SKIN DISEASES, 
INCLUDING THEIR 
DEFINITION, SYMPTOMS, DIAGNOSIS, PROGNOSIS, 
MORBID ANATOMY, AND TREATMENT. 
A MANUAL FOR 
STUDENTS AND PRACTITIONERS. 
By MALCOLM MORRIS, 
JOINT LECTURER ON DERMATOLOGY AT ST. MARY’S HOSPITAL MEDICAL SCHOOL, 
AND FORMERLY CLINICAL ASSISTANT, HOSPITAL FOR DISEASES OF THE 
SKIN, STAMFORD STREET, BLACKFRIARS. 
WITH ILLUSTRATIONS. 
PHILADELPHIA: 
II E N R Y C. LEA. 
1 8 8 0. PREFACE. 
In undertaking this little work, ray object has been to 
supplement, not to supplant, existing treatises upon a sub- 
ject which it is difficult to condense and arrange, and one, 
therefore, which has proved tedious to the student. 
Commenced some months ago, to assist not only the 
students, but myself also, in the delivery of a course of 
Lectures at St. Mary’s Hospital Medical School, it has 
by degrees so far exceeded its original limits as to have 
suggested the second half of its present title; for, while 
its simplicity will, it is hoped, adapt it to the wants of the 
student, its conciseness may commend it to the general 
practitioner. 
To Mr. Jonathan Hutchinson and Mr. Warren Tay 
r am especially indebted for the useful knowledge which 
I obtained from them whilst acting as Clinical Assistant 
at the Hospital for Diseases of the Skin, Blackfriars; and 
to my friend and colleague, Dr. Cheadle, I owe my sincere 
thanks for kind assistance and for special opportunities 
of observing many interesting cases. 
Moreover, I have not hesitated in the process of com- 
pilation to make constant requisition upon numerous au- 
thorities on Dermatology, both British and Foreign. 8 
PREFACE. 
The Anatomy of the Skin in the first chapter is 
founded chiefly upon Biesiadecki’s article in Strieker’s 
“Manual,” and Klein and Noble Smith’s “ Atlas of His- 
tology.” The plates which have been placed at my dis- 
posal by Dr. Klein form but a part of the kindness I have 
received at his hands, and which I here heartily wish to 
acknowledge. For the skilful execution of the woodcuts, 
I think I am justified in speaking in no measured terms 
of the able work of Mr. Noble Smith. 
I must also express my thanks to my friend, Dr. Alfred 
Sangster, for much valuable assistance. 
M. M. 
63 Montagu Square, Hyde Park, W. 
November, 1879. CONTENTS. 
CHAPTER I. 
Anatomy and Physiology, ........ 13 
CHAPTER II. 
Morbid Anatomy, 31 
CHAPTER III. 
Classification, .......... 40 
CHAPTER IV. 
Scarlatina—Morbilli—Rotheln, ....... 46 
CHAPTER V. 
Variola—Varicella—Vaccinia, 61 
CHAPTER VI. 
Typhus—Enteric—Diphtheria, . . . . . . .74 
CHAPTER VII. 
Equinia—Pustula maligna—Verruca necrogenica—Frambcesia 
—Erysipelas—Septicsemic rashes—Surgical rash, . . 85 10 
CONTENTS. 
CHAPTER VIII. 
Syphilis—Infantile syphilis—Vaccino-syphilis, ... 97 
CHAPTER IX. 
Erythema simplex, laeve, fugax, intertrigo; multiforme, including 
papulatum, tuberculatum; annulare, iris, gyratum—Erythema 
nodosum—Roseola—Urticaria—Pellagra, .... 117 
CHAPTER X. 
Lichen simplex, ruber, planus, marginatus, scrofulosorum—Prurigo— 
Prurigo infantum—Relapsing prurigo, . . . .129 
CHAPTER XI. 
Herpes febrilis, gestationis, iris—Hydroa—Pemphigus vulgaris, foli- 
aceus, 142 
CHAPTER XII. 
Eczema simplex—Acute: Eczema erythematosum, squamosum, papu- 
latum, vesiculosum, pustulosum, fissum seu rimosum, rubrum, 
Ecthyma — Chronic: Eczema capillitii, faciei, articulorum, 
manuum et pedum, crurale, genitale, corporis—Intertrigo—Por- 
rigo or Impetigo contagiosa, . . . . . .150 
CHAPTER XIII. 
Pityriasis rubra—Psoriasis vulgaris—Pityriasis, . . . 168 
CHAPTER XIV. 
Furunculus—Anthrax—Delhi boil—Ulcers, .... 177 
CHAPTER XV. 
Hvpenemia—Anaemia—Haemorrhages of the Skin—Purpura simplex, 
papulosa, rhemnatica, heemorrhagica—Scorbutus—Haematidro- 
sis, 1S7 CONTENTS. 
11 
CHAPTER XYI. 
Zoster—Cheiro-pompholyx—Pruritus—Dystrophia cutis, . 197 
CHAPTER XVII. 
Ephelis — Lentigo — Melanoderma — Morbus Adaisonii—Chloasma 
uterinum — Ichthyosis — Xeroderma — Morphoea.—Scleroderma 
—Sclerema neonatorum—Elephantiasis Arabum—Elephantiasis 
teleangiectodes—Dermatolysis, 209 
CHAPTER XYI 11. 
