis, publisher, Detroit, Mich., 1885, p. 35. TREATMENT. 117 u When we desire to modify the cutaneous sensibility and nutrition in general, we make use of static electricity; when we wish to limit electricity to a group of muscles, or when we wish to restore con- tractility to certain muscles, wTe use the faradic machine; when, finally, we wish to modify the molecular state of certain nerves, or to give a new activity to certain tissues, we employ galvanism." The latter form is also used in performing electrolysis for the destruction of hair- follicles or removal of new growths. Since in experiments in electrical decomposition of chemical compounds (electrolysis) the acids always go to the positive pole, and alkalies and similar basic bodies go to the negative pole, the former is sometimes called the acid pole and the latter the alkaline pole. Similar modifications tend to occur in living tissues under the in- fluence of strong currents, and this is made more effective if the electrodes are wet with saline solutions which are decomposed by the current. When this occurs, part of the medicament passes directly into the skin and may flow with the current entirely through the body, as demonstrated conclusively by Munk, Von Bruns, Adamkiewicz, Peterson, and others. This procedure is known as electrical cata- phoresis, and it has recently been utilized for the introduction of chloroform, quinine, mercury, and other agents through the skin. Dr. F. Woodbury has used lithium iodide in solution in this way for the removal of syphilitic tubercular lesions from the skin with good re- sults.* In connection with the polar effects just mentioned, it is in- teresting to note that Glatz confirms the clinical observation that, in bipolar applications, the positive pole is the more sedative and calma- tive in neuralgic affections.f He applies the positive pole at the seat of pain with a small electrode, while the negative is placed at a conven- ient distance with a larger electrode. The current must be of medium intensity. In such cases chloroform or cocaine solution can be applied to increase the sedative action, and make the relief more lasting. Static electricity is very beneficial in many nervous affections of the skin; and the psychological effect of the sparks undoubtedly con- tributes to the curative action. Paraesthesia, or pruritus, is frequently relieved by it, especially wdiere it is a symptom of senile or other changes in the skin; and formication accompanying central nervous disease may also be held in abeyance by franklinic electric baths. The lividity of the skin in nervous disorders may be entirely relieved by this acceleration of the circulation under a series of short sparks. Neuralgia or dermatalgia of the scalp, soles of the feet, and other parts of the body, are sometimes benefited by franklinism after the failure of other forms of electrical treatment. Horns, corns, callosities, warts, * " On the Employment of the Cataphoric Action of the Galvanic Current for the Removal of Syphilitic New Growths," Medical News, June 21, 1890. f Revue Medicale de la Suisse Romande, May 20, 18S&. 118 - DISEASES OF THE SKIN. hardened cicatrices, and other hypertrophic developments of the skin, are often removed by daily applications; while a similar result follows in cases of the tendency to repeated eruptions of blind boils, hard papules, acne-marks, and sluggish lymphatic glands, by strong sparks. In eczema and psoriasis I have repeatedly observed good results from franklinism, especially where infiltration has occurred, and there is obstruction to the local circulation by inflammatory deposits, which are speedily caused to be absorbed by these applications. Konghness of the skin in scrofuloderma is in a great measure remedied by thorough franklinization, while there is noted a general systemic tonic effect. In hyperidrosis, bromidrosis, in parasitic affections, such as ringworm, favus, and tinea versicolor, I have also observed undoubted benefits follow from static treatment; and two instances have been reported in which Guinea-worm has been cured by its aid. As a general tonic to the skin or as a counter-irritant, franklinism is as reliable as galvanism or faradism. Faradic electricity is useful for about the same class of cases as static electricity, and stands between this and galvanism in its effects upon the skin. In haemophilia and haematidrosis, faradism causes con- traction of the capillaries, and by a similar action it is curative in chilblains. In acne lesions, papular and chronic eczema, psoriasis, pem- phigus, and paraesthesia or pruritus, faradism often relieves the itching and reduces the infiltration that may be present. In scrofuloderma, chronic sycosis, chronic ulcers, and obstinate syphilitic patches, the writer has frequently had marked good results follow the judicious use of faradism alone, or alternating with franklinization or galvanization. It is hardly necessary to say that thorough cleanliness and antisepsis of the electrodes are necessary, and these may be secured by covering the electrodes with absorbent cotton, which is to be changed for each seance. In .chronic eczema and psoriasis, especially when the patches are much thickened, and attended with marked itching, the author has ac- complished by daily treatment with galvanism the very best clinical results. The infiltration and itching usually lessen, and the skin is rendered more active and more amenable to other local treatment that formerly failed to act. Mild currents are needed, and, if there is liver or stomach disorder, the positive pole is to be placed over the affected organ, and the negative to the lesions upon the skin. Erysipelas may be checked by galvanism, the anode being placed in the centre of the patch, and the cathode moved slowly around the circumference. Sup- purative swelling of the skin or of the subcutaneous connective tissue, such as boils, incipient abscesses or carbuncles may be averted, aborted, or cured by prompt galvanization, if the disorganization has not pro- ceeded too far. In psoriasis due to nervous depression the constant current acts both as a tonic and as a local therapeutic agent, and is frequently curative. TREATMENT. 119 In herpes, simplex or zoster, mild but continued galvanization removes the intense burning and prostration, and the progress of the disease is retarded. Similar good effects are seen in rhus-poisoning or dermatitis venenata. Discoloration of the skin, lentigo (freckles), chloasma, vitiligo, acne, seborrhoea oleosa, rosacea, and birth-marks, are generally amenable to galvanic treatment combined in the latter two affections with galvano-puncture, if necessary. Galvanization is required for thorough epilation (electrolysis), and is unequaled as a stimulant in alopecia, if the hair-bulbs are still living. Antiparasitic applications are more efficient when applied by the electrodes, and a moderately strong current is employed to drive them into the skin (cataphoresis). In chronic ulcers of the leg, remarkable results may be obtained by driving in weak solutions of corrosive chloride of mercury in this way. In tinea versicolor and cancer, benefit may be looked for in the same direction.* In the treatment of condylomata and warty growths of the urethra and verrucous pigment naevi of the face, Ehrmann, of Vienna, uses a sharp-pointed steel needle for the cathode, which is inserted into the mass about to be re- moved, while the anode, a moist electrode, is placed indifferently or held in the hand. Where the warts are numerous, from three to six needles attached to one electrode are inserted at the same time. He objects to the use of lancet-shaped needles, preferring round ones, which are easier to introduce, and cause less destruction of tissue. The strength of current employed is from one to one and a half milliamperes. M. Vogel, of Eisleben, in the treatment of vascular nasvus, teleangiectasis, employs one electrode which contains both in- sulated poles, consisting of two orf more fine steel needles separated from each other by one millimetre. The advantage of this is that it leaves the hand of the operator free. Scarring may be avoided by using weak currents, and not continuing the seances too long. Graefe follows Voltolini in having both poles terminate in needle-points, and not the cathode only. In fibromata of the skin he thus obtains cures after several sittings. This same authority also reports an interesting case of a physician, who during a post-mortem inoculated his index- finger with tubercular disease, which subsequently manifested itself by tubercular nodules. These entirely disappeared by electrolysis without any glandular infection taking place. No new nodules were apparent at the end of nine months, f Electro-puncture used by Magendie in the treatment of neuralgia has been lately revived in the form of galvano-thermy, which is a most powerful revulsive method. By means of a storage battery, a wire electrode is heated to redness, and it is then introduce to the depth of * See paper, " Electricity in Carcinoma," by Robert Newman, of New York, Proceedings American Electro-Therapeutic Association, 1891. f Annual of the Universal Medical Science, F. A. Davis, publisher, vol. v, p. c. 27. 120 DISEASES OF THE SKIN. half a millimetre at points some little distance apart over the tract of the affected nerve. They cause considerable inflammation, but afford marked relief in neuralgia. With the aid of an anaesthetic, this might be used in malignant pustule, lupus, epithelioma, and carcinoma. Among the individual applications of electricity, it should be noted that in scleroderma, Schwimmer reported success- ful results in one case after eighteen months' treatment by subaural galvanization. In morphoea, Liebig and Rohe * declare that localized applications of galvanism have long been regarded as the only treatment that promises success. In true keloid, as also in simple hypertrophied scars, success has followed multiple galvano-puncture. If the essential feat- ure of all inflammation be the presence of certain forms of bacteria, and we have in the positive pole an agent which will remove the causa morbi, electricity is destined in the future to play a still more impor- tant role in skin diseases than it has hitherto. The galvano-cautery is useful for many minor surgical operations upon the skin in primary syphilis, chancroids, epithelioma, and lupus. Peognosis. The prognosis of cutaneous diseases depends upon the nature and intensity of the causative morbid processes. It is also influenced by the extent of surface involved, and the length of time that may have elapsed between the appearance of the lesions and the institution of a plan of treatment. Age, sex, occupation, habits of life, and the presence or absence of the various diatheses are also factors which must be taken into consideration.* As a general rule, however, the prognosis is favorable. A large number of skin-diseases are either acute or subacute in character, and tend to a spontaneous cure ; many others run a more or less chronic course, but eventually yield to judicious and persevering treatment. Some, on the other hand, are exceedingly obstinate, and are not amenable to any known method of treatment; fatal results rarely occur except in leprosy, cancer, and the acute contagious diseases. Disorders of the sebaceous, and functional disorders of the sudo- riparous secretion, are usually only temporary in character, and may be readily cured or alleviated by appropriate remedies. Changes in character of the sudoriparous secretion are more persistent and less amenable to treatment. Hyperaemia of the skin is symptomatic of congestion of the vessels of the papillary layer, and is usually of brief duration. The acute contagious inflammatory diseases vary in severity. Some invariably pursue a benign course, or are only occasionally * Practical Electricity in Medicine and Surgery, F. A. Davis, Philadelphia, 1890 p. 372. TREATMENT. 121 fatal, while others are noted for their malignancy. The non-con- tagious inflammatory diseases also vary in course and duration. Many of them terminate in a few days in complete recovery. Occasionally death may ensue from the violence of the inflammatory action, or the accompanying constitutional debility, as in some cases of pemphigus and anthrax. Other diseases of this group, as prurigo and pityriasis rubra, are essentially chronic in character, and may remain for years without any apparent chauge. Cutaneous haemorrhages are generally small in amount, and of trivial importance. Hypertrophies are usually benign in character and slow in development; they are difficult to remove, and manifest a tendency to recur. Atrophies of the skin or its appendages are gener- ally permanent. The prognosis of neoplastic diseases varies with the benignity or malignity of the process concerned in the deposition of new material in the skin. Some, as fibrous molluscum and the different forms of naevi, are harmless in character; others, as lupus and scrofuloderma, tend to ulceration and destruction of the adjacent tissues ; while lep- rosy, carcinoma, and sarcoma generally terminate fatally. The neuroses are extremely variable in duration and severity. Sometimes they disappear as if by magic, after the employment of one or two simple remedies, while at other times they resist all treat- ment. The parasitic affections are all curable. PART II. CLASSIFICATION. The purpose of the following classification is to arrange the differ- ent varieties of skin-diseases so that they can be readily referred to and studied in a simple and practical manner. Numerous systems have been proposed, all of which, however, are so complex as to be of little or no utility. Hebra's classification, modified, made upon an anatomical and pathological basis, is adopted in this work in order to prevent any confusion, as it is the most commonly accepted system now in vogue. Class I. Disorders of Secretion and Excretion (Anomaliai Secre- tionis et Excretionis).—Seborrhoea, comedo, milium, sebaceous cyst, hyperidrosis, anidrosis, bromidrosis, chromodrosis, sudamina. Class II. Hyperemias (Hyperemia).—Erythema simplex, ery- thema intertrigo. Class III. Haemorrhages (Hamwrrhagiw).—Purpura, haemophilia, hasmatidrosis. Class IV. Exudations (Exudationes).—Rubeola, rotheln, scarla- tina, variola, varicella, vaccinia, typhoid-fever rash, typhus-fever rash, cerebro-spinal fever rash, diphtheritic spots, erysipelas, chancroid, syph- ilis, erythema multiforme, erythema nodosum, urticaria, lichen pla- nus, lichen scrofulosum, prurigo, herpes, miliaria, pemphigus, hydroa, pompholyx, acne, rosacea, sycosis, impetigo, impetigo contagiosum, ec- thyma, pityriasis rubra, furunculus, carbunculus, anthrax, equina, ab- scesses, ulcus, eczema, dermatitis, combustio, congelatio. Class V. Hypertrophies (Hypertrophic). — Lentigo, chloasma, naevus pigmentosus, callositas, clavus, cornu cutaneum, keratosis pila- ris, psoriasis, lichen rubra, verruca, ichthyosis, scleroderma, sclerosis, morphoea, elephantiasis, dermatolysis, hirsuties, onychogryphosis. Class VI. Atrophies (Atrophia).—Albinismus, vitiligo, canities, atrophia cutis, atrophia senilis, striae et macula? atrophica?, alopecia, alopecia circumscripta, atrophia pilorum propria, onychatrophia. Class VII. Tumors (Keoplasmata).—Rhinoscleroma, lupus erythe- DISORDERS OF SECRETION AND EXCRETION. 123 matosus, lupus vulgaris, scrofuloderma, molluscum epitheliale, lepra, epithelioma, sarcoma cutis, carcinoma cutis, keloid, molluscum fibro- sum, xanthoma, lipoma, angioma, lymphangioma, neuroma, myoma. Class VIII. Neuroses (Neuroses).—Hyperaesthesia, anaesthesia, paraesthesia, dermatalgia. Class IX.—Parasites (Parasitce).-—Animal: scabies, pediculosis, cimex lectularius. Vegetable: tinea versicolor, tinea favosa, tinea tri- cophytina. CLASS I. DISORDERS OF SECRETION AND EXCRETION. {Anomalies Secretionis et Excretionis.) SEBORRHOEA. Synonyms. — Steatorrhea — Pityriasis — Acne sebacea—Seborrhagia — Cutis unctuosa— Tinea furfuracea—Ichthyosis sebacea—Schmeerfluss—Dandruff. Seborrhea is a functional disease of the sebaceous glands, charac- terized by an excessive and altered condition of the sebaceous secre- tion, forming an oily coating, crusts, or scales on the skin. Symptoms.—Seborrhoea may occur upon any part of the body, but is usually limited to certain localities. The favorite seats are the scalp, face, back, chest, umbilicus, and the genital regions. It may in rare cases as a disease involve the entire body, as in the instance recorded by Biett. The vernix caseosa of new-born children, as well as that which affects certain races, particularly the negro, are illustra- tions of general seborrhoea, occurring, however, as a physiological and not as a diseased process. As a disease, its course will be found to vary according to the region affected and the state of the patient's health. It is usually more marked on the scalp, and less so on other portions of the body. It is especially liable to occur in those who are out of health, particularly the anaemic and chlorotic, and tends to lessen or disappear as the system returns to its normal condition. It may be so trifling as to require little or no treatment, often vanishing with the removal of the cause ; again, it may be extremely severe, often lasting months or years, and even with the most careful atten- tion being subject to frequent relapses. In some instances it may ob- stinately persist throughout life, notwithstanding careful treatment. The seasons may have an influence, it often disappearing in summer and returning in winter. The condition of the integument affected will also vary according to the extent of the disease and the state of the poured-out secretion. It is.mostly of a pale tint, and either dry 124 DISEASES OF THE SKIN. or greasy. At intervals it may be more or less inflamed. Subject- ive sensations of either itching or burning, or both, may be present, or sometimes absent. The disease is encountered in two forms, ac- cording to the secretion discharged, whether oily, or firm and dry, which are known respectively as seborrhoea oleosa and seborrhoea sicca. They occur occasionally together, either upon the same or different regions of the body, but usually receive the subjoined separate consid- eration. Seborrhoea Sicca.—This is the most common variety of the disease. It is characterized by the formation of dry, yet somewhat greasy, dirty-white or yellowish scales or crusts. As it occurs both upon the hairy and non-hairy parts, it will be described under the following local forms: Seborrhcea Capitis is a local variety of seborrhoea. It may ap- pear in children as a continuation of the vernix caseosa, and persist for some time. It is met with on the vertex, the anterior fontanels, and occasionally over all the scalp, in the form of thin or thick, dry, fri- able, or fatty scales, crusts, or scabs, which are firmly adherent to the surface. The color will vary from a light yellow to a brown or black, the tint depending upon the dirt coming in contact with the parts and the care which they receive. The skin beneath may be normal, slightly macerated, or sometimes complicated with eczema; the hardened, ad- herent material exciting inflammation of the skin. After a time the disease generally subsides, the scales and crusts disappearing with the growth of the hair. In adults the disease manifests itself by the forma- tion of thin or thick, gray or yellowish, dry or greasy scales. They are either loosely situated or adherent to the scalp ; in the latter event the thick, fatty masses may bind the hair in close contact with the surface. As a rule, the disease invades the scalp uniformly; occasionally, how- ever, it appears as one or several patches. The scaling will vary— scarcely visible in some, and so great in others as to hang loosely upon the hair-brush and drop off on the clothing, causing considerable annoy- ance. This abnormal condition of the hair-follicles and the coating upon the scalp may interfere with the growth of the hair. It—the hair—may become dry and dull in appearance, the lustre disappearing, and slowly or rapidly thinning, which may, perhaps, lead to perma- nent depillation. In other cases the morbid action may continue, often becoming severe without any structural alteration of the follicles or loss of hair. On the removal of the scales in this affection, the skin beneath may be normal or of a pale, dull-white tint, or somewhat hyperaemic. Itching or a burning sensation is liable to occur, and is aggravated by errors of diet and loss of sleep. Perspiration of the scalp is common. The disease is chronic in its course, often continu- ing for years or a lifetime, especially upon its favorite seat, the crown of the head, probably producing premature baldness. Seborrhoea oc- DISORDERS OF SECRETION AND EXCRETION. 125 curring upon other hairy parts of the body, as the eyebrows, mustache, beard, and pubic region, follows a similar course to that of the scalp. Seborrhcea Faciei.—This phase appears chiefly about puberty, or between that period and thirty. It is more frequently observed in females than in males, and is met with particularly upon the forehead, cheeks, and nose. It is apt to occur as the oily variety, which will be referred to under seborrhoea oleosa. In the dry form it appears as thin or thick, yellowish, greenish, brownish, or blackish scales or crusts, well adherent to the skin, forming sometimes a mask, and occasioning much deformity. Extraneous substances frequently become entangled in the scales If raised from the surface, they will be seen to reach into the follicles. On their removal the skin beneath will be found to be nor- mal or reddened, but the scales quickly reform. Itching and burning sensations may be present. Acne, comedones, and eczema often appear at the same time. The disease, also, is a sequence of variola and syphi- lis. This form of the disease in the aged may terminate in epithelioma. Seborrhea Corporis.'—Seborrhcea of the body calls for special consideration, as it has an appearance very different from that ob- served on other parts. It generally appears on the back, between the scapulas, the clavicular and sternal regions, and about the umbilicus, in patches of varying size and shape. One or more of these regions may be attacked at the same time. These patches are either large or small, round or irregular, or sharply or ill defined. They may appear isolated, and remain so, or, what is more common, tend to coalesce, developing larger ones, invading the upper part of the back about the shoulders. In color they are pale-reddish, and partially or generally covered with yellowish or greenish scales. The scaling is usually scanty, and can be entirely removed, particularly by the friction of the clothing. The scales are also loose, or partially detached. The follicles of the parts are, in addition, patulous, and there may be acne papules and pustules about the margin of the patches. They will very often, particularly if the patches assume a circular arrangement with a clear centre, look very much like ringworm. Those on the chest usually incline to be circular in form, and to be covered with slightly shrivelled, yellowish or grayish, greasy or dry scales. There is generally only a single one, but several may exist, which sometimes continue or coalesce into one. The disease in this situation very often has the appearance also of ringworm, and not infrequently of a syphi- litic patch. In seborrhoea of the umbilicus the collected sebaceous material rapidly decomposes, developing an offensive odor, and an irri- tation, with often an inflammation of the parts. Itching, and occa- sionally a burning sensation, are generally present in seborrhoea of the body. The course of the disease is essentially chronic, and it is liable to frequent relapses. Seborrhcea Genitalium.—The genital organs in both sexes are 126 DISEASES OF THE SKIN. abundantly supplied with sebaceous glands, and, owing to a too free use of water and soap, or a neglect of cleanliness, or from abuse of the parts, not infrequently become affected with seborrhcea. The affection may be so slight as not to be considered a diseased state, or so severe as to give rise to marked inflammation of the skin. In males it involves the glans penis and sulcus. A white, greasy matter, the secretion of Tyson's glands, caused by the heat and moisture present, rapidly de- composes, producing a fetid odor, and more or less inflammation. A discharge from the inflamed parts very often follows, which closely resembles and may be mistaken for gonorrhoea. In females the seba- ceous material collects between the labia and nymphae, and about the clitoris, occasioning at times an inflammation with a similar discharge to that just described. Seborrhcea of this region is liable to occur both in women and young girls. Seborrhcea Oleosa.—This form, which is not as frequently en- countered as the other, appears as a fatty coating both on the hairy and non-hairy portions of the skin. It is, however, more common on the latter parts. The skin has a greasy appearance and impres- sion to the touch, especially on bald heads. It may assume in color a dirty, unctuous look, owing to the dust which readily adheres to the surface. The secretion may be discharged in a sufficient quantity to collect in minute drops, which have a yellow color; or the oily fluid can be easily detected when a piece of very thin paper or muslin is ap- plied to the skin. There are present sometimes crusts from the con- sretion of the poured-out secretion. The integument may have in addition a pale or reddened appearance, and patulous or plugged- up follicles, and give to the touch a cold sensation. The usual seat of the disease is the face, especially the nose, forehead, and cheeks, but it may appear upon other portions of the body. Its course of development may be slow or rapid. It may be so slight as neither to cause any annoyance nor attract any attention. On the other hand, it maybe so severe as to produce an itching or burning sensation, and by its disfigurement give rise to much annoyance, and in some instances to very great distress. Diagnosis.—Seborrhoea may resemble and be mistaken for eczema, psoriasis, lupus erythematosus, epithelioma, syphilis, ringworm, and ichthyosis. On the scalp it is liable to be confounded with eczema. The latter affection, if present, ordinarily has a history of discharge : the itching is constant and severe. Seborrhoea, on the other hand, is a dry disease, and the itching is often intermittent and is rarely intense. Eczema inclines to occur in patches,* and is apt to spread to the ad- joining portions of the integument. Seborrhcea, on the contrary, as a rule, appears uniformly over the scalp and is likely to be confined only to it. In eczema the scales are commonly scanty, dry—being made up chiefly of inflammatory products; in seborrhcea they are DISORDERS OF SECRETION AND EXCRETION. 127 more numerous, greasy, and are composed of sebaceous material. In eczema the skin is also red and inflamed, while in seborrhcea it is pale. Seborrhoea of the face occasionally resembles erythematous ecze- ma, but the history of the disease, together with the presence of the greasy crusts, and often patulous follicles beneath, are sufficient for diagnosis. Seborrhoea and eczema, while differing in many respects as pointed out, may coexist upon the same subject. The one affection may bring into existence the other, as in eczema of infants, which is liable to excite seborrhoea. In a similar way seborrhoea of the face, of the ster- nal and genital regions, may develop at the same time eczema of these parts. Seborrhcea is even more likely to resemble psoriasis, either of the scalp or body. If seborrhoea exists, it generally covers the entire scalp ; if psoriasis, the disease appears in patches circumscribed with intervening healthy skin, and similar lesions are present on other parts of the body, particularly on the extensor surfaces. The scales in seborrhoea are small, thin, and of a gray or yellow color, while in psoriasis they are larger, thicker, and white in tint. The skin of the scalp in seborrhoea is pale or deadened in color, and seldom exhibits any inflammatory symptoms; in psoriasis, upon the removal of the scales, it is at all times red and infiltrated. Seborrhoea may also have the appearance of, and be mistaken for, lupus ery- thematosus. The latter, it is known, begins sometimes as a congestive seborrhoea, but, once formed, its symptoms are characteristic. Again, seborrhoea, virtually, is neither sharply limited nor inflafmed, as is always the case in lupus. In seborrhcea the skin may be reddened and covered with many easily detached, greasy scales; in lupus it is more of a dark, reddened tint, and the scales, which are fewer, are also tenacious and dry. The disease is also distinguished from lupus by not being followed by the characteristic' cicatricial tissue of the latter disease. Seborrhoea and epithelioma, in their early stage on the face of old people, may present such marked similarity as to be easily confounded. The attendant atrophy, and the slight degeneration around and beneath the patch, are usually distinctive symptoms of epithelioma ; but, if the peculiar small nodular lesions of the latter occur, the diagnosis can be readily established. Seborrhoea may re- semble, both on the scalp and the body, especially on the face and chest, some forms of syphilis. The history of the case, the involve- ment of the glands, the dark-red or ham color of the skin beneath and around the crusts, and the detection of other lesions in the form of mucous patches or old scars, would point to conclusive evidence of syphilis. It should be remembered, in this connection, that both diseases may likewise coexist—syphilis frequently exciting seborrhcea. Seborrhoea of the body may look very similar, especially on the chest, 128 DISEASES OF THE SKIN. to ringworm. In ringworm, however, there is the history of con- tagion, its rapid course, the circular arrangement of the patches, the tendency to heal in the centre with the inflammatory periphery, and the evidence of a vegetable parasite, by microscopical examination; which should serve to prevent any error. Seborrhcea can hardly be confounded with ichthyosis, the latter being a congenital, general, permanent disease, while the former is an acquired, local, and curable affection. In seborrhcea the skin, upon the removal of the scales, presents a soft and natural condition, but in ichthyosis it is dry, harsh, and rough. Pathology.—Seborrhcea, which is a functional affection, consists in an increased and generally changed secretion of the sebaceous glands. There may also be an escape from the glands and their follicles of a certain quantity of epithelial scales. The secretion thus poured out may remain oily or solidify, and occasion the oily or dry form of the disease. If the disorder be permitted to become chronic, it may eventually terminate in atrophy of the glands and their ducts, giving rise to loss of hair, which may be permanent. If the discharged secretion is placed beneath the microscope, it will be seen to be made up of an amorphous, fatty, somewhat granulai material, with more or less epithelial cells. Etiology.—A normal quantity of the sebaceous material in the skin assists in keeping it in a healthy condition. If the secretion at other than the physiological period in the new-born becomes excessive or unnatural, a diseased state has taken place. The causes which produce this change, while many, are mostly due to some general dis- turbance of the system. It may occur as the result of tuberculosis, cancer, the exanthematous and other fevers, an anaemic or chlorotic state, or any cutaneous disease which may impair the general health ; or it may depend upon alimentary, uterine, or ovarian disorders. Again, it may be brought about by any local means which will give rise to an irritation or congestion of the skin in persons who are otherwise healthy. Exposure to cold and heat sometimes occasions the disease, particularly on the face. Uncleanliness of the scalp, the use of hair-powders, dyes, pomades, irritating lotions and oils, or too severe combing and brushing, or the too frequent use of water or soap, or both, are no doubt active factors in causing the affection. Occasion- ally it occurs in the healthy without any apparent cause, but with care may often be traced to one of those I have stated. It appears at all periods of life, but is more common at the age of puberty, and in the female than in the male. The development of one or the other variety is not dependent upon any special cause, but upon the tem- perament of the person in whom it occurs. For this reason, indi viduals with light hair and complexion are subject to the dry variety, while those with dark hair and complexion to the oily. DISORDERS OF SECRETION AND EXCRETION. 129 Treatment.—Seborrhoea generally requires both constitutional and local treatment. The laws of hygiene should be rigidly enforced. Fresh air, sunlight, exercise, and nutritious food are requisites. The administration of internal remedies is to be directed against the cause upon which the disease depends. The bitter tonics, the prepara- tions of malt, arsenic, iron, cod-liver oil, phosphoric acid, and the phosphates are indicated in the debilitated, anaemic, and scrofulous. In derangement of the alimentary canal, the preparations of pepsin and nux vomica, with an occasional laxative or cathartic, will be found of service. In cases depending upon dyspepsia, especially the atonic form, the following combination will be valuable : I£ Pepsini sacch...................... gr. x. Strychninae sulph.................. gr. ^5-. 01. menth. pip.................... Tq, ^, M. Ft. chart no. j. Sig.: Take after meals. If constipation is present, one tenth of a grain of aloin may be ad- vantageously added to each powder. Seborrhoea, occurring at the age of puberty in those who are otherwise healthy, is often alleviated by the iodide of iron, two grains three or four times daily, or the sirup of hydriodic acid, one half a teaspoonful three times daily. It is some- times of advantage to add from one to five drops of liquor potassii arsenitis to each dose of the latter medicine. Sulphur and its com- pounds, especially the sulphide of calcium, in small doses, have also been recommended. In well-marked seborrhoea oleosa, Brocq thinks that he has derived some benefit from a combination of ergotin, belladonna, and hama- melis. Other drugs may be associated with these if indicated by the constitutional condition. I have seen decided improvement follow the use of hoang-nan,* which seems to exert a tonic effect upon the sebaceous glands. The local treatment is of the utmost importance. It will, how- ever, vary according to the region involved, the duration of the dis- ease, the extent of crusting or scaling, and the irritability, if any, of the skin. As seborrhcea of the scalp is the most common form, it will be re- ferred to more in detail. It is not necessary to cut the hair, as it will in no way assist or facilitate the treatment. The remedies can be applied effectively whether the hair be long or short. A simple or medicated oil is, perhaps, the most advisable to employ, particularly if the hair be long. It softens and loosens the accumulated masses of sebum and scales, and removes them from the surface. The oil •"Notes on Hoang Nan," by the author, Therapeutic Gazette, November 15, 1S89. " Notes on IIoang-Nan in Diseases of the Skin," The Journal of the American Medical Association, October 26, 1S89. 9 130 DISEASES OF THE SKIN. of ergot is the best agent to use for this purpose, as it possesses not only the power of removing the sebaceous material, but, by its astrin- gent and slightly stimulating action, proves of benefit to the diseased follicles and glands. In ordinary cases of seborrhoea of the scalp, or other parts of the body, it alone generally suffices as a local remedy, if the surface be occasionally washed with water and soap. It may be combined with an equal quantity of the fluid oleate of mercury, oleic acid, glycerine, or a fifty-per-cent. solution of boro-glyceride, and scented with some agreeable essential oil. It will be of advantage to stimulate the parts by the addition of a small quantity of carbolic acid, balsam of Peru, or similar substances. Olive, almond, and other bland oils may also be used for removing the sebum and scales, but they do not possess the medicinal qualities of the oil of ergot. In severe cases, in which the sebaceous material is thick and caked on the scalp, it may be necessary to saturate the parts with oil in order to soften the mass. The application should be made just before retiring, and the head covered with a flannel cap and then protected with a bandage or, even better, oiled silk. On arising, the dressing should be removed, and the scalp washed with water and soap. Soft or potash soap, or spirit of soap, is usually recommended, but I have found soda soap, particularly when medicated with chamomile and sulphur, to be sufficient. If the sebaceous material reform, the ap- plication should be repeated. Lotions occasionally prove effective. They are to be preferred to oils in seborrhoea oleosa, especially of the face. One or two grains of corrosive sublimate to the ounce of rose-water is an excellent application. Naphthol, in from three to five grains to the ounce of water, is also valuable. Equal parts of glycerine and alcohol, or a fifty-per-cent. solution of boro-glyceride have been found serviceable. Benefit has also been derived from the use of a fifty-per-cent. solution of bicarbonate of sodium. Pincus recommends lotions con- taining lactic or citric acid. Others prefer acetic acid, solution of ammonia, or carbolic acid. Besorcin is advised by Ihle, who uses it dissolved in olive-oil, castor-oil, or balsam of Peru, some of the preparation being rubbed into the scalp every day wTith friction. A solution of ichthyol in alcohol and ether is sometimes of advantage. The conjoined internal and external employment of jaborandi has likewise been proposed. Treatment should begin early in order to prevent baldness. The following formulae are also recommended : R, Tinct. nucis vomicae............... f ? ss. Chloral, hydratis.................. 3 j. Tinct. capsici..................... f 3 ij. Spts. rosmarini.................... q. s. ad f t. f § iv. M. Sig.: Apply night and morning. DISORDERS OF SECRETION AND EXCRETION. 131 R, Tinct. quillaiae (1 to 10)............. f f iij. Tinct. capsici...................... f § ss. Sp. odorati........................ f § j. Glycerini.......................... f | ij. Ammon. carb...................... 3 j. M. R, Sp. aetheris........................ f | iij. Tinct. benzoin..................... f 3 ij. Vanillin........................... gr. ss. Heliotropin........................ gr. jss. 01. geranii........................ th, ij. M. Spirit of ammonia, tincture of cantharides, and other stimulating substances are useful in the form of lotions. Lime-water also is fre- quently of service. Ointments are sometimes beneficial, especially if bland medica- ments are required. As a rule, they seldom yield good results on the scalp and hairy parts of the body; they mat the hair together, and do not always reach the diseased scalp. The ointment of mercuric oleate, well rubbed in, either alone or combined with naphthol or one of the tarry preparations, is the most effective. Those of the nitrate and the ammoniated and the red oxide of mercury are worthy of trial. The annexed formula has been prescribed with excellent results: R, 01. anthemidis..................... Til x. Quininae tannat.................... gr. xv. Ungt. bovis........................ § j. M. Sig.: Rub in a small quantity once or twice daily. A useful formula for an ointment is : R, Acid, salicylici..................... 3 ss. Sodii boratis....................... gr. xv. Balsam Peruvian................... ni xxv. 01. anisi........................... v\ vj. 01. bergamii....................... Tq, xx. Ungt. aquae rosae................... § j. M. Zinc or lead ointments, with or without opium, may be demanded, if there is much irritation or inflammation of the skin. In seborrhoea sicca of the scalp Vidal advises the following preparation : Precipitated sulphur, fifteen parts ; castor-oil, fifty parts; cacao-butter, twelve parts; balsam of Peru, two parts. The ointment should be rubbed into the hairy scalp every morning and evening. Sulphur is highly esteemed by French dermatologists, and is ap- plied in the form of powder, lotion, or ointment. In seborrhcea oleosa Piffard has seen advantage from the use of the 132 DISEASES OF THE SKIN. constant electric current. He also recommends two to four per cent. solutions of hydrochloric or chromic acid and precipitated silica made by adding a dilute solution of silicate of soda to dilute hydrochloric acid. Lanolin is an excellent excipient for ointments in this affection. Other serviceable ointments in the treatment of seborrhoea are those containing hamamelis, hydrastine, arsenic oleate, and iron oleate. Powders which have a combined astringent and soothing action are serviceable in the oily form about the face and in seborrhoea of the prepuce. They can be used alone, or in connection with a lotion or ointment. Powdered zinc oleate, mixed with an equal quantity of arrow-root, starch, or bismuth subnitrate, forms an excellent applica- tion. Salicylic acid may be usefully added to any of these powders. The local treatment of seborrhoea of other parts of the body is sim- ilar to that of the scalp. The sebaceous material, if accumulated, should be removed in the manner already described, and suitable appli- cations then be made. The selection of remedies and the frequency of their application—whether daily, once or twice a week, or every few days—will depend upon the variety of disease and the condition of the affected surface. In cases in which soap and water increase the irrita- tion, their use must be avoided. Prognosis.—Seborrhoea is a chronic but generally curable disease. It may at times disappear spontaneously, or yield rapidly to treatment. Again, it may prove obstinate, requiring a prolonged course of treat- ment. If it involves the scalp, or other hairy parts of the body, or has continued for some time, temporary and not infrequently per- manent loss of hair may follow. The prognosis is very unfavorable in cases in which the entire surface is involved, and also in those afflicted with carcinoma and tuberculosis. COMEDO. Comedo is a disease of the sebaceous glands, due to retention of sebum within the follicles, and marked by the appearance of whitish, yellowish, or blackish points at their orifices. Symptoms.—Comedones vary from a pin's point to a pin's head or larger in size. They may be elevated or non-elevated, and more or less numerous, irregularly distributed on the skin. They are situ- ated, as a rule, about the face, neck, chest, and back. The face, espe- cially the forehead, nose, and chin, is usually involved, being studded with black points, and often also presenting a greasy and muddy ap- pearance. In some cases double comedones have been observed. In these a communication exists between the ducts of neighboring glands, or a duct may bifurcate before reaching the surface. Dr. George Thin has DISORDERS OF SECRETION AND EXCRETION. 133 described cases of grouped comedones in which the occluded ducts are so closely grouped upon defined areas of the face as to give a uniform dirty-black appearance to the part affected. H. Radcliffe-Crocker has met with several cases in which grouped comedones were symmetri- cally arranged upon both sides of the face. In rare instances come- dones occur on all portions of the body except the hands and feet. The disease is frequently accompanied by acne and seborrhoea oleosa, and inflammatory symptoms will at times result. It occurs chiefly in the young of both sexes, especially about the age of puberty. The course of the disease is very slow, disappearing, to again reappear, it may be for years, unless checked by appropriate treatment. Diagnosis.—Comedo might possibly be mistaken for acne punctata, but inflammatory symptoms exist in the latter which are not usually present in the former disease. The differentiation between comedo and milium is referred to under the latter affection. Pathology.—The disease develops in the sebaceous glands and folli- cles, and consists in the retention of sebum and epithelial cells leading to the dilatation of the openings upon the surface. The black point upon the skin is generally ascribed to dirt, but Unna states that it is produced by pigment. The formed comedones rarely excite any in- flammation, and if removed and examined are found to consist of sebaceous matter, epithelial cells, free fat, occasionally one or more small hairs, dirt, and at times the Demodex folliculorurn. The latter parasite is not a causative element in producing the disease. Other forms of micro-organisms are invariably present, and the whole is .inclosed in a layer of stratified horny cells. According to the latest researches, the original cause of a comedo is a hyperplasia of the cells of the corneous layer—that is, a hyperkeratosis—in and about the seba- ceous follicles. Etiology.—The physiological activity of the glands and develop- ment of the hairs at the age of puberty are provocative of the disease. Chlorosis, scrofula, and menstrual disorders and affections of the gas- trointestinal canal very often assist in its development. According to Piffard, comedones at times have their origin in masturbation. In fact, it may be brought about by the functional derangement of any of the organs of the body, including the skin, and its causes are essen- tially the same as those'of acne. The action of local irritants, as in certain occupations, often give rise to the disease. This result will frequently be seen in those working in tar, among chemicals, dyes, wool, etc. Treatment.—Constitutional and local treatment are of advantage. Chlorotic subjects are benefited by cod-liver oil, iron, the simple bit- ters, with occasionally saline aperients. An appropriate diet and proper hygiene are of the greatest value in all cases. Dyspepsia, constipation, and uterine disorders should be corrected by .suitable 134 DISEASES OF THE SKIN. treatment. Ergot, and the tincture of the chloride of iron, or dilute phosphoric acid, alone or combined, can often be employed with good results, especially in weak and nervous patients. Local treatment is all-important for the purpose of removing the offending plugs and stimulating cutaneous activity. The comedo-plugs, if a source of an- noyance, from the deformity which they occasion, can best be removed by nicking the side of the follicles and scooping out with a needle- knife, or gently pressing the contents. If an attempt is made to re- move them by squeezing the comedones between the fingers, or by ap- plying a watch-key over them, and by violent pressure forcing out the contents, the delicate epidermis may be lacerated and inflammation result. The use of soap and water, followed by friction with rough towels once or twice daily, affords most excellent results; medicinal soaps can also be advantageously employed, especially sulphur, chamo- mile, ergot, salicylic acid, and sublimate, either in the form of potash or, even better, soda soap. Soap combined with alcohol, or any one of the spirits, is likewise effective. Stimulating lotions containing corrosive sublimate, one of the tarry preparations, sulphur, borax, bicarbonate of'soda, or sulphate of zinc, are well borne and yield good results. The French are much in the habit of employing camphorated alco- hol. Prof. Hardy recommends a solution of alum, and Brocq has often obtained satisfactory results from the use, night and morning, of a de- coction of saponaria-root, to which is added about a drachm of Cologne water and half a drachm of water of ammonia. I herewith give a formula that has proved useful in my private and hospital practice, and is well worthy of trial: R, Thymol................................ gr. x. Acidi borici............................. 3 ij. Aquae hamamelis Virg. dest............... f 1 iv. Aquae rosae.............................. f | j. M. Sig.: Mop well over the surface once or twice daily. The appended is also a very good application : R, Sol. boro-glyceride (50-per-cent. solution), Spts. vini rectif.......................aa f § ij. M. Sig.: Rub well into the part with flannel. The various stimulating ointments, particularly those containing sulphur, borax, Peruvian balsam, tar, and the mercurials, or an oint- ment composed of one part of carbonate of ammonium to eight parts of simple cerate may be used when soaps or lotions are not suitable. If the part has unfortunately been over-stimulated, and the skin as- sumes a rough and inflamed appearance, soothing and slightly astrin- gent ointments or dusting-powders should be employed, among the best of which is a mixture of equal parts of oleate of zinc and finely powdered talc, as proposed by Dr. Jamieson. DISORDERS OF SECRETION AND EXCRETION. 135 Prognosis.—Favorable results invariably follow well-directed efforts to remove the disease. Relapses may occur if the exciting cause re- mains, but persistent treatment will restore the skin to its normal condition. MILIUM. Synonyms.—Grutum—Strophulus albidus—Acne albida—Tubercula miliaria—Tubercula sebacea. Milium consists in the development of small, round, whitish forma- tions, located beneath and covered by the epidermis. Symptoms.—Milia appear as small, round, flat, or acuminated bodies, usually situated on the face, particularly about the upper eyelids, cheeks, and temples. They may occur, however, on other portions of the body, especially on the penis'and scrotum. They may or may not be elevated, and are hard and firm to the touch; in size they vary from a pin's head to a small pea, but commonly they are about that of a millet-seed, from which they derive their name. They are whitish, translucent, pearl, or yellowish in color. They may appear singly or multiple, but are ordinarily observed as several—usually four to twelve —upon one of the regions named. They develop, as a rule, slowly, and, after reaching a certain size, remain for years. They occur more frequently in women than in men, particularly at and after adult age. Milia may exist alone or occasionally in connection with other erup- tions, as acne, comedo, lupus, and syphilis. They give rise to no sub- jective symptoms, but, simply by their presence, if on the face, occasion more or less deformity. Diagnosis.—Milia may resemble comedones, from which, however, they may be distinguished by their anatomical formation. Milium, anatomically, is a very small sebaceous tumor, covered with epidermis; while comedo is simply a dilatation of the duct, with a retention of the secretion, and a free or open extremity. Occasionally the retained material of milium undergoes calcification. The little tumor then feels hard and constitutes, in fact, a cutaneous calculus. Milia usually project from the surface, and occur as the sole dis- ease; comedones, on the other hand, have a smooth surface, with prominent black points, and generally coexist with acne or some other eruption. Pathology.—Milium is thought by many investigators to consist in a retention of the sebaceous secretion, together with an oblitera- tion of the aperture of the gland. An incision through one of the formations will demonstrate that it lies beneath, and is covered with the epidermis. Virchow and Rindfleisch believe that the cysts pro- ceed from the hair-follicles. Robinson also states that he considers a milium, where superficially located and under certain circumstances, 136 DISEASES OF THE SKIN. may be a case of wandering embryonic epithelium from a hair-follicle or from the rete. Etiology.—The origin of this disease is in many cases unknown. It may arise from a constitutional derangement, or local source of irritation. Treatment.—The free use of soap and water, especially the potash soap, will often cause milia to disappear. But the best and most radi- cal treatment is by means of the knife. A small incision in conjunc- tion with an application of MonsePs solution or the tincture of iodine will insure their destruction. They may also be removed by electrolysis. SEBACEOUS CYST. Synonyms.—Steatoma—Atheroma —Sebaceous tumor—Follicular tumor—Encysted tumor—Wen. Sebaceous cyst is a prominent, roundish, or semiglobular tumor, situated in the skin or subcutaneous tissue. Symptoms.—Sebaceous cysts or wens consist of an accumulation of the secretion in the sebaceous glands. They are met with chiefly upon the scalp, forehead, eyelid, neck, shoulder, back, buttocks, and scrotum. They may occur singly, as is usually the case, or be multiple. An unusual case of such multiple development has been described by Prof. Chiari.* The patient was a man seventy-four years of age. The tumors were of all sizes, from an almost imperceptible nodule to that of a walnut. In some regions more than twenty were counted within an area of about four square inches. They vary in size from a pea to a small orange, and are semi- globular, rounded, or flattened in shape. They may be firm, soft, or fluctuating in consistency, according to the condition of the retained material. They are usually freely movable; but this depends upon their age, size, and the condition of the tissue in which they are seated. The overlying skin is either normal or paler in color, from the compression of the blood-vessels. It may be devoid of hair, and, in the aged, rough or red or greasy in appearance. The orifice of the gland- duct may remain in some and be obliterated in others. They are un- attended by pain, slow in their development, and often remain for years without producing annoyance. Occasionally, however, they inflame, suppurate, and ulcerate, giving rise to an offensive discharge. The periods at which they most frequently appear are childhood and mid- dle age; instances, however, have been known where they have existed before birth. They are also said to be hereditary. Diagnosis.—Sebaceous cysts are liable to, be confounded with fatty tumors. The latter, however, seldom invade the scalp, have more of a doughy consistence, their degree of mobility is slight, and they may attain a very large size. In case of doubt as to the diagnosis, an incis- * British Medical Journal, April 12, 1890. DISORDERS OF SECRETION AND EXCRETION. 137 ion should be resorted to. They may also resemble gummata and os- teomata. Gummata are usually attended by other syphilitic lesions, and are both rapid and painful; but are not as freely movable as the sebaceous tumors. Osteomata are hard and immovable; sebaceous cysts are soft and movable. Pathology.—A sebaceous tumor is a cyst of the gland, caused by retention of the secretion. It consists of a strong sac and its contents —the sac being formed by a distention of the gland, producing more or less hypertrophy of its walls. The contents are variable both in color and consistence—whitish, yellowish, or grayish, and hard and friable, or soft, cheesy, and fluid—and composed of sebum, epidermic cells, cholesterine, with occasionally a hair. The cyst may break down, and be attended with a fetid odor, or be partially or entirely filled with calcareous matter. Treatment.—The most certain remedy is excision. The operation, however, should be performed only when the system is in good condi- tion, or after proper preparation has been made for it. If this pre- caution be not taken, erysipelas may follow with dangerous and pos- sibly fatal results. After incision, the cyst-wall should be entirely torn or dissected out; otherwise, the growth may return. The cyst may also be destroyed by caustic applications or injections of iodine, carbolic acid, or other irritating substances. A convenient and successful method, according to a writer in the " British Medical Journal," consists in puncturing the cyst with a Graefe's cataract-knife, gently expressing the contents, and afterward introducing a very small piece of nitrate of silver. On the following day, by means of a pair of forceps, the capsule of the cyst can be with- drawn without any portion being left adherent. It is stated that in no case has this procedure been followed by return of the growth or ill effects. Prognosis.—As a rule, the prognosis is favorable. Fatal results may happen in the aged and debilitated, but seldom when they have been prepared for the operation. HYPERIDROSIS. Synonyms.—Ephidrosis—Hydrosis—Idrosis—Sudatoria—Increased secretion of sweat. Hyperidrosis is a functional disorder of the sweat-glands, character- ized by increased sweating. Symptoms.—Hyperidrosis may be either acute or chronic. It may be general, in which the entire body is affected, or local, and limited to certain regions. General sweating may occur in healthy individuals from nervous excitement, or from an increase in the surrounding tem- perature, especially in corpulent persons. It is often liable to appear in connection with tuberculosis, pneumonia, rheumatism, malaria, and 138 DISEASES OF THE SKIN. certain nervous, febrile, and debilitating diseases. The temperature under such circumstances may rise or fall. Long-continued hyperidrosis may depend upon anaemia. In this case, according to Hebra, warty thickenings, corns, or callosities always form upon the palms and soles. The fingers may assume a drumstick form, and the nails become large and broad. Local hyperidrosis may occur upon any part of the body, but the scalp, face, axillae, genitals, and palmar and plantar surfaces are most frequently involved. It may be temporary, continuous, intermittent, or periodical. It may be symmetrical or unilateral. Many cases have been recorded in which, owing to some derangement of the nervous system, the sweating occurred upon one or opposite sides of the body. It may be slight, or it may be so excessive as to saturate the clothing and macerate the integument. In the axillary region the poured-out sweat, mingling with the sebaceous secretion, particularly in women, discolors and destroys the clothing, creating a most disagreeable and offensive odor. The same annoying, and occasionally even more vexa- tious, effects follow from hyperidrosis of the genital regions. In the involvement of the palms and soles, the sweat may exude in drops, col- lect on the surface, and flow in quantity from the members. The palms when affected are bathed in a profuse perspiration, even after drying. The secretion can often be seen issuing from the ducts as a clear or yellowish fluid. The amount varies according to the condi- tion of the health and the state of the temperature. The skin presents a white, wrinkled, and macerated appearance, and the parts are cold and clammy to the touch. Similar and often even more severe symptoms occur in hyperidrosis of the soles. The stockings and shoes, or boots, become saturated with the secretion, which decomposes, adding a further source of irritation to the parts. The skin becomes macerated, sodden, fissured, especially in the flexures of the toes, and strips off, exposing a delicate and tender surface beneath. In a case under the care of Vidal, hyperidrosis of the foot was so excessive as to cause confluent vesicles with the eventual formation of bullae as large as an egg at several different points.* A disagreeable odor develops, and the pain and suffering may be so severe as to interfere partially or entirely with walking. Hyperidrosis may at times be attended with itching, burning, pricking, tingling, or other unpleasant sensations. It is often a most obstinate and persistent disorder, occurring in both sexes, and usually more severe in summer than in winter. It may give rise to other cutaneous affections, especially eczema. Diagnosis.—The diagnosis is easy, but the disease may resemble seborrhoea oleosa and prickly heat. In seborrhoea oleosa the poured- out secretion.is oily, and in prickly heat vesicles are formed, with at- * Journal of Cutaneous and Genito-Urinary Diseases, May, 1S88. DISORDERS OF SECRETION AND EXCRETION. 139 tendant surrounding inflammation; in hyperidrosis the secretion is serous, and vesicles and inflammation, as a rule, are absent. Pathology.—In a case of phthisis, attended with hyperidrosis, Yir- chow observed that the glands were enlarged, with fatty degeneration of the epithelium. The sweat-glands and tissue of the part involved are not usually changed in the least. Etiology.—Hyperidrosis may sometimes be congenital and heredi- tary. Functional or organic disease of any of the organs, or a derangeT ment of the nervous system, is often the exciting cause. A nervous influence has frequently been noted to be active in occasioning it. The direct cause can not be ascertained at times, even after careful examination into the condition of the system. Jamieson states that hyperidrosis of the hands is particularly apt to occur in those who are in the daily habit of using spirituous liquors to excess. Treatment.—The treatment should be appropriate to the case under consideration. If the cause of the disease can be detected, it should be removed or counteracted. Lung, heart, and kidney affections, or hysteria, neuralgia, anaemia, chlorosis, scrofula, or syphilis, may under- lie hyperidrosis, and they should receive the treatment necessary for each individual case. There are a number of remedies which may be employed in arresting excessive perspiration, but their effect, as a rule, is only temporary. Geber refers to the value of white agaric (0-1 to 0-5 gm.), the extract of aconite (0-03 to 0-06 gm.), and to salvia leaves, flor sambuc, the aqueous extract of strychnine, carbolic and salicylic acids. Jaborandi has been of service, as well as pilo- carpin and atropia. The latter is probably the most effective and certain general remedy; it may be given hypodermatically, in from one eightieth to one one hundred and sixtieth of a grain. Ergot, in the form of the fluid extract, and faradization have also been followed by good results. Tannic acid, gallic acid, quinine, sulphuric acid, and digitalis are other constitutional remedies which have been employed. Badliinde * recommends alcohol in excessive perspiration on account of finding that this agent diminishes the temperature of the skin and the trans- piration of fluid during the course of his experiments. The phosphate of calcium has sometimes been advantageously used. When the superabundant secretion seems to depend upon disorder of the nervous svstem, valerian, the bromides, and the cold douche may prove of service. Rheumatic and gouty patients in whom hyperidrosis is present may be benefited by the administration of the iodides. Hoang-nan exerts a special tonic influence upon the sudoriparous glands and restrains excessive secretion. Local treatment is essential in curing or relieving the disease. * Zeitschr. f. klin. Med., Bd. xiii., Heft 5. 140 DISEASES OF THE SKIN. The constant use of water in the form of baths, or applied directly to the part, simple or medicated, is not usually attended with the best results. In its mildest forms, the occasional use of water, as hot as the surface can bear, with naphthol, corrosive sublimate, sulphur, or tar soap, is often productive of good. In light and severe cases dusting- powders are well borne, either alone or after the application of water. Zinc oleate, salicylic acid, and naphthol are perhaps the most useful of all powders. The following I have found of service: R, Pulv. zinci oleatis................. 3 iij- Pulv. amyli...................... I ss. M. R, Acidi salicylici, Bismuth subnit................aa 1 ss. M. R. Naphtholi...................... 3 j. Acidi borici....................•. f ss. M. As soon as the powders become moist on the surface, they should be removed with sweet-oil and reapplied. Care should always be exercised to avoid having the affected part too warmly covered or too well pro- tected. This condition is frequently observed among women who wear shields in the axillae to protect their clothing, and in men who apply varicocele-bags and other means of protection around the genital or- gans. These articles may often cause the secretions to be retained, and produce an inflammation of the skin. Lotions are frequently effectual. They may be aqueous or spirituous, and contain tannic acid, camphor, sulphate of zinc, acetate of lead, acetic, sulphuric, boracic, and salicylic acids, corrosive sublimate, perchloride of iron, or other drugs. Ten grains of corrosive sublimate, in four ounces of Cologne-water or tincture of witch-hazel, forms an elegant and useful application. Alum, one or two drachms to the pint of water or alco- hol, may also be employed. The tincture of belladonna is said to be a valuable remedy. A one-per-cent. aqueous solution of chromic acid is often very effective in hyperidrosis of the feet. A piece of lint satu- rated in the solution should from time to time be applied to the soles and the spaces between the toes. An excellent lotion consists of hydro- chlorate of hydrastine in the strength of two to six grains to the ounce of water or distilled witch-hazel. An infusion of soap-bark is also efficacious. A ten- to twenty-per-cent. solution of formalin in alcohol has been used with good effect. Tannoform, a mixture of formalin and tannin, is a beneficial dusting-powder. Unna recommends that before going to bed the patient should bathe the parts in hot water containing camphor, mustard, or vinegar, after which an ointment of turpentine or ichthyol, each five parts to ten parts of oxide-of-zinc ointment should be applied. In the morning the ointment should be washed off, cold water be rubbed upon the sur- face until redness and warmth are produced, and then dusted with a powder containing mustard-flour. DISORDERS OF SECRETION AND EXCRETION. 141 In obstinate cases, involving the feet, Hebra obtained good effect from the application of diachylon-ointment. The ointm3nt is spread upon pieces- of linen sufficient to cover each foot, likewise on sepa- rate pieces to be placed between the toes. The entire foot is then covered with linen, bandaged, and the stocking and shoe put on. The same procedure is repeated each day for one or two weeks. The upper layer of the skin in the course of a few days after treatment begins to be cast off; after this is complete the feet are washed and powdered, the latter process being continued for some weeks after the ointment. Stewart advises that after bathing the affected parts with warm water, they should be washed with a solution of permanganate of po- tassium, then dried, and, when the hands and feet are involved, that they should be enclosed in bandages spread with cerussa. The plaster is to* be renewed every twelve hours during ten to sixteen days. Thy- mol may be added to the permanganate solution with advantage. Chloral in ten-per-cent. solution, or a weak solution of chlorate of potassium, has also been recommended as useful in this affection. Salicylic and boracic acids, lead oleate, and naphthol are likewise valuable ointments. An ointment of hydrastine or aluminium oleate can also be recom- mended. Of late I have used aristol * with very satisfactory results. Upon sweating feet it may be used alone as a dusting-powder. In other localities I have mingled it with the impure carbonate of zinc or have prescribed it in the form of an ointment made up with the oxide of zinc or subacetate of lead. Lint and absorbent cotton, with or without medication, are also use- ful. Robinson endorses the use of borated absorbent cotton without other adjuncts. Another good plan is to dust subnitrate of bismuth freely into the stockings or gloves. Prognosis.—Hyperidrosis in many cases can only be alleviated. The disease is obstinate and unyielding to the best-known methods of treatment. If the cause can be discovered and removed, the prognosis is favorable. A cure, however, and very often relief, is not obtained, owing to the patient neglecting to thoroughly carry out the treatment advised. ANIDROSIS. Synonyms.—Hypohidrosis—A decreased or complete cessation of the secretion of sweat. Anidrosis is a functional disorder of the sweat-glands, character- ized by a decrease or complete cessation of the secretion of sweat. Symptoms.—Anidrosis may be idiopathic or symptomatic, general or local. It may be congenital or hereditary, there being a diminution * Sec paper on " Aristol," by John V. Shoemaker, A. M., M. D., in the Medical Bul- letin for June, 1891, p. 201. 142 DISEASES OF THE SKIN. or an absence of sweat, under circumstances which generally make the sudoral secretion most active. Examples of general idiopathic anidrosis are to be observed in ichthyosis. The skin in these cases is harsh and dry, and the palmar and plantar surfaces are thickened, fis- sured, and at times painful. Symptomatic Anidrosis, which is far more common, may be either general or local, and may occur from impairment of the nervous sys- tem, or in the course of other cutaneous affections, as eczema, psoria- sis, lichen rubra, and leprosy. It may be temporary, as in fevers and neuralgias, or it may be permanent, as follows sometimes in diabetes, carcinoma, and tuberculosis. The skin, whether the disease be gen- eral or local, temporary or permanent, is dry, rough, and often the seat of itching, burning, and other distressing sensations. Occasion- ally, a sudden arrest of the functional activity of the sweat-glands may give rise to more or less unpleasant constitutional symptoms. An allusion may not inappropriately perhaps be made in this place to a condition described by E. C. Perry under the title of " Adenoma of the Sweat-glands." A woman had for twenty-one years been afflicted with white, firm papules upon the face. The lesions varied in size from that of a millet-seed to that of a pea, were painless, and had never ulcerated. There was no seborrhoea, and the secretion of sweat from the head and face had decreased. The sweat-glands were enormously enlarged. The swellings were pricked with a needle and then removed with scissors or scalpel. The result was a complete cure. Treatment.—Exercise, especially in the open air, or the use of mas- sage, is to be advised. The general health should also be corrected. Baths—the cold, hot, steam, hot-air, or Turkish or Russian—with fric- tion of the skin, are to be commended. Diaphoretics are advisable. The most valuable are the fluid extract of jaborandi, in the dose of from a few drops to one or two drachms, or its alkaloid, hydrochlorate of pilocarpin, given in from one tenth to one half grain. Free diapho- resis will follow in a short time, and continue for several hours. From its tonic influence upon the glands of the skin hoang-nan is useful in this disorder. Emollient ointments or oils will often be required when the skin is dry and fissured. Lanolin, alone or combined with a few drops of oil of eucalyptus, forms an excellent application. The use of dilute glycerine will also sometimes serve a good purpose. BROMIDROSIS. Synonyms.—Osmidrosis—Stinking sweat—Odorous sweat. Bromidrosis is a functional disorder of the sweat-glands, character- ized by an offensive or disagreeable odor from the skin, with more or less sweating. Symptoms.—Bromidrosis may occur either as a general or as a local DISORDERS OF SECRETION AND EXCRETION. 143 disorder. If general, it may be a physiological condition, as is the case in the negro, and occasionally in persons of other races. The exhalation may have a characteristic odor, as of decayed cheese, putrid flesh, urine, or rancid, goaty, or sour; or like that of onions, asafoetida, musk, sulphur; or it may have a peculiar sweet smell, like violets or pineapples. A distinctive scent occurs in certain diseases, as in the fevers, in which it is ammoniacal; in scurvy, putrid ; in syphilis, sweet; in rheumatism, acid; in jaundice and peritonitis, musky. In nervous affections, also, peculiar odors have been noted to occur; Hamilton recording, for instance, that of violets perceptible in a lady of hyster- ical disposition. The ingestion of certain articles of food and drugs may give rise to others. The local forms of bromidrosis are the most common, especially upon those portions of the body abundantly sup- plied with sweat-glands, as the axillae, groin, genital regions, and feet. The odor may vary, being slight and hardly apparent, or so penetrat- ing and offensive as to interfere with the person's intercourse with his fellow-man. It often causes individuals to be shunned by those they come in contact with in their occupation, as well as in social life. The disorder is more severe in the summer than in the winter months. It may occur at all ages, but is more frequently encountered in middle life. The feet, which are the most frequently affected, exhale a most offensive odor. The disorder is mostly symmetrical. The skin, from the irritating action of the decomposed secretion, which is retained in the stockings and shoes, becomes red, excoriated, and tender, or whitish and sodden, and is sometimes so painful as to interfere with walking. Bromidrosiphobia * is a term employed by Piffard to denote that the odor complained of is subjective and referable to perverted sensi- tiveness of the olfactory organs. Two cases of this disease are reported by him. Etiology.—The disorder is frequently connected with some nervous derangement. At times it will be found impossible to trace it to any assignable cause. Treatment.—Bromidrosis, if physiological, may be relieved by fre- quent ablutions with water and soap, the naphthol and carbolic-acid soaps being serviceable. The same may be said of eucalyptus soap. The under-garments should be changed often. When it is dependent upon disease, particularly of the nervous system, it should be counter- acted by appropriate treatment. The internal administration of hoang- nan will be found of material assistance to the local treatment. Small doses of jaborandi by the mouth or of pilocarpin hypodermically are also of advantage. The local forms are treated principally in a similar manner to hyperidrosis. There are, however, certain remedies which are particularly efficacious, and to which special attention is called. Naphthol, boric and salicylic acids are valuable agents, used in the * Loc. cit. 144 . DISEASES OF THE SKIN. form of lotions or ointments. From ten to thirty grains of either in an ounce of water, alcohol, lard, lanolin, or suet, form suitable appli- cations. Sulphate-of-zinc ointment in the same strength is efficacious in removing the offensive odor. An ointment of alum containing thirty or forty grains to the ounce, or of aluminium oleate mixed with equal parts of lard, is of service in this affection. The sulphate or acetate of copper in the form of ointment or lotion or the oleate made into a ten or twenty per cent, ointment may also be advantageously employed. Hydrastine-ointment, made by incorporating from five to thirty grains of the hydrochlorate in an ounce of excipient, diminishes fetor. Thin recommends, in bromidrosis of the soles, the wearing of cork-soles within the shoes; the cork to be soaked, as well as the stockings, in a solution of boric acid, and to be thoroughly dried be- fore wearing A fifty-per-cent. solution of boro-glyceride, used alone or rubbed up with carbonate of lead or zinc, often acts well. The per- manganate of potassium or chloral hydrate, in from five to thirty grains to the ounce of water, alcohol, or tincture of witch-hazel, may have a beneficial effect. Solutions of oxalic acid, ten to twenty grains to the ounce of water, or chloride of zinc, in from three to ten grains to the ounce, may also be recommended. The local application of tincture of iodine has likewise been found successful in some cases. Among other lotions which may be employed with more or less benefit may be mentioned lime-water, and the infusion of soap bark. The hands or feet may be bathed in the latter fluid every day or every other day, while the face or axillae may be washed with a sponge which has been dipped in the infusion. The following formula is highly recommended by Tshappe: R. Zinci sulphat., Ferri sulphat................iia 450 grammes. Cupri sulphat.................. 150 " Naphthol...................... 1_5 « Essen, thym.................... 3-5 " Acid hypophosphor............. 5-7 » Aq. destillat.................... 2500 " The various dusting-powders, especially the oleate of zinc, salicylic acid, and powdered red cinchona, singly or combined, either with or without lotions, often afford much relief. CHROMIDROSIS. Synonym.—Colored sweat. Chromidrosis is a functional disorder of the sweat-glands, charac- terized by a coloration of the sweat-secretion. Symptoms.—Chromidrosis is a very rare disorder, and consists in the commingling df sweat with pigment-matter. The sweat is in- DISORDERS OF SECRETION AND EXCRETION. 145 creased in quantity, and may be of a yellowish, greenish, reddish, bluish, brownish, or blackish color. The secretion is not constant in its periods of development. It comes suddenly, to disappear in a brief interval, and again reappear^ It may occur upon various parts of the body, but is most frequently observed on the face, chest, abdomen, arms, hands, and feet. It is met with more often in females, especially the unmarried and in those suffering from some uterine derangement, nervous affection, excitement, or shock. The coloring-matter in the secretion is said to be due to Prussian-blue, indican, or other pigment. Simulated cases of colored sweating have occasionally been reported. A valuable paper upon chromidrosis has been written by Dr. Foot, who ascertained that since the first case was observed in 1709 until the year 1888 forty-six genuine cases had been placed upon record. Six of these had occurred in men and forty in women. He believes that the absorption of indol from the intestinal canal is the source of the in- dican. Red sweat is due to the presence of the bacterium prodigiosum. The discoloration is associated with increased production of sweat. Dr. Stott, of Blackpool, has described two cases of chromidrosis occur- ring in a father and son. The color was pink, and from a portion of affected skin he succeeded in obtaining a pure culture of a pink torula. Treatment.—The general health should be regulated, and local stimulating applications made. Deception may be guarded against by adopting the following plan: " The spot to be examined is carefully cleansed with oil, and, when perfectly dry, collodion is painted on in a thin layer, and allowed to remain for a few days. When the chromi- drosis is actually present, it will show itself after the collodion pellicle is lifted off." Abnormal changes of the sweat-secretion, different from those.re- ferred to, have often been recorded. Thus, urinous sweat (uridrosis) has been noted in which the urinous elements, especially urea, were mingled with the poured-out secretion. The deposit in urinous sweat consists of colorless or whitish crystalline material, which is slightly adherent to the skin; it can be detected by its solubility in alco- hol and giving with nitric acid the characteristic crystals of nitrate of urea. The disorder occurs from faulty renal action, and has also been known to follow the use of jaborandi. Hmmatidrosis, or sweating of blood, another example of abnormal secretion, will be noticed on a succeeding page. Greenish and other peculiar changes in the color of sweat may appear after the ingestion of copper, iodine, tar, turpentine, and phosphorus, and after eating certain species of fish, and occasionally in the course of phthisis and malaria. The color of the sweat may also become changed from the resorption of excrementitious material in jaundice and yellow fever, in which case the secretion becomes yellow. 10 146 DISEASES OF THE SKIN. SUDAMINA. Synonym.—Miliaria crystallina. Sudamina is a non-inflammatory disease of the sweat-glands, char- acterized by the development of whitish or pearl-colored vesicles about the size of millet-seeds. Symptoms.—Sudamina appears as discrete vesicles which may form upon any part of the body, but are more common on the face, neck, and trunk. They are about the size of millet-seeds, elevated, trans- parent or pearl-colored, and look like minute sweat-drops in the skin. The lesions may be limited to a small area or may occupy a consider- able extent of surface. They develop rapidly, continue discrete but crowded together, and disappear after the absorption of their contents, with desquamation of their covering. The affection is usually unat- tended by any subjective symptoms, though in some cases slight burn- ing or itching sensations are experienced. The course of the eruption is variable; fresh lesions may appear frequently and prolong the dura- tion of the disease. Sudamina is distinguished from other vesicular eruptions, especially eczema and varicella, by the absence of inflam- matory symptoms. Pathology.—The vesicles are formed by the collection of the sweat in some part of the ducts, or between the layers of the epidermis,4 owing to the inability of the fluid to escape upon the surface. Etiology.—-The cause of sudamina is an elevation of temperature, which frequently follows in the course of many systemic affections, especially the fevers. It is observed in typhus, typhoid, and puerperal fevers, scarlatina, variola, rheumatism, pneumonia, tuberculosis, pyae- mia, debility, and many other disorders. Exercise, when excessive in corpulent people, the wearing of a large amount of clothing, and sweating from baths or any cause, particularly in hot weather, may lead to sudamina. Impermeable coverings, such as rubber or oiled silk, may, if too long continued, give rise to sudamina. Treatment.—The treatment applies to the disease which occasioned the sudamina. Local applications of a saturated solution of boric acid, tincture of witch-hazel, or alcohol, alone or with half a drachm of camphor to five ounces, are most acceptable. Bland dusting-pow- ders, as starch, arrow-root, the impure carbonate of zinc, or the sub- nitrate of bismuth, may also be employed. HYDROCYSTOMA. Hydrocystoma is an eruption upon the face of discrete, deeply- seated vesicles, which are due to retention of secretion by the sudo- riparous glands. Symptoms.—In this disease, which was first distinctly described by DISORDERS OF SECRETION AND EXCRETION. 1^7 Dr. A. B. Robinson, of New York, in 1893, vesicles appear upon the face, particularly around the nose, upon the temples and upper lip. They seldom or never occur upon other parts of the body. The lesions vary in size from a pin's head to a barleycorn. They may be few in number or several hundred may be present. As a rule, the vesi- cles are discrete, but in some instances they seem to coalesce. They are spherical in shape and firm to the touch, and have a pearly appear- ance, similar to boiled sago-grains. They may also be of an ovoid or obtuse contour. The color of the lesions varies. Some are of a light yellow hue, some are of a bluish tint, while others again are white. The lesions are not of inflammatory character. Their contents are clear, watery, and redden litmus paper. The disease occasions no pain, but in some instances there is a feeling of tension and a moderate de- gree of smarting. Individual lesions continue for a few weeks, when they disappear and others come out to take their place. The erup- tion is most distinct during free perspiration, and is therefore much more common in summer than in winter. In the absence of perspira- tion the vesicles diminish in size or disappear. According to the expe- rience of Robinson, the disease is not extremely infrequent. It gener- ally attacks women of middle age or older, who perform household work in a heated atmosphere, as washerwomen, cooks, etc., although it has been observed in young men. Examined under the microscope, the corneous layer and rete muco- sum are apparently normal. The papillary layer is normal in the early stages of the affection, but after the lesions become large and approach the rete the circulation is interfered with from pressure. In the upper part of the corium a perivascular invasion of leucocytes is present in moderate degree. The sebaceous glands and hair-follicles are normal. The vesicles are caused by a cystic dilatation of the excretory sweat- ducts lying within the corium, the contents consisting of fluid inter- mingled with granular material. Hydrocystoma differs from sudamina in being more deeply seated and more firm. The lesions of milium contain sebaceous matter. The size, the limited number, and the contents of sebaceous cysts sufficient- ly distinguish them from the vesicles of cystoma. Pompholyx seldom attacks the face, and is accompanied by heat and itching. As regards treatment, the patient must be instructed to avoid as far as possible everything which tends to increase perspiration, and the lesions must be punctured. . • HYDRADENITIS DESTRUENS SUPPURATIVA. Under this title Dr. S. Pollitzer, of New York, describes * an ex- ample of a rare affection which he has recently observed. The patient was a young man, twenty years of age, of good family and personal * Journal of Cutaneous and Genito-Urinary Diseases, January. 1892. 148 DISEASES OF THE SKIN. history. About twenty lesions were situated upon the face and neck. They begin in the subcutaneous tissue, the overlying skin being at first totally free from alteration. Symptoms.—The primary form is that of a hard, painless nodule which, in the course of ten to fourteen days, attains the size of a pea. The epiderm becomes raised, producing the appearance of a small, round tumor. As the growth enlarges the skin covering it becomes reddened, and a drop of pus issues if the nodule be pierced. A few days later retrograde changes commence, the tumor becomes yellowish, the epiderm gives way, and a few drops of blood-stained pus escape. Small shreds of tissue are sometimes extruded. If the secretion ac- cumulate, it forms a discolored crust which falls in a few days, leaving a dark, reddened skin which remains pigmented for many weeks, a slightly depressed scar ultimately occupying the situation of the tumor. About four weeks are consumed in this process. Occasionally neigh- boring nodules coalesce and form a flat tumor as large as an almond, which, in breaking down, discharges through a number of small open- ings. Some of the lesions may remain quiescent for months without enlargement or suppuration. The tubercles appeared upon parts marked by a dense growth of hair. The hairs, however, were not loosened, and even grew normally from the shallow cicatrices, showing that their follicles were not in- jured. The growths developed in crops at irregular intervals of a few days to several weeks. This process continued for about nine months. Adjacent lymphatic glands were not swollen. The temperature was unaffected and the urine was free from albumen or sugar. Diagnosis.—The subcutaneous origin of the nodules distinguished them from acne; no bromides had been administered ; they lacked the severe inflammatory manifestations of furuncles; and the discharge of a central necrosed mass, the non-involvement of the hairs, and the ab- sence of its fungus excluded trichophytosis, while the course of the malady bore no resemblance to that of a syphilitic deposit. Pathology.—Two nodules were excised and examined. One of these was taken from the subcutaneous tissue, while the other illus- trated a later stage of development, just prior to rupture of the cuticle. The appearances were essentially the same in both, the tumors con- sisting of a dense aggregation of small, round cells, epithelioid cells, and large multinuclear masses resembling giant-cells. The small cells were of inflammatory origin. Individual epithelioid cells were seen containing from two to five nuclei, and forms could be traced which merged by indistinguishable gradations into the giant-cells. These were very numerous, and, as a rule, were somewhat smaller than those of tuberculosis or other granulomata. The nuclei varied in number from five to twenty. Most of the cells were of an irregularly round or oval shape, but some were very irregular in form. Blood-vessels could DISORDERS OF SECRETION AND EXCRETION. 149 be traced throughout the entire growth. The endothelium was gen- erally swollen, the capillaries occupying the centre of the nodule being completely occluded. The hair-follicles were numerous and large in and around the tumor, and appeared entirely normal. The sebaceous glands also seemed to be unaffected. No sudoriparous glands were included within the new growth, but were observed in its vicinity. Many of these glands showed peculiar changes. Their epithelium was swollen, and in many instances the tubules were obliterated. In some no further change had taken place, in others some infiltration had occurred within the coil, and the swollen epithelium completely filled the tube with a homogeneous mass. In such glands the mem- brana propria could not be distinguished. The author regards the giant-cells as formed of degenerated and broken-up fragments of the epithelium of the sweat-glands. The epithelioid cells are probably formed in the same way by a breaking up of the degenerated gland epithelium into fragments smaller than those which resemble giant- cells. This mode of formation, the author goes on to say, of giant- cells in the skin has not before been described, but is analogous to that observed by Waldstein in tuberculosis of the testicle and by Taylor and Van Giesen in diffuse orchitis. The sweat-glands are the starting- point of the process. They are the seat of a parenchymatous degener- ation which, in all probability, originates primarily within the glands. The disease would appear to be of infectious origin, but cultures of fresh pus were entirely negative, no organisms whatever being detected. The writer was unable to make any inoculation experiments. Dr. Pollitzer regards the case which he has so carefully studied as being identical with those described by Velpeau, Verneuil, and a few other French writers, and, more lately, by Barthelemy under the name of acnitis. Darier found round, epithelioid, and giant-cells in sections made from Barthelemy's cases. Lukasiewicz has published a paper from Kaposi's clinic describing an affection which strikingly resembles that observed by Pollitzer. Dubreuilh has written of the same affec- tion under the name of hydrosadenitis disseminata suppurativa. Etiology.—This disease, according to Verneuil, may result from either local or general causes. Among the former are uncleanliness, cold, rough friction, irritating applications, parasites, etc. Constitu- tional causes given are " herpetism," dyspepsia, constipation, pruritus, scrofula, fevers, etc. Treatment.—Pollitzer in his case prohibited shaving, covered each nodule with Unna's mercurial carbolic-acid plaster, incised the.nodules when they had softened, and washed the affected region frequently with a three-per-cent. salicylic-acid alcoholic lotion. Toward the ter- mination of the case he administered corrosive sublimate with iodide of potassium. Equal parts of zinc oleate and French chalk together with three per cent, of salicylic acid compose a good dusting-powder. 150 DISEASES OF THE SKIN. CLASS II. HYPEREMIAS. {Hyperarniim.) The class of hyperaemias includes those disorders which are char- acterized mainly by the presence of an increased quantity of blood in the cutaneous vessels. The increase may be universal and affect the entire surface, but it is usually limited to certain regions of the body. It may be active or passive in character, and idiopathic in origin, or symptomatic of disturbances in remote portions of the system. The increased blood-supply is always productive of changes in the color of the affected portion of the skin. The color of hyperaemic eruptions varies from light-red to dark-red or purple, but disappears upon pressure, to return as soon as the pressure is removed. Active hyperaemic eruptions may be accompanied by slight burning or itch- ing sensations, and usually pursue an acute course. Passive hyperaemia is usually indicative of mechanical or functional interference with the circulation. In the former case tight garters, bandages, or clothing may be the cause, and the affection disappears 'when they are removed; in the latter case, cardiac or valvular disease or varicosity of the veins may be the producing cause, when the hy- perasmia is apt to remain for an indefinite period, and finally result in permanent pigmentation of the surface. ERYTHEMA SIMPLEX. Erythema simplex is a hyperaemic cutaneous affection characterized by the formation of reddish, non-elevated macules or patches on the general surface of the body. Symptoms.—There are two varieties of erythema simplex, the idio- pathic and the symptomatic. The idiopathic variety is generally sub- divided into the three groups of erythema traumaticum, erythema caloricum, and eryethema venenatum. The symptoms differ some- what according to the form of the affection which may be present. In erythema traumaticum the skin is reddened and tender at the point which has been subjected to pressure or friction, but normal elsewhere. In erythema caloricum the skin is reddened, and more or less painful, but only at the point which has been exposed to intense solar or artificial heat. In erythema venenatum the eruption is more diffused, but it is painful, and limited to the regions with which the irritating or poisonous material has been placed in contact. In ery- thema symptomatica there is no pain or itching, and the eruption may HYPEREMIAS. 151 appear upon any part of the surface. In some cases the abdomen is involved, in others the face, or perhaps the limbs, and occasionally the whole surface is invaded. The lesions of erythema symptomatica are exceedingly numerous, and of all shapes and sizes, but they are ephe- meral in character, frequently disappearing in a few hours, and rarely remaining longer than two or three days. In erythema traumaticum, venenatum, and caloricum the lesions are but few in number and more persistent. Erythema symptomatica is mostly preceded or accom- panied by gastric or intestinal derangements. Diagnosis.—The diagnosis of erythema simplex is usually easy. The only affections with which it could be confounded are rotheln, macular syphilis, and simple dermatitis. Rotheln, however, is accom- panied by fever and cartarrhal symptoms, phenomena which do not occur in erythema simplex. In macular syphilis the lesions are equal in size, circular in shape, and arranged in groups. In erythema symp- tomatica the lesions are of all shapes and sizes, and irregularly dis- tributed. There is no specific history, and evidences of gastrointes- tinal irritation are present. In dermatitis there is no severe pain, and more or less increase of temperature. Pathology.—The redness of the epidermis is due to dilatation of the capillaries of the superficial layer of the corium. Etiology.—The causes of erythema simplex are numerous and varied. The idiopathic varieties are produced by the action of heat or cold, or by friction or pressure in any form, or by- contact with acids, strong alkalies, aniline dyes, mustard, sulphur, arnica, can- tharides, arsenic, antimony, poisonous plants, and other irritating substances. Symptomatic erythema results from the ingestion of im- proper food, or from worms, or from constipation, or other disorders of the gastro-intestinal tract. It may also arise from the irritation of dentition, or any disturbance of the nervous system. M. Perrin believes that erythema occurs in a certain number of cases of gonorrhoea independent of treatment by copaiba or cubeb, and that the action of those substances in producing a rash is at least as- sisted by a tendency of the disease.* Treatment.—The treatment varies with the cause and extent of the disease. Erythema symptomatica rarely requires any treatment beyond the administration of a gentle laxative. If worms exist, they should be removed by the employment of appropriate anthelmintic remedies. In idiopathic erythema no internal medication is requi- site. In many cases the local irritation is removed by the. applica- tion of cold water alone. In others, soothing ointments or lotions will usually bring immediate relief. Prognosis.—The eruption is always trivial in character and speedily disappears. * Annals de Derm, et de Syph., November, 1890. 152 DISEASES OF THE SKIN. ERYTHEMA INTERTRIGO. Erythema intertrigo is a hyperaemic cutaneous affection produced by heat and the contact of opposing surfaces. It is characterized by a reddened condition of the skin, and accompanied by a sensation of heat or burning. Symptoms.—Erythema intertrigo is that form of erythema which occurs in the natural folds of the skin, and wherever two opposing surfaces come in contact with each other; e. g., as between the nates, beneath the mammae, and in the axillary and inguinal regions. It is observed most frequently during the summer months, but may appear during any season of the year. It occurs especially in fleshy persons and in infants. The skin in the affected regions becomes reddened and chafed, and is more or less hot and painful to the touch. If the exciting cause be removed, or if remedial measures be instituted, the affection may be arrested in this stage. In many cases, however, it passes into a mild form of dermatitis. Occasionally it terminates in eczema. The duration of erythema intertrigo varies from a day or two to several weeks. In some it remains throughout the heated term, and is a source of much annoyance and suffering. When it occurs in in- fants it is more or less obstinate to treatment, especially if the erup- tion is situated between the nates. The perspiration which usually accompanies the eruption may sometimes be so excessive and acrid as to produce extensive maceration and desquamation of the epi- dermis. Diagnosis.—The diagnosis of erythema intertrigo is usually self- evident. The location and character of the eruption are sufficient to distinguish it from the lesions of any other disease. The erythema- tous patches of infantile syphilis occasionally simulate those of the innocent affection, but the existence or speedy appearance of other syphilitic lesions unerringly indicates the true nature of the dis- ease. Pathology.—The only pathological change that occurs in the great majority of cases of the eruption is dilatation of the blood-vessels of the corium. Excessive perspiration may produce maceration and sep- aration of the epidermis, or of its superficial layers. Etiology.—The exciting causes of erythema intertrigo are heat, and the friction or pressure of two opposing cutaneous surfaces. The predisposing causes are numerous, and include all circumstances which increase the temperature of the body or of the affected region, or which produce an irritable or sensitive condition of the skin. Among direct or indirect causes may be mentioned summer weather, unusual exercise, heavy underclothing, tight or ill-fitting garments, sedentary habits, and constipation. In infants the irritation produced by worms HYPEREMIAS. 153 and by acrid discharges from the bowels leads frequently to the dis- ease. Treatment.—No internal treatment is required, as a rule, except when constipation exists. In some cases, however, occurring in very fat persons, the best treatment consists in the daily administration, for two or three weeks, of full doses of any of the saline purgatives, in order to produce copious intestinal discharges. The local treatment is of the simplest possible character, and consists chiefly of cleanliness and rest. The affected surfaces should be bathed with cold water two or three times a day, and gently mopped dry with a soft cloth. Soap and friction are injurious, and should not be used. If practicable, the erythematous surfaces should be kept separate by the interposition of a piece of linen or soft muslin. Where this can not be done, they should be dusted over with any astringent non-irritating powder, as in the following formulae : R, Bismuthi subnitratis, Plumbi carb.........................aa | ss. M. R, Pulv. marantae.......................... 3 ij. Zinci oxidi............................. 3 vj. M. In many cases more benefit will be derived from the application of a bland ointment: R, Bismuthi subnitratis.................... 3 iij. Plumbi carb........................... 3 ij. Ung. zinci oxidi benz................... § iss. M. Ft. ungt. Lotions of lead-water and laudanum, of alum, borax, or sulphate of zinc, will be found serviceable in some cases. Prognosis.—The eruption speedily disappears under treatment, or without treatment when the exciting or predisposing cause is removed. 154 DISEASES OF THE SKIN. CLASS III. HEMORRHAGES. {Hwmorrhagice.) Cutaneous haamorrhages may occur from a rupture of the blood- vessels, as from external injury, or the blood-corpuscles may escape through the capillary walls and pass into the skin. The lesions formed from haemorrhages into the skin may assume certain appearances, which are known by the following names: Petechial consist of small round or irregular spots, varying in size from a pin's point to a finger-nail. Vibices are long, narrow, streak-like spots. Ecchymoses are irregular patches, from the size of a coin to that of the palm of the hand, or larger. Ecchymomata appear as variously sized and shaped patches or tumors, which may be flat or elevated. Haemorrhages into the skin which result from external injury are known as idiopathic, and those wThich occur from internal disease are termed symptomatic. Idiopathic Haemorrhage.—Here the haemorrhage is usually the re- sult of traumatism. Wounds, contusions, and all forms of injury may cause a rupture of the blood-vessels, and an extravasation of more or less blood into the skin and even the underlying tissue. The bites of numerous insects, particularly of the louse, bed-bug, and flea, are also causes of idiopathic haemorrhages. The treatment consists in the ap- plication of remedies to hasten absorption. Occasionally stimulating ointments and lotions are of advantage. Mercurial ointments, espe- cially the oleate, have proved of service. Localized haemorrhagic spots which are on the face or exposed parts can be relieved and ab- sorption hastened by leeching or puncturing, and painting them with a thick paste of carbonate of lead. Symptomatic Hemorrhage.—To this form belong all haemorrhages which arise from systemic disturbance. They occur in connection with small-pox, typhus and cerebro-spinal fevers, and other diseases, and also at times in the course of urticaria, erythema nodosum, and pemphigus. There are several forms which are recognized as inde- pendent diseases, and call for separate description. PURPURA. Synonyms.—Hoemorrhcea petechialis—Blutfleckenkrankheit. Purpura consists in the formation of haemorrhagic patches on the skin of different sizes and shapes, slightly elevated or non-elevated, and not disappearing on pressure. HAEMORRHAGES. 155 Symptoms.—Purpura may occur in three varieties, and, as they differ very much in their symptoms, it has been considered better to describe them separately, as follows : Purpura Simplex.—Purpura simplex is seldom ushered in with constitutional disturbance. Rarely, it is preceded by lassitude, loss of appetite, and slight fever. The eruption may appear suddenly, usually overnight, or gradually in the course of several days. The haemor- rhagic spots are bright or deep red or purplish in color, and are vari- ously shaped, and in size from a pin's, point to that of a pea. They are not elevated, but are situated deep in the skin, and will not disap- pear on pressure. They occur mostly in numbers, irregularly over the surface, but have a predilection for the lower extremities, especially the thighs. Subjective symptoms, excepting a general soreness of the skin, are absent. Occasionally they may be accompanied by moderate itching, but seldom by pain. Wheals, however, at times develop as a complication, the itching being marked, and the condition is then known as purpura urticans. Blebs have also been observed in this va- riety of purpura. The disease usually runs its course in one or two weeks; but it may be prolonged for months by the formation of suc- cessive crops of the eruption. It occurs generally in the debilitated, and especially in old persons. Dr. K. Morin has given the particulars of a case in which, during ten years, an eruption of purpura simplex made its appearance two or three days before each menstrual period, reached its height in twenty- four hours, and disappeared at the end of eight or ten days. The pa- tient was otherwise healthy and had never been subject to hasmorrhage prior to the development of the purpura.* Purpura simplex has been known to result from the use of certain drugs, as quinine, chloral, sali- cylic acid, and iodide of potassium. Purpura Rheumatica, Peliosis Rheumatica.—Purpura rheu- matica is, as a rule, preceded or accompanied by lassitude, despond- ency, impairment of appetite, constipation, fever, and rheumatic pains, especially about the joints. Swelling of one or more joints sometimes occurs. After a time, mostly in several days or a week, an eruption suddenly appears over the body, being more profuse on the abdomen and limbs. The haemorrhagic spots, which are usually well defined, are somewhat raised or on a level with the skin, and the only subjective symptom which accompanies them is soreness of the skin. In color the spots are light-red or purplish, and in size they are generally about that of a finger-nail. They will not disappear on pressure; but in time, as the blood is gradually absorbed, they change into yellowish and greenish tints, until finally they fade away entirely. In rare instances a hemorrhagic spot becomes gangrenous. The rheumatic pains some- times abate, or disappear with the appearance of the eruption. In * See Medical Bulletin, May, 1891. 156 DISEASES OF THE SKIN. many cases, however, the constitutional symptoms continue throughout the disease, or appear in the form of relapses together with successive crops of the eruption. The course and duration of the disease are un- certain, continuing weeks or months, or prolonged for a greater period. Hasmorrhage from the internal organs, especially the kidneys, may happen as a complication, and occasionally prove fatal. Certain cases are accompanied by gastro-intestinal disturbances,- such as colic, vomit- ing, diarrhoea and occasionally haemorrhage. There may be haemor- rhage from the stomach or bowels, and the latter may be so violent as to induce local necrosis, perforation, and peritonitis. The disease is rare, and bears some relation to erythema multiforme, with which it has been associated at times. It occurs in both sexes about middle life, and is seen more frequently in women. It is some- times met with in children and young adults. The cause is obscure. I have seen several cases in which it was due to great nervous exhaus- tion, and in one instance to excessive venery. No relation can be traced between this form of purpura and cardiac disease. It never seems to give rise to endocarditis or pericarditis. Kinnicut, indeed, has detected endocardial murmurs, but these were probably due either to anaemia or to a pre-existent valvular lesion. A very remarkable case of purpura rheumatica complicated with suppurating irido-choroiditis of both eyes has been published by Dr. J. H. Thompson, of Kansas City, Mo.* A girl, eight years of age, of previous good health, born of healthly parents, was suddenly attacked with chill, high fever, followed by coma. At the end of about thirty hours, the fever having moderated and consciousness being restored, the light was painful to the eyes. About twelve hours later she was totally blind in both eyes, the anterior chamber was half filled with pus, a purulent deposit and gelatinous layer of inflammatory exudation cov- ering the irides. At the same time a slight haemorrhagic eruption was discovered upon the arms and legs, together with some swelling of the wrist-joints and fingers. The inner surface of the lips and anterior half of the tongue were covered by a herpetic eruption, which was so con- fluent that it made one continuous mass covering the mucous surface and the skin from the nose around the mouth to the chin. At the time it was yellowish-white, but in twenty-four hours turned black be- cause of the extravasated blood. The general condition of the patient indicated profound depression, but constitutional improvement was rapid, and in a week from the day of attack the child was well. The blindness, however, permanently remained. Dr. Andre Moussous has lately reported two cases of purpura rheumatica associated with severe nephritis. In one, that of a child thirteen years of age, a fatal result took place, and there was found chronic endocarditis, probably due to an antecedent attack * Kansas City Medical Record, November, 1889. HAEMORRHAGES. 157 of rheumatism. Microscopic examination revealed general diffuse nephritis.* Purpura Hemorrhagica—Morbus Maculosus Werlhofh,or Land-Scuuyy.—Purpura haemorrhagica is a severe form of the dis- ease. It is generally preceded or accompanied by pronounced consti- tutional symptoms, as lassitude, languor, debility, headache, loss of ap- petite, and fever. Suddenly haemorrhagic spots appear, usually first on the limbs and afterward upon other parts of the body. The spots appear mostly in numbers, and of all sizes and shapes. In rare in- stances an extravasation takes place between the derm and epiderm, giving rise to a blood-filled vesicle. At the same time, or shortly after the appearance of the eruption, haemorrhages may take place from the mucous membranes, especially the mouth, gums, nose, fauces, and kid- neys. Metrorrhagia, haemoptysis, and effusions beneath the conjunc- tiva into the retina, choroid or sclerotic, have likewise been observed. Epileptiform attacks and paralysis may result from meningeal or cerebral haemorrhage. The disease is uncertain in its course and duration. It may ter- minate favorably, suddenly or gradually, in a short time, generally in from one to four weeks, or lasting, with relapses, for quite a period. It is a dangerous disease, and will sometimes incline to a fatal termina- tion. Death may occur from anaemia, heart-failure with oedema of the lungs, or from cerebral haemorrhage. It occurs in the badly nourished, the debilitated, especially from nervous exhaustion, and also in those apparently of robust health. The duration of purpura haemorrhagica is indefinite, but its average course may be stated as from two to ten weeks. Relapses are not infrequent. Diabetes mellitus has once been seen as a sequela, perhaps in con- sequence of haemorrhage into the diabetic area of the medulla oblon- gata. In six cases Fagge has seen it followed by sarcoma of various organs. Repeated losses of blood may produce decided anaemia. The number of red blood-corpuscles may be diminished and that of the white increased. Marked pallor, exhaustion, shortness of breath, ver- tigo, palpitation of the heart, syncope, and oedema may result from the impoverished state of the blood. An interesting case in which the disease ran an acute course has been described by Zanetti. A woman, aged twenty-three years, after suffering for some time from lumbar pains and headache, suddenly grew worse, with intense sacral pain, prostration, fever, haematemesis, haema- tnria, metrorrhagia, and abundant haemorrhagic spots upon the skin. Death took place from syncope on the third day. Haemorrhages were found into the bowel, peritoneal cavity, and ventricles, the spleen was slightly enlarged, and the liver in the early stage of fatty degenera- tion. * British Medical Journal, February 7, 1891. 158 DISEASES OF THE SKIN. Under the title of purpura fulminans or purpura foudroyant a number of cases occurring in children have been described by Henoch, Herve, and other observers. This form of the disease is characterized by its sudden onset, pain in the limbs which were swollen, cedematous, and cyanotic. There was no haemorrhage from mucous membranes, and death resulted in twenty-four hours to two or three days. Some of these cases had been preceded by illness of another nature, as pneu- monia or scarlet fever. To the list recorded, a similar instance has been added by Dr. Henry Jackson, of Boston. A boy, five years old, about three weeks after a mild attack of measles from which he had entirely recovered, and while apparently in good health, became slightly indisposed for two days, after which a few purpuric spots were seen upon the skin. During the next four days haemorrhages occurred from the bowels, bladder, stomach, and nose. The spots upon the skin in- creased in number and size, and death occurred upon the fourth day. The severe haemorrhages by which it was accompanied distinguished Dr. Jackson's case from those of Henoch, to which, however, it seems allied by the rapidity and fatality of its course. Henoch has also de- scribed a variety marked by gastro-intestinal disturbance and severe colicky pain in addition to the haemorrhagic lesions; in some of these cases there were pain and swelling in and around the joints, together with oedema of the hands or feet. Dr. W. A. Phillips, of Evanston, 111., has reported a case in which purpura occurred as a complication of gonorrhceal rheumatism. There was no previous history of rheuma- tism. It is noted that, though most of the lesions were purely of a haemorrhagic nature, yet some bore a resemblance to those of erythema nodosum. Scorbutus, true scurvy, or sea-scurvy, may, in this connection, be briefly mentioned. The constitutional symptoms are more marked in scurvy, as a rule, but the purpura which it occasions is more apt to involve the deeper structures—the muscles, fascia, and subcutaneous cellular tissue. The internal organs may show in scurvy some com- plication ; but there is less liability to haemorrhage from the mucous membranes than there is in purpura haemorrhagica. The gums in scurvy are, however, more decidedly affected, they are spongy, softened, and painful, and become the seat of ecchymomata and ulcerations. The disease arises from poor hygiene and food, particularly from an insuffi- ciency of fresh vegetables and fresh meat, especially on vessels and in institutions. It appears slowly, and is chronic in its course, but in- clines to disappear with the removal of the exciting cause and the use of appropriate remedies. Dr. Colcott Fox has described the results of an autopsy which he had made upon the body of a boy who died of scurvy. There was extreme atrophy of the fibulae, tibiae, femora, and to a less extent of the bones of the upper extremity; wasting of the muscles; circumscribed scanty haemorrhages between the periosteum HEMORRHAGES. 159 of those bones as well as others; ecchymoses beneath the pleura; sepa- ration of the lower epiphyses of the tibiae, and loosening of the upper ones of the femora.* Scurvy sometimes occurs among infants as a result of deficient nutrition. Pathology.—In purpura the extravasation of blood, as a rule, takes place suddenly, and passes into the different layers of the skin. It is usually found accumulated in the corium or in the subcutaneous cellu- lar tissue. It occasions spots of various sizes and shapes, according to the quantity effused and the permeability of the tissues. The blood, after leaving the vessels, becomes a foreign body. Absorption occurs very slowly, the fluid portion being first removed. The corpuscles and coloring-matter which remain occasion various changes in hue—blue, purple, dark or bright red to green or yellow—as absorption gradually takes place, and the skin returns to its natural condition. No definite or constant change has been discovered in the constitution of the blood, though it is probable that alteration exists. Nor is the condition de- pendent upon any recognized lesion of vascular walls. Rigal and Cor- nil attribute the haemorrhage to disturbance of the vasomotor centre. The viscera are found very pale after death, and not infrequently con- tain extravasations. The spleen is often enlarged, and haemorrhages have been found in the medullary cavities of the bones. Etiology.—Micro-organisms have been detected in the blood in pur- pura by several observers. Blood from patients suffering from purpura, injected by Petrone into the veins of rabbits, produced a general haem- orrhagic condition. Letzerich has isolated a bacillus which has sharp angles and edges, which he cultivated in gelatine, and the pure cultures of which injected into rabbits occasioned haemorrhages, either spon- taneously or upon slight trauma. Steinheil, of Paris, has found a micrococcus in the blood, and has succeeded in making cultivations. He ascribes the haemorrhage to occlusion of small vessels by colonies of micrococci, together with consecutive inflammatory softening. Mar- tin de Uuimard (These de Paris, 1888), who studied twelve cases of purpura in children under the care of Prof. Grancher, found a micro- coccus in the blood during life and in the haemorrhagic spots after death. Cultures of these organisms when injected into a guinea-pig caused haemorrhages in various parts of the body. An accumulation of the cocci occupied the centre of the extravasation. Watson Cheyne found bacilli in one and micrococci in another case of purpura. Hanot and Luzet have reported f a case in which purpura was transmitted from mother to foetus. The woman died, and, though no purpuric spots were found upon the skin of the child, the serous cavi- ties contained a reddish fluid, and disseminated extravasations were * Lancet, May 24, 1890. f Annales de Dermatologie et de Syphilologie, February, 1891. 160 DISEA*SES OF THE SKIN. found in the lung and thymus gland. A streptococcus was recognized in the viscera and blood both of mother and child. Purpura sometimes supervenes after nervous shock. Cutaneous haemorrhage has been observed to follow the injection of diphtheria antitoxin. Purpura haemorrhagica of a severe type may occur during menstruation and pregnancy, not infrequently having a fatal termina- tion. Occurring during pregnancy, it leads to abortion or premature delivery. Purpura occasionally develops during or subsequent to typhoid fever and other severe infectious diseases. It has appeared shortly after an attack of tonsillitis. Treatment.—The treatment will depend upon the cause of the dis- ease. Attention to diet and hygiene is essential. Rest is of advantage, and if the haemorrhage be extensive it is absolutely necessary that the patient be kept in the recumbent position. In purpura simplex the preparations of iron, especially the tincture in full doses, from three to six times a day, are valuable. Equal parts of tincture of iron and fluid extract of ergot often act most decidedly. Quinine, belladonna, and mineral acids are also to be commended. A prescription that has often been serviceable is ten drops of dilute phosphoric acid with one eightieth of a grain of sulphate of strychnine, three times daily. The chlorate of potassium is useful in from five- to twenty-grain doses. The fluid extract of witch-hazel in from ten- to thirty-drop doses, ter diem, has also been productive of benefit. Friction with spirits, tincture of witch-hazel, salt and water, vinegar and water, solutions of alum or tannic acid, cold water or ice, is most suitable and advantageous. Purpura Rheumatica demands most careful attention to hygiene, and often requires rest in bed or a complete change of air, and occa- sionally of occupation. The diet must be nutritious, with the addition of some stimulant. The remedies above recommended may be used. Salicylic acid or digitalis will be found beneficial. Ergotine can be employed hypodermatically if necessary. Purpura Hemorrhagica is dangerous and often fatal, and de- mands active and energetic treatment. Rest in bed is imperative, with nutritious food and stimulation. Any of the remedies already men- tioned may be employed. Digitalis and the tincture of iron often act promptly. Hypodermatic injections of ergotine have also been fol- lowed by good results. Oil of turpentine, acetate of lead with opium, tannic and gallic acids, and large doses of quinine, have been used with success. Electricity is said to have proved serviceable after other rem- edies had failed. The external applications, already referred to, can also be resorted to with good effect. True Scurvy requires fresh air, acids, fresh vegetables, fruits, and meats. Quinine, iron, and strychnine are serviceable remedies. The condition of the gums and mouth may be promptly relieved by chlorate of potassium taken internally, and used also as a wash. HAEMORRHAGES. H)l Prognosis.—In purpura simplex the prognosis is always favorable, although recovery may be tedious. Purpura rheumatica likewise in- clines to recovery. It is, however, obstinate, liable to frequent relapses, and may remain indefinitely. Purpura haemorrhagica is dangerous and at times fatal, and it is often impossible to foretell its termination. HiEMOPHILIA. Haemophilia is a congenital, frequently hereditary affection, consist- ing in a proneness to haemorrhages from the skin and mucous mem- brane. Men are more frequently affected than women. It may take place spontaneously, or from some slight injury. Swelling of joints sometimes coexists with the haemorrhage. Bleeders rarely attain old age- In some instances the disposition is gradually lost after the twenty-fifth year. Microscopic examination of the blood and vessels has shown no apparent change, yet probably the vessels are at fault. According to V irchow and Immerman, the walls of the blood-vessels are abnormally thin. The treatment consists in large doses of tincture of iron or fluid extract of ergot. Locally the same styptics may be employed with com- pression. Cold douches or applications of ice are valuable. Prof. A. E. Wright has obtained encouraging results from the use of calcium chloride and carbonic acid, separately or in conjunction, and also of nucleo-albumens. Calcium chloride is employed internally and locally, satisfactory results having followed the application of finely powdered chalk mixed into a paste with a half-per-cent. solution of calcium chlo- ride. He also prepares a " physiological styptic " by adding one per cent, of calcium chloride to the fibrin obtained by whipping freshly drawn blood. The carbonic acid is administered by leading a stream into the nose through a rubber tube, care being taken that enough oxy- gen is supplied. The local application of a solution of nucleo-albumens was also found of service. After the attack the patient should take for a period larger doses of iron and cod-liver oil, with a nutritious diet. The prognosis should be guarded. HJEMATIDROSIS. Synonyms.—Haemidrosis—Sudor sanguineus, or bloody sweat. Haematidrosis is characterized by escape of fluid containing blood through the sweat-glands. The discharge is generally small in quan- tity, and the condition localized. Bleeding stigmata and neurotic excoriations are only forms of haematidrosis. The disease is seen most frequently in hysterical women, and during menstrual derangement. Debility of the nervous system is also an exciting cause, and it has been known to follow outbursts of passion and great nervous strain. The treatment is similar to that of purpura. Belladonna is reported to have been successfully employed. 11 1G2 DISEASES OF THE SKIN. CLASS IV. EXUDATIONS. (Exudationes.) RUBEOLA. Synonyms —Morbilli—Measles. Rubeola is an acute, contagious, febrile disease, characterized by a papular eruption over the surface, and accompanied by catarrhal in- flammation of the mucous membranes of the respiratory passages. Symptoms.—After an incubative period of nine to eleven days, in some cases prolonged to the fifteenth, nineteenth, or twentieth day, the disease commences with a feeling of chilliness or general malaise, followed in a few hours by fever, headache, muscular soreness, and all the symptoms of a severe cold. The eyes are injected and watery. The nasal mucous membrane is dry and tumid at first, but soon be- comes the seat of a sero-purulent discharge. Sneezing is frequent. The pharyngeal and laryngeal mucous membranes are red and swollen. An eruption of small red spots occurs at this time, according to Koplik, upon the buccal mucous membrane, and is pathognomonic of com- mencing measles. There is a harsh, dry cough, and more or less sub- sternal tenderness. The face is flushed; the pulse is increased in frequency. The urine is high-colored; the bowels are constipated. The temperature rises rapidly, often reaching 103° or 104° Fahr. on the evening of the first day. It then remains stationary until the end of the second or beginning of the third day, when a marked remission occurs, the temperature falling to almost normal. The headache lessens, but the other symptoms do not abate. The eyes become swollen and sensitive to light, and lachrymation is profuse. The voice is hoarse and husky; respiration is increased. The bronchial mucous membrane becomes involved, and the sensation of soreness and constric- tion in the chest is decided. Coughing is frequent and painful, and auscultation reveals the presence of numerous mucous rales. This re- mission lasts about twenty-four hours, when the temperature rises again to its former height, and remains there until the eruption has been fully developed. It usually appears on the fourth day, but may be delayed until the fifth, and consists of numerous coarse, red papules, which vary in size from a pin's head to a small shot. In rare instances the outbreak of the rash has been postponed until the eighth or ninth day. These papules are somewhat crescentic, and are slightly elevated. They are generally noticed first on the face and chest, but spread in twenty-four hours over the entire surface. They are developed more abundantly upon the face, where they are arranged in groups or clus- EXUDATIONS. 163 ters. In some cases adjacent papules coalesce, forming large, irregu- lar blotches. The eruption remains at its height for about forty-eight hours, when it commences to fade in the order of its development, and usually disappears in two or three days. A slight discoloration may remain for a week or two at the site of each papule; in some cases more or less desquamation occurs. The febrile and catarrhal symp- toms decline when the eruption begins to fade, so that convalescence, as a rule, takes place in ten or eleven days from the beginning of the disease. A slight bronchial cough, however, may remain for a week or two longer. In more severe cases all the symptoms are aggravated by the devel- opment of the eruption. The temperature rises to 105° or 100° Fahr., the inflammation spreads to the finer bronchial tubes, or even to the lung-structure itself, producing capillary bronchitis or pneumonia. Diarrhea may appear, and the urine become scanty and albuminous. Conjunctivitis, iritis, and otitis also sometimes occur. Epistaxis occa- sionally takes place either during the prodromic or eruptive period. Herpes zoster, pemphigus, optic neuritis, inflammation of Cowper's glands, enlargement of tracheo-bronchial glands, tubercular meningitis, ovaritis, peritonitis, haematemesis, haemoptysis, and acute nephritis are among the rarer complications. Measles and urticaria pigmentosa have been known to coexist. Gangrene of the skin is occasionally seen in debilitated children suffering with measles. Endocarditis has been occasionally met with as a complication, and Sansom mentions a case in which chorea, pericarditis, and endocarditis developed during convalescence from an attack of measles. Heart clot, followed by pul- monary oedema, is occasionally observed as a lethal complication of measles. The advent of serious complications in the later stages may be heralded by convulsions, and such cases are apt to be fatal. Rare se- quelae are paralysis, muscular atrophy, Pott's disease, and corneal ulcers. In the variety known as black measles the eruption is dark red or purplish in color, and so abundant as to almost cover the entire sur- face. The temperature rises to 106° or 108° Fahr., the pulse is rapid and feeble, the breathing shallow and irregular, and the catarrhal symp- toms intense. The tongue is brown and dry, and the teeth are covered with sordes. Blood oozes from the gums and lips, and haemorrhagic extravasations arise beneath the mucous and cutaneous surfaces. The urine is scanty or suppressed, and offensive or bloody discharges take place involuntarily from the bowels. The patient soon becomes coma- tose, or passes into a low, muttering delirium, and death may ensue on the second or third day after the appearance of the eruption. Cases are occasionally met with in which measles coexists with some other ex- anthem—as, for instance, chicken-pox or scarlet fever, or with typhoid fever. Measles sometimes precedes or follows rotheln. During the wide-spread and severe epidemic of measles which pre- 1<>4 DISEASES OF THE SKIN. vailed in Paris in 1890, Dr. Cauvet closely studied the buccal pheno- mena and complications. Two varieties of lesions may occur, one di- rectly dependent upon the infection of the disease, another which has no direct relation but is a superadded complication. The manifesta- tions which depend upon the infection of measles are: 1. Buccal ery- thema, generally at the same time as the nasal catarrh, and which may attack the tongue, and is often followed by desquamation of the tongue; 2. Follicular stomatitis from glandular hypersecretion, together with obstruction of the excretory ducts. The superadded complications are: 1. Muguet; 2. Aphthae; 3. Ulcerative stomatitis; 4. Diphtheria, which, in consequence of the desquamation following buccal erythema, often primarily attacks the tongue; 5. Gangrene of the mouth, a severe and rare complication.* Diagnosis.—The diagnosis of measles is comparatively easy. The only diseases for which it might be mistaken are variola, rotheln, ty- phus fever, and influenza. In variola, however, the eruption appears on the third day, respectively in the following order: papular, vesicu- lar, and pustular. There are no catarrhal symptoms, and the fever declines as soon as the eruption appears. In rubeola it is seen on the fourth or fifth day, and never becomes vesicular or pustular, but re- mains papular until its disappearance. The catarrhal symptoms are marked, and the fever, which remits on the second or third day of the disease, becomes aggravated prior to or during the appearance of the eruption, and remains high until all the papules have come out. In doubtful cases a day's delay will enable an accurate diagnosis to be made. In rotheln the eruption may appear at any time during the first three days of the disease, but it is irregularly distributed over the sur- face, and consists of rose-colored spots and blotches, which are unlike the coarse crescentic papules of rubeola. In rotheln, moreover, the fever and catarrhal symptoms are comparatively insignificant, and bronchitis, pneumonia, and the other complications of rubeola, do not occur. In typhus fever the eruption is coarsely papular, but is scanty, and limited to the body and limbs, never appearing upon the face. There are no catarrhal symptoms, but the cerebral are intense. The remis- sion of the fever on the second or third day, and the appearance of the eruption on the fourth day, suffice to distinguish rubeola from in- fluenza. Pathology.—The pathological changes in rubeola consist of intense hyperaemia of the capillary vessels of the cutaneous papillae, followed by a slight serous exudation into the surrounding tissue. The respir- atory mucous membranes also become actively congested, and dotted with dark-red sp'ots, apparently similar in character to the cutaneous manifestations. The dark color of the eruption, in the mal gnant * Archives of Pcdriatics, February, 1891. EXUDATIONS. 165 variety, is symptomatic of changes in the blood. The haemorrhagic extravasations are due to rupture of the capillary vessels. In some cases the spleen is swollen and hyperaemic, and the kidneys are enlarged and filled with blood. Etiology.—Rubeola may occur sporadically or as an epidemic. It prevails in all countries and at all seasons, but it happens most fre- quently during the spring and autumn. It is a disease of childhood especially, but is occasionally observed in adults. Infants less than six months of age are not usually attacked. Measles is produced by a specific poison, and is contagious. It may be communicated not only by actual contact, but also through the medium of wearing apparel and other articles in use by the patient. It is also spread by atmos- pheric diffusion. The secretions of the nasal and broncho-pulmonary mucous membranes appear to be the principal agents in spreading the disease. The malady is doubtless due to the growth of a specific micro- organism, and is contagious during the prodromic period prior to the appearance of the catarrhal symptoms or eruption. Bacilli believed to be peculiar to measles have been described by different observers. Whether the organisms are identical is still an undecided question. One attack usually confers immunity for life, but occasional excep- tions are seen. Treatment.—The patient should be given a mild, nourishing diet, consisting chiefly of milk-toast and light soups, and allowed to drink freely of water and lemonade. The room should be well ventilated, but moderately warm, and the face and neck sponged with cold water four or five times a day. Should there be other children in the house, of a weak or scrofulous constitution, it is prudent to send them away at once; if otherwise healthy, they may be permitted to remain. The medicinal treatment should be directed to moderate fever and catarrhal symptoms, alleviate cough, promote expectoration, and pre- vent development of further complications. In ordinary cases I usually direct the patient to take— R, Tinct. aconit. rad.................. ^l xij. Syr. ipecac........................ f 3 ss. Syr. scillae. comp.................. f 3 ij- Syr. lactucarii..................... f 3 x. M. Sig.: One teaspoonful every four hours. I also order the following powders, one to be taken every second or third night at bedtime : R, Hydrarg. chlor. mitis............... gr iij. Resinae jalapa?..................... gr- vj. Pulv. sacchar...................... gr. x. M. Ft. chartae no. vj. If restlessness is exhibited, five to ten grains of sodium bromide may be given three times a day, or from two to five grains of Dover's 166 DISEASES OF THE SKIN. powder at bedtime. In the more severe cases, when the fever is high and the eruption scanty or late in development, ice-bags should be applied to the head, and the patient placed in a cold bath or wet pack, if necessary. When the eruption begins to decline, and the febrile and other symptoms abate, it is good practice to give from three to ten grains of quinine daily, for a week or more. A stimulating expectorant mixt- ure, like the following, is advisable during convalescence: R, Tinct. capsici..................... ni v. Tinct. sanguinariae................. f 3 ss. Tinct. nucis vomicae................ f 3 ss. Tinct. cinchonae comp.............. f 3 iij. M. Sig.: Half a teaspoonful to a teaspoonful four times a day. In black measles, or the malignant variety of rubeola, the high temperature should be reduced by the wet pack or cold bath, and tur- pentine, quinine, and the tincture of the chloride of iron freely ad- ministered. Benefit has also been derived from the use of camphor and the carbonate of ammonia. Carbolic acid and chlorate of potas- sium have also been recommended. On account of the liability of buccal complications, Cauvet advises the free use of disinfectant mouth-washes from the very beginning of the disease. A saturated solution of boric acid will be found of service. In an article upon The Broncho-Pneumonia of Measles: its Nature and Prevention, Dr. L. Bard * states his conviction that this compli- cation is not due directly to the measles, but to a secondary infection to which the exanthem predisposes. Since broncho-pneumonia may become engrafted upon mild cases, Dr. Bard lays stress upon the prophylactic importance of rigid separation of complicated from un- complicated cases. As an illustration, he compares the general harm- lessness of a mild epidemic which prevailed in one of the French can- tons with the fatality attendant upon the broncho-pulmonary compli- cation which, in a certain limited locality, was transmitted from one to another patient. Separation of the two varieties is more particularly demanded in hospital practice, as is shown by the fact that in the Hopi- tal des Enfants Assistes, where cases of measles are placed in a special ward, the average mortality between the years 1867 and 1872 is stated to have been 42-59 per cent., attaining a maximum of 60-81 per cent. in 1871. The complications of rubeola must be met as they arise. In pneu- monia and capillary bronchitis, turpentine, carbonate of ammonia, and stimulants will be found indispensable. When the bronchial tubes are clogged with mucus, emetics will be of service. When the urine becomes suppressed, free diaphoresis and purgation should be produced. If diarrhoea occur, opium and the mineral acids are indi- Lyon Medical, January 13, 1889. EXUDATIONS. 167 cated. Patients of an anaemic or scrofulous disposition should be given cod-lner oil, chlorate of potassium, quinine, and other tonics, for months after convalescence has been established, in order to re- store the tone of the system. Prognosis.—The prognosis is favorable in simple, uncomplicated cases. The deaths which occur are due rather to pneumonia and other complications than to the disease itself. As a rule, the older the pa- tient the severer the case. Weak and scrofulous persons bear the dis- ease badly, and are extremely liable to be attacked by iritis, otitis, or other distressing affections. They are also peculiarly liable to develop phthisis after convalescence. The malignant or purpurous variety of rubeola is very dangerous. Over one half of the sporadic cases end fatally, and when it occurs in an epidemic form over ninety per cent, of those affected die. ROTHELN. Synonym.—German measles. Rotheln is a mild, contagious, febrile disease, characterized by the development of rose-colored spots, of various shapes and sizes, on the general cutaneous surface. Symptoms.—The disease usually begins with a slight fever, accom- panied by moderate headache and a feeling of general malaise. The pulse is increased in frequency, and the temperature varies from 99° to 101° Fahr. The mucous membrane covering the fauces and tonsils is reddened and tumid, and there is some stiffness and soreness at the angle of the jaws. In many cases the conjunctiva is injected, and there is increased lachrymation. The cervical glands are swollen occa- sionally. The eruption usually appears on the first or second day, but may not be observed until the third day. It consists at first of a num- ber of small, round, rose-colored spots, which turn white on pressure. They vary in size from a pin's head to a small pea. They are arranged in clusters or groups, and are slightly elevated above the surrounding healthy skin. They generally appear first on the face and scalp, and rapidly extend over the remainder of the body. Some of the clusters on the body and limbs coalesce, forming large, irregularly shaped red blotches ; but the facial spots almost invariably remain discrete. The eruption attains its maximum development in twenty-four hours. It remains stationary for a day or two longer, and then commences to fade, disappearing completely on the fifth or sixth day of the disease. In some cases a slight discoloration remains for a short time at the site of each spot, but desquamation rarely occurs. The febrile and other symptoms pass away with the eruption. Diagnosis.—The only diseases with which rotheln could be con- founded are scarlatina, measles, and erythema symptomatica. In scar- 1(18 DISEASES OF THE SKIN. latina, however, the fever is higher, the throat symptoms are more intense, and the eruption consists of a diffused scarlet efflorescence, which appears first on the neck and chest, and then spreads over the whole body. In measles the eruption is crescentic and coarsely papu- lar. It appears on the fourth day of the disease, and is accompanied by a marked exacerbation of the fever. Severe coryza and bronchitis are also present. In erythema symptomatica the spots are rose-colored, but they are larger in size and fewer in number than those of rotheln, and they rarely appear on the face. They are usually secondary to some gastric derangement, and are not accompanied by febrile symptoms. Pathology.—An active congestion of the capillaries of a number of groups of the cutaneous papillae occurs, but exudation does not ensue, and the discoloration disappears when the congestion subsides. Etiology.—Rotheln is almost exclusively a disease of childhood, but it may occur in adult life. It is produced' by a specific poison, and propagated by contagion. One attack is protective against the subsequent development of rotheln, but will not secure immunity from measles or scarlatina. Treatment.—The majority of cases do not require any treatment but rest and a light diet, and confinement to the house for a few days. In the more severe, where the patient is restless and decidedly fever- ish, and complains of sore throat, a mild diaphoretic mixture should be ordered, and the bowels opened freely by a saline laxative. Prognosis.—The prognosis is always favorable. SCARLATINA. Synonyms.—Scarlet fever—Scarlet rash. Scarlatina is an acute, contagious febrile disease, characterized by the development of a diffused scarlet rash over the whole or the greater part of the body, accompanied by inflammation of the throat and vari- ous nervous phenomena, and terminating in desquamation of the outer layers of the epidermis. Symptoms.—There are three well-marked varieties of the disease: scarlatina simplex, scarlatina anginosa, and scarlatina maligna. The invasion is exceedingly brief in all three varieties. The period of in- cubation varies from three to seven days ; that of contagion extends from the beginning of the initial fever until about a week after all febrile symptoms have disappeared. In scarlatina simplex the disease is ushered in by a slight chill, or by an attack of apparently causeless vomiting; or, in nervous children, by convulsions. These symptoms pass away in an hour or two, and are immediately followed by fever, which soon becomes high. The face is flushed, the skin hot and dry, the pulse rapid and full, and the respi- EXUDATIONS. 169 rations become more frequent. The urine is scanty and high-colored, and the bowels are usually constipated. The tongue is red at the tip and edges, but covered in the centre with a white or yellowish fur. The throat is reddened, the cervical glands are enlarged, and there is some pain on swallowing. More or less headache and restlessness are also present. The temperature varies from 101° to 103° Fahr., with a slight morning remission and evening exacerbation. The pulse varies with the height of the fever and the age of the patient. In some cases it reaches 130, in others it does not rise above 100. The characteristic eruption appears on the second day of the fever. It consists of a fine pale-red or scarlet efflorescence, which appears first on the face and neck and upper part of the chest, and within twenty- four hours diffuses over the entire surface of the body. In some cases it may present a punctated appearance, but it is not elevated, and it disappears upon pressure. It is most intense in the flexures of the joints In exceptional instances small vesicles are seen either in iso- lated patches or scattered over the entire surface of the body. A rare manifestation has lately been described by Prof. F. C. Curtis.* On the fourth day after the appearance of a typical scarlatinal eruption, a vesicular rash developed upon various parts of the body, the vesicles varying in size from a pin's head to that of a split pea. During its development the throat symptoms increase in severity, and the tongue becomes red and papillated, forming the characteristic " strawberry tongue " of the disease. The fever is uninfluenced by the eruption, and remains at its height until the fifth or sixth day of the disease, when it begins to decline. The throat symptoms also lessen,- the restlessness passes away, and the eruption disappears first from the face and neck, and then from the other portions of the body. The period of decline usually occupies about three days, so that the erup- tion and the fever disappear and the patient is convalescent on the eighth or ninth day of the disease. Some desquamation of the epi- dermis occurs, but it may be so slight as almost to escape notice, or to produce only a roughened appearance. In severer cases the mode of onset is the same, but all the symptoms are more intense. The fever may reach 105° Fahr., the pulse ranging from 110 to 140; the fauces and tonsils become red, swollen, and cov- ered by a pultaceous deposit. Swallowing is difficult and painful. The urine is dark-colored and albuminous, and more or less delirium is present, Convalescence does not occur until the ninth or tenth day, and is accompanied by considerable desquamation. In scarlatina anginosa the temperature may reach 107° Fahr., the pulse varying from 150 to 160, but the throat symptoms are prominent early in the attack, and soon become intense. The cervical glands are hard and swollen. The fauces, tonsils, and pharynx become inflamed, * Albany Medical Annals, February, 1891. 170 DISEASES OF THE SKIN. swollen, and covered by an offensive tenacious deposit. Superficial ulceration occurs at various points, rendering deglutition painful or almost impossible. In some patients the mucous membrane lining the posterior nares and the Eustachian tubes become involved, resulting in serious impairment of smell and hearing. In a majority of cases of this type the disease reaches its height about the eighth or ninth day. The fever then slowly lessens, the swelling of the mucous membrane subsides, the ulcerative process ceases, and reparative action begins. The eruption also gradually dis- appears, so that the convalescent stage begins about the fourteenth day of the disease. The desquamation is usually profuse, and may con- tinue for several weeks. Occasionally the hair and nails are shed. In unfavorable cases the tonsils and fauces become enormously swollen, or attacked by gangrene. The temperature rises rapidly, and the symptoms assume a typhoid type. The pulse becomes small, rapid, and feeble, and the respiration quick and irregular. The urine is sup- pressed or scanty and albuminous. Coma alternates with delirium, and death takes place from exhaustion or uraemic poisoning. In scarlatina maligna the temperature is extremely high from the beginning, frequently rising to 110° Fahr. The pulse varies from 150 to 200. The respiration is irregular and sighing. Convulsions are frequent, but in some cases the patient lies profoundly comatose. The throat is swollen, and covered by a membranous deposit. The glands of the neck are enlarged. The eruption is developed in dark-red or purplish patches, and may not appear until the fourth or fifth day. Sometimes haemorrhages take place in the skin and mucous membranes. Recovery is rare; death usually occurs about the third or fourth day. Anomalous cases of scarlatina are occasionally encountered. Dr. Wertheimer and Dr. Beetz have each reported two cases in which all the symptoms of scarlet fever were present, with but little or no eleva- tion of temperature. The pulse, however, was very rapid, and Dr. Wertheimer suggests that a persistently rapid pulse in the absence of fever is of diagnostic value in these rare cases of apyrexial scarlatina. Again, under the designation of scarlatina sine eruptione, cases have been described in which the throat symptoms and fever occur, but the eruption is absent. Dr. W. R. Lee, of Barneston, Neb., witnessed a number of cases occurring epidemically, having the symptoms and sequelae of scarlet fever without the rash. In certain cases hyperpy- rexia develops without the existence of any complication, but with great disturbance of the nervous system. Sudden death may super- vene on the third or fourth day of the eruption, the symptoms being unexpected loss of consciousness, high fever, rapid pulse, and dyspnoea. In serious and complicated cases peptone and sometimes indican have been found in the urine. The occurrence of peptonuria is an unfa- vorable omen. In rare instances relapse has been observed. EXUDATIONS. 171 Dr. D. Astlcy Gresswell demonstrates that the severity of an epi- demic may vary decidedly from month to month. Endocarditis was not seen in any of his patients who were attacked with arthritis and who had not previously suffered from rheumatism. There was no case of arthritis in children under three years of age. Purulent ar- thritis occurs in some cases. In exceptional instances the articular structures arc rapidly destroyed. The bones as well as the joints are sometimes affected. The bone may remain thickened and muscu- lar atrophy may occur. The disease of the joint may be followed by ankylosis. In Marsden's experience the wrist-joint is most frequently involved. This complication generally occurs during or shortly after defervescence. Myositis, ushered in by a brief rise of temperature, has occasion- ally been observed after disappearance of the acute symptoms of scar- latina. The larger muscles were those usually affected. The mortality from scarlatina among children under five years of age is nearly five times as great as among those between ten and fifteen. In 3,497 cases of scarlet fever there were 362 cases of otitis, 338 of rhinitis, 867 of albuminuria, 55 of measles, 36 of whooping-cough, and 35 of diphtheria. Other complications liable to occur are adenitis, rheumatism, eczema, bronchitis, and conjunctivitis. In a series of 4,000 cases in St. Catherine's Hospital, Stockholm, a few cases were complicated by meningitis due to aural disease. Richardiere has re- corded the case of a child in whom pulmonary gangrene developed during the subsidence of scarlatina. The coexistence of scarlatina and typhoid fever has occasionally been witnessed. In the experience of Dr. E. MacDowel Cosgrave, of Dublin, the severity of neither disease seems to be increased by this concurrence. The relation of scarlatina to pregnant and puerperal women has been investigated by Boxall. He infers that predisposition to the dis- ease is greatest during the first week after delivery. A few cases de- velop shortly before the beginning of labor. During or after parturi- tion the stage of incubation is short, but during pregnancy this stage is longer than normal. Angina is present during pregnancy, but is infrequent when the disease occurs after labor. If parturition take place during an attack, the uterine contractions are feeble and there is a tendency to haemorrhage. Scarlatina in a puerperal woman dimin- ishes or suppresses the secretion of milk. An attack during preg- nancy may or may not affect the foetus in utero. Itching is often present in scarlet fever. The prognosis may be regarded as favorable in cases attended by pruritus. The tables of Dr. Caiger show that desquamation may continue from six to sixteen weeks. It is generally slight and of short duration in infants. Scarlatina sometimes, espe- cially in children, follows traumatism. 172 DISEASES OF THE SKIN. Sequela}.—Dropsy, rheumatism, and otitis are the most frequent. Chorea and valvular disease have been observed to follow. The otitis is usually purulent, and may result in permanent deafness, but a spon- taneous cure may follow after months or years. In a few instances the labyrinth has been primarily affected, giving rise to prolonged suppura- tion, necrosis, and facial paralysis. The rheumatism is generally sub- acute, but may be acute. Dropsy is the most important and frequent sequela. It generally appears after the acute stage, when desquamation has been well established. In some cases it is developed after exposure to cold, but frequently occurs without any apparent exciting cause. Scarlatinal dropsy is due in most cases to acute Bright's disease, but in a small percentage is symptomatic of a slight congestion of the kid- neys. The urine is scanty, albuminous, and high-colored, but rarely suppressed. Recovery is the rule. Dr. C. Henry Willey believes that cases may be divided, in reference to this symptom, into three main groups. In the first nervous and vascular causes, and in the second influences of a more general character, are responsible for the appear- ance of the albuminuria. In the third group, inflammation of the kid- ney is present. In the first class the prognosis is favorable. In the second group, fever, diarrhoea, and delirium were prominent. When dependent upon acute nephritis, the albumen begins as a trace and steadily increases. Septic phenomena occurred -in consequence of sup- puration of cervical glands in a case reported by Caiger. In a case observed by Fruitnight scarlatina was followed by sloughing of the neck, and death from rupture of the artery. J. C. Wilson describes a case in which gangrene of the face and sacral region occurred as a sequela. Mr. John Ewens met with spontaneous dislocation of the hip and necrosis of the tibia in scarlatinal rheumatism. After scarlatina certain diseases of the skin occasionally develop, as acne, urticaria, pemphigus, ecthyma, and pustular eruptions, etc. Diagnosis.—It has been said that scarlatina can be diagnosed dur- ing the prodromal stage by the extreme rapidity of the pulse. This will not hold good in all cases. The rapidity depends upon the age of the patient and the height of the fever, and not upon the precise nature of the disease. I have seen cases of scarlatina in children, aged from five to seven years, in which the pulse never rose above 100. On the other hand, I have observed many of the same age who had ephemeral fever, in which the pulse varied from 120 to 150. Still, if the pulse is 120 or over, and the fever has been preceded by convulsions, or an attack of causeless vomiting, scarlatina may be suspected, and the pa- tient should be isolated, in order to prevent the possible spread of the disease. After the eruption has appeared, diagnosis is easy. The high fever, the sore throat, and the diffused scarlet efflorescence appearing on the second day, form a trio of symptoms which point unerringly to the true nature of the malady. Roseola and rotheln are characterized EXUDATIONS. 173 by the development of irregular scarlet blotches which present a su- perficial resemblance to the eruption of scarlatina, but the high fever and throat symptoms of the latter disease are absent. In dengue, or break-bone fever, the eruption is red and diffused, and the tempera- ture high, but the joints are swollen and painful, while the throat is not involved. The rash of dengue generally appears first upon the hands, wrists, and forearms, may occur at any time from the first to the fifth day of the disease, is not characteristic, but assumes a number of forms, and is, in many cases, altogether absent. In some cases of measles the erup- tion consists at first of a large^ number of bright-red spots, which when closely aggregated present a striking resemblance to scarlatina. In measles, however, there are no throat symptoms, but cqryza and bronchitis are present, and the eruption appears on the fourth day; and, if not papular when first observed, becomes so within a few hours. Pathology.—The eruption of scarlatina is produced by active con- gestion of the capillaries of the papillary layer of the corium. The differences in the intensity of the color in various regions of the body are due to variations in the intensity of the morbid process. Exuda- tion of serum does not occur to any marked degree, but the dilated blood-vessels compress the surrounding tissues and narrow the calibre of the lymph-spaces, so that the nutritive supply of the epidermis is diminished or cut off. The exfoliation or desquamation which follows is due in great part to this interference with nutrition, and probably in part also to a disturbance of the terminal filaments of the trophic nerves. It may be so slight as to escape notice, or merely produce a roughened condition of a portion of the surface, or it may be profuse and continue for months after convalescence. In some cases the skin peels off in large flakes; in others, the hair falls out and the nails drop off. The haemorrhagic extravasations which occur in scarlatina ma- ligna are due to rupture of the capillary vessels. The mucous membrane lining the pharynx and the buccal cavity becomes hyperaemic and swollen. The tonsils become enlarged and covered with a purulent exudation. In severe cases suppuration en- sues, or a diphtheritic membrane is formed, and rapidly extends to the adjacent structures. This false membrane is not, however, of true diphtheritic character, according to the researches of MM. Wurtz and Bourges, who examined material taken from the throats of nine chil- dren in whom the angina was severe. In all these cases the strepto- coccus pyogenes was found associated with other microbes of suppura- tion. The bacillus of Klebs and Loeffler, which is believed to be the causative germ of diphtheria, was in no instance detected. The au- thors conclude that the early throat trouble of scarlet fever, however severe, is not, at least in the great majority of cases, of a diphtheritic 174 DISEASES OF THE SKIN. nature.* A family came under the observation of Mr. J. Holroyde, of Chatham, England, in which, within about a month's time, cases of diphtheria and scarlatina alternately attacked three different children. Ulceration of the soft palate and Eustachian tubes, followed by destruction of the tympanum, may occur. CEdema of the pharynx or larynx may be produced by the infiltration of serum, and either seri- ously interfere with breathing or suddenly prove fatal. In other cases suppurative inflammation of the areolar tissue, followed by the forma- tion of abscesses in distant portions of the neck, has been observed. Granular degeneration of the gastric tubules and of Peyer's patches often follows. Pneumonia, bronchitis, pericarditis, or endocarditis may take place, but present no special alterations at the autopsy. Dr. Carlsson, of Stockholm, in several post-mortem examinations, found alterations in the cardiac muscle, myocarditis, fatty degenera- tion, etc. The changes in the kidneys vary with the type of the disease. In malignant cases they appear paler than normal when cut, but dotted by a few minute haemorrhages. When death is deferred for several days, more haemorrhagic spots will be found, and occasionally minute abscesses. These are the cases in which death ensues before the devel- opment of dropsical symptoms. The dropsy of scarlatina is due usually to acute parenchymatous nephritis, and sometimes to simple congestion of the kidneys. In the latter the kidney-tubules are filled with the endothelium which has been exfoliated. The capillaries are engorged and tortuous, and the cortical substance presents evidences of begin- ning granular degeneration. Etiology.—Scarlatina may occur sporadically or in the form of an epidemic, but never originates spontaneously. Now and then a case occurs in which it is difficult, or, it may be, impossible, to discover the source of infection. Such a one has been placed upon record by Sur- geon-Major R. D. Murray, of the British army, serving in Bengal, f Scarlatina is excessively rare in India, and it is said that there is no record of an authentic case occurring in a native. Dr. Murray's patient was a young English lady, who resided on a lonely indigo plantation, who had not been in Europe for six years, and had not, as far as could be learned, received letters or parcels from infected houses in England. The cows from which the family's milk was obtained were carefully examined, but no trace of disease could be discovered upon their teats or udders. Scarlatina is always produced by a specific poison which is contained in the breath, in the saliva, in the epidermis, and in the excretions of scarlatina patients. The disease may be communicated by the breath * La Tribune Medicale, May 15, 1890; Medical Bulletin, July, 1890, p. 254. f A Case of Sporadic Scarlet Fever, originating de novo, Lancet, October 27, 1888, p. 813. EXUDATIONS. 175 before the eruption has made its appearance. Contagion is active until the close of the desquamative period. This poison is extremely diffu- sive, and attaches itself to the clothing, furniture, carpets, and other articles in the room, and even to the walls of the apartment. Conta- gion is also spread by means of picture-books, letters, and clothing of patient, nurse, or even physician. The medical attendant should take every precaution to disinfect his person before visiting another juvenile patient or a woman in labor. It is also wafted from place to place by the atmosphere. It is exceedingly tenacious of life, and may retain its activity for years. The virus, however, unless carried by a current of air, does not extend many feet from the patient. Hence, isolation is of more value in scarlatina than in many other contagious affections. There is reason to believe that propagation is largely due to atmos- pheric diffusion of the epidermic scales of patients. Dr. L. II. Miller has reported twenty-four cases in which the origin was traced to drink- ing infected milk. Its development is favored by bad hygiene and weakened vitality. Scarlatina may occur at any age, but is most fre- quently met with between the second and twelfth year, and rarely ob- served after the fortieth year. Out of 854 cases tabulated by the Super- intendent of Health of Providence, in 1889, over fifty-seven per cent. occurred in children between the second and eighth years. It has occasionally been transmitted to the foetus in utero. An instance of this fact has been communicated by Dr. W. B. Dorsett, of St. Louis, Mo.* A woman had suffered from a mild attack of scarlet fever about two months prior to delivery at full term. The child's skin at birth presented typical desquamation, furfuraceous upon the trunk, arms, and legs, and scaly upon the palms and soles. A few similar cases have been recorded. One attack is protective, as a rule, against subsequent attacks, but exceptions have been noticed. A second invasion occasion- ally occurs within a short period. Townsend Barker has recorded an instance of a patient who suffered from two attacks of scarlatina within three months. The disease occurs most frequently in early autumn. Treatment.—An appropriate diet is of the utmost importance. The patient's stomach should not be overloaded, but his vital forces must be sustained. With this end in view a moderate quantity of milk, milk-toast, beef-juice, or light, nourishing soup should be given regularly every four hours through the day. In order to prevent the spread of the disease, if there are other children in the household they should be sent away, and the patient placed in a cool, well-ventilated room, as near the top of the dwelling as possible. All clothing, car- pets, pictures, and unnecessary articles of furniture should be removed from the chamber, and no one but the physician and nurse permitted to enter until convalescence has been well established and the room thoroughly disinfected. The clothing and other articles that have * St. Louis Medical and Surgical Journal, February, 1888. 176 DISEASES OF THE SKIN. been in contact with the patient should be disinfected or destroyed, the epidermic scales collected and burned, and the saliva and excreta dis- infected and removed as soon as possible. Dr. J. Lewis Smith, of New York, recommends* that the room of the patient should be continuously disinfected by means of the follow- ing mixture: R, Acidi carbolici, 01. eucalypti.....................aa f 3 j. 01. terebinth....................... f I vij. M. This forms a mixture of no decidedly unpleasant odor. Two table- spoonfuls are added to a quart of water in a flat-bottomed tin vessel and kept simmering over a gas or oil stove Medicinally, the aim should be to secure the elimination of the poison, moderate the intensity of the fever, alleviate the throat symp- toms, and prevent the occurrence or lessen the severity of the cerebral, renal, and other complications. In ordinary cases of scarlatina simplex I usually begin the treat- ment by directing from half a teaspoonful to a dessertspoonful of the following mixture to be taken every four hours, according to the age of the patient: IJ Tinct. aconiti rad................... v\ xxiv. Potassii chloratis................... 3 ss. Infus. digitalis..................... f 3 iij. M. I also order three powders, each containing one grain of calomel and five grains of bicarbonate of soda, one powder to be taken every other night. I advise the entire body to be sponged three or four times a-day with cold water, and to be thoroughly anointed every morning with a mixture composed of ten minims of oil of peppermint and three ounces of cod-liver oil. During the febrile stage inunction moderates the fever. The use of an unguent during desquamation hinders dissemination of the scales, and. therefore checks the spread of the disease. Since the scales from the scalp are fine and shed early, inunction should be applied to that as well as to other portions of the body. Instead of the foregoing combination, the formula of Dr. J. Lewis Smith may be used: R, Acidi carbolici, 01. eucalypti.....................a a f 3 j- 01. olivae........................... f § vij. M. The throat symptoms are generally light, and can usually be alle- viated by permitting the patient to swallow small pieces of ice from time to time, or to drink freely of cool water. When the fever sub- * Archives of Pediatrics, December, 1890. EXUDATIONS. 177 sides, which generally occurs" on' the fifth or sixth day, I discontinue the aconite mixture, and substitute the following prescription, to be taken in the same doses and in the same manner : IJ Tinct. nucis vomicae................ ttj, xij. Tinct. digitalis..................... f 3 ss. Potassii chloratis.................... 3 ss. Aquae............................. f § iij. M. Three or four days later, when convalescence is established, I place the patient upon quinine, chloride of iron, or other tonic treatment. In cases of greater severity, presenting high fever with delirium, diffi- culty and pain in swallowing, I increase the amount of aconite and digitalis, place ice-bags to the head and throat, and follow the calomel and soda with a purgative dose of sulphate of magnesia or of soda. M. Vidal, of Hyeres, uses acetate of ammonium in large doses, one gramme for each year of the child's age, the maximum dose for adults being thirty-five grammes. In scarlatina anginosa the fever and delirium can be moderated in the same manner. Phenacetin is valuable when the temperature is very high, though it should be cautiously used, or not at all, when there is a tendency to malignancy. The throat symptoms require vigorous treatment. The offensive pultaceous deposits should be removed by mopping the surface or gargling four or five times daily with a solution of common salt, chlorate of potassium, boric acid, or thymol. Corrosive sublimate, two grains to the pint of water, is also efficacious. It may be used as a gargle or a spray every second hour. The same solution may be advantageously applied to the nasal mucous membrane when it is red, swollen, and the seat of a discharge. The peroxide of hydrogen, applied in the form of a spray, is another good remedy. It may be used in the proportion of one part to four parts of water. The nares should also be disinfected, either by means of peroxide of hydrogen, one to eight, ior the wash recommended by Dr. J. Lewis Smith, of which the formula is: IJ Acidi borici........................ 3 ij- Sodii borat......................... 3 ij. Sodii chloridi....................... 3 j. Aq. purae........................... Oj. M. Sig.: One teaspoonful to be injected warm into each nostril hourly. The application of a five- or ten-per-cent. solution of resorcin in glycerin is also a good procedure. If the swelling of the tonsils becomes excessive, they should be painted with tincture of the chloride of iron or a thirty-grain solution of nitrate of silver. If suppuration occurs, the pus should be let out at once. If a diphtheritic membrane forms on the tonsils or fauces, equal parts of the solution of chlorinated soda and water should be used as a gargle, or applied, full strength, to the affected surface with 12 178 DISEASES OF THE SKIN. a camel's-hair brush. Benefit can also be obtained by gargling the throat with yeast or with a solution of capsicum. Immediate and permanent improvement sometimes follows the use of an emetic of ipecac, apomorphia, or of common salt and water. The stomach is emptied by this means of a mass of foul pus which has gradually oozed down into it, and, without this precaution, would be absorbed into and poison the general system, and the membrane is detached from the pharynx and fauces, and a clean surface left,, to which appro- priate applications can then be made. If oedema of the pharynx or of the glottis occurs, the affected part should be freely scarified, or tracheotomy performed. Ulcerations of the tonsils, fauces, and soft palate can be treated by the application of a five-grain solution of nitrate of silver. In cases of scarlatina in which the pulse is quick and feeble, aconite should not be employed. Instead, I give the patient small doses of turpentine or of belladonna and digitalis every three hours, and from one half to two grains of quinine in combination with half a grain of capsicum every four hours. Camphor or carbonate of ammonia may sometimes be used with benefit. According to Dr. Illingworth,* the biniodide of mercury will yield excellent results. In the " British Medical Journal" for October 26, 1889, Mr. J. Brendon Curgenven warmly praises the internal and external employ- ment of the oil of eucalyptus. He administers it in one to four drop doses every four hours in an emulsion. Externally the remedy is atomized and vaporized in the sick-room and applied to the patient's body by inunction night and morning for the first few days, subse- quently at night only until ten days have elapsed. Dr. Shakowaki claims excellent results from the administration of salicylic acid. He states that in 125 grave cases occurring in children the mortality under this treatment was but three and a half per cent. Barkes and subsequently De Rossa have attributed prophylactic powers to salicylic acid in scarlatina. The latter administered it in daily doses of from one and a half to four and a half grains according to age to sixty-six children who had been exposed to contagion, and in only three cases did the disease develop. He believes that given in time and in sufficient quantity it is capable af averting an attack, while if employed too late in too small a dose it mitigates the severity of the disease. It has been objected to the use of salicylate of sodium, how- ever, that it is liable to produce relapse or excite nephritis. Sulphonal is reported as being useful in the relief of restlessness and insomnia. In scarlatina maligna every effort should be made to reduce the high temperature—the cause of all the other complications of this va- riety of the disease. The patient should be placed in a cold bath, or wrapped in a wet pack and ice applied to the head and neck. The * Provincial Medical Journal, August, 1886. EXUDATIONS. 179 bowels should be freely opened, and aconite, veratrum viride, or other arterial sedatives promptly administered. After the temperature has been reduced to the safety limit, the treatment may be conducted in the manner indicated for the other varieties of the disease. In the treatment of 3,460 cases, Reimer made use in 978 of differ- ent forms of hydrotherapy. According to this large experience, cold compresses or cold envelopment exerted a favorable influence upon the respiration and circulation, but little upon the temperature. In cases attended by cyanosis, stupor, and collapse, cold envelopment combined with affusions of water having a temperature of 12° to 14° C. (53-6° to 572° F.) generally gave good results, but did not lower the tempera- ture. Immersion in a bath of 12° to 14° C, however, frequently caused the temperature to fall 2° C. After being removed from the bath, the patients were rubbed briskly and wrapped in a woolen blanket. Of antipyretic drugs this writer derived most benefit from antipyrin, but advises that it be used cautiously, as it is liable to produce collapse. The same remark should be made concerning the use of acetanilid and phenacetin, which are not devoid of toxic influence. Cases have been reported in which these agents have also produced collapse. In the employment, therefore, of all the coal-tar products in this disease, especially in children, they need be administered with great circum- spection. In scarlatinal dropsy small doses of digitalis and acetate of po- tassium may be given with benefit, and the patient permitted to drink water and cream-of-tartar lemonade freely, but stimulating diuret- ics should be avoided. Diaphoretics and hydragogue cathartics are mainly to be relied on to secure the elimination of effete material, and relieve the engorged kidneys. In addition, leeches or cups are useful, applied to the lumbar region. The convulsions that occur in the early stages of scarlatina are due to cerebral congestion arising from the height of the fever or the excessive arterial pressure, and can be relieved by the application of ice to the head, and the administration of purgatives and arterial sedatives; chloral and the bromides are also of service. Convulsions in the later stages of the disease are usually due to uraemic poisoning from the suppression of urine, and can only be relieved by free diaphoresis and catharsis, followed by a re-establish- ment of the functions of the kidneys. The use of Marmorek's serum has in most cases disappointed expectation. Prognosis.—The prognosis varies with the type of the disease and the age of the patient. The average mortality in all cases has been estimated from seven to ten per cent. In some epidemics over half of those who are attacked die in spite of all treatment. Cases of scar- latina simplex generally recover. The greatest danger in this form of the disease is from nephritis, which may be severe in an other- wise mild case. The majority of patients, however, recover under 180 DISEASES OF THE SKIN. appropriate treatment, even after the dropsical accumulation has be- come extensive. A guarded prognosis should be given in the cases of adults and very young children. Pregnancy also exerts an unfavor- able influence. In scarlatina anginosa the prognosis is always grave, but from twenty-five to fifty per cent, usually recover. Scarlatina maligna almost invariably terminates fatally. VARIOLA. Synonyms.—Small-pox—Blattern—Variole. Variola is an acute, specific, contagious, febrile disease, character- ized by the development of an eruption which is papular at first, but speedily becomes vesicular, and then pustular. There are four well-marked varieties—variola discreta, variola con- fluens, variola maligna, and varioloid—all of which are preceded by a period of incubation, varying from five to fourteen days. Symptoms.—Variola Discreta.—This form of the disease is gen- erally ushered in by a moderate chill, accompanied by a dull, aching pain in the lumbar regions. The pulse is small and feeble, the face pale, and there is more or less nausea. The chill is of short duration, and is usually succeeded, in an hour or two, by fever, which soon be- comes high. The pain in the lower portion of the back increases in severity as the temperature rises, and extends into the hips and thighs. The respiration is increased, the face is flushed, the conjunctivae are injected, and more or less headache supervenes. The patient is disin- clined to take food, but suffers from thirst. The tongue is coated with a thick, white fur, the stomach becomes disordered, and vomit- ing is frequent. The skin is dry and hot. The urine is scanty and high-colored, micturition is painful, and the bowels are constipated. The patient is restless, and in some cases slight delirium occurs. The temperature may reach 106°, but usually ranges between 103° and 104°, with a slight morning remission and an evening exacerba- tion. The pulse varies in accordance with the height of the fever. In adults it ranges from 100 to 140, and in children from 120 to 180. About the end of the'third or the beginning of the fourth day of the fever the characteristic eruption appears. It consists of a number of coarse, reddish, papular spots, which feel like particles of small shot imbedded in the skin. They are hard, and slightly elevated above the surrounding surface, and become pale on pressure. They first appear around the lips and on the cheeks and. forehead, and then on the chest and arms and remaining portions of the body. They may also appear on the pharynx, larynx, trachea, and other mucous surfaces. They are isolated, or arranged in clusters, as in the so-called corymbic variety, but do not manifest any disposition EXUDATIONS. 181 to coalesce, as in variola confluens. As soon as the eruption appears the fever declines, the nausea, headache, and backache become less severe, and, in mild cases, almost completely disappear. The pap- ules, however, produce more or less itching and discomfort. Ordi- narily, they are all developed within twenty-four hours, and no new ones appear after that time. On the second day of the eruption, or the fourth or fifth day of the disease, the top of each papule may be observed to present a vesicular appearance, and, on the following day, each papule is completely transformed into a vesicle which con- tains a clear, serous fluid. The vesicles increase in size until the fourth or fifth day of the eruption, which corresponds with the sev- enth or eighth day of the disease. They are then surrounded by an indurated inflammatory areola, and present an umbilicated appear- ance. Their contents undergo a marked change at this time, first be- coming turbid, then milky, and finally purulent in character. This process marks the beginning of the stage of suppuration, and the transformation of the vesicles into pustules, and is accompanied by marked symptomatic or secondary fever. The temperature rises higher than ever, even reaching 105° or 106°. The pulse and respiration increase in a corresponding ratio. The headache, backache, nausea, and vomiting return in an aggravated degree. The pustules enlarge, and the surrounding skin becomes intensely swollen. The mucous membrane lining the nasal passages and the buccal and pharyngeal cavi- ties is irritated and inflamed. Swallowing is painful, and bronchitis, pneumonia, or pleurisy may occur. Some of the pustules rupture spontaneously, or from the pressure of the clothing ; others are torn by the patient in his endeavor to obtain relief from the heat and itching. The remainder begin to dry up about the eleventh day of the eruption, or the fourteenth day of the disease. A dark-brown spot appears in the centre of each, which increases in size until it forms a brown crust or scab which covers the whole area of the pust- ule, and is firmly adherent to the underlying surface. The febrile symptoms lessen as soon as the process of desiccation commences, the tumefaction gradually disappears, and the patient passes into the stage of convalescence. The process of healing continues beneath the scabs, but, as more or less of the corium is destroyed by the sup- purative process, minute cicatrices*or pits are formed at the site of each pustule. The scabs finally drop off about the sixth or seventh day after desiccation begins. The surface is then seen to be rough- ened and reddened ; the face is especially disfigured. The hair fre- quently falls out during convalescence, and the nails occasionally drop off. Variola Coxfluexs.—This variety is marked by the greater severity of the symptoms of every stage of the disease, and by the earlier development and confluent character of the eruption. The 182 DISEASES OF THE SKIN. initial chill is violent and protracted, and the precursor of others. The primary fever, the backache, headache, and gastric disorders then follow in painful succession. Delirium is usually present, and con- vulsions may occur. The eruption appears on the third day, and in a few hours spreads over the whole body. Adjacent papules coalesce to form large elevations, which are soon transformed into broad blebs filled with a sero-purulent fluid. The face presents an extremely re- pugnant appearance. The mucous membranes are also involved. The fauces, pharynx, naso-pharynx, larynx, and tongue become swollen and covered with pustules, and oedema of the glottis may result. The parotid and sublingual glands are likewise affected. The conjunctiva and cornea suffer, wdth sometimes ulceration and perforation of the latter. Erysipelas is a frequent complication of this variety, and ex- tensive sloughing and gangrene often ensue. The temperature, which may reach 107° during the primary fever, falls only slightly or not at all when the eruption appears, and rises higher than ever when suppu- ration begins. The urine is scanty and loaded with albumen. Pneu- monia, bronchitis, and pleurisy often occur. The disease may assume a typhoid type, ending with suppression of urine and uraemic poison- ing. A few recover after protracted convalescence, but with more or less deformity from the destruction of tissue by suppuration and sloughing. Paraplegia, disseminated spinal sclerosis, suppurative peri- tonitis, and ovaritis are occasional complications or sequelae. Variola Maligna.—Variola maligna is characterized by the in- tensity of its symptoms and the irregularity of their development. The initial chill is very severe, and is followed by violent fever, the temperature rising during the first day to 108° or 110°. The respira- tion is quick, feeble, and irregular. The pulse is rapid and tremulous, varying from 120 to 170. The face and neck are deeply suffused. The headache and backache are distressingly severe. Vomiting is constant. The urine is scanty or suppressed. The bowels may be loose. Delirium is usually present, but in some cases the patient is apparently comatose. In many cases a scarlatiniform or an erythema- tous eruption appears on various portions of the body on the second day of the disease. On the third day the characteristic papular eruption appears and rapidly becomes diffused over the entire surface, but the fever does not subside. The papules, black or dark-blue in color, in- crease in size, and become surrounded by haemorrhagic extravasations, which vary in size from a pin's point to an inch or more. Those adja- cent coalesce, forming large, irregular masses. The face is swollen and distorted, the conjunctivae are injected, and the eyelids are turgid with blood. The tongue is thick and coated. The buccal and pha- ryngeal mucous membrane is covered by a purulent haemorrhagic exu- dation, from which a sickening odor emanates. Bronchitis or pneu- monia is usual. Haemorrhage from the stomach or the bowels is not EXUDATIONS. 183 infrequent. The urine is loaded with albumen, and finally becomes dark and bloody. Death generally takes place in this variety of the disease between the third and the eighth day after the development of the initial symptoms. Indeed, some malignant cases end fatally be- fore the appearance of the eruption, in which event the body turns black. In a contribution on haemorrhagic variola as observed in Paris in 1887, M. de Grandmaison describes a comparatively benign form which he terms cutaneous haemorrhagic variola. The haemorrhages are lim- ited to the pustules, the eruption is discrete, constitutional reaction is not extreme, and recovery generally takes place. Varioloid.—Varioloid is a mild or benign form of variola, occur- ring in those whose susceptibility to the action of the disease has been modified by vaccination or by a previous attack of variola. It is ush- ered in by a slight chill, followed by a moderate fever. The character- istic lumbar pain is also present, but not severe. There are also slight headache and nausea. The papular eruption is apt to be a day late, appearing on the evening of the fourth day, rather than on the third, and is accompanied by complete relief from the other symptoms of the disease. The number of papules vary from five or six to a hundred or more. They increase in size, and are converted first into vesicles, then into pustules. Many of the latter become aborted as soon as formed, and the remainder are rarely more than half-filled with pus. The suppurative process is consequently very short, and the secondary fever is absent. There is a slight inflammatory areola around each pustule, but the adjacent skin is not swollen. The mucous mem- branes may be involved, but only slightly. Desiccation commences from the fifth to the seventh day of the eruption, or the ninth to the eleventh day of the disease, and is usually complete in four or five days. The majority of the pustules dry up without rupturing, and, as there is not much destruction of tissue, there is usually little or no pit- ting. Convalescence is generally rapid. Some cases are so mild that the patient does not suspect the nature of the disease until informed of it. Gubler and Robin have determined that, in variola, urea is generally increased during the first few days. The increase may be more marked in light than in severe cases. Uric acid is usually increased in the early stage and diminished after the occurrence of. suppuration. Dur- ing the stage of invasion the quantity of urine is diminished and its density increased. The chlorides, at first diminished, are increased during suppuration. Phosphoric acid progressively increases from the beginning and diminishes suddenly with the cessation of the fever. The sulphates increase slightly during the course of the disease. Va- lerianic acid, fatty acids, leucine, and tyrosine have been detected. In severe cases indican is increased. The liquid and non-crystallizable 184 DISEASES OF THE SKIN. extractive matters are increased, and from them Pouchet has obtained a very toxic ptomaine. Diagnosis.—While it is impossible to make a certain diagnosis of variola before the eruption, the occurrence of high fever, vomiting, and severe lumbar pains, preceded by a chill, are highly significant, and may be considered pathognomonic if the patient has been exposed to the contagion of the disease, or if other cases have previously been observed in the neighborhood. When the eruption is fully developed, the diagnosis is comparatively easy. The only diseases with which it could then be confounded are measles, scarlet fever, varicella, typhus fever, and pustular syphilis. The papules of variola bear a superficial resemblance at first to those of measles, but the former become vesic- ular within twenty-four hours, and then pustular, while the latter re- main unchanged. The papules of measles are also larger than those of variola, and are crescent-shaped. The constitutional symptoms are also widely different. In variola the temperature is high during the initial stage, and falls to nearly normal when the eruption develops. In measles the temperature is only moderately high during the initial stage, and rises rapidly a few hours before the eruption appears, and re- mains at its maximum height for from twelve to twenty-four hours after the rash is all out. Measles is invariably accompanied by a " watery eye," and other symptoms of coryza. More or less bronchitis is also present. Coryza is absent in variola, and bronchitis occurs , only as a complication of the later stages. The malignant form of variola is frequently preceded by an erythematous rash which might be mistaken for that of scarlet fever, but it is less diffused and more ir- regular in development, and is followed in a few hours by the charac- teristic papular eruption. The gravity of the constitutional symptoms is also significant. M. Grisolle states that while the papular stage of the eruption may present a very similar appearance, if the papule become impalpable to the touch when the skin is stretched, the eruption is caused by measles; whereas, if the papule is still felt when the skin is drawn out, the eruption is due to small-pox. The vesicles of varicella may resemble those of variola, but they begin as vesicles, and remain as such until they dry up. They appear on the second day of the disease. They are usually developed upon the body and scalp, And are rarely seen upon the face. The accom- panying constitutional symptoms are very slight. The eruption of ty- phus fever is either macular or papular in character. It appears from the fifth to the seventh day of the disease, and is never seen upon the face. The pustules of syphilis have been mistaken for those of small-pox. Several years ago a sailor, who was covered from head to foot with pustular lesions, was sent to the Philadelphia Health-Office as a small- EXUDATIONS. 185 pox patient. The attendant physician, recognizing the nature of the malady, immediately procured his admission in the Hospital for Skin and Venereal Diseases. Several other physicians had previously seen the case and pronounced it one of small-pox. Inquiry into the his- tory of the patient, and a consideration of the symptoms presented by him, would have rendered the mistake impossible. In syphilis a history of infection can usually be obtained, and an examination will reveal some traces of the primary sore or its accom- panying bubo. The eruption, moreover, is seldom purely pustular; macules, papules, vesico-pustules, and other lesions usually coexisting in varying numbers. In some rare cases, however, as the one just referred to, it consists solely of pustules identical in appearance with those of variola. The patient may also be weak and feverish, and complain of pain in the back and loins. The elevation of temperature does not exceed one or two degrees, however, and the constitutional symptoms partake more of the nature of general malaise than of a violent infectious disease. Further, the pustules in syphilis are chronic in character, often remaining for some time, and are not accompanied, as a rule, by pain or itching. In variola the fever is high, the prostration profound, and the eruption is acute in character, accompanied by in- tense itching, and disappearing by maturation in from eleven to four- teen days. Pathology.—The first step in the production of the eruption con- sists of active congestion of the capillary vessels of a number of the . papillae of the corium. Exudation then takes place into the connect- ive tissue and the rete mucosum, by which the outer layers of the epidermis are elevated and papules formed. As the inflammatory process continues, more fluid oozes out, the epidermic layers are sepa- rated from each other and from the corium, and vesicles result. The contents of the vesicles consist at first of pure serum, but in a day or two pus-corpuscles transmigrate, and the former become transformed into pustules. The umbilicated appearance which they present is due to the fact that the epidermis in the centre of each pustule is continu- ous with the duct of a hair-follicle or a cutaneous gland. The pus does not differ, microscopically, from that of any ordinary inflamma- tion. Guttmann found it to contain the ordinary microbes of suppura- tion, to the action of which he attributes the cutaneous lesions, though they fail to account for the contagion. In variola confluens great numbers of adjacent papillae become in- volved. The haemorrhagic extravasations of the malignant variety are due to rupture of cutaneous vessels. The dark or purple color which the papules and extravasations sometimes assume is significant of disso- lution of the blood. The pustules which form on the mucous mem- branes may incite general catarrhal, croupous, or diphtheritic inflam- mation of the regions in which they are found. After death, the 186 DISEASES OF THE SKIN. liver, spleen, kidneys, and heart are found to be the seat of granular and fatty degeneration. Pustules have rarely been observed upon the gastric mucous mem- brane. Dr. James Nevin Hyde, however, records the fact that in an autopsy made by himself " there was no portion of the alimentary canal from the mouth to the anus which was not studded by thickly set pustules." Etiology.—Variola occurs at all ages and in all countries. It is produced by a specific poison, the exact nature of which has not yet been discovered. Analogical reasoning would lead us to conclude that the source of the infection is to be found in a specific micro-organ- ism which has not at this time been isolated. More recent investiga- tions appear to render it probable that the specific cause is an animal parasite belonging to the class of sporozoa, although the organism has not yet been identified with certainty. Again, Le Dantes has isolated a streptococcus which he calls variolacoccus. This organism was found constantly present in the blood, viscera, and pustules of more than fifty cases. Amid such diverse results the whole subject must be re- garded as unsettled. One attack is protective, as a rule, against subsequent outbreaks of the disease, but exceptions occur. A few recurrent cases have been reported in which the symptoms and eruption of small-pox reappeared a few days or weeks after recovery from the first attack. Vaccination affords almost complete protection. Variola is highly contagious. It may be communicated by inoculation with the contents of the pus- tules, but is spread principally by the diffusion through the atmos- phere of the emanations from the patient. Small-pox may be transmitted from the mother to the foetus, and the death of the latter be followed by abortion. The transportation of rags often conveys the virus from one country to another, and Dr. Matthew Hay has reported a case* in which raw flax and jute acted as the carrier of infection from Russia to Aberdeen. It is infectious at every stage, from the beginning of the disease until the process of des- quamation has been completed, but it is especially dangerous during the period of suppuration, when the secondary fever is at its height. The poison is active and virulent, and retains its power for a long time. Even contact with the bodies of those who have died with the disease may result in its development. The clothing and other articles in contact with the patient become saturated with the poison, and, unless destroyed or thoroughly disinfected, will become the foci for future epidemics An apposite example of the mode of infection and the length of time during which infected rags remain virulent is given by Dr. W. F. Suiter, of La Crosse, Wisconsin. A man convalescent from a broken * British. Medical Journal, May 25, 1889. EXUDATIONS. 187 leg but still confined to bed was seized with small-pox. Upon inquiry it was found that he had pulled out from the wall near his bed a piece of rag which covered a wooden pin, and had idly picked the rag to pieces. It was afterward learned that a family had died of variola in the same room twenty-eight years previously, and the rag had in all probability been handled by one of those patients. Treatment.—Diet is of the utmost importance. Milk, milk-toast, eggs, oysters, or beef-juice should be administered regularly every four hours from the beginning of the disease. Lemonade will be found agreeable and cooling, and may be given freely. Cold water or ice- water can be taken without restriction. The medicinal treatment is mainly symptomatic, as no remedy has yet been discovered by which variola can be aborted or its duration lessened. Cerni and Ory have lately claimed admirable results from the use of cocaine in doses of from two to five centigrammes (one third to three quarter grain). Ory gives to adults ten drops of a five- per-cent. solution of hydrochlorate of cocaine four times daily, and to children eight drops of a one-per-cent. solution four times a day. It is asserted that by this treatment the suppurative stage is remarkably abridged and ameliorated and pitting much reduced. Dr. Montefero, of Naples, has reported favorably of the internal employment of small doses of carbolic acid. He asserts that this drug aborts or limits pus- tulation and reduces fever. Adynamia is a contra-indication to its use, and it failed entirely in haemorrhagic variola. The sulpho-carbolates have been recommended by some authorities. Hydrochloric acid in doses of ten to twenty drops every two or three hours may be adminis- tered in order to assist digestion. Some practitioners rely upon the carbonate of ammonium. During the stage of invasion the aim should be to lower the temper- ature, lessen the arterial tension, allay gastric irritability, and quiet the nervous system. In the stage of suppuration the treatment should be directed not only to meet the foregoing indications, but also to prevent or counteract the development of pyaemic poisoning. The complica- tions that arise at this period must be promptly met, and means taken to prevent or lessen the disfigurement caused by the formation of pits. In ordinary cases of variola the most efficient treatment consists in the administration of small doses of aconite and morphine during the primary fever, and the same drugs in alternation with quinine and tincture of the chloride of iron during the secondary fever. The bowels should be-freely opened, in the beginning of the disease, by a purgative dose of calomel and soda, and one or two passages secured every day afterward by the assistance of saline laxatives. If pharyngi- tis or other throat symptoms develop, the patient should be directed to use a gargle of chlorate of potassium, ten grains to the ounce, four or five times a day. The bronchitis can be most effectively relieved by a 188 DISEASES OF THE SKIN. combination of sanguinaria, capsicum, and squills, or other stimulating' expectorants, rather than by opiates and depressants. Nervous exalta- tion can usually be allayed by the bromides and chloral, but in some cases full doses of Dover's powder will be found more efficient. Occa- sionally it may be necessary to resort to the hypodermic use of mor- phine. Du Castel treats variola by means of hypodermic injections of ether night and morning, full doses of the tincture of the chloride of iron, and the extract of opium, which are increased in case of delirum. This method is adapted to relieve prostration, and is claimed to exert a favorable influence upon the eruption. The irritability of the skin is relieved by frequent sponging with cold water. Inunctions of cod-liver oil are also grateful. According to Dr. Galewouski, of Paris, excellent results are obtained in the small-pox hospital of Brunn, Austria, by baths colored with permanganate of potassium. The temperature is reduced, the general condition improved, and the pustules undergo resolution. Various antiseptic remedies have been used with the object of neutralizing the specific cause of the disease. The benzoate of sodium, it is said, reduces the temperature and modifies the severity of small- pox. Petresco commends the action of Van Swieten's solution. This consists of ten grains each of corrosive sublimate and chloride of am- monium dissolved in a pint of distilled water, the dose being from half to one drachm repeated at proper intervals, the effect being carefully watched. Sulphurous acid has also its advocates. Pitting can be reduced to a minimum by keeping the patient in a cool, dark room, and applying tincture of iodine freely to each papule. An ointment containing iodol, aristol, or sulphur may likewise be employed for the same purpose. Each pustule should also be punct- ured early, and the interior touched with nitrate of silver after the pus has been evacuated. This, however, is a tedious and painful pro- cess. The late Dr. Addinell Hewson, of Philadelphia, insisted that better results were obtained with less pain by covering the affected surface with a thick paste composed of fine clay and water. Weak mercurial plasters are frequently employed for a like effect. In order to lessen suppuration, Talamon makes use of an ethereal solution of corrosive sublimate applied in the form of a spray. The formula recommended is as follows : IJ Acid, citrici...................... gr. xv. Hydrarg. chlor. corros............. gr. xv. Sp. vini rect. (90°)................ Ttl lxxv. Ether....................'. q. s. ad. f 3 xijss. M. For the first or second day of the eruption the face is first washed with soap and water, rinsed Avith borated water, and dried with absorb- ent cotton, after which the spray is used, the eyes being protected by borated cotton. The spray is directed upon the face for barely a min- EXUDATIONS. 189 ute. Fifteen minutes after the use of the spray the face is rubbed with a pledget of cotton dipped in a glycerin solution of sublimate, half a drachm to the ounce. The spray may be discontinued after the sixth or seventh day, the glycerin solution being applied until the scabs begin to loosen. Schiermmer reports favorably of a paste com- posed of five parts of carbolic acid, forty of olive-oil, and sixty of pre- cipitated chalk. Colleville prefers an ointment consisting of one part of iodoform to twenty parts of vaseline. A plan described by Bianchi was attended by considerable success. The patient is first placed in a tepid bath containing one part in twenty of boric acid. During the bath he is covered with an antiseptic soap. This bath, or one of a 1:1,000 solution of corrosive sublimate, is repeated every fourth hour. After each bath an ointment of iodoform and vaseline of one to five per cent, strength is applied. All the pustules are opened with an asep- tic needle. The linen of the patient and the bed must be frequently changed; the floor, walls, and furniture washed every second day with a 1: 200 solution of corrosive sublimate. Lotions of carbolic acid or of mercuric bichloride relieve the tension of the skin and lessen the fetor of the discharge. In the treatment of pregnant women suffering from small-pox Richardiere orders immersion once or twice daily, in a sub- limate bath, the external parts being, in the meanwhile, kept covered with compresses saturated in Van Swieten's solution. Coste reports good results from the application of boric lint with slight pressure. The masks are kept moist by spraying with fresh lotion every four or five hours. It has long been known that darkness mitigates the sever- ity of the eruption, and Gallavardin has called attention anew to the value of this plan. It has been suggested that the efficacy of darkness depends upon exclusion of the chemical or ultra-violet rays. This may be accomplished by the use of red window-panes or covering the win- dows with red curtains. Finsen, Svendsen, Juhel-Renoy, and Feilberg have written favorably concerning this mode of treatment. Guimard and Geley have shown that the local application of sparteine and some other alkaloids (cocaine, solanine, helleborine) has the effect of reducing temperature. The use of sparteine in this manner in a case of conflu- ent small-pox rendered the suppurative process abortive. In a case of confluent small-pox Baudon obtained a satisfactory result by covering three times a day the face, limbs, and chest with a pomade of one part of salicylic acid to twenty-five parts of vaseline. A powder of talc, oue part, and salicylic acid, twenty-five parts, was then dusted upon the sur- face. Lewentaner, of Constantinople, used a paste composed of three per cent, of carbolic or salicylic acid, made up with starch or oil of sweet almonds and held in position by means of a mask. Ulcerations of the cornea should be touched at once with the solid nitrate-of-silver stick. In variola confluens, and in the more severe cases of variola discreta, when the fever remains high, ice-bags may be 190 DISEASES OF THE SKIN. applied to the head and chest, or the patient placed in a cold bath. When the fever assumes a typhoid type, and the pulse becomes soft and feeble and the mind dull and wandering, full doses of strychnine and digitalis are to be given every four hours, and from ten to fifteen drops of oleum terebinthinae once in three hours. Camphor, caffeine, carbolic acid, and carbonate of ammonia will also be found serviceable. Favorable results have been obtained also from the subcutaneous injec- tions of fifteen to twenty minims of ether, repeated two or three times during the course of the day. The diarrhoea which sometimes follows can readily be controlled by dilute sulphuric acid and opium. If petechial spots appear on the surface, or haemorrhagic extravasations occur, full doses of chloride of iron and strychnine should be given, in alternation with oleum terebinthinae, every two hours. Alcohol is in- dispensable in the treatment of all grave cases. If symptoms of pneu- monia, pleurisy, or pericarditis appear, a blister should be placed over the affected region, and stimulants freely administered. Gastric and intestinal haemorrhage can be checked by Monsel's solution, given as required, in from five to ten drop doses, well diluted. Variola ma- ligna usually defies all medication, but occasionally recovery has been effected. The treatment of this variety should begin with free purga- tion, after which dilute sulphuric acid, strychnine, camphor, carbolic acid, and oleum terebinthinae are indicated in appropriate doses. Dr. II. Russell, of Superior, Wis., has reported a case in which recovery followed the administration of tincture of iodine every three hours. Dr. N. S. Davis,* of Chicago, has obtained good results in some des- perate cases from a combination of carbolic acid and the hyposulphite of sodium, as in the following formula : IJ Acidi carbolici.................... gr. x. Sodii hyposulphitis................ 3 vj. Aquae menth. pip................. f § iv. M. Sig.: One teaspoonful in water every one or two hours. Cases of varioloid do not require much medicine. The adminis- tration of a laxative and a diaphoretic mixture during the initial stage, arid a chalybeate tonic after the disease is well developed will usually be sufficient. Those afflicted with variola should be rigidly isolated, and no one permitted to come near them who is not protected by vaccination or by a previous attack of the disease. The discharges from the patient should be disinfected with common salt, carbolic acid, sulphate of iron, or mercuric bichloride. All clothing and articles used are to be disin- fected or destroyed. The room should be thoroughly fumigated with chlorine, iodine, or sulphurous-acid gas, after the patient has been re- moved from it. The scabs should be carefully collected and burned. * Lectures on the Principles and Practice of Medicine. By N. S. Davis, A. M., M. D., LL. D. Chicago, Jansen, McClurg & Co., 1884. EXUDATIONS. 191 Prognosis.—The prognosis of variola is largely influenced by the age of the patient and the extent of the eruption. The greatest fatal- ity occurs, as a rule, in young children and in old people. Very few who are attacked before the sixth or after the sixtieth year recover. Young adults are more likely to recover. The prognosis is favorable in all uncomplicated cases of variola discreta. It is also good in cases of variola confluens in which only a few large patches are present; but when the tendency to coales.ce becomes general, the result is doubtful. It has been estimated that, while the mortality in variola discreta varies from three to five per cent., in variola confluens it exceeds fifty per cent. Variola maligna has a fatal tendency. Varioloid is a benign affection, rarely ending in death. VARICELLA. Synonym.—Chicken-pox. Varicella is a mild, contagious, febrile affection, characterized by the development of a vesicular eruption on the general surface of the body. Symptoms.—Varicella is a disease of infancy and early childhood, seldom seen after the tenth year. The incubation period varies from eight to seventeen days. The chief symptom, and that which usually first attracts attention, is the appearance of a vesicular rash after a premonitory fever of twenty-four or thirty-six hours' duration. The fever rarely rises above 101°, and in some cases is so light as to es- cape notice altogether. The pulse is usually increased in frequency, and there may be some headache . and restlessness. The vesicles ap- pear first on the chest and abdomen, and then rapidly extend to the extremities. In some cases they may be observed on the forehead, scalp, and neck, and on the conjunctiva and the roof of the mouth, but they seldom ever appear upon the lower part of the face. They are circular in shape, and vary in size from a pin's head to a large pea. The first step in their formation consists of the appearance of a number of rose-colored spots, on which vesicles develop after a few hours. They contain a clear, serous or yellowish fluid, neutral or alkaline in reaction. They are all out upon the surface and attain their full size on the second day. On the following one they begin to maturate or dry up, forming small brown or yellowish crusts, which drop off in two or three days. A small cicatrix is left at the site of each, but, as the corium is not involved, it usually disappears after a time. The fever subsides when maturation commences, and the whole course of the disease is terminated within a week. Diagnosis.—Varicella might be confounded with varioloid or with measles. In varioloid, however, the eruption is first papular, then vesicular, then pustular. It appears on the third day of the primary fever, and may be limited to the face, where it is usually first observed. 192 DISEASES OF THE SKIN. In measles, the eruption is seen first on the face on the fourth day of a severe fever, but it is coarsely papular in character, and accompanied by marked coryza and bronchitis. In varicella, on the other hand, it appears on the first or second day of a mild fever; rarely upon the face, and is never papular or pustular. Pathology.—The rose-colored spots which precede the development of the vesicles are due to active • congestion of the capillary vessels of isolated cutaneous papillae. As the morbid process continues, an exu- dation of serum occurs which, penetrating between the layers of the epidermis, separates them, and results in the formation of a vesicle. Etiology.—Varicella may occur sporadically or as an epidemic. It is propagated by contagion, and is evidently due to a specific poison, but neither the nature of the poison nor the exact method of its com- munication is known. Efforts to discover a specific micro-organism have not as yet been attended by decided success. Tenholdt discovered a micrococcus in the contents of the vesicles, and in thirty cases Pfeiffer found a germ which went through successive stages of amoeboid, cyst, and spore formation. It was impossible to cultivate this parasite upon any soil. But these observations are far from conclusive. Treatment.—If the fever and headache become, severe, from one ;eighth to one fourth of a minim of the tincture of aconite, or half a minim of the tincture of gelsemium, may be given in sirup and water every three hours, and a saline laxative administered. The majority of cases, however, require no other treatment than rest and a mild diet. The patient should be kept indoors for a few days, and restricted to a diet of bread and milk and fruit. Prognosis.—The prognosis is favorable. Only a few deaths from varicella have ever been recorded, and, being debilitated children, they were probably dying from inanition when the disease appeared. In rare instances haemorrhage, catarrhal pneumonia, or nephritis has occurred as a complication of chicken-pox. Dr. Walter T. Roberts, of Louisville, Ky., has chronicled the case of a previously healthy infant of nine months in whom, on the fourth day of an attack of varicella, a dermatitis gangraenosa began to develop and terminated life upon the sixth day. The dermatitis was peculiar in being unilateral.* Under the name of varicella gangraenosa Mr. Hutchinson has described some cases in which ulceration took place in the varicella vesicles. The late Prof. Demme observed a case in which the eruption was preceded by high temperature and a convulsive seizure, and another in which there were severe blood-stained diarrhoea and fever, rapidly disappearing after the outbreak of the rash. In two cases the eruptive period was unusually prolonged, with successive crops of pocks, accompanied by a scarlatiniform erythema and followed by nephritis. Mr. Nisbet, of Townsville, Queensland, records a fatal case * Medical Progress, February, 1891.. EXUDATIONS. 193 of uncomplicated chicken-pox occurring in a previously healthy infant. The eruption covered the entire body, and numerous spots, changing to irritable ulcers, appeared upon the tongue and mucous membrane of the mouth. Dr. John Thomson, of Edinburgh, describes a case of haemorrhagic varicella with pemphigoid bullae ending in death. Haemorrhages occurred in both vesicles and bullae. Dr. Boucheron, in an inaugural thesis upon the respiratory complications of varicella, mentions bronchitis, broncho-pneumonia, pleuro-pneumonia, and puru- lent pleurisy. In one case of double broncho-pneumonia which ended in death, he found near and upon the vocal cords small vesico-pustules analogous to those upon the skin. Dr. Coulon has reported two cases in which chicken-pox coexisted with scarlet fever. Chicken-pox and measles also occasionally coexist in the same individual. Varicella occasionally attacks the larynx, this localization occurring with the beginning of the cutaneous eruption or a little later, giving rise to laryngitis with stenosis or spasm of the glottis. The spasm may prove fatal or death may be caused by a secondary broncho-pneu- monia. Varicellar laryngitis is characterized anatomically by small circular ulcers, few in number, situated by preference upon the lower vocal cords. Paralysis has also been occasionally observed as a sequela. In a case observed by Dr. J. P. Crozer Griffith the disease was complicated by diphtheria and measles. VACCINIA. Synonym.—Cow-pox. Vaccinia is a specific, contagious, eruptive disease, attacking cat- tle, and which, when transmitted to man by inoculation, so modifies the entire system as to render it insusceptible for a long time to the poison of variola. Confusion and controversy have arisen as to the nature, relationship, or identity of the affections loosely denominated pox, and which occur in several of the domestic animals. An able summary of this vexed subject has been given by Mr. Fleming in a paper upon "Variola in Animals and Men." Sheep-pox and goat-pox differ from each other and from cow-pox, horse-pox, and variola. Both cow-pox and horse-pox, or " grease," when inoculated into the human subject prevent the development of variola. Prof. Peuch, of Toulon, has demonstrated that vaccine derived from the horse and passed through the calf to the child is much more powerful than a variola which has passed for a long time between children and calves. Ordinary human lymph passing from one calf to another loses its power in the third or fourth generation, while the energy of horse-pox vaccine seems undiminished at the eleventh generation. Upon this point, however, the experience of Dr. Leonhard Voigt, of 13 194 DISEASES OF THE SKIN. Hamburg, differs, as he found that variolous lymph was still active after being transmitted through twenty-one calves, and used it success- fully for public vaccination. When it has passed through only one or two removes from the human being (i. e., through one or two animals inoculated with variolous lymph), it may prove undesirably energetic. King, Shordt, and Hime made use of the seventh and Fischer even the third remove. The process of inoculation is termed vaccination. All children should be vaccinated during the first six months of infantile life, and revaccination performed about the eighth year of age, and then again at puberty. If the vaccination takes properly at each of these periods, further repetition will be unnecessary. Statis- tics show that while varioloid may occur in seven per cent, of those who have been vaccinated once, it is rarely seen in those who have been vaccinated twice, and never observed in those who have under- gone it three times. It is advisable to vaccinate an unprotected person immediately after exposure to the contagion of small-pox. Even if the operation is not performed until symptoms of variola are manifested, the course of the disease is favorably influenced; the pustules dry up without secondary fever. Either bovine or humanized virus may be employed, but, in using the latter, care must be taken to select only that which has been ob- tained from healthy persons, uncontaminated by syphilis or scrofula. In performing the operation, almost any part of the integument may be used. The arm or leg is generally selected and scarified longi- tudinally and transversely over an inch of the surface. The scarifica- tion should be made lightly, so that it will merely bring the blood to the surface, and not cause it to ooze out in drops. If the vaccine matter is in a liquid condition, it can then be placed on the surface. If quills or points are employed, they should be dipped in water and then rubbed freely into the selected spot. If a scab is used, it may be dissolved in a few drops of water or glycerin, and then applied on the wounded spot. Mr. W. R. Buckell, of Cheltenham, England, has narrated * the his- tory of a peculiar case in which a vaccine vesicle developed upon the tongue. A mother had run a fish-bone into her tongue two days be- fore her baby was vaccinated. The tongue remained sore for some time. One week after vaccination the mother kissed the babe upon the arm at the site of vaccination. Six days later her tongue began to swell. In order to avoid the possibility of septic accidents, it is well before operating to have the arm thoroughly cleansed and to hold the blade of the lancet, if one be used, for a moment in a flame. More elaborate antiseptic precautions have been suggested, but are likely to destroy the virus and thus defeat the very object of the operation. Dr. Alfred * British Medical Journal, June 22, 1889. EXUDATIONS. 195 Leach has followed an antiseptic method of vaccination for six years, during which period he had but one case of inflamed arm. His cus- tom is to wash instruments, lymph tube, and patient's arm in a disin- fecting solution, and to make in four places small scarifications and valvular punctures with a Graefe's cataract knife charged with lymph. Bismuth is dusted upon the wounds when perfectly dry. The rapid destruction of animal lymph in hot countries has been a serious difficulty. In India the lymph seldom retains its power for more than three days. It can be preserved in boro-glyceride for about fifteen days. Surgeon-Major W. G. King,* of Madras, has succeeded in producing a vaccine paste which remains efficacious for about a month. The paste consists of the pulp of the vaccine vesicle mixed with pure lanolin in the proportion of one of the former to four of the latter material. Immunity may also be produced by subcutaneous inoculation of vaccine virus, being developed gradually and not completely until the . eighth day. Symptoms.—If the vaccination has been properly performed, and pure vaccine matter employed, a hard, red papule will appear at the site of inoculation on the third or fourth day. This papule will en- large and become vesicular on the fifth or sixth. The vesicle is um- bilicated, is surrounded by a red areola, which increases in size. On the eighth or ninth day it is converted into a pustule, which reaches its full development on the tenth or eleventh. The conversion of the vesicle into the pustule occurs rather suddenly. The areola then be- gins to fade, a dark-brown spot appears in the centre, the contents dry up, and a dark-brown or mahogany-colored scab is formed by the four- teenth or sixteenth day. Cicatrization continues beneath until about the twenty-first or twenty-third. The scab then falls off, leaving a cir- cular, depressed, reddish cicatrix, which usually remains through life, but gradually becomes whiter than the adjoining skin. The constitutional symptoms accompanying true vaccination con- sist of slight fever, headache, and restlessness during the evolution of the eruption. Occasionally the fever is quite high and a brief delirium is produced. In some cases the axillary glands become swollen and painful. In other cases a diffused scarlatiniform, papular, or papulo- vesicular eruption may appear over the whole body. These, how- ever, are only of brief duration, and usually disappear within a few days. A case of generalized vaccinia has been observed by Gaucher. A child was vaccinated with calf-lymph. Eight days later three good vaccine pustules were present upon each arm and the fever became * " Concise Report on Results obtained in the Madras Presidency with Lanoline-vac- cine during the Experimental Issue from November, 1890, to July 1891." By Surgeon- Major W. G. King, M. B., D. P. H, in The Indian Medical Record, December 1, 1891. 196 DISEASES OF THE SKIN. severe. On the eleventh day a general eruption was scattered over nearly all the body. Some of the pustules advanced to umbilication while the development of others was arrested. The general condition grew worse, and the child died with symptoms of asphyxia. The lungs were found congested, the spleen enlarged, kidneys softened, and the liver in the early stage of fatty degeneration. Vaccination with impure matter may entail the most serious con- sequences. The eruption produced by improper virus does not pursue the typical course of true vaccination. The areola appears early, and is large and irregular in outline. The papules appear earlier, also, and change rapidly into vesicles and pustules, which are not umbilicated, and either dry up early, forming a thick, black scab, or extend into large suppurating ulcers, which spread widely and deeply, and mani- fest no disposition to heal. Erysipelas not infrequently occurs as a complication. Boils and abscesses may also form, and run a tedious and painful course. The subject of vaccination eruptions was discussed in the Section of Dermatology at the meeting of the British Medical Association in 1890. Mr. Malcolm Morris divided these rashes into two groups, one being due to pure vaccine inoculation, and a second caused by mixed infection—that is, by vaccine together with an additional virus. Cer- tain rashes of the first class appear within the first three days before the development of the vesicles, and are probably originated by reflex nervous influences from the part operated upon. They assume the forms of urticaria, erythema multiforme, vesicular, and bullous erup- tions. Those which follow the evolution of vesicles and due to the absorption of virus may take the form of roseola and resemble measles; of erythema, resembling scarlatina, or of purpura. Roseola and erythema generally appear upon the eighth or tenth day after vaccination, spread from the vesicles, and are accompanied by slight constitutional symp- toms. Sequelae of vaccination are eczema and urticaria ; psoriasis and pemphigus have occasionally occurred. Eruptions due to mixed infec- tion introduced at the time of vaccination are impetigo contagiosa and dermatitis or erythema. Affections due to introduction through the wound subsequent to vaccination are erysipelas, cellulitis, boils, gan- grene, and, in very rare instances, pyaemia. Mr. Hutchinson has re- ported a case in which a general vaccinia became gangrenous. Some individuals appear to be insusceptible to the action of vac- cination. It is probable they are also at that time insusceptible to the poison of variola, but, as that peculiarity of the constitution may be modified by time or other circumstances, repeated efforts should be made to induce the mild disease in them. I recollect several cases in which six or seven vaccinations failed, but a later one proved suc- cessful. When former attempts have failed, vaccination should be repeated at each new epidemic. EXUDATIONS. 197 The cutaneous symptoms of other eruptive fevers may be briefly described as follows: Typhoid Fever.—In typhoid fever the eruption appears about the seventh day, but may be delayed until the tenth or twelfth. It consists of a few small pale-red or rose-colored spots, which are not at all or only slightly elevated. They are circular or oval, and disappear upon pressure, returning as soon as it is removed. These spots are usually developed only on the chest and abdomen, but in some cases they may be observed upon the back. They vary in number from one to twenty- five or more. Occasionally the eruption is more disseminated and abundant. Spots may appear upon the extremities as well as upon the trunk. Murchison mentions one case in which they appeared upon the face. Each one remains visible for three or four days. It then fades, and another is developed near the site of the first. Successive spots appear and disappear in this manner for a week or more. They then disappear without either pigmentation or desquamation, but return if a relapse occurs. Sudamina sometimes occur in the later stages of typhoid fever, but are not characteristic of the disease. These sudamina are in some cases followed by desquamation ; in rare instances also small blue spots, taches bleudtres, have been observed. They are not peculiar to typhoid fever, generally precede the rose-colored eruption, are not ele- vated, and do not disappear on pressure. Accidental rashes occasionally appear and may embarrass the diag- nosis. An eruption similar to urticaria or a scarlatiniform erythema has been observed. The erythema generally occurs at the end of the first or in the third week of typhoid fever, and may be followed by dif- fuse desquamation. An epidemic of infectious erythema in the course of typhoid fever has been described by Hutinel.* Most cases devel- oped during the third week. The access of this complication suddenly increased the prostration of the patient. A difference in severity was observed, some cases being comparatively benign. The urine is scanty and contains much albumen. If the advent of the erythema is pre- ceded by vomiting, change in the features, reduction of temperature, and retardation of pulse, the termination is generally fatal. In the ab- sence of these symptoms a very slow recovery took place. The average duration of an attack was two and a half days. Typhus Fever.—In typhus fever the eruption appears from the fifth to the seventh day of the disease. It consists of numerous coarse dark-red spots or papules, which are elevated above the surrounding healthy skin, and are not influenced by pressure. They are abun- dantly developed upon the trunk and the extremities, but never appear upon the face. In some cases of typhus the spots turn purple or be- come surrounded by black petechiae. Dark or purple linear and irregu- lar haemorrhagic extravasations may also occur. * Revue mensuelle des Maladies de l'Enfance, March, 1890. 198 DISEASES OF THE SKIN. The eruption attains its maximum development in twenty-four or forty-eight hours, and remains permanent until the fourteenth or fifteenth day, when it slowly fades as convalescence begins. If the disease ends fatally before that time, the eruption remains after death. Cerebro-spinal Fever.—In cerebro-spinal fever the eruption usually appears, if at all, within the first twenty-four hours, but may not develop until the third day. It consists of purpurous or cherry- colored elevated spots, which do not disappear upon pressure. They are found upon all portions of the body except the face, and vary in number with the severity of the attack. They disappear with con- valescence, but remain on the surface in cases which result fatally. Diphtheritic Spots.—Severe cases of diphtheria are sometimes complicated by an eruption resembling that of cerebro-spinal fever. It may appear at any time after the third day. It consists of dark-red or cherry-colored spots, which are not influenced by pressure. They are not elevated, however, and are usually few in number and limited to the face and chest. Diphtheria may also be accompanied by an erythematous rash similar to that of scarlatina. It is not as vivid, however, as the scarlatina efflorescence, and never extends beyond the neck and breast. Influenza.—Although influenza is attended by no characteristic eruption, yet in the epidemics from 1889 to 1892 rashes were seen in quite a number of cases by different observers. Sometimes the eruption assumed a papular form and again appeared like that of scarlatina and was followed by desquamation. Occasionally a purpuric lesion was encountered. Among other cutaneous lesions manifested during its course were urticaria, ecthyma, erythema nodosum, roseola, erysipela- toid dermatitis, and a morbilliform eruption. A few cases of herpes zoster were also reported, some complicating, others following the in- fluenza. Dr. Mapother observed that the great debility due to influenza converted, when the patients were eczematous, a serous into a pustular discharge. It also predisposed to acute attacks of pustular eczema. Shelly notes the frequent occurrence in influenza of small sago-like vesicles upon the soft and sometimes the hard palate. ERYSIPELAS. Synonyms.—The rose—St. Anthony's fire. Erysipelas is an acute specific, eruptive, febrile disease, character- ized by an intense inflammation of a limited area of the skin or mucous membranes, accompanied by various constitutional phenomena, and terminating in desquamation of the affected portion of the epidermis. It is feebly contagious in character. Symptoms.—Erysipelas usually begins abruptly with a slight chill, or an attack of nausea and vomiting. This is followed in a few hours EXUDATIONS. 199 by high fever, and more or less headache and pain in the back and limbs. The tongue becomes coated with a thick white or yellowish fur, the skin is dry and hot, the urine is scanty and high-colored, and the bowels are torpid. The pulse is rapid and forcible, varying from 100 to 130. The temperature ranges from 102° to 10-1°. There is in- tense thirst, but no desire for food. The eruption usually appears within the first twenty-four or thirty-six hours. It consists of a cir- cumscribed deep-red or rose-colored spot which generally appears first upon the nose, cheek, ear, or scalp. It may, however, develop upon any portion of the cutaneous or mucous surfaces. In some cases it is first observed upon .the fauces, in others the vulva. Erysipelas of the larynx is generally an extension from the face or nose, though it is sometimes witnessed in connection with or consequent upon erysipelas seated in some distant part. In rare instances it may occur as a pri- mary manifestation. A case of primary erysipelatous broncho-pneu- monia has been reported by Dr. M. Mosny. M. Papillon has reported a case of erysipelatous pleuro-pneumonia without external erysipelas, and M. Cuffer has published the history of a patient in whom symptoms of pulmonary inflammation were present for four days before a characteristic rash appeared upon the face. The ear may be involved in erysipelas. The disease may extend from the face, the nose, or naso-lachrymal canal. The color disappears on pressure, but returns as soon as the pres- sure is removed. It is preceded or accompanied by a sensation of heat and tension, and more or less tingling or pain. There is intense itch- ing, the surface is glossy and swollen. The eruption and tumefaction rapidly spread in all directions. If the face or scalp is involved, the features become distorted to such an extent that they can scarely be recognized. The lips are stiff and tumid, the nose, cheeks, and scalp are infiltrated and swollen, and the eyelids can not be separated. In severe cases large vesicles or blisters filled with serum are developed. In grave cases the vesicles become black or purple from an extrava- sation of blood. The eruption reaches its maximum development in about three days. It then ceases to spread, and gradually loses its vivid- red appearance, assuming a yellowish hue. The swelling also subsides, the vesicles shrivel up, and the febrile and other symptoms disappear. Convalescence is established about the eighth or ninth day. Moderate desquamation of the epidermis then takes place, and in some cases the hair falls out, but a new growth is soon developed. Various complica- tions are observed during an attack of erysipelas. The cervical and axillary glands are frequently enlarged. Delirium may be caused by the height of the temperature, or from embolism of the cerebral capil- laries. The urine may become loaded with albumen, or it may be completely suppressed, and urafmic poisoning ensue. Endocarditis, pneumonia, and pleurisy have also been noticed. 200 DISEASES OF THE SKIN. Suppurative arthritis may complicate erysipelas of the limbs or face. Facial erysipelas is occasionally followed by blindness. In the phleg- monous variety the areolar tissue is extensively infiltrated with serum ; suppuration and much destruction of tissue occur. In gangrenous ery- sipelas the surface turns black, large sloughs are formed, and the patient dies from pyaemia. In erysipelas of the fauces the tongue, pharynx, and larynx are swollen, and death may suddenly ensue from oedema of the air-passages. Erysipelas ambulans is a semi-chronic variety in which the eruption recurs from time to time, but always upon a differ- ent region of the body from that previously attacked. Diagnosis.—The diagnosis is easy. The only affections which pre- sent any resemblance to it are erythema and eczema. In erythema there is neither fever nor pain, and little or no swelling. The erup- tion usually appears upon the trunk or extremities, and consists of large spots or blotches, which are not circumscribed, but fade imper- ceptibly into the surrounding normal skin. In eczema the surface is fiery red and burning, and covered with minute vesicles or fine scales; but there are no constitutional symptoms. Erysipelas of the fauces or pharynx might be mistaken for an ordinary irritative inflammation of those structures. The diagnosis can be made, however, by contrast- ing the dusky-red color, the rapid development, the migratory tend- ency, and the constitutional symptoms of erysipelas, with the bright- redness, the restricted development, and the comparatively mild nature of ordinary inflammations of the pharyngeal or buccal cavity. Pathology.—The first step in the morbid process consists of active hyperaemia of the blood-vessels of the affected surface. Exudation of serum and migration of the white corpuscles then occur. All the layers of the skin become oedematous and infiltrated with serum and masses of leucocytes. Vesicles are formed by an accumulation of fluid between the layers of the epidermis and between the epidermis and the corium. In severe cases rupture of isolated capillaries may follow. The blood is thinner and darker than normal. The heart, kidneys, liver, and spleen undergo more or less granular degeneration. Embo- lism of the cerebral vessels sometimes happens. Etiology.—Erysipelas may develop at any age, but is most frequent- ly met with from the twentieth to the fiftieth year. It is not limited to any season, but is most prevalent during the spring and autumn. According to the investigations of Prof. J. M. Anders it prevails above all in the spring. One attack predisposes to others. Some suffer from frequent recurrent attacks of erysipelas. In wom- en the disease may return at menstrual periods. The same phenome- non has been witnessed in connection with uterine fibroids. Erysipelas is produced by a specific poison, and is propagated by in- dividual contact as well as by atmospheric diffusion. It usually prevails in epidemics of varying extent and severity, but isolated cases are not EXUDATIONS. 201 uncommon. Erysipelas may be produced by a blow, or by exposure to cold or damp weather, or by reflex irritation from alcoholic indulgence or other causes. It may occur in consequence of wounds, or, in women, after confinement. Facial erysipelas may depend upon intra-nasal lesions, such as ex- treme turgescence of the mucous membrane or occlusion of the nares by enlarged turbinated bones. Of seventy-four cases of facial erysipelas, Lehrnbecher found in forty-seven some chronic inflammation of the nasal mucous membrane or cracks, crusts, and ulcers. A specific microbe of erysipelas has been isolated and cultivated. It does not, however, lend itself readily to artificial cultivation. Grown in gelatine, it soon atrophies. The streptococcus of Fehleisen devel- ops well at 70° F., flourishes abundantly at 95° to 100°, ceases to be prolific at 107°, and is destroyed above 120°. It survives at as low a temperature as 20° F. Below this point it probably can not live. An interesting communication made to the Biological Society of Paris by M. Leroy, of Lille, may throw light upon the obscure origin of certain cases of erysipelas. In December, 1887, M. Leroy prepared a gelatine tube with a pure culture of this organism. As usual, it did not thrive well, and at the end of four or five weeks appeared to be entirely atrophied. But to his surprise, in the latter part of January, 1889— that is to say, after an interval of more than a year—the microbe which had been considered dead resumed growth and gave rise to active new colonies. The tube had remained during the year at a distance from the stove, exposed only to the ordinary temperature of the room. Animals inoculated with the revived culture demonstrated its activity and virulence.* According to the investigations of Fehleisen, the streptococci erysip- elatis enter, through some lesion, the skin, its lymph-spaces, and ves- sels, where they develop rapidly until the vessels are more or less oc- cluded. An active hyperaemia is excited, together with an exudation of plastic, cellular material. By the time the inflammatory action has reached its height the colonies of micro-organisms have disappeared. Infection extends by way of the lymphatic vessels. As a rule, micro- organisms do not seem to enter the blood, and those which do so are speedily destroyed. These germs are capable of development outside the human organism, which fact serves to explain the occurrence of epidemics of facial erysipelas and the increased number of cases at cer- tain seasons of the year. They have been detected by v. Eiselsberg and Emmerich in the air of a dissecting-room. They are disseminated by particles of desquamated skin, to which they adhere. When brought into contact with favorable organic media, they develop and are sub- sequently dispersed through the atmosphere. It is probable that they are frequently present in decomposing organic matter. This view is * Medical Bulletin, May, 1890, p. 170. 202 DISEASES OF THE SKIN. supported by the fact that decomposing secretions of wounds, espe- cially when mixed with blood, cause erysipelas.* The streptococcus discovered by Fehleisen and believed to be the exciting cause of erysipelas bears a marked resemblance to the strepto- coccus pyogenes. On the grounds of the different results of inocula- tion experiments, however, Fehleisen disbelieves that the erysipelas germ is a pyogenic microbe. Pure erysipelas can not, according to this conception, be attended by suppuration. Phlegmonous erysipelas is regarded as due to mixed or secondary infection. From the evi- dence furnished by inoculation it appears that the stage of incubation is of three or four days' duration. The erysipelas microbe has been de- tected by MM. Verneuil and Clado in products taken from cases of lymphangitis. These observers, therefore, hold that erysipelas and lymphangitis are simply different forms of the same disease. Cult- ures derived from patients suffering from acute lymphangitis pro- duced erysipelas in rabbits. Treatment.—The most effective treatment of idiopathic erysipelas in young and robust adults consists in the hypodermatic administra- tion of from one sixth to one fourth of a grain of pilocarpine hydro- chlorate. It produces profuse diaphoresis, during which the pulse and temperature fall to almost normal, the eruption becomes pale, the tumefaction diminishes, and the further progress of the disease is checked. This method is of striking benefit when erysipelas has at- tacked the larynx. In cases where hypodermatic injections are not deemed advisable, pilocarpine or jaborandi may be given by the mouth. Neither of these remedies should be ordered, however, to anaemic or debilitated subjects, as serious cardiac depression might result. In such cases some other plan of treatment is preferable. The adminis- tration four times daily of a pill containing three grains of the sulphate of quinine and one twelfth of a grain of the extract of belladonna has been recommended, and is often followed by good effect. A com- bination of aconite, fliij, and carbolic acid, ttiss, every four hours, has also produced excellent results, but is not suitable for asthenic cases. M. Tison speaks highly of the use of aconitine in facial erysipelas. He administers every sixth hour ^ grain of Duquesnel's crystallized aconitine, and has seldom found it necessary to continue the treat- ment beyond the third day. Usually it could be discontinued within forty-eight hours. Some patients require to be stimulated from the beginning, and will not tolerate the employment of aconite, pilocarpine, or any other cardiac depressant. The pulse should be the guide, and aconite or belladonna employed in accordance with its indications. These agents, however, have no direct influence on the course of the characteristic * Lehrbuch der Pathologischen Oynaecologie, Vorlesungcn fur Aerzte und Studirende von Dr. P. Baumgarten, Braunschweig, 1888. EXUDATIONS. 203 manifestations of the disease, and can only be regarded as adjuvants in its treatment. The tincture of iron is almost a specific. It acts equally well in the sthenic and in the asthenic forms. It should be taken in large doses, one half to one or two drachms, every three hours, until convalescence is established. The bowels should be freely opened by a calomel or calomel-and-jalap purge, followed by a saline. Rest in bed in a dark room is essential. According to a fragment found among his papers and published since his death, camphor was the favorite remedy of Pirogoff. He gave it in half-grain doses six times during the first day, afterward increasing one grain. When camphor failed he administered calomel or tartar emetic. The former was preferred when the tongue was heavily coated, and was given in the dose of six grains once a day. The tartar emetic was employed when the patient had eaten too heartily twenty-four hours previously to the develop- ment of erysipelas. Various antiseptic substances have been admin- istered internally with more or less success. Among these may be mentioned creasote, permanganate of potassium, and /3-naphthol, the first and last named being the most efficient. Rhus toxicodendron has been found of avail by Phillips. In severe cases, characterized by high fever, bounding pulse, and throbbing carotids, ice-bags should be ap- plied to the head and face, and full doses of aconite or veratrum viride administered every hour until relief is obtained. If there be fierce delirium and high fever, the same measures may be resorted to; but if the delirium is low and muttering, and evidently due to suppres- sion of urine, one or two drops of croton oil or an eighth of a grain of elaterium should be placed on the tongue, or sufficient pilocarpine injected hypodermatically to produce profuse diaphoresis. In an un- usually severe case which spread from the face to the trunk and up- per extremities, Dr. Favre obtained a strikingly good result from the use of antipyrin. If symptoms of embolism supervene, I advise the free use of carbonate of ammonium and the alkalies. In phlegmonous erysipelas, quinine, iron, belladonna, and stimulants are the remedies to he relied upon. In the gangrenous variety, camphor, strychnine, the mineral acids, and oil of turpentine may be resorted to. In mala- rial erysipelas large doses of quinine are necessary. Marmorek claims good results from the injection of antistreptococcus serum, or anti- toxin of streptococcus infection, the dose varying from 10 to 20 com. In erysipelas of the larynx the constitutional treatment should be conducted upon the general principles already stated, and ice should be applied to the neck, and the patient directed to swallow pieces of cracked ice. Morphine or cocaine may be used locally in order to abate pain. If swallowing is difficult, alimentation by the oesophageal tube or by rectal injection may be resorted to; if dyspnoea is urgent, scarification of the swollen mucous membrane or tracheotomy may become necessary. If the nasal cavity be the seat of the disease, tarn- 204 DISEASES OF THE SKIN. pons of corrosive-sublimate cotton should be introduced; and if there is much suppuration the nares should be washed out with a weak solu- tion of the same substance (1 :4,000 or 5,000). It has been said that externab applications in erysipelas are useless, and, when ordered, are only of the nature of placebos. This is a grievous mistake. The itching and burning demand relief, and if it is not obtained, the patient tears his skin with his fingers, and at times becomes almost frantic. Various preparations have been recommended for external use in erysipelas, but the majority are useless and many are injurious. Tincture of iodine, mercurial ointment, and solutions of nitrate of silver and carbolic acid can be employed, but they are all more or less painful and often inefficient. The ointment of the oleate of bismuth, on the other hand, is an elegant and effective application, which can be depended upon to allay the itching and burning, and lessen the pain and nervous irritability. M. Marc See is accustomed to use a permanent antiseptic dressing chiefly composed of the subnitrate of bismuth, either as a prophylactic in the case of unhealthy wounds or as a remedy in actually developed erysipelas. Pirogoff's method was to cover the diseased surface with slices of common lard, covered by a layer of cotton-wool and held in place by a bandage. As a local dressing, he also recommended a piece of linen cut into a mask when the face was affected, and thoroughly saturated with camphorated olive-oil. As a local application, M. Tison recommends a solution of camphor in ether. In erysipelas of the trunk and limbs, Dr. A. Rose, of New York, has seen great advantage from immersion of the affected part in a bath of a temperature of 90° to 95°. The inflammation and pain are rapidly relieved and the fever reduced.* The ointments of carbonate of lead and boric acid are also valuable. Another useful but not so elegant an application is the earth-dressing of Dr. Addinell Hewson. This dressing consists of a thick paste of clay and water. It relieves the pain and burning almost instantly, lessens the fever and swelling, and in many cases exercises an abortive effect upon the disease. Sir Dyce Duckworth recommends a thick chalk-ointment, f Dr. George C. Kingsbury advocates the local use of ergotin in the form of a fifty-per-cent. solution in distilled water, frequently applied with a camel's-hair brush to and around the affected area. A few ap- plications suffice to reduce swelling and relieve pain.\ Various anti- septics have of late years been widely employed as local applications. Unna considers that ichthyol and resorcin exercise almost specific in- fluence. Concentrated solutions of the latter are capable of producing oedema and blebs. It is therefore prudent either to begin with a weak solution and increase the strength to the point of tolerance, or the * Therapeutic Gazette, January 16, 1890. -f- Practitioner, January, 1887. X British Medical Journal, March 15, 1S90. EXUDATIONS. 205 remedy may be conjoined with some substance which shall mitigate its action, and among the best of these are oxide-of-zinc ointment and linseed or olive oil. Upon hairy parts, especially the scalp, it is better to use an oil. As a rule, equal parts of resorcin or ichthyol and zinc ointment forms a serviceable application. In a number of cases of ery- sipelas in recently vaccinated infants, Dr. Himmelfarb used one half drachm of purified resorcin to one ounce of glycerine. This solution was painted every hour by means of a camel's-hair pencil upon the dis- eased area and a surrounding healthy zone, and complete recovery took place within twenty-four hours. Dr. Fessler, first assistant of Prof. Nussbaum, of Munich, has pub- lished in a monogram the results of numerous bacteriological experi- ments and clinical observations relating to the influence of ichthyol upon cultures of the specific streptococcus of erysipelas. Weak solu- tions were found very destructive to this micro-organism, and the au- thor concludes that ichthyol, employed early and energetically, will cure the disease by destroying its germ. The method of treatment con- sisted in rubbing vigorously, for ten minutes at a time, a strong ichthyol- ointment into the affected surface and its vicinity. Any wound must be carefully disinfected and antiseptically dressed. From the author's tables it appears that while from 1880 to 1888 the mean duration of the cases treated by other methods was about twelve days, and in no single year less than nine days, the ichthyol treatment reduced the length from 1886 to 1888 to an average of less than seven days, and in the first half of 1889 the duration had fallen to 5-6 days. Cavelli claims good results from the use of picric acid. He states that the swelling and pain are markedly decreased in from twelve to twenty-four hours. He employs an aqueous solution, one and a half parts of picric acid to two hundred and fifty parts of distilled water, applied externally five or ten times a day.* He conceives that the drug penetrates the horny layer, acts as a protective to the stratum Malpighii and restrains in- flammation by its astringent properties. He suspects, moreover, that it is able to gain the interior of lymphatic conduits and destroy the micro-organisms on which the disease depends. Excellent results have been reported from Rosenbach's treatment, which consists in washing the erysipelatous patch and the surrounding skin with soap and after- ward applying continually a five-per-cent. solution of carbolic acid in absolute alcohol. For an alcoholic solution Prof. Ebstein substi- tutes a five-per-cent. carbolized vaseline with, it is said, equally good results. Dr. Churiloff obtained good results from inunction with one or two per cent, parachlorophenol and ortho-bromophenol. Since the erysipelas cocci are destroyed by ninety-per-cent. alcohol, Behrend has employed this agent as a local bath to a part attacked by * Gazetta degli ospitali, 1889. 206 DISEASES OF THE SKIN. erysipelas. The application repeated thrice daily was made to extend one half inch beyond the border of the diseased patch. He found that the disease was quickly arrested and completely cured within three to five days. Creolin, likewise, has been found efficacious. It has been used in the strength of three parts to twenty-five parts of lanolin, or one part of creolin and four parts of iodoform to ten parts of lanolin. The hypodermic injection of three or four syringefuls of a three-per- cent, carbolic-acid solution is advocated by Hueter. The injection should be made along the border of the erysipelatous patch and into the tissues which the disease is about to invade. Dr. M. Strizover, of Soroki, Bessarabia, makes use of hypodermic injections of corrosive sublimate one grain, and carbolic acid ten grains, dissolved in two ounces of distilled water. His method is to inject a Pravaz syringeful of the solution at several points, a few drops at each. The same fluid is then rubbed into the parts for several seconds by means of cotton-wool; a layer of wadding saturated in the solution is then laid upon the surface and held in position by a gauze bandage. The dressing is changed in six or eight hours, and not more than one injection is generally needed. An ointment of corrosive sub- limate made with lanolin has also proved of benefit. Wolfler asserts that the gentle and equable pressure of strips of sticking-plaster is successful in limiting the disease to the area covered by the dressing. He reported* twenty-four cases, in twenty-one of which this method had proved efficacious. A plan devised by Krask'e, and slightly modi- fied by Biedel and others, consists in surrounding the patch by a line of incision which is to be intersected throughout its length by short cuts crossing it at right angles. Ordinarily the incisions need to be but little deeper than those made in vaccination. The scarified sur- face is then washed with a five-per-cent. solution of carbolic acid, and kept constantly wet with compresses soaked in a two-and-a-half-per- cent, solution. Some prefer using a sublimate solution (1 :1,000) in- stead of the carbolic acid. Dr. A. Seibert, of New York, has designed two small-toothed instruments by which the operation may be conven- iently performed. If done upon the face, great caution will be re- quired lest the incisions be made too deep and an unsightly scar be produced. Carbolic acid or corrosive sublimate may be used, as by De Amicis, without scarification. This writer generally employs equal parts of carbolic acid and glycerine, applied every second hour to the affected patch and a surrounding zone. In phlegmonous erysipelas he follows Ilueter's method of hypodermic injections. If the odor of carbolic acid is intolerable to the patient, a one-per-cent. solution of corrosive sublimate in glycerine is substituted. Nolte applies mucilage of acacia containing three to five per cent, of carbolic acid. Inunctions of tur- * Zeitschrift fur Therapie, July 15, 1889. EXUDATIONS. 207 pentine have likewise proved beneficial. The following mixture is recommended as a topical remedy by Dr. Rothe: R Acid, carbolici.................... gr. xxj. Sp. vini rectificat, Tr. iodi........................aa m xxx. 01. terebinth...................... f | j. Glycerini......................... f z iij. m. Salicylate of sodium dissolved in glycerine is highly recommended by Inglessis. An ointment containing creasote or salol has been found beneficial. Dr. Dewar praises the action of a dressing composed of equal parts of sulphurous acid and water. A. H. Neuth has observed good results from the topical employment of acetanilid made into an ointment with lard, lanolin, or other suitable excipient in the proportion of twenty grains to the ounce. As erysipelas may originate from a point of infection within the nose, it is well to cleanse the nares at intervals with a three-per-cent. solution of boric acid, as advised by Lehrnbecher. Prognosis.—Uncomplicated idiopathic cases of erysipelas invariably terminate favorably. The occurrence of delirium indicates a grave case, but not necessarily a fatal one. GSdema of the air-passages and embolism of the cerebral vessels are seldom followed by recovery. Pneumonia, pleurisy, and endocarditis are unfavorable complications. Pyaemic and uraemic cases usually die. Phlegmonous cases pursue a tedious course, and present a high death-rate. Gangrenous erj^sipelas is generally fatal. Alcoholic subjects are unfavorable cases. CHANCROID. Synonyms.—Soft chancre, non-infecting chancre—Chancroi'de—Schanker. Chancroid is a localized virulent, contagious, specific venereal dis- ease, characterized by the formation of one or more peculiar ulcers upon the cutaneous or mucous surfaces, accompanied by inflammation of the adjacent lymphatic glands, but not followed by any other symp- toms of constitutional infection. Symptoms.—The lesions of chancroid may occur upon any portion of the body, but they are most frequently observed on the genital organs. The glans and prepuce in the male, and the fourchette, labia majora, labia minora, and the lower part of the vagina in the female, are especially liable to be involved. The body of the penis and the urethra and scrotum in the male, and the uterus, urethra, perinaeum, and anus of the female, may also be affected. Chancroid of the fingers has occurred in gynaecologists and accoucheurs as a result of infection through a cut or an abrasion while making a vaginal examination. Chancroid has no period of incubation. The morbid process be- gins as soon as its essential virus is absorbed. If a drop of chancroidal pus be inserted beneath the epidermis, the point of insertion will be 208 DISEASES OF THE SKIN. surrounded in a few hours by a faint reddish blush, which gradually increases in size and distinctness until the second day, when it appears as a well-marked inflammatory aureola. A vesicle is then developed at the point of inoculation, and becomes converted into a pustule, which usually breaks spontaneously in a few days. The resulting ulcer is a typical chancroid, which does not differ in appearance or course from those which result from impure sexual intercourse. The interval of several days which sometimes elapses between ex- posure to contagion and the appearance of the lesion, is due to the fact that no abrasion of the surface occurred, and that absorption con- sequently could not take place until the acrid virus had corroded away the outer layers of the epidermis or insinuated itself through the follicles into the interstitial spaces of the rete mucosum. Ab- sorption is rarely delayed longer than a week, however; and, if an abrasion exists, well-marked symptoms may develop within a few hours. It has been estimated that in twenty-five per cent, of cases the lesions appear within two days; in twenty-five per cent, more, within four days ; in thirty per cent, more, within six days ; and in the remaining twenty per cent, at various times, from a week to twelve days. . Usually, within two or three days after infection, the characteris- tic lesion of chancroid becomes manifest. It consists of a sharply- defined round, oval, or irregular ulcer, with abrupt, perpendicular, or sloping edges. Its base at first is red and smooth, but soon becomes irregular and granulated, and covered with a gray or yellowish-white pultaceous material, consisting principally of pus. It is surrounded by an inflammatory non-indurated aureola, and is continually secreting more or less thick w7hite or yellowish pus, which may or may not be tinged with blood. If no treatment be instituted, the ulcer gradually increases in size for one or two weeks, frequently attaining a diameter of half an inch. In mild cases, a process of spontaneous repair may then begin. The inflammatory aureola disappears ; the secretion be- comes altered in character, and finally ceases ; healthy granulations spring up, and, if the destruction of tissue has not been too great, the healing process will be completed without the formation of a per- manent cicatrice. In severe cases, the ulceration continues to extend in all directions until a large area of the surface is involved. It then tends to assume a chronic character, and is subject to various modifications. In ma- lignant or phagedaenic chancroid the ulceration spreads deeply and widely, producing intense pain and great destruction of tissue. In some cases the rapidity and severity of this process are so excessive as to result in the sloughing of the glans penis, and destruction of the scrotum in a few days. In the female it is frequently productive of frightful and loathsome deformities. EXUDATIONS. 909 Chancroidal ulcers may be single, but, as a rule, they are multiple. Owing to the auto-inoculability of their secretions, as well as to the fact that several abraded points may be infected at the same time, there is no limit to the number which may be present. I have seen a patient who had thirty-seven distinct chancroids, and instances are recorded in which a still greater number were observed. All chancroidal ulcers are accompanied by more or less inflam- mation and infiltration of the surrounding tissues. In some cases the entire penis is enormously swollen ; in others the infiltration is limited to the prepuce or the glans penis, producing phimosis or paraphimosis. The most frequent complication of chancroid is bubo, or inflam- mation of the neighboring lymphatic glands. At times the lymphatic vessels leading to the glands also become red, inflamed, and hardened, and can be felt like hard cords beneath the skin. When it assumes this phase it is a genuine lymphangitis, which may eventuate in sup- puration and the formation of small abscesses along the course of the inflamed lymphatics. It usually, however, terminates in resolution in a few days. A bubo pursues a more prolonged course. Its presence is an- nounced by swelling of the affected gland, and a sense of tenderness or pain upon motion. Buboes may occur upon any region of the body, but, as their exciting cause generally exists upon the genital organs, they are usually found in the groin. They develop during the first few days of the existence of the chancroid. They vary in size from a hazel-nut to a small cocoanut, in accordance with the number of glands involved, the intensity of the morbid process, and the state of the patient's constitution. They also vary in duration and termi- nation. In mild cases there is no pain, but merely a sensation of dis- comfort, which passes away in a few days, and the swelling which is only moderate disappears in two or three weeks without suppuration. In severe cases the glands increase largely in size, and become in- tensely painful. The overlying integument is red and tender, and suppuration progresses so rapidly that fluctuation can be perceived in five or six days from the commencement of the swelling. The pain increases with the formation of pus until the bubo is opened or spon- taneous evacuation of its contents occurs. The cavity of the ulcer which is exposed is similar to the chancroidal ulcer from which it originates. It secretes the same virulent pus, and is subject to the phagedaenic and other complications of chancroid. If left untreated it may become chronic in character, and involve a large area of surface. Usually, however, the character of its secretion gradually changes, healthy granulations spring up, and a cure is finally effected by cicatrization. Diagnosis.—The diagnosis of chancroid is frequently difficult. The 14 210 DISEASES OF THE SKIN. principal affections with which it may be confounded are chancre, herpes, eczema, epithelioma, and innocent erosions or abrasions oc- casioned by sexual intercourse. Chancroidal ulcers are painful to the touch, rapid in development, and have no marked period of incu- bation. They are usually multiple, their secretion is copious, puru- lent, and auto-inoculable ; their base is not indurated, and they rarely involve more than one lymphatic gland at a time. Chancre, on the contrary, is slow in development, painless to the touch, and has a well-marked period of incubation. It is usually single, its secretion is thin, sanious, and not auto-inoculable. Its base is indurated, and it involves a chain of lymphatic glands, which rarely suppurate. The subsequent history of the case is also different. It must not be for- gotten, however, that it is possible for the same lesion to contain the poison of both chancroid and chancre, and that while the rapid de- velopment of the symptoms of the former may obscure those of the latter for a time they will not prevent their final appearance. Con- sequently, a patient who is suffering from chancroid should not be assured that he has not contracted syphilis until the ordinary incuba- tive period of that disease has elapsed without the development of its characteristic symptoms. Herpes may usually be distinguished from chancroid by the pres- ence of the minute vesicles of the former disease, the severity of the local irritation, the history of former similar eruptions, and the ab= sence of progressive ulceration and glandular involvement. Eczema is attended by excessive itching and irritation, but is devoid of ulcera- tion. In epithelioma the secretion is either absent, as in the early stages, or thin, sanious, and fetid, as in the later stages. The knobbed, wart-like, or cauliflower appearance, and painful character of the growth is also significant. Simple erosions or abrasions of the glans, or of the prepuce, or of the body of the penis are of frequent occurrence, and may be mistaken for commencing chancroids. They are bright-red in color, and often cover a large area, and are at times the seat of a serous discharge. They do not extend in depth, however, and, if not irritated, will in- variably disappear in a few days. Balanitis has been mistaken for chancroid, but that error can readily be avoided. In balanitis the greater portion of the glans is involved, and the discharge is thick and purulent, but there is no inguinal involvement, no destruction of tissue, and all the symptoms rapidly disappear under appropriate treatment. The ulcerations of tertiary syphilis present a striking resemblance to those of chancroid. Their edges, however, are more indurated, their history is different, their course is slower, their secretion is not auto-inoculable, and they are not accompanied by the formation of buboes. Pathology.— The pathological conditions which are present in EXUDATIONS. 211 chancroid do not appear to differ in any respect from those which oc- cur in ordinary ulcerative processes. The floor of the ulcer is formed by the corium, destitute of papillae, uneven and covered with pus-cells, The rete mucosum and the papillary layer of the margins are oedema- tous, and infiltrated with cells. The underlying corium is also thick- ened and infiltrated. The vessels of the corium are dilated and tortu- ous ; their walls are swollen and surrounded by a network of new fibrous tissue. Etiology.—Chancroid is due to the absorption of the peculiar virus of another chancroid. The poisonous principle resides chiefly in the pus-corpuscles, and we are warranted in supposing that it consists in a hitherto undiscovered specific micro-organism. Unna has described a streptobacillus, growing in the form of chains, which he has found in sections of chancroids. It is conveyed exclusively by contagion, which may, however, be mediate or immediate. There have been instances where it has been contracted by accoucheurs or gynaecologists while making a vaginal examination, but in the main it is due entirely to< impure sexual intercourse. Treatment.—The prophylactic treatment of chancroid is of the first importance. The parts should be thoroughly cleansed immediately after a suspicious intercourse, in order to remove any poisonous mate- rial. If any abrasions be noticed, a physician should be consulted at once. After a chancroid has developed, the most effective treatment con^- sists in cauterizing the entire affected surface. By this means all dan- ger of further contagion is averted, and the specific ulcer is changed1 into an ordinary simple sore. Any active caustic may be used for this; purpose, but those which are most frequently employed are the gal- vano-cautery, the actual cautery, nitric acid, and sulphuric acid. The- galvano and the actual cauteries possess the advantage of being only momentarily painful; their action can also be easily restricted to the- affected spot. Acids will sometimes diffuse over a portion of healthy tissue in spite of every precaution. The caustic alkalies are still! more diffusive and very painful. Fournier advises the use of a three-per-cent. solution of nitrate of silver, applied thrice daily upon a pledget of absorbent cotton. Solu- tions of peroxide of hydrogen or chloral or Labarraque's fluid are like- wise of service. Liquid carbolic acid is also a good cauterant. No matter what agent may be employed, care must be taken to thoroughly cauterize every portion of the sores, for if any of the virus be left undestroyed it will speedily multiply and invade fresh areas of the surface. The patient should avoid as far as possible severe labor or exercise. Alcoholic drinks should be prohibited. After the chancroid has been thus effectually treated it should be covered with powdered bismuth, subiodide of bismuth, or zinc-oint- 212 DISEASES OF THE SKIN. ment, or any non-irritating application, and permitted to heal by gran- ulation. The use of pyoktanin in weak solution or as a diluted powder promotes the healing process. If nitric or sulphuric acid be used, a solution of cocaine, creasote, or dilute carbolic acid may be first applied to the surface in order to lessen the pain. Letzel has* found the solution of the chloride of iron an efficacious application. In the course of four days a bright granu- lating surface results. Calomel may then be used as a dusting-powder, and in about five days more the sore will generally be healed. Iodo- form is an excellent dressing, but its odor is often an objection. In such cases iodol, aristol, or europhen may be employed as a substitute, either in the form of a powder or a five-per-cent. ethereal solution. If deemed advisable, iodol may be combined with alum or subnitrate of bismuth. It is not, however, according to the comparative studies of Dr. Szadek, of Kiev, as efficient as iodoform. Prior to applying the iodol the surface of the ulcer should be carefully cleansed by means of a corrosive-sublimate solution and be cauterized. The powder should not be applied in a thick layer, which causes retention of the discharge. Prof. Stiikovenkoff, of Kiev, praises the action of benzoate of mercury, which may be used either as a powder or in watery solution (1 to 3 parts to 500). As it gives rise to considerable burning, it is advisable to add cocaine to the lotion. The sub-benzoate of bismuth is advocated by Dr. Finger. Dusted over the sore it gives rise to a slight burning sen- sation, which, however, soon passes off without any local irritation. In from three to six days the sore begins rapidly to cicatrize. Other efficient applications are: Bromine, tij, x to the ounce of olive-oil; a weak solution of sulphate of copper; a diluted fluid extract of hama- melis or hydrastis; an ointment of resorcin, naphthaline, ichthyol, or nitrate of mercury. Salicylic and pyrogallic acids have also been recom- mended. The former is used as a powder, the latter as a pure powder, or mixed with starch or bismuth, as a ten- or twenty-per-cent. oint- ment, or dissolved in collodion or -traumaticin. Formalin has been found to be an excellent application, producing very rapid cicatrization. Dr. Oscar V. Peterson advocates scraping out the chancroid with a sharp spoon, as is done in lupous ulcers. He previously cleanses the sore and surrounding skin with a solution of corrosive subli- mate or carbolic acid, afterward wiping the parts with a piece of cotton-wool soaked in ether. In order to render the operation pain- less, a two-per-cent. solution of hydrochlorate of cocaine is injected beneath the skin. After the operation a dressing of iodoform powder and gauze is applied. He states that by this method the duration of a case is materially shortened. The same writer speaks favorably of painting the surface of the sore with pure tincture of iodine, and excision of the sore and adjacent skin with subsequent application of sutures. The wound heals in three days by first intention. Besides EXUDATIONS. 213 being painf.il, excision is unsuitcd to ulcers situated on the glans.* For the purpose of absorbing the discharge from the sore, keeping the surface dry, promoting cure, and preventing auto-inoculation, absorbent cotton has been usefully employed in the wards of Bellevue Hospital. The method of application is to surround the penis just behind the corona with a small roll of cotton kept in place by a rubber thread band. The dressing is light, and can be easily renewed as often as necessary. The more dry the surface of a chancroid can be kept the more rapidly will it heal. Resorcin and acetanilid are other substances which have been em- ployed with advantage. If severe or erysipelatous inflammation de- velop, the affected part should be elevated and kept moist and cool by the application of cold water or lead-water and laudanum. If phagedenic ulceration occurs, all sinuses and fistulae must be laid open, all sloughs cut away, all pus removed from the surface, and un- sparing cauterization promptly resorted to. Prolonged immersion in hot water has an excellent effect. If the pain be severe and the constitutional excitement high, morphine and aconite are to be administered, in suffi- cient quantity to allay pain and to moderate nervous and arterial ten- sion. After these symptoms have abated, constitutional tonics, such as iron and quinine, with generous alimentation, are required. The formation of a bubo can not be prevented, but judicious treat- ment will frequently promote its resolution or prevent suppuration. As soon as the inguinal glands become enlarged or tender, the patient should be sent to bed, a saline cathartic administered, and tincture of iodine painted freely over the skin of the affected region. If the gland continues to enlarge and the pain to increase after this treatment has been persevered in for twenty-four hours, another saline cathartic may be administered, and a bag of ice applied at short intervals to the swol- len gland. If there be no pain or inflammatory symptoms, but merely a progressive increase in the size of the bubo, constant pressure, as from a bag of shot or a disk of metal, held in place by a spica band- age, will be the most effective remedial measure. If suppuration ensues, the bubo must be opened as soon as fluctua- tion is perceived, and its contents thoroughly evacuated. Its interior surface should then be thoroughly cauterized, and afterward dressed with an emollient ointment, and permitted to heal by granulation. Tonics and stimulants must be given Avhenever indicated. In place of a large incision which will leave an indelible and un- sightly scar of proportionate size, it will usually be found better to evacuate the pus either by a small opening made with a narrow-bladed bistoury or by aspiration. The cavity should then be irrigated by a weak solution of corrosive sublimate,,and slight pressure be maintained by means of a compress and bandage. A small quantity of nitrate-of- * Journal of Cutaneous and Genito-Uiinary Diseases, September, 1889, p. 360. 214 DISEASES OF THE SKIN. silver solution may be used instead of the bichloride. Welander has used benzoate of mercury by injection in one hundred cases of buboes. He finds that if the injection is made before fluctuation has occurred, it will in most, cases prevent or greatly limit the produc- tion of pus; and that even when fluctuation is decided, if the skin be thick and well nourished, in about half the cases the necessity of evacuation will be obviated. A bubo may be very advantageously opened by the galvanic knife, and proper drainage is thereby favored, since the opening does not close so readily as that made by the ordinary bistoury. Phimosis and paraphimosis may be relieved in accordance with the methods appropriate to each individual case. Prognosis.—The prognosis of chancroid is always favorable so far as danger to life is concerned, but it occasionally pursues a tedious course, and may result in the production of permanent cicatrices or other deformities. SYPHILIS. Syphilis is a virulent, chronic, contagious, systemic disease produced by^the absorption or inoculation of a specific virus, and manifesting itself primarily by the development of an infectious lesion at the point of inoculation or absorption, accompanied by an involvement of the ad- jacent lymphatic glands, and followed by a series of morbid manifesta- tions which first involve the skin and mucous membranes, and finally extend to all the organs and tissues of the body. As a general though not invariable rule, one attack renders the patient insusceptible to a second infection. Symptoms.—There are four more or less well-marked stages of syphilis: the primary, in which the force of the disease appears to be concentrated at the point of infection and in the contiguous lymphatic glands; the secondary, in which the cutaneous and mucous surfaces are mainly involved; the tertiary, in which the osseous, cartilaginous, muscular, and fibrous tissues are invaded; and the quaternary, in which the nervous system and the viscera are profoundly affected. Primary Syphilis.—After a period of incubation, which varies from ten days to several weeks, the presence of the virus of syphilis in the circulation is announced by the development at the point of infec- tion of the characteristic initial lesion of the disease. This lesion, which is ordinarily known as " a chancre," is generally situated upon the genital organs, but may appear upon any portion of the body which has been exposed to contagion. It sometimes forms at the meatus urinarius, or even within the urethral canal in the region of the fossa navicularis. In these situations, and especially the latter, it may lead a careless or inexperienced observer to a mistaken diagnosis of gonor- rhoea. The discharge, however, is more scanty than that of gonorrhoea, EXUDATIONS. 21.5 the pain more localized, and an indurated spot is suggestive of chancre. The lesion rarely occurs in the deeper urethra, but Fitzgibbon has re- ported a case, under the title of " syphilitic gonorrhoea," in which an induration about half an inch in diameter could be felt at and just an- terior to the membranous urethra. Urination was impeded, a thin semi-purulent discharge existed, and the inguinal glands were en- larged. A papular syphiloderm subsequently made its appearance. Accidents, careless or uncleanly habits, or unnatural connection, may lead to the development of a chancre in many unusual situations, upon the lip, tongue, tonsil, nipple, eyelid, nose, chin, anus, extremi- ties, etc. During the ten years from 1878 to 1887 inclusive, Prof. A. Pospelow, of Moscow, saw 198 cases of extra-genital chancres among patients belonging to the working classes. Of this number the lesion occurred upon the lip in 49 cases (in 20 men and 29 women); upon the gums in 1 (a man); the tongue in 3 (1 man, 2 women); the throat in 46 (14 men, 32 women); the breast, 69 (all women); the chin in 1 (a woman); the eyelids in 3 (men) ; the nose in 1 (man); the trunk in 10 (5 men, 5 women); the upper extremities in 6 (3 men, 3 women); the lower extremities—thigh, nates, 4 (women).* Statistics upon the same subject have been collected by Nivet, Morel, Lavallee, Veslin, and Foulard, from the service of Prof. Fournier. Chancre of the tonsil is, in fact, of more frequent occurrence than is generally supposed. This circumstance should be borne in mind, and lead us, in cases where an eruption is of doubtful origin and the initial lesion can not be elsewhere found, to carefully inspect the mouth. Chancre of the tonsil is limited to one side, and is accompanied with difficulty in swallowing and enlargement of the glands in front of the ear and below the jaw. The conjunctiva is the seat of the initial lesion in occasional instances. The sclerosis is usually situated upon the free margin of the lid, but has been seen upon more remote portions of the palpebral membrane, and in six cases upon the ocular conjunctiva. A chancre usually consists at first of a small round or oval abrasion of the skin or mucous membrane, which varies in size from a pin's head to a three-cent piece. It is almost invariably single. Its base is slightly depressed, dark red in color, and indurated, especially in men. The induration is sometimes less in women,f and in some cases en- tirely absent. This primary lesion is not surrounded by an aureola, and rarely suppurates unless irritated. Its secretion, which is thin, serous, and scanty, is highly contagious, but not auto-inoculable. If ulceration occurs, the secretion becomes sero-purulent in character, and the base of the ulcer is covered with a layer of gray or dirty-white aplastic lymph. At times deep and extensive ulceration occurs, especially when the * Medical Bulletin, January, 1890, p. IT. f YV. E. Cant, F. R. C. S., in a report on clinical observations on " Induration, in the Primary Lesions of Syphilis in Women." British Medical Journal, February 12, 1887. 216 DISEASES OF THE SKIN. general condition of the patient is bad. Perforation of the urethra* with establishment of a urinary fistula, has been known to occur. Chancres situated in the groove behind the glans are particularly apt to ulcerate deeply, and those located in the pubic region often take on an ecthymatous appearance. In the Hunterian variety of chancre the ulcer is deep and funnel- shaped, its edges are sloping and indurated, its base is hard and cov- ered with lymph, and the lesion in its entirety feels to the touch like a split pea set into the skin. Another variety of chancre is that which appears as an elevated indurated papule, which may or may not become excoriated or ulcerated. The initial lesion occasionally varies considerably in appearance from the preceding description. Dubuc has described a manifestation which he terms " herpetiform multiple syphilitic chancre," in which from five to fourteen small, round excoriations occur on the prepuce and glans. Induration is but slightly marked. • Braquehaye has re- ported from the Bordeaux Polyclinic the case of a woman, aged twenty- four years, in whom three chancres developed upon different parts of the face.* However atypical the form, in fact, the presence of indura- tion is the most constant and characteristic feature of the chancre. Nevertheless, there are exceptions even to this diagnostic sign. In women it is often extremely difficult to demonstrate any hardness of base. Even in men, cases are sometimes met with in which no hard- ness can be detected by the most careful examination. On the other hand, a case may be occasionally seen, as has been described by Kaposi and Dr. Edwin C. Burnett, of St. Louis,f in which sores with every mark of the Hunterian chancre, including the hardened base, are not followed by any secondary outbreak. Dr. Burnett offers the suggestion that in such cases the virus of the disease may be rendered inert in the first stage through some influence which we do not understand. Finally, the fact should never be forgotten that chancroids or non-venereal le- sions may acquire an inflammatory hardness from cauterizing agents which patients have often used before seeking the surgeon. In some instances hardness due to inflammatory exudation very closely simu- lates the induration caused by cell proliferation. Ulceration, though usual, is not invariable, and the chancre occa- sionally appears in the form first described by Lanceraux as papule seche, or dry papule, the induration feeling like a pea buried beneath the skin, the epithelium remaining absolutely intact. Very often it appears as what Bassereau has called the superficial erosion, the sore being- small, oval or circular in outline, with a reddish floor, scanty secretion, and resting upon a thin, hardened base known as parchment- induration. Mauriac has called attention to a rare form of the initial * Medical Bulletin, November, 1889, p. 357. f Journal of Cutaneous and Genito-Urinary Diseases, September, 1889, p. S25. EXUDATIONS. 217 lesion which he has called " infecting balano-posthitis," which might easily be mistaken for simple balano-posthitis. The mucous mem- brane of the prepuce is of a deep red color and thickened, and is usually slightly eroded. The glans may also be superficially thickened, and is generally eroded. Chancre, as a rule, is not accompanied by pain or any other sub- jective symptoms, and usually disappears in a few weeks without either cicatrization or pigmentation. In some cases the lesion becomes at- tacked by phagedaenic ulceration or by gangrene, but these complica- tions are extremely rare. When a chancre is of large size and accompanied by a great deal of oedema and ulceration it is apt to be followed by unusually severe con- stitutional symptoms. Syphilitic bubo, or enlargement of the adjacent lymphatic glands, is a constant accompaniment of chancre, and usually occurs contem- poraneously with the development of that lesion. It may exhibit it- self upon any portion of the body where lymphatic glands exist, but is usually observed in the inguinal regions. It involves a group or cluster of glands, Which become indurated and swollen, and rarely sup- purate. They vary in size from a small marble to a walnut. They are freely movable under the skin, and are not painful to the touch. They reach their maximum development in from two to four weeks, and after remaining stationary for several months gradually return to their normal size and condition. Suppuration is not usual, but may occur, probably from adventitious causes. Diagnosis.—The diagnosis of primary syphilis is not usually at- tended with much difficulty. The principal affections with which it is liable to be confounded are chancroid, herpes, and simple erosions of the cutaneous or mucous surfaces. Chancroid, however, usually begins as an angry-looking ulcer, which has no period of incubation, and is rapid in progress and attended by a high degree of inflammation. Its edges are abrupt and non-indurated, and its secretion is copious, puru- lent, and auto-inoculable. It is usually multiple, and more or less painful. Finally, its accompanying bubo is extremely painful and highly inflammatory in character, tending to suppuration, and, with rare exceptions, is limited to a single gland. Chancre has a well-marked period of incubation, and usually begins as an apparently insignificant erosion, which is slow in progress and attended by a low degree of in- flammation. Its edges are sloping and indurated, and its secretion is thin, scanty, and not auto-inoculable. As a rule, it is single and pain- less, and finally its accompanying bubo is composed of a number of glands Avhich become hard and swollen, but are not painful and rarely suppurate. In herpes there is generally a history of previous similar eruptions, and the lesions disappear in a few days without producing anv glandular involvement. Accidental simple abrasions frequently 218 DISEASES OF THE SKIN. can not be distinguished in appearance from the erosive form of chan- cre. They may be observed immediately after intercourse, however, and heal kindly in two or three days under the protective covering of a layer of bismuth subnitrate, zinc oxide, or some similar non-irritating application. If the intercourse has been of a suspicious nature, how- ever, it must be remembered that there is a possibility of inoculation having occurred at the point of erosion, and consequently a decided opinion should not be given until sufficient time has elapsed without the appearance of any other symptoms. Later Syphilis.—In secondary syphilis the cutaneous and mucous membranes are principally affected, but iritis, orchitis, and other com- plications may develop. In tertiary syphilis the deeper tissues of the body are involved, but lesions of the skin and mucous membranes may also be present. In quaternary syphilis the cerebro-spinal system and the internal organs are the subject of the disease. The line between these varieties is not always well marked, however. Some of the erup- tive symptoms belonging to the secondary group may be delayed until the tertiary stage, while occasionally grave nervous symptoms appear early in the course of the disease. The development of the symptoms of secondary syphilis is usually preceded by marked constitutional derangement. The appetite is im- paired, the bowels are constipated, the urine is scanty and high-colored and there is a sensation of general malaise. The patient is irritable and despondent, as if from a foreknowledge of impending illness. There is pain in the bones and around the joints, especially at night, and glandular swellings occur in various portions of the body. Muscular pains may also be present. Headache and vertigo are not uncommon. Insomnia not due to pain may occur, and in rare instances, especially among women, considerable mental disturbance may attend the out- break of the secondary period. More or less feverishness may be pres- ent. In some cases the fever is periodical in character, and erroneously assumed to be of malarial origin. In others it may assume a continued type, may last for several weeks, during which the temperature may at times reach 104° F., and in rare instances may closely simulate typhoid fever. The absence of epistaxis, tympanitis, gurgling in the iliac fossa, should, however, be sufficient to establish the diagnosis. In- stead of the scanty eruption that belongs to typhoid fever, the sym- metrical roseolar or papular rash of secondary syphilis makes its ap- pearance. As a rule, the spleen is not enlarged in syphilitic fever. Prolonged syphilitic fever leads to emaciation, anaemia, and serious debility. During the febrile stage a decided loss of red blood-corpuscles oc- curs, varying from eleven to sixty-five per cent. At the same time the white blood-corpuscles are increased. This alteration in the composi- tion of the blood leads in some instances to shortness of breath, palpi- EXUDATIONS. 219 tation of the heart and basal murmurs, oedema, and epistaxis. With the fever and development of the eruption an increased excretion of urea, creatinine, phosphates, and sulphates takes place. Dr. J. V. Iljelmman states that a manifest anaemia is produced and is at its height during the period of eruption. As the general symptoms sub- side the blood tends to regain its normal composition. Syphilitic fever occurs most frequently in those of delicate nervous organization, and especially in anaemic women. According to Dr. Oscar V. Petersen, albumen appears in the urine in 3-8 per cent, of patients with recent syphilis, in 3-8 per cent, of those having secondary symptoms, and 5-8 per cent, of those with late manifestations. After premonitory symptoms have existed for several days, any doubt that may have been entertained is dispelled by the appearance of one or more of the characteristic syphilitic eruptions, or syphilides. Secondary syphilis usually manifests itself about six weeks after the appearance of the chancre, though exceptionally the period may be pro- longed to eight or ten weeks. During the course of secondary syphilis a diminution or loss of the different forms of sensibility in certain regions has occasionally been observed. In certain cases syphilis runs a very rapid course. Grave cutaneous lesions, which ordinarily do not appear for a year or more after infec- tion, develop within the first few months and are accompanied by symptoms due to involvement of the viscera or nervous system. These cases are known as galloping or precocious malignant syphilis. A case of malignant may be contracted from benign syphilis. In- temperance and bad hygienic surroundings have much to do with the production of this severe form of the disease. According to Fournier, the previous occurrence of malarial intoxication is an important factor in causing malignity. All the syphilides possess general features peculiar to them as a class, and serve to distinguish them from non-venereal cutaneous erup- tions. The most important of these characteristics are the color and course of the eruption, the polymorphism of the lesions, the character of the ulceration, the color of the crusts and scales, and the absence or insignificance of the subjective symptoms. Color.—Their color varies with the size and situation of the lesions. The small macules and papules are usually bright red at first, but grad- ually acquire a dark-red or coppery hue. The large papules and tuber- cles present the characteristic raw-ham or copper-colored appearance from the beginning. As the lesions disappear this hue fades and changes into brown, yellow, or dark-gray. In some cases the normal pigment of the skin is destroyed or absorbed, and large white patches, resembling vitiligo, are formed. All the syphilides develop slowly, pur- sue a tedious course, and manifest a "marked tendency to recur. 220 DISEASES OF THE SKIN. m W Polymorphism.—Polymorphism, or the tendency of several forms of lesions to appear at the same time, is especially characteristic of the earlier syphilides, but it is also a feature of the later eruptions. A macular eruption is occasionally complicated by the development of papules. Papules, vesicles, and vesico-pustules may frequently be ob- served to be commingled, while in other cases tubercles, pustules, and ulcers are often present at the same time. Scales.—The scales are usually few in number, and white or trans- parent in color. They are thin, friable, and easily detached. They are developed over the centre of the lesion, and rarely extend to the periphery. Crusts.—The crusts or scabs are brown, dark-green, or black in color, and are firmly adherent at the periphery to the subjacent tissues. * They are thickest in the centre, and frequently present a conical, vaulted, or laminated appearance. Ulcerations.—The ulcerations of late syphilis are apparently cause- less in origin, and usually painless in character and protracted in duration. Subjective Symptoms.—The syphilides, as a rule, are not accom- panied by any subjective symptoms. In some cases there is an itching sensation, but examination may show that it is not due to the develop- ment of the syphilide, but to pressure of the clothing or some other external irritation. In exceptional instances decided itching may occur. The lesions are seldom painful. The syphilides may appear upon any portion of the cutaneous sur- face, but certain forms manifest a predilection for different regions of the body. The macular variety usually develops first upon the abdo- men and thorax, and then extends to the back and extremities, but it rarely appears upon the face. The papular eruptions sometimes in- volve the forehead and cheeks, but are generally limited to the body. The pustular syphilides attack the entire surface, but are most marked on the scalp, the face, and the extremities. The squamous variety is most frequently observed on the elbows and knees, and the palmar and plantar surfaces. The syphilides may be divided into two principal groups—those which occur in the secondary, and those which occur in the tertiary stage. The first group comprises the macular, the pigmentary, the papular, the papulo-squamous, the vesicular, and the small pustular varieties; the second consists of the large pustular, the tubercular, the bullous, and the gummatous. The lesions of the secondary group are superficial, generalized, numerous, and symmetrical; those of the tertiary are deeper-seated, localized, few in number, and asymmetrical. Rebellious syphilides have occasionally been known to disappear under the influence of an attack of erysipelas or variola. EXUDATIONS. 221 Macular Syphilide. Synonyms.—Roseola syphilitica—Erythematous syphilide—Macular syphiloderm. This eruption is usually the first symptom of secondary syphilis, and is generally developed about six weeks after the appearance of the initial lesion. It may appear at the end of the fourth week, however, or may be delayed for two or three months. It consists of a number of small round or oval spots, which are indistinct in appearance at first, but soon become bright-red in color, and then gradually change to dark-red or brown. They are generally on a level with the sur- rounding surface, but occasionally they are slightly elevated or semi- papular in character. They usually appear first upon the abdomen, and then extend over the thorax and the extremities, but they rarely involve the face or the hands. The eruption attains its maximum development in three or four days, and then-remains unchanged for sev- eral weeks or months, after which it slowly changes in color to dark- yellow or yellowish-brown, and then finally disappears without pigmen- tation or desquamation. The spots often pass unnoticed by the pa- tient, but probably occur in all cases. The macular syphilide sometimes recurs, not, however, as a rule, soon after its subsidence, but after the lapse of several months. The relapsed eruption is apt to be limited to certain parts of the body. It is not attended by any subjective cutaneous symptoms, but is fre- quently preceded and accompanied by marked sore-throat and severe osteocopic pains. Alopecia is also of frequent occurrence. Relapses are common. The earliest form of sore-throat is that known as erythema, injec- tion with or without swelling of the roof of the mouth, soft palate, or fauces. Somewhat later, in the same situations and upon the tonsils or in the pharynx, the mucous membrane may be seen studded with opaline patches. These present a milky appearance, and resemble spots to which a solution of nitrate of silver or carbolic acid has been applied. Synovitis sometimes coincides with the development of rose- ola. Occasionally a dry pleurisy is met with at this stage. Diagnosis.—The diagnosis of the macular syphilide is compara- tively easy. The only eruptions resembling it are those of rotheln, roseola, tinea versicolor, and those due to the administration of cer- tain medicinal substances. The eruption of rotheln, however, con- sists of irregular blotches, and is accompanied by more or less catarrhal symptoms, and rarely occurs after childhood. The spots of roseola are irregular in size and ephemeral in character, and are caused by some gastro-iutestinal disturbance. The patches of tinea versicolor are yellowish or brown in color, furfuraceous in appearance, irregular in outline, and increase in size by peripheral extension. Medicinal erup- tions are sudden in development and are accompanied by more or less 222 DISEASES OF THE SKIN. itching, and usually disappear as soon as the exciting cause is sus- pended or removed. Pigmentary Syphilide.—This rare affection is characterized by the development of round, oval, or irregular patches of pigmentation in the skin. Sometimes there seems to be rather a disarrangement than an actual excess of pigmentation. Spots of variable size and shape develop, exhibiting a blanched centre surrounded by a dark margin. This form is most frequent upon the sides of the neck. They vary in color from dark-gray to yellowish-brown, and in size f torn that of a pea to an inch or more in extent. They have even been seen as large as the palm. Neighboring spots may coalesce as they en- large. They are smooth to the touch, and are not elevated above the surrounding normal skin. The coloration is in some cases so faint that they are with difficulty perceived unless viewed in a strong light and in an oblique direction. They are most frequently met with upon the face and neck, but they also occur upon the thorax, the abdomen, and the extremities. They are not accompanied by any subjective symptoms. They appear more abundantly on women than on men, and do not appear to differ in any essential respect from the lesions of chloasma. They run a protracted course, remaining for several months or years, and are not amenable to anti-syphilitic treatment. These patches may eventually disappear, leaving no trace behind them, or the pigment may be entirely absorbed and a spot resembling vitiligo re- main. They are usually met with during the first year of the syphilitic manifestations, and are probably produced by the disturbing effect of the syphilitic poison upon the terminal filaments of the cutaneous nerves. Audry has had the opportunity of examining sections taken from a case of generalized pigmetary syphilide. The pigmented spots were formed by a pigmentary infiltration composed of small, yellowish blocks, themselves formed by finely aggregated granulations. They are also found here and there in the papillae, and were seen in the su- perficial layers of the derma. But their chief deposition is in the gen- erative layer and the adjacent stratum mucosum. The arterioles and capillaries were intact, and no evidence of recent or remote haemor- rhage was detected. Audry believes that the pigment is brought from the derma by the pigmentiferous corpuscles. He found no signs of chronic inflammation.* Papular Syphilide. The papular eruptions of syphilis consist of two principal groups or classes—the small acuminated, or miliary papules, and the large, flat, or lenticular papules. The papulo-squamous syphilide and the * Journal of Cutaneous and Genito-Uriaary Diseases, July, 1890, p. 2S1. Plate II. Xi 3 ft fin EXUDATION'S. 223 broad condylomata or mucous patches may be regarded as modifica- tions of the lenticular variety. Small Papular Syphilide (Synonyms: Miliary papular syphi- lide ; lichen syphiliticus).—This eruption consists of a number of minute, round, acuminated papules, which vary in size from a mustard- seed to a small shot. They are bright-red in color at first, but become dark-red or reddish-brown in a few days. They are firm to the touch, and are slightly elevated above the surrounding integument and cov- ered with minute scales. Some, especially those which are formed around the hair-follicles, may become transformed into vesicles, and then into pustules, but the majority remain papular, and finally disap- pear by resolution or by fatty degeneration and absorption. This erup- tion is one of the earliest manifestations of secondary syphilis, generally appearing within three months after the development of the primary lesion. It is symmetrical in character, and diffused more or less over the entire surface. The papules manifest a tendency to develop in groups or clusters of a dozen or more. This grouping is especially well marked upon the face, shoulders, and arms. The eruption is chronic in character, and liable to recur, but is not accompanied by pain or itching. In severe cases it is followed by the formation of minute per- manent cicatrices, indicative of atrophy of the corium. Slight pig- mentation may also remain. Diagnosis.—The small papular syphilide might be mistaken for papular eczema, lichen ruber, or lichen scrofulosus. The lesions of papular eczema, however, are usually localized, and accompanied by marked itching and burning sensations. They soon become vesicular in character, but do not develop in clusters. The miliary papules of syphilis, on the contrary, are generalized, and are not usually accom- panied by any subjective symptoms. They only occasionally become vesicular, and almost always develop in clusters. Very often there is a history of an antecedent specific lesion. In lichen ruber the erup- tion is accompanied by severe itching and burning, but it never appears upon the face, and pursues a different course. In lichen scrofulosus the papules are situated upon the trunk, and are accompanied by other evidences of the scrofulous diathesis. Larue, Flat Papular Syphilide (Synonym: Lenticular syphi- lide).—This eruption appears later, as a rule, than the miliary syphi- lide, and is significant of a more obstinate form of the disease. It con- sists of a number of large, flat papules, which vary in size from a small shot to a bean. They are round or oval in shape, firm and smooth to the touch, and are elevated above the surrounding surface. They are light-red in color at first, but soon assume the characteristic raw-ham or copper color. They are devoid of scales, and present a dull, glazed appearance. They are usually developed in large numbers, but not as abundantly as the miliary lesions. They run a protracted course, and 224 DISEASES OF TEE SKIN. frequently recur. They may appear upon any portion of the bod}', but are especially observed upon the neck, back, shoulders, and the ex- tremities, and around the genital organs. They are also found upon the scalp, and on the forehead, where they form the characteristic " corona veneris." They slowly increase in size by peripheral growth during the first few weeks of their existence. They then remain sta- tionary for several months, usually disappearing by disintegration and absorption, leaving more or less pigmentation and atrophy to mark their location. Occasionally, while the centre undergoes retrogression, the periph- ery has invaded the surrounding integument, blending perhaps with other lesions of the same kind, forming annular, oval, or circinate fig- ures. Usually the border exhibits a fine scaling. In favorable situ- ations the lesion may be converted into a mucous patch. This mani- festation of the disease is much more common in negroes than in whites, as has been pointed out by Dr. Atkinson, of Baltimore, and Dr. Hardaway, of St. Louis. In some cases excoriation and "ulceration take place; in other cases they become converted into pustules. In depressed conditions of the system or when the disease is unusually violent the large, flat papules may, after superficial necrosis has occurred, become covered with a thin diph'theroidal membrane of a dirty-gray color. In exceptional cases the large papule occurs as the first cutaneous manifestation of the. disease. In others a few large papules maybe present at the same time with a macular syphilide. Usually, however, this form of eruption is developed in the later periods of the secondary stage and may be encountered as late as the second or even the third year after the original infection. It is generally more abundant the earlier it appears. Thin, yellow, and easily detached scales sometimes form upon the surface of the lesions when they are situated upon parts which abound in sebaceous glands. In rare cases the papules, growing unusually large, project above the surface so as to bear some resem- blance to a cauliflower or raspberry. The rounded prominences are smooth, red, of different size, and between them slight ulceration gives rise to some pus. This'pus may become dry and form a crust. When abundant it gives rise to a very offensive odor. This unusual transfor- mation has been most often seen upon scalp, face, shoulders, and geni- talia. It has been termed the framboesoid, vegetating, or verrucous syphilide. A very similar appearance is sometimes presented by the ulcerated tubercular syphiloderm; and De Amicis, of Naples, has seen macules of the forehead become converted into a berry-shaped mass. The most common forms of transformation which they undergo, however, are into moist and squamous papules. Moist Papules (Synonyms: Mucous papules; mucous patches; condylomata).—Moist papules, or mucous patches occur only in syph- ilis. They consist of large, flat papules, which have been modified EXUDATIONS. 225 by the combined influence of heat and moisture. They are seen on the tongue, lips, anus, vulva, and other mucous surfaces. They are also found on the perinaeum and the scrotum, in the axillae, beneath the mammae, between the toes, in the groins, around the umbilicus, and on any other portion of the body where apposing surfaces come in contact with each other. They vary considerably in size. Some of the large condylomata frequently measure one or two inches in diameter. They are usually slightly elevated above the adjoining surface, but may be depressed beneath it. They are soft and smooth to the touch, and vary in color from dark-red to gray. Their surface is usually moist, and covered with epithelial debris. Adjacent lesions frequently coa- lesce, forming large patches. Excoriation and ulceration may also occur, or hypertrophic granulation take place, resulting in the forma- tion of large warty or vegetative excrescences. Mucous patches of the tongue and lips are irregular in shape, and usually deeply fissured, and more or less painful, but they rarely ulcer- ate, or become the seat of vegetative growths. Papulo-squamous Syphilide. —This eruption usually appears late in the course of the disease. It is symmetrical in character, and may involve any portion of the integument, but its favorite seats are the palmar and plantar surfaces. It consists of a few large, round, oval, or oblong, flat papules, which are slightly elevated above the surrounding surface, and arc covered by a thick, dry, white or grayish non-imbricated scale. These papules increase in size by peripheral growth, and frequently coalesce, forming large irregular patches. The scales are only slightly adherent, and can easily be detached, expos- ing the dark-red surface of the papules beneath. When the scales are removed they are slowly replaced. This form of syphilide is chronic in character, and may remain for years. It finally disappears by cessation of the scaling process, and absorption of the infiltration. In severe cases, affecting the palmar and plantar surfaces, the so- called syphilitic psoriasis, the patches attain a large size, and are deeply fissured and painful. The nails occasionally become involved. Diagnosis.—The diagnosis of the large papular syphilide is usu- ally easy. The only affections resembling it are lichen planus, acne, and psoriasis. The papules of lichen planus, however, are angu- lar in outline, depressed in the centre, and are limited to the fore- arms and legs, never appearing upon the face or neck. They are also covered by a large, waxy, transparent scale. The lesions of the syphilitic eruption are round or oval in outline, not umbilicated or depressed in the centre, not covered with a waxy scale, and they are diffused over several regions of the surface. The papules of acne are acuminated in form, bright-red in color, and are confined to certain regions of the body, as the face and neck. They are also mostly brief in duration, frequently becoming pustular, and disappearing by ab- 15 226 DISEASES OF THE SKIN. sorption. The eruption of psoriasis may at first resemble the lesions of the papular .syphilide, but the development of the characteristic mother-of-pearl scales of the former disease will effectually settle the question of diagnosis. Lesions resembling moist papules or mucous patches are sim- ple acuminated or non-syphilitic papillary new formations. They are due to local irritation of the cutaneous or mucous surfaces by acrid discharges, and spring from apparently normal tissues. The syphilitic lesions, on the other hand, are surrounded by more or less infiltration. The papulo-squamous syphilide might be mistaken for one of the forms of psoriasis, or for squamous eczema. The lesions of psoriasis, however, are numerous and diffused, while those of the syphilide are few and localized. Psoriasis rarely affects the palmar or plantar sur- faces, and never appears there without involving some other portion of the integument at the same time. Superficial desquamation is pro- fuse in psoriasis, and scanty in syphilis. When the scales are removed in psoriasis, a bleeding or bright-red surface is exposed; when they are detached in syphilis, a dark-red papule is discovered. The lesions of psoriasis develop rapidly, and are accompanied by more or less itch- ing ; those of syphilis develop slowly, and are not attended, as a rule, by any subjective symptoms. Finally, the lesions of psoriasis are uni- form in character, manifest a predilection for the extensor surfaces, and are covered by the characteristic waxy or mother-of-pearl scales ; while those of syphilis are polymorphous, and are found on the flexor rather than on the extensor surface, and are covered by a grayish or dirty-white scale. The patches of squamous eczema are irregular in shape, and are accompanied by itching and burning. They pass imperceptibly into the surrounding healthy skin, and are not surrounded by infiltration. Vesicular Syphilide. This is a rare manifestation of secondary syphilis. It usually ap- pears within six months after the development of the primary lesion, but in some instances not for a year or more. The vesicles vary con- siderably in size, shape, and distribution. In some cases they are small and clustered together, as in eczema; in others, they are large and isolated, as in varicella. In the former they are minute in size, conical in shape, and arranged in groups or patches, and are generally observed on the trunks and extremities, rarely or never appearing on the face. They are seated upon a dark-red base, and are usually situ- ated around the hair-follicles. They terminate either by absorption, or by transformation into pustules which break and discharge, leaving a small ulcer, which heals without the formation of a scar. They are not accompanied by any subjective symptoms. EXUDATIONS. 227 The large, varicella-like vesicles are developed upon a reddened, infiltrated base, and frequently attain the size of a bean. They are few in number, and scattered over the face, trunk, and extremities. They contain at first a clear, serous fluid, which becomes purulent in a few days. They finally either dry up, or rupture spontaneously and discharge their contents. A greenish-brown crust is then formed, which is cast off in a fortnight, leaving a slight purplish discoloration, which gradually disappears. Again, successive crops of vesicles may appear and protract the eruption for months. Itching and burning are absent during the whole course of the disease.* Diagnosis.—The small vesicular syphilide resembles eczema in many particulars, but the distinction can always be made by remem- bering that the vesicles of eczema are of brief duration, accompanied by intense itching and burning sensations, and are not situated upon a reddened, infiltrated base. The lesions of the large vesicular syphi- lide might be mistaken for varicella or varioloid, but a consideration of the dark-red, infiltrated base, the history of the case, and the course of the eruption, will lead to a correct conclusion. Pustular Syphilide. Pustular manifestations, as a rule, are indicative either of a more severe form of the disease or a depraved or impoverished condition of the patient's tissues. Individual pustules differ in size, shape, and number. They are usually surrounded by a reddish areola, and are situated around the hair-follicles and sebaceous glands. Sometimes they are diffused over all portions of the surface, but are most frequently met with upon the trunk and the extremities. They generally begin as papules or vesicles, which are rapidly transformed into pustules; indeed, so quickly, in some, that the papular or vesicular stage of the eruption escapes observation; in others, the pustules are slowly de- veloped upon lesions which have been in existence for weeks or months. The pustular eruptions of syphilis are sometimes termed " pustulo- crustaceous eruptions," from their tendency to terminate in crusts. This tendency is especially manifested by the larger pustules. The crusts generally correspond in size and shape with their pre-existing lesions. They may be soft and friable, but are usually firm and bard; and in color range from yellow or brown to dark-green and black. Each crust is situated over an ulcer, which may be superficial or deep, in accordance wdth the character of the primary pustule. The ulcer presents a clean-cut or punched-out appearance. Its edges are sharply defined, and surrounded by a slight area of infiltration. Its base is uneven, and covered with a profuse gray, yellow, or greenish purulent secretion. Repair is protracted, but finally takes place by granulation, * Some recent writers regard the vesicular eruption as an accidental manifestation and not distinctive of syphilis, classifying it with the pustular syphilide. 228 DISEASES OF THE SKIN. ending in the formation of a perhaps permanent cicatrix. More or less pigmentation also results. The pustular syphilides may be conveniently regarded as consisting of four principal groups : the small acuminated, the large acuminated, the small flat, and the large flat varieties. Small Acuminated Pustular Syphilide (Synonym: Miliary Pustular Syphilide).—This variety of the pustular syphilitic eruptions is the first of the manifestations of secondary syphilis. It, with a few exceptions, appears in from six weeks to three months after the development of the initial lesion, and is usually accompanied by syphi- litic fever, erythema and soreness of the fauces, and more or less fall- ing of the hair. It may not appear, however, until later in the prog- ress of the disease. It consists of a number of minute pustules, which are developed around the orifices of the hair-follicles, and are generally penetrated by a hair. They are 'rarely larger in size than a grain of barley. They are situated upon a minute, reddish, elevated or papular base. They are spherical or acuminated in form, and contain a drop of sero-purulent matter, which soon becomes converted into a yellow, friable crust. This crust drops off in a few days, leaving a slight de- pression in the epidermis, which is likely to become the seat of sub- sequent pigmentation or desquamation. The pustules sometimes are isolated, but they are usually arranged in irregular groups, and widely diffused, occasionally covering the entire surface. The thorax and back and the extremities are most frequently involved, however. The eruption is often complicated by the presence of papules, vesicles, and papulo-pustules. Large Acuminated Pustular Syphilide (Synonyms: Acne syphilitica ; Variola-form Syphiloderm).—This variety of the syphi- lides is seen early, but not as soon as the miliary form. It usually appears from the fourth to the sixth month after infection, but may be delayed for a year. It consists of a number of pustules, which are round and acuminated in form, and vary in size from a split pea to a small bean. They are situated around the hair-follicles, and are developed upon a dark-red or copper-colored base. They are ele- vated above the surface, and surrounded by a coppery aureola. They develop first as small red spots, which rapidly become papular and then pustular. They contain a yellow, purulent fluid, which sooner or later becomes dried up and converted into a thick, yellowish or brownish crust, beneath which a superficial ulcer exists. The crust finally drops off, and the ulcer heals by granulation followed by a minute cicatrix. The pustules may be disseminated, but are usually grouped. They are few in number, and limited to the face and shoulders. They may, however, extend to the scalp and trunk, and in severe cases involve the entire surface. They develop either rap- idly or slowly. They are not often attended by pain or itching, or EXUDATIONS. 229 any other subjective symptoms. The individual pustules generally disappear spontaneously within two or three weeks after their first appearance, but new lesions appear from time to time for several months. . Small Flat Pustular Syphilide (Synonym: Impetigo syphi- litica).—There are two varieties of this form of eruption—the super- ficial or disseminated, and the deep-seated or discrete. The superficial variety is characterized by the formation of a number of small, flat pustules, which are seated upon a dark-red, infiltrated base. They begin as circumscribed, reddish elevations of the surface, which speedily become papular and then pustular. They are developed in groups, and frequently coalesce to form large irregular patches. They are surrounded by a dark-red aureola, and soon become covered by dry, yellowish, greenish, or brownish crusts, beneath which more or less superficial ulceration exists. They rarely appear before the second year of the disease. They may appear upon any portion of the body, but are most frequently observed upon the face and scalp and around the genital organs. They are also met with upon the legs and fore- arms. They run a comparatively mild course, and heal without much permanent cicatrization. The deep-seated pustules are isolated and few in number. They usually occur upon the scalp or on the extremities, and rarely involve the face. They belong to the tertiary rather than to the secondary stage, and may not appear until the third or fourth year of the dis- ease. They begin as papules, and become transformed into pustules, which pursue a protracted course. They are surrounded by a coppery aureola, and covered by a thick, blackish-green crust. The underlying ulcer is deep and indolent, and covered with a grayish or greenish purulent secretion. Repair gradually occurs by granulation and cica- trization, but it may be delayed for months, and is always followed by permanent disfigurement. Large Flat Pustular Syphilide (Synonym: Ecthyma syphi- liticum).—This eruption consists of large, flat, isolated pustules, which are situated upon a reddened, infiltrated base, and surrounded by a coppery aureola. They are irregular in shape, and are from a sixteenth to a half or an inch in area. They belong to the tertiary stage, sel- dom appearing before the third year of the disease. They evince a marked tendency to break down early, and become covered with their characteristic crusts. Any portion of the body may be affected, but they are usually confined to the back, shoulders, and extremities. There are two varieties of this form of eruption—the superficial and the deep. In the former the pustules are numerous and disseminated, and run a comparatively brief course. The crusts which are formed by the breaking down of the pustules are flat and firmly adherent, and yellow or dark-brown in color. The underlying ulcer is super 230 DISEASES OF THE SKIN. ticial, and heals with slight cicatrization. The pustules of the latter are few and isolated, and generally limited to one region or one side of the body. The crusts which are formed by the breaking down of the pustules are conical in shape and dark-green or blackish in color, and seated upon large, deep, unhealthy ulcers. The edges of the ulcers are infiltrated, and their surface is covered with a foul, greenish-yel- low secretion. In some cases the ulcerative process remains station- ary, in others it extends peripherally. As a result of this extension, and the continual drying up of the matter which is poured out, the crust is elevated still higher in the centre, and gradually assumes a stratified or oyster-shell appearance. This form of crust is known as rupia, but is not peculiar to the pustular syphilides.- It is frequently observed in the bullous group, and is symptomatic of the malignancy of the disease. It is invariably followed by marked cicatrization. Diagnosis.—The pustular syphilides are not difficult of diagnosis. The lesions of the acuminated variety might be mistaken for the pust- ules of acne or of variola. In acne, however, the pustules are usually limited to the face and shoulders. They are not surrounded by the coppery aureola of the syphilides, and are not arranged in groups. They run a rapid course, appearing and disappearing quickly, but are followed by successive crops, which protract the course of the eruption. Moreover, there is no history of a specific infection, nor are there any other symptoms of syphilis present. Rare cases of universal pustular syphilis may present a striking resemblance to variola, but the slightest examination of the pulse, temperature, and history of the patient will suffice to show the true nature of the disease. The small, flat pustular syphilides can be distinguished from sim- ple impetigo and pustular eczema by their infiltrated base, their cop- pery aureola, their chronic character, and the absence of subjective symptoms. Moreover, the crusts of the syphilitic lesions are situated upon an ulcerated base, while those of eczema and impetigo are seated upon a simple reddened or oozing non-ulcerated surface. The large, flat pustules can be recognized from those of ordinary ecthyma by the history of the case, the presence of a coppery aureola, the appearance of the crust, and the obstinate character of ulceration. In a certain class of cases, fortunately rare, lesions that usually occur only in the later secondary stage develop rapidly at an early period of constitutional involvement. This variety is appropriately termed ma- lignant precocious syphilis. The outbreak is often preceded by a severe fever, which may assume either a periodical or continued type. The eruption is generally of pustulo-crustaceous form, and exhibits the appearance of syphilitic ecthyma. Iritis, periostitis, and visceral in- volvements may be simultaneously manifested. Nutrition is seriously impaired, and death not infrequently results within a few months of infection. EXUDATIONS. 231 Tubercular Syphilide. This eruption belongs to the tertiary stage of syphilis. It rarely appears before the second year of the disease, but most frequently dur- ing the third and fourth years. It may be delayed, however, for five or ten years, or even longer. On the other hand, in exceptional cases it may appear during the secondary stage, when it is generally dis- tributed over the entire body. It consists of a number of tubercles, or solid elevations of the skin, which vary in size from a split pea to a chestnut. The spots are round or oval in shape, dark-red or reddish- brown in color; are firm and smooth to the touch, and present a glis- tening appearance. They are usually seated in the corium, but may extend into the subcutaneous connective tissue. The tubercles are gen- erally multiple, but are not often present in large numbers. They may be widely disseminated, but are usually limited to one or two regions of the body. The face, neck, and shoulders appear to be favorite locali- ties for their development. They are seldom observed upon the ex- tremities. When a number of tubercles appear upon any portion of the body they manifest a tendency to form clusters or groups, or seg- ments of circles, and finally coalesce and form irregular or serpiginous patches. In some cases these patches are kidney-shaped, in others they resemble a horse- shoe. The development of the tubercles is slow and unac- companied by any subjective symptoms. After attaining their max- imum growth they remain sta- tionary for several months, and then disappear, either by fatty degeneration, absorption, or by ulceration. When they disappear by absorption, more or less pigmentation and de- pression of the epidermis are observed at their site for a long time. Finally, however, the skin regains its normal color and appearance. The ulcerative process may Fig. ll.—Tubercular syphilide. begin either upon the surface, or in the interior of the tubercles; but, no matter where it commences, it does not cease until all of the material composing the tubercle has been destroyed. The resulting ulcer will be either superficial or deep, 232 DISEASES OF THE SKIN. in accordance with the depth to which the syphilitic new formation has been imbedded in the skin. Its edges are dark-red and infiltrated, and its base is covered by a grayish, yellowish, or greenish, secretion. It is round, oval, or irregular in shape, and not infrequently crowned with a thick, pigmented crust. When a group of tubercles become attacked by the ulcerative pro- cess, an extensive irregular or serpiginous excavation is produced, in- volving the whole affected surface. Repair gradually occurs by granu- lation, leaving large permanent glistening cicatrices, which are usually depressed beneath the level of the adjacent skin. The ulceration is sometimes complicated by exuberant papillary or wart-like excrescences, which spring up from the base of the ulcers. They are covered by an offensive, yellowish, semi-purulent secretion, and vary in size. They are met with most frequently upon the scalp and around the genitalia, forming the so-called syphilis cutanea papil- lomata. Diagnosis.—The tubercular form of syphilis is usually not difficult of diagnosis. The only affections which resemble it are lepra, lupus vulgaris, epithelioma, and ordinary varicose ulcers. The tubercles of lepra, however, are slower in growth, larger in size, and more chronic in character. They are accompanied by more or less anaesthesia, and are productive of extensive deformity. Lupus vulgaris usually manifests itself early in life, while tubercu- lar syphilis rarely appears before middle age. The tubercles of lupus are smaller, moreover, and softer than those of syphilis, and pursue a more chronic course. The ulceration in lupus is superficial, the dis- charge is scanty and serous, and the crusts are thin and reddish. In syphilis the ulceration is deep-seated, the discharge is copious and purulent, and the crusts are thick, and present a greenish, yellowish, or dark-brown appearance. The cicatrices also differ, being hard in lupus and soft in syphilis. In syphilis there is also a history of previ- ous infection, and other symptoms of the disease are apparent. In epithelioma there is ordinarily only one lesion, which is slow in growth, obstinate and painful in character. Its base, which bleeds at the slightest touch, is fungiform, or red and granular, and covered with a thin, sanguineous, or sero-purulent secretion. The age of the patient is also significant. Ordinary varicose ulcers may be confounded with those which are due to the degeneration of syphilitic tubercles. The situation of the former, however, and their occurrence in persons who are compelled to stand for hours at a time, and the varicose condition of the sur- rounding veins, will point to a correct diagnosis. r Plate 111. Gummatous Syphilide, with ulceration and necrosis of frontal bone (from Nature). EXUDATIONS. 9;];; Bullous Syphilide. Synonym.—Pemphigus syphilitica. This eruption occurs only in debilitated individuals, in the ad- vanced stages of the disease, and in infants who are the subjects of he- reditary syphilis. It consists of a number of bullae, or blebs, which vary in size from a small bean to a walnut. They are situated upon a red- dened, infiltrated base, and are surrounded by a dark-red or coppery areola. They are firm to the touch at first, and filled with a clear, serous fluid, which becomes opaque in a few days. In some individuals the contents of the bullae are purulent or bloody in character. In others the eruption is of a mixed nature, consisting of both bullae and pustules. The eruption may appear upon any portion of the body, but is usually limited to the trunk and the extremities. After a variable time the bullae rupture spontaneously, and the watery portion of their contents escapes. The remainder dries up into thick, yellowish, green- ish, or brownish crusts, which vary in shape and size in accordance with the character of the ulcer upon which they are seated. The crusts of superficial, indolent ulcers are flat and easily detached, while those of the deep-seated, spreading variety are conical, stratified, and firmly adherent, forming the condition known as rupia. Rupial sores pursue a tedious course, and are always followed by the formation of permanent, depressed, round, oval, or kidney-shaped cicatrices. Diagnosis.—The lesions of this form of syphilide present a super- ficial resemblance to those of pemphigus vulgaris. The latter, however, occur in successive crops, and are not followed by ulceration cr cica- trices, and the crusts are thin and yellowish. The bullae of syphilis are characterized by the rapid production of large, thick, pigmented crusts, and end in protracted ulceration and permanent cicatrization. An unusual cutaneous alteration effected by syphilis has been de- scribed by Dr. Coulhon under the title of wasting secondary syphilide or abdominal streaks. The lesion begins in the form of small, linear, violaceous patches in certain situations. These patches disappear after a while, leaving behind them white lines similar to those observed upon the abdomen of pregnant women, but differing from the latter in be- ginning as violaceous spots and in their symmetrical arrangement. They are not regarded as characteristic of syphilis, but as evidence of profoundly disturbed nutrition of the integument.* Gummatous Syphilide. It consists in the formation of one or more circumscribed tumors or nodes in the subcutaneous connective tissue. They commence as small, round, firm nodules, which can be slightly moved beneath the epi- * New York Medical Journal, March 8, 1890. 234 DISEASES OF THE SKIN. dermis. They are painless to the touch, but are usually accompanied by nocturnal osteocopic pains. When first observed they are about the size of a split pea. They slowly increase in diameter, by the deposition of additional material, until they attain the dimensions of a chestnut or a walnut. There are two varieties, the superficial and the deep- seated. The superficial form visible tumors, which project above the , surrounding surface. The overlying epidermis is normal in color at first, but finally becomes pinkish or reddish in hue. The deep-seated are situated in the loose fascia, between the skin and the muscles, and rarely project above the surface. They can be plainly felt, however, and outlined by the fingers as firm oval or oblong tumors. They are rarely seen before the second or third year of the disease, and may not occur until a much later period. Gummata are liable to appear upon any portion of the body, but are more often met with in those regions where the subcutaneous connective tissue is abundant, as on the buttocks, the abdomen, the sides of the neck and thorax, and on the flexor surfaces of the extremities. They are seldom observed upon the palms or soles; are usually single, but may be multiple. The number present at one time, however, is scarcely ever more than three or four. Gummata attain their maximum in about two months. They then remain stationary for a period, after which they become soft and fluctuating, and disappear by absorption or ulceration. When the latter is about to take place, the gumma becomes slightly painful or tender, the skin bursts near the centre of the lesion, and a small quantity of semi-purulent or blood-streaked material oozes out. The morbid process continues until an excavated ulcer as large as or larger than the original lesion is formed. Its base is uneven and covered with a yellowish or reddish aplastic deposit. Its sides are usually steep, but may be undermined or sloping. The ulcer pursues a protracted course, and may extend to the underlying structures, producing great destruction of tissue. Healing finally occurs by granulation, with a white depressed cicatrix. Diagnosis.—The diagnosis of gummata is usually self-evident. They might be mistaken for small fibrous or fatty tumors, but the history of the case, the situation of the lesions, the nocturnal osteo- copic pains, and other symptoms of the disease, will prevent an error from being made. Gummatous ulcers can readily be distinguished from varicose ulcers by the history of the case, the character of the secretion, absence of pain, and existence of other syphilitic lesions. Syphilitic paronychia, onychia, and alopecia are described under the affections of the nails and hair, in another part of this book. The syphilitic affections of the viscera, and of the osseous, muscular, fibrous, and nervous systems, cannot be even briefly mentioned in this article without expanding it far beyond the space to which it is limited. Their consideration, moreover, properly belongs to a work on syphilis EXUDATIONS. 235 alone. It is sufficient to say that there is not a tissue or a portion of the body which may not be invaded by this omnipresent disease, and that many baffling or obscure cases may frequently be relieved by ap- propriate methods when the possibility of their being of a syphilitic origin is recognized. It should not be forgotten, however, that visceral syphilis may exist at an early period of the secondary stage; and, indeed, I believe that this happens more often than is commonly supposed. Jullien has lately described * a unique complication which was observed four months after the appearance of a chancre. A painless, smooth, indis- tinctly lobulated swelling occupied the helix, antihelix, and fossa of the antihelix. The reporter denominates it a " lymphochondric syphi- loma." Pathology of Syphilis.—The pathology of syphilis has been thor- oughly investigated by Auspitz, Biesiadecki, Kaposi, Neumann, Otis, and others, and may be said, in brief, to consist of local cell-prolifera- tion, and an accumulation or infiltration of small, round cells. The induration of the initial lesion is produced by infiltration of the papillae of the corium and the subcutaneous connective tissue with small round, nucleated cells composed of finely granular protoplasm. They not only fill up the interstices of the corium and subcutaneous connective tissue, but penetrate into and through the walls of the cutaneous vessels, increasing their size but lessening their calibre. The ulcera- tion which finally occurs is due to the interference in nutrition pro- duced by the increased pressure upon the minute arterioles. The glandular complications of syphilis are produced by the same cellular multiplication. The macular syphilide is characterized by similar round-cell infil- tration in the papillae of the corium, and around and within the walls of the papillary vessels. The papular lesions are due to a circumscribed, dense, round-cell infiltration in the papillary and sub-papillary layers of the corium, and in the upper portion of the subcutaneous connective tissue. The depth and extent of the infiltration correspond with the size of the papules. The mucous patches or moist papules are preceded by a similar process in the superficial portion of the corium. The papillae are enlarged and branched or club-shaped, and the papillary vessels are swollen and tortuous. The tubercles and gummata consist of masses of closely packed round cells, which surround and penetrate all the cutaneous structures, and finally, by their increasing pressure, ob- literate the capillaries, and produce atrophy and ulceration of the affected structures. The pustular lesions are preceded by round-cell infiltration of the corium and its vessels, but more or less exudation and migration of * Annales «le Dermatol, c-t Syph., February, 1889. 236 DISEASES OF THE SKIN. leucocytes also take place. When absorption occurs, the exudation is carried away through the lymph-spaces. In the vesicular and bullous lesions the exudation of serum is large, producing oedema of the adja- cent tissues. The characteristic round-cell infiltration is also present, however. The various lesions of the muscular, fibrous, osseous, and nervous systems, and of the internal organs, are also due to cellular proliferation and infiltration. The gumma consists of an accumulation of embryonic cells. It grows at its peripheral while its central portion undergoes retrograde metamorphosis. According to the recent histological researches of Marfan and Toupet, the gumma originates around small blood-vessels, which become surrounded by a mass of round cells intermixed with fibrillated tissue forming a coarse reticulum. Thus arises a nodule or sclerosed area. The larger vessel which supplies this area likewise suffers alterations of its outer and inner tunics. The calibre of the vessel is progressively narrowed. Obliteration of the vessel is followed by degeneration of the central portion of the nodule. Etiology of Syphilis.—Syphilis is due to the entrance into the sys- tem of the specific virus which is contained in the blood of syphilitic subjects, and in the secretions of syphilitic lesions, and is known as the virus of syphilis. The exact nature of this virus has not been de- termined. Many attempts have been made of late years to demonstrate that syphilitic infection is due to a specific micro-organism, and Lustgar- ten, of Vienna, believed that he had succeeded in isolating the patho- genetic microbe of the disease. The subject cannot yet, however, be regarded as settled. Dr. Smirnoff, of Kazan, examining one hundred cases of syphilis, failed to find a characteristic micro-organism con- stantly present in secretions taken from syphilitic sores or in indurated syphilides. In many cases but few microbes could be detected; in others they were identical with those normally present in healthy tis- sues and in the normal secretions of the genital organs, or so many different germs were present as to render it difficult or impossible to identify any one as characteristic and the exciting cause of syphilis.* That the virus may infect the system through an unbroken surface by absorption after long contact, is probable, but an abrasion or some other breach of continuity of the surface is generally necessary. The virus enters the circulation through the medium of the lymphatic sys- tem. It first produces a low grade of inflammation and cell-prolifera- tion in the walls of the lymphatic vessels at the point of contagion. These cells become infected and are detached from the vessel-walls and conveyed to the "lymphatic glands. They then enter the thoracic duct, and, after mingling with the general blood-current, are carried to the various tissues of the body. * Brooklyn Medical Journal, September, 1888. EXUDATIONS. 237 Risking superfluous mention, I may remark that syphilis can be communicated by direct or indirect contact, or by hereditary trans- mission. The most ordinary method is by sexual intercourse with one diseased. It may be contracted, however, in a variety of other ways. Gynaecologists and accoucheurs have been infected through an abrasion of the fingers while making a vaginal examination. The disease has not infrequently been communicated by infected instruments in cathe- terization of the Eustachian tubes. The dentist is in danger of ac- quiring syphilis from contact with lesions or secretions of the mouth. On the other hand, dental instruments may serve to convey the virus from one patient to another, as Dr. L. D. Bulkley has suggested; smokers likewise may become infected by using the pipe or cigar of a syphilitic friend. Surgical instruments have also been the medium of spreading the disease. Reports are made from time to time of the out- break of syphilis in consequence of tattooing, the operator suffering from mucous patches and moistening the needle or colors with his saliva. A number of cases of this nature were under the care of the late Dr. F. F. Maury in the Philadelphia Hospital in 1877. A similar observation was made in 1876 by Albert Josias.* In 1885 a man was arrested in the neighborhood of this city for the same offence. In the " British Medical Journal" of May 4, 1889, Surgeon F. R. Barker, of the British Army, communicates the histories of twelve soldiers who had been infected in the same manner; while in the issue of Septem- ber 14, 1889, of the same journal, Surgeon Whitehead alludes briefly to five soldiers syphilized by tattooing at Land our, India. Syphilis may be contracted by kissing a person whose mouth is the subject of mucous patches, or by suckling a syphilitic child, or by using the tow- els, sponges, cups, knives, forks, spoons, or other utensils which have been used by diseased persons. Cases are on record in wdiich it has been transmitted by a bite. A patient recently brought before the Berlin Medical Society had been bitten by a man upon the lip. Though the wound healed in two or three days, in six weeks it reopened and the lip became greatly swollen. Five weeks later the inner surface of the lip was the site of an ulcer which was surrounded by great swelling and induration. The sub- maxillary and cervical glands were much enlarged and in time a typi- cal syphilitic eruption developed.f A similar case is reported by Dr. Tchagin,J while others have been reported by Dr. Sturgis and Mr. Bryant. In fact, this method of transmission was noticed by Sir Everard Home, in his addition to John Hunter's Treatise on Venereal Disease. Syphilis may be conveyed through vaccination, by employ- ing the lymph or scabs taken from syphilitic subjects. Washer-women * Le Progres Medical, 1877, p. 205. f British Medical Journal, September 27, 1890. X Provincial Medical Journal, March 2, 1891. 238 DISEASES OF THE SKIN. may become infected through abrasions of the fingers while washing clothing stained with syphilitic discharges. Prof. Founder concludes that out of 887 women treated by him for syphilis in private practice, no less than twenty-four per cent, had acquired the disease in «some non-venereal manner. Chancre of the eyelid has occurred in infants in consequence of the mother or nurse washing the eyes with spittle. Physicians have occa- sionally contracted syphilis from the accidental projection of infected saliva upon the eyelid. Chancre of the face has been caused by a cut of a razor in shaving. Fournier mentions a case in which the operation of skin-grafting was followed by the development of a chancre in the cicatricial tissue. The possibility of its transmission through the seminal fluid alone is denied by the most eminent authorities. Otis states as a maxim, that to make the infection of an embryo possible, the organism of the mother must first be involved. This doctrine is, nevertheless, strenu- ously opposed by Prof. Fournier, who cites a number of arguments to support the view that syphilis may be communicated directly from either parent. Syphilitic children are frequently born of syphilitic fathers and mothers healthy at least in appearance. Of 103 pregnan- cies in perfectly healthy women, but whose husbands were syphilitic, forty-one, or thirty per cent., were known to have terminated in abor- tion or premature labor. A father who, prior to treatment, has trans- mitted the disease to his child, becomes capable after treatment of begetting healthy offspring. In " conceptional syphilis,'' to use the phrase of Prof. Fournier, a woman previously healthy, impregnated by a syphilitic father, develops syphilis during her pregnancy, although the father presents no actual lesion capable of directly communicating contagion. Disease inherited from the mother, however, is more dis- astrous to the offspring than when communicated by the father. Ac- cording to Fournier, twenty per cent, of the children die when the father is. syphilitic, sixty per cent, when the mother is diseased, and sixty-eight per cent, when both suffer. Treatment of Syphilis.—The plan of treatment most effective in syphilis is that which is directed to secure the elimination of the virus from the system, to prevent the development of complications, and to preserve the general health of the patient. It consists in the adoption of suitable hygienic measures, the internal administration of tonics, eliminative and specific medicines, and the external application of pro- tective, stimulating, or specific remedies; but success can be obtained only by perseverance in the effort to eradicate the poison for a period varying from eighteen months to four years. There is no abortive treatment for syphilis. It may sometimes be advisable to excise or cauterize the initial lesion in order to allay the patient's anxiety, or to hasten the disappearance of the lesion ; but the EXUDATIONS. 239 germs of the disease are in the system, and secondary symptoms will appear sooner or later. The initial sclerosis may be very effectually destroyed by the use of the galvano-cautery. A new plan designed to avert the evolution of the secondary stage has been proposed by Dr. Bronson, of Sew York. This method rests upon the belief that during {he primary period syphilis is only a local disease, and its author thinks it possible to prevent extension of the virus beyond the primarily affected ganglia. Prophylaxis is to consist in a series of hypodermic injections of corrosive sublimate beneath the, initial lesion and into the mass of the indurated glands, or, indeed, into' the entire district whose lymphatic vessels tend toward the diseased glands.* In objection to this scheme it may be urged that the most powerful considerations warrant the conviction that in primary syphilis the system is already, in fact, contaminated ; that the initial lesion with its connected glandular involvement is but the first manifestation of one indivisible process. Again, the hope of being able to destroy in situ or in its course of transit the infectious virus by a series, how- soever multiplied, of injections, is, in view of the rich abundance of lymph-conduits, nothing less than chimerical. Jullien thinks that if the primary lesion be excised at a very early period, before involvement of the lymphatic vessels and glands, the development of constitutional symptoms may be checked. Ordina- rily, however, it will be sufficient to direct the patient to apply a small quantity of mercurial ointment to the sore two or three times a day, or to use the officinal black-wash or yellow-wash night and morn- ing. If the chancre assumes a sluggish, ulcerative character, it may be induced to heal rapidly by dusting its surface twice a day with a powder composed of one part of calomel arfU seven parts of bismuth subnitrate. Another effective application consists of equal parts of bismuth subnitrate and powdered cinchona-bark. The subiodide of bismuth and aristol are likewise excellent dusting-powders. Iodo- form is invaluable, but its odor is offensive, and precludes its use ex- cept in hospital practice. The odor may be modified or partially sup- pressed by mixture with balsam of Peru, Tonka bean, naphthalin, creolin, recently ground coffee, and other substances f which may be used for this purpose if the .condition of the sore furnishes no contra- indication. Iodol is an excellent substitute for the latter drug, and can be applied alone or combined with another powder, or in the form of an ointment. Europhen is also reported to be of service. A one- per-cent. solution of osmic acid has sometimes proved a useful topical remedy in the case of tubercular syphilide. Salol is of service in chancres attended with ulceration. It may be used as a powder weak- * Journal of Cutaneous and Genito-Urinary Diseases, June, 1888, p. 231. f See Materia Meclica and Therapeutics, with Especial Reference to the Clinical Ap- plication of Drugs. By John V. Shoemaker, A. M., M. D., pp. 689 and 692. 240 DISEASES OF THE SKIN. ened by a mixture with starch or some other inert substance, or it may be incorporated into an ointment. Other substances which may be beneficially applied to open chancres are : resorcin, one or two drachms to the ounce of suitable excipient; ichthyol ointment of about the same strength. Chancres indisposed to heal may be stimulated by the oint- ment of nitrate of mercury, red oxide of mercury, or by naphthalin, one half drachm or more to the ounce. The official mercurial oint- ment or plaster proved very efficacious in removing the characteristic .sclerosis. Powdered benzoate of bismuth is an excellent dressing to ulcerated chancres. /?-naphthol in powder, either alone or mixed with subnitrate of bismuth, or made into an ointment, is likewise serviceable. Good results are obtained from the use of stimulating or astringent lotions. The following are especially valuable : R, Hydrarg. cblor. corrosiv............. gr. ij. Chloral, hydratis................... gr. v. Aquae............................ f 3 ij. M. Sig.: Apply externally. R Zinci chloridi...................... gr. j. Acidi hydrochlorici dibit............ f 3 j- Aquae............................ f § j. M. Sig.: Apply externally. The sulphate of copper in the strength of five grains to the ounce of water, with or without the addition of a small quantity of Syden- ham's laudanum, is a useful lotion.. Dr. Willard Parker Worster treats the primary lesion successfully by spraying it with a fifteen-volume solution of hydrogen dioxide at sixty pounds' pressure, subsequently dressing the sore with iodol. If the ulceration extends widely and deeply, and becomes phagae- denic, its entire surface should be thoroughly cauterized with fuming nitric acid, or the actual cautery. When cauterization is performed for moral effect or prudential reasons, any form of caustic may be em- ployed, but the galvano-cautery is preferable. Its action is instantane- ous, and limited to the seat of the lesion; the pain which it produces is momentary, and the resulting cicatrix is usually slight. As a rule, the less irritation to which a chancre is subjected the sooner will it dis- appear, and the smaller will be the cicatrix. The internal treatment of chancre is that of the disease of which it is the first manifestation, and should be commenced as soon as the diagnosis is made. Hygienic Treatment.—As syphilis is pre-eminently a disease of degeneration, the patient should be placed under the best possible influences to resist its debilitating tendencies. He should be warmly clothed, and live as much as possible in the fresh aid and sunlight, his diet nourishing and easily digested, consisting largely of meat, milk, and vegetables; tobacco and alcoholic drinks should be prohibited alto- gether, and excesses of all kinds avoided. The functions of the skin, EXUDATIONS. 241 kidneys, and bowels should not be permitted to become disordered, and at least eight hours out of the twenty-four are to be given to sleep. Bathing in lukewarm water two or three times a week is essential. The addition of sulphide of potassium to the bath enhances its effect. The patient must be cautioned against thinking about his disease, and be urged to cultivate an even, cheerful frame of mind. There is no malady more distressing or more difficult to cure than syphilo- phobia. Tonic Treatment.—Tonic remedies are always useful, and fre- quently indispensable, in enabling the system to withstand the ravages of syphilis. In some cases their employment is of even more service than the administration of specifics. Iron, especially in the form of the chloride and the sulphate, will almost always be found beneficial. Its value is due to the fact that its presence in the system increases the number of red corpuscles in the blood, thus counteracting in part the destructive influence exerted by the disease. Cod-liver oil, arsenic, quinine, strychnine, the mineral acids, and the bitter tonics, may also be given with decided advantage. Hoang-nan is another remedy of service, especially in those whose constitutional powers are notably depressed. Under the same circum- stances the chlorate of potassium will be found of decided utility. Eliminative Treatment.—The elimination from the system of the products of degeneration is secured in part by attention to the functions and hygiene of the patient, and in part by the action of the specific remedies. Marked benefit can be obtained in addition, how- ever, by the use as adjuvants of agents that promote destructive meta- morphosis, and increase the action of the various secretory organs of the body. Antimony, sarsaparilla, guaiac, stillingia, and sanguinaria are the most important of this class. The reputed efficacy of ephedra, or Mormon tea, has been investigated Dr. H. H. Rushy, who concludes that its depurative action is second only to that of iodide of potassium, with which it may therefore be advantageously alternated or com- bined.* Specific Treatment.—The specific treatment of syphilis consists in the administration of mercury during the early stages of the disease, and iodide of potassium, either alone or combined with mercury, during the later stages. This is the treatment par excellence of syphilis, and the only one which can be relied upon to eradicate the virus from the system and prevent a return of the disease. It can be assisted by the simultaneous employment of hygienic, tonic, and eliminative measures, but without it for a basis they are of comparatively little value. The manner in which the curative influence of mercury and potassium iodide is exerted in syphilis is not known. It is probable, however, that they act in part as eliminative agents, and in part as direct an- * Druggists' Bulletin, 1888, p. 220. 16 242 DISEASES OF THE SKIN. tagonists of the process of cell proliferation and degeneration. Whether they act directly upon the protoplasmic matter which contains the virus of the disease, or indirectly by profoundly altering the constitu- tion of the blood, is still an undecided question. This course, however, should never be followed as a mere matter of routine, but be from time to time intermitted and replaced by a tonic regimen. Leloir has pointed out that a too rigid reliance upon specific treatment induces a condition of neurasthenia with dilatation of the stomach simulating severe cerebral syphilis. In such cases it is a serious mistake to continue or increase the doses of specific drugs, as this serves only to aggravate the manifestations. General Medicinal Treatment of Early Syphilis.—The general medicinal treatment of syphilis may be appropriately divided into that of the early and the late manifestations of the disease. The primary and secondary lesions are included in the former class, and the tertiary and quaternary in the latter. Mercury is by far the best remedy in both the primary and secondary stages, and it should be employed as soon as the diagnosis is made. Nothing can be gained, and much may be lost, by deferring its use until secondary symptoms have appeared. The advocates of delay admit that the early adminis- tration of mercury will postpone or modify the development of the cutaneous manifestations, but they urge that this delay or modification prevents the formation of an accurate prognosis, and is of no ultimate benefit to the patient. This claim is wholly erroneous, however; but even admitting it were partly true, the welfare of the patient is not to be endangered in the endeavor to make the physician a true prophet. At a meeting of the Medical Society of London, February 20,1888, Mr. Jonathan Hutchinson read a paper on what he styles the " abor- tive treatment" of syphilis. Without insisting too strongly upon the literal accuracy of the term as indicating absolute annihilation of the disease, he believes that it may be fairly used as a treatment which is planned to prevent the secondary phenomena and which usually suc- ceeds. If a patient with indurated chancre and no other symptom be at once placed upon a mercurial course and continued for at least six months, the experience of Mr. Hutchinson has been that secondary symptoms will not make their appearance. His choice as a remedy is the gray powder administered in one-grain doses three times a day at least. The induration will generally soften rapidly within a week. If the treatment be given up at the end of six months, a general erythe- matous rash often develops within a few weeks. This eruption never becomes papular or scaly, and disappears after a few days' return to the mercurial treatment. For this reason he regards it as judicious to con- tinue the treatment for nine or twelve months. He does not affirm that this method will prevent the occurrence of tertiary symptoms. EXUDATIONS. 243 Though I do not feel justified in going so far as to assert that the skin and throat symptoms of syphilis can be suppressed by the ad- ministration of mercury in the primary stage, I am positive that these symptoms are so remarkably ameliorated as to relieve the sufferer from much annoyance and alarm. Furthermore, though the virulence of the disease in the early period of constitutional involvement usually expends itself upon skin and mucous membrane, the important fact should never be forgotten that lesions of the brain, spinal cord, liver, spleen, bone, and other structures not infrequently occur during the so-called secondary stage. I am, indeed, of the opinion that visceral syphilis is much more common in the secondary stage than is usually supposed. On the other hand, Kaposi, of Vienna, believes that when constitutional treatment is begun before the outbreak of secondary symptoms, a predisposition to future involvement of the nervous sys- tem is created. Mercury can be introduced into the system by internal adminis- tration, inunction, fumigation, or hypodermic injection. The former method is usually adopted in the early stages of syphilis, as it is the most convenient, and possesses the fewest disadvantages. Any of the preparations of mercury are useful, given alone or in combination with any other remedies which may be indicated. The preparations which I most frequently employ are the green iodide and the corrosive chloride of mercury; but cases sometimes occur in which the red iodide, the mild chloride, blue-mass, or hydrargyrum cum creta can be used with more advantage. No matter what form of mercury is adopted, it should be given in small doses at first, in order to avoid the danger of producing salivation at the beginning of treat- ment. The susceptibility of individuals varies so much, that too great care can not be taken in this respect. Dr. Petersen has ascertained that the gums are peculiarly sensitive in those patients whose kidneys are involved. A practical deduction from this fact is that whenever ptyalism occurs in a syphilitic patient the urine should immediately be examined. If the patient's general condition is fair, I usually begin by direct- ing him to take one of the following pills, half an hour after each meal and at bedtime : R, Antimonii et potassii tart.......... gr. ss. Hydrarg iodidi vir................ gr. iij. M. Ft. pibilae no. xxiv. If they do not produce any intestinal irritation or soreness of the gums, I increase the amount of the green iodide until a fourth or a third of a grain is taken four times daily. At the end of the third week the tartar emetic may be discontinued, but the green iodide con- tinued in incre.'ised quantity without intermission for three or four months. I then either stop it for one or two weeks, or reduce it to 244 DISEASES OF THE SKIN. the one sixteenth of a grain twice a day. During the intermission I generally place the patient upon one of the following formulae: R, Strychninae sulphatis.............. gr. ss. Potassii chloratis.................. 3 ij. Acidi hydrochlorici dilut........... f 3 j. Aquae........................... f 1 iij. M. Sig.: One teaspoonful in water after meals. R, Tinct. belladonnae................. f 3 jss. Tinct. fer.ri chlor.................. f § jss. Aquae............................ f § ijss. M. Sig.: One teaspoonful in water after meals. R, Tinct. ignatiae.................... f 3 jss. Tinct. serpentariae................ f % ss. Tinct. coptis trifoliae............. f § ijss. M. Sig.: One teaspoonful in water before meals. Erythroxylon coca is highly esteemed as a tonic adjuvant by Dr. R. W. Taylor, who administers it in the form of a reliable fluid extract, and frequently combines it with the compound tinctures of cinchona and gentian. After one or twro weeks of this simple tonic treatment I renew the maximum doses of. the mercurial for three or four months more. An- other week of intermission then ensues, after which the mercurial is given for another protracted period, but in somewhat smaller doses. After this plan of treatment has been faithfully carried out for a year, the intermission may be lengthened to a month, and the periods dur- ing which the mercurial is continuously given reduced to six or eight weeks. If no lesions are manifest at the expiration of six months of this interrupted treatment, or a year and a half from the beginning of the disease, the mercurial is discontinued for two or three months, then administered in small doses for a week or two, and then dropped for two months more. If any lesions occur in the mean time, the treatment is resumed at once. If none appear, however, the patient may be considered to be practically cured, but should be advised not to marry for at least one year after all symptoms of the disease have disappeared. By pursuing such a prolonged course of administration, Prof. Fournier estimates that tertiary manifestations will be prevented in from ninety to ninety-five per cent, of the cases. If the person is anaemic or debilitated, a smell quantity of iron or of quinine may be added to each pill, or given separately, as in pither of the following formulae : R, Strychninae sulphatis.............. gr. j. Quininae sulphatis................. 3 ss. Acidi phosphorici dilut............ f 3 - j. Aquae........................... f | iv. M. Sig.: One teaspoonful before meals. EXUDATIONS. •245 R, Liq. potassii arsenitis.................. f 3 j. Elix. gentianae ferrat.................. f 3 iij. M. Sig.: One teaspoonful after meals. If the movements of the bowels exceed three a day, or griping colicky pains occur, from a twelfth to a fourth of a grain of opium should be added to each pill. In come cases it may be necessary to discontinue the use of the mercurial for a few days. Dr. Dixon Mann has recently used iodide of mercury haemol with benefit in this class of cases, the dose being two or three grains three times a day. Haemol is a derivative of haemoglobin. If salivation occur, or the gums become spongy, the mercurial must be stopped at once, and belladonna, chlorate of potassium, and the mineral acids, given in full doses. R, Acidi hydrochlorici dilut.............. f 1 ss. Aquae............................... f § iv. M. Sig.: Dessertspoonful in water before meals and at bedtime. R, Tinct. belladonnae................... f 3 j. Potassii chloratis..................... 3 ij- Aquae............................... f | iv. M. Sig.: Two teaspoonfuls in water one hour after meals. In addition, the mouth should be thoroughly rinsed every two or three hours with a weak solution of common salt, or chlorate of potas- sium, or with a lotion composed of half an ounce of compound tincture of cinchona and six ounces of rose-water. The tincture of hydrastis diluted with water is also useful as a corrective mouth-wash. The corrosive chloride of mercury is an effective remedy. It is less irritating when given in solution. The doses should vary in the begin- ning from the one thirtieth to the one twenty-fourth of a grain, and be gradually increased until the one sixteenth or the one tenth of a grain is taken four times a day. In exceptional cases no impression is pro- duced upon the disease until the dose has been increased to the one eighth of a grain. The permanence of the solution may be insured by the addition of a small quantity of the chloride of sodium, as in the following formulae: R, Hydrarg. chlor. corrosiv............... gr. j. Sodii chloridi........................ 3 j. Aquae............................... f 3 ijss. M. Sig.: One teaspoonful after meals and at bedtime. R, Hydrarg. chlor. corrosiv............... gr. j. Sodii chloridi....................... 3 j- Tinct. cinchonae comp................. f 3 ijss. M. Sig.: One teaspoonful four times a day. In case the corrosive sublimate is not well borne, the substitution for a certain period of the chloride of gold and sodium has been found of advantage. The dose of this double salt is from one fiftieth to one 246 DISEASES OF THE SKIN. tenth of a grain three times a day. It is freely soluble in water, but is best administered in the form of a pill or tablet triturate. In anaemic or debilitated subjects the best results can be obtained from the combined administration of the corrosive chloride of mercury and the chloride of iron— R. Hydrarg. chlor. corrosiv............ gr. j. Tinct. ferri chlor.................. f f ss. Aquae............................ f § iijss. M. Sig.: Dessertspoonful in water after meals and at bedtime. The biniodide of mercury is highly esteemed by many practitioners. It may be given alone or combined with potassium iodide. The dose varies from the one thirtieth to the one twelfth of a grain. Exceptional instances are met with in which mercury has no power to alleviate violent headache. In these cases the substitution of the iodide, alone or in combination with the bromide of potassium, may be substituted with advantage. In the headache of the secondary period not dependent upon serious cerebral lesion, Leroy has found aconitine serviceable. He administers the drug in minute doses. It can be given in from -5-^ to ^4/g- grain during the course of the twenty- four hours. The mild chloride is one of the best preparations of mercury that can be used in syphilis, but it must be administered with caution. Its action is so prompt that salivation is sometimes produced by it with startling rapidity. It is especially valuable where an immediate mer- curial impression is desired, as in syphilitic iritis. It may be given in grain or half-grain doses four times a day, but where prompt mer- curialization is required, one eighth of a grain should be given every hour or two. Blue mass is also valuable for internal use. It is slow in action but certain in results, and seldom produces gastric irritation. The dose varies from half a grain to two grains, four times daily. It is usually given in pill-form, and may be combined with iron, quinine, antimony, or opium, when necessary. Hydrarg. cum creta, or gray powder, is an effective and non-irri- tating preparation. The dose varies from one *o three grains, four times daily. It may be given as a powder or in pill-form, or combined with other remedies. Several new mercurial combinations have during the past few years been introduced into practice. These have all in clinical experiments proved themselves more or less efficacious in virtue of the mercury which they contain, but none has as yet been able to supersede the older salts. Sufficient evidence has accumulated to demonstrate the utility of the tannate of mercury. This is considered by Schwimmer to be more active than corrosive sublimate. It is not prone to cause alimentary disturbances, and can be continuously administered for a EXUDATIONS. 247 long time. The dose is one and one half grain, twice or thrice daily either in pill or solution. The neutral salicylate of mercury was brought to the notice of the profession by Dr. Silva Araujo, of Rio Janeiro. Favorable reports have been given of its action by various Brazilian physicians; Szadek, of Kiev; Prof. Newmann, of Vienna; Dr. W. C. Caldwell, of Chicago, 111.; Dr. A. F. Buchler, and others. The usual dose in which it is given is one third to one half grain, in pill or tablet, three times a day. The last-named writer * treated thirty-two cases of syphilis with this compound. He found it a prompt and efficient remedy, well borne by the gastro-intestinal tract and system at large. It is thought to re- semble the protiodide of mercury more closely than any other salt, but is said to be better tolerated. Prof. Schwimmer found this salt of value in seventy cases of constitutional syphilis, but states that it is apt to cause stomatitis. This writer administered it either in the form of powder or pill. Dr. De Lucca treated twenty patients—ten adults and ten children— by means of his mercuric alanine. No case of stomatitis was produced, and but one of gastric intolerance. He does not advocate this drug as superior to the tannate and some other forms of mercury, but thinks that the ease with which mercuric alanine is tolerated and its excel- lent results in infantile syphilis render it an important addition to the list of our resources. The dose is from one tenth to one sixth of a grain. The benzoate of mercury, chiefly used hypodermatically, has also been tested by Stukovenkoff as an internal medicament in the dose of one tenth to one third grain, in pill, twice daily. It was found to be slow in action, and in a number of cases it gave rise to diarrhoea. This salt was also administered internally by Balzer and Thiroloix,f who substituted it for the biniodide in the sirup Gibert, as it readily dis- solves in a solution of iodide of potassium. Though they confess that their experience had been insufficient for any decided expression of opinion, yet they found that the benzoate mixture was well borne by seven patients in whom Gibert's preparation excited immediate vom- iting. The influence of heat with consequent free diaphoresis is of decided benefit as an adjuvant to specific medication. Dr. Radestock, of Geit- hain, in Saxony, is in the habit of ordering a hot bath, continued for about thirty minutes or until the skin becomes red. The action of the skin is promoted by hot decoctions or infusions or by the hypo- dermic injection of two cgm. (one third grain) of hydrochlorate of pilocarpin daily. A striking exemplification of the effect of heat upon cutaneous syphilis is the series of observations made by Dr. Kalashnikoff, of St. Petersburg. Partial hot-air baths were admin- istered to accessible affected parts for half an hour twice a day. In * Journal of Cutaneous and Gcnito Urinary Diseases, May, 1830. \ loc. cit. 248 DISEASES OF THE SKIN. the intervals the part was enveloped in hot flannel. The tempera- ture never exceeded 116° Fahr. When the hot-air chamber could not be used, India-rubber hot-water bottles, or tubes through which hot water flowed, were employed. When both arms or legs were affected, the hot applications were made to the limb of but one side, in order to make comparison. The treatment was generally found to have a very favorable effect upon syphilitic eruptions, even when employed alone; and, in fact, was often beneficial where mercurials or iodides had failed.* Mercurial Inunction.—This is a rap'id and effective method of bringing the system under the influence of mercury, and is especially useful in all cases where a speedy effect is desired, as in syphilitic iritis, syphilis of the nervous system, or of the internal organs. It is also serviceable in many old cases of the disease, and in those in which mercury will not be tolerated by the stomach. The difficulties attend- ing its use are so great, however, that it is seldom ordered in private practice, except in the urgent cases previously referred to, and in some forms of hereditary syphilis. The preparations employed in inunction are the ordinary blue oint- ment and the ointment of the oleate of mercury. The ointment of the mercurous oleate, however, as I have already shown, is far supe- rior to the ordinary blue ointment. It is a powerful remedy, which should be employed with caution. It possesses deep penetrating pow- ers, and by its quick diffusion frequently produces a rapid constitu- tional impression. Its further advantages over the blue ointment are its cheapness, and cleanliness of application. A small piece about the size of a bean, rubbed in each axilla daily, and in the surface of each thigh, will be quickly absorbed, without soiling or discoloring the clothing; and, while the friction may produce a reddening of the sur- face, the eczematous condition, which may follow the use of any mer- curial ointment, can be avoided by having the patient take a vapor or a hot-air bath two or three times a week. An experience of several years has convinced me that frequent opening and cleansing of the follicles of the integument are necessary for the success of the inunc- tion treatment; otherwise they will become clogged, an eczematous inflammation will be set up, and absorption rendered impossible. Dr. 0. Dymnicki, of Busk, has contributed an excellent paper to the Polish weekly, " Gazeta Lekarska," No. 19, 1889, upon the advan- tage in certain cases of combining the internal administration of qui- nine with mercurial inunction. The quinine was given in the daily dose of one to one and a half grammes (fifteen and a half to twenty- three grains). His conclusions are drawn from the results in 178 con- secutive cases. The patients in whom the conjoined use of quinine proved most beneficial were those having severe ulcerations, and * Journal of Cutaneous and Genito-Urinary Diseases, July, 1890, p. 284. EXUDATIONS. 249 whose temperature, pulse, and body-weight underwent considerable fluctuations. The value of the quinine appears to depend upon the inhibitory influence which it exerts upon this tissue-change. As a consequence, the quinine supports the system and enables it to bear larger doses of mercury. Quinine proved useless in those cases in which tissue-change was retarded. Dr. R. Bovero employs calomel inunction, from eight to fifteen grains being made into an ointment with forty-five grains of lanolin and fifteen grains of cacao-butter. Mercurial Fumigation.—This practically consists in placing the patient in a mercurial vapor-bath. It is a valuable method, but difficult to employ in private practice. The patient, completely stripped, is seated on a chair or stool, beneath which are a spirit-lamp, a pan of water, and a tin containing mercury. A large blanket or rubber cloak is then thrown around the patient, covering him from the neck downward. The lamp is lighted, and profuse perspiration is produced. The mercury becomes volatilized, and, deposited upon a thoroughly relaxed skin, is finally absorbed. The lamp should be re- moved in fifteen or twenty minutes, and the patient permitted to cool off gradually. Any form of mercury may be used in this method, but the mild chloride is most frequently employed, as it vaporizes promptly, and its fumes are not irritating. From twenty to thirty grains are sufficient, and the process should be repeated two or three times a week. Mercurial fumigation is especially valuable in obstinate eruptions of the secondary or tertiary stage. It is also useful in all old cases of syphilis, and where the internal administration of mercury is productive of severe gastric disturbance. Its good effects are due in part to the increased elimination of morbid products by the skin, and in part to the rapid absorption of the finely divided particles of the remedy. Mercurial Plaster.—M. Quinquaud, of Paris, has proposed a new method of treatment which consists in the application of a mer- curial plaster over the spleen. The mass is prepared as follows: Diachylon plaster............. 60 ounces. Calomel..................... 20 " Castor-oil.................... 6 " Mix, and make into plasters four inches square. After washing the skin with soap and water, a plaster is applied and left in position for eight days. It is then removed, and the skin is left free for eight days, when a second plaster is put on and allowed to remain eight days. After the first plaster has been in position for four or five days, mer- cury will begin to appear in the urine, and will gradually increase, reaching its maximum on the eighth to the eleventh day. If no second plaster be used, mercury will continue present in the urine for a month or six weeks. By discontinuing the use of the plaster every eighth day for an equal period ptyalism is said to be entirely avoided. This is a con- venient mode, and M. Quinquaud claims that the results are effective. 250 DISEASES OF THE SKIN. Mercurialized " Traumaticin.—In some cases the method of Peroni, of Turin, may be employed as a convenient way of introducing mercury into the system. To traumaticin, which is a ten-per-cent. solution of gutta-percha in chloroform, Dr. Peroni adds a quarter of its weight of calomel. The patient is given a bath, and if there are any lesions they are painted over with the liquid. If no lesions are present the preparation is applied over the entire back. The evaporation of the chloroform leaves a closely adherent mercurial varnish upon the skin. The treatment is repeated three times a week until the symp- toms disappear. Hypodermic Injection of Mercury.—The hypodermic admin- istration of mercury* is the quickest and most effective method, and should be resorted to in all grave cases, and where a prompt removal of the lesions is of importance. This method of treatment was intro- duced by Scarenzio, and improved and popularized by Lewin. Scaren- zio employed injections of the mild chloride, suspended in mucilage and distilled water, and Lewin an aqueous solution of corrosive subli- mate. The albuminate, cyanide, green iodide, formamide, peptonate, metallic mercury, the salicylate, succinimide, and other preparations of mercury, have also been experimented with and followed by good re- sults. Liebreich claimed that the formamide of mercury was the best preparation to employ hypodermically by reason of its being neutral in reaction, most soluble in water, and not coagulating albumen. The dose of this substance for hypodermic use is one sixth of a grain; and Zeissl, of Vienna, found twenty injections the maximum number re- quired to remove severe syphilitic manifestations. Kopp, however, after an experience of 3,000 injections, asserts that the formamide of mercury is valuable only in mild forms of primary and secondary dis- ease. Martineau demonstrated thoroughly the utility of the peptonate of mercury in a large number of syphilitic patients. A compound known as glutine-peptone sublimate, containing twenty-five per cent, of bichloride, has been employed by Dr. Hurler in Strumpell's clinic at Erlangen. The injections are said to be pain- less, unproductive of local irritation, and prompt in effect. The dose is two thirds of a grain, equal to one sixth of a grain of mercuric chlo- ride. This substance is made by first acting.upon gelatine with dilute hydrochloric acid, from which results hydrochlorate of glutine pep- tonate, containing about twelve per cent, of hydrochloric acid. It is soluble in alcohol and forms a double salt with corrosive sublimate. Dr. De Lucca, a clinical assistant in the University of Catania, has published the results of his experience with alaninate of mercury or mer- curic alanine. This substance is a combination of mercury with alanine or amido-propionic acid. The compound is soluble and easily absorbed, * Remarks on Treatment of Syphilis by Hypodermic Injections of Corrosive Chloride of Mercury. By the Author. The Lancet, London, September 6, 1884. EXUDATIONS. 251 It was employed in twenty cases in the daily dose of one thirteenth to one sixth of a grain. The average quantity of the drug used was three and a half grains to each patient, the average duration of treatment 3705 days. Suppuration occurred only in one half per cent, of the total number of injections. No stomatitis was produced. The cures seemed to be permanent.* Wellander, of Stockholm, recommends the hypodermic injection of an acetate of thymol-mercury. It is said to cause less pain than calomel, to be less apt to create abscesses, and that more mercury can be introduced into the system by its means than by the use of corrosive sublimate. The compound is insoluble in water and requires to be suspended. It has been used with success by Ta- dassohn and Zeissing, whose formula was as follows: IJ, Hydrargyri thymolo-acetici............. 1 part. Paraffini liquidi...................... 10 parts. M. Ft. suspension. The new preparation is likewise endorsed by Dr. Szadek, of Kieff, who administers it in a mixture of gum-arabic, of which the formula is— R Hydrargyri thymolo-acetici............. 1-5 part. Mucilag. acaciae....................... 0-5 part. Aquae destillatae....................... 20 parts. M. Ft. suspension. Every three or four days Szadek made an injection of this com- bination. He reports that in ordinary cases six to ten injections are sufficient to suppress the manifestations. This mode of treatment is particularly valuable in the early stages of the disease. The benzoate of mercury is preferred by Prof. Stukovenkoff, of Kiev. This salt contains forty-three per cent, of metallic mercury, is a tasteless and odorless white crystalline substance, slightly soluble in cold water, but easily soluble in a weak solution of sodium chloride. The favorable reports of its action have been endorsed by Balzer and Thiroloix.f Benzoate of mercury is not apt to cause pain, abscesses, or indurations, and may be employed in solution, four grains to the ounce of distilled water, together with one grain of chloride of sodium and two grains of hydrochlorate of cocaine, in order to counteract the pain. It may likewise be used in the form of a ten-per-cent. emulsion with liquefied vaseline. One injection should be given daily, and it should be discontinued upon the appearance of stomatitis. The salicylate of mercury is another salt which has of late been used for hypodermic or intramuscular injection. It is a white, amor- phous powder, devoid of odor or taste, scarcely soluble in alcohol or water. It is therefore prepared in the form of an emulsion, and is much less apt to excite local irritation than calomel. It exerts a prompt and decided effect upon the manifestations of syphilis. Szadek, who * Journal of the American Medical Association, April 21, 1888. f Annales de Therapeutique Medico-Chirurgicales, January, 1890, p. 11. 252 DISEASES OF TnE SKIN. has employed this salt with satisfactory results, recommends the follow- ing formula: R. Hydrarg. salicylat................. gr. xvj vel xxiv. Mucilag. acaciae................... gr. viij. Aq. destillat...................... f 3 vss. M. Fifteen minims of this mixture were injected into the gluteal region every fourth day. He thus treated a long series of cases, without ob- serving a single local abscess due to the operation. After using most of the preparations just referred to, and the vari- ous combinations in which they are suspended, I prefer the solution of the corrosive chloride in distilled water, as being the most readily pre- pared, and just as effective as any that have been suggested. The only valid objection to the hypodermic administration of the remedy is that pain is necessarily produced by the puncture of the needle. This pain is trifling in character, however, and speedily dis- appears. Another objection frequently urged is, that abscesses may be formed at the seat of the puncture. This complication will not occur, however, if care be taken to thrust the needle of the syringe deep into the subcutaneous or muscular tissue, so that the fluid can be speedily absorbed. In fleshy persons I usually make use of the sub- cutaneous cellular tissue, inserting the injection deep into its meshes, preferring the integument of the back or buttock for the operation. In thin individuals I always deposit the solution in the muscular tissue of any portion of the body, but more particularly the regions just alluded to. In 113 cases which I reported to the American Medical Association,* 2,132 injections were administered in 206 days, without being followed by abscesses or any other inflammatory sequelae. Since that time I have employed the same method 3,163 times in 441 cases, and in no instance have abscesses resulted. The formula which -I use is— Hydrarg. chlor. corrosiv............ gr. iv. Aquae........................... f \ j. In some cases I begin by administering one hypodermic injection daily, of five minims of this solution, and increase the dose minim by minim every second or third day, until the disease begins to abate, or until the constitutional effects of the drug are manifested. I then lessen the dose sufficiently to keep the system gently under the influ- ence of the remedy until all traces of the affection have disappeared. In others, particularly the more robust, it has been my practice for sev- eral years to give hypodermically as much as one quarter to one half a grain of the corrosive chloride of mercury at intervals of every three or four days. In a communication to the Medical Society of London, April 23, 1888, Mr. J. Astley Bloxam, F. R. C. S., stated that since 1884 he had * Transactions of the American Medical Association for the Year 1882. EXUDATIONS. 253 used hypodermic injections of the same form of mercury 1,924 times at the Lock Hospital. He recommends the solution for injection be made fresh for each seance, and that one third of a grain of the salt just named be inserted once a week deeply into the muscular tissue, especially of the buttock. Many of the patients in whom I employed the above method of treatment had previously been given mercury in- ternally without much benefit; others presented such marked irrita- bility of the gastro-intestinal tract that the administration of mercury per orem could not be entertained. In such cases the hypodermic method enables the physician promptly to neutralize the poison of the disease, preserve the tone of the stomach and support and invigorate the patient by a nutritious diet and the administration of tonics. The injection of calomel is not altogether devoid of danger. Kraus has reported a case in which one and a half grain led to fatal dysentery and peritonitis. Prof. Runeberg has seen two cases in which death resulted, in one from two and in the other from three injections, a week or more intervening between each operation. In each case there was diphtheritic infiltration of the large intestine, and in one perforation had occurred at the sigmoid flexure with consequent peri- tonitis ; acute nephritis was also present. In the other case there was found at the spot of injection an abscess which contained unhealthy pus and a considerable quantity of mercury. Hebra, however, has not witnessed abscess or any ill result in a single case out of 16,000. Neu- mann, after 344 injections of calomel in fifty-two cases, concludes that the method is less effective than the treatment by inunction. It has been asserted by certain French writers that much better results are obtained by using vaseline oil in preference to other fluids in preparing calomel or gray oil for injection. Dr. Watraszewski argues in favor of the yellow oxide of mercury in doses of from two thirds to one grain. He believes that mucilage is a better vehicle than an oil or glycerine, the oil exciting serious embolic pneumonia, while the mucilage merely produced small embolic foci which were absorbed without important subsequent reaction. The following formula is recommended by Besnier: R, Hydrarg. oxid. flav................. gr. xv. Pulv. tragacanth................... gr. v. Aquae destillat..................... f 1 j. M. Twenty-four minims, equal to three quarters of a grain of the salt, are injected every ten days until mercury appears in the urine. Dur- ing the earlier months of the disease it is said that four grains of the yellow oxide suffice to hold the manifestations in abeyance. With the development of new lesions, a fresh series of injections is instituted. Gray oil has also been used as an injection; but a fatal case is reported. Stomatitis and instances of fat embolisms in the lungs have occurred. 254 DISEASES OF THE SKIN. Eichhoff has lately experimented with europhen, given hypodermi- cally, in both secondary and tertiary syphilis. The results seemed to be very satisfactory. His method was, to give each day an injection of three fourths to one and a half grain of europhen dissolved in olive- oil, beginning with the smaller dose. Electrical Cataphoresis.—Gaertner and Ehrmann, of Vienna, have devised a bath by which mercury may be introduced into the system through the action of electricity. The tub is made in two com- partments, one above the other, separated by a diaphragm formed of an insulating substance and fitting almost hermetically to the human body. The body thus acts as the only communication between the two compartments, one of which is in contact with the positive and the other with the negative pole. The intensity of the current may be measured by means of a galvanometer. Either side of the body may be alternately subjected to the action of the positive electrode. Mer- cury appears in the urine within twenty-four hours, and may still be detected on the fourth day after the bath. General Medicinal Treatment of Late Syphilis.—As the boundary between the secondary and tertiary stages is not always well defined, the term late syphilis is frequently employed to include the obstinate secondary manifestations as well as the lesions of the tertiary and quaternary stages. The treatment in this period is varied and dif- ficult. The remedies which are of especial service are the iodides of potassium and sodium. Some physicians prefer the former and others the latter. According to my experience, they are of equal value; but I do not prescribe the sodium salt to patients of the uric-acid diathesis, as it may result in the deposition in the system of crystals of the insol- uble urate of soda. The initial dose of the iodides should not exceed ten to fifteen grains four times a day. In case the potassium or sodium salt prove depressant the iodide of ammonium may be substituted. Dr. G. Darzens believes that a combination of the iodides enhances their efficacy. In laryngeal and cerebral syphilis Victor Augagneur advocates the association of potassium bromide and iodide. If no appreciable effect is produced, or if symptoms of iodism do not appear, the dose should be rapidly increased, until one or two drachms have been given three or four times a day for several weeks. Still larger doses, as high as an ounce and a half daily, have been administered in cases of cerebral syphilis with safety and advantage. Wolff recommends that when given in such quantities the salt should be dissolved in decoction of rice in order to prevent iodism. The iodides can be given in water or in the simple sirup, or in any of the bitter tonics. The good effect is enhanced by giving mercury in addition, either in the same prescription or separately, at the same or different hours through the day. I usually administer them sepa- rately, directing the patient to take one sixth of a grain of the green EXUDATIONS. 255 iodide in pill-form, or one sixteenth of a grain of the corrosive chloride in a bitter tonic before meals, and ten to fifteen grains of the iodide of potassium in water about an hour after meals. Where necessary, I give the corrosive chloride hypodermically, and the iodides per orem. Again, I have employed in some cases iodides,* preferably the potas- sium iodide, from three to five grains injected deeply into the muscular tissue every two or three days, with most decided effect in eradicating the disease. Occasionally I have given one of the mercurials by the mouth and used the iodide f hypodermically, and at times the former has been injected and the latter given by the mouth. Obstinate cases yield rapidly to this treatment. The iodide may also be administered by rectal injection when the stomach is disordered. For this purpose the following formula has been recommended : R Potass, iodid...................... gr. xv. Extr. belladonna.................. gr. i- Aquae........................... f 3 iv. M. When it is desired to give both drugs in combination, by the ali- mentary canal, the following may be employed : R Hydrarg. chlor. cor................ gr. ij. Potassii iodidi.................... 3 v. Syr. zingiberi.....................f 1 iv. M. Sig.: Teaspoonful in water after meals. The well-known sirup Gibert is also justly esteemed by many prac- titioners. Its formula is: R, Hydrarg. iodidi rub................ gr. j. Potassii iodidi..................... 3 j- Aquae........................... f 1 j- Syr. simp......................... f f v. M. Sig.: One tablespoonful three times a day. Van Buren and Keyes recommend the following: R Hydrarg. iodidi rub................ gr. jss. Ammonii iodidi................... 3 j. Potassii iodidi..................... 3 ij. Syr. aurantii cort.................. f 1 j- Tinct. aurantii cort................ f 3 j- Aquae.....................q. s. ad f § iij. M. Sig.: Teaspoonful in water after meals. Hutchinson, in the lesions of late syphilis, is fond of a combination of the iodides of potassium, sodium, and ammonium, together with a small quantity of free ammonia. Iron, quinine, arsenic, strychnine, and the mineral acids given at times are useful. Marked benefit will be derived from the occasional * Intra-muscular Injections of Preparations of Iodine in Syphilis. Schadeck, in St. Petersburg, medicin. Wochenschrift, No. 29, 1S86. f Hypodermic Use of Iodide of Sodium. Arcari, in Wien. med. Woch., No. 4, 1886. 256 DISEASES OF THE SKIN. administration of stillingia, guaiacum, sarsaparilla, sanguinaria, and other vegetable alteratives and sudorifics, as alder-bark, corydalis, meze- reon, phytolacca, helianthemum, lappa, sambucus, and manaca. The most important of these have been combined with the iodide of potas- sium to form a serviceable mixture known as the compound sirup of red clover. In his experiments with iodol, Szadek ascertained that this drug is more beneficial in late than early syphilis. It may be substi- tuted for iodide of potassium in doses of one quarter to five grains three or four times a day. Dr. Haines has witnessed excellent results from the exhibition of cascara amarga in late syphilis. In secondary and tertiary syphilis I have administered with very good results the iodo-sulphate of cinchonine in doses of one to five grains three or four times a day. Baths, fresh air, and a nutritions diet are of paramount importance. Anodynes must be given when necessary, to relieve pain or procure sleep. Dr. J. D. Menzies has, in several cases of precocious malignant syphilis, observed speedy improvement under the use of thyroidin tablets. The serum of the lamb, ox, or dog has been used subcutane- ously in constitutional syphilis and is claimed to be of benefit. The quantity of serum injected at a time was about one and a half fluid drachms. These methods may be mentioned and may deserve trial, but our present knowledge of them is defective and inconclusive. Local Treatment.—The local treatment of the initial lesion has been described. Macular eruptions are usually uninfluenced by oint- ments or lotions, but are materially modified by fumigation treatment, or by ordinary vapor-baths. Papular manifestations may be improved by baths and fumigation. The following lotion is serviceable, especially in the facial papular eruptions : R Hydrarg. chlor. cor...... .......... gr. ij. Spt. vini rect...................... f 1 ss. Aquae rosae........................ f § iijss. M. Sig.: Use externally every three or four hours. Ointments are also of value : R, Hydrarg. chlor. mitis............... gr. xx. Bismuth subnit.................... 3 ij. Ung. aquae rosae.................... § j. M. Ft. ung. Sig. : Apply externally night and morning. R, Hydrarg. chlor. cor................. gr. j. Acidi carbolici..................... gr- v. Plumbi carb....................... 3 iij. Adipis............................ | j. M. Ft. unguent. Sig.: Use externally twice a day. The ointments of the nitrate and oleate of mercury, diluted in the proportion of one part to five or six parts of the base, may also be used EXUDATIONS. 257 with benefit. Moist papules should be cleansed with soap and water, or salt and water, and then dusted over with a powder composed of equal parts of bismuth subnitrate and powdered chinchona-bark ; or one part of the mild chloride of mercury and seven parts of bismuth sub- uitrate. Caustic lead is recommended by Bockhardt * as an applica- tion to condylomata. He made use of Gerhardt's formula, 3-3-per- cent, solution of oxide of lead in a thirty-three-per-cent. solution of caustic potash. One of the most efficient methods of treating condy- lomata is by the galvano-cautery. The ointment of arsenic oleate is an effective application to this lesion. It is also good practice to touch their surface with a solution of chromic acid, ten grains to the drachm of water. Aristol is an excellent application to ulcerated lesions. It may be added that this drug has been found efficacious in the local treatment of syphilitic ozaena and the ulcerations of late syphilis. Mucous patches or ulcers within the mouth may be touched with silver nitrate, copper sulphate, or mercuric nitrate in solutions of vary- ing strength. A solution from ten to fifty per cent, of chromic acid has also a good effect. In alopecia local applications are serviceable in addition to the con- stitutional treatment. Besnier recommends that the following liniment should be well rubbed into the scalp every night with a soft brush: R Spir. rosmarin...................... f 3 xxv. Tinct. cantharid.................... f 3 ijss. M. In the morning, the scalp having been washed with soap and hot water, the following ointment is applied : R Acid, salicylici...................... 3 ss. Sulphur-precip..................... 3 iij. Lanolini, Vaselini..........................aa 3 xijss.f M. The papulo-squamous and tubercular lesions are obstinate, and re- quire the protracted use of stimulating mercurial applications. Fumi- gation and vapor-baths in addition will be found beneficial. The pus- tular, rupial, bullous, and ulcerative lesions run a tedious course, and are more amenable to internal than to external treatment. Their heal- ing may be hastened, however, by detaching the crusts, removing all discharges from the underlying surface, and then cauterizing it with a strong solution of nitrate of silver, corrosive chloride of mercury, or carbolic acid. A protective dressing of bismuth subnitrate or of oxide of zinc may then be applied. Other excellent applications in this class of lesions are iodol and iodoform, but the peculiar and diffu- sive odor of the latter will limit its employment to hospital practice. Gummata should not be opened unless the fluctuation becomes * Monatshefte fur prakt. Dermatol., vi, 1888. f La France Medicale, Sept. 5, 1889. 17 • 258 DISEASES OF THE SKIN. pronounced. When this takes place, an incision may be made at the most dependent part of the swelling, its contents evacuated, and the cavity syringed out with a strong solution of tincture of iodine or corrosive chloride, and then permitted to heal by granulation. Prognosis.—The prognosis is not unfavorable, as a rule. The im- provement in personal habits and hygiene, and adoption of a methodi- cal rational treatment, have divested the disease of many of its terrors. It would be folly to deny, however, that it is a serious affection, and that it does not tax the skill of the physician to the utmost extent. Much depends upon the age of the patient and state of his constitution, but more upon the prompt and systematic administration of appropriate remedies. In young, robust adults properly treated the disease seldom passes beyond the secondary stage. Old people, young children, and the debilitated of all ages, are unfavorable subjects, but frequently re- cover promptly. According to Prof. Fournier, syphilis accidentally acquired by physicians from patients is of exceptional gravity, a result which he attributes to moral and physical depression. Intemperate or dissolute persons suffer more than those who lead an even life. When the syphilitic poison is added to the gouty, the rheumatic, or the scrof- ulous diathesis, it is apt to pursue an obstinate course. The prognosis is also influenced by the character of the cutaneous manifestations. Macular or papular eruptions usually indicate a mild case. Pustular eruptions are symptomatic either of a more severe in- fection, or a debilitated condition of the patient. Rupia is significant of a malignant form of the disease. Tertiary syphilis is always serious, but varies in severity in accordance with the organs involved. Syphilis of the nervous system is invariably grave, and frequently fatal. Syphi- lis of the internal organs is also to be dreaded. The disease is always amenable to treatment, however, and even in the most hopeless stages can frequently be cured or considerably ameliorated. " How long after syphilis has been apparently cured should a patient remain single be- fore he can marry, without endangering his wife and expectant off- spring?" is a question often asked. The general consensus of opinion is that if a patient has been under observation for three years, and no manifestations of the disease have appeared during the last year, he may marry without fear of communicating the disease to his wife or entailing it upon his children. In imperfectly cured cases, even though the disease exhibit no notable manifestations, it remains transmissi- ble for a long and perhaps indefinite period. Barthelemy has report- ed a case in which a child inherited syphilis from parents, both of whom had had the disease fourteen years previously, and though irreg- ularly treated, had been free from symptoms for many years. Prof. Fournier has seen it inherited after a lapse of twenty years. As a rule, hereditary syphilis is acquired during the three years following the first manifestation of the disease in the parent. After this time, EXUDATIONS. 259 even in the absence of treatment, susceptibility to inheritance is greatly and progressively diminished. As a rule, one attack of syphilis confers subsequent immunity. The victims of hereditary disease are protected against acquired infec- tion. To this rule, however, exceptions doubtless occur. It is usual to consider that a second infection is evidence that the first attack was completely cured ; and, in fact, this is one of the arguments relied upon to prove that the affection is curable. An interesting exceptional case has been observed by Dr. Augusto Ducroy.* The patient, a woman, forty-six years of age, whose body was much scarred as a result of ulcerated syphilides, and who likewise exhibited a gumma of the scalp, was reinfected. The new infection manifested itself by an induration of the right labium majus, general glandular enlargement, syphilitic roseola on the trunk and limbs, mucous patches on the soft palate and velum, syphilitic fever, and osteocopes. Subsequently iritis and a pust- ular syphiloderm developed. Coincidently the gumma upon the scalp became deeply ulcerated. Congenital Syphilis.—Infantile syphilis is either acquired or congenital. If acquired, it is the result of inoculation with the secre- tions of a syphilitic lesion during parturition or after delivery. Nu- merous cases are recorded in which the disease has been communicated by a mucous patch or tubercle on the nipple of a wet-nurse. The large majority of cases are congenital in character, however, and are the result of infection in utero. There are many unsettled problems in regard to the transmission of syphilis to the embryo, but the weight of authority is in favor of the opinion that infection can only occur through the medium of the ma. ternal circulation. If the mother is suffering from syphilis when im, pregnation occurs, or if she become infected then or at any time pre- vious to the seventh month of pregnancy, the disease will certainly be communicated through the utero-placental circulation. One of the most frequent results of maternal syphilis is a succession of abortions or miscarriages. In post-mortem examinations of the bodies of twenty-eight still-born syphilitic infants, M. Barthelemy failed in most cases to discovei any lesion. Gummata were found in five cases, while in eight others the liver was granular, and, upon mi- croscopic examination, miliary gummata of the liver and kidneys were observed. The spleen was in most cases somewhat larger than normal, but in other respects unaltered.f As a rule, the earlier the ovum is infected, the sooner will it be ex- pelled. The pregnancy may, however, go on to full term, and termi- nate in the birth of a still-born child. One of the most characteristic symptoms of syphilis in mothers is a recurrence of apparently cause- * Giornale Italiano delle Malatti Venerec e della Pelle, December, 1888. f British Journal of Dermatology, October, 1890. 260 DISEASES OF THE SKIN. less still-births. In some cases the child is born alive, but covered with an eruption, which needs no explanation. Generally, however, when the child is born alive it presents an apparently healthy appear- ance, but evidences of parental vice or misfortune become manifest in a short time. In one hundred and fifty-eight cases of hereditary syphilis, which were recorded by Diday, the first symptoms appeared in eighty-six during the first month after birth, in forty-five during the second month, in fifteen during the third month, and in the re- mainder during the fourth and fifth months. These statistics show that the disease appears almost uniformly in from two to twelve weeks after birth. If no symptoms occur during the first six months of in- fantile life, the probability is that infection did not take place. The disease, however, may be latent, and appear unexpectedly at a much later period. Infants in whom the symptoms of syphilis are evident at birth are usually puny and undeveloped, and present a withered or prema- turely aged appearance. The skin is dry, loose, and wrinkled, and of a tawny or dull-yellow hue. In some cases large areas of pigmenta- tion are observed. The hair is dry and scanty, and the nails are brit- tle, distorted, or stunted. The neck is thin and wrinkled, and the sub- maxillary glands are enlarged. Various forms of eruptions are pres- ent upon the skin, especially tubercles and bullae. Patches of erythema are scattered over different portions of the body, beginning upon the lower part of the abdomen, as a rule, and spreading thence to the limbs, chest, and face. The tubercles are large and flat, and widely disseminated. When situated on the buttocks and around the genital regions, and in the flexures of the joints, they become converted into mucous patches, but in other regions of the body frequently break down and ulcerate. The bullae are similar in appearance to those of pemphigus. They are round or oval in shape, and vary in size from a small bean to a walnut. When first developed they contain a clear, serous fluid, which finally becomes opaque or greenish-yellow in color and purulent in character. They are seated upon a reddened, infil- trated base, surrounded by a dark-red or coppery aureola, and are gen- erally confined to the palms and soles, but are liable to appear upon any portion of the body, and in malignant cases not infrequently cover the entire, surface. They burst spontaneously in a few days, forming yellowish or greenish crusts, which cover superficial or deep ulcers. Sometimes the ulcerations gradually heal, and the child slowly im- proves in health and strength, and finally makes a good but a tedious recovery. On the contrary, however, especially when the eruption is disseminated or the ulceration severe, the child suffers greatly, cries continually, and either refuses to take any nourishment or only a small quantity at long intervals. It gradually becomes weaker and weaker, and dies in a few days, either from inanition or from an inter- EXUDATIONS. 201 current diarrhoea. Occasionally it recovers from the first eruption, but a new crop of bullae appears after a short interval, and, from the irritation and exhaustion which it induces, death speedily follows. Infants who have been infected with syphilis during uterine life, but who do not exhibit any symptoms of the disease when born, may remain apparently well for several weeks or months, and even show a progressive gain in weight and color. As a rule, however, they pre- sent a peculiar melancholy appearance, and although nursing with avidity they do not get plump. They are feverish and restless, and suffer from more or less diarrhoea. The countenance is pallid or of a sallow hue, and the eyes have a peculiar staring aspect. Finally, they begin perceptibly to fail in health and strength, becoming weak and emaciated, and crying nearly all the time. The subcutaneous fat diminishes or disappears, and the skin is dry, harsh, wrinkled, and sallow. These changes are especially noticeable about the face, which assumes a wdthered-up or wizened appearance, like that of a little old man or woman. Erythematous spots and patches are devel- oped upon various portions of the body. They are irregular in shape and in size. They are usually light-red in color, but may be of a yel- low or coppery hue. They are first observed upon the buttocks, or on the genital regions, but may be diffused over the entire surface. Many of the spots or patches become elevated in a few days, and are transformed into papules and mucous patches. Mucous patches, or moist papules, are the characteristic manifestations of hereditary syphilis. They are developed, first, at the junction of the skin and: mucous membrane around the mouth, nose, anus, and other natural. orifices of the body; then in the axillae, between the toes and fingers,, behind the ears, around the umbilicus, between the buttocks, and; wherever heat, moisture, and friction coexist, as in the flexures of the joints; also on the tongue, roof of the mouth, and back of the pharynx. and in the larynx. Svphilis of the larynx is much less common in hereditary than in: acquired syphilis, but laryngitis and mucous patches, followed by strict- ure or perichondritis, have been seen by several authors, especially Mackenzie, of Baltimore. The voice is hoarse or entirely lost. Several cases of this kind have been reported by Sevestre. In some cases superficial desquamation of the epidermis occurs at the site of the eruption; in others, the papules and erythematous patches become fissured or excoriated, and finally become the seat of extensive ulcera- tion. Pustular eruptions are seen less frequently; they are usually commingled with vesicles and papules, and run a rapid course, termi- nating in ulceration and the formation of brownish or greenish crusts. Large bulla?, seated upon a reddened, indurated base, and surrounded by a pigmented aureola, are sometimes developed upon portions of the body, or the entire surface. They contain a clear, serous fluid, which 262 DISEASES OF THE SKIN. gradually becomes sanguineous or purulent. They rupture spontane- ously, and are followed by superficial ulceration and the formation of crusts. A succession of bullae may occur from time to time, until the infant perishes from exhaustion. This form of syphilide is usually complicated by tubercles, pustules, and other lesions. In some cases, however, the bullae are the only symptoms present. Another marked symptom of hereditary syphilis, and one which is frequently observed before the cutaneous lesions become manifest, is " the snuffles." This is a peculiar noise heard during inspiration, and is due to the obstruction in breathing caused by the sero-puru- lent discharges of an accompanying syphilitic coryza or syphilitic inflammation of the nasal mucous membrane. The discharge is thin and watery at first, but soon becomes thick and tenacious, and accu- mulates in the nares to such an extent that breathing is interfered Avith, and the peculiar snuffling sound produced. As the disease pro- gresses the obstruction increases, and finally becomes so complete that no air passes through the nostrils. The child is then compelled to breathe through its mouth altogether, and, as it can not do this and suck at the same time, nursing is rendered difficult or impossible. Necessarily the child suffers from want of nutriment, and also from pain. If the morbid process still continue, the nasal discharges assume a fetid character; the mucous membrane becomes the seat of ulcera- tion, which may involve the cartilage, "and even extend to and destroy the small bones of the nose or of the palate. The mucous membrane lining the pharynx and larynx is usually more or less infiltrated and swollen, producing the characteristic syphilitic roughness or hoarseness of voice. In some cases the swelling is so excessive as to produce com- plete aphonia. Conjunctivitis, keratitis, and otitis may also follow. In severe cases the child becomes more and more emaciated; death ensues in a few days or weeks from inanition or from an exhausting diarrhoea, or from an intercurrent attack of pneumonia or capillary bronchitis. In rare cases death has taken place in a few hours from oedema of the glottis. In less severe cases the coryza and the cutane- ous lesions gradually disappear, the child slowly gains in weight and strength, and recovers with more or less nasal or palatine deformity. Corneal opacity, or purulent otitis, with impairment of sight or hear- ing, may also result. In mild cases an apparent recovery sometimes takes place without any deformities or sequelae whatever. The poison, or its impression, frequently remains in the system, however, and be- comes manifest at a later period in the production of various lesions of the periosteum, the bones, the teeth, the skin, the viscera, and the nervous system. The consideration of these lesions properly belongs to a treatise on general syphilis. Furthermore, so profoundly is nutrition modified by congenital syphilis that many morbid conditions besides the lesions symptomatic EXUDATIONS. 263 of the disease are attributed by Fournier to this fatal inheritance. Such are, in addition to those already described, the arrests of devel- opment not infrequently witnessed—delayed dentition, slow general growth, retarded puberty, etc. He agrees with Lannelongue in believ- ing that this taint is often the remote origin of congenital deformities, as club-foot, spina bifida, hare-lip, cleft palate, etc. Finally, it certain- ly predisposes to the acquisition of scrofulo-tuberculosis. Tarnowsky regards inherited syphilis as a predisposing cause of rachitis. Mani- festations due to inherited syphilis may continue to recur for many years. A case is related by Dr. Bristow of a boy, fifteen years of age, admitted to St. Thomas's Hospital on account of a tumor of the liver, accompanied by a peculiar temperature record, ranging from subnormal in the morning to 100° or 103° F. in the evening. Examination of the eyes gave evidence of past syphilitic keratitis, and a history was obtained of an infection of the eyes when the boy was seven years of age. Anti- syphilitic treatment reduced the febrile temperature to normal within a few days, and the swelling of the liver gradually disappeared. An unusually severe case of congenital syphilis in a girl of thirteen years of age has been described by Saint-Germain. In addition to ex- tensive and obstinate ulcers, necrosis of bone, and deformed extremi- ties, fracture of the humerus and femur resulted from such slight force that the accident might almost be considered spontaneous. Hereditary syphilis in some instances occasions deafness, generally upon both sides and without premonitory symptoms. Giddiness and pains in the ears are sometimes present. Ocular symptoms, due to in- terstitial keratitis, iritis, or choroiditis, usually precede the deafness. This loss of hearing is more frequent in females and between the ages of eleven and thirteen. It is unamenable to treatment, and its pathol- ogy is uncertain. Diagnosis.—The diagnosis of hereditary syphilis is generally self- evident. The senile facies, snuffling inspiration, and cutaneous lesions, form a trio of symptoms never present in any other disease. Simple coryza may produce difficulty of breathing, and will interfere with nursing, but disappears in a few days, and is not accompanied by cuta- neous manifestations, or the syphilitic countenance. The papular rash, termed " red gum," which occasionally appears after birth, might be regarded as specific, but is a trivial affection, and disappears spontane- ously in a few days. Intertrigo and papular eczema sometimes present a superficial resemblance to the erythematous and papular syphilides, but their course, history, and concomitant symptoms are widely differ- ent. Syphilitic bullae may resemble those of pemphigus, but are situ- ated on a reddened, indurated base, surrounded by a dark-red or cop- pery areola, and followed by superficial ulceration and the formation of thick, brown, or dark-green crusts. Coryza, the senile countenance, and other indications of syphilis, are also present at the same time. 264 DISEASES OF THE SKIN. Jonathan Hutchinson has pointed out that after the second denti- tion the teeth, especially the central upper incisors, testify to the pres- ence of hereditary taint. These teeth are usually short and narrow, presenting a broad vertical notch at the edges and being rounded off at the corners. This appearance, if present, is regarded as pathogno- monic. It is, however, often absent. Treatment.—The treatment of congenital syphilis is both prophy- lactic and remedial, and should be commenced at the earliest possible moment. If a pregnant woman is suffering from a suspicious erup- tion, or presents a history of a succession of apparently causeless mis- carriages or still-births, or manifests any other appearances of syphilitic infection, she should be placed at once upon a mild mercurial course. Chalybeate and other tonics may also be given. The plan of treatment which I frequently adopt consists in the administration of a teaspoon- ful of the following combination one hour before meals: R Hydrarg. chlor corros............. gr. j. Tinct. nucis vomicae................ f 3 j- Tinct. gentianae comp............. f § iij. M. and ten drops of tinct. ferri. chlor., or ten grains of potassium chlo- rate in water, half an hour after meals. The patient is placed upon a generous diet, and directed to stay in the open air three or four hours every day. If the mercury derange the stomach, it may be omitted from the above prescription, and given by inunction. This, however, will seldom be necessary. Besnier reports favorable results from the administration of the sirup of the iodide of iron with wine of cinchona, a pill containing one sixth of a grain of bichloride of mercury, one twelfth of a grain of ex- tract of opium, and one twelfth of a grain of extract of gentian being also given thrice daily. The iodide of potassium in amounts from seven and a half to fifteen grains daily is furthermore advised. When the child is born it should be nourished by its mother's milk, if possible. If the supply is inadequate, or if the parent's condition is such that nursing is not advisable, the infant must not be given to a healthy wet-nurse to suckle, but fed with cow's milk, or some of the many substitutes for its natural food. This is a rule to be rigidly enforced, or the gravest consequences may follow. Whole families have been infected by nurses who unwittingly contracted the disease from the lips of syphilitic infants while in their charge. The suggestion has been offered by Dr. Fredet that in order to avoid such calamities syphilitic infants should, whenever possible, be suckled by goats 'or other animals not subject to this disease. This method has, in fact, been previously attempted and is no doubt bene- ficial, but has been found very difficult to faithfully carry out in practice. If the milk disagrees with the child's stomach, or fails to be prop- erly digested, from one to three grains of pepsin may be given with EXUDATIONS. 265 each feeding. The child should be warmly clothed, well supplied with fresh air, and bathed every day in water in which a little common salt has been added. Inunctions of cod-liver oil are beneficial. The medicinal treatment of infantile syphilis consists in bringing the system under the influence of mercury as rapidly as possible. This can usually be done by giving one sixtieth of a grain of the corrosive chloride of mercury and ten drops of Huxham's tincture in water, four times a day. Good results can also be obtained from the administra- tion of one twelfth of a grain of mild chloride of mercury or one quarter of a grain of mercury with chalk three times a day. Again, the protiodide of mercury may be beneficially employed and is especially valuable when combined with half a grain of the saccharated carbonate of iron. For a child six or seven months of age a combination of biniodide of mercury with iodide of sodium is useful, according to Floy. The good effects of mercury will usually be enhanced, and its disadvantages minimized, by giving from one to three minims of tincture of chloride of iron three times a day. In cases in which the stomach will not tolerate mercury in any form, its internal adminis- tration must be suspended, and half a drachm of mercurial ointment, diluted with three drachms of lard, thoroughly rubbed into the skin every day. Lanolin forms an excellent excipient for mercurial ointment. Wiederhofer, of Vienna, prefers the red precipitate, one part to one hundred parts of lanolin, to the mercurial ointment. After inunction has been practised for a few days it is advisable to administer a warm bath. Eloy writes favorably of the effects of corrosive sublimate baths in hereditary syphilis. Three grains of corrosive sublimate and fifteen grains of chloride of ammonium are dissolved in a half-pint of dis- tilled water and then added to the quantity of warm water which has been drawn for the bath. Moncorvo and Ferreira have recently ap- plied the hypodermic method of treatment to infants and children. They obtained the most favorable results from the use of gray oil and corrosive sublimate. The injections, made under strict antiseptic pre- » cautions, occasioned little pain and were not followed by subsequent reaction. The ages of the children varied from three months to four- teen years. The doses of corrosive sublimate employed were one or two milligrammes (JT to -£% grain), and were repeated every third, fourth, or fifth day, according to indications. The local treatment should be of a mild, protective nature. The nostrils can be kept clean with a camel's-hair brush dipped in gly- cerine. Mucous patches are to be dusted with calomel, painful fis- sures touched with a strong solution of nitrate of silver, and all ulcer- ated or excoriated surfaces covered with a powder consisting of one part of mild chloride of mercury and five parts of bismuth subnitrate. Obstinate cases, or cases in which the symptoms do not become 266 DISEASES OF THE SKIN. manifest at an early period, generally exhibit marked improvement when half a grain or a grain of potassium iodide is added to each dose of the mercurial. In all cases, however, the treatment should be con- tinued for several months, then suspended for a week or two, to be again resumed for a prolonged period. Chalybeate and other tonics are advisable at intervals. The sirup of the iodide of iron, in doses of from half a minim to three minims, will be found especially service- able. Quinine, strychnine, potassium chlorate, and the mineral acids are also invaluable as adjuvants to the specific treatment. Prognosis.—The prognosis of hereditary syphilis varies in accord- ance with the extent and severity of the lesions, the time of their manifestation, and the general condition of the child. As a rule, the more extensive the eruption, and the earlier the time of its appearance, the more unfavorable will be the prognosis. Children who are covered with papules or bullae at birth usually die within a few days. Severe coryza is also a bad symptom, but not necessarily indicative of a fatal result. When the eruption is pustular or tubercular in character the prognosis is more unfavorable than when it consists solely of macules or papules. Children who are born apparently healthy, and who re- main free from any affection of the skin or mucous membranes for several weeks, seldom develop the malignant form of the disease. ERYTHEMA MULTIFORME. Erythema multiforme is an acute inflammatory cutaneous affection, characterized by reddish or varicolored macules, papules, or tubercles, differing in size and shape. Symptoms.—Erythema multiforme is preceded or accompanied by headache, gastric disturbance, and pain in the joints. The intensity of the pain is variable, sometimes being very slight and again equalling in severity that of acute rheumatism. Occasionally inflammation of the throat is experienced a few days before the appearance of the erup- tion. In some cases a slight rise of temperature is observed. The eruption is varied in character, and consists of either macules, papules, or tubercles. The name of the affection—erythema multiforme—is significant of the protean character of its lesions. The eruption usually commences, however, as small roseolous spots or macules, which rap- idly increase in size, forming large, erythematous patches. The pe- culiarities of form which these patches assume have led to the em- ployment of the terms annulare, iris, and marginatum, as indicative of their shape and appearance. When the erythematous area increases by peripheral extension, but fades in the center, it is termed erythema annulare. When a new patch is developed within an existing ring, and rapidly undergoes the same process of peripheral extension and central resolution, a series of concentric rings is formed, exhibiting a EXUDATIONS. 267 variety of colors; this is the condition known as erythema iris. When two or more circles meet, to form serpentine bands, the eruption is termed erythema gyratum. When an erythematous patch attains a con- siderable size, and presents a sharply defined border, which is slightly raised above the adjacent normal surface, it is known as erythema marginatum. In some cases the eruption commences as small papules, which vary in size from a pin's-head to a split pea. They are round or oval in shape, and bright red or violaceous in color. They are firm to the touch, and are slightly elevated above the surrounding surface. They pursue a variable course, but usually disappear spontaneously in five or six days. This form of the disease is known as erythema papillosum. When the papules increase to the dimensions of a small bean or larger, the affection is termed erythema tuberculosum. In some cases the eruption is complicated by the development of vesicles and bullae. The eruption is usually symmetrical in character. It may appear upon any portion of the body, but is met with most frequently upon the dorsal surfaces of the extremities. The mucous membrane is occa- sionally affected. The lesions pursue an acute course, usually disap- pearing by resolution in three or four days, leaving more or less pig- mentation of the surface. The disease may be protracted for a week or more by the appearance of a second or third crop. The accom- panying subjective symptoms are usually slight. Diagnosis.—The only diseases resembling erythema multiforme are papular eczema, urticaria, and erythema nodosum. The papules of erythema multiforme are large, irregular in shape, and are not attended by much itching or burning. Those of eczema are small, and are accompanied by intense itching and burning. The lesions of urticaria are ephemeral in character, appearing and disappearing in a few min- utes; those of erythema multiforme remain for days. The color and subjective symptoms are also different. In erythema nodosum the eruption consists of large, firm nodes, and not of elevated patches or papules. Pathology.—The pathological processes concerned in the produc- tion of the lesions of this disease are dilatation of the capillaries of the corium, and exudation of serum into the surrounding tissue. In some cases haemorrhagic extravasation takes place. Etiology.-—The etiology of erythema multiforme is still unsettled. It may occur in either sex and at any period of life. This affection in babes frequently occurs upon the nates as a result of irritating diarrhceal discharges. It is said to appear more frequently during the spring and autumn, but it may happen at any period of the year. In some cases it appears to be dependent upon the rheumatic or lithaemic diathesis, in others it is evidently due to disturbances of digestion. Malarial influences are also potent factors in its production. According to 268 DISEASES OF THE SKIN. Lewin, it may at times be reflex in character, from genito-urinary disorders. Erythema occasionally makes its appearance during pregnancy or after delivery. It is sometimes seen after operations upon the uterus. In other cases it occurs in connection with irritation of the urethra or bladder. Polotebnoff has observed a papular erythema in a case of icterus and one of papulo-tubercular erythema in cirrhosis of the liver with ascites. The same writer states that in some years ninety per cent, of the cases of erythema which he has met with have been asso- ciated with acute catarrh of the stomach. Dr. Paul de Molenes has seen erythema in a case of gonorrhoea, and suspects that the rash at- tributed to cubebs or copaiba may not infrequently be due to the ure- thral inflammation, since he has often found that upon increasing the dose of the balsam the rash disappeared. M. Dujardin reports a case in which an attack of infectious conjunctivitis was followed by ery- thema multiforme. Erythema multiforme occasionally develops in consequence of emotional paroxysms. Luzzato has found isolated and grouped cocci in the blood of a patient with erythema multiforme. Treatment.—The treatment must be symptomatic and somewhat empirical in character. If there is any reason to suspect malarial poi- soning, quinine should be administered in full doses. If the patient is of the lithaemic diathesis, colchicum, lithium, and the alkalies are indicated. If there is a rheumatic taint in the constitution, more benefit will be obtained from the administration of the salicylates. They are also of service in relieving the articular pains that may be present. When evidences of gastric disturbance exist, the diet should be regulated and the digestion assisted by large doses of pepsin, either alone or in combination with mix vomica and hydrochloric acid. Iron may frequently be given with advantage, especially to anaemic or debili- tated patients. The functions of the bowels should be carefully regu- lated in all cases. Local applications are useless, unless there are marked itching and burning, and when such is the case, weak lotions of car- bolic acid or creasote will be found effective. Ointments may be used instead of lotions, if advisable. A warm bath containing bicarbonate of sodium is often useful in relieving the subjective symptoms. Prognosis.—The prognosis is always favorable. The eruption inva- riably runs a benign course, and terminates in recovery in from one to three weeks, but relapses may take place from time to time. ERYTHEMA NODOSUM. Synonym.—Dermatitis contusiformis. Erythema nodosum is an acute inflammatory cutaneous affection, characterized by a number of reddish or purplish nodules, of different shapes and sizes. EXUDATIONS. 269 Symptoms.—The development of the eruption is usually preceded by slight fever, general malaise, gastric disturbance, and pain around the joints. In some cases sore throat occurs. In others these premoni- tory symptoms are not observed. The eruption consists of a varying number of nodules, which are seated in the corium and subcutaneous connective tissue. They range in size from a bean to a large walnut. They are round or oval in shape, and firm and slightly painful to the touch. Their color changes at first from a light red to purple. Ery- thema nodosum may be developed upon any portion of the surface, but occurs most frequently upon the lower extremities, especially over the anterior surface of the tibiae. The nodules are also often observed upon the ulnar surface of the forearms. They are frequently developed in crops, which may appear in succession upon various regions of the sur- face. As a rule, they are accompanied by more or less itching and burning sensations. In some cases their growth is attended by marked febrile excitement. The nodules number from one to thirty, or more, and reach their maximum in about three days. They then remain with- out change for a period, after which they become soft and painless, and gradually disappear by absorption. During this stage they present a brown, green, and yellow appearance, in accordance with the changes produced in the haemoglobin of the effused blood while undergoing ab- sorption. The first nodules usually disappear in from ten to fifteen days after their development, but, as they may be followed by a succession of others, the disease rarely terminates for two or three weeks, and in some cases it is prolonged for months. Nodules may form on the tongue or on the mucous membrane of the mouth and pharynx, producing so much pain and difficulty of deglutition as seriously to interfere with nutrition. The eruption may be complicated by the simultaneous development of vesicles or bullae, or by an inflammation of the adjacent lymphatic vessels. Suppuration never occurs, but usually a slight pigmented spot remains at the side of each node for an indefinite period. Polo- tebnoff, however, speaks of seeing suppuration take place in one case of erythema nodosum. A case has also been recorded by Hoisholt * in which papules and tubercles having every characteristic of erythema nodosum terminated in pustules; and, in one situation, the coalescence of a number of these caused an abscess. Diagnosis.—The diagnosis of erythema nodosum is comparatively easy. The only affections which present any similarity to it are urti- caria nodosum, the gummatous syphilide, and ordinary contusions of the surface. In urticaria nodosum, however, the cutaneous lesions are ephemeral in character, appearing and disappearing in a few minutes or hours, and are not followed by pigmentation. In erythema nodosum the lesions remain for days, and are always followed by pigmentation. The subjective symptoms are also different. * Monatshefte fur prakt. Dermatologie, Bd ii, No. 5. 270 DISEASES OF THE SKIX. Syphilitic nodules, or gummata, are soft, painless to the touch, single or few in number, slow in development, and frequently termi- nate in ulceration. The lesions of erythema nodosum are firm, painful to the touch, rapid in development, usually multiple, and never end in ulceration. The gumma is generally accompanied by other evidences of syphilis. Ordinary contusions may resemble the lesions of erythema nodosum when first seen, but their number, location, history, and course will prevent any error of diagnosis from being made. Pathology.—The pathological changes in erythema nodosum consist of dilatation of the blood-vessels of the corium and subcutaneous con- nective tissue, and an enormous exudation of serum and blood into the interstices of the corium and the rete mucosum. The lymph-vessels are also swollen, and migration of numerous lymph-cells occurs. Etiology.—The cause is not known. It is met with in adults and children, females and males, in apparently robust as well as debilitated subjects. It has been considered by Bolm and others analogous in ori- gin to purpura rheumatica, while Lewin considers it an angio-neurosis. In several cases which have come under my observation, lithaemic diath- esis was the apparent cause. Quite a large proportion of cases occur in rheumatic subjects. Garrod states that this association is occasionally direct; that chorea or old heart-lesions point, in some cases, to a rheu- matic origin, and that in others, though no articular pains are present, the patients have formerly suffered from rheumatism. He concludes that both erythema multiforme and nodosum are often, perhaps usual- ly, manifestations of the rheumatic process, though we are not justified in concluding that this is always their origin. Dr. Stephen Mackenzie has made a study of 108 cases of erythema nodosum. He coincides with the opinion of Garrod, and writes that " these conclusions justify the inference that erythema nodosum is frequently, if not generally, an expression of rheumatism, even when no definitely rheumatic symp- toms are present." Baumler, of Freiburg, considers erythema multi- forme and nodosum to be different forms of one disease, which is of in- fectious origin. Taylor has seen it accompany chronic bronchitis and acute pneumonia. Dr. Hermann Schulthess states that damp dwell- ings seem to play an important part in its causation, and that a rapid bodily growth possibly constitutes a predisposing cause in children. An occurrence related by Launois might raise the question of a possible contagious element in erythema nodosum. Three cases developed in patients occupying the same row of hospital beds within eight days after admission of a case of the cutaneous disorder. A case has been reported by Dr. Titomanlio of a woman who had suffered, within two years, from eleven attacks of erythema nodosum. During the first an acute glaucoma of the left eye developed, and in the sixth attack the right eye was affected in the same manner, but less severely. Ery- thema nodosum occasionally follows typhoid fever. EXUDATIONS. 271 Treatment.—The patient should be kept in bed until the febrile symptoms subside, after which he is to be encouraged to take mod- erate exercise in the open air every day. The diet should consist prin- cipally of milk, bread, fruit, and vegetables. The medicinal treatment must be varied in accordance with the requirements of each individual case. In stout or robust subjects good results may be obtained from the administration of lithium, colchicum, and the alkalies. The iodide of potassium or sodium is particularly serviceable in some cases, according to Brocq. The joint-pains are usually ameliorated by the salicylate of sodium. In the anaemic and debilitated, more benefit will be derived from the employment of quinine and iron. The tincture of the chloride of iron is especially valuable, in doses of twenty or thirty minims, after meals. Saline laxatives are indicated in all cases in which constipation exists. If the digestion is weak, it should be assisted by pepsin and hydrochloric acid. The pain and itching may be relieved by soothing ointments or lotions, as in the following formulae: fy Veratrinae.......................... gr. v. Bismuthi subnitratis................. 3 ij. Adipis............................. | j. M. Ft. ungt. Sig.: Apply externally. IJ Tinct. aconiti rad.................... f 3 ss. Acidi carbolici...................... gr. x. Spts. vini rect....................... f 3 ij. Aquae menth. pip.................... f 1 iv. M. Ft. lotio. Sig.: Use externally. A lotion of hamamelis and arnica is recommended by Piffard. Cold applications or evaporating lotions relieve pain in some cases, while in others warm fluids prove more efficacious. In the later stage of the affection gentle pressure by means of the roller bandage is of service, and the same may be said of the local use of flexible collodion. Prognosis.—The prognosis in uncomplicated cases is always favor- able. Recovery ensues, as a rule, without treatment in two or three months, and with treatment in a much shorter period. Relapses not infrequently take place. URTICARIA. Synonyms.—Hives—Nettle-rash—Fcbris urticata—Urticaire—Nesselausschlag. Urticaria is a mild inflammatory affection of the skin, characterized by the sudden development of a number of wheals, which are ephem- eral in character, and are accompanied by marked stinging, pricking, itching, or burning sensations. Symptoms.—Urticaria may appear at any period of life, but it is most frequently observed during childhood. Its advent is usually pre- ceded by general lassitude, slight headache, epigastric oppression, and 272 DISEASES OF THE SKIN. other symptoms of gastro-intestinal disturbance. The tongue is usu- ally furred, and the temperature is elevated from half a degree to one or two degrees above the normal. Exceptionally very severe symptoms, such as high fever, cerebral congestion, and delirium, precede the erup- tion. In many cases, however, no evidence of constitutional disturb- ance can be observed until after the development of the characteristic eruption. The eruption appears abruptly, and not infrequently reaches its maximum development in a few minutes. It consists of a number of wheals, in size from a split pea to a silver dollar, or larger. They are firm to the touch, and are slightly elevated above the adjacent cutane- ous surface. They number from four or five to a hundred or more. The lesions are generally round or oval in shape, but may assume a variety of irregular forms. They vary in color from white to pink, or bright-red, but .generally present a white elevated spot in the centre, and are surrounded by a more or less distinct aureola. The wheals are usually isolated, but may coalesce and form large, irregular patches. They may be developed upon any portion of the cutaneous surface, but are most frequently met with upon the chest and abdomen and upon the extremities. They have also been found upon the mucous membranes. Kaposi mentions the occurrence of urticaria in the mouth, pharynx, and upon the epiglottis, in which situations it is apt to occasion symp- toms of asphyxia. Bock has reported a case in which the tongue was „ the seat of urticaria. The tongue swelled suddenly and filled the cani- ty of the mouth, was of a bluish color, bright and even glistening, hard and elastic in consistence. The diagnosis of lingual urticaria reposed upon the rapid development of the oedema, absence of traumatism, the peculiar appearance of the tongue, and the knowledge that the patient frequently suffered from attacks of urticaria.* Similar cases have been described by Laveran, Sevestre, and others. Urticaria is accompanied by burning, pricking, or stinging sensations similar to those which are occasioned by contact with the stinging nettle. These differ in sever- ity ; in some producing only trifling annoyance, and in others entailing intense distress. The desire to scratch becomes irresistible in severe cases, and the patient often tears his flesh to obtain relief. The relief, however, is only temporary, and the irritation caused by scratching in- variably produces an increase in the number and size of the wheals. The eruption is extremely ephemeral in character. In some it attacks several regions of the body in succession, but only remaining for a brief period in each location. Urticaria is ordinarily an acute affection, and rarely lasts longer than a few hours or a day or two, during which several outbreaks of the eruption occur. It may continue, however, as a chronic affection. The duration of urticaria depends entirely upon the discovery and removal of its exciting cause. * Medical Bulletin, December, 1889. EXUDATIONS. 273 Acute Urticaria.—An attack of acute urticaria is usually pre- ceded or accompanied by a feeling of languor and general depression. The tongue is coated, the pulse is quickened, the temperature is slightly elevated, and there are more or less nausea and epigastric op- pression. The urine is usually high-colored and strongly acid. The eruption appears abruptly and spreads rapidly, sometimes covering the whole body in an hour or two. Generally, however, it is limited to one or more regions of the surface. The individual wheals are extremely evanescent, disappearing and reappearing several times during the at- tack. Friction and pressure always hasten their reappearance and in- crease their number. When they occur on the face they appear, as a rule, on the forehead, eyelids, cheeks, nose, and ears, producing more or less swelling and disfigurement. They generally remain isolated, however, and, unlike those which are developed on the trunk and extremities, do not coalesce and form large, solid, irregular masses. The eruption of acute urticaria is invariably the seat of intense burn- ing, pricking, or stinging sensations, which sometimes become almost unendurable. Finally, after the lapse of a few hours, or a day or two, the symptoms gradually subside, the itching and burning cease, no new wheals are developed, and those which are present disappear with- out desquamation or pigmentation. There are several varieties of acute urticaria, which, owing to their peculiar features, require special description. Urticaria Papulosa.—This form of the disease is also known as lichen urticatus. It occurs almost always in young children, and particularly in those who are improperly fed or poorly nourished. It is characterized by the development of a number of small, isolated papules, which usually appear suddenly, and after remaining for a day or two gradually disappear. The lesions are in size from a pin's-head to a split pea, and are developed around the hair-follicles. They are generally bright-red in color, except at the centre, which is white or paler than the periphery. They may appear upon any portion of the body, but are most numerous upon the extremities. Urticaria papulosa causes intense itching, and, as a consequence, the little patient resorts to scratching for relief, frequently tearing off the apices of the papules, and covering the surrounding skin with excoriations, which remain after the papules have disappeared. In some cases the papular erup- tion is accompanied or followed by the development of a number of minute vesicles. Urticaria Bullosa.—This is a rare form of urticaria. It is characterized by bullae as well as by large wheals. In some cases the eruption consists at first solely of wheals, which are gradually converted by excessive exudation into bullae. They may become so large as to resemble those which are formed in pemphigus. They are accompa- nied by severe itching and burning sensations. 18 274 DISEASES OF THE SKIN, Urticaria Nodosa.—This variety is also known a3 giant urti- caria, and is of rare occurrence. It is characterized by the develop- ment in the skin and subcutaneous connective tissue of large tubercles or nodules, in size from a chestnut to a small egg." They are hard to the touch, elevated above the adjacent surface, and seldom appear upon the face. They are the seat of intense burning and itching, but gener- ally disappear in a few hours. Urticaria Hemorrhagica.—This form of urticaria is usually seen as a complication of purpura. The latter is, however, the primary and more important affection. The wheals are due to the irritation produced by the lesions of purpura, and are ephemeral in character. Neighboring wheals may coalesce, forming large haemorrhagic eleva- tions. Urticaria Intermittens.—In this variety the eruption appears regularly every two or three days, or on a certain day each week, and after remaining for a short time disappears, to reappear again at the end of the same interval. It may or may not be accompanied by feb- rile symptoms. Urticaria may occur in connection with malaria, rheumatism, Bright's disease, scarlatina, measles, variola, pertussis, asthma, and various nervous and gastro-intestinal disorders. It frequently is a complication of scabies and pityriasis. It has also been observed as a sequela of arsenical poisoning. Chronic Urticaria.—In chronic urticaria the eruption recurs at regular or irregular intervals for months or years until the source of irritation is discovered and removed. In some cases a fresh crop of wheals appears daily. The itching and burning sensations are less severe, however, as a rule, than in the acute variety, and are sometimes absent. Constitutional symptoms may or may not be present. Diagnosis.—The diagnosis of urticaria is easy. The sudden ap- pearance of the characteristic wheals, their brief duration, their disap- pearance without desquamation, and the accompanying itching and burning sensations, form a complexus of symptoms that are not pres- ent in any other disease. The only affections that present any resem- blance to urticaria are erythema simplex and erythema multiforme. In erythema simplex, however, the patches of hyperaemia are larger than those in urticaria. They are uniformly red in color, are not ele- vated above the adjacent surface, and are unaccompanied by the sub- jective sensations of urticaria. The eruption of erythema multiforme sometimes closely resembles that of urticaria. It is more permanent in character, however, usually remaining unchanged for several days, and is not attended by any marked itching or burning sensations. Urticaria nodosum might be mistaken for erythema nodosum, but the nodules of the latter affection are painful to the touch and remain for EXUDATIONS. 275 several days, while those of the former usually disappear in a few hours. Urticaria bullosa can readily be distinguished from pemphigus by the presence of one or more wheals and the course of the disease. Facial urticaria has been mistaken for erysipelas, but a consideration of the history of the case, the ephemeral character of the eruption, and the absence of the constitutional symptoms of erysipelas, would have prevented that error from being made. Pathology.—The lesions of urticaria are due to a sudden exudation of serum into the upper layers of the skin. The vaso-motor system and the muscular fibres of the corium are intimately concerned in their production. The first step in the pathological process consists of irri- tation either direct or reflex of the cutaneous vaso-motor nerves. This produces spasmodic contraction of the cutaneous vessels, followed by dilatation and exudation of serum. The secondary dilatation of ves- sels is denied by Unna, who has excised and examined wheals pro- duced on his own person by nettles. He supposes the existence of spasm in the large cutaneous veins which contain muscular tissue. In consequence of this spasm a stasis of the local lymphatic circulation ensues. The superficial and deep vessels of the corium are involved. More or less migration of white corpuscles takes place. The muscular fibres of the skin remain in a state of contraction, and by forcing the blood toward the periphery produce the pale centre and hyperaemic, aureola of the eruption. Etiology.—Urticaria is due to direct or reflex irritation of the pe- ripheral vaso-motor system, and is produced by either external or in- ternal causes. Among the external causes are the bites of mosquitoes,, bed-bugs, fleas, and other insects, or contact with a star-fish, jelly-fish, or. with a stinging nettle and other plants. The hairs of the caterpillars of several species of moths excite urticaria when brought in contact with the skin. It may also be occasioned by wearing too heavy or too. tight clothing in warm weather, or by flannel underclothing or article* of apparel which have been colored with poisonous d}'es. It is sometimes seen in consequence of applications of the electric current. Persons who* have a delicate skin and a nervous temperament are peculiarly liable to. be attacked by urticaria when they become exposed to any source of irritation. In some persons of a markedly nervous type the charac- teristic wheals of urticaria are produced by the slightest irritation. Lines drawn upon the skin by a blunt-pointed instrument such as a pencil are almost immediately followed by the eruption. In this way the wheals may easily be caused to form the outline of white letters with pink borders. To this phenomenon the French have given the name of autographism. It usually occurs in the subjects of hysteria. Purely hysterical autographism, however, differs from true urticaria in that neither smarting nor itching attends the development of the lesions. 276 DISEASES OF THE SKIN. Among internal causes, gastric and intestinal disorders hold the most prominent place; in fact, ninety per cent, of the cases can be traced to some disturbance of the alimentary canal. Excessive drink- ing of wine or beer, or over-indulgence in rich food, may develop a copious eruption at any time. Certain articles of diet, such as fish, oysters, lobsters, crabs, shrimps, pork, sausage, and mushrooms, are well known as being especially promotive of an outbreak, particularly if eaten during warm weather. It is probable that the irritation is then due to fermentative changes or to a special poison generated by decom- position of the offending substance before digestion is completed. In other cases the attacks always follow the ingestion of particular vari- eties of food, such as rice, oatmeal, strawberries, raspberries, and but- termilk, and are probably due to an individual idiosyncrasy. The eruption sometimes develops so soon after ingestion of the offending substance that it would seem to be due to reflex nervous in- fluence. Owing to a similar idiosyncrasy, outbreaks of urticaria some- times succeed the administration of quinine, salicylic acid, salicylate of soda, kairin, antipyrine, iodide of potassium, turpentine, chloral, cubebs, copaiba, arsenic, and valerian. Intestinal worms are occasion- ally a source of the affection. Urticaria may be provoked by menstrual and uterine disorders. Dr. Manton, of Detroit, has described two cases in which urticaria developed in women who were approaching the cli- macteric period. In a third case an unmarried woman was attacked several months after ablation of the ovaries. Dr. Frank has reported the case of a woman who, at each menstrual period, was attacked by severe urticaria which, within two hours, invaded the entire body. The left ovary and tube being diseased, salpingotomy was performed, since which time the urticaria has disappeared. It may be caused by dis- turbance of the genito-urinary organs in males; and in susceptible subjects by fright, anger, or any intense emotion. Dr. Davoli observed an unusual case of urticaria in a hysterical woman, the beginning of the eruption being always accompanied by extreme agitation of the whole body, and even by convulsive movements, chattering of the teeth, loss of consciousness, and the sensation of impending death. There was also very marked dyspnoea, with elevation of temperature and albuminuria following the crisis. It may occur after or during an attack of variola, scarlatina, measles, rheumatism, Bright's disease, asthma, purpura, per- tussis, neuralgia, and other nervous disorders. Nettle-rash sometimes Occurs in patients suffering from hydatid cysts. A cubic centimetre of filtered fluid from a cyst was injected by Debove under the skin of three individuals who had never had urticaria. In two of these characteristic wheals were developed, whence it maybe inferred that the disease is due to auto-intoxication from absorption of the liquid. Affections of the liver chronic gastritis, and dilatation of the stomach may also be productive of attacks of urticaria. Chronic urticaria is frequently due to malaria • EXUDATIONS. 277 in other cases it is dependent upon gastric or intestinal derangements. Lithaemia and other disturbances of the organs of elimination are also potent causes in its production. Treatment—The most important consideration in the treatment of an attack of urticaria is to discover and remove the exciting cause as soon as possible. In acute cases, inquiry should be made as to the na- ture and amount of the food recently partaken of; and if the indica- tions point to it as the disturbing cause, and there is reason to believe that it is still in the stomach, an emetic of apomorphine, ipecacuanha, mustard, or salt and water, should be administered at once. Imme- diate relief can often be obtained by free vomiting. If several hours, however, have elapsed since the offending substance was swallowed, the probability is that it has passed into the intestinal canal, and emetics will be of no avail. A full dose of the mild chloride of mercury, castor-oil, sulphate of sodium, sulphate of magnesium, or Rochelle salts, should then be given to secure free purgation, and followed by smaller doses once or twice daily until recovery is complete. It is well to restrict the diet to bread, milk, and soup for a few days. Cold water and carbonated waters are not at all objectionable, but wine, beer, and other alcoholic liquors must be rigidly avoided. In those in whom the attack can not be traced to any particular article of food, relief can usually be obtained by regulating the diet and directing the patient to take five grains of blue-mass at bedtime, and a mild saline aperient in the morning. In cases in which there is marked acidity or irritability of the stomach, and the urine is scanty, high-colored, and strongly acid, bicarbonate of potassium in ten-grain doses every two hours will be found invaluable. Acetate of potassium, liquor potassae, and bicarbonate of sodium are also of service. When the irritability of the stomach can not be traced to any assignable cause, I have obtained marked benefit by the administration of oxalate of cerium in ten-grain doses, either alone or combined with a sixteenth of a grain of morphine. Bismuth, belladonna, dilute hydrocyanic acid, ether, chloral, and chloroform will also be found at times beneficial; likewise the mineral acids. In all cases, however, one or two move- ments of the bowels should be secured each day. According to Lassar, an attack may often be cut short by salicylate of sodium in doses of twenty-four grains, thrice repeated at intervals of two hours. In the subacute variety the following combination will generally afford prompt and often permanent relief : R, Magnesii sulphatis.................. | ss. Ferri sulphatis...................... gr. xij. Acidi sulphurici dilut............... f 3 j- Aquae......................q. s. ad. f 5 iij. M, Sig.: Two teaspoonfuls, well diluted, three times a day. 278 DISEASES OF THE SKIN. Alkaline mineral waters may also be administered with benefit. In chronic urticaria the source of irritation should be diligently sought for and removed. The food should be light and nutritious, and the clothing warm and non-irritating. If lithaemic or gouty symptoms are present, great relief can often be obtained from— R, Tinct. aconiti rad.................. ff[ xvj. Vini colchici rad................... f 3 ijss. Potassii acetatis.................... § ss. Aquae............................. f ! iijss. M. Sig.: Dessertspoonful in water three times a day. If digestion is slow or incomplete, good results may be derived from the administration after meals of a powder containing ten grains of pepsin, one grain of ipecacuanha, and one fortieth of a grain of strych- nine, Apollinaris or Vichy water, unrestricted as to quantity, is bene- ficial in these cases, and often aids materially in effecting a cure. Quinine in five-grain doses, three times a day, will be found to be in- valuable in cases of an intermittent type, as well as in chronic urticaria, though, according to Quinquaud, arsenic in the form of Fowler's solu- tion is generally more efficacious. Gueneau de Mussy administers thrice daily a pill containing one and a half grains each of powdered jaborandi and extract of guaiac with three grains of benzoate of lithium. Pilocarpine, given hypodermically or by the mouth, is, in the opinion of some writers, an excellent remedy in both acute and chronic urticaria. Brocq recommends a pill composed of three-fourth grains each of quinine and ergotin with one-fiftieth grain extract of belladonna, from eight to sixteen pills being given during the twenty-four hours, with two hours' interval between doses. If the patient be decidedly rheu- matic or gouty, he combines about one-eighth grain extract of colchi- cum with one-quarter grain powdered digitalis, and administers from two to eight during the course of the day. Salicylate of sodium or the bromide of lithium will sometimes effect a cure when quinine has failed. They are especially indicated in those attacks which depend upon the rheumatic or gouty diathesis. Arsenic, atropine, chloride of ammonium, sulphur, naphthol, and the sulphites and hyposulphites are of value in some cases, Ichthyol may occasionally prove useful in chronic urticaria. The remedy from which I have obtained the best results, in obstinate cases, however, is sulphurous acid. I usually give it in doses of from one half to one drachm, three times a day, well diluted with water. In those cases wTiich are dependent upon nervous causes, Dr. Nitot ascribes an almost specific virtue to antipyrin. In one case the eruption appeared periodically each day. Seven and a half grains of antipyrin were administered two or three hours before the expected time of attack. After four days of this treatment the urticaria permanently disappeared. In cases due to reflex irritation from the genital organs, prompt EXUDATIONS. 279 • relief is effected by drachm-doses of the fluid extract of salix nigra. Bromide of potassium is also serviceable. Cases attended with chronic constipation which have resisted other treatment may be benefited and often cured by hypodermic injections daily of two to four drachms of castor-oil. For the relief of the distressing itching and soreness, Blaschko, of Berlin, has found antipyrin of value. For infants he prescribes— R, Antipyrin........................ 3 ss. Syrup, simpl...................... f 3 j. M. Ft. sol. Sig.: Half a teaspoonful at night before going to bed. Occasionally he has known larger doses to be necessary. Attention has been called by Dr. Riffat, of Salonica, to strophan- thus as a remedy in acute and chronic urticaria. His plan is to give the tincture in doses of fifteen to twenty drops during the twenty-four hours. He states that in the acute form a single dose will often be followed by the disappearance of the wheals as well as the itching. In five cases of subacute, acute, and chronic urticaria, Stein obtained sat- isfactory results from administration of the iodide of potassium after failure of the salicylate of sodium, atropine, quinine, and strophanthus.* External treatment is of prime importance in both acute and chronic urticaria. The itching and burning sensations are usually so intense as to demand immediate attention. All tight, coarse, or im- proper articles of clothing, and other external sources of irritation, should be removed, and soothing applications made to the affected surface. Various lotions and ointments may be used for this purpose. In some, cold water, either in the form of a douche or the cold com- press, will be sufficient. In others a lotion, composed of equal parts of vinegar and water, will be found beneficial. Another excellent ap- plication is composed of one part of whiskey and two parts of water. Sometimes a hot mustard foot-bath gives almost instantaneous relief. Gratifying results can usually be obtained from the use of alkaline lotions or baths, containing a drachm of bicarbonate of sodiujn or a drachm and a half of bicarbonate of potassium to the gallon of water. Weak carbolic-acid lotions will often be found useful. I sometimes use: R, Acidi carbolici...................... f 3 ss. Spts. vini rect...................... f 3 iv. Aq. camphorae...................... f 1 yj- M. Sig.: Apply externally. The officinal creasote-water may also be employed with advantage. Another efficacious application is : 3 Tinct. aconiti rad................... f 3 j- Aq. menth. pip..................... f 1 iv. M. Sig.: Use as a lotion every hour. * Miinchener med. Wochenschrift, October 1, 1890. 280 DISEASES OF THE SKIN. A solution composed of menthol five grains, and water one ounce, is a good remedy. A variety of other lotions have been recommended, the most valuable of which are: benzoic acid ten grains, alcohol four drachms, water six drachms; chloral thirty grains, water one ounce ; chloroform five minims, alcohol one drachm, water four ounces; cor- rosive chloride* of mercury two grains, water four ounces; dilute hy- drocyanic acid ten minims, water three ounces; dilute sulphuric acid one drachm, water eight ounces; citric acid two drachms, water six ounces; acetic acid one drachm, water five ounces; carbonate of am- monia one drachm, water four ounces. One part of ether to two parts of lukewarm water is recommended by Quinquaud. Sweet spirit of nitre, either plain or diluted with water, or spirit of Mindererus and alcohol in equal parts have sometimes proved efficacious. The following combination will frequently be found useful, espe- cially in chronic cases: R, Hydrarg. chlorid. corros............. gr. ss. Tinct. benzoini..................... f 3 ijss. Glycerini.......................... f 3 ij- Aq. rosae........................... f 1 vj. M. A lotion containing belladonna may also be recommended. In many cases ointments may be employed with advantage. I some- times use: R, Acidi carbolici..................... 3 ss. Camphorae........................ 3 j- Chloral hydrat..................... 3 j- Ung. aq. rosae...................... | ij. M. Ft. ung. Sig.: For external use. Another excellent combination is: R, Bismuthi subnitratis................ 3 ij. Ung. veratrinae..................... | j. M. Ft. ung. Sig.: Apply externally. The ordinary benzoated oxide of zinc ointment is also a service- able application. Neuth states that an ointment containing twenty grains of acetanilid to the ounce effectually relieves the itching and tingling sensations. The distressing itching may be alleviated by diachylon, menthol, cocaine, naphthol, belladonna, or ichthyol oint- ment. In chronic cases great benefit can be obtained from the em- ployment of baths containing half an ounce of dilute nitro-muriatic acid to the gallon of water. Ordinary salt-water baths are of value. Warm baths containing sulphurated potassa, as recommended by Jamie- son, are likewise beneficial. Two ounces of the salt are added to thirty gallons of water. Quinquaud, on the contrary, asserts that chronic urticaria is aggravated by the use of baths, and recommends envelopment of the affected parts, whenever practicable, in cotton-wooL EXUDATIONS. 281 Prognosis.—The prognosis of urticaria is always favorable. Acute cases can be promptly relieved by appropriate treatment, and fre- quently subside spontaneously without any medication. Relapses may occur from time to time, but they are as amenable to treatment as the primary attack. Chronic urticaria is a more stubborn affection, and sometimes baffles all treatment for months, but it disappears when the irritation which produces it is discovered and removed. Urticaria Pigmentosa.—A brief description may be given here of a rare affection which has been termed urticaria pigmentosa by some writers, and xanthelasmoidea by others. It manifests itself dur- ing infancy or early childhood. It is characterized by the sudden ap- pearance of wheals, tubercles, or large papules, which are elevated above the surface, and vary in color from pink to yellow or dark- brown. They remain prominent for several days or weeks, and then slowly subside, leaving large, green, brown, or yellow pigmented and indurated spots to mark their location. In some cases the wheals do not disappear, but remain as permanent new formations in the skin and subcutaneous connective tissue. The eruption is accompanied by intense itching and burning, and more or less constitutional disturb- ance. The pathology of this affection is unknown. Some observers regard it as a distinct disease, while others believe it to be only a vari- ety of urticaria. The treatment should be palliative and symptomatic. Acute Circumscribed CEdema of the Skin.—This condition bears a certain resemblance and perhaps relationship to urticaria, with which it has probably often been confounded. It was first particularly described in 1876 by Milton,* who unfortunately bestowed upon it the name of giant urticaria, a name also applied to urticaria nodosa. Sub- sequently cases were reported by Quincke, Striibing, and others under the title which heads this paragraph, and Dr. M. B. Hartzell has pub- lished f an account of a case which came under his care. The affec- tion usually develops upon the face, though other portions of the body may be attacked. The cedematous swelling is generally soft, pitting upon pressure, but exceptionally it is hard and no indentation can be made upon it. The tumors vary considerably in size, some- times being as large as a fist. The skin which covers them is usually unchanged in color, occasionally it is reddened. As a rule, itching and pain are absent, and the only sensation experienced is that of ten- sion. The trouble is apt to make its first appearance during the night, twenty-four hours often sufficing for its development and retrocession. The lesion develops rapidly, and is of comparatively brief duration. Most often it is rapid also in its disappearance. Frequently but one tumor is produced at a time; sometimes two or three may coexist, but the number which simultaneously appear is never large. As a result of * Edinburgh Medical Journal, 1876. f University Medical Magazine, May, 1890. 282 DISEASES OF THE SKIN. recurrent attacks the skin may lose its elasticity and hang downward in a fold. The disease may attack the mucous membrane of the mouth, tongue, or larynx, and give rise to difficult respiration or deglutition. Alarming dyspnoea has, in fact, been produced, and in one case death occurred from oedema of the larynx. In some instances the dyspnoea has preceded the evolution of the cutaneous lesion. Most of the cases reported have been accompanied by symptoms of gastro-intestinal dis- turbance. In a minority the patients were subject to attacks of urti- caria. In some the lesions of urticaria and of oedema were both present. Generally the two did not coexist. A number of cases have arisen from prolonged anxiety or severe grief, but in others no cause could be detected. There seems to be a strong tendency to heredity, and Osier alludes to a family in which cutaneous oedema could be traced through five generations. The disease once established is liable to recur fre- quently for an indefinite period. Tonics and laxatives are employed, but the treatment is unsatisfactory. In Hartzell's case small doses of the salicylate of sodium together with a saline laxative appear to dimin- ish the frequency and severity of the attacks. LICHEN PLANUS. Lichen planus is a chronic inflammatory cutaneous affection, char- acterized by small, flat, circular or quadrilateral, reddish, umbilicated papules, which pursue a chronic course, but finally terminate in reso- lution, and are followed by more or less pigmentation of the surface. Symptoms.—The eruption usually develops without premonitory symptoms. It is symmetrical, and consists at first of a variable number of minute red papules, about the size of a mustard-seed, accompanied by more or less itching, apt to be worse at night. In certain cases par- oxysms of intense itching have been observed to occur periodically every afternoon. They may appear upon any part, but are most frequent upon the anterior surface of the forearms and the tibial surface of the legs, and seldom occur upon the palms or soles. They rarely, if ever, develop upon the face, but have been observed upon the tongue and mucous membrane of the mouth and fauces. Bulkley has seen them appear primarily on the glans penis. The lesions attain their full devel- opment in a few days, and are in size from a pin's-head to a split pea. They are then quadrilateral or irregularly rounded, slightly elevated above the surface, from which they rise abruptly, dark-red, umbilicated, and not surrounded by an inflammatory areola, firm to the touch, but not painful. Their surfaces are usually smooth, but may become the seat of slight furfuraceous desquamation. According to Louis Wick- ham, striae and grayish points can be detected upon the top of the older papules, and are more marked when the papules coalesce into patches. He regards these peculiarities, when present, as pathognomonic. The papules may be isolated and disseminated over a wide area, but gener- EXUDATIONS. 2S3 ally manifest a tendency to form groups or bands of various sizes. In some instances they exhibit a linear arrangement and follow the course of certain cutaneous nerves. They remain discrete, however, and do not coalesce and form large patches. Individual papules pursue an independent course of development, some attaining greater size or persisting longer than their fellows. The course of the eruption varies. It may subside spontaneously in a few weeks, or it may re- main for an indefinite period. Fresh lesions occur from time to time. When the papules finally disappear, marked pigmentation of the epi- dermis is seen at their site. This pigmentation may finally fade and the normal appearance of the skin be regained. In some cases, how- ever, atrophic spots or patches may follow. In others more or less desquamation may also be observed, but neither vesiculation nor pus- tulation takes place. The epiderm covering the papules sometimes be- comes markedly thickened. This result mainly occurs in regions where the cuticle is normally thick, as upon the knees, elbows, etc., but is not restricted to those localities. The intervening skin remains normal in structure and appearance throughout the course of the disease. The nails are rarely if ever involved. Diagnosis.—The only affections which present any resemblance to lichen planus are lichen ruber, lichen scrofulosus, papular eczema, psoriasis, and the papular syphilide. The papules of lichen ruber, however, are rounded and acuminated, and accompanied by intense itching; those of lichen planus are quadrilateral, flattened, and um- bilicated, with little or no itching. In lichen ruber the intervening surface becomes reddened and infiltrated, and the whole system is pro- foundly involved. In lichen planus the intervening skin remains nor- mal, and the general health is unaffected. In lichen scrofulosus the papules are reddish-yellow in color, and are situated around the hair- follicles. They are only observed in persons of the scrofulous diathesis, and rarely occur after the twenty-fifth year. The papules of lichen planus are dark-red in color, and are developed around the orifices of the sudoriparous glands. In papular eczema the papules are arranged in groups, but thoy are seated upon an inflamed surface, and severe itching and more or less vesiculation and desquamation follow. Some cases of psoriasis may, in their early stages, present a slight resem- blance to lichen planus, but the development of the characteristic mother-of-pearl scales will make the diagnosis certain. The papules of syphilis are developed in groups, but their large size, coppery color, and extensive distribution, and the presence of other symptoms of the disease, will prevent any diagnostic error. Pathology.—The lesions of lichen planus are the result of a cir- cumscribed inflammation of the papillae and the upper portion of the corium. The vessels of the papillary layer are dilated and tortuous, and the interspaces are crowded with leucocytes. The umbilicated ap- 284 DISEASES OF THE' SKIN. pearance of the papules is due to the fact that they are situated around the orifices of the sudoriparous ducts, and that while their margins are elevated by the exudation, their centres are prevented from rising by their attachment to the duct. The pigment changes are due to the escape of the red corpuscles and deposition of the coloring-matter. Etiology.—The cause of the eruption has not been definitely ascer- tained. It attacks male and female, but is apt to be more severe and rebellious in women. It is most frequently observed between the twentieth and fortieth year. According to my experience, it is almost invariably associated with evidences of general debility. Improper or insufficient food, nervous depression, and mental anxiety are probably the chief causes in its production. Dr. C. P. Russell, of Utica, N. Y., reports in the " Journal of Cutaneous and Genito-Urinary Diseases " for June, 1889, a case in which lichen planus invaded the forearm and arm of a man in whom four fingers of the corresponding hand had been partially amputated on account of injury. The reporter quotes a few other cases in which the evolution of lichen planus seemed to depend upon the condition of some portion of the nervous system. It sometimes occurs in persons of rheumatic tendency. Treatment.—This should be both constitutional and local. Exer- cise in the open air is essential. The diet should consist principally of beef, milk, eggs, and fruit. The condition of the alimentary canal is to be carefully ascertained. If any digestive disturbances exist they must be remedied. If constipation is present, it must be removed. If there are evidences of general debility, gentian, serpentaria, coptis trifolia, and quinine may be given with advantage before, and iron and nux vomica after, meals. In cases arising from nervous depression or mental fatigue, great benefit will be derived from the administration of one drachm of the fluid extract of erythroxylon coca half an hour before, and one drachm of the following combination half an hour after, meals: R, Liq. potassii arsenitis................ f 3 j. Tinct, nucis vomicae................. f 3 ss. Acidi phosphorici dilut.............. f 3 ij. M. Syr. simp.......................... f § ij, Kobner, Besnier, and others have practised with good results hypo- dermic injections of arsenical solutions. Hydrotherapy in the form of douches has been used with asserted advantage. In rebellious cases Quinquaud obtained excellent results by sending his patients to moun- tain resorts. In cases accompanied by marked anaemia, rapid improve- ment will result from the administration of ten minims of the tincture of the chloride of iron before, and seven to fifteen grains of chlorate of potassium after, meals. Cod-liver oil and the extract of malt are valu- able in debilitated cases. Arsenic sometimes appears to yield good re- sults. Itching may often be relieved, according to Blaschko, by the in- EXUDATIONS. 2S5 ternal use of antipyrin. The tincture of belladonna, valerianate of ammonium, and carbolic acid are also recommended for this symptom. Robinson has had good results from the use of acetate of potassium with spirit of nitrous ether. If the eruption consists of a few scattered papules, no local meas- ures will be necessary, except to avoid the use of irritating under- clothing. When the papules are numerous and grouped, and accom- panied by more or less itching, various soothing lotions or ointments may be employed, or the surface covered with a saturated solution of the bicarbonate of sodium. A ten-per-cent. solution of chrysarobin-traumaticin, applied with a brush twice weekly, is recommended by Herxheimer. Bran-baths to which vinegar has been added, inunction with glycerole of starch or glycerine containing tartaric acid, are recommended as useful external treatment by Vidal and Brocq. A corrosive sublimate wash or the emplastrum Vigo of the French may also be employed with advantage. A two to four per cent, solution of ichthyol in water has also been employed. In obstinate cases Unna advises the application of diachy- lon-ointment containing carbolic acid in a proportion as high, perhaps, as four per cent. To this mixture corrosive sublimate is added in quan- tities gradually increasing from two grains to the ounce. In severe cases alkaline baths, friction with the compound tincture of green soap, and the application of tarry ointments, are advised byA Dr. R. W. Taylor. Prognosis.—The prognosis is always favorable. The eruption is not accompanied by any constitutional symptoms, and, while it may occasionally manifest a disposition to linger, it eventually becomes amenable to treatment and disappears. More or less pigmentation remains for a long time at the site of the eruption, but finally the epi- dermis resumes its normal color. LICHEN SCROFULOSUS. Lichen scrofulosus is a chronic inflammatory cutaneous disease, at- tacking persons of a scrofulous diathesis, and characterized by the for- mation of a number of minute papules, which are situated r.round and over the hair-follicles. Symptoms.—The eruption of lichen ecrofulosus consists of a num- ber of small papules; in size ranging from a mustard-seed to a small pea. They vary in color from pale red to yellow, or reddish-brown. They arc firm to the touch, and are slightly elevated above the surround- ing surface. The lesions are observed most frequently upon the thorax and abdomen, but may occur upon the back, the extremities, the face, the scalp, or any other region of the body. They are usually devel- oped in groups, which occasionally coalesce and form large, irregular 2S(] DISEASES OF THE SKIN. patches. The apex of each papule is covered with a small whitish scale. The eruption pursues a chronic course. The papules first de- veloped gradually disappear by absorption and desquamation, but are followed by a second crop. These in turn become absorbed and are succeeded by others. Finally, the morbid process ceases, the existing lesions disappear, and recovery ensues. The papules do not itch, and are not accompanied by subjective symptoms; but the presence of the scrofulous diathesis is usually manifested by enlargement of the cervi- cal or axillary glands, or other significant signs. More or less discolor- ation of the general surface may also exist. Diagnosis.—The lesions of lichen scrofulosus resemble somewhat those of lichen ruber, keratosis pilaris, papular eczema, and the small papular syphilide. In lichen ruber the papules are bright-red, however, and gradually involve the whole surface, but do not manifest any tend- ency toward grouping. In keratosis pilaris the papules are gray in color, and are generally confined to the extremities. They are formed exclusively of epidermic scales, and are not developed in groups. The papules of eczema are irregular in size, bright-red, and usually limited to one area. They are complicated by the formation of vesicles, and are accompanied by severe itching and burning sensations. They run an acute course. The papules of syphilis are dark-red or reddish-brown in color, and irregular in size. They are widely distributed, and are attended by other symptoms of the disease. Pathology.—The pathology of lichen scrofulosus has been studied by Kaposi. The papules are produced by exudation and cell-infiltra- tion into the hair-follicles and sebaceous glands, and the tissues which immediately surround them. The morbid process begins around the blood-vessels and in the connective tissue at the base of the hair-folli- cles. The cells finally penetrate into the cavities of the follicles and the glands, distending them to elevate the epidermis and produce the characteristic papules. The lesions may disappear by absorption, or by superficial ulceration and the formation of minute cicatrices. Etiology.—Lichen scrofulosus is rarely met with in the United States. It appears to be more common in males, and is usually en- countered about the age of puberty. It may, however, appear at any age. It is probably due indirectly to the scrofulous diathesis, but its immediate exciting cause is not known. In many cases the eruption has coexisted with or preceded tubercular lesions in the lungs or other organs, Jacobi, of Freiberg, refers to a case in which lichen scrofulo- sus occurred in a woman who was subsequently attacked by lupus of the scalp and tuberculosis of various glands. The microscopical ap- pearance of sections of the papules resembles that of miliary tubercle. Treatment.—Nutritious food, fresh air, sunlight, and warm cloth- ing are of paramount importance. The patient should be directed to sponge the entire surface with salt water two or three times a week. EXUDATIONS. 287 Medicinally, the best results can be obtained from the administra- tion of large doses of cod-liver oil. Inunctions or hypodermic injec- tions of the same remedy are also of service. The iodide of iron will often be found valuable. Quinine, strychnine, and phosphorus may also be administered. Arsenic is sometimes of service. The external treatment consists of baths containing bran or starch, washing the affected surface with tar-soap, or inunction with cod-liver oil. Prognosis.—The prognosis is always favorable. The eruption may prove obstinate, but time and proper treatment will finally effect a cure. PRURIGO. Synonyms.—Prurigo (Hebra)—Juckblattern—Strophulus prurigineux (Hardy). Prurigo is a chronic disease, characterized by the development of small solid, pale, or somewhat red and isolated, deeply seated, or slightly elevated papules, accompanied with intolerable itching, thickening and pigmentation of the skin. Symptoms.—The disease almost invariably appears early in life, often during the first or second year, by the formation of wheals or a general irritability of the skin. It occasions violent scratching, the symptoms disappearing to again reappear, and the peculiar eruption gradually developing from the second to the seventh year. The small, isolated, and irregularly distributed papules which make their appear- ance are sub-epidermic, and about the size of a pin's-head, or a little larger. They are detected better by touch than by sight, as they are scarcely raised above the level of the skin. They are firm, and differ little, if any, from the surrounding integument in color, but at times present a red or purplish hue. They may be pierced with hairs, and covered with a dry and attenuated epidermis. They occur most frequently upon the outer surfaces of the extremities, particularly of the legs; the extensor part of the arms, the lumbar and gluteal regions, may also be involved. The other portions of the skin may be affected likewise; the axillary, popliteal, palmar, and plantar regions are, how- ever, always exempt, and in well-marked cases present quite a contrast to the adjoining invaded skin. The lesions, even before being perfectly developed, are attended with intolerable and persistent itching, which causes the sufferer to scratch and tear off the apices of the papules, from which exude serum and blood, which dry into crusts. The itching and scratching con- tinue as the disease progresses, the skin becoming, in addition, thick- ened, rough, fissured, and pigmented. In a case closely observed dur- ing a period of eight months by Dr. R. W. Taylor, individual papules at times underwent involution, and with this comparative quiescence of the disease the pigmentation became less marked. Small scattered white 288 DISEASES OF THE SKIN. spots, denoting slight loss of tissue and resulting from involution of papules, were also perceived. These atrophic spots gradually disap- peared. The hairs may be removed or torn off by the scratching. At times buboes may follow from the severe irritation, or inflammation, which is set up in the same way. Eczema may also arise as a complica- tion, either from the use of the finger-nails in scratching, or the appli- cation of irritating remedies. In some instances suppurative lesions, as impetigo, ecthyma, or furuncle, result from the incessant scratching, and produce a polymorphism which does not belong to uncomplicated prurigo. Prurigo is divided into two forms, namely, prurigo mitis and prurigo ferox or agria; in the first the symptoms are mild, while in the second they are more severe. They begin in one or the other form, and, as such, run their course singly. The disease generally lasts a life- time, and, by its constant annoyance, gives rise to debility and often great emaciation. Diagnosis.—The symptoms of prurigo are so marked and charac- teristic as to be rarely mistaken for any other affection. Occasionally it is liable to be confounded with pediculosis, scabies, paraesthesia, and eczema. The absence of the pediculus on the skin or in the clothing, and the exemption of the hands, are sufficient to establish the diagno- sis. Prurigo may be confounded with scabies, but the latter generally attacks the flexures, the penis, the scrotum, or fingers, while the former involves particularly the extensor portions of the legs. Paraesthesia, of all diseases, is most likely to be mistaken for prurigo. Paraesthesia may happen at any period of life, and the lesions are secondary ; pru- rigo commences generally in childhood, and the lesions are primary. Prurigo occurs, as a rule, among the badly nourished, and paraesthesia among all classes. In paraesthesia the integument is normal, except when irritated; in prurigo it is the seat of papules primarily, and is accompanied with thickening of the skin, which seldom follows in the former. Prurigo invades particularly the extensor surfaces of the legs, while in paraesthesia any part or the entire body may be involved. Prurigo is attended with persistent itching ; the disease continues for years, or a lifetime. In paraesthesia the irritation is frequently relieved or cured by a suitable course of treatment. Eczema may arise as a complication of prurigo from scratching, but the location of the papules, their color, grouping, and the existence of other lesions or evidences of eczema, are sufficient for the diagnosis. Pathology.—Microscopical examination reveals that the appear- ances observed are similar, in many respects, to those of papular ecze- ma. The papillae and the rete are filled with young cells and an exu- dation of serum occurs. As the disease becomes chronic more or less hypertrophy takes place in the corium, with pigmentation, the glands becoming enlarged or atrophied, and the epithelium may undergo fatty degeneration. EXUDATIONS. 280 Dr. Kromayer, in a microscopical examination of skin, excised from four patients of different ages and sexes suffering from typical prurigo, found the horny layer of the epidermis thickened. Small cysts were present in or under that layer. These cysts, which were only twice found in the rete mucosum, are probably the results of an exudation. He considers that the essential cause of prurigo consists in vasomotor changes in the blood-vessels by which the epidermis is nourished.* Prof. Campana, of Genoa, ascribes the origin of this affection to some alteration in the nervous system, and asserts that in prurigo he has found changes in the terminal fibrils of the nerves. He has seen that in the subcutaneous tissue many of the nerves of the skin have lost their form and are much thicker than normal.f Portions of skin from Dr. Taylor's case were submitted to micro- scopical examination by Dr. Ira A7an Gieson, who describes the blood- vessels of the lower corium as surrounded by groups of small round and small polygonal cells. The papillae were but little changed, though some were infiltrated by the same small round and polygonal cells. The hair-follicles exhibited alterations, some being shrunken while in others pouch-like dilatations were observed. The nerve- trunks were unchanged except when situated in or near the cell clus- ters in the derma. Some of the papules were due to small cysts in the epidermis. These appeared to be due to distention of the intercellular spaces in the rete Malpighii by exudation of fluid from a subjacent (edematous papilla together with degenerative liquefaction of the cells. The cysts may subsequently atrophy. Those nodules which were only perceptible to the touch disappeared in the process of hardening by osmic acid. With the exception of some cell-clusters in the derma the skin was almost normal. Van Gieson coincides with Kromayer's statement, especially in regard to the sub-epidermal nodules, that hardened material is not suitable for a study of the changes in prurigo. Etiology.—The cause of prurigo is obscure. It is rare in this and other countries, but is common in Austria. During a period of five years Dr. Zeisler met with twelve cases of prurigo in Chicago, and concludes that the disease is not so extremely rare in this country as had been supposed. In many of his patients the disease was of the mild variety, though most of his cases of prurigo ferox were imported, yet typical examples of the severe form do occur in natives. It devel- ops, according to the experience of Hebra, usually among poor chil- dren who are badly nourished. Sometimes it is also observed among the better classes. It is more severe in winter than at any other time of the year. Krastilefsky has reported the case of a woman who had borne fifteen children and on each occasion had suffered from prurigo, the attack beginning a week before and continuing until the second day after delivery. * British Medical Journal, May 17,1S90. f British Medical Journal, October 13,1888. 19 290 DISEASES OF THE SKIN. Treatment.—Remedies which improve the general health assist the local agents to relieve persistent itching. Cod-liver oil, iron, quinine, and arsenic may be used, according to the requirements of the case. The association of carbolic acid with cod-liver oil seems, according to the statement of Brocq, to relieve the intense itching. He advises the acid to be given in daily doses of twenty to sixty centigrammes. The sirup of the iodide of iron or of hypophosphites may be employed when cod-liver oil is badly borne. Antispasmodic remedies are indi- cated when the patient is of an extremely nervous temperament. An- tipyrin, phenacetin, potassium bromide, and canabis Indica have been used with success. Simon, Pick, and Schwimmer have given daily hy- podermic injections of 0-01 gramme of pilocarpine with beneficial effect. Schwimmer states that the same may be said of ergotin, in doses of from 0-05 to one gramme per day. In one case I obtained good results from subcutaneous injections of one eighth to one fourth of a grain of cocaine hydrochlorate. The local treatment, which is all-important, should consist of baths, particularly the water bath with soap, the vapor and the medicated vapor. Tar, naphthol, and sulphur, used aloue or com- bined in the form of ointments, may remove or temporarily arrest the disease. The occasional application of sapo viridis, followed by inunc- tion, is often serviceable. Cod-liver oil is particularly recommended as a topical remedy in this disease. Massage is said to relieve itching and remove infiltration. Prognosis.—Prurigo is generally considered incurable, but the mild- er forms occurring in children are reported by Kaposi to be amenable to treatment. HERPES. Herpes is an acute, non-contagious, inflammatory affection, charac- terized by the development of one or more clusters of vesicles, seated upon a somewhat reddened base. Symptoms.—The eruption may be preceded by chilliness, headache, and fever, or it may be developed without any constitutional symp- toms. Again, it may appear in connection with fevers, other dis- eases, or exist alone; or be preceded by sensations of heat, burning, and itching. Sometimes it is accompanied with pain. The lesions appear as vesicles, from the size of a pin's head to a split pea, situated upon a reddened base. They are usually few in number, and arranged in clusters. They generally contain a serous or purulent fluid, and seldom burst, the contents usually drying into yellowish or brownish crusts, which fall off, exposing a reddened and afterward normal skin. An excoriation occasionally results from rubbing or interfering with the vesicles, but it also heals kindly, cicatrices rarely resulting. Herpes is an acute affection, lasting about one week, and liable to relapses. In some instances so much constitutional disturbance accompanies the eruption as to warrant the designation of herpetic fever. The lesions EXUDATIONS. 291 of herpetic fever are usually located upon mucous membranes, as those of the mouth, genitalia, or conjunctiva. More rarely the skin alone or skin and mucous membranes are affected. Herpes zoster may occur at any age, but is probably more frequent between the twelfth and twenty-fourth year. It is thought to be rather more common among men than women. Tuberculosis and other thoracic affections, rheu- matism, and gout seem to predispose to attacks. Herpes is divided into several varieties, according to the location and arrangement of the lesions, which may be separately described as follows: Herpes Facialis.—Herpes occurring on the face is also known as herpes or hydroa febrilis, and fever-sores. It may be observed upon any part of the face, as the forehead, cheeks, ears, eyelids, conjunctiva, cornea, and chin. The lips, especially the upper, are a favorite point of attack; the vesicles being small, few in number, and forming gen- erally but one group. They may continue isolated, or they may run together. The vesicles may also involve the mucous membrane of the anterior nares, the mouth, and tongue. They develop and run their course in the manner already described, except when the mucous mem- brane is affected, when, owing to its delicate structure and the heat and moisture present, they usually rupture early, exposing an excoriated patch, or patches, covered with a purulent secretion, or with a yellow- ish or brownish crust. Herpes facialis may follow cold, pneumonia, fever, or any impair- ment of the mucous membrane of the respiratory or digestive tract. Relapses are frequent. Recurrent attacks of herpes of the tongue sometimes occur in those who had been infected with syphilis, but who had apparently been cured. The erosions are small, scattered, of short duration, and seem not to be specific manifestations, since they are aggravated rather than ameliorated by anti-syphilitic treatment. They seem to be due, in fact, to prior irritation of the mouth by mer- cury and the use of tobacco.* IIerpks Iris.—This variety is similar in many respects to erythe- ma multiforme. It begins as one or more vesicles, or vesico-papules, arranged in the form of a ring on the dorsal surfaces of the hands and feet. At times two or more rings develop, and the changes which they undergo give the patch a varied hue, resembling somewhat the colors of the rainbow, whence the name iris. Occasionally the vesicles run together, forming large bullae. It is one of the rare form's of herpes, occurring most frequently in young persons in spring and autumn. The subjective symptoms of itching or burning are not, as a rule, marked, and in some cases are absent. The eruption usually disappears in one or two weeks, but the skin remains pigmented, and relapses may occur. Dr. J. H. Thompson, of Kansas City, Mo., has reported f a rare * Fournier, La Semainc M6dicale, 1887. f Kansas City Medical Record, Nov., 1889. 292 DISEASES OF THE SKIN. condition in which a very diffuse herpes iris coexisted with croupous conjunctivitis. The eruption was abundant upon head, trunk, and limbs. It was confluent upon the soles and palms. The conjunctival sac was entirely filled by a croupous membrane, which glued the lids together and to the eyeball. The disease lasted a month. The skin eruption disappeared and the eyes recovered their usefulness. The patient was a widow, aged twenty-seven years, of delicate physique. Herpes Progenitalis.—This is also known as herpes praeputialis. It occurs in the male, ordinarily on the prepuce, either on the external or internal surface, and on the glans and other portions of the skin of the penis. In the female the disease is more rare, and appears about the vulva, especially upon the labia majora and minora. In excep- tional cases these become immensely swollen, the herpetic vesicles coa- lesce, the parts are the seat of itching and burning sensations, together with pain. The patient is unable to walk, the contents of the vesicles escape and, mingled with the leucorrhoeal or gonorrhoeal discharge which may be present, produce a very offensive odor. In rare instances the vagina or neck of the uterus is the seat of herpes. The eruption is generally observed in young people and during adult age. It is preceded or accompanied with itching and burning, and at times with neuralgic pains, followed by the development of one or more clusters of vesicles, seated upon an inflamed base. The lesions may be few or many, and are about a pin's-head in size. They may be accompanied with much inflammation, leading, in addition, to more or less swelling. The lesions occasionally dry up, and the resulting crusts fall off in one or two weeks. As a rule, owing to the heat and moisture present around these parts, the vesicles burst within a very short time after their formation, and serum, pus, or blood, is poured out upon the surface. The excoriations and superficial ulcers which result are covered with serous, bloody, or purulent exudation, or with a crust, and may, from their appearance, be mistaken for syphilitic lesions. The diagnosis becomes at times even more perplexing, from scratch- ing or irritating applications, leading to severe inflammation, harden- ing of the tissues and enlargement of the inguinal glands, simulating chancre or chancroid. Herpes may be distinguished from chancroid by the fact that the ulcerative action of the latter leads to a depression or excavation. A chancre is usually attended by dryness and pressure at its base, and will not cause the escape of serum or pus as in the case of herpes or chan- croid. An accurate and positive diagnosis can, in the above condition, be obtained only by inoculation, or by treating the case for a time and awaiting the result. If the disease is herpetic, it will yield under sim- ple treatment within a few days or a week's time, but if, on the con- trary, it be syphilis, little or no impression will be made from simple applications. Herpes progenitalis is liable to frequent relapses. It EXUDATIONS. 29tt may arise from gastric or intestinal disturbance, and follows often from coitus, particularly in those having a long prepuce. It is apt also to develop in those who have suffered from gonorrhoea, chancroid, and chancre. When the subject of recurrent herpes suffers from a severe disease the attacks of herpes temporarily cease, but when convalescence is established they reappear. The constant repetition of attacks some- times has deplorable mental and moral consequences. This form of herpes is said to be more common in rheumatic subjects. Bataille has described an elevated form of herpetic erosions of the genitalia which closely simulate mucous patches. Herpes Gestatioxis.—This form occurs during or after preg- nancy. It appears on the extremities as vesicles, papules, or bullae, at- tended with itching and burning. The vesicles are the most predomi- nant lesions, are ordinarily grouped, and vary in size from a pea to a wal- nut. It may be complicated with urticaria, neuralgia, and other diseases of a similar nature. Relapses tend to follow with other pregnancies. Herpes gestation is may begin as early as the third or fourth week of a pregnancy, but not usually until the third or fourth month, remains until after delivery, and during a few days subsequent to parturition the eruption may experience a decided aggravation. It then, as a rule, more or less gradually disappears. In some cases its first appearance has occurred after confinement, but has recurred during the progress of subsequent pregnancies. In a case observed by Liveing intense pruritus and neuralgic pains marked the latter months of a pregnancy, but the eruption did not appear until the third day after accouchement. In after-years relapses occurred in the absence of pregnancy. In two of these relapses the mucous membrane of the mouth was severely affected. The herpes of gestation is identified by Duhring and Brocq with the herpetic dermatitis described by the former author. No exact knowl- edge exists concerning the pathogenesis of this affection. Leloir and Vidal suggest that it is caused by the modification of nervous activity due to pregnancy. Herpes Zoster (Synonyms: Zoster; Zona; Ignis sacer; Shingles). —In herpes zoster or shingles the lesions are similar to those already described, but the groups of vesicles differ somewhat in their arrange- ment. They develop along-the course of, or near, several cutaneous nerves, often extending around one half of the body. The disease is frequently preceded by constitutional symptoms of varying severity. Fever occurs in some cases. Pain of a neuralgic character may occur for days, rarely weeks, and commonly some hours before the appearance of the eruption, or it may be altogether wanting. It may be felt over the entire affected surface, or it may be limited to one or several points. It is generally severe, is a prominent symptom, and may be lancinating, smarting, or burning. The eruption appears first as a patch or patches of reddened skin, surrounding the seat of pain. Sooner or later there 294 DISEASES OF THE SKIN. occur one or more groups of red papules, which develop into vesicles, generally discrete, but occasionally they coalesce, producing bullae. The lesions thus formed are usually in size from a pin's head to a split pea. Successive crops continue to form during the course of the disease, and undergo their respective changes, giving a different appearance to the lesions in different parts of the patch or patches. In the course of three or four days after the appearance of each group, their contents become opaque, and in time purulent. In one or two weeks they have dried into yellowish-brown crusts, which fall off, exposing a normal, pigmented, or more or less scarred, state of the skin. Neighboring lymphatic glands sometimes become enlarged. Occasionally the mus- cles near the eruption are the seat of painful cramps or clonic spasms. In rare instances local paralysis accompanies or follows an attack. Schlesinger has reported the case of a man who, after frontal zoster, developed complete paralysis of the corresponding motor-oculi nerve and paresis of the first branch of the first division of the trigeminus for all sensations, together with loss of sensibility of the upper segment of the cornea.* Dr. Ch. Fere states that facial zona maybe complicated with hallu- cinations. The vesicles show no inclination to burst, as in eczema; they are deeply located, and remain until they dry up, unless interfered with. In some rare cases the contents of the lesions may be discolored by an infusion of blood into them (herpes zoster haemorrhagicns). They may run the usual course of the eruption just described, or may burst, leaving an ulcerating surface, which is followed by cicatrization. Ul- ceration and cicatrization may also result from scratching or rubbing. This process has been termed herpes zoster gangraenosus. Occasionally the initial lesions forming the papules do not pass into vesicles, but gradually disappear, with desquamation; this is known as the abortive form. Herpes zoster is an acute affection, and, according as it is slight or severe, may run its course in from one to two weeks, or longer. It occurs equally in both sexes, but more frequently in the young, espe- cially during atmospheric changes. It may attack almost any part, but has a predilection for certain regions, as the face, shoulders, back, ab- domen, and upper portion of the thigh. A case of herpes zoster which involved the anus, left side of buttocks, scrotum, and penis, causing paresis of the bladder and inactivity of the bowels, has been reported. Zoster is usually limited to one half of the body, especially the right side, but at times, and rarely, it may be bilateral. It seldom attacks the patient a second time. The neuralgic pains and burning, as a rule, disappear with the evolution of the eruption, but may persist during its entire course, or remain for a long time after all traces of the dis- * Dr. Hermann Eichhorst has reported a case in which facial paralysis preceded herpes zoster. Only four such cases are known. New York Medical Journal, June 5, 189*7. EXUDATIOXS. 295 ease have vanished, especially in elderly persons. Neuralgia is gener- ally much less severe in children than in adults. To this great annoy- ance there may also follow, particularly in the aged, anaesthesia of the region involved, local paralysis, muscular atrophy, and falling of the hair and teeth. The eye may at times be involved in zoster of the or- bital region, with consequent inflammation of the organ and loss of sight, or death. These complications, however, do not often happen. Ophthalmic zoster may sometimes coexist with the same disease in oth- er situations. M. Brissaud has observed three cases in which crossed hemiplegia succeeded to ophthalmic zoster. Though ordinarily of rather rare occurrence, zona sometimes presents itself as an epidemic. The type of the epidemic varies, being sometimes mild and at other times severe. The affection, moreover, usually manifests itself but once. In these circumstances herpes zoster resembles the infectious fevers, and the theory is now supported by a number of authors that it is primarily a constitutional disorder which exerts a special influence upon nerve- ganglia and that the cutaneous lesions are secondary consequences. A few cases have been observed in which a succession of vesicles was of constant recurrence, arranged along the course of a nerve-tract and ac- companied by neuralgic pain. To this form the term chronic zoster has been applied. According to the anatomical region or the nerve-tract invaded the disease is named : Z. frontalis, Z. ophthalmicus, Z. auricularis, Z. faciei, Z. occipito-collaris, Z. cervico-subclavicularis, Z. cervico-brachialis, Z. pectoralis, Z. lumbo-femoralis, Z. sacro-ischiadicus, Z. sacro-genitalis, etc. Of all the above varieties, the most common is that affecting the chest and abdomen. Kaposi has described four cases of what he con- siders to be atypical herpes zoster. Three occurred in hysterical young women, the fourth in a male. The lesions consisted of groups of pap- ules and vesicles, some of which were associated with necrosis of the corium and a keloid development of the scar. Though symmetrical, recurrent, and not following the course of any cranial or spinal nerve, yet the eruption presented characters which, while unusual, are not un- known in herpes zoster. A vesicular eruption sometimes appears upon the tongue, mouth, or throat, and has been described by various writers under the name of herpetic angina. The vesicles frequently coalesce, rupture, and leave an erosion or ulcer. In some instances this affec- tion of a mucous membrane appears to be identical with herpes zoster. Dr. B. Pouzin has observed two cases of herpetic angina with vesicu- lar lesions, which corresponded in situation to the course of various mucous and cutaneous branches of the trifacial nerve. Diagnosis.—Herpes is not often confounded with other diseases. It may bear some resemblance to eczema, but the vesicles are larger, differently arranged, and tend to dry up, symptoms which serve to dis- tinguish it from the latter affection. 296 DISEASES OF THE SKIN. Herpes zoster is to be diagnosed by its history, the premonitory or attendant neuralgic pain, distribution of lesions, and tendency not to rupture. Herpes is known from herpes zoster by appearing as one group of vesicles, attacking certain regions by preference, with a lia- bility to relapses—diagnostic points which are wanting in herpes zoster. Pathology.—Herpes, and especially zoster, is due to irritation or in- flammation of the sensitive nerves or ganglia, the Gasserian, or spinal, being especially affected. Barensprung first demonstrated its seat in the nervous system, and particularly involving, in zoster, the spinal ganglia. Wyass showed in a fatal case of zoster facialis the Gasserian ganglion softened and altered, together with inflammatory changes along the nerve after entering the ganglion. Similar pathological changes in the sensitive nerves and the Gasserian and spinal ganglia have been pointed out by other observers. Dr. Graham has found bacilli and diplococci within the blood-vessels of the Gasserian gang- lion, bunrjhes of leptothrix-like cells within the arterioles and lepto- thrix in the sheath of the ganglia. These organisms were absent in other portions of the brain and medulla. Kaposi, from his investiga- tions, has concluded that the disease is not always occasioned by in- flammation of the ganglia, but that it may arise in the nerve, often at its peripheral distribution, and that it may likewise be spinal or cere- bral in origin. Microscopic examination of the vesicles in zoster shows that they are developed in the rete. Barensprung, in his examinations, found in the affected part the papillae enlarged, the blood-vessels dilated and infiltrated, with new cells extending even into the corium and the subcutaneous tissue. Spindle-shaped cells were noted also, passing from the papillae into the rete, which were pushed aside, the latter be- ing thus made to appear linear in form. The nerve at the site of the eruption was found to be attended with inflammatory changes, the neu- rilemma being filled with cell infiltration. Etiology.—Herpes occurs mostly in those possessing an irritable or a delicate skin. It may be due to a variety of causes, but is chiefly pro- duced by some derangement of the mucous membrane of the respira- tory, digestive, or genito-urinary tract. It frequently results from cold, atmospheric changes, nervous depression, and from injury to the nerves from blows or pressure, and from direct action of local irritants on the skin. Dr. Bulkley, of New York, has seen herpes zoster de- velop in consequence of Pott's disease, and in another case where a tumor of the neck pressed upon the nerves. Zoster has been observed to follow the inhalation of carbonic-oxide gas, and the internal use of arsenic. In a series of 557 cases undergoing arsenical treatment in the Copenhagen Hospital from 1864 to 1869, Neilsen found that herpes zoster occurred in ten cases, or 1-8 per cent. Dr. Janin relates a case in which an exceedingly painful herpes zoster developed in immediate consequence of a trifling traumatism. Zona has been seen as a sequela EXUDATIONS. 297 of epidemic influenza, and M. Fere reports four cases which occurred almost contemporaneously among his 150 patients at the Bicetre. Ma- larial intoxication may cause herpes zoster, as has been demonstrated by Dr. James M. Winfield, of Brooklyn, who found the plasmodium malariae in the blood of several patients. In a case observed by Dr. E. Adinot herpes zoster occurred in the tract of the radial nerve during an attack of measles in an adult. Dr. Maurice Eden Paul witnessed an attack of typhoid fever which was immediately preceded by an erup- tion of herpes zoster in the lumbar region. M. Carriere encountered a case of herpes zoster in a patient suffering from uterine cancer. The eruption was situated in the tract of the left ilio-iuguinal nerve, which exhibited the lesions of interstitial neuritis. The spinal cord was abso- lutely intact. M. II. Koebner has reported a case in which the appli- cation of a weak galvanic current in nervous headache excited intense pain, followed the next day by an eruption of herpetic vesicles. They occupied positions corresponding to the transverse cervical branch of the superficial cervical plexus. In the lymph of herpetic vesicles on the lip of a boy suffering from croupous pneumonia a great number of bacilli were found by Dr. William St. Clair Symmers. These, when cultivated under favorable conditions, elaborated a beautiful pea-green pigment. Though unfavorable circumstances may abolish the chro- mogenic power during several generations, this is restored when the micro-organism is cultivated under suitable conditions. Treatment.—The exciting cause, if found, should be removed. Aperients and diaphoretics may be useful, as well as occasional blood- letting. Opiates, bromides, or chloral may also be necessary to relieve the pain, particularly in zoster. The latter is often greatly ameliorated by hypodermic injections of one quarter to half a grain of sulphate of morphine with one eightieth of a grain of sulphate of atropine. Anti- febrin and antipyrin have been used for the relief of pain, given either by the mouth or by hypodermic injection. Ether and chloroform have been subcutaneously injected for the same purpose. Three or four five- grain doses of phenacetin, administered at hourly intervals, have usually alleviated the pain of zoster. The phosphide of zinc, given in one- fiftieth-grain doses every three or four hours, may also mitigate all the symptoms. Iron, quinine, arsenic, and the various bitters or the mineral acids, are remedies that can be resorted to, according to the indica- tions. A course of cod-liver oil may prove beneficial. Jamieson ad- vises a mixture of equal parts of tincture of mix vomica and tincture of gelsemium, of which he orders twenty to forty drops to be given during the day. According to Phillips, rhus toxicodendron is occa- sionally of advantage. In some cases the salicylate of sodium has been reported of service. The local treatment is especially useful. The object should be to protect the lesions, prevent their rupture, and all irrita- tion which may follow. If seen very early, Unna states that painting 298 DISEASES OF THE SKIN. with ichthyol, covering the eruption with wadding saturated with a ten-per-cent. solution of ichthyol or resorcin, or the application of equal parts of zinc-paste and resorcin will cause the vesicles to abort. But if vesicles have already formed, suppuration may be prevented by the use of a zinc-sulphur paste or alcoholic solution of corrosive sublimate, iodoform, carbolic acid, or resorcin. In order to abort the vesicles, it has been proposed to open them and lightly touch their cavities with a stick of nitrate of silver, or to paint the affected surface with a solu- tion of the same salt. Other substances which have been recommended in the local treatment of zoster are carbolic acid, ointments of lead, belladonna, opium, or cocaine, liniments containing chloral or chloro- form, a two-per-cent. alcoholic solution of menthol, grindelia robusta, etc. Brocq's method is to carefully open all the vesicles as soon as they have formed, wash with an aqueous solution of boric acid con- taining a little alcohol, and cover the surface either with a layer of antiseptic cotton or a paste composed of oxide of zinc and boric acid, as follows: R. Acid, borici................... 1 gramme. Zinci oxidi................... 2 " Pulv. amyl................... 2 Vaselin pur................... 16 " If this preparation is not sufficiently adherent, six parts of the vaseline may be replaced by lanolin. Starch-powder is dusted over the ointment, and a thick layer of cotton completes the dressing. A suitable quantity of cocaine or morphine may be incorporated in the above formula if the pain be excessive. Some practitioners prefer coating the lesions with flexible collodion or solution of gutta-percha. Five grains of morphine sulphate to the ounce of collodion will often soothe the pain. Dusting-powders are valuable, both for the protec- tion wrhich they afford and for the medicinal action which they have upon the resulting excoriation. They are particularly to be recom- mended for use in herpes of the genitals. They not only are the best means of medicating these parts, but, in instances in which it may be a question of the lesion being specific or not, the application of a dusting-powder speedily settles all doubt. If the lesion is herpetic, the dusting-powder usually causes it rapidly to dry up and disappear, while but little change will be observed should the disease be of specific origin. The subnitrate of bismuth, lycopodium, carbonate of zinc, calomel, alone or combined with some other powder, the oleate of zinc, and powdered red cinchona-bark, are all useful applications. It may be well to add morphine and camphor if there be much pain. Aristol, europhen, and iodoform are also useful dusting-powders, the two former remedies being preferable on account of their compara- tive freedom from odor. Some practitioners prefer to make use of lotions in the treatment of herpes progenitalis, and Feulard recom- EXUDATIONS. 299 mends weak solutions of acetate of lead, vinegar, and water, or aromatic wine. If the ulcers are slow to heal, a weak solution (two to four per • ■out.) of nitrate of silver is applied to them, or they are dressed with an ointment of the same strength. In order to prevent recurrence lint may be laid between the glans and the prepuce, either dry or moistened in some tonic and astringent solution. Compression with a bandage, or a simple or medicated plaster, is a most useful means of relieving herpes. Sometimes herpes of the lip is better treated by applying a plaster at once to the part. It lessens the irritation, and often speedily gives relief. Simple absorbent cot- ton, or borated cotton, is a valuable application, particularly if the lesions have ruptured. A solution of borax with the addition of a grain or two of cocaine and of morphine is likewise a good application to herpes of the mouth and lips. Anodyne lotions, containing lead- water and witch-hazel, are valuable. A ten-per-cent. ointment or al- coholic solution of anthrarobin has sometimes proved useful. Astrin- gent lotions of tannic acid, alum, sulphate of zinc, or boric acid, are frequently best borne, especially if the part has become excoriated. Prof. Schwemmer reports good results in zoster from a ten-per-cent. solution of thiol used twice a day. A lotion containing menthol affords relief. Rapidly curative or even abortive virtue is ascribed by Prof. Leloir, of Lille, to alcohol and alcoholic solutions, according to the inaugural thesis of Dr. Dupas. Compresses saturated in the solution are ap- plied to the lesions and kept in position by means of absorbent cotton or some impermeable material. The dressings should be changed fre- quently during the day. The substances employed are ninety per cent, alcohol, two or three parts of resorcin to one hundred of alcohol, one per cent, of thymol, or three per cent, of menthol in ninety five per cent, alcohol. Two per cent, of hydrochlorate of cocaine or five per cent, of extract of cannabis Indica may be added when the pain is severe. This plan of treatment has been found useful both in herpes labialis and zoster. Sedative or astringent ointments, possessing any of the ingredients just named, may be employed. Ointments containing cocaine, conium, or aconitine, have a local analgesic effect, though the use of the last two requires great caution, especially if the surface be abraded. The use of the galvanic current applied directly to the affected nerves, every day, will often lessen or relieve the pain of zoster. Oleum choenoceti, or whale-oil, is extolled by Dr. Gustav Guldberg as pos- sessed of great penetrative powers and as a valuable vehicle for chloro- form when a local analgesic is required, as in herpes zoster. It is a refined oil derived from the Balmna rostrata, and is of lower specific gravity than any other animal oil. A mixture of equal parts of the oil and chloroform is rapidly absorbed, and produces a sedative effect upon 300 DISEASES OF THE SKIX. terminal nerve-fibres. The treatment of herpes gestationis is identical with that of dermatitis herpetiformis, and is given in the description of the latter affection. Prognosis.—The prognosis is favorable, except in orbital zoster, which it is said may occasionally be fatal. The other varieties disap- pear in one or more weeks, but they are liable to relapses. Herpes zoster may be persistent, often continuing for some time, and disappearing, to be followed by a relapse. Obstinate neuralgic pains may also occasionally remain in the part for months or years after the eruption has been removed. This is especially apt to be the case in the aged. Dr. Lemounier * has encountered ten cases in which zona was fol- lowed by tuberculosis. In some patients the latter developed immedi- ately or within a few months after the appearance of the zoster. In one case the outbreak of tuberculosis was delayed four and a half years. MILIARIA. Synonyms.—Miliaria rubra—Miliaria alba—Lichen tropicus—Prickly heat. Miliaria is an acute inflammatory affection of the sudoriparous glands, characterized by the formation of numerous minute papules or vesicles, and accompanied by marked prickling, tingling, or burning sensations, and more or less itching. Symptoms.—The eruption of miliaria usually appears without any premonitory symptoms. In the majority of cases it consists entirely of papules. It may, however, be purely vesicular in character, or it may consist of both papules and vesicles. The papular variety is sometimes termed lichen tropicus, from its frequent occurrence in tropical climates, but it is popularly known as prickly heat. It is characterized by the sudden development of a number of exceedingly minute papules. They are acuminated in form, and bright-red in color. The papules vary in size from a small pin's- head to a grain of mustard-seed. They are situated around the ori- fices of the sudoriparous ducts, and are slightly elevated above the sur- rounding surface. They are usually developed in great numbers, and are closely set together. They do not coalesce, but remain discrete throughout their existence. The lesions may appear upon any portion of the body, and in severe cases not infrequently involve the entire sur- face. They are most frequently observed, however, upon the scalp, neck, chest, back, and arms, and generally remain for a few hours or days and then disappear as suddenly as they came. In severe cases the papules may be present for several weeks. Relapses are of fre- quent occurrence. The eruption is almost invariably preceded and accompanied by * Bulletin Medicale, No. 38, 1S90. EXUDATIONS. 301 marked increase of sweat. In some exceptional cases the secretion of sweat is notably diminished. The entire cutaneous surface upon which the papules are developed is intensely reddened, and is the seat of more or less itching, stinging, and burning sensations. The eruption may be complicated by the formation of vesicles and vesico-papules. The vesicular variety of miliaria is characterized by the develop- ment of a number of exceedingly small vesicles, which are acuminated in form and surrounded by an erythematous aureola. They are trans- parent at first, and contain a drop of clear serous fluid, but become opaque or yellowish in a few days. The vesicles generally occur in large numbers, and are placed close together. They may appear upon any portion of the body, -but are most frequently observed upon the neck, chest, back, and arms. They run an acute course, usually terminating in absorption and desquamation in a few days. The eruption is accompanied by itching and burning sensations, which are sometimes so severe that the patient tears the skin and ruptures the vesicles in order to obtain relief. The crusts which are formed by this procedure are small in size and insignificant in character, and usually disappear by desquamation in a few days. Relapses may occur, however, and protract the disease for several weeks. I have seen cases in which the eruption recurred at intervals for four months before it finally dis- appeared. Diagnosis.—The only affection which presents any resemblance to the papular variety of the disease is eczema papillosum, but the dis- tinction between them can readily be made by considering the history, course, and subjective symptoms of each. The papules of miliaria appear suddenly during intensely hot weather. They are exceedingly numerous and closely set together, but never coalesce to form large patches. They are usually accompanied by excessive perspiration and marked stinging, prickling, or burning sensations, and more or less itching. They are ephemeral in character, and ordinarily disappear as soon as their exciting cause is removed. The papules of eczema occur more frequently during winter than in summer. They are compara- tively large in size and few in number, and are not so closely aggre- gated as in miliaria. They are developed slowly, and manifest a tend- ency to remain for weeks. They are not accompanied by any increase of perspiration, or by the characteristic prickling of miliaria. The itching in eczema, however, is distressingly severe. The vesicular variety of miliaria may be mistaken for sudamina or for vesicular eczema. In sudamina, however, the lesions usually ap- pear as pearl-colored drops of sweat beneath the superficial layers of the epidermis, and are rarely elevated in the form of vesicles. They are not accompanied by any inflammatory or subjective symptoms, and disappear by absorption, without any noticeable desquamation. 302 DISEASES OF THE SKIN. In miliaria vesiculosum the vesicles are numerous and well defined. They are surrounded by an inflammatory aureola, and are accom- panied by marked prickling, burning, and itching sensations. In eczema the vesicles are not surrounded by a distinct aureola, but are situated upon an intensely reddened surface. There is intense itching, and they usually rupture spontaneously, terminating in the formation of crusts, beneath which more or less exudation occurs. In some cases the vesicles become transformed into pustules. In miliaria, however, the vesicles never rupture spontaneously, or become pustular, but usually disappear by absorption as soon as the exciting cause has ceased to act. Pathology.—The pathological process concerned in the production of the lesions of miliaria consists of active hyperaemia of the vessels of the sudoriparous glands, producing, primarily, a marked increase of the sudoriparous secretion, and, secondarily, more or less exudation into the substance of the glands and their ducts, and into the sur- rounding tissues. If the exudation is small in amount, the resulting eruption is papular in character; if it is large in quantity, vesicles are formed. When the hyperaemia subsides, the exudation is absorbed and the eruption disappears. Etiology.—Miliaria is produced by exposure to unusual heat. It may happen in tropical climates at any time during the year, but in countries situated in the temperate zone it is met with only during warm weather. It may be developed or aggravated by wearing too heavy or too light clothing. The corpulent and children are most liable to the attacks of the papular variety. According to my experience, it is much more preva- valent in subjects of nervous temperament and fair complexion than in those of lymphatic disposition and dark complexion. As those who are subject to it are usually in robust health, its appearance is fre- quently regarded by the laity as " a healthy sign." Weak and anaemic persons are more subject to the vesicular variety than the stout and well-nourished. It is often observed in pale, over- worked wTomen, and in puny, ill-fed infants and young children. Treatment.—The majority of cases of papular miliaria require no treatment other than the substitution of light for heavy under-cloth- ing, and the frequent application of cold water to the seat of the eruption. In obstinate cases, or in very fat persons, the bowels should be freely opened with saline cathartics, and meats and condiments excluded from the diet for a few days. Acidulated drinks may be partaken of with advantage. Chalybeate and other tonics may be employed with benefit in the vesicular form of the disease when it occurs in debilitated patients. The best local treatment consists in the free application of cold water, after which the parts should be mopped dry with a soft cloth, EXUDATIOXS. 303 and dusted with bismuth subnitrate or oxide of zinc. If the itching and stinging be severe, immediate relief can usually be obtained by the use of a lotion containing two grains of carbolic acid to an ounce of water. Good results can also be derived from the use of the ordinary officinal pepperment-water, or from a solution of menthol, five grains to the ounce. In India, a lotion composed of ten grains of sulphate of copper to the ounce of water is much employed. Aqua creasoti will also be found palliative. Lotions of alum, or of sulphate of zinc, or of acetate of lead, are occasionally serviceable. In some cases soothing ointments will be found more available. The ointment of the oleate of bismuth is especially valuable. Prognosis.—The prognosis is always favorable. The eruption speedily disappears as soon as measures are taken to counteract the effect of the excessive heat. PEMPHIGUS. Synonym.—Blasenausschlag. Pemphigus is an acute or chronic disease, characterized by the successive development of variously sized and shaped bullae, which are filled with a colorless or yellowish serous liquid. It mostly runs a protracted course, and in subsiding leaves on the skin only dark stains. Symptoms.—There are two varieties of pemphigus, namely, pem- phigus vulgaris and pemphigus foliaceus, each of which, on account of the marked variation in their symptoms, requires separate considera- tion. The former, which is most frequently observed, is generally either acute or chronic, while the latter, which is very rare, is at all times chronic. Pemphigus Vulgaris.—The disease may be either acute, pem- phigus acutns, or chronic, pemphigus chronicus. The acute variety occurs usually in children, sometimes in the form of an epidemic, and runs its course in from two to three weeks. This form may or may not be attended by marked constitutional disturbance. In pronounced epidemics it is apt, in infants, to be complicated by purulent con- junctivitis. The chronic form is the one most frequently observed, especially in the adult. The disease may be ushered in without any prodromal, or with mild or severe constitutional symptoms. If consti- tutional symptoms are present, they may simply consist of a feeling of lassitude, or of chilliness or rigors, headache, pains through the body, quick pulse, occasionally delirium, and irritability of the mucous membrane, especially of the stomach. Fever, if present, usually ceases with the subsidence of the eruption, to return again on a fresh out- break. The eruption may appear first in the form of erythematous spots or wheals, on which blebs develop. At other times blebs may form at once on the skin, and neither be preceded by erythematous 301: DISEASES OF THE SKIN. spots or wheals. The formed blebs are seldom accompanied with any inflammation, their bases only being reddened, and the encircling skin normal or slightly erythematous. They may be attended with itching and burning, the former being usually more marked. Occasionally both these symptoms may occur to a decided degree, leading to great suffering; this form of the disease is spoken of as pemphigus prurigi- nosus. The blebs may develop rapidly or slowly, and may attack all portions of the skin or mucous membrane. The scalp, the palmar and plantar surfaces, and the conjunctivae * are, however, rarely invaded. Steffan, in 1884, contributed an article to Zehender's Monatsblattern upon pemphigus of the conjunctiva, and its relation to so-called essen- tial xerosis of the conjunctiva, in which, in addition to his own case, he collected fifteen observations from other authors. Since that time simi- lar cases have been placed upon record by Gelpke, Baumler, Schmidt- Rimpler, and Deutschmann.f Steffan concluded that the rare cases hitherto described as essential xerosis of the conjunctiva are really due to localized chronic pemphigus of that membrane. With this opinion Prof. Deutschmann coincides, since he has had under observation a decrepit old lady, seventy-one years of age, in whom a typical process of xerosis was associated with pemphigus of the conjunctiva and roof of the mouth. Pemphigus may also invade the mucous membrane of the pharynx and larynx. In these situations it is obstinate and fatal. In pemphigus the number of the blebs vary from one to many, and they may be isolated or arranged in groups. In size they range from a pea to a hen's-egg, or larger. In form they are mostly hemi- spherical or oval, but if they become confluent their shape is de- stroyed. Their walls are tense at first, but, by absorption of the poured-out fluid they may become somewhat flabby. Their contents, in the beginning clear or opaque, gradually become in time sero- purulent. In some instances they present a reddish or dark appear- ance, from blood being effused into them. They run their course in from two to eight days, and are succeeded by successive crops of new blebs. They disappear, as a rule, by absorption, their walls becoming shrivelled, with newly formed epidermis beneath. At times they burst, developing excoriated surfaces, or, after rupturing, their contents may dry into thin scabs. Dark stains are always left, for a long time, to mark their location. The skin in pemphigus may therefore present the characteristic appearance of being covered with few or many blebs, in their various stages of formation, with excoriated spots, thin scabs, and dark stains. * Cohn describes only one case in fifty thousand eye-patients.—Breslauer aer-zt. Ztsch., 1885. + Ueber pemphigus conjunctivae und essentielle Bindehautschrumpfung, von Prof. R. Deutschmann in Beitrage zur Augenheilkunde, II. Heft. Hamburg und Leipzig, Leopold Voss, 1801. Plate IV. L_ Pemphigus (from Nature). EXUDATIONS. 305 The differing appearances produced by the bullae in their different stages and sizes have led to a needless and confusing enumeration of varieties of the disease, no less than ninety forms having been distin- guished by various writers. In a case narrated by Mr. Arthur Clarke, of Street, Somerset, Eng- land, bulla1, some of which were as large as small oranges, developed upon the inner side of the forearms, arms, and in the axillae; also along the inner side of both thighs. The attack occurred in a multi- para, thirty-six years of age, on the fourth day after delivery, lasted but a few weeks, and was not accompanied by much constitutional disturb- ance. The course of the disease will largely depend upon the state of the patient's health, Avhich influences the development of either benign or malignant pemphigus. The former is of a mild type, and usually runs its course rapidly. In the latter variety the blebs are large in size and number; they develop rapidly, coalesce, dry up, or rupture, dis- charging puriform or bloody exudation; crusts form, and perhaps ex- coriated or ulcerated surfaces result. The subjective symptoms of itching and burning are markedly severe, the health becomes under- mined, and death often follows, especially in cachectic patients. Pemphigus Foliaceus.—This variety of pemphigus is exceedingly chronic. It usually appears as one or more bullae on the front of the chest, which are not tense, as in pemphigus vulgaris, but flaccid, the fluid tending to burrow beneath the epidermis, instead of elevating it in blebs. These imperfect formations are the characteristic features of the disease, and contain a milky or yellowish-red fluid. The bleb, or blebs, thus formed is succeeded by others, which develop around or unite with them; or the primary bleb spreads by peripheral exten- sion. The contents are poured out by the rupturing of the bullae, and dry into thin and friable crusts. The epidermis hangs in shreds from the excoriated surface, giving it the appearance of a superficial scald. It seldom reforms on the invaded part, or, if it should, it is removed by successive formations of blebs. The disease gradually, as the bullae increase and multiply, spreads until the entire body is involved. The epidermis no longer forms a sufficient covering, the surface becomes the seat of fissures, with here and there crusts, and the movements even are painful. The hairs become thin and fall out, the eyelids ectropic, and the nails friable. The general health is decidedly inter- fered with, usually after the disease has lasted for some time. Sleep- lessness, fever, loss of appetite, diarrhoea, and other serious systemic disturbances follow, which may ultimately terminate in death. The cure of the foliaceous variety, though not impossible, is rare. In some cases death supervenes within a few months from the beginning of the attack. Pemphigus Vegetans.—A few cases of a fatal variety, known as pemphigus vegetans, have been encountered, mostly in Germany. An 20 306 DISEASES OF THE SKIN. account of this form was given at a meeting of the Royal Medical and Chirurgical Society, March 12, 1889, by Dr. H. Radcliffe Crocker, who had met with a case, the first known to have occurred in Eng- land. Dr. J. Kevins Hyde, of Chicago, has reported the first observed case in the United States. The first symptom usually experienced is pain in the mouth from formation of bullae upon the mucous membrane. In a few days or weeks bullae form upon the integument. Instead of disappearing in the usual way these blebs burst and leave superficial ulcers, which remain unhealed for a long time. In some cases the larynx and con- junctiva are attacked. Owing to the condition of the mouth, it is with great difficulty that nourishment can be administered. Suppura- tive onychitis, with loss of nails, occurred in five cases. But seventeen undoubted cases of this grave disorder are on record. In women the disease may begin upon the vulva and invade the rectum and cervix uteri. In warm and moist regions, such as the groins and axillae, fun- gating papillary growths develop upon the site of the ulcers, and fur- nish a very offensive muco-purulent discharge. The strength is gradu- ally undermined, and all the cases terminate in death. Diagnosis.—The diagnosis of pemphigus, when fully developed, is not, as a rule, difficult. It must, however, be remembered that the mere presence of blebs is not always indicative of pemphigus. They may be produced by artificial means, and in the course of certain dis- eases, such as scabies, eczema, syphilis, herpes iris, impetigo contagiosa, erysipelas, urticaria, and leprosy. They may be caused by friction and pressure, as from walking, riding, rowing, and wearing tight apparel or bands, or from applications to the skin of chemical substances, as nitric acid. The non-existence of successive outbreaks of blebs over a large surface, and the absence of depression, weakness, and emaciation, attendant, as a rule, upon pemphigus, will usually establish the diag- nosis. In case of doubt, the opinion should be suspended, and the patient carefully watched, to decide whether the eruption is the result of accident or design, in order to feign disease. Scabies may at times simulate pemphigus. The history of scabies, its contagiousness and peculiar predilection, and possibly the recogni- tion of the burrows and the itch-mite, point at once to the nature of the disease. Eczema rubrum may be confounded with chronic pem- phigus foliaceus; the denuded surface, covered, perhaps, with more or less crusts and scales in both diseases, might readily lead to a mis- take in diagnosis. The characteristic constitutional symptoms in pemphigus, with possibly the successive outbreak of the blebs, the slight itching, and the absence of infiltration, with the deeply pig- mented skin, cause the disease at once to be recognized. Syphilis may give rise to a bullous eruption, which is incorrectly called syphi- litic pemphigus. The use of the latter term should always be avoided, EXUDATIONS. 307 as it implies a connection between syphilis and true pemphigus, which is erroneous. In syphilis the blebs dry into thick, bulky, greenish crusts, beneath which exist excoriations or ulcers; in pemphigus these conditions are wanting. In herpes iris the bullae may likely be mistaken for pemphigus. Herpes iris is always an acute affection, continuing usually a few weeks; pemphigus is mostly a chronic dis- ease, lasting for some time. In herpes iris severe systemic symptoms are absent, and the eruption occurs generally on the arms, hands, and feet; in pemphigus constitutional symptoms exist, often severe, and the disease has no particular seat. Again, in herpes iris the vesicles and blebs are of varied colors, being arranged concentrically, and surrounded by an erythematous aureola; in pemphigus there is an absence of color, the lesions are not arranged concentrically, and the surrounding skin is usually normal. Impetigo contagiosa may bear a close resemblance to pemphigus, but the absence of constitutional symptoms in the former, and its tendency to involve the lower ex- tremities, with the slow course of its lesions, should assist in distin- guishing it from pemphigus. In erysipelas the development of blebs is not uncommon, but the course of the eruption, which is so distinct from pemphigus, enables one to detect its real nature; Blebs may occasionally develop in urticaria, but the occurrence also of ordinary wheals should clearly demonstrate the disease. The blebs of leprosy are usually attended with cutaneous anaesthesia and other character- istic symptoms which are not present in pemphigus. Pathology.—The formation of the bullae may be preceded by hy- peraemia, or they may appear before any congestion can be detected. Their contents, in the early stages, are a colorless or yellowish fluid, which consist of serum, epithelial cells, and sometimes blood-corpus- cles, pus, and fatty acid crystals. Some observers have also claimed to have discovered free ammonia and uric-acid crystals. The fluid is either neutral or alkaline in reaction, and becomes more alkaline as it grows older. Jarisch gives its specific gravity as 1-019G, and adds that it is composed of 941-9 parts of water and 58-1 parts of solid matter. A microscopical examination of the blebs, in chronic pem- phigus, shows that they exist between the rete cells, or between them and the corium. The lower rows of rete cells may remain nor- mal, or be destroyed. The bullae, after having attained a certain size, - usually consist of but one chamber, but they may be divided into compartments by bands of a fibrinous material. The corneous layer, as a rule, is normal, but the papillae and blood-vessels are enlarged, and the corium and subcutaneous tissue are infiltrated. In pemphigus foliaceus, Xeumann also discovered " the connective-tissue bundles of the cutis thickened, the rete cells clouded by finely granular masses, the sweat-glands enlarged and filled with necrotic cells, the excretory ducts dilated, and the horny layer imperfect." In fatal cases an ex- 308 DISEASES OF THE SKIN. amination may show general anaemia, flabbiness of muscles, oedema of brain and lungs, chronic degeneration of the liver, spleen, and kidneys. In pemphigus foliaceus Petrini found lesions of the cutaneous nerves, roots of the spinal nerves, and the spinal ganglia. Etiology.—Pemphigus is rare, and, as a rule, non-contagious. Cases not infrequently occur, however, of communication of the disease by direct contagion. Dr. Salvage relates the case of an infant in whom pemphigus manifested itself on the third day after birth. Four days before the bullae ceased to develop on the child several appeared on the breasts and forearms of the mother, which came into direct contact with the lesions upon the babe. Shoenberg reports the case of a child, five years old, who suffered from pemphigus, apparently contracted from cows. The disease began in a vesicle, which developed from a scratch upon the finger. An acute pemphigus of very fatal character, in some instances, attacks butchers or those whose occupation obliges them to handle animals or dead portions of animals. The disease occurs in consequence of a wound of the hand or fingers, and is proba- bly of infectious origin. The evidence of the infectious character of the disease is at present conflicting. Experimental inoculations have generally proved unsuccessful, and cultures have failed to reveal the presence of a specific micro-organism. On the other hand, as has been said, cases of transmission are sometimes met with; while Vidal and Colzat claim to have successfully inoculated adults from the liquid contained in bullae, and Gibier has described a special bacillus. An organism has also been studied by Lukasiewicz. A diplococcus was found in acute pemphigus by Demme. Dahnhardt found a similar organism in a case of chronic pemphigus. The disease is sometimes epidemic among infants and children. Pemphigus in children has been known to follow the attendance of certain midwives or nurses. It is met with in all countries, but more frequently in Europe than in the United States. Its causes are obscure. It is more common in infants and children. After childhood it occurs with equal frequency at all periods of life. It affects both sexes; pemphigus foliaceus is said to be more frequent in women. Occasionally it has been known to be hereditary. It is prevalent at all seasons. Atmospheric con- ditions do not appear to influence its production. Unsuitable diet may assist in developing it. Pemphigus arises, as a rule, from a de- praved state of the system. This condition may be caused primarily through the blood, or it may be due directly to an impairment of the nervous system. Jarisch has shown the connection with the latter, in a case in which he discovered anatomical changes in the spinal cord. Dejerine and Leloir have also demonstrated its relationship with the nervous system as manifested by changes in the peripheral nerves. Worry, overwork, excesses, exhaustion, and menstrual troubles are fruitful causes. Henoch has met with acute pemphigus in chil- EXUDATIONS. 309 dren, as a sequel of one of the exanthematous fevers. It may make its appearance after recovery from scarlet fever or measles, may be accom- panied by a tolerably high fever, and may even prove fatal. On the other hand, it may pass into the chronic variety, and last for months or years. Henoch conceives that these cases may be due to the influence of vari- ous deleterious products which had been produced during the course of the fever, and which had not yet been eliminated from the circula- tion. Pemphigus has been known to develop after severe fright. In a case reported by Kaposi,* an injury to the right middle finger was followed by the development of a pemphigus, which gradually ascended the right arm to the right side of the neck, passed thence to the left side, and finally invaded a great portion of the body. Treatment.—Both local and constitutional treatment are necessary. Attention to hygiene and rest, with freedom from all excitement, are essential. The food should be of the most nutritious nature, and should consist principally of meat, eggs, and milk. Attention should also be directed to correcting any functional derangement, and remedies given which will overcome debility and tone up the system. Spirit- uous and malt liquors, the preparations of malt, and the oils, particu- larly cod-liver oil, or substances containing oil, as linseed-meal—used successfully by Sherwell—are very good for this purpose. The gen- eral tonics, the mineral acids, the preparations of ammonia, are some- times indicated. In the acute forms, in which the febrile symptoms are severe, it maybe necessary to have recourse to general blood-letting, with purgatives and antiphlogistic regimen, so well advised by Wilson. Pain, if present, may be counteracted with an opiate, particularly in the form of a hypodermic injection of morphine. All complications which may arise are to be treated according to the indication in each case. Arsenic is effective, especially in the form of small doses of so- dium arsenite. Hutchinson reports the curative action of arsenic, and believes it acts almost as a specific for the disease. Quinine, in full doses, is a valuable remedy, as well as hydriodate of potassium, which was recommended by Wilson. T. McCall Anderson f recommends quinine and arsenic as being more certainly effectual if injected subcu- taneously. Potassium chlorate has been used with benefit by Baren- sprung, and I have also found it a useful remedy in large doses. Til- bury Fox likewise employed potassium chlorate from the outset of the disease, in children, with quinine and wine. In one case, unamenable to the influence of arsenic, G. 11. Fox saw improvement follow the administration of cbaulmoogra-oil. Blaschko has found that the internal administration of antipyrin gives relief to the itching which * Archiv fur Dermatobgic und Syphilis, Heft vi, 1S90; British Medical Journal, December 20, 1890. f A Treatise on Diseases of the Skin, by T. McCall Anderson, M. D. London, Charles Griffin & Co., 18S7. 310 DISEASES OF THE SKIN. attends some cases of pemphigus. In pemphigus vegetans Hutchin- son recommends small doses of opium, given three times a day. Local treatment is of great advantage, in at once relieving the dis- comfort produced by the eruption. The blebs should first be punct- ured, and the contents permitted to escape. This operation is need- ful, in order to bi ing the elevated epidermis in contact with the corium, and thus prevent the blebs from rupturing spontaneously and causing excoriations. A dusting-powder of equal parts of starch and the im- pure carbonate of zinc, or one more stimulating and astringent, as three parts of starch to one of powdered zinc oleate, should then be applied over the surface. It is sometimes more beneficial first to use either a lotion or an ointment, and afterward dust the powder over the surface. Lotions of tincture of witch-hazel, fluid extract of arnica, likewise of grindelia robusta, the tincture of opium, lead-water, and chlorate of potassium may be used; the latter being especially service- able when the mucous membrane of the mouth is involved. Oint- ments of zinc, lead, and bismuth are also of benefit. The external use of cod-liver oil is likewise advantageous. Naphthol-ointment is a use- ful application and relieves the itching, which is often troublesome. Tar-ointment, either full strength or diluted, or the compound tar- ointment of our national formulary, is also of service. If the blebs have burst, and excoriations resulted, the same applications are rec- ommended. If the sores persist, a weak mercurial ointment—five or ten grains of calomel to the ounce—may be applied, or they may be touched with lotions of two to ten grains of silver nitrate or zinc sul- phate to the ounce. Baths, either simple or medicated, are frequently of service, particularly if there is much irritation or inflammation of the skin. The bath may be either warm or tepid, or made emollient by starch, bran, or gelatin, or alkaline by bicarbonate of sodium. The bath of corrosive chloride of mercury—one to two drachms of the salt being sufficient—has been of advantage. The liquid tar-bath has also been recommended, especially in pruriginous pemphigus. Severe cases are benefited by the constant application of one of the ointments already mentioned, or by the continuous water-bath, as recommended by Hebra and Kaposi. The bath just alluded to, however, is not well borne in all cases, and, when it is, can only be practically used in hos- pitals. It requires a bath-tub specially arranged, in which the patient eats and sleeps. Antiseptic and slightly astringent powders or oint- ments are advised in pemphigus vegetans. Prognosis.—Pemphigus is an obstinate and at times a fatal disease. The prognosis, however, depends much upon the variety, being more favorable in pemphigus vulgaris than in pemphigus foliaceus. In the former, occurring in young and vigorous persons, if the lesions appear slowly and are not attended by fever, the result is, as a rule, favorable. In old persons, on the contrary, or if attended in the young with bron- EXUDATIONS. 311 chial, intestinal, or kidney complications, the termination maybe fatal. The prognosis is also unfavorable in cases attended with continuous fever and debility, and in which the blebs appear in numbers, rapidly and successively, and whose walls are flabby and tend to rupture. The disease is liable to frequent relapses. HYDROA. Synonyms.—Pemphigus prurigineuse—Herpes gestationis—Herpes circinatus bullosus. Hydroa is an acute or chronic inflammatory affection, characterized by the appearance of circular erythematous patches of various sizes, upon which vesicles or bullae become developed. It is accompanied by intense itching and more or less constitutional depression. Symptoms.—Hydroa is usually preceded by general malaise, loss of appetite, and various gastric disturbances. The eruption is more or less symmetrical in character, and usually commences as small, red, circular spots, which itch intensely. They rapidly increase in size, and become slightly elevated above the surrounding surface, assuming a papular or semi-papular form. Occasionally adjacent spots mingle and form large, irregular patches. They may appear upon any portion of the body, but are more frequent on the face and the extremities. After a period, extending from a few hours to several days, a number of vesicles may be observed upon each erythematous area. They are arranged in groups, and frequently coalesce and form large bullae, from half an inch to an inch in diameter. The further course of the erup- tion varies in different cases. The vesicles and bullae may disappear by resolution, they may rupture spontaneously and terminate in the formation of crusts, or they may be ruptured by the patient while scratching. In rare cases they become transformed into pustules, which finally break down and cover the surface with yellowish or green- ish crusts. The eruption may pursue an acute course, but it usually remains with remissions and exacerbations for several months, or even for two or three years. It is always accompanied by marked itching and burning sensations, and various symptoms of nervous depression or general debility. Hydroa may occur at any age and in either sex. It is not infrequently observed during pregnancy. A rare variety, termed hydroa vacciniforme by Hutchinson, is characterized by the production of crusts which, when they fall, leave deep cicatrices. Quinquaud has published the description of a case which he de- nominates hydroa-stomatitis. The patient was a young woman in whose mouth were found small bullae. A similar eruption, without a trace of erythema, was found upon the hand. Their development was accompanied by fever, and microbes were found in the urine and the blood. Diagnosis.—The affections from which hydroa is to be distin- 312 DISEASES OF THE SKIN. guished are herpes zoster, herpes iris, pemphigus, and varicella. In herpes zoster the vesicles are seated upon a reddened base, but they are usually small in size, and are developed over the course of the peripheral nerves. In hydroa the lesions consist of large vesicles or bullae, and are not limited to the track of the nerve-supply. In herpes zoster there is little itching, but the pain is intense, and the lesions are almost invariably limited to one side of the body. In hydroa the pain is trivial, but the itching is violent, and the eruption appears on both sides of the body. Herpes iris frequently closely resembles hy- droa, but the concentric character of the rings, and the absence or trivial character of the itching, will prevent any error from being made. The large bullae of hydroa have been mistaken for those of pemphigus. In pemphigus, however, the itching is seldom marked, and a fatal result not infrequently ensues. In hydroa the itching is intense, and recovery is the rule. The vesicles of varicella present a superficial resemblance to those of hydroa. Varicella, however, is a disease of childhood, characterized by the development of a variable number of isolated disseminated vesicles, accompanied by elevation of temperature, but unattended by marked itching. Hydroa usually ap- pears during adult life, the vesicles are grouped, there is no fever, but the itching is intolerable. Pathology.—Reflex irritation of the peripheral nerves is probably an important factor in the production of the various lesions of the disease. The capillary vessels of the corium become dilated, and an extensive exudation of serum occurs, resulting in the infiltration and elevation of the papillary layer, and the formation of vesicles and bullae. Etiology.—Hydroa is probably neurotic in origin, and dependent upon mental depression or anxiety. It is usually associated with evi- dences of general debility or ill-health. In some cases it is apparently due to malarial infection. When it occurs in pregnant women, it may be symptomatic of an irritable condition of the nervous system, dependent upon impoverished blood. Gibier supposes the exciting cause to be a specific micro-organism. Treatment.—The treatment should be directed to improving the general nutrition of the patient, and removing any sources of irrita- tion that may be observed. The patient should be placed upon a diet of milk, eggs, fruit, and bread. All the bodily functions should be regulated, and exercise taken daily in the fresh air. In cases in which a malarial origin is suspected, quinine may be given in large doses. In those in which nervous depression is the most prominent symptom, the best results can be obtained from the administration of mix vomica and phosphoric acid. Anaemic individuals will be bene- fited by the various chalybeate preparations. According to Crocker,* * British Medical Journal, May 22, 1886. EXUDATIONS. 313 arsenic and belladonna exercise almost a specific effect upon the dis- ease. In a well-marked case which recently came under my observa- tion, the eruption disappeared rapidly under the administration, after meals, of three minims of Fowler's solution combined with one minim of tinct. opii deodorata and half a minim of tinct. capsici. The in- tense itching can usually be rapidly relieved by the application of lotions or ointments of carbolic acid and other anti-pruritics. Secretan has reported a case in which lotions of one-per-cent. carbolized water not only relieved the itching, but were followed by gradual improve- ment of the lesions. Prognosis.—The prognosis is favorable if time be conceded. The eruption sometimes proves obstinate to treatment, but it finally dis- appears when the general health improves, or when the source of irri- tation is removed. POMPHOLYX. Synonyms.—Dysidrosis—Cheiro-pompholyx. Pompholyx is an acute, exudative, cutaneous disease, characterized by the formation of a variable number of deep-seated vesicles, which terminate in a few days by spontaneous rupture or absorption, and are followed by slight desquamation of the epidermis. Symptoms.—The eruption is symmetrical in character, and is usu- ally limited to the sides of the fingers and the palms of the hands. It may, however, appear upon the soles of the feet and other portions of the body. Jamieson has seen a case in which the face and mucous membrane of the mouth and tongue were attacked, in addition to the hands and feet. At first they are minute, isolated, transparent vesicles, deeply imbedded in the skin. They slowly increase in size, and be- come whitish or opaque, resembling grains of rice or sago beneath the epidermis. The process may be arrested at this stage, and reso- lution take place by absorption. Generally, however, the exudation continues, the vesicles increase in size and are elevated above the sur- face, and may even coalesce and form large bullae. In a few days the fluid begins to disappear by absorption, or the walls of the vesicles and bullae rupture and the contents escape. More or less desquamation of the epidermis follows, resulting in the exposure of a reddened, abrad- ed, non-discharging surface, which rapidly heals. The eruption is usually accompanied by slight itching and burning, and more or less nervous depression. When the eruption is extensive, it occasions stiff- ness of the hands and fingers. Pompholyx of the face may cause pain- ful fissures. Diagnosis.—Mild forms of this affection might be mistaken for sudamina, but the presence of more or less itching and burning will suffice to make the diagnosis. Severe cases may present a slight re- semblance to eczema vesiculosum. In eczema, however, the subjective 314 DISEASES OF THE SKIN. symptoms are more intense, the surrounding surface is hot and ery- thematous, and the rupture of the vesicles is followed by the formation of crusts and the exposure of an exudative surface. Pathology.—Fox and Crocker believed this affection to be due to retention of sweat and dilatation of the sweat ducts or glands, and termed it dysidrosis. Robinson,* however, has shown that these structures are perfectly normal, and that the vesicles are formed by an exudation of serum from the papillary vessels into the deeper layers of the rete mucosum. Etiology.—The etiology of pompholyx is unknown, but it is probably associated with some disturbance of the nervous system. It occurs in those suffering from depressed nutrition and also in those whose general health appears to be good. It is most frequent during adult life and in the summer season. In winter it commonly attacks those who, like cooks, are exposed to the influence of heat. Treatment.—According to Robinson, arsenic exercises almost a specific effect, and, when given in time, will invariably abort the eruption. Full doses- of Fowler's solution, or arsenious acid, should be given until all traces of the vesicles have disappeared. Quinine, iron, and strychnine, and the mineral acids, will also be found serviceable. A full supply of nourishing food is of the utmost importance. Locally, any soothing ointments or lotions may be applied to lessen the itching and burning, or to protect the abraded surface. Prognosis.—The prognosis is always favorable. The eruption dis- appears, with or without treatment, in a few days or weeks, but relapses may occur at intervals. ACNE. Synonyms.—Acne disseminata—Acne vulgaris—Acne boutonneuse—Varus-Finnen. Acne is an inflammatory disease, involving the sebaceous glands, usually chronic in character, and appearing in the form of papules, tubercles, pustules, or abscesses, either alone or combined, and affect- ing more particularly the face, neck, chest, or back. Symptoms.—Acne is one of the most common diseases of the skin, existing either alone or in combination with comedo or seborrhcea. It appears in the form of papules, pustules, tubercles, or nodules, from the size of a pin's-head to a bean, solid or filled with pus, isolated or arranged in patches. It may occur on any portion of the body ex- cepting the palmar and plantar surfaces, but its chief predilection is for the face, neck, chest, and back, the regions most plentifully pro- vided with sebaceous glands. When acne attacks the face, the forehead, cheeks, and chin are the portions usually involved. It may appear on the face and trunk at * A Manual of Dermatology, by A. R. Robinson, M. D. D. Applcton & Co., New York 1886. EXUDATIONS. 3i;» the same time. In other instances the trunk, arms, and thighs alone will be the seat of the eruption. Acne is usually symmetrical, but irregular in its distribution. It is observed in both sexes, especially about the age of puberty. Acne may occur at any time of life, but is rarely seen after youth and middle age. Acne may be acute or chronic, the latter being the general rule, suc- cessive crops of the eruption appearing, disappearing, and reappearing from time to time for many years. The eruption may be mild or severe—consisting in the former case of a few isolated or scattered, pale, bright, or dark-red papules, and in the latter of groups or bunches of papules, of various shades of color, with or without a central point of suppuration—with pustules, nodules, and abscesses, often accompa- nied by comedo and seborrhoea. In many cases the disease may be observed in all its stages, from the retention of secretion to the inflammation and suppuration of the glands. The inflammation may be superficial or deep-seated, giving rise, in the latter event, to the formation of pustules and abscesses, which will leave the skin marked with indelible scars. These scars may be slight or severe, and when the latter occurs the face, when involved, is very much disfigured. There are several well-marked varieties of the disease. Acne Papulosa.—In this, the mildest form of acne, the eruption consists of a number of more or less conical, pale-red papules, varying in size from a pin's-head to that of a pea. The lesions are generally mingled with comedones, and are scattered over the face, especially around the forehead. The centre of the papules may present a darkened appearance, exhibiting the opening of the ducts, blackened by dirt and exposure, forming the condition known as acne punctata. The eruption exhibits different degrees of severity in different individuals, from a few irregu- lar! v scattered to many papules, at times associated with pustules in various stages of development. Acne Pustulosa.—This is the most frequently observed variety of acne. The lesions vary in size from a pin's-head to a split pea. They are in all stages of development, and are 'generally associated with papules, papulo-pustules, and at times with seborrhoea. The inflammation may be mild or severe, and consequently the amount of suppuration may be slight or abundant, leading to the formation of either small or large pustules. Each pustule contains a drop or more of pus. When the inflammation is severe, abscesses containing a large amount of pus mixed with bloody serum may develop. The pustules generally form rapidly, and terminate by absorption and desiccation, or burst, and in scabbing over and healing leave behind a slight cicatrix. The pustules are either round or conical in shape, and are surrounded by an inflammatory aureola. In some instances 31G DISEASES OF THE SKIN. neighboring lesions coalesce, lose their hemispherical form, and become oval-shaped. This appearance has been called acne hordeolaris (that is, in the shape of an oat or barley grain). The larger pustules are frequently attended by pricking and burn- ing sensations and the abscesses by considerable tenderness. If the inflammation is deep-seated, the subcutaneous cellular tissue is involved to a considerable extent, the base of the pustule is hard and indolent, and perhaps purplish, with little or no tendency to sup- purate. This condition is known as acne indueata, and is fre- quently met with on the face, but more particularly about the sub- maxillary region. In consequence of long-continued congestion of the parts, hyper- trophic growth of the connective tissue may set in, the skin becomes red, rough, and greasy, the glands enlarge, and small tumors form, giving rise to what is termed acne hypertrophica. At times the acne-spots are succeeded by atrophy of the skin, and they are then named acne atrophica. Under the title acne varioliformis Hebra describes an eruption which attacks the forehead near the margin of the hair, and may involve the hairy scalp. The lesions are reddish-brown papules varying in size, from a pin's-head to that of a lentil, and sometimes surrounded by an inflammatory zone. These papules do not develop in connection with the sebaceous glands. To their summit a dry, brown crust is closely attached, and so remains for a long time, leaving a cicatrix when it falls. Boeck gives the name acne necrotica to an eruption of small, shining papules of a pale-red or yellow color, upon which after a time dry, brownish-red crusts form. Large crusts result from a coalescence of many papules, and beneath these crusts the corium is eroded. The eruption, when appearing in strumous, anaemic, and tubercu- lar subjects, is known as acne cachecticorum. The lesions gener- ally develop on the trunk and extremities, are dark-red, purplish, or violaceous papulo-pustules, of all sizes, and are noted for their indolent and sluggish course. Acne Artificialis.—Acne-spots are often developed during the use of various drugs, either internally or externally, as well as by the application of various irritating substances to the skin. Thus, the internal administration of iodine and iodide and bromide of potassium is followed in many persons by numerous crops of papules on the face, neck, back, chest, and at times on the thighs and arms, which may remain unaltered or rapidly changed to pustules. Again, the use of certain cosmetics, powders, and paints, on the face, neck, and chest, resorted to by ladies, or rubbing the same parts with dyed ribbons or flannel, to give a healthy hue to the countenance, will often cause an outbreak of papules and pustules. The enamelled bands of men's hats sometimes give rise to an eruption of acne upon the forehead. The Plate V. it' *yrf 'Mr m Acne Indurata (from Nature). EXUDATIONS. 317 wearing of chest-protectors, bands, and flannel next to the skin, fre- quently causes an outbreak of papulo-pustules. The use of tar, carbolic acid, and chrysarobin will produce an attack of acne, which will per- sist until these substances are discontinued. The summits of the pap- ules, in these cases, usually present a black point, corresponding to the duct of the sebaceous gland or hair-follicle, from one or another of the substances having lodged there. The same effect may be observed in those who work among grease, petroleum products, tar, and arsenic preparations, and especially in dyeing establishments where woollen fabrics are colored. In many instances the vapor, coming in contact with the skin, is sufficient to set up an irritation and inflammation of the glands, and the development of acne. Diagnosis.—The characteristic.symptoms of acne are so well marked in the great majority of cases as to make the diagnosis simple and easy. The age of the patient, the situation and chronic course of the eruption, the typical, irregular, scattered or grouped lesions, appearing and disappearing, are significant. It might, however, be confounded with papular, papulo-pustular, or tubercular syphilis, variola, eczema, and rosacea. Syphilis and variola may both assume precisely the same appearances as acne. The examination should, therefore, be made with great care, and an opinion expressed only after a thorough study of the course of the eruption. Acne can be distinguished from syphilis by the history and course of the latter, and its tendency to ulceration, and its appearance at the same time in other parts of the body. I have seen subjects, however, in which both affections were commingled, the acne appearing either before or during the eruption of syphilis, and very often hiding the true nature of the latter affection. It will be found, upon inquiry in these cases, that iodide of potas- sium, or some medicinal substance, has been taken internally or applied locally, and produced an outbreak of acne. The discontinu- ance, for a time, of the medicine or local application used, will en- able the physician to say which is the predominating affection. Variola differs from acne in its history, course, and constitutional symptoms. The eruption of variola is first papular, then vesicular, and finally pustular. It is acute in character, preceded by a chill, and ac- companied by high fever and other grave symptoms. In acne there are neither vesicles, chill, nor fever, and the eruption pursues a chronic course. Papular and papulo-pustular eczema may simulate acne. In the former the lesions are not necessarily located in the follicles, and scales and an interpapular infiltration are usually observed, which are not present in the latter. Rosacea, although frequently complicated with acne, differs from it in the local congestion which primarily arises without particularly in- volving the sebaceous glands. 318 DISEASES OF THE SKIN. Pathology.—Acne is due usually to a retention of the sebum within the hair-follicles and sebaceous glands connected with them, followed by its decomposition, which often leads to a peri-folliculitis. During the first stage hyperaemia, with exudation and emigration of corpus- cles, may take place, followed sometimes by a destruction of the follicles and glands. If the inflammation is active, suppuration gen- erally ensues, resulting at times in induration, hypertrophy, and atro- phy of the tissues of the parts. In some cases, as Hebra observed, the sebaceous plug is wanting, and the epidermis lining the follicles ap- pears to be abnormally developed, setting up irritation and occasioning inflammation of the parts around. In others, the changes may occur alone within the sebaceous glands. As a rule, the disease is primarily a folliculitis, and, as Robinson has noted, differs from sycosis, which begins as a peri-folliculitis. The vessels which surround the hair-follicle are dilated and en- gorged. According to Leloir and Vidal,* the pus is primarily derived from the adjacent derma. They speak of having seen the distended hair-follicle crowded with epithelial cells but perfectly free from pus, while little collections of pus surrounded or lay beneath the follicle. Eventually the lining membrane of the follicle is destroyed, and the pus gains entrance to the cavity. The sebaceous gland itself may or may not become involved. These authors consider that acne, in most cases, begins with a peri-folliculitis. In atrophic acne the hair-follicle and its sebaceous gland are entirely destroyed, their place being taken by a mass of epithelial cells which, to a certain degree, preserves the form of the gland and follicle. Etiology.—Acne appears in both sexes, and can be induced by either constitutional or local irritation. In many instances it arises from some reflex affection. Among the various internal causes are the physiological changes which take place at the period of puberty, a time when the blood-vessels and nerves of the sebaceous glands and the hair-forming apparatus are especially active. Any constitutional or local irritation that may then arise will very often, more than under ordinary circumstances, excite congestion of the parts, lead to the retention of the sebaceous secretion, inflammation, and the develop- ment of the disease. It is under such circumstances that all debilitating conditions, dis- orders of organs or portions of the economy which have a reflex action on the face (particularly the gastro-intestinal canal, genito-urinary tract, and mental troubles), excite and aggravate it. That mental emotions will affect facial circulation is well shown by the sudden dilatation and contraction of the cutaneous capillaries in blushing and in paling. Puberty, with the attending physiological changes, therefore, fre- * Traite descriptif dcs Maladies de la Feau, p. 14. EXUDATIONS. 319 quently gives rise to acne, especially when some irritation is present, which may continue until the system has passed through this period and has returned to a state of rest. Again, some persons are born with the organ of the skin naturally weak. The skin is then oily or scaly, or both conditions are combined, from the debility of the glands. The lymphatic and strumous frequently present this condition of the skin. They are therefore prone to acne, and any reflex irritation will lead to the retention of the sebaceous secretion; the glands be- come blocked up, and inflammation sets in, often with the formation of pus. The amount of pus production will depend upon the intensity of the inflammation and the state of the constitution. In subjects pre- senting a strumous condition the inflammation is usually severe, the connective tissue around the glands is implicated with a free formation of pus, with resulting atrophy or pitting of the surface. In persons of this diathesis the lesions will usually present the appearance of a scrofulous affection, differing only from ordinary acne by its obstinate and indolent nature, the intense inflammation, the rapid and abun- dant formation of pus, and the tendency to leave behind indelible cicatrices. Acne may occur at any period of life, but is most common at puberty. It attacks both rich and poor, regardless of nationality, climate, or complexion, although those having a light skin are more predisposed to it than those of a dark one. It may be occasioned by debility, anaemia, chlorosis, or from a derangement of the alimentary canal or genito-urinary system. Experience will point out to every physician that stomachic and intestinal disorders, especially when attended with constipation, and ovarian and uterine affections, will, by their reflex action, cause its appearance. The lesions will abate, to crop out again, depending entirely upon the treatment they receive, whether judicious or other- wise. In the subjects of acne the eruption is frequently aggravated by dietetic errors. The ingestion of certain articles of food, par- ticularly cheese, may be sufficient to cause a fresh outbreak of pust- ules. Barthelemy, of Paris, lays especial stress upon the existence of dyspepsia with dilatation of the stomach as a cause of acne. He de- clares that of 169 cases studied within the period of five years, he has in 105 detected splashing (clapotage), an important sign of dilatation of the stomach. A seborrhoea is first excited in consequence of the ill elaboration of aliments in the stomach. The oily, seborrhceic skin be- comes an excellent culture-medium for the acne-germ, assuming the existence of such a germ. This writer supposes that acne, pure and simple, is always papular, and that it is by the co-operation of other germs—generally, according to Gibert, the staphylococcus albus—that 320 DISEASES OF TEE SKIN. acne becomes pustular, nodular, phlegmonous, etc. He sums up the etiology of acne in the following phrase : The interior prepares the soil, from the exterior comes the seed.* Climate has a certain influence in the production of acne, which is more common along the sea-coast than in the interior. Patients will, however, occasionally present themselves in whom the physician will not be able to trace the disease to any assignable cause. Acne may also result, as has already been stated, from the internal use of the iodides, bromides, and other me- dicinal substances. It may likewise be developed by any local irrita- tion, as uncleanliness, the use of caustics, soaps, tar, carbolic acid, chrysarobin, creasote, powders, paints, and various cosmetics. Those who work among oils, dyes, arsenic, and woollen fabrics are often affected. Among the causes occasionally productive of acne Brocq names epilation or the application of depilatory ointments. The micro- organisms known to excite suppuration are generally found in pus from the lesions of acne. The form most frequently met with is the staphylococcus albus. Treatment.—Although acne is at times a very obstinate affection, nevertheless it can be relieved and cured by good management and patience on the part of both physician and patient. The treatment usually pursued is constitutional and local. With some, attention to the general health suffices; with others, direct application alone an- swers ; while in certain instances a combination of both internal and external remedies is required. Constitutional Treatment.—It is necessary in every case care- fully to inquire into the habits of the patient; in fact, to attempt no treatment until it has been satisfactorily settled that the affection is or is not dependent upon an exciting cause. The first point should be an examination into the condition of the alimentary canal, to see if a coated tongue, eructations, diarrhoea, constipation, or one of the many functional derangements of this part of the economy, wThich are such prolific sources of acne, is an active factor in producing the affec- tion. To find the cause and remove the lesions, the practitioner must be proficient in the principles of general medicine, and able to apply a thorough knowledge of therapeutics to the case under consideration. If the tongue is furred, small doses of the mild chloride of mercury, blue pill, or mercury with chalk, given alone or in combination, occa- sionally with jalap, or compound extract of colocynth, will be found efficacious for the abnormal state of that organ, as well as for constipa- tion often alternating with diarrhoea. The late Prof. Joseph Pancoast frequently prescribed, during my service on his clinic, for similar con- ditions, with much advantage, the following: * Medical Bulletin, May, 1890, p. 172. EXUDATIONS. 321 IJ Pilulae hydrargyri, Pulveris jalapae, Extracti colocynthidis co........aa gr. xij. Olei menthae piperitae..'........... til 3- M. Ft. pil. no. xij. Sig.: One or two pills when necessary, every second or third niglt on retiring. Constipation may also be combated with aloin, podophyllin, cascara sagrada, or any one of the numerous vegetable or saline laxatives. When the intestinal canal is torpid, small doses of nux vomica, bella- donna, physostigma, or muscarine, or the use of faradization over the abdomen, will often afford relief, or entirely remove the constipation. The use of the natural mineral waters, especially the Bedford, the Congress and Hawthorn Springs of Saratoga, the Capon Springs of West Virginia, taken regularly before meals, will be found beneficial in overcoming constipation and in toning up the alimentary canal. In case the patient can not go to the springs, it will then be best to have the spring-water procured in bottles or barrels, and taken at home. It is often advantageous to combine the internal administra- tion of one of the ferruginous preparations with a natural mineral water, or to give a saline containing a large quantity of iron, which adds additional vigor to the alimentary canal. Or, a sea-voyage, and residence at Cheltenham in England, Baden-Baden or Kissingen in Bavaria, or Carlsbad in Bohemia, and drinking their waters, will often effect a very happy change. If this io impracticable, beneficial results may be obtained by taking, at home, before meals, the mineral waters of these places, imported in bottles, but they should be drunk in a regular and systematic manner; the Carlsbad in particular being noted for curing many derangements of the digestive tract. The use of stewed fruits for their laxative effects is also of benefit. The following prescription has proved beneficial in many under my care, suffering from acne due to stomachic and intestinal dis- orders : IJ Tincturae ignatiae................. ""I lxxx. Tincturae coptis trifolia.....q. s. ad. f 1 iv. M. Sig.: Two teaspoonfuls in water half an hour before meals. The tincture of the burdock-seed combined with the tincture of the gold-thread and ignatia also forms a most excellent tonic, and acts beneficially on the glands of the skin. Hoang-nan is another remedy which I have employed with much satisfaction in those cases which are obviously linked with dietetic errors. This drug fulfils a number of important indications in the management of acne. It stimulates the appetite, improves digestion, both gastric and intestinal, promotes intestinal secretion and peristalsis, and acts as a gentle laxative. Moreover, it exerts a peculiar selective 21 322 DISEASES OF THE SKIN. influence upon the sebaceous glands, correcting both the quantity and quality of their secretion when disordered, softening the sebaceous plug and facilitating its expulsion, and therefore indirectly favoring the subsidence of the inflammation in and around the glands. I am usu- ally accustomed to administer the fluid extract in doses of five to thirty drops in water just before meals. Naphthol, likewise, as an agent powerful in securing intestinal antisepsis, is a valuable constitu- tional remedy in the treatment of acne. In other cases, where there is much acidity, the subnitrate of bis- muth, in ten-grain doses, can be employed with decided benefit. When it is desired to give the bismuth in a mixture, the following prescrip- tion is of service: R, Bismuthi subnitratis.............. 3 ij. Pulveris myristicae................ gr. xl. Syrupi zingiberis.................. f f iij. M. Sig.: Two teaspoonfuls in water after meals. An equally good and often preferable preparation is pepsin, bis- muth, and strychnine, given in the form of a powder or pill after meals. In scrofulous subjects, and in those who are poorly nourished, the preparations of malt, or cod-liver oil, either alone or combined, are especially indicated. If the digestive organs are weak, it will be better to give dilute phosphoric acid with the compound tincture of cinchona or with cod-liver oil. The hypophosphites and phosphates, in this same class of patients, and in those who are pale, with loss of appetite and lack of vigor, cer- tainly prove efficacious. Quinine and strychnine are likewise beneficial, improving the appe- tite, digestion, and general strength. The preparations of sulphur and arsenic can frequently be given with excellent results. The first can be used in the form of the sul- phide of calcium,* as recommended by Ringer, in from one tenth to one half grain, four times daily. The continued use of five-grain doses of precipitated or washed sulphur, given in milk or capsules, or the same quantity made into a lozenge, with one grain of cream of tartar, as suggested by Garrod, will also be found beneficial in many cases. This remedy acts favor- ably upon the biliary and intestinal secretions, stimulates the muscu- lar coat of the bowel, and is therefore an efficacious depurant. Unna is fond of using ichthyol internally in acne, but the virtues of this substance principally depend upon the sulphur which it con- tains, and I have found it frequently irritating to the gastro-intestinal canal. * For further research on this remedy, see " Report of Committee on Restoratives, of the Therapeutic Society of New York, on the Use of the Calcium Sulphide as an Anti- suppurative." New York, April 24, 1882. EXUDATIONS. 32o Arsenic can be used, either in pill form or given as the liquor potassii arsenitis, in one or two drop doses before meals. It is a valu- able agent in relieving certain forms of dyspepsia, particularly chronic gastric catarrh, chlorosis, and anaemia, and will thus often, after bene- fiting or curing one or another of these affections that may be pres- ent, also completely eradicate acne. Piffard has derived good results from the use of bromide of arsenic in small doses. The chlorate of potassium is a serviceable constitutional remedy in acne, and checks the tendency to suppuration. It is stated by Gubler, of Paris, that glycerine, in acne punctata, will sometimes be found useful. In some cases of acne very good results have been yielded by the administration of ergot, as suggested by Denslow; one half drachm of the fluid extract or three grains of ergotin are given three times a day. According to Dr. G. 11. Fox, it succeeds best in lymphatic subjects in whom the skin is thick and pasty and the circulation sluggish. Prof. Hardy recommends the administration of 30 grains of chlo- ride of sodium daily in severe and obstinate cases of acne indurata. Young adults suffering from derangements of the genital organs should have, if possible, all such irritation removed by suitable treat- ment, and should be advised to gratify their sexual desires by mar- riage, after being completely cured. The passage of a cold steel sound twice a week is serviceable in some cases. Young women having uterine and ovarian affections, being usually those that are anaemic and debilitated from leading a sedentary or a gay or dissipated life, or one of over-work in schools, stores, or machine-rooms, need, above all things, a complete change in their mode of living, and should take iron, quinine, or strychnine, or one of the many bitter tonics. Appropriate treatment addressed to the uterine disorder may be required, and the hot vaginal douche is some- times of value in chronic cases. The disease in some may be so severe as to require a uterine examination and appropriate local treatment. Hygienic measures are of the utmost importance in acne, especially in scrofulous subjects. The general surface of the body should be bathed frequently, to promote a more healthy and vigorous action of the skin. Cold water is to be used, when there is no counter-indica- tion, by either sponging the surface, or by the cold douche, or by im- mersion of the entire body. Many are not able to bear cold water in one or other of the forms just suggested, and with such the warm, hot, or vapor bath may be substituted. Moderate and regular exercise in the open air during sunlight, either walking, riding, driving, boatmg, skating, or in taking sun-baths, will have the happiest effect in bring- ing about a cure. The last but by far the most important consideration in treating the disease, is the selection and use of proper food. During youth, when there is such a physiological activity of the glands, blood-vessels, and 324 DISEASES OF TnE SKIN nerves, there is active waste and repair taking place in the economy. It therefore behooves acne subjects to be abundantly supplied with food that is rich in nitrogen and inorganic constituents, to meet the demand of the growing body. Food that is indigestible and unwhole- some, such as pastries, jams, sweetmeats, pickles, and cheese, should always be avoided. The health and functions of the skin in acne may be decidedly promoted by the employment of electricity and by the practice of massage. The use of these agents has a stimulating and corrective influence upon the sebaceous glands, and they may be very beneficially employed in acne, especially when the disease presents itself in a stub- born form, as acne indurata, or occurs in a markedly debilitated subject. Massage performed daily along the course of the large intestine is also to be recommended. This manipulation materially assists the action of medicines given to act upon the gastro-intestinal secretions. It is of importance, moreover, that the feet should be kept warm, as patients with acne are habitually troubled with cold feet. The usual means of stimulating local circulation should be employed, as by walking, massage, foot-baths impregnated with salt or mustard, flagellation with hot and cold water, frictions with camphorated alcohol, etc. Local Treatment.—As acne is an inflammatory affection, due to an irritation, the local treatment should first be directed to the removal of this irritation, after which the parts should be soothed, and the con- gestion relieved with appropriate remedies. A very simple and appro- priate remedy consists in the application of hot water to the parts, ad- vising that it should be as hot as the patient can bear; the addition of a small quantity of starch, or borax, or both, can be made to the water when the congestion is very great. The systematic use of hot water is, in fact, an excellent topical remedy in this disease. The application may be made two or three times a day for about five minutes at a time, and may be made by means of a sponge or a soft handkerchief. A cheap and convenient little instrument for the application of hot water has been devised by Dr. Leviseur, of New York. It consists essentially of a glass test-tube fitted to a holder. The tube is half filled with cold water and its opening tightly plugged wdth absorbent cotton. Reversing the tube the pressure and adhesion of the water holds the cotton firmly in place. The holder with the cotton is then dipped in hot water and can be ex- actly expressed upon the area of disease. After the use of the hot water, Brocq advises touching the lesions with absorbent cotton which has been dipped in equal parts of hot water and eau de Cologne or camphorated alcohol, the latter of which he esteems more generally efficacious. The quantity of water is gradu- ally lessened until the alcoholic lotions can be borne without dilution. EXUDATIONS. 32.-) Alcohol containing one-thirtieth of salicylic acid has also been recom- mended. In the early stages of the affection I usually prescribe applications of the ointment of the oleate of lead, or the ointment of the oleate of bismuth, or zinc, adding at times arrow-root, mercury, creasote, or morphine, as in the following combination : R. Unguenti plumbi oleatis............ 3 ij. Pulveris marantae.................. 3j. Olei olivae........................ q. s. M. Ft. unguentum. Sig. : Apply lightly over the surface. In case it is necessary to stimulate the lesions, the addition of from ten to thirty grains of beta-naphthol can be advantageously made. Another very good application is : IJ Unguenti bismuthi oleatis.......... 3 j- Sig. : Apply night and morning. An ointment containing iodide of sulphur will often prove bene- ficial. It is advisable to begin with a strength not exceeding ten grains to the ounce. If the parts are thickened and indurated, add from one to five grains of naphthol. Another excellent combination is : IJ Unguenti zinci oleatis.............. 3 ij- Naphthol....................••--- gr- ij- Pulveris marantae.................. 3 ss. Cerati simplicis.................... 3 ij. M. Sig.: Apply frequently to the parts. Many other medicinal substances of a soothing or stimulating na- ture, according to the indications, can be beneficially combined with the above oleates. Soothing lotions may also be used in some cases, and are often more acceptable than ointments. I occasionally recom- mend : IJ Atropinae sulphatis................ gr. ss. Pulveris sodii biboratis............. 3 jss. Aquae rosae........................ f 1 iv. M. Sig. : Sponge over the surface. Again, I often use : R Liquoris plumbi subacetatis......... 5 ij. Aquae sambuci flor................. f 1 ij- M. Sig. : Saturate an old piece of muslin, and apply for a short time, night and morning. The following will also be found beneficial : IJ Acidi borici....................... 3 iij- Aquae aurantii flor................. f f ij- Aquae rosae....................... f- 3 lj- M. Sig. : Use externally. 326 DISEASES OF THE SKIN. Barthelemy recommends carbolized and sulphurated pastes, paints of camphorated naphthol, or atomization with ether holding in satu- rated solution camphorated tannin, salicylic acid, or iodoform. For stubborn cases the following formula is employed in Lassar's clinic: IJ Pulv. cretae albae.................... 5-0. Naphthol, Camphor, Vaselin......................... aa 10.0. Sapon. virid........................ 15. M. Sulphur precipitat.................. 50. The above preparation should not be left upon the skin more than fifteen minutes, on account of the irritant properties of the camphor. Another useful formula is: IJ Resorcin, Zinc, oxid.......................aa 5.0. M. Vaselin............................ 10.0. In many cases where large portions of the body are covered with the eruption it is of great value, either to soothe or slightly stimulate the lesions by the addition of a medicinal substance. I frequently use with advantage a steam, medicated, or liquid bath. The last can be made emollient by the addition of starch or linseed ; alkaline, with bi- carbonate or biborate of sodium; acid or iodine bath, by the addition of one or another to the water. Medicinal vapor-baths of sulphur, mer- cury, and naphthol have likewise proved of service. Soap may also be used with the bath, either alone or combined with such drugs as sul- phur, tar, mercury, carbolic acid, naphthol, thymol, and chamomile. Dr. II. S. Purdon reports good results from washing the affected part at night with the oil of amber, removing it the next morning with soap and hot water. Mr. James Startin describes a method by which, in addition to die- tetic and medicinal treatment, he has obtained'good results. It consists in applying to the diseased area a plain or medicated steam bath by means of an apparatus similar to the familiar carbolic spray-producer, but smaller. As soon as steam is produced it can be applied at about a foot and a half from the patient for twenty minutes or half an hour. Its action is similar to that of the Turkish bath; it is refreshing to the skin, beneficial to the complexion, and speedily removes comedones. A method introduced by Dr. Walter Smith, often attended by satisfactory results, consists in touching each pustule with a drop of liquefied car- bolic acid and then covering with collodion. If a simple case should not yield to the foregoing treatment, I then resort to the use of a mechanical remedy by puncturing all the papules and pustules, and scooping out the sebaceous plugs with the needle- knife which is represented in Fig. 10, and which I described in 1878. This knife is like a fine needle, having flat sides pointed upon the ex- EXUDATIONS. 327 tremity, and presenting the appearance of a spear. Each papule, pust- ule, or abscess is punctured by inserting in a perpendicular manner the needle-knife, and the blood and broken-down sebum will then readily flow from most of them. Occasionally the accumulated sebum manifests a tendency to remain, but gentle pressure at the sides of the lesion will usually bring it away. It will likewise be necessary to nick the sides of the dilated follicles that contain plugs, pass the needle down, and scoop out the sebum. The use of this needle-knife will free the follicles and delicate tissue of a substance that acts as an irritant, and to deplete the skin. It will also relieve all stagnation, and awaken the action of the absorbent vessels, so that applications can now be more effective when used on the parts. This operation not only accomplishes the purpose just set forth, but it likewise prevents the rupture of the epidermis, the discharge of pus, and the formation of scars. The lesions, when punc- tured or cut in the manner I have described, will always heal nicely, and will not leave any trace of the operation. On the other hand, the means used by some to rid themselves of these acne-spots by squeezing out their contents between the nails or fingers, or pressing over them a watch-key, in order to remove the plug of the sebum, inflicts on the skin a large amount of injury. It intensifies the disease by breaking the epithelium, produces scarring on healing, and leads to disfigure- ment. Patients in whom these scars have formed, either from neglect- ing the eruption or resorting to the injurious habit just mentioned, can be benefited and often cured (when the subject is not too old) by tap- ping the spots with the needle-knife. After the operation, which should be repeated in three to four days, the lesions should be allowed to bleed freely, and very warm or hot water dashed on the surface to favor as much as possible a copious flow of blood. It is well also to wash the surface with a disinfectant, such as a l-to-1,000 corrosive- sublimate solution, a carbolic-acid dilution, hydrogen dioxide, or a solu- tion of resorcin. The parts are then to be mopped dry with an old towel or piece of muslin, and one of the soothing oleates or lotions pre- viously recommended lightly applied over the surface. In extremely obstinate cases it is well to have recourse to electro-cautery. The use of stimulating remedies, such as sulphur, mercurials, alco- hol, the distilled water, and the tincture of witch-hazel, etc., separately or in combination with other substances, is at times serviceable. The hydrochlorate of hydrastin is also a useful remedy when a mild stimu- lant is required, made into an ointment in the strength of 10 or 20 grains to the ounce. Both alpha- and beta-naphthol are valuable in sluggish cases. They may be employed in the form of a lotion, being slightly soluble in water, or may be incorporated in lard in the propor- tion of 10 grains or more to the ounce. Occasionally patients will pre- sent themselves who can not at once be induced to try the mechanical treatment. In such instances, which are very rare, if the soothing 328 DISEASES OF THE SKIN. remedies with or without the baths will not succeed, I then resort to an ointment composed of— IJ Sulphuris sublimati................. 3 j- Zinci carbonatis..................... 3 ij- Naphthol.......................... gr. ij. M. Adipis recentis..................... § j. The following prescription may be applied with advantage : IJ Sulphuris sublimati................. 3 j- Olei anthemidis.................... ui x. Zinci oleatis......................... 3 j- M. Adipis recentis..................... 3 j. IJ Olei eucalypti...................... TH, iv. Zinci carbonat...................... 3 j- M. Ungt. sulphuris iodid............... § ss. Stimulating substances may be employed in the form of lotions, viz.: ]J Sulphuris sublimati................. 3 ij- iEtheris sulphuris, Spiritus vini rectificati............aa f § ij. M. Sig.: Shake well, and mop over the surface. Again, the use of the following formula will give gratifying results: R. Hydrargyri chlor. corros............ gr.- ij. Aquae hamamelis Virginicae dest...... f § ss. Aquae rosae......................... f § vss. M. Sig.: Apply over the face on retiring. Shake the vial before using. Renaut recommends a preparation thus composed: R. Hydrarg. chlor. corros., Ammonii chlorid.................aa 0.1. Emuls. amygdal amar............... 200 M. Sig.: To be applied morning and evening. A favorite formula at the Hopital de Saint-Louis is : IJ Sulphuris precip................... 15 to 30 grm. Alcohol camphorat.................. 30 grm. Aquae rosae........................ 100 " M. Aquae destillat...................... 150 " Instead of sulphur we may use ichthyol, so highly lauded by Unna. This substance may be applied as a lotion dissolved in alcohol and ether or as an ointment. For indurated acne the following combina- tion may be of service : IJ Calaminae prep...................... 3 j. Iodol.............................. gr. xx. Ichthyol........................... 3 jss. Adipis............................. 1 j. M. Ft, ungt. EXUDATIONS. 329 Among many other substances employed in ointment form are the English hypochloride of sulphur, the sulphuret of potassium, the mild chloride, the biniodide, and the ammonio-chloride of mercury com- pounded of various strengths, or the mercurial plaster, as recommend- ed by Neumann, or a plaster made of salicylic acid and gutta-percha, applied on strips of linen. The sulphate or acetate of copper, the oleate of copper in the form of a 10 to 20 per cent, ointment, erythrox- ylon coca (gr. xxx- | j), hamamelis, and iodide of lead are applicable to certain cases. The same may be said of glycerine, brushed upon the papules or pustules. Osmic acid has been found beneficial in chronic indurated acne, and Piffard has seen improvement in some cases from the application of a mixture of quillaia with glycerine. The iodo-sul- phate of cinchonine, a recently introduced non-toxic antiseptic powder, containing 50 per cent, of iodine is of value in chronic acne, and I have witnessed very good results from an ointment composed of 20 grains of this substance rubbed up with an ounce of oxide-of-zinc ointment. Another method of treating acne locally is to dust the lesions freely with sulphur and other stimulating powders. It should, however, be remembered that if sulphur or any of its salts be applied with a mer- - curial, the sulphuret of mercury will form on the skin, filling up the follicles with black points and causing disfigurement of the counte- nance. I have been consulted by persons who have been disfigured by these applications, and, for removal, have advised the sponging of the skin with a solution of boric acid. Chrysarobin, carbolic, and sali- cylic acid ointments have been recommended by different writers. An ointment containing hydrastine hydrochlorate, thymol, or iodide of sulphur is also of service. The same may be said of the officinal alka- line sulphur ointment. The soap treatment of acne, which was recommended and so largely used by Hebra in the form of his alcoholic solution of soap—the tinct- ure of green soap—consists in vigorously rubbing the affected part with the alcoholic solution of the potash soap, and is efficacious with some patients, particularly those having a thick and tough skin. For the majority of Americans, whose epidermic covering is usually soft and delicate, I have found less powerful stimulants sufficient. In rebellious cases Fournier advises friction with the oil of cade, or the application of Vigo's plaster. Some authorities touch the acne spots with tincture of iodine, tinct- ure of cantharides, the acid nitrate of mercury, and other caustics, but I have never seen any good results follow their use. They are even more severe than the alcoholic solution of soap, and when employed will at times run off on the surrounding skin, producing great pain and distress. Ellinger * strongly recommends for acne frictions of the skin with * Wiener med. Wochenschrift, No. 45, 1876. 330 DISEASES OF THE SKIN. fine sand. It should be free from dust, and the grains almost as large as a poppy-seed. The skin should be washed with ordinary soap and water, after which the affected parts are to be rubbed for a short time with the sand slightly wet. After this procedure any adhering par- ticles must be sponged or brushed away. I have had good results in obstinate cases of acne from the frequent local applications of electricity, either in the form of the faradic, gal- vanic, or static currents. Prognosis.—Acne, although one of the most obstinate and relapsing of the skin affections, can either be limited or cured by remedies, or may terminate spontaneously after the individual has passed beyond the age of puberty, and the system is in a state of repose. The prognosis is, therefore, always favorable, but an early cure can seldom be promised. The probable duration of the disease—an inquiry usually made of physicians—will largely depend upon the exciting cause, the amount of the eruption, and the habits and occupation of the subject. Simple acne, with a small number of papules and pustules, and those due to external irritants, can often be rapidly cured by mild treatment and a removal of the exciting cause. Acne indurata and acne cachecticorum, occurring in the debilitated - and scrofulous, accompanied with many lesions, often last for years, and are followed by much scarring, and relapse with the least indis- cretion or neglect. ROSACEA. Synonyms.—Acne rosacea —Gutta rosacea—Couperose. Rosacea * is a chronic inflammatory disease of the face, characterized by vivid redness, due to an enlargement of the capillary blood-vessels, and later by hypertrophy of the subcutaneous cellular tissue. Symptoms.—Rosacea usually attacks the nose, cheeks, forehead, and chin. In rare cases it may affect the entire face, and also involve the scalp and the neck. Bazin speaks of having once seen rosacea develop in the groin. This disease is confined to the hairless portions of the face, and is, con- sequently, more common upon the chin in women than in men, and only appears upon the bald scalp. It may present three stages—the congestive, varicose, and hypertrophic. It may not, however, run suc- cessively through all of them. Rosacea is a chronic and obstinate affec- tion, beginning in one or another of the above forms, remaining for months or years in that condition, or passing on to the most advanced. The first stage consists in an intense reddening of the nose, at times the same condition existing on the cheeks, forehead, or chin, without either swelling or tension of the parts. This redness will disappear on press- * This description of the disease has been extracted from my paper on " Rosacea." See Transactions of the Medical Society of the State of Pennsylvania, vol. xii., 1878. EXUDATIONS. 331 ure, to reappear upon its removal. Rosacea will be seen on close in- spection to be due to an engorgement of the blood-vessels. The enlarged and tortuous vessels are particularly apparent upon the sides and bridge of the nose. It is, however, more common for rosacea to occur alone upon the nose, but it may also be found occasionally isolated on the cheeks, forehead, and lips. It may either be uni- formly distributed over the part involved, or appear as small patches with normal skin between them. The disease usually begins in the form of spots, and spreads until the most prominent portion of the face is covered by a diffuse redness, which when exposed to the cold assumes a livid tint. The definite establishment of the first stage is preceded, during an indeterminate period, by attacks of erythema upon the nose or cheeks. These attacks are of temporary duration, and generally occur ui.ring or after a meal. They may also be excited by exposure to a strong or cold wind. Sometimes, owing to the excessive vascularity of the part, the seba- ceous glands are excited, and rapidly accumulate and discbarge oily sebum. The nose will then have, in addition to the redness, an oily and shining aspect, and the patient will complain, especially after meals, or after walking against the wind, or from exposure to cold, of a warm sensation in the parts. The progress of the disease in the majority of cases is very slow, often requiring months, and even years, for its development. Rosacea occasionally, however, runs rapidly through the different stages, this being generally due to the condition of the system and the violence of the exciting cause. It may continue in the first stage for an indefinite period, but this is more frequently succeeded by the next, in which small capillary blood-vessels appear upon the surface. The skin now remains constantly injected, and the superficial vessels become tortuous and varicose. The vessels may be fine or thick in calibre, and usually run in an irregular manner. The integument thickens, and as the disease encroaches upon the glands it causes in- flammation, suppuration, and the formation of scattered papules and pustules. The habitually injected skin, covered with papules or pust- ules, and the enlarged features, cause great mental distress, especially in females. The disease, which at first involved only the nose, may now extend to the cheeks, forehead, chin, and at last cover the whole face. The redness may no longer remain uniform, but it may become livid in hue where there are papules and pustules. The skin in this stage is often rough and granulated, giving to the patient a very repulsive appearance. The second stage, like the first, is usually very slow in its development, and the affection may not pass beyond it. The morbid action may, however, in some rare cases, still continue, more especially in men, until either the subcutaneous cellular tissue undergoes successive hypertrophy, or the glands and blood-vessels be- come distended and enlarged. 332 DISEASES OF THE SKIN. In one form of the disease the blood-vessels become enormously dis- tended, the skin has a greasy and shining appearance, the temperature of the nose is lowered, and it is cold to the touch. In another form the skin between the blood-vessels is very much thickened, and of a dark- purple color. In the most severe form of the third stage, tubercular elevations, or a lobulated condition, livid in color, may also appear on the nose, owing to the thickening and hypertrophy of the parts. Noses having these pendulous masses seriously alter the appearance of the countenance, and have been termed rhinophyma. Fluellen's allusion, in Shakespeare's " King Henry V.," to Bardolph's countenance, aptly expresses in the following words the distortion of this stage: " His face is all bubukles, and welks, and knobs, and flames of fire; and his lips plows at his nose, and it is like a coal of fire, sometimes pine and sometimes red." In a case under my observation some years ago—an old English brandy-drinker—the nose assumed, as Hebra has expressed it, the form of a clapper of a bell; the excrescences were enormous, the sebaceous glands very large and filled with plugs of sebum; the skin was almost purple and cold to the touch. The nose has been known to acquire the size of two fists, and hang down in front of the mouth as far as the chin. In these extreme cases the hypertrophy may cause decided inconvenience, as in a case described by Ohmann-Dumesnil, where the mass produced marked stenosis of the nostrils, necessitating respiration by the mouth. The pressure of pendulous tissue upon the upper lip also rendered speech somewhat indistinct. The hypertrophic form is restricted almost exclusively to males. Diagnosis.—Rosacea can be diagnosed by its history, course, and the alterations in the skin. It may be distinguished from acne by the in- creased vascularity in the former affection, its persistence, the varicose condition of the blood-vessels, the thickening of the integument, and its limitation to the face. Acne, on the other hand, when present as the primary disease, is simply an acute inflammation of the glands and follicles, and is not confined to the face. Rosacea may likewise be mistaken for syphilis or lupus; but such an error should not occur, and, to avoid it, the following diagnostic points will be given between these affections : Syphilis is attended with a history; it is preceded by malaise, sore throat, and the roseolous rash, and usually attacks one side of .the nose. Syphilitic tubercles and pust- ules do not involve the cutaneous glands; they are rarely developed alone on the face; have a dull, coppery color, and may be complicated with fissures, ulceration, or the formation of crusts. Again, they are usually larger and more firm than in rosacea. In rosacea there is no syphilitic history, nor any of the concomitants of specific disease. As a rule, the disease involves first the end of the nose, and the color of the patches is a vivid red from the enlarged and tortuous blood-vessels, which are absent in syphilis. The pustules and tubercles of rosacea EXUDATIONS. 333 are of a bright tint, and have their seat in the glands of the face, but do not ulcerate or form fissures or crusts. Lupus erythematosus may be mistaken for rosacea. The surface of the diseased patches in lupus erythematosus is covered with fine yellowish scales, adherent to the follicles beneath, which are not present in rosacea. The margins of a patch of erythematous lupus are more distinctly marked, its color is usually a brighter red, it exhibits some tenderness upon pressure, projects slightly above the level of the surrounding skin, and the cicatriform spots are distinctive. Lupus vulgaris may bear a resemblance to rosacea. In lupus vulgaris the well-known papules, tubercles, and scales are present; ulceration occurs, and cica- trices result. In rosacea no scales are present; the part is covered with varicose blood-vessels, the tubercles never ulcerate, and no attempt is made at the formation of cicatrices. Hyde * refers to a case of herpes zoster which he had seen-, which involved the nose and resembled rosacea. He adds that the painful character of the disorder, its limitations to one side of the face, its transitory career, with the vesicular lesions, were sufficiently characteristic. Finally, rosacea may have the appearance of frost-bite. In the latter the parts are bluish-red, shining, and much swollen; in the former the skin is red, greasy, and little or no swelling is present. Pathology.—-The anatomical changes in rosacea consist first in con- gestion of the minute blood-vessels of the parts. The vessels of the deeper portion of the skin are involved from the first. In the second stage the blood-vessels become hypertrophied and permanently dilated, develop seborrhoea or acne-spots, and those surrounding the hair folli- cles and sebaceous glands become enlarged. An infiltration of lym- phoid cells takes place into the tissue surrounding the vessels, and the connective-tissue corpuscles proliferate. This second stage, with the alteration in the blood-vessels, may continue for a long period, improving and again relapsing from time to time, or passing into the third stage, in which there is hypertrophy of the cutaneous glands and tissues of the part, and the growth of a new connective-tissue element. Hebra has shown an abnormal growth and development of con- nective tissue. Piffard f found that the horny portion of the epider- mis was insufficient; the mucous layer thickened, that the papillae con- tained round and fusiform cells, and were enlarged both in length and breadth. The corium had the appearance of a formed tissue, being very much thickened; some of the sebaceous glands were normal, while others were undergoing degenerative changes. * Hyde's Diseases of the Skin, Philadelphia, 1883. f Archives of Clinical Surgery, vol. i., p. 21. 334 DISEASES OF THE SKIN. A microscopical examination which I made of a piece cut from the nose of a patient in attendance at the Dispensary for Skin Dis- eases, Philadelphia, and reported,* showed just a vestige of the horny layer of the epidermis, while the mucous layer was very thick. The papillae were much enlarged, and the blood-vessels markedly dilated and varicose. The subcutaneous cellular tissue was hypertrophied, and the sebaceous glands were degenerated by the pressure of the surround- ing tissue. Leloir and Vidal distinguish two varieties of the hypertrophic form of rosacea. In one, hypertrophy of the'sebaceous glands is the most prominent feature. These may attain twelve or fifteen times their normal size. In a second, that to which the name rhinophyma is generally applied, the glandular lesions are entirely secondary. The vessels, and especially the veins, are dilated and engorged, so that in some places they form sinuses and constitute a sort of erectile tissue. The arteries are thickened and sclerotic. In extreme cases the lym- phatic vessels are implicated, and a section presents an appearance comparable to that of an angioma or lymphangioma. Etiology.—Rosacea is met with in both sexes, but more frequently in men. It may happen in youth, but it appears mostly in middle or advanced life. In women it may occur about the age of puberty, dur- ing uterine and ovarian disorders, and at the cessation of the menses, and will not usually pass *beyond the first and rarely to the second stage of the disease. In men rosacea seldom appears before the fortieth year. Heredity has a certain degree of influence in the production of rosacea, and a predisposition to this affection exists in the gouty and rheumatic. The application of cosmetics, paints, and irritating lotions is an immediate cause of it. I have found these preparations to be produc- tive of the disease in both men and women in the theatrical profession, and in women in the decline of life, notwithstanding all the care that they have taken in applying the cosmetics. Among other of the prominent causes are chlorosis, anaemia, excesses of the table leading to dyspepsia, chronic affections of the stomach and intestines, morbid conditions of the liver, and wrant of cleanliness. The attitude made necessary by certain occupations, which causes an increased flow of blood to the face, is also an inciting factor. Thus we see it in bakers, engineers, etc., who are compelled to work with their faces in prox- imity to hot fires. In some instances rosacea is consecutive to acne, the long-continued congestion accompanying repeated attacks of acne at length becoming permanent, and causing dilatation and engorgement of the vessels. The habitual use of vinous, spirituous, and malt liquors is also a common source of the disease. The powerful action of these * See Transactions of the Pennsylvania Medical Society, 1878. EXUDATIONS. 335 liquors in producing increased facial circulation, leading to a hideously swollen condition of the nose, can be observed daily. These deformi- ties are commonly known as "grog-blossoms," "brandy-nose," and "wine-nose." Frequent exposure to cold winds often provokes rosa- cea. In a few cases it is impossible to trace the disease to any external or internal influence. Treatment.—The method of treatment to be employed will largely depend upon the stage and the cause of the affection. The physician should therefore, in all cases, carefully examine into the patient's con- dition, and, if any constitutional derangement exist, give the appro- priate remedies. Women suffering from uterine or ovarian disorders should have the proper treatment to eradicate them. Men who in- dulge in liquors and dissipation of other forms should be advised to adopt a temperate mode of living. The diet should be plain and sub- stantial, especial care being taken to avoid rich food of all kinds. It is of extreme importance that the functions of the liver and bowels be properly performed. Alkaline mineral waters may be recom- mended. In those who are anaemic and debilitated, the ferruginous prepara- tions, minute doses of arsenic, cod-liver oil, the extract of malt, nux vomica, and the dilute phosphoric acid, with bitter tonics, are of great advantage. Those in whom no cause can be traced are often benefited by a change of climate. In women who have depraved health, nerv- ous depression, menstrual disorders, or are at the change of life, and who are often great sufferers from rosacea, with frequent flushing of the face and throbbing of the blood-vessels, the judicious use of the nitrite of amyl, as suggested by Ringer,* will often bring relief, either given by inhalation or the stomach, the latter form being usually preferred— two minims dissolved in one drachm of rectified spirits; the dose of this is from three to five drops on sugar every three hours, the first dose to be taken as soon as the flush appears. When rosacea seems to depend upon the presence of a rheumatic or gouty habit, it may be of advantage to administer an alkali, or advise the use of an alkaline min- eral water. Under the same circumstances Brocq speaks favorably of the effects of the following combinations : IJ Quinin. bromhdydrat., Ergotin...................aa 5 cgm. (gr. §). Extract, belladonn............. 1-2 mgm. (gr. -fa to -g^)- Lithii benzoat................. 5 cgm. (gr. f). G lycerini.................... q. s. Ft. in pil. no. j. Mitte tales no. xl. Two of these pills are given before breakfast and dinner. * Ringer's Handbook of Therapeutics, seventh American edition, p. 370. 336 DISEASES OF THE SKIN. IJ Pulv. digitalis................. 5 mgm. (gr. T^). Extract, hamamelidis........... 5 mgm. (gr. y1^). Extr. gentian., Lithii benzoat...............aa 5 cgm. (gr. £). Glycerin...................... q. s. Ft. in pil. no. j. Mitte tales no. xl. Two pills are ordered to be taken before each meal. Rhubarb or aloes may be added to the above formulae, according to the indications. The use of electricity and massage will often likewise be found to be valuable adjuvants for their beneficial effect upon the system. The local treatment is, however, important and advantageous in almost all cases. Soothing remedies will answer in some, in others stimulating, and often the addition of one or another of the many mechanical means will modify and frequently arrest the disease. In the first stage I endeavor by soothing applications to relieve the congestion and allay the irritation. The ointment of the oleate of bismuth, which I suggested in papers read before the Pennsylvania State Medical Society in 1879 and 1882, will often fulfil this purpose. The ointment, lightly pencilled over the surface two or three times daily, will soothe the hyperaemic skin, relieve the engorgement of the glands, and bring comfort and ease to the patient. In some, a dusting- powder of either the oleate of zinc, the subnitrate of bismuth, or equal parts of each combined, with powdered starch or arrow-root dusted over the surface after using the ointment of the oleate of bismuth, will not only assist very much the action of the oleate, but will relieve the face of its greasy appearance. Ladies can in this manner use the above preparations, lightly applied as a cosmetic, to hide the disease in place of one of the many injurious face-powders, and can have the satisfac- tion of knowing that the application is beneficial, and may cure the dis- ease. The following soothing ointment has also been efficacious in other cases, used either alone or with one of the dusting-powders just named: IJ Zinci carbonatis..................... 3 j. Pulveris marantae................... 3 j. Hydrargyri ammoniati............... gr. x. Unguenti simplicis.................. | j. M. Ft. unguentum. Soothing lotions are especially effective in some instances: IJ Plumbi acetatis, Zinci acetatis.....................aa gr. x. Aquae rosae.........................f 1 iv. M. Sig.: Apply with an old piece of muslin spread over the sur- face for an hour or two night and morning. Sulphur ointment may be used with good effect in the first stage or chrysarobin in solution of gutta-percha, beginning with ten grains to the ounce, increasing or diminishing the strength as required. EXUDATIONS. S37 In the second stage I have had good results from the extract and tincture of witch-hazel, weak solutions of chloride of zinc, and caustic potash, glycerine, the various mercurials, precipitated sulphur, chrys- arobin, and the English hypochloride of sulphur. Some practitioners make use of Vleminck's solution diluted with five parts of water, which may gradually be withdrawn if the preparation does not provoke irri- tation. Besnier recommends the following combination : IJ Sulphur, precip..................... 50 grammes. Glycerin........................... 30 " M. Alcohol, camphor................... 80 " Some of these remedies can be used in the form of an ointment, and others as lotions. It is a good plan sometimes, especially when the nose alone is involved, to brush collodion along the course of the blood-vessels, which compresses them, and thus lessens their calibre. In several cases I have obtained excellent results from this method alone. Again, the vapor-bath is valuable both in the first and second stages; it renders the skin soft and smooth, and hastens the absorption of the lesions. Another efficacious application is the oil of ergot, or half an ounce each of glycerine and oil of ergot, with one drachm of the extract of belladonna. Unna recommends ichthyol internally and externally. Internally he gives it for a long time, fifteen to thirty grains daily, and applies it exter- nally in watery solution. He also makes use of the following ointment: IJ Zinc ointment...................... 20 grammes. Powdered rice....................... 5 " M. Sulphur........=................... 2 More recently Unna has devised an impermeable application which he terms ichthyol-varnish, and recommends as a decided improvement on his earlier preparations. The formula for this varnish is : R Ichthyol........................... 40 parts. Starch............................. 40 " Solution of albumin................ 1~H " M. Water enough to make............... 100 " The varnish is brushed upon the affected skin at night, dries in about two minutes, and can be readily removed by water in the morn- ing.* In rebellious cases, Brocq f advises the use of green soap, alone or associated with sulphur, naphthol, or salicylic acid. Among other applications which may prove of service may be mentioned Goulard's extract, solution of sulphate of zinc or of alum, pyrogallic acid, iodized glycerine, and erythroxylon or cocaine hydrochlorate. Natural sulphur baths, whenever attainable, are of service. A solution of alpha-naph- thol frequently proves beneficial. The ointment of lead oleate is often- times useful, while an ointment of iron oleate is of decided advantage in either the first or second stage. * Medical Bulletin, July, 1891. \ Op. cit, p. 53. o-2 338 DISEASES OF THE SKIN. If the preparations named should fail, poultices and fomentations may next be employed. In obstinate cases I have a good starch- poultice prepared, which is bland and unirritating to the skin, and applied moderately warm, usually just before retiring, and allow it to remain one hour. It is a ready and convenient method of applying a hot bath directly and effectually to the parts. A poultice allays all irritation, burning, flushing, pricking, or pain, limits and checks the inflammation, and abates the tension. It also relaxes the tissue, and renders the absorbents more active in the application of the oleate of bismuth or any other soothing remedy, which should be immediately applied after the removal of the poultice. All stages of rosacea are often materially benefited by the local use of massage and the application of the faradic and galvanic currents. In case the congestion of the skin still lingers and remains obstinate, I puncture the surface with the needle-knife. During the operation I hold the knife in the right hand, and rapidly apply it oyer the patches, while with the left hand I sponge the surface with hot or very warm water, in order that the bleeding may continue freely. The water applied in this manner will remove the poured-out blood, and will prevent it from clotting in the incisions and obscuring the operation. I always allow the knife to penetrate to various depths according to the thickened condition of the integument. In some points of the diseased patch simple hyperaemia may be present, while in others tubercles and ex- cessive hypertrophy may exist; consequently, the former will need very slight punctures, while the latter will require deep incisions according to the amount of hypertrophic growth. In this manner I reach all the larger and smaller patches, relieve the congestion and stagnation, equalize. the circulation, and awaken the action of the absorbents, so that local applications may have some effect. This operation should be repeated after an interval of from four to seven days, according to the requirements of the case. After each operation one of the bland and soothing preparations, or one of the astringent and stimulating remedies recommended, can be used much more effectually. Hebra* suggests, in treating this affection, the use of an instrument made after the form of a lancet-needle, with cutting edges oh both sides, and pro- vided with a stop, so that it may not penetrate too deeply into the derma. He adds that the perpendicular punctures are made for the purpose of destroying the blood-vessels, and that the bleeding can be easily arrested by compressed wadding. Squire operates on rosacea by means of an instrument which he calls the multiple scarifier. It con- sists of a number of needles attached to a handle, and arranged par- allel to one another with a covered shield on each side. . He maps out the diseased patches with a solution of black sealing wax, freezes the surface with an ether-spray, and then applies the multiple scarifier. * Wien med. Wochenschrift, January, 1878. EXUDATIONS. 339 Should the scarifier be too broad for some of the smaller patches, he advises that they be operated on at a subsequent sitting with a single scalpel. The bleeding which follows the use of this instrument, he states, may be copious, but it can be immediately arrested by press- ure with the fingers, a layer of wet blotting-paper being interposed between the fingers and the skin pressed. Aube, who recommended linear scarification, believes that it is to be relied upon in rosacea only before the hypertrophy has become far advanced. The same object, it can be seen, is obtained by either of the operations named, but the one I am accustomed to employ appears to be the easiest and simplest for practical use in all respects. The tortuous and varicose blood- vessels may be obliterated by passing into them an ordinary needle heated to redness, by using the galvano-cautery with a fine-pointed needle, or by electrolysis. In this latter method a very fine cambric- needle is selected and connected with the negative electrode of a gal- vanic battery of from six to ten cells. The needle is then inserted into the varicose vessel, after which the patient is handed the positive electrode, which completes the circuit; the latter electrode is dropped before withdrawing the needle, which will prevent the patient from experiencing a shock on breaking the circuit. The deformity of the third stage may be reduced by either puncturing deeply the hypertrophic blood-vessels and tissue, by scarification, by using the ordinary needle heated to redness, by electrolysis, by faradization, by the galvano-cautery, or by operative procedure with the knife. Chea- dle* reports good results from the faradic current. Piffard states that he has obtained very decided shrinkage of hypertrophic noses by the use of the galvanic current. Prognosis.—The prognosis depends largely upon the cause of the disease. If the affection has not passed beyond the first or second stages and the exciting cause can be eradicated, it can usually be re- lieved or cured. The result, however, depends essentially upon the habits of the patient. Rosacea will at times in women subside spon- taneously, especially after the climacteric period. In the third stage, as a rule, particularly when it is due to bad habits and all kinds of over-indulgences, where a decided change in the tissues has taken place, the results, even under the most experienced practitioners, are not usually favorable. SYCOSIS. Synonyms.—Sycosis non-parasitica—Mentagra—Acne mentagra—Folliculitis barbae— liichen menti—Bartfinne—Sycosis non-parasitaire. Sycosis is a non-contagious, inflammatory disease, acute or chronic in its course, involving the hair-follicles, chiefly of the bearded part of the face, and characterized by the formation together of pustules, * Practitioner, London, July, 1874. 340 DISEASES OF THE SKIN. papules, and perhaps tubercles, usually perforated with hairs, and accompanied by more or less infiltration of the part. Symptoms.—The disease usually occurs on those portions of the face on which the beard, whiskers, and mustache grow, although it may be seen upon other parts of the body supplied with hair. It gen- erally begins on the cheek, chin, or upper lip by the appearance of small, discrete pustules or papules, or both, the lesions being perfo- rated by hairs, which are usually firmly fixed at first, but at a later stage of the disease become loose, and are easily removed. The lesions may appear in successive crops at longer or shorter intervals, and may remain isolated throughout their course, or become crowded together, forming well-marked patches. The pustules or papules may be either flat or conical, varying in size, being usually about that of a millet- seed. The pustules are not generally inclined to rupture, unless there be more or less severe inflammatory action. The surrounding skin is reddened, swollen, and infiltrated; there may be present papulo-pust- ules and tubercles, and, if the pustules rupture, scales and crusts may also exist. The disease is usually preceded or accompanied by heat, tension, smarting, burning, and occasionally pricking or painful sensations. Sometimes patients will describe the pain as proceeding along the course of the hair which traverses the lesion, and refer to it now and then as a hair-pain. Sycosis may commence in some cases within the nostril, or pass up from the upper lip and affect the follicles of the stiff hairs or vibrissae, the disease becoming excessively obstinate and at times extending to the Schneiderian membrane. In this event the columna that divides the nose becomes swollen and inflamed, the organ itself hot and very painful, upon the slightest movement of it tears flowing from the eyes. The disease, while affecting most com- monly the cheeks, chin, and upper lip, may also appear on the scalp, eyebrows, eyelashes, neck, axillae, and pubic regions. Sycosis may appear in one or more points, and spread until it involves all of the region invaded, or it may develop simultaneously over all the parts just named. The character of the disease will also vary considerably, according as the eruption is isolated or confluent. In some the lesions are dis- tinct and few in number, while in others they coalesce, the inflam- mation penetrates deeply into the derma and subcutaneous cellular tissue, infiltration and thickening are marked, the parts become cov- ered with tubercular elevations, scales, and crusts, and occasionally unhealthy granulations and abscesses appear, with many openings, and the surface becomes extremely tender and painful. If the affec- tion be allowed to progress, the follicles and the tissues of the parts will be destroyed by ulcerative action, leading to permanent scars and loss of hair. Sycosis is modified according to the condition of the hair of the affected part. If the hair is thin and feeble in EXUDATIONS. 341 growth, or if it should be cut close or shaved, the disease can be better seen and managed; on the other hand, if the hair is long, thick, and vigorous in growth, the diseased surface can be seen only by sepa- rating the hairs; it will also be difficult to treat until the hair is cut close to the part. When the condition of luxuriant growth exists, the hairs become matted together with poured-out products, giving the countenance a disgusting appearance. The course of the disease is usually chronic, often as the result of being improperly managed, or, more frequently, being over-treated. Diagnosis.—Sycosis is liable to be mistaken for tinea barbae, or barber's itch, as both diseases invade the hair-follicles; but the symp- toms of each are distinct and characteristic. The diagnostic signs of pustules, papules, and tubercles, pierced in the centre by hairs in their normal condition, firmly seated in the follicles, except when removed by suppuration or extraction, when the root-end is found to be enlarged and covered with pus, are observed only in sycosis. On the other hand, barber's itch is usually ushered in by small red or scurfy patches, the hairs are loosened in the follicles, being brittle, altered in texture, and, as the disease advances, finally break off, producing the characteristic stubbled condition of the surface. In case the disease under consideration is attended by marked inflammatory action, judg- ment should be suspended until the poured-out products can be ex- amined by the microscope, in order to demonstrate the presence or absence of the fungus. It is also sometimes difficult to distinguish between sycosis and pustular eczema. All doubt, however, can be set at rest by the absence of discharge, the perforation of the pustules by hairs, and the limitation of the disease to the parts supplied with hair. Again, should eczema be present, not only may there be a moisture of the surface, the eruption extending to the adjacent parts, but the symptom of itching is usually marked and characteristic. Syphilitic or scrofulous pustules and tubercles, developed on the hairy parts of the face, might be confounded with sycosis. The former lesions, how- ever, are usually preceded by a history, and accompanied by other evi- dences of the disease. Further, in specific affections, if crusts be present, upon their removal a well-marked ulcer, with sharpened edges, will be seen, while in sycosis there is little or no loss of integu- ment. Pustular acne might resemble the early stage of sycosis, but the lesions are not pierced by hairs, nor is the disease limited to the male in whom the beard has grown. Pathology.—Sycosis, in its early stage, is a peri-follicular inflam- mation of the skin. While Wertheim * and Kobner f were the first to invoke the aid of the microscope in determining the nature of this dis- * Zcitschrift der k. k. Gesellschaft der Aerzte, 1861. f Klinische und experimented Mittheilungen aus Dcrmatol6gie und Syphilidologie, Erlangen, 1864. 342 DISEASES OF THE SKIN. ease, yet they confined themselves to the examination of the extracted hairs only, and not the affected tissue. Subsequently, Robinson ex- amined portions of the skin obtained from a living subject, and showed the changes in the invaded part from the commencement to the ter- mination of the disease. According to the observations of this patholo- gist, the transuded serum penetrates the hair-follicle, and increases in quantity as the inflammation proceeds. Pus is also poured out, and the follicle-sheaths become softened and more or less destroyed, per- mitting free ingress of pus into the cavity of the follicle. The cells of the root-sheath and hair-root become swollen and infitrated with sero- purulent matter and pus-corpuscles, and finally become broken down and separated from the follicle-sheaths, so that the hair lies loose within the follicle, and can be easily extracted. The pus reaches the surface by oozing out between the hair-shaft and the follicle-sheath, or by breaking through the epidermis near the hair. In the majority of cases the follicle-sheaths are more or less destroyed, but the hair-papilla remains uninvolved, and in time produces a new hair. In severe cases the follicle-sheath, root-sheath, hair-root, and hair-papilla are all de- stroyed, and permanent loss of hair ensues. The sebaceous and sudo- riparous glands and other tissues of the skin may also become disinte- grated and replaced by cicatricial tissue. Etiology.—Sycosis is a non-contagious inflamm'atory affection, usu- ally occurring between the ages of twenty-five and fifty, and is gener- ally due to some constitutional derangement. It is often dependent upon a debilitated state of the system. It is observed among those who are mentally or physically overworked. Sycosis follows the use of un- wholesome and unsuitable food, excesses of all kinds, and occasionally appears in individuals convalescing from exhausting diseases. It may be excited by local irritants, as want of cleanliness, and in persons who are subjected, particularly by their occupation, to either a high or low temperature. Chronic rhinitis has also been enumerated among the local causes, as well as a faulty relation between the hairs and the fol- licles in which they are contained. According to Bockhart the com- mon micro-organism of suppuration is the exciting cause of sycosis. Treatment.—It will be found that the employment of both consti- tutional and local treatment will yield the best results. Cases treated with only local applications are generally protracted an unusual length of time, and, under such circumstances, it is by a recuperative action of the system that recovery takes place. The internal treatment is often advantageously begun with a brisk purge, the use of one of the mercurials being advisable. The diet should be carefully regulated and should consist of easily digestible and nutritious substances. Cheese should be strictly prohibited. The simple bitters, alone or combined with strychnine and a mineral acid, will assist very much, especially in the debilitated or those out of health, in combating the disease. Mas- EXUDATIONS. 343 sage and static electricity are serviceably employed when debility is marked. The fluid extract or the tincture of hoang-nan may be given with advantage, while some have observed good results to fol- low the combined internal and external use of phytolacca. Iron, arsenic, phosphorus, and cod-liver oil can be beneficially employed. The iodide of iron is particularly serviceable, in from two to three grains, in pill-form three or four times daily. Another valuable prepa- ration is the liquor arsenici et hydrargyri iodidi, as recommended by Tilbury Fox, in from three to ten drops, three times a day, especially if there be much inflammatory thickening of the parts. If there is a tendency to the formation of a large quantity of pus, the phosphates, hypophosphites, calcium sulphide, or potassium chlorate will gener- ally assist in counteracting this condition of the system. The local treatment, which is all important, requires, in the acute stage, emollient and soothing applications. The hair may be cut as short as possible, or it may be allowed to remain in the natural condi- tion, providing it will not mask the disease and interfere with the local applications. Shaving, which is usually recommended, is pain- ful, and I have never seen it attended with good results. Scales and crusts, if present, should be removed by oil-dressings or a poultice. As applications, lotions are more agreeable to some patients, either warm or cold, and, such being the case, lead-water and laudanum, weak solutions of witch-hazel, zinc and lead acetate, or of corrosive sublimate, can be used. Oils are likewise effective upon others, espe- cially the oil of ergot, olive-oil, with fluid mercury oleate, or cod-liver oil, alone or combined with arrow-root, zinc or lead carbonate, opium, arnica, or belladonna, lightly pencilled over the surface. Among the serviceable ointments at this stage are the zinc, lead, and bis- muth oleates, alone or combined with other agents; calomel or white precipitate, ten grains to the ounce of cold cream or rose ointment, forms a valuable application. Diachylon ointment, with a few grains of camphor, will also be found efficacious. Sometimes applications that are more stimulating are more effective, especially in the later stages of the disease. One of the very best remedies to use under such circumstances is the ointment of oleate of mercury, of from five to twenty per cent, strength, according to the condition of the parts, and applied alone or in conjunction with other remedies. The oint- ment of nitrate of mercury, in from one to three drachms to the ounce of zinc ointment, is also useful. Sulphur, tar, naphthol, or carbolic acid can also be advantageously combined with any of the prepara- tions advised. Resorcin, ichthyol, corrosive sublimate, salicylic or boric acid may also be beneficially brought into requisition. A two-per-cent. alcoholic solution of pyrogallic acid is recommended by Veill, and a solution of tar in alcohol by Prof. Pick, of Prague. Dr. McCall Anderson ad- 344 DISEASES OF TEE SKIN. vises, as a convenient application for use in the daytime, Provan's tragacanth paste, the formula of which is: IJ Tragacanth........................ § ss. Glycerin........................... f § ss. Sodii boratis........................ 3 ss. M. Aq. destill.......................... q. s. In addition to the employment of the remedies just suggested, it is often of the utmost value to open the various lesions which may be present with a knife, and to puncture the surface thoroughly, thus re- lieving the enlarged and congested blood-vessels, allowing the stagnated blood to circulate, the effused serum to escape, and preventing the formation of pus. Depletion is not only useful in the early stage of the disease, in conjunction with other suitable topical remedies, but in the subacute and chronic forms especially; if there is much thickening of the skin, it is followed by decidedly beneficial results.* Epilation, which is resorted to by many physicians to prevent per- manent alopecia from resulting, and which is extremely painful, be- comes unnecessary if the lesions and parts are thoroughly depleted in the manner described. Depletion also awakens the activity of the absorbents of the parts much better than such heroic agents as green soap, acetic acid, etc., and thus assists the action of the local applica- tions. The abstraction of blood should be resorted to frpm one to three times a week, the parts encouraged to bleed freely by the use of warm water, the surface mopped gently dry, and the remedy applied well over the surface. The incisions and punctures usually heal rap- idly, the thickening lessens, the symptoms disappear, and a cure is effected without any scar or deformity. Bockhart advises that for some time after active treatment has ceased the patient should wash his face once or twice daily with a one-per-cent. sublimate solution. Prognosis.—Sycosis yields rapidly in some, and in others it is pro- tracted for a long period of time, even months and years. Relapses are common, especially in persons who are subjected to continued local irritation. It is, however, curable when properly managed, but the treatment should be continued until all evidence of the disease has entirely disappeared. IMPETIGO. Impetigo is an acute inflammatory affection, which is characterized by the development of discrete, rounded, elevated pustules, of the size of a split pea or larger, situated upon a base inflamed to some extent, and which disappears without leaving pigmentation or cica- trices. Symptoms.—The eruption may or may not be preceded by mild * Report of the treatment of a case of sycosis, by the author, in the Medical and Surgical Reporter, p. 298, October 13, 1877. EXUDATIONS. 345 febrile symptoms. It consists of round, elevated pustules, which are slightly acuminated, but not umbilicated. They are situated upon a somewhat inflamed base, with, in the beginning, a slight surrounding aureola. Their contents are sero-purulent, purulent, and very rarely bloody. They present a whitish, yellowish, and occasionally a reddish color. In number they may vary from one to many. The postules are isolated, and, even if in close proximity, do not incline to coalesce. They do not tend to rupture, but their contents several days after maturity are partially or altogether absorbed, or dry into yellowish or brownish crusts. They may, on the contrary, occasionally be ruptured through friction or picking, in which event a thin purulent secretion escapes, which also dries into crusts. The amount of crusting may be slight or abundant, and after they have fallen off an erythematous surface remains, without pigmentation or scar. The disease has an acute course, the eruption generally appearing suddenly. The duration of impetigo is usually several weeks. Subjective symptoms are, as a rule, absent, but occasionally there may be slight itching. All parts of the body may be invaded, but it occurs by preference on the face, hands, and lower extremities. Diagnosis.—Impetigo may bear some resemblance to pustular ecze- ma, impetigo contagiosa, and ecthyma. The pustules of impetigo are large, isolated, few in number, and do not incline to coalesce, while those of eczema are small, clustered, numerous, and tend to run to- gether. The pustules in impetigo, further, are attended with but slight if any infiltration and itching, and have no inclination to break; in eczema infiltration is present, itching is marked and often constant, and the lesions rupture soon, with more or less crusting. In impetigo contagiosa the primary lesions are vesicles, and the pustules when formed are frequently flat and umbilicated, with a tendency to coalesce. Impetigo is not contagious, and can not be traced to several of the same family, as in impetigo contagiosa. In ecthyma the lesions are distinguished from those of impetigo by the pustules in the former being flat, and seated on a hard, inflam- matory base, and surrounded by a marked aureola. The crusts also differ materially, being in ecthyma brown or black in color, large, flat, and thick, and seated upon an excoriated surface. Pathology.—The inflammation of the skin in impetigo is super- ficial, and is limited to the corium, involving only the papillary layer. Robinson states that it is a corpuscular inflammation, the embryonic or pus corpuscles being present in great numbers in comparison with the amount of serum. Etiology.—Impetigo is a rare, non-contagious disease. It is en- countered chiefly among children, particularly those that are improp- erly cared for and badly fed. It is also associated with disorders of the gastro-intestinal tract, and may occur after any debilitating affection. 346 DISEASES OF THE SKIN. Its lesion depends upon the development of microbes of suppuration. Celoni reports a case of impetigo in a boy, followed by acute paren- chymatous nephritis which had a fatal termination. Treatment.—Suitable hygienic measures, and good, nutritious food are of the utmost importance. If any special functional derangement exist, it should be corrected. It is often of advantage to put the pa- tient upon tonic doses of quinine. The affected surface should be protected against irritation, and when the pustules are fully developed _ they should be incised and the pus evacuated. A mild mercurial, or other slightly stimulating ointment, may then be applied to the parts. Sozoiodol has been used advantageously as a dressing. If scabs have formed, they may be removed by water or oil dressings, or poulticing, after which the ointment can be applied to the surface. Prognosis.—The prognosis is good. Impetigo Herpetiformis.—This rare and serious affection was first described by Hebra, who observed but few cases, nearly all termi- nating fatally. It prevails, according to his ex'perience, only among pregnant women. Kaposi, however, has met with one case in a man. The eruption is characterized by the development of small, yellow pustules, arranged in groups or in the form of rings. The lesions incline to run together, and to dry into yellowish or brownish crusts, and at the same time similar pustules form around the periphery of the patch, pursuing the same course as in impetigo. The peculiar annular formation of the lesions presents a resemblance to herpes iris. The surface beneath the crusts is red, moist, excoriated, and infil- trated. The disease attacks chiefly the anterior portion of the trunk and the inner surfaces of the thighs, but may occur upon the face, neck, arms, legs, and other parts of the body. In Hebra's patients there was marked constitutional disturbance, every outbreak of pust- ules being preceded by chills and fever. Duhring describes the disease as consisting in the majority of cases of pustular and bullous lesions combined, or occurring alternately. The eruption in his cases was similarly arranged, and had a like course to those of Hebra's. The constitutional symptoms, he reports, were variable, but the itching was always violent. Duhring's patients were not pregnant women, and in no instance was there a fatal result. The eruption, he adds, manifested a disposition to recur, and was but little influenced by treatment. Ileitzmann reports the case of a woman at the climacteric period, which was followed by a fatal termination. Robinson also records what he calls a well-marked case in a boy ten years of age, the lesions developed being papular, vesicular, pustular, and bullous, and occur- ring over all the body, except the palmar and plantar surfaces. Treatment.—The disease is to be managed upon general principles, the symptoms being the guide. EXUDATIONS. 347 IMPETIGO CONTAGIOSA. Impetigo contagiosa is an acute, inflammatory, contagious affection, characterized by the development of isolated, flat, or elevated vesicles, blebs, or vesico-pustules, the size of a split pea, or larger, which dry into slightly adherent crusts. Symptoms.—The disease is generally ushered in with mild febrile symptoms. The eruption appears as small, isolated, flat or raised vesi- cles, or blebs, which soon increase in size, and become transformed into vesico-pustules, or pustules. They are usually round or oval, and occa- sionally umbilicated. They may, though rarely, be irregular in form. They may "have a slight areola, or it may be wanting. The number of lesions is, as a rule, small, and at times, when closely seated, they may run together and form a patch. They may appear simultaneously, or in successive crops. In the course of a few days they dry into yel- lowish, straw-colored, and slightly adherent crusts, beneath which some slight excoriation exists, covered with a thin, purulent secretion. If the scalp is involved, the patches are circular, usually isolated, and covered with flat crusts, which mat the hair. The crusts, soon after their formation and drying, fall off, exposing an erythematous surface, which also in time disappears. Subjective symptoms are generally absent, but there may be at times slight itching. The affection, in the majority of instances, attacks the face, head, arms, and hands, but may likewise appear on other parts, even the mucous membrane of the eyes and mouth. The lymphatic glands in connection with the diseased surface may become enlarged and tender. Impetigo contagiosa may begin in one region, and, by scratching, spread by direct inoculation to other parts. The duration is from seven to ten days. Dr. Radcliffe Crocker has lately described a rare form characterized by gyrate lesions. Single lesions may equal an inch in diameter, but adjacent figures may coalesce and form patches of considerable size and gyrated outline. Diagnosis.—Contagious impetigo may be confounded with impetigo, eczema pustulosum, and varicella. In impetigo the pustules are raised ; in the contagious form they are, or become, flat. In eczema the lesions are not isolated, and the itching is often marked and constant, thus differing in these respects from impetigo contagiosa. Varicella is dis- tinguished from impetigo contagiosa by the lesions remaining vesicular throughout the disease, as well as by their smallness in size and their general distribution over the body. Pathology.—Vegetable organisms have been detected in the crusts. Tilbury Fox and others declare that they are merely accidental. No decided evidence has yet been adduced to account for the development of the lesions. Piffard considers contagious impetigo as connected in some manner writh vaccination. Etiology.—The disease is contagious and auto-inoculable. It oc- 348 DISEASES OF THE SKIN. curs principally in poorly nourished and unclean children, and has at times appeared after vaccination. It has also been known occasion- ally to be epidemic in form. Treatment.—The constitutional treatment should consist of fresh air, cleanliness, nutritious food, and tonics. Locally, the crusts should be first removed and the pus likewise carried off by irrigating the ex- posed surface with some antiseptic solution. This having been accom- plished, zinc or lead ointments act beneficially. An ointment of five or ten grains of calomel or white precipitate to the ounce of lard has been found to be a useful application. Prognosis.—The eruption disappears, often very rapidly, under suitable treatment. ECTHYMA. Ecthyma is an inflammatory disease, characterized by the develop- ment of one or many isolated, flat pustules, situated upon an inflam- matory base, and followed by cicatrization of the skin and temporary pigmehtation. Symptoms.—Ecthyma may occur as an acute or as a chronic affec- tion. In the acute variety, which is rare, the eruption may be pre- ceded by slight febrile symptoms, which usually disappear upon its appearance. Locally, there may be heat, burning, itching, and some- times pain, followed by the formation of reddish raised spots, with hardened bases and a well-marked reddish aureola, tender to the touch. These spots rapidly pustulate, and are in size about that of an ordinary pea, or larger. They are usually round in form, but some- times are flat, sharply limited, and few or many in number. They give exit, in the course of a few days-, to pus, which dries into thick, hard, yellowish to reddish or brown adherent scabs. The character of the scabs, however, will vary according to the quantity of blood which may be discharged with the pus. On their removal, the surface be- neath may be excoriated or superficially ulcerated, and covered with a purulent, bloody, or sanious secretion. The disease runs its course in from one to three weeks, after which the scabs fall off, exposing slight spots of pigmentation or cicatrices. The pustules may, during the course of the disease, appear in successive crops or persist and pass into the chronic state. Chronic ecthyma, which is more common than the acute variety, occurs mostly from some irritation of the skin, like that produced by animal parasites. . The lesions are, howTever, similar in all respects to those of the acute variety. Ecthyma occurs at all ages and in both sexes, particularly in those who are badly nourished, unhealthy, and do not receive proper care. It usually attacks the extremities, but the back, buttocks, and other parts of the body may also be invaded. The pustules of ecthyma have never been met with upon a mucous EXUDATIONS. 349 membrane. In feeble or unhealthy babes ecthyma may assume a grave form, the lesions be converted into deep ulcers involving the entire thickness of the skin and even the subcutaneous tissue. This variety is frequently accompanied by visceral disease, and usually has a fatal termination. Complications are occasionally encountered, such as lymphangitis, adenitis, subcutaneous abscess, or phlebitis. Diagnosis.—Ecthyma is liable to be confounded with ezcema pus- tulosum, impetigo, impetigo contagiosa, impetigo herpetiformis, and flat pustular syphiloderm. It may be distinguished from eczema by the pustules being discrete, as well as by their size and form. The character of the pustules and crusts, already described, serves to point out its difference from impetigo. It is known from impetigo contagi- osa by the history or absence of contagion, the part affected, and the character of the lesions. Ecthyma may resemble impetigo herpeti- formis, but the history, the grouping, and the peripheral spread of the lesions in the latter affection will assist in establishing the diag- nosis. The affection may closely resemble the flat pustular syphilo- derm ; but the history of the latter, its slow course, the peculiarity of the pustules, crusts, and ulcers, with other evidences of syphilis, are sufficient to separate the one from the other. Pathology.—In ecthyma the inflammation, which is often very severe, is located in the upper layers of the corium. It leads to the development of pustules and destruction of tissue, followed by cica- trization and pigmentation, both of which in time may disappear. Etiology.—General debility and a depraved state of the blood are the most frequent predisposing causes. These are mostly produced through bad or unsuitable food, improper hygienic surroundings, especially bad air. Uncleanliness, excesses, overwork, fatigue, and the effect on the system of acute or chronic diseases are also potent factors in producing the disease. Among other predisposing causes are alcoholism, nephritis, diabetes, scrofula, and syphilis. Ecthyma sometimes occurs in the last week of typhoid fever or during convalescence. The exciting causes are any influences which may irritate or inflame the skin, as scabies, pedicu- losis, and scratching. The workmen in sugar refineries are apt to suffer from ecthyma. The virus of the disease may be conveyed by inoculation or auto- inoculation. The contents of a matured pustule deposited in the skin of another person or an animal may excite the development of a lesion, typical as regards its rate of progress and its production of a perma- nent scar. Upon the patient the lesions are spread by the act of scratch- ing. These facts have been demonstrated by E. Vidal. The lesion begins to form a few hours after inoculation. Treatment—The first requirement is the removal of the cause of the disease. At the same time the patient should receive wholesome 350 DISEASES OF THE SKIN. and nutritious food, together with the necessary exercise, bathing, and fresh air. Diet and hygienic measures will therefore be found to be the most certain means of restoring the system to its proper condition. The ordinary tonics are serviceable. Aperients, in addition, often prove of great value. Acute cases are frequently benefited by large doses of iron and quinine. The chlorate of potassium, given alone or in connection with strychnine or belladonna, lessens very much the tendency to the formation of the lesions. The phosphates, hypophosphites, the mineral acids, and cod-liver oil can be administered as they may be required. On account of their power in promoting nutrition, hoang-nan and small doses (one- twentieth grain three times a day) of sulphate of copper have been sometimes found advantageous. Chronic cases may also be given the foregoing systemic treatment in addition to the hygienic measures. The local treatment will depend upon the cause and the stage of the eruption. If it is secondary to some other affection, as scabies or pediculosis, the exciting cause should as soon as possible be removed. In the early stage of the disease alkaline and emollient baths are always of service. Sulphur baths are likewise of benefit. Lotions which are of an anodyne nature may also be used ; of these, lead-water and laudanum, or a weak lotion of witch-hazel, will be found the most effective. Crusts should be removed with oil, or water- dressings or poultices, and cleansed with an antiseptic wrash, as, for instance, a one-per-cent. solution of carbolic acid, a two-per-cent. solu- tion of chloral hydrate or a solution (1: 1,000) of corrosive sublimate. A Aveak mercurial ointment, ten grains of calomel to the ounce of lard, can then be applied. The red plaster of E. Vidal may be used for the same purpose, as recommended by M. Brocq. Red plaster is, however, an unsuitable application for aged people. In some cases powders may be preferred to ointments, and iodoform, iodol, aristol, or salol may be dusted upon the surface of the sores. When the inflammation leads to sloughing, stimulating washes should be used. For the ulcerative form of the disease in children Brocq advises astringent lotions made from walnut leaves and containing a small quantity of chloral, or dry dressings consisting of powdered oak- bark, coffee, quinine, rhatany, or sub-carbonate of iron. One drachm of boric acid or sulphur, or a scruple of naphthol to an ounce of zinc ointment, is also recommended. If the sores obstinately resist treat- ment, a fifty-per-cent. solution of boro-glyceride, or a weak lotion of either carbolic acid or nitrate of silver, will stimulate them to healthy action. Prognosis.—The prognosis is good, except in old persons afflicted with other diseases, when it may be serious. It is often fatal in cachectic infants and in those suffering from diabetes. EXUDATIONS. 351 PITYRIASIS RUBRA. Synonym.—Dermatitis exfoliativa. Pityriasis rubra is an inflammatory disease affecting generally the entire surface, and characterized by a deep-red color of the skin, with abundant exfoliation of thin, whitish scales. Symptoms.—Pityriasis rubra, which is a rare affection, commences as small, red, scaly patches, which rapidly spread until the whole sur- face is involved. The skin presents a uniformly deep-red color, which is lessened by pressure. Whitish or grayish thin scales are quickly and continuously formed and cast off. The scales, which consist of exfoliated epidermis, are generally abundant, and vary considerably in size. They may be large, even several inches in diameter, or small and branny. They are attached, as a rule, only at their centres, be- ing free at their edges and slightly turned up; on their removal the skin beneath exhibits a shining appearance. The exfoliation is rapid and abundant in severe cases, a large amount of scales often being cast off in the course of a day. The changes in the skin, as a rule, involve the upper layers. The surface is dry, as there is no discharge. Thickening is generally absent, but in chronic cases may be present. Occasionally there may be oedema of the extremities. The nails may be attacked in severe cases, and may be opaque, softened, and at times fall out. In markedly severe cases there may be great tension of the skin, the eyelids being ectropic, the mouth opened with difficulty, the fingers bent, the skin greatly affected on the elbow, knee, and soles, walking being interfered with. The hair may also become thin and fall out, and the patient finally die of marasmus. In the majority of cases of pityriasis rubra, itching and burning sensations are either not present or exist but to a mild extent. The skin is tender, and the patient usually complains of being cold or chilly. Constitutional symptoms, if present, consist of more or less fever, ele- vation of temperature, and debility. The disease may be acute or chronic, and may persist for months or years. It occurs generally dur- ing adult life, and the cause of its development is involved in doubt. A very remarkable case of skin shedding has been described * by Dr. J. Frank. The exfoliation, which was complete, had recurred for thirty-three consecutive years on the same day of the month and with- in a few hours of the same time of the day. The patient was a man, thirty-four years of age, a miner by occupation, strong and, in other respects, perfectly healthy. He had never suffered from any of the eruptive fevers. The first attack occurred when he was six months old. He was suddenly taken ill, vomited, was feverish for three or four hours, when the symptoms subsided. On the fourth or fifth day afterward the entire cuticle was cast off, and a few days later the nails * Western Medical Reporter, February, 1891. 352 DISEASES OF THE SKIN. were also shed. A paroxysm always begins abruptly with a feeling of lassitude, which lasts fifteen or twenty minutes, and is followed by mus- cular tremors, nausea, and vomiting. The temperature rises rapidly, the skin and mucous membrane of the tongue and mouth become red and inflamed. Perspiration is suppressed until the attack is at an end. Acute symptoms begin to ameliorate at the end of three or four hours, and have disappeared by the twelfth hour, the skin remaining red for thirty-six hours longer. At times delirium occurs during an attack. In early life the cuticle began to be shed on the third day after appearance of the symptoms, and the process was complete by the fifth day. The time, however, has lengthened with each succeed- ing year until now ten or twelve days are required. The epidermis can be detached in large sheets, and from his hands and feet the patient can remove it intact in the form of gloves or moccasins. The nails loosen and fall off in about four weeks after the acute stage. When the eruption is at its height the appearance resembles that of scarlet fever, and a touch excites a sensation like that of an electric shock. Microscopical examination of a section of the skin gave nega- tive results. Similar cases have been reported by Ferriol and Besnier, but lacked the feature of periodical recurrence. At the International Congress of Dermatology and Syphilography, August, 1889, in the course of an exhaustive review of the varieties which have been classified as pityriasis rubra or primitive exfoliative dermatitis, M. Brocq asserted his belief that a great number of differ- ent affections are characterized objectively by a generalized redness of the derm, and a more or less abundant desquamation of the epiderm. The group is not homogeneous. Excluding the pityriasis rubra pilaris of Devergie, the pernicious lyphodermia of Kaposi, generalized red and desquamative eruptions of artificial origin, and those which may occur in the course of an eczema, psoriasis, or lichen planus, there remains a class known as essential. To these the generic title should be confined. They are : (a) desquamative scarlatiniform erythema, or acute benign exfoliative dermatitis; (b) generalized exfoliative derma- titis, properly so-called, or subacute ; (c) chronic dermatitis; (d) chronic pityriasis rubra, type Hebra; (e) subacute or benign pityriasis rubra.* Diagnosis.—Pityriasis rubra may be confounded with eczema squa- mosum, psoriasis, pemphigus foliaceus, and lichen ruber. From eczema it is to be distinguished by the absence of marked thickening, the for- mation and character of the scales, and also the absence usually of subjective symptoms. From psoriasis it differs generally in involving all surfaces. In psoriasis the scales are also different, being thicker, and seated upon infiltrated bases. Pityriasis rubra may be mistaken for pemphigus foliaceus from the * Le Progres Medical, August 10, 1889; Medical Bulletin, March, 1890. EXUDATIONS. 353 distribution and character of the exfoliation, but the formation of bullae in the latter serves to distinguish the two diseases. Lichen ruber may be diagnosed from pityriasis rubra by always exhibiting papular lesions, and having some thickening of the skin; conditions which are not present in the disease under consideration. Pathology.—Hebra has shown in mild cases cell-infiltration of the rete and corium, the papillae, glands, and hairs presenting a normal appearance. In severe attacks he observed marked chronic inflamma- tory infiltration. The cell-infiltration was abundant in all layers of the skin, and particularly beneath the epidermis, where there was a thin layer of compressed rete-cells largely filled with infiltration-cells. A thick, flat, connective layer existed beneath, with still below a layer of thick, elastic tissue, thrice the thickness of the three layers already mentioned, and having also a collection of yellow granular pigment. The papillae were absent, and the blood-vessels in the sub-epidermal tissue were surrounded with rete cell-infiltration. The sebaceous and sweat glands were also absent, with, however, occasionally one of the former present. The hairs were scanty and the hair-sheaths infiltrated with cells. Etiology.—Nothing is positively known concerning the origin. It has occurred in connection with tuberculosis, albuminuria, and glyco- suria, while in other cases its subjects appeared in perfect health until attacked. Tilbury Fox held that it was due to nervous disturbance. Treatment.—The results of treatment are unsatisfactory. Consti- tutional treatment will vary according to the condition of the patient; as a rule, sustaining measures act most beneficially. Iron, quinine, cod- liver oil, linseed oil, and arsenic are remedies which may be resorted to with advantage. The use of carbolic acid is reported to have been fol- lowed by good results. Aperients and diuretics may sometimes be indicated. In a case which had resisted the action of various local and constitutional remedies, Dr. Walter Scatchard obtained a good result from the use of thyroid tablets. Improvement began at the end of the twelfth day and gradually continued until, in the course of three months, the skin was almost normal. Dr. Stephen Mackenzie advises daily hypodermic injections of pilo- carpine, and a lotion composed of one ounce each of glycerole of lead and glycerine to a pint of water. Bandages saturated in this mixture should cover the patient from head to foot, a mask being used for the face and scalp. The patient, thus enveloped, should lie between blank- ets on a spring or water mattress. The strength of the lotion may in some cases be increased, though if too strong it gives rise to burning and irritation. After the scales have been removed some simple oint- ment is rubbed over the entire body. Weak alkaline and emollient baths are occasionally productive of good effect. The constant protec- tion of the surface, by the application of a bland fat or oil, is service- 23 354 DISEASES OF THE SKIN. able. Olive, linseed, and cod-liver oils are the most effective remedies for this purpose. In cases attended by itching some carbolic acid or menthol may be incorporated in any of the oils just named. Prognosis.—The prognosis is not, as a rule, favorable. The general and severe forms are usually fatal. Pityriasis Rosea.—Gibert first described and named this affec- tion. Duhring, Weyl, and others have given a detailed account of it under the same name. Bazin, Hardy, and Horan have spoken of it as "pityriasis maculata et circinata." The disease is rare, may or may not commence with fever, though it is seldom absent, and generally accom- panied by severe headache. The fever is followed by the appearance of macular or maculo-papular patches, principally upon the trunk. The limbs and face are sometimes invaded, and in rare instances the disease begins upon and is confined to the upper extremities. The lesions may or may not be slightly elevated, or they may be de- pressed. In size the patches vary from a pin's head to a split pea, or larger, and they are either isolated or confluent. They are round or oval, mostly light or dark red, which gradually becomes yellow. The patches are dry and scaly, with a tendency to spread in the periphery and heal in the centre. The primary lesion is surrounded by a zone of erythema. Neighboring patches may coalesce and form pictures of varying contour, as semicircles, circles, or disks. Subjective symptoms may be wanting, or may be present in the form of more or less itching. According to Barduzzi, itching or a sensation of heat, burning, or pricking usually occurs intermittently, especially where two folds of skin are in contact. The tactile sense appears to be somewhat lessened in the centre of the patches. The lesions appear gradually or suddenly, the patches coalescing and then spreading until a large surface is in- volved. The eruption generally remains from four to eight weeks, and spontaneous recovery follows. The affection occurs chiefly in adults of both sexes in good health. We possess no definite knowledge as regards the cause of this affection. Pityriasis rosea does not seem to be con- tagious, though an epidemic was observed by Peroni. Vidal reports the finding of small spores in the epidermis of pityriasis circinata, which is said to be identical with this disease, though it has no special localization nor regular evolution. Pityriasis rosea may resemble ring- worm, but the absence of the peculiar fungus of the latter will at once settle the diagnosis. Besnier points out that seborrhceic eczema may bear, when seated upon the trunk or limbs, a very close resemblance to pityriasis rosea. In these cases the presence of seborrhcea, sebor- rhceic scales, or eczema upon the scalp is of diagnostic import. Treatment.—Weyl believes that active treatment is contra-indicated. Baths, mild dusting-powders, and soothing ointments may, he thinks, assist in a more rapid recovery. Barduzzi advises plain diet, alkaline diuretics, and, it may be, a saline cathartic. EXUDATIONS. 355 FURUNCULUS. Synonyms.—Furuncle—Boil—Blutschwar. Furunculus is a circumscribed inflammation of the true skin and subcutaneous tissue, developing one or more various-sized, hard, and painful tumors, which terminate in suppuration and the formation of a central necrosed mass or core. Symptoms.—The affection may be ushered in by slight or severe constitutional symptoms, or they may be entirely absent. Locally, the first evidence of the disease is an itching, burning, or painful sen- sation in the skin, followed by the appearance of a slightly reddened, elevated spot, which is tender, often painful, hard, and deep seated. Gradually it increases in size, and manifests a tendency to suppurate. In the course of a fewr days, usually from three to six, or more, accord- ing to the region involved, it reaches maturity. When fully formed the lesion appears as a round or conical tumor, with a collection of pus in the apex. The tumor is usually around the opening of a follicle, or is pierced by a hair. In some cases there may be no formation of pus, when the tumor is known as a blind boil. In size it may vary from a split pea to a pigeon's egg. In color it is usually of a deep or bright red to a purple. The pain which is generally present is of a throbbing or burning character, being more intense at night, and increasing in severity until the lesion is opened or bursts, when it ceases. Furun- cles rarely appear singly, but are generally multiple. They may occur in successive crops, several appearing as others are disappearing. As a rule, they are isolated. They may invade any region of the body, but attack by preference the face, neck, axillae, back, breast, buttocks, the anal and genital regions, and the extremities. Boils at times develop as a complication with eczema, scabies, and other diseases of the skin. Diagnosis.—The diagnosis of furuncle is always easy, and, after considering the symptoms, errors are almost impossible. The affec- tion differs from ecthyma in being deeper and having a central core. In like manner it can be separated from pustular syphilis by the ab- sence, in the latter, of a central core, and in the history of the disease, with the presence of specific lesions upon other portions of the body. From carbuncle it differs in being smaller, with but a single point of suppuration, and being usually multiple. Carbuncle is larger, with two or more points of suppuration, and occurs singly. Pathology.—The furuncle arises, no doubt, from some derangement in the circulation, leading to necrosis of the tissue. The attempt by suppuration to throw off this dead tissue constitutes the peculiar pro- cess of the disease. An embolus forms in the capillaries around the glands, developing mortification of the gland, with consequent cir- cumscribed inflammation and plastic infiltration. The plastic infil- tration is followed by a purulent one, which is discharged with the 356 DISEASES OF THE SKIN. central mass or core. On the separation of the core there remains a cavity, with surrounding infiltrated tissue, which gradually closes by granulation. Etiology.—Boils are most frequently occasioned by some internal derangement. Nervous impairment, chlorosis, diabetes, albuminuria, rheumatism, gout, tuberculosis, scrofula, dyspepsia, fevers, and de- bility are among some of the more active causes which lead to their development. They also occur from many functional derangements of the system, from changes in the habits and modes of living, diet, seasons, and as the result of poisons, debilitating diseases, and from great fatigue. The blood very often, from one or another of the above conditions, has an effete product circulating in it, and only requires some local irritation of the skin as a cause; e. g., the wearing of dyed clothing, bathing, scratching, blisters, contact with pus, poisons, oint- ments, and other substances. Hergott records an epidemic of boils in the lying-in hospital at Nancy from an infected bed-pan. Boils occur at all periods of life, but are more frequently seen in young and old people. Dr. Schimmelbusch, of Cologne, has made many examinations of pus taken from boils, and has invariably found it to contain the staphy- lococcus pyogenes aureus and albus, the first-named variety being particularly numerous. A pure culture of this organism gave rise to boils when rubbed into the skin. Microscopic examination of a piece of this skin showed that it was intact and that the germs had entered the hair follicles thence penetrating the adjacent tissue. Loewenberg, of Paris, concurs in this opinion. Treatment.—This affection demands both constitutional and local treatment. Hygienic measures, such as frequent ablutions, with ex- ercise, and possibly a change of air, often prove of service. The diet required should be very nutritious, and administered as a medicine if the patient, as is often the case, has lost all desire for food. It is well to forbid the use of coffee, pork, salted meat, cheese, fish, and shell-fish. The cause should be sought, and appropriate remedies given accord- ing to the indications. If the secretions are disordered, they should at once be corrected. In broken-down and debilitated subjects, iron, quinine, strychnine, the mineral acids, cod-liver oil, and arsenic are the most suitable to employ; the selection to be made as the case may require of one or another of these agents. Small doses of opium are advisable when the pain and discomfort are very great. The moderate use of malt and spirituous liquors in the weak and aged is advisable. Bouchard has known furuncular eruptions to be arrested in their progress by disinfection of the alimentary canal, and Le Gendre has obtained excellent results by this mode of treatment, administering 30 cgm. (four and a half grains) each of beta-naphthol, salicylate of EXUDATIONS. 357 bismuth, and magnesia every four hours, making use of local antiseptic washes at the same time. In cases dependent upon gout Brocq has obtained good results from prolonged use of the extract of colchicum in the daily dose of three to four centigrammes (one half to two thirds of a grain). Tonics, especially the simple bitters, with the alkalies, are useful. Young, plethoric, and vigorous individuals in whom there is a deficient elimination often improve rapidly upon alkalies, diuretics, and aperients. The most active remedies as prophylactics, and in overcoming the tendency to suppuration, are the chlorate of potassium, the sirups of the phosphates, the hypophosphites, the sirup of hydriodic acid, and the sulphide of calcium, used alone or in conjunction with various other tonics and aperients. If there is a tendency to the development of boils, or even when they are established, I invariably give five or ten grains of the chlorate of potassium, three or four times daily, in water, or as in the following formula : IJ Potassii chloratis................... gr. c. Aloini............................. gr. ij. Syr. phosphatis co................... f 3 v. M. Sig. : Two teaspoonfuls three or four times daily. The chlorate of potassium may be well combined, in cases needing it, with the sirup of the lactate or the iodide of iron. Another excel- lent remedy is the sirup of hydriodic acid, twenty to thirty drops, three or four times daily. The hyposulphite of sodium has been used for the same purpose, as well as a mixture containing equal parts of the sul- phides of sodium and potassium, the sulphate and bicarbonate of sodium, tartaric acid, and gum arabic. Of this mixture seven and a half grains are administered several times a day dissolved in half a glassful of water. Yeast has been thought to have an influence in pre- venting the formation of boils. A combined internal and external employment of boric acid is recommended by Dr. Alison for the pur- pose of aborting boils, curing those which have already developed, and for preventing new eruptions. He administers about twelve grains daily for several days, and applies a hot four-per-cent. solution of boric acid, rubbed upon the surface, followed by hot compresses moistened in the same solution. Local treatment is also valuable, but not so effective, in relieving or eradicating the disease. The boils may be aborted by applying compression in the form of a bandage or one of the medicated plasters, the soap-plaster being considered most useful for this purpose. They may also at times be aborted by applying to their apices one of the caustics, as the stick nitrate of silver. The same object may be accomplished by an ointment of silver oleate, the salt being first dissolved in an equal quantity of oleic acid and then mixed with lard in the proportion of five to sixty grains to the ounce. Carbolic acid, injected diluted, is also recommended. 358 DISEASES OF THE SKIN. Prof. Verneuil, of Paris, states that a boil may often be prevented by spraying the surface with a two-per-cent. solution of carbolic or boric acid. If suppuration has already taken place, the spray will materially assist the effect of the incision and hasten recovery. The body and clothing of the patient should be protected by towels and the imme- diate vicinity of the furuncle by diachylon plaster. Others seek to accomplish the same purpose by the injection of a few drops of a two-per-cent. solution of carbolic acid into the base of the swelling. The external application of an alcoholic solution of carbolic acid, the use of the electro-cautery, camphorated alcohol, or tincture of iodine have also been recommended. In order to prevent recurrence it is well to make use of a lotion consisting of equal parts of the tincture of iodine, tincture of arnica, and camphorated alcohol, as advised by Brocq. Dr. Jamieson gives the following formula for a preparation that may be used in the hope of aborting a boil: IJ Tr. arnicae......................... f 3 j- Acid, tannic...................... 3 ss. M. Pulv. acacise...................... 3 ss. This mixture is painted upon and a little beyond the inflamed surface, each layer being allowed to dry before another is applied. The process is continued until a tolerably thick coating covers the part.* Sir Peter Eade claims that the development of a furuncle may be checked by freqently soaking the swelling, in its formative stage, with a solution of salicylic acid. Jorissen's method of accomplishing the same purpose is by one or more frictions daily with an ointment composed of five grains of red oxide of mercury to an ounce of lanolin, each friction lasting for three or four minutes. Spohn warmly recom- mends f the topical application of a solution of chloral (two and a half drachms to ten fluid drachms each of glycerine and water). In the treatment of furuncles of the external auditory canal, Dr. Cholewa has derived much advantage from the use of a twenty-per-cent. solution of menthol in oil, which reduces swelling, relieves pain, and at the same time exerts a specific bactericidal action. A twisted pledget of cotton moistened in this solution is introduced within the meatus. The plug should be large enough to exert a gentle pressure and be renewed daily. A slight burning sensation is at first produced by the applica- tion, but soon disappears. If suppuration has occurred, the boil should be opened and the tampon reapplied. J In the same condition Loewen- berg advises a supersaturated solution of boric acid in alcohol. A weak solution he declares to be useless. A good application in the same condition is a twenty-five-per-cent. solution of aluminium acetate, dropped frequently into the ear and the canal plugged with cotton. A solution of pyoktanin, one part to five * Jamieson, op. cit., p. 193. f Archives Med. Beiges, July, 1891. X Therapeutische Monatshefte, June, 1889. EXUDATIONS. 359 hundred or even one hundred, is a good application to the surface of a boil. An ointment of belladonna, of mercury, or a mixture of equal parts of these . preparations, is sometimes successful in aborting the progress of a boil. Iodol ointment, ten grains or more to the ounce of lard, is useful on account of its antiseptic properties. Ergotin made into a paste with water has been suggested as an application in the formative stage. A paste of powdered opium and water likewise af- fords relief at the same period. An ointment of the oleate of iron may be used with success. After the boil has been formed, and in its early stage, Cold applications—viz., ice, ice-water, lead-water, and lauda- num, diluted tincture of witch-hazel, and the tincture of arnica—are beneficial to relieve the tension and inflammation present, and lessen the pain. Veiel recommends a paste composed of oxide of zinc and vaseline with four per cent, of boric acid. When suppuration has set in, warm and hot applications are serviceable, and assist in hastening the expul- sion of the inclosed dead mass. The judicious use of poultices at this period is advisable, but care must be taken not to use them too early or too continuously, as they may increase the irritation and excite the for- mation of a new crop. The application of compound resin cerate, or what is popularly known as Deshler's salve, by its stimulating action hastens suppuration decidedly. It may become necessary, owing to the severe inflammatory action that may be present in and around the affected integument, to apply soothing and sedative ointments, especially those containing opium, lead, arnica, etc. When suppuration is established, a free incision will lessen the in- flammation, hasten the expulsion of the broken-down tissue, and assist in restoring the parts to their normal condition. Early incision, on the other hand, is not advisable at all times, as it often lessens, but will not remove, thetendency to suppuration. Prognosis.—The prognosis is generally good. The lesions may appear successively, and be prolonged for months, but the eventual result is favorable. OARBUNOULUS. Synonyms.—Anthrax—Brandschwar—Carbuncle. A carbuncle is a circumscribed, painful inflammation of the skin and subcutaneous cellular tissue, sometimes involving the deeper structures, and terminating in gangrene of the affected part. Symptoms.—The development of a carbuncle is generally preceded by either slight or severe constitutional symptoms. After more or less malaise, there may be headache, chill, and fever, or even more decided systemic disturbance. The skin of the affected part then becomes hot, hard, swollen, painful, and bright or dark red in color. The pain, which is often very severe, is of a dull, burning, or throb- bing character. Sooner or later, the swelling assumes a brawny ap- 360 DISEASES OF THE SKIN. pearance, followed by softening of the tissue; the overlying skin be- comes thin; vesicles or pustules may form, which rupture; or many openings occur, through which sanious pus oozes. The openings are centres of suppuration, which are blocked up with necrotic masses or cores, giving the part a cribriform appearance. The necrotic tissue, or cores, may come away after a time in portions, or slough out entire, the morbid action in severe cases destroying thus not only the super- ficial, but all the deep, soft structures of the part involved. There remains after the removal of this mass a cavity, or deep ulcer, with undermined edges and uneven base, which is filled up slowly by gran- ulation, forming usually a pigmented, and often lasting, cicatrix. Carbuncles generally occur singly, and may be associated with boils. They are variable as to size, being usually from that of an ordinary hen's egg to a saucer, or larger. They occupy as their select- ive seat the back of the neck, the back, and buttocks. The course and duration of the disease will vary according to the age of the pa- tient, the condition of the system, its power of resistance, the region invaded, and the size of the carbuncle. In broken-down and elderly people it is a serious and at times a fatal disease. Diagnosis.—Carbuncle differs from furuncle, about the only dis- ease with which it might be confounded, in being mostly solitary, larger, and containing many points of suppuration. In its early stages it might also resemble erysipelas, but the circumscribed character of the inflammation, together with its hardness and painfulness, should always serve to distinguish it. Pathology.—The pathology of the disease is similar to that of furuncle. The inflammation, however, is more extensive, beginning in many points, and extending downward to the deeper structures, as well as horizontally, and terminating in gangrene of the entire part involved. Etiology.—The causes of carbuncle are similar to those of furuncle. It can not always be traced to any assignable cause. It frequently attacks those who are broken down in health. Diabetes, albuminuria, rheumatism, and gout are among some of the prominent causes which occasion it. It occurs more frequently in summer than in winter. Men are more prone to the disease than women, and it is more fre- quently observed in middle and old age. Treatment.—The treatment required is both constitutional and local. The systemic depression is more severe and serious, and there- fore must be met more promptly and actively than in boils. Hygienic measures, and especially good nursing, are essential. The diet should be nutritious, consisting largely of animal food, as beef-tea, milk, and mutton-broth. Stimulants should be resorted to, and often employed for decided effect, particularly if there is much attendant depression and exhaustion. Whisky, champagne, and the preparations of ammo- EXUDATIONS. 361 nia are the most appropriate agents to administer in the above con- dition, as assisting to support the flagging powers of the body. The most effective remedies to employ are the tincture of the chloride of iron and quinine. If the case is simply an ordinary carbuncle, the patient may do well on moderate doses of these drugs* but if the con- stitutional symptoms are marked they should be given in large and often-repeated doses. Thus, in severe forms of the disease, I generally prescribe one-drachm doses of the tincture of the chloride of iron every two or three hours, with ten or fifteen grains of quinine three times daily. Opium, or some other anodyne, is often necessary to overcome or lessen the pain and afford rest to the patient. The internal admin- istration of potassium chlorate is beneficial and diminishes suppu- ration. The local treatment is frequently most beneficial in relieving the throbbing pain and expelling the offending mass. In the early stages cold applications, especially of ice, may give much relief. Dr. A. E. Spohn has witnessed excellent results from the applica- tion of a ten-per-cent. solution of chloral hydrate in glycerine and water, sulphide of calcium being given internally at the same time. By this method the necessity of incision was avoided. Painting with carbolic acid or cantharidal collodion is also recommended. Hypodermic injec- tions of a five- or a ten-per-cent. solution of carbolic acid has been known to be effective. (Camphor and carbolic acid is an excellent combina- tion, and has the advantage of being free from disagreeable odor.) An ointment of iodol, ten grains or more to the ounce, is a good antiseptic application and promotes cicatrization after ulceration has occurred. An ointment of silver oleate, if applied early, may prevent the forma- tion of pus. The diluted fluid extract of hamamelis is a serviceable lotion. Puncturing deeply with a long, thin knife will lessen the tension and relieve the pain. Piercing the carbuncle in a number of places with a stick of caustic potash, or allowing small pieces of the potash to become inserted in it, and permitting them to remain, as recommended by Physick, assists in separating the diseased mass. A strong solution of carbolic acid in water or glycerine inserted into the cribriform openings is warmly recommended by Sir Peter Eade.* M. Beauquinque advises the application to the openings of tincture of iodine by means of a brush or pledget of cotton or injected into the interior. A solution of pyoktanin may also be used as an antiseptic application. Dr. McReddie reports success from the use of equal parts of iodoform and oxide of zinc. The surface is first cleansed with a solution of carbolic acid or corrosive sublimate, then covered with the powder and lint soaked in carbolized oil. He makes no incisions, but removes sloughs with the forceps. Polaillon makes use of sticks of Canquoin's paste in a manner similar to that in which caustic * British Medical Journal, May 19, 1S88. 362 DISEASES OF THE SKIN. potash is employed. The preparation consists of one part of chloride of zinc, two of wheat flour, and enough water to form a paste, which can be moulded into the form of rods. Dr. Riedel advocates complete extirpation of the carbuncle by means of a circular incision, from which a number of radial incisions are made to the surrounding healthy parts. The infiltrated tissue is dissected out, the flaps approximated on the following day, with an opening in the center providing for drainage. The temperature, it is said, falls to normal on the evening of the day of operation, the loss of tissue is reduced to a minimum, healing advances rapidly, and a good cicatrix is the result. As soon as suppuration has set in hot applications, especially the use of poultices, are advisable. The moment pus is formed a free in- cision or incisions—the crucial being the best—should be made, the dead tissue scraped or dug out, and the parts kept clean by antiseptic dressings. The resulting ulcer may be dressed with carbolized oil or an ointment containing balsam of Peru. Or, the surface having been washed with a weak solution of corrosive sublimate, iodoform may be employed. Applying bicarbonate of sodium over the surface of a car- buncle and allowing the dry dressing to remain a day or two is a very efficient treatment. Dr. J. T. McShane, in the " Medical Mirror," advises the use of the rhigolene spray before opening a carbuncle. Not only is the opera- tion rendered painless, but he believes that the sloughing is thereby accelerated and consequently the cure hastened. The part should be deeply frozen by allowing the spray to act upon the surface for about two minutes. Prognosis.—The prognosis should always be cautiously given. It will depend to a great extent upon the age, condition of the patient, amount of disease, and the existence of complications. It is serious after middle life, especially if the carbuncle is large, the subject in poor health, and if disease of the kidneys or other organs be present. A fatal termination at times follows, particularly under the above con- ditions, but not so frequently as is generally supposed. Anthrax (Pustula Maligna).—Malignant pustule is a rare dis- ease, produced by inoculation from a poison developed in the lower animals. It may be contracted from partaking of milk, butter, or meat from diseased animals, or even through the agency of flies or insects. Tincolini witnessed an epidemic which caused the death of four per- sons and infected twenty-six others. The outbreak, in all probability, originated from a diseased calf which was killed and sold for food. Goldschmidt describes a case which occurred in the person of a brush- maker and in which infection seemed to be due to the bristles used by the man in his work. After death extravasations were found in the cervical glands, bloody transudations in the serous cavities and ecchy- moses upon the mucous membrane of the stomach and small intes- EXUDATIONS. 363 tines.* A similar occurrence has been reported from Lille, where five work-people in a brush maker's employ were fatally contaminated by handling bristles imported from Persia. Commonly it is contracted by handling diseased dead animals, or their hides, and it is even said to be brought about by inhaling dust containing the virus. Butchers, tanners, furriers, and wool-sorters are most liable to it. Intestinal lesions may be provoked by the consumption of raw or insufficiently cooked food, and pulmonary anthrax is seen especially among wool- sorters as a consequence of inhaling an infected atmosphere. A few hours after inoculation a burning, itching, or painful sensation sets in on the affected surface. This is followed by the development of a papule, vesicle, or pustule; the latter lesions extend until they become as large as a coin, and rupture, exposing gangrenous tissue, or an un- healthy ulcer. In the great majority of cases the lesion is single, but exceptionally two or three may coexist. The surrounding integument is of a dark-red color, and there is considerable swelling and infiltra- tion in the neighborhood of the pustule. Around the sore secondary vesicles, or satellites, are arranged in circles more or less regular in outline. The parts most commonly attacked are the face, arms, and hands, particularly the dorsal surface. There is another form in which charbonous disease appears, called malignant oedema of the eyelids, in which the integument is hard and swollen. At first the swelling ap- pears to be only cedematous, the skin is not discolored, and there is scarcely any pain or itching. In the course of twenty-four or forty- eight hours they become hard, the two lids approximate, and it is diffi- cult to expose the eye. Little blisters soon form and break, leaving a gangrenous surface. Malignant oedema is most often observed upon the eyelids, but may occur upon the lips, tongue, upper limbs, and breast. The constitutional symptoms are usually pronounced in both forms, but are more serious in the latter. The systemic symptoms may be entirely absent, or there may be fever, delirium, and even a typhoid state, ending in death. The fatal result takes place from the sixth to the ninth day, though it is not uncommon at the end of the fourth or fifth day. Death is usual if the case is untreated or misman- aged, but in rare instances spontaneous cure has been observed. Post-mortem examination reveals extensive change in the parts involved, as well as in the various tissues and organs of the body. The blood is black and has lost its property of coagulation. The venous system is engorged. The spleen is enlarged, black, and softened. The mucous membrane of the bowel, and sometimes of the stomach, is studded with ecchymoses and patches of gangrene. Many congestive or apoplectic foci are found in the lungs. Bacilli are present in the blood, spleen, lymphatic glands, and marrow of the bones. The characteristic anthrax bacillus is an aerobic organism, staff- * Munchener MoJicinische Wochenschrift, February 10, 1891. 364 DISEASES OF THE SKIN. shaped, comparatively large, sometimes isolated, at others joined to- gether, straight or curved, in the form of a crosier. It develops rap- idly under cultivation and takes the form of long, twisted threads. The local lesion, according to Davaine, begins on the first to the third day after inoculation as an elevation of the epiderm, a vesicle seated in the stratum mucosum, and contains a blackish serum full of bacteria. The derm is soon involved, infiltrated with organisms, and an area of necrosis results. Bacteria are likewise abundant in the eschar, and the surrounding cedematous cellular tissue, whence they find their way into the blood.* Treatment.—The best treatment consists in sustaining the system with food, and stimulants, as whisky, ammonia, and ether. Quinine and ipecacuanha are both indicated in large and frequently repeated doses. Local treatment is absolutely necessary ; the papule, vesicle, or pustule should be at once excised and afterward cauterized, either with the actual cautery, the galvano-cautery, or with one of the mineral acids. Mr. S. L. Woolmer reports excellent results from destruction of the lesion and some surrounding healthy tissue by means of the actual cautery without previous excision. He insists that the application should be thoroughly made, as otherwise the growth of the pustule may be greatly accelerated. Of forty cases so treated, he lost but one, and this he did not see until the tenth day, and great generalization had existed from the first. Dr. Lande obtained a favorable result in two cases from the injection of a ten-per-cent. solution of carbolic acid in glycerine and water thrown into the subcutaneous tissue around the border of the anthrax. In less severe cases, a five-per-cent. solution would probably be suf- ficiently powerful. The treatment, though very painful, was followed by rapid improvement. The injections were made at five different points, and represented a total dose of fifty cgm. (seven and three quarter grains). They should be repeated until threatening symptoms begin to abate. Dr. Rinonapoli advises the injection into and around the seat of the pustule of a ten-per-cent. solution of iodoform in ether. Severe burning pain is occasioned, but is said to be not of long contin- uance. Improvement is so rapid that the treatment may almost be re- garded as specific. In an interesting and erudite communication, Dr. H. W. Blanc, of New Orleans, identifies the disease of the Egyptian plagues with anthrax, f Equinia.—Equinia, also termed glanders and farcy, is a specific contagious affection caused by inoculation with a virus derived from the horse. The disease is characterized by inflammation of the nasal and respiratory mucous membranes, together with the lvmpbatics and skin. In the course of a few days to several weeks after inoculation marked constitutional symptoms arise. There may be headache, * Leloir and Vidal, op. cif. f New Orleans Medical and Surgical Journal, July, 1890. EXUDATIONS. 365 malaise, chill, and pains of a rheumatic character, followed by the appearance of an erysipelatous eruption around the inoculated part. Vesicles, pustules, and papules, and tubercular formations develop, and break down, exposing gangrenous tissue, or unhealthy, discharg- ing ulcers. The lymphatics become swollen and inflamed, and bull* appear in various portions of the body, followed by suppuration and destruction of the tissue. Large and painful hardened masses of cell collections can also be detected in the subcutaneous tissue, which break down and ulcerate. The nasal and respiratory passage and the contiguous mucous membranes become inflamed. A yellowish and muco-purulent and later bloody discharge takes place from the nos- tril, the glands become swollen, and unhealthy ulceration and gan- grene of the mucous membrane follow. The inflammation may extend to the buccal cavity and the throat, and the patient may die from the grave constitutional involvement, or from the disease affecting the glottis. The skin and mucous membrane may or may not be affected at the same time. The disease is not common ; it is contagious, being produced by direct contact or through the air, which may contain the peculiar virus. Bacilli have been found in the blood and pathological products of individuals suffering from glanders. Treatment-—The chief treatment consists in sustaining the patient with food, stimulants, and by the employment of large doses of the tincture of the chloride of iron and quinine. The local treatment mainly to be relied upon is cleanliness, by using antiseptic solutions of the corrosive chloride of mercury. In two cases Gold has obtained satisfactory results by incising the phlegmonous areas, dressing the wounds with corrosive sublimate (1:1,000) and iodoform gauze, and, in addition, practising a course of mercurial inunctions. The nasal cavities should be frequently cleansed with injections, and the lesions cauterized thoroughly, and afterward treated with suitable soothing applications. Delhi Boil, Aleppo Evil, and Biskra Boutont.—The above three diseases occur endemically in India, Aleppo, Algeria, and other foreign countries. They have been described »by Farquhar, Willemin, Geber, Tilbury Fox, D. D. Cunningham,* and others, to whose writ- ings for a more detailed account the reader is referred. Fox, who has given a most careful account of them, believes that they are allied in many particulars to carbuncle. They are very chronic, appearing usually first as a papule or tubercle, which suppurates and finally ulcerates. The disease has a stage of incubation, though the usual length of this period has not yet been determined. It may appear as a primary affection or may follow various cutaneous lesions, such as acne, impetigo, burns, vaccination, or even the sting of an insect. * They are said to be due to a peculiar form of parasitic organism. (See researches by Dr. Cunningham, Indian Medical Gazette, February, 1886.) 366 DISEASES OF THE SKIN. During the months of September and October trifling wounds may be transformed into this malady, which by preference attacks the face Or limbs and is rare upon the trunk. A number of lesions may develop consecutively in the same region and may blend to form a single ulcer. The ulcer, accordingly, may enlarge by peripheral extension, or by the coalescence of several tubercles. In the beginning the ulcer is cov- ered with a yellowish, greenish, or blackish crust. When this crust is removed and the surface cleansed it is seen to be studded with irregu- lar granulations. In the commonest form of the affection the lesion is papulo-crustaceous, in a second the ulceration is deep and extensive, while in a third the granulations are exuberant and assume a papillom- atous or villous aspect. Complications are unusual, though lymphan- gitis, phlebitis, or erysipelas may occur. When it attacks debilitated persons or drunkards it may prove fatal. The duration of the disease is from three months to a year. Hyde, who personally examined these affections during a visit to Arabia and Africa, states that the numerous furuncular, papular, and pustular affections encountered differed in no single instance from those in temperate climates, except in being ag- gravated by filth, meagre diet, climate, ignorant medication, and the syphilitic diathesis. Heydenreich proposes to classify these several manifestations under the title of " tropical boil." He has isolated a microbe which he believes to be causative of the affection. This organism, discovered by Heydenreich in an epidemic which raged among Russian troops stationed on the borders of Afghanistan, is iden- tical with that detected by Duclaux in the Biskra bouton. The disease is inoculable and auto-inoculable, as has been shown by Laveran, Hick- mann, and Weber. One attack does not ensure absolute immunity. It has been surmised that flies and mosquitoes act as carriers of the contagion. According to Leloir and Vidal and to Cornil the presence of a microbe in sections of Biskra bouton is very inconstant. Riehl and Paltauf found numerous organisms in the embyronic cells of the granulation tissue, encapsulated and recalling the appearances described by Cunningham. Chantemesse has found a microbe analogous to that of Duclaux and Heydenreich, and though it is probable that this or- ganism is, in fact, the exciting cause of the tropical boil, the fact can not yet be regarded as demonstrated. If this disease occurs in a debilitated individual the system should be supported by means of iron, quinine, strychnine, or cod-liver oil. As regards the sore, it should be dressed, after the crust has been removed, with tannin, iodoform, iodol, aristol, or covered with an antiseptic dressing of carbolic acid or corrosive sublimate. It would be good practice to attack the ulcer radically by the actual cautery or caustic potash. Abscessus.— Cutaneous abscesses are circumscribed cavities con- taining pus. They occasionally arise from some systemic derange- EXUDATIONS. 367 ment, but are generally the result of local irritation or intense inflam- mation in connection with other diseases of the skin. Abscesses appear sometimes in connection with eczema, acne, scabies, and pediculosis. They may be formed on all regions of the integument, but are ordi- narily seen on the scalp, face, neck, back, and axillae. Treatment.—Abscesses may require to be treated upon antiphlo- gistic principles. They usually only need to be opened and their con- tents allowed to escape. During the early stage suppuration may be prevented, it is said, by the application of a yeast poultice upon the surface. Frictions of an ointment containing about two drachms of salicylate of bismuth to the ounce of lanolin are also recommended, with, internally, a moderate dose of calomel. Prior to maturation we may endeavor to prevent or limit the for- mation of pus by the application of an ointment consisting of mercury rubbed up with an equal part of lard, with the addition of a suitable amount of extract of belladonna or opium. A mixture of equal parts of the fluid extract of arnica root, soap liniment, and laudanum is also serviceable in the formative stage. After incision, some antiseptic powder or solution may be applied to the surface. Wounds and Contusions.—The skin and deeper structures may be incised, lacerated, contused, or bruised and punctured, in numerous ways, and may occasion slight or severe constitutional symptoms. The treatment in all instances is to be conducted upon general prin- ciples. The unsightly discolorations due to effused blood may be prevented by applying the tincture or a strong infusion of capsicum annuum mixed with an equal bulk of mucilage of acacia, with the addition of a few drops of glycerine. This combination should be applied to the surface with a camel's-hair brush, allowed to dry, and the same pro- cedure may be repeated once or twice or when necessary.* There are, however, two very important forms of wounds of the skin, namely, poisoned and dissecting wounds, which demand special consideration. Dissecting Wounds.—Dissecting wounds are due to direct inocu- lation from dead bodies, mostly during post-mortem examinations and dissecting. The symptoms may be local, or both local and consti- tutional. The latter may be both severe and grave. Commonly, how- ever, dissecting wounds occasion only a local inflammation. Inocula- tion may occur through an existing abrasion, or a wound made with the instrument used, or in handling the body. A vesicle, pustule, or other lesion may form, followed by redness, infiltration, burning, itch- ing, and pain. Occasionally there will be in addition more or less systemic disturbance; the pain will pass up the arm as far as the * Therapeutic Gazette, June 16, 1890. 368 DISEASES OF THE SKIN. axilla, and lymphangitis follow. Rarely the constitutional involve- ment may become marked, and typhoid symptoms supervene. The condition of the system, doubtless, has much to do with the occurrence of dissecting wounds. When the nervous force is depressed, the liver inactive, the blood loaded with excrementitious products, when a rheumatic, gouty, scrofulous, or tuberculous diathesis is present, or the kidneys are unsound, an accidental prick received in making an autopsy is likely to be followed by grave consequences, or even death. Ex- amples illustrating this statement have occurred in several instances in Philadelphia. On the other hand, when the organism is in vigorous health, evil results seldom follow such accidents, which are of daily occurrence in the dissecting and post-mortem rooms. I can speak from personal experience on this point. During a service of twelve years in anatomical rooms and in conducting necropsies I have often been wounded, sometimes rather severely, but in no instance did any but the most trifling inflammation follow. Treatment.—The moment the wound occurs the part should be sucked by the patient and then incised and allowed to bleed freely. The author can state, from practical experience as an anatomical demonstrator, that when wounds are treated in this manner promptly the part heals rapidly without the least bad effect. I have yet to see a single instance in which a dissecting wound so managed caused any local or constitutional symptoms. If the wound has not been attended to in time, it should be cut open, sucked, and allowed to bleed freely and afterward cauterized, the chloride of zinc being the very best caustic to employ for this purpose. Poisoned Wounds.—Poisoned wounds may be inflicted by insects, animals, and the bite of man. Flies, bees, wasps, spiders, scorpions, and snakes, by their bites or stings, produce all forms of lesions on the skin and severe inflammatory action. Bites of inferior animals, as rats, mice, cats, etc., and of the dog and horse, are also poisonous. No wound is so frequently venomous as that produced by the human bite, and it is also occasionally followed by severe constitutional symptoms. The skin may simply be denuded by the contact with the tooth, or the tooth may make a punctured wound. Poisoned wounds may also be caused by birds, fishes, and other living things besides those which have been mentioned. The symptoms which arise from wounds so produced are frequently of an erysipelatous nature, followed by pro- found general depression. Abscesses and mortification may follow, necessitating amputation of the affected part, and in some instances producing pyaemia and death. The internal treatment is opium for the pain, mercury when necessary, and stimulation with whisky and carbonate of ammonium. In very serious cases it may be necessary to resort to hypodermic injections of a stimulant, or a fluid drachm of a one-per-cent. solution of permanganate of potassium, suggested by EXUDATIONS. 369 Lacerda, which, he claims, acts decidedly in a very few minutes. The local treatment of stings of insects consists in the use of solutions of bicarbonate of sodium, naphthol, corrosive sublimate, ammonia, and tincture of witch-hazel and camphor. Solutions of carbolic acid and thymol are also useful. The application of earth is a popular and valuable remedy also for both stings and bites. Poisoned wounds inflicted by bites of the inferior animals are frequently best treated by emollient poultices, lotions of lead-water and laudanum, leeching, or free incisions. The latter should be used early and effectively. Ulcers. — Ulcers are suppurating sores extending to various depths. They may be acute or chronic. An acute ulcer is rapid in its course, and attended with the symptoms of acute inflammation. It may invade the skin alone, or the skin and subcutaneous connective tissue of any part of the body. It is variable in size and shape. It is generally oval, circular, or irregular, but may be creeping, serpigi- nous, or angular in form. The surface of the sore may have a red and inflamed appearance, or be red in certain portions and white in others. The base of the ulcer, particularly if the inflammatory action is high, may present a brownish or even blackish hue, and the discharge may be of a serous, purulent, or bloody character. The edges of acute ulcers may be straight, thin, undermined, everted, or ragged. They may be complicated with sinuses. The surrounding integument manifests all the local symptoms of inflammation, being reddened, swollen, and attended with more or less pain. There is usually some constitutional disturbance, which sometimes may be most severe. The Chronic Ulcer.—Chronic ulcers partake of all the phenom- ena of chronic inflammation. Their seat, number, shape, size, and appearance will vary greatly. They are mostly confined to the leg, at its lower third and inner surface. They are usually solitary, and, like the acute, may be of all sizes and shapes. The color of the ulcer, as in the acute, may vary from a deep red to a livid, and the integu- ment around may likewise present all the phenomena of chronic in- flammation. The surface of the ulcer may present a red, raw, irregu- lar appearance, and one portion may be deeper than another. Gran- ulations may be wanting, the bottom of the sore being covered with a sanious exudation, or they may develop exuberantly, presenting an unhealthy appearance, commonly known as proud flesh. The surface may incline to bleed on the slightest manipulation, and be insensitive or excessively sensitive to touch or motion. The edges may be ele- vated, everted, inverted, or undermined. They may be thick, thin, or ragged; hard, callous, insensible, or very sensitive. They may de- generate into malignant disease, and may be attended with some con- stitutional disturbance. Acute ulcers may be caused by a depressed condition of the sys- tem, colds, and excesses of various kinds. They, as well as the 24 370 DISEASES OF THE SKIN. chronic ulcers, are frequently induced by many other diseases of the skin. Varicose veins, especially in elderly people, are very often pro- ductive of chronic ulcers. Du Castel describes a species of ulcer asso- ciated with varicose veins, and occurring generally in young persons, dependent upon disturbed innervation of the limb, rather than upon the condition of the vessels. The ulcers are not very deep, and usually heal without difficulty. Fractures, wounds, and other injuries may likewise cause them. Treatment.—Ulcers, particularly the acute, require to be treated antiphlogistically. Rest in the recumbent position is essential; blood- letting, cathartics, aconite, antimony, or other similar agent, should be employed to lessen vascular action, and opium when necessary to relieve pain. A change of air, stimulants, and tonics may be demanded, and attending complications should be corrected. Small doses of opium administered internally several times a day are of undoubted efficacy in promoting the cure of painful and chronic ulcers. Phagedaenic ulcers are also decidedly benefited by a grain or two of opium every three hours. The administration of hoang-nan will aid the repair of chronic ulcers. The part or limb, if possible, should be elevated and kept at rest, and bathed occasionally with hot water. Light compression can also be made with a muslin or gum bandage. The latter and the woven-gum stocking are more useful in the chronic ulcer. In place of the thin rubber bandage a sheet of " gutta-percha paper" has been used with satisfactory results. The surface should be first cleansed by an antiseptic solution; the gutta-percha, after having been washed in the same solution, is then applied, covered by a thin layer of cotton- wool, held in position by a light bandage. Warm medicated lotions, particularly those containing lead-water and laudanum, or tincture of witch-hazel, are valuable. The application of weak lotions of chloride of zinc, pyrozone, the acid nitrate of mercury, or a strong solution of nitrate of silver, may be beneficial in both the acute and chronic varie- ties. Pyoktanin is a good antiseptic and stimulant application to chronic ulcers. This substance may be used in the form of a two-per- cent, powder, moulded into pencils or in solution. If these pencils are broken, the disrupted surfaces should be moistened with water and gen- tly pressed together, which causes them to cohere when they become dry. The powder is made by mixing the methyl-violet with talc or other inert material, and the solution may be of the strength of one to a thousand or one to five hundred parts. The stain which this sub- stance leaves upon the hands or linen may be removed by washing with a ten-per-cent. solution of Castile soap in alcohol, with the alcoholic solution of green soap, peroxide of hydrogen, alcohol, cologne-water, Labarraque's solution, dilute hydrochloric or nitric acid. The employ- ment occasionally of a poultice has a soothing action upon an irritable ulcer. Local depletion of the ulcer is also valuable; the engorgement EXUDATIONS. 371 is lessened, and the application of other agents to it are rendered more effective. The various soothing, astringent, and stimulating ointments and plasters are alike serviceable in both the acute and chronic forms. Dr. A. II. Newth states that an ointment containing twenty grains of acetanilid to the ounce of lanolin allays the pain of irritable ulcers. Stramonium or cocaine ointment also has the same influence. The subiodide of bismuth is a good antiseptic application to ulcers, and may be used as a powder or incorporated into an ointment. Other substances particularly useful are iodoform, iodol, aristol, europhen, alpha- or beta-naphthol, camphorated naphthol, and saloL Chronic ulcers may be stimulated by eucalyptus, balsam of Peru, hydrastin, naphthalin, iodosulphate of cinchonine, quillaia, mercuric, cadmium, or nickel oleate. A five-per-cent. mixture of scale-pepsin with lanolin will clean the surface of old ulcers. Foul and unhealthy ulcers are benefited by the application of aluminium oleate, resorcin, styrone, eucalyptus, salicy- lated camphor, hydrastin, benzoic acid or benzoate of bismuth, or sul- phurous acid. A substance styled " dermatol" has lately been brought forward as a desirable addition to the list of local disinfectant remedies. It is a subgallate of bismuth, an odorless, insoluble, and astringent powder. Dr. E. Diver has advantageously utilized chlorine gas in the treat- ment of ulcers. The gas is readily generated in a pickle jar by the reaction of potassium chlorate and hydrochloric acid. A layer of cotton-wool, impregnated with the gas, is bandaged upon the affected limb. A four- increasing to six-per-cent. oily solution of thiocamf has been used with good results by Dr. Duffy, of Dublin. The surface is then covered with a strip of protective and an antiseptic dressing. Galvanism and skin-grafting are to be recommended in old chronic ulcers. Sponge-grafting will also, in some cases, prove successful, while Dr. Nesterovsky and others have reported very satisfactory results from grafting with pieces of skin taken from the abdomen of the common water frog, following the method proposed by Dr. Allen in 1884. The advantages of frog's skin are that it is free from glands and hair, and is easily obtainable.* Autoplasty has been successfully practised in some instances. A flap or flaps are taken from an adjacent or accessible region, with which they are allowed to retain their connection by means of a pedicle. When the graft is successful the pedicle is divided. Two patients operated upon in this manner for extensive ulcers of the leg were shown to the French Academy of Medicine by M. Berger. This method aims not only to obtain a firm scar, but also to furnish the limb with normal skin, together with subcutaneous connective tissue. * British Medical Journal, June I, 1889. 372 DISEASES OF THE SKIN. In several cases of extensive ulceration Dr. Z. J. Lusk, of Warsaw, N. Y., has successfully employed pieces of exfoliated epithelium from the patient's own body, the fragments, prior to use, being softened and sterilized in a warm boric-acid solution. This writer and others have also, in a similar manner, utilized the epidermis raised by fly-blisters. A method devised by F. von Mangoldt, and termed " epithelial sowing," consists in scraping the epithelium from any healthy cutaneous surface, and placing the mass of cells, mixed with a little extravasated blood, upon the ulcer. The most satisfactory results are obtained in old and stubborn ul- cers by the process of skin-grafting introduced by Thiersch. In this method long slices, including the epiderm with about a half or third the thickness of the true skin, are shaved from the thigh by a razor and bound upon the ulcerated surface. In removing the strips the skin must be stretched and held flat. Before operation the thigh must be thoroughly disinfected. As they are removed the strips are placed in a half-per-cent. solution of table salt, from which they are trans- ferred to the ulcerated surface. Unhealthy granulations must be scraped away before the grafts are placed in position. After the grafts have been applied they are covered with rubber tissue moistened with the salt solution, and these are overlaid with compresses wet with the same fluid. The dressings are changed every second day, and at the end of a week dry applications can usually be substituted. This process of grafting accomplishes its results much more rapidly than the older methods, and the cicatrices formed are more pliable and less unsightly. Another method, devised by Dr. F. Krause, of Altona, consists in the implantation of a cutaneous flap, generally taken from the inside of the patient's thigh, and which may be as large as eight or ten inches in length by two inches in breadth. Before the transplantation the ulcer- ated surface is cleared of indolent or unhealthy granulations, and carefully cleansed with an antiseptic solution. It is directed that the flap should be a third larger than the defect, in order to allow for shrinkage. In a case of large ulcers due to a burn, Dr. M. E. Van Meter,* in addition to ordinary skin-grafts, employed pieces of skin taken from two puppies of the Mexican hairless breed. The puppy grafts proved superior both as regards the number which thrived and their rate of growth. Mr. Alexander Milro, of Edinburgh, in a similar case obtained satisfactory results by transplanting strips of skin taken from the ab- domen of a greyhound puppy seven days old.f Jequirity infusion often acts promptly and decidedly in setting up an acute reparative inflammation in obstinate cases, leading to a per- manent cure. * Annals of Surgery, August, 1890. f Lancet, March 15, 1890. EXUDATIONS. 373 ECZEMA. Synonyms.—Tetter—Eczein—Eczema—Crusta lactea—Scabies humida. Eczema is a non-contagious, inflammatory affection of the skin, acute or chronic in character, appearing at its beginning in the form of any one of the elementary lesions, such as erythema, papules, vesi- cles, pustules, or a combination of them, accompanied with itching, more or less infiltration, and frequently attended with a discharge and the formation of scales and crusts. Symptoms.—Eczema, which is a manifold, changeable, and poly- morphous affection, may appear as one or all of the results of inflam- mation, either successively or simultaneously. It may also be followed by some such secondary results of inflammation as a discharge, with the formation of scales and crusts, fissures, abscesses, oedema, and hy- pertrophy. Eczema is decidedly a variable affection, often changing rapidly from one to another form. In one case erythema may begin the series of symptoms, and the diseased surface may in turn become moist, in- filtrated, dry, and desquamating. In another the affection may be manifested by the appearance of groups of either papules, vesicles, or pustules, alone or commingled, seated upon bases which are more or less inflamed, and attended with some or all of the local symptoms of inflammation, such as discoloration, pain, itching, smarting, or burning, swelling, heat, tension, with functional disorder of the part. In some rare cases marked constitutional symptoms supervene, espe- cially when an extensive surface is involved. In others, the vesicles which are formed may burst or rapidly change to pustules, and so give rise to a red, weeping surface from the poured-out products, which quickly form yellow, gum-like crusts from the drying up of this dis- charge. The eruption may now either suddenly or slowly undergo a change of form from the red, moist, and excoriated state to a more or less infiltrated, reddened, dry, fissured, and desquamating condition of the surface. Again, the only evidence of the eczematous disease in still other instances may be the development of fissures or cracks, especially upon the palmar and plantar surfaces, depending upon in- filtration, and rendering every movement extremely painful, and at times completely incapacitating the sufferer from actively using the parts affected. Further, several or many of these lesions may appear or manifest themselves in turn in the same case. It will also be found that more or less infiltration is one of the prominent features in every case of eczema. The fluid which escapes from the vessels with some leucocytes is either retained in the meshes of the corium, becoming organized and giving rise to thickening, or, as is more frequently the case, discharges and crusts upon the surface. The appearance of this discharge is not, as was formerly held, the diagnostic feature of eczema. 374 DISEASES OF THE SKIN. It may or may not be present, and its appearance depends entirely upon the form of the disease. In the event that either the vesicular or pustular lesion is developed, the fluid exudation may be very great, as well as the thickening, crusting, and desquamation. On the con- trary, should the erythematous, papular, or fissured form appear, des- quamation and at times thickening may supervene, but no crusting; and the amount of the secondary changes that occur will depend en- tirely upon the stage of the disease, the age and state of the constitu- tion, the seat and extent of eruption. In short, these are briefly some of the many phases under which this changeable disease appears from time to time—a disease which is essentially different from all other cutaneous eruptions in the development of both the primary and sec- ondary lesions, which frequently undergo, either rapidly or slowdy, many changes in their form, often appearing as several varieties in the same subject, or being accompanied with marked and peculiar secondary changes. The prominent and at the same time the most constant symptom of eczema is itching. It may be so slight in some as hardly to attract any attention, while in others it may be intolerable. The extent and degree of this symptom will, however, vary according to the amount of irritation, the location of the eruption, and the power of resistance of the individual. In some cases and in certain localities, as, for in- stance, on the palmar and plantar surfaces, itching and all other sub- jective symptoms are at times absent. In others the symptom of itch- ing may be accompanied with a disagreeable burning, prickling, or tickling sensation, or the latter unpleasant impressions may alone be present. Occasionally in neurotic cases of eczema, though rarely, pain may be the prominent local manifestation present. Eczema may be acute, subacute, or chronic, the acute appearing and running its course for several days or weeks, and finally disap- pearing, or remaining in a subacute condition for a time, to develop again into the acute form upon the least irritation, or to subside gradually into a chronic state, and so remain for an indefinite period, unless the condition is overcome spontaneously or by appropriate treatment. Acute Eczema is characterized by inflammatory redness, attended by itching, smarting, burning, or tingling of the skin, together with swelling, heat, tension, and functional disorder of the parts. These initial local symptoms may attack all or part of the body, and may be mild or severe according to the locality invaded, and may at times be ushered in with restlessness, horripilation, trembling, as well as sleeplessness, gastric and intestinal irritation, and fever. Suddenly the reddened skin, which may also be ©edematous and swollen, may be covered with a greater or a less number of minute vesicles, papules, pustules, and scales, alone or commingled. In place of vesicles, EXUDATIONS. 375 papules, or pustules appearing, the surface may simply present a red- dened condition, with or without swelling or the formation of scales; and the epidermis may in some instances be rapidly stripped off, leav- ing the raw exuding corium exposed beneath it. If the eruption be vesicular in character, which is usually the case, the lesions either dry up, or, more probably, quickly rupture, giving exit to their contents, which often cause considerable irritation to the surrounding parts, after which the secretion is formed into yellowish or brownish scabs, together with some scales. The eruption of acute eczema, if not ex- cited by further irritation, will usually subside in a few days or a week; the tendency to the inflammation will, however, linger for some time in the tissues, to break out again from the least exciting cause. It is more often the case that the eruption, after disappearing for a short interval, will again recur and gradually pass into the subacute variety. Thus it may be seen from this brief outline that eczema may be said to be acute when the eruption is of short duration, the inflammatory symptoms high, the primary changes prominent, and the secondary slight or insignificant. The course of acute eczema is occasionally complicated with lymphangitis, adenitis, or abscesses, and may be fol- lowed by an eruption of boils. Subacute Eczema is a variety in which the inflammatory action is less marked than in the acute. It is often represented by the period of decline in the acute eruption, in which the surface is reddened, slightly thickened, moist, and covered more or less with crusts and scales, or groups of papules or pustules, from which issues an ichorous fluid, occasioned by being torn by the scratching as the result of the intense itching, the pus from the pustules usually drying into yellow- ish, gummy crusts. Any slight or severe irritation from a constitu- tional or local cause may rapidly bring the eruption again into an acute eczema, or it may gradually, or from frequent relapses and scratching, which bring fresh morbid appearances and deeper changes in the skin, subside into the third variety. Chronic Eczema.—The line which separates the acute, subacute, and chronic varieties from each other can not be sharply defined. Chronic eczema may be preceded by an acute attack, or the disease may be chronic from its commencement. The appearances in the chronic stage coincide in every respect with those already described— to wit, the vesicles, the papules, the pustules, and the red, weeping surface covered with scales and crust. But something more will also be observed, namely, marked swelling, thickening, and a hard and often fissured state of the skin, attended with intolerable itching. Eczema may therefore be said to become chronic from a persistence of the eruption, with frequent relapses, causing the secondary changes to predominate over the primary lesions. The changes leading to chronic eczema will, of course, vary according to the region with its 376 DISEASES OF THE SKIN. peculiarities that is invaded, the duration of the eruption, and the effect of numerous external influences upon the part. While all parts of the body may become the seat of chronic eczema, nevertheless some portions, from their peculiar anatomical formations, especially those which are richly supplied with sebaceous glands and follicles, are particularly subject to this stage of the disease. Thus, for example, the head, the flexor surfaces of the joints, the groins, the scrotum, and adjacent parts, are surfaces in which the eruption lingers and settles in the skin. These changes will also depend upon the length and thick- ness of the hair, the amount and extent of attention to the skin and its appendages, the form and method of the dress, and the habits and occupation of the subject. Again, the duration of the attack will have an important bearing upon the condition of chronic eczema. Thus, in protracted cases, the exudation will be increased, the swelling and thickening greater and more marked, and the tendency of the affection is to spread to both adjacent and distant parts, or eventually cover all the body. In some cases the infiltration extends so deeply that the integument is scarcely movable upon the underlying connective tissue. Further, the air and irritating substances in contact with the affected parts, as from clothing or by scratching, are external agents which modify very much the appearance of chronic eczema. It is not uncommon, as E. Besnier has especially pointed out, for a patch of eczema to persist in- definitely, and become, as it were, a starting-point for successive acute attacks involving other portions of the body. The form in which the eruption of eczema manifests itself varies according to the predominant anatomical lesion Avhich may be pres- ent. At its commencement it may assume an erythematous, vesicu- lar, papular, or pustular form, or a combination of these lesions, at- tended with secondary changes. It may appear either as a limited or as an extensive eruption, of every size and shape, and arranged in single or multiple patches. The four clinical varieties of eczema which may follow in succession as stages of the disease will now be respectively described: Eczema Ekythematosum (Erythematous- Eczema).—The promi- nent lesion in this variety, from the beginning to the end, is erythema. It usually appears as a small or large red patch, attended with a cer- tain amount of heat, swelling, and itching ; the spots may be of any size and shape, but are generally undefined in outline, gradually pass- ing imperceptibly into the surrounding healthy skin. The color of the skin is subject to great variation in the same and in different indi- viduals, according to the exciting cause, the condition of the system, and the seat of the eruption. At times it may be almost imperceptible to the naked eye, the subjective symptoms of itching or burning alone being felt, while at others the color may vary from a bright-red to EXUDATIONS. o'-T o i ( a violaceous hue, or even a yellowish complexion, which old erythem- atous eczema often acquires. Thus the color, as is frequently the case, may be uniformly diffused, or mottled, as blotches over the affected surface. This variation in color ■ can usually be observed upon some portion of the face, in which it is now pale or a bright red, and again a dull shade. As this latter form is more commonly seen at a time when the skin is darker in hue, as in middle-aged adults, the general color is then of a dark-red tint. Some swelling may be present, the extent of which will largely depend upon the locality invaded. After the eruption has existed for several days, the surface, which, by reason of the interference with the free action of the glands, has a peculiar hard and rough feel, caused by the absence of the normal unctuous material also becomes covered with fine scales. There is usually experienced a feeling of tension, burn- ing, and irritation, with either slight or severe itching. Moisture and all signs of a fluid discharge are commonly absent, unless the epidermis has been stripped off, exposing the corium beneath. The initial lesion, therefore, that is alone present is erythema, although in some instances minute vesicles and papules can be seen upon close and careful observa- tion. The portions of the body thus invaded are generally the face and genitalia, although the disease may attack any part of the surface. Erythematous eczema, when seated upon the face, may give rise to conjunctivitis. This form, which is very liable to relapse, may remain localized to a small patch, or it may, as is usually the case, rapidly or slowly spread over a large surface. The morbid action is apt to be both variable and capricious in course and intensity. This variety of eczema may disappear for quite an interval, to return again ; or may improve to-day, to reappear to-morrow; or it may cease for weeks or months, to relapse again without any assignable cause. External and internal in- fluences which modify the circulation, such as sudden changes of tem- perature, violent exercise,'excesses of the table, and spirits, are often the active factors in these repeated relapses. Eczema erythematosum may therefore either continue in the manner stated, or, as a result of the frequency of its attacks and a change of its stage, together with the appearance of secondary lesions, gradually pass into the chronic form of the disease. It may, on the other hand, terminate by delites- cence or resolution, marked by a rapid or gradual diminution of the redness, heat, and swelling, and by a relief of the subjective symptoms. Further, the termination of the, process may give rise to a slight des- quamation of the epidermis or to the appearance of small areas of healthy skin between and in the affected patches. As has been noted, this variety of the disease is liable to undergo certain changes, depend- ing upon the locality, the exciting cause, and the external influences; as, for example, when the lesions occur upon two surfaces that are in apposition, as about the breast, the axillary spaces, the groins, the nates. 378 DISEASES OF THE SKIN. and the genitalia, a moist, weeping surface results, which is known as eczema intertrigo or eczema mucosum, and usually terminates in desquamation. Frequent relapses from some exciting cause increase the infiltration and cutaneous irritation, which leads to scratching, and excoriations and crusting follow in turn, being marked secondary changes of other manifestations of eczema. Erythematous eczema generally occurs in middle-aged or old persons. Eczema Vesiculosum (Vesicular Eczema).—This variety of the affection is characterized at the outset by the formation of minute vesicles. Typical eczema is not, however, necessarily limited, as was formerly thought, to the development of this particular lesion, which has thus led to much confusion by practitioners searching always for vesicles, or the catarrhal discharge, on which to base their diagnosis. The formation of vesicles and other lesions, to be described later, is merely one manifestation, or one of the successive stages of this vari- able affection. Typical vesicular eczema may be ushered in with sharp pyrexia, headache, loss of appetite, thirst, coated tongue, and either diarrhoea or constipation. These constitutional symptoms are, however, usually present only when the morbid process is intense and the surface involved extensive. The affected part, for a short time prior to the appearance of the eruption, feels hot, tumefied, tense, and irritable, after which minute red points, or a diffused redness, appears, attended with itching, burning, or prickling, which is often very great, and only ceases or lessens shortly after the appearance of a greater or less number of minute vesicles. The erythema which pre- cedes the development of vesicles varies in color, being in some cases of a pale rose, and in others of a deep red hue. The borders of the diseased area are usually ill defined and of irregular contour. The vesicles vary in size from a pin's point to the head of a large toilet-pin, and are either discrete, or, as is more frequently the case, are closely packed together, quickly coalescing, forming patches, and often becoming confluent. In some instances blebs of considerable size are produced and simulate the lesion of pemphigus. Each vesicle con- tains clear serum, or an opaque or yellowish fluid of an alkaline reaction, sticky to the touch, and which stiffens the linen with which it comes into contact. In some of the mild cases, especially if the eruption is discrete, the vesicles dry up in the course of six or eight days, the minute white or dark scales of epidermis which cover them drop off, leaving the skin in its normal condition. In other instances, which is far more frequently the case, the vesicles burst in their earliest stage from the excessive congestion and the effused serum in the tissues, or from scratching induced by the intense itching, before being seen by the physician, and expose the parts, which are more or less excoriated. The surface, which is now swollen, hot, and red, pours out a serous fluid, which dries into light or dark, thin, yellow, EXUDATIONS. 379 and gummy crusts. The vesicles either continue to appear in successive crops, or the excessive effusion is poured out so rapidly on the former site of the vesicles that no reparative process can occur, hence no vesiculation, and in place of that lesion a small or large quantity of a sirupy or ichorous fluid, the latter usually predominating, comes directly to the surface, dries at once into crusts, or runs off in drops, which at times are taken up by the meshes of the linen. The morbid action under such circumstances has now reached its height; the amount of secondary changes which are present will depend upon the state of the patient's system, the attention to the parts, and the ex- tent of scratching or other irritations, as, for example, the access of air to the surface. At times the swelling alone is the most prominent and marked feature on the surface, the vesiculation being very slight, eczema cedematosum giving the part an appearance very closely resem- bling erysipelas. Typical vesicular eczema usually presents the features just described. It will be found that erythema, papulo-vesicles, vesico- pustules, pustules, and many other lesions, are also frequently associ- ated with the vesicular eruption. The lesions of this variable affection are thus often so thoroughly commingled that it is at times out of the question to say which one predominates. The eruption may show itself either upon a small surface, or it may involve part or all of the body. Vesicular eczema frequently occurs upon the face of adults as well as in children, and can also be observed about the hands, par- ticularly upon the fingers. The most prominent subjective symptom is itching, which persists with so much intensity as to bring about an irresistible desire to scratch the parts, and so afford relief after the vesicles have burst or have been torn and the serum has been per- mitted to escape and the tissues are benumbed. The serum which has been poured out in this manner, and which thus checks or lessens the itching, may in turn cause considerable irritation both to the affected patch and the surface with which it comes in contact. The act of scratching may cause the discharge to become sanguinolent. The irritation sets up a burning sensation, which is as annoying and intolerable as the itching. This teasing subjective symptom may also be attended with itching in addition, should another crop of vesi- cles appear; or sometimes, with the eruption of a fresh crop of vesicles, the burning subsides and is succeeded by itching. The subjective symptoms are always more pronounced in the case of nervous, irritable subjects. Acute vesicular eczema may continue for a few days or weeks, and slowly subside with the drying up of the vesicles or the lessening of the swelling and the discharge. The redness gradually fades, the margin of the affected patches becoming less distinct, the crusts loosening and falling off, exposing a surface covered with scales, beneath which can be observed reformed, soft, tender, and delicate epidermis. The skin 380 DISEASES OF THE SKIN. generally remains in a somewhat red, tender, and delicate state for some time after the inflammation has entirely disappeared from the part. In the event that delitescence or resolution will not take place, the vesicles may pass into pustules, or relapses may occur, and thus produce the inflammatory form, eczema rubrum, or gradually pass into the chronic variety. Eczema Pustulosum (Pustular Eczema).—This form of eczema is known also as impetiginous eczema, or eczema impetiginosum, or impetiginodes. The lesions may be developed as pustules at the out- set, or change from either the erythematous, papular, or vesicular varie- ties—more commonly from the latter—into the pustular form of the disease. The pustules are, therefore, in the majority of instances, formed in the same way, and from the vesicles, their initial stage, to which they are closely associated, and are often commingled with the vesicles. In fact, the two lesions, with their secondary changes, are so blended that it is not only difficult but may be impossible to decide which was originally the prevailing primary lesion. Usually minute vesicles appear either alone or in groups, and slowly enlarge, attain a firmer consistency, and become distended with a purulent secretion. These pustules, from the accumulation of the purulent secretion and consequent distention, or from any irritation, burst, and the poured- out ichorous secretion dries into greenish-yellow or dark-colored scabs and crusts, which become friable, and, falling or crumbling off, expose a red, tender, and irritable surface. The ichorous secretion also fre- quently gives rise to considerable irritation of the surrounding surface. The subjective symptoms of heat, swelling, and itching are mild, ex.- cept in aggravated cases. In this latter class the pus formation and infiltration are often very great. If the morbid process in these cases occurs upon the hairy parts, especially the scalp, and the sebaceous glands are involved, the discharge becomes mixed with altered glandu- lar secretion, mats together the hairs in an inextricable mass, causing intense itching, sometimes a rancid odor, and great disfigurement. When this is the case the disease is both distressing to the patient and obstinate to the ordinary course of treatment. Pustular eczema is very common in the lymphatic and the debilitated, in those who are poorly fed and who do not receive proper care, especially in young children. It may occur upon all or any part of the body, but as a rule is confined to a limited "surface. It shows itself most frequently upon the scalp and face, especially in children. In this form of eczema the neighboring lymphatic glands become swollen. Eczema Papulosum (Papular Eczema).—In this form, often incor- rectly called lichen, the predominant lesions are papules; although imperfect papules, partially developed vesicles, and even pustules, may also occur. Sometimes a papule is surmounted by a vesicle. The eruption appears as small, round, or acuminated hard papules, of dif- EXUDATIONS. 3S1 ferent sizes, from a very small to a large pin's head. They vary in color from bright to dark red, are usually formed quickly, remaining for days or weeks, to disappear or reappear, and often persist for a long period. In some cases the papules are discrete, in others conflu- ent, and seated upon a reddened base. They may be distributed over the entire surface, or limited to one or more regions. The subjective symptoms are more marked and violent than in the other varieties previously named, consequently the summits of the papules are usually scratched or torn, causing them to bleed. Papules will therefore often be seen having upon their apices a drop of dry blood, and the normal skin around and between them may likewise be covered with excoriations from the scratching. Papular eczema is most common during adult and old age. It usually invades the arms and lower extremities, especially the flexor surfaces, together with the trunk and thighs. AVhile papular eczema in typical cases begins and ends with the formation of papules, yet in very many the latter lesions develop into vesicles, and even pustules, or the eruption is preceded by red, scaly patches, or all varieties heretofore noticed are present at the same time side by side—papules, isolated or in groups, usually predomi- nating. Again, typical papular eczema, when torn from scratching caused by the intolerable itching, will often be followed by a weeping state of the surface, irrespective of the presence of either vesiculation or pustulation. Usually the eruption, after reaching its climax, gradually declines as resolution is accomplished, leaving only a slight redness and some desquamation- as evidence of the previous inflammation of the skin, but the morbid process may be indefinitely prolonged by secondary changes into chronic eczema. Papular eczema is prone to exacerba- tions and relapses. All of the four chief varieties of eczema just considered may be- come intensified, and often chronic, as a consequence of secondary changes resulting from continued morbid action. Eczema Rubrum, or Eczema Madidans, is the most severe form of the disease. For a day or two preceding the appearance of the erup- tion the affected part is the seat of itching, and, at the same time, consti- tutional symptoms are often manifested, such as loss of appetite, malaise, and fever. In drunkards the fever may be accompanied by extreme agitation and delirium. The systemic manifestations vanish with the development of the eruption. Eczema rubrum may result from either the erythematous, vesicular, pustular, or papular varieties, and is charac- terized by a reddened, weeping, or tumefied, hot, and often shining sur- face, and at times covered with sero-purulent exudation. A portion or all of the epidermis may be shed, or, as is more common, the exposed and excoriated corium gives free exit to serum or an ichorous secretion, and often also to blood. The discharge, which varies in quantity ac- 3S2 DISEASES OF THE SKIN. cording to the grade of the inflammation, dries into yellowish or yellow- ish-black crusts, which often partially or completely cover the eczema- tous surface, remaining for an indefinite period, unless removed artifi- cially, the morbid action in the mean time going on beneath. If the crusts are removed by artificial means, a red, angry, swollen, and, it may be, an oozing surface is exposed. This form of inflammatory eczema ordinarily becomes chronic in character, marked infiltration follows, and the parts involved become hard, rough, and thickened. It in- creases in severity, and shows no tendency to spontaneous cure. This form of the disease may occur upon any portion of the body, but is especially observed to follow the erythematous variety about the flex- ures, as in the axillae, about the elbow, the wrist, and the cleft between the nates and the groin. It is also noticed on the scalps and faces of infants, and the lower extremities of persons of advanced years. Eczema Squamosum.—Squamous eczema is a subacute or chronic form of the disease, in which exfoliation of the epidermis is a marked feature. It may show itself either at the declining stage of any form of eczematous eruption, or last during the entire course of any of the varieties of eczema. Squamous eczema may be present with erythem- atous eczema, and often succeeds it. It also frequently follows the papular form, especially when the lesions coalesce, forming confluent patches. In marked cases of squamous eczema, the reddened, dry, and scaly patches are of all sizes and shapes. The extent and amount of desquamation depend upon the locality invaded and the persistency of the eruption. In addition to the desquamation there is also more or less infiltra- tion of the affected surfaces. Squamous eczema may be prolonged for an indefinite period of time. Eczema Fissum.—Fissured or cracked eczema is a chronic form of the disease, which is generally observed upon those portions of the animal economy which are in almost constant motion. It shows itself particularly upon those parts in which the epidermis is usually very thick, as, for example, on the palmar and plantar surfaces. A peculiar mottled appearance in the parts of the hands and feet above referred to is at times observed before the cracks are formed from the congested true skin beneath, or the surface may have a white or dark leathery ap- pearance, and be hard, dry, and unyielding. Fissures usually follow in these cases as the result of the primary congestion, the product of which is either unable to find ready exit through the thickened epider- mis, or an escaped serosity excites a marked irritability of the now in- elastic skin, which tears and cracks upon the slightest motion. Fissures are not confined to these surfaces, but may be found on any part of the body, and are especially noticed about the mouth, the joints, the fingers, and the toes. They may occur upon any portion of the surface of the skin, but are usually seen in the course of the natural furrows. exudations. 333 Sometimes the fissures may be superficial and slight, as noticed on the ends of the fingers and toes, or they may be extensive, as found about the mouth and on the palmar and plantar surfaces. When the cracks are deep and extensive, they show the red and angry true skin beneath, and cause great pain and intense suffering upon the least movement; especially is this the case when the feet are involved. Some individuals have a peculiar predisposition to this form of eczema, usually in winter, the least change in the atmosphere pro- ducing fissures upon some portions of their integument. The debili- tated, the poorly nourished, the strumous, the tuberculous, and those who depress and lower the vital powers of their body by mental cares, overwork, and the various forms of dissipation, are especially liable to be afflicted in this manner. The slightest irritation in such subjects, such as the handling of irritants, exposure to the variations of the weather, frequent use of water and soap, will set up a fissured state of the skin. Thus, individ- uals, working in certain occupations, having a tender and often poorly nourished skin, are very great sufferers from cracking of the integu- ment. I have frequently noticed this to be the case in compositors; in wool-pickers, the irritation being caused in some cases by the wool, in others by the dye in the wool; in mill-hands handling dyes and dyed goods; in plasterers; in those working considerably in water, and in many other manual occupations in which the hands come in contact with irritating substances. In addition to the secondary changes already mentioned, the integument from the morbid eczema- tous action may become exceptionally thinned or hypertrophied; in the latter event large and shapeless masses of tissue result with or without ulceration, or the surface may be hardened and thickened, entire or in patches, cedematous or warty. These latter states have been dignified by various writers by the names E. sclerosum, oedemato- sum, and verrucosum, but the use of these terms only confuses the reader, and unnecessarily increases the number of the varieties of eczema. In fact, in such cases the atrophy and hypertrophy which occur are directly the result of the congestion, with the attendant special deviation of tissue nutrition leading to either thinning, hard- ening, an cedematous state, or papillary growth in the parts. These secondary changes will be referred to more in detail when considering the local manifestations of eczema. Seborrheic Eczema.—Novel views upon the nature and origin of chronic eczema have been advanced by Unna since the appearance of the first edition of this work. These doctrines were detailed in a paper read before the Dermatological Section of the Ninth International Con- gress.* After declaring himself dissatisfied with a mere routine diag- nosis of chronic eczema, and after distinguishing briefly the nervous ec- * Journal of Cutaneous and Genito-UriDary Diseases, December, 1887. 384 DISEASES OF THE SKIN. zema of dentition and tuberculous eczema, he proceeds to describe what he has termed seborrhceic eczema. This form usually originates upon the scalp, spreading thence to other portions of the body, especially to such as are normally well provided with hairs. For the fatty material hitherto attributed to disordered secretion of the sebaceous glands, Unna declares, upon the ground of his own investigations and those of Malassez and Schuchardt, is in reality derived from the sudoriparous glands. Instead of exhibiting augmented activity, the sebaceous glands are occluded by abnormally compact masses of epidermis. That the perspiratory glands are the source of this fat Unna conceives is proved by the identity of the fat found in the cutis, epidermis, and epidermic scales with the fat of the coiled glands; by the increased activity and inflammatory changes in the coiled glands; by the dilatation of the sweat pores and the constant increase of their normal products. Seborrhceic eczema begins insidiously upon the scalp, and generally first attracts attention by an unusual scaliness or collection of crusts, attended by severe itching. The agglutinated scales may simply in- crease in quantity, but remain white and only moderately fatty; they may accumulate as fatty crusts between the hairs, or catarrhal symp- toms may become more pronounced and weeping occur. The fatty scales are lost and the usual appearance of eczema is approximated. Thus three varieties of seborrhceic eczema are differentiated. The first of the three corresponds to what is usually called pityriasis capitis, the second is the so-called seborrhoea sicca, the third includes a large number of cases hitherto grouped as chronic eczema of the scalp. The sternal region, next to the scalp, is the favorite seat-of seborrhceic eczema, with which Unna would identify that form which has been known as lichen anulatus serpiginosus (of Wilson) or the eczema marginatum of the French. A patch of seborrhceic eczema has a yellow color with an outer fine-red border when the scales have been removed. It spreads by fresh outbreaks of characteristic raised papules and yellowish-white or yellow crumbling fatty scales, the centre of origin changing into a yellow-colored, quite smooth, but slightly scaling spot. In the axilla crusts are scarcely ever seen, the yellow color of the centre of the patch is usually absent, and the disease tends to assume the moist form and spread rapidly over the thorax. The diagnostic points of this variety of eczema are given as follows: The spread of the affec- tion downward, generally in the middle line of the body; the invariable history of seborrhoea; the fatty and crumbling character of the scales and the yellowish color of the whole affection; and the configuration of the separate lesions, " the thickened plaques spontaneously flatten- ing out in the middle or on one side, the red color changing to a yel- low, and the scaly surface becoming smooth, to suddenly again break out at the margin in a raised, red, scale-covered, bow-formed wall.'1 EXUDATIONS. 385 Gamberini has made many experiments in order to ascertain whether fat is secreted by the sweat-glands, but has met with no success. He regards any affection of the sebaceous or sudoriparous glands in eczema to be secondary, and concludes that seborrhceic eczema can only be looked upon as a distinct form of eczema in consequence of its attack- ing certain regions rich in glands. A secondary implication of the glands and a commingling of their secretions with the serous exuda- tion characteristic of eczema may alter the typical appearance of the latter disease. Dr. William II. Merrill, of Pepperell, Mass., has recent- ly discovered two varieties of diplococci in the scales of seborrhceic eczema. It seems that the disease is of parasitic origin, and that the yellow scales are due to a chromogenic and the whitish to a non-chro- mogenic organism. Diagnosis.—It will be seen from the description already given that eczema is one of the most common of eruptions, and it is therefore of the utmost importance to distinguish it from the many diseases* with which it is liable to be confounded. Eczema is the most vari- able of affections, but it has certain general phases differing from all other diseases. Thus it appears now as erythema, vesiculation, papu- lation, or pustulation, with primary or secondary changes, alone or com- bined ; again presenting a weeping or moist surface with or without the above changes; or with a mixture of all these lesions in their various stages. This protean disease has some main features invariably present, and may be indicated as follows: Redness and itching are constant symptoms, the former being either mild or severe, the latter being so slight as to occasion little or no inconvenience, or so intense as to be almost unbearable. Again, infiltration or thickening, varying, of course, in degree, is present in almost every case and stage of the disease. Fi- nally, the continuous exudation of fluid or plastic material is another characteristic feature of eczema, a symptom that, in the majority of cases, appears during some stage of the disease. It is, in fact, a symp- tom present only in eczema, and is recognized by the trickling or flow- ing, in small or large quantities, of either a clear, milky, yellowish, or dark serum, or serum mixed with blood. This discharge, weeping, or moisture of the surface quickly dries into more or less yellowish, green- ish, or brownish crusts, often seated upon the above moist base. While eczema has these general conditions, which separate it from all other cutaneous affections, yet there are certain diseases which resemble it. The diagnosis can therefore be better and more accurately drawn by referring to the characteristic features of each eruption that is liable to be confounded with it. Erythema.—This affection is a hyperaemic condition, and is usu- ally of short duration, with an absence of all the inflammatory symp- toms of eczema. Thickening, vesiculation, papulation, crusting, scaling, and itching, so characteristic in eczema, are wanting in erythema. 25 38G DISEASES OF THE SKIN. Acute Zymotic Diseases.—Acute eczema might be mistaken at first for one of the acute zymotic diseases on account of the constitu- tional disturbance that may be present; however, the systemic dis- turbance is greater, the fever more constant, and the peculiar features of eczema are absent. Scarlatina, erysipelas, and small-pox are the most prominent affections with which eczema is liable to be con- founded. In scarlet fever there is not only the history, perhaps, of contagion, but the rapid and irritable pulse, the peculiar state of the tongue, the involvement of the fauces, the appearance of the eruption, the second day of the illness, on the neck and face, and then spread- ing all over the body, desquamating about the eighth or ninth day—a series of symptoms that never occur in any variety of eczema. Ery- sipelas resembles in some respects eczema, especially of the face. Erysipelas is usually a severe disease, with more or less constitutional symptoms, accompanied with a shining, tense, and swollen state of the parts, with a smarting or burning sensation; no discharge occurs, except after the disease is well established, or when blebs follow, or in its decline, or in the phlegmoides or grave variety—symptoms which are peculiar to erysipelas and are absent in eczema. Further, ery- sipelas spreads rapidly, tends to invade the scalp and all adjoining regions, with a well-marked line or border between the affected and natural skin. Eczema, on the other hand, never passes through these rapid changes, rarely invades the scalp from the face, and the outlines of the patches are poorly defined. Lastly, small-pox in its papular stage may be mistaken for papular eczema of the face and upper por- tion of the body; but in small-pox, the gastric disturbance, fever, head- ache, and lumbar pains, and the eruption on the hard and soft palate, are sufficient to remove all doubt. Herpes.—Herpes and herpes zoster sometimes resemble eczema, although the vesicles in the latter are smaller and are not as flat as those in the former affections. The peculiar grouping and definite but short course of herpes, the vesicles situated on a red base, which do not rupture but dry up, are sufficient to differentiate between it and eczema. Herpes zoster is attended with neuralgic pains, which are not present in eczema, and the eruption is distributed along the course of a nerve. Lichen.—Papular eczema is sometimes called lichen, but a wide difference exists between the two diseases. In lichen the general health may be affected, while in eczema there is little or no systemic disturb- ance. The papules of lichen develop slowly, undergo no change during their entire course, while those of eczema appear rapidly, frequently passing into other lesions. The papules of lichen are flat, pink-colored, covered with minute scales, with their centres somewhat depressed, while those of eczema are pointed and have a smooth, bright-red sur- face. Lastly, it will be observed that lichen-papules are followed by pigmentation, which will not occur in eczema. EXUDATIONS. 387 Sycosis.—The diagnosis between pustular eczema and sycosis of the beard is often difficult. Sycosis is an inflammation of the hair- follicles, beginning in the deeper portions, ascending to the surface, loosening the hairs, which can be easily removed without pain, and developing pustules, papules, or tubercles, or all combined. In eczema the inflammatory action is superficial, commencing in the papillary layer. The hairs are not usually loosened except in very severe or chronic cases, and on extraction give rise to severe pain. In some exceptional cases the inflammation in eczema may involve the deeper structures; the pus, passing down, gradually loosens the hairs, but this is rare. The process may, in addition, extend to the surround- ing regions devoid of hairs; in sycosis, the follicles alone are in- volved, unless accompanied by some complication. In sycosis there is very often a deep-seated pain or stinging sensation, with more or less tenderness, while in eczema itching is generally the most promi- nent symptom. Dermatitis.—Simple inflammation of the skin, known as derma- titis, produced by heat, poisons, acids, alkalies, or any substance that may excite such a condition, is distinguished from eczema by its his- tory and the rapid disappearance of the eruption on the withdrawal of the cause. Rosacea.—Erythematous eczema is distinguished from rosacea by its more general infiltration and distribution over the face and adjoin- ing region. Eczema is present at all periods of life, rosacea more especially at puberty, middle and old age. In rosacea there is usually evidence of acne-spots, scars, dilatation of the superficial capillaries, furnishing the best indications of the disease not being eczema. Psoriasis.—Typical psoriasis, with its small red, slightly elevated points, or larger patches covered with peculiar whitish scales, which can easily be removed, exposing a bleeding corium, should not be mistaken for eczema. The eruption in psoriasis may, through the use of medicine, or the advance of the disease, change, the infiltration becoming more marked, the scales disappearing, and such a condition may in many respects resemble eczema. The history and course of psoriasis will always point to a dry, uniform eruption, characterized by the presence at one time of many whitish scales, and involving by preference the scalp and extensor surfaces. On the contrary, eczem- atous patches will show a history at some time of moisture and a poly- morphous eruption, the spots fade gradually into the healthy skin, the scales, if any are present, are thin and sparse, and the disease'involves by preference the flexor surfaces. As both affections may involve the scalp, the diagnosis is sometimes difficult. The patches in psoriasis are well defined, manifesting a tendency to clear in the centre, and the scales are abundant and dry, Avhile in eczema the infiltration gradually shades into the healthy skin, there being no tendency in 388 DISEASES OF THE SKIN. the beginning to heal in the centre, and the scales are thin and scanty. Seborrhcea.—Seborrhcea may be mistaken for eczema, especially on the scalp and other hairy parts. In seborrhoea there is no dis- charge, the surface is simply covered with yellow, flat, or often dirty- colored, greasy crusts, which upon removal expose a surface that is either pale and not at all altered, or red and dry, at times slightly glazed, and showing distended sebaceous follicles. In eczema, on the contrary, there is often a discharge with infiltration, the scales are drier, less abundant, and well attached to a thickened and hyperaemic surface. In seborrhcea oleosa there is a discharge, but it is oily, and not of the fluid or plastic nature of that of eczema. In some cases these two affections may exist at the same time, or the one precede the other. Thus, severe seborrhoea may excite eczema, and vice versa, and in such states the history and course of each case, with a clear understanding and separation of the local changes, will, demonstrate which affection has been primary and which secondary. Pemphigus.—The large isolated blebs of pemphigus vulgaris are never observed in eczema. That variety described as pemphigus foli- aceus bears some resemblance to eczema, but the history, course, and symptoms, particularly the constitutional disturbance in the former, and the absence, usually, of itching and infiltration, always exclude the latter affection. Scabies.—This disease presents, at the beginning, a resemblance to eczema—more, perhaps, than any other cutaneous affection. All the lesions of eczema may be observed during its course; the vesicles are, however, more scattered, not so confluent, and have connected with them little black lines or furrows, at the ends of which the itch-mites are imbedded, and may be detected by the aid of a needle and the microscope. It often happens in scabies that these furrows have been destroyed by scratching or by treatment. The only way, therefore, of distinguishing scabies from eczema, or detecting the excit- ing cause, is by the history of contagion and the locality affected. The contagiousness of the disease, and its attacking by preference certain regions, as the fingers, hands, anterior surface of the arm, and axillae in both sexes, the breast and nipple in the female, the penis in the male, and the buttocks in children, are strong proofs against the erup- tion being primarily eczema. Sometimes even these valuable indica- tions fail, from an inability to glean any history of contagion, and the part or parts involved may be in such a high state of inflammation, from scratching and applications, as entirely to mask all the evidence of the true nature of the disease. In that event the diagnosis will de- pend upon the results of treatment. The use of antiparasitics will lessen the irritation and afford relief if it be scabies, but if it be eczema there will be no change, but rather an aggravation of the erup- EXUDATIONS. 389 tion. In a person predisposed to eczema scabies may give rise to a genuine attack of the former affection. Syphilis.—The lesions of syphilis are sometimes mistaken for eczema, but it much more frequently happens that an ordinary inflam- mation of the skin is termed a specific affection. In syphilis, whether of the erythematous, vesicular, papular, or pustular variety, the his- tory of infection, the signalization of the introduction of the poison into the system by syphilitic fever and other constitutional symptoms, the involvement of the glands and mucous surfaces, and the presence of either stains, ulceration, or cicatrices, are characteristic features which are wanting in eczema. It occasionally happens, however, that even with these evidences the diagnosis is difficult, especially in erup- tions of the scalp, face, anal and genital regions. Syphilitic lesions that involve these parts usually present the following features: On the scalp a pustular eruption, or red and raw patches with adherent crusts and slight superficial ulceration, and sometimes cicatrices, also the presence of an unpleasant odor not occurring in eczema; on the face, particularly in infants, large, flat, red, and indolent papules, either separate or in circular groups, and somewhat scaly; on the genital regions the same form of lesion may be present, occasion- ally slightly changed by the moisture of the parts, or the surface may be red, raw, and indolent—symptoms, with others, that indicate the syphilitic nature of the eruption. The subjective symptom of itching, that is generally spoken of as being so constantly absent in syphilitic eruptions, and relied upon often as a means of diagnosis between it and eczema, can not, as I have already stated, be depended upon in this connection. Tricophytosis.—Ringworm, in various parts of the body, may simulate eczema, or it may, by scratching and applications, occasion, at the same time, an eczematous eruption. Ringworm of the scalp is distinguished from eczema by the history of contagion ; the diseased surface has a dirty, scaly, deadened, circular appearance, the outlines of the patches being sometimes erased in severe and chronic cases, and the hairs lack lustre, are split up, and broken off. Ringworm of the beard is similar in appearance to that of the scalp, with often more inflamma- tory action ; the patches tend to clear in the centre; their borders are also somewhat elevated, scaly, and slowly creep from point to point; the hairs become loose ; occasionally the surface is covered with papules, pustules, tubercles, and assumes a baggy condition. In eczema of the scalp there is usually moisture ; scales, if present, are of a light color, covering a surface that is red, often infiltrated ; the diseased patches are not so well defined, and the hairs are usually unaffected. When eczema attacks the beard there is no tendency to spread in the man- ner just cited, or for the affection to disappear in the centre ; the hairs are usually unchanged, and the inflammatory action is not so severe as 390 DISEASES OF THE SKIN. in ringworm. All doubt can finally be set at rest by removing some of the scales or hairs, placing them beneath the microscope, and ascertain- ing the presence or absence of the fungus of ringworm. Ringworm of the body is usually easily distinguished from eczema, by its beginning in a small point, and developing into red, circular, desquamating patches which tend to heal in the centre while spreading peripherally. Eczema and ringworm, however, occurring about the genitals have some points in common, in the red, raw, and intensely itching surface; and, in fact, the two affections may coexist, the eczema being excited by the irritation. The parasitic disease can always be detected by the advancing border of the. eruption, and the use of the microscope will make the diagnosis complete. Favus.—The peculiar, yellowish, cup-shaped, friable crusts of favus can seldom be mistaken for eczema, but the latter may occur as a complication. The appearance, however, of these characteristic crusts, or some cicatrices, and the presence of the parasite, as shown by a microscopic examination, would demonstrate conclusively the nature of the affection. Lupus.—Lupus vulgaris can at all times be differentiated from eczema by its chronic and destructive course ; the red, glazed, and scaly patch having soft, gelatinous tubercles around the border of the diseased surface. Lupus erythematosus may bear even a stronger re- semblance to erythematous eczema, but the history, the firm attach- ment of the scales to the surface, the involvement of the sebaceous glands, and the absence of itching, are sufficient to distinguish it from the latter disease. Pediculosis Capitis and Corporis.—Lice on the head or body will excite lesions which closely resemble eczema, and often give rise to an eczematous eruption, but the detection of the pediculi and their nits is all that is necessary to complete the diagnosis. Pediculosis may also occur on the scalp as a secondary complication of eczema, and in such cases the eruption may extend beyond these parts to the neck and face, or it may be seen on other portions of the body. Pedicu- losis corporis causes abrasions of the integument very much like ecze- ma; the presence of hemorrhagic spots over the surface, especially around the shoulders and loins, should at once excite suspicion, and the finding of the lice and their nits in the folds of the clothing es- tablishes the diagnosis. Pediculosis Pubis.—Crab-lice, which infest the inguinal and pubic regions, and at times also the thighs, abdomen, the front of the chest, the axillae, beard, eyebrows and lashes, occasion an eruption which has been mistaken for eczema. When these regions are in- volved, a careful examination should be made, and, if the pediculi can be detected as dark specks clinging to the base of the hairs, the diag- nosis is clear. EXUDATIONS. 391 Dysidrosis.—This rare affection is of a vesicular nature, occurring upon various portions of the body, by preference the palms and sides of the fingers, and sometimes resembles eczema. The pearl-like vesicles which are developed in this disease are isolated, do not rupture, but dry up, and the epidermis after a time becomes macerated, thus differ- ing very much from the same class of lesions in eczema in their forma- tion, distribution, and course, the latter disease appearing also on other parts of the body and being attended with more marked inflammation of the skin. Pityriasis Rubra.—This rare disease is distinguished from ec- zema by its uniform and intense redness, the abundant epidermic exfo- liation, the marked symptoms of a burning sensation, itching and infiltration, so common in eczema, being usually absent. Epithelioma.—Severe cases of this disease, with the ulcerated surface and hard, everted edges, do not in any way resemble eczema, but the superficial variety, which appears sometimes as a thin, scaly mass on the face, and on its removal, or being picked off, exposes a moist and often bleeding surface, which soon becomes covered again with the same kind of a crust, resembles to some extent, and is occa- sionally misnamed eczema. The sharp, defined border in the form of epithelioma just referred to, together with the absence of thickening and the solitary or limited number of lesions, presents a marked contrast to the fading border, the infiltrated surface, and the mul- tiplicity of the lesions of eczema, and its presence perhaps on some other part of the skin. Paresthesia.—Paraesthesia may give rise to a condition like ec- zema, or it may develop a secondary inflammation of the skin. The history of paraesthesia, the absence of an eruption at the outset of the disease, the involvement of certain localities, the paroxysmal nature of the symptoms, and its occurrence in neurotic cases, and often at cer- tain seasons of the year, distinguish it from eczema. Prurigo.—Prurigo, a very rare affection, in one case coming under my observation was mistaken for eczema. The chronic course of the disease, its development early in life, the formation of papules that may be of the natural color of the skin, pale or red, irregularly distrib- uted, with predilection for the extensor surfaces, the enlargement of the inguinal glands, and the presence of spots of pigmentation, with the constant and irresistible desire to scratch, are all characteristic symptoms, indicating a markedly different disease from eczema. Impetigo and Impetigo Contagiosa.—In both these affections the pustules are larger and more isolated, and the resulting crusts are larger in size and darker in color than those of eczema. In pustular eczema the eruption occurs in patches, or spreads until a large surface becomes red, raw, and secretes more or less pus, which dries into large, firm crusts, the opposite condition being seen in the irregularly 392 DISEASES OF THE SKIN. scattered pustules of impetigo. In the contagious variety of impetigo there is usually a history of its spread by contact, or several members of the same household are affected by it. Pathology.—The pathological changes in eczema will vary accord- ing to the stage and duration of the disease. In the acute stage the capillaries are engorged, and there may be a partial or diffuse redness of the skin, and an effusion of serum, plasma, and even blood may follow. Neumann * demonstrated these changes on the skin of ani- mals by friction with croton-oil. He selected for the purpose of his experiment a rabbit, and rubbed croton-oil into the ear for ten or fifteen minutes, and watched its results for several hours beneath the field of the microscope. Rhythmical contraction of the vessels was first observed, they being at one time full of blood and at another empty; afterward dilated, followed by permanent stasis; the ears, which were normally transparent, now became opaque, swollen, hot, and, within a few hours, numerous vesicles appeared with serous con- tents. At the end of forty-eight hours the animal was killed, and the tissue was found to be filled with serous fluid and a great quantity of cells. The researches of Biesiadecki f show the changes observed in both the papular and vesicular varieties. The papillae are enlarged in breadth and length, being filled with serous fluid and cells; the con- nective-tissue corpuscles are remarkable for their size and number. Numerous spindle-shaped cells are observed, extending from the papil- lae between the deepest cells of the rete mucosum, through which they crowd and prolong themselves even to the epidermic layer. The cells in the mucous layer form a dense network, penetrating it in all direc- tions. Within this network are seen somewhat swollen epithelial cells, whose protoplasm has a granular appearance. This circumscribed infiltration of the papillae develops the papule of eczema. In the con- tinued development of this morbid action a vesicle is formed by an increase of the new formation of cells within the papillae, and the su- perficial cells of the mucous layer swell up, possibly rupture, and so elevate the epidermis. The spindle-cells are here found even more numerously acting as nutrient canals, and no doubt convey the ele- ment of nutrition to the mucous layer. In instances of rapidly de- veloped eczema they are found in great numbers, and form a dense network. With the increased quantity of these cells there is likewise a larger amount of serum exuded, Avhich is often so abundant as to push forward the epidermis, developing a bleb. The removal of this epidermis causes the fluid to ooze out, forming moist eczema. This poured-out product, which may be a clear yellow or milky fluid, differs * Hand-Book of Skin Diseases, New York, 1872, p. 167. f " Beitrage zur physiol. und pathol. Anat. d. Haut." Sitzungsberichtc der Wiener Akad., vol. lvi., p. 225, 1867. EXUDATIONS. 393 in no way microscopically from ordinary serum. Biesiadecki states that when pus-cells are present they have their origin in the connective- tissue corpuscles. Virchow, Cohnheim, and other pathologists, on the contrary, have shown that pus-cells are derived both from the blood and the cell elements of the affected tissue. The investigations of Gaucher, Vulpian, Heitzmann, and others, also show that the epidermis, no doubt, plays a most active part in the initiative step of this disease. For example, according to Gaucher, vacuoles are formed within the mucous layer, seemingly by the distention of individual cells with fluid, which, uniting, form vesicles. Chronic eczema exhibits many different changes, depending entirely upon the duration of the disease. The skin is inflamed, but much less actively than in the acute variety; it is also thickened, hard and more or less infiltrated; the papillae are enlarged, often to such an extent as to be observed, in some cases, by the naked eye. The infiltration may involve the entire corium, and may also extend even to the subcutane- ous cellular tissue. According to the minute investigations of Unna, as given in his recent work,* the positive characters of eczematous infiltration consist mostly of small, multiform connective-tissue cells, poor in protoplasm, lying closely together, and having a well but not very deeply stained nucleus. In addition, there may be pigment de- posits in the mucous layer and corium, especially about the vessels, the lymphatics are enlarged, and, in long-continued inflammation, the fat- cells disappear, the con-nective tissue becomes hardened, and the folli- cles and glands may be destroyed. Finally, many of the changes just described point to the probable nervous origin of the eruption, which has been suggested, particularly by Fox, who believed that in eczema both cells and vessels play an important and somewhat independent part, in obedience to a nerve paresis. Hebra was also of the opinion that faulty innervation is the most important element in the production of eczema. Bulkley, Bronson,f and others, have expressed similar views. Etiology.—Eczema is one of the most common and obstinate affec- tions of the skin. Statistics carefully compiled—which space at my disposal in a practical work of this nature will not admit of being given in detail, and, if stated, would not be of any special utility to the practitioner beyond the mere knowledge of figures—show eczema to be more frequent in certain countries than others. In the United States, and especially in the large cities, the percentage of reported cases of eczema among the cutaneous diseases appears to be greater than in Europe. In Philadelphia at least thirty to thirty-five per cent, of all cases of diseases of the skin coming under my obser- * The Histopathology of the Diseases of the Skin. By Dr. P. G. Unna, Edinburgh and New York, 1896, p. 211. f Eczema, its Pathology and Treatment, Journal of Cutaneous and Venereal Diseases, vol. i., No. 5, p. 132. 394 DISEASES OF THE SKIN. vation, are eczema. It occurs among all classes and at all periods of life, and is not infectious, but may in some cases be contagious. Clini- cal experience shows it to be rather more frequent in the male than in the female. Certain persons have a peculiar predisposition to the de- velopment of eczema ; strumous subjects and those having light hair and complexion being more liable to it than those of the opposite tempera- ment. The hereditary character of the disease can occasionally be rec- ognized by tracing it to a part or the whole of the family, or to one or more generations. Individuals so affected are usually born with a weak skin, just as other organs of the body are often in a debilitated condition at birth. The skin of persons in ordinary health is not usually affected by any constitutional or local derangement, or, if so, only very mildly, and it quickly subsides. On the contrary, in the unhealthy the least change in the system, or the slightest external irritation, may de- velop an obstinate eczematous or other cutaneous eruption. Cases of this nature will generally be found to have also associated with them a derangement of some other part of the body, as, for instance, a functional disorder of one of the viscera. Eczema, from clinical experience, is therefore no doubt directly traceable in the majority of cases to some constitutional impairment, that may either be from a peculiar predisposition or from an acquired cause. In referring, which I shall next do, to the constitutional and local causes of eczema, I wish it understood that I believe, in speaking of the latter, that whatever may be the source of the irritation, the disease is developed usually when there is present some faulty condition of the system. It is to be observed, moreover, that eczematiform eruptions due solely to local cause are confined to that portion of skin which has come into contact with the irritant substance, that the inflammation generally rapidly subsides, and that there is no tendency to successive attacks. Constitutional Causes.—The use of improper or even of proper food either in too large or too small quantities, especially in infants and growing children, acts as an exciting cause. Imperfect assimila- tion often supervenes under such circumstances, accompanied by the numerous disorders that it produces, any one of which would be suf- ficient fcr developing eczema. The retention in the system of the. elements of gout and rheumatism from the above or even other causes, and their circulation in the capillaries of the skin, often furnish the exciting cause. Again, certain diseases of the viscera, especially of the lungs, heart, liver, and kidneys, and of the blood-vessels, are active in calling the disease into existence. A striking instance of this kind is found in imperfect action of the kidneys, the deficiency in excretion leading to the retention of the waste products, and thus inducing eczema. The opinion was long entertained that the cure of an eczema, particularly if it affected an extensive surface or occurred in infants, EXUDATIONS. 395 was a dangerous procedure. Most modern writers have denied that this view contained any truth, but M. Gaucher, in the " Bulletin Medi- cal," September 1,1889, plausibly argues that it rests upon a reasonable basis. Chemical metastasis produces eczema in diabetes, gout, and Brigbt's disease, and, upon similar principles, the existence of a chronic eczema may point to its causation by toxic materials which are habitu- ally eliminated by the skin. If the eruption be supjjressed these sub- stances accumulate within the organism, and may give rise to more serious consequences. His theory is founded upon nine observations, and he therefore advises that we should not hasten to heal the entire diseased area at once, but attack it in segments, that our local applica- tions should not be too energetic, and that, in fact, we should endeavor to obtain full elimination through the kidneys and bowel instead of the skin. Besnier and Brocq likewise admit that the old opinion con- tains some elements of truth. The former advises that the kidneys should be carefully watched during the treatment of old cases of eczema of the legs and the chest in eczema of the trunk. Dr. Brocq remarks that in some cases an eczema makes its appearance upon the subsidence of neuralgia, migraine, asthma, or bronchitis, and that these diseases are apt to reappear if the skin trouble be energetically treated. It is not maintained that such relationship is frequent, much less that chronic eczema should receive no treatment. It is well, however, to observe caution in dealing with chronic eczema in those who have formerly been subject to such attacks to which allusion has been made. Dr. Robert M. Simon * states the case of a child whom he attended on account of an extensive eczema of the scalp and face, but who seemed otherwise in good health. Two younger brothers had died of acute tuberculosis. The eczema was rapidly cured, but its disappear- ance was followed by acute hydrocephalus, from which the child soon died. The writer remarks that, though this might have been merely a coincidence, yet, in view of the family tendency, the treatment had probably been injudicious. Another cause may be observed in a varicose dilatation of the subcutaneous veins, particularly when involving the rectum and lower extremities ; the impeded circulation is quickly fol- lowed by serous exudation, the activity of the capillaries and lym- phatics is arrested, the effete elements are retained, and these com- bined conditions excite an eruption upon these parts, which is very difficult either to relieve or cure. The appearance of eczema about the anus, perinaeum, and lower limbs can very often be traced directly to a diseased state of the veins in these regions. In a similar manner a change in the character of the blood, either through the circulation of certain abnormal products, as bile, pus, and drugs, or from the effects of pregnancy, lactation, malaria, anaemia, fevers, vaccination, wounds, improper hygienic surroundings, and other causes, by which * Wood's Medical and Surgical Monographs, vol. i, No. I, January, 1889. 396 DISEASES OF THE SKIN. the life-current is depleted or vitiated, may lead to an eczema. Dia- betes mellitus and Bright's disease are frequently attended by eczema. On the other hand, acute nephritis occasionally develops during the course of an eczema. Several cases of this kind have been reported during the last few years. Dr. C. Bruhns, of Leipsic, describes seven cases in which this complication occurred, and in all the kidney trouble may be regarded, either with certainty or a high degree of probability, as having been caused by the eczema. Similar cases, some of which proved fatal, are placed upon record by Canali, Regoli, Felici, and Caloni. Eczema sometimes alternates with attacks of asthma or bron- chitis. It often takes its origin in the various disorders of the gastro- intestinal canal. Dyspepsia is, perhaps, the most common, with its long chain of symptoms. Patients so affected will usually be attacked about the face, hands, and arms. Another of the same class of causes is dentition, which occasionally sets up an irritation of the mucous membrane, which, becoming reflected, disturbs digestion, no doubt producing some pernicious effect on the nervous system, and thus de- velops and augments the disease. The examination of the gums in these cases will show the mucous membrane to be intensely congested, hot, and tumefied, attended with evidence of a derangement of the gastro-intestinal canal; the free use of the lancet to the parts will soon allay all irritation, relieve the imperfect digestion, lessen the eruption, and settle conclusively the cause of the appearance of the eczema. In- testinal wrorms, haemorrhoids, and fistula in ano are also other instances of disorders of the gastro-intestinal canal that may give rise to eczema either by their reflected irritation or by the tone and vigor of the system becoming lowered by their presence. Eczema is likewise generated through many derangements of the nervous system. It is in this way that neuralgias, nervous debility, exhaustion, shock, excesses of all kinds, and the various ailments of the system act in developing this disease. Eczema of the eyelids sometimes follows measles. The malady is often excited through a disordered condition of the genital organs. In the male it may be occasioned by varicocele, orchitis, hydrocele, phi- mosis, paraphimosis, affections of the bladder, particularly irritability, gonorrhoea, spermatorrhoea, and stricture. In the female, eczema may also be excited by any one of the ovarian and uterine diseases; in young women, from disordered menstruation, and also from the same cause in those who have reached the climacteric period of life, the eruption appearing either upon the scalp, face, neck, or extremities. Local Causes.—The local causes which give rise to this disease are very numerous, yet they generally require suitable soil upon which to act for the existence and continuance of the eruption. Thus the skin of one class of individuals can be brought in contact with almost every irritant material, with little or no impression, while with others EXUDATIONS. 397 the least change of the weather, or the slightest irritation from any source, lights up a mild or severe eruption. It must, however, be borne in mind that the former class, even in the most robust health, may occasionally, by certain local causes, as either climatic changes, occupation, the use of dyes, tobacco, etc., so depress and enervate their vitality as to render themselves susceptible to the disease. Local causes, however, in the majority of cases, only call at once into exist- ence the inherent susceptibility of the system. Atmospheric changes are, no doubt, among the most important causes that excite eczema. For instance, the skin of some persons is susceptible to the least variation in the atmosphere, from warm or hot to cold, or vice versa, and from dry to moist. Cold weather and high winds, by checking perspiration or chilling the surface, will bring about eczema, or aggravate it, or cause an old eruption to reappear which had previously disappeared with the advent of summer. In the latter season certain eczematous eruptions, chiefly those in infants, will also at times burst out with renewed vigor, after lying dormant during the cold weather. In a similar way, heat, dry- ness, or moisture in the atmosphere acts in some cases in developing or aggravating the disease. As an example of the effect of heat may be named the action of the heat of the sun on exposed portions of the skin. Further, the elevation of the temperature of the body wdth excessive perspiration, the acrid condition of the secretion, or the friction of the moist folds of the skin, or contact with clothing, occasions the disease. Again, the heat, whether dry or moist, of the various baths, especially the Turkish or Russian, may have the same effect upon a sensitive skin. Occupation is, perhaps, next in importance as an external cause. Exposure to all kinds of weather, or vitiated or heated air, fires, soap and water, together Avith sitting, standing, or Avalking too much, are also conducive to the disease. It might be well, in this connection, to refer more in detail to the injurious results of the excessive use of Avater and soap for cleanliness or for the toilet. Water alone may excite eczema if used excessively in connection with certain substances or in washing certain parts of the body; also in bathing, applying water-dressing, and fomentations. Simple or compound soaps provoke upon the skin of many persons one or another of the A'arieties of eczema. The ordinary soft or pot- ash soap, sapo viridis or green soap, by its injudicious use in certain affections, as scabies and the different forms of eczema, may increase or excite the eruption. Mild and intense forms of eczema frequently follow the external use of acids, alkalies, mustard, cantharides, capsi- cum, croton-oil, tartar emetic, turpentine, tar, the mercurial and copper salts, arnica, belladonna, sulphur, chrysarobin, chloral, chloro- form, and many other medicinal substances. The same result en- sues in handling dyes, dyed goods, some Avoods, or in coming in con- ■398 DISEASES OF THE SKIN. tact with certain plants or vegetable substances. An illustration of this is the inflammatory effect of the poison-vine (Rhus toxicoden- dron) and poison-tree (Rhus venenata) on those susceptible to their influence. Drs. Sym and Clarke have reported cases in Avhich eczema was caused by handling the Primula obcon'uxi. Other fruitful sources of eczema are uncleanliness, the irritant action of clothing, especially dyed and Avoollen under-clothing, and the effects of either pressure or friction from bands, dresses, corsets, trusses, instruments, saddles, and crutches. Finally, eczema may be occasioned by or follow many other cutaneous eruptions, such as psoriasis, erythema, and herpes zoster, or by the irritant action of either the vegetable or animal parasites. The latter, especially the louse, itch-mite, bedbug, flea, or mosquito, give rise to scratching, Avhich is one of the most prolific causes of the development of eczema. The finger-nail in scratching, a prolific cause of eczema and other cutaneous eruptions, may not be the only means to assuage the irri- tation, but there are others which are sometimes employed, such as brushes, combs, etc. One of the most violent cases of eczema I have ever seen was brought about in this way : the patient, a butcher, having scabies, endeavored to relieve the irritation by scraping the surface, especially around the thighs and limbs, with his cleaver. In a like manner, eczema of the scalp is often induced in the effort to scratch the scalp or other hairy parts of the body with brushes or combs, or by the inordinate use of these toilet articles. It is probable that certain cases of eczema are of parasitic origin. If this be so, it would serve as a rational explanation of those cases seen from time to time, in which one follows another in families or public institutions and which suggest the idea of spread by contagion. Treatment.—In considering the treatment of the most frequent,* obstinate, and at the same time the most curable affection of the skin, the management of the standard varieties, and their secondary changes, just described, will first be discussed; after Avhich the erup- tion, as it occurs in the infant and upon the different regions of the body will receive special consideration. In entering upon the treat- ment of the disease, hoAvever, two important indications are always necessary: first, the detection and removal, if possible, of the exciting cause, and all sources of irritation ; and, secondly, the modification or cure of the morbid condition of the skin. In regard to the first, it is obvious that Avhile the disease may be modified by treatment, yet it will often be impossible to effect a permanent cure as long as the exciting cause or any source of irritation exists. Thus, for example, in eczema arising from gout or rheumatism, it would be useless to expect or hope for a cure as long as the abnormal elements of these affections remain in the body. The eruption may for a time disappear, but a relapse is EXUDATIONS. 399 liable to occur sooner or later, until the original disorder has been eradi- cated. It will not always follow, on the other hand, that Avith the re- moval of the exciting cause the eczema will at once subside; the altera- tion in the skin may be so decided as to require in addition a patient and tedious course of treatment. The factors which frequently play an active part in producing or aggravating the disease may be improper internal or external medication, or any of the numerous sources of external irritation. Many of the so-called tetter specifics, or blood- purifiers, really increase or prolong the eruption, until the patient is compelled by necessity to seek the physician's aid. Again, many of such preparations as Fowler's or Donovan's solutions, and the iodides, which to those well informed are valuable drugs, become in the hands of the ignorant often the most injurious. In truth, these and other remedies may be useful at one stage of the disease and injurious at another, and therefore, when taken by patients upon their own responsibility, will very often aggravate the eruption. It is Avell, therefore, in the majority of cases, particularly if the physical! suspects that the patient has been self-treated, or that the eruption has increased under the administration of the internal or external medication, or both combined, to discontinue, or give an expectant treatment, and watch the result. Again and again have I—as well, no doubt, as many others—seen the eruption disappear under such circumstances without the least interference upon the part of the physician. External medi- cation alone, Avhich has just been mentioned, may in a like manner, either from applications of improper or too strong agents, such as the various tetter-ointments, or from the use of stimulating remedies at the wrong stage of the disease, produce the most harmful results. Scratching, rubbing, and tearing the skin are also injurious, and in this respect patients must either exercise some restraint or be restrained. In like manner the Avearing of flannel and dyed goods in contact with the inflamed skin and the excessive application of water with or without soap are often fruitful sources of irritation, which must be remoAred before improvement can be secured. All atmospheric changes, and other means of irritation that prove harmful, should also at once be remedied. Lastly, the parts involved should, if necessary, be placed at rest. Every organ is universally admitted to need rest when disordered except the skin ; and this im- portant part of the economy may become inflamed, and yet patients continue in their active duties, expecting a cure to be effected by in- ternal and external medication alone. Is it reasonable to suppose, for instance, that eczema of the hands can be easily relieved or cured while the patient is pursuing the occupation that originally gave rise to the disease ? Can the genital organs, Avhen inflamed, recover their healthy state Avhile subjected to the irritation excited by the friction of the clothes in Avalking ? Can the legs respond well to treatment while 400 DISEASES OF THE SKIN. the sufferer constantly stands or walks upon them ? The answer is, that these cases imperatively need or demand rest. Rest is not only a benefit at certain periods of eczema, but it is also sometimes an essen- tial element in the ultimate cure of the disease. Yet, while it is an element of much good at certain times of this disease, at others it is also harmful, and should be enforced only Avhen necessary, and then neither too rigidly nor too long in duration. Remember that the opposite state of rest, motion or activity, unless contra-indicated, is productive of benefit to the skin, as well as all the organs of the body. The second indication in the treatment of eczema is to modify or cure the morbid action of the skin by the employment of either inter- nal or constitutional remedies that may affect the cause of the disease, or by the use of local means that act upon the diseased surface. In some, internal medication may be all that is necessary, while in others local remedies may alone act efficiently. Experience has led me, how- ever, to view eczema as being dependent upon systemic disturbance, and therefore in the majority of cases I usually recommend both in- ternal and local treatment. Constitutional Treatment. — Abundant evidence has shown that most cases of eczema are benefited by the use of general treat- ment. Cases appear, however, where local measures alone will suffice. The distinction should be made after a judicious and careful exami- nation, and the case managed accordingly. When general treatment is demanded, it should be instituted as soon as possible, and continued without interruption until the purpose for which it was intended has been entirely fulfilled. In the first place, diet and hygiene are both more or less essential in the general management of eczema. In reference to diet, it is important that it should always be suit- able to each case, whether it be the acute or chronic form. Thus, certain individuals, particularly those that are plethoric or dyspep- tic, Avill often require a restricted or mild diet, while others will demand the most nutritious food. Certain substances, however, will, in most cases, be found injurious to the patient. Among these may be mentioned strong coffee or tea, alcoholic fluids, pork, cheese, and shell-fish. Hygienic measures are equally important; proper rest, sleep, bathing, suitable clothing, and ventilation, good air, sunshine, and regular exercise, walking, riding, and massage, unless contra-indi- cated, Avill often be of the greatest assistance in the treatment. Nurs- ing is also of the utmost value, particularly in young children and old persons. Preparing and administering properly the food and medicine are essential to many at both periods of life, as Avell as carrying out suitable hygienic measures and making the local applications in the manner in which they are required. Generally the treatment should be commenced by correcting any abnormal condition of the secretions ; carthartics and diuretics are usu- EXUDATIONS. 401 ally of service, particularly in the acute variety. The moderate un- loading of the bowels by a purgative or laxative prepares the system for the more successful action of other remedies. They also—with agents that promote the action of the kidneys—lessen the cutaneous congestion, and thus afford much relief. Blue mass or calomel, Avith or without some additional cathartic, will often answer the purpose. Eupatorium is recommended also for this purpose by Piffard, avIio gives the fluid extract in doses of thirty minims night and morning. Sometimes a saline aperient alone, or following the mercurial, will be most suitable. Cream of tartar, Epsom, Rochelle, and the various aperient salts, with or without iron or a bitter tonic, are all valuable. The following combination can be employed with advantage: IJ, Magnesii sulphatis................ 3 v. Ferri sulphatis....................gr. x. Acidi sulphurici dil................ f 3 ss. Tinct. cardamom.................. f § j. Infus. coptis trifoliae.....q. s. ad ft. f § v. M. Sig. : A tablespoonful in a wineglassful of water two or three times daily. The quantity of the magnesia and iron can be increased or decreased, according to the requirement in each case. Quinine and strychnine may be added if desired. The saline and alkaline purgative waters of Saratoga, Epsom, Kis- singen, Carlsbad, and Friedrichshall also are of service. In cases characterized by marked constitutional excitement, the skin being inflamed, often hot, and very irritable, moderate blood- letting will unload the capillaries and allay the active symptoms. Again, tartar-emetic, aconite, ipecacuanha, veratrum viride, gelse- mium, strophanthus, and digitalis are all valuable remedies, given in small doses, alone or with neutral mixture, or spirit of Minde- rerus, to relax the skin and produce a prompt and beneficial effect upon the eruption. The kidneys may be rendered active by the above means, especially if the skin is very inactive, or by the use of such alkalies as potassium or sodium acetate, in doses of from ten to twenty grains in water, or combined with sweet spirit of nitre or infusion of digitalis. The benzoate of lithia, in doses of three to five grains in water before meals, answers a very good purpose. The diet should be light, especially in the acute form, and any alimentary derangement corrected according to the indication present—one may need pepsin, bitters, or mineral acids, and another alkalies or one of the silver salts. Imperfect assimilation, and the various disorders which it gives rise to, may be corrected by an occasional blue pill, followed by a saline, together with the toning up of the digestive organs. If the patient possesses a rheumatic or gouty diathesis, diaphoretics, diuret- ics, and alkalines are of advantage, with or without aperients. Thus, 26 402 DISEASES OF THE SKIN. the potassium or sodium acetates, in from ten to twenty grains, three- to six times daily, are often useful in rheumatic patients. Salicylic acid, sodium salicylate, the oil of gaultheria, salol, the lithia salts, and the alkaline natural-spring Avaters, alone or combined, will prove of advantage in both rheumatic and gouty subjects. The following will be found of service in the latter class of patients: IJ Extracti colchici acet .-..............gr. viij. Extracti digitalis...................gr. iv. Extracti colocynthidis co............ gr. xvj. Quininae sulphatis.................. gr. viij. M. Ft. pil. no. xvj. Sig.: One pill three or four times a day. The benzoate of sodium, also, is beneficial in cases dependent upon rheumatism, while in eczema associated Avith gout the benzoate of lith- ium is of service. In the violent attacks of eczema to which rheu- matic and gouty individuals are occasionally liable, Brocq is accus- tomed to begin the treatment by the administration of large doses of quinine as soon as the premonitory symptoms are manifested. Strychnine, cod-liver oil, malt, and the various bitter tonics are beneficial in those who are debilitated or present evidence of imper- fect nutrition. Iron in the form of one of the salts, tinctures, wines, or sirups, or any of the chalybeate waters, by its tonic action upon the system renders most efficient service in eczematous subjects, particu- larly in those who are anaemic. Cascara amarga has been thought to possess tonic and alterative virtues. The sirups of the phosphates and the hypophosphites are also valuable. In the eczema of aged people, in whom the disease usu- ally assumes a chronic form, quinine, as Bulkley points out,* is of special service, both on account of the malarial taint often at the bot- tom of the trouble and as a pure tonic. In the same class of patients a hypnotic is often required, and among these phenacetin, in five-grain doses, and antifebrin, in six-grain doses, at bed-time are recommended. Alcohol should usually be forbidden, though if the patient has been accustomed to its use, a regulated quantity may be allowed with the meals. Tea and coffee may be taken in moderation and an ordinary mixed diet permitted, though it should be remembered that aged people require less sustenance than those in the prime of life. Arsenic is a powerful and valuable agent in eczema, but its indis- criminate use is often followed by injurious results. It should not usually be employed in the acute stage, as it very often aggravates the eruption. It is especially indicated in the chronic form, alone or com- bined with iron and other preparations, and is equally efficacious in nervous cases and those that are accompanied by malaria. It is not * On the Treatment of Eczema in Elderly People. By L. Duncan Bulkley, A. M., M. D. Reprinted from Transactions of the New York State Medical Society, 1890. EXUDATIONS. 403 usually prescribed if digestive disorders exist, but even in such cases in very small doses, one or two drops before meals, the result from its use is often most gratifying. In administering arsenic I usually pre- fer to use arsenious acid or the arseniate of sodium, for the reasons already stated under the general head of treatment, and the drug should be continued for a time after all eruption has disappeared. The following pill I frequently use in chronic eczema with benefit: R; Extracti calami.................... gr. xxx. Extracti digitalis................... gr. v. Sodii arseniatis.................... gr. j. Extracti ignatiae................... gr. ij. M. Ft. pil. no. xxx. Sig.: One pill three times a day. . Warburg's tincture is likewise of service when eczema is associated with malaria. In some cases of chronic eczema, where arsenic will not be Avell tolerated by the stomach, it can be used by the rectum in the form of a suppository, or hypodermically. One eighth to one quarter of a grain of arsenious acid, or arseniate of sodium, may be giAren by the former method twice a day. In injecting either of the preparations just men- tioned into the subcutaneous cellular or muscular tissue, from one twentieth to one half of a grain may be administered once a day. I have often built up old eczematous cases by tonics and good, nutritious food, and at the same time brought the system thoroughly under the influ- ence of arsenic by injecting it beneath the skin. In some old cases of eczema Klotz has obtained very satisfactory results from the daily hypodermic injection of ten to fifteen drops of a one-per-cent. solution of pilocarpine hydrochlorate. Nervous subjects often require, in addition, the preparations of phosphorus, the use of electricity, or a complete change of air and scene. The mercurial salts, especially the corrosive sublimate, in very small doses, are often followed by successful results. Viola tricolor has long been employed by French practitioners Avith good effect, and also by Piffard, who recommends one or two drachms of the herb with a half-pint to one pint of hot Avater, to be made into a tea and taken in twenty-four hours, either alone or combined Avith senna. He also uses the fluid extract of the drug in five- to ten-drop doses, once, twice, or three times daily, before meals. Tar and sulphur have both been used with advantage in chronic cases; the former can be given in the form of pix liquida, in from one to six grains, three times daily, and the latter as milk of sulphur, or, Avhat is even better, by drinking some one of the sulphur-spring waters that exist so abundantly throughout this country. Calcium sulphide, in from one thirtieth to one grain, three or four times daily, will prove of service in both acute and chronic eczema. 404 DISEASES OF THE SKIN. It is particularly useful in the pustular variety, often lessening rapidly the tendency to the formation of pus. Potassium chlorate has an analogous action, in from one- to ten-grain doses, several times daily. Valuable properties have also been attributed to the internal use of chloride of calcium. Small doses of antimony or antimonial wine are often beneficial, especially in the chronic form. Further, the derange- ment of the system, or any of its organs, must always be considered, and treated accordingly. For instance, those possessing a predisposition to the development of eczema, inheriting a weak skin, or having Avhat is knoAvn as the scrofulous diathesis, are successfully treated with a good nutritious diet, bathing, fresh air and plenty of outdoor exercise, massage, cod-liver oil, malt. The ferruginous preparations, potassium chlorate, quinine, strychnine, and sometimes arsenic, may be indicated. A combination of wine of iron and Pearson's solution, as in Wilson's ferro-arsenical mixture, often yields good results in scrofulous subjects. Preparations of iodine and sulphur may also be advantageously pre- scribed, or may be given together in the form of the iodide of sulphur. Again, a change of climate will often exert a most decided influence in assisting to overcome the general debility of this unfortunate class of sufferers. In squamous eczema Jamieson has witnessed decided im- provement follow the hypodermic injection, twice daily, of one sixth to one third grain of pilocarpine. The subjective symptoms of itching, burning, or pain often be- come so distressing as to call for the administration of suitable consti- tutional remedies to afford relief from the persistent and continuous suffering. Besnier advises that when pruritus is present the patient should be restricted to a milk diet until the case has been thoroughly studied. Opium or morphine are of service in some cases, but entirely fail in others. Belladonna or hyoscyamus, pushed to full doses, at times act with good effect. Paraldehyde, chloral, and the bromides, especially the tAvo latter in combination, often act effectually. I very often resort, in cases of great irritability of the skin, especially when there is disorder of the alimentary canal, to the use of suppositories containing one or more of the drugs just named. R; Extracti opii, Extracti belladonnae, Extracti hyoscyami...............aa gr. iv. Olei theobromae.................... q. s. M. Ft. suppositoria xij. Sig.: Insert one into the rectum every two or three hours or until relieved. In case the opium will not agree with the patient, but aggravates the eruption, it can be replaced by adding five or ten grains of chloral to each suppository. Chloral is valuable used in this way, particularly in infants and children, the dose being from one to five grains in each EXUDATIONS. 405 suppository. Bulkley recommends the tincture of gelsemium for the itching, beginning with ten-drop doses, to be gradually increased every half hour until the patient is relieved, or has experienced some of the physiological effects of the drug. The antispasmodic remedies, as / valerian, asafoetida, castor, or musk, are also to be recommended for the purpose of allaying itching and nervous excitement. They are admin- istered in the form of injections or suppositories. Carbolic acid and salicylate of sodium are given internally in appropriate doses for the relief of the same symptoms. Antipyrin sometimes succeeds in reliev- ing itching. Cypripedium is occasionally used with advantage for the same purpose; and urethan may afford relief Avhen administered in doses of twenty to forty grains, repeated at two-hour intervals until two or three doses have been taken. Spirit of turpentine in ten-minim doses, thrice daily, gradually increasing to twenty or thirty minims, is, according to Crocker, useful in rebellious cases. Favorable reports have been made concerning the use of the thyroid gland or its extract in chronic eczema. Cases have been reported by Byron Bramwell and Arthur T. Davies. In a later communication upon thyroid feeding Zum Busch gives his results in twelve cases, of which nine were cured and two improved, while in one case the disease was aggravated under the treatment. Local Treatment.—While constitutional treatment alone may fre- quently cure, yet the addition of judicious external applications will, in most cases, be of advantage. If no sufficient evidence exists for general treatment, owing to the cause having disappeared, attention should be directed to the local measures alone. Viewing the disease as being dependent upon constitutional impairment, I generally employ both methods, unless reasons indicate its purely local nature. The local treatment, whether used in conjunction with general measures or alone, is of the utmost importance. The first step to be considered is the history and the symptoms. Inquiry will reveal the condition of the skin, whether naturally weak, sensitive, or healthy before the out- break of the eruption. The duration of the disease, if a first attack or a relapse, and the region and extent of surface involved, will be shown. A careful examination will point out the condition of the affected skin, the presence of few or many primary or secondary lesions, and whether the disease is active, passive, or on the decline. Having discoArered the stage and variety of the disease, as well as any peculiarities that the skin may possess, external treatment can be carried out usually in the most satisfactory manner. If these precautions be neglected, unsuitable applications are liable to be made, with injurious effects. For exam- ple, the treatment Avhich is appropriate for one stage is often unsuited for another; the means employed for the acute are ineffective in the chronic; and, in like manner, that which is effective in the chronic is usually irritating or harmful in the acute. 406 DISEASES OF THE SKIN. The next indication in the local treatment is the removal of any hairs, secondary products, or foreign material, which have collected upon the part, in order that the desired application can be made directly upon the unhealthy surface. Too often this is neglected; the poured-out products are allowed to remain or are but partially removed, or the ap- plications are dusted or smeared on from time to time without once cleansing the surface. The diseased parts are then not at all medicated, and the foreign elements irritate and still more aggravate the erup- tion. Patients and nurses must be impressed Avith the necessity of cleansing the surface and exposing the disease according to the method thought best by the attending physician. The method generally em- ployed to loosen and remove scales, crusts, and any extraneous matter is the use of oils, fats, water-dressings, or water and soap. The surface to be cleansed is generally saturated with an oily preparation, and the crusts, scales, or other foreign material that may be present disap- pear after one or more applications, and in case of much difficulty the addition of water and soap brings about the desired result. Acute and Subacute Eczema.—The principle of local treatment in both the acute and subacute stages of eczema, after cleansing the diseased surface, is the employment of means to protect, soothe, and sometimes produce a mild astringent and stimulating effect, in order to modify and relieve the inflammatory symptoms. Certain precau- tions should, however, be considered in using local applications. The skins of all persons are not alike; some are more sensitive than oth- ers, and therefore agents which are beneficial to one Avill often prove harmful to another. Remedies that are indicated may be used cau- tiously upon a part, and not to the entire surface at once, and if the effect is good, it can be made general, and should be persisted in as long as the result is beneficial. If the application should fail, or ex- cite and aggravate the inflammatory symptoms, others should be used ; and in case all means do more harm than good, then all active treat- ment must be discontinued and the expectant method adopted. It is also well to bear in mind, and particularly to caution patients, that acute eczema is frequently irritated by both air and water, especially soap and water. The applications usually employed in acute eczema are lotions, medicated dusting-poAvders, and fatty and oleaginous sub- stances. If one is not suitable to the surface, another, or a combina- tion, may be. Water.—Water is an element which is much abused in the toilet of eczematous patients, and often aggravates acute-cases; if used in moderation it will agree with some, but, on the contrary, not with others, and, of course, it should not be hard, but should be made soft by some mucilaginous substance in it. Water, alone or medicated, can be employed both to cleanse an eczematous surface and to allay the inflammatory symptoms.. It can be used at all temperatures, and EXUDATIONS. 407 can be medicated Avith many remedial substances. Thus, water, applied in the form of either hot or cold fomentations or by sponging the sur- face, often relieves the inflammatory action and allays the local irrita- tion. The combination of water and a fatty substance is also of service; the inflamed skin, after being anointed with some fat, should be im- mersed in a water-bath kept at the temperature of the blood. Medicated water, in baths and lotions, is a most agreeable form of treatment for acute eczema. The emollient and alkaline baths, or both combined, are perhaps the most valuable of medicated waters, and often prove most grateful in alleviating the hot, tense, and itching condition of the skin. •Baths containing bran or starch of ten afford decided relief, though it should be known that bran will sometimes aggravate the condition of the integument. In certain cases chamomile Avater proves beneficial. The peroxide of hydrogen is a valuable application. It will frequently, however, be found too strong unless diluted with several parts of water, or the water may be medicated and used in the form of a lotion. Lead-water and laudanum, two ounces of each to a pint of Avater, will at times be very beneficial. Lime-water, glycerine, and Avater, in equal parts, form an acceptable application. After the initiatory manifesta- tions have somewhat subsided the glycerite of tannin serves a useful purpose, applied twice during the day. It relieves the stinging pain and itching. Boric acid, borax, sodium bicarbonate, or sodium sul- phite, or sodium hyposulphite, one to two drachms of either to a pint of water, are valuable lotions. I frequently employ, w7ith good success, from tAvo to four drachms each of powdered alum and borax, in three to four pints of hot Avater, applied to the surface with 'old pieces of muslin. It must be mentioned, in this connection, that in using lotions care should be taken not to place too much material in contact with the part. The muslin or substance used should be thin and not bulky, permitting free evaporation from the part, other- wise it may act as a poultice, developing heat and moisture, and ag- gravating the inflammatory symptoms. A diluted fluid extract of hamamelis or grindelia robusta has also been used with success. I have also employed with benefit, in vesico-papular and papular eczema, carbolic acid, a drachm to the pint of water. Tilbury Fox recommended the following effective application: An ounce of fine levigated calamine-powder, two drachms of glycerine, half an ounce of oxide of zinc, and six ounces of water—to be well shaken, and sponged frequently on the part. The sediment which is deposited on the skin should be allowed to remain, as it excludes the air from the inflamed surface. An equally serviceable lotion is composed of zinc oxide four drachms, glycerine one ounce, rose-water two ounces, lime- water three ounces. To make it more sedative a drachm of spirit of camphor, or six drachms of laudanum, may be added. If stimula- tion is required, as in the circumscribed papular variety, ten or fif- 408 DISEASES OF THE SKIN. teen grains of thymol, or a drachm of either liquor picis alkalinus or liquor carbonis detergens, can be added. Black-Avash and yellow- wash are both valuable in the papular variety of acute eczema, fulfilling the indications mentioned—protection with moderate stim- ulation. When the disease is attended by excessive itching, lotions containing carbolic acid or chloral are serviceable. In applying water alone or medicated it will often be of the utmost benefit, immediately after mopping the parts, to apply one of the dust- ing-powders, while the surface is yet moist, in order to exclude the air from the sensitive skin. Dusting-powders are most useful when the surface is more or less covered with redness, vesiculation, papulation, pustulation, or a serous exudation. They may be either perfectly bland and soothing, or they may have some astringent, sedative, or other remedial action. Among those that may be employed are starch, arrow-root, rice, buck- wheat, lycopodium, talc or French chalk, magnesium carbonate, zinc oxide, pure and impure; zinc carbonate and oleate, bismuth sub- nitrate, and lead carbonate. The most emollient and soothing are. the first three; the magnesium, zinc, bismuth, and lead are astringent as well as sedative. Boric acid is likewise a good antiseptic dressing, and may be employed alone or mixed with some one or other of the above- mentioned substances. One or more of these remedies can be com- bined Avith other medicinal agents with advantage. For protection and for soothing I generally employ equal parts of arrow-root and rice- powder, and, if there is much itching and burning, the addition of a little camphor and morphine, will be of service. The use of stramonium, hyoscyamus, or cannabis indica, after the method proposed by Dr. Faithful, aids the soothing effect of the afore-mentioned remedies. Finely powdered carbonate of calcium is a drug which may be ad- vantageously employed. When a mild astringent action is indicated, a drachm or two of powdered zinc oleate to one half to an ounce of powdered arrow-root is of utility. The following combinations have also been found beneficial: R, Pulv. marantae...................... \ j. Pulv. zinci oleatis................... 3 ij. Pulv. camphorae.................... 3 ss. M. 1$ Bismuthi subnitratis................ 3 ij. Pulv. amyli........................ 3 vij. Morphinae acetatis.................. gr. j. M. Pyoktanin mixed with talc in the proportion of two per cent, has been successfully employed. Dusting-powders may be used with advantage, after the application of fatty and oleaginous substances and lotions, to protect the surface and retain the medicaments upon the parts. Powder-bags have been introduced by Unna as particularly suitable to the treatment of eczema EXUDATIONS. 409 of the scrotum and penis, the groin, under the mammary gland, or in other situations where opposing surfaces of skin come in contact. They are made of thin cambric or muslin, quilted across so that the powder can not shift from one to the other end. The powder is expelled gradually from the bag by movements of the body or part. Anderson recommends, as a good application in acute eczema, a cold potato-starch poultice, with a small quantity of absorbent powder sprinkled over its surface. Ointments are much better adapted for many cases than either powders or lotions. They may be simple or medicated. They are of service not only in removing scales, crusts, and other products of eczema, but they also protect and act remedially upon the inflamed surface. It is essential that they should be free from rancidity and well prepared. They should be carefully smeared over the inflamed surface, and, if possible, kept at all times in contact with it, thus ex- cluding the air and preventing the formation of crusts. This purpose can be accomplished by spreading an ointment upon muslin, lint, or cotton, and applying to the parts, or by saturating the surface with oil and using a light cloth or bandage over it. The sahre or plaster muslins devised by Unna are of service in maintaining the chosen medicament in continuous contact with the diseased surface. They are made of muslin the meshes of which are filled Avith rather stiff ointment, and • a variety of different drugs suitable to the treatment of eczema and other diseases of the skin have been put up in this man- ner. The dressing of eczema should be changed two, three, or more times daily, according to the indications in each case, and the pent-up secretions permitted to escape; otherwise they may give rise to con- siderable irritation. If the successive layers harden into a firm coat and act as an irritant to the diseased surface, they must be removed by some appropriate oily substance. The best of the soothing ointments are the zinc oxide or carbonate, one drachm to the ounce of cold cream; and bismuth oxide or subnitrate or lead carbonate, one drachm to an ounce of lard. Cold cream, or cucumber-ointment, alone or combined with a drachm or two of arrow-root, is bland and useful. The ointments of bismuth, lead, and zinc oleate are serviceable in many acute cases. Diachylon-ointment,* which is a valuable soothing application, is pre- pared as follows: R Olei olivae opt...................... f f xv. Lithargyri.......................... 3 iij, 3 ij- Coque, dein adde Olei lavanduli...................... f 3 ij- M. Ft. ung. * The following are the details of its preparation: " The olive-oil should be first mixed with two pounds of water and heated ; then, while fresh water is constantly poured 410 DISEASES OF THE SKIN. This ointment, which is yellowish in color and of the consistence of butter, is substantially an oleate of lead, and can be applied to any part of the body, except where covered with hair, on which it is un- suitable, on account of its tendency to mat the hair, and thus to pre- vent its absorption by the skin. A weak ointment of aluminium oleate or iron oleate and the ointment of bismuth oleate are useful applica- tions in acute eczema. The following combination, suggested by McCall Anderson, is very effective in many cases : . R Pulv. camphorae................... 3 ss. Pulv. zinci oxidi................... 3 ij- Glycerini......................... f 3 ij- Adipis benzoati.................... § j. Cochinillini....................... gr. j. Olei rosae......................... irt j. M. The ointments that I frequently use are : R Pulv. marantae.................... 3 j- Plumbi carbonatis................. 3 j- Cerati Galeni..................... § j. M. Ft. ung. R Zinci carbonatis.................... 3 j- Bismuth subnitratis................. 3 j. Olei anthemidis................... m x. Ungt. aquae, rosae.................. § j. M. Ft. ung. R Hydrarg. chlorid. mit.............. gr. x. Pulv. amyli....................... 3 j. Pulv. camphorae...................3j. Pulv. zinci oxidi................... 3 j. Adipis benzoati.................... § j. M. Ft. ung. R Ung. zinci oleatis.................. | j. Extracti opii, Extracti belladonnae..............aa gr. v. M. Ft. ung. An acceptable sedative and astringent application is: R Ung. plumbi oleatis................ § ss. Pulv. marantae..................... 3 ss. Olei anthemidis.................... v\v. M. Ft. ung. in and the mixture stirred, freshly sifted litharge should be gradually added. The whole should be kept in motion until cooled, and, lastly, the lavender-oil should be added. In cold weather an extra ounce of olive-oil should be allowed for every pound of the ointment." Hebra on Diseases of the Skin, vol. ii, New Sydenham Society, Lon- don, 1868. EXUDATIONS. 411 The following is especially of service in papular eczema: R Ung. bismuthi oleatis.............. 3 ss. Pulv. camphorae................... gr. x. Pulv. amyli....................... 3 j. Morphinae acetatis................. gr. j- M. Ft. ung. An ointment of aconitine, eight grains to the ounce, is useful in . papular, eczema, but care is needed in its application to avoid bringing it in contact with any absorbing surface. Chloral, in the proportion __ of twenty to thirty grains to the ounce, may also be serviceably made v into an ointment in order to relieve itching. It is very well combined with an equal quantity of camphor. Oils are even more grateful than ointments in some cases of eczema. For this purpose any bland oil can be used—e. g., olive, linseed, sweet almond, lard, palm, cotton-seed, and cod-liver oil—alone or com- bined with other suitable remedies. Thus equal parts of sweet-oil and lime-water are useful. Again, the following will often act well in either the erythematous or vesicular varieties: R Olei olivae........................ f § iv. Plumbi carbonatis................. 3 ij. Zinci carbonatis................... 3 ij. M. An other excellent prescription is: R Olei amygdalae.................... f § iv. Calaminae........................ 3 ij. Olei anthemidis................... tti x. M. Pastes have of late years been much employed by Unna and other German physicians in the treatment of eczema. They are made by stiffening an ointment by means of some dry innocuous poAvder, such as starch, silica, or carbonate of magnesium. Such preparations are held to be superior to ointments, in that they are able to absorb secre- tions and leave a poAvder closely attached to the integument, from which it is not easily removed. Chronic Eczema.—It is often impossible to decide positively when the acute stage ends and the chronic begins. The former, how- ever, is usually of short duration, from several days to a few Aveeks, to be succeeded frequently by the latter. The secondary changes which then occur, especially the infiltration, require decided measures, to stimulate the action of the absorbents and induce a reabsorption of the exudation. Baths.—Baths become, in this stage, the most effective means not only of removing scales, crusts, and other secondary products, but also of arousing the dormant blood-vessels and lymphatics to renewed activity. AVhile baths will not be suitable in all cases, the irritation and even inflammation occasionally increasing under their use, yet in 412 DISEASES OF THE SKIN. the majority of chronic eczematous conditions they are most valuable additions to the treatment. Thus the hot-air, electro-vapor, simple and medicated vapor baths assist in relieving the red, infiltrated, rough and scaly condition of the surface by awaking the sluggish skin to activity, and softening and detaching the scales and crusts, if any are present. The medicated vapors, especially the sulphur, have very often the additional effect of relieving the itching Avhich may exist. The medicated liquids are not only useful in cleansing the surface, but may be made soothing by the addition of starch, bran, and sodium bicarbonate; stimulating by sulphurous and boric acids; and astrin- gent by alum, tannic, and gallic acids. Soaps.—Soaps may frequently be employed with advantage, not only for the purpose of cleansing the surface of scales, crusts, and all extraneous material, but also for their stimulating or caustic ac- tion, and as a convenient method of bringing certain medicinal substances in contact with the skin. Either the soda or potash soap can be employed alone or combined with other remedies. The best example of the former is the Avell-knoAvn Castile soap, in which can be incorporated sulphur, tar, naphthol, one of the mercurials, carbolic, boric, or salicylic acid, forming special medicated soaps which are valuable in the treatment of chronic eczema. The potash or soft soap (sapo viridis) can be employed as recommended by Hebra until the infiltrated epidermis is softened, macerated, and removed; then Avash the surface and apply a suitable ointment, generally the diachylon. The green-soap treatment of chronic eczema is more adapted to local- ized patches of the disease, and even then the integument of Ameri- cans, which is usually very sensitive, will frequently become worse under the use of so harsh a procedure. Dr. G. II. Fox, of New York, has made use of a soft olive soap Avhich he finds equally effective and a more elegant preparation than the green soap. It is made from cold-pressed olive-oil, has a green color due to the chlorophyll of the olive, is homogeneous, free from unpleasant odor, and forms a perfectly clear solution Avith strong or dilute alcohol. Tar.—Tar, and some of its products, as carbolic acid, creasote, naphthol, and naphthaline, are among the most valuable external remedies that can be employed in chronic eczema, but contra-indicated in the acute stage, especially if there be much redness, elevation of temperature, swelling, vesiculation, and infiltration. In employing tar and its products, even in the chronic stage, care should be ob- served that they are diluted properly, and then applied first on a small area of the surface, in order to test their action upon the patient's skin. All individuals do not bear these preparations well, and occa- sionally a chronic eruption is aggravated by their employment into an acute condition. The forms of tar commonly used are Avood-tar EXUDATIONS. 413 (pix liquida), coal-tar (pix mineralis), Burgundy pitch (pix Burgun- dica), terebinthina Canadensis (balsam of fir), all of which are cheaper, and therefore of more advantage to prescribe in dispensary and hos- pital practice than the more elegant preparations of oil of cade (oleum cadinum) and the oil of white birch (oleum rusci), Avhich are more suitable for private practice. Any of the above can be combined in various proportions with ointments, oils, spirits, and soaps. In which- ever form tar is used it should be firmly rubbed into the part with a piece of flannel, one or more times daily, according to the condition of the skin. In some cases it is well to allow the tarry preparation to remain upon the skin until it is naturally cast off, while in others it becomes necessary to cleanse the surface with oil or water and soap. In many instances tar is better borne in the form of an ointment, especially where there are more or less infiltration and a tendency to the deArelopment of fissures. The proportion of the tar to the ointment varies with the requirements of each case. One or two drachms of the former is generally used to an ounce of the latter. R Olei cadini........................ f 3 j. Olei verbenas...................... nr. Adipis benzoati.................... 3 j. M. Ft. ung. The above is a useful combination, with or without zinc oxide or sublimed sulphur. Zinc and lead ointments, especially the diachy- lon, and the mercurials are valuable as vehicles for tar and for the additional remedial action that they exercise upon the skin. Tar may be advantageously combined Avith olive, cod-liver, and other oils for use upon the hairy portions of the body. Another excellent method of using it is in the form of a lotion, especially in regions covered with hair : R Olei rusci......................... f § ss. Olei lavandulas.................... f 3 j- Aquae Cologniensis................. f 3 vi. M. Sig.: Rub firmly into the skin. Tar can also be suspended in alcohol alone, or with the addition of sapo viridis. The tincture of witch-hazel and spirit of rosemary are also suitable solutions to which tar may be added. Among other valuable preparations of tar is the tinctura saponis viridis cum pice of Hebra, the compound tincture of green soap : R Olei cadini, Saponis viridis, Spiritus vini rectificati...........aa f 3" j. M. filtra et adde Spiritus lavandulae................. f 3 ij- M. et ft. lotio. 414 DISEASES OF THE SKIN. Bulkley recommends the following useful solution, which is mis- cible in all proportions with water : R Picis liquidae...................... f § ij. Potassae causticae.................. § j. Aquae destillatae................... f § v. 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. In circumscribed patches of chronic eczema in old people the same writer makes use of a tar ointment : R Zinci oxidi........................ 3 j- Ung. picis liq..................... 3 iv. Ung. aquae rosas................... § j ss. M. If the thickened tissues do not soften under this application he adds a quarter-part of diachylon-ointment to the above, and in still more obstinate cases, ten to twenty grains of salicylic acid to the ounce. McCall Anderson * states that an English pharmacist has discov- ered that by the addition of laminaria saccharina (Sea-Belt) to pix liquida, it is miscible with hot water in all proportions. Carbolic acid and creasote are useful in chronic as well as in acute eczema. They may be employed either as lotions or ointments for their stimulating and anti-pruritic effect. Carbolic acid, probably the better of the two, can be dissolved in water or added to any of the ointments or oils in the proportion of five to thirty grains to the ounce, decidedly enhanc- ing their value. The compound tincture of benzoin, or a solution of benzoic acid in cologne water is often useful in relieving the attendant itching. Cam- phor is another remedy which is employed for the same purpose, and may be effectively combined as follows: R Camphorae........................ gr. x. Sulphur sublimat.................. 3 ss. 01. eucalypti...................... tit. x. Creasoti.......................... ttj, viij. Ungt. aquae rosae, Ungt. zinci oxidi................aa | ss. M. A five-per-cent. solution of chloral will also alleviate this symptom, as will also a lotion or ointment containing cocaine. Beta-naphthol f and naphthaline have been used as substitutes for the tarry preparations in the treatment of chronic eczema. Of those two remedies the more u-seful and effective is naphthol.J It has a * Loc cit. \ See paper on Naphthol, by the author, Transactions of the Philadelphia County Medical Society, 1883. X See paper on the " Treatment of Skin Diseases by Novel Means and Methods," Transactions of the International Medical Congress, Copenhagen, Denmark, 1884. EXUDATIONS. 415 decided action upon the skin, and obtunds the sensibility of the cuta- neous nerves. It is a serviceable remedy in rough, infiltrated, and irritable conditions of the integument, stimulating the absorbents, and at the same time is one of the very best anti-pruritic agents. I fre- quently employ— R Naphthol........................... 3 i. Unguenti plumbi oleatis.............. 1 ss. M. R Naphthol........................... 3 ss. Sulphuris sublimati.................. 3 j. Unguenti zinci ox. benz............... § j. M. When the skin is markedly thickened and itching is a prominent symptom Vidal makes use of an application consisting of one part of tartaric acid to twenty parts of glycerole of starch or glycerine. Brocq is of the opinion that the above preparation is improved by the addition of salicylic acid, and gives the following modified formula: R Acid tartarici.............. 1 grm. Acid salicylici.............. 50 cgm.—1 grm. Glycerit. amyli vel glycerini. 25 grm. M. In obstinate cases of eczema, especially when it attacks the hairy scalp or the genitalia, Vidal and others have witnessed good results from the use of storax, which may be applied pure or diluted with two or three parts of olive oil or oil of sweet almonds. Creolin has been found of value in chronic eczema. It may be used as a lotion in the proportion of one drachm to half a pint of Avater. Mercury.—The mercurial preparations are among the most valu- able remedies that can be used in chronic eczema. They are particu- larly valuable in localized forms of the disease, and are more effective after the infiltration has lessened. The bichloride of mercury dis- solved in water, in the proportion of from one to five grains to the ounce, sponged frequently over the surface, often lessens the inflam- matory action and allays the itching. The white precipitate and calomel in from five to sixty grains to the ounce of lard, cold cream, or benzoated zinc-ointment, are of great value. The red and black oxides are also beneficial, but the nitrate and oleate are more effective when used in the form of weak ointments, or incorporated Avith tar, naphthol, or sulphur ointments. Of the many remedies that are of service in the chronic stage of eczema, few are superior to sulphur, in from one half to two drachms to the ounce of some fatty substance. Ichthyol, which was introduced by Unna, contains a large percentage of sulphur, and is also useful. Inunction with the ointment of arsenicum oleate is followed by good results in some cases of chronic eczema. In cases attended by marked infiltration the cadmium oleate ointment has been of decided service. Under the same conditions, especially when the extremities 416 DISEASES OF THE SKIN. are invaded, the skin being hard and of a leathery consistence, the oleate of nickel, mixed with a suitable excipient in the proportion of one to sixty grains to the ounce, will generally prove of benefit. Iodo- form, chrysarobin, pyrogallic, salicylic, and boric acids—the first four in the form of ointments, and the last one as a lotion in from ten to sixty grains to the ounce—are at times quite effective. Gallanol is re- ported to be useful in relieving pruritus and promoting cure. It is used in the form of a ten- to twenty-five-per-cent. ointment. A one- or two-per-cent. ointment of losophan is useful in old infiltrated cases attended with itching. It is particularly adapted to scaly and fissured eczema. Chrysarobin may likewise be servriceably applied, suspended in col- lodion or gutta-percha solution. Thymol, five to fifteen grains to the ounce of Avater or lard, is also useful. An ointment of tannic acid, a drachm to the ounce, is sometimes beneficial, or a mixture of one part of tannic acid to two parts of iodoform. Ointments of aristol or euro- phen constitute good applications in squamous or seborrhceic eczema. Unna states that for the treatment of seborrhoeic eczema we possess four valuable remedies—sulphur, resorcin, chrysarobin, and pyrogallol, J of which resorcin is the best, being least apt to produce local or consti- tutional ill effects, though in a few instances an idiosyncrasy exists which Avill not permit the use of resorcin. This substance may be used in the form of powder, paste, soap, ointment, watery or alcoholic solu- tion. Resorcin giAres rise to a SAvelling of the epidermis, by which pain- ful fissures are healed in a single night. The favorite formula of the writer named is a solution of three drachms of finely powdered resorcin with an equal quantity of glycerine in six ounces of alcohol, diluted with four times the quantity of water or chamomile tea. Cavelli advocates the use of picric acid, one and a half part being dissolved in two hundred and fifty parts of distilled water, and applied to the affected surface five or ten times daily. Salicylic acid and borate of sodium are likewise useful local applications in this form of eczema. Ointments containing sulphur sometimes prove too irritating, in which event Brocq recommends the following combination: R Sodii boratis................ 50 cgm.—1*50 grm. Acid, salicylici.............. 25 cgm. Zinci oxidi pulv............. 2 grm. Vaselin.................... 8 grm. M. Brocq has derived good results from the following preparation: R Yellow precipitate........... 50 cgm.—1 grm. Olei cadini................. 1-3 grm. Vaselin.................... 20 grm. M. This combination is thought to be particularly beneficial when seb- orrhceic eczema is located in articular folds. Lotions and ointments containing beta-naphthol are also efficacious. The glycerole of the EXUDATIONS. 417 subacetate of lead, prepared as follows, is especially valuable in some cases: R Plumbi acetatis................ gr. cxx. Plumbi oxidi.................. gr. lxxxiv. Glycerini...................... f § j. Digest the acetate of lead and litharge in the glycerine (heated to 300° in an oil-bath) for half an hour, constantly stirring. Then filter in a chamber heated to 300°. Sig.: Dilute the above from three to seven times with water and glycerine for application to the condition just named. . The various oils, especially chaulmoogra-oil, are useful. The oil of cajeput, weakened Avith olive-oil, has sometimes given good results. Oil of cloves, rubbed up with lanolin, has at times been beneficially employed. The application of vulcanized rubber Avas recommended by Colson, and largely used by Hebra and Hardy. Beyond protecting the parts, excluding the air, and macerating the epidermis, its curative action is rather uncertain. It often aggravates the eczematous erup- tion by preventing the escape.of the secretions and acting as an addi- tional irritant. The same may be said of the medicated gelatine bandage introduced by Prof. Pick. While many useful and valuable remedies may be suspended in gelatine, as has been pointed out by George Henry Fox, Morrison, Morrow, and others, and kept in contact with the skin in a stable and fixed manner, with often effective results, yet, as a rule, they are open to the objection just mentioned, and are only applicable to limited areas, and other methods of treatment have been found in most cases to be more efficacious. Dr. Lanara has ob- tained good results from an application composed of an ounce of the alcoholic tincture of male fern, half an ounce of rectified alcohol, one drachm of tincture of myrrh, and one drachm of crude pulverized opium. Dr. John Morton ascribes an excellent effect to an ointment made of the juice of the leaves of the mudar plant rubbed up with lanolin. In old patches of eczema cantharidal collodion, tincture of iodine, liquor potassae, and other caustic preparations, in varying strengths, are sometimes used as blistering agents. In eczema mar- ginatum Dr. Tarabrin relies upon tincture of iodine painted on the affected surface once daily or, as a substitute, two daily applications of tincture of iodine and spirit of turpentine, mixed in equal parts. This mixture may be added to an equal quantity of the camphorated oil of the Russian Pharmacopoeia (one part of camphor to nine parts of olive-oil). The method of treatment just referred to is said to have marked effect in relieving the itching. Solutions of nitrate of silver varying in strength from ten to thirty per cent, in old patches of eczema have also been successfully employed. A better agent to resort to, when the disease is circumscribed and obstinate, is cauterization, either with the galvano-cautery or the actual cautery. Massage, com- 27 418 DISEASES OF THE SKIN. pression, and bloodletting are likewise powerful and useful adjuvants in the treatment of the chronic stage of eczema. Massage acts in a most happy manner, whether the disease be ex- tensive or localized. In the subacute form, in which the surface is dry, slightly thickened, or covered with papules, massage awakens the action of the dormant absorbents, increases the circulation, less- ens or arrests the itching, and very often restores the skin to its nat- ural condition. In chronic cases, in which there is marked infil- tration, the skin being hard, fissured, dry, rough, thickened, even to a leathery state, and in which all medication has failed, the judicious use of massage will not only break up all exudation, but likewise stimulate the absorbents and assist in removing the inflam- matory products from the tissues, and also lessen the irritation and re- lieve the itching. Compression, which is usually applied in the form of bandages or medicated plasters, protects the parts, limits the spread of the disease, lessens the muscular tension, tones up the dilated capillaries, preATents the escape of serum, and assists in removing the products of inflam- mation. The ordinary muslin or gum bandage, or the medicated plas- ters * recommended by Unna and others, are the measures usually em- ployed to make compression. Bloodletting is an efficient means of assisting to eradicate chronic eczema. It is usually accomplished by puncturing the eczematous surface with a small, pointed knife; the engorged blood-vessels are thus relieved, the circulation becomes equalized, the action of the absorbents is re-established, and the exuded products are remoA'ed from the tissues, which, with the assistance of suitable local applica- tions, soon regain their normal condition. General and Local Varieties of Eczema.—Having thus far described the standard varieties of eczema and their immediate sec- ondary changes, I next purpose to consider the peculiarities of the disease as it is observed in infancy, as well as in different parts of the body at other periods of life. Eczema may show itself upon all or any portion of the body, either covering the entire surface or being limited to certain parts. When it involves the whole surface of the skin, which is by no means a common occurrence, it is known as general eczema (eczema universale), in which the erythematous, the vesicular, the papular or vesico-papular lesions, or all combined, are present. The eruption is more or less diffused, and attended Avith intense itching and burning. It may run a brief course, and disappear entirely, or, as frequently happens, in subsiding either leave a general irritable condition of the skin or one or more patches which may lin- ger for some time. At times a general chronic eczema may follow the * See paper by author—''• Medicated Plasters in the Treatment of Diseases of the Skin "—Transactions of Medical Society of the State of Pennsylvania, 188*7. EXUDATIONS. 419 universal acute variety, in which the whole surface from head to foot, is red, raw, thickened, and fissured, covered partially with crusts and scales, and intolerably itchy. Ordinarily, however, eczema manifests a preference for certain regions of the body, and appears in the form of one or more patches of all sizes and shapes, varying, of course, ac- cording to the exciting cause and the part attacked. As it exhibits peculiarities and modifications in its course, due to age and the part invaded, it will be necessary, first, to speak of eczema as it appears in the very young—the infant; and, secondly, of its manifestations as seen upon certain localities of the body. Eczema Infantile.—Infantile eczema is the most frequent of the cutaneous diseases of childhood—that is, from the birth of the babe until about the fifth year of age. The eruption presents at this early period of life certain characteristics not usually observed in the adult, owing to the soft and delicate structure of the skin in children. The integument at this time of life is exceedingly tender and sensitive, and therefore becomes more readily congested and inflamed from the least internal disturbance, as from improper or insufficient food, nenrous excitement, etc. A scanty supply or altered quality of mother's milk, is a powerful factor in the production of infantile eczema.* The milk is rendered unwholesome by menstruation, pregnancy, passion, anxiety, or disease. In the absence of any unhealthy character in the lacteal fluid, faulty assimilation renders the babe prone to attacks of eczema, while many rebellious cases are due to deficient excretion from the slightest outward irritation, as from the influences of heat and cold, or the too frequent use of soap and water. Among other causes of local irritation may be enumerated woollen clothing, light clothing, dyed clothing, and wet diapers. Infantile eczema may appear in the form of any of the varieties al- ready described, usually beginning Avith erythema and running through all the primary forms of the disease, and attended Avith marked second- ary changes. It ordinarily commences at a very early age as an acute variety, subsides into the chronic, and often remains stationary for years. The eruption may be mild or severe, and may involve all or a portion of the body. It generally appears about the head and face, the cheeks in particular being first affected with a variously sized red- dened patch, Avith some papulation, and more or less heat, itching, and swelling. The local irritation causes the little sufferer to scratch incessantly. This gives rise to an increase of the disease, and the pouring out of serum, Avhich dries into crusts and scales, which may in turn be torn off in the vain effort to obtain relief. The con- tinued irritation may thus deA'elop a reddened, raw, and excoriated surface, covered more or less Avith crusts and scales. In some, espe- * See paper by author on " The Cause and Treatment of Infantile Eczema," the Med- ical Bulletin, January, 1888. 420 DISEASES OF THE SKIN. cially the scrofulous, the eruption will partake of the pustular variety, and cover at times the entire head and face; the surface being also the seat of high inflammatory action, pus is rapidly poured out, which desiccates into thick yellow and yellowish-brown crusts and scales, beneath which the parts arc raw and exuding. This condition is com- monly called crusta lactea, or milk crust. The irritation is intense, causing the child to suffer agony; the high inflammation, the raw and torn surface, thickened and often enormously swollen and studded with crusts, having a most pitiable aspect. The desire to scratch will con- tinue unabated, even though the hands be muffled, and the child closely watched by day and night. Sufficient sleep is often out of the ques- tion, the little one only dozing for a time, after having become thor- oughly exhausted, soon to awaken with renewed efforts to allay the intolerable itching. Children thus affected lose flesh, become pale, thin, take their food badly, and often pass into a marasmic state. Death may even occur, as in the case of generalized eczema described by Le Gendre, the patient being a child, six months old, in whom the disease had existed for two months, associated Avith an uncontrollable diarrhoea. At times the cervical glands, from sympathetic irritation, will be- come enlarged and cutaneous abscesses supervene, particularly upon the scalp, from inflammatory action involving the sebaceous glands and deeper parts. These secondary lesions may appear at once or in suc- cessive crops. They exhibit a low grade of inflammation, and are at- tended with very little pain. They are of all sizes and shapes, in color a deep red or purple, soft and fluctuating in some, and discharging in others a thin or purulent secretion, often mixed Avith blood. The ears are sometimes affected, and become red, swollen, moist, or dry, and frequently covered with scales. Fissures occur at the junction of the pinna with the scalp and at the lower margin of the lobule. The ears may be affected primarily, or by extension of the disease from the head or face. The forehead may be the seat of eczematous patches, usually passing down from the scalp. When the eyelids are involved, the Mei- bomian glands become red, thickened, and increased in activity, the cilia stick together, causing the eyelids to be glued together in the morning. The nose is usually exempt, but the mucous membrane with- in the nostrils may be plugged with crusts. Eczema is frequently ob- served in infants in the flexures of the joints, and upon those regions where the integument is arranged in folds, or Avhere one portion comes in apposition Avith another, as on the neck, axilla, abdomen, groins, and nates. These surfaces, which are red, raw, and moist from close con- tact and friction of the two parts, constitute the condition described by some writers as Eczema Intertrigo. This form of infantile eczema ap- pears and disappears usually very rapidly, often relapsing, however, to disappear again upon proper treatment. It will not cause, as a rule EXUDATIONS. 421 much itching, but when occurring about the groins and nates the pain is often very great from the chafing of the clothes and the irritant action of the discharges. Finally, eczema may attack both the superior and inferior extremi- ties. The eruption, especially when it attacks the bends of the elbows and knees, is often attended with considerable infiltration and cracking, causing much pain and interference in the ordinary movements. After the severe character of the eruption has passed away the surface be- comes generally red and thickened, showing also more or less papula- tion, with the formation of scales. Besnier distinguishes three forms of facial eczema among children. One occurs in lymphatic or scrofulo-tuberculous subjects, and is not attended by much itching, but gives rise to free secretion and is often associated with phlyctenular keratitis. A second form coincides with dentition, and is marked by intense itching as Avell as by symptoms of buccal irritation. A third variety has but little pruritus, and takes its rise around the sebaceous and sudoriparous glands, begins in the scalp, causes abundant desquamation and thinning of the hair. The diagnosis of infantile eczema can generally be made without any difficulty. The only diseases Avith Avhich it is liable to be con- founded are syphilis, pediculosis, vegetable parasitic affections, scabies, and urticaria. Infantile syphilis resembles eczema more perhaps than any other of these affections. The history, however, of the case, the senile facies, and the presence of snuffles frequently establishes the diagnosis before an examination of the eruption is made. Syphilis in the infant has a predilection for certain parts, as the face, especially around the mouth and nose, the anus, buttocks, and genital regions. The eruption is of a darker color, like raw ham, and the papules, if present, are larger and more flat than in eczema. The syphilitic eruption has also a circular, puffy, and dry appearance, attended with the formation of a feAV dirty, adherent scales, but is red and raAv about the anal and genital regions from the irritation of the secretion of these parts and the contact of one surface with another. The characteristic moisture of eczema is not present except around the mucous outlets; neither is there the infiltration and itching so constant in the former affection. Pediculosis may give rise to an eruption that resembles eczema, but the presence of the insects or nits, the scattered lesions, and the peculiar haemorrhagic spots on the body, would be conclusive against the disease being eczema. Vegetable parasitic diseases rarely affect infants in arms; tAvo cases of ringworm, in Avhich the little patients were less than nine months old, have, hoAvever, come under my ob- serAration—the one on the cheek, the other on the head. Both cases were traced to contagion. The first contracted the disease from 422 DISEASES OF THE SKIN. the mother; the second from an older sister having ringworm, who nursed the infant. The parasite in both set up marked irritation on the surface very similar to eczema. The history of contagion, the cir- cular arrangement of the patches, the elevated borders, and finding of the fungus by a microscopical examination, set all doubt at rest. Scabies in infants may simulate eczema, but the development of the eruption between the fingers, the flexures of the wrist, ankles, and feet, its absence from the face and scalp, the history of contagion, and the discovery of the furrows terminating in one end in a vesicle or pust- ule, in which the acarus is imbedded, are features which distinguish it from the latter disease. Papular urticaria may resemble eczema. The acute and sudden development of wheals upon some part of the sur- face, which disappear to reappear again; the occurrence of scratched papules, with an erythematous surface and fading wheals, with the absence of moisture and infiltration, should prevent any error. The etiology of infantile eczema has been incidentally mentioned in the consideration of the first part of this subject. It is important in this connection again to make some reference to its causes, as upon their detection and removal depends in great part the eradication of the disease. Some infants are born with a predisposition to eczema or other cutaneous affections—that is, they have either poor blood, a weak, nervous system, or some of the organs, mainly the skin, are in a debili- tated condition. Such a predisposition being present in the system, the slightest exciting cause produces the disease. According to my experience, the most prolific source of infantile eczema is improper or insufficient food. In many cases it will be found that the infant has been given various articles of table-food that are unsuited to its delicate stomach. Irregularity in the time of feeding, whether frequently or at times at too long intervals, often produces functional derangement of the digestive organs, followed by an attack of eczema. The time of feeding, and the quantity allowed may be correct, but the quality of the mother's milk may be at fault. This latter may be due to debility or mental anxiety, or to indiscretion in diet on her part. Among the many other causes that excite eczema in infants are too frequent washing with strong soaps, which irritate the sensitive skin; neglect of cleanliness, scraping the scalp with combs and brushes to remove the sebaceous collections, exposure to heat and cold, and vaccination. The use of rough and harsh clothing, as flannels, dyed goods, and the negligent arrangement of bands, pins, and buttons, are also sources of the disease. In one case I examined, a pin run through both skin and roller by a careless nurse had been the starting-point of the eruption; in another, a large, hard, rough button ; and in many, flannel and dyed goods brought in contact with the skin were the cause. EXUDATIONS. 423 Constitutional Treatment.—The successful treatment of infantile eczema depends upon, first, good hygiene; the room should be suitably heated, ventilated, and kept free from slops and soiled linen. The child should be properly but not tightly clothed, and taken out in the fresh air and sunshine daily for several hours. Great care must ahvays be exercised to avoid changes of temperature both in the nursery and while out of doors. Rest and plenty of sleep are essential, and if they can not be procured naturally, owing to the irritation of the disease, appropriate remedies should be administered. The diet should receive the strictest attention from those in attendance; the time of feeding should be regulated, say every two hours, and the infant should not be allowed too much at once. The quality of the food should be carefully ascertained, and, if poor, should be corrected. The mother's milk can frequently be improved by giving her certain nutritious articles, as milk, cream, broth, and cod-liver oil, and cautioning her against the use of those that conduce to a faulty state of her milk. Notwith- standing all efforts, the quality of her breast-milk may continue poor, and then it will be necessary partially or completely to Avean the infant and substitute either a wet-nurse or artificial feeding; the latter often having to be resorted to from birth. The most efficient substitute for breast-milk is pure, fresh, undiluted cow's milk, sweetened with sugar, given in from two to eight tablespoonfuls at a meal. A little barley-water or lime-water may be added if necessary to prevent coagulation. Con- densed milk, properly prepared with water, barley, or arrow-root water, is also valuable. Goat's or ass's milk, diluted with about one third of barley-water and boiled, can be advantageously employed, if diarrhoea exist. Imperfect digestion may be overcome by pancreatizing the milk, or adding to it a teaspoonful of some aromatic water, as mint or cinnamon water. A change from one form* of food to another is often attended Avith good results. About the sixth month it may be well to add to the milk either a teaspoonful of wheaten flour or oatmeal, the lat- ter especially if there be constipation. All other forms of food should usually be interdicted until at or near one year of age, when animal broths, milk and bread, the yolk of an egg, slightly boiled, either alone or mixed with milk, can be given. Meat and other solid food should not be allowed until the child is at least fifteen or twenty months old, and even then it sometimes produces indigestion, develops an eruption, and must be stopped for a time. In older infants, when the gastro- intestinal irritation is great and the integument much inflamed, imme- diate improvement may be obtained by Avithdrawing their usual food, and placing them again upon a milk diet. It is well in the majority ■of cases of infantile eczema, in the beginning of the treatment, espe- cially if the alimentary canal is in any Avay at fault, to evacuate it thoroughly by the administration of calomel or mercury with chalk, rhubarb, or castor-oil, the doses to be graded according to age. I 424 DISEASES OF THE SKIN. generally use calomel, occasionally adding a few grains of sodium bi- carbonate, to be followed Avith a small dose of magnesium carbonate. Podophyllin and leptandrin are likewise useful. This preparatory treatment, which washes out the disordered se- cretions and often makes a marked impression on the irritable skin, should be repeated every second or third day, according to indications. Persistent indigestion may be removed by giving from one to two grains of pepsin, alone or with a half a drop of the tincture of nux vomica, three times daily. If diarrhoea remains after the indigested food and acrid secretions are removed, warm applications may be made to the abdomen, and from three to five grains of bismuth sub- nitrate and from one half to three grains of Dover's powder may be given every three hours. Bismuth and chalk, rhubarb and chalk, chalk mixture, with or without a few drops of laudanum, and the fluid extracts of geranium, rhatany, hasmatoxylon, and kino are also useful. In the majority of cases, however, the bowels are constipated, and require the laxative remedies previously mentioned. Manna, sen- na, or sulphur, may also be used. Frictions over the abdomen, with cod-liver oil, castor-oil, and tincture of aloes dissolved in olive-oil are excellent means of overcoming constipation. When there are no contra-indications, and the infant is fed from the breast, the use of laxatives or cathartics by the mother will prove of service. Healthy, robust, plethoric infants respond promptly to mercurial cathartics, fol- lowed by one half to one drachm of the diastasic extract of malt, after meals. Among the systemic remedies which are of value in the treatment of infantile eczema, cod-liver oil and the sirup of the lactate of iron are the most effective. The compound sirup of the phosphates, sirup of the lacto-phosphate of lime, sirup of the hypophosphites of soda, lime, and iron, and the sirup of the iodide of iron, gi\en in from three to forty drops in water, three or four times daily, are also valuable. Iron in some form is indispensable in many cases. The administration of alkalies to the mother, either in the form of one of the alkaline waters or of sodium or potassium acetate, ten to twenty grains, three times daily, often has a most beneficial effect. In infants artificially fed, and when the skin is hot, dry, and irritable, sodium acetate is the best remedy. If there is much constitutional excite- ment, rapid pulse, and marked irritability of the surface, sweet spirit of nitre or neutral mixture, with one thirtieth to one twelfth of a drop of tincture of aconite in each dose, is often followed by rapid amelioration of the symptoms. The pale, weak, and strumous are benefited by cod-liver oil, iron, the phosphates, hypophosphites, potas- sium chlorate, and at times very small doses of lime-Avater. It should be remembered that in case the child will not bear cod-liver oil by the stomach, the inunction method can be resorted to advantageously. EXUDATIONS. 425 Minute doses of corrosive sublimate in from one hundredth to one seventieth of a grain, three times daily, are sometimes followed by marked lessening of the congestion and itching, together Avith a rapid subsidence of the eruption. The older French writers, and recently Piffard, commend viola tricolor, especially in the pustular variety of the disease. It can be give in the form of the powder, tincture, extract, or infusion; the latter is usually the most preferable. The dose of the infusion varies from ten drops to a drachm, gradually increased until some effects are experienced from its use. Arsenic is said to be well borne by children, even in comparatively large doses, but it often happens that the reverse occurs, and eczema becomes aggravated by its use. The fact is that each case requires to be carefully considered, and the constitutional treatment carried out accordingly. Some will improve upon proper diet or alkalines, with or without laxatives, and others upon tonics and alteratives. Arsenic is rarely necessary, and may, as a rule, be discarded from the thera- peutics of infantile eczema. Quinine is not infrequently of service, especially in malarious districts and when the disease occurs during the spring or autumn months. The alkaloid may be very well given in the sirup of yerba santa, the dose varying from one half to a grain once or twice a day. Local Treatment.—Infantile eczema can not be treated locally in the same vigorous manner as in the adult, for, while the general indi- cations may be similar, yet the delicate structure and extreme sensi- tiveness of the infantile integument render harsh measures unad- visable. Soothing applications are therefore demanded in the ma- jority of cases, more especially in the acute forms, moderate stimula- tion being permissible only in the chronic variety of the disease. The affected part should not be washed too frequently, and soap should usually be avoided. Crusts, scales, and other extraneous material can be removed by an alkaline or emollient bath, alone or combined, or by some soothing oil or a poultice. A good alkaline bath, which is sooth- ing and valuable, can be made by adding one half or a tablespoonful of either powdered borax or carbonate of sodium or potassium to one gallon of water. From two to four tablespoonfuls of starch or gela- tine, to the same quantity of water, will form an emollient applica- tion which may be used in alternation with the former. The medi- cated water thus prepared should be dashed or mopped over the sur- face, and the parts lightly sponged dry, and not rubbed. If it appears necessary to use soap, either to cleanse the parts or for the purpose of mild stimulation, either chamomile, sulphur, borax, naphthol, or camphor soap can be employed. Applications of cold water, ice-water, or lead-water and laudanum are also found grateful and beneficial. Saalfeld advises * the applica- * Deutsche Medicinische Wochenschrift, July 3, 1890. 426 DISEASES OF THE SKIN. tion of equal parts of lead-Avater and a five-per-cent. solution of boric acid or a five-per-cent. boric-acid ointment. The skin, when moist, should be dried with powder before the ointment is applied. The inflamed areas can be soothed and protected by either oint- ments, oils, dusting-powders, or lotions. The ordinary ointments, the benzoated zinc and others alone, often irritate the surface, and should not, as a rule, be employed. Cold cream, simple ointment, lanolin, and purified and prepared suet are preferable bases for ointments for the tender integument of the infant. Powdered arrow-root, lead or zinc carbonate, oxide of zinc, bismuth subnitrate, one or two drachms of either to one ounce of one of the above bases, form most efficacious ap- plications in acute infantile eczema. They should be spread on an old piece of muslin and applied to the surface. The folloAving combination is especially useful: R Pulveris marantae.................. 3 j- Zinci carbonatis................... 3 j- Plumbi carbonatis................. 3 j- Ungt. aquae rosae.................. § j. M. It frequently becomes necessary to use a mild stimulant or altera- tive agent in order to relieve the irritation of the skin. The most serviceable and useful are the mercurials, sulphur, naphthol, camphor, and oil of chamomile. These agents can be added to one of the sooth- ing ointments already named. The oleate of bismuth and the oleate of zinc are also excellent applications, and can be used, the latter in the form of powder and the former as an ointment. The following prepa- ration can likewise be recommended : R Pulv. opii......................... gr. iij. Acid, tannici...................... 3 ss. Plumb, carbonatis.................. 3 j- Olei anthemidis.................... in, v. Adipis............................ 1 j. M. Another very good procedure is to brush a tAventy-five-per-cent. solution of the fluid extract of geranium over the surface after the scales have been removed. Cucumber ointment or weak salicylic-acid ointment are sometimes found beneficial. Cases due to external irri- tation are, after removal of the source, readily cured by application of a simple dusting-powder. If eczema of the scalp be due to lice, the hair should be cut short and an ointment containing ten grains of calomel or naphthol or forty grains of sublimed sulphur to the ounce of ex- cipient, with or without a few drops of carbolic acid, applied to the seat of disease. In rebellious cases Boeck makes use of compresses moistened with a weak solution (1 : 500) of nitrate of silver. These are covered Avith gutta-percha paper and left in position two or three hours morning and evening. In the intervals a sedative ointment is applied. Where the itching is severe, five to ten grains of calomel, ten to sixty EXUDATIONS. 427 grains of sulphur, three to thirty grains of naphthol or camphor, five to thirty drops of oil of chamomile, or one to three grains of carbolic acid to the ounce of a fatty base, will often afford the most happy relief. The ointments of the ammoniated, the red or yellow oxide, and the acid nitrate of mercury are also valuable. A lotion containing one minim of creasote to the ounce of Avater or one composed of chloral hydrate, two and a half grains to the ounce of peppermint-water, also allays itching. For seborrhceic eczema of the scalp, Besnier advises that the hair be cut, the scalp washed with soap, the face with warm water containing a little milk in order to dissolve the greasy secretions. An ointment of resorcin or sulphur is then applied. More effective stimulation can be obtained when necessary by the addition of a small amount of one of the tarry preparations. Fearing the irritant proper- ties of tar, Saalfeld prefers an ointment containing one part of ammo- niated mercury, five parts of balsam of Peru, and thirty parts of ben- zoated oxide-of-zinc ointment. In severe and obstinate general eczema in children, vaccination with animal lymph has been known to effect decided improvement. When the disease is associated with painful dentition, the gums should be lanced or rubbed with a solution of cocaine, insomnia controlled by a mixture containing bromide of sodium alone or in combination Avith a little chloral, while the oxide-of-zinc ointment with a little sulphur and camphor constitutes an effective local application. Eczema of the Scalp (Eczema Capitis).—Eczema of the head is of very frequent occurrence, and manifests itself usually as the erythematous, the vesicular, or pustular variety, the lesion differing generally according to the age of the patient. In infants and children the pustular form is the most common, while in adults the erythem- atous and vesicular are most often encountered. In the adult, there- fore, the last two forms are generally observed as the initial lesions which tend to become chronic and develop slowly into that well-knoAvn secondary stage termed eczema squamosum. The eruption in its course may present at different times the erythematous, the vesicular, and pustular stages, followed by the formation of crusts and scales; on the contrary, it may begin in any form, and continue throughout its course unchanged. It may also present erythematous or vesicular patches upon one place, pustular in another, and a dry and scaly spot upon still another portion of the scalp. These conditions may be present at one and the same or at different times. The disease may involve a part or the Avhole of the scalp. It may begin in one or more patches, and continue thus Avithout spreading, or it may, as is often the case, extend over the entire region of the scalp, and even down behind the ears, on the neck, and forehead. The itching is usually decided, except in the pustular variety, in which it exists in a modified degree. 428 DISEASES OF THE SKIN. Eczema of the scalp, however, presents certain modifications due to the presence of the hair, its length, its thickness, and the various methods of dressing it, according to habit or the demands of fashion, that call for special consideration. These modifications depend upon the discharges matting together the hair, and forming adherent crusts and scales. Thus, a secreting eczematous state of the scalp occurring in an individual Avith the hair cropped short presents a different ap- pearance from that which is observed in one having long, thick, bushy, and neglected hair. In the former the hairs do not become readily matted together, and, if matting occurs, they can be easily separated and the crusts and scales removed. In the other, the exuding fluid entangles the hairs, which, with the crusts and mingled sebaceous secretion, form a compact mass. This matting together of the hair is increased by persons neglecting either to comb, brush, or disentangle it for fear of still more increasing the inflammation. The unkempt mass upon the scalp excites considerable irritation and causes the parts to be thoroughly scratched. This stimulates the numerous sebaceous glands to pour out their contents, the secretions mingle upon the surface and, by decomposing and setting free fatty acids, produce a rancid, musty, disgusting odor. This repulsive condi- tion attracts lice, and at times vegetable parasites, and has been termed, in Vienna, plica polonica. In one instance, in the outdoor department of the Philadelphia Hospital for Skin Diseases, some five years ago, I observed a young girl, about fourteen years of age, Avho presented a loathsome appearance; upon separating the matted hair, and picking off some greenish-yellow crusts from the parts, the surface beneath was seen to be raw, covered with pus and filled with maggots, from Avhich issued a foul and sickening odor. A swelling of the posterior cervical glands often occurs as an ac- companiment to eczema capitis, with, at times, the formation of ab- scesses and loss of hair. These enlarged subcutaneous glands, Avhich are sympathetically excited, increase or diminish in size as the affec- tion becomes severe or improves. This swelling of the glands, as well as the formation of abscesses, happens more frequently in those who are scrofulous or poorly nourished. This form of eczema may continue for years, if not arrested; or it may, after lasting months, undergo spontaneous involution. In the latter event, in patients having long hair, when the eczematous fluid ceases to be poured out, the young and growing hairs push' for- ward the old mass of matted-together material, and permit it to be easily removed by the scissors. As a rule, the condition just described is succeeded, after the removal of the hair, by a red and scaly sur- face which may continue to exfoliate epidermic scales for some time. In persons having short hair the cessation of the exudation and the falling off of the crusts is followed by the same squamous condition, EXUDATIONS. 429 The loss of hair which sometimes occurs is usually only temporary, the instances in which permanent baldness results being exceedingly rare. The treatment of eczema of the scalp requires the removal of the cause, attention to the general health, if necessary, and the use of cer- tain local measures, according to the variety and stage of the eruption. In case the disease be of the pustular variety, and the surface covered generally or partially with crusts, the long hairs pasted down or matted together by the exudation, the parts should be thoroughly saturated with some one of the oils—olive, sweet, almond, ergot, petroleum, or cod-liver oil—which softens up the mass, removes the crusts, and pre- pares the surface for further medication. If the exudation is great and the crusting extensive it may be necessary to leave the oil on for some hours. The application of one of the oils—I generally prefer ergot, on account of its also having some slight astringent action— should be repeated twice or three times daily for several days until the parts are relieved of the inflammatory products. In the event that it becomes necessary to use water and soap, some days at least should elapse before applying it, and then one of the medicated soaps, having in it either, naphthol, tar, or corrosive sublimate, should be employed. Shaving and cutting the hair are unnecessary in the great majority of cases, and should in particular be avoided by girls and Avomen having a long and luxuriant growth. If pediculi or nits or any vegetable parasitic disease exist as a com- plication, they can be removed by solutions of mercury or copper oleate and other appropriate remedies. After the surface has been cleansed or the complications removed, if the pustules continue to appear or the erythematous or vesicular condition remain, the oil of ergot can be applied in the same way, or lead or zinc carbonate, or bis- muth subnitrate, one or two drachms of either to three or four ounces of the former, can be used. In case a mild stimulant is required, equal parts of the solution of mercury oleate and oil of ergot are valuable. Tannic or gallic acid can be added to one of the oils, glycerine, or petroleum, and applied to these parts. The folloAving has proved of service: R Hydrargyri chloridi corros......... gr. v. Glycerini........................ f 3 v. M. The fluid extract of geranium is also valuable. Oils, solutions, and even ointments should be lightly sponged or mopped over the surface, in order to avoid rough rubbing or irritating still further the parts. Soothing ointments can likeAvise be used, although I prefer oils and lotions, on account of their easy application. Zinc, lead, and bismuth ointments are most useful, and can be made stimulating when desired by the addition of sulphur, oil of chamomile, or a small quantity of naphthol. FoV a more marked stimulation, especially in the squamous variety, the various tarry preparations and 430 DISEASES OF THE SKIN. mercurials are all valuable, beginning with a moderate strength, and gradually increasing until the desired effect is produced. in place of tar Piffard makes use of the following preparation: R Acidi salicylici................ gr. x-xx. 01. lavandulae................. f 3 iij- 01. citronellae................. f 3 j- 01. eucalypti.................. f 1 ij. 01. ricini..................... f 1 ij. M. Again, similar agents are most efficacious in the squamous vari- ety, used in the form of a lotion. Thus the oil of cade, a drachm or two to the ounce of either alcohol, spirit of rosemary, or five to ten grains of corrosive sublimate to the ounce of water, will be found of great utility. Very obstinate cases that resist all the ordinary remedies yield sometimes to the application of tincture of iodine or one of the various blistering agents. Oils are adapted to some, ointments to oth- ers, and instances occur which can not bear the least stimulation, owing to a peculiarly sensitive condition of the skin. Great care should therefore always be observed to avoid stimulating unduly the scalp, thus increasing the eruption in the endeavw to do good. Eczema of the Ears (Eczema Aurium).—Eczema may affect the auricle and the external auditory canal, and the hearing may suffer by the involvement of the latter part. The erythematous, vesicular, papular, and pustular varieties may attack these parts, or spread to them from adjacent surfaces affected with the disease. Eczema of the ears occurs either as an acute or a chronic affection among all ages and in both sexes, but is more frequently observed in children and females. One or both auricles may be involved, usually both, and the disease may implicate the entire ear or be limited to certain portions. In the acute variety the ears are red and swollen, and are attacked Avith mild or severe burning, itching, or stinging sensations. The morbid action may extend into the meatus, closing it, and producing tempo- rary deafness. Very often, by the formation of vesicles or pustules, the whole or part of the auricle becomes covered with crusts, or is the seat of general redness, moisture, and considerable infiltration, Avith more or less desquamation. The eruption may be confined to the pos- terior surface of the ear, the natural depressions being the seat of fis- sures, disappearing at times to reappear and spread over all or part of its surface. In other cases the external auditory canal is alone involved, being dry and scaly, and the seat of intolerable itching, vesicles appear- ing sometimes on the meatus and the membrana tympani. There may be in these cases a feeling of fulness, giddiness, noises, or temporary deafness. As a few of the direct causes that assist in bringing about these obstinate cases of eczema of the ears, may be mentioned exposure to changes of temperature, spectacle-frames, ear-rings, dyed fabrics, especially ribbons, uncleanliness, picking the auricle, the meatus, or EXUDATIONS. 431 the canal for the removal of wax, and acute or chronic catarrhal otitis. It is often difficult to apply remedies on account of the anatom- ical arrangement of the ears. All scales and crusts should be re- moved, and soothing ointments of zinc, lead, or bismuth should be carefully spread over the affected surface. Sulphur or naphthol with extract of opium and belladonna can be added Avhen necessary. After the acute stage has passed, ammoniated mercury, ten to thirty grains to the ounce of cold cream, is of advantage; also tar in large or small quantity, according to the indications, for stimulation is likewise of value. In the involvement of the canal the crusts or wax should be first softened with a few drops of oil of sweet almonds, and washed out occasionally with hot water. The following combination, painted in night and morning, will allay and sometimes remove the irritation: R Plumbi carbonatis............... 3 ss. Atropinae sulph.........:....... gr. ij. 01. olivae..............•......... f 1 ss. M. The canal may also be painted Avith tannic acid dissolved in glycerine, one to two drachms of the former to an ounce of the latter, or weak or strong solutions of zinc sulphate, carbolic acid, silver nitrate, or potassa caustica, or a thirty-per-cent. solution of the fluid extract of geranium. Care should always be exercised to prevent injuring the membrana tympani by the use of any one of these prepa- rations, and agents should be at hand to counteract their effect in case of accident. Eczema of the Face and Neck (Eczema Faciei et Colli).—Ec- zema frequently occurs on the face and neck, either by spreading down from the scalp or developing originally upon these parts. The erup- tion, however, Avhen attacking the chin and neck has no special pecul- iarities, and it will not, therefore, be necessary to treat of it sepa- rately, beyond the general description already given in the first part of this chapter. On the contrary, eczema, when attacking the face, presents so many modifications in its general character, according as it affects the smooth or hairy surface and each individual part, as to call for a particular description of each condition and portion invaded. Eczema of the smooth part of the face may be either acute or chronic. It may appear in the form of any of the standard varieties, attended with more or less secondary changes. The erythematous, Aresicular, and pustular are common; the former more particularly during and after adult life, and the latter in children. The entire surface may be red, infiltrated, moist, crusty, and scaly, or patches may be noticed on the forehead, eyelids, cheeks, nose, and lips. The itching is most intense, especially in the chronic form, the sufferer often fill- ing the buccal cavity with air and pounding with the hands on the 432 DISEASES OF THE SKIN. surface of the cheeks and adjoining portions in a A'ain effort to get relief. Relapses frequently occur on the least exposure or the slightest cause, owing, no doubt, to the delicate nature and the highly organized condition of the skin of the face. Naphthol and carbolic acid are beneficial in these cases, from five to twenty grains of the former or from three to ten grains of the latter to an ounce of cold cream, or the same quantity of lanolin. A drachm of lead or zinc carbonate or arrow-root also added may be of service. The ointments of zinc oxide and bismuth subnitrate are likewise valuable. The efficacy of any of the above preparations is often increased by dusting equal parts of zinc oleate and arrow-root powders, or bismuth subnitrate, over the surface, first having, of course, applied a thin film of oint- ment. Corrosive sublimate, naphthol, or carbolic acid, suspended in water, in the proportion of five to ten grains of either of the former or five to ten drops of the latter to four ounces of rose-water, sponged over the surface, gives occasionally great relief. Hyde recommends strips of cold raw meat, laid over the surface, for immediate beneficial effect. In senile eczema of the head and face Bulkley is fond of the follow- ing preparation: R Acidi carbolici................... gr. v-x. Acidi tannici..................... 3 j- Ung. aq. rosae.................... § j. M. Eczema of the Beard (Eczema Barbce).—Eczema in attacking the hairy portion of the face assumes a similar condition to that ob- served on the scalp in the same disease. The alteration will not, hoAv- ever, be so great from neglect of the face, as it usually receives more care and attention than the scalp. The eruption generally appears in pustular form, as a rule at the orifice of the hair-follicles, each one being pierced by a hair, and involves all or a portion of the beard, ex- tending in some cases to the eyebrows, eyelids, and outlets of the nos- trils. The pustules dry up into yellowish, greenish, or brownish crusts, which mat together the hairs, cling to the skin, and, upon their re- moval, expose a red, infiltrated, scaly, or moist surface. Patients may complain of itching, but more commonly a burning sensation or pain is experienced, especially during the formation of the pustules. The eruption may disappear spontaneously after the acute stage, but more frequently it is continued into the chronic form. In passing into the latter the inflammatory process extends deeper, and affects the hair- follicles as in sycosis. Abscesses may now form, the skin become more thickened and infiltrated, and the pressure and inflammatory action ob- literate the follicles, leading to permanent loss of hair, and often to the formation of scars. The sparse and poorly developed hairs, with all the now marked and apparent secondary changes, occasion very great EXUDATIONS. 433 disfigurement. Eczema may be limited to the beard, or it may spread to the adjoining smooth parts. It will thus be seen to differ from sycosis. In sycosis the inflammatory process is situated deeply in the corium and subcutaneous connective tissue, Avhile in eczema it is more superficial. Again, papules and tubercules may be present in sycosis, but are absent in eczema of the beard. The diagnosis between eczema and ringworm has already been considered. The treatment, owing to the tedious nature of the affection, is often slow and unsatisfactory, but the ultimate result is usually good. Some are benefited by shaving the beard as often as every other day, or when required; others derive no benefit from this procedure, and noAV and then cases are aggravated by it. I usually cut the hair short, remove, by one of the oils already named or a poultice, crusts and all exudation, and apply one of the soothing ointments. The disease may then be treated upon the general principles laid down for the management of acute eczema. Shaving may be tried in the event that the disease shows no signs of yielding. In obstinate cases, after removing the crusts, I puncture with the small needle-knife all the pustules and the infiltrated skin every day or two, allow the parts to bleed freely by dashing very warm water on them, mop the surface dry, and apply the benzoated zinc ointment Avith or without sulphur, or a small quantity of one of the mercurials, or diachylon-ointment over the surface. This method of treatment I usually find all-sufficient, both in the acute and chronic varieties. Anderson, in some stubborn cases, has epilated with advantage. Eczema of the Edges of the Eyelids (Eczema Tarsi; Oph- thalmia Tarsi).—This is a common disorder in scrofulous subjects, more particularly in children, and may or may not be accompanied with conjunctivitis, or strumous ophthalmia. It involves the hair- follicles and glandular apparatus of the eyelids, and appears in the form of small pustules, similar to those observed in eczema of the other hairy parts of the face. The edges of the eyelids are red, swollen, excoriated, infiltrated, covered Avith purulent exudation, exhibiting gray or yellowish crusts, the hairs and often the edges being glued to- gether. Itching is occasionally present. A continuation from neglect of this morbid condition may cause lachrymation, which irritates the skin and gives rise to an eczematous eruption; or, the discharges being retained, ulcers may be developed, the glands and follicles obliterated, and, finally, a partial or complete loss of the eyelashes may supervene. The retraction of tissue may be so great as to occasion entropion or ectropion. The treatment demanded is usually both general and local. Cod-liver oil, quinine, iron, and calcium should be given in alternation. The eves should be bathed frequently with hot water, to which a small quantity of bicarbonate of sodium or borax may be added. In case the lids are difficult to separate, notwithstanding the bathing, a small piece 28 434 DISEASES OF THE SKIN. of fresh butter or a few drops of olive-oil can be smeared along the edges, facilitating their opening and preventing their adhesion. Per- manent benefit can be obtained by removing the discharge, everting the lids, and painting the diseased edges with a weak solution of silver nitrate or potassa caustica. In addition, the patient or attendant may employ on the lids, once or twTice daily, a weak ointment of the yellow oxide of mercury, and, in the more chronic cases the ointment of the red oxide of mercury, from one half to a grain to the ounce. An ointment consisting of about ten grains of resorcin to the ounce of cold cream is sometimes service- able in this condition. Weak ointments of the white precipitate or of the nitrate of mercury have also been employed for the same purpose. In more severe cases, it may become necessary to extract the eye- lashes. Eczema of the eyelids will often be found to depend upon some disease of the eye, and the attention of a skilled oculist is not only required but demanded to correct or remove the cause. Eczema of the Nose (Eczema Nasi).—Eczema may attack the nose either alone or in connection with other parts of the face. The entire or part of the organ may be red, thickened, covered with exu- dation, and greatly increased in size. The disease usually affects the surface around the alae and the entrance of the nostrils, which become red, swollen, the seat of pustules pierced with hairs, the mucous mem- brane likeAvise participating in the morbid process. The pustules some- times run together, a thick, purulent secretion exuding, which forms into crusts, stopping up the entrance to the nostril. This condition impairs the nasal respiration and the mucous membrane beneath be- comes congested, thickened, sometimes ulcerated. This, in rare cases, owing to the crust being picked off constantly, has led to perforation of the cartilaginous septum. Eczema of the nose is apt to excite rosacea. Syphilis and lupus of the nose might be confounded with eczema of these parts, but the diagnosis is rendered comparatively easy in the former by the history and the presence of other concomitant symptoms of syphilis in the body, Avhile in the latter the characteristic chronic nature of the affec- tion, the absence of itching, and the peculiar local lesions of lupus, are sufficient evidence upon which to base an opinion. The success of the treatment largely depends upon the assistance of the patient. The surface must not be picked or torn in the effort to remove the crusts, but should be first softened Avith oil or a mild ointment, and then they can be taken away with ease and without injury to the parts. Zinc oleate, weak citrine or white-precipitate ointment, with a few drops of oil of chamomile or oil of cade, in case the parts require more stimula- tion, form important and useful applications. In the involvement of the mucous membrane, pencilling the surface with solutions of zinc sulphate or silver nitrate is effective. Zinc-oleate powder, as employed EXUDATIONS. 435 by McCall Anderson as a snuff, or nasal suppositories, composed of zinc oxide, tAvo grains, Avith cacao-butter, will be found valuable. The ex- tracts of opium and belladonna or hyoscyamus, with a small quantity of lead acetate, can also be used with decided results. Eczema of the Lips (Eczema Labiorum).—This occurs either on the lips alone or with the disease upon some other part of the face. The eruption may appear on one or both lips, and may implicate the vermilion border and mucous membrane alone, or it may invade to- gether or separately the integument covering the orbicularis oris mus- cle. In case it should be confined to the latter, it will partake of the nature of the eczema previously described, either on the smooth or hairy part of the face. Limited to the former, the disease generally assumes the inflammatory or squamous form. The lips usually become red, hot, swollen, the exudation of serum not only filling up the loose cellular tissue, producing much deformity, but often oozing out on the surface, frequently gluing the lips together, especially during the night while asleep. The mucous membrane may, on the other hand, be simply red, and the seat of constant desquamation. The eruption is often complicated with secondary changes, the formation of fissures at the angles of the mouth and the centre of the lips, those in the lower one being the most common. The movement of the lips, under such circumstances, causes a very uncomfortable feeling, often absolute pain; the parts become more irritable in proportion to their activity, the fissures extend deeper, blood as well as serum being frequently poured out. The unpleasant sensation thus experienced, Avhether from the severe inflammation, fissured state, or loss of epithelium, causes the patient often to move the lips backward and forward, or to apply the tongue to the parts to convey mucus or saliva to the surface in order to obtain some relief. These increased movements of the parts, and the natural effort to alleviate the suffering, only aggravate the eczema. Again, scraping the mucous membrane of the lips with the teeth (which is one of the prominent exciting causes of the disorder) to get rid of the desquamation, or picking the latter from the surface, further increases the disease, and prolongs the suffering. In strumous children eczema of the upper lip is not infrequently produced in consequence of chronic coryza. Eczema of the lips exhibits a tendency to recurrence. Kaposi describes a form Avhich is met with most frequently in elderly women, attacking particularly the A'ermilion border. Herpes labialis and syphilis of these parts may be mistaken for eczema. Herpes appears as groups of vesicles, and runs an acute course. Eczema involves all or part of the surface, and is usually tedious or chronic in its course. Syphilis of the lips seldom affects the entire surface, but generally tends to locate itself as elevated patches and fissures at the angles of the month. The treatment of eczema of the lips is most difficult, owing to the 436 DISEASES OF THE SKIN. fact that they are usually in constant motion. The various astrin- gent lotions are useful. The ointments of zinc, lead, and bismuth oleate, lightly smeared OArer the surface, are often invaluable. Tar- taric acid and salicylic acid in the form of ointments are also recom- mended as effective, especially in the case of children. The compound tincture of benzoin and the fluid extract of gera- nium are also exceedingly efficacious, pencilled frequently over the sur- face and into the fissures. Before a cure can be effected it will often be necessary, especially when fissures exist, to afford rest and support to the parts by the application of adhesive or medicated plasters, as described by me in 1879.* The beneficial influence of plasters, cut in strips and applied to the surface, is most strikingly evinced in eczema of the lips. The mucous surface in this disease is torn open with every movement of the lips, and all the lotions, ointments, and powders will not soothe the muscular irritation and heal the parts until they are protected and placed at rest. In order to accom- plish this purpose, adheshre strips can be made to encircle the head and allowed to meet posteriorly at the nape of the neck. In this manner the movement of the lips is controlled, the raw surface pro- tected, the irritation soothed, and the disease promptly and effectually arrested. In removing the strips, care should always be taken to detach both ends, and draw gradually to the centre, otherwise the mucous surface may again be torn open. Eczema of the Tongue (Eczema Ungues).—Eczema occasionally attacks the tongue. Its development is particularly favored by the ex- istence of gastro-intestinal disorder. The evolution of eczema of the tongue is essentially similar to that upon the skin, and it may assume the most fantastic outlines. Treatment should above all be directed to the condition of the digestive tract. Tobacco, liquors, and spices must be avoided. Locally, boric acid, salol, sulphur, or hyposulphite of sodium should be used in the form of pomade, gargle, or glycer- ide. Cases have been recently reported by Besnier and De Molenes.f The latter, in a very stubborn case, made use of equal parts of lac- tic acid and water. Light scarifications or galvanism may also be advised. Eczema of the Breast axd Nipple (Eczema Mammarum). Eczem,a may attack one or both breasts, and run an acute course or become chronic. Both breasts, however, are usually involved. It occurs either as the erythematous or vesicular variety, with or without secondary changes, covering part or all the breasts, and often extending between or below them. The nipples of females are frequently the seat of the * See paper by the author, " Some Important Topical Remedies and their Use in the Treatment of Skin Diseases." Transactions of the Medical Society of the State of Pennsylvania, vol. xii., 1879 f Medical Bulletin, May, 1890, p. 171, and June, 1890, p. 250. EXUDATIONS. 137 eruption, Avhich takes on the vesicular or inflammatory form, with the development of crusts and fissures. In some the nipple is surrounded Avith a thickened patch, the sur- faces are denuded of epidermis, and are red, swollen, fissured, hot, dry, or moist, and attended Avith intense itching or pain. In severe cases the nipple is retracted and covered with crusts or serum; occasionally blood oozes from the fissured surface, and sometimes abscesses form. Mothers are often compelled, owing to the great suffering, to discon- tinue suckling for a time or to wean entirely their infants. Nursing women are more liable to be affected Avith this form of eczema, but it is also met with in those avIio are not nursing, occasionally being seen in single Avomen, and has sometimes been met with in men. Eczema of the nipple usually appears during pregnancy or lactation, but may follow as a scrofulous manifestation, or be dependent upon scabies. This form of the disease exhibits a marked tendency to recurrence. The disease of the nipple and areola, described by Sir James Paget,* referred to by Thin f and Munro, \ is sometimes mistaken for eczema, but can be distinguished from the latter by its well-defined margin and the presence of deep infiltration in the papillary layer, absence of itch- ing, and the fact that it is nearly always followed by cancer of the breast. Dr. Radcliffe Crocker has met with a very similar condition upon the scrotum and penis. A well-marked patch resembling eczema, but more sharply defined, was excised after having persisted for about eighteen months in spite of a great variety of treatment. The micro- scopic picture was that of carcinoma, and the disease seemed to origi- nate in the sudoriparous and sebaceous glands and hair-follicles. Prof. Pick, of Prague, has recently reported a case# in which Paget's disease Avas located upon the glans penis, and Dr. Ravogli de- scribes a case in Avhich the disease occurred upon the nose. Paget's disease of the nipple occurs in advanced life, generally after the grand climacteric has been passed. In a communication made to the Biological Society of Paris in April, 1889, M. Darier attributed the origin of Paget's disease to coct cidia or psorosperms, one of the five classes into which, according to Bal- biani, the protozoa are divided. This affection of the nipple is therefore regarded as a parasitic affection, a form of cutaneous psorospermosis, generally but not necessarily located upon the nipple. The investiga- tions of Darier have been continued and confirmed by Wickham, Lust- garteu, Macallum, and others. The organisms are usually found in the lower layers of the epidermis and in the lactiferous ducts. In other situations they inhabit the ducts of the sudoriparous and sebaceous glands and the sheaths of the hair-follicles. They are often situated * St. Bartholomew's Reports, 1874. f London Lancet, June, 1881. X Olaspjow Medical Journal, November, 1881. * Deutsche rued. Zeitung, November 5, 1891. 438 DISEASES OF THE SKIN. near the centre of a mass of flattened epithelial cells. As a rule, they somewhat exceed in size the normal cells of the deeper layers. Coc- cidia occur in the form of roundish or elongated cells of granular proto- plasm and containing one or more nuclei. They develop by surround- ing themselves by cysts, the interior of Avhich become filled with spores. The cysts finally rupture, the spores escape, and again generate the roundish and granular coccidia. The cyst-wall has a double contour from which the protoplasm is retracted in places, being attached to the enveloping membrane by ray-like prolongations. Several nucleated bodies may exist within one cyst-wall. These appearances are charac- teristic. They are, moreover, of practical value, as it has been found feasible to detach scales from the affected surface, and, by a process of mounting and staining, identify the psorosperms. From this doctrine of pathogenesis is deduced a rational treatment for Paget's disease by parasiticidal remedies. The affection is curable in the early stages without a recourse to excision. By other observers the supposed coc- cidia are regarded as nothing more than degenerated, modified, or cor- nified epithelial cells. Nevertheless, Darier points out that the bodies which he believes to be coccidia can not be transformed epithelial cells, since in the Malpighian layer, where they are best observed, they are destitute of the prickles normally characteristic of the epithelial cells of the stratum mucosum. The treatment of eczema of the breasts is similar in many respects to that of the other local varieties of the disease. It is of the utmost advantage to support and protect the parts by compression, in the form of bandages or medicated plasters. If the nipple is involved, it should be protected from irritation by a shield or breastplate. In more severe cases, the withdrawal for a time or the entire removal of the child from the breast may be necessary. Pencilling the parts with silver nitrate, or a saturated solution of zinc chloride or the compound tinc- ture of benzoin every two or three days, is often attended with good results. In the mean time the surface may be anointed several times daily with the following : R Acidi tannici....................... 3 j. Extracti belladonnae................. gr. x. Extracti opii........................ gr. v. Ungt. aquae rosae.................... § ss. M. Zinc oleate, camphor, or naphthol can be added to the ointment, or diachylon ointment can be employed. Beef-marrow, lanolin, or sheep-suet, alone or with some of the astringent agents, as ergot, kino, geranium, or boric or salicylic acid, will be useful. A solution of salol in ether and flexible collodion has been used with advantage. The oil of cade, resorcin, and pyrogallic acid will at times be service- able. After the application the nipple should always be washed with either oil or water and soap before the child is put again to the EXUDATIONS. 439 breast; care, however, should be exercised to avoid cleansing the parts too much and aggravating the disease. Dr. Van Allen has found the white of eggs beneficial, painted upon the nipples after the babe has nursed. M. J. Blechmann recommeuds gold-beater's skin, the nipple first being Avet with water, the skin, pierced in the centre by a number of fine holes Avith a needle, is applied around the nipple, to Avhich it adheres like a second epidermis. The external surface of the pro- tective is moistened before the child takes the breast, and is renewed after each act of nursing. Eczema of the Umbilicus (Eczema Umbilici).—The navel, alone or with other parts of the integument, may be affected with eczema. It may take on the inflammatory or pustular form without much swelling, or may project out like a small tumor, being red, infiltrated, moist, dry, or fissured, and occasionally covered with crusts. The course of the disease is thus seen to be very similar to that of eczema of the nipple. Syphilis may here simulate eczema, but ulceration is usually present in the former, with a very offensive odor, and other manifesta- tions of the specific affection. The treatment consists of mild com- pression, by a bandage or a medicated plaster, with cleanliness and a dusting-powder. Zinc oleate, bismuth subnitrate, or very fine zinc car- bonate, Avill act efficiently. The ointments of zinc, lead, and bismuth, alone or combined with naphthol, thymol, or sulphur, are all service- able. Eczema of the Flexor Surfaces of the Joints (Eczema Ar- ticulorum).—The flexor surfaces of the joints and the adjacent parts are favorite localities for the development of eczematous eruptions. The axillae, the elbow-joints, the groins, and the popliteal spaces are the regions which are thus attacked by preference. The eruption is usually symmetrical; for example, when one axilla is invaded the other is likewise affected. Again, when eczema is found at the bend of the elbow, the popliteal space also usually suffers; and in the same manner, Avhen the wrists are affected the ankles are also usually in- vohed. The skin upon the region attacked becomes red, infiltrated, and scaly, or raw, and covered with serum and crusts, the epidermis being macerated. Owing to this condition the movements of the af- fected joint are often painful, consequently it is more or less flexed or bent at an angle. As the disease progresses the infiltration and crust- ing increase, and fissures of various depths form, from Avhich exude serum or blood. The eruption now often spreads to the neighboring parts, particularly the exterior surfaces, and the limb is held in a fixed position, both flexion and extension being very painful. Eczema in- volving the regions just described will yield, in the acute and subacute forms, to some of the mild applications already described, and in the chronic condition to preparations that are more stimulating, such as the various mercurial ointments, Avith or without tar. Care must be 440 DISEASES OF THE SKIN. taken to protect the parts and to give them support and rest by moder- ate compression, in the form of a bandage. Eczema Intertrigo.—Eczema intertrigo is different from ery- thema intertrigo, Avhich is a simple hyperaemia; in the former the morbid process has passed beyond the latter condition, the surfaces being red, moist, macerated, with marked weeping. Eczema inter- trigo is met with in those parts of the body, particularly in fat people, where two portions of the integument come in contact, as the flexor surfaces of the joints, the neck, between and beneath the breasts, in the folds of the skin of the abdomen, and the inner sur- faces of the nates. It occurs more frequently during the summer months, and is often occasioned or aggravated by uncleanliness, fric- tion of clothing, tight bands, walking, and driving. The treatment recommended for acute eczema will be sufficient to relieve the major- ity of cases. Thin films of prepared or medicated cotton or patent lint, laid between the apposing surfaces, alone or medicated with either a bland ointment or dusting-powder, will rapidly overcome the disease. Thymic or carbolic acid may profitably be added to what- ever lotion is employed if the discharge becomes fetid. Eczema of the Genital Organs (Eczema Genitalium).—Ec- zema of the genital as well as the perineal and anal regions is far more frequent than is generally thought by the profession. Patients under my observation often state that their trouble was supposed to be simply chafing or the result of piles, or that shame of exposure has caused them to conceal the disease and apply various home remedies or one of the many advertised nostrums, until, all means being ex- hausted, they have been driven by necessity to consult a physician. How many, however, who are even more sensitive, go on trying in their own way to obtain relief, and continue for an indefinite time to suffer from perhaps the most distressing of all the local varieties of eczema. Eczema may affect the genital organs alone, or may extend to or from some of the adjacent regions, or may appear simultaneously with the disease in other parts of the body. It occurs in both sexes and at all ages, but is more common during adult life and in declining years; it may be mild or severe, acute or subacute, but exists more commonly in the chronic form. The part affected may be the seat of the papular or vesicular variety, attended with redness, heat, and swell- ing, but more frequently the erythematous form will be present, Avith more or less secondary changes. The rich supply of blood-vessels, lymphatics, and nerves of the parts fully explains the marked changes and harassing and painful symptoms that follow the appearance of the various lesions. In the male, either or both the penis and scrotum may be affected. The erythematous form usually first involves the penis, in part or over the whole organ, extending sometimes up to the pubes. It generally attacks the transverse folds of the integument EXUDATIONS. 441 upon the dorsal part, appearing as elevated red lines, while on the under surface of the organ the skin may be red and moist. The organ may be more or less swollen, the surface occasionally rough and scaly, and the parts the seat of most distressing itching. Balanitis and phi- mosis sometimes result in consequence of a thickened condition of the skin of the prepuce. The same variety, the erythematous, may extend from the penis, groins, anus, or perinaeum to the scrotum, or the disease may appear on the latter and spread to all the adjacent parts. When the scrotum is affected, the skin is red, slightly scaly, and often relaxed, stretching or hanging down to a considerable extent, and, coming in contact with the limbs, develops irritation, frequently causing an ex- tension of the disease. As the affection progresses the relaxation disap- pears, the infiltration or thickening increases to a great degree, and the sides of the scrotum are covered with moisture, the parts sometimes becoming absolutely raw or fissured, Avith occasionally the formation of crusts. The itching, pain, and distressing feeling under such cir- cumstances are intense. The female organs suffer in a like manner. The labia are usually the seat of the disease, but the mons veneris, the lower portion of the abdomen, and the mucous membrane of the vagina may be attacked. In rare instances the disease extends as far as to the neck of the Avomb. Eczema of the vulva does not usually occur until after the menopause. The adjacent portion of the thighs, and the perinasum and anus, may also be involved. The labia, when affected, may be either slightly red and scaly, or severely inflamed, thickened, dry, and hot, or covered with abundant secretion, the apposing surfaces glued together, the discomfort from the itching and pain being at times unendurable. The nervous exhaustion due to the constant itching and Avant of sleep is often so intense as to interfere seriously with the patient's health. The causes that especially excite and aggravate eczema of these parts are the various disturbances of the general system, genital errors and disorders in particular, uncleanliness, and friction of the apposing surfaces, clothing, and the various appliances that are brought in contact with these parts. It may likewise be due to diabetes. Ring-worm, syphilis, herpes, acne, pediculosis, and paraesthesia, occurring upon the genital regions, may be mistaken for eczema. Ring- worm may be recognized by the crescentic border of the patches and the discovery of the parasite; syphilis by the history of infection, the usual absence of pruritus, and the presence of other characteristic feat- ures of the disease. Herpes will be known by the preceding burning, smarting, and neuralgic pains, succeeded by the appearance of A'esicles in groups, mainly around the mucous outlets; while in eczema of these regions vesicles rarely occur, and Avhen they do, they usually appear upon the cutaneous surface. Acne may occasionally develop in these parts, often from the use of one of the bromides or iodides, but the peculiar features of acne, with the scattered lesions, limited to the 442 DISEASES OF THE SKIN. glands and adjacent parts, will dispel any doubt as to the diagnosis. In pediculosis the pubic louse can always be detected by close observa- tion. Paraesthesia, which may attack the genital organs, and Avhich may give rise to eczema, can be recognized by the history of the case and the absence of lesions of the skin in the beginning of the disorder. The treatment of eczema of the genital organs, while usually con- ducted upon the same plan pursued in other parts of the body, re- quires, in addition, some special consideration. Acute cases can often be better managed by soothing ointments, bland oils, and dusting- powders, little or no water and soap being applied to the surface during the continuance of the eruption. The parts must be kept at rest, all excitement avoided, and the surface protected from the apposing parts and the clothing by thin films of simple or medicated cotton, lint, or old muslin. Light compression, by bandaging with old muslin, both for protection and to ghre rest and support to the congested and in- filtrated integument, is of the greatest value, in both the acute and chronic forms. The scrotum may be supported in a suspensory band- age. Scarification of the scrotum aids absorption of the infiltration. The patient must be instructed to desist from rubbing or scratching the surface. If the torment and suffering become very great, and the disease appears on the increase, the patient should be put in the re- cumbent position, and then, with perfect rest and proper medication, the affection can soon be relieved. The following is useful in the acute form : R Hydrarg. chlor. mit................ gr. x. Zinci carbonatis................... 3 j. Pulveris marantae.................. 3 j. Extracti belladonnae............... 3 ss. Extracti opii......................gr. x. Ungt. aquae rosae.................. | j. M. The calomel can occasionally be omitted, and ten or fifteen grains of naphthol or a drachm of sulphur substituted in place of it. This ointment, or some one of those previously suggested for eczema, can be applied night and morning, and one of the ordinary dusting-powders sprinkled or puffed over the surface. It is well to apply the dusting-pow- der frequently during the day, if occasion permits. Again, it is of advan- tage to occasionally use an emollient or alkaline bath, to lessen the irri- tation. Astringent baths of either alum, tannin, or sage are also of serv- ice. An ointment composed as follows is recommended by Lustgarten: R Cocain. oleatis.................... gr. x-xv. 01. olivae.........................3 ss. Lanolini......................... 3 iij. M. Two daily applications are made, and the parts are subsequently dusted with an absorbent powder. In cases attended with free secre- tion and formation of scabs, Avarm baths are useful. EXUDATIONS. 443 In chronic cases the skin should be cleared off by oil, or, if neces- sary, water and soap—Castile, sulphur, tannin, and naphthol all being useful—every second or third night, and the ointment gentlv reap- plied. The following has likewise been found effective : R Ungt. hydrarg. nitrat................ 3 iij. Olei anthemidis.................... ij[ x. Naphthol......................... gr. v. Zinci carbonatis.................... 3 j. Ungt. aquae rosae.................... = j. M. The subjoined lotion will be serviceable : R Liquor calcis....................... f | iij. Extracti belladonnae................ 3 j. Glycerini.......................... f § iij. m. Lotions of tannic or gallic acid, or the extract of kino, are also beneficial. Carbolic acid and the tarry preparations can likewise be used in the form of an ointment, and the diachylon ointment is also sometimes of value. The application of a strong solution of nitrate of silver is useful in stubborn cases, particularly if fissures be present. In some the tincture of benzoin is of service. The employment in obsti- nate cases of the alkaline or acid baths, or liquid medicated baths of potassium sulphide or sodium salicylate, will often give great relief. Vaginal suppositories containing morphine and cocaine are indicated when the vulva and vagina are the seat of disease. Galvanization and faradism may also be applied in order to relieve infiltration. Eczema of the penis, especially the glans, is often symptomatic of diabetes mellitus. The urine should be examined, and if sugar be present the appropriate regimen and treatment should be adopted. Locally, scrupulous cleanliness, with the use of an antiseptic powder, is required. Eczema of the Anus and Anal Region. — Eczema is often limited to the anus (Eczema Ani), or it may extend between the nates, in the cleft over the perineum back of the genital organs, or down the inner surface of the thighs. In the involvement of the anus alone there may be a slight muco-cutaneous congestion, Avith the most dis- tressing itching, burning, or painful sensation up even into the mucous membrane of the rectum, or the parts may be red, swollen, and infil- trated. The surface may or may not pour forth a fluid exudation, Avhich dries into crusts over the affected region. Fissures frequently form, Avhich are exceedingly painful in walking, sitting, and especially during each moA^ement of the bowels. In exceptional cases the inten- sity of the inflammation may even excite the growth of vegetations. Again, it may cause inflammation of the rectum with a discharge of mucus, pus, and blood. The violent itching, burning, and painful sen- sations usually increase during and after defecation and toward night, especially after the patient has retired to bed. The parts are strained 444 DISEASES OF THE SKIN. by the tenesmus, picked and torn in the effort to get relief, so much so that the muco-cutaneous surface is frequently cedematous, hypertro- phied, and at times partial prolapsus ani may follow. The affections with which this variety is liable to be mistaken, especially paraesthesia, have been discussed under eczema of the genital regions, and the dis- tinguishing points there considered. The treatment suggested for eczema of the nose, lips, and genital organs will be equally effective for the eruption involving this region. Too much stress, however, can not be laid upon the value of the various medicated suppositories for re- lieving and curing eczema of the anus. The ointment of the oleate of silver is a remedy of particular value in this localization of eczema, as well as when the disease involves the external genitals. Opium, bel- ladonna, and hyoscyamus may be appropriately added. (Regarding the use of the oleates in eczema, see the author's volume, Ointments and Oleates, especially in Diseases of the Skin. 1890 ; second edition.) Eczema of the Legs (Eczema Crurum).—The legs of both sexes, more particularly in middle and advanced years, may be attacked by any one of the forms of eczema. The extent and severity of the erup- tion Avill vary according to the cause, the condition of the health, and the occurrence of such complications as varicose veins. Eczema of the legs usually first shows itself on one or both members as the erythema- tous or vesicular variety, generally being limited to these parts, and run- ning through an acute course into the inflammatory form. Sometimes it appears as one or more patches of various sizes, generally upon the front of the limb or on the ankle, Avhich often coalesce until the whole member is involved. The majority of cases, however, that present themselves for treatment have become chronic, the surface being red, thickened more or less, covered with yelloAvish or brown- ish crusts and scales of variable sizes, between which may be seen a clear, purulent, or bloody exudation. On removing the crusts and scales, the exposed surface will be found to be denuded of epidermis, reddened, moist, and weeping. In others, the legs may be the seat of one or more large or small red, infiltrated, dry, and scaly patches. The inflammatory process gives rise usually to the most intolerable itching, and the scratching which the patient will often resort to, sometimes during sleep or in a state of semi-consciousness, always aggravates the eruption. Eczema of the legs is frequently the re- sult of varicose veins, and is thus not only associated with them, but is further complicated by ulcers and other changes which they produce. In old cases the thickened skin may assume a papillomatous appear- ance and simulate Elephantiasis. The diagnosis is usually plain. Syphilitic ulcers of the legs may be distinguished from varicose ulcers by their sharp-cut edge, somewhat undermined, filled with abundant fetid pus, and being usually situated on the posterior part of the legs. On the other hand, varicose ulcers are everted and hard on the edge, EXUDATIONS. 445 the secretion is scant, often without odor, they are very vascular, and usually appear on the front or sides of the limbs. Further, it must be remembered that this disease sometimes accompanies Elephantiasis Arabum, but that the eczematous eruption is secondary to the devel- opment of the latter affection. The treatment will not differ from that suggested for the disease in other regions, except in the use of compression, Avhich here becomes almost a necessity, in order to give support to the relaxed vessels and tissues. In beginning the treatment in both the acute and chronic forms, I first try to tplace the patient, if possible, in the recumbent position. It is often impossible to have patients submit to this pro- cedure, but in some of the more obstinate cases it is absolutely essen- tial for the relief or cure of the disease. The parts in the acute va- riety should be bathed once or twice daily with an alkaline or emollient bath, and the surface covered with the folloAving ointment: R Hydrarg. ammon.................. 3 j. Creasoti.......................... nj, v. Ungt. zinci oxidi................... \ j. M. In place of this combination, four drachms each of lead and zinc carbonate, with four ounces of sweet-oil, may be employed. An emol- lient powder can next be dusted over the surface, and a soft muslin bandage applied to retain the dressing, protect the denuded parts, soothe the muscular irritation, tone up the dilated capillaries, remove poured-out products, and prevent the escape of serum into the tissues. Chronic eczema of these parts, on the other hand, demands a more stimulating treatment; the surface should be washed occasionally with sulphur, tar, or naphthol soap, and hot alkaline and astringent baths employed every day or two, unless contra-indicated. The following ointment may also be employed with advantage : R Ungt. hydrarg. nit.................. 3 ij- Sulphuris sublimati................ 3 j- Zinci oxidi........................ 3 j- Olei anthemidis.................... TH, x- Adipis recentis.................... 1 j- M. If ulcers exist, either bismuth subnitrate, bismuth subiodide, pul- verized red cinchona bark, or some other astringent powder can be sprinkled over their surface. Carbolic or salicylic acid or balsam of Peru, camphor or the oil of cade, or any of the tarry preparations, can be employed with benefit. Diachylon ointment is also useful, either alone or combined with other agents. Compression, by means of mus- lin, simple or compound medicinal plaster, or the rubber bandage, is a most valuable adjuvant in affording support, rest, and protection to the parts. Eczema of the Hands and Feet (Eczema Mamtum et Pedum). —The hands and feet may be the seat of all the varieties and changes 446 DISEASES OF THE SKIN. found elsewhere in eczema. The hands, by reason of their exposure, especially in the various occupations, are more frequently affected than the feet. One or both hands may be the seat of the disease— more frequently the latter is the case—and occasionally, though rarely, the feet may be involved at the same time. Eczema may manifest itself on the hands with more or less inflammation, vesiculation, papulation, and pustulation, with a slight or large amount of swelling. It more frequently appears as the subacute or chronic variety, charac- terized by the continued development of groups of vesicles and papules on the back of the hands and sides of the fingers, or on the soles and palms, the vesicles remaining long on these parts, or the serum bur- roAving beneath the infiltrated patches. The surface may become the seat of superficial or deep fissures, especially about the knuckles and upon the palms. The thickness of the epidermis of the palms of the hands, as well as the soles of the feet, not only occasions these fissures of various lengths and depths to form, but also leads to more or less infiltration, hardening, and peeling of the skin as far forward as the ends of the fingers and toes. One or both palms or soles may be affected, and the entire or part of the surface may be involved. The itching, pain, and suffering from this fissured skin, which may be inelastic or excessively dry, or exude serum or blood, are usually so great as to render all motion exceedingly painful, and in some cases impossible. Eczema occurring between the toes is a most trouble- some affection, OAving to their constant action, contact, and the fric- tion betAveen the apposing surfaces, the retention and decomposition of the perspiration acting as an irritant, producing great itching, pain, and maceration of the epidermis. Eczema of the fingers and toes may, by its action on the matrices, affect the nails of one or all the members. (Eczema Unguium.)—In this form of the disease the skin around the base or at the sides of the nail is usually either red, thickened, or abraded, while the nail itself is somewhat depressed at the root, lacks polish and smoothness, and is rough and uneven. In some cases the nail becomes very brittle, in others thin, and at times it assumes a worm-eaten or club-shaped appearance. The nail may remain for a time in this condition, occasionally being broken and cast off, to be again replaced, but often regaining its natural aspect by degrees with the disappearance of the disease. Eczema, wherever located, not uncommonly induces nutritive changes of a general character in the nails. This condition, however can not be properly termed eczema of the nails. Eczema may attack the nails as a primary or secondary affection. In most cases the disease is an extension from eczema of the hands or fingers. Isolated eczema unguium is met Avith in two forms: (1) Perionychial eczema, with subacute ungueal lesions. The integument surrounding the nail is red EXUDATIONS. 447 swollen, and humid, the nail becomes eroded and deformed and may be shed, leaving exposed a rough, red, and thickened bed. (2) Ungueal eczema or dry eczema of the nails. In this form there is no redness or discharge. The nail becomes rough and thickened, and in some cases arched like the roof of a house. Longitudinal fissures or transverse grooves, little pits arranged longitudinally, partial or general exfolia- tion of the nail, are among the observed phenomena. In other words, the evidences are those of profoundly depressed nutrition, but are not distinctive unless taken in connection with the actual presence of eczema in other portions of the body or a history of preceding attacks. Caldwell has described * a peculiar affection of the nails in an individ- ual avIio had had attacks of eczema and periodical copious deposits of urates. There was enormous hypertrophy of the bed of the nails, Avith the production of hard, scaly, mortar-like material, which raised the nail sometimes to a right angle with the axis of the finger and caused it to break off short. The four extremities were attacked, but in all some nails escaped. Eczema of the hands and feet may closely resemble syphilis, pso- riasis, and scabies. In syphilis the lesions are smaller and more isolated than in eczema. They are also deeper, the edges ragged, with adher- ent dirty, gray scales, the surface beneath being of a red or coppery hue. Again, syphilis Avill not usually extend to the dorsal surface of the hands and feet, and is not attended Avith itching. Occasionally the two diseases exist side by side; the history, the appearance of the eruption, and the presence of syphilitic lesions on other portions of the body will, by a little care, demonstrate the points of difference. Psoriasis of these parts is, as a rule, accompanied by patches in other regions, the fissures are generally dry, and the scales' large, white, and abundant. In eczema, on the other hand, the cracks exhibit more or less moisture, and the scales are scanty and of a yellowish hue. Finally, scabies, which involves especially the hands, may be detected by the furrows, the itch-mite, the contagious nature, or by its rapid yielding to antiparasitic remedies. The treatment of this variety of eczema can be briefly summed up : Rest, and the application of an emollient or stimulating ointment. The frequent use of Avater, or Avater and soap, should be interdicted, as cases are often thus aggravated. The parts may occasionally Avith advantage be cleansed and stimulated Avith sapo viridis, or one of the medicated soaps, but the interval be- tween such applications should usually be long. It is better, in the majority of cases, to use a bland oil for softening the surface and re- moving all effete products from the parts. Dusting-powders, or one of the oils, or a mild stimulating ointment, may then be used if the indi- vidual must continue at his usual occupation. I prescribe very often, in the acute form, rose-water ointment, with half a drachm of sulphur, * British Medical Journal, May 10, 1890. * 448 DISEASES OF THE SKIN. and one or two drachms each of lead and zinc carbonate. Cod-liver oil, alone or combined with a few drachms of oil of cade, is beneficial in both the subacute and chronic forms. In the chronic variety the following Avill be of service : R Ungt. hydrarg. nitratis................ | ss. Olei cadini........................... f 3 j- Adipis recentis........................ | ss. M. Another good application is: R Ungt. hydrarg. oleatis (10 to 20 per cent.). § ss. Naphthol............................ 3 ss. Adipis recentis........................ § ss. M. An ointment of ammoniated mercury has also been successfully employed. In the involvement of the fingers and toes, the ointment of zinc oleate—one or two drachms of the oleate to the ounce of lard—is use- ful. The remedy can be applied on muslin or lint, and placed be- tween the members and confined by a bandage. An ointment of re- sorcin, fifteen to thirty grains to the ounce of excipient, is likewise a valuable application. In subacute or chronic eczema affecting the back of the hand, Jamieson highly esteems Lassar's paste, which Jie looks upon almost in the light of a specific. It is not adapted to use on the palm on ac- count of the absence of sebaceous glands in that situation. Lassar's paste is prepared according to the following formula: R Acid, salicylic......................... gr. x. Vaselini opt.......................... § ss. Zinci oxidi.......................... 3 ij. Pulv. amyli........................... 3 ij. M. Fiat pasta. If the nails are affected, the ointment of tin oleate will assist in re- lieving the irritation and in giving a polish to the nails. Salicylic acid, in the form of an alcoholic lotion, ointment, or plaster, is also use- ful when eczema involves the nails. Compression is as efficacious in eczema, particularly the chronic form, of these parts, as in the legs and other portions of the body. The entire or part of the hands or feet or each finger and toe can be covered with the medicament, and then bandaged with muslin, or a medicated plaster of zinc, lead, etc., can be used. Tightly-fitting porous stockings applied over the dress- ing, or a stocking woven with some gum material, may also be em- ployed. The hands, in a like manner, can be covered with cotton gloves, or, what is much better, a woven glove, with cotton and gum in the fabric. Eczema sometimes invades mucous membranes. As a rule, the dis- ease extends from a contiguous portion of skin. From the eyelid it may spread to the conjunctiva, from the external to the internal EXUDATIONS. 449 surface of the nose, from the vulva to the vagina and cervix uteri, and from the anus into the rectum. Exceptionally, it is met with on the tongue as a solitary manifestation. The mucous membranes, when at- tacked, are red, swollen, and painful. Small vesicles or ulcerations may be perceived upon their surfaces. Prognosis.—Eczema is a curable disease, if properly managed. In very many instances, however, either the hygienic, dietetic, constitu- tional, or local treatment ordered will be so neglected, changed, or modified by the patient as to prolong the eruption, and often interfere materially with its cure. The prognosis, therefore, largely depends upon the patient following in every respect the directions of his medi- cal adviser. An opinion as to the probable duration of the dis- ease depends upon the exciting cause, the variety and stage of the eruption, whether acute or chronic, the locality invaded, and the length of time the affection has been upon the surface. Thus, when eczema is dependent upon old cases of nervous debility, dyspepsia, chronic OArarian or uterine disorders, the cutaneous inflammation may remain obstinate or rebellious until one or another of these conditions that may be present is removed. Every case must be thoroughly investi- gated, so as to ascertain, if possible, the exciting cause, and the prog- nosis based upon the removal of the condition that produced the disease. It is also essential, before expressing an opinion, to take into consideration whether the disease is acute or chronic, as Avell as > its variety and stage; for instance, the result of treatment is much more rapid and certain in acute than in chronic eczema. Again, acute vesicular eczema has a shorter and more definite course than papular eczema, which tends to become chronic. Finally, the duration of the eruption, Avhether it is the first onset of the disease or a relapse, and the region invaded, are points of the utmost importance in giving an opinion. Acute eruptions of short duration, properly managed, may quickly disappear, or return once or twice and then vanish, but re- lapses usually denote a long and tedious course of the disease. The prognosis also depends upon the locality invaded; eczema of the scalp, beard, and other hairy parts, for example, are invariably both obsti- nate and chronic. Eczema of the hands and feet is generally unyielding on account of the constant exposure of the hands, and the necessary activity of the feet, in the patient's daily employment. Other examples of rebellious and persistent eczema are observed Avhen the disease attacks the scro- tum and adjoining parts, and the limbs of old persons. In the in- volvement of the former portion of the economy, the apposition of surrounding parts, their anatomical formation, and in the latter the presence of varicose veins or ulcers, tend to complicate the disease and render it for a long time unyielding, even under the most careful treat- ment. 29 450 DISEASES OF THE SKIN. DERMATITIS. Dermatitis is a simple inflammation of the skin occasioned by violence, the external application of irritating materials, extremes of heat and cold, reflex disturbance from various diseases, or is produced by the ingestion of certain medicinal substances. In other cases it is probable, as pointed out by Mr. David AValsh,* that dermatitis results from direct irritation of the epithelial cells constituting the excretory apparatus of the skin. Such irritation may be due to drugs, to chemi- cal bodies generated by tissue metabolism, or by bacterial activity. An increased production of normal substances representing waste, as urea, may have the same effect. The irritation caused by the excretion of drugs is strictly analogous to that excited by the poisons of disease. Dermatitis will vary according to the nature and intensity of its cause, the susceptibility of the skin, the state of the individual's health, and many other circumstances. It may begin as a mild or severe erythema, and continue as such, or may change to a papular, vesicular, pustular, bullous, or gangrenous condition. Dermatitis may be limited to a small area or diffused over almost the entire surface. The attendant symptoms of inflammation, redness, swelling, heat and itching, or pain, exist in varying degree. There are five varieties of the disease—dermatitis traumatica, dermatitis venenata, dermatitis calorica, dermatitis gangrenosa, and dermatitis medicamentosa. Dermatitis Traumatica.—This variety includes all active and passive inflammatory conditions of the integument due to violence. It embraces punctures, incisions, excisions, contusions, lacerations, and all injuries which may happen to the skin. Among the many causes which may give rise to traumatic dermatitis are pressure and friction from clothing, shoes, bands, etc.; excoriations from scratch- ing in the course of many cutaneous diseases, especially the animal parasitic affections, pediculosis, and scabies, and the bites and stings of the lower animals. Finally, certain superficial cutaneous affections, particularly erythema, may terminate in simple inflammation. The irritation incident to certain occupations may occasion derma- titis, as in the affection described by Leloir under the title of follicular and circumfollicular dermatitis of spinners and tacheurs. The erup- tion is a disseminated inflammation of the hair-follicles, which form small dark red papules and sometimes become ecthymatous or furun- cular. There is much itching. Half the workmen are attacked by the affection, which is caused by the Russian petroleum-naphtha and other mineral oils employed. Cleanliness is protecthTe, and the disease soon disappears when the subject is removed for a few days from the source of irritation. Dermatitis Venenata.—This form of dermatitis comprises all * Medical Press and Circular, October, 1890. Plate VI. Dermatitis Venenata (from Nature). EXUDATIONS. 451 inflammations which are, the result of the contact of various poi- sonous and irritating substances with the integument. The inflam- mation may be of a mild or severe type, according to the suscepti- bility of the individual and the character of the substance coming in contact Avith the skin. Various chemical and medicinal substances— such as acids, alkalies, and other caustics; cantharides, ether, chlo- roform, savin, mustard, mezereon, arnica, and turpentine; the tarry preparations, used locally—may cause dermatitis. Tartar emetic also occasions a A^esicular and pustular eruption, particularly when used in the form of an ointment. Croton-oil applied to the skin pro- duces similar lesions attended Avith oedema, swelling, and often pain, with itching; the severity of the lesions and symptoms depending upon the quantity of oil and the extent of friction employed. Mer- curials, especially the ointments, may likewise give rise to derma- titis, particularly if used carelessly, or upon a sensitive or suscep- tible skin. The many dyes used for coloring toys, hat and cap bands, under-garments, more especially flannel shirts and drawers and cheap colored hose, often produce violent inflammation. Nor- mal and abnormal secretions, by their retention or contact Avith the skin, as an excessive secretion of sweat, excessive discharges from the boAvels, the dripping of urine, the pus from gonorrhoea, wounds, or other diseases, may also produce similar inflammatory conditions. The vegetable kingdom furnishes many substances which, Avhen applied to the skin, occasion irritation and more or less severe inflam- mation. Among the plants that possess these properties are the net- tle, the smart-weed, cowhage, and, by far the most common, the rhus family—the rhus venenata, the rhus toxicodendron, ordinarily referred to as poisonous sumach or dogwood, or poison oak or ivy. The poi- sonous principle which exists in several members of this family has been isolated by Prof. Maisch, of Philadelphia, and shown to be a volatile acid known as toxicodendric acid. In order to distinguish poi- sonous from harmless species it should be borne in mind that the three- leaved ivy is dangerous, while the five-leaved is innocuous. The poi- sonous sumachs bear white berries; the red-berried varieties may be handled Avithout harm. The susceptibility to these plants varies in different individuals. Some can handle them with impunity; in others, the moment they come in contact Avith the plants, or even approach them, the most violent and severe inflammation of the skin appears in a feAv hours, and, in rare cases, sometimes a day after. The disease usually begins in the hands, the lateral parts of the digits being first affected, and next the dorsal and palmar surfaces. From the hands it is most liable to pass to the parts Avith which they come in contact, as the face and genitalia. It may also spread to other or all parts of the body. The eruption generally appears in an erythematous form, accompanied 452 DISEASES OF THE SKIN. by vesicles, pustules, and even abscesses, and attended with more or less oedema, swelling, heat, and itching. The serous infiltration and swelling may at times be so great as to occasion great disfigure- ment, especially of the hands, arms, and genitalia. The lesions may be discrete or confluent. The vesicles are usually small, being situ- ated upon an inflamed and cedematous base, and often develop into pustules, Avhich may rupture, the discharge drying into yellowish crusts. The affection may run an acute course in from one to six weeks. The period of recovery from it will, of course, vary according to the condition of the patient and the promptness with which treat- ment is instituted. Dermatitis Calorica.—This variety of dermatitis is produced by extremes of heat and cold; and, inasmuch as both inflammatory conditions which they occasion are so common and require most care- ful treatment, they will, in due order, be described later under the titles of Combustio, or burn, and Congelatio, or frost-bite. Dermatitis Gangrenosa.—An idiopathic and a symptomatic form of dermatitis, ending in gangrene, has been reported. It may appear either in the form of diffused or circumscribed patches. The idiopathic variety, which inclines to be symmetrical, may begin in some cases as large or small, circular, reddish or purplish hyperass- thetic or anaesthetic spots. In other cases it may appear in the early stages as haemorrhagic macules, or as spots presenting a white, parch- ment, or alabaster appearance. Fagge, Brodie, Stockwell, Charcot, Rooke, Petri, Leloir, Dejerine, and others, have reported many interesting cases of this form of der- matitis. It has been known to follow various cerebral, spinal, and nervous diseases, and also diabetes and cachexia.* Instances have been recorded in which this variety of dermatitis has been produced by cer- tain substances, chiefly caustics, for the purpose of deception. Dermatitis Medicamentosa.—Many cutaneous eruptions of an inflammatory character are the result of the internal administration or the external application of drugs. Their occurrence is, however, not common, and is usually due to individual idiosyncrasy. The accom- panying list of drugs f comprises most of those that have been observed to give rise to various disorders of the skin : Acidum Benzoicum, taken internally or inhaled, may in exceptional cases produce an erythematous or small papular eruption. The same result occasionally follows the ingestion of benzoate of sodium. Acidum Boricum.—An erythematous eruption, involving the face, * Dr. A. Douglas Heath, of Birmingham, describes in the British Medical Journal for June 3, 1897, a fatal case affecting the scalp of a child who had suffered from whooping- cough for six weeks. f For a more detailed account, see Drug Eruptions, by Prince A. Morrow, A. M., M. D. New Yoik: William Wood & Co., 1887. EXUDATIONS. 453 trunk, and extremities, has been recorded from washing out the pleura with a solution of boric acid. Papules and blebs have likewise resulted from an injection of boric acid. Confluent rubeola-like eruptions, ery- thema, eczema, and generalized urticaria have also, in some instances, followed the internal use of large doses of boric acid. Acidum Carbolicum—Creasoturn.—Strong solutions of these reme- dies applied to the surface incite more or less violent dermatitis, characterized by erythema, oedema, itching, and pain; used undi- luted, they destroy the portions of the integument to which they are applied. Acidum Nitricum, when applied to the integument diluted, will produce a yellowish discoloration. Stronger applications give rise to a bullous eruption resembling pemphigus, and are occasionally employed for this purpose by hysterical women. Acidum Picricum.—A case of violent dermatitis from picric acid has been described by Dr. v. Haesslin. A man had bought a pair of shoes lined with orange-colored leather. After wearing them for about a week his feet began to itch intolerably; they were colored yel- low, hot, and swollen. Innumerable vesicles formed and coalesced until the epidermis of both feet, as far as they had been covered by the shoes, was raised by a purulent serum. Some constitutional reaction was present. The leather was found to be saturated by picric acid.* An intolerable and persistent urticaria was seen by Dr. C. H. Hughes, of St. Louis, Mo., to follow the administration of a few doses of picrate of ammonium. The sclerotic likewise became yellow and the urine brownish-red. Acidum Pyrogallicum.—The local use of pyrogallic acid may give rise to dermatitis of varying severity, and may produce extensive ulcer- ation and sloughing. Acidum Salicylicum.—Salicylic acid has been knoAvn at times to produce various cutaneous lesions. Thus, Heinlein reports a diffuse erythema on the left side of the face, chest, and loAver extremities, with oedema of the eyelids, lips, and legs, together with an intolerable itch- ing and tingling of the skin, accompanied with fever, from large doses of salicylate of sodium. On decreasing the medicine the eruption dis- appeared, but on again renewing large doses an urticarial eruption appeared upon the greater part of the body. The eruption disappeared on the folloAving day, and small doses of the drug did not occasion any relapse. Vesicles and pustules on the hands and feet, with much sweat- ing, have also been recorded as due to the use of this drug. Ecchy- motic patches have likewise been noticed on the back from the «ame cause. Acidum, Tannicum.—An erythematous eruption has been reported to follow from the injection, inhalation, and ingestion of tannic acid ♦Journal of Cutaneous and Genito-Urinary Diseases, March, 1889, p. 116, 454 DISEASES OF THE SKIN. in a case recorded by Dr. Williamson. In some individuals the local application of tannic acid will provoke an attack of urticaria. Aconitum.—A decided diaphoresis has sometimes folloAved the in- ternal use of aconite, together Avith vesiculation and more or less itch- ing. Its external application has also been attended Avith redness and the development of vesicles, pustules, and blebs. Alcohol.—Dr. G. Kaempfer has published an account of a case of erythema following the ingestion of alcohol. The patient, under treat- ment for rheumatism, had been an excessive drinker. Half an hour after taking beer, whiskey, or brandy erythematous patches, of various size and differing in depth of color, appeared upon the surface. The smaller areas were more highly colored. The retinal vessels were swollen and the pharynx was intensely injected. The flush upon the skin began to fade half an hour after its development, and by the end of the hour had entirely disappeared. There was a subjective feeling of heat in the parts and the local temperature was nearly a degree above normal. The pulse was rapid. In this case it is presumable that alcoholic addiction had disturbed the equilibrium of the vaso-motor centres. Amygdala Amara.—The ingestion of bitter almonds has been re- ported to produce an eruption similar to urticaria. Anacardium, or the cashew-nut, when applied to the skin, pro- violent dermatitis of an erysipelatous character. Antimonium.—In some cases the internal administration of anti- mony has been followed by the development of wheals, papules, and pustules. Antipyrine.—This drug is frequently productive of cutaneous dis- turbances. The eruption resulting from its use consists of numerous and widely disseminated erythematous spots, or small, hard, dark-red or purplish papules and may simulate the exanthem of measles. At times the remedy gives rise to a scarlatinaform rash. Severe urticaria has been produced by a single dose of five grains. It has been known to cause erosive glossitis simulating mucous patches. Arnica.—Notwithstanding the esteem in Avhich arnica is held as a domestic panacea, its external use is frequently productive of violent erythematous and pustular eruptions. M. Dupuy has met with a case of pseudo-erysipelas produced by the application of tincture of arnica. Arsenicum.— Erythematous, vesicular, bullous, papular, pustular, or ulcerative lesions may follow the ingestion or absorption through the skin of arsenic. The eruption may resemble syphilis, measles, erysipelas, or erythema multiforme. Occasionally it may be purpuric or urticarial in appearance. The use of arsenic will occasionally give rise to herpes zoster. Arsenic eruptions generally occur on the face, neck, and hands, and may disappear in one to two weeks after the remedy is discontinued. EXUDATIONS. 455 Balsamum Peruvianum.—An erythematous, urticarial, or eczema- tous eruption may follow the application of this drug. lU'lladonua—Atropine.—An erythematous or scarlatinoid rash may develop after either the internal or external use of belladonna or its alkaloid. It is one of the most common medicinal rashes, and very frequently appears within a Aery short time, often a few moments or an hour, after the employment of the drug. The effloresence is accom- panied Avith headache and dryness of the throat, but neither fever nor desquamation is observed. It is of more frequent occurrence among children than adults, probably owing to the drug being more largely administered to the former class. The eruption is mostly limited to the face, neck, and chest, but it may, in rare cases, involve the entire surface. Benzole. — Lewin reports erythema from the application of this agent. Box.—Dr. J. C. White has reported a severe case of dermatitis of the face produced by a decoction of garden-box, which a young woman had applied to her scalp for the purpose of preventing loss of hair. The liquid ran down upon her face. The scalp was not affected. Bromine—Bromides. — The eruption produced by the bromides, especially the potassium and ammonium bromides,* usually consists of acne or acneform furuncles, first developing on the face, neck, chest, and back. Vesicles and pustules may appear at the same time, with occasionally an erythematous efflorescence, or brownish discolor- ation, the eruption assuming now the appearance of eczema, and again resembling the papular syphiloderm. Wheals and ulcers have also been known to follow the use of these preparations. The erup- tion may appear within twenty-four to forty-eight hours after the administration of the drug, but usually it develops only after the sys- tem has been saturated with it. The use of small doses of arsenic with the bromide frequently prevents the development of the lesions. Dr. Beevor met with a case in which there occurred upon the arms of a child the usual acne form, which soon took on the appearance of a varicella, being ultimately transformed into warty growths resembling condylomata. A bromide eruption occasionally shoAvs itself upon a suckling infant whose mother is upon a course of bromide treatment. Calx Sulphurata.—The sulphide of calcium given internally may sometimes produce vesicles, pustules, and furuncles. Cannabis Indica.—A papulo-vesicular eruption, coATering almost the entire body, has been reported by Hyde, after a patient had taken one grain of the drug. The pruritus was marked, but all the symp- toms disappeared in a few days. Cantharis.—The vesicating qualities of this drug render it invalu- * The ammonium bromide, according to Ringer, is most active in producing bromide eruption. 456 DISEASES OF THE SKIN. able in many affections where counter-irritation or derivation is requi- site, but it occasionally produces obstinate and extensive ulceration. Capsicum.—The external use of capsicum is sometimes followed by erythema and a mild form of dermatitis. Chloral.—An erythematous or scarlatinaform eruption may result from the use of chloral hydrate. The lesions appear usually on the face, neck, chest, and extremities, and are especially liable to develop when the drug is administered with stimulants. The administration of chloral may occasion fever, with tenderness of the skin, glandular enlargement, or wheals; papules, vesicles, pustules, even petechia and ulceration may appear, and in toxic doses be followed by symptoms of purpura haemorrhagica and death. Chloralamide.—Dr. Pye-Smith relates * a case in which eighty grains of this lately introduced hypnotic, given in two doses of forty grains each at eight hours interval, gave rise to severe universal derma- titis. Fever lasted a week, the urine Avas slightly albuminous, and profuse desquamation followed, resembling that of exfoliative derma- titis. Chlorine.—Dr. J. C. White has met with a case of dermatitis due to chlorine. A school-girl, aged eighteen, had turned hydrochloric acid upon black oxide of manganese in a jar, and the gas thus generated had come in contact with her face held just above the vessel. The in- flammation extended from the middle of the forehead down the neck as low as the level of the dress. Chrysarobin, chrysophanic acid, or Goa powder, is extremely irri- tant to the normal integument, producing marked oedema, accompa- nied by the formation of nodules, pustules, and large vesicles. Cinchona—Quininai Sulphas.—Quinine may ghe rise to an ery- thematous eruption, resembling at one time scarlet-fever rash, and again measles or erysipelas. It may occur from small doses, and may or may not be preceded or accompanied by the well-known symptoms of cinchonism. The eruption first appears upon the face and neck, and spreads until all the body is invaded. The local symptoms of burning and itching are very intense. The eruption terminates in desquamation, which may continue for some time. Papular, bullous, and purpuric forms have also been recorded. Rashes are also provoked by the direct action of cinchona. Workmen employed in preparing quinine are subject to erythema, vesicles, or pustules upon the face, arms, forearms, and genitals. Condurango.—According to Guntz, furuncular and acneform le- sions have developed after the administration of condurango for the treatment of syphilis. Conium.—An erythematous or papular eruption with diaphoresis may result from the administration of this drug. * Lancet, March 9, 1890. EXUDATIONS. 457 Copaiba.—A bright-red papular or maculo-papular rash, with in- tense itching, may appear from the ingestion of copaiba. It resem- bles urticaria and erythema multiforme, and occurs by preference on the extremities, but may involve all the body. The eruption may appear immediately after the medicine has been taken, or, in rare cases, a long time after its employment. In one case under my obser- vation, the eruption, covering the entire body of a college student, was mistaken for small-pox. Within a few days the eruption sub- sided with the discontinuance of the drug, as it will in all cases, and my diagnosis was verified. A bullous eruption has also been seen to follow the administration of copaiba. Creolin.—Dr. J. Wackez reports that in a series of seventeen cases of incised and lacerated wounds occurring in children he employed a 1: 1000 dilution of creolin as a local remedy. In seven of the patients a more or less severe eczema appeared upon the third day. The tem- perature was raised, the neighboring lymphatic glands swollen, there was loss of appetite, headache, and frequent vomiting. The urine showed elimination of phenol and an increase in the aromatic ethereal sulphuric-acid compounds.* Cubeba.—A bright-red discoloration of the skin, with millet-seed papules, coalescing in spots, involving the face, arms, trunk, and limbs to a slight extent, has been recorded from the ingestion of cu- beb berries. The eruption occurs mostly in young subjects after the use of large quantities of the drug. It disappears in a few days after the cubeb has been discontinued, but may be followed by a furfura- ceous desquamation. Digitalis.—The internal and external use of digitalis have been known to produce an erythematous, papular, and even an erysipelatous eruption. Morrow reports an erythematous efflorescence followed by urticaria from the administration of infusion of digitalis with acetate of potassium. Dulcamara.—In susceptible subjects, large doses of dulcamara pro- duce a diffused but temporary scarlatinaform efflorescence. Ergot.—A vesicular, pustular, and furuncular eruption, with petechiae, has been known to result from the prolonged ingestion of ergot. Ferrum,.—The internal use of iron will at times develop an acne- form eruption. Hydrargyrum—Mercury.—The administration of small doses of mercury may occasionally produce a partial or general deep-red erup- tion. The region attacked is ordinarily the face, but it may spread over part or all of the surface. The skin is smooth, shining, dry, itchy, and has very much the appearance of being attacked by erysipelas. Eleven hours after a subcutaneous injection of calomel Lesser saw the * Therapeutic Gazette, August 15, 1889. 458 DISEASES OF THE SKIN. skin of the entire body assume a scarlet color. This began to fade on the second or third day while desquamation began on the fifth day, and subsequently involved the entire epidermis. Guelpa speaks of a case in which a variola-like eruption followed the use, in a primipara, of a one-half-per-cent. sublimate solution used as a vaginal wash, conjoined with the application of a mercurial ointment to the abdomen. Dr. John A. Fordyce observed a case of scarlatiniform erythema, followed by des- quamation, caused by the application of mercurial ointment. Similar cases have been reported from exposure to the fumes of mercury. Hyoscyamus.—Hyoscyamus may produce a scarlatiniform eruption, which disappears as soon as the drug is eliminated. Iodine, Iodides, and Iodoform.—Erythematous, papular, vesicular, bullous, vesico-pustular, pustular, and purpuric lesions have been caused by the administration of these medicines. The erythematous form, which is not rare, develops generally upon the forearms, face, and neck, An eruption which took the form of erythema nodosum is reported by Lesser as making its appearance after two days' internal use of iodide of potassium. The papular and vesicular forms, which are not so com- mon, are usually the result of long-continued use of these drugs. The lesions occur on the chest and limbs, as well as on the scalp and scro- tum, and are attended with severe itching. An eczematous eruption, with high inflammatory, constitutional, and local symptoms, has also been recorded from the ingestion of small doses of the iodides. The pustular form is the one most commonly met with; it resembles, both in appearance and location, the eruption produced by potassium bromide. It is commonly acneform, and develops upon the face, shoulders, back, chest, and arms. On examination, iodine has been detected in the pus. Occasionally both the iodide and bromide of potassium are productive of furuncles. The bullous form has been observed principally upon the head, neck, and upper extremities, although instances are men- tioned of its occurring on the lower extremities, and the trunk, but rarely in the mouth. The eruption may begin as small vesicles or papules, which remain so, or slowly become, especially if the drug be persisted in, bullous, the fluid continuing serous, or becoming purulent or sanguinolent. Hallopeau has witnessed a case in which occurred a consecutive production of bullae, depressed cicatrices, and condyloma- tous vegetations, together with serious ocular lesions. The outbreaks were accompanied by fever and diarrhoea. Russell observed a case in which death occurred upon the tenth day from inanition and a low grade of pneumonia. Purpura may also follow the use of iodine or the iodides. It generally occurs on the legs, and may assume the haemor- rhagic form and terminate fatally. Besnier had a patient in whom iodide of potassium caused purpura, but who could take tincture of iodine with impunity. Dr. R. AY. Taylor has described a very remarkable case of iodic EXUDATIONS. 459 eruption in Avhich, after the administration of increasingly large doses of iodide of potassium to a young man, a number of tumors appeared upon the face. The excrescences were of a deep-red color, varied from the size of a three-cent piece to that of a quarter of a dollar, of oval or rounded outline, pedunculated, and sessile. The surfaces Avere papil- lomatous, and the orifices of the sebaceous ducts exhibited trumpet- shaped dilatations from which a small quantity of pus could be ex- pressed. So fungous were some of the growths that they assumed the form of mushrooms. All lesions usually disappear rapidly Avithin a few days after the iodine or iodides have been discontinued. A case of generalized urticaria due to the local use of iodoform has been reported. A purpuric eruption has been occasioned by the internal employment of iodoform. Erythema has been caused by local application of europhen. Ipecacuanha.—This drug, when placed in contact with the skin, is productive of erythema, papules, and pustules. Its ingestion is occasionally followed by outbreaks of urticaria. Linum.—Workers in flax are apt to be attacked by eczema. Matico.—Erythema may result from the use of matico. Napltthalin.—This substance has been knoAvn to excite a general- ized, measles-like, papular eruption, which soon disappeared after with- drawal of the drug, and was followed by desquamation. Olea—Fats.—Oils and fats, especially cod-liver oil, occasionally after ingestion produce erythematous or acneform lesions. Oleum Ricini.—When this oil is accidentally or designedly substi- tuted for ofhe-oil in preparations for internal or external use, erythe- ma and pruritus may result. Oleum Tiglii.—The pustulating properties of croton-oil are well known, but occasionally the pustules become the initial point of an obstinate ulcerative process. Opium—Morphine.—An erythematous eruption, resembling that of scarlet fever, may occur after the internal use of opium and its alkaloids. In other cases the employment of these preparations may simply give rise to an intolerable itching, without any efflorescence, or there may develop an urticarial efflorescence, with heat and itching, or only a profuse sweating and sudamina may appear. The eruption, if mild, may disappear in the course of a few hours, or, if severe, it may continue longer and be succeeded by desquamation. Orange.—Painful erythema, oedema, vesicles, and pustules are some- times produced by paring bitter oranges (citrus vulgaris). Petroleum.—The workmen in petroleum refineries are apt to be- come subject to acne of the scalp, face, trunk, and limbs. Those who are careless and uncleanly are especially affected. Phosphorus—Phosphoric Acid.—Phosphorus will occasionally de- velop purpura Avith fatal result. A bullous eruption resembling pem- phigus has been observed to follow the use of phosphoric acid. 460 DISEASES OF THE SKIN. Pix Liquida—Turpentine.—Erythematous, vesicular, and papular eruptions, mostly occurring on the face and trunk, accompanied Avith intense itching, occasionally follow the internal use of tar and turpen- tine, and their various products. In a case narrated by Dr. Feiber, of Aix-la-Chapelle, the administration of turpentine for several days Avas followed by a papular eczema with severe itching. A repetition of the drug caused the development of a mixed form of cedematous and papu- lar erythema. Plumbum.—The salts of lead used internally may produce an ery- thematous eruption or petechias. Their external application may also result in brownish or blackish discolorations of the skin. Podophyllum Peltatum.—More or less cutaneous irritation of the scrotum has been observed by Winterburn in those avIio work with the resinoid podophyllin. Potassii Bicarbonas.—This salt has, in rare instances, given rise to a vesicular eruption resembling eczema. Potassii Bichromas.—Workmen engaged in manufacturing this salt, or using dyes in which it is an ingredient, are frequently attacked by papular and pustular eruptions of a malignant character, succeeded by ulceration and sloughing. M. Ridant has met with eczema of the hands in Avorkmen as a result of the bichromate solution used in dyeing cloth. The dye is made by adding sulphuric acid to a solution of bi- chromate of potassium. A certain proportion of the chromic is dis- placed by the sulphuric acid, and the solution therefore contains free chromic acid in addition to the bichromate of potassium. Perforation of the septum nasi not infrequently occurs. The wearing of garments dyed with this substance is a not uncommon cause of ulcerative der- matitis. Potassii Chloras.—An erythematous and papular eruption has been reported to follow the internal use of chlorate of potassium. Rheum.—Dr. Litten, of Berlin, has reported the case of a man who had been attacked by a rash several times after taking rhubarb. The eruption consisted of large haemorrhagic maculae together with pus- tules and blebs. The latter ran together in many places so that large patches resembling pemphigus foliaceus were produced. All the visi- ble mucous membranes were likewise affected. Free haemorrhage oc- curred from the urethra. Santoninum.—Urticaria with swelling of the face and oedema of the eyelids has been recorded from giving a child three grains of santonin. In a case observed by Underwood a morbilliform eruption, with a punc- tiform rash on the buccal and pharyngeal mucous membrane occurred. Sodii Benzoas.—An erythematous eruption, attended with itching and desquamation, has been reported by Rohe after the ingestion of sodium benzoate. Sodii Boras.—An eruption similar to psoriasis, occurring on the EXUDATIONS. 461 arms, trunk, and legs, has been reported by Gowers from the employ- ment of borax. The use of arsenic with the above salt caused the eruption to fade in two cases of the three reported. Fere and Lamy have, in two instances, seen eczema result from the internal adminis- tration of borax The patients, who were epileptics, had taken in one case two grammes (31 grains), and in the other three grammes (4G| grains) daily. The eruption was limited to the sides of the trunk and to the arms, lasted about six Aveeks, and disappeared on cessation of the remedy. Sodii Salicylas.—Dv. Cavafy testifies * to having seen free desqua- mation follow an erythematous eruption due to salicylate of sodium. Salol has given rise to urticaria or a rash resembling herpes zoster. Stramonium.—An erythematous eruption, simulating the efflores- cence of scarlet feA^er, has frequently been observed during the admin- istration of datura stramonium. Strychnine.—A scarlatinaform eruption has been noticed even after the use of one twenty-fourth of a grain of strychnine. Sulphonal.—This drug has given rise to a troublesome general pruritus and to a bright scarlet-red erythema, accompanied by burning and intense itching. Sulphur.—Sulphur, when taken internally or applied externally, may be the exciting cause of erythema, papules, and pustules. Tanacetum.—Hyde cites Porter's case in which a variolaform erup- tion developed after the ingestion of a drachm and a half of oil of tansy. Thapsia.—Thapsia applied externally produces intense dermatitis, followed by pustulation. Veratria.—An erythematous, pustular, and at times a petechial rash may folloAV the application of veratria to the skin. Veratrum Viride.—An erythematous and even a pustular eruption has been known to follow the internal use of Areratrum viride. Violet Water.—Dr. J. C. White met Avith a case in which a bright-red, finely papular rash of sharply defined outline was produced upon the breast of a young girl by the local application of violet toilet-water. The preparation used smelled strongly of orris-root, which possesses decidedly irritant properties. Diagnosis.—The diagnosis in almost all the varieties of dermatitis largely depends upon the history of the case. Care should ahvays be exercised to detect the distinction, if possible, between genuine erup- tions and those which are produced Avith a view to deception. If the eruptions are simulated, they will be found to occur usually upon regions of the body Avhich are easily reached by the hands, and more particularly in hysterical women. The gangrenous ATariety of dermatitis should not be mistaken for * Lancet, April 21, 1883. 462 DISEASES OF THE SKIN. senile gangrene of the lower extremities, Avhich, unlike the former, involves both the skin and the deeper parts. The diagnosis of the many medicinal eruptions referred to is often very difficult, and if fraud be suspected a most careful examination of the history and mode of living of the patient should be made. A medicinal rash may be suspected when the eruption appears suddenly, and particularly when a variety of lesions occur. Again, the wide dif- fusion of the eruption, its presence upon exposed and protected parts, the attendance of itching and absence usually of fever, together with the knowledge that the patient is taking some substance upon the decrease or removal of which the rash suddenly disappears furnish sufficient evidence for the diagnosis. Treatment.—Internal medication in dermatitis is necessary only in a few cases. The free use of alkalies, in the form of the natural waters, is often valuable in some, while in others the tincture of the chloride of iron acts promptly in giving relief. Antipyretics and tonics may be especially serviceable in rhus-poisoning and other simi- lar conditions arising from contact with vegetable substances. Iodide eruptions may often be prevented or relieved by drinking freely of water. The local treatment in all varieties of dermatitis is the same as that already suggested for acute eczema. Soothing and astringent lotions in the beginning of the eruption, and, later, bland and slightly stimulating ointments, with or without the ordinary dusting-powders, are indicated. Lotions of lead-water and laudanum, tincture of witch- hazel and water, black-wash, bicarbonate of sodium and borax, alone or combined in the form of solution, are all most useful applications. Boric acid or subnitrate of bismuth, one drachm of either to the ounce of simple ointment, will be serviceable in many cases, and the same may be said of ointments containing oxide of zinc or calamine, ery- throxylon, aluminium oleate, glycerine of subacetate of lead, nitrate of lead, or sozoidol. The addition of a small quantity of naphthol or sulphur, or both, to the ointment is often of advantage. The use of weak mercurial ointments will frequently be efficacious, especially in the later stage of the eruption. Rhus-Poisoning.—This variety of dermatitis often requires the most active local treatment to afford relief to the suffering patient. If the lotions already recommended fail to alleviate the suffering and remove the eruption recourse may then be had to one to six drachms of hyposulphite of soda to the quart of water, to be used constantly on the inflamed parts. Decoctions of white or black oak-bark, or black alder, or geranium maculatum, will prove of value. From one half to one drachm of the fluid extract of Grindelia robusta, Avith four to six ounces of water, has been highly extolled. Dr. S. B. Straley, of Hunts- ville, N. J., reports * very favorably of the use of a strong decoction of * Times and Register, November 22, 1890. EXUDATIONS. 463 chestnut leaves, bathing the inflamed parts every three or four hours. He states that the inflammation is allayed in from twenty-four to seventy-two hours. Dr. J. J. Levick, of Philadelphia, has derived de- cided advantage from dusting the surface freely with powdered aristol. Lime water or Labarraque's solution may likewise be advantageously applied. The earth treatment, or the use of fresh clay, will act most successfully in many cases. According to Hyde, an ointment of great value can be made " by incorporating a decoction of the inner bark of the American spice-bush (Benzoin odoriferum) with cold cream." Un- diluted yelloAv wash will often have a good effect.* Medicinal Eruptions may often be prevented or relieved by simple baths, hot air or steam, the Turkish being preferable. Baths eliminate the drug, and so prevent or lessen its irritating action on the skin. The various soothing and slightly stimulating ointments are also of advantage. The lesions resulting from the action of arsenic are effectively relieved by a weak ointment of iron oleate, from ten to sixty grains of the salt to an ounce of lard. Bromine and bromide eruptions may be alleviated by the free application of a solution of salicylic acid, one grain to the ounce of water, as recommended by Prowse. M. Ch. Fere has recently called attention to the value of intestinal antisepsis in the treatment or prevention of bromism. All the symptoms, and especially the cutaneous manifestations, disappear. Antisepsis by means of naphthol and salicylate of bismuth may be continued for months without evil consequences. In several cases M. Fere has been able to administer as much as four to four and one half drachms of the bromide daily without detriment to the general health. He states that this method is equally advantageous to those under treatment by borax. Arsenic and the sulphide of calcium have been recommended as having some antidotical influence against the action of the bromides; arsenic, belladonna, atropine, and Vichy water, against the effects of iodine. Hydrobromic acid is considered to be beneficial in the case of dermatitis due to cinchona or quinine, sul- phur in that produced by pyrogallic acid and chrysarobin. The min- eral acids, likeAvise, according to Unna, are useful in neutralizing the effects of pyrogallic acid and chrysarobin. For iodoform rashes Dr. WicheskieAvicz recommends gauze compresses soaked in a solution of one part of tannin in three of glycerine. The dressing is covered Avith waterproof paper. He also advises that for several days after the eruption has disappeared the parts be covered by a tAVO-per-cent. boric-acid ointment. When the irritant is of acid reaction its effects will generally be best relieved by an alkaline application, whereas an acid remedy, such as vinegar, boric or carbolic acid, is preferably employed to counteract the consequences of an alkali. Dermatitis Herpetiformis.—Under this name Professor Duhr- * See paper by Dr. Joseph H. Hunt, in Brooklyn Medical Journal, June, 1897. 464 DISEASES OF THE SKIN. ing described in 1884 a number of cases which he considered to rep- resent a distinct form of disease. An attack is generally preceded for several days by intense itching or a combination of itching and burn- ing sensations. In some cases there are at the same time signs of con- stitutional disturbance, as chilliness, headache, fever, and gastro-intes- tinal disturbance. The first cutaneous manifestation is an erythema upon which papules develop, and may afterward be transformed into vesicles, bullae, or pustules. The evolution of these different lesions may be either simultaneous or successhe. The most characteristic appearance is that of bullae situated upon an erythematous base. The disease may attack any portion and may involve almost the entire in- tegument. It has been seen upon the tongue, mucous membrane of the mouth, throat, and nose, and may first make its appearance in the mouth. The severe itching causes extreme restlessness and insomnia. In some instances an outbreak is characterized by the development principally of vesicles or pustules, but multiformity of lesions is the rule, vesicles, bullae, and pustules being observed in different localities. The lesions vary greatly in size, some being as small as a pea, others as large as a hen's egg. The contents of the vesicles and bullae are either clear or turbid, and not infrequently become purulent. Papillary growths or cutaneous haemorrhages are sometimes observed. It is remarkable that the slightest pressure may excite a fresh eruption. The erythematous patches are, in the beginning, of a dark-red or purplish color. The disease extends sometimes irregularly and capriciously, at other times with the utmost regularity. The regions of preference of the affection are the upper and lower limbs, and it is particularly apt to develop in the bend of the elbow or knee. The lesions readily rupture or are picked open by scratching, and brownish crusts form, which cover excoriations. After subsidence of the eruption the skin remains for some time infil- trated and pigmented. The process is superficially situated, and cica- trices are never left except as a result of excoriations produced by scratching or in consequence of an outbreak of furuncles, which are not uncommon in dermatitis herpetiformis, especially in the interval of at- tacks. The pigmentation remains for a long time. Itching is in some cases confined to the affected patches, while in others it is experienced over the entire body. Notwithstanding the severity of the local manifes- tations the general condition of the patient remains comparatively good, although in some cases there has been general debility and the disease occasionally terminates in death. The disease is essentially of a chronic nature, and exhibits a marked tendency to relapse at the end of some Aveeks or months. Dermatitis herpetiformis may occur in young in- fants, and is then described by Leloir and Vidal as a special variety of the disease. In infancy the lesions exhibit less polymorphism, and prin- cipally assume the form of papular erythema with vesicles or bullae, the contents of which are free from pus. Attacks recur during childhood, EXUDATIONS. 4155 and most frequently during the summer months. The general health is impaired even before manifestation of the eruption, and pain is a more prominent feature than pruritus. Male children are probably more subject than females to this affection. Toward the age of puberty attacks become less frequent and less severe, and they may entirely disappear during adult life. The process above described bears a closer resemblance to hydroa, or pruriginous pemphigus, than to any other malady. It seems doubt- ful, in fact, whether they should not be regarded as identical. Derma- titis herpetiformis appears more rebellious to treatment than hydroa is generally found. From pemphigus dermatitis herpetiformis is distin- guished by the polymorphism of the eruption, the intense itching, and the longer duration of individual lesions. It differs from erythema multiforme in the prevalence of bullae, its chronicity, and itching. We have no definite knoAvledge as to the cause of the affection, though it seems to be connected with a disturbed condition of the nerv- ous system, an attack not infrequently being preceded by depression of spirits, grief, or anxiety. The disease may occur at any period of life. No special micro-organism has yet been detected in the lesions, and experiments relative to auto-inoculation have proved negative. It has been observed in connection with pyaemia, tuberculosis, and disease of the cerebro-spinal nervous system. Treatment.—This affection is singularly unamenable to treatment, either local or general. Our efforts should be directed toward main- taining the strength of the patient by means of a nutritious and easily digestible diet, together with tonic remedies, such as strychnine, iron, and the vegetable bitters. Arsenic is of but little, if any, value, though Brocq regards the arseniate of sodium as of advantage, given in increas- ing doses and pushed to the limits of tolerance. He also mentions ergotin, cod-liver oil, asafoetida, valerian, and belladonna as worthy of trial. The iodide of potassium seems to aggravate the condition. We may have recourse, likeAvise, to castor or musk in order to allay restlessness and insomnia. Chloral, opium, and cannabis Indica have also been given for the same purpose. The hydrobromate of quinine, four to eight grains daily, combined with small doses of extract of bel- ladonna, has also been recommended. Coffee, tea, tobacco, and alcohol should be prohibited, as well as those foods which, like straAvberries and shell-fish, have a tendency to produce eruptions upon the skin. On the other hand, a milk-diet is advisable. The activity of the secretions should be sedulously promoted. Topical applications must be of the blandest character. When the disease is very extensive and excoriations are abundant the continuous warm bath may afford relief, as in a severe case reported by Ravogli. This writer inclines to think that ichthyol, used internally and externally, is of more avail than any other drug. Duhring has sometimes found the employment of sulphur of serv- 30 466 DISEASES OF THE SKIN. ice. Among other applications which may be used in the local treat- ment with more or less success may be enumerated lotions containing carbolic acid, menthol, corrosive sublimate, hydrocyanic acid, borax, cocaine, ointments of oxide of zinc, oleate of bismuth, dusting-powders such as starch, talc, oxide of zinc, subnitrate of bismuth, etc. The glycer- ole of starch, cod-liver oil alone or with the addition of a small quantity of oil of cade or beta-naphthol, may also be used with some benefit. Prognosis.—Dermatitis herpetiformis, though exceedingly stubborn, has, in this country, rarely proved fatal, though Hebra and Kaposi have observed cases which terminated in death. Dermatitis Epidemicus.—Dr. Thomas D. Savill, of London, Medical Superintendent of the Paddington Infirmary, has described * an eruptive disorder which he had observed in that institution. The lesions were accompanied by constitutional manifestations. The cases were 163 in number, being nineteen per cent, of the inmates of the infirmary and sick-wards of the adjacent work-house. Examples of the same malady also occurred at the Marylebone Infirmary, St. Mary's Hospital, Western General Dispensary,f and at other places. Symptoms.—The characteristic eruption was a dermatitis, at times attended by the formation of vesicles, and in other instances free from any obvious exudation—a dermatitis humida, and a dermatitis sicca. Most of the cases belonged to the moist variety. A feAv presented a mixed type, the several varieties being simultaneously present upon different portions of the body. The moist generally ran a more rapid course than the dry form, and the quantity of exudation was at times profuse. Intense burning and itching accompanied the eruption. The onset Avas often rather abrupt. Considerable variation was observed in different cases in regard to- the extent and distribution of the rash. The eruption frequently began upon the flexures of the joints and between folds of the skin, as the mammae and behind the ears. It was often first seen upon the face. The parts first attacked did not, how- ever, correspond to those which are most open to the action of local irritants. Some patients suffered from conjunctivitis with oedema of the eyelids. The first manifestation usually appeared in the form of papules, the intervening skin being erythematous. Some of the cases began with the formation of serpiginous rings. The eruption some- times remained localized within narrow limits, while in others it cov- ered an extensive surface or even became universal. The invaded skin was decidedly thickened, especially in the more severe cases. Fissures often resulted. In many of the cases the cervical glands were enlarged. Desquamation in the form of scales or flakes followed the fading of the rash. In one case the entire cuticle of the palm and palmar surface of the fingers was shed. Falling of the hair took place in some in- stances even when the scalp had not been implicated. Desquamation * British Medical Journal, Dec. 5, 1891. f British Medical Journal, Jan. 30, 1892. EXUDATIONS. 467 also occurred in parts which had not been the seat of eruption. In some cases the nails were lost. Recrudescence of the rash was some- times observed after the skin had begun to heal, but true relapse was infrequent. Most of the patients presented marked constitutional dis- turbance, Avithout, as a rule, the occurrence of fever. The tempera- ture was not raised except when the eruption reached its height and covered a large surface. With this exception the temperature was apt to be below normal. The gravity of the systemic manifestations corresponded to the extent of the rash. The appetite failed and the strength diminished. The tongue, generally coated in the beginning, subsequently lost its epithelium. Vomiting, diarrhoea, and muscular tremors accompanied some cases. In one, wrist-drop and suppression of urine preceded death for a few days. Albuminuria occurred in about half the cases. Serious maladies, such as meningitis and gan- grene of the feet sometimes existed as complications. The disease proved fatal in 12-8 per cent, of the cases. The immediate cause of death Avas, as a rule, asthenia, but in some instances coma. The dura- tion of the malady was from six to eight Aveeks. Diagnosis.—The gradual deA'elopment, absence of fever, the forma- tion of vesicles upon some parts of the body, distinguished this affection from erysipelas. Some cases began with scattered macules, which bore a strong resemblance to those of rotheln, but the persistent nature of the rash, its subsequent scaly character, and the apyrexia, Avere features in which the malady differed from rotheln. The disease presented a much closer likeness to pityriasis, but the epidemic character, the preference for old people, and the moisture of its lesion, are thought by Dr. Savill to constitute it an independent disorder. From eczema he would separate the affection by the following points: The greater thickening and inflammation of the skin, the exfoliation of large flakes, the definite course, the age of the patients, and its epidemic nature. Pathology.—The lesion was an inflammation of the derma. A con- siderable effusion of cells and fluid was interposed betvveen the derm and epiderm. Even in the dry form secretion could, by the aid of a lens, be discovered upon the under surface of the flakes. The changes in the derma consisted, in the earlier stage, of a large excess of leucocytes; in the later stage, of a large excess of fibrous tissue. In most of the fatal cases hypostatic congestion of the lungs was found. Etiology.—Age Avas a predisposing cause, most of the sufferers being in advanced life. Children, though exposed to the same influences, usually escaped. Men Avere more subject to attack than women, and the disease Avas in males more severe and more frequently fatal. Oc- cupation seemed to furnish no predisposition. Previous ill health had a decided influence in its production. The greatest number of cases occurred in July and August. 468 DISEASES OF THE SKIN. The epidemic and in all probability contagious nature of the dis- order suggested that it might depend upon the activity of a micro- organism. Serum taken from the lesions was examined under the microscope and numerous culture experiments were made. Cocci were abundantly present in the serum. Their appearance was that of the staphylococci, but certain peculiarities in their mode of groAvth left it uncertain whether they should be considered identical with that organism. Treatment.—Local measures proved of but little avail. When once established the lesions seemed unamenable to treatment. In an early stage of development antiseptic applications, such as creolin, were beneficial. It was noticed in some cases that patches did not enlarge if covered with collodion. Tonic and stimulant remedies were de- manded on account of the depression, and it was necessary to promote elimination by reason of the tendency to renal failure. COMBUSTIO. Synonyms.—Dermatitis combustionis—Burns—Scalds. Burns and scalds are inflammations of the skin, and occasionally of the deeper structures, the former being due to the action of dry and the latter to that of moist heat. Symptoms.—Burns may be divided, according to their degree, into three varieties : dermatitis ambustionis erythematosa, dermatitis ara- bustionis bullosa, and dermatitis ambustionis escharotica. Dermatitis Ambustionis Erythematosa,—The erythematous variety is the result of exposure to the rays of the summer sun, or contact Avith steam, flame, ignited gases, or heated solids or liquids. The surface is reddened, slightly swollen, painful, and may be the seat of a few small vesicles. All the symptoms disappear in a few days, to be succeeded by more or less desquamation of the epidermis. Dr. Robert Bowles, from a study of sun-burn in the presence of snow, concludes that the effects are not due to mere heat, but to the radiation of violet or ultra-violet rays from the surface of the snow. These chemical rays are decomposed into heat-rays in passing through the epithelial layers of fair skin. The action upon the integument may be prevented by painting the face brown. Dermatitis may be caused by exposure to the Rontgen rays. Pic- mentation and swelling of the skin, falling of the finger-nails, and loss of hair may occur under their influence. Conjunctivitis has also resulted. Dermatitis Ambustionis Bullosa.—The bullous variety of burns and scalds is due to a more prolonged contact with one of the above forms of heat. The pain is intense, the inflammation marked, and great serous exudation occurs, elevating the epidermis, forming blisters and bullae of all sizes and shapes. The serum poured out presumably contains fibrinogen, since it is capable of becoming solidified. Coagu- EXUDATIONS. 46<) lated serum is, in fact, as Mr. Heath points out, sometimes seen beneath the intact epithelial layer of the blister. As the result of an increased escape of serum, or from external violence, a few or many of the lesions; may rupture, and the epidermis lie in rolls or hang in shreds, with the- inflamed corium visible beneath. The neighboring glands become swollen and painful. Under the most favorable circumstances the serum may be absorbed, the blebs drying into crusts, which drop off, exposing a thin epidermis beneath. In other cases repair takes place by granulation, cicatrices seldom resulting unless the corium is destroyed. Scald of the larynx is not an infrequent accident among the children of the poor whose parents are obliged to leave them alone for many hours, and who, from thirst, are led to drink boiling water from the tea-kettle. CEdema occurs within a few hours, with dangerous obstruction to respira- tion. Dermatitis Ambustionis Escharotica.—The escharotic form of burns and scalds is the result of exposure to an intense or continuous degree of heat occasioning death of the skin, with possibly the deeper parts. The integument in some cases presents a brown, black, or a smooth, white, gray, or yellowish appearance. It may also be hard, dry, or moist, and without the least sensation. In more severe cases, the integument and the subcutaneous muscular fibrous tissues, and even the bones, are completely carbonized. The skin surrounding the eschar is reddened, swollen, and painful. The depth of the destruction of the tissue can not even be surmised from the appearance of the sur- face. Pain Avhich may be present at the time of the burn is generally slight, or may disappear, to be soon succeeded by severe or intolerable suffering. Reactive inflammation follows from about the third to the fifth day, after which the line of demarcation forms, separating the mortified mass from the living part. The eschar is generally cast off in from ten days to two weeks, to be followed by the formation of granula- tions. Healing occurs by the formation of fibrous connective tissue, which is destitute of nerves and glands, and which by its contraction frequent- ly produces hideous cicatrices. This form of burn occurs usually from the direct effect of flame, molten metals, electricity, caustic lime, boil- ing liquids, steam, or ignited gases. Constitutional Symptoms.—The erythematous variety may be at- tended with mild fever. The second, or bullous, form is usually accompanied by severe fever and great systemic disturbance. It is exceedingly dangerous in the debilitated, in children, and in old per- sons, especially if a large portion of the skin is involved. In fact, the involvement of one third of the cutaneous surface by burns or scalds is invariably fatal, and for one fourth of the skin to be affected is al- 470 DISEASES OF THE SKIN. most equally dangerous. A patient having such an extensive burn suffers very much at the time of the accident, but after the surface has been dressed may appear comparatively comfortable. The urine is often retained, and if an attempt is made to draw it off, not any or but little can be obtained. In severe cases, in the course of from six to thirty-six hours a comatose condition appears, the tempera- ture declines several degrees, the pulse becomes small, the respiration rapid, the extremities cold, vomiting may take place, and the coma end in death. Sometimes restlessness and delirium may occur, with clonic spasm and opisthotonos. Haemorrhage has been known to fol- low at times from the various mucous surfaces. Dr. A. Wagenmann relates* a case in which three weeks after the occurrence of extensive burns double retinitis haemorrhagica was observed. This serious conse- quence is more apt to take place when the burn involves the anterior surface of the body. Death may occur in the course of forty-eight hours from shock, or at a later period from erysipelas, pyaemia, tetanus, pneumonia, or other complications. In a certain number of cases in- flammation, or even ulceration, of the duodenum may occur in conse- quence of a burn. The ulcer may cause perforation and fatal haemor- rhage, and may develop within three or four days from the time of the accident, or may not appear for many weeks. Pathology.—The red corpuscles of the blood are, in severe burns, changed in form, and their vitality is impaired or even destroyed. Ac- cording to Silbermann's investigations, numerous thrombi, both arte- rial and venous, result from the altered form of the corpuscles and stasis of the circulation in many organs, particularly the lungs, kid- neys, stomach, intestines, spleen, liver, skin, and brain. Thrombi are most numerous in the smaller branches of the pulmonary arteries. This circumstance embarrasses the action of the right ventricle, and gives rise to general venous stasis, Avith, on the other hand, arterial anaemia. The alteration of the circulation explains the haemorrhages and lesions Avhich take place in different organs, as well as the dyspnoea, cyanosis, coma, eclampsia, anuria, and lowered temperature of the skin.f Silbermann's conclusions are corroborated by Frankel, who found in the convoluted tubules and loop-tubes of Henle a finely granular and strongly refractive material. The tubules are occluded by degenerated epithelium combined with masses of haemoglobin. Dr. Hunter, in a communication J to the Pathological Society of London, January 7, 1890, suggests that the duodenitis may be occasioned by the irritant action produced by the products of destructive tissue change eliminated by the bile. Dr. Emil AVelti, of Zurich, attributes the formation of parenchymatous lesions to an accumulation of the blood-plaques de- scribed by Bizzozero. Dr. J. Salvioli, of Turin, studying the action of * Medical Bulletin, Aug., 1889, p. 25. f Centralblatt fur med. "Wissenschaft, 28, 1889. X Lancet, January 11, 1890, p. 81. EXUDATIONS. 471 heat upon the exposed mesentery of living animals, found that a depo- sition of blood-plaques took place upon the walls of the blood-vessels. lie furthermore observed an alteration in the vessels themselves, and a certain change in the form of the red blood-corpuscles. According to this investigator, the thrombi and emboli are formed by blood-plaques, which have been detached from the walls to which they had adhered and swept into the circulation. Treatment.—In the most severe form of burns the constitutional symptoms demand immediate attention; the depression, shock, and pain should be relieved by a full dose of opium (a hypodermic of morphine being preferable); a hot, stimulating drink of ginger-tea, or whisky or brandy, is also valuable. After the patient has been made locally comfortable, the opiate and stimulants should be continued, to- gether with full doses of quinine and plenty of nutritious broth. The preparations of ammonia, especially the aromatic spirit and the carbonate, in full doses, frequently repeated, will be serviceable, especially if there is profound depression or shock. Locally the pain of the erythematous variety can be immediately relieved by applica- tions of cold water, lead-water, and laudanum, a solution of cocaine, or a three-per-cent. solution of creasote or carbolic acid, or a saturated solution of bicarbonate of sodium. The carbonates of lead and zinc, the nitrate of lead, and the subnitrate of bismuth are also beneficial, and may be used either as a dusting-powder or ointment. Some prac- titioners employ a solution of nitrate of silver, ten grains to the ounce, painted upon the affected surface. This certainly protects the area from the air, but is open to the objection that it blackens the skin and is not attended by -any compensating advantage. Mr. Christopher Heath is fond of using a mixture of one part of collodion to two of castor-oil for face burns. Both flexible collodion and solution of gutta percha are beneficial, by exercising gentle compression and excluding air. Relief is also given by the application of the fluid extract of Ja- maica dogwood. Plantain leaves made into a paste by bruising in a mortar are said to be an efficient remedy. In the bullous variety the healing process may be hastened by pricking the blebs, permitting their contents to run out, but retaining their covering as a protection to the corium beneath. Any of the lotions, ointments, or powders above suggested may then be applied to the affected surface. At the Friedrichshain Hospital, of Berlin, Bar- deleben gives the preference to finely powdered subnitrate of bismuth, which is freely dusted upon the surface after the bullae have been opened and the part thoroughly washed with two and a half or three per cent, carbolized water or a solution of salicylic acid, three parts in 1,000. Aristol is an excellent dressing to erythematous or bullous burns. It may be applied in the powder form or made into an oint- ment. Lanolin with ointment of rose-water may very effectively be 472 DISEASES OF THE SKIN. used as an excipient, and cocaine incorporated for its anaesthetic effects. The ointment of aluminium oleate may be mentioned as a good dress- ing. Zinc, lead, or borax ointment, with arrow-root, may suffice in some cases; while in others, olive-oil, alone or with a small quantity of mer- cury or carbolic acid, may be more acceptable. Equal parts of linseed- oil and lime-Avater form an old and valuable application. An ointment containing europhen is beneficial. Tannic acid is said to relieve pain and promote healing. The epidermis having been removed, a five-per- cent, solution is expressed from a sponge, and the part dressed with some ointment either with or without tannin. According to Grigoresen, the application to the affected surface of pure glycerine, though it may at first cause smarting, soon gives rise to local anaesthesia and allays inflammation. Dr. Zubofl recommends compresses moistened in a solu- tion of permanganate of potassium. Other substances beneficial in the erythematous and bullous varieties are grindelia robusta, a drachm of the fluid extract to four or six ounces of water; hamamelis ointment, fifteen or twenty grains to the ounce; and a wash containing fluid extract of phytolacca. A strong solution of Epsom salt is also said to relieve rapidly the pain, heat, and swelling. It has been recently ascer- tained that picric acid has the same effect. It is used in strong solu- tion, and the yellow stains which it leaves may be removed by washing with boric acid. Potassium nitrate is recommended by Dr. Poggi in burns of all degrees. M. Vergely has successfully used, in erythematous and bullous burns, calcined magnesia, made into a paste with water. A. Bilder, of Berlin, reports favorable results from the use of a mixture of equal parts of thiol and water. In the escharotic variety the clothing should be removed and the patient placed u])on some soft fabric. Detached or charred fragments should be snipped off, and any of the remedies previously mentioned gently applied. If the part involved is extensive, oil, alone or combined with a powder dusted over the surface, may be used to create a protect- ive coating. Carbolized or salicylated cotton, lint, gauze, or borax lint, Avill also be useful. The dressing should not be changed too frequently. Spraying with a two-per-cent. solution of cocaine hydrochlorate will facilitate the dressing, while it scarcely exposes the sufferer to the dan- ger of constitutional effects. The condition of the surface should be carefully watched, the dressing renewed once in twenty-four to forty- eight hours, or even oftener, should the discbarges become copious and troublesome. The continuous water-batb, as employed by Hebra, may be resorted to occasionally Avith benefit. In bullous or escharotic burns the application of iodoform according to the method of Von Mosetig- Moorhof has proved very efficacious, especially in the relief of pain. The bullae are opened, the surface cleansed with a very Aveak solution of common salt, several layers of iodoform-gauze are placed upon the burn, and the whole covered Avith a layer of oil-skin. This dressing is EXUDATIONS. 473 not changed for one or even perhaps two weeks. After the eschars have separated, resorcin in a one- or two-per-cent. solution is preferred by M. Hebra to iodoform. Dr. J. G. Carpenter reports two cases in which ice-Avater Avas successfully used. Soft linen cloths saturated in ice-water were kept constantly applied to the surface, renewed every ten or fifteen minutes for twelve hours, then every hour or two for twenty-four hours, and every two or three hours for a further period of twelve hours. The patients suffered from no pain, and in forty-eight hours the burns Avere virtually cured. Sozoiodol is recommended as a substitute for iodoform. The former allays pain, prevents suppuration, is free from odor, and does not cause systemic poisoning. After the vesicles have been punctured and their contents have escaped, a mix- ture of sozoiodol (ten-per-cent.) and starch is dusted upon the surface and a bandage applied. Ulcerated surfaces or exuberant granulations may be overcome by stimulating ointments, the application of solid nitrate of silver or sulphate of copper, or by skin-grafting. Thiersch's method of grafting is particularly appropriate to the treatment of large ulcers caused by burns. The resulting scars exhibit much less than the usual tendency to contraction. An excellent and often effective remedy is powdered red cinchona bark. Old, obstinate ulcers may be induced to take on healthy action by the application of the infusion of jequirity. Scars, which frequently remain, may be removed by massage, galvanism, the application of collodion, or by surgical pro- cedures. In oedema of the larynx from a burn or scald the inhalation of ether, ethyl iodide, nitrite of amyl, or chloroform with creasote, may be of service. Scarification of the part may also be practiced, and, if relief will not follow this procedure, resort may be had to laryngotomy. CONGELATIO. Synonyms.—Dermatitis congelationis—Frost-bite. A frost-bite is a dermatitis, or an inflammation of the skin, with occasionally the involvement of the deeper tissues—the result of the action of cold. Symptoms.—Healthy persons must usually be subjected to long and excessive exposure to cold before inflammation of the skin supervenes. Anaemic and debilitated cases, however, frequently suffer from frost- bites at a temperature at which healthy individuals are not in the least affected. Frost-bites may disappear with return of health, but more frequently the inflammation lingers long after the exciting cause has been removed, disappearing with the advent of spring and summer, to return in fall and winter, or upon the slightest change in the atmosphere. The chief local symptoms of frost-bites are redness, heat, itching, an intolerable smarting or burning sensation in mild cases, and high inflammatory action and often absolute loss of sensa- 474 DISEASES OF THE SKIN. tion in the affected part in severe cases. They may be divided into three classes, or degrees, as follows: Dermatitis congelationis erythematosa, dermatitis congelationis bullosa, and dermatitis congelationis escharotica. Dermatitis Congelationis Erythematosa.—Frost-bites of this form generally occur on the most exposed parts, as the hands, feet, ears, cheeks, and nose. Previous to their development the affected skin, owing to the contraction of the blood-vessels, is pale and want- ing in sensation ; but on the cold abating, or the patient passing into a warm atmosphere, the vessels dilate, the part becomes livid, and often pains, burns, smarts, or itches. The local symptoms, therefore, are not much noticed during the day unless the person is in a heated room, but are decidedly annoying in the winter evenings when near the fire or after retiring. The skin may not only be reddened, but it may be exceedingly thin, shining, and swollen from serous infiltration. Blis- ters may develop from friction or scratching, and finally degenerate into one or more indolent ulcers. A case has been recorded by Taen- zer, in which an individual had suffered for twenty years from " chil- blain of the lip." The affection, which recurred every winter and dis- appeared in the spring, was attended by fissures, desquamation, and pruritus. Dermatitis Congelationis Bullosa.—This more severe grade of the disease is the effect of prolonged subjection to moderate cold, or comparatively brief exposure to excessive cold. The inflammation is more intense, leading at once to great serous exudation, with the for- mation of blebs of varying sizes filled with a clear or bloody fluid. Ulceration of the affected parts may follow and extend even to the bone. The pain and itching are violent, and great oedema of the sur- face is present. Dermatitis Congelationis Fscharotica.—This is the most severe form of frost-bite, and is observed especially among drunkards and those who have been exposed for a long time to the action of moist and intense cold. The skin is usually the seat of large blisters, containing blood, with perhaps mortification of the tissue beneath. If no blisters have formed, the part involved is livid or white in color, cold and insensible, the circulation being suspended or absolutely destroyed. If the vitality of the part be only interrupted, upon its restoration all the symptoms of severe inflammation follow, or, as is more common, gangrene results, and the usual line of demarcation occurs. Pyaemia or septicaemia may develop in this form of frost-bite and result in death. Constitutional Symptoms.—The systemic effect of excessive or long- continued cold is, first, stimulation, to be followed by a dull and heavy sensation, with an intense desire to sleep, Avhich, if yielded to, will result in coma and death. Treatment.—Constitutional remedies are of the greatest value. If EXUDATIONS. 475 anaemia exist, tincture of the chloride of iron and other ferruginous preparations are of the utmost service. Patients predisposed to chil- blains should receive a nutritious diet, be warmly clothed, especially Avith flannels, woollen gloA'es, and stockings, and avoid all exposure, if possible, to cold. It is advisable that socks or stockings should be changed as soon as they have become damp, and it is Avell that they should be washed, or, at least, thoroughly dried before they are again Avorn. Strumous children are particularly susceptible to the influence of cold, and it is therefore advisable to strengthen their systems by the frequent use of cod-liver oil, malt, and sirup of the iodide of iron. Brocq speaks favorably of the administration throughout the winter months of pills containing sulphate of quinine, ergot, digitalis, and belladonna, the remedies being from time to time suspended. Those who have great systemic depression or suspended animation from excessive or long-continued exposure to cold should be treated as fol- lows : The use at once of hot applications all over the body, or the hot bath; covering them with hot blankets; hot drinks, if they can be taken ; moderate massage or friction; and prolonged artificial respira- tion, if life has been apparently destroyed. Local Treatment.—Opinion is divided in reference to local treat- ment, some believing that the frost-bitten surface should be vigorously rubbed with snow or cold water, in order to avoid producing reaction too rapidly ; others claiming that hot applications, used at once to the skin, are the most efficacious. The experiments of Laptchinkski upon frozen dogs show that, "of tAventy animals treated by the method of gradual resuscitation in a cold room, fourteen perished ; of twenty placed at once in a vvarm apartment, eight died ; while of twenty im- mediately put into a hot bath, all recovered." Applications at once of hot water to the affected area will be most acceptable in the majority of cases, especially if the part has been frozen. Occasionally cold applications act better. The drugs and com- binations recommended are numerous, but few of them are effective. All remedies are, however, always more decided in their action when the circulation of the part is not interfered with by the use of tight apparel and close-fitting boots or shoes. The tincture of myrrh and the compound tincture of benzoin, in equal parts, form, for ordinary cases, an excellent application. An ounce and a half of the compound tincture of benzoin, with half an ounce of spirit of chloroform, is also valuable. Cocaine hydrochlorate, one to ten grains to the ounce of peppermint-Avater or dilute nitric acid, may be painted over the surface with good results. The tincture of aconite often gives relief. The following are useful applications : R Olei camphorae.....................in, x- Bals. Peruv........................f 3 j. Scvi...............................ij. M. 476 DISEASES OF THE SKIN. R Lanolini.......................... § ss. Naphthol......................... gr. xv. Olei terebinthinae.................. f 3 ss. M. R Lanolini.......................... § ss. Acidi carbolici..................... gr. iij. Pulv. camphorae.................... 3 ss. M. Balsam of copaiba, collodion, tincture of iodine, and weak solutions of corrosive sublimate, alone or combined Avith other remedies, are like- wise valuable. Mercurial ointment, or creasote ointment, petroleum, and turpentine have been used Avith more or less advantage.. The oil of cajuput diluted with olive-oil, the tincture of capsicum, alone or mixed with equal parts of mucilage of gum arabic and a tincture of rhus toxicodendron (one to tAvo of alcohol), half a drachm in a pint of water, have also been recommended. Prof. Boeck, of Christiania, rec- ommends resorcin when the skin is unbroken. When ulceration super- venes, the following combinations will be of benefit: R Bals. Peruv........................ f 3 j. Ungt. hydrarg. nit................. 3 ij. Zinci carb......................... 3 j. Ungt. aquae rosae................... § j. M. R Ungt. plumbi subacetatis........... | ss. Ext. arnicae....................... 3 ss. Ext. cocae......................... 3 ss. 01. anthemidis.....................Tt[ v. Ungt. aquae rosas................... | ss. M. Besnier and Brocq recommend that, after the part has been bathed in a decoction of walnut leaves, it is dried and rubbed with camphor- ated alcohol, after which it is covered with a poAvder consisting of one part of salicylate of bismuth to nine parts of starch. To alleviate itch- ing, they rub the surface with equal parts of glycerine and rose-water containing about half a grain of tannin to the ounce; the powder is then reapplied. As a dressing to ulcers they employ walnut leaves soaked in warm water. The value of agaricus muscarius in frost-bite is eulogized by a writer in the " New York Medical Journal" for Jan- uary, 1891. He uses it both internally and externally, an alcoholic solution containing one tenth of the drug being applied to the affected surface and a tablet of the one-tenth dilution given per orem every two hours. Alum, borax, weak solutions of nitrate of silver, oil of turpen- tine, and cantharides have also been used with advantage. The oint- ment of aluminium oleate, nut-gall, or tannic acid, sulphurous acid, one or two drachms to the ounce of water, or glycerine and water, or an ointment containing storax, are applications which may be service- able under the same circumstances. If gangrene occurs, the sloughs should be cut away as soon as the line of demarcation is formed, and the healthy granulating surface dressed with a mild stimulating ointment. HYPERTROPHIES. 477 CLASS V. HYPERTROPHIES. (Hypertrophic.) LENTIGO. Synonyms.—Freckle—So mmersprosse. Lentigo is an excesshe deposit of pigment in the skin, appearing as small, round, or irregular-shaped pin's-head or pea-sized, yellowish, brownish, or blackish spots, situated commonly on the face and the dorsal surface of the hands and arms. Symptoms.—This familiar affection is observed as small, round, or irregularly-shaped spots, varying in size from a pin's bead to a small pea. They vary in color from a light yellow to a yellowish brown or black, and often, when largely distributed, give the skin a dirty or dis- figured appearance. The lesions may be either isolated or aggregated, and tend to coalesce. Their favorite seat is the face, particularly the forehead, nose, and cheeks, but they also appear in numbers upon the backs of the hands, neck, shoulders, and forearms, and other portions of the skin which are uncovered and exposed. They are, however, ob- served at times upon regions of the body which are covered, as the buttocks and penis. They occur in both sexes and at all ages, but are seldom seen before the third year. Persons with fair skins, and par- ticularly those Avith red hair, are especially liable to their development; nevertheless, they appear in brunettes and mulattoes. Freckles are usually more conspicuous in summer, as at that season they generally appear, lessening or disappearing in the winter, often to reappear the following summer. In some cases, however, they are influenced neither by light nor heat, and are as intense in color in Avinter as in summer. Freckles are unaccompanied by subjective symptoms. They are chronic in course, continuing for years, but with advancing age they may dis- appear permanently. They may occur as the result of, or in connec- tion with, other skin diseases. Pathology.—A freckle is shown by microscopical examination to consist essentially of a circumscribed collection of normal pigment in the rete mucosum. Chloasma differs from it simply in the shape and size of the patches. Etiology.—The disease is not due to any constitutional disorder, and is in some cases probably the result of slight peripheral nervous dis- turbances. Heat, especially that of the sun, and the high Avinds of the spring and fall months, are exciting causes. Treatment.—The treatment of freckles consists in the application of a mild stimulating or caustic agent, Avhich will either excite the skin 478 DISEASES OF THE SKIN. to healthy action or will destroy the affected areas, and thus cause the epidermis to be reproduced in its normal condition. Copper oleate, in from five to sixty grains to the ounce of lard, lanolin, or rose-water ointment, is an excellent combination. Salicylic-acid ointment, five grains to the ounce, is also valuable. Corrosive sublimate, in from two to five grains to the ounce of a fatty base, or in water, is an effective application. A preparation composed of one drachm each of white precipitate and subnitrate of bismuth and four ounces of glycerite of starch has also been recommended* for the same purpose. Electrolysis has been used, the needle being superficially inserted over the freckle. Galvan- ism may also be applied frequently to freckles with the most decided effect. Another useful method consists in touching each spot with strong carbolic acid ; as a result of this the epidermis within a few days peels off, leaving a slightly red but clear skin, which soon becomes per- fectly normal. The tincture of myrrh and a decoction or fluid extract of smart-weed (polygonati radix) ha\re likeAvise been employed for the purpose of removing freckles. The folloAving combination has been employed with good result: R Zinci oxidi......................... 3 ij. Hydrargyri chlori corros............ gr. iij. Aquae hamamelidis dest............ f 3 ij. Glycerini......................... f 3 iij. M. Sig.: Apply once a day. Freckles may also be removed by the use of the following lotion : f R Zinc, sulpho-carbolat................ 3 j- Glycerini..........................f 3 ij. Sp. vini rectif.....................f § j. Aquae amant. flor...................f § jss. Aquas rosae..................q. s. ad. f | viij. M. CHLOASMA. Synonyms.—Liver-spot—Moth. Chloasma is a pigmentary disease, attended with partial or general discoloration of the skin, but usually appearing as one or more smooth, yellowish-brown or blackish patches, round or irregular in form and size. Symptoms.—Chloasma is simply the result of an abnormal deposi- tion of pigment in the rete mucosum. It may involve part or all of the surface. It usually appears as one or more smooth patches, of various shapes and sizes, but commonly round or irregular in form and moderately well defined. Their color may vary from light or dark yel- low to brown or even black (melasma, melanoderma). They may be * L'Union Medicale, March, 1889. f L'Union Medieale, March, 1889. HYPERTROPHIES. 479 either idiopathic or symptomatic. The former are due to external causes, which occasion long and continued determination of blood to the skin, as scratching in eczema, scabies, and urticaria, the discolora- tion following being somewhat diffuse, and of a grayish or brownish hue. Injuries from blows and wounds, friction and pressure from clothing, shoes, trusses, belts, and other substances, the action of chemi- cals and the use of sinapisms and blisters, may occasion either a slight or severe discoloration. Heat and cold, as from the sun's rays, fires, frost-bites, and high Avinds, are all active agents in bringing about pig- mentary changes of the skin. The symptomatic form of chloasma occurs as the result of various changes of the system, and of diseases of the internal organs, as tuber- culosis, cancer, malaria, syphilis, and uterine and ovarian affections. The pigmentation may be circumscribed, general, or diffuse, varying from a pale brown to a brownish olive or bronze hue. The discolora- tion is more conspicuous upon those parts in which there is a natural tendency to it, as on the face, dorsal surface of the hands, axilla;, nipples, genitals, and even the hair. Chloasma may likewise appear during the course of scleroderma, morpho'a, senile atrophy, etc. The most frequent of the symptomatic chloasmata. which require special mention are those Avhich develop from uterine and ovarian affections, and which will be described as follows: Chloasma Uterinum.—This form of the disease usually involves the face, especially the temples, forehead, and eyelids. The pigmenta- tion may be slight or severe, but is particularly marked in those of a dark complexion. The disease may be transient, disappearing within a short time, or it may remain permanently. It generally occurs as one or more patches, of all forms and sizes, upon the forehead, frequently extending continuously or interruptedly from temple to temple, and from the scalp to above or beloAv the eyebrows, or to and upon the lids; the trunk, particularly about the nipples, may at times also be involved. The patches vary in color from a pale or muddy yelloAv to a broAvn, and they may be well or poorly defined, occasionally passing indistinctly into the surrounding healthy skin. The surface is, as a rule, smooth and natural, but seborrhoea may occasionally exist at the same time. The patches may, especially during pregnancy, be so ex- tensive as to cover the Avhole region, or almost the entire surface, giv- ing it a diffuse discoloration which may be mistaken for the healthy skin, while that of the normal tint which remains may be regarded as diseased. Chloasma uterinum may occur in both married and single women, but is seldom observed after the climacteric period. It appears par- ticularlv in connection Avith hysteria, pregnancy, and various uterine and ovarian affections, as amenorrhoea and dysmenorrhoea. It usually disappears upon the removal of the exciting cause. 480 DISEASES OF THE SKIN. Diagnosis.—Chloasma is liable to be confounded with chromophy- tosis or tinea versicolor. In chloasma the patches are usually single, unless the disease is general, appearing mostly on the face, while in chromophytosis they are multiple, rarely invade the face, but commonly occur on the trunk. The surfaces of the patches of the two affections are likewise dissimilar, those of chloasma being smooth and exhibiting no alteration in structure, while those of chromophytosis are hyperae- mic and furfuraceous, as shown by scraping the parts with the finger- nail. The microscope demonstrates chloasma to be pigmentary, and chromophytosis to be parasitic. Lastly, the patches of chloasma, hav- ing become fully formed, spread slowly, if at all, and have rarely any subjective symptoms; on the other hand, chromophytosis usually de- velops rapidly, and is commonly attended with itching. Pathology.—The seat of the pigmentary deposit is the rete mu- cosum. Etiology.—The affection appears at all ages and in both sexes, but is more common in women. Disorders of the internal organs, malaria, and certain blood affections, particularly anaemia, are its most frequent exciting causes. It may also be produced by profound excitement, and many nervous diseases. Local irritation or inflammation may produce the disease, as, for example, the pressure of a hat, bonnet, or a band, or it is the result of eczema, erysipelas, and other cutaneous affections. Treatment.—The treatment applicable in lentigo is also suitable in chloasma. The general or local cause should, if possible, be removed, in order that the topical applications may act effectually. As the pig- ment is deposited in the rete cells, the object of the local treatment is to destroy the epidermis containing them and thus remove the deform- ity. In selecting local remedies avoid the use of mustard, mineral acids, cantharides, croton-oil, or any other substances which may cause pigmentation. Among the many suitable drugs are the tincture of iodine, acetic and carbolic acids, mercurials, the alkalies, especially caustic potash, and the potash and soda soaps, veratrina, and copper oleate. The pigmentation may be easily removed by touching the spots with strong acetic or carbolic acid. Hebra's method consists in dissolving five grains of corrosive sublimate in an ounce of distilled water, alcohol, or collodion, and applying it by means of a compress to the affected part for four hours. A blister results, which should be pricked and dressed with powdered starch. The epidermis falls off, and is replaced by new skin which is lighter in color, but which will not always remain permanently free from pigment. Hydrogen dioxide, applied by means of a camel's-hair brush, may be used with good effect. Pyrozone has been used with success by Dr. Charles Allen. Pyro- zone is a standard solution of hydrogen dioxide in water or ether, the strength of the former being three per cent, and the latter five per cent. HYPERTROPHIES. 4S1 Unna suggests ( " Berliner klinische Wochenschrift") the follow- ing procedure : The skin is first washed off with spirit of wine, after which a mercurial plaster, prepared from Avhite precipitate, is applied to the pigmented area and permitted to remain overnight. The next day the following combination is used : R Bismuth, subnit................... 3 jss. Kaolin........................... 3 jss. Vaselinae......................... 3 vj vel 1 jss. M. The tincture of iodine or sulphur, with acetic acid, as recom- mended by Neumann, or the application of potash soap continuously for a part or an entire day, will be very effective. Remedies may, however, be used which are less irritating and act more gradually. I prefer for this purpose either the ointment of mercuric or mercurous oleate, or one containing from thirty to sixty grains of copper oleate to the ounce. The ointment of nitrate of mercury, alone or diluted, or veratria, ten to thirty grains to the ounce, or an ointment contain- ing equal parts of white precipitate and subnitrate of bismuth, as sug- gested by Neumann, may be employed. Corrosive sublimate, acetic acid, tincture of benzoin, tincture of soap and borax, are also valuable. The following may be used with advantage : R Hydrargyri chloridi corrosivi. ..;... gr. x. Spt. vini rect..................... f § ij. Aquae rosae........................ f 3 ij. M. A preparation recommended by French authors is composed as follows: R Hydrarg. chlorid. corros., Ammon. chlorid.................aa gr. 0-15-0-30. Emulsion, amygdal................ gr. 120-130. The application frequently of the galvanic current is one of the most suitable and effective agents, according to the experience of the author, in removing an abnormal deposit of pigment in the skin. [It is necessary, in this connection, to refer to certain other tran- sient or permanent discolorations which resemble chloasma. A marked example of this occurs in icterus or jaundice ; the coloring-matter of the bile passing into the skin changes its color to deep yellow. The main treatment, then, is that of the disease which gives rise to it. The itching and pigmentation may, hoAvever, be lessened by massage and the simple vapor or the Turkish or Russian bath. Another instance may arise from extravasated blood. The treatment depends upon the exciting cause. When the extravasation and discoloration, its se- quence, are due to traumatism, leeching and the subsequent applica- tion of Avhite precipitate ointment are Araluable. Discoloration of the skin may also result from the use of nitrate of siher, developing a varying shade of color, according to the quantity deposited, from a 31 482 DISEASES OF THE SKIN. grayish slate to a blackish. The staining may be over the general sur- face, but is more common on the mucous membrane of the gums, the face, and hands. Metallic silver is deposited in minute granules in the internal organs and the mucous membrane as well as the skin. For this condition, which is known as " argyria," the internal use of iodide of potassium has been recommended; but the results are usually negative. The skin may be colored of various hues by tattooing. Vermilion, charcoal, gunpowder, and indigo are the substances generally used. The pigment is introduced by a needle or a series of them, and remains where it has been inserted. Cases showing remarkable and elaborate effects have been publicly exhibited in this and other countries. Tattoo marks may be removed by electrolysis or by the action of some cauter- ant, which excites enough inflammation to destroy that portion of the skin in which the foreign substance is deposited. A scar, of course, is the result of the use of a cauterant. If the tattooed area is not ex- tensive and the cauterant has not penetrated the entire thickness of the integument, the scar may not be very noticeable, and becomes almost obliterated in course of time. Nitric acid and ethylate of sodium haAe also been used for their cauterizing action, applied by means of a pointed piece of wood or glass rod, allowed to remain upon the surface for a minute or two and then washed off with water. Dr. Variot, of Paris, claims invariable success from the use of the following manoeuvres: A concentrated solution of tannin, having been poured upon the tattooed parts, is worked into the skin in the same manner as in the tattooing operation. The surface is then rubbed with a stick or solution of ni- trate of silver, which is alloAved to act until the prick-marks stand out as black points from the formation of tannate of silver. Any excess of liquid is then wiped off, and the surface treated soon turns black. Moderate inflammation ensues; after fourteen or eighteen days the eschar drops off, leaving a reddish, superficial cicatrix, which gradually grows paler, and at the end of two months has almost disappeared. Stains due to gunpowder may be removed by first washing the skin with equal parts of biniodide of ammonium and distilled water, which causes the spots to grow gradually red. The red stains are made to disappear by the application of dilute hydrochloric acid. Dr. Ohmann-Dumesnil advocates tattooing the pigmented surface with glycerol of papoid, six to ten fine cambric needles bound together being used as the implement.] Prognosis.—Chloasma only demands attention on account of the staining it occasions. It may disappear with the removal of the cause or by the application of suitable remedies. Frequently it may remain permanently, or quickly reappear notwithstanding all efforts. Discol- oration resulting from metallic silver or from tattooing is usually per- manent. HYPERTROPHIES. 483 N2EVUS PIGMENTOSUM Synonyms.—Pigmentary mole—Naevus maternus—Naevus pilosus—Naevus verrucosus— Fleckenmal—Naevus pigmentaire. Pigmentary naevus, Avhich may be congenital or acquired, consists generally of a circumscribed deposit of an excessive quantity of pig- ment, alone, or together Avith hypertrophy of the connective tissue, or of all the cutaneous structures, including the hair. Naevi are of all dimensions, but are usually small, about the size of a split pea, or covering a large part of the surface, as stated by Wilson.* They may be round, oval, or irregular in shape, and vary in color from yellow to brown or blackish. Naevi may be flat—often on a level with the skin, or more or less raised. Their surface may be smooth and unaltered, and they are then known as naevus spilus; or rough and warty, naevus verrucosus; or there may be a marked connective-tissue hypertrophy, producing thick, soft, or firm variably sized growths, known as naevus molluscaformis, or lipomatodes. Naevi may or may not be supplied with a groAvth of hair. If hair is present, it may be soft, but more commonly it is stiff. A naevus supplied with hair is known as naevus pilosus. Pigmentary naevi oc- cur in both sexes, and may be single or multiple. They appear on all parts of the body, but are most frequently met with on the face, neck, and back. Occasionally they follow the course of nerve-tracts. Their growth is usually slow, but sometimes they increase rapidly in size. Hairy moles are frequently of large size. Dr. Max Joseph has described f a case in which the lower part of the trunk and the thighs were covered with a pigmented mole from which grew brown hairs over an inch in length. The pigmentation Avas irregular. A large number of small moles were seated upon the back, chest, and face. The subject, a robust young man, Avas beardless, but the hair of the scalp and eye- brows was normally developed. Pathology.—Pigmentary naevus consists usually of a circumscribed deposit of an excesshre quantity of pigment in the mucous layer of the epidermis, Avith more or less connective-tissue hypertrophy. Etiology.—No cause has as yet been assigned for the development of pigmentary naevi. Treatment-—Excision is, beyond all doubt, the best method of re- moving all the forms of this disease. They may be removed also by ligature, or by the application of ethylate of sodium and other caustics. The galvano and the actual cautery act promptly. Prognosis.—Pigmentary naevi usually continue a lifetime, and sel- dom disappear spontaneously. They should, unless too numerous, be removed or destroyed, as they may, according to Rindfleisch, degen- erate into pigmentary sarcoma. * Wilson on the Skin and Hair, Philadelphia, 1876. f Brit Med. Jour., Jan. 11, 1S90. 484 DISEASES OF THE SKIN. OALLOSITAS. Synonyms.—Callus—Callosity— Tyloma—Tylosis. Callosities consist merely of a hypertrophy of the horny layer of the skin, characterized by the formation of thickened, translucent, or grayish, yellowish, or broAvnish patches of various sizes and shapes, oc- curring most frequently on the hands and feet. Symptoms.—The epidermis increases in thickness, and assumes a grayish, yellowish, or brownish color. It presents a more or less horn- like, firm, dense structure, which may be insensitive and smooth, or upon which the normal furrows and lines are less marked. Occasion- ally, when a large area is involved, the surface may be roughened, raised in ridges, or cracked and extremely painful. The color, appear- ance of surface, consistency, size, shape, and subjective symptoms, if any be present, will vary according to the exciting cause. The thick- ening usually occurs in circumscribed patches, which are usually round, but they often conform to the part which is covered. In size they vary from a five-cent piece to that of the entire region which is involved. They have their seat generally upon the palmar and plantar surfaces, on the fingers and toes, especially on the ball of the great and the side of the little toe, or upon any part Avhere pressure exists. A callosity occasionally forms beneath a toe-nail. Callosities are gradual in their development. They may remain unchanged indefinitely, or they may be complicated with a mild or severe inflammation, which may terminate in their removal. Some- times the thickened skin, more particularly on the removal of the cause, may by spontaneous inArolution be restored to its normal condi- tion. The thickening may be preceded by profuse perspiration, as in a case recently described by Radcliffe Crocker.* Pathology.—The callosity is simply hypertrophy of the horny layer of the skin. Simon has shown that this change takes place in the horny layer alone, the corium remaining normal. Robinson notes that the latter is not involved to any extent, yet the excessive cell-growth must derive its basis from the vessels of the true skin. Etiology.—Callosities may occur at all ages; but they are more frequently observed in middle and old age, and oftener in men than in Avomen. They are almost always produced by external influences ; but cases may appear—as, for example, on the dorsal surface of the fingers and on the glans penis—without any known cause. Percussion, press- ure, or friction, or the handling of certain substances, as water and chemicals, may cause their growth. Their location frequently indicates the occupation of the individual affected, as they are often seen on the tips of the fingers in violin, harp, and guitar players. Treatment.—Callosities are generally a protective envelope to the * British Journal of Dermatology, June, 1891. HYPERTROPHIES. 48j parts beneath, and should be interfered with only when they occasion de- formity, inconvenience, or pain. Circumscribed callosities may be re- lieved or cured by the application of the galvanic current or the use of static electricity. Medicated plasters of either mercury, salicylic acid, lead, or copper oleate are also useful, particularly when a large surface is thickened and painful, interfering with the occupation of the patient, as when the feet are involved. Salicylic-acid plaster, or, even better, a plaster composed of four parts of the above drug to one part of copper oleate, is especially valuable. Thin demonstrated the practical value of salicylic-acid plaster before the London Clinical Society, and Will * and others have likewise testified to its efficacy. Lactic acid, hot water, oils, poultices, soft soap, tar, or mercury, may also be used to soften and remove callosities. The application of acids or alkalies, especially caustic potash, and the employment of the knife, should always be avoided when milder remedies are at our disposal. If inflammation arises, it should be treated upon general principles. CLAVUS. Synonyms.—Corn—Leichdorn—Huhnerauge—Cor. , Clavus is a more severe but localized callosity, painful on pressure, and usually limited to the feet. Symptoms.—A corn is a small, somewhat elevated thickening of the epidermis, varying in size, but usually being about that of a split pea. It may be yelloAvish or yellowish broAvn in color, smooth, polished, hard, and horny, or white, flat, soft, and spongy. The former is known as the hard and the latter as the soft corn. Corns may occur on \Tarious parts of the body, and they may be single or multiple in number. They are most commonly met Avith on the feet; the toes, especially the little one, and the plantar surface are the portions generally affected. Exceptionally a corn develops beneath a nail. Those which occur between the toes become macerated and softened by the moisture of the parts. A blister may form under one of these soft corns, and the poured-out fluid discharge from a little central opening in it, which may be folloAved by severe inflammation of the toe, or even the foot. All corns are attended with more or less uncomfortable feeling or suffering, more particularly in changeable weather. There may also be a sharp, darting, or shooting pain, occasionally so great as to prevent the individual from either standing or walking. Pathology,—A corn is a hypertrophy of the horny layer of the skin in the form of a cone, Avith its base looking outAvard and its apex turned inward toAvard the cutis. The cone is made up of epidermic cells, arranged in concentric layers. It may have one or more projections passing down to the true skin, which are commonly referred to as the ♦British Medical Journal, March 29, 1884. 486 DISEASES OF THE SKIN. roots or cores, and which by pressure on the sensitive papillae occasion pain. The corium around the base of the cone may be hypertrophied, as well as the papillae ; but the latter are more frequently atrophied. Etiology.—Corns, like callosities, are an effort of nature to protect the parts subjected to pressure. Pressure and friction arc the causes of their development. They are usually occasioned by Avearing tight or badly fitting shoes. Treatment.—The most essential point of the treatment is to remove all pressure and friction from the part affected. Corns may at once disappear or cease to occasion trouble after being thus treated. In the event that further treatment becomes necessary, they may either be removed by an operation or be palliated or caused to disappear by static electricity, galvanism, or by certain medicinal applications. A hard corn can be successfully removed by carefully separating the base with a knife from the adjoining portion of the sensitive skin, and then with a still smaller one cutting out the one or more apices or cores which exist. The entire fibrous mass may thus be lifted or pulled out in one piece. This operation requires considerable experi- ence and skill in order to perform it successfully. Corns may be relieved and protected from pressure by pieces of cotton or felt, alone or medicated. The frequent use of hot water, or oil, or poultices ,to the corns, or paring off the thickened base, will also give temporary relief, and will assist the action of such preparations as alcohol, collo- dion, compound tincture of benzoin, turpentine, nitrate of silver, and caustic potash. Among other useful applications are salicylic acid, cannabis indica, lead and copper oleate, either in the form of ointments or plasters. They have been destroyed either by the juice of drosera, cheliodonium, or sedum acre. The application of bichromate of potassium solution or the ointment of arsenic, oleate have also proved of service in remov- ing corns. The following combination is recommended by Gezon : R Acidi salicylici................... gr. xxx. Ext. cannabis indicae............. gr. x. Collodion....................... f 1 ss. M. This should be applied twice daily with a brush for several succes- sive days, and the corn afterward macerated in warm water, when it may be readily removed. Instead of cannabis indica, from ten to thirty grains of lactic acid may be substituted in the preceding formula. A good corn plaster is made by melting six parts of resin, adding five parts of balsam of fir, and stirring in ten parts of salicylic acid as the mixture cools. The mass may be spread upon any suitable material. Another formula contains salicylic acid, lanolin, cocaine hydrochlorate, and creasote. The acetate of copper, half a drachm, to two drachms of Venice tur- pentine and one ounce of yellow wax, is also said to be a useful corn- HYPERTROPHIES. 487 plaster.* In the treatment of corns upon the soles Unna makes use of his strongest salicylic plaster-muslin which is impregnated with equal parts of salicylic acid and creasote. This is held in contact with the corn by means of glycerine-jelly painted around and over it, the whole being covered with a layer of cotton-Avool held in place by a light bandage. Soft corns may be cured or relieved by cutting aAvay the thickened skin with the scissors and applying salicylic acid in powder or oint- ment, from thirty to sixty grains to the ounce, and a piece of cotton or wool kept constantly between the toes. Prognosis.—On the removal of the exciting cause, corns as well as callosities usually disappear. CORNU OUTANEUM. Synonyms.—Cornu humanum—Cutaneous horns—Horny excrescence—Horny tumor— Hauthorn—Corne de la peau. Cornu cutaneum is a hypertrophic disease of the epidermis, char- acterized by the formation of a true horny outgrowth of varying shape and size. Symptoms.—Horny outgrowths, which resemble very much in ap- pearance the horns of the lower animals, are occasionally developed upon the human skin. The shape and size of these excrescences vary; they may be straight or curved, but are usually twisted in various directions, sometimes assuming the appearance of a ram's horn, as in Fig. 12, taken from a photograph of a man under the care of Prof. W. H. Pancoast, of Philadelphia. In other cases they are cylindrical, conical, or flattened in appear- ance. The free end may be pointed, but it is generally blunt or split up. The growth outside is solid and hard, but Avithin it may be soft and crumbling. The surface is dry, wrinkled, and fissured. In color horns are generally grayish, but they sometimes vary from a light yel- I)w to a dark yelloAV, brown, or even black. In size they are generally small, but they may grow from one to many lines in length and thick- ness. Thus, Porcher described a horn Avhich developed from the fore- head of a negress, which was seven inches long and two and three quarter inches in diameter. The bases of horns are broad, flattened, and concave, resting directly upon the skin, which is either normal, hypertrophied, or more or less inflamed. They may appear upon any part of the body, but are observed most frequently about the head, particularly on the face and scalp ; their next most common situation is the genitals.f Drs. Jules Felix and Alfred Stocquart have described * Dr. II. M. Whelpley in Notes on New Remedies, June, 1890. f " Report of Horny Growths on the Penis," by Pearce Gould. Medical and Surgical Reporter, March 19, 1877. 488 DISEASES OF THE SKIN. the case of a boy of ten, the entire left side of whose penis was covered with a spiculated horny growth of a dirty yellowish-white color. A spot upon the same side had presented a roughened aspect at birth. Cutaneous horns are usually single, but may be multiple, as in Boettge's cases, the one being a man who had six growths on his face, and the other a young girl the lower half of whose body was studded with them. Horns are more frequently seen on old people than on the young. They Fig. 12. are slow and painless in growth, and, after having attained a certain size, they are generally shed or broken off, often leaving an ulcerating surface. As a rule they redevelop after having been shed, but a few instances have been met Avith in which there Avas no return. Curious cases have occurred in which such horns have been periodically shed at the end of every four, six, or twelve months. After a horn has existed for some time, or if irritated or injured, it may become painful, par- 7310 HYPERTROPHIES. 489 ticularly about the base. During the period of formation and before the horn has protruded from the surface it may give rise to itching or even, as in some cases which luwe been reported, to severe pain, which generally ceased soon after projection of the deformity. Demarquay in 1803 had collected the reports of six cases in Avhich horns grew from mucous membranes—in one case from the conjunctiva, in one from the tongue, and in the remainder from the glans penis. Other cases affecting the glans have since been published. Pathology.—Microscopic examinations demonstrate that cutaneous horns consist of a hyperplastic growth from the stratum mucosum, which is situated either over the papillae of the corium or within the follicles and glands. Enlarged papillae with bloodvessels have also been observed. The cornified epidermic cells are arranged in the form of longitudinal columns corresponding to the papillae. These cells are at times disposed in concentric layers similar to those of epithelioma. Again, they may resemble sections of the cavities, filled with epidermic cells, seen in certain warts or sections of enlarged cutaneous glands full of cornified epithelial cells. A horn may usually be regarded as a species of papilloma or wart, the epidermic cells of which are intimate- ly joined to each other like those of the nails and superimposed upon each other in layers. Etiology.—Pressure, Avounds, and various other injuries to the in- tegument may occasion the development of cutaneous horns. They sometimes originate from sebaceous cysts or warts. Treatment.—Horns should either be ligated at their base or, what is even preferable, the entire growth should be excised, with a portion of the skin from Avhich it springs, and the surface cauterized Avith either the actual cautery, the galvano-cautery, or with zinc chloride or arsenic oleate. Prognosis.—Horns are apt to recur if they are shed, broken, or torn off from their base. Experience has shown that their removal is ne- cessary, both on account of the deformity which they occasion and their tendency in old people to degenerate into epithelioma. If removed by the operation just suggested, they seldom redevelop. KERATOSIS PILARIS. Synonyms.—Lichen pilaris—Pityriasis pilaris. Keratosis pilaris is a hypertrophic disease, characterized by the appearance of pin-head-sized conical elevations about the orifices of the hair-follicles. Symptoms.—The affection appears in the form of an accumulation of epithelial cells and sebaceous material about the orifices of the hair- follicles, forming minute conical elevations or papules. These papules are pin-head in size, pierced with a hair, or contain a convoluted or 490 DISEASES OF THE SKIN. twisted hair, and around them the epithelial and sebaceous material is arranged in the form of laminae. The hairs may project from the apices of the papules, or be broken off close to the surface, showing a dark or black point in their central part, or they may be invisible, be- ing contained within the accumulated masses. In color the forma- tions are dirty white, gray, or broAvn, and are situated on the skin, Avhich may be normal in hue or reddened, scaly, and dry. The skin to the touch feels rough and harsh, as in ichthyosis ; the elevation, hoAvever, being marked, and in severe cases resembling a nutmeg- grater. The favorite seat of the disease is the extensor surfaces of the extremities. It is most frequently met with upon the thighs, the arms, and forearms, but it may occur as well upon all the body. It occasionally involves the face and may produce falling of the hair of the eyebrow. The skin contiguous to the affected follicle may even become atrophic. Keratosis pilaris may be present to a slight or to a great extent. It is chronic in course, and may or may not be attended with itching. Diagnosis.—The disease is most likely to be confounded with cutis anserina (goose-flesh), but the latter is a transient condition arising from a temporary erection of the hairs from either nervous excitement, cold, or heat, and rapidly disappears. It is to be distinguished from lichen scrofulosus by the latter tending to occur in groups, particularly upon the abdomen, and in the lesions being firmer and not so scaly. Keratosis pilaris may also bear a close resemblance to desquamating miliary papular syphiloderm, but differs from the latter in the lesions not developing in groups, and being neither so scaly nor so deeply seated. Etiology.—Keratosis pilaris may be due to the physiological activ- ity of the hair-follicles and glands which takes place at puberty. The neglect to employ water and soap sufficiently, as well as their too free use, has also been known to occasion the disease. Brocq expresses the belief that the disorder is congenital. Treatment.—The moderate use of water and soap, the solution of boro-glyceride, sublimate, or, in seArere cases, sapo viridis, will usually be all the treatment needed. The warm water, the alkaline, the vapor, Turkish, or Russian bath can also be used. In severe and obstinate cases, the oil of ergot, almond-oil, glycerine, and petroleum-ointment are also serviceable. Prognosis.—The disease quickly yields in most cases to treatment, but if not counteracted it may persist indefinitely. PSORIASIS. Synonyms.—Lepra—Alphos—Lepra alphos—Psora—Schuppenflecte. Psoriasis is a chronic inflammatory cutaneous disease, characterized by an outgrowth of the epithelial layers of the skin, and generally ap- HYPERTROPHIES. 491 pearing as slightly elevated, round, and reddened patches of various sizes, covered with dry, white scales. Symptoms.—Psoriasis usually begins with the development of very small papules covered with dry, white scales. They are present in considerable numbers, but are invariably separated by large or small areas of healthy skin. They are about the size of a pin's-head, and from their punctiform appearance are termed psoriasis punctata. If the scales be gently scraped off, the reddened surface beneath will readily bleed. The papules may remain stationary, but generally increase in size until they are as large as lentils, and resemble in color and appearance drops of mortar; they are then designated psoriasis guttata. In the mean time new punctiform points may appear in the inter- vening healthy skin. When the papules attain the size of a pea or a Avalnut, coA'ered with a quantity of dry, white, firmly adherent scales, and having the appearance of an ordinary coin, they are known as psoriasis num- mularis. Spots of psoriasis punctata or psoriasis guttata can also be recog- nized, scattered over the surface, Avhich have developed while the older patches have been increasing in size. The patches in many cases coa- lesce, becoming irregular in form and of all sizes. New spots continue to break out, until the disease may cover the whole surface of the body. This condition is termed psoriasis diffusa, or psoriasis univer- salis. Sooner or later the masses of epidermic cells separate, partially or generally, and, in falling off, expose reddened spots, slightly raised above the level of the natural skin. In those cases in which the epi- dermic cells have partially dropped off from the centre, the scales remain- ing adherent at the margin of the patches, a circular or annular appear- ance is presented. As the affection progresses, the central red spots become pale, like the healthy skin, and surrounded with rings of scales, if they have remained adherent, or with erythematous aureolae, if the scales have fallen off. The blending of these rings or segments produces serpentine lines and patterns of striking appearance. Psoriasis may remain in the condition just described, now improving and again relapsing into its former state; or it may occur—which is more frequent—as small patches scattered over the chest, and in larger spots over the elbow, sacrum, and knee. In many instances, hoAvever, patches which were large and prominent gradually lose their characteristic appearance, fade, and disappear, but are quickly succeeded by others. In addition, fresh spots crop out, and, although an alteration and change occur, yet the eruption will not undergo a cure. Inveterate psoriasis may be- come complicated with deep and painful fissures of the hands and feet, with warty formations or even epithelioma. In other cases, while 492 DISEASES OF THE SKIN. fresh patches appear, the original ones remain, and together they grad- ually invade all the unaffected healthy skin. At times, but rarely, the affection may subside spontaneously. In that event the scales become less adherent, and finally fall off entirely, leaving the reddened, circu- lar patches slightly elevated above the surrounding healthy epidermis. The redness gradually lessens until the normal appearance of the skin is restored, without pigmentation or scars. The nummular and annu- lar forms occasionally, from various causes, especially traumatism, be- come the seat of inflammation, furnish a discharge, and closely simulate eczema. This condition is known as inflamed psoriasis. The affec- tion may also display a bright-red color, and is by some writers called scarlatinaform psoriasis. This name is, hoAvever, more properly ap- plied to cases of acute psoriasis, or severe exacerbations of the chronic disease, in which, spontaneously or otherwise, the skin is swollen, of a bright-red color, and partly covered with large, thin scales. At the same time fever may be present and the general condition of the pa- tient be bad. The patches are occasionally considerably elevated above the general surface of the integument. Psoriasis may attack any portion of the body, but it is at times limited to the elbows and knees. After these sites it next most frequently affects the head, the red or scaly rings extending somewhat beyond the hair to the forehead, ears, and neck, producing more or less disfigurement. When the erup- tion develops on the scalp the hairs are usually not involved; they seldom fall out, and they retain their normal lustre and color. While the eruption may pass doAvn to the forehead, neck, and ears, and the hearing occasionally become impaired by the scales blocking up the auditory canal, yet the face is rarely affected in its entirety. The disease may appear upon the prepuce and glans penis in the form of small red spots, covered with scales that are slightly adherent and are often soft. The coexistence of typical patches upon other portions of the body serves to point the diagnosis between this condition and the lesions of secondary syphilis. Psoriasis seldom involves the palmar and plantar surfaces, but will, in some cases, attack the nails. When the disease, however, invades the palms and soles it is peculiarly obstinate. The form of psoriasis that affects the nails was first described by Biett, and generally co- exists with the disease in other portions of the body. Upon the first ap- pearance, of the disease, while the nail is transparent, a spot of psoriasis may at times be observed beneath it. In many instances this elementary development may escape obser- vation, the morbid action having already involved the matrices of the nails, giving the nails a thickened, rough, yellowish, or brownish appear- ance. They lack their peculiar lustre, are brittle and fissured, and do not extend beyond the ends of the fingers. HYPERTROPHIES. 493 Little pits are seen scattered upon the surface, giving rise to a worm- eaten appearance. The nail may finally be loosened and fall. Psoriasis as a rule will not develop on the vermilion border of the lips nor on the mucous membranes. Hebra, in all his large experience, never observed a single case in which any organ other than the skin could with certainty be said to be involved. Psoriasis is especially a chronic, non-contagious disease, attended with itching in its early de- velopment, at the time of its relapses, and upon the appearance of new- spots. The itching may be severe, but gradually subsides with exten- sion of the spots, and is often absent. I have noticed a subjective symptom, not usually described, in some cases of psoriasis; in those in which the larger portion of the skin was involved patients complained of a tight, tense feeling of the surface, and could predict a fresh out- break by a preceding flushing of the skin. The scales in some cases are very abundant, and may be firmly at- tached to the patches, or, as is more common, especially if the disease is extensive and has been of long duration, are shed in large quantities in the bedclothes or on the patient's clothing. Patches that have many firmly adherent scales have a dirty-white appearance, while those that are sparsely covered present a red tint. In some inveterate cases in which the scales have almost entirely fallen off, the patches are deep red, angry in appearance, attended with heat, burning and pain on motion, become fissured, and are hard, rough, and uneven to the touch. The eruption, however, is always dry from the beginning to the end, and is never attended with any other lesions except those that have already been noted. It may be, and is, at times, associated or complicated with other affections, both internal and external. Krie- beln refers to a pricking sensation in the tips of the fingers and toes, and Hebra has said that neuralgia, especially sciatic, is a frequent com- plication. A case in which the distinctive lesions of psoriasis and purpura rheumatica were combined has fallen under the observation of Dr. John A. Fordyce, of New York. Gaucher has described several cases in which the suppression of psoriasis Avas followed by severe constitutional disorder, as endocarditis with cerebral complications, organic disease of stomach and bowels, and asthma. Diagnosis.—An eruption presenting the course and symptoms just described could hot possibly be due to any other affection. The dis- eases which most resemble it are eczema squamosum, syphilis, sebor- rhoea, lupus erythematosus, ichthyosis, lichen ruber, pityriasis rubra, and tinea capitis. Eczema squamosum, Avhile differing very much from psoriasis, is frequently mistaken for it. In psoriasis the most prominent lesion is the mass of epidermic cells. The sensation of itching, Avhich is usually slight, is present 494 DISEASES OF THE SKIN. only when the patches first appear; the scales are silvery, thick, and are seated on dark-red patches involving by preference the extensor surfaces. In eczema the primary lesion is usually the erythematous patches or the vesicles, pustules, crusts, or moist spots; the subjective symp- tom of itching is greater, and usually lasts during the entire course of the disease; the scales are not silvery, but are thin, loosely situated on bright-red patches, manifesting a preference for the flexor rather than the extensor surfaces. The course of the two affections can thus be seen, from the dry, uniform eruption in psoriasis, and the polymorphous lesions in eczema, to be dissimilar in every way. Again, psoriasis of the head may be distinguished from eczema by the patches being discrete, with inter- vening healthy skin, and covered with scales that are thicker, darker, and drier than those of eczema. Psoriasis spreads in segments over the forehead, the neck, and ears, and rarely moves beyond these limits. Eczema passes rapidly from the scalp to the forehead, neck, and ears, and Avill often invade the entire face. Further, the patches of psoriasis are ahvays clearly outlined and show a tendency to heal in their centre, while those of eczema fade away into the healthy skin, and have no inclination to repair in the middle of the spots of infiltration. The adherent scales, situated on red spots over the forehead, arms, and limbs, separated by tracts of healthy skin, in a limited syphilitic eruption may be mistaken by the casual observer for psoriasis. A more careful examination of the scales will show that they are of a dirty color, and that the red spots on which they rest pass beyond them; in psoriasis the scales are silvery or whitish in color and gener- ally extend beyond the red bases which they cover. The preceding symptoms of lassitude, backache, headache, furred tongue, sore throat, and all the symptoms of syphilitic fever, with their entire disappear- ance upon the breaking out of the eruption, will be additional evidence of a syphilide. A scaly eruption may be present in the palms of the hands and soles of the feet, regions often attacked by syphilis, but rarely affected with true psoriasis. In cases of long standing, the ap- pearance of crusts, mingled with scales, spots in the process of fading having a coppery hue, mucous patches, scars, or the enlarged lymphatic glands, particularly the post-cervical and epitrochlear, will always stamp the case as syphilitic. Professor Neumann* describes two cases in which psoriasis coexisted with a syphilitic eruption. Appropriate treatment caused the latter lesions to disappear, but had no effect upon the psoriatic patches. Seborrhcea sicca may resemble psoriasis of the scalp. The patches of the former will be found to be crusts composed of sebaceous mate- * Wiener Medicinische Wochenschrift, No. 7, 1890. HYPERTROPHIES. 495 rial, fatty and greasy to the touch, leaving upon removal a pallid sur- face, and not a reddened, bleeding base as in psoriasis. In seborrhoea the scales consist of dried sebum, while in psoriasis they are composed of epidermic cells. Psoriasis may develop on any part of the body, and Avhen it involves the scalp, may pass down on the forehead. Seborrhcea, on the contrary, is generally confined to the scalp, the eruption forming only a scurvy mass just beyond the margin of the hair. The hair in seborrhcea often loses its lustre and falls out in large quantities, while in psoriasis no loss or change whatever takes place. Lupus erythematosus is usually confined to the face, while pso- riasis is seldom seen in that situation alone. The lupus spots are covered with thin, scanty, firmly adherent, dry, or greasy white or yellowish - broAvn scabs and crusts, upon the removal of which the ducts of the follicles to which they were attached appear plugged with comedones; the scales in psoriasis are abundant, ahvays dry, white or silvery, fall off, or are easily removed, and rest upon reddened }>atches. Lupus as a rule is a disease of adult age, and is attended Avith pain and tissue-destruction, with the formation of scars; psoriasis occurs during all ages, and is not accompanied by pain or scarring. Ichthyosis is a congenital disease, developing during or after in- fancy ; psoriasis usually appears at a later age. Ichthyosis is unat- tended with any evidence of irritation or inflammation, the skin is mapped out in spaces, harsh, rough, dry, with fine, broyvnish scales. while in psoriasis the inflammatory patches are separated by perfectly healthy skin, and the spots are covered Avith whitish, silvery scales. Lichen ruber occurs much less frequently than psoriasis, and its lesions are characteristic and distiuct. Lichen ruber is attended with great constitutional disturbance, while psoriasis is not accompanied with any impairment of health. The papules in lichen ruber are cov- ered with scanty yellow scales, unlike the Avhitish ones of psoriasis. Pityriasis rubra attacks the unhealthy, psoriasis the healthy. The scales do not accumulate as in psoriasis and fall off, but exfoliate in large flakes, leaving the skin beneath red and tender. Tinea capitis will give rise to a scaly condition which might at times be mistaken for psoriasis, but the hairs are affected, lustreless, and broken off; the scales are scanty, except where the parasite is most active, around the margin of the patch. In psoriasis the hairs are usually normal, and the scales abundant over the entire diseased area. The history of the case, its limitation generally to one patch, and the occurrence of vesicles and pustules around the periphery, should lead to a microscopical examination for the parasite, the discovery of which will remove all doubt. 496 DISEASES OF THE SKIN. Pathology.—The pathological anatomy of psoriasis has been care- fully studied by many investigators. Hebra examined the skin of per- sons affected with psoriasis who died from some intercurrent disease, and reported that no abnormal condition could be detected, either with or without the microscope, upon structures that were the seat of the disease during life. He therefore limited himself to the morbid products as they appeared on the living body to the naked eye, as heaps of scales made up of epidermic cells situated on a hyperaemic skin. Wertheim, after excising and examining portions of the skin of psoriasis patients, found constant enlargement of the papillae of the skin, and conjectured that their vessels were also enlarged. Auspitz * Avas perhaps one of the first to call attention to the action of the cells of the rete Malpighii in an article on the relation of the epidermis to the papillary layer. Neumann found the epidermal cells and the rete Malpighii greatly developed, the papillae considerably en- larged, especially in chronic cases, the corium and papillae also filled Avith cells. From these observations he concludes that psoriasis is a disease of the most superficial strata of the corium and papillary layer, accompanied Avith cell proliferation, in which disease the papillae ap- pear considerably enlarged. Further, that " the excessive formation of scales is only a hyperplasia of the cells of the rete Malpighii, accom- panied by increased desquamation of the epidermis." Luciani has found in the cutis numerous leucocytes in a condition of karyokinesis. He concludes, therefore, that the epidermis and the cutis vera are affected at the same time. Tilbury Fox, reasoning upon both his OAvn and Neumann's observa- tions, added later that he " was constrained to believe that the disease consists primarily and essentially in a misbehavior of the cell-elements themselves, a perversion of the ordinary cell-life of the epidermis." The pathology of psoriasis has also been studied by Thin,f Jameson,! and Robin son.# According to the latter, the disease consists essential- ly of a hyperplasia of the normal constituents of the rete Malpighii. The increase occurs principally in the interpapillary portion of the layer, which, growing downward, gives the papillae of the corium the appearance of increased size, which is not found to be increased upon a closer examination. The superficial blood-vessels of the corium, in the more advanced form of the disease, become dilated, the white cor- puscles migrate, and the blood-vessels and the connective tissue of the corium become the seat of round cell-infiltration which, with the effused serum, divides the connective tissue into open meshes. The sebaceous and sudoriparous glands are not at any time involved, but * Achiv fiir Derm, und Syph., Erstes Heft, 1870. f British Medical Journal, September, 4, ! 8S0. X Edinburgh Medical Journal, January, 1S79. * New York Medical Journal, July, 1878. HYPERTROPHIES. 497 there is hyperplasia of the external root of the hair, extending into the cutis, Avhich corresponds to the Malpighian layer of the epidermis. Unna has described more particularly the condition of the blood-ves- sels in the papillae. He states that " there follows, on a moderate general dilatation of the vessels in the psoriasis papule, an excessive dilatation of the venous roots of the descending limb of the papillary capillaries; and further, there is added at the papillary loop a quite unusual length- ening of the vessel for a short distance." Etiology.—Psoriasis may depend upon hereditary or acquired dis- ease, or may follow any derangement which interferes with the nutri- tion of the skin. Thus it is known to arise frequently from rheumatism and gout.* Garrod, however, denies that gout is concerned in the causation of psoriasis, and believes that the association is accidental. It is at times noted to follow eczema, scrofula, syphilis, and other affec- tions Avhich produce an impoverished condition of the blood. Psoriasis occasionally develops after an attack of scarlet fever. It is sometimes associated with diabetes mellitus. Pregnancy and lactation not infre- quently aggravate the disease. It may also have a nervous origin, arising, as Weyl has said, " from a functional weakness of the nervous centre regulating the nutrition of the system." In certain cases a rela- tionship seems to exist between asthma and psoriasis. Neuralgia and paraesthesia occur as complications in rare instances. Psoriasis not uncommonly develops in subjects of chronic alcoholism. Wilson viewed psoriasis as a manifestation of the syphilitic poison after transmission through one or more generations. Lang, on the other hand, believed it to be due to a fungus which he claimed to have discovered, and named epidermidophyton. Destot reports having inoculated himself with psoriasis by inserting into his shoulders scales taken from a child. Sixteen days later patches of psoriasis appeared on both his elbows. Unna has knoAvn a nurse to communicate the disease to three children under her charge. Psoriasis is met with in the apparently robust as well as those who are weak and poorly nourished. It is at times appar- ently the result of mechanical or chemical irritation, as from pricking the integument in vaccination or pressure of clothes and bands, cup- ping, leeching, blisters, wounds, and injuries. Psoriasis, in the opinion of the writer, follows the action of local irritants only in those predis- posed to the disease by some constitutional condition. The affection may appear at any period of life, but it is more commonly encountered at the age of puberty. The disease is more common in men. It has been known to appear in consequence of acute emotion. Treatment.—The treatment of psoriasis is usually unsatisfactory. In order either to relieve or eradicate the disease months of careful at- tention to hygienic means, as well as internal and external medication, * See paper by author on " The Cause and Treatment of Psoriasis." The Medical Bulletin, December, 1888. 32 49 8 DISEASES OF THE SKIN. must be resorted to. The hygienic measures of most importance are exercise, massage, and bathing. The diet, especially in recent cases, should contain a less proportion of nitrogenous food. The functional acthrity of the skin, alimentary canal, and kidneys, should be increased so that the blood may be depurated and oxidation promoted. The skin may be rendered more active by exercise, mas- sage, and baths, or administration of diaphoretics, such as antimony, ipecacuanha, pilocarpus, or pilocarpine. The alimentary canal may be stimulated by the natural mineral waters, especially Friedrichshall, Congress, or Bedford. Epsom or Rochelle salts, senna, rhubarb, cas- cara sagrada, podophyllin, or one of the mercurials, will answer the same purpose. The activity of the kidneys may be increased by colchi- cum, digitalis, copaiba, potassium acetate, lithium carbonate, and other diuretics. In the majority of recent cases, and in some of the more chronic, I usually begin with the hygienic measures just suggested, with an occasional diaphoretic, diuretic, and cathartic. When the disease is dependent upon a rheumatic diathesis the most efficacious remedies are salicin, quinine, salicylic acid, the salicylates, salol, oil of wintergreen, iodide of potassium, antipyrin, antifebrin, and phenacetin. In gouty subjects, besides those drugs which have been mentioned, guaiacum and alkaline waters are of benefit. Dr. H. Radcliffe Crocker has observed marked improvement follow the use of sodium salicylate, salicin, or salophen in cases not apparently dependent upon rheumatism. The cases to which he finds these remedies best adapted are those in the period of active development and attended by hyperaemia. No favor- able influence upon the disease resulted if the preparations excited digestive disorder. The preparations of iron, diluted phosphoric acid, cod-liver and chaulmoogra oils, fluid extract of berberis aquifolium, and preparations of antimony and turpentine are at times found ser- viceable. Hura brasiliensis, rhus radicans, daphne mezereum, hydro- cotyle Asiatica, gurjun balsam, manganese, barium chloride, carbolic acid, tar, tincture of cantharides, and sulphydrate of zinc have also been made use of at times. When of nervous origin, the oxide of zinc, nitrate of silver, chloride of gold and sodium, and the galvanic current are of service. The bromides and preparations containing valerian are also advantageous in such cases. Nervous patients should be warned to avoid tobacco, coffee, and all forms of excitement. A remedy brought forward by Dr. Napier is chrysarobin, from which he reports good re- sults, given in one-half-grain dose, combined with sugar of milk, and the dose increased to the limits of toleration. After giving this remedy in a number of cases and having observed no decided effect from it, I am inclined to believe that it acts simply as a purgative, Salines, espe- cially the natural spring waters and other purgatives, have been highly extolled at different times, and chrysarobin acts in a similar manner by producing free elimination from the intestinal canal. HYPERTROPHIES. 499 The eruption becomes pale under its use and disappears, but again reappears upon discontinuing the drug. It would be unwise to purge a patient continually to keep the disease in abeyance. Burdock-seed, made in the form of a tincture Avith Avhisky, has also been lauded as a specific for the eruption. Unfortunately, I must say that it too, after a fair trial, has proved utterly valueless in my practice in psoriasis. In the majority of cases, hoAvever, notwithstanding all treatment, the disease will continue and gradually become chronic. In the latter stage of the disease almost every known drug has been Araunted at some time or another as possessing a specific action. They have all been tried, by the alimentary canal and by the epidermic and hypodermic methods, with decided "benefit from only arsenic, sulphur, and iodide of potassium. I regard arsenic as one of the most efficient of all inter- nal remedies after the acute stage of the disease has passed. The ad- ministration of arsenic must, however, be accompanied by a careful observation of hygienic rules, and the activity of the secretions should be sedulously maintained. The preparations of arsenic which I employ are arsenious acid, the arseniate of sodium (Pearson's solution), and the solution of arseniate of potassium (FoAvler's solution). Arsenious acid, or the arseniate of sodium, is to be preferred to the solutions of arsenic, for the reasons stated in the chapter on treatment. The solu- tions of arsenic, if given, should be employed first in minimum doses and gradually increased. From one to twenty drops of either the solu- tion, of arsenite of potassium or of sodium can be administered. The average dose of either is from five to ten drops three times a day. Arsenious acid or arseniate of sodium may be given in from one for- tieth to one tenth of a grain in pill-form. I have in some cases admin- istered them in combination with other drugs with a very happy effect, as in the folloAving prescriptions: $ Acidi arseniosi.................... gr. j. Quininae sulphatis.................. gr. xl. M. Ft. pil. no. xx. Sig. : Take one pill after meals. I> Sodii arseniatis.................... gr. j. Extracti hyoscyami................ gr. v. Extracti gentianae................. gr. xx. M. Ft. pil. no. xx. Sig.: Take one pill after meals. Occasionally the value of arsenic is much enhanced by giving both quinine and strychnine with it, as in the following com- bination : I£ Quininae sulphatis.................. gr. xxx. Acidi arseniosi.................... gv- j- Strychninae sulphatis............... gr. ss. Aloini............................ gr. j. Extracti belladonnae............... gr. iij. M. Ft. pil. no. xl. Sig. : Take one pill after meals. 500 DISEASES OF THE SKIN. The hypodermic administration of arsenious acid, or, even better, arseniate of sodium, often acts most decidedly in lessening or in entirely removing the eruption, after the remedy has failed to accomplish the least good by the stomach. I use for this purpose the arseniate of so- dium, beginning with one tenth of a grain, dissolved in water, and injected daily into the deep cellular tissue of the back, arms, or but- tocks. The dose is gradually increased until the patient can tolerate one half grain doses given twice a week or daily in this way. The dose of arsenic, whether it be given by the above method or by the stomach, should be gradually increased until some effect is pro- duced. The evidence of its action will be in the lessening of the scales and redness of the patches, which slowly acquire a brown tinge and finally entirely disappear. It will often be necessary to give the remedy for along period before this effect is observed, and to continue admin- istering it for some time after the eruption has disappeared. While arsenic is no doubt effective, it is by no means a specific, and under its use new spots may crop out, and in some instances relapses occur. Notwith- standing the occurrence of relapses, the persistent use of the remedy Avill, in many cases, eventually eradicate the disease. In others, how- ever, the disease will remain or undergo relapses, even though the phy- sician may give the arsenic as recommended and exercise the best skill in managing the affection. All that can be hoped or looked for in such cases is that the eruption may be kept in abeyance, and the dis- figurement of the body averted. Sulphur, in some cases of psoriasis, has a marked action in relieving and curing the affection. It acts upon the skin, the mucous membrane, the glands, especially the liver, and thus assists in overcoming the infiltration or patches of the disease. The author has employed from five to ten grains of precipitated sul- phur, given in the form of a powder, lozenge, or capsule, three or four times a day, Avith sometimes curative effect. In 1881 attention was called by Dr. GreAre, of Norway, to the iodide of potassium in massive doses as a remedy in psoriasis. His statements were confirmed by Dr. C. Boeck, of Christiania. Encouraged by their results, Dr. Haslund, of Copenhagen, adopted the treatment in a series of cases. His ex- perience * shows that in the majority of persons this drug may be ad- ministered in very large doses without ill effects. In forty cases the disease was entirely cured, in four there was considerable improvement, while in six cases no benefit resulted. In six of the cases cured the average duration of treatment was from seventeen to twenty-five days, in the remainder the average was slightly over seven weeks. In the six cases so rapidly cured the eruption was chronic and almost universal. In some patients improvement began when a daily dose of seven to eight grammes (one hundred and eight to one hundred and twenty-three grains), in others Avhen ten grammes (one hundred and fifty-four grains) * British Medical Journal, January 7, 1888. HYPERTROPHIES. 501 were taken. In most cases even larger doses Avere required ; in a number thirty to forty grammes (four hundred and sixty-three to six hundred and seventeen grains) and in one patient as high as fifty grammes a day (seven hundred and seventy-two grains) were given. In most of the cases no signs of iodism appeared. In three instances the blood was examined during treatment. The corpuscles were unaffected in num- ber, size, or form. In four cases the urine was systematically examined. No effect Avas produced upon the elimination of urea. Neither was any wasting of fatty nor glandular tissue observed. The same method of treatment has been tested by Dr. Barduzzi and Dr. Paolo Luciani with encouraging results. Grutteling experimented with large doses of iodide of potassium in twenty-two cases, giving an average daily dose of one hundred and fifty to three hundred grains. In five patients he was obliged to discontinue the remedy. In several after a certain improve- ment had been made the disease remained stationary, Avhile in five com- plete recovery ensued. Dr. M. P. Vander Horck, of Minneapolis, has reported * ten cases of psoriasis, of Avhich eight were entirely cured by the iodide of potassium and two were improved. In three instances relapse occurred. In one albuminuria developed. In the light of this experience it seems that heroic doses of iodide of potassium are tolera- bly well borne and rarely give rise to serious consequences, that they undoubtedly exert a beneficial effect in many with psoriasis and should be resorted to in those cases which are not improved by arsenic. In my own experience the iodide has been particularly serviceable in rheumatic and gouty cases, and it is probably to the existence of these conditions of the system that the remedy OAves, in most patients, its efficacy. As regards the prolonged use of large doses of the iodide, M. Fere has demonstrated f in the case of the bromides the advantage of maintaining intestinal antisepsis by means of naphthol and salicylate of bismuth, and this practice is probably equally valuable Avhen the iodides are being administered. Small doses of belladonna or of arseni- ate of sodium have also been combined with the iodide in order to prevent the occurrence of iodism. In view of the probable parasitic and infectious origin of psoriasis, Dr. E. D. Mapother advocates \ a mercurial therapy. His usual method is to give three grains of blue mass every night for about eight weeks, and generally finds that the eruption is removed in six weeks. The green iodide may be employed in preference, or Donovan's solution, which is efficacious both by means of the mercury and arsenic which it contains. The frequent administration of small doses of antimony has been found to have a beneficial influence upon the diseased skin. The fluid extract of cascara amarga, given in doses of half a drachm to a drachm * Northwestern Lancet, April 1, 1890. f La Tribune Medicale, February 5, 1891 ; Medical Bulletin, April, 1891. X British Medical Journal, January 17, 1S91. 502 DISEASES OF THE SKIN. several times daily, has been thought to aid in ameliorating the mani- festations. Fucus vesiculosus has been used with some success. I have often, especially when the skin Avas greatly congested, seen advantage result from a combination of strophantus and hoang-nan. Favorable results have been reported from the internal employment of gurjun oil. In several cases I have obtained excellent results from the hypodermic injection of corrosive sublimate, in the dose and manner described in the chapter on syphilis. The injections were followed by a complete disappearance of the eruption. I can also speak favorably of the action of the iodosulphate of cinchonine, given in doses of one to five grains three or four times a day. A number of cases of obstinate psoriasis have been reported in which thyroid feeding or the use of tablets of thyroid extract was productive of decided benefit. This method of treatment has been tested by the author and a number of other ob- servers in this and foreign countries. Although in certain cases un- doubtedly good results have been obtained, yet in others the remedy has either relatively or absolutely failed. In some instances the treatment aggravated the cutaneous disease. It has been known also to produce undesirable constitutional symptoms. It is impossible to formulate any positive judgment as to the class of cases likely to be benefited by thy- roid therapy. In inveterate cases, where other remedies have proved use- less, recourse may be had to this method with some hope of advantage. Local Treatment.—Local remedies are of great assistance. It is necessary, however, to macerate and remove the epidermic scales, and expose the hyperaemic skin beneath. This may be accomplished by a warm, hot, or medicated bath, by packings and frictions, by rubbing well into the patches lard, olive or cod-liver oil, which should be allowed to remain for a time, after which it should be washed off with a simple or medicated soap, in a Avarm or hot bath. Soap used in this manner, containing naphthol, tar, or carbolic acid, frequently assists in soften- ing the epidermis. If the patches are not extensive, the scales may be removed by poultices, or oil and water, applied Avith cotton, lint, or bandages. They can also be taken aAvay by producing active diaphore- sis, covering the affected surface with oiled silk and rubber cloth, or, even better, by Avaxed or oiled paper. The latter application, which I use entirely in hospital practice, is a cheap, convenient, and easy means of promoting elimination from the surface, and is Avithin the reach of almost every individual. In some subjects copious draughts of Avater, with plenty of exercise and long immersion in Avarm or hot baths, will be sufficient to render the skin active and macerate and remove the scales. In others, particularly the very busy, one or more patches may be. selected and covered Avith oil packing, while engaged in reading, smoking, writing, or some quiet social enjoyment. Thus, night after night, scales may be softened and removed from the various patches. The greatest difficulty the physician experiences is in making the HYPERTROPHIES. 503 patients fully comprehend the importance of remaining in the bath until the scales become thoroughly macerated and easily removed. The mineral waters and baths of certain resorts, both in this coun- try and in Europe, have gained at times a reputation for curing this affection. Their successful use in some instances is due to the low diet, a long walk to and from the spring, with copious and frequent draughts of the Avater, all of which promote profuse diaphoresis, fol- lowed by exfoliation of the scales, together Avith a lessening of the in- filtration, aided, even more, by frequent and long-continued bathing. The scales can also be removed by friction with sand, as suggested by Ellinger, or with green soap, as recommended by Hebra and Kaposi. The soap is to be well rubbed into each patch until the blood is seen to ooze from the base, the same operation being repeated for six or eight consecutive days. During this period the patient is kept lying in a blanket impregnated with soap. Under this process the patches assume a brownish color, and in three or four days afterward, while yet in the blanket, the bed or body linen not being changed, extensive desquama- tion takes place, the Avhole cuticle peeling off in large lamellae. A general bath Avhich follows thoroughly cleanses the surface. The green soap is frequently applied, without using the blanket or rubbing the soap in in the manner described. It may be applied with the aid of water, or in the form of tincture of green soap. I have, upon a num- ber of occasions, thoroughly tested this method. It is effecthe in cleansing the patches, but the pain is so intense that I depend en- tirely upon the means I have advised as being sufficient to bring about the same result, Avithout suffering. The milder methods of treatment I believe to be the most efficacious, particularly with Americans. In France it is very customary to remove the scales by means of the alternate use of starch and vapor baths. During the night caout- chouc is applied, not, however, to the whole body. If the treatment by baths is impracticable the folloAving ointment is recommended as being painless and effective: B; Amnion, carb..................... 10 grammes. Lanolini.......................... 2~> " M. Ungt. aquae rosae.................. 50 " A plaster containing salicylic acid will also facilitate the removal of the scales, or a two-per-cent. solution of salicylic acid in castor-oil may be used as adA'ised by Dr. G. II. Fox. After the patches have been freed from scales, the next step is to apply a remedy Avhich will have a curative action upon the vascular integument. Among the preparations used for this purpose are tar, carbolic acid, creasote, naphthalin, and beta-naphthol; also thymol, turpentine, Yleminck's solution of sulphuret of calcium, Rochard's and Wilkinson's ointments, the mercurials in ointment form, pyro- 504 DISEASES OF THE SKIN. gallic acid, chrysarobin, or chrysophanic acid, hydroxylamine, iodo- form, iodol, aristol, and europhen. Tar can be used either as pix liquida, the oleum fagi, the ol. cadini, ol. rusci, and the ol. ligni fossilis empyreumaticum. These preparations may be incorporated Avith lard, suet, lanolin, or one of the ordinary ointments in the proportion of from one to four drachms to the ounce. They may also be combined with soda or potash soap, with glycerine, the various oils, such as olive and cod-lhrer oils, alcohol, and the tincture of green soap. Wilkinson's ointment, as modified by Hebra, is composed as follows: R; Sulphur sublimati, 01. cadini.......................aa § ss. Saponis viridis, Adipis.........................aa § j. Cretae praeparatae.................. 3 ijss. M. Ft. ung. Another mixture proposed by Hebra, consisting of equal parts of pix liquida, alcohol, and sapo viridis, has been tried and highly recom- mended. Anderson's tinctura saponis viridis cum pice, Guyot's solu- tion of tar, Bulkley's liquor picis alkalinus, and the liquor carbonis detergens are useful and effecthe applications. All tarry prepara- tions, however, are more or less objectionable, especially in private practice, by reason of their disagreeable smell, the dark color that they impart to the skin, and the unpleasant and even toxic effects which sometimes result from their local use. The penetrating odor and darkening of the skin, as well as the clothes, is so great that it is often out of the question to prevail upon some patients to continue their use. Patients will state that they can usually hide the disease, but the disagreeable odor of the tar attracts universal attention. Fur- ther, the local application of tar is occasionally followed by an increase of temperature of the parts, with swelling, tension, pain, redness, papules, vesicles, and every symptom of dermatitis. Again, tar may be well borne at first; but headache, fever, nausea, dark-colored urine and faeces, and other unpleasant evidences of its absorption into the circu- lation develop, and compel the use of the drug to be suspended. Carbolic acid and creasote, while neither so active nor effecthre as tar, have been successfully used both in the form of lotions and oint- ments. Naphthalin, a white, crystallizable product of tar, is at times used as a substitute for the latter, possessed, it is claimed by some, of all its advantages, and devoid of its black color and disagreeable smell. Beta-naphthol, another product obtained by distillation of tar, and introduced to the profession by Kaposi, is a gray, granular substance, very pungent, Avhich can be combined with either alcohol or simple ointment in the proportion of one or more drachms to the ounce. The odor of beta-naphthol is especially acceptable; it will not stain, and its local action is equally as effective as tar. Thymol, being a color- HYPERTROPHIES. 505 less preparation Avithout a disagreeable odor, has been suggested as a substitute for tar by Crocker, in the strength of from five to thirty grains to the ounce of ordinary ointment. Turpentine, either alone or mixed with olive oil, can be applied with good result; great care, how- ever, must be exercised in using it to avoid strangury. The solution of sulphuret of calcium, first used by Vleminck, of the Belgian army medical service, has been found useful. The formula is: R, Calcis............................ z ss. Sulphuris sublimati................ § j. Aquae............................ f | x. M. Coque ad 1 vj, deinde filtra. This compound is a dark orange-yellow fluid, and is slightly caus- tic. It should be freely rubbed into each patch with a brush or flan- nel until the surface bleeds, then reapplied and alloAved to J.y, cftcr which a warm bath is given in which the subject is allowed to remain about an hour, folloAved by washing the surface again with either cold or warm water. After this procedure the surface is anointed with a bland ointment. Ichthyol has likeAvise been employed, and Barduzzi makes use of a ten-per-cent. preparation of sulphydrate of zinc. Creo- lin is another recently introduced substance which has been found ad- vantageous in psoriasis. It is applied in the form of a twenty-per-cent. ointment. Rochard's ointment is also an effective application Avith the folloAving formula,: I> Iodi.............................. gr. xi. Hydrargyri chloridi mitis........... 3 ss. Ungt. simp........................ I j 3 vj. M. Ft. ung. It should be applied to the patches once or twice daily until vesi- cles are formed. Although Vleminck's solution and Rochard's ointment are effica- cious, especially in inveterate cases, neArertheless the intense suffering Avhich they produce makes them even more objectionable than the green soap and sand methods of Ellinger, Hebra, and Kaposi. In cases presenting obstinate patches, the dermal curette can be used in conjunction with the remedies already mentioned. Acetic acid and cantharidal solutions haAre also been suggested, but the mercurial oint- ments have, in my experience, yielded the best results. The biniodide, the ammoniated chloride, and the protiodide can be prescribed in from two grains to the drachm to the ounce of lard or simple ointment, with decided advantage. Great care, however, should ahvays be exercised in using the biniodide, as in large quantity it may cause severe irritation of the skin. The nitrate and oleate of mercury are the best and most effective of the other mercurials. I usually dilute the officinal ointment of the nitrate or oleate of mer- cury with one half or two thirds of lard or butter, and add to it in 506 DISEASES OF THE SKIN. private practice a half to a drachm of either naphthol or chrysarobin. In hospital service I generally order the nitrate of mercury ointment in conjunction with the ordinary tar. If one or more patches are selected and treated with any of the mercurials at one time, care being taken not to cover too much surface, no constitutional effects can pos- sibly be experienced. Mapother relies upon some form of mercurial ointment in connection with the internal administration of mercury. Among many of the valuable local remedies in the treatment of psoriasis are chrysarobin and pyrogallic acid. Chrysarobin was first introduced to the profession by Balmanno Squire,* of London, and has been highly commended by the best dermatologists in the world. It should be incorporated in lard while hot, Avith the addition of a little benzole to increase its solubility. Chrysarobin can be prescribed in the Strengcn of from fifteen grains to tAvo drachms to the ounce of lard. It is best to learn its special action on each individual by beginning with a weak ointment of about fifteen or twenty grains to the ounce and gradually increasing its strength. Chrysarobin should be handled with great care and applied, if possible, under the direction of one familiar with it. If an ointment of chrysarobin is given to those who can not comprehend the necessity of care in its employment, and who will daub it over the surface in an indiscriminate manner, general cutaneous irri- tation Avill undoubtedly follow. If applied judiciously and carefully night and morning, the affected patches lose their scales and undue morbid thickness; they are transformed into a polished, smooth sur- face, which becomes white like the normal skin. The skin around the patches is stained a dullish-broAvn color, and slightly desquamates under the stimulus of the drug. Unless the parts are well covered Avith old muslin or a bandage, Avhich I always insist upon, the linen Avill be stained a brownish yellow. The ointment should be Avell rubbed in, great care being exercised to prevent it from running off on the surrounding skin. Chrysarobin ointment should not, if possible, be brought in contact with the hair, which Avould be dyed a purplish color; neither should it touch the nails, which Avould also be stained. Patients should ahvays be instructed not to put their hands near the eyes if they have handled the drug or the "hands have been in contact with the diseased surface after the appli- cation. Fox, of New York, has suggested an excellent method of applying chrysarobin by making a paste with the addition of Avater to it and smearing the paste upon the patches after the scales have been removed, alloAving the mixture to harden, after Avhich collodion is pen- cilled over the surface. The drug is thus kept in contact with the dis- eased patches and is also prevented from involving the surrounding skin or staining the linen. Another plan, also suggested by him, is * British Medical Journal, November, 1876. "The Treatment of Psoriasis by an Ointment of Chrysophanic Acid," London, 1878. HYPERTROPHIES. 507 to dissolve the chrysarobin first in a little alcohol and ether, and then add the collodion. Chrysarobin may also be incorporated in soap, and employed very effectively upon the skin for the removal of the scales and infiltration. Even with the greatest care, in those who have a sen- sitive or irritable skin, chrysarobin will set up an intense dermatitis, characterized by heat, swelling, itching, and pain, or an erythematous and furuncular inflammation, attended with a broAvnish, prune-juice discoloration of the skin. It is even stated by some that violent sys- temic effects of the drug are at times developed by its local use. That chrysarobin is absorbed by the skin and can be detected in the urine, causing albuminuria during its application, has been demonstrated by Israel (Virchow, Archiv IV). I believe, however, that any injurious effect Avhich may supervene is largely due to a lack of judgment in its application. If the drug is used in an indiscriminate manner upon all subjects, whether children or adults, and Avithout regard to the condition of the skin, Avhether sensitive or not, bad effects must neces- sarily follow an abuse of so powerful an agent. In limited spots of psoriasis, the most effective way of applying the drug upon the sur- face is in the form of chrysarobin plaster. The parts are protected, and inflammation rarely follows. Anthrarobin is an efficient substitute for chrysarobin, is productive of less irritation and staining, and is said to be devoid of toxicity. It is best used in the form of a ten-per-cent. ointment, which may be very Avell combined with the ointment of the nitrate or oleate of mercury. Aristol and europhen are likeAvise excel- lent local applications, staining neither skin nor clothing, and are in- capable of causing conjunctivitis. Aristol and europhen may be made into ten-per-cent. ointments Avith lanolin, oxide of zinc, or Goulard's cerate. Pyrogallic acid, likewise a valuable remedy, Avas used for the first time in psoriasis by Jarich.* It is less acthe than chrysarobin, pain- less, and will not give rise to inllammation of the surrounding skin, but Avill produce a broAvnish stain upon the surface, Avhether diseased or healthy, Avith which it comes in contact. This agent Avill stain the hair, nails, and linen, but not to the same extent. It can be incorporated in lard in the strength of from five grains to two drachms to the ounce. Pyrogallic acid may also be advantageously employed dissolved in flexible collodion in the proportion of half a drachm or a drachm to the ounce, Avith the addition of fifteen grains of salicylic acid. Another method of using pyrogallic acid is to dissohe half a drachm in an ounce of rectified spirit with fifteen minims of glycerine. As this agent will not produce the inflammation caused by chrysarobin, it is especially valuable in psoriasis of the head and face. Care should be exercised in using pyrogallic acid not to cover too much of the surface at any one time, as absorption may take place, giving rise *Ann. dc Derm, et de Syph., December, 1882. 508 DISEASES OF THE SKIN. to fever, strangury, and black evacuations. Besnier reports four cases of poisoning from the external application of pyrogallic acid, two of which were fatal. The prominent symptom in all Avas haematuria or haemoglobinuria. Another new substance which, according to the ob- servation of certain authors, exerts a good local effect is gallanol, the anilide of gallic acid. Gallanol is used in the form of an ointment, in a strength varying from one to thirty to one to four of excipient, as a powder mixed with talc, and as a ten-per-cent. solution in alcohol or liquor gutta-perchae. Gallanol occurs as colorless crystals, soluble in hot water, ether, and alcohol. Hydroxylamine hydrochlorate has been used with success in psoriasis. It is decidedly irritant, and should not be applied, to begin Avith, in greater strength than one tenth of one per cent, dissohed in equal parts of alcohol and glycerine. The proportion can be gradually increased and the application be made every day, or every second or third day, according to the effects produced. It will not stain the skin, but is capable of producing toxaemia. Aristol, on account of being free from the disadvantages just related, is a remedy decidedly to be preferred. An ointment containing aristol should be kept applied to the affected patches. Its action is less rapid than that of chrysarobin, without staining the skin, and, according to present experience, is absolutely Avithout ill effects. Chrysarobin and pyrogallic acid have also been applied dissolved in chloroform, ether, collodion, or solution of gutta-percha. Provided the patches are not too large or numerous, this method of medication has the advantage of being cleanly. The agent is maintained in constant contact with the diseased area, but it is apt to be painful and excite inflammation. Those drugs which have been found of service may also be used in the form of plas- ters. Chaulmoogra oil, made into an ointment in the strength of twenty to thirty grains to the ounce, has proved beneficial in some cases. Iodol, resorcin, and ichthyol ointments are good local applica- tions. Myrtol is said to have been used with good effect. A derivative of pyrogallol, termed gallacetophenon, has been proposed as a substitute for pyrogallol, has given evidence of power, and may eventually be found of service. It is said to be much less toxic than pyrogallol and does not stain the linen. Gallacetophenon is a pale-yellow crystalline pow- der, soluble in hot water, alcohol, ether, and glycerine. The addition of acetate of sodium promotes its solubility in cold Avater. It has decided antiseptic properties. In the treatment of psoriasis it A\ras used in the form of a ten-per-cent. ointment. Prognosis.—Psoriasis is very difficult to cure, especially when it is of long standing. Relapses vary in different individuals: thus it may recur after a month or months, or after a period of years. Psoriasis may disappear under appropriate treatment, to reappear within a feAv days, or it may be kept partially under control, the patient never being entirely free from some traces of the eruption. In some of the most HYPERTROPHIES. 509 inveterate cases, however, even where the whole surface is involved, the morbid changes in the skin have been at times completely and permanently remoA^ed by a long course of treatment, The mild form of the disease, particularly if seen upon its appearance, is more amen- able to treatment. To sum up, psoriasis is one of the most obstinate and unyielding inflammatory affections of the skin. LICHEN RUBER. Lichen ruber is a non-inflammatory affection of the skin, charac- terized by the development of a number of small, firm, red papules which do not increase in size, but manifest a tendency to become chronic. They frequently involve the entire cutaneous surface, and are accompanied by more or less itching and constitutional irritation, and in some cases appear to be the initial manifestation of general de- bility, mal-assimilation, and death. Symptoms.—There are no prodromal symptoms, as a rule. The onset of the disease is announced by the .appearance of the eruption, Avhich consists at first of numerous isolated, bright-red, or reddish - broAvn papules, varying in size from a mustard-seed to a small pea. Each papule is conical in shape, firm to the touch, and presents a scaly appearance at the apex. They remain unchanged in size throughout the entire course of the disease, except when large, reddish patches are formed by the coalescence of adjacent papules. The eruption may develop upon any portion of- the body, but it usually appears first upon the extremities, and in severe cases becomes diffused over the entire surface. The eruption always remains papular, but in rare cases it is accompanied by vesicles and small bullae. More or less itching is always present, and is increased by Avarmth and activity of the circulation. The mucous membranes are never attacked. In mild cases resolution occurs either spontaneously or as the result of treatment, and the lesions disappear without any appreciable desqua- mation or pigmentation. In severe cases, fresh papules develop upon other regions of the body, until, finally, the entire surface is covered by them and presents a uniformly reddened, infiltrated, and furfuraceous appearance. As the morbid process continues, the infiltration of the skin becomes so great in some cases as to interfere Avith its natural flexibility, and painful fissures are formed near the joints and folds of the body. The skin of the face and neck is fissured, brittle, and scaly, the eyelids droop, and the lips are thickened and indurated. The skin of the palms and soles becomes thickened and infiltrated, so that pain- ful rhagades are formed and. Avalking is productive of intense suffering. The hairs and nails become brittle and thin, and finally fall out. In other instances the nails are thickened, of a dull yellowish color, and marked by longitudinal ridges. The itching is frequently almost un- 510 DISEASES OF THE SKIN. endurable. The course of lichen ruber is irregular, long periods of re- mission being succeeded by exacerbations. The general nutrition of the body is not affected in mild cases, but, when the eruption extends over a considerable portion of the cutane- ous surface and obstinately defies treatment, the functions of digestion and assimilation are seriously impaired. The appetite fails, sleep is obtained with difficulty, and the patient progressively emaciates, until death results from general marasmus or from some intercurrent dis- ease induced by the gradual failure of nutrition. Years may elapse, however, before a fatal termination occurs. Diagnosis.—Mild cases of lichen ruber might be mistaken for acne, papular eczema, psoriasis, papular syphilis, lichen planus, and pityriasis rubra. The papules of acne, however, usually appear first upon the face, are large in size, frequently become pustular, and are not accom- panied by itching. The papules of lichen ruber are small, are usually developed first upon the extremities, neither increase in size nor become pustular, and are attended by a variable amount of itching. In papu- lar eczema the papules are very numerous, and limited, as a rule, to one region of the surface. They are accompanied by intense itching, and pursue a rapid course, either disappearing or becoming vesicular in a short time. In psoriasis the lesions rapidly increase in diameter, and are covered by large white or silvery scales, which, when detached, expose a bleeding or excoriated surface. In papular syphilis the papules also increase in diameter and frequently become pustular, and are not attended by any subjective symptoms. The papules of lichen planus are larger in size than those of lichen ruber, and usually present a depressed or umbilicated appearance. They disappear by resolution, but more or less pigmentation and atrophy of the epidermis result. The hair and nails do not become affected. Severe cases of lichen ruber might be confounded with pityriasis rubra. In pityriasis, howev-er, there are no papules, the skin is not thickened or infiltrated, and itching is either absent or comparatively slight. Pathology.—All the layers of the skin are affected in lichen ruber, but the epidermis is the seat of the principal changes. If a papule be excised and a vertical section made, the stratum corneum will be observed to be greatly thickened from an increase in the number and size of the epidermic cells and scales. The stratum mucosum is also thicker than normal and irregular in outline. This layer, in Taylor's cases, was found infiltrated with leucocytes and many of the deepest cells were pigmented. The stratum lucidum and stratum granulosum appear indistinct in consequence of an imperfect transformation or de- velopment of their cells. Many of the cells of the corneous layer con- tain nuclei. The papillae of the corium are thickened, and appear to be elongated in consequence of the projection of the inter-papillary HYPERTROPHIES. 511 processes of the rete. The blood-vessels of the corium are someAvhat dilated, but there is no exudation of serum, and few or no white cor- puscles can be observed. The subcutaneous connective tissue presents nothing abnormal, except that some of the blood-vessels appear to be slightly dilated, and a few leucocytes can be seen in the lymph-spaces. The glands are unaffected, with the exception of the upper portion of their ducts, Avhich passes through the stratum corneum and participates in the overgrowth of that layer. The upper portion of the hair-follicles is similarly increased in thickness. The unstriped muscles of the corium are slightly hypertrophied. As the morbid process continues, the pres- sure of the corneous layer frequently obliterates or lessens the caliber of the minute vessels of the papillary layer, so that the nutrithre supply of the rete mucosum and the superficial portion of the corium is less- ened or cut off entirely. Retrograde changes then ensue, terminating in death of the rete mucosum, exfoliation of the stratum corneum, and destruction of a portion of the corium. It is probable that the peripheral nerves are involved, but the exact nature of the changes Avhich occur has not been determined. Etiology.—The etiology is unknown. The most plausible theory attributes its production to a reflex disturbance of the cutaneous branches of the trophic nervous system. Dr. Joseph Grindon, of St. Louis, met with a case in which the eruption disappeared after a serious accident from Avhich the patient suffered. After recovery from the injury, however, the disease of the skin returned. Lichen ruber may occur at any age, but is most frequently met Avith between the thirtieth and fiftieth year. It may develop in either sex, and in the debilitated as well as in the apparently healthy. The disease is of rare occurrence in the United States, but is not unfrequently observed in Germany. Treatment.—Attention must be paid to the general health. The diet should be nourishing, and consist principally of meat, milk, and fruit. The boAvels should be kept soluble, and any derangement in the functions of the other organs of excretion and elimination must be remedied. The treatment Avhich promises best results consists in the early and persistent administration of tonic and alterative medicines. Iron, quinine, and cod-liver oil Avill be found serviceable in all cases. Benefit can also be derived from the use of the chalybeate mineral Avaters. The most valuable remedy, hoAvever, and one Avhich experience has shown to be almost a specific, if administered during the early stages of the disease, is arsenic. It should be given continuously and in gradually increasing doses until some effect is produced upon the eruption, or the point of tol- eration is reached. The dose should then be lessened, or its administra- tion suspended for a short time, and again resumed until the eruption has entirely disappeared. The drug may be given in the form of solution of arsenite of potassium, commencing with five-minim doses and gradually 512 DISEASES OF THE SKIN. increasing until tAventy minims or more are taken after each meal, or from three to six of the well-known Asiatic pills may be administered daily. If arsenic is not well borne by the stomach, much benefit can be obtained from its hypodermic administration. Kobner, who origi- nally employed arsenic in this manner in lichen ruber, commences with one to two minims of solution of arsenite of potassium, diluted with an equal quantity of water, and gradually increases the dose. Blaschko is accustomed to giving antipyrin internally Avhen itching is a prominent symptom. Locally, the best results can be obtained in the early stages of the disease from the use of Unna's carbo-sublimate-zinc ointment. This preparation consists of corrosive sublimate, one grain; carbolic acid, twenty grains; and ordinary oxide-of-zinc ointment, one ounce. It will also be found valuable as an anti-pruritic in the advanced stages. Carbolic-acid lotion, composed of carbolic acid, one drachm; alcohol, two drachms; and water, one pint, may also be used to allay the itch- ing, which is sometimes severe. Warm alkaline baths are highly esteemed by Dr. R. W. Taylor,* as they allay itching, remove dead epidermis, and promote absorption. He advises also brisk friction every day with the compound tincture of green soap two or three hours before the bath is taken, and, if practi- cable, a mild friction after the bath should be made and the skin then left Unwashed. This writer considers it very important that the skin should be kept well anointed. Wherever the epidermis is much thickened, and especially if it be fissured, he recommends the applica- tion of an ointment composed of balsam of Peru, one drachm, and diachylon ointment, one ounce, covered by a roller bandage. Prognosis.—If treatment is begun early and perseveringly con- tinued a favorable result will probably be obtained, but a guarded prog- nosis should always be given. Many cases terminate fatally notAvith- standing all treatment, and those Avhich have lasted for several months before remedial measures are instituted usually pursue an unfavorable course. The prognosis is influenced also by the extent of the eruption. Patients on whom the lesions are few in number and localized are more amenable to treatment than those on whom they are numerous and diffused over the entire surface. VERRUCA. Synonyms.—Wart—\Varze—Yerrue. Verruca consists of hypertrophy of one or more of the cutaneous papillae, forming round, flat, pointed or irregular, soft or hard circum- scribed elevations, which are Variable in shape and size. Symptoms.—Warts may be congenital or acquired. They appear in * New York Medical Journal, January 5, 1S89. HYPERTROPHIES. 513 many different forms, depending upon the situation and exciting cause. They may be sessile or pedunculated ; round, flat, pointed, or irregular in appearance. Their surface may be smooth, or roughened and fissured. Warts vary in color, size, and consistence. They develop at all ages, but are more frequent in children and old persons. Their growth may be slow or rapid, persisting for years, or disappearing spontaneously after a short or long duration. Warts may be single or multiple. They appear upon all parts of the body, but are most com- monly observed on the hands, face, scalp, neck, genitals, and feet. They sometimes occur under the finger-nail. There are several varieties, Avhich may be described as follows : Verruca Vulgaris.—This is the ordinary variety. They occur most frequently on the hands, especially the fingers, but may also appear upon other regions. They are small, circumscribed growths, attached to the skin by a broad base, and are from a pin's head to a pea in size. Their surface may be smooth, roughened, fissured, or lobulated. Their color is usually similar to that of the adjacent normal skin, but they may be grayish, yellowish, brownish, or blackish, these various shades being due to irritation or to dirt. This variety of Avarts may be soft, or firm, or even hard and horny, being insensi- tive, except when irritated; they then may become painful. They generally appear in crops or groups, but may be single. Verruca Plana (Verruca Senilis).—Warts of this variety are flat, and generally round and broad, varying in size from a small pea to a five-cent piece, and are only slightly raised above the level of the skin. They are soft or greasy to the touch, smooth or slightly roughened, and grayish, yelloAvish, broAvnish, or blackish in color. They are usually met with on the back and face of elderly people, and may be either single or multiple. Verruca Digitata.—This variety of Avart is commonly met Avith on the scalp. It is also flat and broad, but is studded with finger- like projections Avhich give it a crab-like appearance. The digitated Avart is more common upon the scalp of women than of men. Verruca Filiformis.—Filiform Avarts are commonly observed on the face, eyelids, and neck. They are small, fine, thread-like eleva- tions, of about an eighth of an inch in length, existing, as a rule, sepa- rately, but occasionally occurring in groups. Verruca Acuminata.—The A-enereal Avart, pointed wart, moist wart, fig-wart, caulifloAver excrescence, verruca elevata, spitzen condy- lom, vegetation dermique. This variety of wart consists of one or a number of pointed, club-shaped, or irregular mulberry- or cauliflower- like elevations situated upon the genitalia and adjoining regions. They may be sessile or pedunculated, and single or multiple, at times forming more or less solid masses of excrescence. In the male they appear most commonly on the penis, cropping out from the glans, the 33 514 DISEASES OF THE SKIN. sulcus, and the inner surface of the prepuce; in the female, they are an outgrowth from the inner surface of the labia, or from the vagina. They are also met with on the perinaeum, anus, mouth, axillae, umbili- cus, toes, and other portions of the body. Warts of this variety vary from pale to blood red, or even purple, the tint depending upon the region involved, its vascularity, and the condition of the epidermis. When the surface is dry and the epidermis is preserved, they present the normal color of the skin. On the other hand, when, from hyper- secretion or friction, the epidermis is macerated, they assume a bright or deep red color. In the latter event, their surface is covered with decomposing pus, and occasionally crusts, from which a most unpleas- ant or offensive odor emanates. They groAV luxuriantly, sometimes becoming as large as or larger than the fist. They may remain for an indefinite time. Moist warts assume various appearances in different regions, according to the manner in which they are arranged, and have been compared by writers to cauliflowers, mulberries, raspberries, bunches of grapes, and cockscombs. They occur in both sexes and at all ages, but are of more common occurrence in young persons. Pathology.—Anatomically, the various forms of warts differ to some extent, but all have a connective-tissue base, from which papillary ex- crescences spring. In the ordinary wart one or more papillae become greatly enlarged, and are supplied with dilated vascular loops, and cov- ered with more or less hypertrophied epidermis. The filiform wart consists essentially of connecthre tissue containing a minute capillary. In condylomata or venereal warts the papillae are greatly hypertrophied, but the horny layer is usually absent or macerated. Etiology.—Warts may develop without any apparent cause, or they may depend upon constitutional impairment or local irritation; want of cleanliness, contact with various substances, pressure, friction, and exposure to cold or heat may be mentioned as conditions which produce them. Workmen in petroleum refineries are subject to warty growths, principally upon the hands and forearms. Dr. Kuhnemann has found in sections of warts slender bacilli, both in and between the cells. This organism is said to be always present in the prickle layer and to exhibit distinctive qualities as regards its capacity for color. In several instances Dr. Jamieson has been able to trace the origin of verruca digitata to the use of rancid oil or pomade. Condylomata or venereal warts—which are never a manifestation of constitutional syphilis, and should not be confounded with the vegetating syphiloderm—are caused by the irritation of the secretions of gonorrhoea and leucorrhoea. Treatment.—It is occasionally advisable to give remedies which will have a tonic action upon the system, such as iron, cod-liver oil, bitter tonics, and arsenic, the latter being particularly recommended by Mc- Call Anderson. Constitutional treatment is especially necessary in weak, anaemic, or scrofulous children who are afflicted with large crops HYPERTROPHIES. 515 of papillary excrescences. The tincture of iodine in ten-drop doses twice daily is sometimes successful in removing or checking the growth of warts. Thuja occidentalis, in the form of fluid extract or tincture, is often able to effect the removal of warty growths. The tincture is given in doses of five to thirty minims or more three times daily, and may at the same time be employed as a local application. Magnesia has been thought to favor the retrogression of warts. It is given in small doses tAvice daily, before meals, from three to fifteen grains in all being administered. Epsom salt has been used for the same purpose. Locally, warts may be removed by excision, scraping, caustics, electrici- ty, compression, and various medicated substances. The common and filiform wart is best cut out with a knife or curved scissors, and the base touched with a stick of nitrate of silver or chloride of zinc, or the parts draAvn together with sutures. The application of compression with a baud or bandage, when a large surface is involved, is effective. Plasters containing mercury or salicylic acid are likewise of service. Electricity, either static or galvanic, by discharging the spark into the groAvth, has also been found useful. The tincture of iron, salicylic or boric acid, in solution, ointment, or plaster form, is also valuable. Carbolic, chromic, and mineral acids are efficient; but the surrounding skin should be protected by a circle of wax. Kaposi recommends a solution of corrosive sublimate, one in thirty parts of flexible collodion. The solution is applied once daily by a brush to the surface of the wart and around its base. Another formula emanating from the same source contains 150 grains of flowers of sulphur, 375 grains of glycerine, and 75 grains of pure acetic acid, applications being made every day. Salicylic and lactic acids have also been successfully employed dissolved in collodion. Hardy has advised lotions of pure vinegar. Vigier has used with success aseptol or sulphocarbol (orthophenol-sulphuric acid), with which the growth is touched once or twice daily. Unna * em- ployed a combination containing ten grains of arsenic and five grains of corrosive sublimate to the ounce. This preparation was applied on gauze, and kept on night and day for tAvo weeks, at the end of which time all the Avarts had disappeared. The same practitioner is in the habit of using mercurial ointment containing from five to ten per cent. of arsenic. Applied upon linen, the wart gradually softens and is ab- sorbed, leaving no trace. A creasote-salicylic plaster is also recommended by the same author- ity, or the following f ointment may be used as a substitute : IJ, Acid, salicyl........................ 3 iij- Creasoti............................ f 3 vj. Cerae, Adipis..........................aa q. s. M. * Monatsschrift f. pract. Dermat., 3, 1882. f Monatshefte fur Praktische Derraatologic, 1S88, No. 13. 516 DISEASES OF THE SKIN. Enough excipient is employed in order to make a firm ointment Avhich will adhere to the skin. The flat wart can be removed by excis- ion, with the dermal curette or scraping-spoon. The latter is the most effective in warts occurring in the old—afterward applying a weak solu- tion of chloride of zinc, or an ointment containing five to ten grains of arsenic oleate to the ounce. Venereal warts, particularly if very vascu- lar, are most successfully removed by the ligature, or by the galvano- caustic wire. The ligature of one or tAvo will sometimes cause a group rapidly to disappear. The application of equal parts of powdered zinc oleate and bismuth subnitrate, or calomel, alone or combined with boric acid, lycopodium, or salicylic acid, or powdered red cinchona- bark, will often cause them to vanish, leaving the skin normal. Forma- lin has been applied with excellent results to venereal warts in the clinic of Dr. Max Joseph, of Berlin. The warts were painted with formalin, and the surrounding healthy surface protected by a layer of vaseline. When the formalin had dried it was covered with a powder or small piece of cotton. G. E. J. Greene calls attention to the sun spurge, euphorbia helioscopia, popularly termed wart-Aveed, as a remedy for warts. Its juice applied to the wart several times a day will cause disappearance. Cleanliness in many cases will be the only treatment required. Prognosis.—Warts are benign in childhood, and sometimes during adult age, but in the latter period and in elderly people they may, especially if picked or irritated, become the focus of malignant epithe- lial degeneration. Warts that receive treatment in time can generally be eradicated. Occasionally they are so extensive as not to permit of any interference. It is advisable, when warts are large or vascular, to remove only a portion at a time, in order to avoid haemorrhage and subsequent inflammation. Papilloma.—An inflammatory formation or tumor similar to ver- ruca acuminata has been described under this term by Duhring, Hyde, and others. ICHTHYOSIS. Synonyms.—Xeroderma—Ichythyoides—Ichthyosis congenita—Porcupine disease—Fish- skin disease—Fischschuppenausschlag—Ichthyose. Ichthyosis is an hereditary or congenital hypertrophic disease, char- acterized by a general or local dryness, harshness, and scaliness of the epidermis, with sometimes an outgrowth of the papillary layer of the skin. Symptoms.—Ichthyosis usually appears over the entire surface, but may affect only certain areas. It may be mild or seA^ere. If mild, it is denominated ichthyosis simplex; if severe, ichthyosis hystrix. The dis- tinction between the two is one of degree. The disease may be so slight as to be scarcely noticeable, or, by the change or deformity that may Plate VII. Ichthyosis (from Nature). / HYPERTROPHIES. 517 folloAV from its development, may cause great anxiety and annoyance. While but two forms are usually met with, still there is a third called ichthyosis congenita. Ichthyosis Congenita.—This form of ichthyosis, which is rarely seen, begins in intra-uterine life. The child is generally born before the usual period of gestation; it is small, weak, and imperfectly formed ; the eyelids, ears, and lips may be wanting ; the skin is inelas- tic, mapped out in furrows, split, and fissured, the fingers and toes being shortened and bent. Should the child be living, it usually dies a few days after birth. Jahr has recorded the case of a child Avhich lived nine days. At times an infant apparently healthy at birth develops ichthyosis during the first week. Two such cases have been reported by Rona. Ichthyosis Simplex.—This is the mildest form of the disease, and is the one generally encountered. It has been designated xero- derma (dry skin). The hypertrophy appears to be confined to the epidermis. The entire surface is not only dry, but also harsh, wrinkled, and poorly nourished, instead of being soft, smooth, and pliable. As a consequence, the integument has an unnatural, and often a parchment- like, appearance. There seems to be less subcutaneous fat than usual, and the natural lines and furrows stand out more than in the nor- mal condition, and are attended Avith more or less scaliness. The scales vary in size, some being small, thin, and fnrfuraceous; others large, thick, and in the form of plates, like those of a fish. The furfura- ceous or bran-like scales are usually seen on the head, and the larger ones on the extremities. In shape the scales correspond to the natu- ral lines and furrows of the part on which they occur. The scales form on the extremities polygonal or diamond-shaped plates, separated from each other by lines or furrows. They are usually firmly attached in the centre, loosely at the periphery, and have a Avhite or farinaceous appear- ance ; or, if thick and Avell developed, assume a shade ranging from dirty, grayish Avhite to yellowish green, brown, or even black. These different hues of the scales are due to dirt and other extraneous mat- ter, as well as to the presence of pigment-granules. The extent and amount of the scales depend upon the character and duration of the disease, the age of the patient, and the attention given to bathing and other external means of treatment. The parts most often affected are the extremities, though the disease may manifest itself upon the face, and in some instances the lips alone are involved. Ichthyosis Hystrix.—This seA-ere variety is but an exaggeration or a higher deArelopment of the milder form of the disease. The line of demarcation may be very slight or well marked. It may occur in localized patches, or be distributed unequally oAer part or all of the surface, sometimes folloAving certain nerve-tracts. An interesting case of the latter description has been reported by Dr. August Koren at a 518 DISEASES OF THE SKIN. meeting of the. Christiania Medical Society, April 24, 1889. The dis- ease, which Avas named ichthyosis linearis neuropathica, extended in the form of broAvnish, papillomatous stripes along the course of the radial, median, and ulnar nerves. The stripe situated over the median nerve reached only as far as the Avrist joint, that over the radial ex- tended as far as the dorsal surface of the first joints of the thumb and index finger, Avhile that over the ulnar pursued its course along the palm of the hand to the tip of the little finger. The tips of the other four fingers were likeAvise slightly affected. The subject was a boy, nine months of age. A bilateral case of the same nature was observed by Dr. Butruille, linear stripes of ichthyosis being developed over both sciatics.* In ichthyosis hystrix the part affected is the seat of irregular or polygonal masses of all tints, more commonly greenish and black, and between them the normal lines and furrows stand out distinctly. These masses can be picked off, exposing a dry and shrivelled skin, beneath which can be seen sebaceous ducts distended by plugs of sebum that have been left clinging to the detached plate. In some cases the patches present a rough, papillary, or warty growth, having a horny, pointed, round, or spinous appearance, the latter often being several lines in length, and, from its resemblance to the quill of a por- cupine, this form has been termed hystrix. These patches are usually situated around the elbows and the back, also the neck, the axillary region, the umbilicus, the knees, and the ankles. The age of the patient, the duration of the attack, and the attention given to the re- moval of the masses, are factors in the severity and development of both varieties of the disease. Ichthyosis seldom manifests itself until a few months or about the second year after birth. The child is generally born healthy, but gradually the roughness and dryness of the skin become visible. The disease first makes its appearance upon the surface of the limbs, espe- cially the elboAvs and the adjoining parts of the arm and the forearm, the legs, and about the knees and ankles, and on these members it is always most marked and virulent. In some instances the disease is limited to the palms and soles. A case of ichthyosis plantaris has been reported f by Dr. Allan Jamieson. The patient was a man, aged thirty-five years, whose father had a similar affection. The horny growths had reached a thickness of nearly half an inch.' Ichthyosis, if not confined to the regions named, spreads until it covers the whole surface. The disease usually manifests itself in the latter way, the en- tire skin having the appearance of being sprinkled over with meal; the thick, rough, and scaly condition being especially prominent on the extensor surfaces, the contrast being noticeable in comparison with the flexor regions, Avhich are ordinarily free from incrustation. The * Journal of Cutaneous and Genito-Urinary Diseases, February, 1890, p. 57. f British Medical Journal, February 23, 1889. HYPERTROPHIES. 519 sculp is rough and dry, and covered with f urfuraceous or branny scales. The hair is also rough, dry, brittle, and lacks its peculiar lustre. On the face the skin may be mapped out in the form of plates, or the eye- brows and eyelids may be slightly scaly, but, as a rule, this region is seldom affected. Ichthyotic persons are usually thin, and their skin is extremely sensitive to atmospheric changes. In severe weather especially the in- tegument becomes'tender, irritable, and frequently cracks. Sometimes there may be slight itching on exposure to the air, more marked on retiring at night. The skin is dry and wrinkled, the normal lines and furrows stand out prominently, and perspiration is generally slight; the extremities are usually cold; the nails poorly deA^eloped, dry, and break easily. As a rule, little or no itching accompanies the disease. The thickening of the epidermis is great, especially on the palmar and plantar surfaces. Again, there may be seen over portions of the body small polygonal plates, resembling those of the alligator. Dr. Fox has reported a case presenting this appearance.* Ichthyotic, more or less pigmented patches are sometimes observed along the course of certain nerves. The papillae may or may not be enlarged. In the former case perversions of sensibility may be present. The disease is essentially chronic, lasting, perhaps, the lifetime of the afflicted person, but, singularly, never involving the general health. In winter the disease is more severe and more marked than in summer. During the latter season and sometimes in the spring the increased activity of the sweat-glands so modifies the altered epidermis as to leave the skin for a while apparently normal; but a relapse occurs with the advent of cold weather. Cases are reported as having been cured after an attack of an acute exanthem. Diagnosis.—The history of the disease, its congenital or hereditary nature, the dry, rough, scaly condition of the skin, and more or less hypertrophy of the papillas, its distribution in certain regions, the dull- white appearance of the surface, and the absence of redness, are suffi- cient to distinguish ichthyosis from all other cutaneous diseases. Lo- calized patches of old cases might, howe\rer, be confounded with seb- orrheica. In the latter disease there is no evidence of an ill-nourished state of the skin, or papillary hypertrophy,.as in the former, and the scales Avill be found to cover the dilated ducts of the sebaceous glands. Pathology.—Ichthyosis will present different morbid conditions, in accordance with the severity of the disease. In a Avell-marked case, from Avhich I made a section, the epidermis was enormously increased, and consisted of many heaped-up lamellae. The mucous layer was somewhat hypertrophied and slightly separated from the stratum cor- neum. The papilla? were enlarged and slightly infiltrated with cells. * " The Alligator Boy." A case of ichthyosis well illustrated. Journal of Cutaneous and Venereal Diseases, April, 1884, p. 91. 520 DISEASES OF THE SKIN. The blood-vessels were also enlarged, but the glands and follicles re- mained unchanged. Neumann, in addition to other hypertrophic changes, found the vessels dilated, the cutis thickened, and its con- nective tissue condensed in bands; the hair-follicles lengthened and containing lanugo; an increase of the external root-sheath ; the glands dilated, particularly the sebaceous, which had a cyst-form; and the subcutaneous fat diminished. In some typical cases the epidermis was in lamellae, ranging in color from yellowish to dark brown; and the hair-follicles and sebaceous glands were absent. Kaposi has also re- ported a case in which the sebaceous and sweat glands Avere absent. Etiology.—Ichthyosis is a congenital or hereditary disease, develop- ing at an early period of life. It is found among all races and in all parts of the world. Ichthyosis occurs in both sexes, and can be trans- mitted from either father or mother, and has been traced to the grand- parents. The parents of ichthyotic children are devoid of constitu- tional taint, and, with their offspring, always enjoy, excepting this deformity, the best of general health. In some large families several children may be affected, while in other families, equally large, only one member will present the disease, the others being entirely free from it. Dr. J. W. Hunt, of Anderson, Ind., has communicated to the author notes of two marked cases occurring in a brother and sister. When the affection makes its appearance, it gradually increases until adult age, and continues with but little change for the remainder of life. Again, cases will occasionally be seen that can not be traced to either parents or grand-parents, but may have arisen from some in- fluence which affected the mother during pregnancy. A condition ap- proximating or analogous to ichthyosis occasionally occurs among the laborers in petroleum oil works. Treatment.—Arsenic and the nutritive oils are the only remedies which appear to make any impression upon the disease. The persist- ent employment of these agents will produce a beneficial effect on the integument, which is, however, by no means permanent. It is prob- able also that the persistent use of small doses of pilocarpine will at least ameliorate the manifestations of ichthyosis. Thyroid medication seemed to be beneficial in a number of reported cases. Local Treatment is by far the most important and beneficial. Agents should be employed that have the power of softening and removing the accumulated epidermic masses and the extraneous mat- ter, exercising at the same time a favorable influence upon the skin. Water is the best remedy for this purpose, used either alone or in combination with soft or medicated soap, or in the form of a medi- cated bath, the alkaline being especially serviceable. At intervals a hot-air or vapor bath, simple or medicated, should be employed. In severe cases, w7here the caking is marked, it is necessary to scrape off the masses with the curette or a knife, and to touch the parts after- HYPERTROPHIES. 521 ward with a mild caustic solution. After the bath, and on rising in the morning and retiring at night, if convenient, an oily substance should be applied to protect the affected surface and aid its nutrition. Among the useful remedies to employ for the local treatment may be mentioned the oil of ergot, the oil of corn, oil of sweet almonds, olive- oil, linseed and cod-liver oils, simple and benzoated ointment, suet, lano- lin, glycerine diluted with rose-water, or one of the petroleum prod- ucts. The following formula may be used with advantage: R; Olei ergotae...................... f | iij. Ung. hydrarg. oleatis (10$)........ f § j. M. Sig. : Apply once or tAvice daily, especially after bathing. The following ointment is also valuable : R, Acidi benzoici....................gr. v. Ung. aquae rosae................... 3 j. Lanolin.......................... | ss. M. Ft. ungt. Milton and Duhring recommend an ointment composed of potas- sium iodide, ten to twenty grains, and lard, one ounce. An ointment containing ichthyol or sulphur is of service in soften- ing the skin and removing the epithelium. Sulphur can also be ap- plied to the skin in the form of a vapor. A resorcin ointment has also been employed in the strength of three to tAventy per cent., according to the severity of the disease. Prognosis.—Ichthyosis is an incurable affection. Patients should always be apprised of this fact. They should likewise be informed that, by the use of the proper external treatment, the deformity can be lessened, but that no remedy or class of remedies have been known to cure the disease. Ichthyosis will continue throughout the life of the person affected, occasionally almost disappearing during warm weather, to return again during atmospheric changes or the Avinter months. SCLERODERMA. Synonyms.—Sel:rema—Scleriasis—Scleroma adultorum—Chorionitis—Sclerostenosis— Cutis tensa chronica—Dermatosclerosis—Sclerosis corii—Hautsclerem—Sclereme des adultes. Scleroderma is an acute or chronic affection, characterized by a diffuse or circumscribed, pigmented, indurated, rigid, and hide-bound condition of the skin. Symptoms.—Scleroderma commences, as a rule, without either con- stitutional or local disturbance, the first symptom to which the patient's attention is usually attracted being a slight stiffness or hardness of some portion of the skin. It is not uncommon for pain to occur as an early symptom. In exceptional cases it may begin with chills, fever, swell- ing, and a feeling of numbness and formication or a pigmentation of 522 DISEASES OF THE SKIN. the part. The rigidity which then sets in increases gradually in ex- tent and severity, often requiring months or years, or rarely more rap- idly spreading, until the affected part is more or less sclerosed. The morbid process may occur on any portion of the body, but it is most frequently observed on the upper and to a much less extent on the lower extremities. The disease may be diffused over all or the greater part of the surface, or be limited to one or more patches or streaks which bind doAvn the skin, as, for example, across the mammae. Sclero- derma generally develops upon both sides of the body, though the lesions may not be symmetrically arranged. The skin of the affected part is thick, rigid, hard, and has a feeling to the touch of firmness, tightness, and coldness, or, as Thirial states, very much like the skin of a frozen corpse. The sclerosed tissue passes insensibly into the normal skin, presenting no line of demarcation, but having at times a hyperaemic tract around it. The surface is swollen, moderately ele- vated or shrunken, smooth, shining, somewhat scaly, pale white in color, as if it were bleached, or like wax, brownish-red or pigmented in patches, with sometimes a slight or severe papillary hypertrophy similar to a local ichthyosis. The mucous membrane, particularly around the mouth and vagina, may likewise show a similar change. The mucous membrane of the genitalia is usually attacked about the period of the grand climacteric. Generally the entire mucous mem- brane is affected, but at times the disease is confined to patches, the membrane being pale, indurated, dry, and inelastic. The entrance to the vagina becomes gradually more and more constricted.* It is almost impossible to pick up a fold of the skin, as it is immovable on the underlying tissue, neither will pressure produce any depression of the part. In typical cases the various layers of the skin and muscles appear as if they had become united to the bones beneath. The face, if affected, becomes altered in every way. The orifices of the eyes appear diminished in size, the alae nasi stretched, and the mouth contracted. The skin no longer wrinkles, and the features become rigid and immovable, like an inanimate object, failing in all respects to por- tray the impressions of the mind. To this aspect the term "sclero- dermic mask " is applied by the French writers. If the morbid pro- cess extends to the neck, rotation of the head is interfered with or can be made only with difficulty. Again, if the integument of the chest or abdomen becomes sclerotic, respiration is sometimes impeded. Lastly, if the limbs be involved, they appear as if shortened; the joints, espe- cially those of the fingers and toes, become semi-flexed, and their mo- tion impaired, frequently interfering with the occupation of the pa- tient. In this form of the affection the skin becomes atrophied, smooth, and attached to the phalangeal bones. The nails are atro- phied and deformed. Finally, the bones undergo absorption in situ, * Lancet, April 19, 1890. HYPERTROPHIES. 523 the fingers assume a slender, conical form, and are shortened by mutila- tion ; except in rare instances, no pieces of bone are ever discharged. Dr. Eichhoff has described a case in which scleroderma was associated with and apparently dependent upon favus of the nails. Upon the basis of the favus ulcers a general progressive scleroderma was devel- oped and gradually involved the entire surface of the body. The scleroderma retroceded as soon as the original affection was cured. Rosenthal met with a case in which a little girl had suffered from scleroderma of the left side of the face and neck and upon the scalp. In consequence of this condition, atrophy of the left half of the face and alopecia circumscripta of the left side of the scalp had resulted. Krevet describes a case of general scleroderma in which the skin ap- peared to be too short over the entire body. In a case observed by Friedheim the disease of the skin was complicated by cutaneous haem- orrhages. In some cases the disease of the skin follows the course of certain nerves. The surface temperature in this affection is either normal or slightly lower than in health. The secretory functions may be natural, excess- ive, or diminished, the skin often feeling greasy or dry. The sensibil- ity of the part may be quite normal or slightly diminished. The sub- jective symptoms become more and more annoying. The skin, Avhich was swollen, becomes contracted as the affection progresses, and gives the sufferer a hide-bound feeling/ Spontaneous neuralgic pains some- times appear Avhich may only be temporary, and usually seated in the bones and joints rather than the affected tissue. Pressure upon the sclerosed patches is frequently painful. The general health, as a rule, continues good, but in some instances diseases of the lungs, heart, or kidneys may develop and terminate in amyloid degeneration and death. Rapid action of the heart and exophthalmos associated Avith scleroder- ma Avere observed by Dr. Beer, and Dr. G. Singer found degeneration of the thyroid gland in a patient avIio had died from scleroderma. Eczema, acne, erysipelas, herpes zoster, variola, morphcea, and keloid may occur as complications. Scleroderma may in rare cases disappear by involution, the hardness and discoloration of the surface fading, and softness, elasticity, and natural color returning. This retrogression may occur only in spots, the disease at the same time spreading by the development of neAV patches upon another area. In other cases the affected surface sooner or later becomes the seat of atrophic degenera- tion. The integument becomes thin, smooth, soft, shining, often some- what wrinkled, milky Avhite, red, or irregularly pigmented, and adherent to the bone. The immobility of the parts, Avith the disturbance of the circulation, leads to mortification, with ulceration of the skin. The disease may change from time to time, now becoming better, again worse, and so persist for years, the attending pain, loss of sleep, and disturbed nutrition leading to a fatal termination. 521 DISEASES OF THE SKIN. Diagnosis.—The diagnosis of scleroderma is not generally difficult; the cold, hard, callous, pigmented integument, which can not be lifted in folds, is seen in no other affection. It sometimes manifests a re- semblance to keloid, but the latter consists of one or more circum- scribed, cicatricial, usually reddish elevations, more or less painful. Scleroderma is liable to be confounded with morphcea, from Avhich it may be differentiated as folloAvs : Scleroderma usually begins Avithout any subjective symptoms, the stiffness or hardness simply appearing over large areas, as, for instance, the face, the neck, the trunk, or all the surface. Morphcea begins by the development of a congestive reddish or purplish soft spot, of small area, and may be attended with pain or a tingling sensation. Sclero- derma is generally symmetrical and rarely appears over definite nerve- tracts. Morphcea usually commences on one side of the body and fol- lows the course of the large nerves. Scleroderma presents an ill-de- fined margin which passes insensibly into the healthy skin, while morphcea is sharply defined, with a surrounding purplish or lilac border. In scleroderma the integument is hard and immovable; in morphcea the skin is soft, can be raised in folds, is altered in structure, and con- tains enlarged vessels and striae atrophica?. In scleroderma the skin ap- pears to be irregularly pigmented ; in morphcea it is usually a sombre yellow or ash color. Finally, scleroderma increases slowly, is persistent, and causes in- convenience and pain by the contraction of the integument produced by it; morphcea, on the other hand, increases rapidly, but may disappear spontaneously, or, if not, produces little or no inconvenience, and con- traction rarely supervenes. Pathology.—The immediate pathological changes in the skin in scleroderma consist of an increase and condensation of the connective- tissue elements. The corium and subcutaneous tissue are the portions chiefly involved. The elastic fibres are increased, the fat-cells atrophied, and the thickened mass comes at once in contact with the bones. The vessels are numerous, but diminished in calibre by the pressure of the surrounding connective tissue. Cells accumulate in the perivascular lymph-spaces, around the vessels, and in the connective tissue of the part. According to Kaposi, the pathological changes occurring in this dis- ease are due to a thickening and stasis of lymph from an abnormal condition of the nutritive processes, the stagnation taking place in the lymph-spaces. The epidermis and the papillae are primarily unaltered, but secondarily there may be an increased deposition of pigment in the rete, as well as in the upper layer of the corium. Papillary hypertrophy may at times occur as well as hypertrophy of the muscular fibres and dilatation of the sweat-glands. The glands usually remain normal, except in the atrophic stage, Avhen the neAV tis- HYPERTROPHIES. 525 sue decreases and mostly disappears, at Avhich time they also undergo atrophy. Scleroderma, therefore, appears to be primarily a connective- tissue hypertrophy, probably arising from nervous disturbance, and end- ing in either resolution or atrophy. Goldschmidt has observed that the muscles Avere invaded in some cases of scleroderma. Mery has had the opportunity of making a post-mortem examination of the body of a girl, twenty-tAVO years of age, in whom the malady ran a rapid course and Avho died in consequence of pericarditis. He found the muscles of the limbs hard, atrophied, and discolored. The microscope shoAved that a considerable development of interstitial connective tissue had taken place. Periarteritis, and especially endarteritis, affected the muscular arteries. The muscular substance of the heart was markedly sclerotic. In the case of Mr. Foulcrton the muscles had undergone complete degeneration and Avere of a grayish, Avaxy appearance, while the bones were much atrophied. Jacquet and De Saint-Germain, in a fatal case, found a number of small cavities in the gray matter of the spinal cord, occupying principally the loAver part of the cervical enlargement. The cells of the cord throughout the greater part of its extent had under- gone alteration. Etiology.—The cause is involved in doubt. It is a very rare affec- tion, but is seen at all periods of life. It is much more frequently met with among women, and the greater number of cases occur in middle age. Schwimmer reports three cases in Avhich the thoracic duct was entirely unchanged. Among the causes that have been referred to as exciting the disease are exposure to cold, rheumatism, and great nerv- ous strain or shock. The nervous origin of the disease has been point- ed out by Schwimmer, whose cases showed disease of the peripheral nerves. Westphal observed pathological changes in the brain. Cases have been encountered in which scleroderma was associated with sclero- sis of the cord, infantile paralysis, and Raynaud's disease. Treatment.—Good hygiene, food, and travel, with iron, quinine, arsenic, cod-liver oil, or other tonics and alteratives, Avill be of benefit. Locally, baths, massage, and stimulating ointments may be used, the mercurial and iodine being especially valuable. Dr. Moreau employs hot baths of three to four hours' duration, and conceives that their virtue is enhanced by adding to them a strong decoction of valerian root, and giving daily massage Avith a pomade containing five drachms of extract of valerian and six drops of essence of valerian to ten drachms of vaseline. Massage was used Avith striking advantage in a case re- ported by Prof. Breda. Diffused sclerodermic patches bad developed upon different portions of the body subsequent to a long attack of rheumatism. Applications of mercurial potash soap (sapo viridis 1 ss. and ungt. hydrarg. 3 j) and the ointment of copper oleate, one half a drachm to the ounce of lard, are also of benefit. The constant galvanic current has been recommended by Piffard, Fieber, and others; 526 DISEASES OF THE SKIN. Schwimmer suggesting also the galvanization of the sympathetic. Boisseau has reported the successful treatment of a case by means of static electricity. A few cases have been reported cured by Bock, Brambilla, and Friedlander. The patient of Dr. Bock Avas a girl aged nineteen years, of healthy parentage and neurotic type, in whom the disease appeared after sleeping Avith the upper part of her body exposed to a draught. She came under treatment a few days later, and Avas cured by frequent frictions, massage, sulphur, and Turkish baths. Brambilla's patients Avere treated by means .of copious diaphoresis and the internal use of salicylate of soda and tonics. Similar methods Avere employed by Friedlander, Avhose patient Avas a girl five years of age; about six months Avere required before the cure was effected. Pilocar- pine may probably also answer a good purpose by virtue of its action on the sweat-glands. Debove reports amelioration of a case invohing the upper extremity by spraying the surface with chloride of methyl. Brocq has witnessed marked improvement by means of electrolysis in a case involving the arm and forearm in the form of a band an inch or two in Avidth and very thick. After fourteen sittings, each comprising tAvelve or sixteen punctures of the electrolytic needle, the disease was arrested, and has since remained stationary. Though treatment has, in a feAv instances, proved of advantage, yet the disease, as a rule, is unin- fluenced by any therapeutic method. Prognosis.—The prognosis of scleroderma should ahvays be care- fully guarded, as the disease varies in course and termination. Recov- ery sometimes occurs through spontaneous involution, or the malady may continue during the entire life of the sufferer. A fatal termina- tion may at times follow complication with some other affection. If the stage of atrophy has begun, the normal condition of the surface will not return. SCLEREMA NEONATORUM. Synonyms.—Scleroderma neonatorum—Induratio tclae cellulosce neonatorum—Algor pro- gressiva—Das Sclerem der Neugeborenen—Decrepitude infantile—Sclerema of the new-born. Sclerema neonatorum is a disease occurring usually a few days after birth, and consisting of an induration of the cutaneous cellular tissue, generally of the lower extremities, characterized by discoloration, cedem- atous SAvelling, coldness, and hardness of the affected part. Symptoms.—The disease, which may be congenital, appears in new- born infants usually in from three to ten days, and rarely several months, after birth. At times the local symptoms are preceded by rapid malnutrition and wasting, with more or less restlessness. The morbid process is usually observed first upon the lower extremities, beginning on the cahes and rapidly spreading upward to the thighs, abdomen, arms, neck, and'face, frequently inArolving the entire body. HYPERTROPHIES. 527 In some cases, though rarely, it is said to attack the face or body first, and later extend to the extremities. The skin of the affected part appears tense and shining, and may be pallid, red, livid, or of a brownish or yellowish color. It may be more or less mottled, and the epidermis may be smooth, Avrinkled, or fissured. The part is also swollen and cedematous, the surface cold, resistant, and indurated to the touch, incapable of being raised in folds, but pressure Avith the finger produces a depression in the skin. The cedematous swelling, however, is sometimes absent, or hardly apparent; if present, it dimin- ishes in a feAv days, but the parts remain cold, hard, and Avrinkled. The temperature usually decreases, and the pulse and respiration also fall in frequency, although cases have been reported in which the temperature was normal and the pulse increased in frequency. The affected parts become almost or entirely immovable. If the disease involves a greater part or all of the skin, the body presents the ap- pearance of a corpse. The child remains motionless for hours, or shows faint evidence of life by feeble movements of the unaffected parts. The pulse and respiration at times become almost impercepti- ble, the rigidity of the lips interferes with or renders feeding impossi- ble, and the patient dies within a feAv days. Pneumonia, or other derangement of the respiratory or the circulatory systems, intestinal or urinary disease, usually coexists with sclerema neonatorum. Dr. Angel Money has observed this disease, occurring in three sisters, accompanied by partial paralysis of the extremities. All ended fatally, death being preceded by local clonic spasms of the face. Diagnosis.—There is no difficulty in recognizing sclerema neonato- rum. The cedematous, cold, hard, characteristically colored skin, feeble circulation and respiration occurring in early infancy are sufficiently suggestive of the disease. The only affection with which it is liable to be confounded is oedema of the neAv-born, both diseases having the symptoms of falling of the temperature, pulse, respiration, and the rigidity of the body in common. (Edema of the new-born differs from sclerema neonatorum in being of longer duration, less fatal, the skin being movable over the underlying structures, the rigidity being slighter and the SAvelling more pronounced. The tAvo diseases, ac- cording to Eustace Smith, may exist together, or sclerema neonatorum may succeed oedema, as reported by Perot. Pathology.—The skin of children affected Avith sclerema neona- torum becomes more decided in color after death, often changing to a blue, but the hardness and rigidity remain. On cutting the integ- ument, dark bloody serum oozes out, followed by a yellowish fluid, the oedema in the mean time disappearing and the indurated tissue becoming soft. Sclerema neonatorum is said to show no other important change apart from this cedematous infiltration and a firm, stearin-like de- 528 DISEASES OF THE SKIN. posit in the subcutaneous tissue. The results of the post-mortem ex- amination of an infant who died of sclerema three days after birth have been reported * by Dr. J. W. Ballantyne. Upon making a sec- tion of the skin and subcutaneous tissue a sensation Avas conveyed to the hand like that produced by cutting bacon rind. The subcutaneous cellular tissue had a peculiar white, glistening aspect. No serous fluid could be expressed from the cut surface. Examined under the micro- scope, an abundant connective tissue A\7as seen subdividing the subcu- taneous adispose tissue into numerous patches of varying size. The connective-tissue bands Avere not only increased in number, but Avere much thicker than normal. The fat cells in some instances had lost all their fat. Small vessels were seen here and there, surrounded by num- bers of leucocytes, and pushing their way into the clumps of fat cells. The papillae were not well marked, and the outlines of the cells of the rete Malpighii were ill defined. The horny layer appeared to be normal. Etiology.—Sclerema neonatorum appears most frequently in chil- dren who are born prematurely, and occurs more often in winter than in summer. It may be caused by any constitutional or local condition which disturbs the respiration and circulation, such as pneumonia, bronchitis, heart disease, syphilis, premature birth, hydrocephalus, me- ningeal apoplexy, malnutrition, and exposure to cold. Treatment.—The treatment should be first directed to removing the cause; if this can be done, the disease may be cured. The most important part of the treatment consists in keeping up the nourish- ment of the child either with milk or a suitable substitute, together with a certain amount of stimulant, as good brandy or Avhite wine with sugar. As the child can not suckle or partake of sufficient nourishment, the food should be ghren through a tube. Forced feed- ing can be best carried out by passing an elastic catheter through the nose and into the stomach, through which liquid food can be given regularly, as recommended by Eustace Smith. It is equally important to keep up the temperature of the body by moderate friction and by warm applications to the surface. Dr. Ballantyne advises that young infants be placed in an incubator. Dr. Money has reported the cure of a case by means of mercurial frictions. Prognosis.—Sclerema neonatorum is usually a fatal disease, but recovery may ensue in mild cases. MORPHCEA.f Morphcea is a chronic disease of the skin, characterized by the appearance of one or more isolated points, lines, bands, or patches, * British Medical Journal, February 22, 1890. f Morphcea is held by some authorities to be a circumscribed form of scleroderma. HYPERTROPHIES. 520 which are primarily hyperaemic, sometimes slightly elevated, sur- rounded with a pink aureola, and Avhich later become level with the skin or slightly depressed, white or yelloAvish or pinkish, with a pol- ished aspect. Symptoms.—This disease, which was knoAvn as Addison's keloid, presents a number of appearances, as it assumes one form or another, and according to its stage of development. It frequently begins with one or more isolated, circumscribed, rounded, ovalish, or elon- gated, hyperaemic, pink, or violet patches, varying in size from a fraction of an inch to several inches in diameter. The patches may continue to increase, or several may coalesce until they become as large as the hand. After having become well defined and circum- scribed, they are surrounded with a pink or violaceous aureola com- posed of a network of vessels. At times bunches of these minute capillaries are also distributed over the surface. The affected skin in its early stage may be slightly sAvollen or elevated. At a later stage * this condition disappears, and the patch becomes level Avith the sur- rounding skin or somewhat depressed. In color the patch is pink or purplish, yellowish or whitish. The surface is usually smooth and shining, appearing like polished ivory, wax, marble, or alabaster, and looking as if a substance like lard or bacon had been deposited in the skin. Tilbury Fox likewise observed the same change in the mucous membrane of the inside of the lips, and others have seen it in the surface of the pharynx. In old cases there may be more or less desquamation of the skin. The adjacent skin is apt to become yel- low, brown, or mottled. To the touch a fully developed patch is generally firm, braAvny, and inelastic, and can be pinched up only with difficulty. It is not uncommon to find, on palpation, little or no change of the integument; the sensibility may be diminished, but, as a rule, in the early stage continues normal. In some cases the patches, having become fully developed, may remain in this condition indefi- nitely, or they may rapidly or sloAvly undergo spontaneous involution, the skin returning to its ordinary condition. In other instances, atrophic changes occur, the patches becoming contracted, dry, shrunk- en, parchment-like, and often bound doAvn to the underlying parts. The glands are also generally atrophied, and their secretions are diminished or absent. After a time the subcutaneous and muscular tissues undergo atrophic alteration. Small or large, round, elongated, or irregularly shaped cicatriform lesions result, with more or less de- formity and loss of power. Morphcea may also appear in the form of groups or scattered, small, pit-like scars, intermingled with capillaries, and white, glazed macu- lae and furroAvs developing the maculas et stria1 atrophicae. In addi- tion there may be present reddish or purplish telangiectases Avith more or less yellowish or brownish pigmentation around the patches. 34 530 DISEASES OF THE SKIN. These lesions may continue indefinitely or undergo spontaneous invo- lution, or they may gradually assume the waxy, lardaceous condition already described. Morphcea manifests no tendency to symmetry. The lesions may occur upon any part of the body, but appear by preference on the face, neck, chest, back, abdomen, arms, and thighs. They may be quite irregular in their distribution, or may, as is frequently the case, follow certain nerve-tracts, as, for instance, the fifth or the sciatic. Subjective symptoms are apt to be absent, the lesions developing and persisting without any marked symptoms, although pain, tender- ness, and a tingling have been known to precede and accompany the disease. Morphcea is a rare affection, chronic in its course, often con- tinuing for years. Diagnosis.—The diagnosis between scleroderma and morphcea is discussed under the former disease. The atrophic striae, as observed in one form of morphcea, are with difficulty distinguished from the normal lineae albicantes. The anaesthetic spots of leprosy, which resemble those of morphcea, as well as many other phenomena common to each, point very strongly to the neurotic origin of both affections. The patches of leprosy, how- ever, are not waxy white from the beginning of the disease, as they be- come very soon in morphcea; and, further, the other well-marked symptoms, which in addition occur in the former most serious affec- tion, are all-sufficient to lead to a proper diagnosis. The spots of vitiligo bear more or less resemblance to morphcea patches, but in vitiligo there is simply a diminution of the pigmentary matter of the rete Malpighii, with no textural change whatever, while in morphcea there is a structural alteration in the skin. Pathology.—Microscopical investigations have thus far developed very little in reference to the pathology of morphcea. Crocker, who examined patches in the early stages, noted pigmentation of the deeper layers of the epidermis, atrophied papillae, and a copious infiltration of cells around the glands and vessels. In the later stages these cells de- veloped into fibrillar connective tissues, which shrank, followed by obliteration of blood-vessels and atrophy of the glands. Duhring, on the other hand, found, from an examination of a white patch of some months' standing, simply a condensation of the connective tissue of the corium, Avith a shrinkage of the papillary layer. Etiology.—The cause of the disease is not positively known. Hutch- inson believes it is neurotic in origin. Wilson, Tilbury Fox, Crocker, and others have pointed out its frequent occurrence along the course of distinct nerve-tracts, but it has also been observed remote from them. In confirmation of those who believe that the nervous system is in fault in producing morphcea may be mentioned it occurrence with HYPERTROPHIES. 531 such other neurotic affections as canities and alopecia circumscripta. It occurs at all ages, and in the robust as Avell as in the Aveak, but is more frequently observed in women than in men. Treatment.—The milder forms of morphcea, which are hid by the patient's clothing, generally require no attention. Such cases some- times recover without any treatment. The more severe cases of the disease, especially if on the face or exposed portions of the body, call for both constitutional and local treatment. Iron, quinine, phos- phorus, cod-liver oil, arsenic, and the chloride of gold and sodium are especially useful. Locally, massage, galvanism, mercurial pot- ash soap, and mercurial lotions, singly or in combination, are of service. Prognosis.—The course of the disease is usually chronic, continu- ing often for life. Spontaneous recovery may occur in a short time after its appearance. This is especially the case in the milder forms of the disease. If atrophy, however, has occurred, the skin can not be restored to its natural condition. Hemiatrophia Facialis.—In connection with morphcea it might be well to mention the disease known as hemiatrophia facialis, or unilateral atrophy of the face. This appears to be closely related to or is a variety of morphcea, but the morbid process is deeper seated than in the latter affection. It consists in atrophy not only of the skin but of the subcutaneous cellular tissue, the muscles, and sometimes even the bones of a portion or of all of one side of the face. Inasmuch as the lesions of morphcea have been observed in some of the cases of unilateral atrophy of the face, it is probable that both diseases are of the same nature. ELEPHANTIASIS. Synonyms.—Elephantiasis arabum—Pachydermia—Bucnemia tropica—Spargosis—Mor- bus elephas—Elephant leg—Barbadoes leg. Elephantiasis is a chronic hypertrophic disease of the skin and sub- cutaneous connective tissue, characterized by an increase in size of the affected part, accompanied by inflammation of the vessels and lym- phatics, swelling, oedema, thickening, induration, more or less pig- mentation, fissures, and warty growths. Symptoms.—The disease generally manifests itself as an erythema, or an erysipelatous inflammation, or a dermatitis, accompanied by more or less severe constitutional symptoms. The skin is red, swollen, hot, and painful, and the entire affected region is someAvhat enlarged. Re- lapses occur from time to time Avithout any assignable cause, as a result of Avhich the part still further increases in size and becomes fissured, indurated, discolored, and covered Avith papillary excrescences giving it a most deformed appearance. Elephantiasis occurs on various portions of the body, attacking by preference the legs, feet, scrotum, penis, labia, 532 DISEASES OF THE SKIN. and clitoris; less frequently, the anus and upper extremities are in- volved. Cases are also recorded in which the external ear, eyelids, nose, cheeks, and mammae have been invaded, and in rare instances the dis- ease has developed upon the chest, back of the neck, the abdomen, or the tongue. A case of naevoid elephantiasis of the face has been described * by Dr. B. Merrill Ricketts, of Cincinnati. A port-Avine discoloration ex- tended from the loAver margin of the wing of the nose to the top of the ear on each side. The skin of the nose was neither thickened nor discolored. The ears suffered from discoloration alone; but the skin upon the chin was so heavy from increased thickness that the lower lip was pulled down and became a part of the hypertrophic mass. The diseased skin Avas from a half degree to one degree loAver in tempera- ture than the skin of the forehead, and more sensitive to cold. The hypertrophied skin was of the same deep-red color. The symptoms of elephantiasis will differ according to the part in- vaded. When the legs are involved the disease is usually confined to one member, which, after repeated attacks, is enormously increased in size, especially from the knee to the ankle, the foot, when involved, be- coming a shapeless mass. The thickened and umvieldy limb presents a most distorted aspect. The cutis, which is tightly stretched, is united to the underlying tissues and pits on pressure. Pressure or deep manipu- lation develops a hard, resisting, conglomerated tissue; the separate structures, especially the muscles, can not be distinguished from the mass. Enlarged lymphatics or the saphenous vein may be traced to the upper part of the thigh as hard, rigid bands. The skin may be either smooth, shining, pale, red, brown, brownish-red, or rough and dark in appearance. Fissures, warty growths, tubercles, and often an eczema- tous condition, occur on various parts of the limbs. The skin may here and there be deprived of epidermis, bleed, and weep; or lymphatic ves- sels be opened up, causing lymphorrhoea; scales and crusts may follow from the poured-out material. Ulcers of various sizes may also de- velop, from which a sanious and offensive fluid oozes over the surface. Movement of the limbs is painful, and either greatly impeded or ren- dered almost impossible. More or less febrile disturbance accompa- nies each attack, and there may also be pricking, stabbing, or boring pain. Headache, gastric irritability, or even delirium may occur. A remarkable case has been recorded by Dr. T. J. Bennett, of Austin, Texas. The patient was a negress aged fifty years, and nat- urally corpulent. The disease had existed for fifteen years, nearly the whole of the body being more or less affected, the trunk and upper extremity as well as the lower limbs, the woman's weight being four hundred and forty pounds. In elephantiasis the labia, clitoris, and scrotum, when affected, be- * Journal of Cutaneous and Gcnito-Urinary Diseases, April, 1889, p. 140. HYPERTROPHIES. 533 come enormously enlarged. The scrotum may extend to the knees or feet; the penis contracts and is completely lost in the thickened mass. The skin becomes hard, rough, warty, and tuberculated; the urine in being voided passes along a furrow formed in the hypertrophied skin ; fissures, excoriations, and ulcers are developed, or the lymphatic vessels are corroded and pour out their contents, producing a most obnoxious and offensive appearance and odor; walking becomes impossible and the patient's very existence a burden. Elephantiasis is sometimes ac- companied by chyluria, especially in tropical countries. Diagnosis.—In the early stages of the disease, and before the thickening and enlargement of the parts has set in, it is almost im- possible to make the diagnosis. The recurrent attacks of inflammation of the part, especially Avhen confined to one limb, point to the probable disease which may develop, and will be a valuable guide for the physi- cian to watch its course carefully and note any increase in the size of the part. After the affected region has become hypertrophied, and covered by the primary and secondary lesions referred to, an error in diagnosis is almost impossible. Pathology.—The diseased tissue is hard and resisting, and when cut through to the bone exhibits a homogeneous, white, yellowish, or lardaceous mass, from which a yellowish-white fluid exudes spontane- ously or from pressure. The various layers of the skin are matted together and can hardly be distinguished. The corium is thicker and more dense in structure, but the subcutaneous tissue is enor- mously hypertrophied. The fascia and intermuscular septa are thickened, exhibit evidences of fatty degeneration, and are changed in color, being generally pale or brownish-yclloAv; the bone is thick- ened, hardened, smooth or irregular, and covered with exostoses. According to Virchow, these exostoses may unite together the tibia and femur, the tibia and fibula, the ankle-joint and the metatarsal bones. Hauke has pointed out that in the midst of the sclerosed portion of bone there may be likeAvise carious or necrosed parts. Microscopic examination has demonstrated that while the epidermis and corium are altered in structure, they are increased in thickness at points Avhich are the seat of papillary and warty elevations. The papillae in these regions are Avidened and elongated. The blood- vessels and lymphatics are enlarged ; new connective tissue, formed of delicate fibres, Avith many nuclei and cells commingled, is also encountered. The glands and follicles may be found unal- tered or widely separated, or, by the pressure of the hypertrophic mass, they as well as the fat-cells may be pushed aside, altered, or destroyed. Etiology.—Elephantiasis arises from inflammation and prolonged obstruction of the lymphatics. It is said by Manson and others to be due to the presence of a nematode worm—the filaria sanguinis—and its 531: DISEASES OF THE SKIN. ova in the blood and lymphatics. This parasite has been shoAvn, by microscopic examination, to be almost invariably present in subjects of the disease in countries Avhere it is common, and Manson believes that the mosquito is instrumental in propagating and spreading the dis- ease. The female Avorm is slender, and fully three inches in length. Aside from all theories, elephantiasis may develop from any causo which occasions local obstruction of the circulation. Dr. Vicira de Melo states, in a valuable monograph on the subject, that it is devel- oped in consequence of successive attacks of lymphangitis. This ac- counts, he further adds, for its comparative frequency in warm coun- tries, where the causes of external irritation are so numerous. Ele- phantiasis may arise from the irritation of varicose veins, chronic ecze- ma, ulcers, lupus, and even fracture of the bones of the limb. Wounds and erysipelas are also among the more common causes of the affection. Prof. Kaposi has met with two cases in Avhich elephantiasis followed lupus vulgaris. Elephantiasis is seen in all regions, but is more com- mon in certain tropical countries. It is of frequent occurrence in the West Indies, especially the Barbadoes Islands, in Africa, Arabia, Egypt, China, Australia, and Japan, being more prevalent along the sea-coast of those countries. Climate will therefore be seen to favor the devel- opment of the disease to a certain extent. Elephantiasis occurs in both sexes, but is more frequent in the male. Surgeon-General Bidie, of the Indian Medical Service, states that elephantiasis is endemic in the Madras Presidency, and is especially common upon the sea-coast in places in which there is a subsoil sat- urated with organic filth from which the natives draw their water- supply. He instances a village lying between the canal and the sea, in which scarcely an individual escapes after the years of puberty. The water is very bad, being taken from shallow ponds fed by surface drainage, full of decaying vegetable matter and overgrown with reeds. Elephantiasis is equally liable to occur in both sexes, and young chil- dren are affected, though the disease is not common before fifteen or sixteen years of age. Europeans are generally spared, but it is not uncommon among Eurasians. A case of congenital elephantiasis was brought before the eighteenth congress of the German Surgical Association by Herr Waitz, of Ham- burg. The child was the first-born of healthy parents. At two years of age its loAver limbs were already extraordinarily enlarged. Both blood-ATessels and lymphatics were increased in size, and the extremities were covered with vesicles filled with lymph.* Dr. Moncorvo has met with a number of cases of congenital elephantiasis and believes that it is much more common than is generally supposed. Dr. William Cald- well, of Belfast, has given f a brief account of a case in which elephan- * Medical Bulletin, October, 1889, p. 323. f Biitish Medical Journal, January 4, 1890. HYPERTROPHIES. 535 tiasis and fibroma molluscum co-existed in the same individual. Both conditions had been present since infancy. Elephantiasis, however, usually develops between the twenty-fifth and fiftieth years. Treatment.—If the disease is seen in its early stages it should be treated upon general principles. A change of climate is often advan- tageous. It is necessary that the patient have a nutritious diet. In- dulgence in alcoholic drinks should be prohibited. In reference to internal medication, iron and quinine have a good effect upon some, while either general tonics, arsenic, or one of the iodides, benefit others. Thomasz, of Ceylon, claims * to ha\Te obtained very good results from the sulphide of calcium, more particularly when given from an early period of the disease. His practice is for an adult to begin Avith a one-grain pill of the drug morning and evening, after meals. In the course of a month this quantity is increased to one and a half grain, and subsequently to two grains. Inunctions and bandaging were con- joined. He states that elephantiasis of six months' standing may be completely cured by this method in one and a half to two months. Cases of long standing may be improved. Since Surgeon-Major E. Lawrence has reported f the cure of two cases of chyluria dependent upon the presence of filaria sanguinis by thymol, it should be advisable to make trial of that drug in those cases of elephantiasis presumably due to the same parasite. Rest of the affected part during the inflam- matory attacks is all-important, and if the extremities be involved they should be placed in a horizontal or elevated position. At these periods also it is appropriate to act upon the bowels by means of a saline cathartic. Suitable lotions of either lead-water and opium, arnica, or opodeldoc, hot, warm, or cold, may be applied until after the inflammatory action has subsided. Soothing or slightly astringent ointments may be substituted if more grateful to the patient. After the disappearance of this stage of the disease, the alkaline, simple, or medicated vapor-bath should be employed, to remove all poured-out products and to soften up any thickening of the surface. Frictions may then be made with one of the mercurial or iodine ointments, to- gether Avith the application of compression, which may diminish the pathological process or elephantoid SAvelling. In case the limbs are affected, compression may be made by a cotton or gum bandage. In the event that the part Avill not diminish rapidly, the entire surface may be punctured thoroughly with a small needle-knife from two to four times a week; the OArerd is tended vessels are thus relieved, absorp- tion assisted, and the hypertrophied extremity lessened in size. If eczema, warty growths, or ulcers are present, they may be treated ac- cording to the methods usually resorted to for these conditions. Elec- tricity has been folloAved by favorable effects in the early stages of the dis- ease. Dr. Silva Araujo, of Rio de Janeiro, has obtained very satisfactory * Ceylon Medical Journal, August, 1888. \ Lancet, February 16, 1891. 536 DISEASES OF THE SKIN. results * by means of continuous and interrupted currents of electricity with electrolysis, together with massage and compression by the rub- ber bandage. His experience has extended through many years, during which four hundred cases have been under observation and treatment. It is essential that the treatment should be continued for a long time. Massage, likewise, has proved of benefit. Deep manipulation of the affected part has been productive of very striking and permanent re- duction of size. In the intervals between each seance compression should be maintained. Ligation of the external iliac and femoral arteries has often been resorted to, with a decided improvement or cure in some cases and a complete failure in others. Pyaemia sometimes follows the operation, but recent statistics show a number of permanent cures. Leonard has shown that in sixty-nine cases upon which arterial ligature was applied, forty recovered and thirteen were benefited. Weber recently reported an interesting case of complete recovery fol- lowing ligation of the femoral artery. Digital and instrumental com- pression of the femoral artery have also been followed by a reduction in the size of the limb. Nerve-stretching and excision of the sciatic have also yielded good results. Morton, of this city, excised a portion of the sciatic in a patient having the disease fourteen years, in whom the external iliac had previously been ligated without any appreciable effect, and the result of the last procedure was to lessen the growth to one half its former size. The removal of the offending mass entire by the knife sometimes becomes necessary, especially Avhen the genitals are involved. The amputation of a limb, which has been frequently performed, is not usually well borne by the patient. In a case of elephantiasis of the left leg just above the ankle, Dr. Raimundo Menocal, of Havana, secured a good result by excision. The disease appeared subsequent to a violent blow upon the foot. Just above the ankle were two extensive fleshy masses which had been in existence for about a year. A long incision Avas made over the anterior mass, the skin reflected, and the hypertrophied cellular tissue removed en masse. Under antiseptic dressings union by the first intention took place, and a month later the posterior mass was removed in a similar manner. Prognosis.—It will be evident from what has been stated that the prognosis of elephantiasis may be regarded as not unfavorable. If the disease is seen early its growth may be arrested, and the same re- sult may be reached even in the later stage by appropriate treatment or by operative procedure. It may persist throughout the patient's life, notAvithstanding the best efforts, interfering with the movements, and thus being a great burden and deformity. While it is at all times a dangerous disease and may have a fatal termination, yet the latter result rarely folloAvs unless pyaemia supervenes. * Atlas des Maladies de la Peau, 3me fascicule, 1889. HYPERTROPHIES. ^ o ^ DERMATOLYSIS. Synonyms.—Elephantiasis telangiectodes—Cutis pendula—Pachydermatocele. Dermatolysis is a more or less circumscribed hypertrophied condi- tion of the skin and subcutaneous tissue, as the result of which it may hang in loose folds. Symptoms.—This affection, which may be congenital or acquired, consists in an hypertrophy of all the structures of the skin. Derma- tolysis may be so slight as neither to be noticeable nor occasion the least inconvenience, or it may be so severe as to be both cumbersome and a great deformity. In slight cases the skin may be apparently normal in appearance, but soft, sensitive, movable, extensible, and at times elastic to the touch. A case exhibited in this city showed this form of hypertrophy over almost the entire surface, especially marked on the head, trunk, and extremities. This individual was, to all appearances healthy and the skin was apparently nor- mal. To the touch, however, it was soft, sensitive, but not painful, movable, extensible, and exceedingly elastic. The skin could, for in- stance, be easily drawn from between the scapula forward over the back of the head, and from the sternum up almost to cover the face. When the skin was drawn out and held before a light, the circulation in it was well defined. In the more or less severe forms of this disease the skin is thick- ened and tends to hang in rolls of various sizes, sometimes overlapping each other like the folds of a loose garment, or appearing like deAvlap on the necks of cows. These folds of skin are generally broAvnish or broAvnish black in color, rugous, but smooth and soft to the touch, appearing as if a distended, spongy substance had been compressed. Bell related a remarkable case in which the skin hung down from the ears, neck, the trunk, and abdomen, the subject being compelled to carry the masses in a table-cloth. Wilson, Stokes, Mott, Keen, and Piffard have also reported cases attended Avith unusual deformity. This form of hypertrophy may involve the whole surface, but it has been observed more frequently on the scalp, back, abdomen, and thighs. There died at the London Hospital, April 11, 1890, a person known as the " elephant man " * who was extremely deformed in con- sequence of an extensive dermatolysis combined with congenital hypertrophy of the bones of the skull, right arm, and feet. There was no family history of any similar malformation. When a child, his skin was thickened, loose, and rough. As he grew older papillary masses developed on his skin, especially over the back, buttocks, and occiput. In some regions of the trunk heavy, pendulous flaps developed. In the latter years of his life the enlargement of the upper jaAV-bone and its * British Medical Journal, April 19, 1S90. 538 DISEASES OF THE SKIN. overlying skin—the so-called trunk—rendered his speech difficult to understand. The head became so large and heavy that he Avas un- able to sleep in a recumbent position. Death took place unexpectedly, and it was supposed that while he was asleep his heavy head had fallen backward and dislocated his neck. In dermatolysis the functional activity of the skin is unimpaired. Between the folds the perspiration is frequently excessive, fetid, and gives rise to intertrigo or erosions. The latter sometimes occasion more or less abundant haemorrhage. Pathology.—Dermatolysis is a hypertrophy of all the integument, more especially the subcutaneous tissue. The veins of the affected parts are considerably enlarged and the fatty tissue increased. The elastic fibres are left intact, but the fibrous tissue of the derma under- goes, according to Seifert, a myxomatous transformation. The cause of the growth is unknown. It has been noted to be closely related to molluscum fibrosum, and at times occurs in connection with that dis- ease. Treatment.—Excision, when the disease is not too extensive, is the only method by which the mass can be removed, if this procedure is at all possible, or necessitated by the inconvenience or suffering of the pa- tient. The galvano-cautery is useful when the disease is limited to a small area. Prognosis.—This is usually good. The deformity and inconven- ience due to the growth are the only unpleasant effects that arise from the disease. Excision sometimes affords satisfactory results. HYPERTROPHY OF THE HAIR. Synonyms.—Hypertrichosis—Hypertrichiasis—Polytrichia—Trichauxis—Hirsuties. Hypertrophy of the hair consists of an abnormal or excessive growth of the hair. Symptoms.—Hypertrophy of the hair, which is an increase beyond its normal limits either in thickness or length, may take place in tAvo different forms. First, upon regions provided with hairs of consider- able length, as the head, face, eyebroAvs, axillae, chest, and pubes. Cases of this form of inordinate growth, which may be hereditary or acquired, are frequently observed, many curious examples having been recorded by various writers of ancient and modern times. In these cases the hair grows unusually, both in quantity and length, measuring, for in- stance, on the head of some women reported by Wilson, six feet, and in Leonard's case, over seven feet in twelve years' groAvth. The second form is that in Avhich an abnormal growth of the hair takes place either over the general surface, or locally on certain areas where it exists normally only in a fine, downy condition. Hypertrophy of the hair may be either hereditary, congenital, or acquired. Thus, HYPERTROPHIES. 5S9 Ficinus has reported an infant entirely covered with hair at birth. Wilson relates a case, not congenital, of an unmarried Avoman thirty- three years of age, in Avhom the entire surface was covered with hair. Numerous instances of a similar groAvth are likeAvise recorded, as the renowned dancer Xegreui, whose hair, after recovery from an acute disease, increased over three yards in length; and the case of Julia Pastrana, who had both a fine beard and a hairy body. The case of Shwe-Maon, the hairy Burmese, and his children, reported many years ago, furnishes a remarkable instance of hairy development being both congenital and hereditary. The palms and soles, the prepuce and glans penis, are never affected by this abnormal growth. Certain races also are said to be noted for their excessive hairiness, as the Ainos of Japan ; but Von Krusenstern and Habersham declare the extreme hairiness of these people to be exaggerated. Abnormal growth of hair may occur in both sexes and at all times of life. When it develops be- tween the eyebrows, on the arms, and the face of women, forming a mustache or beard, considerable disfigurement and great mental suffer- ing follow. Hairs may sometimes in their growth take an abnormal direction Avithin or without the follicle, especially upon the scalp, eye- brows, or eyelashes, often in the latter situation turning in toward the eyeball, producing the condition known as trichiasis. Hairs may also groAv abnormally long and pigmented on smooth and warty mother's marks, when they are called respectively naevus pilosus and naevus ver- rucosus. Hypertrichosis over the spine occasionally conceals a spina bifida. Etiology.—The causes which give rise to an abnormal groAvth of hair are unknoAvn. It is observed more frequently in those having a dark rather than a light complexion. An excessive, growth of hair is also knoAvn often to develop from sexual disorders in women at the climacteric period, and during and after various diseases. For example, I have witnessed its appearance after fevers. Cases have also been recorded of its occurrence in insane persons, those mentally disturbed, and on paralyzed parts in certain nervous diseases, and from nerve injury. According to Dr. Andrea Cristani, hypertrichosis occurs much more frequently among the insane than among the sane. Hypertrophy of the hair may likewise occur from any cause Avhich "determines more blood than usual to a part. Local inflammation, continued friction on a region, or the application of any irritating substance—powders, lotions, liniments, or poultices—are, no doubt, frequently the cause of an abnormal growth of hair. Treatment.—A general abnormal growth of hair can not be either relieved or removed. Small areas, Avhich generally occur on naevi and the faces of Avomen, may be successfully destroyed or may be removed temporarily. The most rapid and radical means of eradicating the majority of circumscribed hairy growths is by the knife, the operation 540 DISEASES OF THE SKIN. generally being slight, and, when properly performed, little or no sign of it remains on the skin. The next best method is the removal of the superfluous hairs by electrolysis or a galvanic current, which was first contrived and rec- ommended by Michel, and afterward successfully used by Hardaway, George Henry Fox, Piffard, and others. The apparatus needed for the operation is an ordinary galvanic battery * containing from six to fifteen cells, two electrodes, a sponge being on the positive, and on the negative a fine platinum wire, or a thin cambric needle inserted in a small holder, a lens, and a pair of good broad-blade forceps. The patient is placed first in a strong light; the needle, which is connected with the negative pole, is carefully inserted into the follicle by the side of the hair as far as the base, and the circuit is completed either by the patient touching the positive pole, or by applying it near the seat of the operation. The needle is allowed to remain a few seconds; decomposition of the tissue follows, which will be shown by the appear- ance of minute bubbles or froth at the point of entrance. Care should noAV be exercised to avoid breaking the circuit as the needle is removed thus avoiding a shock to the patient. Caution should also be employed in introducing the needle, to avoid puncturing small vessels, as the bleed- ing which follows delays the operation and also leads to considerable swelling from the escape of blood into the tissue. If gentle traction after the operation removes the hair, the probability is that the papilla is destroyed, otherwise the needle should be reintroduced and the same process repeated. A' certain amount of congestion, swelling, or a wheal, followed by a papule or pustule, may develop around the fol- licle. The time required for the destruction of each, hair will vary according to the dexterity of the operator and the sensitiveness of the patient. In one sitting from ten to forty hairs may be removed ; the operation is, however, very tedious, and extremely severe on the eyes of the physician, often necessitating the use of a lens. Further, the operation is not only trying to the physician, but it is also painful to the patient, especially when the upper lip or neck is involved, the pain extending along certain nerves, particularly the dental branches, caus- ing the teeth to ache severely. The pain sometimes diminishes after repeated operations, as the parts become more tolerant of the action of the galvanic current. If judged advisable on account of sensitiveness of the patient, the surface about to be operated upon may be covered with an ointment containing cocaine. This procedure has the effect of mitigating the pain to a certain extent. The large hairs should be removed first, and the operation repeated on the smaller ones. A * Heitzmann recommends the Leclanche battery, containing six large cells. He adds that the advantage of this battery is that it is painless; even the most sensitive person can bear it without inconvenience. Journal of Cutaneous and Venereal Diseases, Novem- ber, 1885, New York. HYPERTROPHIES. 541 simple water-dressing, or the application of the benzoated oxide-of-zinc ointment, will lessen Avithin two or three days the congestion and swell- ing of the part. In order to facilitate the operation so that the bottom of the cul-de-sac may be reached without injury to the surrounding tis- sue, an instrument has been devised by Dr. Frederick J. Leviseur, of New York. A needle-holder is modified in such a manner that the needle can be inserted and fastened by screw arrangement in three dif- ferent positions so as to form with the handle a right, acute, or obtuse angle. The operator stands behind the patient, holds the instrument like a writing-pen, and introduces the needle by a slight movement of the wrist. Dr. Morton Prince, of Boston, calls attention to the fact that imperfect methods or insufficient apparatus are responsible for failure of the operation or resultant cicatrices. The current should be neither too strong nor too long continued, and should invariably be measured by the gahanometer. He uses a fifty-cell Barrett chloride- of-silver battery connected with a subsidiary carbon-zinc battery of equal electro-motive force, and in the circuit are inserted the rheostat and gahanometer. he never exceeds three milliamperes as measured by the Hirschman galvanometer, and thinks that a strength of one half to one milliampere is often sufficiently strong. Dr. Arthur Jamieson states that for several years he has been in the habit of treating this condition by means of a solution of the ethylate of sodium. He had observed that Avhen applied to naevi and hairy moles the follicles were destroyed and the hair failed to be reproduced. He describes the case of an infant in whom a-large portion of the face was covered by an overgrowth of long, dark hair. Upon several suc- cesshe occasions, the child being under the influence of chloroform, portions of the hairy area were treated, the ethylate being rubbed thor- oughly over the surface. The final result was very satisfactory, and the skin remained hairless and smooth. The author's experience on the application of this caustic has been to the contrary, the ethylate of sodium, Avhile acting well, ahvays by its deep penetration*leaves more or less scarring of the skin. An abnormal growth of hair may be removed temporarily by shav- ing, epilation, and the application of certain caustics to the affected surface. Shaving, however, merely cuts off the hairs on a level Avith the skin, and leaves the stumps shoAving as black points at the orifices of the follicles; the skin also becomes someAvhat rough, and a certain disfigurement remains. This procedure for women will not, therefore, be advantageous. Epilation, with or without the insertion of red-hot needles or acid into the follicles, is not only very painful, but the hairs groAV Avith reneAved vigor, and its constant repetition changes a smooth integument to a rough, discolored, and uneven surface. The Rontgen rays have caused the hair to fall, and may probably be utilized in the treatment of hypertrichiasis. 54:2 DISEASES OF THE SKIN. Caustics or depilatories have been employed from ancient times for the removal of hairs. They usually have, as their main ingredient, either the sulphide of calcium, arsenic, sodium, or barium. One of these substances is made in the form of a paste with Avater, and applied with a piece of wood or bone to the affected area and allowed to remain about ten minutes, Avhen it becomes dry and is quickly scraped from the surface. ' The parts are then cleansed with Avater and anointed with cold cream or sweet-oil, and later the congestion may be still more concealed by dusting a mild powder, as carbonate of zinc or magne- sium, on the skin. As the caustic paste or depilatory not only destroys the hairs on a level with the skin, but likewise partially within the fol- licles, and as no black points or hair-stumps remain, the operation is certainly superior to shaving. Again, shaving requires to be practised more frequently, usually every day or two, while it is necessary to use a depilatory only every three or four days. Sulphide of barium and oxide of zinc are recommended as forming an efficient depilatory, and may be combined as follows : ty, Barii sulphidi..................... 3 iij. Zinci oxidi.....................aa Pulv. marantae.................... 3 ij. M. The sulphate of strontium has been reported to be an excellent depilatory. All depilatories should be employed with care, as their improper or prolonged use Avill set up inflammation, and often produce greater dis- figurement than the superfluous growth of hair. While thus briefly giving an account of epilation and the use of depilatories for the removal of an abnormal growth of hair, because people will demand and physicians wrill often be compelled to supply or use them, I wish in this connection to condemn the employment of both most decidedly. They' relieve only temporarily, and eventually increase the growth, rendering the skin red and rough, and frequently produce unsightly marks and scars. Excision and electrolysis are the best and only certain methods, under all circumstances, to practise. HYPERTROPHY OF THE NAILS. Synonyms.—Onychogryphosis—Onychauxis. Hypertrophy of the nail consists of an abnormal increase of either its length or thickness. Symptoms.—Hypertrophy of the nail may manifest itself by an in- crease in its substance either in length, Avidth, or thickness, or all combined, and frequently with more or less secondary changes. The nail may, for example, grow unusually long, occasionally curving doAvnward like a claw, or it may expand laterally, pressing into the tissue, developing inflammation, or what is knoAvn as in-groAving of the HYPERTROPHIES. 543 nail, or paronychia. It is more usual in this latter condition, in which the internal angle of the great toe is involved, for the nail in front and lateral margins to curve inward. This form of hypertrophy fre- quently gives rise to irritation or inflammation of the adjoining soft parts, Avith pain that is often unbearable, swelling, suppuration, the formation of granulations, and occasionally leads to destruction of the tissue and necrosis of the bones, and, in rare cases, to a loss of the affected member, as the foot, or even to imperilling the life of the patient. In others the nail may be thickened throughout, or in one or more parts, being more or less eleArated from its bed, assuming the appearance of a cone or wedge, leading to great deformity, and . often interfering with the movement of the limb except under great pain. When the finger-nails are affected, tactile sensibility is impaired, and the performance of fine work is rendered impossible. In addition to these variations in size and shape, the upper and lower surfaces of the nail may be more or less changed. The upper surface may be un- even, furrowed, ridged, lustreless, and partially or entirely discolored ; being either streaked, opaque, white, yellow, yellowish brown, or black. The under surface may be covered Avith epidermic scales, brittle, and dirty brown in color. The consistency of the nail may likewise be someAvhat changed, being either thicker or thinner, harder or softer, or tougher or more brittle, than normal. There are two other conditions of the nails which may be men- tioned here in which the nail-substance is structurally altered. The first is termed onychia, or inflammation of the matrix, the syphilitic form t being frequently attended with its characteristic lesions around the affected digit or in other parts of the body. The other has been named ► onychomycosis, and is due to the invasion of the nail-substance by vege- table parasites. A form of onychia to Avhich confectioners are liable has been described by Dr. Poncet, of Lyons. The nail becomes dark- colored, dry, and brittle, and falls in the form of little chips. Recur- rent attacks may lead to extreme deformity. The makers of candied fruits are particularly attacked. The cause is complex, and the action of sugar, acids, and heat, evidently co-operate to develop the disease. A cure depends upon cessation from Avork. The treatment is prophy- lactic. The hands should not be dipped in the sugar solutions, or, at least, should be carefully Avashed and the sugar removed from beneath the nails. When the disease is established, the patient should desist from Avork, and antiseptic remedies are recommended. The term ony- chauxis is also used to designate other abnormities of nail formation Avhich sometimes occur, as, for instance, the growth of a double nail upon the same finger or toe, or in unusual situations, as upon an ampu- tated stump, or, as sometimes happens, upon the shoulder over the scapula. The talon-shaped deformity is known as onychogryphosis. 544 DISEASES OF THE SKIN. Hypertrophy of the nails may be either slight or marked, and may involve one or seAreral or all at the same time. It may affect the nails of the fingers or of the toes, but is more common upon the latter. Pathology.—The nail-substance which grows from the papillae of the matrix becomes hypertrophied. On examination, the papillae of the matrix, especially in severe and chronic cases, are found enlarged, with more or less hypertrophy of the entire nail-bed. Etiology.—Hypertrophy of the nails may arise from many causes, occasionally being congenital, but mostly acquired. It occurs most frequently from neglected care of the nails and from injury to the member, particularly from pressure of coverings of the hands and feet, as from tight-fitting gloves, stockings, boots, shoes, and slippers. Hypertrophy of the nail may also develop as the result of certain local and constitutional affections. Thus, it occurs in connection with ec- zema, psoriasis, ichthyosis, syphilis, leprosy, lichen ruber, small-pox, scarlet fever, typhoid fever, consumption, rheumatism, and certain neiwous diseases. According to Prof. Verneuil, diabetes mellitus pre- disposes to the occurrence of in-growing nail. Old age constitutes a predisposition to liypertrophy of the nails. Treatment.—The treatment of hypertrophy of the nails will vary according to the cause and the condition of the parts. Internal reme- dies are indicated when it occurs as a result of other diseases. Arsenic, iron, sulphur, or their various salts, may assist in restoring the healthy condition of the matrix, and thus indirectly influence the nutrition of the nails. All sources of pressure upon the affected member or mem- bers must be removed. The growth itself may be partially or entirely removed by the knife, scissors, cutting-pliers, or the saw. The prefer- able way of locally managing hypertrophy of the nails on general prin- ciples is by paring the free end of the nail, avoiding scraping and filing, and by pressing back, with the blunt end of the knife, scissors, or a piece of wood or bone, the free margin of the skin at the base and sides of the nail. This simple procedure, with the application of a soothing or an astringent ointment about the base and sides—either the tin or lead oleate ointment being serviceable—will often suffice to relieve or cure mild cases. If the free edge of the nail be brittle, it may be protected by wax, gum, or some other mechanical contrivance. Salicylic acid is likewise of service applied in the form of an ointment. If vegetable parasites have invaded the nail-structure, the discontinu- ance for a time of water to the parts, and the use of either the mer- curous oleate or copper oleate ointments, will speedily effect a cure. Severe or chronic forms often require more active measures, as punct- uring the soft parts with a knife, or leeching them, or removing the offending mass, and afterward applying soothing lotions or ointments. Many severe cases, especially of in-growing of the nail, can, if seen early, be relieved by working in a small piece of absorbent cotton be- HYPERTROPHIES. 545 tween the nail and skin-fold; the offending portion, which presses into the cutis, can thus gradually be elevated, and later cut off without en- tailing suffering. Mr. E. J. Domville, of Exeter, England, recommends bathing the surface if granulations be present with a solution, ten grains to the ounce, of cocaine hydrochlorate, after which absorbent cotton can be painlessly introduced between the nail and inflamed soft tissues. If the cocaine solution be applied every other day for tAvo or three weeks, the surface of the sore becomes hardened and may be readily removed without causing suffering. Dr. Patin reports very favorable results from the use of gutta-percha, ten parts in eighty parts of chloroform. The nail having been thoroughly cleansed, the solution is applied with a brush to the interstices between the nail and the granulations. This procedure is repeated several times upon the first day and afterward at lengthened intervals. By the means just related the nail is gradually lifted from its bed, and can be removed without pain by the scissors. Dr. Hofmann, of Erlangen, after disinfecting the toe with a sublimate solution, slightly raises the edge of the nail and deposits a few drops of the solution of the chloride of iron. The application is repeated in the same manner upon the second or third day. If suppuration occurs, the hardened scabs are removed from the granulations by the forceps and the solution reapplied. The crust is again removed after the lapse of three or four days, and after a few such reapplications the nail has become soft and brittle and can be easily excised by the scissors or a dull knife. Another simple method of treating ingrowing of the nail, which Avill not oblige the patient to relinquish his daily pursuits, is that practiced by Dr. Piirckhauer, of Bamberg. The portion of nail imbedded in the soft tissues is painted with a forty-per-cent. solution of caustic potash. At the end of a feAv seconds the upper layer of the nail has become so soft that it can be scraped off with a sharp-edged piece of glass. The painting with potash and scraping are continued until all that remains of that portion of the nail is a scale as thin as a leaf of paper. This scale can be grasped by the forceps beyond the swollen soft tissues by which it is covered and removed by means of a pair of fine scissors. No further treatment is at the time necessary. If, when the nail is subsequently reproduced, pain again occurs, the corresponding portion of nail may be softened by the same procedure, and will not need to be excised. It will be observed, however, that the majority of cases of in- growing nails do not reach the physician until the inflammation is so great and the toe so swollen and painful as to interfere with locomotion and lead to restless days and nights. I find, even under such circum- stances, that speedy relief can be afforded by cauterizing thoroughly the affected part, usually the internal angle of the great toe, with a crayon of silver nitrate or pure carbolic acid, after which the cotton can be used in the manner already indicated. This method of treatment is 35 546 DISEASES OF THE SKIN. preferable to removing all or part of the nail, as it preserves the nail and is less painful. Prognosis.—Appropriate treatment is, as a general rule, followed by the removal of the abnormal groAvth of the nail. In some congeni- tal cases, and those of long standing, it is difficult to effect a cure. When occurring in connection with leprosy, ichthyosis, psoriasis, eczema, and certain other affections, it is necessary first to cure the disease before the nails can be restored to their normal condition. CLASS VI. ATROPHIES. {Atrophia,.) ALBINISMUS. Synonyms.—Albinism—Congenital achroma—Congenital lcucopathia—Congenital leuco- casmus—Congenital leucoderma. Albinismus is congenital absence of the pigment of the skin. It may exist either over the whole body (albinismus universalis), or be limited to certain parts (albinismus partialis). Individuals affected Avith universal albinism are known as albinos, and are met with among all races. The skin, hair, iris, and choroid of these persons are more or less completely wanting in pigment. The skin is of a milky-white or pink shade, the hair over the entire body fine, soft, silky, and generally white or yellowish-white, and, in rare cases, red in color. The eyes are of a pinkish-red color, owing to absence of pigment in the choroid and the iris. They are vrery sensitive to the light, the pupils constantly dilating and contracting, Avith more or less rotation of the eyeballs, and winking, making sight rather diffi- cult except Avhen the luminous rays become less powerful, when vision grows stronger. Albinos are generally short of stature, and are weak both in mind and body, being said to be especially predisposed to pulmonary affections. Albinismus Partialis appears most frequently among the darker races, as in the negro, but it is occasionally met with among Cau- casians. It occurs as one or more snowy-white or pinkish patches, which are usually circumscribed, but which may be of every variety of size and form. They may exist upon any region of the body, but are mostly confined to the scalp, face, the dorsal surface of the hands, nipples, and the genital region. The patches are generally irregular in their distribution, but occasionally are symmetrical, and found along ATROPHIES. 547 the course of certain cutaneous nerves. The hairs upon the patches are frequently white. The eyes are normal, and do not exhibit an ab- sence of pigment. Negroes affected with this form of albinism are spoken of as pied or piebald. The skin Avhere patches have been has, through a redeposit of pigment, been known in several instances to resume its normal condition, but this restoration is very rare. The patches usually remain unchanged throughout life, or gradually ex- tend until a large surface becomes covered and additional patches make their appearance. The cause of albinism is unknown. It is said to be sometimes hereditary. By Wilson, the cause of the disease is referred to the nervous system. VITILIGO. Synonyms.—Acquired leucoderma—Acquired lcucopathia—Acquired achroma—Acquired leucasmus—Acquired piebald skin. Vitiligo is an acquired disease of the skin in which round, oval, or irregularly formed, sharply defined, smooth white patches develop, which incline continually to increase in size, and are usually sur- rounded by an abnormally yellowish or darkly pigmented skin. Symptoms.—The disease appears as one or more circular, sharply defined, Avhite spots, notable for their absence of pigment. The sur- face of these spots is smooth, not scaly, and neither elevated above nor depressed below the general' surface of the skin. These sharply out- lined spots are surrounded by an abnormally dark pigment, which gradually fades into the healthy skin. This surrounding pigmenta- tion is almost a constant feature of the disease, and may exist to either a slight or a marked degree. In form the spots are generally round or oval, but they may be angular and irregular. In size, they vary from a small to a good-sized coin, and may be even larger. They may increase in size and numbers, and may finally coalesce, forming patches Avhich may involve the entire region affected, or perhaps nearly the whole body. Their color is milky or pinkish-white, their tint varying, hoAvever, to some extent in accordance with their age. To the touch, the spots feel just like any adjacent normal skin, ex- hibiting neither anaesthesia, pain, itching, nor any subjective symp- toms. If hairs are present, they are Avell fixed in their follicles, and are in color sometimes normal, but are more frequently pigmentless. The disease may, as intimated, manifest itself upon all parts of the body, and even involve the hairs. The sebaceous and sudoriparous glands are unaffected. Vitiligo generally appears on the backs of the hands, the forehead, the scalp, and the trunk. The tendency of the disease is to assume the chronic form, usually continuing during the en- tire life. The spots may increase either slowly or rapidly, and neAV ones from time to time make their appearance, until a portion or the 54S DISEASES OF THE SKIN. greater part of the body becomes affected. Marked disfigurement en- sues from the disease, especially if the spots appear upon regions ex- posed, as the face, neck, and hands. In some instances a symmetrical arrangement of the patches is observed, as upon both limbs and particularly upon both hands. Brocq speaks of having met with cases in which the lesions, almost perfectly symmetrical, occupied the face, neck, trunk, and extremities. In such cases of general distribution they are often especially well marked in certain regions, as the neck or lower part of the abdomen. Fig. 13.—Vitiligo. Cases sometimes occur in which patches of vitiligo appear on the backs of the hands and on the face every summer and disappear as winter approaches. Diagnosis.—Vitiligo is liable to be confounded with leprosy and morphcea. In the last two affections,.hoAvever, there is, in addition to the white spots, a structural alteration of the skin, and in leprosy it may also be anaesthetic, while in vitiligo the only change observable is simply an absence of pigment in the patches, with an increase of the same material around their periphery. Pathology.—There appears no other abnormity beyond absence of pigment in the white patches and increase of it in the skin surround- ATROPHIES. 549 ing them. Leloir has, in certain instances, found an alteration in the nerves of the affected region. Etiology.—Vitiligo, which is a rare disease, occurs in both sexes and at all ages, but is most common in early adult life, particularly in the darker races, as the negro. It is known to be caused by disturbance of general innervation, Avhich may follow from both acute and chronic diseases. Dr. Mansel Sympson, of Lincoln, has described a case of vitiligo which occurred in a dark-complexioned English woman as a sequela to a severe attack of influenza, which was followed Avithin a week by facial erysipelas. Soon after recovery from the latter affection small patches made their appearance, enlarged and extended. Vitiligo has been observed asso- ciated with hysteria, melancholia, exophthalmic goitre, neuralgia, and in consequence of severe shock. It has also been knoAvn to develop after strong mental excitement, and has occasionally followed an injury. At times it appears among those apparently enjoying the best health, the cause of its development in these cases being unknoAvn. Treatment.—Treatment is practically of no value, there being no remedies at our disposal which will either remove or arrest the progress of the disease. It is suggested, in cases which appear to be clearly de- pendent upon a morbid condition of the nervous system, that treatment addressed to that disturbance may exercise a favorable influence upon the patches of leucoderma. The Vigo plaster is particularly mentioned by Brocq. This is a preparation of complex composition, containing a considerable propor- tion of metallic mercury in association with storax, Venice turpentine, gum ammoniac, bdellium, olibanum, myrrh, and saffron, made up Avith yelloAv wax and simple plaster. In my experience, the many drugs Avhich have been recommended, especially arsenic, have been entirely inoperative. All local treatment is equally powerless upon the patches, but the surrounding yellowish or brownish pigmentation may be removed so as to lessen materially the disfigurement. Galvanism is suitable for this purpose, as Avell as the use of such remedies as the mercurials, carbolic and acetic acids, the tincture of iodine, and the potash and soda soaps, alone or medicated. Various irritants have also been ap- plied by friction to the patches in the hope of exciting a fresh deposit of pigment. Among these may be mentioned tincture of cantharides, or of capsicum, croton oil, turpentine, and spirit of ammonia. Sina- pisms have been employed for the same purpose. Prognosis.—The disease is only a disfigurement, and in no manner affects the health of the patient. It is at present, as has been said, an incurable affection. The patches tend to increase until they oc- cupy a large surface. Occasionally, however, their growth ceases, and they remain stationary throughout life. 550 DISEASES OF THE SKIN. CANITIES. Synonyms.—Atrophy of the hair-pigment—Grayness or whiteness of the hair—Blanching of the hair—Poliosis—Trichonosis discolor. Symptoms.—Atrophy of the hair-pigment may be either congenital, premature, or the result of advancing age. The congenital form is occasionally met with in albinism, the pigmentless, silvery, or silky hairs appearing over all the surface or only upon isolated parts of the body. Occasionally a patch or tuft of white hair is hereditary. Dr. John H. Morgan met with a case in which a tuft of white hair grew from the middle of the forehead, and learned upon inquiry that the same peculiarity had been observed in members of the family during four generations. Similar observations have been made by Riggoli and Mr. H. N. Joynt, of Birmingham. Bourneville records a case in which alternate patches of black and light colored hair occurred upon the scalp. The eyebrows and eyelashes exhibited the same variation in hue. The singular circumstance may here be mentioned of the change of color in a cock's feathers from fear. From a beautiful black without a trace of any other color the feathers of the head became entirely white, Avhile on the back and neck about half had changed color, so that he presented a speckled appearance. Premature atrophy of the pigment of the hair may come on at almost any period of life, and may take place either gradually or suddenly. The change in the color of the hair may be to almost any shade, and may involve either a part or the whole of the hairy system. Flaxen hair may become chestnut, red, broAvn, black, or white; dark brown may change to red or light brown ; black turn to flaxen, or become gray or white. Numerous instances are on record exhibiting such changes at various periods of life. Wil- son * mentions several, and Smythe f and Prentiss also report cases of great interest, while I myself have seen in practice some, in which the change of color of the hair has been gradual. Dr. D. W. Prentiss has recorded \ two cases in which the color of the hair was very remarkably changed by jaborandi or pilocarpine, given hypodermically on account of uraemia. The first was the case of a woman twenty-five years of age. Within about nine weeks twenty-two injections were given, one sixth of a grain at first and the quantity being subsequently increased to one third of a grain. The hair had been originally of a light blonde color, but during and after treatment it changed to chestnut broAvn, and then to almost black. The hue afterward returned to dark brown, which remained permanent. The second case Avas that of a lady aged seventy- two years, whose hair and eyebrows had been snow-white for twenty years. From twenty to thirty drops of the fluid extract of jaborandi * Wilson on Skin and Hair, p. 108, Philadelphia, 18V6. f Arch, of Derm., July, 1880. X Jour. Amer. Med. Assoc, Dec. 21, 1889. ATROPHIES. 551 were given several times a day for sixteen months. After the remedy had been used for about a year it Avas noticed that the eyebrows were growing darker and that the hair of the head was darker in patches. This gradual alteration of color progressed until death occurred. It is known that the plumage of birds may be varied in hue by the influence of certain articles of diet. Cayenne pepper is employed for the purpose of giving a rich orange color to canary birds. According to Dr. Sauer- mann, the effect is produced only in young birds before they moult. The change does not depend upon the pungent principle, but upon the coloring matter. The pigment is deposited in the egg-yelk as well as in the feathers. The experiments were carried out upon canaries, fowls, pigeons, and other birds. The Indians of the Amazon are said to cause green parrots to change to yellow and red by feeding them upon the fat of a certain fish allied to the shad. Dr. Elliott Coues is of the opinion that this change may take place in individual feathers, and is not lim- ited to the newly produced feathers after moulting. Young persons, especially women, often call upon the physician and ask for some application to turn their hair again light or dark, as it was at one time. I have had two cases under observation: one a young woman who had beautiful blonde hair, which gradually changed, fol- lowing a severe fever, to a chestnut color; the other, a young girl suf- fering from general debility, who had light-broAvn hair, which slowly changed to a dark-brown. Sir James Paget knew a lady whose hair, during attacks of nervous headache, whitened in places, but regained its original color in a few days. The most annoying change is that in Avhich the hair turns gradually or suddenly gray or white. This latter form of atrophy of the hair-pigment may come on at any period of life, and, while many cases are met with in the young, it is by far more common at adult age. Premature grayness of the hair in most instances develops slow- ly, but a great many cases are recorded of the hair turning suddenly gray or Avhite Avithin a very few hours, or during the course of a sin- gle night. Dr. Parry has described the remarkable case of a Sepoy prisoner whose hair turned white within half an hour from fright. The change in color may be slight, giving the hair-substance a gray appearance, or it may be more decided, the hair becoming silvery or entirely Avhite. Atrophy of the hair-pigment may involve a part of a hair, or only certain segments of it, or the entire hair. Wilson reported a case which exhibited an alteration of white and brown segments from one end to the other of the hair. It thus presented the peculiarity of marking in the porcupine's quill. Dr. George W. Griffiths, of Louis- ville, Ky., has recorded a curious instance in which, after prolonged exposure to cold, the hair of a man, sixty-five years of age, was changed, within about a day, from white to black. Premature grayness or white- ness of the hair may be partial or universal. Again, the change in the 552 DISEASES OF THE SKIN. color may involve hairs scattered through one or many portions of the affected part, or may involve only certain locks, or the entire part may be invaded. It is usual to see in advancing years a few silvery hairs scattered through the hair of the head or of the whiskers, or tufts of gray or white hair. Grayness of the whiskers usually appears first on those parts which have been most often shaved. Loss of pig- ment in the hair through age appears earlier in those possessing broAvn hair. It generally takes place first in a few isolated hairs on the temples. Sometimes the beard is the first part affected, and thence grayness spreads by degrees, until the scalp and the hairs upon all parts of the body become involved. Etiology.—Premature atrophy of the hair-pigment may be caused by any one of the numerous internal derangements that have been re- ferred to, and that give rise to alopecia. Cares, anxiety, severe wear and tear on life, prolonged mental strain, shocks, and all conditions that make a decided impression upon the nervous system, will bring about a gradual or sudden atrophy of the hair-pigment. Cases have been reported in which the eyelids have become white in sympathetic ophthalmia occurring in consequence of destruction of the other eye. Gray hair is caused by various severe diseases, as typhus or typhoid fever, erysipelas of the scalp, scarlatina, gout, and rheumatism. The use of certain forms of food and drugs, and increase in age, change in habits, seasons, and climate, will produce atrophy of the hair-pigment. Arsenic or pilocarpine, given internally, has been proved to produce this effect, while a growing youth's hair often changes with age, habits, and seasons, being light in winter and darker in summer. A dark-haired person, in passing from a southern to a northern climate, may lose a certain quantity of pigment of the hair, which, of course, causes a change in the color of the hair. Various external injuries, applications, and agencies, as exposure to air and sun, make a most decided change in the pigment of the hair. Certain occupations influ- ence, through chemical action, the color of the hair. Thus, among Avorkmen in copper the hair may become green, blue among those who labor in cobalt or indigo. According to Leloir an$ Vidal, children born of elderly parents Avhose hair has become gray are more predis- posed to premature canities than their older brothers and sisters. Wilson, Pincus, Landois, and others have shown that the hair shaft in cases of sudden blanching contains gas, and supposed that this gas masks the pigment of the hair. This explanation, hoAvever, is in- adequate : for though, if the pigment remained intact, its color might be modified by the presence of gas, it could not be completely changed. The pigment granules must have lost their color. The gaseous matter can not be atmospheric air, but must arise from chemical alterations in- volving the destruction of the normal pigment. The decomposition is probably due to the formation, under disturbed nervous conditions, of ATROPHIES. 553 destructive secretions in the generative apparatus of the hair at the root, and their passage by capillary attraction into the substance of the hair.* Treatment.—Change of color in the hair may sometimes be arrest- ed or concealed, in the case of young persons, by the use of suitable systemic treatment, as indicated for each individual case, and by the employment of such agents as will, to a moderate degree, color the hair- substance. Among the most useful applications for this purpose are the oil of walnuts, oil of chamomile, oil of eggs,f oil of mace, oil of cassia, and oil of colocynth. A walnut hair-dye may be prepared by bruising forty parts of fresh green walnut peel Avith five parts of alum, and digesting with t\vo liundred parts of olhe-oil until all moisture has been driven off, straining and perfuming.J A simple yet valuable agent is the ordinary sage, which is made into an infusion, and the hair frequently sponged and washed with it. Tannic or gallic acid, mixed with oil, glycerine, or lard, in the proportion of a drachm of either acid to an ounce of glycerine or lard, forms a most excellent preparation, that often decidedly darkens the color of the hair. In the event that gray or white hairs appear, all that can be accomplished by the physician is to arrest, if possible, their rapid formation, and, Avhen the patient wishes to conceal the loss of pigment, to recommend cer- tain harmless agents which will permeate the hair and in a measure produce the effect of the lost natural color. The formation of gray or white hairs may be temporarily restrained by neutralizing the cause of them, by the application of any of the local remedies mentioned, or by plucking out the silvery threads. If the atrophy of the hair-pigment has become extensive, the hair, whether gray or silvery Avhite, can then be concealed thoroughly only by dyeing the hair. The proper application of hair-dyes requires an acquaintance with the nature of the agent employed ; the skill to increase or decrease its strength according to the shade of color desired; and, lastly, dexterity in manipulation. Before using a dye the hair should be cleansed Avith soap and water or with a solution of soda or of spirit of ammo- nia, and allowed to dry for about one hour, after which the agent de- sired can be applied with advantage. The most lasting hair-dyes are the mineral ones, the vegetable dyes being often feeble in their action and uncertain in their effect, especially when employed by one un- skilled in their application. Vegetable hair-dyes are usually consid- ered the most harmless, although some of them—as, for instance, pyro- gallic acid, largely used'—may produce justly alarming symptoms. The most valuable of the class already named is the Eastern or Persian combination of the powder of the dried henna-plant with the powder * See paper by author on "Sudden Change of Color in the Hair," Medical Bulletin, April, 1891. f The oil is prepared from hard-boiled yelks. X Druggists' Circular and Chemical Gazette, March, 1891. 554 DISEASES OF THE SKIN. of the indigo-plant. The two powders should be mixed separately with water and formed into a thick paste. The henna-paste is first spread on the hair, which develops, in the course of an hour, a red color, the indigo-paste being then applied in a similar manner. In the course of several hours the pastes are removed by water, leaving the hairs dyed a deep black. It is alleged by those who introduced this dye from Persia that, by means of regulating the proportions of the two ingredients, the length of time, and the degree of moisture, any shade of color of the hair that may be desired can be produced. Gawalowski asserts that ammonium anacardate, obtained from the fluid secreted under the pericarp of the cashew nut, will dye the hair a more or less dark color Avhich is tolerably persistent. After the hair has been moistened by the fluid it is combed with a comb which has been dipped in a solution of ferrous sulphate. An oleate of iron may be used instead of the sulphate. The anacardate may be also used as an ointment or mixed with oil.* Chrysarobin, goa, or araroba powder, one or two drachms to the ounce of lard, will give a dark-blue color to the hair. Pyrogallic acid communicates a dark-broAvn stain to the hair. This substance may be used as a pomade or in solution with eau de cologne and rose-water. The salts of iron produce a brown color. The best, and at the same time the most popular mineral hair-dye, to produce a dark-brown or black color in the hair, is the nitrate of silver, either in the form of a solution or of an ointment. I usually prefer to employ a solution of silver nitrate, from fifteen to sixty grains to the ounce of water. After preparing the hair, as al- ready described, the solution of silver nitrate is applied. With a good- sized comb in the left hand, the operator lifts up the locks of hair, and with a soft, long-haired tooth-brush in the right hand, the dye is brought carefully in contact with the hair. The brush is moved up and down, rubbing the dye well in toAvard the hair follicles, for, on ac- count of the arrangement of the hair-cells, the silver oxide, as it decom- poses from the menstruum, is thus better communicated to the hair-sub- stance. The operator should endeavor to prevent the dye from coming in contact with the skin, and should hasten the process of drying the hair by rapidly fanning it. In case any dye should fall upon the skin, either fifteen grains of potassium iodide, or thirty grains of sodium sulphide, to the ounce of water, or a solution of sodium chloride, will remove it. Dyeing the hair requires from t\vo to three hours' time. Evening is the best period for the operation, and the process will have to be repeated at intervals of from four to eight weeks, as the granules of siher oxide are mechanically rubbed off or otherwise lost, and white hair reappears. The length of time that the color will last largely depends upon the more or less perfect manner in Avhich the operation * Pharmaceutical Journal and Transactions, October 3, 1891. ATROPHIES. L»00 is performed. In the same way another dye, a weak solution of silver nitrate (ten to fifteen grains to the fluid ounce of water) can be used. After applying it, from one to two drachms of potassium sulphide to the fluid ounce of Avater are brought immediately in contact .with the hair, forming, in combination with the nitrate of silver, a dark-brown or black color. Again, silver nitrate can be used with lead acetate. The dye can be applied in the form of an ointment, as follows: Silver nitrate and ammonia carbonate, each twenty to thirty grains; lard or simple ointment, one ounce. The best material for producing a blond hue is peroxide of hydrogen. Light shades of hair are also obtained by the use of rhubarb or turmeric. Prognosis.—Premature canities is generally permanent. Occasion- ally the pigment returns to the hair, particularly when the affection has been superinduced by some acute disease, but instances of this reversal are, as a rule, rare. ATROPHIA CUTIS. Synonyms.—Atrophia cutis propria—Atrophy of the skin. Atrophy of the skin is characterized by a diminution in the thick- ness of one or more of its layers, or by the absorption or degeneration of the tissues of which they are composed. It may be either idiopathic or traumatic in origin, or may occur as a symptom in the course of various nervous and constitutional disorders. It may involve the entire surface, as in the senile form and in certain rare diseases. Senile atrophy may be properly regarded as the type of general cutaneous atrophy. The skin becomes thinner, lax, Avrinkled, dry, dis- colored, and scaly, or the atrophy may be restricted to narrow lines and spots, as in the lineae albicantes of Avomen who have borne children. In simple atrophy there is a more or less uniform decrease in the size and number of the constituents of each layer of the skin. In degen- erative atrophy the elements are altered in structure as well as dimin- ished in number and size. General idiopathic atrophy of the skin is an exceedingly rare affection. In a characteristic case observed by Erasmus Wilson the patient Avas a Avoman avIio had been in good health until her nervous system had been subjected to a severe strain. She then lost strength, and complained of severe pain in the left side, beneath her heart. In a feAv days her skin became sallow, and gradually hard and con- tracted, until it appeared to be too small for her body. Her fingers and toes were bent and distorted, and her lower lip was drawn aAvay from her mouth, so that her teeth and gums were exposed. In a case described by Kaposi the atrophy Avas extensive, but not universal. The skin of the face, ears, neck, shoulders, and breast was perceptibly thinned, and so tightly stretched that some difficulty Avas experienced 556 DISEASES OF THE SKIN. in raising it into folds. The surface was smooth in some places, and coArered with furfuraceous scales in others. Sensibility was not im- paired, and no subjective symptoms, other than a sense of tightness, were present. The affected skin was normal in color in some places, and yelloAvish broAvn in others. A feAv small, bright-red telangiectases were observed on the surface. The abnormal condition of the skin ceased abruptly at the level of the third rib. BeloAv that point the skin was normal in all respects. In Hardaway's case * the patient was a blind man, twenty-three years of age, of healthy parentage. His cutaneous malady dated from infancy, and his loss of sight from his sev-enth year. His face was rosaceous and scarred. The integument of the neck was pigmented in spots and reddened on the side, where numerous enlarged vessels could be seen. The front of the trunk presented a shining, check- ered aspect, due to the alternation of pigmented spots with atrophic macules. The abdomen and chest were covered with cicatrices, and the umbilicus was stretched and elevated to the level of the surround- ing skin. The skin around the elbows was pigmented and scaly. The skin and muscles of the hands Avere atrophied. The feet were normal, but the integument covering the legs and thighs was atrophied and pigmented. The entire skin, in fact, except that of the feet, was tense and atrophic. The hairs over the entire body were short and scanty. The cutaneous sensibility was normal, but the perspiratory function of the skin was imperfectly performed. There were no ob- jective symptoms. Examination of the eyes shoAved xerosis of the conjunctivae, corneal opacities, and adhesion of the lids to the balls. Partial idiopathic atrophy has been occasionally observed. This form may be congenital or acquired and may manifest itself at any age. The affected areas vary greatly in size. A partial atrophy is one of the symptoms of facial tropho-neurosis. The lesions are circular or oval in form, pigmented, have ill-defined margins, and neighboring spots may coalesce. When the scalp is attacked the hairs become gray and fall out, leaving a patch of baldness. The patches of atrophy are irregularly distributed along the course of the trigeminal nerve, al- though exceptionally they have occurred upon the neck. In all the observed cases except one the manifestations have been limited to one side. Circumscribed atrophy of the skin occasionally follows infantile or diphtheritic paralysis or severe eruptive fevers. XERODERMA PIGMENTOSUM. Taylor f and Duhring \ have described a series of cases, under the name of " xeroderma of Hebra," which can be most appropriately * Transactions of the American Dermatological Association, 1884. f Ibid., 1878. X American Journal of Medical Sciences, October, 1878. ATROPHIES. 557 mentioned here. This affection is characterized by the appearance at first of a number of small, discrete, disseminated, yellowish, brownish, or blackish spots, similar in appearance to the lesions of lentigo, and found on the face, neck, trunk, and extremities. After a time small telangiectases, or circumscribed aggregations of dilated capillaries, ap- pear betAveen or upon the primary lesions. Finally, the spots become gradually changed into smooth, whitish, glistening cicatriform macules of various shapes and sizes. It appears to begin as a localized hyperae- mia, with dilatation of the capillaries, leading to subsequent formation of a number of telangiectases, which finally contract and induce atro- phy of that portion of the integument upon which they are situated. McCall Auderson recently exhibited a boy who was the subject of this affection, and whose sister had suffered from the same malady, and died at the age of nine from some disease of the chest, the exact nature of which could not be ascertained. Hebra and Kaposi were the first, in 1870, to recognize this disorder. It generally begins at a very early age, upon the face and under the eyes, the health being unimpaired. The disease progresses at an irregular rate with periods of exacerbation and remission but no permanent amelioration. In a few cases no ad- vance had occurred beyond pigmentation with slight atrophy, though it can not be positively affirmed that the malady shall not subsequently progress. The telangiectases and pigmentation may be regarded as a stage of hypertrophy. The disease occurs on both sides of the body, but is not symmetrical. The skin may become as thin as parchment and the follicles are destroyed. Incomplete stenosis of the nasal and oral apertures is apt to occur. When the atrophic process is at an end, no further pigmentation takes place. This disease leads to the forma- tion of epithelial new growths, Avhich may fall off and leave a surface which heals spontaneously, or an intractable ulcer, which becomes the starting-point of a new growth. Of the thirty-nine reported cases, malignant growths had developed in sixteen, and non-malignant groAvths in six. The period of greatest malignancy seems to be under the tenth year, though there is not much variation until the twentieth; after the twentieth year this unfortunate tendency diminishes. Unna, in fact, goes so far as to include it among the carcinomata, and writes that " xeroderma pigmentosum is a typical carcinomatous disease." The disease is rare. Of the fifteen cases known in this country, ten have involved members of four families. The disease seems to be en- tirely uninfluenced by treatment. Brocq thinks that in certain cases he has induced some amelioration by the long-continued use of Vigo plaster. Early removal of the tumors is advisable. In traumatic atrophy due to an injury of a nerve all the tissues which are supplied by that nerve suffer to a greater or lesser extent. The muscles become thin and flabby, the subcutaneous fat disappears, the skin becomes thin, dry, and wrinkled. The integument is harsh to 558 DISEASES OF THE SKIN. the touch, and usually presents a dull, lustreless yellow or brown ap- pearance. The nails fall off or become brittle and distorted. The hairs also fall out, or become thin, dry, and brittle. The condition known as glossy skin is indicathe of impaired nutri- tion, and is usually the result of some lesion of the nervous system. It is observed as a sequence of obstinate neuralgia, or of an injury to a nerve-trunk, and may also occur in the course of progressive mus- cular atrophy. Ravogli saAV it associated with chorea and epilepsy. It is attended with more or less burning pain, and is characterized by a smooth, glossy, pinkish, or reddish appearance of the skin, someAvhat resembling that which occurs in chilblains. The hairs and nails of the affected region become involved and drop out, and the surface may be- come the seat of superficial fissures or excoriations. SENILE ATROPHY. Senile atrophy is due, as its name implies, to the changes produced by advancing age. It may be either simple or degenerative in char- acter, but usually both forms occur together. The integument is thin, dry, and wrinkled, and presents a more or less pigmented ap- pearance. All of the layers and structures of the skin are involved. According to Neumann, the rete Malpighii is thin, and its cells are shrunken; the horny layer is dry and brittle, more or less fur- rowed and easily detached; the corium is diminished in thickness, and the papillae are absent or small in size. The subcutaneous con- nective tissue is usually devoid of fat. The pigmentary matter is brown or yelloAvish brown in color, and is distributed irregularly throughout the rete and the corium. Many of the hair-follicles either disappear completely or shrink considerably in size and depth. The hair-papillae become flattened, the hairs are diminished in number and in size, and in many regions are entirely absent. The seba- ceous glands undergo various alterations. The glands which are con- nected with the follicles of the lanugo hairs are usually either trans- formed into cysts (milium) or are completely obliterated. In some cases they are simply enlarged in size. The glands which are connected with the follicles of the large hairs are invariably found to be distended, and those which empty directly upon the surface of the skin are also enlarged. The blood-vessels are dilated and tortuous, and the muscular fibres undergo more or less granular degeneration. In some cases the entire substance of the corium becomes the seat of granular or of hyaloid degeneration. The sudoriferous glands do not exhibit any structural change. The destructhe processes of senile atrophy do not occur uniformly throughout the surface, but are more marked in some regions than in others. ATROPHIES. 559 STRI2E ET MACUL2E ATROPHICJE. Synonym.—Atrophic lines and spots. There are two varieties of this form of atrophy, the idiopathic and the traumatic. The lesions of the idiopathic variety deA^elop slowly, and without any apparent cause. They consist of irregular cicatriform streaks, lines, spots, and furroAvs, which are more or less depressed beneath the surrounding normal surface. They are soft and thin to the touch, and present a glistening, bluish-white, or pearly appearance when fully developed. The spots are round, oval, or irregular in shape, and vary in size from that of a pin-head to that of a finger- nail. The lines and streaks are of varying Avidth, and may be one or several inches in length. The furrows vary greatly in depth and size. The spots are usually isolated. They may occur upon any portion of the surface. The lines and streaks are usually numerous. They are placed parallel to each other, and run in a more or less oblique direc- tion. They may appear upon any portion of the body, but are most frequently observed on the buttocks, thighs, arms, legs, and abdomen. They may occur in either sex. These marks appear at any period of life, and are unaccompanied by any objective or subjective symptoms. They run a protracted course for many years. In what is sometimes termed the neurotic form of cutaneous atrophy the lines and furrows are developed along the course of one or more of the peripheral nerves. The minute pearly atrophic lines are the result of slight distention of the skin or of incomplete separation of the superficial rhomboidal bundles of connective tissue. The large streaks and furroAvs are pro- duced by complete separation, followed by obliteration or absorption of more or less connecthe tissue. Kaposi has examined the lesions micro- scopically, and has found the epidermis, and especially the rete muco- sum, to be much atrophied. The corium is greatly thinned, and the papillae are absorbed or destroyed. The sudoriferous and sebaceous glands are more or less obliterated, the fat-cells are absent, the blood- vessels are feAv and contracted, and the connecthe and elastic tissue is much diminished. In some cases the lesions first deAelop as red, elevated lines or spots at points on the surface Avhich are subjected to tension, but they gradually assume their characteristic atrophic appearance. The lesions of the traumatic variety consist of atrophic lines and furrows of vari- ous shapes and sizes. They may be produced by any cause which occasions extreme distention of the skin. They are most frequently observed in the abdomen of women who have borne children, as the result of abdominal distention during pregnancy (lineae albicantes). They may be due, hoAvever, to distention through dropsy or obesity, to flatulence, or to the pressure of abdominal or other tumors. They may occur on the mammae as the result of excessive distention of those 560 DISEASES OF THE SKIN. organs during the period of lactation. They occur more readily in debilitated persons than in those Avho are robust. Transverse lines of this description occasionally occur on the arms or thighs after an attack of typhoid fever in adolescence. Traumatic lines and furrows are due to rupture or disarrangement of the connective-tissue bundles of the corium. They do not give rise to any inconvenience, but usually remain without modification throughout life. ALOPECIA. Alopecia is a partial or complete falling out of the hair from the scalp or other parts of the body naturally supplied with hairs. Symptoms.—Alopecia may be either congenital, premature, natu- ral, or circumscribed. Congenital baldness of the entire body, or of only a single part, is such a rare infirmity that, not being frequent, and seldom yielding to treatment, it will receive but a passing notice. Instances of persons being born without any hair are occasionally re- ported. Schede relates a case of an individual under his observa- tion having no hair or sign of the follicles on the scalp. Neumann cites instances of certain species of the horse in Little Thibet, and of certain races of African dogs and hogs, having no evidence of hair on their hides. In the human family congenital absence of hair is usually limited to certain regions, or the hair is deficient or scanty in its development. Paul de Molenes has reported a case * of congenital baldness in a girl, whose mother at nineteen and brother at six years of age had suffered from alopecia circumscripta. The interval being too long to permit the phenomenon to be ascribed to contagion, it was probably an inherited trophoneurosis. Under active stimulating treat- ment the hair gradually greAV during three years until the scalp was covered Avith the exception of a small patch behind the ear. Con- genital alopecia is often associated with anomalies of the teeth and nails. It generally occurs as a hereditary condition. Premature Alopecia.—Premature loss of hair, either partial or complete, is so common, and occasions so much distress to all who are thus afflicted, as to demand from the physician who may seek to check or to relieve it the most careful consideration. It occurs, as indicated by its designation, in persons who have not reached an ad- vanced age, and may be either an acute or a chronic affection. Sud- den and rapid loss of hair, occurring in the course of from a feAv days to twelve or sixteen weeks, constitutes acute alopecia. It may or may not be attended by a change in the appearance of the hair (in syphilis the hair becomes rough, dry, and brittle), and inflamma- tion or other cutaneous alterations of the skin may or may not super- vene. *Annales de Dermatologie et de Syphilologie, 1890, i, 548. ATROPHIES. 561 In some cases the scalp is not changed in appearance, and the hairs fall or are combed or brushed out daily to the number of from thirty or fifty to hundreds. The individuals so afflicted may or may not have neuralgic pains; most frequently no subjective symptoms are present. In other instances the rapid loss of hair is preceded or ac- companied by an inflammation or eruption. Formation of crusts or scurf may be either slight or marked, and itching, smarting, burn- ing, and even painful sensations may be experienced. Chronic alope- cia, the most common form met with, may or may not, like the acute, be accompanied with primary or secondary changes of the scalp. At times, before or during the loss of hair, the scalp is affected Avith dry seborrhoea or some other cutaneous disease. In very many cases, however, no alteration is apparent either in the general appearance of the hair or on the surface of the scalp. Alopecia usually begins long before the sufferer's attention is attracted to it by the concomi- tant of a lessening in the length of the hairs and their places being supplied by shorter ones. This first stage, in which the length of the hair decreases, may be observed by women, but rarely by men, unless they wear the hair very long. In due course of time this condition is succeeded by the second stage, in which, as Pincus truly describes it, the hair becomes thin, falls out, and is succeeded, not by hair having its original thickness, but generally by fine, short, and often downy hair. Even this downy hair may, in the course of time, drop out, and entire baldness supervene. Chronic Alopecia usually begins at the vertex and extends for- ward on the frontal bone, and on each side, over the parietal bones to the pinna of the ear. Sometimes the loss of hair begins just above the forehead, and so spreads to the parts already named. It comes on so gradually as often to escape the most obseiwant, until the second stage is reached, when baldness is almost certain to follow. Senile Alopecia.—Natural or senile alopecia is due to an alter- ation and atrophy of the hair-forming apparatus. It is observed in old persons, and is caused through the agency of the changes that the cutaneous tissues have undergone. Senile alopecia begins generally on the croAvn of the head, where the scalp, not being so vascular as else- where, is in consequence easily inAraded. It is usually preceded by the hair becoming short, thin, rough, dry, turning gray, and being cast off, slowly or rapidly, not to be restored. The hair upon other portions of the body may be cast off in a similar way, but seldom is to the same extent as upon the scalp. Pincus and Neumann have investi- gated the alterations in the integument of senile baldness, and the change usually observed is atrophy of the follicles, sebaceous glands, , and skin. Diagnosis.—The diagnosis of the forms of alopecia just mentioned is simple; the only difficulty that may arise is the separation of one 36 562 DISEASES OF THE SKIN. variety from another and the recognition of the causative element in each case. It is, of course, important to be able early to distinguish between acute and chronic shedding of the hair. In the former case it will be noted that the shedding of the. hair is usually diffuse and rapid, the hairs, on examination, not shoAving any evidence of disease in change of diameter toward the root-end or any change of color there ; whereas, in the latter case, the very opposite condition is to be observed, the hair being cast off gradually, its loss often hardly apparent at the beginning, although the thickness is lessened and the color often altered. In the event of difficulty being experienced in distinguish- ing chronic from acute alopecia, the following method, described by Pincus in " The Laws of Hair Development," is a most certain way of detecting it: " On three days collect [the fallen hairs] morning and evening, and, if the hair be worn long, separate those over six inches from the shorter ones. If the number of short ones is one third of the whole, there is disease. If the hair be worn short, those hairs which bear traces of the scissors should be separated from the point-hairs, those whose terminal extremity shows no trace of the scis- sors. If the hair be worn four or five inches long, the number of those point-hairs must not exceed one fourth or one fifth of the gen- eral loss." It is also necessary to be able early to distinguish between ordinary and syphilitic alopecia. In syphilis the alopecia may be either slight or marked, and the hair is usually rapidly cast off, either in a uni- formly diffused manner or in patches having much the appearance of alopecia circumscripta. The previous history of the patient, the altera- tion of the hair and the scalp itself, and the concomitant symptoms should all furnish a ready means of separating ordinary from syphilitic alopecia. According to Fournier, alopecia appears most often in asthenic cases of syphilis, in which debility is out of proportion to the usual syphilitic manifestations. It generally occurs between the third and sixth months, and in irregularly treated cases may be postponed until the second year. Syphilitic alopecia may be occasioned by syphilides of the scalp, though generally the hair falls without any obvious disease of the scalp. Alteration of the hair-bulbs has been found. Fournier states that this form of baldness is never permanent, but even in the absence of treatment the hair begins to grow again at the end of five or six months. When the eyebroAvs are attacked a characteristic appearance is produced, the hairs are left sticking out in all directions. Alopecia from favus is a form that should easily be recognized by the history, the presence of the crusts, and by the em- ployment of the microscope. Pathology.—In premature alopecia the pathology, as a rule, is at first identical with that of seborrhcea sicca. The epithelial cells of the sebaceous glands and hair-follicles are shed; the nutrition of the hair ATROPHIES. 563 is impaired—they loosen and fall. At a more advanced stage of the disease the wall of the hair-follicle becomes the subject of an ascending hypertrophy, and the cavity is gradually obliterated from below upward by a new development of fibrous tissue. Finally, the derm itself un- dergoes atrophy; its muscular fibres are notably decreased, while its connective-tissue elements become more abundant. The coils of the sudoriparous glands are enlarged and the tubes are increased in diame- ter. The sebaceous glands are often enlarged during the early stage, but in the final stage may become atrophied. The subcutaneous con- nective tissue is considerably thickened and firmly attached to the derm by a species of induration. Neither the vessels nor the nerves appear to be altered. Etiology.—Premature loss of hair is more common in men than in women, and this fact is no doubt principally due to the large quanti- ty of subcutaneous fat in Avomen. It is also owing to the attention that woman devotes to this, Nature's ornament, with which she is usually abundantly supplied, that she enjoys greater immunity than man from its premature loss. AVomen are more apt, through the fact of the length and the constant dressing of their hair, to detect the first inroads of the disease, and to apply at once suitable reme- dies. They are able, through the various methods of dressing the hair noAv in vogue, to conceal (more often the case than generally sup- posed) any and all evidence of thinning and baldness. Premature loss of hair may be occasioned by both constitutional and local causes. Among the internal causes are the use of improper food by infants and growing children, as well as by youths and adults. Magendie showed that the feeding of dogs exclusively on cheese for a long time caused their hair to be shed. In a similar way persons Avho take poor food, especially one or two articles exclusively, or wTho feed on SAveets, necessarily interfere Avith the hair-forming ap- paratus. " The nerA'ous system, which is one of the most important parts of the human organization, and which controls circulation, secretion, and nutrition, often plays a prominent part, if impaired, in the pro- duction of baldness. It has been demonstrated by modern investiga- tion that defective action of the nerves of nutrition is often the cause of the thinning and loss of hair. The nutritive action of a part is known suddenly to fail, the hair-forming apparatus ceases to act, the hairs drop out until few remain, and the part becomes entirely bald. It is the overtaxing of the physical powers, excessive brain-work, the exacting demands made by parents and teachers upon children's men- tal faculties, the loss of sleep, incessant cares, anxiety, grief, excite- ment, sudden depression and exaltation of the spirits, irregular and bolted meals, the lack of rest, recreation, and the abuse of tobacco, spirits, tea, coffee, and drugs of all forms, that are fruitful sources of 564 DISEASES OF THE SKIN. this defective action of the nerves of nutrition and of general thinning and loss of hair." * Among other sources may be named debility, anaemia, syphilis, irritation of the gastro-intestinal canal, impoverished blood, and the strain and exhaustion attendant upon the presence of any disease in the body. A symptomatic baldness often follows attacks of serious disease irrespective of whether the scalp has been the seat of an erup- tion. It occurs after child-birth, typhoid and typhus fevers, and fre- quently takes place in convalescence from the eruptive fevers, espe- cially scarlatina. In some cases alopecia develops without any assignable cause, and often, in such instances, it will be found that the individual inherits weak and poorly developed hair, and that the affection is hereditary baldness, derived from one or the other of the parents. The local causes are likewise very numerous. For instance, it is often brought about in both men and women by pressure interfering with the cir- culation, from some head-covering, as by the constant wearing of some one or other of the modern hats or bonnets. The improper use of combs, brushes, rubbing or scraping the parts roughly with one or the other of these articles, or the too frequent application of toilet preparations may promote the affection. Dyeing the hair, constant shampooing and close cutting, in men, are likewise factors in pre- mature loss of hair. Both sexes and individuals of all ages con- tract alopecia from large quantities of dust commingled with gaseous products floating in the air of factories and workshops. The too frequent use of water on the scalp and other hairy parts of the body, especially of soapy water, or of water used in the form of a shower- bath, often causes irritation of the glands of the skin and a conse- quent wasting of the hair. Local cutaneous affections, as seborrhoea, eczema, and the ravages of animal and vegetable parasites, occasion loss of hair. In that variety of alopecia which occurs in consequence of seborrhcea sicca Malassez has described a parasite which he be- lieves to be the exciting cause of the latter affection. This organism has been found only in the form of spores located in the horny layer of the epidermis, and entering the hair-follicles, but not penetrating be- yond the orifice of the sebaceous glands. Treatment.—It is important, before considering the use of drugs for the relief or cure of alopecia, to point out briefly the care that the hair requires both to check and prevent its loss. The general hygiene of the patient should receive careful attention, especially after fevers, or any other debilitating and exhausting affections. The exciting cause should be sought out, and the patient be treated AA'ith such remedies as are required. The general health should be promoted by * Extract from the author's paper on nair ; its Use and Care. Transactions of the Medical Society, State of Pennsylvania, vol. xv. ATROPHIES. 565 exercise and the employment of preparations like cod-liver oil, bitter tonics, iron, quinine, mix vomica, strychnine, arsenic, and phos- phorus. Minute doses of one of the mercurial salts often have a most beneficial effect in arresting the progress of ordinary alopecia. In cases of syphilis, either mercury, the iodides, or tonics are necessary. Local care of the hair is of the utmost value. It is essential that the hair, particularly that of the head, should receive marked atten- tion. In reference to the use of coverings for it, I know of no better rules than those given in my chapter on clothing in "Household Practice of Medicine" (vol. i, p. 218, William Wood & Co., New York), in Avhich I state that the head is the only part of the body so protected by nature as to need no artificial covering. " The stiff hats, so extensively worn by men, produce more or less injury. Premature baldness most frequently first attacks that part of the head where pressure is made by the hat. It is, indeed, a pity that custom has so rigidly decreed that men and women must not appear out of doors with heads uncovered. It Avould be far better for the hair if to be bareheaded were the rule, and to wear a hat the exception. Since, however, we can not change our social regulations in this respect, we should endeavor to render them as harmless as possible. The forms of hats that are least injurious are, for winter, soft hats of light weight, haA'ing an open structure, or pierced Avith numerous holes; for summer, light straAV hats, also of open structure. " As regards the head-covering of Avomen, the fashions have been for several years favorable to proper form. The bonnet and hat have become quite small, and cover but little of the head. This beneficial change is, "however, in part counterbalanced by the weight of false curls, SAvitches, puffs, etc., by the aid of which Avomen dress the head. These, by interfering Avith evaporation of the secretions, prevent proper regulation of the temperature of the scalp, and likeAvise lead to the retention of a certain amount of excrementitious matter, both of Avhich are a prolific source of rapid thinning and loss of hair in Avomen. False hair has likeAvise sometimes been the means of intro- ducing parasites, Avhich give rise to loss of hair and obstinate affections of the scalp. *" Cleanliness of the entire surface of the skin should demand at- tention, and that should be accomplished by Avater, the best medium of ablution. It is a well-known physiological law that it is necessary, in order to enable the skin to carry on its healthful action, to wash off with Avater the constantly cast-off scales of scarf-skin which, other- Avise, mingled with the unctuous and saline products, together with particles of dirt coating the pores, also interfere with the development of the hairs. Water for ablution may be of any temperature agree- able to the bather, according to habit and the condition of the bather's * Extract from the author's paper loc. cit. 566 DISEASES OF THE SKIN. health. Many chemical substances can be combined Avith water to rinse effete products off the skin. Soap is, however, the most effica- cious of all for cleanliness, health, and the avoidance of disease. Soap combines with water to render these unctuous products miscible, and readily removes them thoroughly from the skin. The best variety of soap to use for bathing purposes is the pure white soap, which escapes noxious qualities often introduced with coloring material, and can not evade detection of inferiority through the introduction of some perfume or medicinal substance. Ablution with soap and water should be performed once or twice a week at least, particularly ablu- tion of the head and beard, in order to keep open the.hair-tubes, so that they may take in oxygen, ghe out carbon, carry on their nutri- tion, and maintain the hairs in a finely polished and healthy condition. In using water on the scalp and beard, care should be taken not to use soapy water too frequently, as it often causes irritation of the glands and leads to the formation of scurf. It is equally important to avoid using daily on the head the shower-bath, which, by its sudden, rapid, and heavy fall, excites local irritation, and, as a result, speedy loss of hair. In case the health demands the shower-bath, the hair should be protected by a bathing-cap. The best time to wash the hair, for those not accustomed to doing it Avith their morn- ing bath, is just before retiring, so that they may avoid going into the open air, or getting into a draught and taking cold. After washing, the hair should be briskly rubbed with rough towels—the Turkish towel, heated, being particularly well adapted to the purpose. Those Avho are delicate or sick, and fear taking cold, or being chilled from the Avet or damp hair, should have rubbed into the scalp a little bay- rum, alcohol, or oil, a short time after the parts have been well chafed with towels. Oil is particularly serviceable at this period, as it is easily absorbed, overcoming the undue dryness of the skin which often follows washing. " It might be Avell to add in this connection the advice that I have frequently given, when consulted by those taking salt-water baths, as to the care of the hair during and after the bath. If the bather is in good health, if the hair is normal, the bather can go into the surf and remain at least fifteen minutes, and on coming out should rub the hair well with dry towels. Ladies should permit the hair to re- main loose until thoroughly dry, after which it can be advantageously dressed. It is, hoAvever, injurious to both men and Avomen experi- encing some wasting of the hair to go into the surf Avithout properly protecting it. Sea-water has not, as is often thought, a tonic action on the scalp; on the contrary, it often excites irritation and general thinning of the hair. Again, it is most decidedly injurious to the hair for persons to remain in the surf one or two hours, the hair wet, and the head unprotected from the rays of the sun. This latter class ATROPHIES. 567 of bathers, and those who hurriedly dress the hair while wet, which soon becomes mouldy and emits a disagreeable odor, are frequent sufferers from general loss and thinning of the hair. " An agreeable and efficient adjunct after ablution, already men- tioned, is oil. Oil has not only a cleansing action upon the scalp, but it also relieves any rough or uneven condition of the hair, and gives it a soft and glossy appearance. The oil of ergot is particularly serv- iceable in producing these effects, and at the same time, by its sooth- ing and slightly astringent action upon the glands, will arrest the formation of scurf and assist in checking loss of hair. In using oil, the animal and vegetable oils should ahvays be preferred, as mineral oils, especially the petroleum products, have Arery poor affinity for animal tissues. Pomatum is largely used by many persons instead of oil, as it remains on the surface and gives a full appearance to the hairs, thus hiding sometimes the thinness of the hair. No harm, and no special good, will follow the use of pomatum containing pure grease, wax, harmless perfume and coloring matter. This toilet preparation is often highly adulterated, and, the fat in it decomposing, sets up irritation in the parts to Avhich it is applied. I therefore generally advise against its use. " The comb and brush are agents of the toilet by Avhich the hair is kept clean, vigorous, and healthy. The comb should be of flexible gum, with large, broad, blunt, round, and coarse teeth, having plenty of elasticity. It should be used to remove any scurf or dirt that may have become entangled in the hair, and to separate the individual hairs and prevent them from becoming twisted and matted together. The fine-tooth comb, made with the teeth much closer together, can be used in place of the regular toilet-comb just named when the hair is filled with very fine particles of scurf, dirt, or when parasites and their eggs are present. It should, however, always be borne in mind that combs are only for the hair, and not for the scalp, which is too often excoriated by roughly pulling these valuable and important arti- cles of the toilet through the scalp as well as the hair. The brush, with moderately stiff bristles, may be passed gently over the hair sev- eral times during the day, to brush out the dust and the dandruff, and to keep the hair smooth, soft, and clean. Rough brushing of the hair, with brushes having very stiff bristles or wires in them, is of no service, but often irritates the parts and causes the hair to fall out. The use of the so-called electric brush is injurious, as is also the at- tempt to remove dandruff by the aid of the comb and brush. The question noAV arises, should the hair be periodically cut? It may be that cutting and shaving may for the time being increase the rate of the groAvth, but they have no permanent effect either upon the hair- bulb or the hair-sac, and will not in any way add to the life of the hair. On the contrary, cutting and shaving will cause the hair to 568 DISEASES OF THE SKIN. grow longer for a while, but in the end will inevitably shorten its term of life, by exhausting the nutritive action of the hair-forming apparatus. When the hairs are frequently cut, they will usually become coarser, often losing the beautiful gloss of the fine and delicate hairs. The pig- ment will likeAvise change—brown, for instance, becoming chestnut, and black changing to a dark brown. In addition, the ends of very many hairs will be split and ragged, presenting a brush-like appear- ance. If the hairs appear stunted in their growth upon portions of the scalp or beard, or gray hairs crop up here and there, the method of clipping off and singeing * with a taper, a candle, or piece of heated metal the ends especially of the short hairs, of plucking out the ragged, withered, and gray hairs, will cause them to grow stronger, longer, and thicker. " The hair of growing children should not be cut at certain periods of the year (during the superstitious time of full moon, for instance), in order to increase its length and luxuriance as they bloom into womanhood and manhood. This practice of cutting the hair of chil- dren is condemned by the distinguished worker in this department, "Kaposi, who states that it is well known that the hair of women Avho possess luxuriant locks at the time of girlhood, never again attains its original length after having once been cut. Pincus has by repeated experiment determined the same fact; and he says, as to the general opinion that frequent cutting of the hair increases its length, that the effect is opposite to that generally supposed. He states that, upon one occasion, he cut off circles of hair an inch in diameter from the heads of healthy men, and from week to week compared the intensity of groAvth of the shorn places with the rest of the hair. The result Avas surprising to this close and careful observer, for, although in some cases the rate of development was equal in those places to that on the rest of the head, he never observed an increase in rapidity of growth. " I might add that I believe that many beardless faces and bald heads in middle and advancing age are often due to constant cutting and shaving in early life. The young girls and boys seen daily upon our streets with their closely-cropped heads, and the young men with their clean-shaven faces, are year by year through this fashion having their hair-forming apparatus overstrained. I must also condemn the modern practice of curling and crimping, the use of bandoline, and all varieties of gum solutions, sharp hair-pins, long-pointed metal orna- ments, and hair-combs, the wearing of chignons, false plaits, curls, and frizzes. The last four articles mentioned tend to cause conges- tion and headaches. Likewise, I protest against the use of castor-oil and the various mixtures extolled as the best tonics and restoratives, as they are often highly injurious instead of beneficial. " * See paper by author on " Cutting and Singeing the Hair." The Medical Bulletin, March and April, 1892. ATROPHIES. 569 In the use of local agents for alopecia, the aim should be the ap- plication of such as are indicated for each case. In many, local reme- dies of a stimulating and astringent nature are demanded, while in others soothing and nutritive agents produce the best effect. If the hairs are cast off and no appreciable change has taken place in them or in the .scalp, the use of either balsam of Pern, tannate of quinine, cinchona, and naphthol, one drachm of either to the ounce of scented lard, is often attended with good results. In alopecia Dr. Besnier advises that the hair be cut short, a mild sinapism or rubefacient be applied to the scalp, after which every five days the following lotion should be used : R, Acid, acetici.......................... f 3 i Chloroformi.......................... f 1 iv. M. This preparation should be used cautiously, on account of its ir- ritant properties. In addition to the lotion, the following pomade is employed every morning, the scalp having been previously Avashed: R, Acid, salicylici...................... gr. xv. Sulphuris precipitat................. 3 jss. Vaselini........................... 3 v. M. Kaposi recommends a solution of green soap in alcohol, about five drops of oil of lavender being added to each fluid ounce. Lassar advises that the scalp be washed every day Avith tar soap for ten or fifteen minutes and the lather be removed by an abundance of water. After the scalp is thoroughly dried he directs a lotion of corrosive sublimate to be applied. This preparation consists of one hundred and fifty parts of a half-per-cent. solution of the mercuric chloride with fifty parts each of glycerine and cologne-water. The head is again dried and an ointment composed of the folloAving ingredients is applied : I> Acid, salicylici................... gr. xxx. Tinct. benzoini................... m xlv. Olei pedum tauri................. f 3 iij. M. He esteems pilocarpine as of value in the treatment of baldness, and proposes the following formula : Pilocarpine hydrochlorate, thirty grains ; quinine hydrochlorate, sixty grains; precipitated sulphur, tAvo and one half drachms; balsam of Peru, five drachms, and ox-marroAV, twenty-eight drachms. If the hair falls or combs out in large quantities from some fever or acute constitutional disease, the physician should make an exception to the general rules upon cutting just described. Under such circum- stances the hair should be cut short, and in some cases shaved several times. After Avhich some one of the ointments or stimulating lotions already referred to should be well rubbed into the scalp several times a day. The application in addition of galvanism, alternating with the faradic current every day or two, will still further produce a stimulating action upon the growth of the hair. When the hair has attained an 570 DISEASES OF THE SKIN. inch or two in length the terminal ends should all be singed every two or three weeks, to give increased activity to the hair-forming apparatus. If, hoAvever, the scalp should be covered with sebaceous secretions, the glands plugged up (which is often the case), the hairs dry and lustre- less, the employment of stimulating oils, especially the oil of ergot and oil of eucalyptus, may prove of service. A very useful application for this condition is equal parts of the oil of ergot and the fluid mercury oleate, scented Avith oil of roses and verbena. A mixture of the oleate of iron with oil of ergot or any of the ordinary oils may likeAvise be used Avith advantage in this condition. Another valuable remedy, the quillaya saponaria, the soap-bark, I first pointed out in a communica- tion in 1879.* The soap-bark can be used in the form of the fluid ex- tract, or infusion, mopped over the surface several times daily. In case the affection persists, the employment of local galvanism, or faradism, by the sponge or brush, often assists in arresting the loss of hair. If more decidedly stimulating agents become necessary, the ap- plication of remedies used in the treatment of the circumscribed form of alopecia may be employed. Prognosis.—Congenital alopecia can seldom be benefited; senile baldness is irremediable. The premature form may be checked or cured; the prognosis will, hoAvever, largely depend upon the duration of the disease and the exciting cause. Individuals with good habits, treated when the disease is early recognized, are often cured, or benefited. Alopecia sometimes, even under the the most favorable circumstances, progresses to permanent baldness, notwithstanding our best efforts. The prognosis of old cases of premature alopecia is usu- ally very unfavorable. ALOPECIA CIRCUMSCRIPTA. Synonyms.—Alopecia areata—Area celsi—Porrigo decalvans—Tinea decalvans. Alopecia circumscripta may be either a neurotic or a parasitic affection of the hair-forming apparatus, generally characterized by the sudden loss of hair over one or more circumscribed patches of various sizes and shapes. Symptoms.—Alopecia circumscripta usually begins on the scalp, in one or more isolated patches, each one appearing suddenly and alone, or simultaneously, or in succession, without any premonitory symp- toms. It may attack any hairy part of the body, but its usual seat is the scalp, the beard, the axillae, and the pubes. The disease generally first develops on the scalp of those persons who have been endowed with a luxuriant growth of hair, and, next in order, the beard, although the latter, and other parts of the body, are seldom invaded by it. On the scalp the hairs are cast out of the follicles Avithout having been * "Loss of Hair," by the author. The Medical Bulletin, vol. i, March, 1879. Plate YIII. •Vv »•- •/- X Alopecia Circumscripta (from Nature). ATROPHIES. 571 broken off beyond the skin, the loss of hair in spots spreads peripheral- ly, and is often increased by the addition of other spots. The affection usually comes on very suddenly, often without the least warning, a per- son's attention being sometimes first attracted to it during the-course of the toilet. The hair may thus be shed unnoticed. Occasionally the loss of hair comes on slowly—days, and at times weeks, passing by dur- ing the process of the shedding, until the bald spots are fully estab- lished. The patches may be circular, circumscribed, long, or irregular in shape, and may vary in size from a small point to a very large sur- face, at times covering the entire scalp. They are usually from one to three inches in diameter, isolated, unilateral, well outlined, and, when once thus determinately formed, they seldom increase. During the progress of the disease the patches occasionally spread, coalesce, assume all manner of shapes, and are either arrested or denude the entire scalp. Sometimes, in the former case, shedding occurs in other parts of the body, the hairs falling from the entire surface, as from the eye- broAvs, the eyelashes, the chest, and, in the case of the male sex, from the axillary and pubic regions. The denuded patches are someAvhat paler than the normal skin, or slightly raised, especially in the beginning, reddened, and studded with follicular openings. In some cases the skin is thin, smooth, polished, and the follicles closed, while in others a few straggling, poorly de- veloped hairs are observed over the surface and around the margins of the patches. The hairs around the spots are usually loose, coming out on the slightest pull, until the falling out has been arrested, when they become firmly fixed in the follicles. The skin of the patches has either a normal or else a softish feel, and is characterized by a dimin- ished or a positive absence of sensibility. These latter conditions, Avhen present, follow the development of the patches. Itching is a symptom that may appear either before or during the course of the disease. In the majority of cases, hoAveAer, all subjective symptoms are absent, except the great mental annoyance which the disease causes, from contemplation of the marked deformity produced by the bald spots. When the disease is arrested, or restoration sets in, the patches be- come covered with light-colored, fine, Avoolly hairs, which are often, in turn, partially or generally shed, to be in time increased in numbers, thickness, length, and pigmentation, until normal hair covers the parts. This affection may seem to be entirely cured, and yet a recurrent attack may come and again denude the spots. The duration of the disease is variable, depending largely upon the age of the individual and the state of the system. Cures are sometimes effected rapidly, but sometimes weeks, months, and years succeed one another before a favorable change appears, and in some cases the baldness remains permanent. Diagnosis.—Alopecia circumscripta is liable to be confounded with 572 DISEASES OF THE SKIN. the other forms of loss of hair already described and with tinea capi- tis and favus. The sudden shedding of the hair in more or less iso- lated, smooth, bald patches and their gradual encroachments, and the absence of the circumscribed spots, are the most ready means of dis- tinguishing this disease from the other varieties. Syphilitic alopecia, which is usually diffuse and rapid, might, of all the forms already men- tioned, be most easily mistaken for alopecia circumscripta. The his- tory of the case, however, the presence of seborrhoea, as Avell as con- comitant symptoms of syphilis on the scalp or some part of the integu- ment, ought to enable it to be so easily diagnosed as to render impossible its being confounded with alopecia circumscripta. Alopecia circum- scripta is to be distinguished from ringworm of the scalp by the sud- denness of the onset in the former affection, its characteristic isolated, smooth, bald spots, and by the atrophy about the root-end of the falling hairs; while in the latter affection the disease begins and spreads grad- ually, the patches are filled with hair-stumps, scales, and often crusts, and the microscope reveals, instead of atrophied hairs, mycelium and spores. Alopecia circumscripta may be distinguished from favus by the absence of the peculiar yelloAvish crusts of favus and of all sign of vegetable parasitic irritation. Pathology.—The anatomical condition of the skin and hairs in this variety of alopecia has been examined by numerous investigators without yielding any satisfactory result in accounting for the morbid process. Rindfleisch reports, in the " Archiv fur Dermatologie und Syphilis," a nodular swelling of the hair " between the hair-bulb, on the one hand, and the narroAvest part of the follicle, on the other." This condition was shown by Kaposi to be found in other diseases, and to be producible by the mechanical extraction of the hair. Jamieson * examined a specimen of skin removed from a patient, and was not able to find any changes in either the follicles, glands, or tissue. A microscopical examination of a hair from the area, or from the margin of a patch, shoAvs an atrophied condition similar to that observed in the normal loss of hair. The root-extremity of the hair, instead of being bulbous, as it is found in healthy hair, is attenuated and often markedly atrophied. The degree of this condition varies, of course, according to the stage which the affection has reached at the period when the hair is removed for inspection. In examining the hair still further, it may be found gradually dilated along the shaft and bulging just before terminating either in a split end or a hair-point. This swollen, ragged, or split condition of the hair is owing to the fact that it has not received sufficient nutriment. The bundles of cells, deprived of their natural stimulus, haAre separated and given rise to the condition described. The same change that time brings to the normal loss of hair has taken place prematurely from alopecia circum- * Edinburgh Medical Journal, March, 1879. ATROPHIES. 573 scripta. Some disturbance or impairment in the nervous system, no doubt, plays an active part in bringing about these changes in the hair, thus causing its sudden and unexpected loss. In many specimens Behrend and Besnier observed the appearance of an air space in the root of the hairs and the absence of the hair marrow. Etiology.—The disease occurs in both sexes. Children, adults, and old persons are equally liable to be attacked by it. Alopecia circum- scripta often follows some nervous affection, as epilepsy and neuralgia. Sudden shocks and frights are also well-known causes of it.* Dr. Cutler has described the case of a boy who, two weeks subse- quent to a well-marked attack of herpes zoster on the right side of the neck and scalp, suffered from a rapid loss of the hair, in patches, on the affected side. The affection may likewise arise from debility, during and after fevers, and from any severe illness. Mr. C. F. Williamson reports f a case which developed a few months subsequent to an attack of epi- demic influenza. Direct or indirect injury is also among the many causes that may occasion it. Dr. Pontoppidan, of Copenhagen, has met with a case in which alopecia circumscripta appeared three weeks after removral of a glandular tumor from the left carotid region. The hair was spon- taneously reproduced within a feAv months. Similar cases have been cited by Askanazy. Max Joseph has produced circumscribed fall of the hair in cats and Guinea-pigs by lesion of the cervical ganglia or section of certain nerves. Behrend, in repeating these experiments, failed to produce baldness by dividing the sympathetic in the neck. The view is promulgated by certain writers that alopecia circum- scripta is of parasitic origin. It is probable that in some instances the disease has been confounded with tinea tonsurans. Besnier, Vi- dal, and others conclude that it sometimes arises from perturbed nerv- ous influence and in others from parasitic agency. With this opinion II. Leloir agrees J after an analysis of one hundred and forty-two cases. He was able in ninety-two of these to study closely the question of etiology : thirty-six were obviously of nervous causation ; in thirty-five the origin Avas obscure, no facts pointing to disorder of the nervous system, traumatism, or irritation of the scalp; in twenty-one cases a contagious element seemed to be present. Dr. Charles P. Putnam, of Boston, has given details of an epidemic of circumscribed baldness occurring in an asylum for girls. In all, sixty-three children (out of sixty-nine from three to fourteen years of age) had the disease to a greater or less degree. No micro-organisms were found, nor Avas anything observed, except that the roots were * Wiener medicinische Wocbenschrift, July 19, 1884. f Lancet, June 7, 1890. X Gazette des Ilopitaux, June 30, 1888. 571 DISEASES OF THE SKIN. atrophied and the hairs somewhat more slender than usual. The ap- pearance was decidedly different from that of ringworm, and the spores and mycelium of the trichophyton were absent. In some of the chil- dren the spots were numerous, but of small size. Lewis Wickham, in a paper read at the fortieth annual meeting of the American Medical Association, states that the prevailing idea among French dermatologists is that there exist two distinct diseases called alopecia. One is a trophoneurosis, the other is due to a para- site which acts indirectly on the hair-papilla through the mediation of the nervous system. Wickham cites instances which he has himself observed in the wards of Hallopeau and Vidal in the Hopital St.-Louis, and alludes to several epidemics in schools and among troops. The parasite has not yet been discovered. It is not claimed that the dis- ease is highly contagious. Sabouraud, who has spent much time and labor in studying the micro-organisms which infest the scalp, has recently announced some very interesting and startling conclusions. He has discovered a mi- crobe constantly present in the lesions of seborrhcea, and believes it to be the specific exciting cause of that disease. By methods Avhich he describes the bacillus of seborrhcea may be obtained from the oily secretion, stained, and identified. It is found in rounded masses in the upper third of the hair-follicle. The same bacillus affects the se- baceous glands of the scalp, where it causes falling of the hair, either diffuse, as in ordinary alopecia, or localized, as in alopecia circum- scripta. He therefore regards the circumscribed form of baldness as an acute local attack of seborrhcea. Sabouraud has detected the bacil- lus of seborrhoea in sections of the skin in an early stage of alopecia circumscripta. These two diseases are, in his opinion, essentially iden- tical. Furthermore, in his opinion, baldness is the result of the spread and coalescence of circumscribed patches, or, to use his own words, " The bald only become bald by a diffused process of chronic alopecia areata." These views explain the origin of baldness and the relation between seborrhcea and loss of hair. They ascribe a common origin to ordinary and circumscribed baldness, and give precision to the earlier hypothe- sis of parasitic influence. The bacillus to which Sabouraud attributes seborrhoea had been previously recognized by Unna, who had looked upon it as the exciting cause of acne. This Avas due, according to Sabouraud, to the fact that the two organisms were found in association. Alopecia circumscripta has been observed in consequence of ex- posure to the Rontgen ray. Treatment.—Attention to the general system is essential. The patient should have a generous diet, especially those forms of food that afford ample nourishment. Change of diet, as well as of air, and the employment of all measures, especially hygienic, to invigorate the ATROPHIES. 575 nervous system, will be found most efficacious. The use of general and local galvanism is often followed by the most beneficial results. As this form of the affection may be traced to an imperfect condition of the nervous system, I usually endeavor, by the use of the means already mentioned, and by proper medicines, to attack the latent source of the disease. The employment of such agents as arsenic, strychnine, phosphorus, quinine, iron, and cod-liver oil, preparations that have likewise been suggested for the treatment of the premature form of alopecia, Avill be found of great value. Radcliffe Crocker suggests the hypodermic injection of one thirtieth grain of pilocarpine into the scalp. The local treatment referred to, when speaking of premature alope- cia, can be used advantageously in mild cases also, especially if the sur- face of a patch be elevated and congested. Pale, smooth, and depressed patches demand more active stimulation—agents that Avill make a decided and quick impression. The most valuable of all remedies for strong stimulation, both upon and in the parts, is the ointment of mercurous oleate. Naphthol and sulphur iodide are both useful reme- dies, used either alone, ten to sixty grains to the ounce of lard, or com- bined, in the same proportions. An ointment containing one or two drachms of resorcin or ten grains of thymol to the ounce may also be beneficially employed. Shaving the patches frequently, especially when they become covered Avith very fine hairs, will often stimulate the hair- forming apparatus. Singeing the hair the moment it appears above the surface Avith a taper, or by means of heated metal, will also often assist the active groAvth of the hair. The ointments just named can be employed at the same time. Turpentine, chrysarobin, cantharides, veratria, tannic or gallic acids are agents that can be used in the form of ointment Avith good result. Stimulating or blistering agents are often of value, and among the most important are alcohol, the various spirits, essential oils, and acetic acid. The following can be used advantageously: Ro Spiritus vini rectificati..............f § j. Tincturae cantharidis, Tincturae capsici.................aa f 3 ij. Spiritus rosmarini.................. f 5 j. Spiritus ammonii fort.............. f § j. M. Cantharidal collodion, painted over the patches, if small, every week or ten days is often of advantage. If the spots are very large, or the entire scalp or surface be involved, other remedies not so active may be called into requisition. A useful lotion I have employed consists of: IJ, Ammonii mur..................... 3 j- Hydrargyri chlor. corros............ gr. x. Aquae hamamelis dest.............. f § ij. Spiritus vini rectificati............. f 3 iij. M. 576 DISEASES OF THE SKIN. Glacial acetic acid, painted over small patches from time to time, is also of service. Horand has found croton-oil of value, applied long enough to produce vesication. The use of this agent demands circumspection. . Besnier denies the value of electricity, which the author has found very serviceable, especially in the form of galvanism. Lassar, an advocate of the contagious nature of the affection, claims remarkable success from his plan, of treatment, mentioned under pre- mature alopecia. Pyrogallic acid has also been used with success in some cases. The expressed oil of mace is very popular in Vienna. The application of either simple or compound hot poultices are of the greatest value, particularly if a large part of the scalp be involved. A useful agent to add to a poultice so employed is mustard or capsicum. The retention of heat and moisture, either by a poultice occasionally applied, or by wearing constantly a Avig over the denuded surface, hid- ing also the disfigurement, is often folloAved by the most happy results, especially in stubborn and long-standing cases. Prognosis.—Alopecia circumscripta is generally curable, but its course may be protracted into months and years. The age of the patient and the exciting cause are factors upon which an opinion should be largely based. As a general rule, young persons and adults recover their hair; the prognosis is not so favorable for those advanced in age. Continuous and long-protracted diseases, especially those of the nervous system, often leave, as has also been already noted, per- manent baldness as a consequence of alopecia circumscripta. Mild, and occasionally severe, cases sometimes recover in an apparently spon- taneous manner, from the system having again returned to healthy working order. The deformity entailed by the disease, especially if a conspicuous part of the body be invohed, often leads to great mental distress, and it is only by persistent encouragement and the constant use of the remedies mentioned that a cure can in the majority of cases be hastened and made permanent. ATROPHY OF THE HAIR. Synonym.—Atrophia pilorum propria. Symptoms.—Hair itself occasionally undergoes atrophic alteration in its structure. It becomes changed in part or in all of its length, either by increase or diminution in diameter. In some instances the shaft of the hair is the seat at one point, or at irregular intervals, of small bulbous SAvellings, which ha\Te a dark or shiny appearance, and is liable to break off between and at these nodosities, leaving a ragged, brush-like end. This nodose condition occasionally results, through the collection of pigment in the swellings, in the hair's presenting alternately bright and dark color, giving a bead-like effect throughout the mass of hair, causing its great disfigurement. Atrophy of the ATROPHIES. o< < Fig. 14.—Atrophy of hair-root. hair of this form is more especially con- fined to the beard and mustache, but is occa- sionally met with on the scalp and other hairy parts of the body. It is usually described as tricho- rexis nodosa; and an- other condition, simi- lar to it, is knoAvn as piedra. The last- named affection, com- mon in Colombia, has been investigated by M. Juhel Renoy, Avho has applied to it the name of trichomycosis nodosa (tricomycose nodulaire). An affection has been described under the same title by Dr. Patteson. The account of the microscopic ap- pearances given by these tAvo observers agrees very closely, though the re- sults of their histological examinations do not pre- cisely correspond. Dr. Juhel Renoy states that the nodes are formed by an agglomeration of very refractive spores glued together by a greenish- yellow material consti- tuted by compact col- onies of rods. The di- ameter of the spores is about one hundredth of a millimetre—larger, that is to say, than those of trichophytosis. The rods seem to have noth- ing to do Avith the my- celium, which, in fact, is small upon the hairs as though atrophied, but develops rapidly in cultures. The parasite does not penetrate the interior of the hairs, 37 Fig. 15.—Atrophy of hair-substance, not of parasitic origin. 578 DISEASES OF THE SKIN. but is wholly exterior. Cutting the hair short is a preliminary to suc- cessful treatment, but Dr. Juhel Renoy has not yet had sufficient expe- rience to be able to recommend any particular parasiticide.* Another variety of atrophy of the hair, generally known as fragil- itas crinium, is characterized by a brittle and cleft state of a part or all the hair-substance, often within as Avell as without the hair-follicle. The hairs, more particularly those of the head and beard, are irregu- larly thin or flattened, rough, uneven along the shaft, at points brittle, breaking off and splitting up, often into several fibrillae (see Fig. 15). The alteration goes on within the follicle; the hairs may be curled up Avithin it, and considerable irritation often, in consequence, followrs in the integument, chiefly observable in the region of the beard and on the lower limbs. The atrophy may involve the hairs to either a slight or a marked extent. In case the latter condition supervene, the poor growth, with its marked changes, produces great deformity. Diagnosis,—The broken-off, cleft, and deadened condition of the hairs, Avith often attendant irritability of the surrounding integument, has occasionally been mistaken for ringAvorm. The history of conta- gion in the latter affection, the circular arrangement of the patches, and the presence of the vegetable parasite, discoverable by the employ- ment of the miscroscope, will always serATe, however, to establish the diagnosis of the latter affection, and distinguish it conclusively from the other. Etiology.—Atrophy of the hair, producing many of the curious appearances that haAre been reported from time to time, may result from either constitutional or local diseases. Many cases, hoAvever, do occur that can not be traced to any .assignable cause. It often follows from fevers, or from debilitating and exhausting conditions that affect the hair-forming apparatus. Phthisis, malaria, syphilis, and excesses of various kinds are prolific among the causes that bring about atrophic alterations in the structure of the hair. Among the local conditions that lead to it are seborrhcea, eczema, the effect of the rav- ages of vegetable and animal parasites, and the use of applications to eradicate these affections. Atrophy of the hair also follows from the many local causes that have been already mentioned, that produce premature loss of hair. Treatment—The exciting cause, if any can be detected, should, if possible, be removed. Tonics and remedies that re-establish nutrition in the system are usually indicated. Cod-liver oil and small doses of arsenious acid, or sodium arseniate, are often producthe of much good. As a general rule, the persistent use of local means will lead to the best results. Plucking out or breaking off the diseased ends of the hair, if too many hairs are not involved, and rubbing into them a ten-per-cent. ointment of mercury oleate, once or twice daily, will at times restore * Journal of Cutaneous and Genito Urinary Diseases, September, 1889, p. 343. ATROPHIES. 579 the hair to healthy growth. If a large number of hairs are involved, shaving the entire surface is generally recommended ; but I prefer to clip off the affected ends, or, if necessary, the whole hair-shaft, and then to apply the ointment just suggested. If the greater part of the hair-shaft be the seat of bulbous SAvellings, or only the portion of the hair situated within the follicle be involved, I find that better results follow from cutting the hair very short, and then using the ointment, than from shaving. The ointment of the nitrate or the ammoniated mercury, thirty to sixty grains to the ounce of lard, are also good preparations to use on the affected hairs. The application of either lanolin or suet, with a few drops of oil of chamomile, will often assist in restoring the hairs to their normal condition. I sometimes use the following prescription with good effect: f> Olei myristicae, Olei anthemidis..................afi f 3 ij. Hydrargyri oleatis fl. 10 per cent...... f §* ij. Olei verbenae....................... hi, v. Olei rosae.......................... ni, j. Olei ergotaa........................ f § ijss. M. The various stimulating remedies and combinations previously mentioned, for the treatment of the premature and circumscribed forms of loss of hair, will often be found advantageous to employ. 'The tincture of cantharides is, perhaps, the most efficient agent in the nodose form of atrophy. Prognosis.—Young subjects, by persistent attention to the treat- ment, may cause sound and vigorous hairs to replace those previously diseased. Failure very often folloAvs the best means and efforts to cure this distressing affection. The prognosis for persons of advanced years, and for cases of long standing, irrespective of age, is not favor- able. ATROPHY OF THE NAILS. Synonym.—Onychatrophia. Atrophy of the nails, or their absence, may be congenital or ac- quired. In the congenital form there is frequently associated with this affection an imperfect development of the phalanges and an absence of hair. Acquired atrophy, or a deficient development or ■groAvth of the nails, may be caused by any local or general disturb- ance Avhich may affect the matrix or the bed of the nail, as from an injury. Syphilis, fevers, and often hypertrophy of the nails, are some- times secondarily succeeded by this kind of atrophy. Among other causes may be mentioned ichthyosis, tuberculosis, ataxia, and cerebral paralysis. Gay has seen it folloAv compression of the subclavian artery. Atrophied nail-substance may undergo alterations similar to those described for hypertrophy of the nail, becoming changed in size, 580 DISEASES OF THE SKIN. shape, consistency, and color. Thus, the nail may become both small- er and thinner, flexible, or brittle and easily broken; or soft, granu- lar, and even present a worm-eaten appearance. The surface of the nail may be smooth and unaltered in appearance, or may be discolored, opaque, or yellow and fissured. Dr. Foxwell has described the case * of a girl, aged nineteen, in Avhom six finger and three toe nails had almost completely crumbled away, their remains feeling like pieces of parchment beneath the cicatricial-like tissue which had grown over them from the superficial layer of the matrix. In two fingers this cicatricial tissue alone could be detected. There was no history of any injury or ulceration nor, indeed, of any acute period of the dis- ease. A form of atrophy is sometimes observed in the nails of chil- dren, the ungueal matrix first becoming swollen and more or less pain- ful, after which the nail is raised, breaks, and finally almost or entirely disappears. The affection is symmetrical and attacks progressively several and sometimes all of the finger-nails. Treatment.—The treatment of atrophy of the nails depends mainly upon the cause, which should first be removed, if that be possible. If the diseased nails are painful, or interfere with the occupation of the patient, the application of soothing ointments, as the zinc or lead oleate, will be beneficial, and the use of wax or gum over the nails, as a protective layer, will be found most grateful. The nails may at times be benefited, and their healthy growth promoted by applications of either sweet-oil, cod-liver oil, oil of cade, mercuric-oleate ointment, or mercurial plaster. AVhen the condition depends upon chronic inflammation of the matrix, G. H. Fox has seen improvement result from repeated immersion of the end of the finger in a mixture com- posed of 10 parts each of chrysarobin, salicylic acid, and ether to 100 parts of collodion. Nutritive Alterations of the Nails in Constitutional Diseases.f—The color, transparency, and lustre of the nails are a good index to the general state of the health. Anaemia is as readily recognized in the pallor of the nails as in that of the skin and mucous membranes. In leukaemia the nails assume a deadly white color; in chlorosis they generally become pale and sometimes exhibit nutritive changes in progressive pernicious anaemia, becoming thickened, fis- sured and crumbling off at the free edges. Haemorrhage may occur beneath the nails in scurvy, and give rise to inflammation of the bed Avith subsequent loss of the nail. Falling of the nail is not infrequent in the course of diabetes mellitus. The accident may or may not be associated Avith perionychial or subungueal inflammation. In some cases of diabetes ecchymoses occur beneath the nail. Locomotor ataxia * British Medical Journal, February 16, 1890. f See "Diseases of the Nails," by John V. Shoemaker, A.M., M.D., in Journal of Cutaneous and Genito-Urinary Diseases, vol. viii, 1890, Nos. 96-99. ATROPHIES. 5S1 may be attended by spontaneous and intermittent falling of nails un- accompanied with suppuration or ulceration of the matrix. A patient of Dr. Aclaud exhibited symmetrical trophic lesions of the nails pro- duced, as was supposed, by Raynaud's disease. The nails are variously altered in Morvan's disease. They may be lost, be reduced to small plates lying upon the stump of the finger, or may assume the most fan- tastic alterations. Sometimes they are curved like talons. Again, they may be hard, thick, irregular and present numerous transverse furrows. In multiple neuritis Bielschowsky saw the finger-nails marked by trans- verse milk-white patches without other alteration. The microscopical examination seemed to show that the discoloration Avas due to the pres- ence of air.* In acromegaly the nails participate in the enlargement of the fingers and may be changed in shape. Dr. De Sanctis has given the history of a case in which necrosis of all the nails of both hands appeared due to lesion of the central nervous system. Arnozan has de- scribed a case in which spontaneous fall of nails coincided with alope- cia circumscripta. Spontaneous fall of the nails in a hysterical woman has been observed by Dr. Falcone, and Dr. J. Leslie Foley is cognizant of a case in which all the hair and every nail was lost in consequence of the alarm excited by a violent thunder-storm. According to Dr. Lan- cereaux, dystrophy of the nails is present in a large proportion of cases of chronic rheumatism. They become furrowed, if not thickened and scaly. The nails occasionally are cast off when no impairment of the health can be detected. A case of repeated spontaneous shedding of the nails has been narrated by Dr. Hilbert, who was himself the subject. The process occurred in September of four successive years. In the fifth year but one nail was shed. The general health had been good, and the reporter Avas unable to account for the nutritive disturbance.! Dr. E. L. Standlee, of St. Louis, relates the case of a healthy Avoman attacked ten years ago, in August, by typhoid fever. In the same month of the folloAving year, after a redness of the fingers, extending to the entire body, accompanied by fever and vomiting, the nails loosened and fell off, desquamation occurred and the skin remained red for some time. This process has been repeated in August of each succeeding year. A similar case has been related by Dr. Livius Furst, in which, hoAveArer, the effect was probably due to a disturbance of circulation in consequence of prolonged contraction of the fingers. The nails some- times fall during convalescence from typhoid fever, Avhile in other cases they exhibit alterations due to depressed nutrition during the febrile stage. They are frequently crossed by transverse bands or furrows. The portion Avhich developed during the disease lacks normal thick- * British Medical Journal, January 17, 1891. f Dr. Douglass W. Montgomery, of San Francisco, describes in the Journal of Cuta- neous and Genito-Urinary Diseases for June, 1897, a case of hereditary and continuous shedding of the finger-nails. 582 DISEASES OF THE SKIN. ness, is rough, dull, and white. An attack of typhus fever, likeAvise, leaves white bands or furrows upon the nails. They sometimes fall after scarlet fever or small-pox, while in other cases they are channelled by grooves. The pustules of variola occasionally form beneath the nail. During the early stage of fractures the growth of the nail is re- tarded and is resumed as repair advances. White bands or furroAvs upon the nails occur in consequence of acute rheumatism and relapsing fever. In gout the nails lose their lustre and polish, are apt to become fragile and manifest a tendency to break and scale. FurroAvs may appear upon the nail after sea-sickness, diarrhoea, and nervous exhaus- tion. In tuberculosis the nails are often thick, curved, and clubbed. In scrofulosis they are sometimes deeply grooved, enlarged, and of a firm, horny consistence. A severe inflammation of the nail-bed knoAvn as onychia maligna is met with usually among children, and is considered by most authori- ties as a local form of tuberculosis. A finger-nail is the general seat of the disease. The inflammation is preceded by more or less pain for two or three weeks. The bed then becomes swollen beneath the free border of the nail, the redness and sAvelling increase, and terminate in the formation of an obstinate ulcer, situated at first beneath the free border, but extending gradually backward toward the lunula, until at last the whole bed and matrix are involved. The ulcer is of a fungous character, bleeds easily, and gives rise to a very fetid, sanious sup- puration. The nail is dry, broAvnish or black, and gradually becomes loosened as the ulcer advances to the matrix. The nail may fall in one piece or in fragments. In other cases, again, the nail may remain and even groAV, although, as a rule, it develops badly as to form and direction. The nail is apt to assume a vertical position. Sometimes it becomes thickened or curved. The last phalanx acquires a charac- teristic, bulbous appearance. The integument surrounding the nail is hard, shining, and livid. The affection is not a very common malady, but is very obstinate and manifests no tendency to heal. It may con- tinue for years and lead to suppurative lymphangitis and lymphade- nitis. The phalangeal bone may become involved, but is not generally attacked. Onychia maligna is, in all probability, dependent upon a predispo- sition to tuberculosis, though the immediate exciting cause is often a traumatism. Dupuytren and St. Germain have subdivided this affec- tion into scrofulous and syphilitic. Constitutional treatment is de- manded. The nail-groove may be sliced off and the matrix scraped, or the nail may be entirely removed and the ulcer covered with eithei powdered nitrate of lead, bromide of potassium, iodoform, iodol, aristol, or europhen. The white spots so often seen upon the nails are indicathe of de- pressed nervous force, whether the result of exhausting disease, dissi- ATROPHIES. 5S3 pation, sexual excesses, overwork, or anxiety. A very unusual case has been related by Dr. Robert B. Morrison, of Baltimore. The patient Avas a young woman, twenty years of age, suffering from acne, very pale but in fairly good health, and had had no acute illness. The finger- nails were marked by white stripes stretching across the nails, which Avere smooth, lustrous, and in other respects well formed. The white bands had been appearing regularly for several months. They seemed to be due to air spaces within the nail. The nails not infrequently suffer in syphilis. They may become involved at any time after the constitutional symptoms have been established. One of the earliest manifestations is separation of the nail, either in whole or in part. In another form, known as friable onychia or onychia sicca, the nail loses its polish and color, becomes dry, thickened and brittle, readily splits or breaks, its surface being rough and its free edge transversely ridged. In hypertrophic onychia the nail acquires an immense thickness, be- comes grayish or yellowish, rough and furrowed. Other forms of altera- tion are occasionally met with in syphilis. Dr. Charles J. White, of Boston, has described * the case of a young man who exhibited extensive alterations of the hair and nails. His general health was good. The condition was hereditary, at least seven men in four generations of his family having shown similar defects of the hair and nails. Alterations of the Nails from Local Causes.—The local causes of diseases of the nails are (1) traumatism, (2) implication of the matrix or bed of the nail in some cutaneous disorder, and (3) the action of parasites. The nature of these alterations is described in the discussion of the various cutaneous maladies of which they form or may form a part. * Journal of Cutaneous and Gcnito-Urinary Diseases, June, 1896, p. 220 seq. 584 DISEASES OF THE SKIN. CLASS VII. TUMORS. (JVeoplasmata.) RHINOSCLEROMA. Rhinoscleroma is a new growth of the skin, characterized by the appearance of flat and somewhat elevated, sharply defined, isolated, or conglomerate tubercles, rounded prominences, or plate-shaped masses around the nose and adjacent parts. Symptoms.—Hebra and Kaposi conjointly, in the year 1870,* first described this rare affection, which usually begins without pain or in- flammatory symptoms, in the septum or single ala of the nose. Occa- sionally the disease originates in the pharynx or larynx, and one case has been recorded in which it started from the hard palate. The growth, which is Avell defined and elevated above the normal skin, pre- sents an uneven but plate-shaped surface, formed from the variously sized tubercles of which it is composed. In color, the tubercles and rounded prominences may be either of the tint of the natural skin, or of a bright or dark brownish red, intersected with dilated vessels, pre- senting a smooth, polished appearance, devoid of hairs and follicles. From the epidermis over them, which is dry and somewhat fissured, is secreted a viscid fluid that is converted into yellowish, dry, adherent crusts. The structures are of great density, and to the sense of touch they feel like cartilage or ivory. The skin over the tubercles is not movable, and can be picked up between the fingers only by the growth. Pressure upon the parts develops a certain perception of elasticity and also more or less pain, which is about the only subjective symptom, except the impediment which the formation opposes to respiration. The portions of the skin adjacent to the growth remain perfectly nor- mal, and are not affected with any inflammatory symptoms. The growth, as has been before mentioned, invariably attacks the septum and alae, and thence spreads to the mucous membrane of the*contigu- ous parts, especially the upper lip. In a feAv instances it has been known to extend to the Eustachian tube, tongue, or lachrymal duct. Hebra cites, in this connection, cases in which the hard and soft palate, especially the uvula, the pharynx, and the true vocal chords were in- volved. As the disease, which always becomes chronic, progresses, there is little or no alteration in the sense of smell, the parts, however, becoming swollen, deformed, the caliber of one or both nasal passages narrowed, and at last partially or completely occluded, thus stopping respiration through those channels. * Wien. med. Woch., No. 1, 1870. TUMORS. 5S5 At an advanced stage the growth affects the mucous membrane of the lips, and eventually the periosteum of the alveoli, even the alveoli themselves perhaps becoming involved. During the course of the dis- ease the tubercles do not, as a general rule, undergo any change, but Zeissl reports a case in Avhich ulcerative action was followed by the de- struction of the tip, the right ala, and the left nostril of the nose. There are, however, at times, superficial excoriations Avhich manifest hardness. If a portion of the growth be excised, or otherwise de- stroyed, the remaining parts will not suppurate or break down, but become coated over Avith a thin, brown crust, heal very soon, and rap- idly reproduce themselves. The disease generally develops betAveen the tAventy-fifth and fortieth years of life, and appears to have no effect upon the general system. Inasmuch as the malady is not always confined to or indeed begins in the nose, Wolkowitsch prefers to entitle it scleroma respiratorium. Diagnosis.—The diagnosis of rhinoscleroma is often rendered very difficult, owing to the great resemblance between it and lupus, syphi- lis, keloid, and epithelioma. The location of the growth, the change in the appearance of the nostrils, the elevated, dense condition of the tissues, experiencing pain on pressure, and the exceedingly chronic course of the disease, undoubtedly suffice to distinguish it from these affections. Pathology.—The pathology of the disease has been extensively in- vestigated by Kaposi, Geber, Mikulicz, Frisch, Pellizari, Chiari, Cornil, Alverez, Paltauf, and Wolkowitsch. Kaposi, in referring to his ex- aminations, adds that, on cutting into a tubercle of rhinoscleroma, one is surprised at the ease with which the knife makes its Avay, tak- ing into consideration the hardness apparent to the touch. The cut surface is of a pale-red color, uniformly and finely granular, and bleeds moderately. He further states that the epidermis and the rete are normal. The papillae are longer, their connecthe-tissue frame- work exists only in the form of a delicately fibrillated, small-meshed network. Their vessels are scanty and small. This network of the papilla? is filled Avith small cells, closely packed together, the cellular infiltration here and there extending deeply into the corium, being uniformly dense throughout the vascular stratum, and the papillae also being croAvded with cells. The cells are smaller, especially in the pro- toplasm, than the so-called granulation-cells. They are generally such as are met with in acute or chronic inflammation of the skin, and in places where a new groAvth of connective tissue is taking place. The nuclei of the round cells are small and refract light feebly, and are finely granular. The cells appear to be simply lodged in the delicate connective-tissue stroma of the papillae and the upper layers of the corium, and can easily be removed by manipulation. They are, in ad- dition, unimpaired, and have a sharp outline and distinct nuclei. The 586 DISEASES OF THE SKIN. deep layers of the corium show a dense connective-tissue netAvork. Vacuoles are likewise observed, and are due to hyaline degeneration of the larger cells. Kaposi concludes that the groAvth is most closely allied to the forms of small-celled or granulation sarcoma. Geber and Mikulicz, while they give the same anatomy for this groAvth, yet con- sider the affection a chronic inflammatory process. According to Wolkowitsch, the hair-follicles and SAveat-glands are atrophied. Frisch, Pellizari, Chiari, Cornil, Alverez, and other histologists, believe it to be parasitic in nature. Etiology.—The cause of rhinoscleroma is obscure. According to the observation of some histologists, just cited, it depends upon the presence of micro-organisms. A micro-organism which appears to stand in a causative relation to the disease has been identified by Frisch, Cornil, Alverez, Paltauf, and Wolkowitsch. By all these ob- servers it is described as being very similar in form and size to Fried- lander's pneumococcus.* Paltauf, however, succeeded in demonstrat- ing certain differences in the mode of growth by which the tAvo forms may be distinguished by cultivation. Inoculation experiments have not as yet succeeded. The disease prevails particularly in eastern Austria and southwestern Russia, and generally appears between the fourteenth and thirtieth years of life. Treatment.—The treatment of this affection, although very un- satisfactory, becomes a necessity for temporary relief in respiration. Occlusion of the nostrils may be prevented, and the growth kept in abeyance by the use of such caustics as nitrate of silver, caustic pot- ash, and chloride of zinc, or by the removal of part or all of the mass with the knife. The employment of sponge-tents, alone or medicated, in the nostrils, is also useful. The groAvth returns in time, however, notwithstanding the use of these and other agents. Lang f reports a most excellent result in a case from the employment of, first, salicylic acid, externally and internally, and subsequently the local use of carbolic acid. Simon relieved one case by means of a ten-per-cent. pyrogallic- acid ointment. Kaposi succeeded in destroying a large portion of the new growth by interstitial injections of salicylic and osmic acids. Doutrelepont has seen considerable amelioration take place in conse- quence of the use of corrosive sublimate made into an ointment with lanolin. Removal by the knife followed by the use of the actual cautery or thermo-cautery has also, in some instances, seemed to pro- duce amendment. Prognosis.—This is always unfavorable, as the growth recurs, even if removed. The disease becomes, of course, serious, if the obstruc- tion of the nasal passages be sufficient to interfere with respiration. * See paper by Kaposi on " Pathology and Therapeutics of Rhinoscleroma." Inter- nal Klin. Rundschau, 1891, Nos. 30 and 31. f Wien mcd. Wochensch., June 16 and 23, 1883. TUMORS. 587 Dr. Lubliner has seen a case in which the lesions of rhinoscleroma almost entirely disappeared in consequence of an attack of typhoid fever. LUPUS ERYTHEMATOSUS. Synonyms.—Lupus erythematodes—Lupus superficialis—Lupus sebaceus—Seborrhoea congestiva—Scrofulide erythemateuse. Lupus erythematosus is a new cell-growth of the skin, appearing in the form of one or more reddish, circumscribed, rounded, ovoid, irregular, and slightly elevated spots, covered with 'thin, grayish or yellowish adherent scales. Symptoms.—The disease generally begins with one or more bright or dark-red, circumscribed, rounded, and somewhat elevated spots, Avhich have a shiny look, and a centre that is paler or slightly de- pressed, or covered Avith a thin adherent scale. The small primary lesions may be in size from that of a pin's head to that of a pea, and may be either single or multiple. If but a single spot appears, it de- velops by peripheral growth very sloAvly, the central depression at the same time enlarging and becoming more apparent. After the patch has attained the size of a small coin, the contrast becomes Avell marked betAveen the somewhat elevated, red, advancing border and the central depression. The small single spot may, in the course of months or years, gradually attain a considerable size, covering, for instance, the entire cheek. When there are more spots than one they gradually approach one another and coalesce, forming one or more patches with Avcll-defined margins. They usually exhibit a round or linear form, but may be irregular. Their configuration varies according to the part on which the morbid process appears. The bright or dark red color of the spots sometimes varies, they having also in some cases a translucent or gelatinous appearance. The slightly depressed skin within the peripheral margin has a white, shiny, almost cicatricial appearance, or else is covered with dry, thin, or greasy Avhite scales, Avith or Avithout yellowish-broAvn crusts. The elevated border also, which is from half a line to a line in breadth, has a firm feeling, is cov- ered Avith similar scales or crusts, and the surrounding sebaceous glands are open and often filled with comedones. At times the orifices of the glands are obliterated and an appearance like that of milium is produced. The amount of scales varies very much, being great in some cases ar.d small in others. Upon removal they are found' to be attached to glands Avhich frequently appear distended and patulous. After a spot has attained a certain size it may remain unchanged for months or years, but will eventually disappear, the border fading and undergoing the same atrophic change observable in the central part of the patch. The morbid process may thus disappear entirely, and may leave 588 DISEASES OF THE SKIN. either superficial or deep scars. When the scalp is involved it will cause permanent loss of hair. The affection may persist in repeated attacks, sometimes during life, upon portions not at first affected. The disease is therefore of exceedingly chronic tendency. Its usual seat is the face. The nose, cheeks, eyelids, and ears are generally first invaded; and then the scalp, the back, the vermilion border of the lips, the hands, the feet, and other portions of the body may become affected. When occurring on the bridge of the nose and the cheeks, the affec- tion may, in form, resemble a butterfly or a bat Avith extended wings. In rare instances the disease begins upon the hands or feet, to which it may even be confined, though the lesions, as a rule, subsequently ap- pear upon the face. The palms are seldom involved. Occasionally the arm and hand are affected. Erythematous lupus of the hands and fingers has been seen in women more frequently than in men. There are usually no subjective symptoms, the only annoyance to the patient being occasioned by contemplation of the effects of the disease in the scars or loss of hair that may take place. In some extreme cases there is a slight or severe, constant or intermittent, itching or burning sen- sation. The state of the health usually remains good, except in the more general form described by Kaposi, which is known as lupus ery- thematosus disseminatus. In this last variety the lesions are generally distributed over the body, even the mucous membrane of the gums and cheeks being sometimes invaded. The spots are in the form of nodules, show no tendency to spread peripherally, but increase by con- tinuous cropping out of new ones among the old. In rare cases the disease covered the entire body. The patches go through the same changes just enumerated for the ordinary variety. This variety of lupus is accompanied by both local and constitutional symptoms, as ©edematous and painful swelling of the skin and tissues around the joints, and pains in the bones. There may be, also, a development of serous and haemorrhagic blebs, adenitis, and erysipelas, especially of the face, the patient sometimes passing into a typhoid condition, ending in death. In a patient of Dr. Hallopeau's the central parts of the patches, in place of being atrophied, were the seat of little wart-like projections. This is a feature Avhich had never heretofore been de- scribed. Diagnosis.—Lupus erythematosus is easily recognized, especially Avhen the face is invaded, the diagnostic points being the location, the peculiar color and shape of the patches, the central scar, the absence of subjective symptoms, the chronic tendency, Avhich should serve to distinguish it from every other skin affection. The diseases with which it is most likely to be confounded are lupus vulgaris, ringworm, ecze- ma, and syphilis. From lupus vulgaris it is distinguishable by the absence of papules, tubercles, and ulcers, and by the involvement of the sebaceous glands, which are not affected in the former. TUMORS. 5SH Lupus erythematosus seldom appears before the age of puberty, while lupus vulgaris may deArelop during childhood. The former usually also involves the upper part of the skin, the resulting scar, if any, being superficial, while the latter extends to the deeper struct- ures, and there is a tendency to ulceration and disfiguring cicatrices. Ringworm, particularly that of the face, with its advancing border, may at times look like lupus erythematosus; but its rapid course, the presence of vesicles and papules, hair-stubble, and the detection of the parasite by the microscope show its distincthe character. Pustular and squamous eczema may likewise bear some resemblance to lupus erythematosus, but the course of the former, the itching, ex- udation, the absence of the scarring and characteristic scales ought to be sufficient to prevent all error of diagnosis. Syphilis is distinguishable from the disease under consideration by its history, course, its presence in other regions of the body, and by the absence of the thin, firmly adherent scales with their attachment to the sebaceous plugs. Pathology.—Investigations have sIioavii that lupus erythematosus is a chronic inflammation of the cutis leading to its degeneration and atrophy. It was thought at one time that the inflammatory process originated in or around the sebaceous glands, which is often, no doubt, the fact; but in very many persons the disease may affect all struct- ures of the skin, and may have its primary seat in any of them. Hebra was the first to point out the invohement of the glands as the most essential characteristic of lupus erythematosus. Neumann, Geddings, and, at a later period, Kaposi, by a careful study of the disease, not only confirmed Hebra's views, but, in addition, specified the successive steps of the inflammatory process. Kaposi and Thin have shown that the disease could also have its seat as well in the sweat as in the seba- ceous glands. Geber, StroganoAV, and Robinson assert, in addition, that the disease may have its origin in any of the structures of the skin. The microscopic examination of portions of skin affected Avith lupus erythematosus indicate some inflammatory changes of one or other of the component parts of the integument. The glands are thickened, both by an increase of connective tissue and by an accumu- lation of cells, externally and internally. According to Robinson, the blood-vessels are dilated, and the surrounding connective tissue is in- filtrated with embryonic cells, the affected portion being filled with small-celled inflammatory new growth, acquired from both the vessels and the connective-tissue cells of the part. The cells are not collect- ed in the form of nodules. Many of them undergo fatty or colloid degeneration. Nerve filaments are unaffected. The layers of the epidermis become atrophied. The changes take place in either the superficial or deeper parts of the corium, and the result is seen in the proliferation of the gland-cells developing seborrhoea, and in the in- 590 DISEASES OF THE SKIN. filtration and desquamation of the epidermis. The course will, from this stage forward, vary in different cases, the inflammatory action sometimes terminating, absorption setting in, the integument returning to its natural state, Avithout leaving any evidence of the disease upon the affected part. The tendency in most cases, hoAvever, is for the inflammation to cause degenerative changes, leading to atrophy of the affected tissue. The hair-follicles and glands may be destroyed, result- ing in cicatricial atrophy of the part affected by the disease. Etiology.—Lupus erythematosus, which is a rare disease, generally occurs as the result of a defective state of the general nutrition. It is no doubt met with occasionally in those Avho are in comparatively good health, but the majority of those affected are poorly nourished, chlorotic, or tubercular. While persons of all temperaments may be attacked, yet the disease is more frequently observed in those having light skin and hair, Avho are especially liable to an irritable condition of the seba- ceous glands. A scrofulous state will thus be seen to be a predisposing cause of its production. The bacillus tuberculosis, however, has not been found in the lesions, nor have inoculations with pieces taken from lupus erythematosus produced tuberculosis in animals. Kaposi has pointed out that a severe local seborrhcea is, in some cases, the active cause of it. It occurs more frequently in Avomen than in men, and rarely appears before the age of puberty. Malcolm Morris observed a case in which it followed the bites of mosquitoes. Treatment.—The first indication is to counteract the constitutional impairment, if any exist, that has led to its development, and keeps up the process. There is no internal remedy that has special curative effect upon the disease, but general hygienic attention, Avith a nutri- tive and tonic treatment and proper local measures, affords, beyond all doubt, the best results. Cod-liver oil, alone or with iodine, iron, arsenic, and phosphorus, may be used with benefit. Iodide of starch, recommended by McCall Anderson, can be taken in teaspoonful doses in milk or malt. Iodoform has been administered by Besnier, in doses of from eight to fifteen grains daily, with the effect of curing several patients. Potassium iodide or chlorate, in doses of from five to ten grains, three or four times a day, may likewise be used at times with advantage. Dr. H. Radcliffe Crocker suggests that sodium salicylate may prove a useful remedy. It is also important to employ external treatment in order to cause absorption or destruction of the lupus patches. Great care should be exercised, in applying local measures, not to add to the disfigurement of the part occasioned by the disease itself. It should be remembered that, while the affection usually leaves, through treatment, scars, and sometimes telangiectases, it may disap- pear spontaneously, leaving the skin in its normal condition. The mildest methods should, therefore, first be exhausted in the endeavor to eradicate the disease. If more radical means be required, they TUMORS. 591 should be continuously employed, and the moment the patch shoAvs signs of yielding to such treatment, by becoming pale and on a level with the surrounding integument, the milder applications should again be resumed. Resorcin has been recommended, fifteen grains to the ounce, applied once or tAvice a day, and the parts aftenvard covered with an India-rubber mask.* One of the most useful applications is the mercurial plaster, from which Kaposi has obtained some unusually good results. Salicylic-acid plaster has likeAvise proved efficient. The copper-oleate plaster also I have used several times, Avith the effect of removing the patches. The various mercurial ointments are also beneficial, but the ointment of oleate of mercury, of a five- or ten- per-cent. strength, has been found the most valuable of all of them. I have had the most satisfactory results from depleting the parts two or three times a week with a small needle-knife, and applying constantly to them the ointment of zinc oleate. Kaposi, Veiel, Squire, and Vidal, all speak well of manifold scarification or puncturing, which has a similar effect to that just recommended. Sapo viridis is a valuable remedy, applied on a cloth to the patch or rubbed into the part once or twice a day, especially when the disease involves a part covered with hair, as the scalp and the face. It can be used alone or with Avater, or, much better, mixed Avith equal or less than equal parts of alcohol. The thorough rubbing of the soap into the patch not only stimulates the part, but also removes all the scales, and cleanses the surface for any additional treatment. Zinc, bismuth, or oint- ment of lead oleate, or any simple ointment or lotion, may then be advantageously applied as an after-dressing. Chrysarobin, pyrogallic acid, or naphthol, in amounts of from ten to fifty grains to the ounce of some fatty substance, all form ointments that have been success- fully employed. Carbolic acid, applied in the form of an ointment, ten to twenty grains to the ounce of fatty substance, often proves serviceable. Tar and its preparations, used alone in the form of an ointment or mixed with alcohol or green soap and sulphur, has been found to do Avell in some cases. Sulphur, either alone or suspended in alcohol, glycerine, or some other oily matter, acts sometimes re- markably well. Iodine is likeAvise especially useful, in the form of tincture, or as the glycerine of iodine, as recommended by Hebra and Anderson, or as the compound iodine ointment. The application of the ointment of siher oleate has been attended Avith good results in several cases occurring under my observation. If the measures al- rcadv detailed do not suffice, and the disease obstinately persists, more radical treatment will then be demanded. Pure carbolic acid may now he applied with advantage, lightly pencilled over the surface, according to the indication, or a solution of caustic potash, one draclim to two of Avater. The latter application should be made Avith a piece of absorb- * British Medical Journal, May 15, 1886, p. 956. 592 DISEASES OF THE SKIN. ent cotton or charpie, every three or four days, care being taken not to allow the lotion to penetrate too deeply into the parts, and to neutralize its action after the operation by pencilling diluted acetic acid over the surface. Glacial acetic acid, strong liquid ammonia, arsenic pure or in the form of the ointment of the oleate, zinc chloride, silver nitrate, chromic acid, sulphuric, nitric, and hydrochloric acids, the acid ni- trate of mercury, and solution of sodium ethylate, are all valuable caustic applications, any of which may be employed, but always with great caution. In using these caustic remedies, the part should im- mediately afterward be dressed with some soothing lotion or ointment. Aristol, used in the form of a powder or as an ointment, constitutes an excellent dressing at this time, and as soon as possible recourse should again be had to the simpler remedies first mentioned, until the cure is effected. Erasion, with the dermal curette or spoon, has been success- fully used by Dubin, Neumann, Auspitz, and many others, especially in some of the more obstinate cases. The actual cautery and the galvanic cautery have also been employed in many cases with the most beneficial results, the eventual scar often being very slight. Piffard resorts to surgical procedure in case the patch is small and conveniently situ- ated, excising some of the surrounding healthy integument with the morbid tissue. Prognosis.—The prognosis of the ordinary form of this affection is good. The disease may be protracted, often becoming obstinate and apparently unyielding, or liable to relapses ; but the ultimate result is the restoration of the part to recovery, usually with scarring or loss of hair. In the disseminated or general form of the disease the prognosis is not so favorable, many cases terminating fatally. LUPUS VULGARIS. Synonyms.—Lupus exedens—Lupus vorax—Noli me tangere—Fressend Flecte—Esthi- omene—Dartre rongeante—Scrofulide tuberculeuse. Lupus vulgaris is a new cell-growth of the skin and adjacent mu- cous membranes, appearing in the form of variously sized and shaped reddish or brownish spots, consisting of papules, tubercules, or infil- trations, which are removed by interstitial absorption, or by ulceration and cicatrization. Symptoms.—This disease commences with the appearance of many small discrete or grouped, reddish, brownish, or yellowish-red spots, from the size of a pin's head to that of a pea or a bean, deeply seated in the true skin. These Avell-defined spots, situated beneath the epi- dermis, through which their color is observable, give to the skin a punctated appearance. In the early stages of the disease they are not sensible to the touch, which merely causes them to assume a lighter color. In the course of some months they slowly increase in size, and Plate IX. Lupus Vulgaris (from Nature). TUMORS. 593 gradually approach the surface of the skin, until finally they become evident as papules and tubercles, through both appearance and pal- pation. They usually present themselves in large numbers and of sizes Avithin the range already indicated. Their color is brownish red, with surfaces either rough or smooth, sometimes more or less covered with shiny, whitish epidermis. Through their mass, exteriorly and interiorly, they are permeated with small blood-vessels. The papules and tubercles may be either soft or firm to the touch, and are not pain- ful. The lesions may, at this stage, remain discrete, or unite and form flat or prominent infiltrations of greater or lesser extent, usually of a circular or serpentine form. Having reached this stage of develop- ment, the lesions, sooner or later, undergo either absorption, leaving behind a desquamating and more or less atrophied skin, constituting what is known as lupus exfoliativus, or else disintegration and ulcera- tion of the infiltrated skin occur (lupus exulcerens or exedens). The lupoid ulcerations, which are painless, may be superficial or deep, and in appearance are usually flat, rounded, or irregular, with reddish, soft, but well-defined margins. There may be a moderate purulent secretion, with crusting, and when the base of an ulcer is exposed it is red, smooth, or covered with granulations, and easily bleeds. During the course of the ulceration, or as healing begins, papillary, outgrowths may occur, lupus hypertrophicus, folloAved by more or less of Avarty, cicatricial tissue, lupus verrucosus. The forms of lupus just mentioned are merely degrees of one and the same pro- cess, Avhich may be arrested or modified during its course, resulting in some special variety of the disease. The affection, however, fre- quently presents at the same time several kinds of lesions—that is to say, the same region may present various phases of evolution and in- volution of the malady. The disease, under such circumstances, pre- sents a most striking and characteristic appearance, there being often, at one point, the small primary spots, at another papules and tubercles unchanged, or else undergoing the process of absorption or ulceration, with here and there scales, crusts, exuberant granulations, cicatricial- ly atrophied spots, commingled with areas of unaffected skin. Lupus may occur upon any region of the body, but its common and favorite seat is the face, especially the nose, cheeks, and ears. It may appear also on the trunk and extremities, either in connection Avith or inde- pendent of the development on the face. Besnier has seen lupus develop upon the site of a vaccinal cicatrix. It occasionally manifests itself also in consequence of a traumatism. Dr. Balmanno Squire has called attention to the fact that although lupus of the fingers is capable of completely destroying those members yet it spares the matrices and the nails. As the finger is shortened the nail remains intact at the end of the stump, and may finally recede to the level of the metacarpo-phalangeal joint, where it remains in an 38 51*1 DISEASES OF THE SKIN. apparently normal condition. On the other hand, lupus may be fol- lowed by or transformed into carcinoma. Two cases of this kind have lately been published by L. Nielson. Forty-six cases are on record in Avhich acthe lupus was transformed into carcinoma, and tAvelve cases in which the latter disease developed in the scars of a former lupus. A form of the affection occasionally met with has been termed acne-lupus or lupus miliar is. Discrete, slightly elevated tubercles, of a deep-red color and pin-head size, resembling the lesions of acne in an early stage, may make their appearance upon the face. They show, hoAvever, no tendency to suppuration, but gradually enlarge, become purplish in color, and exhibit a characteristic, honey-like transparency. It is probable that lupus may begin in this manner more often than is generally supposed.* Lupus of the extremities was observed in 24-5 per cent, of all the cases of lupus treated in Doutrelepont's clinic during a period of seven and a half years. In nearly half of the number the first manifestation of the disease was upon the extremities, but in only eight cases was this the sole localization of tuberculosis, glandular or pulmonary lesions being coexistent. The extensor were more often affected than flexor surfaces. Usually the disease upon the limb did not interfere with its functions, but occasionally the pressure of cicatrices obstructed the circulation. The vulvo-anal region is occasionally involved. Macdonald f and Isaac E. Taylor \ recited some interesting cases, and the latter has shoAvn that the deformity and disfigurement from the ulceration and cicatricial contortions are greater and more disgusting than the cor- responding changes in the face resulting from this disease. It should be stated, however, that Dr. R. W. Taylor, after a prolonged and ex- haustive study of disease of the vulva, is convinced that these cases have been erroneously diagnosticated. Various causes, common or specific, may lead to chronic ulceration and extreme deformity of the female genitalia, some of which lesions may be mistaken for lupus vulgaris.* Professor Zweifel has related the history of a case in which the vagina and uterus Avere attacked by lupus. The father of the patient, a woman aged twenty-eight years, had died of phthisis, and her child was lame from hip-joint disease. The uterus was extirpated and a lupous ulcer was found upon its mucous membrane. Dr. Kocks, of Bonn, had met with a case in Avhich labor was impeded by the exist- * Medical Bulletin, February, 1890, p. 58. f Edinburgh Medical Journal, April, 1884. X American Gynaecological Transactions, vol. vi, p. 199. *" Chronic Inflammation, Infiltration, and Ulceration of the External Genitals of Women, etc.," by Dr. R. W. Taylor. The New York Medical Journal, January 4, 1890. TUMORS. 595 ence of a lupus of the cervix uteri. The patient had at the same time lupus of the face. According to Dr. Max Bender, Avho has analyzed a series of three hundred and eighty cases treated in the clinic of Prof. Doutrelepont, of Bonn, the mucous membrane is primarily attacked by lupus more frequently than is generally supposed. He found that in 312 per cent, of the cases the mucous membrane was inAaded before the disease appeared upon the skin. The mucous membrane and the cartilage may be invaded either primarily or by the disease extending from the affected skin. The parts most frequently affected are the raucous membrane of the eye, mouth, and throat, and the cartilage of the ear, eye, alae, and septum nasi. When the nostrils are attacked, atresia or even complete oblit- eration of those orifices may be the result. From the auditory meatus the disease may extend to the membrana tympani and middle ear and occasion graA-e otitis. According to the observation of Dr. Brieger, of Breslau, the middle ear becomes invohed in most cases of lupus of the nose. The altera- tions are sometimes trivial, at others of a serious character. Lupus, when involving the mucous membrane, is not very appar- ent in the early stage of the disease, as there is no evidence of its presence in the peculiar eruptive spots, as in the case of the skin. The mucous membrane first attracts attention through the fact of its being reddened with spots about the size of a pin's head, someAvhat prominent, and closely packed together. The spot may be firm to the touch, excoriated, easily bleeding, and appear at different points, of a silvery-gray color. Later, the patch may become more irregular, the color more gray, or opaque. The thickened epithelium desqua- mating, there is left an inflamed superficial or else a deep-fissured or an ulcerated surface. Gradually these conditions disappear, and there remain simply scars that may have a shining and silvery- gray appearance. On the other hand, the patch may be depressed, from being bound doAvn to the underlying tissue, or secondary inflam- matory infiltration may develop, leading to suppuration, abscesses, and ulceration of the part, attended Avith cicatrization. The destructive action of this disease, therefore, occasions unsightly scars and con- siderable deformity upon whatever part of the body it may occur. Lupus vulgaris is not usually attended Avith subjective symptoms in its earlier stages, but in the course of time pain may be present, especially if ulceration has set in, and the surface be exposed to atmospheric changes, to movement of the part, or to friction of the clothing. Lupus may ghe rise to inflammatory enlargement or to caseous degeneration of lymphatic glands anatomically connected with the diseased area, infective material being conveyed by the communicating lymphatic vessels. Leloir states that tubercular adenopathies are rare and are quite late in making their appearance. On the other hand, 596 DISEASES OF THE SKIN. lupus of the skin, as pointed out by Radcliffe Crocker and J. F. Payne, may be secondary to tuberculosis of neighboring glands. Dr. V. Le- spinne has described certain severe infectious phenomena which he has occasionally observed to complicate the course of lupus. The tempera- ture rises abruptly, the patient is profoundly prostrated, the stomach and boAvels are disordered, bronchitis occurs, and perhaps endocarditis. These manifestations develop very rapidly and almost simultaneously; the condition of the patient resembles that of typhoid fever or acute miliary tuberculosis. The constitutional disturbance, moreover, sug- gests what is seen after the injection of tuberculin. In some cases the disturbance entirely disappears, Avhile in others, general tuberculosis supervenes. Organic disease of the heart may be left as a result of the endocarditis. Lupus is apt to become complicated with local attacks of congestion, inflammation, oedema, or erysipelas. Bar and Thibierge have studied the effect of pregnancy upon lupus. The influence is variable, the lesions being sometimes improved, in certain cases aggravated, and in others unaffected. Diagnosis.—The principal points, sufficing in most cases to establish the diagnosis of the disease, are its occurrence early in life, the existence of primary eruptive spots, their development into papules, tubercles, and ulcers, the chronic course of the malady, and the attempt at repair in the shape of unsightly cicatrices. The affections liable to be mistaken for it are syphilis, epithelioma, and lupus erythematosus. From syphi- lis it can be distinguished by the previous history and the rapid devel- opment and characteristic grouping of the lesions in the former affec- tion. The tubercles, hoAvever, in both diseases resemble each other, and between them it is often most difficult to distinguish. The tubercles of lupus develop sloAvly, being generally confined to one region, as the face, and are flatter and softer than in syphilis, and of a brownish or yelloAvish-red color, covered Avith thin scales; whereas, in. syphilis the tubercles develop rapidly, appearing upon several portions of the body at the same time, and they are round, hard, larger than in lupus, and of a coppery hue. The ulcerations in lupus are, on the contrary, very dif- ferent from those that are met Avith in syphilis. They are generally round, sometimes irregular in shape, and are not so excavated, and the margins not so infiltrated and painful as those of syphilis. Lupous ulcers usually occur at several points, and tend to coalesce, while in syphilis, if more than one ulcer be present, they generally remain apart. The edge..of the lupous ulcer is dull-red, non-everted, and the secretion is slight, but not foul, and if there are crusts, they are reddish, broAvn, and scanty. On the contrary, the edge of the syphilitic ulcer is sharply cut and everted, the secretion copious, foul, and the crusts Avhich are usually present are greenish and abundant. Lupous ulcers, as indicated, develop Avith relative sloAvness, and are attended with ugly scars and deformities; Avhereas, syphilitic ulcers appear and run Plate X. m Lupus Vulgaris (from Nature). TUMORS. 597 a rapid course, the resulting cicatrices being smooth, white, superficial, and not unsightly. Lupus may also be mistaken for epithelioma, but the history, ap- pearance of the lesions, and the course of the diseases, are altogether different. Lupus generally begins in childhood, and is seldom at- tended Avith subjective symptoms. Epithelioma usually occurs late in life, and is frequently painful. In lupus, moreover, there are several or many nodules, Avhich are soft, whereas in epithelioma the nodule is single, and is particularly hard. Furthermore, it must be remembered, lupoid ulceration is superficial, the margin non-everted, not hardened, the surface covered Avith a bright-red granular tissue, and there is a tendency to repair, ending with cicatrices. Ulcerated epithelioma, on the contrary, is usually deep, the margin eA'erted, hardened, undermined, the surface fungoid; there is no attempt at the formation of cicatrices; the adjacent glands are usually in\Tolved. Lupus, likeAvise, is more sIoav in its de\relopment than epithelioma,, and rarely affects the general health, whereas epithelioma is relatively more rapid, and generally attended, sooner or later, Avith constitu- tional impairment. It should, hoAvever, be born in mind that the tAvo diseases occasionally appear upon the same surface. Lupus- may, moreover, in rare cases, at certain points degenerate into eph thelioma. Lupus erythematosus can scarcely be confounded Avith the disease under consideration. The development of the former only after puberty, the appearance of reddish, circumscribed, slightly elevated patches, covered with thin, grayish, or yellowish, adherent scales,, the involvement of the sebaceous glands, and the absence of papules,. tubercles, and ulcers, should suffice to differentiate it from lupus vul- garis. Rosacea may in some cases resemble lupus in certain respects,. but its history, course, color, and the presence of dilated ATessels, acne papules, and pustules readily serve to distinguish it from the latter disease. Professor Oscar Liebreich, of Berlin, has devised tAvo new instru- ments Avhich serve the double purpose of assisting the diagnosis of lupus and determining Avhether impro\rement is apparent or real. The first of these instruments is called the phaneroscope, and is thus de- scribed : * "It consists of a lens placed at one end of a cylindrical tube, the other of Avhich is funnel-shaped, and terminates in a small aper- ture. If a light be properly placed behind the lens, and the phanero- scope be applied to the skin so that the small aperture almost touches it, the skin is rendered luminous and translucent. Where healthy skin is present, an inner, yclloAvish circle of light is seen surrounded by an outer circle of a bright-red color. By means of the phaneroscope any portion of skin can be rendered luminous. The greater the * Berlin Correspondence of British Medical Journal, May 9, 1891. 598 DISEASES OF THE SKIN. number of capillaries the brighter is the red of the illuminated spot. Where anaemic skin is present the illuminated circle is pale. The second instrument is a small round plate of glass set in a metal frame, Avhich Liebreich uses instead of digital pressure in lupus examinations. The advantages of this simple arrangement (which may be called a ' transparent finger') are obvious. The skin can be observed not only after but during pressure. By its help portions of lupus which might otherwise escape detection can be seen, the redness not disappearing under the pressure. If instead of the plain glass a lens is used, the skin is illuminated during pressure and the examination is thus much assisted. The lens can be pushed from place to place, and will show lupus beloAV the surface when it is not visible to the unassisted eye." Pathology.—The pathology of lupus vulgaris has been investigated by very many physicians, and its relations to tuberculosis and other affections, frequently the subject of debate, are still unsettled questions. Friedlander and Koster assert that they have shown the morphological identity of this disease with tuberculosis, but the characteristic tubercle cell is observed in gummata and other morbid processes. While the subcutaneous inoculations of animals with lupus tissue have at times been unsuccessful in the production of tuberculosis, yet Leloir * has, by injecting the virus into the anterior chamber of the eye, beneath the peritonaeum, or into certain other places, brought about either local or general tuberculosis. Similar results from the inoculation of lupous matter have also been reported by Koch, together with the detection of bacilli in seA*en cases, he claiming to have produced indubitable tuberculosis in those cases by means of the inoculation of the culture-fluid. Doutrelepont also reports the presence of the bacillus from culture and inoculation; while Leloir and Cornil have not, according to the former, as yet succeeded in the discovery of any form of microbe belonging to lupus. The question of the relation, if any, of these two affections, lupus vulgaris and tuberculosis, requires, therefore, more research definitely to settle it beyond all doubt. While the views respecting the pathology of lupus vulgaris are still at variance, all modern investigators agree at least in this, that the morbid process appears as a chronic inflammation, and consists of a small-celled infil- tration, having its primary seat in the corium, and spreading seconda- rily to all the layers of the integument. According to the researches of Kaposi, Lang, Stilling, Thin, Ja- risch, and others, the blood-vessels act the chief part in the genesis of the lupus infiltrate. A microscopic examination of one of the more deeply seated nodules of recent origin will shoAV that the deli- cate network of connective tissue proper to the skin contains a small- celled infiltration, the cells being gathered together into a nest-like * Le Progres Medical, October 4, 1884. TUMORS. 599 formation in the lower portion of the corium, the upper or papil- lary layer above them, and the rete appearing normal. The nest will also be found surrounded with a dense layer of connective tissue, and to be sharply defined from the normal corium in which it is em- bedded. The cells, Avhich are very small, contain numerous highly refractive nuclei, which can be stained by carmine. These nest-like accumulations of cells have no firm connection with the network in which they lie, and part or all of them may lose form, even during the short time of preparation for microscopic examination, leaving in the connective tissue empty spaces and many blood-vessels. In the further development and retrogressive metamorphosis of lupus vul- garis is produced a most complicated change, both in the lupous tissue and in all the elements of the skin. In respect to the nodule itself, after it has, existed for a greater or less length of time, retrogressive changes begin in its centre. The vascular supply being interfered with by the cell-growth, fatty degeneration ensues, and the larger part of the nodule is absorbed or throAvn off. A part, hoAveA^er, or- ganizes into connective tissue and undergoes contraction. While the solitary lupous nodule undergoes the changes just described, the mor- bid process usually becomes more extensive in its ravages. The in- filtration extends along the vessels beneath the papilla?, as Avell as those ascending into it, until, meeting with like spreading growth, the whole of the affected part is crowded with the small, cells above mentioned, and the areas involved undergo, in the same Avay as Avith the single nodule, fatty degeneration and absorption, with cicatricial contraction of the skin. In some persons chronic inflammatory changes occur in the affected connective tissue, and the papillae, becoming hypertrophied, lead to lupus verrucosus. According to Kaposi, the epithelial structures are in this disease early affected. As the infiltration passes doAvn and involves the papillary layer, proliferation and degeneration of the rete cells occur, and, Avhen the latter are destroyed by suppuration, the lupous lesions are exposed and ulceration follows. At an early stage, as the disease spreads, it affects the hair-follicles and the glands of the skin, causing hypertrophy and degeneration of the epithelial lining. The hairs, therefore, fall out in consequence of the atrophy of their papillae, and many of the sebaceous glands are cut off from communication with the surface, the dilated glands appearing as milium corpuscles. At times there are ontgroAvths of the epithelium Avhich pass down into the corium, and Avhich, uniting with similar growths in the root-sheaths and sweat- glands, develop an epithelial network, described by Kaposi, Avhich may form the histological basis for the production of epithelioma. Etiology.—The cause of lupus vulgaris is someAvhat doubtful. It is knoAvn that it develops during childhood, and rarely after puberty, unless some sign of the disease, evident in the form of scars, had pre- 600 DISEASES OF THE SKIN. viously appeared. Lupus vulgaris is neither congenital nor hereditary, and occurs in about equal proportions in both sexes. It is a rare af- fection in the United States, but is much more common in certain European countries, as in Germany, Austria, and France. It is as- serted by some observers to be OAving either to syphilitic, scrofulous, or tuberculous taint; while many hold that lupus vulgaris is a disease of its own kind, with an unknown cause. Abundant clinical experi- ence has shoAvn the error of associating it Avith syphilis, for the reason that the history and course of the two diseases have nothing in com- mon, and that syphilitic treatment has usually no influence on lupus. As to its relation to scrofula and tuberculosis, no one can deny that many cases of lupus have associated with them the elements of either the one or the other of these affections. That lupus is an expression of scrofulous diathesis, is held by Piffard and others in the United States, and by many observers in France, England, and Italy. Friedlander and many others consider the disease a local manifestation of tuberculosis. Doutrelepont, of Bonn, who believes that lupus vulgaris is a tuberculosis of the skin, has given the result of his researches in several able articles. The pres- ence of the tubercle bacilli in lupus tissue has been reported by Koch, from cases examined by him. Benson, of Dublin, also has observed * some interesting experiments, shoAving that granulations taken from the conjunctha of a child and inoculated into the eye of a rabbit de- veloped tuberculosis of the cornea and iris of the animal. At the Dermatological Session of the International Medical Congress at Co- penhagen, Doutrelepont read an interesting paper f on the subject, citing in support of his opinion the histological structure of the lupous tubercles, and mentioning the presence of the bacillus, Avhich he had found in many cases, culture and inoculation experiments having yielded good results, and stating that the clinical course of the disease was in favor of the view of the intimate relation betAveen lupus vul- garis and tuberculosis. Most of those Avho took part in the discussion that followed coincided Avith this observer, and many additional facts Avere produced in support of the same vieAV. Kaposi, who believes with Hebra and others that the disease is sui generis, in replying, rejected unqualifiedly the opinion that lupus is tuberculosis of the skin. He did not deny the presence of the bacillus in lupus, which he had seen, and to which was attached no importance. He spoke to the point of the course of the disease, having seen twelve hundred cases, Avhich he deemed in no Avay corresponding to our notion of tuberculosis of the skin. In support of his vieAV he also shoAved some draAvings of true tuberculosis of the skin, an exceedingly rare disease, and the ulcers there depicted Avere in no Avay like those of lupus. Leloir also opposed * British Medical Journal, January 1*7, 1885. f Transactions of the International Medical Congress, Copenhagen, Denmark, 1884. TUMORS. 601 Doutrelepont's vieAV, and reported that Cornil and himself had, after extensive investigation, succeeded in finding only one single bacillus, and that was in an individual decidedly phthisical. It is admitted by all that the number of tubercle bacilli present in lupous lesions is small. It has been suggested that the comparatively low temperature of the skin, and possibly its continual movements, render it a poor culture ground for the bacilli. In a more recent paper Leloir suggests that the course of lupus may be determined by the combined influence of the bacillus of Koch and the microbes of suppuration. Dry lupus contains no microbes of sup- puration. Leloir believes that the ulceration depends not upon the pathogenetic germ of lupus, but upon independent pathogenetic organ- isms, in all probability those of suppuration. The bacillus tuberculosis and the treatment adopted in consequence of its presence open a gate of entrance to the pathogenetic agents of suppuration. " Lupus, prop- erly so called, gives rise to a tubercle which ulcerates, perhaps only under the influence of the agents of suppuration." Pick, of Prague, has also thought that lupus Avas.a form of tuber- culosis of the skin. Ilaslund has pointed out that, while many lupous patients die from tuberculosis, yet, if lupus is tuberculosis of the skin, it is a form of the latter disease which has not hitherto been known as such in a clinical sense. The experience of a large number of observers no doubt goes to shoAV some relation between lupus and tuberculosis, although the former disease appears in many who are in apparently good and often vigorous health. In 1883, of thirty-eight cases of lupus at the Hospital St. Louis, eight had Avell-marked signs of phthisis. I have also seen tAvo women, to all appearance healthy and well developed, have lupus vulgaris, and both die of tuberculosis, one in six months, the other in about fifteen months, after lupus on the face had been cured. A Avoman operated on for lupus of the face at the Skin Hospital, shortly aftenvard had cough and all other constitutional evidence of the devel- opment of tuberculosis of the lungs. She is still living, and under observation at the present time. A family history of tuberculosis may be obtained in certain cases of lupus. From the statistics of eighty hospital cases Fox has shown that scrofulous or tuberculous lesions of the skin, bones, glands, or joints Avere frequent complications. Koch, Leloir, Benson, Trousseau, and others, have succeeded many times in producing tuberculosis of the iris or general tuberculosis, by introducing lupous material into the anterior chamber of the eye or the peritonaeum. Mr. Eve inoculated the ear of a rabbit Avith lupus. Two cases having a direct and important bearing upon the .subject have been reported by Dr. Jadassohn from the clinic of Prof. Neisser, of Breslau. In one instance accidental inoculation followed a Avound of the finger received by a butcher in cutting up the tuberculous car- 602 DISEASES OF THE SKIN. cass of an ox. In the other, a woman was tattooed upon the forearm by a consumptive man who moistened the Indian ink with his saliva. In each case nodules having the microscopic appearance of lupus de- veloped at or some distance from the site of inoculation, upon the same limb. The nodules gradually broke down, forming ulcers Avhich, Avhen excised and examined microscopically, showed typical lupous tissue. A few tubercle bacilli were likewise detected. Mr. Clement Lucas has seen lupus upon the glans penis probably as a result of inocula- tion from the operation of circumcision. The same observer describes a case which occurred in the attendant to a lady Avho had long suf- fered from lupus. The nurse was in the habit of dressing her mis- tress's sores. He likewise kneAv of a case in which a policeman's knuckle was affected with lupus in consequence of a tooth-Avound. Besnier has seen lupus arise from inoculation with vaccine lymph in- fected with the element of tuberculosis. Treatment.—Lupus vulgaris is a stubborn and troublesome affec- tion, sometimes resisting the very best treatment in the most skillful hands.' It requires both well-directed and persistent measures for its successful treatment. In the first place, it is important that the hy- gienic surroundings should be suitable and in the best possible condi- tion. The patient should be properly clothed and the sleeping-apart- ment Avell ventilated. Bathing, active or passive exercise, plenty of fresh air and sunshine, and all other hygienic measures that add to general health and vigor, are of great value. A change of climate also, if practicable, will often assist in causing some of the most obsti- nate cases to yield eventually in a satisfactory manner. It is essential to employ both constitutional and local treatment at the same time, the former to act against and remove the source of the disease, and the latter to destroy, or at least to cause to disappear, the existing lupoid tissue. Constitutional Treatment. — As many lupus patients are pale, anaemic, scrofulously or tuberculously inclined, and perhaps have not been receiving the proper kind of food, such indications suggest a good, nutritious diet. Animal food, with a large amount of milk, and in the case of adults a moderate amount of stimulants, are often most suitable. Cod-liver oil, in full doses and long continued, either alone or in combination with malt or other preparations, is perhaps the most efficacious remedy that can be employed, especially for the class of patients mentioned. Besnier and Neisser both report good results from iodoform, which can be given in from one half to one grain, in pill-form, three times a day. Morel-Lavallee has derived advantage from the hypodermic injection of iodoform. He believes that this treatment is an advan- tageous preliminary to mechanical methods. The injections need not be made at the site of the disease. The dose is about one third grain TUMORS. 603 daily for an adult or one sixth grain every two days for a child, and the iodoform is suspended in liquid vaseline with the addition of euca- lyptol. Rusin reports a case of very extensive lupus in Avhich benefit followed the subcutaneous injection of a one-per-cent. solution of chlo- ride of gold in combination with a one-per-cent. solution of cyanide of potassium. Six injections were made in eleven days, the total quantity of each of the salts amounting to yffg- grain, single doses of the chlo- ride ranging from ^^ to y^ grain, and of the cyanide from y^Tr to ^l5 grain. Dr. William Robertson reports good results in the first stage from the subcutaneous injection of corroshe sublimate in one- per-cent. aqueous solution, five or six minims of this being injected into the affected part. Prof. Landerer claims good results from injection into the nodules once a week of an alcoholic solution of one part of cinnamic acid, one part of cocaine hydrochlorate, and twenty parts of alcohol, one or two drops being injected till ten drops have been used at one seance. Creasote has been used in the treatment of lupus, as in other manifestations of tuberculosis. Potassium chlorate, the chalyb- eates, and phosphorus, alone or in various combinations, particularly for the class of cases mentioned, are most valuable. The alimentary canal should always receive attention, and weak digestion be regulated. In the latter contingency, an occasional aperient or purge, followed by mineral acids and bitters, is often most beneficial. Robust and Avell- nourished individuals often do Avell under potassium iodide or iodine. Sometimes small doses of one of the mercurials act in the most happy manner by hastening absorption of the lupous tissue. Arsenic is some- times of service. It may be prescribed alone ip the form of arsenous acid, FoAvler's or Pearson's solution, or in combination Avith iron. Prof. Hardy, of Paris, esteems chloride of sodium a valuable remedy. He administers it in daily doses of fifteen to forty-five grains. The chlo- ride of calcium is also a very good constitutional remedy. 1 have seen decided benefit from the iodosulphate of cinchonine in the dose of one to five grains three times a day. This is a valuable antiseptic combi- nation, especially useful when the patient is of a scrofulous or tuber- culous type. Tuberculinum—Tuberculin (Koch's Lymph).—Koch's lymph has been used as a means of diagnosis and treatment. Under the influ- ence of this fluid local and constitutional reaction takes place in the subjects of tuberculosis. In lupus, from three to eight hours after an injection the ulcer reddens, SAvells, and begins to secrete a thick serum. The temperature rises to 102°, 103°, or 105° F. This elevation con- tinues for eight to twelve hours. During the course of the treatment the oozing gradually subsides, and the ulcer begins to cicatrize. The experience of the author has shoAvn that this mode of treatment has neither been superior nor equal to the older methods Avhich have been described. Neither are these injections without danger to life. 604 DISEASES OF THE SKIN. As an aid to diagnosis the procedure is certainly not infallible, for in some cases general reaction has occurred in the absence of pulmo- nary disease, but without benefit to the local lesions. According to observations made in Vienna, Koch's fluid caused reaction in other neoplastic processes, as lupus erythematosus, syphilis, epithelioma, lep- rosy, carcinoma, and sarcoma.* H. Levy, of Berlin, in April, 1891, exhibited the young Avoman who Avas the first lupous patient treated by tuberculin, and in Avhom the effect of a nearly six months' course of treatment could be observed. Although in some regions cicatrization had been produced, yet in others the diseased tissue had been entirely unaffected or only partially destroyed. The thyroid therapy has been applied to lupus, and in a number of reported cases with encouraging results. Dr. Byron Bramwell in some cases observed decided improvement from this method. Zum Busch witnessed several cases of improvement from thyroid feeding or thy- roidin. Malcolm Morris also has had the same experience in an old and severe case of lupus. A compound termed thiosinamin has been introduced by Dr. Hans Hebra, of Vienna, as useful in this disease. Thiosinamin is a Avhite crystalline substance, of a slight aromatic odor, soluble in alcohol and ether, but decomposed by solution in water. WThen hypodermically injected, thiosinamin causes a local reaction in lupus. The diseased surface is swollen for several hours, but it is said that no constitutional symptoms occur. In consequence of the injection it is reported that the nodules undergo involution, ulcers become clean, and cicatrization takes place Avithin a feAv Aveeks. The potassium cantharidate treat- ment for tuberculosis, introduced by Prof. Liebreich, has also been applied to lupus. This substance is hypodermically injected in doses of one to tAvo decimilligrammes (^l^ to ^-|-g- grain). It does not usu- ally occasion a decided febrile reaction. It has of late been proposed to treat lupus by the inoculation of erysipelas. In some cases a good result has been reported; in others the improvement Avas but tem- porary. Furthermore, the severity of the erysipelas can neither be foreseen nor controlled, and the treatment may expose the patient's life to danger. Local Treatment.—The employment of local measures is important in effecting the absorption or the destruction of the existing lupous tissue, and in averting any complication or secondary change. In selecting the most suitable applications, it is important to take into consideration the stage and variety of the disease, for the employment * Koch has recently devised a modified tuberculin by mechanically reducing the ba- cilli to a detritus and removing the fatty acids by which they are enveloped. The new fluid is to be used hypodermically, and the initial dose is 7^7, milligramme. Injections are repeated every second day and the dose gradually increased. Little prac'.ical experience with this method in the human subject has as yet been obtained. TUMORS. 605 of too active measures often tends to stimulate the morbid process and enlarge the patch. In the earlier stages, local depletion Avith the small needle-knife may be employed for the purpose of bringing about ab- sorption—a method Avhich I much prefer to that of multiple scarifica- tion, as proposed by Volkmann, and modified by Dubini, Squire, and others. The sharp point of the knife in the hands of a skillful opera- tor can be rapidly passed to the required depth into the diseased tissue with a more satisfactory result than that secured by the use of any edged blade, Avhich necessarily goes through normal as Avell as abnor- mal skin at the same time. The operation may be repeated every three or four days, the parts being allowed to bleed freely from the application of warm Avater, thus lessening very much the congestion of the patch. A mild mercurial ointment, the white precipitate, calo- mel, or the oleate, can be used as an after-dressing. Auspitz recom- mended puncture combined with the introduction into the lupous nod- ule of iodized glycerine; to be folloAved by the introduction of a caustic convTeyed by means of a rubber pipette attached to a hypo- dermic syringe needle. Encouraged by the efficacy of balsam of Peru in local tuberculosis, Saalfeld, of Berlin, has made use of this agent in the treatment of ulcerated lupus. The remedy Avas applied twice daily with a brush. The results were rather inconclusive, though it Avas thought that a certain ameliorative influence was exerted. Vidal speaks well of the value, in the earlier stages, before ulceration appears, of frictions over the part, every three or four days, of oil of cashew- nut. Iodine and glycerine, or carbolic acid, the latter in moderate strength, are often useful, painted over the part. In order to destroy the nodules, they have been punctured by nitrate of silver cones or by pointed sticks dipped in carbolic or chloro-acetic acid. Dr. Cordero has in some cases been successful in securing cicatrization by means of atomization of a ten-per-cent. carbolic acid solution for fifteen or twenty minutes daily. The same solution is used meanwhile as a dressing to the ulcer. Jequirity, as I have pointed out, is especially efficacious, though considerable inflammation and destruction of the lupous tissue follows. Drs. Smith ToAvnsend and Hamilton report a good result, in an old case of lupus of forty years' standing, from the application of the alve- loz, a neAvly discovered South American plant, Avhich acts in a similar manner to jequirity. The mercurial as Avell as subiodide-of-bismuth plaster will also noAV and then exercise a beneficial influence. The ointments of tar, naphthol, salicylic acid, chrysarobin, and iodoform have been advantageously employed in some cases. Dr. Filgien has witnessed improvement from the use of iodoform gauze saturated Avith cod-liver oil. Unna recommends that lupous nodules be operated upon in series of tens according to the folloAving method: A small incision is made into the nodule by means of an acne lance. A shred of ab- sorbent cotton is Avrapped around the end of a pointed piece of stick 606 DISEASES OF THE SKIN. dipped in a solution of corrosive sublimate one part, carbolic acid (or creasote) four parts, alcohol twenty parts. The moistened cot- ton is carried into a nodule by a spiral motion and allowed to remain ten or fifteen minutes. The deposits so.treated are absorbed within a feAv days. The same observer also reports favorably of the effect of massage of the nodules. He has satisfied himself, moreover, that repeated application of the oil of cloves will cause retrogression of the nodules. Resorcin is an efficient local remedy. It may be used as an ointment in the proportion of one part to tAvo of excipient. From its peculiar action in causing necrosis without suppuration formalin will probably be found a useful application to lupous nod- ules. Dr. M. F. Coombes, of Louisville, claims a good result from the application of three parts of methyl violet to one thousand parts of water. Among other useful ointments are those of red iodide of mercury, iodide of sulphur, salol, creolin, beta-naphthol, and salicylated cam- phor. The latter preparation is made by heating together eleven parts of salicylic acid with fourteen of camphor. The use of an unguent containing from twenty to thirty grains of chaulmoogra-oil to the ounce has in some instances been attended with success. The iodosulphate of cinchonine is an excellent topical remedy, preferably in the form of an ointment in the strength of a drachm to the ounce. Good results can often be obtained in lupous ulcers by covering them with powdered red cinchona bark, or iodoform. Moorhof and others have derived good effects from the application of lactic acid to the surface of lupous ulcers. Ointments containing ten per cent, or more of aristol or euro- phen are of value in ulcerated lupus. Hydroxylamine promotes cica-, trization. Eade highly esteems yeast as an application to lupous ulcers, in its pure state or made into a poultice with flax-seed. Lysol has been employed with advantage. This is a new tar combination, made by boiling tar oils with alkalies and fats. It has the consist- ence of soft soap, is soluble in water, and is a good antiseptic, more powerful than carbolic acid, less variable in composition than creolin, and. not as poisonous as either of these susbtances. Lysol may be applied either to ulcerated or non-ulcerated surfaces by means of cot- ton. It is allowed to dry on the surface, and should not be applied too often, as it will cause pain and cracking of the skin. If used in this manner the pain which lysol produces is not of long duration. In lupus of the nasal mucous membrane it is well to cocainize the surface before making the application. If the patch shows no sign of yielding, if fresh tubercles continue to appear, and there is every evidence that the disease is spreading, then there is no alternative but to cauterize, with certain chemical substances, the actual or galvano-cautery, or to treat the part by erosion, alone, or in conjunction with the measures just enumerated. TUMORS. 607 Cauterization, when used, should be made once or twice a week, or repeated at such intervals as necessary, until all evidence of the disease has disappeared. Sodium ethylate solution is no doubt one'of the most powerful and active remedies that can be used. Pencilled lightly over the surface, it penetrates deeply, destroying the morbid tissue, and leaving a black and burned surface more or less covered with serum, Avhich it rapidly abstracts from the parts. Pyrogallic acid likewise possesses the power of deep penetration, analogous in this respect to sodium ethylate. It has the additional advantage of acting only upon the diseased tissue, the normal skin around it being in no- wise affected by its application. Pyrogallic acid may be used in the form of an ointment, one or two drachms to the ounce, and the appli- cation renewed every twenty-four hours. In the course of three days or more the surface becomes black and covered with inflammatory products, which can be removed by a poultice, or oil, and the part dressed with a soothing ointment. There may be pain from this reme- dy, particularly about the third day, but it is not severe. The applica- tion may have to be repeated three or four times, and the resulting scars are found smoother and better than from the use of many other remedies. SchAvimmer has also employed pyrogallic acid either as an ointment or by painting the lesion Avith an ethereal solution, and then covering it with a layer of traumaticine. Considerable irritation at first results, accompanied sometimes by swelling, but this soon subsides, and the method is said to produce a smooth cicatrix. Caustic potassa is also a powerful cautery, that may be applied to the lupoid tissue either in the solid form, with a pair of forceps or with a piece of wood, or as a lotion. The solution may be made of equal parts of caustic potash and Avater, or of one to three drachms of caustic potash to the ounce of Avater, applied over the surface with a camel's-hair brush or Avith cotton. Vienna paste, Avhich consists of equal parts of caustic potassa and lime, with a sufficient quantity of alcohol to blend them into a proper mass, can be applied, instead of using the caustic potassa alone. The pain from the application of caustic potash, either in solid or in solution form, is often very severe, and to lessen it, acetic acid, a neutral ointment, or a poultice, should be employed immediately after cauterization. A dressing of iodoform then applied over the surface and alloAved to remain for several days, or a week, often assists in com- pleting the destruction of the diseased tissue. Arsenic is also a valuable caustic that has been sometimes favor- ably used in lupus. It is an exceedingly painful application, but has the property of acting only upon the lupoid tissue, leaving the healthy skin unaffected. Arsenic oleate, one half to one drachm to the ounce of any fatty substance, is the best method of employing it. This com- pound should be thickly spread on muslin or linen, and used directly to the part for a period of two or three days, the dressing being re- 608 DISEASES OF THE SKiN. newed every twenty-four hours. The pain, which is very great after the first day's application, can sometimes be lessened by adding a feAv grains of the extracts of opium and belladonna to the ointment. There may also be, in addition to the pain, a SAVollen and cedematous condi- tion of the parts, but arsenical poisoning has never been knoAvn to occur from the application either of this or other forms of arsenic to limited portions of the integument. After the removal of the dressing the lupous nodules will be found to have been destroyed, the spots to have been cauterized a gray or brownish-black, and to be covered per- haps Avith pus, the adjacent portions of healthy skin being unaffected. F. Huber reports good results from the external application of FoAvler's solution. The nitrate of silver, either as a concentrated solution or in the form of the solid stick, may be used as a mild and safe caustic. It is a most suitable application to the skin, and to the mucous membrane also, when involved. The pain from its employment is not great, and leaves moderate, smooth, white scars. A most convenient Avay of apply- ing nitrate of silver is by means of the solid stick, which can be pushed over the surface and bored into all the papules, tubercles, and deep spots, coagulating the albumen of the parts. It easily penetrates into the lupoid tissue, but only to a limited depth, its action being superfi- cial. Cauterization with this agent should be made once or twice a week, with a soothing dressing applied at once to the parts. Silver oleate, one or two drachms to the ounce of a fatty substance, is also a \raluable caustic application. Zinc chloride is frequently employed, and is Avell adapted for its caustic effect, used either alone in the form of a stick, or with water, alcohol, or other caustics made into a paste. The objections to the use of chloride of zinc are that it is not deep in its penetration, will not coagulate the blood, which often flows, inter- fering with further cauterization, destroys healthy as well as morbid tissue, and occasions the most severe pain. Hebra employed this caus- tic made into a paste in the following manner : Tavo drachms each of zinc and antimony chloride are rubbed up in a mortar with sufficient strong hydrochloric acid until the former is completely dissolved ; poAV- dered licorice is then added in such quantity as to form a thick, tena- cious paste. The prepared zinc paste is spread quickly on linen and applied in strips for twenty-four hours. On removal of the strips, the skin that has been covered has become changed into a yelloAvish or broAvnish eschar. In applying chloride of zinc alone or as a paste, or any preparation of similar action, the surrounding healthy skin should ahvays be protected by strips of adhesive plaster, or some neutralizing agent, the latter, when necessary, being used on the part if it be wished to arrest the action of the caustic, and a suitable after-dressing should at once be employed. The acetate of zinc, acid nitrate of mercury, glacial acetic, chromic, and carbolic acids are likeAvise all useful prep- arations that can be employed as caustics. TUMORS. 609 Iodine and its combinations have been used, in the form of ointment or glycerole, or carried directly into the tubercle upon the point of a needle. Plasters of salicylic acid, creolin, salicylic acid combined with pyrogallic acid or creasote, or creasote and lead plaster, have occasion- ally been found beneficial. Camphorated naphthol is likewise of service in promoting the cicatrization of ulcers. Doutrelepont is in the habit of covering the infiltrations with compresses wet in a solution of cor- rosive sublimate (1 to 1,000). The dressing is covered with a strip of caoutchouc held in place by a bandage. No mercurial intoxication has been observed, and a smooth, pliable scar is obtained. By others the same salt has been used dissolved in glycerine or collodion. Parachlorphenol has been employed with alleged good results. This is a solid substance, scarcely soluble in water, but readily soluble in alcohol. The parts being previously cleansed, they were repeatedly touched with a solution of parachlorphenol. An ointment containing equal parts of the same substance with lanolin, vaselin, and starch was then applied for ten hours. Finely powdered picric acid has been used after curettage by Dr. T. Spannocchi, dusted freely upon the raw surface. After the crusts fell the parts were dressed with a five- or ten-per-cent. picric-acid ointment. The actual cautery and the galvano-cautery have been employed, often with decided success. Hutchinson and Anderson speak favor- ably of the former, and Hebra, Kaposi, Neumann, Piffard, and others have had good results from the latter. The patient is usually placed under the influence of an anaesthetic, although the operation can be performed rapidly, by means of suitable instruments, Avith either cau- tery without this procedure, producing only a moderate amount of pain. All the lupous tissue may be destroyed in one treatment, but some- times the operation requires to be repeated. Brocq advises what he calls a mixed method of treatment, consisting of a combination or alternation of scarifications and cauterization, the latter by means of the thermo-cautery or galvano-cautery, preferably the latter. When it appears that scarification is no longer beneficial it is Avell to resort to cauterization. In this manner he believes that the cure is more rapid and the scars less disfiguring. The scarified or cau- terized surfaces may be dressed with a solution of boric acid, corrosive sublimate, \ igo plaster, iodoform, or subcarbonate of iron. The ad- vantages of electrolysis are that it is comparatively painless, an anaes- thetic being unnecessary, there is no loss of blood or detention from business, no deformity or swelling produced by the treatment, and the scar is smooth and not unsightly. Excision of the offending tissue is the most radical means of treat- ment. It is proper to resort to this only in the case of lupous patches of comparatively small size, and plastic operations often become neces- sary. The resulting scar is usually very great, often markedly dis- 39 610 DISEASES OF THE SKIN. figuring, and the disease may reappear even in the transplanted skin. The treatment by erasion, or scraping with a sharp spoon or a dermal curette, as recommended by Volkmann, yields far better results than from excision. By means of this instrument only the diseased tissue is bored or scraped out. The pain attending the operation is often very great, and can be avoided by etherizing the patient, or lessened by freezing the part. A case has been reported by Klaus Hanssen in which a lupus of the lower lip had been aggravated and rendered ex- ceedingly sensitive by the use of cauterants and the sharp spoon. By the application of ice the pain was entirely removed within three days. At the end of several weeks a cure was effected. After mechanical treatment the part should always be dressed with a soothing applica- tion, and the resulting scars are sometimes less disfiguring than those from the other measures already described. As it is almost impossible to reach with any instrument all the neAV growths in the tissues, it will ahvays be safer to apply, after the erasion, some one of the caustics already named, so as thoroughly to destroy, if possible, all the remains of the disease. An instrument having an effect similar to that of the curette, but much more radical in its action, is the double-threaded screw used by Malcolm Morris. I witnessed the successful use of this instrument upon several cases of lupus in St Mary's Hospital, London, the operator passing it rapidly into the lupus nodule, which it bores out, leaving the usually healthy external integument, thus avoiding scarring to any great extent.* Dr. Brooke, of Manchester, reports it advantageous, before scrap- ing, to employ a preliminary local treatment. For this purpose he recommends the following ointment: Ro Hydrarg. oleat. (2^ $-5 $).......... § j. Acidi salicylici................... gr. x-xv. Ichthyol......................... gr. xv. 01. Lavandulae.....................q. s. M. The preparation is applied by inunction for twenty minutes in the morning and ten in the evening. This method has been most success- ful in cases which have never been operated upon, but is of use in re- lapses after previous scrapings. Dr. Schiitz, of Frankfort,f believes the reason why the scars result- ing from the treatment of lupus are often so disfiguring is that the disease is scattered in the various layers of the skin, which heal at dif- ferent rates. In order to equalize the healing process, this writer, after destroying the groAvth by means of curette or cautery, applies pyrogal- lic acid or chloride of zinc. AVhen, under a sublimate bandage, the eschar is cast off, he covers the wound with a gutta-percha plaster- mull containing carbolic acid and mercury. The mull is then covered *The Medical Bulletin, September, 1884, p. 216. •f Munch medicin. Wochenschrift, November 6, 1888. TUMORS. 611 by a number of coats of collodion. This dressing is left in place from six to twenty-four hours, when it is removed, and reapplied after the wound has been cleansed. The cicatrix which finally forms is de- scribed as soft and mobile, and should be treated daily with massage and rubbing Avith marble-poAvder and soft soap. Erysipelas, caries, necrosis, and other complications that may arise, should be managed upon general principles. Prognosis.—As regards the general health of the patient, the prog- nosis is usually favorable. In the majority of cases, notwithstanding the long and persistent course of lupus, the patient enjoys the best health. Occasionally, individuals having the disease die from tuber- culosis of the lungs. The tissue can sometimes be restored to health, although the disease may be obstinate for some length of time and yield very slowly to the best treatment. Relapses are of frequent oc- currence, and often set in wlien the affection is thought to be under perfect control. The more localized the disease, the more amenable is it to successful treatment, and likely to reach a favorable termination in cure. The scars which follow generally lead to marked disfigure- ment. An attack of typhoid fever may effect a cure of lupus, as in a case narrated by Lubliner. This result is in accordance with the occa- sional arrest of pulmonary tuberculosis by typhus fever or other acute febrile disease. SCROFULODERMA. Until Avithin a comparatively recent period the term scrofuloderma Avas erroneously employed to designate all affections of the skin oc- curring in persons of scrofulous diathesis. It is, however, now gen- erally admitted that the various forms of erythematous, vesicular, papular, and pustular eruptions that are occasionally developed dur- ing the progress of scrofula are merely incidental complications, not essential symptoms of that disease. The only cutaneous lesions that are characteristic of scrofula are those Avhich were formerly described under the title of scrofuloderma phlegmonosum, or ulcerative scrofu- loderm, and which are the secondary results of scrofulous involve- ment of the subjacent lymphatic glands. The lesions usually occur upon the face and neck, but may also be observed upon the chest, back, and other portions of the body. They are preceded by hard- ening and enlargement of the lymphatic glands, which frequently attain the size of a large walnut, and become slightly sensitive to the touch. After a variable period of several weeks or months the lesions begin to soften and disintegrate, and the overlying skin assumes a reddened and then a violaceous color, becomes perceptibly thinued, more or less inflamed and painful. Fluctuation finally becomes pro- nounced, and one or more small openings appear on the surface of the tumefied glands, from Avhich more or less thin, unhealthy, sanious 612 DISEASES OF THE SKIN. pus exudes. These openings gradually increase in size, and result in the destruction of the integument with the formation of a deep, un- healthy-looking ulcer, covered by a thin and firmly adherent brown- ish, yellowish, or grayish crust, under which disintegration of the glandular structure rapidly progresses. The formation of pus con- tinues, and the crust breaks open from time to time. The ulcer groAvs slowly and imperceptibly deeper, and involves the subcutaneous cellular tissue. Its base is irregular, granular, and covered with pus and cell debris. Its edges also are irregular and are undermined, and possess the characteristic purple color. The ulcer ultimately, but very slowly, tends to heal by granulation and cicatrization, forming irregular and reticulated, puckered-up, unsightly scars, which are long subsequently perceptible on account of their red and purplish aspect, finally becom- ing white and glistening. Extensive ulceration may not always take place, but the characteristic violaceous color of the skin is for some time apparent, and an unsightly atrophied scar may form over the apex or centre of the swelling. The scrofulous ulcer may, however, take on unfavorable action and in crowded hospitals give rise to wThat Lebert and Guersant have described as scrofulous gangrene. This form of gangrene is non-contagious, and may occur without affecting other scrofulous patients in the same Avards. It is accompanied Avith gastric disturbance, anorexia, diarrhoea, and febrile symptoms. The ulcer becomes red, inflamed, intensely painful, and increases rapidly in size. If cicatrization has begun, the ulcer breaks down again, and its surface becomes covered with blood and pus, dying into thick, firmly adherent, dark-red or brown crusts. Extensive phagedenic ulceration of the subcutaneous connective tissue and the adjacent muscles and tendons may take place beneath the crusts. The resulting odor is offensive, but not so foul as in ordinary gangrene. The destructive process ceases, as a general rule, in eight or ten days. New and healthy granulations then appear and cicatrization rapidly ensues. In superficial scrofulous ulcers this gangrenous action is of little conse- quence. Diagnosis.—Phlegmonous scrofuloderma can readily be recognized as such by its situation on the face or neck, its concomitant scrofu- lous lesions, and the tumefaction of the glands, to which, if viola- ceous color be added, no doubt can remain as to the nature of the disease. The chronicity and color readily distinguish the affection from simple ulcers of traumatic or idiopathic origin. The purple tint, irregular shape, and intractable nature of the ulcer will likewise differ- entiate the disease from the ulceration of tertiary syphilis. The lesions of congenital syphilis may, in truth, present a superficial resemblance to those of scrofula, but the age of the patient should assist in making a correct diagnosis, as true scrofuloderm is rarely found in infants. Pathology.—The lesions of scrofuloderma are secondary to scrofu- TUMORS. 613 lous involvement of the lymphatic system. The affected glands be- come infiltrated Avith lymph-cells and giant-cells, and are enormously increased in size. The pressure of the new cells gradually produces more or less obliteration of the minute capillaries and lymph-spaces, followed by various inflammatory or degenerative changes in the tis- sues that are deprived of nutrition. Ordinarily the glands become dotted with cheesy nodules, which gradually undergo softening or liquefaction. In some cases the product of liquefaction is absorbed as soon as formed, and the gland gradually decreases in size. Usually, however, suppuration is excited in the adjacent tissues, and a cavity containing pus is formed. The inflammation then extends through the various layers of the skin, resulting in the destruction of the epi- dermis and corium, and the production of a typical scrofulous ulcer. Etiology.—Scrofula may occur in either sex and in all races. It may be inherited or acquired, but rarely manifests itself before the first or second year. When inherited, it may be due to phthisical or to scrofulous parentage, or to the circumstance of consanguineous mar- riages. Scrofula is not the result of syphilis, however, and should not be confounded with the hereditary evidences of that disease. Acquired scrofula may be produced by any cause that impairs the nutrition of the system. The most potent factors in its development are insufficient and improper food, exposure to cold and damp, want of exercise and fresh air, deprivation of sunlight, or systemic de- pression produced by measles, scarlet fever, dipththeria, typhoid and typhus fevers, and other exhausting maladies. Scrofula occurs more frequently in the negro than in the Avhite race, mulattoes being espe- cially liable to it. In a series of experiments undertaken by E. Madigliano, of Pisa, in order to determine the relation between scrofulosis and tuberculosis, it was found that Guinea-pigs Avhen inoculated with matter taken from human scrofulous glands became tuberculous, and the microscope re- vealed the presence of Koch's bacillus. Madigliano concluded, as a re- sult of his researches, that the scrofulous is an attenuated form of the tuberculous virus ; that inoculation with scrofulous material produces tuberculosis in Guinea-pigs but not in rabbits. The tuberculosis so produced in Guinea-pigs is capable of exciting tuberculosis in rab- bits.* These results are in accordance Avith the investigations of Dr. Victor B. Huebbenet, of St. Petersburg. In scrofulous glands removed from fourteen patients, whose ages varied from eight months to twenty- three years, tubercle bacilli Avere found, and inoculation with fragments of the tissue produced general miliary tuberculosis in the Guinea-pig. Treatment.—The treatment of scrofuloderma is similar to that of scrofula in general, and consists of the employment of both constitu- tional and topical measures. Mr. Frederick TreAres, of London, warmly * Weekly Medical Review, November 2, 1889. 614 DISEASES OF THE SKIN. recommends a long-continued residence upon the sea-coast, especially in those localities Avhere large quantities of sea-weed are thrown upon the shore and exposed to the action of the sun. He insists also upon the importance of proper clothing, advising the skin to be covered with wool from the neck to the wrists and ankles. Medicinally, the sul- phide and chloride of calcium, quinine, cod-liver oil, iodine, the iodide of iron, and other chalybeates, have been warmly recommended by vari- ous authors, and are certainly of great value in many cases. Unfor- tunately, these remedies sometimes produce so much gastric disturb- ance that their administration must be suspended. The chlorate of potassium I have found to be equal, if not superior, to any of those hitherto mentioned, and a drug that is usually well borne by the stomach. The chlorate of potassium may be given alone, or in com- bination Avith any other antistrumous agent, with the effect of increas- ing nutrition and assimilation, promoting the oxidation of the tissues, and changing and improving the quality of the blood. Dr. Harkin, who has used it in tubercular as well as in scrofulous diseases, claims also that it increases the solid constituents of the blood, restores mus- cular energy, and produces even a tendency to plethora. The chlorate of potassium possesses, without doubt, a markedly restraining influence on all suppurative processes. The tumescence and the violet color of the skin rapidly disappear under its use, or, if suppuration has already occurred, the thin, unhealthy character of the secretion rapidly disap- pears. I have usually given this drug in doses varying, according to the age of the patient, from one half to ten grains, dissolved in water, three or four times a day. I generally begin with from one half to one grain, one hour before meals, and gradually increase the dose until the patient shows signs of improvement. If thus continued for some time the chlorate of potassium will increase the appetite, render a pre- viously dark skin clear and florid, and add tone and vigor to the sys- tem. Those Avho are large, flabby, and apparently vigorous Avill im- prove, as a general rule, better under small doses; while, on the con- trary, the pale and feeble bear much larger doses, often increasing rapidly in weight. Dr. Krasnogladoff, of Tiflis, has drawn attention to the Delphinium consolida, knight's-spnr or larkspur, as of great popular repute in the Caucasus in the treatment of scrofulous manifestations. He narrates seAreral cases in Avhich this remedy proved beneficial. It is employed both internally and externally.* Another drug lately introduced, from Avhich I have obtained good results, is the iodosulphate of cinchonine, from one to five grains being administered three or four times a day. The local treatment of scrofuloderma, with the view of promoting resolution, must be instituted early and carried out energetically, if a speedy cure, without hideous cicatrization, is to be expected. * Therapeutic Gazette, April 16, 1888. TUMORS. 615 Attempts at absolutely prophylactic treatment are usually abortive, but we sometimes succeed in preventing the breaking down of tissue and consequent suppuration. The tincture of iodine, as well as the ointments of iodine and iodide of potassium, are of little value for this purpose. They usually irritate the inflamed skin still more, and hasten the issue rather than prevent it. Poultices and warm fomentations act no better, Avhile cold applications are annoying and impracticable. Ex- cellent results can be obtained, however, from the use of a solution of iodoform in oleic acid applied lightly over the tumefied surface with a camel's-hair brush two or three times a day, which will frequently induce resolution without suppuration. Iodoform is non-irritating, while it possesses all the sorbefacient virtues of iodine. The oleic acid in which it is dissolved possesses superior penetrating powers, and Avill carry it deeper into the tissues than almost any other solvent. Oleic acid, which will not evaporate rapidly, like ether, also modifies in some degree the disagreeable odor of iodoform. Compression is likewise an effective means of promoting absorption and preventing the breaking doAvn of the lesions. Strips of plaster have been used for this purpose, but they are not so effective as contractile collodion brushed over the surface every second day. The value of this application may be in- creased by saturating the collodion with iodoform. If this method be adopted in time, it will often produce a reabsorption of the nodule and prevent ulceration and the formation of unsightly cicatrices. Local treatment will, however, be comparatively useless unless constitutional measures be employed at the same time. Exercise, fresh air, sunlight, and plenty of nourishing food, are of paramount importance in all cases. As soon as it is evident that suppuration has occurred, the pus should be evacuated through a small incision made at the lowest point of the gland, or at the point of fluctuation. The interior of the pus- secreting cavity should then be scraped with the sharp spoon and touched Avith tincture of iodine or Avith a tAventy-grain solution of nitrate of silver, in order to induce the formation of healthy granula- tions. Prof. Hofmokl, of Vienna, prefers to stuff the cavity of a gland Avith iodoform gauze, which he removes when granulations begin to form. In a communication to the Surgical Society of Paris, M. Reboul announced good results crom the injection into scrofulous glands of camphorated naphthol. A cure Avas obtained in twenty-one of twenty- seven cases in Avhich the glands were breaking down or in wmich suppu- ration bad actually occurred. Seven or eight drops of the preparation Avere, with antiseptic precautions, throAvn into the gland. If suppura- tion had already taken place, the cavity was first cleansed. The injec- tions Avere repeated every other day, and cure resulted in from one to three months. Nelaton likewise testified to the favorable action of 616 DISEASES OF THE SKIN. naphthol upon caseous glands exposed by ulceration of the overlying skin. A tampon of naphthol placed upon the gland promoted resolu- tion of it together with neighboring enlarged glands. When the swollen gland is softened and we have reason to believe that caseation or sup- puration has occurred, total excision is an excellent practice. Union by first intention is the general result. In truth the extirpation of scrofulous glands is a radical and bene- ficial procedure. In ninety-three of one hundred and forty-nine cases operated upon in the clinic of Tubingen and reported by Noorden, there was no return of the disease after periods varying from three to fourteen years. In thirty cases the glands again became affected, but in no instance did the disease return later than six years after opera- tion. Noorden calculates that twenty-eight per cent, of all patients suffering from strumous disease of the glands die of other forms of tuberculosis, of which the most frequent is pulmonary consumption. He concludes, therefore, that early extirpation lessens the danger of systemic infection. If the glands have broken down and the pus has passed through the integument, the undermined edges of the resulting ulcers should be trimmed off with the knife or scissors, the venous stasis should be removed by free scarification, and the crusts detached with a warm solution of borax in water, carbolized water, or a solution of potassium chlorate in water. The unhealthy, flabby granulations should then be destroyed by the application of either nitrate of silver, sulphate of copper, or diluted acid nitrate of mercury, or, perhaps better than either, by the galvano-cautery, and the wound dressed with a stimulating ointment of nitrate of mercury or the yellow oxide of mercury. Dr. Quenu recommends the application of a one- or two- per-cent. solution of hydrofluoric acid by means of a tampon of absorb- ent cotton held in contact with the ulcer for five or six minutes. The treatment is repeated every second day until healthy granulations ap- pear, and in the mean time the sore is dressed with cotton moistened in a carbolized solution. Instead of the above method, the ulcer may be advantageously scraped with the curette, and the cautery applied subse- quently. If laudable pus appears and the surface assumes a healthier look, the ulcer may be dressed with powdered potassium chlorate, iodo- form, subiodide of bismuth, or iodol dusted freely over the surface night and morning. Aristol is another substance Avhich may be em- ployed with marked benefit. Europhen has also proved a useful topi- cal remedy. While unsightly cicatrices can not ahvays be prevented, they can be reduced considerably by the repeated application of tinc- ture of iodine or collodion, or by gentle but continuous massage or the use of galvanism and faradism. Scars which remain may often be re- moved by excision, freeing the edges of the wound and uniting them by means of sutures. Prognosis.—The prognosis may be stated as ultimately favorable. TUMORS. 617 It must be acknowledged, however, that the cutaneous lesions are fre- quently intractable, and, although they may not involve any actual danger to life, the long-continued suppuration may, together with the general nutritive impairment, produce the most serious systemic de- pression. If energetic treatment be adopted early, the disease may prove less obstinate than if permitted to pursue a chronic course. Scrofuloderma may terminate, in any event, in the formation of dis- figuring scars—a result which should be anticipated, and the patient so informed. While cicatrices may to some degree be prevented by timely and proper treatment, they may yet occur in cases in Avhich the inflammatory period has been shortened and suppuration almost entirely prevented. Tuberculosis of the Skin* (Tuberculosis cutis).—Tuberculosis of the skin and mucous membrane is a rare affection. Cases have been observed by Chiari, Jarisch, Kaposi, and others. It is character- ized by the occurrence of superficial ulceration, Avithout any apparent cause, generally during the course of general tuberculosis. The ulcers vary considerably in size, are bright red in color, and round, oval, or irregular in shape. Their edges are slightly infiltrated, and their base is uneven, granular, and covered with a thin, yelloAvish secretion. They are slightly painful, but do not bleed readily when touched. The lesions manifest no tendency to heal, but slowly increase in size by peripheral extension. They usually appear upon the skin immediately surround- ing the natural orifices of the body and upon the adjacent mucous membranes. In five cases observed by Chiari the lesions all occurred upon the lips. In two cases reported by Kaposi, the lips, the nose, and the pharyngeal and tracheal mucous membranes were the seat of ulcers of various shapes and sizes. In one case described by Jar- isch the velum palati was covered with miliary degenerations, and a crescentic ulcer was situated on the left ear. On microscopical ex- amination of the lesions, the corium is found to be infiltrated with lymphoid cells and masses Of miliary tubercles in various stages of degeneration. Dr. Kraske has reported two cases of tuberculosis of the penis. In one, the urethra was ulcerated from the membranous portion to the neck of the bladder; in the second, a tuberculous ulcer was situated upon the dorsum of the glans. The source of infec- tion could not be discovered. Tuberculous infiltration of the skin, followed by ulceration, is sometimes the result of inoculation of a wound. Infection has been traced to Avearing the ear-rings of a con- sumpthe, to injury by a vessel Avhich contained bloody sputum from a subject of phthisis, to the rite of circumcision performed by a phthisi- cal operator, and to Avashing handkerchiefs in which tuberculous spu- tum had been received. Tuberculous lymphangitis and lymphadenitis * See paper by the author on " Tuberculosis of the Skin." Journal of Cutaneous and Genito-Urinary Diseases, March and April, 1890. 618 DISEASES OF THE SKIN. may ensue upon accidental inoculation. Cutaneous tuberculosis has been excited also by the practice of tattooing when a consumptive operator has moistened the Indian ink with his saliva. Again, Riehl and Paltauf have described a form in Avhich the lesions appeared upon the fingers, hand, and forearm. The patients were, as a rule, males Avhose daily work brought them into frequent contact with animals. Tuberculosis of the skin is likewise seen upon the fingers of those em- ployed in dissecting-rooms, hospital-wards, and butcher-shops. Besnier and Vidal were the first to observe that it occurred in those Avho had been engaged in dissecting consumptives or slaughtering tuberculous animals. It has been described under the titles of anatomical tuber- cle, tuberculosis verrucosa, and verruca necrogenica. The progress of the affection is extremely sIoav, and systemic involvement is long de- layed. The patch is of small size, raked a little above the surface, of a round, oval, or serpiginous outline, and surmounted by wart-like growths. Surrounding such a patch is a broAvnish or livid zone Avithin which isolated pustules are scattered. External to the zone of pust- ules succeeds one of erythema. A little pus is found in the fissure betAveen the warty outgrowths, but the disease manifests no tendency to ulceration. A singular cutaneous tuberculosis has been observed by Heller in the person of a child whose body was covered with macules, papules, vesicles, and bullae consecutive to the development of cheesy glands adherent to the right innominate vein. Bacilli Avere found in the contents of the vesicles and in sections of the diseased tissues. The tendency of the investigations actively prosecuted since the publication of the first edition of this work is to demonstrate that tuberculosis of the skin manifests itself in a number of distinct clinical forms, and that lupus vulgaris and scrofuloderma are all etiologically related, as all are dependent upon the activity of the same micro- organism, the bacillus tuberculosis. In an address upon the subject, Professor James C. "White has reported* ten cases, the ages of the pa- tients A-arying from nine months to sixty-three years, in which dif- ferent clinical forms concurred in the same individual. The investigations of Dr. Nikolai Blagoveshtchensky, of St. Peters- burg, upon the histology of apparently healthy skin in general tubercu- losis may be alluded to with advantage in connection with this sub- ject. He found, on examining pieces of skin taken from different parts of the trunk and limbs, more or less constantly an infiltration of leucocytes into the lymphatic spaces, Avith enormous dilatation of these spaces; the capillaries were intensely engorged, and in some instances minute extravasations had taken place; in others the vessels were surrounded by an accumulation of leucocytes. The Malpighian * " Clinical Aspects and Etiological Relations of Cutaneous Tuberculosis.'' Boston Medical and Surgical Journal, November 12, 1891. TUMORS. 619 layer was atrophied, the epithelium of the sudoriparous glands was swollen, and Avas undergoing degenerative changes. MOLLUSCUM EPITHELIALE. Synonyms.—Molluscum eontagiosum—Molluscum sebaceum—Epithelioma molluscum— Condyloma subcutaneum—Molluscum sessile—Tumeurs folliculeuses—Acne varioli- formis. Molluscum epitheliale is a disease of the upper layer of the skin, characterized by the formation of rounded, semi-globular, or wart-like papules and tubercles, from the size of a pin-head to that of a pea, which present a whitish, translucent, or pinkish tinge. Symptoms.—The disease begins as small, round, prominent tumors, which may rapidly or slowly attain the size of a split pea, or become as large as a hazel-nut. The larger lesions are generally pedunculated aud the smaller sessile. In color they may haA'e the appearance of the skin of the region affected, or they may have a pinkish, Avaxy, or glisten- ing look, the latter effect being due to the stretching of the skin of the part. Their appearance has been likened to pearl shirt-buttons. They may occur singly, but are usually met Avith in numbers, in all stages of development. The tumors are flattened on the summit, with slight depression, in the centre of Avhich, as a rule, black points can be seen— the openings of the follicles. Their consistency is generally firm, but this, of course, will vary with the condition of the contents. The wall of each lesion is thick, but moderate pressure will cause the contents to escape in the form of a white, semi-fluid substance. The lesions are generally sIoav in development, and rarely attended with any subjective symptoms. They are at times accompanied with inflammation, espe- cially if torn and irritated by scratching. The disease generally occurs on the face, especially the eyelids, cheeks, and chin. It has been known to invade the vermilion border of the lips. The neck, breast, and genitalia are frequently invaded, and any part of the body may be attacked, except the palmar and plantar surfaces. The tumors are usually confined to a limited area, are occasionally grouped, but seldom affect the Avhole body at the same time. In rare instances a generalized form of the disease has been encountered, the lesions being either dis- crete or conglomerate. Diagnosis.—The disease is usually easily recognized, and is per- haps liable to be mistaken only for molluscum fibrosum. In mollus- cum epitheliale the lesions about the face are feAv in number, while in molluscum fibrosum they are many, and are frequently found over the body. The tumors of molluscum epitheliale, moreover, are, although prominent, superficial, while those of molluscum fibrosum are deep-seated. Again, in molluscum epitheliale a minute black .point, the opening of the follicle, is generally visible in the lesions, 620 DISEASES OF THE SKIN. but in molluscum fibrosum no appearance of this kind is observable. Lastly, molluscum epitheliale is generally a disease of childhood, while molluscum fibrosum is an adult affection. Pathology.—The observations of Virchow, which are Avith refer- ence to this disease the most generally accepted, go to show that it begins in the hair-follicles from a hyperplasia of the epidermis lining them. Thin and Robinson corroborate Virchow. Geber's investiga- tions indicate how the rete cells become changed. He says: " I have become convinced that the large number of the altered rete cells pass directly and uninterruptedly into the condition of cornification, and that a smaller number are converted into molluscum corpuscles, after their cloudy, granular contents have changed into homogeneous, trans- parent hyaline substance. Only a narrow zone of the external part of the body of the cells undergoes cornification. The fully developed molluscum corpuscles consist, therefore, of two substances—namely, a central hyaline and a peripheral keratoid substance." Leloir and Vidal, however, in their recent work,* maintain that the culs-de-sac of the sebaceous gland is the point of departure of the morbid process. According to their sections the tumor, in its earliest stage, consists of a series of lobules corresponding to those culs-de-sac. The molluscum corpuscle is probably due to the invasion of the Malpighian cell by a psorosperm, which attacks a certain number of the cells of the deepest portion of the lobule. Etiology.—Molluscum epitheliale is a rare disease. It occurs mostly in the poor, especially in children improperly fed, who also do not re- ceive general care. The exact cause of it has not been settled satis- factorily. Molluscum epitheliale frequently attacks several members of the family at the same time, and on this account is thought to be con- tagious. Although inoculation has generally failed to reproduce the disease, yet three instances of positive success are on record, and suffice to prove the contagious character of the affection. In these experiments the period of incubation varied from three to more than six months. Geber states his belief that it is due to predisposition of the rete cells to proliferation, and that in a considerable number of cases local irri- tants act as exciting causes. Bodies which have been discovered in sections made from molluscum epitheliale have been regarded by Darier and others as coccidia. This disease has consequently been included by Darier in a class which he terms cutaneous psorospermosis. The class includes also Paget's disease of the nipple and epithelioma, in all of Avhich the growth of coccidia is presumed to be the exciting cause. Neisser considers the disease as a form of epithelioma, and prefers the name epithelioma eontagiosum. He regards the mol- luscum corpuscle as a completely cornified epithelial cell filled with the parasite. * Op. cit., p. 33 et seq. TUMORS. 621 Treatment.—Only local applications are effective. The lesions, especially if numerous, may have applied to them some stimulating preparation, such as tincture of green soap, sulphur, white precipitate, or naphthol ointment, or lotions containing alum, sulphate of zinc, sulphate of iron, or corrosive sublimate. Other astringent or irritant solutions may be used at discretion. Dr. Jamieson applies pure liquid carbolic acid to the lesions, and afterward brushes them wTith flexible collodion. He finds that this procedure usually causes rapid dis- appearance of the tumors, and only occasionally is a second applica- tion necessary after an interval of ten days. If the lesions are few in number, they may be squeezed, scraped out, ligated, or cut out Avith the knife. The most simple and effective means of destroying the lesions is to incise their apices, and aftenvard, Avith- forceps, to force or tear out their contents, including the cell-Avails. The cavity and base should afterward be cauterized, nitrate of silver being gen- erally employed for that purpose. The tumors can also be removed by ligating them and cauterizing their bases. Small tumors may be effectually destroyed by means of the thermo-cautery. Prognosis.—The disease inclines to spontaneous recovery. Proper treatment is folloAved by the complete removal of the lesions, unless they have not been thoroughly destroyed, in which event the groAvths are liable to return. LEPRA. Synonyms.—Elephantiasis Graecorum—Leontiasis—Lepra Arabum—Leprosy—Der Aus- satz—La lepre—Spedalskhed. Lepra is a chronic, malignant, contagious, constitutional disease, parasitic in origin, and characterized by various morbid alterations in the cutaneous, nervous, muscular, mucous, and osseous structures, producing hyperesthesia, anaesthesia, ulceration, necrosis, general atro- phy, debility, deformity, and death. Symptoms.—Lepra is a constitutional disease that involves the entire system, and manifests its presence by general as well as by local symptoms. It is extremely chronic in character. Many years usually elapse between the first appearance and the termination of lepra, but its progress, while slow, is relentlessly certain. Every organ of the body is finally invaded and every function affected, so that its unhappy victims eventually perish from inanition, unless they be fortunately carried off by some intercurrent disease. No definite period of incubation is characteristic of leprosy. In some instances eight or ten years had elapsed since the patient had dwelt where leprosy prevailed, and Dr. P. S. Abraham has cited the case of a man who became leprous though he had not been out of London for more than thirty years. In his youth he had been a sailor in the Mediterranean. It is true that he might in some un- 622 DISEASES OF THE SKIN. known manner have been exposed to contagion while living in London, since the case is reported of a Avoman who lived and worked in that quarter of the city frequented by sailors, and in whom leprosy devel- oped notwithstanding the fact that she had never been beyond the bounds of the United Kingdom in her life. Hallopeau has had under his care a man in whom the first signs of leprosy occurred thirty-two years after a residence of fifteen months in Martinique. Konig relates the history of a case in which the first symptoms manifested themselves nine years after exposure. The usual period of incubation, perhaps, is from three to five years. Lepra is almost always preceded by premonitory symptoms, which, however, are indefinite in character and present no special significance except in regions where the disease is endemic. They consist of general malaise, loss of appetite, gastric disturbances, nervous prostration, ex- cessive somnolence, irregular attacks of fever, and wandering pains in the bones. The symptoms may present themselves months before the actual outbreak of the disease. A significant one which frequently appears during this prodromal period is the development of a bullous eruption. This eruption can readily be distinguished from that of pemphigus, from the fact that only a few bullae are present at a time, and that no neAV lesions develop until the old ones have disappeared. Another prodromal symptom which, according to Dr. D. B. Simmons, is regarded in Japan as pathognomonic of the disease is an unusually deep flushing or lividity of the face after moderate indulgence in vinous or spirituous liquors. Febrile attacks which occur from time to time Avithout any apparent cause are also significant, and may be mistaken for malaria by those who are unacquainted with the insidious manner in which lepra makes its approach. Among other early manifestations of the disease, Sir William Moore mentions the occasional occurrence of slight enlargement of the ear-lobes, atrophy of the ball of the thumb, affection of the gums resembling mild scurvy, very slight desquama- tion under the ends of the nails, and anaesthesia of the tip of the little finger. According to the same observer the disease in some instances commences by ulceration of the fingers or toes without preceding mac- ules, tubercles, or anaesthesia, by the exuviation of fingers or toes with very little, if any, discharge, or by absorption of articulating surfaces with consequent anchylosis. According to Dr. Hillis, symptoms which precede an unmistakable outbreak of leprosy are rheumatoid pains in various portions of the body, tenderness of the skin, and lancinating pain along the course of certain nerves. This pain is increased by pressure, and gives rise to sensations resembling electric shocks. Again, dryness of the nose, epistaxis, vertigo, headache, increased or dimin- ished activity of the sudoriparous and sebaceous glands, pruritus, and menstrual difficulties have been enumerated among the premonitory symptoms. More characteristic symptoms develop sooner or later, and Plate XL Tubercular Leprosy (from Nature). TUMORS. 623 dispel any doubt that may have remained as to the true nature of the malady. The cutaneous lesions are usually the first to appear, and they remain prominent until the end. According to Marcano and Wurtz the first manifestation of lepra is, in many instances, an isolated macule having no specific characteristics except anaesthesia on its surface and in its vicinity. Disturbances of the peripheral nervous system are also of frequent occurrence, and in some cases may be the only manifesta- tions of the affection. Every organ of the body, however, is finally invaded by the disease. It Avas formerly supposed that there were only two varieties of lepra, the tubercular and the anaesthetic, but Kaposi and others have demonstrated that there are three—the tubercular, the anaesthetic, and the macular. No exact lines of demarcation, however, separate these varieties. The disease may begin with the symptoms of any one of these three forms, but sooner or later the characteristic features of the other varieties also manifest themselves. The classifi- cation given is convenient, however, for purposes of observation and description, and has been adopted by physicians generally throughout the world. Lepra Tuberculosa.—Lepra tuberculosa, or tubercular lepra, is characterized by the development of macules and tubercles upon the cutaneous and mucous surfaces. The macules are the result of the deposition of new material in the superficial tissues. They are usually well defined, but may fade imperceptibly into the surrounding healthy surface. They vary from a quarter of an inch to several inches in diameter, are irregular in shape, smooth, and glistening, and vary from pale red to dark brown. The lesions are firm to the touch, and slightly painful on pressure. When they first appear they are on a level Avith the adjacent surface, but soon become raised. They may develop upon any region, but are most abundant upon the back and the extensor surfaces of the upper and lower extremities. The lesions are frequently met with on the buttocks, palms and soles, and the forehead and cheeks. Occa- sionally some of the patches undergo complete involution, and the skin resumes its natural color. At this stage, as well as at a later period, it is not unusual to observe attacks of an eruption identical in appearance with that of erythema nodosum, accompanied by considerable elevation of temperature. Large but transient tumefactions in the course of the limbs, swellings of the joints, and erysipelatoid redness, have also been witnessed by Brocq. The majority of the lesions, however, increase in breadth and thickness, and produce extensive and prominent elevations of the surface. The skin then appears to be uniformly discolored, and divided into irregularly shaped masses. Finally, as the process of in- filtration continues, more prominent and distinctly limited elevations, termed nodules or tubercles, are formed. The tubercles are round or oval, and vary from the size of a split pea to that of a walnut, or may be larger. They are generally brown or dark red in color, more or less 621 DISEASES OF THE SKIN. painful upon pressure, and are usually developed upon those regions of the surface that have been the seat of infiltration, but they may appear upon apparently healthy skin. The tubercles are frequently surrounded by an inflammatory or an cedematous aureola. They are found upon the back, buttocks, arms, legs, fingers, and toes, but are most abundant upon the forehead, cheeks, eyelids, nose, lips, chin, and ears. The deformity which they produce is so characteristically hideous that, once seen, it can never be forgotten. The face is broad, swollen, discolored, and presents an inexpressibly sad appearance. The skin of the forehead is thickened and thrown into deep folds, which in some cases give a fierce or sullen aspect to the countenance (facies leontina). The nose is broad, flat, and covered with tuber- cles. The eyelids and cheeks are thick and pendulous; the chin is broad and SAVollen; the lips are thick and infiltrated ; and the ears are enlarged and indurated. The hairs of the eyelashes and eyebrows are scanty or absent, and those of the beard are thin and lanuginous. The hands and feet are also horribly deformed. The hands are swollen, discolored, and covered with tubercles and masses of infiltration. The fingers are thickened, fissured, and clubbed at the ends. The thicken- ing and induration, which are especially marked on the dorsal and lateral surfaces of the fingers, interfere more or less with the function of the joints, and sometimes render it impossible to flex the fingers. The finger-nails become pale, fissured, brittle, and finally drop off or crumble away. The feet are SAvollen and distorted, and walking often becomes impossible because of the painful condition of the plantar sur- faces. The lymphatic glands of the whole body also become involved and transformed into hard, prominent masses. After the tubercles have become fully developed they remain for a varying length of time without further change. During this period the general health is usually unaffected and the mental faculties are unimpaired. In some rare cases the disease is spontaneously arrested at this stage, and the existing tubercles disappear by absorption, leav- ing an atrophied, pigmented spot to mark their location. In the overwhelming majority of cases, however, the morbid process eventu- ally receives a fresh impetus, new tubercles are developed, and the old ones become the seat of an erysipelatous inflammation, break doAvn and ulcerate. The tubercles may also ulcerate as the result of pressure, fric- tion, or other injury, and may exist for years without extending in breadth or depth. In many cases, however, the ulcerative process extends rapidly and deeply. The skin and the subcutaneous tissue are first destroyed, the muscles, tendons, and ligaments are also invaded, the joints opened, and the affected parts separated. This is the con- dition knoAvn as lepra mutilans. It is usually confined to the fingers and toes, but has been observed on the wrists and ankles. It some- times attacks all the phalangeal joints in succession. After the ne- TUMCRS. 625 crosed tissue has been throAvn off, the proximal ulceration heals by the formation of a cicatrix. In some the middle phalanx of a finger or toe is alone affected, while the first and third are left intact. In these cases, after the necrosed tissue has sloughed away, the third phalanx is retracted against the first, and a varying degree of distor- tion or deformity results. Each exacerbation of the disease is fol- loAved by a period of quiescence, during which the patient is com- paratively comfortable, and may even believe that he will finally recover. His nutrition and mental faculties are still well preserved, and the only troublesome or annoying symptoms present are those produced by the cutaneous lesions. Fresh accesses, hoAvever, occur from time to time, during which the eruption of tubercles becomes more extensive and the ulcerative processes more destructive. The mucous membranes may become involved, and tubercles appear in the mouth, nose, throat, larynx, and upon the tongue, epiglottis, and con- junctiva. When the tubercles break down, extensive ulceration and destruction of tissue result. The nasal bones may be necrosed, the nose sink in, the uvula and the epiglottis may be partially destroyed, and the voice become toneless and harsh. The tongue may become infiltrated, SAvollen, fissured, and oedema and ulceration of the glottis may occur. Ulceration of the conjunctiva and cornea, Avith destruc- tion of the iris, and partial or complete loss of vision, may also result. Atrophy of the testicles may be noticed at this stage of the disease. Irregular attacks of fever are likewise of frequent occurrence, and an- nounce the invasion of some internal organ by the disease. Finally, mental symptoms appear, and the Avhole organization is profoundly in- volved. The patient becomes listless and helpless, and loses all interest in himself and his surroundings. His eyes are dull and staring, and the Avhole expression of his countenance is indescribably despondent. All desire for food is lost, bed-sores form, profuse diarrhoea sets in, and the patient perishes from inanition. In some cases the fatal termina- tion is accelerated by an intercurrent attack of pneumonia, albumi- nuria, tuberculosis, or some other acute disease. In others, after the tubercular eruption has existed for several years, bullae are developed from time to time, limited patches of the skin become destitute of sensation, the tubercles disappear, and the symptoms of tubercular lepra gradually become merged into those of the anaesthetic type. Norwegian physicians believe that this is the natural course of the disease, and that every case of tubercular lepra would eventually be transformed into the anaesthetic variety if not anticipated by the death of the patient. The average duration of a case of tubercular lepra is from eight to twelve years. Lepra Ana-;sthetica.—Anaesthetic lepra, or the lepra nervorum of Virchow, may appear in conjunction Avith the tubercular and macu- lar varieties, but it frequently occurs as a primary and distinct form cf 40 626 DISEASES OF THE SKIN. the disease. It is preceded by a number of prodromal symptoms, the most significant of which are the formation of bullae and the develop- ment of hyperaesthetic areas in the cutaneous surface. The bullae are few in number, and vary in size from a bean to that of a walnut, or may be even larger. They contain a clear or yellowish fluid, and re- main for a few hours or a few days. They then break spontaneously and their contents escape, after which the epidermis at their site des- quamates and a white or pigmented cicatrix is formed. Other crops of bullae appear and disappear in the same manner, and no other symp- toms of lepra may become apparent for years. Occasionally patches of discoloration or other anomalies of pigmentation may be noticed. Sooner or later, however, the cicatricial or pigmented spots that mark the location of former bullae become exquisitely sensitive. The areas of discoloration and portions of apparently healthy skin also become hyperaesthetic, the slightest touch producing the most intense suffer- ing. In some cases the whole cutaneous surface may be affected so that motion of any kind is painful or impossible. The patient is com- pelled to lie in bed, and must be fed like a child, as he is unable to help himself. During this stage of the disease the ulnar, median, radial,, and other subcutaneous nerves are swollen and extremely pain- ful under pressure. The hyperaesthetic portions of the skin become reddened or slightly cedematous, and are the seat of sharp, lancinating pains. In some cases the patient complains much of formication, or of a sensation of heat and burning in the extremities. This condition may last for months, but finally the pains and hyperaesthesia subside, and the patient imagines that he is getting well. Other and more serious symptoms soon appear and dispel this delusion. Anaesthesia succeeds to hyperaesthesia, and the formerly supersensitive areas be- come devoid of all sensation. Portions of the apparently normal skin become affected in a similar manner. Sensibility to touch, pressure, and changes of temperature are entirely lost, and, although a transient improvement may occur in some cases, anaesthesia eventually becomes complete over extensive portions of the cutaneous surface. The anaes- thetic areas do not correspond to any definite nervous distribution. They vary in size and shape, and may be found upon any portion of the body. As the morbid process continues, the subcutaneous structure also be- comes involved, so that a pin can be thrust deep into the muscles with- out producing any pain. M. Quinquaud, at the meeting of the French Society of Dermatology and Syphilography, held in May, 1890, detailed the results of special studies which he had made of the sensory disturb- ances in the early stage of lepra. For this purpose he had devised an instrument which he called the dynamometric aesthesiometer. This in- strument registered the pressure in terms of grammes, and he was able to exert upon the skin a force amounting to tAvo liundred and fifty TUMORS. 627 grammes. He found that sensibility to puncture is very variable. In one spot there might be found sensation upon pressure of five grammes, while not more than two millimetres away one liundred grammes would be necessary to elicit a distinct sensation. " The same difference was found in regard to sensibility to temperature, Avhich sometimes exhib- ited a considerable diminution. In some cases the thermometer marked 30° C. before any sensation was observed. Beside points where 0° C. Avas perceived, others would be found in which 10° C. Avas not perceived. Again, phenomena of dissociation were witnessed. Some had no per- ception of cold, but felt heat, etc. These modifications of sensibility Avere met with even in the earliest periods of the disease." * This dis- sociation Avas remarked in a case reported by Dr. George W. Jacoby to the meeting of the American Neurological Association, June, 1889. The patient Avas a youth aged eighteen, in whom large territories of pronounced analgesia existed. The sense of touch was normal, but there was no sensibility to pain. In certain parts there was complete loss of temperature sense. The distribution of the territories character- ized by disordered temperature sense was much more symmetrical than that of the areas of analgesia. Neither the analgesic areas nor those Avith disturbed temperature sense corresponded to the distribution of particular cutaneous nerves. Although sensibility to pain and temper- ature was abolished in the same areas, yet the loss of temperature sense affected territories which were normal in other respects. Other trophic changes finally occur. The subcutaneous fat disap- pears, and the skin over the anaesthetic areas grows dry, thin, and wrinkled. The SAveat-glands and hair-follicles are absorbed or de- stroyed, and the hair falls out over the entire body. The finger-nails become fissured and brittle, and drop off or crumble away. The facial muscles atrophy, and the countenance, which at first presented an ex- pression of mingled sadness and despair, is hideously distorted. The eyelids droop, so that the tears escape and flow doAvn on the side of the face. The lower lip hangs pendulous and everted, exposing the gums, and alloAving the saliva to dribble out of the corners of the mouth. The muscles of the hands and feet also atrophy; the hands are bent and deformed, and the fingers flexed and distorted ; the toes are twisted in various directions, so that Avalking is difficult or impossible, and the patient at last is unable to leave his bed. After a time, owing to the pressure of the bony prominences on the skin around the joints, the epidermis becomes fissured and desqua- mates. Superficial ulcerations are then formed, which gradually in- volve the deeper structures. Muscles, tendons, and ligaments are destroyed, articulations are opened, and a phalanx, a hand, or a whole foot is separated from the body. This is the process known as lepra mutilans, and is identical with that which occurs in the later * Le Progres Medical, May 10, 1890; Medical Bulletin, July, 1890, p. 252. 628 DISEASES OF THE SKIN. stages of lepra tuberculosa. The mucous membranes are also attacked by indolent ulcerations that produce extensive destruction of tissue, followed by loss of voice, sight, and smell. Dr. Castor states that out of two hundred and thirty-one cases in Avhich the mucous membrane of the mouth and pharynx Avas exam- ined, anaesthesia was present on both sides in ten per cent, while in only a very few cases was it found limited to one side. Intercurrent attacks of erysipelas and leprous fever are common. Finally, the cen- tral nervous system becomes involved. The patient sinks into a state of profound apathy, remaining motionless for days at a time. His tem- perature is diminished, the heart's action feeble and slow, and the breathing shallow and irregular. The immediate cause of death is usu- ally inability to take sufficient food to prolong life, but diarrhoea, pneu- monia, or Bright's disease often puts an end to the patient's sufferings before that stage is reached. Anaesthetic lepra is the most chronic variety of the disease, and generally lasts fifteen or twenty years from the first appearance of its symptoms. Lepra Maculosa.—This variety of lepra is usually preceded by a number of indefinite prodromal symptoms, after which the characteris- tic macules make their appearance upon the skin. In many cases they appear without any accompanying constitutional symptoms, so that patients become aAvare of their presence only from accidental obser- vation. In others, however, the lesions develop during a febrile attack. They differ in size and color, in some cases consisting of pale- red discolorations, which vary from half an inch to several inches in diameter, and disappear under pressure; and in others, of dark-broAvn or black stains; in rare cases they are white and glistening. The macules are usually slightly elevated above the surrounding surface. They may appear on any portion of the body, but are usually most numerous on the face and hands, where they form a striking contrast to the adjacent normal skin. After a variable length of time the symptoms of one of the other forms of lepra appear and tubercles de- velop, or the macular areas become the seat of hyperaesthesia, anaes- thesia, atrophy, and ulceration, after which the disease pursues its usual course. Attacks of erysipelas and leprous fever are noticed from time to time, more or less destruction of tissue occurs, and death by gradual inanition, or some intercurrent disease, finally closes the scene. In some cases of leprosy the tendon reflexes are increased. Dr. Jacoby found the patellar reflexes much increased upon both sides. The same observation was made by Rosenthal, Vallin, and Rosenbach, while Schulze failed to find any abnormal deviation. Mr. Suzuki, of Tokio, Japan, found increased reflexes in twenty-three cases of leprosy, including both the anaesthetic and tubercular forms.* Dr. Lopez, of * Lance", July 21, 18S9. TUMORS. 629 Havana, has made ocular leprosy the subject of a memoir, which may be condensed as follows: In half of the lepers under treatment in the St. Lazarus Hospital at Havana the eye was attacked. The lids in particular are nearly always affected. They are subject to tubercles, and also to anaesthetic patches, upon which the temperature is lowered and the glands destroyed. Ectropion is frequent, and may involve either lid. Destruction of nerve-filaments leads to paralysis of the orbicularis palpebrarum. Anaesthesia of the conjunctiva is frequent in all varie- ties of leprosy. Conjunctivitis may result from foreign particles which the membrane, deprived of sensibility, is unable to recognize; hence the offending substance may remain and give rise to inflammation. Conjunctivitis may also be due to tubercular deposit. Pterygium is also sometimes produced. The lesions of the cornea are frequent and various. Anaesthesia is the most common alteration. Tubercles may form upon the cornea and lead to destructive inflammation. Corneal staphyloma may develop, and be followed by atrophy of the cornea. Tubercle may be deposited in any part of the iris, but its favorite loca- tion is the arterial circle of the iris, whence it may invade the cornea, sclerotic, iris, and ciliary processes. The iritis of leprosy is insidious, characterized by relapses and exacerbations. Lesions of the crystalline lens are secondary to invasion of the ciliary region. The choroid and retina are less frequently involved than the more superficial membranes, though they may be attacked at a late stage of the disease. Leprous manifestations generally proceed from the surface to the interior. Kera- titis and iritis are the most common causes of loss of vision.* In some cases the perspiratory function of the skin is gradually lost. Complications.—As lepra is a disease of such extreme chronicity, various complications of the cutaneous lesions may be expected to occur. Those which have been most frequently observed are erysipelas, ele- phantiasis Arabum, syphilis, scabies, favus, eczema, fibroma mollus- cum, and herpes. Dr. Beaven Rake, Medical Superintendent of the Trinidad Leper Asylum, narrates a case in Avhich a lesion characteristic of Addison's disease, together with evidences of old syphilis, were found in a leper. The subject Avas a Hindoo, fifty years of age. The skin was very dark, but not darker than that of many East Indians. The pigmentation was evenly distributed, and neither the groins nor the axillae were deep- ened in color. After death there was found darkening of the pia mater over the medulla and upper part of the cord and of the dura mater over the superior longitudinal sinus. The supra-renal bodies were converted into sacs, lined with brown debris and small yellow grains resembling minute tubercles. The medullary portion had disappeared. The gan- glia of the aortic plexus were about three quarters of an inch long, and dark red in color. No lepra or tubercle bacilli Avere found in the supra- * Rccueil d'Ophthalmologie, July, 1890. Medical Bulletin, November, 1890, p. 414. 630 DISEASES OF THE SKIN. renal glands or in the abdominal sympathetic, nor were any tubercles found in the lungs or any other portion of the body. Sir William Moore states that he has several times seen ainhum associated with leprosy, and looks upon it as one of the manifestations of the latter disease. The internal complications are numerous and varied, but do not require any special description. Those which occur most frequently are pneumonia, pleurisy, pericarditis, peritonitis, nephritis, hepatitis, enteritis, and colli- quative diarrhoea. Diagnosis.—The symptoms of a fully developed case of lepra are so characteristic that an error in diagnosis is almost impossible. The hideous countenance, the infiltrated and discolored surface, the tuber- cular eruption, the cutaneous hyperaesthesia, followed by anaesthesia, the ulcerations, atrophy, and deformity that occur from time to time, the history and extreme chronicity of the lesions, all unerringly indi- cate the true nature of the malady. The diagnosis is more difficult in the prodromal stages of the disease. In Japan, the deep lividity of the face, occurring after even moderately imbibing vinous or spiritu- ous liquor, and at the very beginning of the affection, is regarded as pathognomonic, and sufficient to justify the isolation of the person in whom it is observed. Apparently causeless febrile attacks, and the persistent recurrence of a limited number of bullae, should also be vieAved with suspicion. With these exceptions, however, the premoni- tory symptoms are so indefinite in character that they would not excite alarm except in localities where the disease is endemic. The develop- ment of the cutaneous lesions is only a question of time, however, and their appearance is usually sufficient to enable one to make the diagno- sis. In some rare cases the macules and tubercles may be confounded at first with those of syphilis. They differ, however, from the latter in being larger and more irregular in shape and distribution, the erythema- tous macules of lepra being often several inches in diameter. They are also smooth and glistening in appearance, and raised above the leArel of the surrounding skin, are situated on an infiltrated base, and are often as large as walnuts. They also differ in progress and dura- tion from the macules of syphilis. The macules of lepra have been confounded with those of vitiligo. This mistake can readily be avoided by remembering that vitiligo con- sists only of a deficiency of pigment in a circumscribed area of the skin, with a slight increase of pigment around the borders of the altered area. The general health in vitiligo is unaffected, and the skin remains normal in texture and sensation. In lepra, on the con- trary, the affected areas are infiltrated and elevated above the adjacent surface, and are also the seat of various disorders of sensation. Mor- phcea, which was formerly supposed to be a benign variety of lepra, can be differentiated in a similar manner. Its patches sometimes resemble those of lepra in appearance, but they are normal in sensi- TUMORS. 631 bility, unaccompanied by constitutional symptoms, and tend to sponta- neous disappearance. Sarcoma and elephantiasis Arabnm have been mistaken for lepra, but their symptoms and progress are so different from those of the last-mentioned malady that it is difficult to perceive why error should have arisen. In any doubtful case the blood from the suspected lesion should be examined, in order to determine the presence or absence of the specific bacillus of lepra. Zambaco has argued that Morvan's disease is essentially identical with leprosy, but the lepra ba- cillus has not been found in the former affection, nor are the alterations in the peripheral nerves characteristic of leprosy present in the malady described by Morvan. The loss of phalanges, muscular atrophy, anaes- thesia or ulcerations, are suggestive of lepra, but in other features the progress of the two diseases by no means coincides. Pathology.—The pathology was first placed upon a true foundation by Danielssen and Boeck. Further investigations in all parts of the world have confirmed the correctness of their views. The lesions of the disease are produced by deposition of new material composed of small, round cells. The cells are similar in appearance to those which occur in lupus and syphilis, but are more closely aggregated and more permanent in character, and contain the specific bacillus of lepra. Dr. E. T. Wynne regards the leprosy cells as leucocytes, the protoplasm of which is enlarged to two or three times its ordinary size. If new for- mation of connective tissue occurs, it often becomes spindle-shaped or unipolar. Multinuclear giant cells resembling those of tuberculosis are occasionally seen. The recognition of the bacilli is comparatively easy. They appear as fine, minute rods of about -^fa^ of an inch in length. They are usually pointed on both ends, and the majority of them con- tain spores. This bacillus was first demonstrated by Dr. Armauer Hansen, of Bergen, Norway, and must be recognized as the exciting cause of the disease. These organisms have been found in the skin, mucous membranes, nervous tissue, lymphatic glands, eyes, testicle, liver, spleen, and blood. In their recent Avork Hansen and Looft assert that they haAre never seen a leprous bronchial or mesenteric gland, and conclude, therefore, that the disease does not attack the lungs or intes- tines. Attempts to culthate them externally to the human body have almost iiiArariably failed, and inoculations of animals have seldom proved successful in causing general leprosy. Hansen and Neisser, however, have succeeded in producing cultures and in inoculating animals. Dr. Beaven Rake says that he failed to grow the bacillus leprae, and that he Avas never able to discover in animals any local growth or general dis- semination of the bacillus after inoculation. The lepra bacilli are readily stained with aniline colors, with the exception of vesuvin, or Bismarck-brown. They are easily detected by the double method of staining. Dr. Patrick Manson describes a ready procedure by which lepra bacilli may be obtained. After the blood has been expressed from 632 DISEASES OF THE SKIN. a nodule, the blanched lesion is pricked with a needle, when a drop of " leper-juice " escapes. This leper-juice is treated in the same manner as sputum for the detection of tubercle bacilli, and the lepra bacillus can usually be found in great profusion. In the anaesthetic form the specific bacillus is not present in the insensithe patches in the inter- stitial connective tissue of nerve trunks. The nerves become so com- pletely altered that a longitudinal section presents more resemblance to tendon than to nerve. It has been found that lepra bacilli are destroyed with great difficulty; they live and multiply for a considerable period after the death of the patient. Burial, therefore, becomes a source of danger. The new material first appears in the corium, and gradually invades all the cutaneous and subcutaneous structures. It compresses the blood-vessels, lymphatics, and the peripheral nerves. In the later stages the papillae are atrophied. The Cells of the rete Malpighii disappear, the leprous growth approaches the horny layer, and an ulcer results. Bacilli are seldom, if ever, found primarily in the cells of the rete Mal- pighii. It has likewise been shown that multitudes of lepra bacilli may be present in the rete mucosum for long periods of time without exciting any local reaction. From this situation they invade the hair- follicles. The general and, as it were, accidental distribution of the bacilli upon the surface, and the tolerance of the tissues toAvard them, explain the absence in leprosy of an initial lesion. The leprous deposit produces trophic disturbances that manifest themselves by alterations in color, sensation, and nutrition. As the process of infiltration con- tinues, elevations, nodules, and tubercles develop upon the surface, while the hair-follicles and glands become obliterated. The hairs fall, and the finger-nails decay. Unna, in his latest work, defines the tubercle, or leproma, as " a diffuse granuloma, whose peculiarity consists on the one hand in its limitation to the connective-tissue elements, and especially to the lymphatic system of the skin, and on the other in the enormous growth of organisms, Avhose number far exceeds anything we are accustomed to find in other infectious diseases." Fatty degeneration of the cells of the neAvly formed tissue occurs, and ulceration and necrosis of the adjacent structures is the result. The lymphatics and blood-vessels carry the infection to the mucous membrane and internal organs. The pathological process then becomes a geueral one, and the same deposi- tion and infiltration of small, round cells take place in the lungs, liver, kidneys, spleen, intestines, and testicles. Lesions of the central nerv- ous system, including degeneration of the cord and myelitis of the pos- terior cornua, haATe also been obser\-ed. As a result of many patho- logical examinations Beaven Rake is able to confirm the statement of Danielssen and Boeck, that the blood of lepers contains a largely in- creased proportion of fibrin. TUMORS. 633 In anaesthetic lepra the infiltration and deposition of the neAV cells are in the beginning limited to the interstitial substance between the primitive fibrillae of the cutaneous nerves. As the process continues, the pressure upon the delicate fibres produces severe irritation, which is coincident Avith the stage of cutaneous hyperaesthesia. More or less neuritis is then developed, the cell-growth is increased, the nerves be- come enormously SAvollen, and atrophy or fatty degeneration of a num- ber of primitive fibres occurs. The areas that Avere dependent upon the fibres for innervation then become anaesthetic. Atrophy, ulcera- tion, and other trophic changes follow in time. After death, the ul- nar, radial, median, musculo-cutaneous, and peroneal nerAes are found to be irregularly swollen along their entire length, harder than usual, and altered in color from white to dark gray, and the neurilemma transformed into a tough, fibrous material. The specific bacilli are present in the cells and in the connective tissue between the nerve- fibres. Combemale and Marestang have found calcareous degeneration of the median and ulnar nerves * taken from a case of anaesthetic leprosy. Numerous deposits of carbonates and phosphates were found inter- mixed with the fibrils or occupying the lumen of empty nervous tubules. Etiology-—Lepra has existed in all ages and in all countries. At the present time it is endemic in northern and eastern Africa, Mada- gascar, Arabia, Persia, India, China, Japan, Liberia, and the islands of the Pacific and Indian Oceans. It is also known in Brazil, Vene- zuela, Central America, Mexico, and the West Indies. Leprosy has been practically eradicated from Avestern and central Europe by the most rigorous isolation, but is still active in Nonvay, southern Russia, and at various points along the Mediterranean. The total number of lepers in his country was not long ago estimated by Dr. Olavide, of Madrid, at from 1,000 to 1,500.f The maximum number of lepers in the British Empire alone is given in the " Journal of the Leprosy Investi- gation Committee " as 500,000. From a comparison of previous cen- suses, hoAvever, the "British Medical Journal" (December 26,1891) suspects that 100,000 is nearer the truth. In North America it appears to have obtained a permanent foothold at Tracadie, in Canada, and in certain districts of Louisiana, South Carolina, and Minnesota, in the United States. Leprosy Avas introduced into Louisiana by the Acadi- ans in 1158. In 1888 forty-tAvo cases of the disease Avere reported in the city of New Orleans besides those which existed in the Teche River district. It has prevailed in Mexico ever since the time of Cortez. Dr. Blanc makes the statement that one fourth of the lepers in New Orleans have relatives avIio are also subjects of the disease. Pregnant lepers gen- * "La Tribune Medicale," June 25, 1891; The Medical Bulletin, August, 1891. f British Medical Journal, December 21, 1889. 634 DISEASES OF THE SKIN. erally abort, though some bear healthy children. Isolated cases have also been observed in New York, Maryland, and California, having been introduced into the last-named State by Chinese. It has also been brought to Salt Lake City by natives of the Hawaiian Islands. The in- vestigations of Dr. Holmboe among the Scandinavians in our north- Avestern States have shown that not any of the lepers were born in this country; that most of the patients were affected before immigration, though in some cases the first manifestations have appeared after ar- rival. All the latter patients were adults at the date of immigration. The course of the disease is longer and milder in America than in Nor- way. A different climate and improved modes of life have ameliorated the disease.* Many theories have been advanced to account for the presence of leprosy in so many different localities and under such vary- ing conditions of climate and modes of life. Lepra was formerly sup- posed to be generated by some peculiarity of the soil or of the atmos- phere, but it is found in dry as well as in moist climates, in mountainous as well as in marshy districts, and in the Arctic regions as Avell as in the tropical zone. The habitual consumption of improper food, such as salt fish, has also been suggested as a cause, but the disease is endemic in many localities where fish is never eaten. Mr. Jonathan Hutchinson is the earnest champion of this theory, which he has laboriously main- tained in a number of publications. This author denies the contagious character of leprosy, but considers that the disease is due in all cases to the ingestion of fish, particularly if this is salted or in a state of de- composition. He consequently teaches that limitation must be sought for in improved habits of diet, and not in enforced isolation. Fish, he conceives, may be the direct means of introducing the causative bacillus within the stomach, or may excite activity in a bacillus already present in the tissues, though he considers the first to be the more probable supposition. Notwithstanding the fact that fish is one of the pro- hibited articles of food among certain castes in East India, he assumes that the rule is in reality secretly transgressed. This vieAV of causation rests entirely upon hypothetical grounds. While it is true that most countries or districts in which leprosy prevails border upon the sea- coast, yet there are exceptions to this fact, as the interior of Hindostan and China. Mr. Hutchinson, under the name of fish, seems to include shell-fish " and all other living things taken out of the Avater." He does not limit the danger to the consumption of salt-water fish only, but regards those from rivers and lakes as equally suspicious. The theory must certainly be considered as sufficiently elastic. Inasmuch as there are few regions upon earth in Avhich either salt- or fresh- water fish are not obtainable, it is surprising that leprosy, if produced by eating fish, should not be far more wide-spread than it actually is at present. It would indeed seem that the theory admits of com- * American Lancet, July, 1890. TUMORS. 635 paratively easy verification, or, at least, that portion of it which re- lates to fish being the general carriers of the lepra bacillus. If this were a demonstrated fact we should be obliged to admit that the hy- pothesis had been verified. It may be impossible to prove or disprove the presence in the human body of latent bacilli Avhich are roused into development by the consumption of fish. Uncooked or improperly prepared fish may lead to depraved nutrition, or, if decomposing, may excite septic phenomena, but I find it difficult to believe that they are under any circumstances capable of giving rise to a specific disease. Besides the inherent improbability of this theory, it is discounte- nanced by certain facts. Dr. Ernest F. Neve testifies that in Kashmir leprosy is quite prevalent among herdsmen, many of Avhom never eat fish, while the fishermen and boatmen are singularly free from the disease. Dr. Arthur Reid observed that leprosy was common in the inland Chinese province of Honan, in which fish were difficult to pro- cure ; yet the disease attacked only the very poor, Avho were neces- sarily deprived of fish on account of the expense. In Pekin, likeAvise, where leprosy is not uncommon, fish is said to be a costly luxury.* Dr. J. Kirkpatrick was for many years in charge of hospitals and dis- pensaries at Bangalore, in the Mysore territory. He saw leprosy not infrequently among Brahmans, who, in that part of India at least, strictly abstain from every kind of animal food. The Parsees are notorious fish-eaters, but are not especially subject to leprosy. The testimony of Prof. Cayley agrees with that of Dr. Kirkpatrick. He has witnessed the malady in a family of strict caste among Avhom the eating of fish was unknown. Impure drinking-water, foul air, and filthy personal habits have been regarded as influential factors in the production of leprosy, but it is obvious that they can act only as pre- disposing causes by lowering the tone of the general system. Heredity, also, has been looked upon as the essential element in the causation of the disease, and numerous cases are recorded in Avhich lepra has occurred in the same families for generations. The phenomena of the disease, however, are in these cases never manifested at birth, rarely appear- ing until the children are four or five years old, and they may not develop until the fifteenth or twentieth year. Dr. Zambaco, of Con- stantinople, asserts that leprosy may appear at or soon after birth. Dr. Navarro has described tAvo cases of congenital leprosy. A Avoman gave birth to an ill-developed male child whose body was covered with leprous spots. In tAvo months leprous tubercles developed upon the face, elbows, and knees. Signs of the 'disease soon afterward appeared in the mother and in a daughter eight years of age, Avho had until then been perfectly healthy. All three died of leprosy within two years. Again, a woman in the last stage of the disease was de- livered of a Avell-formed female child, upon whom Avere many leprous * British Medical Journal, March 8, 1890. 636 DISEASES OF THE SKIN. spots and a well-developed tubercle on the upper part of the concha of the left ear. Many cases are knoAvn in which children have been born of leprous parents, but have remained free from the disease throughout their lives. On the other hand, the disease is frequently met with in persons whose ancestors were free from all leprous taint. The heredity of leprosy is a point upon Avhich much doubt and diversity of opinion exists. The belief that the disease is handed down by in- heritance was formerly well-nigh universally entertained. Of late years many have arisen to deny this doctrine. Very feAv well-authenti- cated cases are on record in Avhich a child was actually the subject of leprosy at birth, or developed unmistakable signs of the disease a few Aveeks or months subsequent to birth. It has very properly been pointed out, that although leprosy is undoubtedly a family disease, yet this fact affords an argument quite as much in favor of contagious- ness as heredity. Among the members of the same family, exposed to the same conditions, living together in the same house, eating the same food at the same table, every circumstance exists which should tend to spread the disease by actual contagion or contact. Nevertheless, there are facts Avhich point in the opposite direction. The procreative ability of lepers is seriously impaired. The wife, even if conception occur, is apt to abort. During seven years, for example, only tAvo living children Avere born in the leper community at Molo- kai. Moreover, the rate of mortality is high among the offspring of lepers. This may merely indicate that the depressed vitality of the parent has been unable to furnish or to nourish a vigorous germ, and does not necessarily indicate any specific implication of the embryo. It may probably be that no more than a predisposition is inherited, a condition by which the tissues are fitted to form a ready field for the culture of the lepra bacilli. There appears, however, to be no inherent improbability, in the case of a leprous mother, of an actual passage of the bacilli, or, at least, their products from the maternal to the foetal blood. We know that the foetus may suffer from small- pox in utero, and that the characteristic micro-organisms of anthrax, relapsing fever, and typhoid fever have been found in the blood of the new-born babe. AVhen the disease is confined to the father, and more especially if it has reached an advanced stage, it seems credible that the seminal fluid or the spermatozoa should impress a morbid inheritance upon the embryo corresponding to Avhat takes place when the infant inherits syphilis from the father. I am not desirous of ad- vocating any doctrine on purely theoretical grounds, yet I am unable to percehe that the arguments against heredity are conclusive. The opinions of physicians who practice in countries where leprosy pre- vails, or who are attached to leper asylums, differ radically upon this subject. It is necessarily very difficult to disentangle the complicated evidence. Dr. de Valence believes that transmission by inheritance is TUMORS. 637 the most active factor in the propagation of the disease. Apart from scientific considerations, it is extremely difficult to gather the exact personal and family histories of patients. Dr. de Valence quotes the record of a family in which he had been able to trace descent of lep- rosy during almost a century. Leprosy occurs rather more frequently in males than in females. The belief that the malady is spread by contagion has existed from time immemorial, and may now be regarded as established beyond doubt by the numerous cases that have been re- corded of persons Avho contracted the disease after residing for a brief period in an infected district. Some very conclusive instances of the manner in Avhich the disease spreads are given by Dr. Heidenstam in his report on leprosy in Cy- prus. The Mohammedans suffer much less than the Christians. Of sixty-one patients in the leper asylum only three were Moslems. The Turks are excessively careful in avoiding contact Avith lepers. The arrival of the first leper in a village is soon folloAved by a propagation of the disease. On the contrary, the villages which rigidly excluded such patients remained free from leprosy. Isolation has been practiced as far as possible, Avith the result that in ten years the number of cases upon the island has been reduced from one hundred and fifty to one liundred. Dr. Hawtrey Benson has reported * the case of a man who had served for many years in India where he contracted leprosy. Re- turning to Ireland, he slept in the same bed with his brother, a laborer, Avho had never left his native land, but who also in course of time de- veloped the disease. Dr. Poupinel de Valence, Avho has had an expe- rience of twenty years in the St. Lazare Leper Asylum, of Mauritius, is fully convinced that leprosy is spread by the agency of personal contact. He remarks that anyone familiar with the wards of such an institution is aware that the air is contaminated by the pulmonary exhalations as well as by the secretions of the patients. The body of a leper exhales a fetid smell Avhich be compares to that of a dead rat in a state of de- composition. He does not expressly so state, but intimates that this odor is not confined to those in whom ulcerative or sloughing processes are present. The writer cited two instances of persons Avho had con- tracted the disease by reason of years of intimacy with leprous individ- uals. The rapidity with which the affection has developed in regions where unrestricted intercourse has been allowed with leprous patients is another proof of its contagiousness. The first case of leprosy in New Brunswick occurred in 1815, in the person of a French woman whose grandparents had immigrated from the coast of Normandy, in which province leprosy has long existed. But no case was known to have developed among her ancestors. The husband and tAvo sisters of this woman became lepers. From this origin the disease gradually spread. A lazaretto was established in * Dublin Journal of Medical Science, 1877, p. 562. 638 DISEASES OF THE SKIN. 1841, but it Avas found impossible to maintain strict isolation. During the last twenty-five years, hoAvever, the leper asylum has been more wisely managed, and the number of cases, compared Avith the popula- tion, is diminishing. It is estimated that since 1815 about tAvo hundred and thirty cases have developed. Forty years ago, according to the inhabitants, leprosy was introduced into the Hawaiian (commonly but erroneously called the Sandwich) Islands by two Chinese coolies. This statement, however, must probably be amended, according to in- formation published by those long familiar with the islands. Drs. Hillebrand and Saxe had written that leprosy was introduced in 1848 by Chinese, but the testimony of missionaries seems conclusive that the malady existed among the natives as early as 1823. It is stated, moreover, that very few Chinese are included among the leper popula- tion. On the other hand, in New South AVales leprosy was early in- troduced, and attacked colonists as well as Chinese. Such was the alarm and aversion of the former in reference to the malady that ener- getic measures were taken to prevent its spread. A leper was univer- sally dreaded and shunned. The consequence is that at the present time all the lepers of the colony, consisting of a few Chinese and one Englishman, are strictly isolated in the Leper Hospital. Sir William Moore instances the case of a person employed to rub ointment upon dispensary patients afflicted with scabies. Among these were several lepers, and the attendant, after an injury to the hand, developed the disease, although she came of a family quite free from taint. In 1805 there were three lepers on the island of Trinidad; in 1878 there were eight hundred and sixty. In Norway, on the contrary, Avhere a rigid system of isolation is enforced, the number of lepers has decreased fifty per cent, within the past twenty years. Local tradition states that leprosy Avas brought into the island of Cyprus about three liundred years ago by pilgrims from Palestine. In a report by Dr. lleidenstam a number of striking cases are cited to exemplify the mode in Avhich the malady gains entrance into communities and is transferred by personal contact. Very direct evidence upon this point is likeAvise afforded by the history of the village of Parcent, in the province of Alicante, Spain, as related by Dr. Zuriaga. In 1849 not a case existed, but in 1850 a leper from a neighboring town became domiciled with an intimate friend. The two men lived in the closest association, using the same table utensils and sleeping in the same bed. The friend became infected within a year. From this second case the disease spread to those relatives and friends Avho maintained any inter- course Avith the first victim. Since 1850 sixty cases of leprosy have occurred in this small village. From Parcent the disease spread to adjacent towns, where the first to become leprous Avas ahvays some per- son who had frequently visited the focus of infection. TUMORS. 639 Leprosy is rapidly spreading in New Caledonia. It is estimated that five thousand out of forty thousand natives are lepers. Dr. Forne, of the French navy, states that the Avhite inhabitants are becoming infected. He relates the history of the first white leper, who was attacked after Avorking in a village which contained many native lepers. The man, a convict, had been transported directly from France to Noumea, and was presumably, therefore, free from either predispos- ing or exciting cause.* Dr. Navarro contributed f some forcible in- stances of the danger which lies in personal contact. The wife of a leper bore tAvo sons, of whom one manifested signs of leprosy at the age of one month and the other at the age of two months. Two healthy servants of a lady leper became infected within a year. A healthy man married a woman Avho Avas a leper and became diseased at the end of three months. An apparently successful attempt to inoculate the disease has been made by Dr. EdAvard Arning. On September 30,1884, this physician in- serted into the forearm of a condemned criminal a piece taken from a leprous tubercle. A very careful examination of the man's family and personal history was made. Four Aveeks after the operation the inocu- lated man began to experience rheumatoid pains in the left shoulder and arm. Subsequently a painful swelling of the ulnar and median nerves occurred. Bacilli leprae were detected in the edges of the scar sixteen months after inoculation. In March, 1887, tAvo and a half years after inoculation, the first signs of leprosy made their appearance by changes on the right ear and copper-colored spots on the right cheek. This case Avas welcomed as decisive evidence that the dis- ease may be propagated by inoculation. Doubt has, however, quite lately been thrown upon the subject by an article in the " Occidental Medical Times" for April, 1890, written by Dr. Sidney Bourne Swift, resident physician at Molokai. From this communication it appears that Dr. Arning Avas misled in supposing that the individual was free from taint. In fact, Dr. Swift has ascertained that the prisoner bad been for three months in the charge of a leprous turnkey, and, further- more, his OAvn son and his sister's son are now the subjects of the same disease. An experiment of this character performed in a community in which leprosy is so preAralent can perhaps scarcely be conclusive. An element of doubt may ahvays attach to such a case. The exact manner in which the contagion of lepra is transmitted is still unknown. Mere contact with the secretions or lesions may fail to produce any evil results. Many cases have been reported in which persons have maintained the most intimate relations with lepers for years and yet did not manifest any symptoms of the disease. We pos- sess as yet but little knoAvledge of the modes by which the affection is *Le Progres Medical, May 3, 1890; Medical Bulletin, July, 1890, p. 253. f Lancet, June 28, 1890. 640 DISEASES OF THE SKIN. transmitted from one individual to another. Lepra is not actively con- tagious, like small-pox or scarlet fever. Physicians and attendants in leper asylums and communities are seldom attacked. In some coun- tries it is positively asserted that no instances are knoAvn of such accidents. But this statement is nullified by the fact that in the HaAvaiian Islands a large number of the attendants have become lepers, and that American and European inhabitants of the islands, who presumably are not brought into such close and intimate contact with diseased natives, nevertheless acquire the affection. In the absence of any proof that the malady is propagated by means of a special food, its virus must be communicated either through the respired air or, in some way, by contact. It is probable that lepra is often acquired through cohabitation. In some parts of the world it is strongly suspected that mosquitoes serve as carriers of infection. Instances have been recorded in which lepra has been acquired from wet-nurses or from vaccination. The accidental absorption of discharge from a leprous lesion into an abrasion of the skin would seem to fulfil the indications for the spread of the affection. Further observations are necessary to perfect our knowledge on this point, but the evidence in our possession now is strongly in favor of the supposition that all the phenomena of the dis- ease are produced by the inoculation and multiplication in the system of a specific micro-organism, the lepra bacillus. Treatment.—Lamentable as is the direful fact, and professionally humiliating as is the confession, it must be acknowledged that leprosy is at present an incurable disease. The safety of the community can be secured only by the isolation of every person Avho may become af- fected with it. Great and immediate improvement can be obtained in many cases by simple change of air and scene, but the risk of spread- ing the disease is so great that this measure should be recommended only in rare cases. The safety of the community must not be imperilled in order temporarily to benefit one individual; and, as Danielssen and Boeck truly observed years ago, " our whole theory of lepra rests incon- testably upon the sad fact that Avithin the bounds where it commits its ravages it can be made harmless to the rest of the people only by isolation." Moreover, this isolation should be carried beyond the point of separating leper^s from the non-infected. The best results are at- tained by separating lepers from each other—that is, by absolute isola- tion. By this method lepra has been circumscribed in certain localities, especially in Norway. Various remedies have been recommended from time to time as of inestimable value in its treatment, but they have been found to be of no Avorth as curative, and at the best are only palliative. Continued observation and experimentation will doubtless ultimately furnish us with an efficient remedy, but at the present time the only plan of treatment from which any benefit can be derived is that which aims to TUMORS. 641 improve the general condition of the patient. Iron, quinine, arsenic, and cod-liver oil should be administered in alternation. The diet should be bland and nutritious. In addition to the tonics referred to, benefit has been obtained from the administration of large doses of creasote and salicylate of sodium. Hoang-nan, the powdered bark of strychnos gaultheriana, which contains both brucine and strychnine, has been used extensively in China by native and European physicians. It is generally given three times a day, in from one to three grains at a dose, and has relieved the symptoms and retarded the progress of the disease. Hoang-nan is a valuable systemic tonic, and as such may claim a place in the therapy of leprosy. I do not, however, believe that it is able to exert any specific influence upon the disease. A leper under my care was kept upon hoang-nan continuously for three months, and, with a possible exception of a slight gain in the general condition, I could perceive no result. Certainly, no effect was produced upon the local lesions.* Strychnine is recommended by Piffard. Chaulmoogra- oil has also been effective in ameliorating the symptoms and modifying the course of the disease. It can be given in doses of from five to fifteen minims, in an emulsion or in milk, and may at the same time be used externally as an ointment, twenty to thirty grains to the ounce. Dr. J. C. Phillippo, of Jamaica, reports decided improvement in a case after the persistent employment of gurjun and chaulmoogra oils. When the treatment was begun the patient had been afflicted for three years. For more than a year the entire surface of the body was rubbed with gurjun-oil mixed with lime-Avater, a bath being taken before each application. During this period the oil Avas administered internally. Chaulmoogra-oil being then substituted, gradual improvement com- menced, at first in the face. After about six years of continuous treat- ment the patient was considered cured and treatment was abandoned. About four years have since passed without return of the disease. Dr. A. Lutz testifies that small doses of chaulmoogra-oil are without effect, but that large doses seem to promote the general health and check the progress of the malady. This writer found gynocardic acid, the active principle of the oil, to be equally effective, and more convenient as re- gards administration. It has also been employed in the form of mag- nesium or sodium gynocardate. The acid has likewise been used as an external application, made into an ointment containing twenty grains to the ounce. Dr. George II. Fox has published the case of a man in whom gradual amelioration occurred while taking chaulmoogra-oil in doses gradually increased from fifteen to sixty and finally one hundred drops daily. This treatment was continued for more than two years, Avhen, in the absence of any manifestation, it was abandoned. Four years later the patient was entirely free from blisters and spots. No trace * "Notes on Hoang-nan in Diseases of the Skin" By John V. Shoemaker, A.M., M. D. Journal of the American Medical Associatiou, October 26, 1889, p. 581. 41 642 DISEASES OF THE SKIN. of the disease remained except numbness and contraction of the fin- gers. These probably should be looked upon as results rather than manifestations. It is proper to add that a change of climate co-operated in bringing about the improvement. Unna has invented a mixed form of treatment from which brilliant results have been reported. An ac- count of a case treated according to this method has been published by Dr. Dreckmann, of Vienenburg. The patient Avas a Brazilian, forty-two years of age, in whom the disease had existed for four years. The fol- lowing procedure was employed: The lower part of both legs and feet, as Avell as the forearms and hands, were covered twice a day with a ten-per-cent. pyrogallic ointment, the remainder of the body with chrysarobin ointment of the same strength. The face, except in the region of the loAver jaw, was covered once a day with strong salicyl- cveasote plaster-mull upon Avhich zinc-glue was spread. A stronger application of pyrogallol Avas found to be soon followed by symptoms of intoxication, while a larger proportion of chrysarobin proved too irritant. The plaster-mull is said to intensify the action of the oint- ments. Single nodules Avhen favorably situated were removed by the knife and the wounds healed well. During the treatment ichthyol was given internally, beginning in doses of 0-4 gramme (about six grains), gradually increasing to one gramme (fifteen and a half grains) daily, in pill. Whether the internal medication was of any service must be considered doubtful. Dr. Dreckmann states that the smaller doses were accompanied by as much improvement as the larger. Unna, however, believes that the ichthyol promotes the appetite and muscular vigor. The patient soon began to improve, the appetite and digestion were better, and within tAvo months his weight increased twelve pounds. At the same time he gained remarkably in strength. At the close of the third month anaesthesia had disappeared. When dismissed, at the end of seven months, the man was apparently cured. In the case of feeble patients with sensitive skins Unna prefers as local remedies ichthyol in the form of a fifty- to seventy-per-cent. ointment, or resorcin ointment in the strength of ten to twenty per cent. A case is described by Dr. Wyndham Cottle in which chaulmoogra- oil was given in doses gradually increased from twenty minims to a drachm. At the end of nine months the spots had faded in color and lost some of their thickening, the anaesthesia was less marked, and the general health had improved. Ten years later the man's health was excellent, and the only evidence that leprosy had ever existed was a slight brownish staining of the skin of the backs of the hands and some loss of sensation about parts of his legs and feet. Dr. T. J. Mouat, of the Bengal Medical Service, reports* a case which was re- markably amended by the external and internal use of the same remedy. Large and deep ulcers of the feet healed rapidly by healthy * Lancet, August 3, 1889, p. 233. TUMORS. 643 granulations, the maculae disappeared, and the general health improA^ed. Dr. Philippe Berge testifies to the same effect. According to Beaven I hike, the influence of this substance upon the tubercles is uncertain and variable. Its most certain action is in allaying the neuralgiform and joint pains. The oil is apt to excite nausea. Dr. John Murray states that, in his experience, the most efficacious remedy is " mudar " {Calotropia gigautica). The powder from the dry bark is generally employed, but he prefers the inspissated milky juice of the plant. Dr. Murray also gave it internally in doses of fhe grains morning and evening. He states, however, that although the ulcers often healed they invariably broke out again; that in most cases the improvement was temporary, and in others inappreciable. According to Dr. Lutz, the exhibition of six to eight grammes (92£ to 123£ grains) of salol daily is of service in the leprous fever, and in some cases leads to rapid disappearance of the acute eruptions. Salicylate of sodium in daily quantities of six grammes (92.} grains) has the same effect, but is not as well borne. Antipyrine is useful in the neuralgiform pains of the anaesthetic variety. Dr. Lutz esteems chrysarobin as the most benefi- cial local application. He believes that ichthyol given internally has no specific poAver, but has a local effect in allaying inflammatory symp- toms. Dr. Rake has seen no definite benefit folloAv the use of ichthyol or resorcin. Picrate of ammonium is useful, he declares, in the head- ache which accompanies the pseudo-malarial attacks. The cantharidine treatment proposed by Prof. Liebreich for laryngeal tuberculosis has been applied to four cases of leprosy. This plan consists in the sub- cutaneous injection of one to tAvo decimilligrammes of cantharidate of potassium. In the cases referred to the tubercles became smaller and softer, the ulcers manifested a disposition to heal, and cicatrization occurred in some places. No pronounced effect was observed with re- gard to the anaesthesia in general, but in certain spots sensation seemed to be improved. No alteration wras perceived in the enlarged nerves. Tuberculin has been used experimentally in leprosy, but, according to Danielssen, has only the effect of aggravating the disease. Other drugs Avhich have at times given apparent good results Avhen administered internally in leprosy are carbolic acid in the daily dose of half to one gramme, iodide and bromide of potassium, hydrocotyle Asiatica, hura Brasiliensis, hura crepitans, phosphorus, and antimony. Dr. H. Radcliffe Crocker has lately had promising results in two cases from the hypodermic injectiob, once a week, of one fifth of a grain of corrosive sublimate. In some instances the use of potassium chlorate in massive doses has been folloAved by improvement. A method of treatment by anti-leprous serum has been advocated by Dr. Carras- quilla, of Bogota. This may possibly prove of advantage, but must at the present time be regarded as in the experimental stage. The local symptoms must be treated as they arise. The cutaneous 644 DISEASES OF THE SKIN. pain and hyperaesthesia may be relieved by subcutaneous injections of cocaine or of morphine and atropine. Aconitine, chloroform, counter- irritation, and wet cups have also been used. The succeeding anaesthe- sia may frequently be lessened or its development retarded by the per- sistent use of a mild galvanic current. Absorption of some of the tuber- cles may be secured, in the early stages at least, by the application of iodine, nitrate of silver, mercurial ointments, or small blisters. Brocq advises destruction of the tubercles prior to ulceration by electro- cautery. x\fter the operation the surface is washed with a sublimate solution (1 to 1000) or a solution of carbolic acid (1 to 20), and an oint- ment containing boric or carbolic acid applied. The tubercles and infiltrations on the tongue and in the mouth and larynx may be rendered less painful by the application of a solution of cocaine. All ulcerations should be dressed with subnitrate or sub- iodide of bismuth, in the hope of inducing early reparative action. If the ulcerathe process manifests a disposition to spread, the bottom and edges of the ulcer should be thoroughly mopped with pure carbolic acid, and the bismuth applied afterward. Iodoform and salol have also been used in dressing leprous ulcers. Ulcers of the mucous mem- brane are touched with nitrate of silver in stick or solution or with tincture of iodine. Sulphur, iodine, and salt-water baths are benefi- cial in all stages of the disease. Nitric-acid baths have also been used, it is said, with good effect. Hillis, Dougal, and Espinet have written enthusiastically in favor of external applications of gurjun-oil. The majority of the patients who employed this remedy were wonderfully benefited, and some were so much improved by its use that they were enabled to resume their former occupations. The oil of cashew-nut was introduced as an external medica- ment in leprosy by Dr. Beauperthuy, of Cumana, in Venezuela, and has been recommended by Dr. R. H. Bakewell, late physician to the Leper Asylum of Trinidad. Cashew-nut oil is contained in the edi- ble fruit of the Anacardium Occident ale, natural order Terebintacea3, a small tree, native of India. The nut is about the size of an almond, and has two shells, between which is found the oil, which is inflammable and exceedingly caustic. Tubercles and a portion of skin surrounding them are painted with the oil, Avhich should then be rubbed into the skin. A little oozing follows, and in a day or two dries up into a scab. When the scab falls the tubercle is diminished in size. The oil should never be applied over a surface larger than six inches square. This writer advises the local use of nitrate of silver to anaesthetic parts. Balsam of Peru, copaiba, naphthalene, and iodide-of-sulphur ointment have likewise been used with more or less success. Nerve-stretching has been practiced for the relief of leprosy with a certain amount of temporary success. In thirty cases reported by TUMORS. 645 Lawrie and thirty-two by DoAvnes, it was claimed that normal sensi- bility was restored to anaesthetic patches. Beaven Rake has published the results of one hundred operations.* The most notable results were obtained in those cases in which the operation was performed on ac- count of pain, especially that associated with perforating ulcer. In two cases the suffering had been intense, but vanished almost immediately after the nerve had been stretched. In some the ulcers likewise improved, but in others they became gangrenous. The results in an- aesthetic leprosy were less encouraging. In a few cases slight tempo- rary gain Avas observed, and in some there appeared to be a certain degree of improvement of sensation a year after the operation. On the whole the results were not satisfactory. No effect upon the growth of tubercles or general infiltration of the skin could be ascribed to the operation. In two cases the separation of necrosed bone seemed to be facilitated. In one hundred cases operated on, without any particular selection, more or less relief was given in half the number. In nearly half the cases the nerve Avas found to be enlarged. The most commonly affected was the median, next the ulnar and external popliteal. The sciatic was never found increased in size. In a later communication f Dr. Rake gives his experience in the treatment of the perforating ulcer of leprosy by a method which is simpler and often efficacious. This consists in passing a bistoury through from the ulcer on the sole of the foot to the dorsum and cutting straight forward through all tissues and bringing the bistoury out betAveen the toes. The operation, he thinks, promises well, and deserves further trial. It is true that such cases as have been cited may encourage the physician to persistent and prolonged effort in the hope of at least checking the course of the malady and relieving its manifestations. It must at the same time be confessed that they do not afford very con- clusive evidence as regards the efficacy of medicinal treatment. In a disease characterized by such chronicity and at the same time by such variations in the rate of progress, the improvement in Dr. Dreck- mann's case, conspicuous and gratifying as it undoubtedly is, has not yet been exposed to the test of time. It may prove that, under favor- able circumstances, chrysarobin and pyrogallic acid, locally applied, may cause retrocession of leprosy. This certainly is a boon to the in- dividual patient, but it would be very hasty to conclude that his leprosy Avas cured, much more so to believe that the same measures would fre- quently have the same happy result. It is not unusual for the disease to remain stationary for a considerable period of time under any mode of treatment, or in the absence of treatment. A pertinent case is re- lated by Dr. Castor, Medical Superintendent of the Leper Asylum of * " The Value of Nerve-Stretching in Leprosy: Based on One Hundred Cases." British Medical Journal, December 22, 1888. f British Medical Journal, November 8, 1890. 646 DISEASES OF THE SKIN. British Guiana. This observer remarks that the tendency to remain stationary is particularly characteristic of non-tubercular cases. The patient's body had been covered with patches; there was anaesthesia over the limbs and parts of the trunk, with paralysis and atrophy of the muscles of both legs. No drug had been used, yet " the patches have all disappeared. Sensation is present over the body, but only partially in the hands and feet and in the lower parts of one leg; in this leg the paralysis is passing off, while the other has quite regained its normal power and function." The only remedial agents were the hygienic advantages of the asylum and good, wholesome food, includ- ing salt fish. He mentions other cases Avhich had so improved that they might be described cured. He had used for two months the oint- ments recommended by Unna without result. Similar cases have been observed in Norway. One, referred to by Dr. Abraham, had remained in a state of arrest for fourteen years. Some years ago Mr. Hutchinson exhibited a woman quite free from leprosy, though twenty years pre- viously she had been the subject of the tubercular form of the disease. Prognosis.—The prognosis of lepra is always unfavorable. Tem- porary improvement may sometimes be obtained in isolated cases, and the disease may seem to be arrested or cured. Sooner or later, hoAv- ever, new symptoms develop, and the disease resumes its inexorable course. The immediate prognosis depends upon the type of the dis- ease, the number of years it has existed, and the presence or absence of complications. Patients affected with tubercular lepra die sooner than those Avho are attacked by the macular and anaesthetic varieties. Pneumonia, erysipelas, Bright's disease, etc., add to the gravity of the prognosis. According to the experience of Dr. Impey, the average duration of anaesthetic leprosy is about six years, and its maximum duration about eleven years from the time that the first symptoms appear. According to Hillis, the ultimate causes of death in leprosy, pro- portionally exhibited, are as follows : Bright's disease.................................. 22*5$ Pneumonia, etc.................................. 17 # Diarrhoea....................................... 10 Petroleum......................... 50 parts. White wax........................ 40 " Alcohol........................... 50 " Soap............................. 100 " M. In similar cases Tresilian has derhed benefit from carbolized oil, in the proportion of one part of carbolic acid to fifteen of olive-oil. The preparation is well rubbed in, and the case is usually cured within two or three days. The anaesthetic action of the acid soon abolishes the itching. Chlorinated oil has also been for some years in my experience 712 DISEASES OF THE SKIN. a most serviceable remedy in scabies. The well-known effects of chlo- rine lotion, a very old remedy, caused the writer to experiment with olhe-oil saturated with dry chlorine gas, with even better results than with the former preparations. What I have termed " chlorinated oil" is ordinary olive-oil saturated with chlorine. It contains many volumes of chlorine, and, as a substitutive compound, the chlorine having lost its identity and odor, makes an unobjectionable remedy that acts with- out irritation or inconvenience to the patient. Styrax is a valuable remedy on account of its pleasant odor and its cleanly and unirritating effect. McCall Anderson recommends, in preference to all other rem- edies, styrax in the form of the following ointment: Styrax, one ounce ; lard, two ounces; melt and strain. Sulphur was formerly the remedy 1 mainly relied upon for the treatment of scabies, used in from one half to two or more drachms to the ounce of lard. While it is, no doubt, a most effective remedy employed alone or in combination with other agents, yet its pungent, penetrating, and unpleasant odor makes it very objectionable for applications in private practice. I esteem sulphur a remedy of much value in dispensary and hospital practice, and often, in long-standing cases that have resisted its application in the form of an ointment, I have obtained additional good effects by administering an occasional sulphur-vapor bath. Combinations of sulphur have also been employed, as the sulphide of potassium, iodide of sulphur, and hyposulphite of sodium. From the observation of Dr. George F. Duffy thiocamf would seem to be an efficacious remedy. It Avas employed in a four-per-cent. solution in olive-oil. Thiocamf is a fluid produced by the action of sulphurous-acid gas upon camphor. Balsam of Peru, sapo viridis, tar in its various forms, carbolic acid, potassium carbonate, the mercurials, staphisagria, lime, the essential oils, iodoform ointment, creolin, turpentine, and a host of other rem- edies, haA*e been recommended either alone or combined, with or with- out sulphur. Creasote ointment has also been found effective. The great objection to the employment of most of the agents named is their unpleasant odor, and frequently their irritant action. In the event that the skin will bear it, the following ointment of Bonrguignon will be found useful; if too stimulating, the oils and sulphur may be de- creased in quantity: IJ Olei lavand., Olei menth., Olei carophyll., Olei cinnamom.................... aa 3 j. Pulv. tragacanthae ................... 3 j. Potassii carbonatis.................... 3 j. Flor. sulphuris....................... | iij. Glycerini............................ | vj. M. Ft. ungt. PARASITES. 713 The following ointment can also be recommended : IJ Sulphuris sublimati.................. 3 j. Olei cadini......................... 3 j. Balsami Peruviani.................... 3 j. Adipis.............................. | j. M. Ft. ungt. Vleminck's solution and Helmerick's ointment are both valuable, providing there is no objection to them on account of their odor, and that they are not too strong applications for the skin. The first- named preparation is made as follows: IJ Sulphuris sublimati.................. 3" j. Calcis.............................. 3 ss. Aquae.............................. 3* x. Coque ad § vj, deinde filtra. After the use of the bath, two applications of this preparation will, it is said, cure the itch. Helmerick's ointment is prepared in the following manner: IJ Flor. sulphur....................... 3 ij. Potassii subcarbon.................. 3 j. Ungt. simplicis..................... § j. M. Hardy and others in France employed at one period a rapid method of treatment, by rubbing the patient for half an hour Avith sapo viri- dis, placing him in a warm bath in which he remained another half-hour, and then rubbing the parasiticide well into the affected part, when the disease Avas cured. AVilkinson's ointment, the formula of which, as modified by Hebra, is often more suitable to employ than the original, is as folloAvs : IJ Flor. sulphuris, 01. cadini....................... aa 3" A'j. Saponis viridis, Adipis..........................aa Oj. Cretae............................. 3 iv. M. Ft. ungt. . Four applications of this ointment are made within forty-eight hours, after which the patient lies between woollen blankets or wears woollen clothing, and at the end of a week the treatment is concluded by a bath. The application, while effective, is tedious, painful, and more adapted to hospital than to private practice. Radcliffe Crocker advocates a mode of treatment by baths containing sulphide of potas- sium in the proportion of four ounces to thirty gallons of Avater at a temperature of 100° Fahr., the patient remaining immersed for a quarter of an hour. He states that one or tAvo baths are usually cura- tive, but that three are generally given. The application of one or another of the remedies or combinations described should usually, un- less contra-indicated, be preceded by a hot bath, with soap, after which 714 DISEASES OF THE SKIN. the preparation to be used should be well rubbed into the part twice a day for at least three days. At the end of this time another bath should be taken, and the skin critically examined to ascertain if the itch-mites have been destroyed. The parasiticide should, however, be continued, notwithstanding that the irritation may have lessened, until all evidence of the presence of the itch-mite has disappeared. The skin may con- tinue inflamed even though the insect has been destroyed. The dis- ease, it should be noted, may be overheated, and the skin so irritated by the remedies employed to destroy the parasite as to demand the use of the soothing or astringent remedies described in the chapter on eczema. It is of importance that, after the disease has been cured, the cloth- ing should be exposed to a heat of 212°, in order to destroy any parasites Avhich may adhere to them and prevent a renewal of the affection. Gloves should be burned. Prognosis.—Scabies is a curable disease in from one to two weeks' time. If the treatment is not properly carried out, or the disease has existed for some time or is complicated Avith severe secondary lesions, the restoration of the skin to its natural condition may be long and tedious. A rapid cure in prhate practice will depend upon a hearty co-operation at all times upon the part of the patient. PEDICULOSIS. Synonyms.—Phtheiriasis—Lousiness—Lausesucht—Phthiriase. Pediculosis is a contagious disease caused by animal parasites called pediculi, or lice, which attack the skin, producing both primary and secondary lesions. Symptoms.—The parasite infesting the human body knoAvn as the louse belongs to the class Insecta, order Hemiptera, and family Pedic- uli'dce. It is a Avingless insect, of which there are three species, the pediculus capitis, pediculus corporis, and pediculus pubis, infesting respectively the head, the body, and the pubes.. These three species of lice cause, in attacking the body, a slight or a great annoyance, some- times entailing much suffering. The various symptoms which they originate may be best described under each of the species just named. Pediculus Capitis.—The head-louse is found chiefly upon the scalp, and but rarely upon other regions of the body. It measures in length about two millimetres, and in breadth one millimetre, the female being larger than the male. Its color is generally grayish, but, as Geber remarks, it may change its tint with that of the skin of its host, being on the Esquimaux white, on the negro black, and on the Chinese yellowish-brown. In shape it is elliptical, and consists of a head, thorax, and abdomen. (See Fig. 21.) The head of this species of louse is triangular or acorn-like in form, PARASITES. 715 and is furnished with a pair of five-jointed antennae and a pair of large, black, conspicuous eyes. The thorax, Avhich is broad, has pro- jecting from its sides six hairy legs furnished with stout claws. The abdomen, Avhich includes more than half the length of the insect, is divided on each side into seven Avell-defined segments. In the male there protrudes from the back a large wedge-shaped penis with testes. The female possesses ovaries, the oviducts of which communicate Avith the vagina, which terminates upon the ventral surface. The female deposits in the course of a week about sixty eggs, or nits, which are -white and elliptical in form. They are usually glued to the lower part of the hairs or along their shafts, a congeries of them sometimes being fastened to a single hair. In the course of from three to six days the young are hatched out, and are capa- FlG- 2].-(Photo-micrograph.) J ° x rediculus capitis. ble of reproduction in from eighteen to twenty days. Lice may occur in small or large numbers, depending upon the duration of the disease and the attention it has received. Pediculi capitis may be observed more particularly in the occipital region of the head. They are generally to be found on the heads of uncleanly children, especially of those who are poorly nourished, and are often thus spread through schools. They are also met Avith in adults, particularly among those who have long and thick hair, in Avhich they find a most acceptable habitat. The parasites excite by their attack upon the scalp a greater or less amount of irritation, which causes itching and scratching, accompanied with wounding of the parts, an escape of serum and of bloody or purulent fluid, which together dry into crusts and mat the hairs. The itching may become almost in- tolerable, and the sufferer become so disturbed in both mind and body as to be affected in general health. AVhen pediculi are present, of course the eggs or nits are to be found. They have the appearance of scales of seborrhcea upon the hairs, in recent cases usually near their roots, and in old cases near the extremities of the hairs. The ravages of lice depend upon the state of the patient's health and that of the scalp, being generally very severe, in the neglected, the poorly nour- ished, and in those avIio are out of health. An eczema of the parts may take place, especially in those predisposed to it, and may extend beyond the scalp forward to the forehead or back to the neck. The inflammatory action may at times be so severe as to occasion the adjoining lymphatic glands to become swollen and tender. In neg- lected and long-standing cases, the head, Avith its dirty, matted, twisted, 716 DISEASES OF THE SKIN. and glued-together hairs, filled with decomposed pus, crusts, lice, and nits, presents a most disgusting spectacle, and exhales an offensive odor. Pediculus Corporis, or body-louse, pediculus vestimenti, or clothes-louse, is larger than the head-louse, but otherwise resembles it. (See Fig. 22.) It is about two millimetres long and one millimetre broad, the females being larger and more numerous than the males. The color of the parasite when not filled with blood is of a dirty white, grayish, or yelloAvish tint. In shape the female is elliptical; the head is acorn-like in form, with conspicuous eyes, and is furnished with tAvo hairy, five-jointed antennae. The thorax is square and plainly separated from the abdomen, and is pro- vided on each side with three jointed, long, hairy legs with strong claws. In the female the abdomen is broader than in the male, the sides being also more deeply serrated, and terminating in a triangu- lar notch. The abdominal sections in the two sexes are less distinctive than in the case of the head- louse. The penis in the male is large and wedge- shaped, and projects from the middle of the abdo- men. The domicile of the body-louse is the cloth- ing covering the body, especially the seams and folds of the undergarments. It lives in the clothing, and frequents the integument only to obtain nourish- ment. In bad or neglected cases in which the lice are numerous, they may be seen drawing blood or wandering over the surface. The female lays in the clothing about sev- enty eggs, which mature in from four to eight days, and the progeny are capable of reproduction in from sixteen to eighteen days. Sometimes, by reason of the clothes having been changed, the only evidence of the disease may be the characteristic lesions Avhich the lice make upon the skin. The peculiar injuries Avhich they make are produced by the ac- tion of their haustella or suckers inserted in the follicles of the skin, developing haemorrhagic spots. A minute quantity of blood escapes from the follicle after the parasite has withdraAvn its sucker, and the spot remains as the primary and characteristic evidence, by which alone the disease may often be detected Avithout searching for the parasite. The parasites cause both by their movements and their attack upon the skin more or less unpleasant irritation. A burning, creeping, stinging, and unbearably itching sensation sets in, and the sufferer, seeking relief, indulges in scratching, that may lead to the de- velopment of excoriations, wheals, papules, pustules, crusts, pigmenta- tion, and thickening of the skin. A striking picture of multiform lesions is thus often presented by patients attacked by the body-louse. The secondary manifestations may be especially varied, the scratch- marks being either short or long, superficial or deep; the excoriations, Fig. 22.—(Photo-mi crograph.) Pedicu lus corporis. PARASITES. 717 crusts, wheals, papules, pustules, and abscesses, of all sizes and forms. These lesions may likeAvise vary according to the duration of the dis- ease and the condition of the patient's health. In some persons af- flicted Avith the malady for a long time, more particularly in cases ex- acerbated by scratching, a brownish or blackish pigmentation results, and occasionally some thickening of the skin. Pediculosis corporis occurs most frequently in old persons, but it may also be met with in the young. The affection is very common in all countries among the uncleanly. The seat of the disease is chiefly about the neck, shoulders, clavicles, chest, back, and abdomen, but it often spreads over the whole surface. Upon the bodies of light-complexioned people spots of a steel- gray color are sometimes produced by body-lice. These marks vary from the size of a pea to that of the finger-nail, and are generally found upon the trunk, inner aspect of the thighs, and arms. They were produced experimentally by Duguet, who introduced into the skin a paste made by rubbing up the pediculi with Avater. Pediculosis Pubis, or phthirius pubis, phthirius inguinalis, mor- pio, or the crab-louse, usually attacks the pubic or inguinal regions, although it may also invade the eyebrows and eyelashes, the beard, the mons veneris, the anus, the axillae, the sternal region, the thighs and abdomen, the scrotum, or, except the head, any part of the body sup- plied with hair. (See Fig. 23.) The crab-louse is smaller than the other species, the male measuring only one millimetre in length and six tenths of a millimetre in breadth, and, as well as in the other spe- cies, being smaller than the female. Its body is short, broad, and flat, and upon it is placed an oval-shaped head provided with two long five- jointed antennae, and having a pair of small, hardly discernible eyes. The thorax and abdomen are united as one, and from the lateral part of the former project two pairs of six-jointed hairy legs furnished with claAvs, the first pair being relatively delicate and weak. The abdomen is heart-shaped, its margin slightly in- dented, and provided Avith eight short, conical feet that terminate in stout hairs. In color the insects are yellow- ish gray, and are somewhat transpar- ent. They arc, on account of their inactivity and transparency, very hard _ \ A . J . *' .. Fig. 23.—(Photo-micrograph.) to detect m their nidus, the lice are Pediculus pubis. usually found with their heads well buried in the orifices of the follicles of the skin, Avith claws and bristles clinging closely to the hairs. Sometimes they are discovered crawding about the hairs or in close contact with the skin. Their ova are smaller than those of the head-louse, but are similar in color and firmly attached to the hairs, occasionally appearing like small pearls glued to the hairs, 718 DISEASES OF THE SKIN. and are sometimes observed on the eyelashes. The excrement of the parasite may also be seen on the skin about the hairs, recognizable as minute, reddish particles. Crab lice are more common at maturity than during adolescence. They are contracted frequently through sexual intercourse, and spread to other hairy parts of the body from the pubes. The insects may be communicated also by clothing or by bed- ding, and are thus sometimes transmitted to children. The amount of irritation or inflammation that they may occasion through scratch- ing varies greatly, being severe in some persons and slight or hardly perceptible in others. Diagnosis.—The circumstance of intense itching without any dis- tinct eruption should ahvays raise suspicion of the presence of parasites and prompt search for them. If pediculi be present, they are readily detected, particularly when numerous. Sometimes, when only a few parasites are present, it is possible to overlook them unless the examina- tion be most critical. Persistent search failing to reveal any trace of parasites, it may be concluded that, even if once present, they are removed or destroyed. Yet, notwithstanding this conclusive test, cases do occasionally occur where persons are so imbued with pediculiphobia that, although free from the parasites, they still imagine them present. The diagnoses of the several Ararieties of the disease may be made as follows: Pediculosis Capitis.—This disease is almost always detected by the presence of the parasites or of their nits. These are generally found at the top and back of the head, about the occipital region, together with more or less secondary changes produced by the animals. They often thus set up an eczema of the scalp that masks the original ailment, but careful search for and detection of the lice or their nits may settle the primary cause of the disease. Occasionally it happens that the eczematous condition of the scalp has furnished a breeding- place for the pediculi. If the two conditions coexist, it is impossible at once to conclude which is the primary affection. The history, course, and the fact that pediculi frequently cause eczema, especially in the case of persons out of health, Avill usually serve to indicate which is the primary disease. Pediculosis Corporis.—Pediculi of the body are often overlooked if no parasites are discovered upon the skin. They are rarely found by examination of the skin, but should be searched for in the seams and folds of the underclothing. The existence of the minute haemorrhagic spots, with blood-crusts and excoriations made by the instrumentality of the finger-nails, especially around the shoulders, the clavicular region, and the back, are in most instances sufficient for a diagnosis. The differential diagnosis between pediculosis corporis and eczema, prurigo, paraesthesia, and scabies, is indicated in the description of those affec- tions. PARASITES. 719 Pediculosis Pubis.—Itching around the pubes, scrotum, mons veneris, anus, axillae, and other hairy regions, except the scalp, should arouse suspicion and lead to a most careful examination of the parts. The detection of dark specks close to the hairs as they issue from the follicles, Avith sometimes small whitish or yelloAvish specks (nits), also in close contact with the hairs, should establish the diagnosis. Pedic- ulosis pubis may be mistaken for eczema or paraesthesia. The char- acteristic difference between them is pointed out under the head of the description of the last disease. Etiology.—Pediculosis is caused by the parasites just described. They may attack any person in any condition of life. Lice are more likely, however, to increase and multiply and occasion marked primary and secondary lesions on those surrounded by bad hygienic influences, Avho live in foul air, drink impure water, do not bathe, are poorly nour- ished, or in bad health. Pediculi, according to the most recent investi- gations, do not, as was at one time supposed, obtain their food with a mouth furnished with mandibles, but with a haustellum or sucker. This sucking apparatus is inserted in the follicle of the skin, through Avhich the blood is drawn, leaving at the opening of the follicle a minute quantity that remains as the haemorrhagic spot previously de- scribed. It is the irritation set up by this act that leads to all the sub- sequent secondary changes. Treatment.—It is necessary, in order to cure pediculosis, first to destroy the parasites and their ova; and, secondly, to remove all the changes Avhich have been caused in the skin. Among the many reme- dies that may be employed for the former purpose are naphthol, the mercurials, tobacco, cocculus Indicus, staphisagria, sabadilla, pyrethrum, carbolic acid, and sulphur. These may be used either as poAvders, lotions, and ointments, and some eATen in the form of soaps. The ointment of the mercuric oleate is very efficient in the different forms of this affection, and may very suitably be combined with one per cent, of picrotoxin. If the latter substance be added, however, care should be taken that the mixture is not brought into contact with an abraded surface. It is essential to add, in this connection, that in employing any remedial agent Avhatsoever the greatest personal cleanli- ness should be adopted or enforced. The debilitated and badly nour- ished, of course, need good food and tonics. Pediculosis Capitis.—Naphthol and corrosive sublimate are most useful in destroying the parasites. The best means of employing these agents is by incorporating them Avith soap. Naphthol or cor- rosive-sublirnate soda-soap, used with Avater once or twice a day, is the most cleanly mode of removing pediculi. These preparations are pharmaceutical^ not only elegant, but they aid in removing the crusts and other extraneous matter which may be on the scalp. The same drills may also be used combined Avith potash soap, if the lat- 720 DISEASES OF THE SKIN. ter do not prove too severe for the integument. Lotions and oint- ments of either naphthol or corrosive sublimate may likewise be used, but they are often objectionable on account of irritating the parts or matting the hairs. It is particularly for the last reason that, in treat- ing pediculi of any hairy part of the body, lotions and oils are prefer- able to ointments. Infusions or tinctures of tobacco or cocculus In- dicus may be used with advantage. The nits, should any remain, may be destroyed by solutions of soda or borax. Vinegar, dilute acetic acid, and alcohol also ser\Te well the same purpose. It is unnecessary to cut the hair either of children or adults, providing that cleanliness and any one of the remedies just named are persevered in until the parasites and their nits are thoroughly destroyed. Fine-tooth combs, which are much resorted to for removing the nits and crusts, should always be employed, if at all,with the greatest care. They are too often used care- lessly, and excite inflammation of the scalp. If it be decided to employ an ointment, white precipitate, five to thirty grains to the ounce of fatty matter, or sabadilla or staphisagria ointment, can be applied with benefit. Crude petroleum, or its refined preparation, kerosene, is also an efficient remedy for destroying pediculi. It may be rendered less inflammable and less disagreeable by mixing it with olive-oil or balsam of Peru. Its unpleasant odor is always perceptible, no matter with what the oil is combined. On account of its offensiveness and uncleanliness, I have abandoned its use, and now confine myself almost entirely to either naphthol or corrosive-sublimate soap. A five- to ten-per-cent. creolin-oil is an efficient antiparasitic agent, and the oil of rosemary and benzin possess the same property. If in the course of pediculosis eczema appears, it is to be treated in the manner referred to in the description of that disease. Pediculosis Corporis.—As pediculi and their ova harbor in the clothes and not on the body, it is necessary, as part of the procedure in treating an attack of the disease under consideration, to bake, boil, burn, or otherwise destroy the clothing that has been worn by the pa- tient, if one would make perfectly sure of the extermination of the para- sites. The underclothing should be continually subjected to examina- tion, and be frequently changed. If this course be not pursued, it will be impossible to eradicate the parasites. Sometimes it may be imprac- ticable at once either to sacrifice the clothing or to subject it to sanitary treatment, and in this event washing the skin with naphthol or corro- sive-sublimate soap, or applying to it an ointment of thirty to sixty grains to the ounce of naphthol, white precipitate, or staphisagria, will keep the parasites from the person. The secondary effects of the at- tack of pediculi may be relieved by either weak mercurial or naphthol ointment, an alkaline or emollient bath, or a carbolized lotion of either oil or glycerine applied to the parts. Pediculosis Pubis.—After the presence of crab-lice has been rec- PARASITES. 721 ognized, they can be destroyed by any of the soaps, lotions, or ointments already suggested. Eczema resulting from the irritant action set up by the parasite is to be treated according to the conditions indicated. Prognosis.—The disease, if properly managed, has but a short dura- tion. Pediculi of the Lower Animals.—The lice peculiar to the lower animals may transfer themselves to the human body, occasion- ing either slight or severe irritation! Goldsmith reported the case of a woman who experienced intense itching, and after excessive sweating had a number of pigeon- or hen-lice come from the sweat-pores. Cleanliness and the use of naphthol soap, a solution or ointment of naphthol or corrosive sublimate, will effectually destroy these lice. CIMEX LECTULARIUS, AOANTHIA LECTULARIA. The bed-bug, a wingless insect, provided with a stinging and suck- ing apparatus, obtains from man its ordinary sustenance, with which, howeA'er, it can dispense for long periods. It is brownish-red in color, and on being crushed emits a most rank and offensive odor. Its habitat is in beds, bed-clothing, in Avood, especially in the cracks of floors, Avails, behind Avail-paper, and in old furniture. It tenants in large numbers old and neglected rooms and houses, especially those of people in the lower walks of life. The bite of the bed-bug makes a haemorrhagic lesion, around which is produced an urticarial wheal. The skin in some persons being very sensitive, particularly in children, the ef- fect of the bite of the insect is at once apparent, through the sensa- tion of a pricking, itching, and burning feeling which stimulates scratching, Avhence, through the combined effects of the poison and abraded skin, secondary changes arise. There are, however, persons whose skin is in no Avise irritated by the bite, the sole effect of which is the haemorrhagic lesion upon the part attacked. The cause of the disease having been ascertained, the wheals and other secondary changes can be at once relieved by applying to them soothing lotions or ointments. Four ounces of camphor-Avater, half a drachm of pow- dered borax, a solution of corrosive sublimate, tAvo to four grains to the ounce; a drachm of boric acid, or half a drachm of carbolic acid to the pint of water, are all effecthe applications. The benzo- ated oxide-of-zinc ointment, combined with either calomel, salicylic or boric acid, is likeAvise useful. The best agents to employ for erad- icating the insect from beds, floors, walls, and other places in Avhich they seek refuge, is corroshe sublimate or naphthol, one or two drachms of either to a pint of water. All substances in Avhich their presence is suspected should be washed thoroughly with one or another of the aboA-e-mentioned lotions every feAv days, until all signs of the insect disappear. 46 722 DISEASES OF THE SKIN. PULEX IRRITANS, OR FLEA OF MAN. This minute parasite, brownish-red in color, is very common, especially in warm climates. It seeks the skin of man, and by its bite sometimes gives rise to very great annoyance. In piercing the skin the insect injects into it an irritating fluid, producing a small haemorrhagic point surrounded by an erythematous aureola, char- acteristic of the flea-bite. A certain amount of irritation, with itch- ing and the formation of wheals, may result. Flea-bites are sometimes so numerous and venomous as to simulate morbilli and scarlatina. The rapid subsidence of the hyperaemic aureola, together with the detec- tion of the parasite, is sufficient to establish the diagnosis as that of simple flea-bites. They can generally be relieved by applications of alkaline lotions, or solutions of naphthol or corrosive sublimate. PULEX PENETRANS. The sand-flea, known also as the chigre and jigger, is egg-shaped, brownish-red in color, and only half the size of the human flea. It is found in tropical countries, along the Pacific slope, and in the Southern States. The male is said to obtain its nourishment from any animal, man or beast. It is, however, only the fecundated female that bur- rows in the skin, developing a painful swelling with vesiculation or pustulation, which may in neglected cases produce ulceration, entail the loss of a member, or even result in death. The favorite point of attack is the feet, about the nail-bed of the toes. Its field of activity, as indicated by its name, is in sand, where children especially are open to its attack. The bite of the insect is at first hardly apparent, but as it becomes gorged and swells to the size of a pea, the bite becomes particularly painful. Sweaty feet are noted to be exempt from its attack. The best preventive treatment is by good, substantial shoes and daily inspection of the feet. The essential oils, particularly the oil of wintergreen, are said to protect against attack. Eadical treat- ment consists in extracting the insect Avith. a red-hot needle, so as to remove also the eggs. The slight resulting Avound can be treated with any ordinary emollient. DEMODEX FOLLICULORUM. This parasite, also termed steatozoon, entozoon, or acarus follicu- lorum, lives in the sebaceous follicles of the majority of healthy persons. It is said to have been discovered both by Henle and Simon. The acarus is a microscopic parasite of Avorm-like form, and, according to Wilson, who has given a most minute description of it, of a length varying from one sixty-fourth to one one hundred and thirty-fifth of an inch. It possesses a head, thorax, and an abdomen which is several times as large as the thorax and terminates in a. PARASITES. 72! pointed extremity. Eight stout conical legs, all of the same size in the fully developed animal, and six in the young parasite, project from the thorax. The demodex of man is said to be similar to the variety that infests cats, dogs, mice, sheep, and Others FlG, 24.—Demodex folilculorum. of the lower ani- mals. The minute insect is discovered lying in a sebaceous follicle with the head directed inward. There may be from one to sixteen or more embedded in the same follicle, and they can be extracted without any difficulty. The contents of a follicle being squeezed out, and the prod- uct coA^ered Avith a little oil and placed beneath the microscope, one is enabled readily to detect the parasite, if present. The entozoon inhab- its the nose, lips, chin, ears, back, and chest, subsisting upon the seba- ceous substance of the follicle, and, according to Wilson and Geber, there is scarcely an adult upon whom they can not be found. They are met with in persons who have acne, comedo, and seborrhoea oleosa, as Avell as in those Avho are perfectly healthy. They have never beeh knoAvn, except in the case mentioned by Eemak, to have the effect of determining any other disease. LEPTUS. There are two species of this insect in the United States—the leptus Americanus and the leptus irritans. They are minute red insects, visible to the naked eye. These mites have six long legs, the body of the leptus Americanus being pyriform, and that of the leptus irritans oval. The former, called harvest-mite, buries only the anterior part of the body in the skin, especially that of the scalp and axillae, giving rise to the formation of a small papule. The latter, the irritating harvest-mite, which is of the two species more numerous in individuals, is found during the summer and autumn months in the fields, on the crops, on the grass, weeds, and bushes, especially upon the blackberry and gooseberry bushes. The harvest-mite usually attacks the ankles and legs, causing the development of papules, vesicles, and sometimes pustules, and occasioning an intense itching. An examination of the lesion will generally show to the naked eye the reddish or yellowish-red insect in its centre. The diagnosis established, care should be taken to prevent any further invasion by the insects. The parasites perish in the skin in which they are buried in the course of a few hours or days, after Avhich all symptoms disappear. The application of a weak naph- thol, sulphur, or mercurial ointment will generally give relief at once. 724 DISEASES OF THE SKIN. CYSTICERCUS CELLULOS2E. The presence of the hydatid of taenia solium in the skin and sub- cutaneous tissue has been demonstrated and reported by many ob- seiwers. It is more frequently met with in northern than in southern regions, and is especially common in northern Germany, where pork is used to a large extent, and sometimes not sufficiently cooked. The disease appears in the form of one or more cutaneous or subcutaneous tumors varying in size from a pea to a vvalnut. Fifty or more haATe in some cases been observed in the same individual. The development of multiple tumors is not simultaneous. If the cysticercus has perished, the tissue is generally shrunken and the tumor reduced to the mini- mum. If, on the contrary, the parasite is still living, the tumor is round or elliptical, smooth, and elastic, although firm to the touch. According to Cobbold, the parasite lives for about eight months, Avhen it dies spontaneously and undergoes fatty and calcareous degeneration. In course of time the tumor and its contents may be completely ab- sorbed. In its early stage the hydatid occasions no subjective symptom, but later, through increase in size, it may cause pain. Cysticerci of the skin generally occur in numbers on the back, the lateral parts of the trunk, and the extremities. They may, after reaching a certain size, remain unchanged for years, additional ones in the mean time crop- ping out. Finally, they may be accompanied by the development of cysticerci of the viscera, or after several years they may become obliter- ated in the skin or break down into abscesses. Cysticerci are sometimes met Avith in the vitreous humor of the eye and in different parts of the brain. A case has been reported by a Eussian observer in which they were present in the heart and lungs. Hydatids may be confounded with syphilitic gumma, lipoma, sebaceous cyst, carcinoma, or sarcoma. If the tumor be opened and the contents examined by the microscope, the parasite can be readily detected and the diagnosis established. The parasite is contained in a vesicle which is filled with colorless fluid. The vesicle, in its turn, is lodged in a cyst composed of connective tissue. The treatment con- sists in carefully incising the tumor, scooping out its contents, and managing the wound upon general surgical principles. FILARIA MEDINENSIS. The Guinea-Avorm is a parasite that is found in tropical countries, especially in India, Africa, and Asia. The young worm, which is of microscopic size, enters the skin, as some authors state, by boring. It is held by others that the Avorm may be taken into the system through food and water, particularly the latter, and find its way to the skin through the circulation. The embryos of the Guinea-worm probably PARASITES. 725 often obtain entrance to the human body by being swallowed in the drinking-Avater and liberated during digestion. Numerous instances of the means of ingress of the parasite have been cited by writers, who have shown that the exposed feet and limbs of the natives are the parts generally attacked. Hyde declares that from merely Avalking upon grounds Avhere the insect abounds, and from bathing in infected Avater, it is impossible that attack can occur. At all events, after its intro- duction into man as well as into the dog and the horse, which it also attacks, the worm remains quiescent for several months. At the end of that time, generally six months, it comes to the surface of the skin, causing more or less systemic irritation, with some local pain, sAvelling, redness, and a boil-like tumor, which breaking exposes the head of the Worm. The opening continues to enlarge uutil the worm with its em- bryos leaves the parts. In the course of some weeks a cicatrix forms in the place Avhich it occupied. In other cases, as in that reported by Dr. Van Harlingen, the lesion presented was that of a sinuous red line beneath the skin, which was slightly elevated by the worm. Death has been knoAvn to occur in consequence of prolonged suppuration, septicae- mia, pyaemia, or tetanus. The fully formed worm is cylindrical, some- what flat laterally,-tapers toward both extremities, and is milky white in color. It is from one tenth to one twelfth of an inch in thickness, and from one half to two or more feet in length. Only one Avorm occu- pies a swelling, but there may be present at the same time a number of tumors and worms in A'arious parts of the body. The treatment recom- mended by Horton is large doses of asafoetida, Avhich assists in destroy- ing the worm and in overcoming any tendency to inflammation and suppuration. Dr. Charles Forbes states that he has successfully em- ployed small doses of precipitated sulphur. Potassium nitrate in two- drachm doses given in buttermilk is reported to be curative. At the same time the head of the worm should be seized through the boil-like opening of the swelling, or through one made by an incision, and the whole animal be extracted as far as possible Avithout breaking. If the whole Can not be withdraAvn, Avhatever length of it has been secured should be wound around a light piece of card-board or wood fastened at the orifice. The winding of the Avorm should be attempted daily until the whole animal is extracted, Avhich may require several Aveeks, when the skin heals. Great care should be taken not to break the worm in the sore, because the part remaining Avould excite severe in- flammation. Dr. Emily recommends injection of a solution of corro- sive sublimate into the body of the worm and surrounding tissues. GESTRUS, THE GAD- OR BOT-FLY. The gad-fly will, particularly in South and Central America, attack the skin, depositing in it its ova. The embedded larvae may give rise to inflammatory boil-like SAvellings, having small central apertures that f26 DISEASES OF THE SKIN. yield a sanious discharge. The furunculoid tumors may change their places, arrange themselves in all forms, like a reddish-purple, tortuous line, as in the case reported by Walker. In a short time after suppu- ration sets in the worm may be squeezed out or extracted from the boils, or they open, forming an ulcer. The parasite attacks exposed parts of the body, especially the neck, back, and extremities. OULEX, GNAT, OR MOSQUITO. The mosquito, which is plentiful in all parts of the United States, attacks man in preference to the lower animals. Its sting occasions an itching which is sometimes most violent, especially with those per- sons having a sensitive skin, and gives rise to the formation of wheals. The irritation may be relieved by ammonia-water, spirit of camphor, peppermint-water, or lotions of corroshe sublimate, naphthol, or borax. A drachm or two of boric acid in four ounces of peppermint or cam- phor water often acts promptly in relieving the irritation. Immigrants from countries where the mosquito is unknown are sometimes, in con- sequence of the sting of that insect, attacked by severe dermatitis, as reported, among others, by Dr. James Nevins Hyde. IXODES, WOOD-TICK, OR WOOD-BEETLE. There are several species of ticks that invade the skin of man and the lower animals. They are met with in woods, on pines and bushes. The female of any of these species attacks the skin, imperceptibly in- serts her proboscis, and gorges herself until the body swells to the size of a pea, or larger. Any forcible attempt at this time to extract the insect is liable to result in breaking off the proboscis, Avhich, remaining in the skin, often occasions considerable inflammation and great pain. Rather than incur this penalty, it would be better to wait until the parasite has become gorged and drops off. But its discomfiture may, without waiting, be speedily accomplished by applying to it an oily substance, such as oil of terpentine, benzine, or tobacco-juice, which compels it to retract the proboscis and let go its hold on the skin. There are numerous other insects, as barley-mites, midgets, flies, ants, bees, wasps, leeches, caterpillars, centipedes, and spiders, which by their bites and stings, and in some cases even by their contact, may ex- cite wheals, papules, pustules, haemorrhagic spots, or even severe in- flammatory action. Death even has been known to result from the sting of a bee. Insects often drop upon and attack persons sitting under trees or on the grass during the spring and summer months, causing, as I have observed, various kinds of lesions that occasion at times a most violent itching or severe inflammation of the skin. The treatment of the effects of bites and stings inflicted by ordinary para- VEGETABLE PARASITES. 727 sites is to oe managed upon general principles. A soothing ointment or lotion is usually required. The pain that may follow the sting or bite may be relieved at once by almost any alkali, ammonia-Avater being one of the very best; and a lotion of permanganate of potassium excel- lent. Naphthol, corrosive sublimate, and borax lotions and ointments, are also efficacious. Dr. Phillipe Kicord, of Newark, instances a case in which he Avas able to employ a spray of hydrogen dioxide to the sting of a hornet directly after it was received. The pain ceased at once and the swelling rapidly disappeared. A raw onion, bruised and applied to the wound caused by such bites and stings, is sometimes an excellent remedy. Some species of spiders found in tropical and sub- tropical countries are so venomous as to produce serious tetanic or nar- cotic symptoms. Dr. T. W. Schaefer, of Kansas City, has pointed out that a poisoned sting is caused by the Belostomo Americana or B. griseus, the so-called "electric-light bug." The bites of human beings are apt to be followed by very serious symptoms, and sometimes by death. Among the bad effects of the human bite, Dr. Soriano, of Mexico, enumerates phlegmon, erysipelas, destruction of tendons, or aponeuroses. Recovery is slow and painful. Deep incisions are re- quired, especially when the aponeuroses is wounded. The membrane itself should be divided. It becomes necessary sometimes to amputate a member, as a finger, toe, hand, or foot, in order to save life. VEGETABLE PARASITES. TINEA VERSICOLOR. Synonyms.—Pityriasis versicolor—Chromophytosis—Kleienflechte. Tinea versicolor is a vegetable parasitic, cutaneous disease, aris- ing from the presence in the skin of the microsporon furfur, and char- acterized by the development of yellowish, reddish, or brownish fur- furaceous patches of various shapes and sizes. Symptoms —The parasite of tinea versicolor does not attack the hair or nails, and only superficially involves the epidermis. It mani- fests its presence by yellowish, reddish, brownish, and in exceptional cases blackish, irregularly shaped furfuraceous macules or patches of various sizes. Tinea versicolor occurs most frequently between the tAventieth and fortieth years, but may appear at any age. The disease usually first develops as small, round or oval, erythematous or yellow- ish spots slightly elevated above the surface. The patches are usu- ally situated upon the chest or shoulders, and may be upon the ab- domen, back, arms, and thighs, but never appear upon the face or hands. They vary exceedingly in number and color as well as in size and shape. In some cases they are few and isolated, not exceeding half an inch in area, but in other cases they are so numerous as almost '728 DISEASES OF THE SKIN. to cover the entire surface of the chest and abdomen. The lesions in- crease in size by peripheral extension, and frequently coalesce to form large, irregular patches. They are, when first observed, usually reddish or yellow, but may be of any shade from light yellow to dark brown. In a remarkable case observed by Tilbury Fox, the patient, who- was from a tropical climate, was covered on the back and sides with black, desquamating patches, which, upon microscopical examination, were found to be patches of tinea versicolor. Dr. George Dock has reported a similar case in a man who had never lived in a warmer latitude than that of Michigan. In general, however, the lesions are of that peculiar fawn-colored cast that the French describe as '•'•cafe au lait." Tinea versicolor never produces constitutional symptoms, and is not accom- panied by any marked subjective phenomena. The skin upon which the eruption is situated may become congested or irritated, and may assume an eczematous or urticaria-like appearance, but this is a rare occurrence. The scales may be abundant, or loose, scanty, and adher- ent. They are very fine, and of a branny appearance, and can readily be detached by rubbing or scraping. Their amount varies with the cleanliness of the patient, being always less after bathing. If not thus removed, but allowed to accumulate, there results a dusty, rough ap- pearance, readily removed by friction. When the skin is bathed with perspiration, they form a mealy paste, or shape themselves in the folds of the skin into pasty rolls. The eruption causes in stout persons, and in those who perspire freely, more or less annoyance from itching. The itching is, however, in many cases absent or so insignificant that the disease is not suspected until the eruption is accidentally detected. Thus, White very rationally explains its more frequent discovery in phthisical than in other patients by the circumstance of its revelation incidentally to examining the chests of those persons for a different specific purpose. The disease has a tendency to invade the surround- ing epidermis, and when removed it is very apt to reappear. In many cases it regularly appears after the winter months have passed away, arid at that period readily yields to treatment in a few weeks, reap- pearing at about the same time in the following year. Patients are occasionally met with who have had these periodic returns of the dis- ease for twenty or more years. It is rarely or never observed in chil- dren, and is equally rare in persons over fifty or sixty years of age. The course of tinea A^ersicolor is steadily progressive. If untreated, the affection may last for many years, but it does not in some cases spread with the same rapidity or invade so large a surface as in others. According to my experience, tinea versicolor occurs more frequently in persons with a harsh skin than in those whose integument is soft and delicate. It attacks either sex. Diagnosis.—While the diagnosis of tinea versicolor may be said to be comparatively easy, nevertheless there are quite a number of VEGETABLE PARASITES. 12\) affections simulating it. A collation of its symptoms, therefore, will constitute the best means of differentiating the disease. The prin- cipal features of the eruption to be remembered are its usual loca- tion on the chest and sides; the absence of the eruption on parts exposed to the light; its frequent fawn color (the " cafe au lait" tint of the French); the slight elevation of the spots; their occa- sional erythematous tendency, especially during the heated period ; and their desquamative character. The last-mentioned point espe- cially should form the salient feature for diagnostic purposes, and, if combined with microscopic examination, will leave little doubt as to the character of the disease. The spots may at times assume the char- acter of wheals resembling those of urticaria, but no scales are pres- ent in the latter affection. In persons who perspire freely the spots may present a punctated appearance, with elevated and inflamed papillae simulating the eruption of eczema ; but eczema is accom- panied by more intense itching and burning symptoms than this affec- tion, and rarely appears upon the regions usually involved in tinea versicolor. The character of the scaling is also different in the two diseases. The resemblance betAveen the patches of tinea versicolor and the lesions of chloasma, vitiligo, lentigo, and the macular syphi- lides, is only superficial. Chloasma consists of a more or less diffused pigmentation of the mucous layer of the epidermis, while tinea versi- color is an affection of the horny layer. The patches of the former are smooth and not elevated, while those of the latter are elevated and composed of fine furfuraceous scales. The regions involved in the two diseases are also different. Chloasma occurs frequently on the face—a region that is rarely invaded by tinea vesicolor. Circumscribed and diffused pigmentation may result from inflam- matory eruptions and cutaneous irritations, and may remain after blis- ters, but the history and the absence of scales will decide the diag- nosis. Vitiligo can not Avell be confounded with tinea versicolor, for the circumscribed areas in the former are white, but discolored in the latter. The borders of the patches in vitiligo are more or less pigmented, smooth and altogether unlike the elevated scaly patches of tinea versicolor. Freckles (lentigo) are of the same nature as chloasma, differing from it only in their size. They may present a superficial resemblance to tinea versicolor in its macular stage, but they have no scales, and they are principally observed upon the face and hands,Avhere the parasite of tinea versicolor is knoAvn not to thrive. Svphilitic macules may prove perplexing in the diagnosis, and may give rise to confounding the tAvo diseases. The color of syphilitic eruptions is, hoAvever, never so decidedly yelloAv as that of tinea versi- color. The eruptions of syphilis show besides neither elevation nor desquamation. They are of a coppery hue, and an examination always .develops a history of infection. The lesions also are not limited to the 730 DISEASES OF THE SKIN. chest, but may occur upon any portion of the body. They are usually small in size, circular in form, and unaccompanied by itching. Other manifestations of syphilis, too, are usually present at the same time. The existence of syphilis in a patient affected by tinea versicolor may, it is true, lead to some doubt as to the nature of the latter eruption, but the presence of scales will point to the correct diagnosis, which the mi- croscope will confirm with unerring certainty. Pathology.—The lesions of tinea versicolor are largely composed of the spores and mycelium of the microsporon furfur. This parasite ramifies through the superficial layers of the stratum corneum, but does not penetrate the rete mucosum nor attack the hairs or nails. The mycelial threads appear to be inextricably woven throughout the epi- dermic scales. The spores manifest a tendency to cluster. If the Fig. 25.—(Microsporon Furfur.) The illustrations here presented are by Bristowe, ano. exhibit: A, a patch of epidermis of chest, showing mycelium and clusters of spores, x 600 diameters. B, sporules springing from one another and from mycelial cells. Some may be seen attached to the latter by stalks x 1200 diameters. scales be detached from a spot and placed in a drop of liquor potassae, and then examined with a microscope having a power of five hundred diameters, the mycelial threads will be seen to form an intricate net- Avork of straight and looped, entangled and braided, crossed, curved, and serpentine lines. The threads vary in diameter from -0015 mm. to ■0036 mm., and frequently terminate in spores. Spores, both isolated and in clusters, may also be observed in the field, are round, irregular, or oval in shape, and vary from -0023 mm. to -0084 mm. in diameter. They are at times nucleated, and are highly refractive. They may be VEGETABLE PARASITES. 731 developed from the mycelium or from pre-existing spores by a process of cell-division. Duguet and Ilericourt* through their researches claim that the bacillus tuberculosis is only a micro-organic form of development of the fungus microsporon furfur. Etiology.—Tinea versicolor is caused solely by the presence on the skin of the vegetable parasite known as the microsporon furfur. The parasitic nature of this disease was discovered by Eichstedt, of Greifs- wald, in 1846. It is contagious only under very exceptional circum- stances, and to a very mild degree. The manner in which the parasite is conveyed to the skin is unknoAvn. It is probable, hoAvever, that the spores are wafted about in the atmosphere, and thence deposited on the patient's clothing, or that they are contained in the water in which the clothing is Avashed, and so conveyed to the skin. Tinea versicolor may appear in either sex, in the rich as well as in the poor, in persons who bathe frequently as Avell as those who are care- less in that respect, and in the robust as Avell as in the weak. But it is the skin of certain subjects only which seems to afford a favorable soil for the development of the parasite. Treatment.—The importance of treatment has always been under- estimated, and the consequence has been either incomplete or total failure in the cure of the disease. Thus, the French have considered the treatment of this affection to be simple, and have thought the prep- arations of sulphur quite sufficient to effect a cure. Hardy recom- mends them either in the form of baths or ointments. He says, fur- ther, that the acid nitrate-of-mercury ointment produces the same effect; also that the parasite disappears equally Avell by applying lotions of corrosive sublimate or by the use of mercurial baths, and that few cases are not amenable to this treatment. The Germans seem to think that cleanliness is about all that is re- quired to effect a cure. They recommend change of underclothing and daily ablutions Avith soap and water, under which treatment it is assert- ed that a gradual cure is effected. When, hoAvever, it is necessary to proceed more rapidly, it is alleged that an application of green soap, left on the skin for several days, is quite sufficient to produce a cure. The method of the late Tilbury Fox was to wash the surface with yelloAV soap and then sponge it Avith vinegar and water, after which he applied a solution of six drachms of sodium hyposulphite in six ounces of Avater. In obstinate cases a bath of sodium hyposulphite is serviceable. Tilbury Fox's idea Avas to get rid of the greasy matter of the skin Avith soap, and then to continue the use of the antiparasitic agent until every trace of the disease had vanished. Balmanno Squire uses a more extended treatment, as folloAvs :• The patient first thor- oughly soaps the affected skin; afterward takes a warm bath, and, * The Pharmaceutical Journal and Transactions, London, May 29, 1886. 732 DISEASES OF THE SKIN. as soon as he has dried himself, scrubs the discolored surface with a flesh-brush. He then, every day, rubs well in over every patch of the disease a weak mercurial ointment. The plan first described has, he asserts, the following advantage: The epidermis is so thoroughly softened that, by rubbing, the more superficial portions of the fungus are readily detached, and the more deeply seated portions are exposed to the direct action of the remedy. By this process patches that have existed for many years may be completely removed in about a week. Balmanno Squire also uses an ointment of precipitated sulphur, in- creasing its effect by the addition of a small quantity of hepar sulphu- ris. He mentions using a twenty-per-cent. ointment of chrysarobin. Startin recommends washing the skin with solutions of sodium hypo- sulphite, a drachm to the ounce; sulphurous acid, two drachms to the ounce; mercuric bichloride, tAvo grains to the ounce; any one of them to be employed two or three times a day, followed by the application of an ointment of white precipitate, thirty grains to the ounce. The author's experience, in private and hospital practice, has led him to view a radical cure of tinea versicolor as not quite so easy of accomplishment as might be inferred from the light manner in which Avriters refer to the subject. Patients, usually after an apparent cure, Avander from one physician to another for treatment, although the usual remedies had been again and again persistently applied without entirely removing all the patches of the disease. Persons of anaemic, phthisical, or cachectical diathesis, who are predisposed to the disease, improve more rapidly when constitutional and external remedies are both employed. The principal treatment must, of course, be local. The fol- lowing prescriptions will be found to be most serviceable. The affected part may be sponged night and morning with either of these lotions: fy Pulveris sodii boratis............... 3 iij. Aquae hamamelidis dest........... f § v. M. I£ Thymol.......................... 3 ss. Spiritus vini rect.................. f § j. Glycerini........................ f § ij. M. Either of these preparations will keep the spots clean, remove all the sebaceous deposits from the surface, and act at the same time as a mild antiparasitic. After this treatment has been carried out for a few days, and the epidermic scales thus softened have become detached, a stronger antiparasitic may be applied. The most effective remedy for this purpose is the oleate of copper, either 'diluted with oleic acid or made into a soft ointment, a ten- to a twenty-per-cent. with lard. The salts of copper, since my experiments with the oleates, have been admitted to possess marked antiseptic and antiparasitic properties. The oleate of copper admits of the most simple and thorough ap- plication. It not only destroys the parasite on the surface, but by a VEGETABLE PARASITES. 733 deeply penetrating action arrests its development in the interstices of the epidermic cells. No parasitic skin-disease yields so readily to any one remedy as tinea versicolor will very often to the copper oleate. The author has succeeded Avith it in relieving and perma- nently curing many obstinate cases of the disease. In applying this oleate it should always be borne in mind that a very small quantity is sufficient to go over the diseased surface. The oleate will rapidly penetrate the skin, and a large amount smeared upon the surface will merely discolor the linen without being of any additional service. I would in all cases advise that the lotions which have here been recommended should be used instead of water to keep the parts clean, thus preventing the spreading of the parasite. In tinea versi- color, and all other vegetable parasitic diseases, the fungi propagate themselves more rapidly when Avater is used on the parts. The author therefore in all cases prohibits the use of water on the regions affected by the parasite, and depends for cleanliness upon the application of the lotions previously mentioned. This treatment should be continued until discoloration and scales are no longer noticeable and a new and healthy surface has formed. Dr. Joseph DrzeAviecki, of WarsaAv, Poland, writes* that he has for years been in the habit of advising persons afflicted Avith any chronic pulmonary complaint to rub the chest night and morning Avith a cloth-brush. This circumstance led him to notice that when tinea versicolor happened to be present it disappeared in ten days or two weeks. This result took place even in those whose skin Avas dry, in which case it became smooth, shining, and elastic. The practice of Dr. Mansurow, of Moscow, is to apply charta picis to patches of tinea versicolor. He reports that on removing the paper at the end of six days the skin is perfectly normal. The epidermis adheres to the paper Avhen removed, and the fungus is em- bedded in the pitch. Small patches have been successfully treated by the application of the tincture of iodine. Among other remedies which may be employed are beta-naphthol, boric acid, resorcin, carbolic acid or chrysarobin ointment, a one-per-cent. ointment of picrotoxin, creolin, and a fifteen- per-cent. solution of chloral hydrate. The author removes the patches sometimes by the daily application with friction of alcohol, or alcohol with boric acid or beta-naphthol. Prognosis.—Tinea versicolor is usually a trivial affection, although it sometimes gives rise to a great deal of annoyance to the patient. It vields with readiness to treatment faithfully carried out. It is apt to reappear if the parasite be not thoroughly eradicated. As a general rule, tAvo to three weeks suffice to bring the disease to a conclusion, but relapses may occur. * Satellite, September, 1889. 731 DISEASES OF THE SKIN. TINEA FAVOSA. Synonyms.—Favus — Porrigo favosa — Dermatomycosis favosa—Crusted ringworm— Honey-comb ringworm—Erbgrind—Teigne faveuse. Tinea favosa is a contagious vegetable parasitic disease produced by the achorion Schoenleinii, and characterized by the development of a number of small, round or oval, cup-shaped, pale-yellow, brittle crusts, which are usually situated over the hair-follicles, and perforated by hairs. Symptoms.—Favus may be limited to the hairs and the hair-folli- cles (tinea favosa pilaris), to the epidermis (tinea favosa epidermis), to the nails (tinea favosa unguium), or it may involve the entire sur- face and all of the cutaneous appendages (tinea favosa universalis). In a case of the latter character, observed by Kundrat and reported to the Vienna Imperial and Royal Society of Physicians, the fungi had been conveyed from the patient's fingers to his food, and then into his stomach, where they had invaded the mucous membrane, de- veloping the characteristic cup-shaped crusts, producing uncontrolla- ble vomiting and diarrhoea (gastritis favosa), that soon resulted fatally. Favus usually appears first upon the scalp, but it may develop upon any portion of the body. It is not infrequently met Avith upon the face and neck. The disease generally develops as a circumscribed, superficial inflammation of the skin, accompanied by slight desquamation and more or less itching, The affected surface is reddened, covered Avith minute scales, and may be the seat of a minute vesicular eruption. In a feAv days several small, bright-yellow bodies may be observed in the hair-follicles. They are depressed beneath the surrounding epidermis, and are perforated by hairs. These favoid bodies are fungous masses that proliferate in the hair-follicles, surround and penetrate the hair- shaft, and insinuate themselves between the upper layers of the epi- dermis, where they ramify in all directions. They ultimately attain the size of a split pea or that of a small bean, and then appear as pale- yelloAV or sulphur-colored cup-shaped crusts situated in and around the hair-follicles. The crusts are umbilicated, and perforated by one or more hairs. Their margins are slightly elevated above the surrounding surface. The lesions consist of a series of concentric layers closely packed together. They are isolated at first, but sooner or later coalesce so as to form large, elevated crusts, in which the circular forms of the component favus cups may be recognized for some length of time. These crusts gradually become dry and brittle, and change in color from light-yellow to a dirty gray or mortar-like hue. The scutula, as otherAvise called, increase in size and become rough and irregular in shape, and are frequently surrounded by an inflammatory aureola. They vary in number and size, and are situated upon a depressed, red- dened, and more or less atrophied surface, from which they can be VEGETABLE PARASITES. 735 * removed without much difficulty. The itching to which the affection gives rise is sometimes so intense that the patient is unable to refrain from violent scratching. This is productive of various complications —the disease is spread over a larger area than before, or conveyed to the finger-nails, or a severe eczematous inflammation terminating in the formation of pustules may ensue. The hairs in the affected area soon become involved, their growth being impaired ; they lose their normal glossy appearance and become dry, dull, and brittle, and finally fall out. The loss of hair is due to atrophy of the hair-papillae and hair-follicles from the pressure of the crusts, and is apt to be permanent. Favus of the body and extremities is characterized by the development of discrete sulphur-colored scutula or cup-shaped crusts at various points upon the surface. The disease not infrequently disappears spontaneously in a few weeks or months by the dropping off of the scutula, as the follicles of the downy hairs are too shallow to admit of an extensive proliferation of the parasite. In some cases, hoAvever, the disease may remain for years. The author has seen the case of a boy nine years old in which the scalp, face, body, and limbs were involved. The disease had persisted without abate- ment for four years. The patient, however, was of scrofulous diathesis, and had been poorly fed and badly clothed. All of his surroundings Avere of the most depressing character, and appeared to combine to render his integument a fertile soil for the proliferation of the fungus. In Kundrat's case the entire surface was affected. Abscesses formed in the thighs, and death finally resulted from severe gastro-intestinal disturbance marked by uncontrollable vomiting and diarrhoea. At the post-mortem examination numerous erosions and diphtheritic SAvell- ings were found on the gastric mucous membrane, and the intestines contained a quantity of foul, putrescent material mixed with mucus. Kundrat at once declared that the swellings were due to the favus fungi, and the microscope confirmed his assertion. It is probable, however, that the gastric mucosa was previously unhealthy, or it would not have furnished a suitable nidus for the parasite. Favus of the nails (tinea favosa unguium) is a rare affection, and is usually second- ary to favus of the scalp or some other region of the body. It appears at first as small, light-yellow or sulphur-colored deposits in the sub- stance of the nail, Avhich increase in size and produce more or less thickening and other changes from defective nutrition. The nails finally become soft or brittle, and undergo a sort of cheesy degenera- tion. Favus of the nails is an obstinate form of the disease. Favus is accompanied by a peculiar odor which is difficult to de- scribe, but which Avhen once experienced can never be forgotten. It is similar to that of moldy straAv, and has been characterized as " mice- smell," which, by the Avay, is really not the odor of mice but of their urine. Favus of the scalp may appear in the form of red, scaly rings, 736 DISEASES OF THE SKIN. simulating tinea tonsurans, but on close examination the characteristic scutula or cup-shaped crusts will be found embedded in the outer ring. Diagnosis.—The diagnosis of favus can usually be made without much difficulty. The characteristic yellow, friable, cup-shaped crusts, with their peculiar odor of mice, are not found in any other disease. When the eruption has existed for some time, however, and the crusts become broken down, or when an eczematous inflammation has devel- oped around them from excessive scratching, the nature of the case may be somewhat obscured. In simple eczema, however, the crusts are brownish in color, not yellowish, and are situated upon an excoriated base; there is no mice-smell, and the hairs are not affected. The reddened furfuraceous appearance of the skin in the early stages of favus is not unlike that which is observed in psoriasis, but the appear- ance of the yellow favoid bodies reveals the true character of the for- mer disease. Tinea tonsurans, when accompanied by suppuration and pustulation, might be mistaken for favus. The resemblance, how- ever, is only superficial. In tinea tonsurans the hairs present a nib- bled or broken-off appearance, whereas in favus they are unchanged in length, and drop out of the follicles. As pointed out by Behrend and DuckAvorth, if a hair affected by the trichophyton (the parasite of tinea tonsurans) be moistened with chloroform, it will turn white in two or three minutes; while, under the same test, normal hair, or the hair from a patch of favus, will not exhibit any change whatever. Tinea circinata has been confounded with favus, but the symptoms and course of the two affections are so widely different that the error should not be made. In all doubtful cases a hair from the suspected patch or a por- tion of the crust, or from the epidermis, should be placed in a solution of caustic potash and examined microscopically for the achorion Schon- leinii. A microscopic power of from two hundred and fifty to five hundred diameters will be necessary to make the characteristic feat- ures of the parasite plainly visible. Pathology.—Favus may affect the hairs and nails as well as the hair-follicles and the adjacent epidermis, but the latter is chiefly in- volved. The crusts are composed almost entirely of the mycelium and spores of the achorion Schonleinii. The mycelium consists of narrow, flattened threads or tubes ramifying luxuriantly in all directions. They are pale green or gray in color, and vary in diameter from -0023 mm. to -0028 mm. There are two varieties of mycelial tubes or threads ■■—those which are apparently empty, and those which are divided into small compartments containing numerous granules or young spores. The fully developed conidia or spores are round or oval bodies, varying in diameter from -0023 mm. to '0051 mm. They are present in great numbers, and are frequently massed in groups. Forms intermediate between spores and mycelium may also be observed. The parasite penetrates into the hair-follicles, and insinuates itself VEGETABLE PARASITES. 737 between the superficial cells of the corneous layer. It also attacks the inner and outer root-sheaths of the hair, and may even invade the hair- shaft. Obliteration of the hair-follicles and atrophy of the hair-papillae finally result from the continuous pressure of the parasitic growth. Various inflammatory and atrophic changes take place in the corium from the same cause. Suppuration and permanent cicatricial depres- FiG. 26.—Achorion Schoenleinii, a, shaft of hair; b, b, hair-follicle ; c, d, e, mycelium and spores. sions may or may not occur. In tinea favosa unguium, m}Tcelium arid spores are found in the nail-substance and in the nail-bed, and are ulti- mately productive of various degenerative changes. The favus fungus has of late been further studied by Quincke, El- senberg, and Favre, but their results do not completely accord. Three forms, designated respectively as a, /?, and y, were indicated by Quincke, who regards the a as the true favus fungus. The material of Elsen- berg's investigations was collected from tAventy-seA-en individuals, and culthations Avere made upon bouillon, nutrithe gelatine, serum, and acar-aarar. He detected but two varieties, of Avhich Varietv 1 resem- 47 738 DISEASES OF THE SKIN. bled Quincke's a, but differed in its behavior under cultivation. Elsen- berg's Variety 2 corresponded neither to the (3 nor y of Quincke, but it Avas always present, and differed but little from his Variety 1. He therefore concludes that his two varieties are different forms of one fungus. In Favre's experiments the favus lesion was removed at a very early stage of its development, as soon as it was visible to the naked eye, or by the aid of the microscope. In a pure culture the fungus corresponded to Quincke's y form. Inoculation of this culture upon the author's arm produced favus. The manifestation was preceded for some days by herpetic vesicles, which could not be distinguished from those of trichophytosis. He could not find the a fungus. Quincke has asserted that his y form was never present in herpetic favus. Favre considers it probable that the y fungus is the common cause of favus. More recently Unna has recognized three varieties or species of the fungus, and connected them with differences regarding the color, con- sistency, and other properties of the crusts. These views have been de- nied by other experimenters, and are by no means universally accepted. Etiology.—Favus is produced by the growth of the achorion Schon- leinii, a vegetable parasite attacking the follicles, the nails, and the up- per corneous layers of the epidermis, and is propagated by contagion. It is exceedingly common in the lower animals, especially in cats, mice, and rabbits, and is frequently communicated by them to man. Often, hoAvever, no history of direct contagion can be established ; in these cases it is probable that the spores of the fungus were transferred through the medium of the atmosphere. Favus may occur at any age, and among the rich as well as the poor. It is met Avith most frequently, however, in childhood, and among scrofulous and debilitated subjects. The susceptibility of individuals to its contagion varies greatly. It is probable that a peculiar condition of the integument is necessary to its continued existence. Treatment.—Constitutional measures are often very advantageous in the treatment of favus, especially in debilitated subjects and in those of a syphilitic or scrofulous diathesis. For patients of the latter class I know of no better remedies than cod-liver oil administered in combination with the sirup of the iodide of iron, or small doses of po- tassium chlorate administered in water after meals. Nourishing food, fresh air, and healthful exercise are also of paramount importance. The parasite can be destroyed, however, only by thorough and per- sistent local treatment. In reviewing the measures advocated by vari- ous writers, it does not appear that much improvement has been made upon the methods of the Freres Mahon. Epilation, so universally recommended, can not be claimed to be in conformity with modern therapeutics. It is injurious to the hair-follicles and painful to the patient, and should be discarded as a relic of medical barbarism of the last century. VEGETABLE parasites. 739 The first object to be accomplished is the removal of the crusts, after which an antiparasitic should be applied to destroy the fungi on the surface as Avell as in the hairs and hair-follicles. The best means for removing the firm crusts is by the application of oil, which softens and loosens them. The oil of ergot will be found the most effective, as it softens and produces also a mild astringent effect upon the epi- dermis. The olive, almond, and carbolized oils possess, in a much less degree, properties suitable for the same effect. The crusts and the surrounding epidermis should be kept saturated with oil for twenty- four hours before using any other application. The poultices of vari- ous kinds that are usually employed to soften and facilitate the removal of the crusts are in various ways unpleasant as Avell as positively injuri- ous to the patient. Through the elevation of the temperature of the surface which they produce, proliferation of the fungus is rendered more rapid than by its natural increase. Providing sustenance for it, they necessarily hasten its maturity. Poultices likewise furnish the epider- mis with moisture, they conduce to its swelling to such an extent that the hairs, entirely filling the follicles, prevent entrance thereto of all antiparasitics. Warm-water dressings and bandages produce the same ill effects, and should for this reason be abandoned. The soap-spirit of the Germans is a severe remedy, not only soaking into and softening the favus-crusts, but acting destructively on the epi- dermis, the upper layers of Avhich are often cast off in consequence, thereby furnishing a rich field for the propagation of the fungus. As a detergent lotion which is at the same time antiparasitic and softening to the crusts, without affecting the epidermis, the author knows of nothing better than a tAventy-five- to a fifty-per-cent. solu- tion of boro-glyceride. This fluid should be sponged thoroughly over the .affected surface after the crusts have been covered with oil of ergot for tAventy-four hours. After an hour or two the crusts Avill readily peel off, and the epidermis will be clear and clean, ready for the application of one of the potent antiparasitics. First among these in order are certainly the mercurials in their many forms. To apply immediately, hoAvever, according to the French method, a solu- tion of mercuric bichloride, is Avorse than useless, for the albuminous surface is sure to be coagulated by it, forming a protective layer of mercuric albuminate over the follicles, beneath which the parasite may live in security. The old salves of Avhite precipitate are no better, for they artificially occlude the follicles, besides congesting the skin in such a manner as to make it grasp the hair tightly and pre- vent the entrance of the remedy into the follicles. In cases of favus complicated by pustular eczema, due to excessive scratching, the author has found the naphtholized zinc-oleate ointment of great service. It would be useless to employ any remedies in the form of ointments or oils immediately after the crusts have been removed, for the moist 740 DISEASES OF THE SKIN. condition of the surface prevents their penetrating deeply, especially where the skin is congested, the hairs swollen, and the follicles almost closed. The author therefore directs the hair and skin to be well dried, and after a few hours applies an active antiparasitic remedy freely over the affected surface. The antiparasitic agents par excellence are the oleates of mercury and of copper. The author does not wish to be understood to mean by the oleates of mercury the numerous and often worthless solutions of mercuric oxide in oleic acid, pharmaceutical^ described by the percentage of mercuric oxide that they are supposed to contain. In speaking of the mercuric and the copper oleates the author refers only to the true and definite chemical compounds between oleic acid and mercury or copper. The oleates just referred to can be prescribed as follows: I£ Ungt. hydrargyri oleatis................§ ss. Adipis...............................3 ss. M. R> Cupri oleatis..........................3 ss. Adipis................................§ j. M. A little of the former ointment is first rubbed in Avell with the finger-tips, and after a feAv days alternated with the latter, which is astringent, and relieves any irritation that may be set up by the former. The author has not obseiwed any irritating symptoms from the external use of these salts, but, on the contrary, has invariably noticed from their use a speedy disappearance of the fungus. These applications should be made every day or two, and continued for three or four weeks. If, after a cessation of treatment for a Aveek or tAvo, the hair does not assume its natural aspect, and new favus-crusts develop, the treatment should be begun afresh. The author has, however, in but feAv in- stances been obliged to resume it. In the manner just described, cures of several severe cases of favus have been effected in about six weeks, and in no instance was epilation used. In all cases, after the crusts have been removed, the use of water is prohibited either as a lotion or as a detergent, for the reason that it acts as an agent in the propagation of the fungus. To determine when the treatment has been sufficient, from time to time a single hair should be extracted from each of the diseased spots, in order to see if the fungus is still present. Favus of the epidermis or parts not covered with hair can easily be cured by removing the crusts in the manner previously described, and then applying either mercury or the copper-oleate ointments. Eesorcin- ointment is also efficient. A ten-per-cent. ointment of boric acid, chrysarobin, aristol, or europhen may also prove efficacious. Electroly- sis has been successfully employed by Dr. II. J. Eeynolds, the sponge attached to the positive pole being saturated with an antiparasitic solu- tion and applied to the seat of disease, the negathe pole being placed some distance to one side. Favus of the nail, when the disease is cir- cumscribed, is best removed by the knife. If the nail be affected in its VEGETABLE PARASITES. 741 entirety with perverted nutrition and hypertrophy, the mercury or copper-oleate ointment should be freely applied. Prognosis.—Favus can be regarded as curable, only one fatal case having been obseiwed. If treatment be instituted in the early stages, a cure may be obtained Avithout any ill effects. If the parasite has been growing for a considerable period, permanent cicatrization and loss of hair result. Favus is seldom accompanied by constitutional symptoms, but the constant irritation may seriously impair the general health. Ordinary cases of favus yield to proper treatment in six or eight weeks; in obstinate or neglected cases the disease may be pro- longed for months or years. It will be found more intractable in scrofulous persons, as well as in those of unclean habits, or who are ill nourished, poorly clad, and badly housed. If left to take its course Avithout interference, favus exhausts its soil very slowly. In some cases the disease disappears spontaneously after the destruction of the hair- follicles ; in other cases it lasts throughout life. Favus of the body is far more amenable than when it involves the scalp. Favus of the nails is obstinate. The disease is subject to relapses in all cases unless the parasite is thoroughly extirpated. TINEA TRICHOPHYTINA. Tinea trichophytina is a contagious parasitic disease affecting the hairs, the hair-follicles, the nails, and the epidermis of various portions of the body. It is produced by a microscopic fungus known as the tri- chophyton, and is characterized by the formation of circular erythem- atous, scaly patches, vesicles, and tubercles, and by various morbid changes in the hairs and nails of the affected area. According to the recent investigations of Sabouraud, confirmed or accepted by other observers, there are several and probably numerous fungi, capable of producing the disease known as ringworm. In chil- dren the affection is noAV said to be generally due to the microsporon Audouini. For coiwenience of description the disease is subdivided in accordance with the region affected. When the scalp is attacked, the disease is termed tinea tonsurans or tinea trichophytina capitis; when the beard is affected, it is called tinea sycosis or tinea trichophytina barbae; and AAdien the nails are involved, it is named onychomycosis or tinea trichophytina unguium ; Avhen, finally, the body is invaded, it is denominated tinea circinata or tinea trichophytina corporis. TINEA TONSURANS. Synonyms.—Tinea trichophytina capitis—Herpes tonsurans—Ringworm of the scalp— Scherende Flechte—Teigne tondante. Tinea tonsurans is a contagious vegetable parasitic disease of the scalp, produced by the trichophyton, and characterized by the forma- 742 DISEASES OF THE SKIN. tion of one or more circular grayish or erythematous scaly patches, upon which the hairs are ragged, broken, or destroyed. Symptoms.—The disease usually manifests itself first as a small, round, pale-red or grayish spot, covered Avith fine, branny scales, and slightly elevated above the surrounding surface. On close examina- tion one or more similar lesions may be discovered at other points upon the scalp. In some cases a ring of minute papules or papulo- vesicles may be observed upon the periphery of each diseased spot. They are ephemeral in character, however, and speedily terminate in desquamation without becoming transformed into pustules. The hairs may not be perceptibly involved at first, but as soon as the para- site penetrates into the follicles they become dry, lustreless, and brit- tle, and finally either drop out spontaneously or break off near the sur- face of the scalp. The disease spreads rapidly by peripheral extension, forming circular patches of varying size that are slightly elevated above the adjacent surface. The lesions are pale-red or bluish-gray in color, and covered by fine white or opaque scales. They are usually situated upon the crown or on the parietal regions of the head, but they may occur upon any portion of the scalp. In some instances the patches are situated partly on the scalp and upon the neck. The follicles of the affected area are prominent, the hairs withered and dull in appear- ance, and either bent or broken off just above their point of exit. The stumps are thickened and uneven, presenting the nibbled, ragged appearance characteristic of the disease. The hairs are held loosely in the follicles, but OAving to their brittleness usually break off at or beneath the surface Avhen an attempt is made to extract them. As the disease progresses they finally become involved throughout their entire length, and then drop out spontaneously, producing more or less baldness. As, however, the hair-papillae are rarely destroyed, the baldness is only temporary. In mild cases the disease does not pene- trate into the follicles, and manifests itself only as a reddened, desqua- mative condition of the surface. The typical erythematous rings oc- casionally observed are due to a spontaneous disappearance of the dis- ease from the centre of the affected area while it is advancing at the periphery. In other instances the hairs are involved, but not so ex- tensively as in the typical form of the disease. In severe cases the hair of the greater portion of the surface may fall out. In scrofulous or debilitated children the diseased areas may become the seat of a pustular eruption, terminating in the rupture of the pustules and the formation of thick yellow crusts upon the surface of the scalp. This is a very contagious form of the disease. It is usually accompanied by enlargement of the cervical glands, and other symptoms of consti- tutional irritation. Tinea tonsurans is seldom attended by any pain, but more or less itching is present in all cases. The disease may run an acute course, VEGETABLE PARASITES. 743 but usually manifests a tendency to become chronic. The patches in chronic cases may be either large and smooth, and almost com- pletely denuded of hairs and scales, or may be covered with a pro- fusion of scales and stumpy hairs, or, as in the disseminated variety, they may consist of a number of minute scurfy spots with ap- parently healthy hairs, among Avhich, however, a feAv black hair- stumps may be observed. In the violent form of tinea tonsurans, known as tinea kerion or kerion Celsi, the fungus penetrates into the deepest portion of the follicles and produces a diffused exudative in- flammation involving all the layers of the skin as Avell as the subjacent cellular tissue. Kerion usually begins as one or more grayish or ery- thematous patches, similar to those which appear in the ordinary form of the disease. The patches, however, soon become yclloAvish or pur- plish in color, and boggy, tumid, and painful to the touch. They are considerably eleA^ated above the surrounding surface, and are covered with a yelloAV, glutinous substance that exudes from the distended follicles. The hairs become brittle and loosened, and finally fall out. When the inflammation is severe, superficial abscesses may be formed and terminate in ulceration of the corium, obliteration of the hair-fol- licles, and permanent loss of hair. Kerion usually runs an acute course, and terminates in speedy recoArery by the destruction of the fungus. In some cases, however, it may assume a chronic character, and remain for a long time. Diagnos.s.—The diagnosis of tinea tonsurans is usually easy. Typi- cal cases, presenting erythematous patches covered Avith fine scales and short, nibbled-looking hairs, can not be mistaken for any other disease. Blackish dots or stumps of hairs situated on disseminated scurfy areas are also significant. The only affections that present any resemblance to tinea tonsurans are squamous eczema, seborrhoea, psoriasis capitis, alopecia areata, and impetigo eontagiosum. In squamous eczema the surface of the scalp is reddened and scaly, but the hairs are normal in character, and are firmly seated in the follicles. There is no history of contagion; the disease is chronic in character, and the diseased area does not continually increase by peripheral extension. In squamous eczema, moreover, the itching is usually intense. In seborrhoea the surface is scaly, but it is normal in color, and the hairs are not involved. The lesions of psoriasis capitis may present a superficial resemblance to those of tinea tonsurans, but the history and course of the two affec- tions are so widely different that they ought not to be confounded with each other. Alopecia circumscripta has been mistaken for tinea ton- surans. In typical cases of the former affection, hoAvever, the smooth, Avhite, polished surface of the scalp, and the complete absence of hairs and scales from the affected area, point unerringly to the true nature of the disease. In doubtful cases a microscopical examination would be necessary to determine the presence or absence of the trichophyton. 744 DISEASES OF THE SKIN. This parasite can be easily discovered. One or two of the affected hairs, or a portion of the epidermis, should be covered with a drop of liquor potassae and placed under a microscopic power of tAvo hundred and fifty diameters, when the fungus and its lesions will be plainly visible. According to Duckworth and Behrend, the chloroform test will also establish the diagnosis. If a hair affected by the trichophyton fungus be placed in chloroform it will immediately turn white, while normal hair will remain unchanged. Tinea favosa in its first stages may simulate the erythematous lesions of tinea tonsurans, but the characteristic yellow, cup-shaped crusts of the former should forbid continuous error. The chloroform test may also be employed if necessary to make the diagnosis, as hairs affected by favus do not change in color when they are dipped in chloroform. In favus, moreover, the hairs can usually be pulled out by the roots, while in tinea tonsurans they are brittle, and break off near the surface if an attempt be made to extract them. Tinea kerion can readily be recog- nized by the boggy and inflammatory character of the lesions, and the semi-purulent, glutinous exudation by which they are covered. The lesions of impetigo eontagiosum are disseminated, and may resemble the pustular complications of tinea tonsurans. Impetigo is an acute affection, however, which does not involve the hairs, and which usually terminates spontaneously in ten or tAvelve days. Pathology.—The lesions of tinea tonsurans are due to the growth of a vegetable parasite, discovered by Gruby in 1844, and termed by Malmsten the trichophyton tonsurans. It affects the hairs, the hair- follicles, and the superficial layers of the epidermis. It is composed of mycelium and spores. The latter are present in great abundance in all the affected structures, are round, colorless, highly refractive, and are stained with difficulty. The parasite is easily culthated in non- acid media. The presence of the fungus betAveen the corneous layers of the epidermis produces more or less irritation, resulting in the forma- tion of vesicles, papules, or pustules upon a reddened, congested base. The growth then invades the follicles, penetrates into the follicular Avails and into the substance of the hair, producing occlusion of the follicles and distortion and disintegration of the hair. In severe cases the inflammation of the perifollicular tissue may be so intense as to re- sult in destruction of the follicles and in permanent loss of hair. In tinea kerion the deepest recesses of the follicles are reached by the parasite, and the resulting irritation is so severe as to produce extensive inflammatory exudation and marked augmentation of the secretions of all the cutaneous glands. The mycelium is scantily developed, and consists of long, slender, forked threads, which are frequently jointed, and ramify in all directions. The spores are small, rounded, refractive bodies that manifest a marked tendency to arrange themselves in rows or groups. They are found in great numbers around the hair-bulbs VEGETABLE PARASITES. 745 and papillae, as well as in the hair-shaft, which is irregularly disinte- grated or else cleft longitudinally. Dr. George Thin has published the result of a series of interesting experiments made Avith a view of determining the vitality of the trichophyton fungus, and the effect upon it of various different agents. From these it appears that the spores retain their power of growth and reproduction for at least eleven months at the ordinary temperature of a London house. They are capable of multiplication after having been soaked in water for two days. Immersion in olive-oil for twenty- seven days had no influence upon their vitality. The same negative result attended the action of lard continued for four days, and of vase- line maintained for eight days. The spores Avere almost completely sterilized by contact with soap-suds for thirty minutes. Exposure for the same length of time to soft soap completely sterilized the spores, but growth took place after a contact of thirteen minutes. One per cent, acetic acid sterilized them in three days, while immersion for the same period in a one-per-cent. carbonate-of-soda solution failed to produce any effect. Sulphur ointment in one-fourth pharmacopoeial strength inhibited the growth of the fungus in tAvo hours, Avhile in an hour and a half it sterilized it to a large extent. Six hours' contact Avith white precipitate ointment of half strength prevented germination, but they survived the contact with the same preparation for tAvo hours. Sterilization was effected in one hour by quarter-strength citrine oint- ment. In all these cases control experiments Avere made, and hairs which had not been submitted to the action of the ointments men- tioned deA'eloped the fungus abundantly. Immersion in croton-oil for seven days had no effect upon the vitality of the trichophyton.* Certain practical conclusions may be deduced from these experi- ments. Washing the scalp with soap arid Avater, unless for a far longer time than can or will be given to the procedure, is incapable of destroying the power of the spores present among the scales on the sur- face. A weak sulphur ointment is able to destroy all the spores except those which have penetrated deeply into the follicles. The destructive power of weak ointments of white precipitate and nitrate of mercury, especially the latter, is experimentally demonstrated. The action of croton-oil is proved to depend upon the inflammation which it pro- duces, f Etiology.—Tinea tonsurans is produced by the trichophyton fungus, and is propagated by atmospheric diffusion as well as by contagion. * A similar course of experiments reported by Schweninger are not in complete ac- cordance with those of Thin. According to the former writer, benzoated lard, yellow and white vaseline, have a slight inhibitory action, while sulphur (0'2 to 1 per cent.) is totally without effect. Substances which Schweninger found to prevent development were pyrogallic acid, ichthyol, resorcin, corrosive sublimate, and iodoform.—Monats- schrift fur praktische Dcrmatologie, August, 1890. f British Medical Journal, February 23, 1SS9, p. 397. 746 DISEASES OF THE SKIN. Vidal and Marfan have demonstrated that it is essentially an aerobic parasite. Quinquaud has ascertained that the spores and mycelium of the trichophyton are destroyed by a temperature of 50° to 55° C. (122° to 131° F.). The disease may affect the rich as well as the poor, and the robust as well as the weak and debilitated. Some persons, hoAvever, are more susceptible than others to its attacks, owing to a peculiar condi- tion of their epidermis, the character of which has not yet been con- clusively determined. Tinea tonsurans is essentially a disease of child- hood. It occurs in the lower animals, and is frequently communicated by them to children. Treatment.—The treatment of tinea tonsurans should be prophy- lactic as well as curative. The patient should, as far as possible, be isolated from other children. He should be compelled to sleep in a separate bed or room, and be cautioned against handling the wrear- ing-apparel, brushes, or combs of other persons. All Avoollen clothes must be discarded and removed from the room, in order that the conidia or spores may not become entangled in their fibres and aid in spreading the disease. As a further precaution, the heads of all other children in the house should be washed daily with a weak alcoholic solution of borax, and then thoroughly oiled with a solu- tion composed of ten grains of thymol and one ounce of olive-oil, or with the fluid oleate of mercury. If this plan be perseveringly carried out, danger of the spread of the contagion will be reduced to a minimum. Constitutional treatment is not generally necessary, but if the patient is debilitated, anaemic, or manifests evidences of scrofulous diathesis, the author usually directs a mild aperient, to be followed by a course of chlorate of potassium or of some one of the chalybeates. The chloride and the iodide of iron are particularly valuable. Cod-liver oil, malt, and the mineral acids, especially phosphoric acid and its compounds, are also of service in improving the nutrition and elevating the general tone of the system. The diet should be nourishing and easily assimi- lated, and consist chiefly of meat, milk, eggs, and fruit. Fresh air and outdoor exercise are also of prime importance. The rooms in which the patient lives should be cool and well ventilated. Care should be taken not to alloAv water to stand and evaporate in the room, or to be used on the scalp, as moisture and warmth, contribute to the propagation of the fungus. The author usually orders the diseased area and the adjacent surface to be cleansed every day or two with the borax solution which has been previously mentioned. Little or no benefit can be obtained from cutting or shaving the hairs over the affected region, or from extracting the diseased hairs. It is true that by cutting or shaving the hairs the diseased surface can be fully ex- posed to view, but the irritation resulting from the use of the scissors or razor intensifies the itching and general discomfort, and indirectly VEGETABLE PARASITES. 747 assists in spreading the disease. Epilation is not only valueless but altogether impracticable, as the affected hairs are usually clasped so tightly by the swollen follicles, and by the ravages of the parasite ren- dered so brittle, that any attempt at extraction would only result in breaking them off short either Avithin the follicles or just above the surface. Vesication during the early stages of the disease is also a useless as well as a barbarous procedure. Instead of employing either epilation or vesication, I usually begin the treatment of a case by directing the diseased spots to be sponged every day or two with a weak alcoholic solution of thymol, borax, naphthol, or mercuric bichlo- ride, and to be then thoroughly saturated Avith a fifty-per-cent. solu- tion of boro-glyceride. The latter solution can not be commended too highly. In the early stages of ringworm of the scalp I have obtained many rapid cures from its use alone. Borax is one of the most efficient antiseptic and antiparasitic agents. It also possesses mild astringent poAvers, and tends to allay the itching and irritation of the disease. The glycerine has great penetrating properties, and carries the parasiticide deep into the follicles. It also has a great affinity for water, which it withdraws from the tissues, thus depriving the fungus of one of the elements most contributive to its existence. The boro-glyceride solution may be applied night and morning with a little sponge or mop, and should be well rubbed into the follicles with the tips of the fingers. It is destitute of any poisonous or irritating qualities, and acts as a prevent- ive of further contagion, as the parasite adheres to the glycerine, and is not cast off to be wafted about by the air. During all this period the author makes no attempt to epilate, as no benefit can be derived from simply breaking off the hairs. If, however, there is no ameliora- tion of the disease within a short time after resorting to this treatment, if the patches extend, and the implicated hairs still break off or con- tinue brittle, the oleate of copper, a stronger and more decided anti- parasitic remedy, can be employed. This oleate, has been found to be the most valuable of antiparasitics. It does not produce any constitu- tional symptoms. Its stimulant and astringent virtues act favorably upon the cutaneous tissue, and it possesses the poAver of penetrating deeply into the follicles. The copper-oleate ointment should be pre- pared with either four or nine parts of aiatty base. It has been used by the author in numbers of cases Avith uni- formly good results. Its use has been objected to by some writers because the clothes are liable to become stained with the ointment. This objection does not hold good, however, when the remedy is prop- erly employed. It should not be thickly smeared on the surface, like an ordinary ointment. Only a small quantity should be applied at a time, and thoroughly rubbed into the affected area night and morn- ino- until all traces of the disease have disappeared, and until a new 748 DISEASES OF THE SKIN. and healthy growth of hair is developed. No water should be applied to the affected part throughout the course of the disease. M. Vidal bases his treatment * upon two ideas: first, the destruc- tion of the fungus; second, the exclusion of oxygen. The first object is secured by the use of spirit of turpentine as a parasiticide, the sec- ond by the application of caoutchouc to the diseased area. He avoids epilation. After the application of a turpentine lotion to the scalp, part of the affected surface is rubbed at each sitting with tincture of iodine. This procedure is repeated two or three times upon each spot until the entire area has been so treated. At intervals every day the scalp is anointed Avith vaseline or iodized vaseline, and finally the head is kept covered with a closely fitting rubber cap. Sulphurous acid is destructive to the fungus of this disease, and is consequently an efficient remedy. An easy method of applying it is that of Dr. Schuster, of Aix-la-Chapelle, who stretches a net of strings across the loAver third of a card-board box which fits to the head and can be closed by a lid of the same material. A saucer containing burning sulphur is laid upon the net of strings and the box covered. The patient must sit still for half an hour. An abundance of sulphurous-acid gas is generated, the sul- phur ceasing to burn, of course, as soon as all the oxygen is exhausted. Jonathan Hutchinson relies mainly on chrysarobin. Twice a week the scalp is well washed with a drachm of Wright's liquor carbonis de- tergens to a pint of hot water, and all scales and crusts removed. The compound ointment Avhich he directs to be rubbed into the scalp more or less freely, according to the effects which it produces, is composed as folloAvs: Chrysarobin, one drachm; ammoniated mercury, twenty grains; lanolin, one drachm ; benzoated lard, six drachms; liquor car- bonis detergens, ten minims. He finds a persistent use of this treat- ment to be followed by a cure. Chrysarobin forms the basis of a treat- ment proposed by Unna.f The hair is cut short and a protective line of zinc gelatine applied to the forehead, temples, and nape of the neck just below the hairy scalp. The affected area is coA^ered with an ointment containing five to ten per cent, of chrysarobin with or without tAvo per cent, of salicylic acid and five per cent, of ich- thyol. Oiled silk, gutta percha, or some other impermeable substance is then drawn over the head and its borders fastened to the. skin by gelatine. Upon this covering is placed a tarlatan bandage, and over the whole a flannel cap or Avax cloth. Once a day the dressings are removed and a new application made. On the fourth day a five-per- cent, ointment of ichthyol is substituted for the chrysarobin. The ichthyol is continued till the end of the week, when all the applica- tions are removed and the head thoroughly cleansed with oil and soap. A second week of treatment according to the same method * Gazette Hebdomadaire de Medicine et de Chirurgie, July 26, 1889. f Monats f. prakt. Derm., 1889, No. 12. VEGETABLE PARASITES. 749 follows, and so on until a cure results. Dr. A. J. Harrison, of Bristol, recommends the use of an unguent composed as follows: Caustic potash, nine grains; carbolic acid, tAventy-four grains; lanolin and oil of cocoa- nut, of each half an ounce. The ingredients are to be well rubbed to- gether, and, if desired, a little oil of cloves, lavender, or rosemary may be added, according to circumstances. A small portion of the prepara- tion is directed to be rubbed on the affected parts every night and morning. He usually finds marked improvement at the end of two weeks, and recovery takes place in about a month in slight, and in about three months in very chronic and severe cases. Drs. Charon and Gcvaert, of Brussels, report * excellent and rapid results from the method proposed by Professor Henry J. Reynolds, of Chicago. This plan consists in the use of the continuous electric current. The sponge attached to the positive pole is impregnated Avith an antipara- sitic solution and placed upon the affected area, the negative pole be- ing applied at some distance—upon the breast, for instance, or the back. The current thus enables the solution to penetrate much more deeply. A one-per-cent. solution of corrosive sublimate may be used, or any other germicidal fluid preferred. The impregnated electrode is applied for several minutes. The duration of the seance need not exceed thirty minutes, and should occur but once a day. Dr. Levi- seur, of New York,f epilates and then rubs into the scalp a lotion composed of tincture of benzoin and bichloride of mercury in the strength of one to three hundred. After the irritation from this measure subsides, which is usually within tAventy-four hours, he makes use of a ten-per-cent. ointment of salicylic acid prepared Avith vaseline. The strength of the applications may be carefully increased, until that of the lotion reaches tAvo to three liundred, and of the salve tAventy per cent. Sulphur has likewise been efficaciously used in the form of an ointment, combined, it may be, with ammoniated mercury, corrosive sublimate, sulphate of copper,'oil of cade, tincture of iodine, or carbolic acid. In this disease some foreign authors advise incorporating the antiparasitic remedy in collodion, solution of gutta percha, or in a plaster. Among other substances Avhich have been employed and recommended are beta-naphthol, aristol, europhen, resorcin, camphor, creolin, salicylic acid, anthrarobin, iodoform, iodol, eucalyptol, and losophan. Another mode of obtaining the action of sulphur, which has been recommended, consists in first Avashing the head with soft soap twice daily, then sponging it with acetic acid, and applying freely Avhile the head is still Avet a Avash composed as folloAvs: t> Sodii hyposulphitis .•................ 3 vj. Glycerini.......................... f 3 jss. Aquae.......................q. s. ad f 3 vj. M. * Western Medical Reporter, February, 1888. f Epitome, October, 1889. 750 DISEASES OF THE SKIN. Dr. Tarabrin, of Ekaterinovka, advocates painting the diseased patches once daily with pure tincture of iodine, or twice daily with that preparation mixed equally with the spirit of turpentine. In other cases he adds to this mixture an equal part of camphorated oil made by combining one part of camphor with nine parts of olive-oil. This plan, however, is no more than a slight modification of the methods practiced by Vidal and Besnier in the Hopital Saint-Louis, Paris. Dr. Purdon, of Belfast, recommends an ethereal tincture of croton-seeds containing salicylic acid. A weak solution (one tenth of a per cent.) of hydroxylamine has been successfully employed by Eichhoff, but is open to the objection that it may occasion systemic intoxication. If seen very early, painting the patches with carbolic or acetic acid may prevent extension of the disease. Dr. J. Hutchinson, of GlasgoAV, Scotland, has praised the action of Siegesbechia orientalis, the tincture, mixed with an equal portion of glycerine, being applied night and morning to the affected spots. The treatment of chronic ringAvorm does not differ materially from that of the acute or recent form, but marked advantage may fre- quently be derived from employing the oleate of mercury alternately Avith the oleate of copper. That in this disease the parasite penetrates to the very bottom of the follicles and into the bulbs of the hairs is beyond doubt, and the only remedies that can be of service in such a case must be those capable of equal penetration. While the oleate of copper is to be preferred for this purpose, there are cases in which the oleate of mercury proves even more effective. The last-named oleate may rapidly cure extensive and inveterate cases that have ex- isted for years, and obstinately resisted all other remedies. Although the author has often used the remedy continuously, yet he has never seen salivation or any other of the constitutional effects of mercury fol- low its external employment. It may be applied in the same manner as the oleate of copper, the five-per-cent. ointment being preferable for very young children, and the ten-per-cent. to thirty-per-cent. for older ones. It should be Avell rubbed into the diseased area night and morn- ing, until the parasite is completely extirpated. While the above methods will seldom fail, there are cases in which the adopted reme- dies do not produce the expected effects, on account of the treatment not being properly carried out in detail, thus baffling all efforts. In these cases, and in these alone, the production of artificial kerion may be justified as a last resort—as one, however, that rarely, if ever, fails. As kerion has been described as Nature's effort to effect a cure, and it is associated with a loosening and falling out of the hairs, this condi- tion is artificially produced with the -view of accomplishing a similar result. The best application for the purpose of producing kerion is croton- oil. As, however, this remedy can not be used carelessly or upon a very VEGETABLE PARASITES. 751 large surface, it should be daintily applied Avith a camel's-hair pencil to small inveterate patches, and should be immediately followed by a poul- tice of flax-seed, or a warm-water dressing, well secured to the parts. This treatment should be daily repeated, even if pustulation follow, un- til distinct infiltration and puffiness of the scalp is observed, and the patches shall have assumed an aspect similar to that of true kerion. The scab is then to be removed, and the ointment of either the oleate of mercury or the oleate of copper applied to the exposed surface. After one spot is thus cured the others may be similarly treated, one at a time, until all traces of the disease shall have disappeared. It may take fhe or six applications to each spot to produce the desired effect, but it is sure to follow if the treatment be properly pursued. As this process is a severe measure, it should never be lightly attempted, and the parents of a child should be duly informed of its character, as other- wise they might become alarmed at the amount of the inflammation, and withdraAV the patient from further treatment. The disseminated variety of the disease which Alder Smith speaks of should be managed in accordance with the preceding methods. The solution of boro- glyceride should also be continuously applied, and the hair be closely examined with a lens for stumps and black dots. If either are found, they should be promptly treated by the method recommended by Alder Smith—that is, by the application of drops of croton-oil to produce pustulation, or by puncturing the follicles with a gold needle dipped in that oil. Treatment should be kept up in this manner until stumps and black spots are no longer visible, and the entire surface is covered Avith healthy, doAvny hair. In the management of epidemics of ringAVorm occurring in schools and asylums, the most important measures are cleanliness and isola- tion. The heads of the healthy children should be frequently exam- ined, and Avashed daily with the solution previously mentioned. When, finally, all those affected have been cured, the sick-rooms should be AvhiteAvashed and painted, the floors washed with a solution of naph- thol or mercuric bichloride, and the clothing, brushes, combs, etc., used by the patients should be burned, so as to destroy all vestiges of the parasite, and to preA'ent the disease from breaking out anew. When kerion occurs idiopathically, all harsh or irritating measures must be avoided. The surface should be saturated Avith the boro- glyceride solution, and Avhen the crusts are removed the ointment of the oleate of mercury should be well rubbed into the follicles of the affected area. Prognosis.—The prognosis of tinea tonsurans is always favorable. The time required to effect a cure varies in accordance with the num- ber and size of the diseased patches, the length of time that has elapsed since their first appearance, and the general condition of the patient. Some cases yield readily to the most simple measures, others 752 DISEASES OF THE SKIN. persist for a long time notwithstanding all remedies; but even in the most obstinate cases the disease exhausts itself sooner or later, and spontaneously disappears. It rarely continues after puberty. Re- lapses are not of frequent occurrence, but if the smallest vestige of the parasite has escaped destruction it will soon redevelop luxuriantly over a large area. TINEA SYCOSIS. Synonyms.—Tinea trichophytina barbae—Sycosis parasitica—Barber's itch—Parasitare Bartfinne—Trichophytie sycosique. Tinea sycosis is a contagious vegetable parasitic affection of the bearded portion of the face and neck, occurring therefore, of course, only in adult males. It is produced by the trichophyton, and is characterized by the formation of papules, tubercles, and pustules, and the occurrence of various morbid changes in the hairs of the affected area. Symptoms.—Tinea sycosis is, as remarked, a disease of the male sex exclusively. It may occur at any time during adult life, but is met with most frequently between the twentieth aud the fortieth years of age. It usually begins as one or more small, round, erythematous, scaly patches situated on the cheeks or the chin. The spots vary from one fourth of an inch to half an inch or more in diameter. They are slightly elevated above the surrounding surface, and are the seat of a more or less itching and burning sensation. The patches are occasion- ally surrounded by a ring of minute vesicles that rupture spontaneously in a day or two after their appearance. If the nature of the lesions be recognized and appropriate treatment adopted, the disease may be arrested at this stage. If neglected, the spots increase in size and become distinctly SAvollen, indurated, and more or less painful. The adjacent patches coalesce, forming one or more large, irregular, dark- red or purplish areas. Finally, as the fungus penetrates deeply into the follicles, the hairs become involved, and violent inflammation of the loAver portion of the corium and subcutaneous connective tissue occurs as the consequence of the irritation by the parasite. Papules, tuber- cles, and pustules are developed around the orifices of the follicles. The papules are usually large in size, and frequently coalesce, forming tubercles which are of various shapes and sizes. The tubercles are firm, and slightly painful to the touch. They are deeply situated in the cori- um and subcutaneous connective tissue, but project more or less above the surface, to which they give a nodular appearance. The pustules are of varying sizes, and tend to rupture spontaneously, forming thick yel- Ioav crusts situated upon a reddened, excoriated, discharging surface. The hairs are not noticeably affected at first, but as the disease pro- gresses they become dry, lustreless, brittle, and either twisted or broken off just above the orifices of the follicles. They are finally diseased VEGETABLE PARASITES. 753 throughout their entire length, or loosened by the suppurative process and drop out spontaneously. In severe cases large areas may in this manner be entirely denuded. Cicatricial deformities may be produced. In mild forms the disease may manifest itself only by a reddened, des- quamative condition of the epidermis, leaving the hairs unaffected. In still other cases, resembling the disseminated variety of tinea tonsurans, congested spots upon Avhich the hairs are brittle and dull may be ob- served at several points, but neither tubercles nor pustules are formed. Tinea sycosis may develop first on the neck or on the face. The malady may attack either or both sides of the face, and not infrequently spreads over the entire submaxillary region. Tinea sycosis seldom involves the upper lip or the upper portions of the cheeks. It is rarely accompanied by manifestations on other regions of the body. In rare instances the disease extends to the mucous membrane of the lips, mouth, or nostrils. The disease may exceptionally terminate in spontaneous recovery, but as a general rule it assumes, if left untreated, a chronic character, and remains for years. Diagnosis.—The only affections for which tinea sycosis might be mistaken are non-parasitic sycosis, pustular eczema, acne, favus, and the syphilides. In non-parasitic sycosis, hoAvever, the inflammation is superficial in character and characterized by the formation of pust- ules. In tinea sycosis the deeper layers of the skin as well as the follicles are involved, and tubercles and nodules are formed in the affected area. Non-parasitic sycosis is usually accompanied by intense pain, itching, and burning, Avhile in tinea sycosis these symptoms are seldom very marked. Non-parasitic sycosis frequently involves the upper lip, Avhile tinea sycosis is rarely or never observed there. Finally, the hairs are not affected in the former disease, Avhile in the latter they are tAvisted and broken off, or spontaneously expelled from their follicles. In doubtful cases the diagnosis can always be placed beyond question by a microscopic examination. The crusts of tinea sycosis sometimes resemble those of pustular eczema. Eczema, how- ever, is accompanied by intense itching and burning. The crusts form rapidly upon an eroded, exudating surface, but there are no tubercles or nodules, the hairs are normal in appearance and texture, and remain firmly fixed in their follicles. When the papules and pustules of acne occur upon the hairy region of the face they might be mistaken for tinea sycosis; but the occurrence of similar lesions on other portions of the face, the absence of itching and desquamation, also of tubercles and nodules, and the normal character of the hairs, make the diagnosis easy. Various syphilitic, pustular, papular, and tubercular manifes- tations may, Avhen they appear upon the face, chin, or neck, simu- late tinea sycosis, but in these the hairs are not involved, there is little or no itching, and microscopic examination will fail to reveal the presence of the trichophyton. The crusts that occasionally form in 48 DISEASES OF THE SKIN. tinea sycosis may resemble those of favus, but in the latter disease there is no excoriated, exudating surface, the hairs have not a nibbled appearance, and no tubercles or nodules are deeply situated in the cori- um and subcutaneous connective tissue. Pathology.—The pathological changes that occur in tinea sycosis are similar to those of tinea tonsurans. The trichophyton fungus pro- duces more or less irritation and hyperaemia of the surface, and then penetrates into the hair-follicles and between the upper layers of the epidermis. It also invades the follicular walls, producing intense irri- tation and inflammation, resulting in the formation of deep-seated papules, tubercles, and pustules. The parasite ramifies around and within the hair-shafts, producing more or less disorganization of their structure. It consists of mycelium and spores identical in arrangement and appearance with those which are found in tinea tonsurans. Etiology.—Tinea sycosis is due to the trichophyton, and is propa- gated by contagion. It may be secondary to the ringworm peculiar to other portions of the body, or be contracted from children suffering from ringworm of the scalp. Tinea sycosis is, however, usually acquired by using the shaving-brush or razor of an infected person. It would be a proper precaution for the barber to immerse "his brush', after being used, in boiling water containing some simple antiseptic. The disease may appear in the robust as well as in the weak, but it seems to require certain peculiar soil for its full development. Treatment.—The treatment usually recommended in this affection . consists in cutting or shaving the beard and epilating the diseased- hairs, and then applying sodium hyposulphite, mercuric bichloride, sulphurous acid, boric acid, and other antiparasitic remedies to the sur- face. I fail to see any advantage in either cutting the beard close or shaving, owing to the irritation produced by both these measures. The remedies specified often act rapidly and effectively. One of the most efficient applications for this variety of the disease is a fifty-per- cent, solution of boro-glyceride, employed in the same manner as in tinea tonsurans. A ten-per-cent. ointment of either the oleate of mer- cury or the oleate of copper will frequently be found serviceable in lessening infiltration and induration as well as in destroying the para- site. It should be applied night and morning until all traces of the disease shall have disappeared. To prevent the communication of the affection, a ten-per-cent. solution of thymol in olive-oil or oil of sweet almonds should be rubbed in over the entire bearded surface. If fol- licular suppuration or fungous granulations occur, a weak ointment of the oleate of nickel will be found invaluable in restoring healthy ac- tion. In obstinate cases, characterized by exuberant granulations and continual destruction of the hairs, the surface should be brushed over with an infusion of jequirity. This will induce violent inflammation and profuse suppuration, but will finally result in a cure. Dr. Cavafy's VEGETABLE PARASITES. 755 boric-acid lotion is also an effective application in both recent and chronic cases. Its formula is : IJ Acidi borici....................... 3 iv. YEtheris sulph..................... f 3 v. Spiritus vini rect............q. s. ad f § xx. M. Ft. lot. Sig.: Apply to the diseased surface three or four times daily. Hydroxylamine has been recommended; aristol and europhen are likewise efficient. Prognosis.—The prognosis is always favorable, but the time requi- site to effect a cure varies considerably. In some cases the most simple measures speedily suffice, in others months may elapse before the dis- ease is eradicated. ftelapses will occur unless the parasite is thoroughly destroyed. TINEA CIRCINATA. Synonyms.—Herpes circinatus—Ringworm of the body—Trichophytie circinee. Tinea circinata is a contagious, vegetable parasitic cutaneous disease, produced by the trichophyton, and characterized by the formation of one or more round or oval erythematous, scaly patches upon the gen- eral surface of the body. Symptoms.—This form of ringAvorm differs from the preceding vari- eties only by its location, being situated chiefly in the superficial layers of the epidermis. It occurs upon portions of the body that are either destitute of hair or scantily provided with lanugo. If ringAvorm spreads to the scalp or other hairy regions of the body, it assumes the form of tinea tonsurans. It usually begins as a small, round, reddish spot, slight- ly eleA'ated above the surrounding surface, presenting a branny or scurfy appearance. Tinea circinata may or may not be accompanied by itch- ing. .The spots rapidly increase in size by peripheral groAvth, attaining a diameter of half an inch or more in a few days. The margins of the patches are distinctly elevated, and in some cases surrounded by a ring" of minute papules, Aresicles, or papulo-vesicles, Avhich terminate in des- quamation. Owing to the tendency manifested by the disease to disap- pear at the centre while it extends at the periphery, the lesions soon as- sume the characteristic annular form. When a large ring is formed in this manner the affection may reappear again in the centre, and by pur- suing the same course terminate by the formation of a series of con- centric rings. When two or more patches are present upon the same region of the surface they frequently coalesce so as to form large, ir- regular, reddish, desquamative areas. When the peripheries of two or more rings meet, a variety of semicircular, serpentine, erythematous, scaly lesions are formed. The lesions are accompanied by slight itch- ing and tingling sensations. In some rare cases the itching is so excessive and producthe of so much scratching, that a mild or severe 756 DISEASES OF THE SKIN. eczema is superadded to the original disease. Tinea circinata varies in intensity and duration in accordance with the amount and activity of the fungus, and the condition of the epidermis of the patient. It may pursue a mild course and disappear spontaneously in a few weeks, or may, if left untreated, become chronic and remain for an indefinite period. When the disease is contracted from the lower animals it is especially obstinate. In chronic ringworm of the body the lesions con- sist of one or more isolated patches, which are reddish or brownish and covered with small scales. They are irregular in shape and variable in size, and as a rule are not accompanied by subjective symptoms. Their color disappears upon pressure, but returns as soon as the pressure is removed. The spots remain either stationary or increase in size very slowly. Occasionally they become markedly diminished in size, or ap- parently disappear during the summer, appearing again in the winter. Tinea circinata may develop upon any portion of the body, but is ob- served most frequently upon the face, neck, and the dorsal surfaces of the hands and arms. It may be occasionally seen beneath the mammae or in the axillae, between the nates, around the genitalia, and upon the inner surfaces of the thighs. When it appears upon the last-named region it is known as tinea circinata cruris. This is the affection de- scribed by Hebra as " eczema marginatum." It is characterized by the development of a number of small, reddish, elevated spots situated in the upper, inner portions of one or both thighs or on the scrotum. Owing to the heat and friction to which these patches are subjected, their surfaces become eroded and covered with crusts. They rapidly increase in size, and coalesce so as to form large, irregular, semicircular or serpentine lesions, that involve the entire genito-crural region, and even extend over the lower portion of the abdomen. Their margins are sharply defined and distinctly elevated above the adjacent normal skin. The lesions are accompanied by intense itching, which induces excessive scratching, resulting in the development of a more or less acute eczematous inflammation. Vesicles and pustules are not infre- quently developed around the margins of the patches. Tinea circinata sometimes occurs upon the sole or dorsum of the foot. In tinea trichophytina unguium, or onychomycosis, the parasite penetrates the nail-substance, producing various hypertrophic and de- generative changes. The nails become dry, opaque, and brittle, more or less distorted and thickened, and manifest a tendency to fissure or to peel off in layers. This variety of the disease is usually secondary to ringworm of other parts of the body. It may, however, occur pri- marily in adults as a result of attending to or caring for children suf- fering from tinea tonsurans. It is a rare form of the disease, however, and is peculiarly obstinate to treatment. Tinea imbricata, Chinese ringworm, India ringworm, Burmese ringworm, and other terms, are those used to designate certain forms VEGETABLE PARASITES. 757 of tinea circinata that occur in various parts of the East. They are characterized by profuse desquamation and extensive inflammation of the surface, are frequently obstinate to treatment, and usually tend to pursue a chronic course. Diagnosis.—The diagnosis of tinea circinata is not, as a rule, diffi- cult. Typical annular, scaly, erythematous lesions can not be mistaken for any other disease. Isolated patches of the affection might, it is true, be confounded with eczema, seborrhoea, syphilis, or psoriasis. In eczema, however, the eruption is not sharply defined, but gradually fades into the surrounding skin. The surface in eczema is hot, painful, and be- sides being, as in tinea circinata, the seat of intense itching, with more or less exudation, has vesicles, papules, or pustules at all points, and not upon the periphery only, as in ringAvorm. Finally, the patches of eczema are not circular but are irregular in form, and never mani- fest any tendency to heal in the centre. In seborrhcea of the body the spots often assume an annular form, and are more or less ele- vated above the surface and covered Avith fine scales. They are nor- mal in color, hoAvever, the scales greasy, the follicles perceptibly dilated, and no vesicles or papules are deAreloped at the periphery. The disseminated form of psoriasis may present some resemblance to tinea circinata, but the history and course of the diseases are so Avidely different that no error should be made in their respective diag- noses. Favus of the body can readily be distinguished from tinea cir- cinata by the presence of its characteristic cup-shaped yellow crusts Avith their peculiar mousy odor. The erythematous and papular cu- taneous manifestations of syphilis might be confounded with tinea circinata, but the number and wide diffusion of the lesions, their slow peripheral groAvth, and the absence of itching, should exclude ring- Avorm as a factor in their development, while the history of infection and the presence of other symptoms of syphilis should make the diag- nosis certain. A microscopic examination of a portion of the epider- mis ought to be made in all doubtful cases, in order to determine the presence or absence of the parasite. A case of tinea trichophytina cruris might tend to be mistaken for intertrigo or ordinary eczema. One has only to recollect that the elevated margins and the annular or serpentine form of the lesions of the former, and the intense itching by Avhich they are characterized, are peculiarities of the parasitic dis- ease. The presence of the trichophyton, if ascertained by micro- scopical examination, will place the diagnosis beyond doubt. Pathology.—The lesions of tinea circinata are due to the presence of the trichophyton fungus. The fungus consists of spores and myce- lium that ramify OATer the surface and insinuate themselves between the superficial layers of the epidermis, producing more or less irrita- tion, resulting finally in desquamation and the formation of erythema- tous or hyperaemic areas of various shapes and sizes. When the irri- 758 DISEASES OF THE SKIN. tation becomes excessive, the stage of congestion passes into that of inflammation, vesicles and papules are formed, and there is more or less exudation. In severe cases, or in those occurring in portions of the body that are subjected to friction or pressure, the irritation and itching may be so severe as to induce violent scratching, Avhich inten- sifies the suffering, and frequently develops a severe eczema as a com- plication of the original disease. Etiology.—Tinea circinata is derived, as already noted, from the trichophyton, and is propagated by contagion. It occurs in both sexes and at all ages, but is more frequently observed in children than in adults. The disease is of frequent occurrence in the lower animals, and may be contracted from them by man. Tinea circinata may attack the robust as Avell as the debilitated, but as a rule a peculiar or weak condition of the epidermis is necessary to its development. Treatment.—Constitutional remedies are unnecessary in tinea cir- cinata, except in anaemic, debilitated, or scrofulous persons, to whom either chlorate of potassium, the tincture of the chloride of iron, iodide of iron, or cod-liver oil, may be given with decided benefit. The indications for local treatment are to use agents that will either destroy the parasite or else indirectly eliminate it from the surface by producing desquamation of the superficial layers of the epidermis in which it is situated. One of the very best local applications is a lotion of two or three grains of mercuric bichloride dissolved in equal parts of alcohol and cologne-water, painted over the diseased area every night and morning. The boracic-acid lotion recommended by Dr. Cavafy is an effective and elegant preparation. Alcoholic solutions of carbolic acid, a drachm to the fluid ounce of alcohol, or of salicylic acid a drachm to the ounce, or of thymol thirty grains to the ounce, may also be used Avith benefit. Strong acetic acid, or pure tincture of iodine, will frequently prove curative after a few applications. Chromic acid has been successfully used in the form of an aqueous solution of one hundred grains to the ounce. In order to avoid a corrosive action upon the neighboring healthy integument, the latter should be protected by some ointment, and the excess of acid immediately neu- tralized by means of an alkaline wash. Among other effective lotions may be mentioned sulphurous acid, one drachm to the fluid ounce of alcohol; hyposulphite of sodium, eighty grains to the ounce; naph- thol, forty grains to the ounce; and creasote, one drachm to the ounce Of chrysarobin, seven grains dissolved in an ounce of chloro- form, as recommended by Alder Smith, will be found remarkably effective. Anthrarobin has likewise been brought forward as a substi- tute for chrysarobin. It may be used in the form of an alcoholic solu- tion. Nitrate of silver dissolved in spirit of nitrous ether, forty grains to the ounce, has also been used with good effect. Ointments are sometimes of more service than lotions. The oint- VEGETABLE PARASITES. 759 ment of the acid nitrate of mercury, combined Avith an equal quantity of lard, Avill be found especially valuable. Among other useful oint- ments are those composed of pyrogallic acid, fifteen grains to the ounce of a fatty base; carbolic acid, tAventy to thirty grains to the ounce; mercuric bichloride, three grains to the ounce; oil of cade, one drachm to the ounce; salicylic acid, forty grains to the ounce; thymol, twenty grains to the ounce; and resorcin, tAventy grains to the ounce. An ointment of oxide of manganese has been reported to yield success. The iodide of lead ointment is commended by Dr. Whitla, and the compound tar ointment of our National Formulary may be employed Avith advantage. The various sulphur preparations may also be used Avith benefit. Chrysarobin, in the form of an ointment or a lotion, twenty grains to the ounce, is effective, but it stains the surface, and if accidentally brought into contact with the conjunctivae will produce vio- lent inflammation. Some have made use of the oil of cajuput as a parasiticide in this affection. Wilkinson's ointment, Coster's paste, and alcoholic solutions of sapo viridis, have long been recognized as potent applications. In the experience of the author, hoAvever, no other remedy is so effective as the ointment of the oleate of copper, used either alone or in alternation with the ointment of the oleate of mercury. In mild cases any of the ointments or lotions previously mentioned will be sufficient to effect a cure in a short time. Nothing can be gained in obstinate cases by employing in quick succession a number of different remedies. If the disease manifest any tendency to linger, the oint- ment of the oleate of copper should be applied at once. It may be Avell in some patients to commence Avith the five-per-cent. ointment, and then increase its strength as may be necessary. In chronic cases the ointment of the oleate of mercury should be used in alternation with the oleate of copper mixed Avith a fatty base. If eczematous complica- tions manifest themselves, the ointment of the oleate of zinc, or of the oleate of bismuth combined with oil of cade, may be employed with advantage. The treatment of tinea trichophytina cruris is essentially the same as that of the other varieties of ringworm. It must not be forgot- ten, however, that in this form of the disease there is, in addition to parasitic irritation, an aggravated hyperaemic condition of the sur- face produced by moisture and friction, and that soothing and astrin- gent remedies are as indispensable as antiparasitics. In several cases that came under my observation immediate relief and rapid cure Avere obtained through the application night and morning of the fol- lowing ointment: I£ Acidi carbolici s.....................gr. v. Cupri oleatis.......................gr. x. Ungt. zinci oxidi benz...............§ j. M. Ft. ungt. 760 DISEASES OF THE SKIN. The affected surfaces were also dusted over with a powder com- posed of equal parts of pulverized starch and the oleate of zinc, in order to prevent chafing and to produce a slight astringent action on the cutaneous glands and vessels. The severe tropical forms of the affection can be most effectually treated by the application of a strong ointment of oleate of copper, the oleate of mercury, or of an ointment of chrysarobin, of thirty grains to the ounce. The best treatment for ringworm of the nails consists in removing as much as possible of the diseased portion with the knife, and keeping the remainder covered with a ten- or twenty-per-cent. ointment of the oleate of mercury until the entire diseased area shall have exfoliated and been succeeded by a new and healthy growth. The ointment of the oleate of copper or of the oleate of tin may be used alter- nately with the oleate of mercury. Before paring the nail it may be softened by means of potash solution. Instead of the oleates men- tioned some authorities recommend solutions of corrosive sublimate and creasote. Prognosis.—The prognosis of tinea circinata is ahvays favorable. Many cases terminate spontaneously, others prove more or less un- yielding to treatment, but a cure is certain even in those most obstinate, if the treatment be judiciously directed and persistently followed. Tinea trichophytina cruris and tinea trichophytina unguium are the most difficult varieties of the disease to ovrercome, but they are less intractable than was formerly supposed. Eelapses may occur if the patient is again exposed to contagion. TRICHOMYCOSIS NODOSA. Under the above title a peculiar affection of the hairs of the axilla and scrotum has been studied by Dr. R. G. Patteson,* of Dublin. This disease had not been entirely unnoticed before, but had never been so closely investigated and traced to its origin. Cases have hitherto been in all probability confounded with atrophy of the hair, or trichorexis nodosa. The affection was described nearly twenty years ago by Paxton in an article " On a Diseased Condition of the Hairs of the Axilla, probably of Parasitic Origin." Sir Erasmus Wilson subsequently wrote of the disease under the name of lepto- thrix. Descriptions have also been given of the same malady by Michelson, Radcliffe Crocker, J. F. Payne, and Walter G. Smith. The affected hairs are dull and dry in appearance, and to the touch are rough and knotty. Examined against the light or by a simple lens it is perceived that the roughness is due to minute con- cretions which project from the side of the shaft. These concre- * Trichomycosis Nodosa: A Bacillary Disease of the Hair. By Dr. R. Glasgow Patte- 'on, B. A., M. B. British Medical Journal, May 25, 1889. VEGETABLE PARASITES. 761 tions may assume two forms, the nodular or the diffuse. The nod- ules are generally seated upon the outer or terminal third of the shaft, and are separated from each other by intervals of healthy hair. The diffuse form may spread along nearly the entire length of the shaft with only narroAv intervals of healthy structure. The two forms represent different stages of the same process, and both are not un- commonly present upon a single hair. The masses adhere very closely to the hair, and can not be forcibly removed without injury. The shaft, nevertheless, is not abnormally brittle, and has little tendency to break in the situation of these nodes. Only the diffuse form oc- curs toAvard the bulb. The disease never penetrates into the hair- follicle. The origin of the affection Dr. Patteson believes to be the growth of a bacillus which he has isolated and described. These organisms appear in the form of short, fine rods Avith slightly rounded ends, about two to three times as long as broad, and about one fourth the diameter of a red blood-corpuscle. They stain readily with any of the aniline dyes. Dr. Patteson did not succeed in cultivating these bacilli upon sterilized potatoes or peptone-gelatine. The heat and moisture of the parts in which the affected hairs grow loosen the epidermic scales of the shaft and allow the bacilli to gain an entrance into the cortex, though they never penetrate deeply into the hair. At first they lie in small pits or depressions on its surface. As they deArelop the cortical fibres split longitudinally. At the same time a hard, homogeneous and slightly granular substance is generated between and around the microbes. The bacteria are en- capsulated by this substance which forms the nodular or diffused pro- jections, and which resembles that by which pediculi fasten their ova to the hairs. The material is extremely hard, insoluble in alcohol, ether, chloroform, and other solvent fluids, and resists the action of strong acid and alkaline solutions. ACTINOMYCOSIS. Actinomycosis is an infectious disease in which globular tumors form beneath the skin. The overlying integument is of a livid color. The tumors may be either hard or soft to the touch, but eventually disintegrate and discharge through fistulous tracts. The matter which escapes is at first purulent, but subsequently becomes sanious. It con- tains numerous yellow granules which vary in size from a pin's head to a hemp-seed. The involvement of the surface is usually secondary to an affection of the deeper tissues, as the lungs or vertebrae. Actino- mycosis is principally a disease of cattle, in which it affects the inferior maxilla, and is therefore popularly knoAvn as "lumpy jaw." The yellow granules are due to an aggregation of a radiate fungus called 762 DISEASES OF THE SKIN. actinomyces. They are also present in the substance of the tumor. The germs generally enter the system through a lesion connected with a decaying tooth, but may also invade it by way of the digestive canal, lungs, or an abrasion of the skin. Before the establishment of fistulae the tumors resemble sarcoma. The yellowish bodies discharged are, hoAvever, characteristic of actino- mycosis, and the microscope shows the mycelial growth of a fungus. If the tumors are superficially situated they may be removed by surgical procedures. The prognosis is bad. Potassium iodide in large doses has in some instances been of benefit. METRIC SYSTEM OF WEIGHTS AXD MEASURES. On account of the growing use of the metric system it has been deemed advisable to insert a key by which the quantities of our apothe- caries' measures may be converted into the corresponding metric terms. The decimal system is employed in the United States Pharmacopoeia and in scientific investigations. Its advantages are simplicity and its position as a uniform standard common to all civilized nations. There seems no doubt that it will eventually be adopted in this country. As regards its use in prescription writing it is only necessary to become acquainted Avith a few equivalents. Its unit is the metre, which is 3 feet 3f inches in length, or 39-37 inches; a thousandth part of a cubic metre is a litre, which contains a little more than two pints (2fa pints). The unit of weight is called a gramme, and is nearly equal to 15£ grains (15*432 grains). Grammes are multiplied by prefixing the Greek numerals, deha = 10 times, hecto = 100 times, kilo — 1,000 times, myria = 10,000 times. They are divided by the use of corre- sponding Latin terms, deci = fa, centi = T^-g-, and mille = yoVo- USE OF THE METRIC SYSTEM IN PRESCRIPTION WRITING. Troy and apothecaries' terms can be readily translated into those of the metric system by remembering the following equivalents: • 15'5 grains = 1 gramme. 1-5 grain = 1 decigramme (or -fa gramme). \ grain = 1 centigramme (or ^-g- gramme). fa grain = 1 milligramme (or j-fa-g gramme). The above equivalents answer for liquids as well as solids, the for- mer also being estimated by weight. Thus: 1 minim = 1 grain = -06 gramme. 1 fluidrachm = 1 drachm = 4*0 grammes. 1 fluidounce = 1 ounce = 32*0 grammes. 16 minims are equal to 1 cubic centimetre or millilitre (Tfa-$ litre). A cubic centimetre therefore corresponds nearly to a gramme. 763 764 DISEASES OF THE SKIN. Ordinary expressions of wreight or measure may be reduced to me- tric terms by the following rule : Multiply grains by 6 and the result will be centigrammes; multiply drachms by 4, or ounces by 32, and the result will be grammes. In the same manner, by dhiding centi- grammes by 6 we obtain grains; or grammes by 4 or 32, and the result Avill be the number of drachms or ounces, as the case may be. In writing prescriptions according to the metric system either deci- mal points or a vertical line is used to separate grammes and their subdivisions. Thus, we may designate : 15!- grains = 1 gramme, as 1-0 or 1 1 drachm = 60 grains = 4 grammes, as 4-0 or 4 1 ounce = 480 grains = 32 grammes, as 32-0 or 32 | The use of the decimal line is perhaps preferable, as it greatly re- duces the possibility of mistakes. The figures upon the left of the line are grammes, while those upon the right are fractions or parts of grammes. A feAv examples of prescriptions translated into French equivalents will render the method clear to the reader: t> Syrup, sarsaparillae co........f | iij Tr. stillingiae................f § ij Sp. aetheris nitrosi...........f § ij M. 5 Amnion, carbonat............3 ijss. Extr. caffeae fl...............f 1 ss. Syrupi.....................f § iv M. 96 96 04 64 64 64 10 10 16 16 28 128 I> Quinin. sulphat..............gr. xxx 2 Calcii sulphid...............gr. x -6 I> Acidi arsenosi...............gr. j Extr. belladonnae............gr. v Extr. calami................ 3ij t> Morphin. sulphat............gr. j Tr. gelsemii.................3 j Sodii bicarbonat............. § ss. Aq. camphor................| ij Sp. aetheris nitrosi........... § ijss. •06 06 •3 3 2-4 2 4 •06 06 4 4 16 16 64 64 80 80 FORMULARY. INTERNAL. ACNE. Take of Pill of carbonate of iron........... ^ drachm. Extract of ignatia................. 2 grains. Arsenious acid................... 1 grain. Mix and divide into twenty pills. Dose : 1 pill after meals. ACNE. Take of Liquid pepsin.................... 2 drachms. Tincture of nux vomica........... 1 drachm. Dilute hydrochloric acid........... 2 drachms. Glycerin......................... 2 ounces. Mint-water.. •..................... 1 ounce. Mix. Dose : 1 teaspoonful after meals. ACNE. Take of Bromide of sodium............... 4 drachms. Sirup of Avild cherry.............. 3 ounces. Mix. Dose : 1 teaspoonful in water every three hours. ACNE. Take of Sublimed sulphur................. \ ounce. Carbonate of magnesium.......... 6 drachms. Mix and divide into twelve powders. Dose : 1 or 2 powders in sirup every morning and evening. ACNE. Take of Sirup of lactate of iron............ 3 ounces. Chlorate of potassium............. 2 drachms. Mix. Dose : 1 teaspoonful four times a day. Efficacious for pustular acne. 766 DISEASES OF THE SKIN. ACNE. Take of Glycerin......................... 3 ounces. Tincture of calamus............. 2 drachms. Cinnamon-water.................. 14 drachms. Mix. Dose : 2 teaspoonfuls three or four times a day. Useful in acne punctata, or black-head. ACNE. Take of Fluid extract of hydrastis......... 2 drachms. Glycerin........................'. 3 ounces. Mix. Dose : 1 teaspoonful before meals. ACNE. Take of Sulphate of iron.................. 15 grains. Extract of dandelion.............. 20 grains. Mix and divide into twenty pills. Dose : 1 pill after meals. ACNE. Take of Sirup of the lactophosphate of lime 3 ounces. Dose : 1 teaspoonful in water three times a day. ACNE. Take of Sirup of the hypophosphites....... 5 ounces, Aloin............................ 2 grains. Mix. Dose : 1 teaspoonful three times a day. ALOPECIA. Take of Sulphurous acid.................. 2 ounces. Sirup of orange-flowers............ 2 ounces. Mix. Dose : 1 to 2 teaspoonfuls in water three times a day„ ALOPECIA. Take of Tincture of ignatia............... 2 drachms. Solution of arsenite of potassium... 2 drachms. Mix. Dose : 5 to 10 drops in water two or three times a day„ ALOPECIA. Take of Corrosive sublimate............... 1 grain. Glycerin......................... 3 ounces. Mix. Dose : 1 teaspoonful four times a day. i FORMULARY. 767 ALOPECIA. Take of Tincture of jaborandi............. £ ounce. Dose : 5 to 30 drops in water four times a day. ANIDROSIS. (A decreased or complete cessation of the secretion of sweat.) Take of Infusion of jaborandi.............. 3 ounces. Spirit of nitrous ether............. 3 ounces. Mix. Dose : 1 to 2 tablespoonfuls every three or four hours. ANIDROSIS. Take of Compound sirup of sarsaparilla..... 3 ounces. Tincture of stillingia.............. 2 ounces. Spirit of nitrous ether............. 2 ounces. Mix. Dose : 1 tablespoonful three or four times a day. ANTHRAX. (Malignant pustule.) Take of Compound tincture of cinchona.... 3 ounces. Solution of acetate of ammonium... 3 ounces. Brandy.......................... 3 ounces. Mix. Dose : 1 tablespoonful in water every tAvo or three hours. ANTHRAX. Take of Creasote......................... 2 drops. Hydrate of chloral................ 2 drachms. Sirup of ginger................... 3 ounces. Mix. Dose : % to 1 teaspoonful in water every three or four hours, BITES AND STINGS OF INSECTS. Take of Oil of sassafras................... 2 drachms. Dose : 2 to 10 drops on sugar or in sirup every two to four hours. C ARBUNC CLUS—CARBUNCLE. Take of Carbonate of ammonium.......... 2^ drachms. Fluid extract of coffee............. % ounce. Sirup............................ 4 ounces. Dose : 1 or 2 teaspoonfuls every two or three hours. CARBUNCULUS—CARBUNCLE. Take of Antipyrine.......................100 grains. Make into 20 powders. Dose : 1 powder in water every one or two hours. i u5 DISEASES OF THE SKIN. CARBUNCULUS—CARBUNCLE. Take of Sulphate of quinine............... 30 grains. Sulphide of calcium............... 10 grains. Mix and divide into 20 pills. Dose : 1 or 2 pills every three or four hours. CARBUNCULUS—CARBUNCLE. Take of Tincture of chloride of iron........ 1| ounce. Glycerin......................... H ounce. Sulphate of quinine,.......... ... 1 drachm. Mix. Dose : 1 teaspoonful in water every two or three hours. COMEDO—SEBACEOUS PLUG OR GRUB. Take of Dialyzed iron.................... 1 ounce. Glycerin......................... 2 ounces. Castor-oil........................ 2 ounces. Mix. Dose : 1 to 2 teaspoonfuls night and morning. COMEDO—SEBACEOUS PLUG OR GRUB. Take of Cod-liver oil..................... -J ounce. Sulphuric ether................... 20 drops. Mix. 1 dose : To be taken three times a day. CHANCROID. Take of Sirup of iodide of iron............ 1 ounce. Chlorate of potassium............ 2-J drachms. Glycerin......................... 2 ounces. Water........................... 1 ounce. Mix. Dose : 1 to 2 teaspoonfuls every two or three hours. CHANCROID. Take of Tartrate of iron and potassium..... 4 drachms. Aromatic spirit of ammonia......... 2 drachms. Water.......................... 3 ounces. Mix. Dose : 1 teaspoonful in water every three hours. CHANCROID. Take of Sulphate of quinine............... 30 grains. Compound powder of ipecacuanha.. 30 grains. Mix and divide into 30 pills. Dose : 2 pills every two or three hours. FORMULARY. 769 DERMATALGIA—NEURALGIA OF THE SKIN. Take of Fluid extract of gelsemium........ 2 drachms. Dose : 2 to 5 drops in water every three or four hours. DERMATALGIA—NEURALGIA OF THE SKIN. Take of Croton chloral hydrate...........■. 36 grains. Glycerite of tragacanth, a sufficient quantity. Mix and divide into 12 pills. Dose : 1 pill every two or three hours. ECZEMA, ACUTE. Take of Tincture of aconite root........... 2 drachms. Water........................... 6 drachms. Mix. Dose : 4 to 8 drops every hour or two. ECZEMA, ACUTE. Take of Tartar emetic.................... ^ grain. Solution of acetate of ammonium... 6 ounces. Mix. Dose : 1 tablespoonful in water every hour or two. ECZEMA, ACUTE. Take of Subnitrate of bismuth............. 2 drachms. Fluid extract of gelsemium........ 50 drops. Powdered nutmeg................. 40 grains. Sirup of ginger.................. 3 ounces. Mix. Dose : 1 or 2 teaspoonfuls in water every hour or two, ECZEMA, ACUTE. Take of Oil of ganltheria.....•............. \ ounce. Carbonate of magnesium.......... 8 drachms, Water........................... 10 ounces. Mix. Dose : \ to 2 drachms in water three times a day. ECZEMA, ACUTE. Take of Carbonate of magnesium.......... \ ounce. Aromatic spirit of ammonia........ 1 drachm. Tincture of rhubarb.............. \ ounce. Peppermint-water................. 4 ounces. Sirup of lemon.................. 2 ounces. Mix. Dose : 1 tablespoonful three or four times a day. 49 770 DISEASES OF THE SKIN. ECZEMA, ACUTE. Take of Sulphate of morphine............. 1 grain. Tincture of gelsemium............ 1 drachm. Bicarbonate of sodium............. \ ounce. Camphor-water................... 2 ounces. Spirit of nitrous ether............. 2£ ounces. Mix. Dose : 1 or 2 teaspoonfuls every three or four hours. ECZEMA, ACUTE. Take of Sulphate of magnesium ........... \ ounce. Tincture of aconite root........... 12 drops. Sirup of senna.................... 1 ounce. Water........................... 3 ounces. Mix. Dose : 1 dessertspoonful every four hours. ECZEMA, CHRONIC Take of Arsenious acid................... 1 grain. Extract of belladonna............. 5 grains. Extract of calamus................ 2 scruples. Mix and divide into 20 pills. Dose : 1 pill three times a day. ECZEMA, CHRONIC. Take of Icthyol (sulpho-icthyolate of sodium) 2 drachms. Dose : 5 to 20 drops in water two or three times a day. ECZEMA, CHRONIC. Take of Icthyol (sulpho-icthyolate of sodium) 1 scruple. Divide into 40 pills. Dose : 1 to 10 pills a day. ECZEMA, CHRONIC. Take of Phosphide of zinc................. 1 grain. Extract of Indian hemp........... 3 grains. Sulphate of quinine............... 1 drachm. Mix and divide into 30 pills. Dose : 1 pill after each meal. ECZEMA, CHRONIC. Take of Venice turpentine................. 5 grains. Extract of belladonna............. 5 grains. Extract of gentian................ 2 scruples. Mix and dhide into 20 pills. Dose : 4 to 6 pills a day. FORMULARY. 771 ECZEMA, CHRONIC. Take of Tartar emetic.................... 2 grains. Sulphate of quinine............... 2 scruples. Mix and divide into 20 pills. Dose : 1 pill four times a day. ECZEMA, INFANTILE. Take of Sirup of iodide of iron............ 1 ounce. Fluid extract of malt.............. 5 ounces. Mix. Dose : £ to 2 teaspoonfuls three times a day. ECZEMA, INFANTILE. Take of Calomel......................... 5 grains. Sugar........................... 1 scruple. Mix and divide into 5 powders. Dose : 1 powder every second or third day, followed by one-half teaspoonful of carbonate of magnesium or a teaspoonful of castor-oil. ECZEMA GENITALIUM—ECZEMA OF THE GENITAL ORGANS. Take of Tincture of Hoang-Nan........... £ ounce. Dose : 3 to 30 drops in water three or four times a day. ECZEMA VULVAE OR VAGINA—ECZEMA OF THE VULVA OR VAGINA. Take of Extract of belladonna............. 5 grains. Arsenious acid.................... 3 grains. Extract of opium................. 2 grains. Sulphate of quinine............,.. 1 scruple. Oil of theobroma................. sufficient. Mix and divide into 20 suppositories. Dose : Insert 1 in the vagina four times a day. ECZEMA ANI—ECZEMA OF THE ANUS. Take of Arsenious acid.................... 3 grains. Extract of hyoscyamus............ 4 grains. Carbonate of iron................. 1 drachm. Mix and divide into 20 suppositories. Dose : Insert 1 four times a day. ECZEMA SCROTI—ECZEMA OF THE SCROTUM. Take of Tincture of Hoang-Nan........... 3 drachms. Dose • 2 to 20 drops in water every three or four hours. 772 DISEASES OF THE SKIN. EPITHELIOMA—EPITHELIAL CANCER —SARCOMA—CARCINOMA. Take of Powdered blood root............... 10 grains. Extract of conium................ 10 grains. Extract of hyoscyamus............ 4 grains. Mix and divide into 30 pills. Dose : 1 pill three times a day. EPITHELIOMA—EPITHELIAL CANCER—SARCOMA—CARCINOMA. Take of Arsenious acid................... 1 grain. Extract of belladonna............. 5 grains. Sulphate of quinine............... 40 grains. Mix and divide into 20 pills. Dose : 1 pill three times a day. EPITHELIOMA—EPITHELIAL CANCER—SARCOMA—CARCINOMA. Take of Arseniate of sodium............... 1 grain. Iodide of iron.................... 40 grains. Mix and divide into 20 pills. Dose : 1 pill three times a day. EPITHELIOMA—EPITHELIAL CANCER—SARCOMA—CARCINOMA. Take of Sulphate of morphine............. \ grain. Bromide of sodium............... 3 drachms. Sirup of lactucarium.............. 5 ounces. Mix. Dose: 1 tablespoonful every two or three hours until re- lieved of pain. ERYSIPELAS. Take of Tartar emetic.................... 1 grain. Camphor-water................... 3 ounces. Spirit of nitrous ether............. 3 ounces. Mix. Dose : 1 tablespoonful in water every one or two hours. ERYSIPELAS. Take of Hydrochlorate of pilocarpine....... 1 grain. Tincture of aconite-root........... 24 drops. Water........................... 3 ounces. Mix. Dose 11 teaspoonful every three or four hours. ERYSIPELAS. Take of Tincture of chloride of iron........ 2 ounces. Glycerin......................... 2 ounces. Mix. Dose ; 1 to 2 teaspoonfuls in a wineglassful of water every two or three hours. FORMULARY. 773 ERYTHEMA. Take of Sulphate of iron.................. 24 grains. Sulphate of magnesium............ 5 drachms. Dilute sulphuric acid.............. £ drachm. Sirup of senna................... 2 ounces. Water........................... 6 ounces. Mix. Dose : 1 tablespoonful in water night and morning. ERYTHEMA. Take of Infusion of quassia................ 4 ounces. Solution of citrate of potassium .... 2 ounces. Mix. Dose : 1 to 2 tablespoonfuls three or four times a day. FURUNCULUS—BOIL. Take of Chlorate of potassium............. 5 drachms. Sirup of lactate of iron............ 4 ounces. Mix. Dose : 2 teaspoonfuls in water three or four times a day. FURUNCULUS—BOIL. Take of Sulphide of calcium............... 5 grains. Extract of belladonna............. 2 grains. Extract of gentian................ 35 grains. Mix and divide into 20 pills. Dose : 1 pill every two or three hours. FURUNCULUS—BOIL. Take of Citrate of iron and quinine......... 2 drachms. Dilute sulphuric acid.............. 1 drachm. Sherry wine...................... 5 ounces. Mix. Dose : 2 teaspoonfuls three or four times a day. FURUNCULUS—BOIL. Take of Compound sirup of phosphates..... 5 ounces. Aloin............................ 2 grains. Mix. Dose : 2 teaspoonfuls three times a day. HERPES, Take of Arseniate of iron.................. 1 grain. Extract of cinchona............... 1 drachm. Mix and divide into 30 pills. Dose : 3 or 4 pills a day. 774 DISEASES OF THE SKIN. HERPES. Take of Phosphide of zinc................. \ grain. Sulphate of quinine.............. 2 scruples. Mix and divide into 40 pills. Dose : 1 pill three or four times a day. HERPES ZOSTER—SHINGLES. Take of Bromide of sodium................200 grains. Hydrate of chloral................100 grains. Sirup of tolu..................... 5 ounces. Mix. Dose : 1 tablespoonful in water every hour until relieved, HERPES ZOSTER—SHINGLES. Take of Tincture of aconite root........... 24 drops. Sulphate of morphine............. 1 grain. Solution of citrate of potassium..... 2 ounces. Sirup of orange-flower water........ 1 ounce. Mix. Dose : 1 teaspoonful every one or two hours. HYPERIDROSIS—EXCESSIVE PERSPIRATION. Taxe of Oxide of zinc..................... 4 grains. Extract of calamus................ 24 grains. Mix and divide into 16 pills. Dose : 1 pill three or four times a day. HYPERIDROSIS—EXCESSIVE PERSPIRATION. Take of Tincture of belladonna............ 50 drops. Fluid extract of triticum.......... 3 ounces. Mix. Dose : 1 teaspoonful three times a day. HYPERIDROSIS—EXCESSIVE PERSPIRATION. Take of Ergotin......................... 10 grains. Dried sulphate of iron............. 20 grains. Mix and divide into 20 pills. Dose : 2 to 4 pills a day. ICHTHYOSIS. Take of Fluid extract of jaborandi......... 2 drachms. Spirit of nitrous ether............. 2 ounces. Solution of acetate of ammonium.. . 2 ounces. Mix. Dose : 2 teaspoonfuls in water night and morning. FORMULARY. 775 LEPROSY. Take of Chaulmoogra oil.................. 1 ounce. Dose : 10 to 30 drops three times a day. LEPROSY. Take of Nitrate of silver.................. 3 grains. Sirup of gum arabic............... 3 ounces. Mix. Dose : 1 teaspoonful in a wineglassful of water three times a day. LEPROSY. Take of Iodide of potassium............... 3 drachms. Glycerin......................... 2 ounces. Water........................... 2 ounces. Mix. Dose : 2 teaspoonfuls four times a day. LUPUS ERYTHEMATOSUS. Take of Cod-liver oil..................... 4 ounces. Sirup of lactophosphate of lime.... 2 ounces. Mix. Dose : 2 teaspoonfuls three times a day. LUPUS ERYTHEMATOSUS. Take of Chlorate of potassium............. 2 drachms. Compound tincture of cinchona .... 6 ounces. Mix. Dose : 1 dessertspoonful in water three or four times a day, LUPUS VULGARIS. Take of Sulphate of quinine............... 20 grains. Carbonate of iron................. 20 grains. Calomel......................... 2 grains. Mix and divide into 20 pills. Dose : 1 pill three times a day. LUPUS VULGARIS. Take of Iodide of potassium............... 3 drachms. Compound sirup of phosphates..... 5 ounces. Mix. Dose : 2 teaspoonfuls in water three times a day. PARESTHESIA, OR PRURITUS—ITCHING OF THE SKIN. Take of Bromide of sodium................ 8 drachms. Tincture of gelsemium............ \ drachm. Sirup of orange-flowers............ 4 ounces. Mix. Dose : 2 teaspoonfuls in water every two or three hours. 776 DISEASES OF THE SKIN. PARESTHESIA, OR PRURITUS—ITCHING OF THE SKIN. Take of Tincture of belladonna............ 3 drachms. Dose : 5 to 15 drops in water every three or four hours. PARESTHESIA, OR PRURITUS—ITCHING OF THE SKIN. Take of Hydrate of chloral................ 2 drachms. Sirup of wild cherry.............. 1 ounce. Sirup of tolu..................... 2 ounces. Mix. Dose : 1 or 2 teaspoonfuls in water every two or three hours. PEMPHIGUS. Take of Nitrate of silver.................. 2 grains. Powdered opium.................. 4 grains. Extract of belladonna.............. 2 grains. Mix and divide into 16 pills. Dose : 1 pill every four hours. PEMPHIGUS. Take of Arsenious acid.................... 1 grain. Black pepper..................... 10 grains. Sulphate of quinine............... 10 grains. Mix and divide into 20 pills. Dose : 1 pill three times a day. PEMPHIGUS. Take of Iodide of potassium............... 3 drachms. Compound tincture of cardamom ... 2 ounces. Compound tincture of gentian..... 2 ounces. Mix. Dose : 1 teaspoonful every three or four hours. PSORIASIS. Take of Fluid extract of dandelion......... 2 ounces. Spirit of nitrous ether............. 3 ounces. Aloin............................ 2 grains. Mix. Dose : 2 teaspoonfuls in water four times a day. PSORIASIS. Take of Acetate of potassium.............. 2 drachms. Infusion of digitalis............... 4 ounces. Infusion of jaborandi.............. 6 ounces. Fluid extract of cascara sagrada .... 2 drachms. Mix. Dose : 1 tablespoonful every three hours. FORMULARY. 777 PSORIASIS. Take of Salicylic acid..................... 2 drachms. Bicarbonate of sodium............. 40 grains. Compound tincture of cardamom... 1 ounce. Water........................... 2 ounces. Mix. Dose : 1 teaspoonful in water every three hours. PSORIASIS. Take of Arseniate of sodium................ 1 grain. Podophyllotoxin.................. 2 grains. Extract of calamus................ 40 grains. Mix and divide into 40 pills. Dose : 2 to 4 pills a day. PSORIASIS. Take of Acetic extract of colchicum........ 10 grains. Arsenious acid.................... 1 grain. Sulphate of quinine............... 30 grains. Extract of leptandra.............. 10 grains. Mix and divide into 30 pills. Dose : 1 pill three times a day. PSORIASIS. Take of Infusion of digitalis............... 2 ounces. Solution of acetate of ammonium... 2 ounces. Mix. Dose : 2 teaspoonfuls in water every two or three hours. PURPURA. Take of Sulphate of quinine............... 40 grains. Venice turpentine................. 5 grains. Mix and divide into 20 pills. Dose : 1 pill four times a day. PURPURA. Take of Dried sulphate of iron............. 16 grains. Extract of Indian hemp........... 8 grains. Mix and divide into 16 pills. Dose : 2 to 3 pills a day. PURPURA. Take of Tincture of chloride of iron---.... 2 ounces. Fluid extract of ergot............. 2 ounces. Mix, Dose : 30 drops to 1 teaspoonful in a wineglassful of water every three hours. 778 DISEASES OF THE SKIN. PURPURA. Take of Chlorate of potassium............. 5 drachms. Tincture of belladonna............. 72 drops. Sirup of wild cherry............... 3 ounces. Mix. Dose : 1 teaspoonful in water three or four times a day. ROSACEA—ACNE ROSACEA. Take of Ergotin.......................... 20 grains. Extract of nux vomica............. 2 grains. Mix and divide into 20 pills. Dose : 1 pill every four hours. ROSACEA—ACNE ROSACEA. Take of Fluid extract of witch-hazel....... 1 ounce. Dose : 5 to 10 drops in water every three or four hours. ROSACEA—ACNE ROSACEA. Take of Tannic acid....................... 12 grains. Extract of dandelion.............. 12 grains. Mucilage......................... sufficient. Mix and divide into 12 pills. Dose : 2 pills three or four times a day. RUBEOLA—MEASLES. Take of Tincture of veratrum viride........34 drops. Camphor-water................... 1 ounce. Solution of acetate of ammonium... 2 ounces. Mix. Dose : 1 teaspoonful in water every three hours. RUBEOLA—MEASLES. Take of Dilute hydrochloric acid........... 1 drachm. Compound tincture of cardamom ... 1 ounce. Simple sirup........ ............ 4 ounces. Mix. Dose : 1 or 2 teaspoonfuls in water every three hours, RUBEOLA—MEASLES. Take of Sirup of tolu..................... 1 ounce. Muriate of ammonium............. 80 grains. Sirup of ipecacuanha.............. ^ ounce. Compound sirup of squill.......... 1 ounce. Sirup of wild cherry............... 1£ ounce. Mix. Dose : 1 to 2 teaspoonfuls every three or four hours. FORMULARY. 779 SCARLATINA—SCARLET FEVER. Take of Infusion of digitalis............... 5 ounces. Dose : | to 1 teaspoonful every three or four hours. SCARLATINA—SCARLET FEVER. Take of Tincture of aconite root........... 20 drops. Neutral mixture.................. 5 ounces. Mix. Dose : 2 teaspoonfuls every two hours. SCARLATINA—SCARLET FEVER. Take of Chlorate of potassium............. 1 drachm. Tincture of belladonna............ 24 drops. Sirup of lemon................... 3 ounces. Mix. Dose : 1 teaspoonful every two or three hours. SCARLATINA—SCARLET FEVER. Take of Chlorate of potassium............. 2 drachms. Tincture of chloride of iron........ 2 drachms. Glycerin......................... 1 ounce. Water........................... 4 ounces. Mix. Dose : 1 to 2 teaspoonfuls in water every two or three hours. SCROFULODERMA. Take of Cod-liver oil..................... 4 ounces. Lime-water...................... 2 ounces. Wine of iron..................... 2 ounces. Mix. Dose : 2 teaspoonfuls after meals. SCROFULODERMA. Take of Sirup of lactophosphate of lime..... 2 ounces. Cod-liver oil...................... 4 ounces. Oil of cinnamon.................. 3 drops. Mix. Dose : 2 teaspoonfuls after meals. SCROFULODERMA. Take of Diluted phosphoric acid........... | ounce. Glycerin......................... 3 ounces. Sirup of orange-peel.............. 1 ounce. Mix. Dose : 1 teaspoonful in a wineglassful of water after meals. 780 DISEASES OF THE SKIN. SCROFULODERMA. Take of Chlorate of potassium............. 2 drachms. Glycerin......................... 1 ounce. Water........................... 2 ounces. Mix. Dose : 1 teaspoonful three or four times a day. SEBORRHEA SICCA—DRY OR SCALY SEBORRHEA. Take of Arseniate of iron.................. 1 grain. Sulphate of quinine............... 32 grains. Mix and divide into 16 pills. Dose : 1 pill three times a day. SEBORRHEA SICCA—DRY OR SCALY SEBORRHCEA. Take of Sirup of hydriodic acid............ 2 ounces. Glycerin......................... 2 ounces. Mix. Dose : 1 small half-teaspoonful in water three times a SEBORRHCEA SICCA—DRY OR SCALY SEBORRHEA. Take of Sirup of iodide of iron............. 2 ounces. Glycerin......................... 2 ounces. Mix. Dose : i to 1 teaspoonful in water three or four times SEBORRHCEA OLEOSA—OILY SEBORRHCEA. Take of Solution of arsenite of potassium... 1 drachm. Sulphate of strychnine............ 1 grain. Aloin............................ 2 grains. Sirup of lactophosphate of lime and iron......................... 6 ounces. Mix. Dose : 1 teaspoonful in water three times a day. SEBORRHCEA OLEOSA—OILY SEBORRHCEA. Take of Sublimed sulphur................ £ drachm, Extract of dandelion.............. \ drachm. Mix and divide into 30 pills. Dose : 1 pill three or four times a day. SEBORRHCEA OLEOSA—OILY SEBORRHCEA. Take of Venice turpentine................ 5 grains. Pyrophosphate of iron............. 35 grains. Mix and divide into 20 pills. Dose : 1 pill three times a day. FORMULARY. 7S1 SYCOSIS—INFLAMMATION OF THE HAIR-FOLLICLES OF THE BEARD. Take of Iodide of iron.................... 2 scruples. Aloin........................... 2 grains. Extract of belladonna............. 3 grains. Mix and divide into 20 pills. Dose . 1 pill three or four times a day. SYCOSIS—INFLAMMATION OF THE HAIR-FOLLICLES OF THE BEARD. Take of Tartrate of antimony and potassium 2 grains. Extract of cinchona............... 2 scruples. Mix and divide into 20 pills. Dose : 1 pill three or four times a day. SYCOSIS—INFLAMMATION OF THE HAIR-FOLLICLES OF THE BEARD. Take of Corrosive sublimate............... 2 grains. Tincture of prickly ash............ 6 ounces. Mix. Dose : 2 teaspoonfuls in Avater three or four times a day. SYCOSIS—INFLAMMATION OF THE HAIR-FOLLICLES OF THE BEARD. Take of Sirup of the hypophosphites....... 3 ounces. Extract of malt...............--- 3 ounces. Chlorate of potassium............. 2 drachms. Mix. Dose : 1 dessertspoonful in water three times a day. SYCOSIS, CHRONIC—INFLAMMATION OF THE HAIR-FOLLICLES OF THE BEARD. Take of Sulphide of calcium............... 10 grains. Sulphate of quinine.............. 2 scruples. Mix and divide into 20 pills. Dose : 1 pill four times a day. SYCOSIS, CHRONIC—INFLAMMATION OF THE HAIR-FOLLICLES OF THE BEARD. Take of Arsenious acid................. .. 1 grain. Pyrophosphate of iron............ 1 drachm. Podophyllotoxin.................. 5 grains. Mix and divide into 30 pills. Dose : 1 pill three times a day. SYPHILIS. Take of Corrosive sublimate.............. 1 grain. Glycerin......................... 2 ounces. Water........................... 2 ounces. Mix. Dose : 2 teaspoonfuls four times a day. 782 DISEASES OF THE SKIN. SYPHILIS. Take of Tannate of mercury............... 5 grains. Gum tragacanth.................. sufficient. Glycerin......................... sufficient. Mix and divide into 10 pills. Dose : 1 pill a day, and gradually increase to three. SYPHILIS. Take of Chloride of gold and sodium....... 1 grain. Extract of gentian................ 15 grains. Powdered licorice-root............ sufficient. Mix and divide into 20 pills. Dose : 1 pill three times a day. SYPHILIS. Take of Iodide of arsenic.................. \ grain. Extract of calamus................ 30 grains. Mix and divide into 15 pills. Dose : 1 pill three times a day. SYPHILIS. Take of Tincture of burdock-seed.......... 2 ounces. Tincture of poke-root............. 2 ounces. Tincture of prickly-ash root........ 2 ounces. Tincture of yaw or queen's root--- 2 ounces. Dose : \ to 1 teaspoonful in water before meals. SYPHILIS. Take of Powdered bloodroot............... 2 grains. Iodide of iron.................... 40 grains. ; Mix and divide into 20 pills. Dose : 1 pill four times a day. SYPHILIS. Take of Guaiac.......................... 40 grains. Protiodide of mercury............. 3 grains. Mix and divide into 12 pills. Dose : 1 pill four times a day. SYPHILIS. Take of Calomel......................... 2 grains. Sugar........................... 2 scruples. Mix and divide into 10 powders. Dose : 3 to 5 powders a day. FORMULARY. 783 SYPHILIS. Take of Arsenious acid.................... £ grain. Sulphate of iron.................. 40 grains. Mix and divide into 20 pills. Dose: 2 to 4 pills a day. SYPHILIS. Take of Iodide of potassium...............200 grains. Tincture of stillingia.............. 2 ounces. Compound sirup of sarsaparilla..... 3 ounces. Mix. Dose : 1 to 2 teaspoonfuls four times a day. ULCUS—ULCER. Take of Fluid extract of witch-hazel........ 1 ounce. Sirup of wild cherry.:............... 1 ounce. Mix. Dose : 30 drops to 1 teaspoonful three or four times a day. URTICARIA, ACUTE. Take of Citrate of potassium.............. \ ounce. Bicarbonate of sodium............. 3 drachms. Peppermint-water................. 4 ounces. Mix. Dose : 1 teaspoonful every two or three hours. URTICARIA, ACUTE. Take of Oxalate of cerium................. 24 grains. Creasote..................-----.. 3 drops. Mix and divide into 12 pills. Dose : 1 pill every one or two hours. URTICARIA, ACUTE, Take of Bromide of sodium .. .............. 5 drachms. Sirup of orange-flowers............ 5 ounces. Mix. Dose : 1 tablespoonful in water every two or three hours, URTICARIA, ACUTE. Take of Salicylate of sodium...............200 grains. Glycerin........................... 1 ounce. Water....................,-------- 4 ounces. Mix. Dose : 1 tablespoonful in water every two or three hours. 7S4 DISEASES OF THE SKIN. URTICARIA, ACUTE. Take of Tartar emetic.................... 1 grain. Solution of acetate of ammonium... 5 ounces. Mix. Dose : 2 teaspoonfuls in water every one or two hours. URTICARIA, CHRONIC. Take of Nitrate of silver.................. 2 grains. Extract of gentian................ 30 grains. Extract of henbane............... 2 grains. Mix and divide into 16 pills. Dose : 1 pill three times a day. URTICARIA, CHRONIC. Take of Oxide of zinc..................... 4 grains. Extract of calamus................ 16 grains. Mix and divide into 16 pills. Dose : 1 pill three times a day. URTICARIA, CHRONIC. Take of Sulphurous acid.................. 2 ounces. Sirup of ginger................... 2 ounces. Mix. Dose : 1 to 2 teaspoonfuls in a wineglassful of water three times a day. URTICARIA, CHRONIC. Take of Arsenious acid.................... 1 grain. Aloin............................ 5 grains. Extract of belladonna............. 2 grains. Extract of calamus.............. 40 grains. Mix and divide into 30 pills. Dose : 1 pill after meals. V A RIOL A—SMALL-POX. Take of Solution of acetate of ammonium... 2 ounces. Salicylic acid..................... 1 drachm. Simple sirup..................... 1 ounce. Mix. Dose : 1 teaspoonful in water every hour or two. (Acts as a febrifuge and moderates the eruption.) VARIOLA—SMALL-POX. Take of Chlorate of potassium............. 4 drachms. Fluid extract of -cimicifuga........ £ ounce. Sirup of tolu---................. 2| ounces. Mix. Dose : 1 teaspoonful in water every four hours. (Moderates the eruption.) FORMULARY. 785 VARIOLA—SMALL- POX. Take of Compound powder of ipecacuanha. 40 grains. Sulphate of quinine.............. 40 grains. Mix and dhide into 20 pills. Dose : 2 to 4 pills every three or four hours. VARIOLA —SMALL-POX. Take of Hydrate of chloral................ 4 drachms. Solution of acetate of ammonium... 6 ounces. Mix. Dose : £ to 1 tablespoonful in water every two or three hours VERRUCA—WART. Take of Carbonate of magnesium......... 1 to 10 drachms. Divide into 12 powders. Dose : 1 powder in sirup or milk four times a day. VERRUCA—WART. Take of Carbonate of magnesium.......... 2 drachms. Sublimed sulphur................. 4 drachms. Sirup of senna.................... 6 ounces. Mix. Dose: 1 dessertspoonful morning and night. VITILIGO—LEUCODERMA. Take of Pyrophosphate of iron............. 20 grains. Sulphate of quinine............... 20 grains. Arsenious acid.................... 1 grain. Extract of ignatia................. 2 grains. Mix and divide into 30 pills. Dose : 1 pill after meals. EXTERNAL. ACNE. Take of Tincture of green soap............ 3 ounces. Use in obstinate cases of acne—add a teaspoonful to one or two tablespoonfuls of water, and sponge over the surface every second or third day. 50 786 DISEASES OF THE SKIN. ACNE. Take of Extract of erythroxylon........... 1 drachm. Ointment of oleate of zinc......... 2 drachms. Ointment of rose-water............ 4 drachms, Mix, Beneficial in soothing acne spots. ACNE. Take of Naphthol........r............... 10 grains. Sublimed sulphur................. 1 scruple. Simple ointment.................. 1 ounce. Mix. ACNE. Take of Ointment of nitrate of mercury..... 3 drachms. Oil of chamomile................. 5 drops. Ointment of benzoated oxide of zinc 5 drachms. Mix. ACNE. Take of Tincture of witch-hazel........... \ ounce. Spirit of lavender................. 1 drachm. Potash or soft soap................ 2 drachms. Alcohol.......................... 4 ounces. Mix. To stimulate indurated acne spots. ACNE. Take of Sublimed sulphur................. 20 grains. Ammoniated mercury............. 10 grains. Oil of camphor................... 5 drops. Ointment of oxide of zinc......... 1 ounce. Mix. ACNE. Take of Boracic acid..................... 1 drachm. Distilled witch-hazel.............. 2 ounces. Eose-water....................... 3 ounces. Mix. Use especially in black-heads, or acne punctata. ACNE. Take of Sublimed sulphur.............:.. £ drachm. Thymol......................... 3 grains. Oleate of zinc.................... 1 scruple. Lanolin.......................... | ounce. Mix. FORMULARY. 787 ACNE. Take of Carbolic acid..................... 2 grains. Ointment of oleate of lead......... 2 drachms. Mix. ACNE. Take of Ammoniated mercury............. 5 grains. Oil of chamomile................. 4 drops. Ointment of oxide of zinc.......... \ ounce. Mix. ACNE. Take of Sublimed sulphur................. 1 scruple. Oil of juniper.................... 10 drops. Carbonate of zinc................. 1 drachm. Ointment of rose-water............ 1 ounce. Mix. ACNE. Take of Tincture of benzoin............... 1 drachm. Corrosive sublimate............... 5 grains. Glycerin......................... 2 ounces. Water........................... 2 ounces. Mix. ALOPECIA. Take of Bicarbonate of sodium............. 2 drachms. Water of ammonia................ 1 ounce. Tincture of cantharides........... 4 drachms. Spirit of rosemary................ 4 drachms. Oil of nutmeg.................... 15 drops. Water of Cologne, sufficient quantity to make................... 10 ounces. Mix. ALOPECIA. Take of Eucalyptus-leaves................. £ ounce. Lard............................ 2 ounces. Mix. ALOPECIA. * Take of Fluid oleate of mercury........... 1| ounce. Oil of ergot...................... 1£ ounce. Oil of rose....................... 2 drops. Oil of bergamot.................. 4 drops. Mix. 788 DISEASES OF THE SKIN. ALOPECIA. Take of Lanolin......................... £ ounce. Lard............................ ^ ounce. Mix. ALOPECIA. Take of Tincture of benzoin............... 2 drachms. Spirit of chloroform.............. 1 ounce. Tincture of nux vomica........... 2 drachms. Alcohol.......................... 2£ ounces. Mix. ALOPECIA. Take of Ointment of oleate of mercury..... \ ounce. Lanolin......................... \ ounce. Mix. ALOPECIA CIRCUMSCRIPTA—ALOPECIA AREATA. Take of Eesorcin......................... 1 drachm. Alcohol.......................... 4 ounces. Mix. ALOPECIA CIRCUMSCRIPTA—ALOPECIA AREATA. Take of Fluid extract of pilocarpus......... 1 ounce. Spirit of ammonia................ \ ounce. Soap liniment.................... \\ ounce. Mix. ALOPECIA CIRCUMSCRIPTA—ALOPECIA AREATA. Take of Ointment of oleate of mercury..... \ ounce. Oil of chamomile................. 10 drops. Mix. ALOPECIA CIRCUMSCRIPTA—ALOPECIA AREATA. Take of Thymol....... ................. \ drachm. Castor-oil........................ 2 ounces. Almond-oil ...,................... 2 ounces. Mix. ALOPECIA CIRCUMSCRIPTA—ALOPECIA AREATA. Take of Oil of turpentine................. -^ ounce. Soap liniment............■....... 4 ounces. Mix. » FORMULARY. 789 ANIDROSIS—A DECREASED OR COMPLETE CESSATION OF THE SECRE- TION OF SAVE AT. Take of Lanolin......................... \ ounce. Oil of eucalyptus................. 10 drops. Lard............................ \\ ounces. Mix. ANTHRAX—MALIGNANT PUSTULE. Take of Sulphate of quinine............... \ ounce. Carbolic acid.................... 5 grains. Powdered arrow-root.............. -J ounce. Oil of turpentine, a sufficient quan- tity to make into a paste, Mix. ANTHRAX—MALIGNANT PUSTULE. Take of Salicylic acid..................... \ drachm. Carbonate of lead................. 1 drachm. Camphor........................ \ drachm. Benzoated lard................... 1 ounce. Mix. BROMIDROSIS—ODOROUS SWEAT. Take of Sulphate of zinc.................. 8 grains. Carbolic acid..................... 5 grains. Glycerin......................... 6 ounces. Mix. Apply with old muslin or lint. BROMIDROSIS—ODOROUS SWEAT. Take of Naphthol........................ 1 drachm. Powdered oleate of zinc........... 4 drachms. Powdered arrow-root.............. \ ounce. Mix. BROMIDROSIS—ODOROUS SWEAT. Take of Dried alum...................... 2 ounces. PoAvdered oleate of zinc........... 2 drachms. Mix. BROMIDROSIS—ODOROUS SWEAT. Take of Salicylic acid..................... 2 drachms. Subnitrate of bismuth............. \ ounce. Mix. 790 DISEASES OF THE SKIN. BROMIDROSIS—ODOROUS SWEAT. Take of Boracic acid...................... 1 drachm. Tincture of witch-hazel............ 2 ounces. Rose-water..........'............. 1 ounce. Mix. BROMIDROSIS—ODOROUS SWEAT. Take of Permanganate of potassium........ 10 grains. Spirit of rosemary................ 2 drachms. Alcohol......................... 4 ounces. Mix. CARBUNCULUS—CARBUNCLE. Take of Carbolic acid..................... 12 grains. Iodine........................... 4 drachms. Glycerin......................... 1 ounce. Mix. CARBUNCULUS—CARBUNCLE. Take of Lead plaster..................... 6 drachms. Turpentine...................... 2 drachms. Galbanum....................... 4 drachms. Extract of opium................. £'drachm. Mix and make into plaster. CARBUNCULUS—CARBUNCLE. Take of Extract of conium................ 1 drachm. Ointment of mercury oleate........ 4 drachms. Resin cerate...................... 1 ounce. Mix. CARBUNCULUS—CARBUNCLE. Take of Honey........................... 2 drachms. Extract of arnica................. 1 drachm. Resin cerate...................... 1 ounce. Mix. CARBUNCULUS—CARBUNCLE. Take of Extract of belladonna............. i drachm. Extract of opium................. 10 grains. Ointment of nitrate of mercury .... \ ounce. Cerate of subacetate of lead........ \ ounce. Ointment of oxide of zinc......... 1 ounce. Mix. FORMULARY. CARBUNCULUS—CARBUNCLE. Take of Extract of stramonium............ 1 drachm. Camphor........................ 1 drachm. Ointment of rose-water............ 1 ounce. Mix. CARBUNCULUS—CARBUNCLE. Take of Carbolic acid..................... £ drachm. Tincture of witch-hazel............ 2 ounces. Water........................... 1 pint. Mix. CHANCROID. Take of Iodol............................ 2 drachms Subnitrate of bismuth............. \ ounce. Mix. CHANCROID. Take of Subiodide of bismuth............. \ ounce. Powdered red cinchona bark....... \ ounce. Mix. CHANCROID. Take of Iodoform........................ \ ounce. Powdered coffee.................. £ ounce. Mix. CHANCROID. Take of Powdered chlorate of potassium--- \ ounce. Carbonate of lead................. 1 ounce. Sulphate of morphine............. 2 grains. Mix. CHANCROID. Take of Hydrate of chloral................ 10 grains. Tincture of witch-hazel........... 1 drachm. Tincture of arnica................ 1 drachm. Water........................... 10 ounces. Mix. CHANCROID. Take of Creasote......................... 3 drops. Corrosive sublimate............... 4 grains. Glycerin......................... 2 ounces. Rose-Avater....................... 3 ounces. Mix. 792 DISEASES OF THE SKIN. CHLOASMA. Take of Chrysarobin...................... 2 scruples, Benzoated lard................... 1 ounce. Mix. CHLOASMA. Take of Corrosive sublimate............... 10 grains. Chloride of ammonium............ 1 drachm. Alcohol......................... 1 ounce. Distilled witch-hazel ............. 3 ounces. Mix. CICATRICES—SCARS. Take of Iodide of potassium............... 1 drachm. Lanolin......................... ^ ounce. Mix. CLAVUS—CORN. Take of Salicylic acid..................... 2 drachms. Flexible collodion................. 4 drachms. Mix. Pencil over the corn night and morning. COMEDO—SEBACEOUS PLUGS OR GRUBS. Take of Tincture of green soap............ 2 ounces. Thymol......................... 5 grains. Water........................... 4 ounces. Mix. COMEDO—SEBACEOUS PLUGS OR GRUBS. Take of Spirit of lavender................. 1 drachm. Spirit of rosemary................ 1 ounce. Water........................... 4 ounces. Mix. COMEDO—SEBACEOUS PLUGS OR GRUBS. Take of Soap liniment.................... 2 ounces. Water of ammonia................ \ ounce. Water............................ 5 ounces. Mix. COMBUSTIO—BURN—SCALD. Take of Prepared suet.................... 2 ounces. Resin cerate...................... 2 drachms. Powdered arrow-root.............. \ ounce. Linseed-oil....................... 1 pint. Mix. FORMULARY. COMBUSTIO—BURN—SCALD. Take of Cerate of subacetate of lead........ 1 ounce. Pure cocaine..................... 4 grains. Ointment of oxide of zinc......... 1 ounce. Mix. COMBUSTIO—BURN—SCALD. Take of Pure cocaine..................... 5 grains. Ointment of oxide of zinc.........• 1 ounce. Mix. COMBUSTIO—BURN—SCALD. Take of Distilled witch-hazel............. 2 ounces. Solution of subacetate of lead...... 1 ounce. Tincture of opium................ 1 ounce. Water........................... 1 pint. Mix. COMBUSTIO—BURN—SCALD. Take of Pure cocaine..................... 8 grains. Olive-oil......................... 4 ounces. Mix. COMBUSTIO—BURN—SCALD. Take of Iodoform........................ % drachm0 Bicarbonate of sodium............ 40 grains. Ointment of rose-water............ 2 ounces. Mix. COMBUSTIO—BURN—SCALD. Take of Bicarbonate of sodium ........... \ ounce. Water........................... 1 pint. Mix. COMBUSTIO- BURN—SCALD. Take of Salicylate of sodium.............. \ drachm, Olive-oil......................... 5 ounces. Mix. COMBUSTIO—BURN—SCALD. Take of Carbolic acid..................... 15 grains. Fluid extract of marigold.......... \ ounce. Olive-oil......................... i pint. Mix. COMBUSTIO—BURN—SCALD. Take of Boracic acid..................... 1 ounce. Water........................... £ pint. Mix. 794 DISEASES OF THE SKIN. COMBUSTIO—BURN—SCALD. Take of Carbonate of lead................. 2 ounces. Olive-oil, enough to make a soft oint- ment. Mix. COMBUSTIO—BURN—SCALD. Take of Levigated calamine............... 4 drachms. Subnitrate of bismuth............. 2 drachms. Simple ointment.................. 1 ounce. Mix. CONDYLOMATA. Take of Calomel......................... 3 drachms. Subnitrate of bismuth............. 3 drachms. Mix. CONDYLOMATA. Take of Tannic acid...................... 1 drachm. Camphor........................ | drachm. Ointment of nitrate of mercury--- 2 drachms. Lanolin......................... 4 drachms. Mix. CONGELATIO—FROST-BITE. Take of Purified chloroform (by weight)--- ^ ounce. Tincture of opium................ ^ ounce. Tincture of aconite............... £ ounce. Alcohol.......................... \ ounce. Mix. CONGELATIO— FROST-BITE. Take of Ointment of oleate of lead......... \ ounce. Extract of opium................. 10 grains. Extract of belladonna............. 10 grains. Extract of arnica................. \ drachm. Mix. CONGELATIO—FROST-BITE. Take of Tincture of witch-hazel............ 2 ounces. Tincture of opium................ 2 ounces. Solution of subacetate of lead...... 2 ounces. Water........................... \ pint. Mix. FORMULARY. 795 CONGELATIO—FROST-BITE. Take of Compound tincture of benzoin..... 3 drachms. Chloroform (by weight)........... 2 drachms. Tincture of aconite............... 1 drachm. Mix. DERMATALGIA—NEURALGIA OF THE SKIN. Take of Tincture of aconite-root........... 1 drachm. Menthol......................... \ drachm. Spirit of chloroform............... 1 ounce. Alcohol.......................... 3 ounces. Mix. DERMATALGIA—NEURALGIA OF THE SKIN. Take of Tincture of opium................ 2 drachms. Tincture of arnica................ 2 drachms. Creasote......................... 5 drops. Soap liniment.................... 4 ounces. Mix. DERMATITIS—INFLAMMATION OF THE SKIN. Take of Lycopodium...................... 3 drachms. Subnitrate of bismuth............. 3 drachms. Powdered oleate of zinc............ 3 drachms. Mix. DERMATITIS—INFLAMMATION OF THE SKIN. Take of Oleate of iron.................... 1 drachm. Ointment of rose-water............ 1 ounce. Mix. Especially valuable in arsenical eruptions. ECZEMA, ACUTE—TETTER. Take of Tannic acid...................... 1 scruple. Subnitrate of bismuth............. 2 drachms. Rose-water....................... 6 ounces. Mix. ECZEMA, ACUTE—TETTER. Take of Carbonate of zinc................. 1 drachm. Carbonate of lead................. 1 drachm. Sublimed sulphur................ 1 drachm. Powdered arrow-root.............. 1 drachm. Mix. 796 DISEASES OF THE SKIN. ECZEMA, ACUTE—TETTER. Take of Carbonate of lead................. 4 drachms. Powdered starch.................. 3 drachms, Lycopodium..................... 4 drachms. Mix. ECZEMA, ACUTE—TETTER. Take of Powdered oleate of zinc............ 1 drachm. Camphor........................ 1 drachm. Powdered starch.................. 2 ounces. Mix. ECZEMA, ACUTE—TETTER. Take of Extract of opium................. 1 drachm. Acetate of lead.................... 1 scruple. Subnitrate of bismuth........ .... 1 drachm. Ointment of rose-water........... 1 ounce. Mix. ECZEMA, SUBACUTE—TETTER. Take of Sublimed sulphur................ 1 drachm. Boracic acid..................... 1 drachm. Simple ointment.................. 1 ounce. Mix, ECZEMA, CHRONIC—TETTER. Take of Red oxide of mercury............. 30 grains. Sublimed sulphur................. 1 drachm. Oil of wintergreen................ 20 drops. Ointment of oxide of zinc......... 3 ounces. Mix. ECZEMA, CHRONIC—TETTER. Take of Calomel......................... 20 grains. Acetate of lead................... \ drachm. Extract of belladonna............. 10 grains. Subnitrate of bismuth............. 1 drachm. Carbonate of zinc................. 1 drachm. Benzoated lard.................... 2 ounces. Mix. ECZEMA, CHRONIC—TETTER. Take of Creasote......................... 10 drops. Carbonate of lead................. 2 drachms, Subnitrate of bismuth............. 1 drachm. Calomel...............,.......... 10 grains. Olive-oil......................... 5 ounces. Mix. FORMULARY. 797 ECZEMA, CHRONIC—TETTER. Take of Oil of cade....................... | drachm. Ointment of nitrate of mercury..... 2 drachms. Prepared suet.................... 1 ounce. Mix. ECZEMA, CHRONIC—TETTER. Take of Icthyol (sulpho - ichthyolate of so- dium)....................... 2 drachms. Lard............................ 1 ounce. Mix. ECZEMA, CHRONIC—TETTER. Take of Icthyol (sulpho-ichthyolate of so- dium) ....................... 2 drachms. Oil of eucaylptus................. 3 drops. Ointment of oxide of zinc.......... 1 ounce. Mix. ECZEMA, CHRONIC—TETTER. Take of Resorcin......................... 5 or 10 grains. Ointment of oxide of zinc.......... 1 ounce. Mix. ECZEMA, INFANTILE—INFANTILE ECZEMA. Take of Calomel......................... 10 grains. Oil of chamomile................. 5 drops. Powdered arrow-root.............. 1 drachm. Ointment of oxide of zinc.......... 1 ounce. Mix. Useful particularly in the pustular variety or milk crust. ECZEMA, INFANTILE—INFANTILE ECZEMA. Take of Carbonate of lead................. 1 drachm. Carbonate of zinc................. 1 drachm. Camphor........................ 1 scruple. Sublimed sulphur................. \ drachm. Ointment of rose-water............ 1 ounce. Mix. ECZEMA CAPITIS—ECZEMA OF THE HEAD. Take of Cod-liver oil..................... 4 ounces. Carbonate of lead................. 2 drachms. Naphthol........................ 8 grains. Mix. 798 DISEASES OF THE SKIN. ECZEMA AURIUM—ECZEMA OF THE EARS. Take of Ointment of oleate of lead......... 3 drachms. Oil of cade....................... 10 drops. Lanolin......................... 2 drachms. Ointment of oxide of zinc......... 3 drachms. Mix. ECZEMA FACIEI ET COLLI—ECZEMA OF THE FACE AND NECK, Take of Ammoniated mercury............. 10 grains. Arrow-root...................... 1 drachm. Oil of Chamomile................. 3 drops. Carbonate of zinc................. 1 drachm. Lard............................ 1 ounce. Mix. ECZEMA BARBE—ECZEMA OF THE BEARD. Take of Cod-liver oil..................... 4 ounces. Carbonate of lead.................. 2 drachms. Naphthol........................ 5 grains. Mix. ECZEMA TARSI—ECZEMA OF THE EDGES OF THE EYELIDS. Take of Yellow oxide of mercury.......... 5 grains. Ointment of rose-water............ 3 drachms. Mix. ECZEMA NASI—ECZEMA OF THE NOSE. Take of Glycerole of subacetate of lead..... 1 ounce. Chaulmoogra oil.................. ^ ounce. Oil of eucalyptus................. 5 drops. Glycerin......................... ^ ounce. Mix. ECZEMA LABIORUM—ECZEMA OF THE LIPS. Take of Prepared suet.................... i ounce. Camphor........................ 1 SCruple. Subnitrate of bismuth............. l drachm. Mix. ECZEMA MAMMARUM—ECZEMA OF THE BREAST AND NIPPLE, Take of Fluid extract of geranium......... 3 drachms. Glycerin......................... 3 drachms. Mix. FORMULARY. 799 ECZEMA MAMMARUM—ECZEMA OF THE BREAST. Take of Boracic acid..................... 1 drachm. Sublimed sulphur................. 10 grains. Ointment of oxide of zinc......... 1 ounce. Mix. ECZEMA UMBILICI—ECZEMA OF THE UMBILICUS. Take of Thymol......................... 1 grain. Powdered red cinchona bark....... 3 drachms. Subnitrate of bismuth............. 3 drachms. Mix. ECZEMA ARTICULORUM—ECZEMA OF THE FLEXOR SURFACES OF THE JOINTS. Take of Naphthol........................ 5 grains. Ointment of nitrate of mercury .... 2 drachms. Oil of chamomile................. 5 drops. Ointment of benzoated oxide of zinc 1 ounce. Mix. ECZEMA GENITALIUM—ECZEMA OF THE GENITAL ORGANS. Take of Acetate of lead................... 8 grains. Calomel......................... 10 grains. Ointment of oxide of zinc......... 1 ounce. Mix. ECZEMA GENITALIUM—ECZEMA OF THE GENITAL ORGANS. Take of Yellow oxide of mercury.......... 10 grains. Extract of opium................. 5 grains. Camphor........................ 10 grains. Ointment of oxide of zinc......... 1 ounce. Mix. ECZEMA SCROTI—ECZEMA OF THE SCROTUM. Take of Extract of belladonna............. £ drachm. Extract of opium................. 10 grains. Tannic acid...................... 1 scruple. Ointment of nitrate of mercury--- 2 drachms. Mix. ECZEMA SCROTI ET ANI—ECZEMA OF THE SCROTUM AND ANUS. Take of Boroglyceride (50-per-cent. solution) \ ounce. Lanolin.......................... \ ounce. Mix. 800 DISEASES OF THE SKIN. ECZEMA ANI—ECZEMA OF THE ANUS. Take of Hydrate of chloral................ £ drachm. Camphor........................ 1 drachm. Prepared suet.................... 1 ounce. Mix. ECZEMA LABIORUM—ECZEMA OF THE LABIA. Take of Extract of opium................. 10 grains. PoAvdered stramonium............ | drachm. Powdered tobacco................ i drachm. Camphor........................ i drachm. Ointment of elder-flowers---...... 1 ounce. Mix. ECZEMA CRURUM—ECZEMA OF THE LEGS. Take of Oil of cade....................... 30 drops. Sublimed sulphur................. 1 scruple. Ointment of oxide of zinc.......... \ ounce. Cerate of subacetate of lead........ | ounce. Mix. ECZEMA INTERTRIGO. Take of Oleate of zinc.................... 2 drachms. Glycerin......................... 2 ounces. Olive-oil......................... 2 ounces. Mix. ECZEMA MANUUM ET PEDUM—ECZEMA OF THE HANDS AND FEET. Take of Naphthol........................ 10 grains. Extract of belladonna............. 10 grains. Ointment of nitrate of mercury..... 3 drachms. Benzoated lard................... 1 ounce. Mix. ECZEMA MANUUM ET PEDUM—ECZEMA OF THE HANDS AND FEET. Take of Salicylic acid..................... \ drachm. Extract of ergot.................. 1 scruple. Ointment of oxide of zinc.......... 1 ounce. Mix. ECZEMA MANUUM ET PEDUM—ECZEMA OF THE HANDS AND FEET, Take of Balsam of Peru................... \ drachm. Ointment of nitrate of mercury .... \ ounce. Oil of cade....................... \ drachm. Lanolin.......................... ^ ounce. Mix. FORMULARY. 801 EPITHELIOMA—EPITHELIAL CANCER. Take of Chloride of zinc.................. 5 grains. Sublimed sulphur................. 1 scruple. Powdered arrow-root.............. 1 drachm. Arsenious acid................... 10 grains. Simple ointment.................. 1 ounce. Mix. Spread the ointment on an old piece of muslin and apply constantly to the part. EPITHELIOMA—EPITHELIAL CANCER. Take of Carbolic acid..................... 3 grains. Lanolin......................... 2. drachms. Mix. EPITHELIOMA—EPITHELIAL CANCER. Take of Oleate of arsenic.................. 5 to 10 grains. Chloride of zinc.................. 5 grains. Powdered arrow-root.............. \ drachm. Extract of belladonna............. 5 grains. Extract of opium................. 10 grains. Lanolin.......................... \ ounce. Mix. EPITHELIOMA—EPITHELIAL CANCER. Take of Oleate of arsenic.................. 5 grains. Ointment of oleate of mercury...... 1 drachm. Simple ointment.................. 1 ounce. Mix. EPITHELIOMA—EPITHELIAL CANCER. Take of Sulphate of atropine............... 4 grains. Sulphate of morphine............. 4 grains. Distilled witch-hazel............... 2 ounces. Water........................... 3 ounces. Mix. Use on old muslin, and renew application frequently for the relief of pain. EPITHELIOMA—EPITHELIAL CANCER. Take of Powdered chlorate of potassium--- \ ounce. Powdered ergot................... \ ounce. Mix. Dust over the surface. ERYSIPELAS. Take of Acetate of lead................... 1 scruple. Infusion of digitalis............... \ pint. Mix. 51 802 DISEASES OF THE SKIN. ERTSIPELAS. Take of Subnitrate of bismuth............. 1 drachm. Carbonate of lead................. 2 drachms. Creasote......................... 3 drops. Ointment of rose-water............ 1 ounce. Mix. ERYSIPELAS. Take of Tincture of chloride of iron........ 1 ounce. Compound tincture of cinchona--- 1 ounce. Glycerin......................... 1 ounce. Mix. ERYSIPELAS. Take of Yellow oxide of mercury........... 10 grains. Powdered arrow-root.............. 1 drachm. Ointment of oxide of zinc.......... 1 ounce. Mix. ERYTHEMA. Take of Borax........................... 1 drachm. Glycerin......................... 1 ounce. Rose-water....................... 2 ounces. Mix. ERYTHEMA. Take of Subnitrate of bismuth............ 1 drachm. Carbonate of zinc................. 1 drachm. Ointment of rose-water............ 1 ounce. Mix. FURUNCULUS—BOIL. Take of Extract of belladonna............. \ drachm. Extract of arnica................. 1 scruple. Sulphate of morphine.............. 2 grains. Lanolin.......................... 1 ounce. Mix. FURUNCULUS—BOIL. Take of Extract of hyoscyamus............ 1 scruple. Ointment of nitrate of mercury..... 3 drachms. Oil of spearmint.................. \ drachm. Ointment of oxide of zinc.......... 1 ounce. Mix. FORMULARY. 803 FURUNCULUS—BOIL. Take of Lead plaster..................... 4 ounces. Opium plaster.................... 2 ounces. Mix. FURUNCULUS—BOIL. Take of Balsam of Peru................... 1 drachm. Iodol............................ 10 grains. Oxide of lead..................... \ drachm. Lard............................ 1 ounce. Mix. HERPES. Take of Sulphate of morphine............. 3 grains. Prepared calamine................ \ ounce. Subnitrate of bismuth............. \ ounce. Mix. Dust over the surface. HERPES. Take of Calomel......................... 2 drachms. Powdered starch.................. \ ounce. Mix. Sprinkle on the affected part. HERPES ZOSTER—SHINGLES. Take of Hydrochlorate of cocaine.......... 5 grains. Fluid extract of belladonna........ \ ounce. Distilled witch-hazel.............. \\ ounce. Mix. Mop over the surface frequently, and a fine powder can at the same time be dusted on the parts; or collodion can be used in place of the latter. HYPERIDROSIS—INCREASED SECRETION OF SWEAT. Take of Sulphate of quinine............... \ drachm. Alcohol.......................... 5 ounces. Mix. HYPERIDROSIS—INCREASED SECRETION OF SWEAT. Take of Naphthol........................ 1 drachm. Glycerin........................ \\ ounce. Alcohol.......................... \\ ounce. Mix. 804 DISEASES OF THE SKIN. HYPERIDROSIS—INCREASED SECRETION OF SWEAT. Take of Naphthol........................ 2 drachms. Tincture of saponin............... 2 ounces. Tincture of witch-hazel............ 2 ounces. Mix. HYPERIDROSIS—INCREASED SECRETION OF SWEAT. Take of Permanganate of potassium........ 10 grains. Alcohol.......................... 1 ounce. Water.......................... 4 ounces. Mix. HYPERIDROSIS—INCREASED SECRETION OF SWEAT. Take of Salicylic acid..................... \ ounce. Powdered oleate of zinc............ 2 drachms. Mix. ICHTHYOSIS. Take of Oil of ergot..................... 3 ounces. Lanolin........,................. 1 ounce. Mix. IMPETIGO CONTAGIOSA. Take of Ammoniated mercury............. 10 grains. Thymol.......................... 1 grain. Carbonate of zinc................. 1 drachm. Prepared lard..................... 1 ounce. Mix. LENTIGO—FRECKLE. Take of Boracic acid..................... 1 drachm. Distilled witch-hazel.............. 5 ounces. Mix. LENTIGO—FRECKLE. Take of Corrosive sublimate............... 10 grains. Alcohol.......................... 2 ounces. Rose-water....................... 2 ounces. Mix. LENTIGO—FRECKLE. Take of Oleate of copper.................. 10 grains. Hydrastin hydrochlorate........... 2 grains. Ointment of rose-water............ l ounce. Mix. FORMULARY. 805 LUPUS ERYTHEMATOSUS. Take of Creasote....................,___ 8 drops. Subnitrate of bismuth............. 1 drachm. Lanolin. .t........................ 4 drachms. Ointment of rose-water............ 4 drachms. Mix. LUPUS ERYTHEMATOSUS. Take of Tincture of green soap............ 3 ounces. Distilled witch-hazel.............. 2 ounces. Mix. Sponge over the surface every day or two. LUPUS VULGARIS. Take of Corrosive sublimate............... 5 grains. Powdered arrow-root.............. 1 drachm. Subnitrate of bismuth............. 1 drachm. Ointment of rose-water............ 1 ounce. Mix. LUPUS VULGARIS. Take of Creasote......................... 5 drops. Salicylic acid..................... 15 grains. Ointment of oxide of zinc.......... 1 ounce. Mix. MILIARIA—PRICKLY HEAT. Take of Calomel......................... 10 grains. Powdered arrow-root.............. 1 drachm. Carbonate of lead................. 2 drachms. Lard............................ 1 ounce. Mix. MILIARIA—PRICKLY HEAT. Take of Lime-water...................... 3 ounces. Levigated calamine............... \ ounce. Glycerin......................... 2 ounces. Mix. MILIUM—ACNE ALBIDA. Take of Tincture of iodine................ 2 drachms. Carbolic acid..................... §- drachm. Mix. Touch each spot every second or third day, exercising care to avoid the natural skin. 806 DISEASES OF THE SKIN. MILIUM—ACNE ALBIDA. Take of Liniment of camphor............. 1 ounce. Tincture of green soap............ 2 ounces. Mix. NEVUS VASCULARIS. Take of Solution of subacetate of lead ..... 2 ounces. Apply once or twice a day for some months. NEVUS VASCULARIS. Take of Solution of arsenite of potassium.... 1 ounce. Paint over the surface several times a day. PARESTHESIA, OR PRURITUS ANI—ITCHING OF THE ANUS Take of Hydrate of chloral................ 1 drachm. Camphor........................ 2 drachms. Prepared suet.................... 2 ounces. Mix. PARESTHESIA, OR PRURITUS ANI—ITCHING OF THE ANUS. Take of Naphthol........................ 1 scruple. Subnitrate of bismuth............. 2 drachms. Ointment of oxide of zinc.......... 1 ounce. Mix. PARESTHESIA, OR PRURITUS SCROTI—ITCHING OF THE SCROTUM, Take of Extract of stramonium-leaves...... 8 grains. Camphor........................ 1 drachm. Benzoated lard................... 1 ounce. Mix. PARESTHESIA, OR PRURITUS LABIORUM—ITCHING OF THE LABIA, Take of Borate of sodium................. 1 drachm. Camphor................ ....... 1 scruple. Carbonate of lead................. 1 drachm. Carbolic acid..................... 3 grains. Ointment of oxide of zinc.......... 1 ounce. Mix. PARESTHESIA, OR PRURITUS LABIORUM—ITCHING OF THE LABIA. Take of Extract of belladonna............. 4 grains. Extract of opium................. 6 grains. Tannic acid...................... 1 drachm. Oil of theobroma, a sufficient quantity. Mix, and divide into 12 suppositories. Insert one in the vagina every two or three hours until relieved. FORMULARY. 807 PARESTHESIA, OR PRURITUS VAGINE—ITCHING OF THE VAGINA. Take of Alum........................... 1 ounce. Borate of sodium................. 1 ounce. Mix. Add to one quart of hot water, and inject into the vagina. PARESTHESIA, OR PRURITUS VAGINE—ITCHING OF THE VAGINA. Take of Hyposulphite of sodium........... 6 drachms. Add to one pint of hot water, and at once inject into the vagina. PEDICULOSIS—LOUSINESS. Take of Fluid extract of delphinium....... 1 ounce. Water........................... 4 ounces. Mix. PEDICULOSIS—LOUSINESS. Take of Ointment of oleate of mercury..... 1 ounce. Chlorinated oil................... 1 ounce. Mix. PEDICULOSIS—LOUSINESS. Take of Naphthol........................ \ drachm. Lard............................ 1 ounce. Mix. PEMPHIGUS. Take of Powdered red cinchona............ \ ounce. Carbonate of lead................. 2 drachms. Subnitrate of bismuth............. 2 drachms. Mix. PEMPHIGUS. Take of Prepared calamine................ \ ounce. Glycerin......................... 2 ounces. Lime-water...................... 4 ounces. Mix. PEMPHIGUS. Take of Subnitrate of bismuth............. 2 drachms. Powdered starch........,.......... 4 drachms. Ointment of benzoated oxide of zinc 1 ounce. 808 DISEASES OF THE SKIN. PITYRIASIS RUBRA. Take of Olive-oil......................... 4 ounces. Creasote......................... 5 drops. Oil of ergot...................... 2 ounces. Mix. PRURIGO. Take of Menthol......................... 1 drachm. Olive-oil......................... 5 ounces. Mix. PSORIASIS. Take of Ointment of oleate of mercury..... 1 ounce. Oil of cade....................... 1 drachm. Naphthol........................ 1 drachm. Mix. PSORIASIS. Take of Ointment of nitrate of mercury___ 1 ounce. Iodol...............:............ 1 drachm. Mix. PSORIASIS. Take of Chrysarobin...................... 1 drachm. Benzoated lard................... 1 ounce. Mix. PSORIASIS. Take of Oil of turpentine................. 1 ounce. Lanolin......................... 1 ounce. Mix. PSORIASIS. Take of Green soap....................... 1 ounce. Ointment of ammoniated mercury.. 1 ounce. Mix. PURPURA. Take of Alum........................... £ ounce. Alcohol.......................... 6 ounces. Mix. PURPURA. Take of Tannic acid...................... ± drachm. Camphor........................ 1 drachm. Benzoated lard................... 1 ounce. Mix. FORMULARY. 809 PURPURA. Take of Spirit of lavender................. \ ounce. Spirit of rosemary................ \ ounce. Tincture of witch-hazel............ 3 ounces. Water............................ 2 ounces. Mix. PURPURA. Take of Tincture of capsicum............. \ ounce. Spirit of myrcia (bay-rum)......... ?>\ ounces. Mix. ROSACEA—ACNE ROSACEA. Take of Hydrochlorate of hydrastine....... 1 grain. Tincture of witch-hazel........... 2 drachms. Rose-water....................... 2 ounces. Mix. Apply twice daily. ROSACEA—ACNE ROSACEA. Take of Tannic acid...................... 10 grains. Sublimed sulphur................. \ drachm. Carbonate of zinc................. 1 drachm. Lard........................... 1 ounce. Mix. ROSACEA—ACNE ROSACEA. Take of Ergotin.......................... 1 scruple. Lanolin.......................... 3 drachms. Mix. ROSACEA—ACNE ROSACEA. Take of Extract of witch-hazel............. 10 grains. Ointment of lead oleate............ 3 drachms. Mix. ROSACEA—ACNE ROSACEA. Take of Ointment of bismuth oleate........ 2 drachms. Oil of juniper.................... 5 drops. Mix. RUBEOLA—MEASLES. Take of Camphor........................ \ drachm. Oil of theobroma................. 1 ounce. Mix. 810 DISEASES OF THE SKIN. RUBEOLA—MEASLES. Take of Menthol......................... 1 scruple. Olive-oil......................... 6 ounces. Mix. SCABIES—ITCH. Take of Naphthol........................ £ drachm. Lanolin......................... £ ounce. Mix. SCABIES—ITCH. Take of Chlorinated oil................... 2 ounces. Prepared by passing chlorine-gas in olive-oil. SCABIES—ITCH. Take of Naphthol........................ \ drachm. Sublimed sulphur................. 1 drachm. Ointment of oleate of mercury...... £ ounce. Simple ointment.................. £ ounce. Mix. SCABIES—ITCH. Take of Oil of cade....................... 3 drachms. Sublimed sulphur................. 4 drachms. Green soap....................... 1 ounce. Lard........................... 2 ounces. Mix. SCABIES—ITCH. Take of Red oxide of mercury............. \ drachm. Balsam of Peru......... ......... \ ounce. Lard................. .......... 3 ounces. Mix. SCARLATINA—SCARLET FEVER. Take of Oil of eucalyptus............... 5 drops. Prepared lard.................... 1 ounce. Mix. SCARLATINA—SCARLET FEVER. Take of Borax........................... j. drachm. Powdered starch.................. 1 drachm. Lard............................ 1 ounce. Mix. FORMULARY. 811 SCROFULODERMA. Take of Iodoform........................ 24 grains. Oleic acid........................ 1 ounce. Mix. SCROFULODERMA. Take of Iodol............................ | drachm. Ointment of oxide of zinc.......... 1 ounce. Mix. SCROFULODERMA. Take of Ointment of oleate of mercury..... \ ounce. Subiodide of bismuth............. 1 scruple. Ointment of oxide of zinc.......... \ ounce. Mix. . SEBORRHCEA GENITALIUM—SEBORRHCEA OF THE GENITALS. Take of Subnitrate of bismuth............. 1 drachm. Carbonate of lead................. 1 drachm. Glycerin......................... 2 ounces. Lime-water...................... 2 ounces. Mix. SEBORRHCEA GENITALIUM—SEBORRHCEA OF THE GENITALS. Take of Powdered oleate of zinc............ 2 drachms. Calomel......................... 1 scruple. Powdered starch.................. \ ounce. Mix. SEBORRHCEA SICCA—DRY OR SCALY SEBORRHCEA. Take of Oil of ergot...................... 3 ounces. Oil of rose....................... 2 drops. Mix. Apply twice a day. Especially serviceable in seborrhoea of the scalp or dandruff. SEBORRHCEA SICCA—DRY OR SCALY SEBORRHCEA. Take of Tincture of saponaria............. 2 ounces. Fluid petroleum.................. 2 ounces. Mix. Useful in seborrhcea or dandruff of scalp. SEBORRHCEA SICCA—DRY OR SCALY SEBORRHCEA. Take of 50-per-cent. solution of boroglyceride 3| ounces. Oleic acid........................ | ounce. Carbolic acid.................... 3 grains. Mix. Good in seborrhoea of face, back, and chest. 812 DISEASES OF THE SKIN. SEBORRHCEA SICCA—DRY OR SCALY SEBORRHCEA. Take of Calomel......................... 10 grains Balsam of Peru.................. \ drachm. Powdered camphor................ 1 scruple. Ointment of rose-water........... 1 ounce. SEBORRHCEA OLEOSA—OILY SEBORRHCEA. Take of Boracic acid..................... 2 drachms. Orange-flower water............... 2 ounces. Rose-water....................... 2 ounces. Mix. SEBORRHCEA OLEOSA—OILY SEBORRHCEA. Take of Chloride of zinc.................. 5 grains. Rose-water....................... 4 ounces. Mix. SEBORRHCEA OLEOSA—OILY SEBORRHCEA. Take of Corrosive sublimate............... 10 grains. Tincture of witch-hazel............ \ ounce. Rose-water....................... 4£ ounces. Mix. SEBORRHCEA OLEOSA—OILY SEBORRHCEA. Take of Oleate of zinc.................... 2 drachms. Powdered arrow-root.............. \ ounce. Mix. SYPHILIS. Take of Iodol............................ 1 drachm. Subnitrate of bismuth............. 3 drachms. Mix. Use in syphilitic ulceration. SYPHILIS. Take of Ointment of oleate of mercury..... \ ounce, Ointment of oxide of zinc......... \ ounce. Mix. SYPHILIS. Take of Ointment of nitrate of mercury___ \ ounce. Oil of cade...................... \ drachm. Ointment of oxide of zinc......... \ ounce. Mix. FORMULARY. 813 SYPHILIS. Take of Powdered red cinchona-bark....... 2 drachms. Subnitrate of bismuth............. 4 drachms. Iodol............................ 3 drachms. Mix. Use in syphilitic ulceration. SYPHILIS. Take of Corrosive sublimate............... 4 grains. Lanolin.......................... 5 drachms. Mix. SYPHILIS. Take of Extract of belladonna............. 10 grains. Ointment of oleate of mercury..... 3 drachms. Lanolin......................... | ounce. Mix. SYPHILIS. Take of Chromic acid.................... 8 grains. Water.. ..;...................... 1 ounce. Mix. Valuable in involvement of mucous surfaces. SYPHILIS. Take of Chloride of zinc.................. 10 grains. Water.........................., 1 ounce. Mix. Also for application on mucous surfaces. SYPHILIS. Take of Ointment of oleate of iron......... \ ounce. Salicylic acid..................... 5 grains. Ointment of oxide of zinc.......... -| ounce. Mix. SYCOSIS—INFLAMMATION OF THE HAIR-FOLLICLES. Take of Boracic acid...................... 1 drachm, Oil of cade....................... 30 drops. Extract of ergot.................. 1 scruple. Ointment of oxide of zinc.......... 1 ounce. Mix. SYCOSIS—INFLAMMATION OF THE HAIR-FOLLICLES. Take of Solution of subacetate of lead...... 3 ounces. Glycerin......................... 3 ounces. Mix. 814 DISEASES OF THE SKIN. SYCOSIS—INFLAMMATION OF THE HAIR-FOLLICLES. Take of Ointment of bismuth oleate........ 3 drachms. Nut gall......................... 5 grains. Mix. SYCOSIS, CHRONIC—INFLAMMATION OF THE HAIR-FOLLICLES. Take of Carbolic acid..................... 4 grains. Glycerin......................... 6 ounces. Mix. SYCOSIS, CHRONIC—INFLAMMATION OF THE HAIR-FOLLICLES. Take of Ointment of mercury oleate........ 1 ounce. Oil of juniper.................... 4, drachm. Mix. TINEA FAVOSA—FAVUS. Take of Oleate of copper.................. 1 scruple. Salicylic acid.................... 5 grains. Calomel......................... 10 grains. Ointment of oxide of zinc......... 1 ounce. TINEA FAVOSA—FAVUS. Take of Boracic acid...................... 1 drachm. Alcohol.......................... 2 ounces. Sulphuric ether................... 2 ounces. Mix. TINEA TONSURANS—RINGWORM OF THE SCALP. Take of Oleate of copper.................. £ drachm. Creasote......................... 5 drops. Lard........................_.. 1 ounce. Mix. TINEA TONSURANS—RINGWORM OF THE SCALP. Take of Oleic acid........................ 1 ounce. !odol............................ 1 drachm. Mix. 2 TINEA BARBE—BARBER'S ITCH. Take of Corrosive sublimate............... 8 grains. Alcohol.......................... 1 ounce. Distilled witch-hazel.............. 3 ounces. Mix. FORMULARY. g15 TINEA BARBE—BARBER'S ITCH. Take of Oleate of copper.................. 1 scruple. Oil of chamomile................. 5 drops. Ointment of oxide of zinc.......... 1 ounce. Mix. TINEA CIRCINATA—RINGAVORM OF THE BODY. Take of Ointment of oleate of mercury..... % ounce. Oil of cade....................... 20 drops. Mix. TINEA CIRCINATA—RINGWORM OF THE BODY. Take of Boracic acid...................... 1 drachm. Thymol......................... 5 drops. Alcohol.......................... 4 ounces. Mix. TINEA VERSICOLOR—CHROMOPHYTOSIS. Take of Ointment of oleate of copper....... 2 drachms. Lanolin......................... 2 drachms. Mix. TINEA VERSICOLOR—CHROMOPHYTOSIS. Take of Resorcin......................... 10 grains. Lard............................ 1 ounce. Mix. ULCERA—ULCERS. Take of Iodol............................ 1 scruple. Ointment of oxide of zinc.......... 1 ounce. Mix. ULCERA—ULCERS. Take of Powdered red cinchona............ 3 drachms. Subnitrate of bismuth............. 3 drachms. Mix. ULCERA—ULCERS. Take of Tincture of witch-hazel............ \ ounce. Hydrate of chloral................. 1 drachm. Water........................... 3^ ounces. Mix. Apply with old muslin or lint. Useful in indolent ulcers. ULCERA—ULCERS. Take of Subiodide of bismuth............. \ ounce. Powdered calamine............... \ ounce, Mix. 816 DISEASES OF THE SKIN. ULCERA—ULCERS. Take of Chlorate of potassium............. 2 drachms. Extract of ergot................... 1£ ounce. Glycerin ........................ H ounce. Mix. Useful in ulceration of the mucous membrane. URTICARIA—NETTLE-RASH—HIVES. Take of Carbolic acid..................... 1 drachm. Alcohol..................•....... 4 ounces. Water........................... 1 pint. Mix. URTICARIA—NETTLE-RASH—HIVES. Take of Menthol......................... 1 drachm, Olive-oil......................... 4 ounces. Mix. URTICARIA—NETTLE-RASH—HIVES. Take of Creasote......................... 10 drops. Water........................... £ pint. Mix. URTICARIA—NETTLE-RASH—HIVES. Take of Boracic acid..................... 2 drachms. Cologne-water.................... 4 ounces. Glycerin......................... 2 ounces. Rose-water....................... 2 ounces. Mix. VA RIOLA—SMALL-POX. Take of Iodol............................ 1 drachm. Salicylate of sodium.............. 2 drachms. Precipitated carbonate of lime...... 2 ounces. Mix. Sprinkle over the surface. VARIOLA—SMALL-POX. Take of Prepared chalk................... 6 drachms. Boracic acid..................... 1 drachm. Oil of wintergreen................ 40 drops. Subnitrate of bismuth............. 3 drachms. Olive-oil......................... 6 ounces. Mix. MEDICINAL PLASTERS. 817 VARIOLA—SMALL-POX. Take of Carbolic acid..................... 5 grains. Prepared chalk................... \ ounce. Subnitrate of bismuth............. 3 drachms. Ointment of rose-water............ 1£ ounce. Mix. VERRUCA—WART. Take of Ointment of oleate of mercury..... \ ounce. Lanolin......................... \ ounce. VERRUCA—AVART. Take of Salicylic acid..................... 1 drachm. Collodion........................ 3 drachms. Sulphuric ether................... 2 ounces. Mix. MEDICINAL PLASTERS. ALUM, ERGOT, HEMLOCK, AND WHITE PRECIPITATE. Alum................................ 20 per cent. Extract of ergot....................... 20 " Extract of hemlock-bark........... ... 20 " White precipitate ..................... 30 " * Plaster mass.......................... 10 " A satisfactory combination for cancerous affections, pustular and tubercular growths, lupus, scrofulous patches, hyperidrosis, and bro- midrosis. BELLADONNA AND BORIC ACID. Extract of belladonna.................. 30 per cent. Boric acid............................ 20 " Plaster mass.......................... 50 Invaluable in excessive and fetid perspiration, subacute and chronic eczema, accompanied with obstinate itching ; erythema, herpes, herpes zoster, and in neuralgia and exalted and diminished sensibility of the skin ; wounds, ulcers, burns and scalds, local itching spots, and in limited patches of vegetable parasites, especially ringworm and favus. * The plaster mass is composed of fifty parts of India-rubber, five parts of honey, and forty-five parts of soap plaster. 52 818 DISEASES OF THE SKIN. CHRYSAROBIN. Chrysarobin (chrysophanic acid)........ 35 per cent. Plaster mass.......................... 65 " Efficient for limited psoriasis, chronic eczema, chronic acne, and acne rosacea, and in old syphilitic and scrofulous spots on the skin. CAMPHOR AND OXIDE OF ZINC. Camphor............................. 5 per cent. Oxide of zinc......................... 40 " Plaster mass.......................... 55 " For chronic eczema attended with severe itching, erythema, and in irritable boils and carbuncles. HYDRASTIN. Hydrastin............................ 30 per cent. Plaster mass.......................... 70 " Useful in chancroid, unhealthy and sloughing sores, cancerous growths, and excessive secretion of the skin. IODOFORM. Iodoform............................. 40 per cent. Plaster mass.......................... 60 " Appropriate and useful for chancre, chancroid, syphilitic and scrofulous spots, ulcers, and wounds. LEAD. Oxide of lead (litharge)................ 30 per cent. Plaster mass.......................... 70 " Useful for fissured nipples and other varieties of eczema, impetigo, erythema, burns, and frost-bites. LEAD AND OPIUM. Lead oxide (litharge).................. 30 per cent. Extract of opium...................... 10 " Plaster mass.......................... 60 " Is beneficial in all irritable conditions of the skin, bed-sores, various forms of ulcers, and carbuncles. MEDICINAL PLASTERS. 819 MERCURIAL. Red oxide of mercury.................. 50 per cent. Plaster mass.......................... 50 " Valuable in syphilitic patches, especially in chronic cases; pig- mentary deposits, particularly chloasma, or yellowish-brown or black- ish spots on the skin ; freckles, syphilitic and scrofulous ulcers, en- larged glands, elephantiasis, and indurated acne spots. Deficiency of pigment, keloid scars, lupus, and in hardened and infiltrated spots of the skin, which result from many skin affections, especially boils, carbuncles, inflammation of the hair-follicles, eczema, and small-pox. OXIDE OF ZINC Oxide of zinc......................... 40 per cent. Plaster mass.......................... 60 " Serviceable in subacute and chronic eczema, acne, seborrhcea, herpes, ulcers, and boils. OXIDE OF ZINC AND WHITE PRECIPITATE. Oxide of zinc......................... 30 per cent. White precipitate...................... 15 " Plaster mass.......................... 55 " Available for irritable syphilitic and scrofulous patches and chronic eczema. PHYTOLACCA AND BELLADONNA. Phytolacca extract..................... 20 per cent. Belladonna extract..................... 20 Plaster mass.......................... 60 Serviceable in obstinate eczema, ulcers, burns, dermatitis, arresting and overcoming tendency to inflammation, particularly of the female breast. SUBIODIDE OF BISMUTH. Subiodide of bismuth.................. 30 per cent. Plaster mass......................... 70 Useful in syphilitic and scrofulous spots, acne, rosacea, chloasma, freckles, and all pigmentary deposits ; orchitis, bubo, and all enlarge- ments of glands; indurated patches following inflammation of the skin. 820 DISEASES OF THE SKIN. SALICYLIC ACID. Salicylic acid.......................... 25 per cent. Plaster mass.......................... 75 " Useful for eczema of the palms of the hands and soles of the feet, and in all thickened conditions of the skin occurring in the course of psoriasis, scrofuloderma, erysipelas, boils and carbuncles, local varie- ties of hyperidrosis and bromidrosis. SALICYLIC ACID AND CANNABIS INDICA. Salicylic acid.......................... 25 per cent. Extract of cannabis indica.............. 20 " Plaster mass.......................... 55 " For corns, horns, warts and callosities, acne, rosacea, chronic ec- zema, and psoriasis. SALICYLIC ACID AND CREASOTE. Salicylic acid.......................... 25 per cent. Creasote.............................. 5 " Plaster mass.......................... 70 " Useful in lupus, chronic ulcers, excessive and fetid perspiration. MEDICINAL SOAPS.* Amber Soap (Eau de Luce).—A liquid soap which has as its chief ingredients tincture of oil of amber and balsam of Gilead, with water of ammonia. Used in enlarged glands, moles, warts, etc. Alum Soap (Sapo Aluminis).—Ten per cent., or 168 grains, alum (potassae aluminis). Alum soap is most useful in hyperidrosis, seborrhcea oleosa, and pustular eczema. It is very efficient in all indolent conditions of the integument as occur in lupus, cancer, ulcers, and in scrofulous and syphilitic skin affections. Arnica Soap (Sapo Arnicce).— Ten per cent, or 168 grains, ex- tracti arnicae. * Each soap referred to should be divided into pieces or cakes that have an average weight of three and a half ounces, or 1,680 grains. MEDICINAL SOAPS. 821 Arnica soap is very good to use in sore nipples, abrasions, wounds, bruises, boils, carbuncles, and many of the pustular skin affections. Balsam Soap.—Five per cent., or 84 grains, balsami Peruviani. Used in indolent ulcers, sinuses, abscesses, etc. Boro-glyceride Soap (Sapo Boro-glyceriti).—Ten per cent., or 168 grains, 50-per-cent. solution boro-glyceride. It is valuable for cleansing wounds, ulcers, suppurating, sloughing, or gangrenous surfaces, lessening inflammation, and preventing the action of atmospheric germs ; in general and local pruritic conditions of the skin, in acne, and in seborrhoea. Camphor Soap (Sapo Camphorae).—Ten per cent, or 168 grains, camp boras. It is most frequently used for the relief of pruritus that attends ec- zema, chilblains, and other irritable affections of the skin. Carbolic-acid Soap (Sapo Acidi Carbolici).—Five per cent, or 84 grains, acidi carbolici. It is excellent for chronic eczema and psoriasis. Chamomile Soap (Sapo Anthemidis).—Ten per cent,- or 168 grains, extracti anthemidis. It is an excellent soap to use in intertrigo or chafing, and in der- matitis and seborrhoea, while it is particularly valuable both for its medicinal virtues and aromatic odor in all conditions of excessive secretion and ill-smelling sores. Chamomile and Sulphur Soap (Sapo Anthemidis Sulphurisque). —Ten per cent, or 168 grains, extracti anthemidis ; 5 per cent, or 84 grains, sulphuris loti. It is beneficial in seborrhcea sicca,, loss of hair, and in acne. Elder-flower Soap (Sapo Sambuci Florum).—Ten per cent, or 168 grains, sambuci florum. Used in intertrigo, rosacea, sunburn, etc. Ergot Soap (Sapo Ergots).—Ten per cent, or 168 grains, ext ergotae. Used in eczema, acne, rosacea, etc. Eucalyptol Soap (Sapo Eucalyptoli).—Five per cent, or 84 minims, ol. eucalypti. It is a useful disinfectant application to all foul-smelling wounds and ulcers. In bromidrosis or fetid perspiration it is very efficacious. Glycerin Soap (Sapo Glycerini).—Fifteen per cent, or 252 grains, glycerini. Used for roughness of the skin, chaps, pityriasis, etc. Iodine Soap (Sapo Iodi).—Three per cent, or 50f grains, iodi resublimati. 822 diseases of the skin. Used in syphilitic and scrofulous skin affections, old granulations, etc. Iodide of Sulphur Soap (Sapo Sulphuris Iodidi).—Three per cent, sulphuris iodidi, 50f grains in a cake. Used in acne indurata, chronic ulcers, freckles, yellowish-brown or blackish patches on the skin, etc. Kino Soap (Sapo Kino).—Ten per cent, or 168 grains, ext kino. Used in eczema, rosacea, ulcers, etc. Lead Soap (Sapo Plumbi).—Three per cent, or 50| grains, plumbi acetatis. Used in boils, carbuncles, abrasions, bed-sores, etc. Naphthol - Sulphur Soap (Sapo Naphtholi Sulphurisque).— Three per cent., or 50| grains, naphtholi; 10 per cent, or 168 grains, sulphuris loti. Used in scabies (itch), pediculosis (lousiness), insects of all kinds on the skin, eczema, psoriasis, seborrhoea, hyperidrosis, bromidrosis, etc. Naphthol Soap (Sapo Naphtholi).—Five per cent, or 84 grains, naphtholi. It is useful for animal parasites. The bite and sting of many in- sects and animals may often be cured or relieved by its use. It often acts well in eczema, psoriasis, pityriasis, ichthyosis, and offensive dis- charges from the skin. Fetid perspiration is not only controlled, but often cured by its use. Salicylic-acid Soap (Sapo Acidi Salicylici).—Four per cent, or 674, grains, acidi salicylici. It is an admirable soap for toilet purposes, and has proved service- able in those thickened conditions of the epidermis that occur in the plantar, palmar, and extensor surfaces. Sycosis and pustular eczema are generally benefited by its use. It is likewise serviceable in fetid perspiration and all foul-smelling wounds or sores. Sublimate Soap (Sapo Hydrargyri Chloridi Corrosivi).—One per cent, or 164, grains, hydrargyri chloridi corrosivi. It is a valuable soap in animal parasitic diseases, such as pedicu- losis or lousiness, scabies or itch, and for destroying insects of all varie- ties that may infest the body. Freckles, pigmentary deposits, espe- cially chloasma, or yellowish-brown or blackish patches on the skin, are greatly relieved and sometimes removed by its employment. It is an effective soap in all kinds of itching of the integument. It is like- wise markedly serviceable in the various syphilitic skin-eruptions. Sulphur Soap (Sapo Sulphuris).—Ten per cent, or 168 grains, sulphuris loti. Used in acne, rosacea, etc. medicinal soaps. 823 Tannin Soap (Sapo Acidi Tannici).—Three per cent, or 50| grains, acidi tannici. Used in seborrhcea oleosa, excessive sweating, ulcers, granulations, etc. Tannin - Balsam Soap (Sapo Tanno - Balsamicus).—Two per cent, or 33| grains, acidi tannici; 5 per cent, or 80 grains, balsami Peruviani. Used in wounds, ulcers, chilblains, etc. Thymol Soap (Sapo Thymoli).—Tbree per cent., or 50f grains, thymoli crystallisati. Used in ulcers, wounds, abscesses, sinuses, pustular eczema, etc. Turpentine Soap (Sapo Terebinthinm Compositus).—This soap has been known as Starkey's, and is composed of equal parts of potas- sium carbonate, oil of turpentine, and Venice turpentine. Used in chilblains, syphilis, psoriasis, etc. Tar Soap (Sapo Picis Liquida).—Ten per cent, or 168 grains, picis liquidae. Tar soap is valuable in chronic eczema, psoriasis, and ichthyosis. Wintergreen Soap (Sapo Gaultherios).—Three per cent, or 50| grains, acidi methylsalicylici. Used in eczema, psoriasis, lichen, acne, etc. Witch-hazel Soap (Sapo Hamamelidis).—Ten per cent, or 168 grains, ext. hamamelidis. Used in fetid perspiration, eczema, loss of hair, etc. FORMULARY TO SECOND EDITION. INTERNAL. ABSCESSUS—CUTANEOUS ABSCESSES. Take of Tincture of pokeroot...............100 drops. Tincture of prickly-ash bark........ 5 ounces. Mix. Dose : Two teaspoonfuls in water three or four times a ABSCESSUS—CUTANEOUS ABSCESSES. Take of Sulphide of calcium................ 40 grains. Extract of belladonna.............. 2 grains. Mix and divide into twenty pills. Dose : A pill three or four times a day. ACNE. Take of Sulphide of arsenic................. 1 grain. Extract of gentian................. 40 grains. Mix and divide into twenty pills. Dose : One pill three times a day. ACNE. Take of Sirup of hydriodic acid............. 2 ounces. Sirup of lactucarium................ 2 ounces. Mix. Dose : One to two teaspoonfuls three times a day. ACNE. Take of Extract of Indian hemp............. 4 grains. Extract of nux vomica.............. 4 grains. Lupulin........................... 30 grains. Mix and divide into thirty pills. Dose: Two pills morning and evening. ACNE. Take of Papain...................... ,.....40 grains. Make into fifteen powders. Dose : One powder after meals. FORMULARY TO SECOND EDITION, j 825 ACNE. Take of Sublimed sulphur..................100 grains. Aromatic powder...................100 grains. Mix and make into twenty capsules. Dose: One capsule three to four times a day. ACNE. Take of Tincture of capsicum............... 1 drachm. Bicarbonate of sodium..............100 grains. Peppermint-water.................. 5 ounces. Mix. Dose : Two teaspoonfuls in water three times a day. ALOPECIA. Take of Tincture of chloride of iron......... 5 drachms. Solution of arsenite of potassium.....100 drops. Solution of citrate of ammonium, a sufficient quantity to make........ 5 ounces. Mix. Dose : Two teaspoonfuls in water three times a day. ALOPECIA. Take of Compound sirup of phosphates...... 3 ounces. Diastasic extract of malt............ 3 ounces. Glycerin.......................... 2 ounces. Mix. A dessertspoonful two or three times a day. ALOPECIA. . Take of Phosphide of zinc.................. fa grain. Extract of nux vomica.............. 1 grain. Powdered capsicum................ 1 draclim. Mix and divide into thirty pills. Dose: From three to four pills daily. ALOPECIA CIRCUMSCRIPTA. Take of Oxide of zinc...................... 2 grains. Arseniate of sodium................ 1 grain. Extract of ignatia.................. 2 grains. Lupulin........................... 1 drachm. Mix and divide into thirty pills. Dose: One pill three to four times a day. ALOPECIA CIRCUMSCRIPTA. Take of Sulphate of strychnine.............. 1 grain. Diluted phosphoric acid............. £ ounce. Elixir of cinchona.................. 74, ounces. Mix. Dose : One teaspoonful in water thrice daily. 826 DISEASES OF THE SKIN. ALOPECIA CIRCUMSCRIPTA. Take of Sulphate of quinine................ 40 grains. Powdered capsicum................. 10 grains. Arsenious acid..................... 1 gram. Mix and divide into twenty pills. Dose : One pill after meals. ALOPECIA CIRCUMSCRIPTA. Take of Nitro-glycerin a one-per-cent. solu- tion in alcohol................... 1 drachm. Dose: One drop in water three to four times a day. BITES AND STINGS OF INSECTS. Take of Tincture of aconite-root............. 2 drachms. Dose: One to two drops in water every two to three hours. BITES AND STINGS OF INSECTS. Take of Infusion of digitalis................ 2 ounces. Spirit of nitrous ether.............. 2 ounces. Brandy........................... 2 ounces. Mix. Dose: One to two teaspoonfuls in water every two to three hours. BITES AND STINGS OF INSECTS. Take of Aromatic spirit of ammonia......... 1 drachm. Tincture of capsicum............... 1 drachm. Mix. Dose: Ten to thirty drops in water every two hours. CARBUNCULUS—CARBUNCLE. Take of Beta-naphthol..................... 15 grains. Carbonate of iron.................. 15 grains. Mix and divide into fifteen pills. Dose: One pill three to four times a day. CARBUNCULUS—CARBUNCLE. Take of Chlorate of potassium.............. 3 drachms. Sirup of hydriodic acid............. 2 ounces. Glycerin.......................... 6 ounces. Mix. Dose: One tablespoonful in water three to four times a day. CHANCROID. Take of Bromide of sodium................. 10 drachms. Tincture of aconite-root............. 40 drops. Tincture of hops................... 5 ounces. Mix. Dose: One to two teaspoonfuls in water every two or three hours until relieved. FORMULARY TO SECOND EDITION. CHANCROID. Take of Tartrate of antimony and potassium.. 2 grains. Sulphate of quinine................ 40 grains. Mix and divide into twenty pills. Dose: One to two pills every three to four hours. CHLOASMA—PIGMENTATION OF THE SKIN—LIVER SPOT. Take of Phosphate of sodium............... 1 drachm. Divide into twelve powders or capsules. Dose : One every two or three hours. CHLOASMA—PIGMENTATION OF THE SKIN—LIVER SPOT. Take of Solution of iodide of arsenic and mercury 2 drachms. Fluid extract of hoang-nan........... 2 drachms. Mix. Dose : Five to ten drops in water three times a day. DERMATALGIA—NEURALGIA OF THE SKIN. Take of Extract of Indian hemp............. 4 grains. Salol............................. 48 grains. Mix and divide into sixteen pills. Dose: One pill three to four times a day. DERMATALGIA—NEURALGIA OF THE SKIN. Take of Urethan.......................... 1 drachm. Elixir of orange................... 4 ounces. Mix. Dose: From one to three teaspoonfuls every two or hours. DERMATALGIA—NEURALGIA OF THE SKIN. Take of Extract of belladonna............... 3 grains. Sulphate of quinine................ 18 grains. Sulphate of strychnine.............. \ grain. Arsenious acid..................... \ grain. Mix and divide into twelve pills. Dose: A pill two or three times a day. ECZEMA, ACUTE. Take of Lime-water....................... 4 ounces. Glycerin.......................... 4 ounces. Sirup of senna..................... 4 ounces. Mix. Dose : One tablespoonful three to four times a day. ECZEMA, ACUTE. Take of Tincture of strophanthus........... 2 drachms. Dose: Five to ten drops in water three to four times a day. 828 DISEASES OF THE SKIN. ECZEMA, ACUTE. Take of Sublimed sulphur.................. 2 drachms. Make into twelve capsules. Dose: One capsule three to four times a day. ECZEMA, ACUTE. Take of Wine of antimony................. 1 drachm. Glycerin.......................... 3 ounces. Mix. Dose : One to two teaspoonfuls every three hours. ECZEMA, ACUTE. Take of Antipyrine........................ 50 grains. Make into ten capsules. Dose : One capsule three to four times a day. ECZEMA, ACUTE. Take of Lupulin.......................... 20 grains. Extract of belladonna............... 3 grains. Sulphate of quinine................. 20 grains. Mix and divide into twenty pills. Dose : From four to five pills daily. ECZEMA, ACUTE. Take of Calomel........................... 8 grains. Powdered nutmeg.................. % drachm. Mix and divide into fifteen powders. Dose : One powder three times a day. ECZEMA, ACUTE. Take of Tincture of rhus toxicodendron (poi- son iyy)................................ 2 drachms. Dose : One to two drops in water every two or three hours. ECZEMA, CHRONIC. Take of Sulphide of arsenic................. 1 grain. Beta-naphthol..................... 24 grains. Mix and divide into twelve pills. Dose : One pill three times a day. ECZEMA, CHRONIC. Take of Iodide of iron..................... 40 grains. Arseniate of sodium....... ........ 1 grain. Mix and divide into twenty pills. Dose : One pill three times a day. FORMULARY TO SECOND EDITION. 829 ECZEMA, CHRONIC. Take of Cod-liver oil....................... 10 ounces. Oil of gaultheria................... 10 drops-. Mix and make into an emulsion. Dose : One tablespoonful three times a day. ECZEMA, CHRONIC. Take of Iodide of potassium................200 grains. Aloin............................ 2 grains. Sirup of sarsaparilla................ 5 ounces. Mix. Dose : Two teaspoonfuls in water three times a day. ECZEMA, CHRONIC. Take of Aloin............................. 2 grains. Sublimed sulphur..................100 grains. Tincture of belladonna.............. 60 drops. Mix and divide into twenty capsules. Dose: A capsule three times a day. ECZEMA, CHRONIC. Take of Solution of arseniate of sodium...... 1 drachm. Fluid extract of hoang-nan.......... 1 drachm. Elixir of ferrated gentian........... 5 ounces. Mix. Dose : A teaspoonful in water after meals. ECZEMA, CHRONIC Take of Sulphide of arsenic................. 2 grains. Aloin............................ 2 grains. Extract of belladonna............... 2 grains. Extract of dandelion................ 40 grains. Mix and divide into twenty pills. Dose: One pill three or four times a day. ECZEMA, CHRONIC. Take of Salol..............................100 grains. Podophyllotoxin................... 2 grains. Mix and divide into twenty capsules. Dose: One to two capsules three times a day. ECZEMA, INFANTILE ACUTE. Take of Pepsin........................... 36 grains. Subnitrate of bismuth.............. 36 grains. Powdered nutmeg.................. 4 grains. Mix and divide into twelve powders. Dose : One powder after feeding three or four times a day. 830 DISEASES OF THE SKIN. ECZEMA, INFANTILE ACUTE. Take of Antimonial wine................... 24 drops. Cinnamon-water................... 3 ounces. Mix. Dose : One teaspoonful from three to four times a day. ECZEMA, INFANTILE CHRONIC. Take of Sublimed sulphur.................. 2 drachms. Glycerin.......................... 3 ounces. Mix. Dose : From one to two teaspoonfuls night and morning. ECZEMA, INFANTILE CHRONIC. Take of Sirup of onion (from Spanish onion). 4 ounces. Compound sirup of phosphates...... 1 ounce. Mix. Dose: One or two teaspoonfuls in water or milk three or four times a day. ECZEMA, INFANTILE CHRONIC. Take of Sirup of lactate of iron............. 3 ounces. Chlorate of potassium.............. 1 drachm. Mix. Dose : One-half to one teaspoonful three times a day. ECZEMA GENITALIUM—ECZEMA OF THE GENITAL ORGANS, ACUTE. Take of Antimonial wine................... 2 drachms. Spirit of nitrous ether.............. 3 ounces. Solution of acetate of ammonium.... 3 ounces. Mix. Dose : Two teaspoonfuls in water every three hours. ECZEMA GENITALIUM—ECZEMA OF THE GENITAL ORGANS, CHRONIC. Take of Copaiba........................... 40 grains. Venice turpentine.................. 5 grains. Extract of belladonna.............. 3 grains. Mix and divide into twenty pills. Dose : One pill three to four times a day. ECZEMA GENITALIUM—ECZEMA OF THE GENITAL ORGANS, CHRONIC. Take of Chanlmoogra oil................... 1 ounce. Dose: Ten to thirty drops in milk three to four times a day. ECZEMA VULVAE VEL VAGINAE—ECZEMA OF THE VULVA OR VAGINA. Take of Lupulin.......................... 50 grains. Camphor......................... 2 scruples. Mix and divide into ten suppositories. Dose : Insert one in the vagina when necessary to quiet the system and relieve the itching. FORMULARY to second edition. 831 ECZEMA ANI—ECZEMA OF THE ANUS. Take of Fluid extract of witch-hazel......... 2 ounces. Glycerin.......................... 2 ounces. Mix. Dose: From one-half to one teaspoonful night and morn- ing. Rectal injections of the same combination can be made with advantage once or twice a day. ECZEMA ANI—ECZEMA OF THE ANUS. Take of Mercury with chalk................ 12 grains. Divide into four powders. Dose : Take in divided doses during twenty-four hours and follow with a saline. ECZEMA SCROTI—ECZEMA OF THE SCROTUM. Take of Sulphide of calcium................ 10 grains. Extract of belladonna............... 3 grains. Arsenious acid..................... 1 grain. Mix and divide into twenty pills. Dose: One pill three times a day. ECZEMA CRURUM—ECZEMA OF THE LEGS. Take of Fluid extract of witch-hazel......... 3 ounces. Dose: From ten drops to a teaspoonful in water three times a day. ECZEMA MANUUM ET PEDUM—ECZEMA OF THE HANDS AND FEET. Take of Protiodide of mercury.............. 5 grains. Extract of ignatia.................. 2 grains. Extract of dandelion............... 20 grains. Mix and divide into twenty pills. Dose: One pill three to four times a day. EPITHELIOMA—EPITHELIAL CANCER—SARCOMA—CARCINOMA. Take of Extract of cannabis indica........... 5 grains. Extract of nux vomica.............. 5 grains. Sulphide of arsenic................. 2 grains. Sulphate of morphine............... 2 grains. Mix and divide into twenty pills. Dose: One pill three to four times a day. EPITHELIOMA—EPITHELIAL CANCER—SARCOMA—CARCINOMA. Take of Hydrochlorate of cocaine............ 5 grains. Sulphate of atropine................ \ grain. Extract of gentian.................. 40 grains. Mix and divide into forty pills. Dose : One pill three to four times a day. 832 DISEASES OF THE SKIN. EPITHELIOMA—EPITHELIAL CANCER—SARCOMA—CARCINOMA. Take of Hydrochlorate of cocaine............ 4 grains. Citrate of caffeine.................. 1 drachm. Simple sirup....................... 4 ounces. Mix. Dose: One teaspoonful in water every two or three hours, until relieved of pain. EPITHELIOMA—EPITHELIAL CANCER—SARCOMA—CARCINOMA. Take of Bromhydrate of cocaine............. 4 grains. Sulphate of morphine............... 1 grain. Orange-flower water................ 1 ounce. Mix. Dose: Ten to fifteen drops, to relieve pain, every three to four hours. ERYSIPELAS. Take of Salol............................. 1 drachm. Sulphate of quinine................ 24 grains. Mix and divide into twelve capsules. Dose: One capsule every two or three hours. ERYSIPELAS. Take of Tincture of belladonna.............. 1 drachm. Tincture of aconite-root............. 1 drachm. Mix. Dose: From four to five drops in water every two or three hours. ERYSIPELAS. Take of Tincture of chloride of iron......... 3 ounces. Sulphate of quinine................ 2£ drachms. Dose : From one half to one teaspoonful in a wineglassful of water every three hours. ERYSIPELAS. Take of Sulphate of quinine................ 1 drachm. Extract of belladonna............... 3 grains. Oil of theobroma, sufficient quantity. Mix and divide into twelve suppositories. Dose: Insert one in the bowel every two or three hours. ERYSIPELAS. Take of Extract of belladonna.............. 2 grains. Extract of stramonium.............. 2 grains. Sulphate of quinine................ 40 grains. Mix and divide into twenty pills. Dose : One pill every two or three hours. FORMULARY TO SECOND EDITION. 833 ERYSIPELAS. Take of Antipyrine........................ 1 drachm. Sulphate of quinine................ 40 grains. Mix and divide into twelve powders. Dose : One powder three to four times a day. ERYTHEMA. Take of Subnitrate of bismuth.............. 1 drachm. Creasote.......................... 5 drops. Sirup of acacia..................... 2 ounces. Peppermint-water.................. 2 ounces. Mix. Dose : One to two teaspoonfuls three to four times a day. ERYTHEMA. Take of Infusion of digitalis................ 2 ounces. Spirit of nitrous ether.............. 2 ounces. Mix. Dose: From one to two teaspoonfuls in water every three hours. ERYTHEMA. Take of Phosphate of soda.................. 2 drachms. Diastasic extract of malt............ 3 ounces. Mix. Dose : One to two teaspoonfuls in milk three to four times a day. ERYTHEMA. Take of Tincture of gelsemium.............. 1 drachm. Tincture of belladonna.............. £ drachm. Mix. Dose : (Adult) four drops in water every three hours. FURUNCULUS—BOIL. Take of Oxide of silver..................... 4 grains. Extract of belladonna............... 2 grains. Sulphate of quinine................. 40 grains. Mix and divide into twenty pills. Dose : One pill three times a day. FURUNCULUS—BOIL. Take of Oleoresin of capsicum.............. 3 grains. Extract of ignatia.................. 2 grains. Pyrophosphate of iron............. 1 drachm. Mix and divide into thirty pills. Dose : One pill three or four times a day. 53 834 DISEASES OF THE SKIN. FURUNCULUS—BOIL. Take of Fluid extract of witch-hazel......... \ ounce. Diastasic extract of malt............' 4 ounces. Mix. Dose : From one half to one tablespoonful in water three or four times a day. FURUNCULUS—BOIL. Take of Tincture of prickly-ash bark......... 6 ounces. Tincture of nux vomica............. \ drachm. Tincture of capsicum............... 1 draclim. Mix. Dose : Two teaspoonfuls in water three times a day. FURUNCULUS—BOIL. Take of Sulphate of cinchonidine............ 16 grains. Extract of prickly-ash bark.......... 16 grains. Extract of burdock-root.............16 grains. Mix and divide into sixteen pills. Dose : Two pills three times daily. HERPES. Take of Aloin............................. 2 grains. Extract of belladonna............... 2 grains. Extract of ignatia.................. 2 grains. Powdered poke-root................ 20 grains. Mix and divide into twenty pills. Dose: One pill three times a day. HERPES. Take of Fluid extract of golden seal......... 1 ounce. Wine of coca...................... 3 ounces. Mix. Dose: From one to two teaspoonfuls in water three to four times a day. HERPES. Take of Ferrocyanide of iron................ 16 grains. Extract of coca.................... 16 grains. Extract of nux vomica.............. 2 grains. ». Mix and divide into sixteen pills. Dose: One pill three times a day. HERPES. Take of Pure pepsin....................... 1 drachm. Subnitrate of bismuth..........3... 1 drachm. Oil of cinnamon...........„....... 5 drops. Mix and divide into twelve powders. Dose : One powder after each meal. FORMULARY TO SECOND EDITION. 835 HERPES ZOSTER—SHINGLES. Take of Sulphate of atropine................ -fa grain. Sulphate of morphine............... | grain. Mix. Dose : Inject hypodermically at once, for the relief of pain, into the subcutaneous cellular or muscular tissue. HERPES ZOSTER—SHINGLES. Take of Compound ipecacuanha powder...... 24 grains. Sulphate of quinine................ 24 grains. Mix and divide into twelve capsules. Dose : One capsule every two or three hours until relieved of pain. HERPES ZOSTER—SHINGLES. Take of Sirup of lactucarium............... 2 ounces. Sirup of lupulin................... 2 ounces. Sulphate of morphine.............. 1 grain. Fluid extract cannabis indica........ 1 drachm. Mix. Dose : Two teaspoonfuls in water every hour or two until re- lieved of pain. HYPERIDROSIS—EXCESSIVE PERSPIRATION. Take of Hydrochlorate of hydrastine......... 1 grain. Protocarbonate of iron.............. 40 grains. Arsenious acid..................... 1 grain. Mix and divide into twenty pills. Dose : One pill three times a day. HYPERIDROSIS—EXCESSIVE PERSPIRATION. Take of Agaricin.........................". 1 grain. Sulphate of cinchonidine............ 50 grains. Mix and divide into twenty-four pills. Dose : One pill three to four times a day. HYPERIDROSIS—EXCESSIVE PERSPIRATION. Take of Aromatic sulphuric acid............ 4 drachms. Tincture of nux vomica............. 1 drachm. Compound sirup of sarsaparilla...... 6 ounces. Mix. Dose : Two teaspoonfuls in water three times a day. ICHTHYOSIS. Take of Cod-liver oil....................... 4 ounces. Lime-water........................ 4 ounces. Aromatic sirup.................... 4 ounces. Mix and make into an emulsion. Dose : From one half to one tablespoonful three times a day. 836 DISEASES OF THE SKIN. LEPROSY. Take of Fluid extract of hoang-nan.......... 2 drachms. Tincture of nux vomica............. 2 drachms. Solution of arsenite of potassium..... 2 drachms. Mix. Dose: Fifteen to thirty drops in water three times a day. LEPROSY. Take of Guaiacol.......................... 3 drachms. Port or sherry wine................. 1 Pmt- Mix. Dose: One tablespoonful three times a day. LUPUS ERYTHEMATOSUS. Take of Sublimed sulphur.................. 1 drachm. Cream of tartar.................... 12 grains. Aloin........................•' • • • 1 g^in. Mix and divide into twelve capsules. Dose: One capsule three or four times a day. LUPUS VULGARIS. Take of Iodide of iron..................... 40 grains. Arsenious acid..................... 1 gram. Mix and divide into twenty pills. Dose: One pill three times a day. LUPUS VULGARIS. Take of Corrosive chloride of mercury........ 2 grains. Tincture of gold-thread............. 5 ounces. Mix. Dose: One to two teaspoonfuls in water three times a day. LUPUS VULGARIS. Take of Creasote.......................... 4 drops. Glycerite of pepsin................. 3 ounces. Mix. Dose : A teaspoonful three times a day. LUPUS VULGARIS. Take of Iodide of arsenic................... 1 grain. Carbonate of iron.................. 24 grains. Extract of belladonna.............. 1 grain. Mix and divide into twelve pills. Dose : One pill three times a day. PARESTHESIA OR PRURITUS—ITCHING OF THE SKIN. Take of Cod-liver oil....................... 3 ounces. Dose : Inject hypodermically from one to two teaspoonfuls into the subcutaneous cellular or muscular tissue every day or two. FORMULARY TO SECOND EDITION. 837 PARESTHESIA OR PRURITUS—ITCHING OF THE SKIN. Take of Solution of arseniate of sodium...... 2 drachms. Dose: Inject hypodermically from five to twenty minims into the skin or muscular tissue every day or two. PARESTHESIA OR PRURITUS—ITCHING OF THE SKIN. Take of Pure carbolic acid.................. 4 grains. Distilled wrater..................... 4/ ounce. Mix. Dose: Inject hypodermically from fifteen to thirty minims (gr. £ to £) when necessary. PARESTHESIA OR PRURITUS—ITCHING OF THE SKIN. Take of Phosphide of zinc.................. 1 grain. Extract of nux vomica.............. 2£ grains. Mix and make into ten pills. Dose : One pill every three or four hours. PARESTHESIA OR PRURITUS—ITCHING OF THE SKIN. Take of Acetanilid.........................100 grains. Lupuline.......................=. 100 grains. Mix and divide into twenty powders or capsules. Dose: One every two or three hours. PEMPHIGUS. Take of Arseniate of sodium................ 1 grain. Pyrophosphate of iron.............. 40 grains. Mix and divide into twenty pills. Dose : One pill three times a day. PEMPHIGUS. Take of Sulphate of quinine................ 1 drachm. Extract of opium................... 6 grains. Extract of belladonna............... 4 grains. Mix and make into twelve suppositories. Dose : Insert one into the bowel three or four times a day when the eruption is attended with much suffering. PSORIASIS. Take of Solution of arsenite of potassium..... 1 drachm. Tincture of nux vomica............. 2 drachms. Mix. Dose: From fifteen to twenty drops in water three times a day. 838 DISEASES OF THE SKIN. PSORIASIS. Take of Sublimed sulphur...........-.......100 grains. Arsenious acid..................... 1 grain. Mix and divide into twenty capsules. Dose: A capsule after meals. PURPURA. Take of Aromatic sulphuric acid............. 2 drachms. Fluid extract of witch-hazel......... 2 ounces. Fluid extract of ergot.............. 2 ounces. Mix. Dose : Two teaspoonfuls in water every two or three hours. PURPURA. Take of Fluid extract of ergot.............. 1 ounce. Sulphurous acid................... 1 ounce. Sirup of orange.................... 1 ounce. Mix. Dose: Two teaspoonfuls in water three or four times a day. PURPURA. Take of Fluid extract of geranium........... 2 ounces. Fluid extract of witch-hazel......... 2 ounces. Glycerin.......................... 2 ounces. Mix. Dose : Two teaspoonfuls in water three or four times a day. ROSACEA—ACNE ROSACEA. Take of Oxide of zinc...................... 3 grains. Extract of belladonna............... 1 grain. Lactate of iron..................... 24 grains. Mix and divide into twelve pills. Dose : One pill three times a day. ROSACEA—ACNE ROSACEA. Take of Fluid extract of hydrastis........... 2 ounces. Glycerin.......................... 2 ounces. Mix. Dose : Two teaspoonfuls in water three times a day. ROSACEA—ACNE ROSACEA. Take of Sublimed sulphur..................100 grains. Diastasic extract of malt............ 10 ounces. Mix. Dose : One tablespoonful three times a day. RUBEOLA—MEASLES. Take of Salol............................. 1 drachm. Subnitrate of bismuth.............. 1 drachm. Mix and divide into twelve powders or capsules. Dose : One every three hours. FORMULARY TO SECOND EDITION. 839 RUBEOLA—MEASLES. Take of Tartar emetic...................... i grain. Chlorate of potassium............... 1 draclim. Sweet spirit of nitre................ 5 ounces. Mix. Dose: One to two teaspoonfuls in water every two or three hours. RUBEOLA—MEASLES. Take of Chloride of ammonium............. 2 drachms. Sirup of lactucarium............... 2 ounces. Glycerin.......................... 2 ounces. Mix. Dose : One or two teaspoonfuls every two or three hours. SCARLATINA—SCARLET FEVER. Take of Fluid extract of pilocarpus.......... \ ounce. Mixture of citrate of potassium...... 2 ounces. Sirup of orange.................... l£ ounce. Mix. Dose : One or two teaspoonfuls every three or four hours. SCARLATINA—SCARLET FEVER. Take of Infusion of digitalis................ 2 ounces. Mixture of citrate of potassium...... 2 ounces. Mix. Dose : One teaspoonful every two or three hours. SCARLATINA—SCARLET FEVER. Take of Cream of tartar.................... 2 drachms. Sweet spirit of nitre................ -| ounce. Infusion of digitalis................. £ ounce. Mix. Dose : One teaspoonful in water every three or four hours. SCROFULODERMA. Take of Cod-liver oil....................... 5 ounces. Cream............................ 5 ounces. Oil of wintergreen.................. 10 drops. Mix and make into an emulsion. Dose: From one teaspoonful to one tablespoonful after meals. SCROFULODERMA. Take of Fluid extract of coto-bark........... 2 drachms. Fluid extract of witch-hazel......... \ ounce. Cinnamon water................... 10 ounces. Mix. Dose : One dessertspoonful three times a day. 840 DISEASES OF THE SKIN. SCROFULODERMA. Take of Diastasic extract of malt............ 5 ounces. Precipitated sulphur................ 3 drachms. Mix. Dose : One to two teaspoonfuls after meals. SEBORRHCEA SICCA—DRY OR SCALY SEBORRHCEA. Take of Tincture of prickly-ash bark......... 4 ounces. Tincture of nux vomica.............200 drops. Tincture of cardamom.............. 1 ounce. Mix. Dose : Two teaspoonfuls in water three times a day. SEBORRHCEA SICCA—DRY OR SCALY SEBORRHCEA. Take of Tincture of collinsonia.............. 1 ounce. Glycerin .. •....................... 4 ounces. Mix. Dose : One to two teaspoonfuls three times a day. SEBORRHCEA OLEOSA—OILY SEBORRHOEA. Take of Oxide of zinc...................... 2 grains. Lactate of iron..................... 20 grains. Aloin............................ 1 grain. Mix and divide into ten pills. Dose: One pill three times a day. SEBORRHCEA OLEOSA—OILY SEBORRHCEA. Take of Sulphide of arsenic................. 1 grain. Extract of belladonna............... 1 grain. Citrate of iron..................... 24 grains. Mix and divide into twelve pills. Dose: One pill three times a day. SYCOSIS—INFLAMMATION OF THE HAIR-FOLLICLES OF THE BEARD. Take of Hypophosphite of lime.............. 20 grains. Arseniate of iron................... 1 grain. Extract of cascara sagrada.......... 20 grains. Mix and divide into twenty pills. Dose : One pill three times a day. SYCOSIS—INFLAMMATION OF THE HAIR-FOLLICLES OF THE BEARD. Take of Iodoform......................... 3 grains. Sulphate of quinine................ 24 grains. Mix and divide into twelve pills. Dose : One pill three or four times a day. FORMULARY TO SECOND EDITION. 841 SYPHILIS. Take of Iodide of lithium.................. 1 drachm. Compound sirup of sarsaparilla...... 5 ounces. Mix. Dose: A half to a tablespoonful three or four times a day. SYPHILIS. Take of Creasote........................... 10 drops. Iodide of ethyl..................... 1 ounce. Mix. Dose : For inhalation, add a few drops on the handkerchief and inhale five or six times a day. SYPHILIS. Take of Iodide of potassium................ 1£ drachm. Fluid extract of cimicifnga.......... 14, drachm. Fluid extract of manaca............ 1-j drachm. Compound sirup of sarsaparilla...... 4 ounces. Mix. Dose : One tablespoonful in water four times a day. SYPHILIS. Take of Iodoform......................... 1 drachm. Sulphuric ether.................... £ ounce. Oil of turpentine................... i ounce. Mix. Dose: From three to ten drops by inhalation four or five times a day. SYPHILIS. Take of Cod-liver'oil....................... 4 ounces. Brandy........................... 4 ounces. Compound sirup of hypophosphites with iron........................ 4 ounces. Oil of peppermint.................. 10 drops. Mix and make into an emulsion. Dose : A tablespoonful three times a day. SYPHILIS. Take of Benzoate of mercury............... 4 grains. Chloride of sodium................. ■£ grain. Distilled water..................... 14; ounce. Mix. Dose : (^l 15 = gr. fa). Inject hypodermically fifteen min- ims into the subcutaneous cellular or muscular tissue every two or three days. SYPHILIS. Take of Corrosive chloride of mercury....... 5 grains. Chloride of sodium................. 10 grains. Distilled water..................... 1 ounce. Mix. Dose : (n 10 to 20 = gr. fa to £). Inject ten to twenty min- ims hypodermically every two or three days. 842 DISEASES OF THE SKIN. SYPHILIS—INFANTILE. Take of Sirup of iodide of iron.............. 1 ounce. Diastasic extract of malt............ 2 ounces. Mix. Dose : From one half to a teaspoonful in milk three times a day. SYPHILIS—INFANTILE. Take of Sirup of hydriodic acid............. 2 ounces. Dose: From five to twenty drops in water or milk three times a day. TUBERCULOSIS OF SKIN. Take of Creasote.......................... \ drachm. Sirup of iodide of iron.............. 3 ounces. Glycerin.......................... 3 ounces. Mix. Dose: From a half to a teaspoonful in water three times a day. TUBERCULOSIS OF SKIN. Take of Cod-liver oil....................... 4 ounces. Oil of eucalyptus................... 10 drops. Creasote.......................... 10 drops. Compound spirit of ether........... 1 ounce. Mix and make into an emulsion. Dose: Two teaspoonfuls three times a day. TUBERCULOSIS OF SKIN. Take of Cod-liver oil....................... 4 ounces. Glycerin.......................... 4 ounces. Sirup of hypophosphites............. 4 ounces. Oil of cinnamon................... 10 drops. Mix and make into an emulsion. Dose: A tablespoonful three times a day. ULCUS—ULCER. Take of Fluid extract of ergot............... 2 ounces. Fluid extract of witch-hazel......... 2 ounces. Fluid extract of geranium........... 2 ounces. Mix. Dose: One to two teaspoonfuls in water three or four times a day. ULCUS—ULCER. Take of Tartar emetic...................... 1 grain- Extract of cascara sagrada.......... 40 grains. Extract of belladonna............... 2 grains. Mix and divide into twenty pills. Dose: One pill three times a day. FORMULARY TO SECOND EDITION. 843 ULCUS—ULCER. Take of Tincture of phytolacca.............. 1 drachm. Tincture of bryonia................. 1 drachm. Tincture of nux vomica............. 1 drachm. Mix. Dose: From three to twenty drops in water three or four times a day. URTICARIA, ACUTE. Take of Creasote.......................... 3 drops. Glycerite of pepsin................. 2 ounces. Peppermint-water................. 2 ounces. Mix. Dose : Two teaspoonfuls before meals. URTICARIA, ACUTE. Take of Lime-water........................ 4 ounces. Soda-water........................ 4 ounces. Mix. Dose: One or two tablespoonfuls every hour or two until relieved. URTICARIA, CHRONIC Take of Fluid extract of coto-bark........... 1 ounce. Fluid extract of witch-hazel......... 1 ounce. Mix. Dose : One half to one teaspoonful in water three or four times a day. URTICARIA, CHRONIC Take of Chloride of gold and sodium......... 1 grain. Extract of gentian................. 20 grains. Mix and divide into twenty pills. Dose: One pill before meals. URTICARIA, CHRONIC Take of Solution of nitroglycerin (alcoholic, 1 to 100)...................■....... Dose : From one to five drops in a little water three or four times a day. VARIOLA—SMALL-POX. Take of Acetanilid......................... 2 drachms. Sweet spirit of nitre................ 3 ounces. Mix. Dose : One to two teaspoonfuls in water every two or three hours. VARIOLA—SMALL-POX. Take of Salol............................. 1 drachm. Lupuline......................... 12 grains. Sulphate of quinine................ 24 grains. Mix and divide into twelve capsules. Dose : One capsule every three or four hours. 844 DISEASES OF THE SKIN. VERRUCA—WART. Take of Tartrate of iron and potassium....... 40 grains. Arsenious acid..................... 1 grain. Mix and flivide into twenty pills. Dose: One pill three times a day. VERRUCA—WART. Take of Fluid extract of thuja............... 1 ounce. Dose : Five to twenty drops in water three times a day. The same remedy may be applied locally. VITILIGO—LEUCODERMA. Take of Sulphide of arsenic................. 1 grain. Lactate of iron..................... 30 grains. Mix and divide into fifteen pills. Dose: One pill three times a day. EXTERNAL. ACNE. Take of Hydrochlorate of hydrastine......... 5 grains. Carbonate of zinc.................. 1 drachm. Ointment of rose-water............. 1 ounce. Mix. ACNE. Take of Hydrochlorate of hydrastine......... 6 grains. Boric-acid ointment................ 1 ounce. Mix. ACNE. Take of Beta-naphthol..................... 10 grains. Calomel ointment.................. 1 ounce. Mix. ACNE. Take of Oil of eucalyptus................... 5 drops. Carbonate of zinc.................. 1 drachm. Iodide of sulphur ointment.......... \ ounce. Mix. ACNE. Take of Europhen........................ \ drachm. Ointment of oxide of zinc........... 1 ounce. Mix. FORMULARY TO SECOND EDITION. 845 ACNE. Take of Aristol............................ \ drachm. Ointment of rose-water............. £ ounce. Ointment of oxide of zinc........... 4; ounce. Mix. ACNE. Take of Precipitated sulphur................ \ drachm. Ointment of oxide of zinc........... \ ounce. Salicylated camphor ointment........ \ ounce. Mix. ALOPECIA. Take of Aromatic spirit of ammonia......... \ ounce. Tincture of capsicum............... \ ounce. Spirit of lavender.................. 1 ounce. Tincture of nux vomica............. \ ounce. Camphor liniment.................. 24, ounces. Mix. Apply with friction to the scalp once or twice a day. ALOPECIA. Take of Fluid extract of pilocarpine......... \ ounce. Soap liniment..................... \ ounce. Cologne-water..................... 2 ounces. Mix. Apply with friction. ALOPECIA. Take of Brandy........................... 4 ounces. Tincture of nux vomica............. 4, ounce. Tincture of capsicum............... 4, ounce. Mix. ALOPECIA. Take of Tincture of saponaria............... 2 ounces. Tincture of capsicum............... \ ounce. Spirit of rosemary.................. 14, ounce. Cologne-water..................... 1 ounce. Mix. ALOPECIA CIRCUMSCRIPTA—ALOPECIA AREATA. Take of Carbolic acid...................... 6 grains. Cantharides ointment............... 1 ounce. Mix. ALOPECIA CIRCUMSCRIPTA—ALOPECIA AREATA. Take of Thymol.......................... 5 grains. Extract of nux vomica.............. \ drachm. Cantharides ointment............... 1 ounce. Mix. 846 DISEASES OF THE SKIN. BROMIDROSIS—ODOROUS SWEAT. Take of Salol............................. £ drachm. Powdered alum.................... 1 drachm. Subnitrate of bismuth.............. 1 drachm. Oxide-of-zinc ointment............. 1 ounce. Mix. BROMIDROSIS—ODOROUS SWEAT. Take of Powdered alum.................... £ ounce. Glycerin.......................... 2 ounces. Distilled witch-hazel................ 4 ounces. Mix. BROMIDROSIS—ODOROUS SWEAT. Take of Lanolin.......................... £ ounce. Boric-acid ointment................ £ ounce. Mix. CARBUNCULUS—CARBUNCLE. Take of Belladonna ointment............... 1 drachm. Lanolin.......................... £ ounce. Cerate of subacetate of lead.......... 3 drachms. Cocaine hydrochlorate.............. 5 grains. Zinc ointment...........,.......... | ounce. Mix. CARBUNCULUS—CARBUNCLE. Take of Powdered poke-root................ 1 drachm. Compound resin ointment........... 1 ounce. Mix. CARBUNCULUS—CARBUNCLE. Take of Aristol............................ 1 drachm. Camphor.......................... 20 grains. Carbolic acid...................... 15 grains. Subnitrate of bismuth.............. 2 drachms. Rose-water ointment................ 1 ounce. . Mix. CHANCROID. Take of Hydrochlorate of cocaine............ 5 grains. Carbonate of zinc.................. 1 drachm. White precipitate................... 10 grains. Atropine ointment................. 4; ounce. Mix. CHANCROID. Take of Europhen......................... £ ounce. Carbonate of zinc.................. \ ounce. Mix. FORMULARY TO SECOND EDITION. 847 CHANCROID. Take of Subgallate of bismuth............... 1 ounce. CHLOASMA. Take of Ointment of oleate of mercury (five to ten per cent.).................... 1 ounce. Oil of eucalyptus................... 10 drops. Mix. CHLOASMA. Take of Boric acid......................... 2 drachms. Distilled witch-hazel................ 2 ounces. Cologne-water..................... 2 ounces. Mix. CHLOASMA. Take of Iodol............................. 1 drachm. White precipitate ointment.......... 1 ounce. Mix. CICATRICES—SCARS. Take of Red iodide of mercury ointment...... -|- ounce. Lanolin........................... j. ounce. Mix. CICATRICES—SCARS. Take of Green soap........................ 1 ounce. Compound iodine ointment.......... 1 ounce. Mix. CLAVUS—CORN. Take of Sulphuric ether.................... 1 ounce. Extract of Indian hemp............. \ drachm. Salol............................. 1 drachm. Mix. COMBUSTIO—BURN—SCALD. Take of Prepared lime..................... 1 drachm. Carbolic acid...................... \ ounce. Olive-oil.......................... 5 ounces. Lime-water........................ 5 ounces. Mix. COMBUSTLO—BURN—SCALD. Take of Carbonate of lead.................. 2 drachms. Creasote.......................... 10 drops. Carbonate of zinc................... 2 drachms. Rose-water ointment................ 1 ounce. Mix. 84S DISEASES OF THE SKIN. COMBUSTIO—BURN—SCALD. Take of Fluid extract of grindelia........... \ ounce. Creoline.......................... 2 drachms. Water............................ 5 ounces. Mix. COMBUSTIO—BURN—SCALD. Take of Subnitrate of bismuth.............. 2 drachms. Powdered arrow-root............... £ ounce. Sulphate of morphine.............. 3 grains. Lanolin........................... 4_ ounce. Rose-water ointment................ 1 ounce. Mix. COMBUSTIO—BURN—SCALD. Take of Cocaine........................... 15 grains. Lanolin.......................... 1 ounce. Bicarbonate of sodium.............. 2 drachms. Olive-oil.......................... 6 ounces. Mix. COMBUSTIO—BURN—SCALD. Take of Cocaine........................... 10 grains. Lanolin........................... 1 ounce. Carbonate of lead.................. 2 drachms. Olive-oil.......................... 5 ounces. Mix. CONDYLOMATA. Take of Iodol............................. 2 drachms. Subnitrate of bismuth.............. 3 drachms. Mix. CONDYLOMATA. Take of Aristol............................ 2 drachms. Calomel........................... | drachm. Mix. COMEDO—SEBACEOUS PLUGS OR GRUBS. Take of Beta-naphthol..................... 20 grains. Turpentine ointment............... 1 ounce. Mix. COMEDO—SEBACEOUS PLUGS OR GRUBS. Take of Oil of cade........................ 1 drachm. Iodide of sulphur ointment.......... i ounce. Mix. FORMULARY TO SECOND EDITION. 849 CONGELATIO—FROST-BITE. Take of Sublimed sulphur.................. £ drachm. Carbonate of zinc.................. 2 drachms. Extract of Indian hemp............. £ drachm. Balsam-of-Peru ointment............ 1 ounce. Mix. CONGELATIO—FROST-BITE. Take of Solution of subacetate of lead........ 1 ounce. Tincture of opium................. 1 ounce. Distilled witch-hazel................ 2 ounces. Mix. CONGELATIO—FROST-BITE. Take of Hydrochlorate of cocaine............ 5 grains. Sulphate of atropine................ 1 grain. Benzoated oxide-of-zinc ointment.... £ ounce. Mix. DERMATALGIA. Take of Hydrochlorate of cocaine............ 12 grains. Sulphate of atropine........... .... 1 grain. Carbolic acid...................... 5 drops. Oil of chamomile................... 10 drops. Oxide-of-zinc ointment............. 1 ounce. Mix. DERMATALGIA. Take of Tincture of belladonna............. 1£ drachm. Tincture of aconite................. 1£ drachm. Menthol.......................... £ drachm. Alcohol.......................... 2 ounces. Glycerin.......................... £ ounce. Rose-water........................ £ ounce. Mix. DERMATALGIA. Take of Hydrochlorate of cocaine............ 10 grains. Carbonate of lead.................. 1 drachm. Powdered arrow-root............... 1 drachm. Oil of eucalyptus................... 4 drops. Oxide-of-zinc ointment............. 1 ounce. Mix. ECZEMA, ACUTE—TETTER. Take of Creolin........................... 10 drops. Carbonate of lead.................. 2 drachms. Powdered impure carbonate of zinc... 2 drachms. Ointment of rose-water............. 1£ ounce. Mix. 54 ^50 DISEASES OF THE SKIN. ECZEMA, ACUTE—TETTER. Take of Salol............................. 2 drachms. Powdered oleate of zinc............. 2 drachms. Subnitrate of bismuth.............. 2 ounces. Mix. ECZEMA, ACUTE—TETTER. Take of Creasote.......................... 10 drops. Subnitrate of bismuth.............. 1 ounce. Distilled witch-hazel................ 4 ounces. Lime-water........................ 4 ounces. Mix. ECZEMA, ACUTE—TETTER. Take of Boric acid......................... 2 drachms. Powdered impure carbonate of zinc... 2 ounces. Mix. ECZEMA, CHRONIC—TETTER. Take of Beta-naphthol..................... 20 grains. Camphor.......................... 10 grains. Menthol.......................... 5 grains. Extract of belladonna............... 20 grains. Ointment of oxide of zinc........... 1 ounce. Mix. ECZEMA, CHRONIC—TETTER. Take of Salicylic acid...................... 30 grains. Aristol............................ 1 drachm. Powdered starch................... 1 drachm. Ointment of oxide of zinc........... 1 ounce. Mix. ECZEMA, CHRONIC—TETTER. Take of Salol............................. 2 drachms. Oil of eucalyptus................... 20 drops. Europhen......................... 1 drachm. Ointment of oxide of zinc........... 1 ounce. Mix. ECZEMA, CHRONIC—TETTER. Take of Balsam of Peru.................... 1 drachm. Menthol..........>................ 10 grains. Oil of cade........................ 1 drachm. Ointment of nitrate of mercury...... \ ounce. Ointment of rose-water............. % ounce Mix. " ECZEMA, CHRONIC—TETTER. Take of Cod-liver oil....................... 6 ounces. Oil of cade........................ 2 ounces. Mix. FORMULARY TO SECOND EDITION. 851 ECZEMA, INFANTILE, ACUTE. T)ake of Oil of chamomile................... 6 drops. Calomel.......................... 10 grains. Oil of eucalyptus................... 5 drops. Lanolin.......................... £ ounce. Zinc ointment..................... 4 ounce. Mix. ECZEMA, INFANTILE, ACUTE. Take of Hydrochlorate of cocaine............ 10 grains. Carbonate of zinc.................. 1 drachm. Beta-naphthol..................... 5 grains. Camphor.......................... 5 grains. Rose-water ointment................ 1 ounce. Mix. ECZEMA, INFANTILE, ACUTE. Take of Boric acid......................... £ drachm. Lanolin.......................... \ ounce. Creolin........................... 5 grains. Carbonate of zinc.................. 1 drachm. Powdered arrow-root............... 1 drachm. Mix. ECZEMA CAPITIS—ECZEMA OF THE HEAD. Take of Creasote.......................... 8 drops. Calomel........................... 10 grains. Camphor.......................... 10 grains. Ointment of oxide of zinc........... £ ounce. Olive-oil.......................... 3 ounces. Mix. ECZEMA AURIUM—ECZEMA OF THE 1?ARS. Take of Aristol............................ 20 grains. Ointment of nitrate of mercury...... 3 drachms. Creolin........................... 5 grains. Ointment of oxide of zinc........... 1 ounce. Mix. ECZEMA FACIEI ET COLLI—ECZEMA OF THE FACE AND NECK. Take of Aristol............................ £ drachm. Camphor.......................... 10 grains. Lanolin........................... £ ounce. Carbolic acid...................... 5 grains. Ointment of oxide of zinc........... £ ounce. Mix. 852 DISEASES OF THE SKIN. ECZEMA BARBE—ECZEMA OF THE BEARD. Take of Calomel...............^........... 10 grains. Beta-naphthol..................... 10 grains. Camphor......................... 10 grains. Carbonate of zinc.................. 1 drachm. Ointment of oxide of zinc........... 1 ounce. Mix. ECZEMA TARSI—ECZEMA OF THE EDGES OF THE EYELIDS. Take of Aristol or europhen................ 5 to 10 grains. Ointment of rose-water............. 4 drachms. Mix. ECZEMA NASI—ECZEMA OF THE NOSE. Take of Acetate of lead..................... 10 to 20 grains. Sulphate of morphine............... 5 grains. Menthol.......................... 10 grains. Creasote.......................... 10 drops. Powdered arrow-root............... 1 drachm. Ointment of oxide of zinc........... 1 ounce. Mix. ECZEMA LABIORUM—ECZEMA OF THE LIPS. Take of Camphor......................... 10 grains. Beta-naphthol..................... 10 grains. Oil of chamomile.................. 5 drops. Subnitrate of bismuth.............. 1 drachm. Ointment of oxide of zinc........... 1 ounce. Mix. ECZEMA. LINGUE—ECZEMA OF THE TONGUE. Take of Tincture of iodine.................. 2 drachms. Glycerin.......................... 3 drachms. Beta-naphthol..................... 5 grains. Mix. ECZEMA MAMMARUM—ECZEMA OF THE BREAST AND NIPPLE. Take of Camphor......................... 10 grains. Carbonate of zinc.................. 2 drachms. Sublimed sulphur.................. £ drachm. Oil of eucalyptus................... 5 drops. Creasote.......................... 10 drops. Ointment of rose-water............. t ounce. Lanolin........................... i ounce. Mix. 2 FORMULARY TO SECOND EDITION. 853 ECZEMA MAMMARUM—ECZEMA OF THE BREAST. Take of Powdered borax.................... 1 drachm. Powdered camphor................. 5 grains. Mix. Powdered oleate of zinc............. £ ounce. Powdered arrow-root............... \ ounce. ECZEMA UMBILICI—ECZEMA OF THE UMBILICUS. Take of Tannic acid....................... \ drachm. Extract of belladonna............... 20 grains. Hydrochlorate of cocaine............ 5 grains. Ointment of oxide of zinc........... 1 ounce. Mix. ECZEMA ARTICULORUM—ECZEMA OF THE FLEXOR SURFACES OF THE JOINTS. Take of Sublimed sulphur.................. \ drachm. Carbolic acid...................... 8 grains. Aristol............................ 20 grains. Ointment of oxide of zinc........... 1 ounce. Mix. ECZEMA GENITALIUM—ECZEMA OF THE GENITAL ORGANS. Take of Hydrochlorate of cocaine............ 10 grains. Carbonate of zinc................... 2 drachms. Menthol.......................... 10 grains. Sublimed sulphur.................. £ drachm. Ointment of rose-water............. 1 ounce. Mix. ECZEMA GENITALIUM—ECZEMA OF THE GENITAL ORGANS. Take of Solution of boro-glyceride (fifty per cent.)........................... 3 ounces. Distilled witch-hazel................ 3 ounces. Mix. ECZEMA SCROTI—ECZEMA OF THE SCROTUM. Take of Hydrochlorate of cocaine..... ,____ 10 grains. Powdered arrow-root............... 1 drachm. Cucumber ointment................ 1 ounce. Mix. S54 DISEASES OF THE SKIN. ECZEMA SCROTI ET ANI—ECZEMA OF THE SCROTUM AND ANUS. Take of Boric acid......................... £ drachm. Carbonate of zinc.................. 1 drachm. Salicylated camphor................ 20 grains. Ointment of oxide of zinc........... 1 ounce. Mix. ECZEMA ANI—ECZEMA OF THE ANUS. Take of Extract of belladonna.............. 2£ grains. Extract of opium................. 3 grains. Iodoform or aristol................. 30 grains. Oil of theobroma................... q- s. Mix and make into ten suppositories. Insert one into the bowel when necessary to relieve local suffering. ECZEMA LABIORUM—ECZEMA OF THE LABIA. Take of Calomel.......................... 10 grains. Benzoate of sodium................. 10 grains. Prepared suet..................... £ ounce. Ointment of oxide of zinc........... £ ounce. Mix. ECZEMA CRURUM—ECZEMA OF THE LEGS. Take of Ergotin........................... 1 drachm. Sublimed sulphur.................. £ drachm. Menthol.......................... 5 to 10 grains. Extract of belladonna............... 10 grains. Ointment of oxide of zinc........... 1 ounce. Mix. ECZEMA MANUUM ET PEDUM—ECZEMA OF THE HANDS AND FEET. Take of Salol............................. 1 drachm. Ointment of nitrate of mercury...... -| ounce. Lanolin.......................... 4 ounce. Mix. ECZEMA MANUUM ET PEDUM—ECZEMA OF THE HANDS AND FEET. Take of Aristol............................ £ to 2 drachms. Ointment of nitrate of mercury...... \ ounce. Beta-naphthol..................... 10 grains. Ointment of oxide of zinc........... \ ounce. Mix. FORMULARY TO SECOND EDITION. 8 EPITHELIOMA—EPITHELIAL CANCER. Take of Powdered chlorate of potassium...... 1 drachm. Sulphate of morphine.............. 4 grains. Sulphate of atropine................ 1 grain. Ergot ointment.................... 1 ounce. Mix. EPITHELIOMA—EPITHELIAL CANCER. Take of Hydrochlorate of cocaine............ 5 grains. Ointment of belladonna............. 1 ounce. Mix. EPITHELIOMA—EPITHELIAL CANCER. Take of Extract of conium.................. 1 drachm. Menthol.......................... 10 grains. Extract of belladonna.............. 10 grains. Ointment of oxide of zinc........... £ ounee. Lanolin.......................... £ ounce. Mix. ERYSIPELAS. Take of Hydrochlorate of cocaine............ 4 grains. Glycerole of lead................... 2 ounces. Distilled witch-hazel water.......... 2 ounces. Mix. ERYSIPELAS. Take of Carbonate of lead.................. 2 ounces. Creasote.......................... 10 drops. Olive-oil, sufficient quantity to make a very soft ointment Mix. ERYSIPELAS. Take of Tincture of iodine.................. £ drachm. Carbolic acid...................... £ drachm. Glycerin.......................... 4 ounces. Mix. ERYSIPELAS. Take of Oil of chamomile.................. 10 drops. Subnitrate of bismuth.............. 2 drachms. Ointment of benzoated oxide of zinc.. 1 ounce. Mix. ERYSIPELAS. Take of Carbonate of lead.................. 1 drachm. Resorcin ointment................. 1 ounce. Mix. 856 DISEASES OF THE SKIN. ERYSIPELAS. Take of Oxide of zinc ointment............. £ ounce. Carbonate of zinc.................. 1 drachm. Powdered starch................... 1 drachm. Witch-hazel ointment............... 1 ounce. Mix. ERYTHEMA. Take of Creasote.......................... 8 drops. Calomel........................... 10 grains. Carbonate of zinc.................. 1 drachm. Ointment of rose-water............. 1 ounce. Mix. ERYTHEMA. Take of Powdered starch................... 2 ounces. Subnitrate of bismuth.............. 1 ounce. Aristol............................ 30 grains. Mix. FURUNCULUS—BOIL. Take of Ergotine.......................... £ drachm. Hydrochlorate of cocaine............ 5 grains. Carbonate of lead.................. 1 drachm. Ointment of rose-water............. 1 ounce. Mix. FURUNCULUS—BOIL. Take of Menthol.......................... 10 grains. Hydrochlorate of cocaine........... 5 grains. Compound ointment of resin........ 1 ounce. Mix. HERPES. Take of Calomel........................... 3 drachms. Subnitrate of bismuth............... \ ounce. Powdered lycopodium............... 4 ounce. Mix. HERPES. Take of Tannic acid....................... 15 grains. Acetate of lead..................... 20 grains. Sulphate of atropine................. 1 grain. Powdered starch................... 1 drachm. Ointment of rose-water............. 1 ounce. Mix. HERPES ZOSTER—SHINGLES. Take of Salol............................. 10 grains. Carbonate of lead.................. 1 drachm. Menthol.......................... 15 grains. Ointment of rose-water............. l ounce. Mix. FORMULARY TO SECOND EDITION. 857 HERPES ZOSTER—SHINGLES. Take of Powdered oleate of zinc............. £ ounce. Powdered arrow-root............... £ ounce. Creasote.......................... 10 drops. Sulphate of morphine............... 2 grains. Mix. HYPERIDROSIS—INCREASED SECRETION OF SWEAT. Take of Aristol............................ £ ounce. Powdered impure carbonate of zinc... 4, ounce. Mix. HYPERIDROSIS—INCREASED SECRETION OF SWEAT. Take of Sulphate of copper................. 5 to 10 grains. Distilled witch-hazel water.......... 5 ounces. Mix. HYPERIDROSIS—INCREASED SECRETION OF SWEAT. Take of Tincture of quillaia................. 1 ounce. Hydrochlorate of cocaine............ 10 to 20 grains. Beta-naphthol..................... 10 to 20 grains. Fluid extract of geranium........... 4 ounces. Mix. ICHTHYOSIS. Take of Cod-liver oil....................... 6 ounces. Oil of eucalyptus................... 10 drops. Creasote.......................... 5 drops. Mix. LENTIGO—FRECKLE. Take of Lactic acid........................ £ ounce. Glycerin.......................... £ ounce. Rose-water........................ £ ounce. Mix. Useful also in other pigmentations of the skin. LENTIGO—FRECKLE. Take of Boric acid........................ 1 drachm. Hydrochlorate of cocaine............ 5 grains. Cologne-water..................... 2 ounces. Mix. LENTIGO—FRECKLE. Take of Corrosive sublimate................ 10 grains. Tincture of benzoin................ £ ounce. Glycerin.......................... 1 ounce. Rose-water........................ 5 ounces. Mix. 858 DISEASES OF THE SKIN. LUPUS ERYTHEMATOSUS. Take of Yellow oxide of mercury............ 10 grains. Salol............................. 10 grains. Ointment of oxide of zinc........... 1 ounce. Mix. LUPUS ERYTHEMATOSUS. Take of Europhen......................... 1 drachm. Lanolin........................... £ ounce. Ointment of oxide of zinc........... £ ounce. Mix. LUPUS VULGARIS. Take of Hydrochlorate of cocaine............ 20 grains. Carbolic acid...................... 2 drachms. Alcohol........................... 1 ounce. Mix. Apply over the surface with cotton or a camel's-hair brush every other day. Use after employing this solution a soothing oint- ment to the diseased skin. LUPUS VULGARIS. Take of Iodol............................. J drachm. Beta-naphthol..................... 15 grains. Ointment of oxide of zinc........... 1 ounce. Mix. MILIARIA—PRICKLY HEAT. Take of Sublimed sulphur.................. 30 grains. Camphor.......................... 10 grains. Carbonate of zinc.................. a ounce. Powdered arrow-root............... \ ounce. Mix. MILIARIA—PRICKLY HEAT. Take of Creasote.......................... 5 drops. Subnitrate of bismuth.............. a ounce. Distilled witch-hazel water.......... 4 ounces. Mix. PARESTHESIA OR PRURITUS. Take of Creasote.......................... 10 to 20 drops. Oil of peppermint.................. 10 to 20 drops. Glycerin.......................... 5 ounces. Mix. PARESTHESIA OR PRURITUS. Take of Carbolic acid...................... 5 to 10 grains. Menthol.......................... 10 to 20 grains. Ointment of oxide of zinc........... 1 ounce Mix. FORMULARY TO SECOND EDITION. 859 PARESTHESIA OR PRURITUS VAOTNE—ITCHING OF THE VAGINA. Take of Hydrochlorate of cocaine............ 10 grains. Carbolic acid...................... 5 to 10 grains. Lime-water........................ 4 ounces. Distilled witch-hazel water.......... 4 ounces. Mix. Apply within the vagina by means of absorbent cotton, or use as an injection. PARESTHESIA OR PRURITUS ANI—ITCHING OF THE ANUS. Take of Aristol............................ 20 grains. Monobromated camphor............ 30 grains. Lupuline......................... 30 grains. Oil of theobroma................... q. s. Mix and divide into twenty suppositories. Insert one into the rectum whenever troubled with itching of the anus. PARESTHESIA OR PRURITUS LABIORUM—ITCHING OF THE LABIA. Take of Boric acid........................ £ drachm. Aristol............................ 10 to 30 grains. Camphor.......................... 10 grains. Carbonate of zinc.................. 2 drachms. Creasote.......................... 10 drops. Ointment of oxide of zinc........... 1 ounce. Mix. PARESTHESIA OR PRURITUS SCROTI—ITCHING OF THE SCROTUM. Take of Cod-liver oil....................... 3 ounces. Extract of witch-hazel.............. 3 drachms. Chaulmoogra-oil................... 3 ounces. Mix. PEDICULOSIS—LOUSINESS. Take of Creolin........................... £ to 1 drachm. Lard or ointment of oxide of zinc.... 1 ounce. Mix. PEDICULOSIS—LOUSINESS. Take of Beta-naphthol..................... 1 drachm. Cologne-water..................... 4 to 6 ounces. Mix. 860 DISEASES OF THE SKIN. PEDICULOSIS—LOUSINESS. Take of Sublimed sulphur.................. 1 drachm. Stavesacre ointment................. 1 ounce. Mix. PEMPHIGUS. Take of Aristol............................ £ drachm. Creolin........................... 10 to 20 drops. Ointment of oxide of zinc........... 1 ounce. Mix. PEMPHIGUS. Take of Hydrochlorate of cocaine............ 10 grains. Subnitrate of bismuth.............. 2 drachms. Carbolic acid...................... 5 to 10 grains. Powdered arrow-root............... 1 drachm. Ointment of rose-water............. 1 ounce. Mix. PITYRIASIS RUBRA. Take of Creolin........................... 10 to 30 drops. Lime-water........................ 4 ounces. Olive-oil or glycerin................ 4 ounces. Mix. PRURIGO. Take of Sublimed sulphur.................. £ drachm. Hydrochlorate of cocaine............ 10 grains. Carbolic acid...................... 5 to 10 grains. Ointment of oxide of zinc........... 1 ounce. Mix. PSORIASIS. Take of Oil of juniper...................... 1 drachm. Ointment of nitrate of mercury....... 4, ounce. Ointment of turpentine............. £ ounce. Mix. PSORIASIS. Take of Antharobin.......,............... 1 drachm. Ointment of nitrate of mercury...... £ ounce. Ointment of oxide of zinc........... 1 ounce. Mix. PSORIASIS. Take of Salicylic acid...................... 1 drachm. Oil of cade........................ 1 drachm. Balsam of Peru.................... 2 drachms. Ointment of rose-water........... 1 ounce Mix. PSORIASIS. Take of Aristol........................... 1 to 2 drachms. Ointment of oxide of zinc.......... 1 ounce Mix. FORMULARY TO SECOND EDITION. 861 PURPURA. Take of Calomel.......................... 10 grains. Beta-naphthol..................... 10 grains. Ointment of oxide of zinc........... 1 ounce. Mix. PURPURA. Take of Oil of cade......................... 1 drachm. Sublimed sulphur.................. 4, drachm. Ointment of oxide of zinc........... 1 ounce. Mix. ROSACEA—ACNE ROSACEA. Take of Ergotine.......................... £ drachm. Ointment of subacetate of lead....... 1 ounce. Mix. ROSACEA—ACNE ROSACEA. Take of Antharobin....................... £ to 1 drachm. Creolin........................... 5 to 10 drops. Ointment of oxide of zinc........... 1 ounce. Mix. RUBEOLA—MEASLES. Take of Cod-liver oil....................... 6 ounces. Creasote.......................... 8 drops. Mix. RUBEOLA—MEASLES. Take of Cucumber ointment................ 2 ounces. Powdered starch................... 2 drachms. Ointment of rose-water............. 2 ounces. Mix. SCABIES—ITCH. Take of Beta-naphthol..................... 20 grains. Ointment of stavesacre.............. 1 ounce. Mix. SCABIES—ITCH. Take of Iodol............................. £ to 1 drachm. Sublimed sulphur.................. 1 drachm. Ointment of rose-water............. 1 ounce. Mix. SCABIES—ITCH. Take of Sublimed sulphur... .............. 1 drachm. Storax............................ 10 to 30 grains. Ointment of oxide of zinc........... 1 ounce. Mix. 862 DISEASES OF THE SKIN. SCARLATINA—SCARLET FEVER. Take of Prepared suet...................... 1 ounce. Camphor.......................... 5 grains. Ointment of rose-water............. 1 ounce. Mix. SCARLATINA—SCARLET FEVER. Take of Menthol.......................... 10 grains. Carbolic acid...................... 5 grains. Lime-water........................ 4 ounces. Olive-oil.......................... 4 ounces. Mix. SCROFULODERMA. Take of Iodosulphate of cinchonine......... £ draclim. Powdered oleate of zinc............. \ drachm. Powdered starch................... 1 drachm. Ointment of oxide of zinc........... 1 ounce. Mix. SCROFULODERMA. Take of Aristol............................ \ to 1 drachm. Calomel........................... 10 to 20 grains. Ointment of oxide of zinc........... 1 ounce. Mix. SEBORRHEA SICCA—DRY OR SCALY SEBORRHEA. Take of Tannic acid....................... 1 drachm. Glycerin.......................... 1 ounce. Balsam of Peru.................... 1 drachm. Oil of rose......................... 5 drops. Lanolin........................... 1 ounce. Mix. SEBORRHEA SICCA—DRY OR SCALY SEBORRHEA. Take of Borax............................. i drachm. Creolin........................... 10 to 20 drops. Cod-liver oil....................... 4 ounces. Mix. SEBORRHEA GENITALIUM—SEBORRHEA OF THE GENITAL ORGANS. Take of Boric acid......................... 1 drachm. Carbolic acid...................... 5 grains. Distilled witch-hazel water....... 4 ounces Mix. FORMULARY TO SECOND EDITION. 863 SEBORRHEA OLEOSA—OILY SEBORRHEA. Take of Hydrochlorate of cocaine............ 5 to 10 grains. Hydrochlorate of hydrastin.......... 3 grains. Rose-water :....................... 4 ounces. Mix. SEBORRHEA OLEOSA—OILY SEBORRHEA. Take of Salicylic acid...................... 2 drachms. Subnitrate of bismuth.............. 1 ounce. Powdered oleate of zinc............. 3 drachms. Mix. SEBORRHEA OLEOSA—OILY SEBORRHEA. Take of Creolin........................... 5 to 10 drops. Carbonate of zinc.................. 2 drachms. Oil of eucalyptus................... 5 drops. Ointment of rose-water.............. 1 ounce. Mix. SYCOSIS—INFLAMMATION OF THE IIAIR-FOLLICLES. Take of Sulphate of copper................. 10 to 30 grains. Boric acid......................... 1 drachm. Creasote.......................... 10 drops. Ointment of oxide of zinc........... 1 ounce. Mix. SYCOSIS—INFLAMMATION OF THE HAIR-FOLLICLES. Take of Powdered poke-root................ 1 drachm. Menthol.......................... 10 grains. Lanolin.......................... £ ounce. Ointment of oxide of zinc........... 4, ounce. Mix. SYPHILIS. Take of Iodosulphate of cinchonine......... 1 drachm. Oil of chamomile................... 10 drops. Lanolin.......................... \ ounce. Ointment of oxide of zinc........... £ ounce. Mix. SYPHILIS. Take of Iodoform......................... 1 drachm. Camphor.......................... 10 to-20 grains. Powdered starch................... 2 ounces. Mix. Use especially upon an ulcerated surface. .864 DISEASES OF THE SKIN. SYPHILIS. Take of Aristol........................... 1 drachm. Creasote.......................... 10 drops. Ointment of oxide of zinc........... 1 ounce. Mix. SYPHILIS. Take of Green soap........................ 1 ounce. Ointment of nitrate of mercury...... 1 ounce. Oil of eucalyptus................... £ drachm. Mix. For old syphilitic patches. SYPHILIS. Take of Ointment of oleate of mercury (ten per cent)....................... 1 ounce. Oil of cade........................ 2 drachms. Oil of cloves....................... 10 to 20 drops. Mix. SYPHILIS. Take of Calomel........................... 10 to 20 grains. Carbonate of zinc.................. 1 drachm. Creolin........................... 5 to 10 drops. Powdered arrow-root............... 1 drachm. Ointment of oxide of zinc........... 1 ounce. Mix. Serviceable especially in infantile syphilis. TINEA FAVOSA—FAVUS. Take of Ointment of oleate of mercury (twenty per cent.)....................... 1 ounce. Aristol............................ a to 1 drachm. Mix. * TINEA FAVOSA—FAVUS. Take of Calomel........................... 10 grains. Beta-naphthol..................... 10 grains. Ointment of oxide of zinc........... 1 ounce Mix. TINEA TONSURANS—RINGWORM OF THE SCALP. Take of Corrosive sublimate................. 10 to 15 grains. Spirit of thymol.................... i drachm. Cologne-water..................... 5 ounces. Mix. TINEA TONSURANS—RINGWORM OF THE SCALP. Take of Boric acid......................... 1 drachm. Creolin........................... 10 to 30 drops. Olive-oil.......................... 6 ounces# Mix. FORMULARY TO SECOND EDITION. 865 Mix. TINEA BARBE—BARBER'S ITCH. Take of Europhen......................... £ to 1 drachm. Ointment of oleate of mercury (ten to twenty per cent.)................. 1 ounce. Oil of eucalyptus.................. 10 drops. TINEA BARBE—BARBER S ITCH. Take of Solution of boro-glyceride (fifty per cent.)........................... 4 ounces. Carbonate of zinc.................. £ ounce. Creasote.......................... 10 drops. Mix. TINEA CIRCINATA—RINGWORM OF THE BODY. Take of White precipitate.................. 10 to 30 grains. Beta-naphthol..................... 10 grains. . Carbolic acid...................... 5 to 10 grains. Ointment of oxide of zinc........... 1 ounce. Mix. TINEA. CIRCINATA—RINGWORM OF THE BODY. Take of Resorcin.......................... £ drachm. Subiodide of bismuth...............• £ drachm. Ointment of oxide of zinc........... 1 ounce. Mix. TINEA VERSICOLOR—CHROMOPHYTOSIS. Take of Antharobin....................... 1 drachm. Oil of eucalyptus................... 10 drops. Ointment of oxide of zinc........... 1 ounce. Mix. TINEA VERSICOLOR—CHROMOPHYTOSIS. Take of Ointment of oleate of mercury (ten per cent)....................... 1 ounce. Beta-naphthol..................... 10 to 30 grains. Mix. TUBERCULOSIS CUTIS—TUBERCULOSIS OF THE SKIN. Take of Creasote.......................... 1 drachm. Compound tincture of benzoin....... 2 drachms. Distilled witch-hazel water.......... 2 ounces. Glycerin.......................... 3 ounces. Mix. Use in an atomizer. Spray over the surface several times a day. J 55 866 DISEASES OF THE SKIN. ULCERA—ULCERS. Take of Calomel.......................... £ ounce. Iodoform or iodol.................. £ ounce. Mix. Sprinkle over the ulcer. ULCERA—ULCERS. Take of Extract of conium................. £ drachm. Extract of belladonna.......'........ £ drachm. Ointment of tobacco................ 1 ounce. Mix. ULCERA—ULCERS. Take of Subiodide of bismuth............... 1 drachm. Powdered red cinchona-bark......... 1 ounce. Mix. ULCERA—ULCERS. Take of Iodosulphate of cinchonine.......... 1 drachm. Carbonate of zinc.................. 2 drachms. Hydrochlorate of cocaine............ 10 grains. Lanolin or prepared suet............ |- ounce. Ointment of rose-water............. | ounce. Mix. URTICARIA—NETTLE-RASH—HIVES. Take of Menthol.......................... 10 grains. Hydrochlorate of cocaine............ 10 grains. Subnitrate of bismuth.............. 2 drachms. Lanolin.......................... ^ ounce. Ointment of rose-water............. ^ ounce. Mix. URTICARIA—NETTLE-RASH—HIVES. Take of Chloroform........................ i ounce. Tincture of opium................. i ounce. Tincture of aconite-root............. -|- ounce. Soap liniment..................... 4£ ounces. Mix. URTICARIA—NETTLE-RASH—HIVES. Take of Creolin........................... 5 to 20 drops. Lime-water........................ 3 ounces. Glycerin or olive-oil................ 3 ounces. Mix. FORMULARY TO SECOND EDITION. ^07 VARIOLA—SMALL-POX. Take of Creolin........................... 10 to 30 drops. Bicarbonate of sodium.............. \ ounce. Powdered impure carbonate of zinc... 4 ounces. Glycerin or olive-oil, sufficient quan- tity to make into a paste. Mix. Apply over the eruption with old muslin. VARIOLA—SMALL-POX. Take of Aristol or europhen................ \ ounce. Prepared chalk.................... 4 ounces. Glycerin or olive-oil, sufficient quan- tity to make into a paste. Mix. Employ upon the eruption by means of lint. V ERRUC A—W A RT. Take of Salol............................. 1 drachm. Collodion......................... 4 drachms. Sulphuric ether.................... 2 ounces. Mix. VERRUCA—WART. Take of Resorcin.......................... 1 to 2 drachms. Traumaticin...................... 1 ounce. Mix. MEDICINAL PLASTERS. ANTHRAROBIN. Anthrarobin.......................... 25 per cent. Plaster mass *......................... 75 " For chronic eczema, psoriasis, acne, rosacea, old syphilitic and scrofulous patches, and old ulcers. ANTIMONY. Antimony............................ 10 per cent. Plaster mass.......................... 90 " Useful in chloasma, keloid, scars, and indurated spots of eczema and acne. * The plaster mass is composed of fifty parts of India rubber, five parts of honey, and forty-five parts of soap plaster. 868 DISEASES OF THE SKIN. ARISTOL. Aristol.............................. 25 to 40 per cent. Plaster mass......................... 75 to 60 " Serviceable in chronic eczema, psoriasis, acne, rosacea, syphilis. scrofuloderma, lupus, and tuberculosis of the skin. CADE. Oil of cade.......................... 25 per cent Beeswax............................ 25 Plaster mass......................... 50 For limited spots of chronic acne, rosacea, eczema, psoriasis, and in old ulcers. CAMPHOR AND OPIUM. Powdered camphor.................... 10 per cent. Powdered opium....................... 5 Olive-oil.............................. 5 " Plaster mass.......................... 80 " Beneficial to employ in herpes, herpes zoster, boils, burns, frost- bites, fissured nipples, bed-sores, and dermatitis. ELM. Resin elm, strained..................... 50 per cent. Plaster mass.......................... 50 " For wounds, ulcers, bed-sores, syphilitic and scrofulous spots, acne, rosacea, freckles, and chloasma. IODOL. Iodol................................. 40 per cent. Plaster mass.......................... 60 " Efficient for syphilitic, scrofulous, and tuberculous patches, chloasma, lentigo, scars, and lupus. ZINC Chloride of zinc....................... 25 per cent. Glycerin.............................. 5 « Plaster mass.......................... 70 " Valuable in epithelioma, lupus vulgaris, and in all old syphilitic and scrofulous ulcers. FORMULARY TO SECOND EDITION. 869 MEDICINAL SOAPS* • Aristol Soap.—Containing five per cent, aristol. For chronic eczema, psoriasis, acne, rosacea, seborrhoea sicca, and indolent ulcers. Benzoic Soap.—Containing five per cent, gum benzoin. A good soap for the toilet, seborrhcea sicca or dandruff, intertrigo or chafing, bromidrosis and hyperidrosis or fetid and excessive sweat- ing. Creolin Soap.—Containing five per cent, creolin. Valuable in eczema, especially upon the scalp, around the genital organs, scabies or itch, pediculosis or lousiness, and in impetigo con- tagiosa. Creasote Soap.—Containing five per cent, creasote. A beneficial soap to use in wounds, ulcers, paraesthesia or pruritus, seborrhcea oleosa, bromidrosis, and hyperidrosis. Hydroxylamin Soap.—Containing five per cent, hydroxylamin. For chronic eczema, psoriasis, acne, rosacea, seborrhcea, and lupus. Iodoform Soap.—Containing five per cent iodoform. Serviceable in wounds, bruises, burns, frost-bites, abscesses, pustular eczema, impetigo, scrofuloderma, syphilis, and in old ulcers. Iodol Soap.—Containing five per cent iodol. Useful in the same diseases enumerated under iodoform soap. Lanolin SoAP.f—Containing two per cent, lanolin and three per cent, olive-oil. An excellent toilet soap. Menthol Soap.—Containing five per cent menthol. An excellent soap for paraesthesia or pruritus, especially around the axillary, anal, and genital regions. Resorcin Soap.—Containing five per cent resorcin. For seborrhcea, pediculosis, scabies, chronic acne, rosacea, eczema, psoriasis, hyperidrosis, and bromidrosis. Salol Soap.—Containing five per cent, salol. Valuable in the treatment of chronic eczema and seborrhoea, espe- cially around the genital organs. * See paper by the author on " Toilet and Medicinal Soaps." The Medical Bulletin, May, 1892. f Lanolin toilet soap is manufactured at the Lanolin Works, Martinikenfelde, Ger- many, and is largely dispensed by Burroughs, Welcome & Co., Snow-Hill Buildings, London. INDEX. Abscess, 366. Abscessus, 366. Absorption, cutaneous, 30. Acanthia lectularia, 721. Acarus folliculorum, 722. Acarus scabiei, 55, 705, 708. Achorion Schonleinii, 55, 734, 738. Achroma, acquired, 547. congenital, 546. Acid baths, 80. Acne, 314. albida, 135, 805, 806. artificialis, 316. atrophica, 316. baths in, 326. boutonneuse, 314. caehecticorum, 316. diagnosis of, 225, 230, 317, 332, 510, 753. disseminata, 314. etiology of, 318. formulary for, 765, 766, 785, 786, 824, 825, 844, 845. hypertrophica, 316. indurata, 316. lupus, 594. mentagra, 339. oleates in, 325. papulosa, 315. pathology of, 318. prognosis of, 330. puncturation in, 326. pustulosa, 315. rosacea, 330. sebacea, 123. sulphur in, 322. symptoms of, 314. syphilitica, 228. treatment of, 320. variolaformis, 619. Acne, vulgaris, 314. Aconitine oleate, 92. Actinomycosis, 762. Addison's keloid, 529. Adenoma of the sweat-glands, 142. Adipoma, 679. Adipose tissue, 2, 8. -.Esthesionieter, 29. Age, effect of, on skin-diseases, 49, 58. Ainhum, 690. Albinism, 40, 546. Albinismus, 40, 546. partialis, 546. universalis, 546. Albino, 546. Aleppo evil, 365. Algor progressivus, 526. 1, Alimentary diseases as cause of skin-dis- eases, 61. Alkaline baths, 80. Alligator boy, 519. 7, Alopecia, 560. areata, 570, 743, 788, 825, 826, 845. chronic, 561. circumscripta, 570, 743, 788, 825, 826, 845. diagnosis of, 561, 571, 743. etiology of. 563, 573. formulary for, 766, 767, 787, 788, 825, 845. natural, 561. pathology of, 562. premature, 560. prognosis of, 570, 576. senile, 561. symptoms of, 560. syphilitic, 234, 562, 572. treatment of, 564, 573. Alphos, 490. Aluminium oleate, 92. 871 8^2 DISEASES Anaemia of the skin, 52. Anaesthesia in skin-diseases, 38. of the skin, 694. Anaesthetics in skin-diseases, 97. Analgesia of the skin, 694. Anal region, eczema of, 443. itching of, 697. Anatomical tubercle, 618. Anatomy of the skin, 1. Aneurysma spongiosum, 680. Angio-cavernosus, 682. elephantiasis, 680, 682. Angioma, 680. diagnosis of, 683. etiology of, 683. lobular, 683. pathology of, 683. prognosis of, 687. symptoms of, 680. treatment of, 684. Anidrosis, 141. symptomatic, 142. symptoms of, 141. treatment of, 142, 757, 789. Anomaliae excretionis, 122, 123. secretionis, 122, 123. Anomalies of excretion, 122, 123. of secretion, 122, 123. Anthrarobin, 106. Anthrax, 359, 362. formulary for, 767, 789. Antimony for skin-diseases, 75. Antiparasitics, 99. Antiseptics, 109. • Anus, eczema of, 443. itching of, 697. pruritus of, 697. Area Celsi, 570. Areola, 40. Areolar tissue, 2. Argyria, 40, 481. Aristol, 108. Arrangement of skin-diseases, 1. Arrectores pili, 18, 21. Arsenate of sodium, 72. Arsenic for skin diseases, 71. hypodermic use of, 74. Arsenicum oleate, 92. Arsenous acid, 72. Astringent baths, 80. Atheroma, 136. Atrophia cutis, 54, 122, 555. pilorum propria, 576. F THE SKIN. Atrophia propria, 555. senilis, 558. Atrophias, 122, 546. Atrophic lines, 559. spots, 559. Atrophy of the face, unilateral, 531. of the hair, 576. of the hair-pigment, 550. of the nails, 579. of the skin, 54, 122, 555. numerical, 54. of the skin, prognosis of, 121. senile, 558. simple, 54. Atropine oleate, 92. Aussatz, der, 621. Axis-cylinder, 23, 24. Bacilli of lepra, 631. of lupus, 598, 600, 601. Bacteria of skin-diseases, 56, 57. pyogenic, 56. Balanitis, diagnosis of, 210. Baldness, 560, 570. Barbadoes leg, 531. Barber's itch, 341, 752. Bartfinne, 339. Bassorin paste, 91. Bathing, 79. Baths in skin-diseases, 79. acid, 80. alkaline, 80. astringent, 80. bromine, 80. electro-vapor, 81. emollient, 80. hot-air, 80. in eczema, 406, 411. iodine, 80. medicated vapor, 81. mercurial, 80. potassium sulphuret, 80. vapor, 81. water, 79. Beard, affections of the. See Eczema, Sycosis, Mentagra, etc. Bed-bug, 55, 64, 721. Biskra bouton, 365. Bismuth oleate, 93. Bites of insects, 725, 726. Blanching of the hair, 550. Blasenausschlag, 303. Blattern, 180. INDEX. 873 Blebs, 43. Bleeding, cutaneous, 53. See Hemor- rhage. Blood, extravasation of, 53. sweating of, 145, 161. Blood-letting in eczema, 418. in skin-diseases, 113. Blood-vessels of the skin, 3, 21. Blutfleckenkrankheit, 154. Blutschwar, 355. Body-louse, 714. Boil, 355. Delhi, 365. Bot-fly, 725. Bouton, Biskra, 365. Brandsehwar, 359. Brandy-nose, 335. Break-bone fever, eruption of, 173. Breast, eczema of, 436. Bright's disease a cause of skin-disease, 62. Bromidrosiphobia, 143. Bromidrosis, 142. etiology of, 143. symptoms of, 142. treatment of, 143, 789, 790, 846. Bromine baths, 80. Bubo, 209. syphilitic, 217. Bucnemia tropica, 531. Bulb of hair, 16. Bullae, 43. compound, 44. Burns, 468. Cadmium oleate, 93. Callositas, 54, 484. Callosities, 54, 484. Callus, 484. Calx sulphurata for skin-diseases, 78. Cancer, 665. en cuirasse, 666. epithelial, 650. Cancroid, 650. corpuscles, 654. Canities, 550. etiology of, 552. prognosis of, 555. symptoms of, 550. treatment of, 553. Carbolic acid for skin-diseases, 78. Carbuncle, 359. Carbunculus, 359. diagnosis of, 355, 360. Carbunculus, etiology of, 360. formulary for, 707, 768, 790, 791, 826, 846. pathology of, 360. prognosis of, 362. symptoms of, 359. treatment of, 360. Carcinoma, cutaneous, 665. cutis, 665. diagnosis of, 663, 666, 690. etiology of, 667. epitheliale, 650. lenticular, 665. melanotic, 666. of the skin, 665. pathology of, 666. prognosis of, 667. scirrhus, 685. symptoms of, 665. treatment of, 667. tuberous, 666. Caseine ointment, 91. Cataplasms in skin-disease, 84. Cauliflower excrescence, 513. Causes, exciting, of skin-diseases, 60. predisposing, of skin-diseases, 58. Caustics in lupus, 607. in skin-diseases, 99. Cauterization by electricity, 115. in skin-diseases, 115. Cells of skin, 4-9. Cerebro-spinal fever, cutaneous symp- toms of, 198. Cerumen, 12. Ceruminous glands, 12. Chancre, diagnosis of, 210. Hunterian, 216. non-infecting, 207. Chancroid, 207. diagnosis of, 209, 217. etiology of, 211. formulary for, 768, 791, 826, 827, 846, 847. pathology of, 210. prognosis of. 214. symptoms of, 210. treatment of, 211. Chancroide, 207. Chapping of hands, 63. Cheiro-pompholyx, 313. Cheloid, 667. Chemical irritants as cause of skin-dis- ease, 63. )F THE SKIN. §74 DISEASES 0 Chian turpentine in skin-diseases, 76. Chicken-pox, 191. Chigre, 722. Chilblains, 63. Chloasma, 478. diagnosis of, 480, 729. etiology of, 480. pathology of, 480. prognosis of, 482. symptoms of, 478. treatment of, 480, 792, 827, 847. uterinum, 479. Chlorinated oil, 84, 99, 712. Chloroform in skin-diseases, 97. Chlorosis, 40. Chorionitis, 521. Chromidrosis, 144. symptoms of, 144. treatment of, 145. Chromophytosis, 727. Chronic malaria, 40. Chrysarobin, 106. Cicatrices, 47, 673. atrophic, 47. hypertrophic, 47. normal, 47. Cicatrices of the skin, 47, 673. treatment of, G74, 792, 847. Cimex lectularius, 55, 721. Circum-anal glands, 12. Claret-stain, 680. Classification of skin-diseases, 122. Clavus, 485, 792, 847. Climate, effect of, on diseases of the skin, 59. Clothes-louse, 716. Clothing as a cause of skin-disease, 62. Coca in skin-diseases, 100. Cocaine hydrochlorate in diseases of the skin, 98. 100. Cocaine oleate, 93. Coccidia, 438. Cod-liver oil in skin-diseases, 70. Coil-glands, 12. Cold as a cause of skin-diseases, 63. Cold cream in eczema, 409. Cold sweat, 21. Colloid degeneration of the skin, 679. milium, 679. Color of the skin, 1, 5, 6. of skin-diseases, 51. Colored sweat, 144. Combustio, 468. Combustio, pathology of, 470. symptoms of, 469. treatment of, 471. Comedo, 132. diagnosis of, 133. etiology of, 133. formulary of, 492. pathology of, 133. prognosis of, 135. symptoms of. 132. treatment of, 133. Compression in eczema, 418. in skin-diseases, 112. Condition, general, effect of, on skin- diseases, 50. Condylom, spitzen, 513. Condyloma subcutaneum, 619. Condylomata, 224, 654, 794. Congelatio, 473. symptoms of, 473. treatment of, 474. Congestion, passive, of the skin, 41. Connective tissue, subcutaneous, 8. subcutaneous, fat in, 8. Constitutional diseases as causes of skin- diseases, 62. Constitutional symptoms of skin-dis- eases, 49. treatment of skin-diseases, 65. Contagion as a cause of sk n-diseases, 64. Contusion of the skin, 367. Copper oleate, 93. Cor, 485. Corium, 3, 6. papillary layer of, 6, 7. reticular layer of, 6, 7. Corn, 485. Corne de la peau, 487. Corneous layer of skin. 3, 4. Cornu cutaneum, 487. humanum, 487. Corpuscles, cancroid, 654. lymphoid, 6, 9. of Meissner, 24. of Vater, 23. of Wagner, 24. Pacinian, 23. tactile, 24. touch, 24. Couperose, 330. Cow-pox, 193. Crab-lice, 717. Cracks, 46. INDEX. 875 Creasote in skin-diseases, 78. Crusta lactea, 373, 420. Crustae, 45. syphilitic, 46, 220. Crusts, 45. Crusts, milk, 420. Cucumber-ointment, 409. Culex, 726. Cutaneous carcinoma, 665. excretion, 33. horns, 487. secretion, 33. Cuticle, 3. of hair, 16. Cutis, 6. anserina, 19, 490. pendula, 537. tensa chronica, 521. unctuosa, 123. vera, 6. Cysticercus cellulosae, 724. Dandruff, 123. Dartos, 21. Dartre rongeante, 592. Debility, effect of, on diseases of the skin, 59. Decrepitude infantile, 526. Delhi boil, 365. Demodex folliculorum, 722. Dengue, eruption of, 173. Dentition, effect of, on diseases of the skin, 60. Depilatories, 542. Derma, 6. Dermalgia, 694. Dermatalgia, 694. formulary for, 769, 795, 827, 849. Dermatitis, 450. ambustionis bullosa, 468. erythematosa, 468. escharotica, 469. calorica, 452. combustionis, 468. congelationis, 473. bullosa, 474. erythematosa, 474. escharotica, 474. contusiformis, 268. diagnosis of, 151, 387. epidemicus, 466. exfoliativa, 351. from rhus, 462. Dermatitis gangraenosa, 452. herpetiformis, 463. medicamentosa, 452. traumatica, 450. treatment of, 462. venenata, 450. Dermatol, 106. Dermatolysis, 537. Dermatomycosis favosa, 734. Dermatosclerosis, 521. Dermatome, 114. Desquamation, 45. furfuraceous, 45. in mass, 45. Diabetes as a cause of skin-diseases, 62. Diagnosis of skin-diseases, 48. Diaphoretics, action of, 34. Diathesis, effect of, on skin-diseases, 59. Diet in skin-diseases, 66. Dietetic errors as a cause of skin-dis- eases, 61. Digestive organs, disturbances of, as causes of skin-diseases, 62. Diphtheria, cutaneous symptoms of, 198. Diphtheritic spots, 198. Discoloration, 40. Dissecting wounds of the skin, 367. Disturbances of internal organs as causes of skin-diseases, 62. Donovan's solution in skin-diseases, 72. Dress in treatment of skin-diseases, 66. Dropsy, scarlatinous, 172. Drugs, eruptions from, 61, 452. Dry papule, 216. Ducts, sudoriparous, 9. Duration of skin-diseases, 51. Dusting-powders, 85. in eczema, 408. Dyes for the hair, 553. Dysidrosis, 313. diagnosis of, 313. Ear, eczema of, 430. glands of, 12. wax, 12. Earth treatment, 85. Eau de Luce, 820. Ecchymomata, 154. Ecchymoses, 40, 154. Ecthyma, 348. diagnosis of. 230, 345, 349, 355. etiology of, 349. pathology of, 349. 876 DISEASES OF THE SKIN. Ecthyma, prognosis of, 350. symptoms of, 348. syphiliticum, 229. treatment of, 349. Eczema, 373. acute. 374. treatment of, 406, 769, 770, 795, 796, 827, 828, 849, 850. ani, 443. articulorum, 439. aurium, 430. barbae, 432. baths for, 406, 411. blood-letting in, 418. capitis, 427. causes of, constitutional, 394. causes of, local, 396. chronic, 375. formulary for, 770, 771, 796, 797, 828, 829, 850. colli, 431. compression in, 418. constitutional treatment of, 400. crurum, 444. diagnosis of, 126, 200, 210, 226, 227, 230, 267, 283, 286, 288, 295, 301, 306, 313, 317, 341, 345, 347, 349, 352, 385, 493, 510, 589, 707, 718, 729, 743, 753, 757. digitorum, 446. dusting-powders in, 408. erythematosum, 376. erythematous, 376. etiology of, 393. faciei, 431. fissum, 382. fissured, 382. formulary for, 769, 795, 827. 849. genitalium, 440. infantile, 419. diagnosis of, 421. treatment of, 423. intertrigo, 420, 440. labiorum, 435. linguae, 436. local treatment of, 405. madidans, 381. mammarum, 436. manuum, 445. marginatum, 756. massage in, 418. mercury in, 415. naphthol in, 414, Eczema nasi, 434. cedematosum, 379. of anal region, 443. of anus, 443. of beard, 432. of breast, 436. of ears, 430. of eyelids, 433. of face, 43 L of feet, 445. of fingers, 446. of flexor surfaces, 439. of genital organs, 440. of hands, 445. of joints, 439. of labia, 435. of legs, 444. of lips, 435. of nails, 446. of navel, 439. of neck, 431. of nipples, 436. of nose, 434. of scalp, 427. of scrotum, 771, 799, 831, 853. of tongue, 436. of umbilicus, 439. of vagina, 771, 830. of vulva, 771, 830. oils in, 411. ointments in, 409. oleates in, 415, 416. papular, 380. papulosum, 380. pathology of, 392. pedum, 445. prognosis of, 449. pustular, 380. pustulosum, 380. rubrum, 381. scroti, 771, 799, 831, 853. seborrhceic, 383. secondary changes in, 380. soaps in, 412. squamosum, 382. squamous, 382. subacute, 375, 406. symptoms of, 373. tar in, 412. tarsi, 455. treatment of, 398. umbilici, 439. unguium, 446. INDEX. Eczema universale, 418. vaginae, 771, 830. varieties of, 418. vesicular, 378. vesiculosum, 378. vulvae, 771, 830. water in, 406, 411. Electric currents of skin, 36. Electricity, cauterization by, 115. faradic, 115, 118. frictional, 117, 118. galvanic,. 117, 119. in skin-diseases, 115. static, 117, 118. Electrolysis in naevus, 685. in skin-diseases, 115. Electro-vapor baths in skin-diseases, 81 Eleidin, 4. Elephant leg, 531. Elephant man, 537. Elephantiasis, 531. Arabum, 531. diagnosis of, 533, 631. % etiology of, 533. Graecorum, 621. pathology of, 533. prognosis of, 536. symptoms of, 531. telangiectodes, 537. treatment of, 535. Emol-keleet, 85. Emollient baths, 80. Encysted tumor, 136. Entozoon, 722. Enucleation in skin-diseases, 114. Ephidrosis, 137. Epidermin, 91. Epidermis, 3. coloring matter of, 4. layers of, 3. Epilation, 541. Epithelial cancer, 650. globes, 654. nests, 654. Epithelioma, 650, 665. calcifying, 651. deep-seated, 650. diagnosis of, 127, 210, 232, 391, 59' 831, 855. eticjogy of, 655. papillary, 650. pathology of, 654. prognosis of, 661. Epithelioma, superficial, 650. symptoms, 650. Equinia, 364. Erbgrind, 734. Erosion, superficial, of syphilis, 216. Eruptions from drugs, 4 j2. pustulo-crustaceous, 227. Eruptive fevers, cutaneous symptoms 197. Erysipelas, 198. ambulans, 200. complications of, 199. diagnosis of, 200, 275, 307, 386. etiology of, 200. formulary for, 772. 801, 832, 855. gangrenous, 200. pathology of, 200. phlegmonous, 200. prognosis of, 207. symptoms of, 198. treatment of, 202. Erythema, 150. intertrigo, 152. diagnosis of, 152. etiology of, 152. pathology of, 152. prognosis of, 153. symptoms of, 152. treatment of, 153. multiforme, 266. diagnosis of, 267. etiology of, 267. pathology of, 267. prognosis of, 268. symptoms of, 266. • treatment of, 268. nodosum, 268. diagnosis of, 268. etiology of, 270. pathology of, 270. prognosis of, 271. symptoms of, 269. treatment of, 271. simplex, 150. diagnosis of, 151, 200. etiology of, 151. pathology of, 151. prognosis of, 151. symptoms of, 150. treatment of, 151. Erythroxylon coca, 100. Escharotics in skin-diseases, 99. Esthiomene, 592. S78 DISEASES OF THE SKIN. Ether in skin-diseases, 97. Etiology of skin-diseases, 58. Evil, Aleppo, 365. Excision in skin-diseases, 114. Excoriationes, 45. Excoriations, 45. Excrescence, cauliflower, 513. horny, 487. Excretion, anomalies of, 122, 123. cutaneous, 33. disorders of, 122, 123. Exercise in skin-diseases, 66. Extravasated blood, 481. Exudationes, 122, 162. Exudations, 122, 162. Eyelids, eczema of, 433. Face, eczema of, 431. unilateral atrophy of, 531. Facies leontina, 624. Faradism in skin-diseases, 115, 118. Farcy, 364. Fat-globules, 8, 13. of skin, 2, 8. Fats, mineral, 87. Fatty tumor, 679. Favus, 734. Febris urticata, 271. Feet, eczema of, 445. Fever, scarlet, 168. Fevers, eruptive, cutaneous symptoms of, 197. Fibroma lipomatodes, 676. molluscum, 674. Fibrous sheath of Kolliker, 17, 18. Fig-wart, 513. Filaria medinensis, 724. sanguinis, 533. Fingers, eczema of, 446. Fischschuppenausschlag, 516. Fish-skin disease, 516. Fissures, 46. Flea, 55, 722. Fleckenmal, 483. Flexor surfaces, eczema of, 439. Follicles of hair, 12, 17. Follicular tumor, 136. Folliculitis barbae, 339. Food in skin-diseases, 66. Foot, fungus, 648. madura, 648. perforating ulcer of, 649. Formulary of skin-diseases, 765, 824. Fowler's solution in skin-diseases, 72, 73. Fragilitas crinium, 578. Fragility of the hair, 578. Frambcesia. 646. Freckles, 477. Fressend Flecte, 592. Frost-bite, 473. diagnosis of, 333. Fumigation, mercurial, in syphilis, 249. Functional diseases as causes of skin- diseases, 61. Fungi, microscopic, 55. Fungoid neoplasm, inflammatory, 692. Fungus-foot, 648. Fungus haematodes, 680. Furuncle, 355. Furunculus, 355. diagnosis of, 355. etiology of, 366. formulary for, 773, 802, 833, 856. pathology of, 355. prognosis of, 359. symptoms of, 355. treatment of, 356. Gad-fly, 725. Gale, 705. Galvanism in skin-diseases, 118, 609. Gefassmal, 680. Gelanthum, 104. Gelatine in skin-diseases, 103. General conditions, influence of, on skin- diseases, 50. Genital organs, eczema of, 440. Genito-urinary diseases as causes of skin- diseases, 62. German measles, 167. Gero-morphism, 62. Glanders, 364. Glands, ceruminous, 12. circum-anal, 12. coil, 12. Meibomian, 13. of hair-follicles, 12. of Montgomery, 13. sebaceous, 12. sebiparous, 12. sudoriparous, 9. sweat, 9. Globules, fat, 13. Glossy skin, 558. Gnat, 726. Goose-flesh, 19, 490. INDEX. 879 Grayness of hair, 550. Grog-blossoms, 335. Grutum, 135. Guinea-worm, 724. Gummata, 233. diagnosis of, 137, 234. Gutta-percha in skin-diseases, 104. Gutta rosacea, 330. Habits, effect of, on skin-diseases, 50, Ibvinatidrosis, 145, 161. Hajmidrosis, 145, 161. Haemophilia, 161. Haemorrhage, cutaneous, 53, 122, 154. idiopathic, 154. prognosis of, 121. symptomatic, 154. Haemorrhagiae, 122, 154. Hemorrhagic spots, 53. Haemorrhcea petechialis, 154. Hair or hairs, 1, 14. atrophy of, 576. pigment of, 550. blanching of, 550. bulbs of, 16. color of, 14. cuticle of, 16. dyes for, 553. falling of, 560. fibres of, 16. follicles of. 14, 17. fragility of, 578. glands of, 12. grayness of, 550. growth of, 19. hypertrophy of, 538. knob of Henle, 19. loss of, 560. number of, 14. papillae of, 15. root of, 16. sacs of. 17. whiteness of, 550. Hamamelis in skin-diseases, 105. Hands, eczema of, 445. Harvest-mite, 723. llauthorn, 487. Ihuitsclerem, 521. Ilcad-louse, 714. Heart diseases as causes of skin-dis- eases, 62. Heat as a cause of skin-disease, 63. Hemiatrophia facialis, 531. Henle's hair-knob, 19. layer, 18. Heredity, effect of, on diseases of the skin, 60. Herpes, 290. circinatus, 755. circinatus bullosus, 311. diagnosis of, 210, 217, 295, 306, 312, 386. etiology of, 296. facialis, 291. formulary for, 773, 803, 834, 856. gestationis, 293, 311. iris, 291. pathology of, 296. progenitalis, 292. prognosis of, 300. symptoms of, 290. tonsurans, 741. treatment of, 297. zoster, 293. atypical, 295. diagnosis of, 295, 333, 386. epidemic, 295. formulary for, 774, 803, 835, 856. gangranosus, 294. haemorrhagicus, 294. Ilirsuties, 538. Hives, 271. Horns, cutaneous, 487. Horny excrescence, 487. layer of skin, 4. tumor, 487. Hot-air baths, 80. Hiihnerauge, 4S5. Huxley's layer, 18. Hydradenitis destruens suppurativa, 147. Hydrastine hydrochlorate, 100. Hydroa, 311. diagnosis of, 311. etiology of, 312. pathology of, 312. prognosis of, 313. symptoms of, 311. treatment of, 312. Hydrocystoma. 147. Hydrogen dioxide, 109. Ilydrosis, 137. Hygiene of the skin, 65. Hyperaemia, 40, 52. active, 52, 150. passive, 53, 150. Hyperaemiae, 122, 150. 880 DISEASES OF THE SKIN. Hyperaesthesia, 694. in skin-diseases, 33. Hyperalgesia, 694. Hyperidrosis, 137. diagnosis of, 138. etiology of, 139. formulary for, 774, 803, 835, 857. general, 137. local, 138. pathology of, 139. prognosis of, 141. symptoms of, 137. treatment of, 139. Hypertrichiasis, 538. Hypertrichosis, 538. Hypertrophiaa, 122. Hypertrophies, 122. Hypertrophy of the hair, 538. etiology of, 539. symptoms of, 538. treatment of, 539. of the nails, 542. etiology of, 544. pathology of, 544. prognosis of, 546. symptoms of, 542. treatment of, 544. of the skin, 54. Hypohidrosis, 141. Ice in skin-diseases, 97. Ichthyoides, 516. Ichthyol, 101. Ichthyose, 516. Ichthyosis, 516. congenita, 516. diagnosis of, 128, 495, 519. etiology of, 520. formulary for, 774, 804, 835, 857. hystrix, 517. pathology of, 519. prognosis of, 521. sebacea, 123. simplex, 517. symptoms of, 516. treatment of, 520. vera, 516. Idrosis, 137. Ignes sacer, 293. Impetigo, 344. contagiosa, 347, 349, 743. diagnosis of, 230, 306,345,347,349,391. etiology of, 345. Impetigo herpetiformis, 346. pathology of, 345. prognosis of, 346. symptoms of, 344. syphilitica, 229. treatment of, 342, 804. Incisions in skin-diseases, 114. India-rubber skin man, 2. Induratio telae cellulosae neonatorum, 526. Inflammation of the skin, 53. Inflammatory fungoid neoplasm, 692. Influenza, cutaneous symptoms of, 198. Insects, bites and stings of, 725, 726. Inspection of skin-diseases, 48. Inunction, mercurial, in syphilis, 248. Iodine baths, 80. preparations of, in skin-diseases, 77. Iodoform, 107. Iodol, 108. Iron and its preparations in skin-dis- eases, 70. Iron oleate, 94. Itch insect or mite, 55, 708. Ixodes, 726. Jaundice, 40, 481. Jequrity, 103. Jigger, 722. Joints, eczema of, 439. Juckblattern, 287. Kelis, 667. Keloid, 667. Addison's,'529. diagnosis of, 669. etiology of, 670. pathology of, 669. prognosis of, 673. symptoms of, 667. treatment of, 671. Kelos, 667. Keratosis pilaris, 489. Kidneys and skin, relation of, 34. Kleienflechte, 727. Knob, hair, 19. Koch's lymph, 603. Kolliker, fibrous sheath of, 17, 18. Kratze, 705. Krause, end-bulbs of, 24. genital corpuscles of, 24. Labia, eczema of, 435. Lactation, effect of, on skin-diseases, 60. INDEX. 881 Land-scurvy, 157. Langerhaus, layer of, 4. stratum of, 4. Lanolin, 88. Lanugo, 12, 14. follicle, 12. Lard as base for ointments, 87. Lausesucht, 714. Layer, granular, 4. Henle's, 18. Huxley's, 18. mucous, 4, 5. of Langerhaus, 4. of Malpighi, 5. prickle, 5. Layers of skin, 3. Lead oleate, 94. Leeching in skin-diseases, 114. Legs, eczema of, 444. Leichdorn, 485. Lentigo, 477, 729, 804, 857. Leontiasis, 621. Lepra, 621. alphos, 490. anaesthetic, 625. anaesthetica, 625. Arabum, 621. bacilli of, 631. complications of, 629. contagion of, 637, 639. diagnosis of, 530, 548, 630, 663. etiology of, 633. formulary for, 775, 836. macular, 628. maculosa, 628. mutilans, 624, 627. ocular, 629. pathology of, 631. prognosis of, 646. symptoms of, 621. treatment of, 640. tubercular, 623. tuberculosa, 623. Lepre, la, 621. Leprosy, 621. Leptus, 723. Americanus, 723. irritans, 723. Lesions, individual, of skin-diseases, primary, 39. secondary, 45. Leucocasmus, acquired, 547. congenital, 546. 56 Leucoderma, 40. acquired, 547. congenital, 546. Leucopathia, acquired, 547. congenital, 546. Lice, 55, 390, 714. Lichen, 282. menti, 339. pilaris, 489. planus, 282. diagnosis of, 225, 283, 386, 510. etiology of, 284. pathology of, 283. prognosis of, 285. symptoms of, 282. treatment of, 284. ruber, 509. diagnosis of, 223, 283, 352, 495, 510. etiology of, 511. pathology of, 510. prognosis of, 512. symptoms of, 509. treatment of, 511. scrofulosus, 285. diagnosis of, 223, 2S3, 286. etiology of, 286. pathology of, 286. prognosis of, 287. symptoms of, 285. treatment of, 286. syphiliticus, 223. tropicus, 300. Lids, eczema of, 433. Light, effect of, on skin-diseases, 48. Linae albicantes, 554. Lines, atrophic, 559. Lipoma, 679. diagnosis of, 680. pathology of, 680. symptoms of, 679. treatment of, 680. Lips, eczema of, 435. Liver, diseases of, as causes of skin-dis- ease, 62. Liver-spot, 478. Location of skin-diseases, 51. Losophan, 106. Lotions, anaesthetic, 98. in skin-diseases, 86. Louse, 55, 390, 714. Lousiness, 714. Lupus disseminatus, 588. erythematodes, 587. 882 DISEASES OF THE SKIN. Lupus erythematosus, 587. diagnosis of, 127, 333, 495, 588, 596. etiology of, 590. formulary of, 775, 805, 836, 858. pathology of, 589. prognosis of, 592. symptoms of, 587. treatment of, 590. exedens, 592. exfoliativus, 593. exulcerans, 593. hypertrophicus, 593. miliaris, 594. sebaceus, 587. superficialis, 587. verrucosus, 593. vorax, 592. vulgaris, 592. bacilli of, 598, 600, 601. caustics in, 607. diagnosis of, 232, 333, 390, 588, 596, 653, 663. etiology of, 599. formulary of, 775, 805, 836, 858. pathology of, 598. prognosis of, 592. symptoms of, 592. treatment of, 602. Lymph spaces of skin, 22, 23. Lymphadenoma, diagnosis of, 663, 666. Lymphangiectodes, 688. Lymphangioma, 688. tuberosum multiplex, 688. Lymphatic warts, 688. Lymphatics of the skin, 22. Lymphoid corpuscles, 6, 9. Maculae, 39. atrophicae, 559. Macules, 39. Madura foot, 648. Mal perforant du pied, 649. Malaria, chronic, 40. Malignant pustule, 362. Malpighi, layer of, 5. Massage in eczema, 418. in skin-diseases, 111. Matrix, 20. Measles, 162. black, 163, 167. German, 167. malignant, 163, 167. purpurous, 163, 167. Mechanical irritants as causes of skin- diseases, 63. Mechanical remedies in skin-diseases, 111. Medicated baths, 79. plasters, 820, 867. soaps, 820, 869. Medicinal eruptions, 452. Medicines as causes of skin-diseases, 61. Meibomian glands, 13. Meissner, corpuscles of, 24. Melanoderma, 478. Melanosis, 662. Melanotic sarcoma, 662. Melasma, 478. Mentagra, 339. Menthol in skin-diseases, 106. Mercurial antiparasitics, 99. baths, 80. fumigation in syphilis, 249. Mercuric oleate, 95. Mercurous oleate, 95u Mercury, hypodermic use of, 76. preparations of, in eczema, 415. in skin-diseases, 76. in syphilis, 76, 242. Merkel, touch-cells of, 24. Metric system of weights and measures, 763. Microscopic examination of skin-dis- eases, 51. Microsporon Audouini, 741. furfur, 55, 727, 731. Miliaria, 300. alba, 300. crystallina, 146. diagnosis of, 301. etiology of, 302. pathology of, 302. prognosis of, 303. rubra, 300. symptoms of, 300. treatment of, 302, 805, 858. Milium, 135. colloid, 679. diagnosis of, 135, 677. etiology of, 136. pathology of, 135. symptoms of, 135. treatment of, 136, 805. Milk crust, 420. Mineral fats, 87. Mole, pigmentary, 483. Mollin, 82. DEX. 883 Molluscum cholesterique, 676. eontagiosum, 619. diagnosis of, 619. etiology of, 620. pathology of, 620. symptoms of, 619. treatment of, 621. epitheliale, 619. fibroma, 674. fibrosum, 674. diagnosis of, 675, 690. etiology of, 676. pathology of, 675. prognosis of, 676. symptoms of, 674. treatment of, 676. pendulum, 674. sebaceum, 619. sessile, 619. simplex, 674. Montgomery, glands of, 13. Morbilli, 162. Morbus caeruleus, 40. elephas, 531. maculosus Werlhofii, 157. Morphine oleate, 95. Morphcea, 528. diagnosis of, 524, 530, 548, 630. etiology of, 530. pathology of, 530. prognosis of, 531. symptoms of, 529. treatment of, 531. Mosquito, 726. Moth, 478. Mother's mark, 680. Mucous layer of skin, 4, 5. membranes, tuberculosis of, 617. Muscles of skin, 20. Muscular membranes of skin, 21. Mycetoma, 648. Mycosis fungoides, 692. Myoma, 690. telangiectoides, 690. Naavus, 483, 680. electrolysis for, 685. flammeus, 680. lipomatodes, 483. maternus, 483. molluscaformis, 483. pigmentaire, 483. pigmentosus, 483. Nsevus pilosus, 483. sanguineus, 680. spilus, 483. vaccination for, 686. vascular, 680. vascularis, 680. verrucosus, 483. Nail-bed, 20. groove, 19. Nails, 19. atrophy of, 579. eczema of, 446. hypertrophy of, 542. nutritive alterations of, in disease, 580. Naphthol, 100. in eczema, 414. Navel, eczema of, 439. Neck, eczema of, 431. Needle-knife in skin-diseases, 113. Neoplasmata, 122. Neoplasm, inflammatory fungoid, 692. Neoplasms of the skin, 122, 584. prognosis of, 121. Nervenschmerz der Haut, 694. Nerves of the skin, 24. Nesselausschlag, 271. Nettle-rash, 271. Neuralgia of the skin, 694. Neuroma, 689. Neuroses of the skin, 123, 694. Neurotic disturbances as causes of skin- diseases, 61. New-born, oedema of, 527. sclerema of, 526. scleroderma of, 526. New formations, 54. Nickel oleate, 95. Nipple, eczema of, 436. Noli me tangere, 592. Nose, eczema of, 434. Obesity, 9. Objective symptoms of skin-diseases, 39, 50. Occupation, effect of, on skin-diseases, 50, 59. Odor of skin, 37. of skin-diseases, 49. CEdema of the new-born, 527. of the skin, acute circumscribed, 281. CEhl, stratum of, 4. CEstrus, 725. 884 DISEASES i Oil, chlorinated, in skin-diseases, 84, 99. Oil in eczema, 411. in skin-diseases, 84. Ointments, astringent, 90. in eczema, 409. in skin-diseases, 86. sedative, 90. stimulating, 90. Oleate, aconitine, 92. aluminium, 92. arsenicum, 92. atropine, 92. bismuth, 93. cadmium, 93. cocaine, 93. copper, 93. iron, 94. lead, 94. mercuric, 95. mercurous, 95. morphine, 95. nickel, 95. quinine. 95. silver, 95. strychnine, 96. tin, 96. veratrine, 96. zinc, 96. Oleates in skin-diseases, 92. Onychatrophia, 579. Onychauxis, 542, 543. Onychia, 543. maligna, 582. syphilitic, 234. Onychogryphosis, 542, 543. Onychomycosis, 543, 741. Ophthalmia tarsi, 433. Organic diseases as causes of skin-dis- eases, 62. Osmidrosis, 142. Osteomata, diagnosis of, 137. Pachydermatocele, 537. Pachydermia, 531. Pacinian corpuscles, 23. Paget's disease of nipple, 437. Pain in skin-diseases. 38. in the skin, 694. Palpation in skin-diseases, 49. Panniculosus adiposus, 8. Papillae of hair, 15. of skin, 7. sensory, 24. THE SKIN. Papillae, vascular, 22. Papillary layer of corium, 6, 7. Papilloma, 516. Papula?, 41. Papule seche, 216. Papules, 41. moist, 224. mucous, 224. syphilitic, 223. Paresthesia, 38, 288, 696. diagnosis of, 391, 698. etiology of, 699. formulary for, 775, 806, 836, 858. pathology of, 698. prognosis of. 704. symptoms of, 696. treatment of, 699. Parasita?, 705. Parasitare Bartfinne, 752. Parasites of the skin, 55, 64, 123, 705. agents for, 99. animal, 55, 123, 705. destruction of, 99. vegetable, 55, 123, 727. Parasitic diseases of the skin, 123. Parasiticides, 99. Paronychia, syphilitic, 234. Pars papillaris, 7. reticularis, 7. Paste, bassorin, 91. Pastes in skin-diseases, 104. Patches, mucous, 224. syphilitic, 224. Pathology of skin-diseases. 52. Pearson's solution in skin-diseases, 73. Pediculophobia, 718. Pediculosis, 714. capitis, 714. corporis, 716. diagnosis of, 288, 390, 421, 698, 718. etiology of, 719. in the lower animals, 721. parasites of, 718, 719. prognosis of, 721. pubis, 716. symptoms of, 714. treatment of, 719. Pediculus, 55, 714. capitis, 714. corporis, 716. | pubis, 717. INDEX. 885 Pediculus, vestimenti, 716. Heliosis rheumatica, 155. Pellagra, 647. Pemphigus, 303. diagnosis of, 233, 275, 306, 312, 352. etiology of, 308. foliaceus, 305. formulary for, 776, 807, 837, 860. pathology of, 307. prognosis of, 310. prurigineuse, 311. symptoms of, 303. syphilitic, 232, 306. syphilitica, 232, 306. treatment of, 309. vegetans, 305. vulgaris, 303. Perforating ulcer of foot, 649. Perspiration, 26, 33. defective, 141. effects of medicine on, 34. excessive, 137. Petechia?, 40, 154. Petroleum as a base for ointments, 87, 91. Phosphorus and its preparations in skin- diseases, 70. Phtheiriasis, 714. Phthiriase, 714. Phthirius inguinalis, 716. pubis, 716. Physiology of the skin, 25. Pian, 646. Piebald skin, 547. Pigment, atrophy of, 550. granules, 14. Pigmentary mole, 483. Pigmentation, 47. Pimples, 41. Pityriasis, 123. circinata, 354. maculata, 354. pilaris, 489. rosea, 354. rubra, 351. diagnosis of, 352, 391, 495, 510. etiology of, 353. pathology of, 353. prognosis of, 354. symptoms of, 351. treatment of, 353, 354, 808, 860. versicolor, 727. Plasters in skin-diseases, 98. medicated, 820, 867 Plethora, effect of, on skin-diseases, 59. Podelcoma, 648. Poisoned wounds of the skin, 368. Poliosis, 550. Polytrichia, 538. Pomphi, 41. Pompholyx, 313. diagnosis of, 313. etiology of, 314. pathology of, 314 prognosis of, 314. symptoms of, 313. treatment of, 314. Porcupine-disease, 516. Porrigo decalvans, 570. favosa, 734. Port-wine stain, 680. Potash soaps, 82. Potassium arsenite in skin-diseases, 72,73. chlorate in skin-diseases, 77. sulphuret baths, 80. Poidtices in skin-diseases, 84. Powders, dusting, 85. Pregnancy, effect of, on skin-diseases, 60. Prickle-layer, 5. Prickles of Max Schultz, 5. Prickly heat, 300. Primary lesions of skin-diseases, 39. Prognoses of skin-diseases, 120. Prurigo, 287. diagnosis of, 288, 391, 698. etiology of, 289. pathology of, 288. prognosis of, 290. symptoms of, 287. treatment of, 290, 808, 860. Pruritus, 696. ani, 806, 859. labiorum, 806, 859. scroti, 806. 859. vagime, 807, 859. Psora, 490. Psoriasis, 490. diagnosis of, 122. 226, 283, 352, 387, 447, 493, 510, 736, 743, 757. etiology of, 497. formulary for, 776, 808, 837, 860. guttata, 491. pathology of, 496. prognosis of, 508. punctata, 491. symptoms of, 491. treatment of, 497. 886 Psorospermosis, 437, 620, 656. Psorosperms, 437, 620, 656. Pulex irritans, 55, 722. penetrans, 722. Puncturing in skin-diseases, 114. Purpura, 154. etiology of, 159. formulary for, 777, 808, 838, 861. haemorrhagica, 157. pathology of, 159. prognosis of, 160. rheumatica, 155. simplex, 155. symptoms of, 155. treatment of, 160. Pustula maligna, 362. Pustulae, 44. Pustule, malignant, 362. Pustules, 44. . primary, 44. secondary, 44. Pustulo-crustaceous eruption, 227. Pyogenic bacteria, 56. Quinine in skin-diseases, 71. oleate, 95. 1 THE SKIN. Ringworm honeycomb, 734. India, 756. Ringworm of the body, 755. of the scalp, 741. parasite, 64. Root-sheath of the hair, 18. Rosacea, 330. diagnosis of, 317, 332, 387. etiology of, 334. formulary for, 778, 809, 838, 8G1. pathology of, 333. prognosis of, 339. symptoms of, 330. treatment of, 335. Rose, 198. Roseola, 39. diagnosis of, 172, 221. syphilitica, 221. Rotheln, 167. diagnosis of, 151, 164, 167, 172, 221. etiology of, 168. pathology of, 168. prognosis of, 168. symptoms of, 167. treatment of, 168. Rubeola, 162. diagnosis of, 164, 167, 184, 191. etiology of, 165. formulary for, 778, 809, 838, 861. malignant, 163, 167. pathology of, 164. prognosis of, 167. purpurous, 163, 167. symptoms of, 162. treatment of, 165. Rupia, 233. Sacs, hair, 17. Saint Anthony's fire, 198. Salicylic acid, 106. Salol, 106. Sand-flea, 722. Sapo acidi carbolici, 821. acidi salicylici, 822. tannici, 823. aluminis, 820. anthemidis, 821. sulphurisque, 821. arnicae, 820. boroglyceriti, 821. camphorae, 821. ergotas, 821. eucalyptoli, 821. Races, color of, 1. Rash, scarlet, 168. Redness of skin, 40. Resorcin in skin-diseases, 405. Respiratory functions of the skin, 27. Rest in skin-diseases, 66. Rete Malpighii, 5. mucosum, 5. Reticular layer of corium, 6, 7. Revaccination, 194. Rhagades, 46. Rheumatism of the skin, 694. Rhigolene in skin-diseases, 97. Rhinophyma, 332. Rhinoscleroma, 584. diagnosis of, 585. etiology of, 586. pathology of, 585. prognosis of, 586. symptoms of, 584. treatment of, 586. Rhus-poisoning, 462. Ringworm, Burmese, 756. Chinese, 756. diagnosis of, 128, 389, 441, 589. epidemic, 751. DISEASES INDEX. 887 Sapo gaultherioa, 823. glycerini, 821. hamamelidis, 823. hydrargyri chloridi corrosivi, 822. iodi, 821. kino, 822. naphtholi, 822. sulphurisque, 822. picis liquidae, 823. plumbi, 822. sambuci florum, 821. sulphuris, 822. iodidi, 822. tanno-balsamicus, 823. terebinthinae compositus, 823. thymoli, 823. Sarcoma, cutaneous, 661. cutis, 661. diagnosis of, 631, 663, 666, 689. etiology of,. 664. melanotic, 662. of the skin, 661. pathology of, 663. prognosis of, 665. symptoms of, 661. treatment of, 664. Sarcoptes hominis, 708. scabiei, 708. Scabies, 705. acarus of, 708. diagnosis of, 288, 306, 388, 421, 707. etiology of, 709. humida, 373. pathology of, 708. prognosis of, 714. symptoms of, 705. treatment of, 710, 810, 861. Scabs, 45. Scalds, 468. Scales, 45. syphilitic, 220. Scalp, eczema of, 427. ringworm of, 741. Scarf-skin, 3. Scarification in skin-diseases, 114. Scarlatina, 108. anginosa, 169. diagnosis of, 167, 172, 184, 386. dropsy from, 172. etiology of, 174. formulary for, 779, 810, 839, 862. maligna, 170. I Scarlatina, pathology of, 173. prognosis of, 179. sequelae of, 171. simplex, 168. treatment of, 175. Scarlet fever, 168. rash, 168. Scars, 47. Schanker, 207. Scherende fleehte, 741. Schmeerfluss, 123. Schultz, Max, prickles of, 5. Schuppenflecke, 490. Scirrhus, 665. Sclerem der neugeborenen, 526. Sclerema, 521. neonatorum, 526. of the new-born, 526. Sclereme des adultes, 521. Scleriasis, 521. Scleroderma, 521. diagnosis of, 524. etiology of, 525. neonatorum, 526. pathology of, 524 prognosis of, 526. symptoms of, 521. treatment of, 525. Scleroma adultorum, 521. Sclerosis corii, 521. Sclerostenosis, 521. Scooping in skin-diseases, 115. Scorbutus, 158. Scraping in skin-diseases, 115. Scratching as a cause of skin-diseases, 64. Scrofulide erythemateuse, 587. tuberculeuse, 592. Scrofuloderm, phlegmonous, 611. ulcerative, 611. Scrofuloderma, 611. diagnosis of, 612. etiology of, 613. formulary for, 779, 811, 839, 862. pathology of, 612. phlegmonosum, 611. prognosis of, 616. treatment of, 613. Scrotum, itching of the, 806, 859. pruritus of, 806, 859. Scurvy, 158. land, 157. sea, 158. 447, 888 DISEASES OF THE SKIN. Scurvy, treatment of, 160. true, 158. Season, effect of, on skin-diseases, 59. Sebaceous cyst, 136. diagnosis of, 136. pathology of, 137. prognosis of, 137. symptoms of, 136. treatment of, 137. Sebaceous glands, 12, 13, 33. matter, 13. tumor, 136. Sebiparous glands, 12, 13, 33. Seborrhagia, 123. Seborrhcea, 123. capitis, 124. congestiva, 587. corporis, 125. diagnosis of, 126, 128, 388, 494, 743, 757. dry, 124 etiology of, 128. faciei, 125. formulary for, 780, 811, 840, 862. genitalium, 125. of the body, 125. of the face, 125. of the genitals, 125. of the head, 124 oily, 126. oleosa, 126. pathology of, 128. prognosis of, 132. scaly, 124. sicca, 124 symptoms of, 123. treatment of, 129. Sebum, 13, 33. Secondary lesions, 45. Secretion, anomalies of, 122, 123. cutaneous, 33. disorders of, 122, 123. Sensation, 28. Sex, effect of, on skin-diseases, 49, 58. Shingles, 293. Silver oleate, 95. Skin, the, abscess of, 366. absorption of, 30. acute circumscribed oedema of, 281. anaemia of, 52. anaesthesia of, 694. analgesia of, 694. anatomy of, 1. kin and kidneys, relation of, 34. atrophy of, 54, 122, 555. blood-vessels of, 3, 21. cancer of, 665. carcinoma of, 665. cells of, 4, 9. cicatrices of, 47, 669, 673. colloid degeneration of, 679. color of, 1, 5, 6. congestion of, 40. contusions of, 367. discoloration of, 40. dissecting wounds of, 367. electric currents of, 36. evaporation from, 26. excretion from, 33. exudations of, 162. functions of, 25. furrows of, 3. glands of, 9. glossy, 558. hajmorrhage of, 53. hyperaemia of, 52, 150. hyperaesthesia of, 694. hypertrophy of, 54. inflammatory fungoid neoplasm of, 692. layers of, 3. lymphatics of, 22. muscles of, 20. neoplasms of, 122, 584. nerves of, 3, 23. neuralgia of, 694. neuroses of, 694. new formations of, 54, 584. non-medullated nerves of, 24. odor of, 37. pain in, 694. papiliae of, 7. parasites of, 55. perspiratory function of, 33. physiology of, 25. piebald, 547. poisoned wounds of, 368. pruritus of, 696. redness of, 40. respiratory function of, 27. rheumatism of, 694. sarcoma of, 661. secretion from, 33. sensation of, 28. sensibility of, 29. temperature of, 25. INDEX. Skin, transpiration of, 26. tuberculosis of, 617. tumors of, 584. ulcers of, 369. vascular papillae of, 22. wounds of, 367. Skin-diseases, acid baths in, 80. alimentary affections as causes of, 61. alkaline baths in, 80. anaesthesia of, 38. anaesthetics in, 97. anthrarobin in, 106. antimony in, 75. antiparasitics in, 99. antiseptics in, 109. aristol in, 108. arrangement of, 51. arsenic in, 71. astringent baths in, 80. bacteria of, 56, 57. baths in, 79. blood-letting in, 113. bromine baths in, 80. calx sulphurata in, 78. carbolic acid in, 78. cataplasms in, 84. causes of, 58. caustics in, 99. cauterization in, 115. chlorate of potassium in, 77. chloroform in, 97. chrysarobin in, 106. classification of, 122. coca in, 100. cocaine hydrochlorate in, 98, 100. oleate in, 93. cod-liver oil in, 70. color of, 51. compression in, 112. constitutional diseases as causes of, 62. symptoms of, 49. treatment of, 65. contagion as a cause of, 64 creasote in, 78. diagnosis of, 48. diet in, 66. dietetic errors as causes of, 61. disturbance of internal organs as causes of, 62. dress in treatment of, 66. duration of, 51. dusting-powders in, 85. electricity in, 115. Skin-diseases, electro-cautery in, 115. electro-vapor baths in, 81. emollient baths in, 80. enucleation in, 114. erythroxylon coca in, 100. escharotics in, 99. ether in, 97. etiology of, 58. excision in, 114. exciting causes of, 60. exercise in, 66. formulary for, 765, 824 galvanism in, 117. gelatine in, 103. general appearance of, 50. considerations in regard to, 1. gutta-percha in, 104. hamamelis in, 105. hot-air baths in, 80. hydrastine in, 100. hydrogen dioxide in, 109. hygiene of, 65. hyperaesthesia in, 38. ichthyol in, 101. idiopathic, 58. incisions in, 114. influence of age on, 49, 58. of chemical irritants on, 63. of climate on, 59. of clothing on, 62. of cold on, 62. of debility on, 60. of dentition on, 60. of diathesis on, 59. of general condition on, 50. of habits on, 50, 63. of heat on, 62. of heredity on, 60. of inspection of, 48. of lactation on, 60. of light on, 48. of mechanical irritants on, 63. of medicines on, 61. of occupation on, 50, 59. of parasites on, 64. of personal habits on, 64. of plethora on, 59. of pregnancy on, 60. of scratching on, 63. of seasons on, 59. of sex on, 49, 58. of temperament on, 49. of temperature on, 48. 890 DISEASES OF Skin-diseases, influence of vaccination on, 61. iodine and its preparations in, 77. iodine baths in, 80. iodoform in, 107. iodol in, 108. iron and its preparations in, 70. jequirity in, 103. leeching in, 114. lesions of, 39, 45, 51. local treatment of, 79, 111. location and extent of, 51. lotions in, 86. massage in, 111. mechanical remedies in, 111. medicated baths in, 79, 81. medicines as causes of, 61, 452. mercurial baths in, 80. mercury and its preparations in, 76. microscopic examinations of, 51. mineral fats in, 87. naphthol in, 100. needle-knife in, 114. neurotic disturbances as causes of, 61. objective symptoms of, 39, 50. odor of, 49. oils in, 84. ointment in, 86. pain in, 38. palpation in, 49. pastes in, 104. pathology of, 52. phosphorus and its preparations in, plasters in, 98, 867. potassium chlorate in, 77. sulphuret baths in, 80. poultices in, 84. predisposing causes of, 58. primary lesions of, 39. prognosis of, 58,120. pruritus of, 38. puncturing in, 114. quinine in, 71. resorcin in, 105. rest in, 66. rhigolene in, 97. salicylic acid in, 106. salol in, 106. scarification in, 114. scooping in, 114. scraping in, 115. secondary lesions of, 45. soaps in, 82. THE SKIN. Skin - diseases, sodium sulpholeate in, 97. subjective symptoms of, 38, 50. sulphur in, 78. symptomatic, 58. symptomatology, 38. tar in, 78, 106. tartar emetic in, 75. thiol in, 102. thio-resorcin in, 102. treatment of, 65. tumenol in, 102. turpentine in, 76. vapor-baths in, 81. venesection in, 114. ventilation in, 65. water-baths in, 79. witch-hazel in, 105. Small-pox, 180. Snuffles in congenital syphilis, 262. Soap or soaps, alum, 820. amber, 820. aristol, 869. arnica, 820. balsam, 821. benzoic, 869. boro-glyceride, 821. camphor, 821. carbolic acid, 821. chamomile, 821. and sulphur, 821. creasote, 869. creolin, 869. elder-flower, 821. ergot, 821. eucalyptol, 821. glycerine, 821. hard, 83. hydroxylamin, 869. in eczema, 412. in skin-diseases, 82. iodide of sulphur, 822. iodine, 821. iodoform, 869. iodol, 869. kino, 822. lanolin, 869. lead, 822. medicated, 820, 869. menthol, 869. naphthol, 822. naphthol-sulphur, 822. potash, 82. INDEX. Soap or soaps, resorcin, 869. salicylic acid, 822. salol, 869. soda, 83. soft, 82. sublimate, 822. sulphur, 822. tannin, 823. tannin-balsam, 823. tar, 823. thymol, 823. turpentine, 823. wintergreen, 823. witch-hazel, 823. Soda soaps, 83. Sodium arsenite in skin-diseases, 72. sulpholeate in skin-diseases, 97. Soinmersprosse, 477. Spargosis, 531. Spedalskhed, 621. Spitzen condylom, 513. Sporozoa, 437, 620, 656. Spots, 39. atrophic, 559. Spotted fever, cutaneous symptoms of, 198. Squamae, 45. Steatoma, 136, 679. Steatorrhcea, 123. Steatozoon, 722. Stings of insects, 725, 726. Stratum corneum, 3, 4. granulosum, 3, 4. lucidum, 3, 4. Malpighii, 5. mucosum. 3, 5. of Langerhaus, 4. of CEhl, 4 Strawberry tongue, 169. Striae atrophica?, 559. Strophulus albidus, 135. prurigineux, 287. Strychnine oleate, 96. Subjective symptoms of skin-diseases, 38, 50. Sudamina, 146. diagnosis of, 146, 301, 313. etiology of, 146. pathology of, 146. symptoms of, 146. treatment of, 146. Sudatoria, 137. Sudor sanguineus, 161. Sudoriparous ducts, 9. glands, 9. Suet as a base for ointments, 86. Sulphur in skin-diseases, 78. Sweat, 11. bloody, 145, 161. cold, 21. colored, 144. glands, 9. increased secretion of, 137. odorous, 142. secretion of, 9. stinking, 142. urinous, 145. Sweating, cessation of, 141. general, 137. local, 138. post-mortem, 35, 36. profuse, 137. Sycosis, 339. diagnosis of, 341, 387, 433, 753. epilation in, 344. etiology of, 342. non-parasitaire, 339. non-parasitic, 339. parasitic, 752. pathology of, 341. prognosis of, 344. puncturation in, 344. symptoms of, 340. treatment of, 342, 781, 840, 863. Symptomatology, 38. Symptoms, subjective, 38. Syphilides, 219. acuminated pustular, 228. bullous, 232. color of, 219. crusts of, 220. erythematous, 221. gummatous. 233. lenticular, 223. macular, 221. miliary, 223. papular, 222. 224. papulo-squamous, 225. pigmentary, 222. polymorphism of, 220. pustular, 227, 349. scales of, 220. subjective symptoms of, 220. tubercular, 231. ulcerations of, 220. vesicular, 226. 892 DISEASES 0 Syphilis, 214. bubo of, 217. congenital, 259. diagnosis of, 263. prognosis of, 266. treatment of, 264. diagnosis of, 126, 151, 152, 184, 210, 217, 317, 332, 341, 355, 389, 441, 447, 494, 510, 588, 596, 630, 653, 663, 757. electrical cataphoresis in, 254. eliminative treatment of, 241. etiology of, 236. formulary for, 782, 812, 841, 863. hereditary, 259. hygienic treatment of, 240. infantile, 259. diagnosis of, 263. later, 218. treatment of, 254. local treatment of. 256. mercurial fumigation in, 249. inunction in, 248. plaster in, 249. mercurialized traumaticin in, 250. mercury in, 76, 242. hypodermic injections of, 250. papules of, 222. pathology of, 235. primary, 214. prognosis, 258. pustules of, 227, 349. secondary, 218. specific treatment of, 241. superficial erosion of, 216. symptoms of, 214. tertiary, 218. tonic treatment of, 241. treatment of, 238. ulcerations of, 220. Syphiloderm, variola-form, 228. Syphiloma, 233. Tache de vin, 680. Tactile corpuscles, 24, 28. sensibility, 27. Tasnia solium, hydatid of, 724. Tar in eczema, 412. in skin-diseases, 78, 106. Tartar emetic in skin-diseases, 75. Tattooing, 482. Teigne faveuse, 734 tondante, 741. THE SKIN. Telangiectasis, 680, 681. Temperament, effect of, on skin-diseases, 49. Temperature, effect of, on skin-diseases, 48. of the skin, 25. sense of, 27, 29. Thiol, 102. Thioresorcin, 102. Thiosinamin, 604. Tick, 726. Tin oleate, 96. Tinea barbae, 752. capitis, 741. circinata, 755. diagnosis of, 757. etiology of, 758. parasite of, 757. pathology of, 758. prognosis of, 761. symptoms of, 755. treatment of, 758. cruris, 756. decalvans, 570. favosa, 734. diagnosis of, 736. epidermis, 734. etiology of, 738. gastritis, 734. parasite of, 736. pathology of, 736. pilaris, 734. prognosis of, 741. symptoms of, 734. treatment of, 738, 814, 864 unguium, 734, 735. universalis, 734. furfuracea, 123. imbricata, 756. sycosis, 752. diagnosis of, 753. etiology of. 754. parasite of, 754. pathology of, 754. prognosis of, 755. symptoms of, 752. treatment of, 754. tonsurans, 741. diagnosis of, 743. etiology of, 745. parasite of, 741, 744. pathology of, 744. prognosis of, 751, INDEX. 893 Tinea tonsurans, symptoms of, 742. treatment of, 746. trichophytina, 741. barbae, 741, 752. capitis, 741. corporis, 741. parasite of, 741. unguium, 741. versicolor, 727. diagnosis of, 221, 480, 728. etiology of, 731. parasite of, 730. pathology of, 730. prognosis of, 733. symptoms of, 727. treatment of, 731, 815, 865. Touch-cells of Merkel, 24 corpuscles, 24. limit of confusion of, 26. Transpiration, cutaneous, 26. Trichauxis, 538. Trichomycosis nodosa, 760. Trichonosis discolor, 550. Trichophytie circinee, 755. sycosique, 752. Trichophyton, 55, 741, 744, 754, 757. tonsurans, 741. Tubercles, 42. syphilitic, 42. Tubercula miliaria, 135. sebacea, 135. Tuberculae, 42. Tuberculin, 603. Tuberculinum, 603. Tuberculosis cutis, 617. of the mucous membranes, 617. of the skin, 617, 842, 865. verrucosa, 618. Tumenol, 102. Tumeurs folliculeuses, 619. Tumor, 42, 122. cavernosus, 680, 682. fatty, 679. horny, 487. of the skin, 584. Tumores, 43, 122, 584 Turpentine in skin-diseases, 76. Tyloma, 484. Tylosis, 484 Typhoid fever, cutaneous symptoms of, 197. Typhus fever, cutaneous symptoms of, 184, 197. Ulcer, perforating, of foot, 649. Ulcera, 369. Ulcerations, syphilitic, 220. Ulcers, 369, 783, 815, 842, 866. acute, 369. chronic, 369. crateriform, 651. treatment of, 370. Ulcus, 369. Umbilicus, eczema of, 439. Unguentum caseini, 91. Uridrosis, 145. Urine, sweating of, 145. Urticae, 41. Urticaire, 271. Urticaria, 271. acute, 273. bullosa, 273. chronic, 274. diagnosis of, 267, 274, 306, 421, 729. etiology of, 275. formulary for, 783, 816, 843,'866. haemorrhagica, 274. intermittent, 274. nodosa, 274. papulosa, 273. pathology of, 275. pigmentosa, 281. prognosis of, 281. symptoms of, 271. treatment of, 277. Vaccination, 193. effect of, on skin-diseases, 61. eruptions, 196. Vaccinia, 193. Vagina, eczema of, 771, 830. pruritus of, 807, 859. Vapor-baths, 81. Varicella, 191. diagnosis of, 146,184,191, 227, 312, 347. etiology of, 192. pathology of, 192. prognosis of, 192. symptoms of, 191. treatment of, 192. Varicose ulcers, diagnosis of, from syph- ilitic, 233, 234 Variola, 180. confluens, 181. diagnosis of, 184, 230, 317, 386. discreta, 180. etiology of, 186. "894 DISEASES OF THE SKIN. Variola, formulary for, 784, 816, 843, 867. maligna, 182. pathology of, 185. prognosis of, 191. symptoms of, 180. treatment of, 187. Variole, 180. Varioloid, 183. diagnosis of, 191, 227. Varus-Finnen, 314. Vascular papillae, 22. Vaseline as a base for ointments, 87. Vater, corpuscles of, 23. Vegetation dermique, 513. Venereal wart, 513. Venesection in skin-diseases, 114. Venice turpentine in skin-diseases, 76. Ventilation in skin-diseases, 65. Veratrine oleate, 96. Vernix caseosa, 123. Verruca, 512. acuminata, 513. digitata, 513. elevata, 513. etiology of, 514 filiformis, 513. formulary for, 785, 844, 867. necrogenica, 618. pathology of, 514. plana, 513. prognosis of, 516. senilis, 513. symptoms of, 512. treatment of, 514. vulgaris, 513. Verrue, 512. Vesicles, 43. Vesicula?, 43. Vibices, 40, 154 Virus, bovine, 194. humanized, 194. Vitiligo, 547. diagnosis of, 530, 630, 729. etiology of, 548. pathology of, 548. prognosis of, 548. symptoms of, 547. treatment of, 548. Vitiligoidea, 676. Wagner, corpuscles of, 24. Wandering cells, 6. Wart, 512. fig, 513. lymphatic, 688. moist, 513. pointed, 513. venereal, 513. Warze, 512. Water-baths in eczema, 406, 411. in skin-diseases, 79. Wax of ear, 12. Wen, 136. Wheals, 41. Whiteness of hair, 550. Wine-nose, 335. Witch-hazel in skin-diseases, 105. Wood-beetle, 726. Wood-tick, 726. Wool-fat as a basis for ointments, 88. Wounds of the skin, 367. Xanthelasma, 676. Xanthelasmoidea, 281. Xanthoma, 676. diagnosis of, 677. etiology of, 678. pathology of, 677. planum, 676. prognosis of, 679. symptoms of, 676. treatment of, 678. tuberosum, 677. Xeroderma, 516. pigmentosum, 556. Vaws, 646. Zinc oleate, 96. Zona, 293. lumbo-femoralis, 295. occipito-collaris, 295. ophthalmicus, 295. pectoralis, 295. sacro-genitalis, 295. sacro-ischiaticus, 295. Zoster, 293. auricularis, 295. cervico-brachialis, 295. cervico-subclavicularis, 295. faciei, 295. frontalis, 295. Zymotic diseases, diagnosis of, from skin- diseases, 386. THE END. A SYSTEM OF GENITO-URINARY DISEASES, SYPIULOLOGY, AND DERMATOLOGY. CONSISTING OF THREE VOLUMES, AS FOLLOWS: VOL. I, GENITO-URINARY DISEASES; VOL. II, SYPHILOLOGY; AND VOL. Ill, DERMATOLOGY. BY VARIOUS AUTHORS. Edited by PRINCE A. MORROW, M. D. SOLD ONLY BY SUBSCRIPTION. " This system, judged by the first volume, will be an invaluable aid to every man who treats genito-urinary diseases—and who does not? It will be more than an aid : it will be a guide and monitor. Moreover, it is not out of place to say that reading such a volume is a pleasure in itself on account of the good paper, clear imprint, and exquisite bookmaking that always characterize Appletons' publica- tions."—Denver Medical Times. " Throughout the work there is noticeable a uniformity of treatment that is seldom attained in works by various authors. Owing, no doubt, to the careful and efficient supervision of the editor, each contributor has evidently entertained a full appreciation of the nature of his task before commencing it. As the work is de- signed for the general practitioner no less than for the specialist, this feature is of great value, since many chapters would otherwise prove disappointing to one not fully capable of appreciating their meaning. No space is wasted in the recitation of historical data or in speculative discussions. Every chapter is eminently practi- cal, and so subdivided by leading lines in black letters as to make it easy of refer- ence."—Ohio Medical Journal. " The scheme of copartnership in book production—especially in works of such pretension—seems to be simply an outcome of the onward march of science and its achievements. No one man could have written this treatise upon syphilis within any period of time at all proportionate to that consumed by the twenty-three con- tributors in making it ready for the printer's hands. No one author could have treated all the subjects equally well; and it seems eminently proper that the eye specialist should write upon syphilis as it implicates the eye tissues, the neurologist upon that of the nervous system, the orthopaedic surgeon upon syphilis of the bones. The prevailing tendency stamped upon every chapter is the avoidance of unimportant details; and the evident intention that each subject shall be the ex- ponent of the author's views and personal experience, has resulted in a striking freedom from bibliographical references. Throughout, the individual work of eaah writer gives the impression of having been carefully done, and with the desire to make it worthy of the scope and aim of the system to which this volume [II] be- longs."—Medical Record. D. APPLETON AND COMPANY, NEW YORK. A Practical Treatise on Diseases of the Skin. By HENRY G. PIFFARD, A.M., M.D., Clinical Professor of Dermatology, University of the City of New York; Surgeon in Charge of the New York Dispensary for Diseases of the Skin; Consulting Surgeon to Charity Hospital; Consulting Surgeon to the Bureau of Out-door Eelief, Bellevue Hospital; Consulting Dermatologist to the Board of Health, etc. With Fifty full-page Original Plates and Thirty-three Illustra- tions in the Text. Folio form. Sold only by Subscription. " The work before us is one of the best yet published for the general prac, titioner. The author's name is sufficient to give it authority on any subject with which it deals. . . . There are no theoretical or controversial discussions, which would serve only to perplex any one but a specialist, and what is necessary to be said is put in the most practical manner, and in the fewest possible words. "The plan of the work and its execution are both indeed excellent. We have seen no work which we can, with so much confidence, recommend to our readers, who are in need of help in the diagnosis and treatment of this very im- portant class of diseases. The plates and figures are really illustrative of the text, are beautifully executed, while the letterpress and binding are all that can be desired."—Canada Lancet. "... Beyond doubt the most important part of the book is the plates, and their excellence and number give it a unique character. Probably photography has never before been used so successfully to illustrate diseases of the skin, and the excellence of some of the plates in the book is so great as far to surpass any- thing of the kind that has as yet come under our observation. . . . Some of the plates are a revelation in so far as they show the extent to which photography may be used to depict the clinical appearances of some diseases of the skin. "... Dr. Piffard has produced a work which testifies unmistakably to his power of observing accurately and of reproducing artistically those appearances on which the diagnosis and treatment of skin diseases chiefly depend, while bis remarks on treatment give evidence of a wide experience in dermatological therapeutics."—British Medical Journal. D. 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