Albinismus—Leucoderma—Atrophia cutis, ! 226 
CHAPTER XIX. 
Clavus—Tylosis—Yerruca — Cornu cutaneum—Keloid—Fibroma— 
Xanthoma—Lupus vulgaris—Lupus erythematosus — Rhino- 
scleroma—Nsevus—Angioma—Lymphangioma, . . 230 
CHAPTER XX. 
Lepra maculosa, tuberosa, ansesthetica—Carcinoma—Epithelioma— 
Ulcus rodens—Sarcoma, 255 
CHAPTER XXI. 
Seborrhcea oleosa, sicca, Ichthyosis sebacea neonatorum—Acne punc- 
tata, comedo, milium—Acne vulgaris—Acne sycosis—Acne ro- 
sacea — Molluscum contagiosum — Hyperidrosis — Anidrosis — 
Bromidrosis—Chromidrosis—Sudamina, .... 269 
CHAPTER XXII. 
Hirsuties—Lichen pilaris—Xtevus pilosus—Canities—Alopecia— 
Alopecia areata—Trichorexis nodosa—Onychia—Onychogry- 
phosis — Onychauxis — Onychatrophia — Changes in the nails 
during general diseases, ....... 285 12 
CONTENTS. 
CHAPTER XXIII. 
Pediculosis—Scabies—Eruptions produced by fleas, bugs, etc.—Tinea 
tonsurans—Kerion—Tinea sycosis—Tinea circinata—Eczema 
marginatum—Tinea versicolor—Tinea favosa, . . . 294 
CHAPTER XX I Y. 
Eruptions produced by drugs, 314 
Index, ........... 317 MANUAL 
OF 
SKIN DISEASES. 
CHAPTER I. 
ANATOMY AND PHYSIOLOGY. 
Anatomy. 
The skin is the covering of the body which protects the 
more delicate tissues from injury, and joins the mucous 
membrane at the various orifices. The surface is not smooth, 
but consists of elevations, grooves, and depressions. The 
elevations form in places, such as the palm of the hand and 
sole of the foot, lines and wrinkles. The smallest elevations 
are caused by the prominence of the papillse of the true 
skin. The grooves correspond to the lines or wrinkles, and 
lie between them. The depressions or pores of the skin are 
produced by the openings of the hair follicles, sebaceous 
and sweat glands, 
The skin consists of two parts: 
The Epidermis, 
The Corium, or true skiu, 
together with more or less subcutaneous connective tissue. 
Besides these two layers there are certain structures to be 
described, viz., adipose tissue, sweat glands, sebaceous glands, 
hair follicles and hairs, muscular tissue, nails, bloodvessels, 
nerves, and lymphatics. 14 
ANATOMY AND PHYSIOLOGY. 
Fig. 1. 
General View of the Skin and Appendages. (After Heit/.inann.j EPIDERMIS. 
15 
Epidermis. 
The epidermis is composed of four different layers or 
strata: 
1. Rete Malpighii, or rete mucosum. 
2. Granular layer. 
3. Stratum lucidum. 
4. Stratum corneum. 
1. Rete Malpighii.—This is made up of a stratified pave- 
ment epithelium. The cells of the deepest layer are co- 
lumnar in form, with oval nuclei; above, there are several 
Fig. 2. 
The Epidermis. 
a, rete Malpighii; 5, granular layer; c, stratum lucidum ; d, stratum corneum. 
(From Klein and Noble Smith’s “ Atlas of Histology.”) 
layers of polyhedral cells, with more or less spherical nuclei. 
The most superficial cells and their nuclei are flattened. 
The polyhedral and the columnar-shaped cells are joined 16 
ANATOMY AND PHYSIOLOGY. 
together by fine fibrils, the so-called prickle cells of Max 
Schultze; these fibres are simply the prolongation of the mass 
of fibrils that constitutes the chief structure of the cells 
themselves. Thus the cells are composed of a delicate net- 
work, called the intracellular network, and a hyaline inter- 
fibrillar substance. Between the cells are the intercellular 
spaces, which are occupied by a clear semi-albuminous sub- 
stance, the intercellular cement. In the spaces are seen 
branched connective tissue corpuscles, and the termination 
of nerves extending from the corium. 
In dark-colored skins the deepest cells contain pigment 
granules. The rete rests upon the true skin, and adapts 
Fig. 3. 
The Structure of Cells. (Klein.) 
itself to the elevations of the papilla?, the prolongations 
between them being named the interpapillary processes. 
2. Granular Layer.—This is a layer of flattened cells, 
spindle-shaped in vertical section, situated on the surface 
or outer aspect of the rete Malpighii. Each cell contains a 
clear nucleus, from the ends of which rodlike granules 
extend. The granular layer is best seen at the mouths of 
the hair follicles and near the nails. 
3. Stratum Lucidum.—This is a bright homogeneous or 
indistinctly striated membrane, composed of closely packed 
scales, some of which contain traces of a nucleus. CORIUM. 
17 
4. Stratum Corneum.—This consists of many layers of 
horny non-nucleated scales. In various parts of the body 
this layer alters considerably in thickness, being very dense 
on the palms and soles. 
Corium. 
The cerium is composed of connective tissue elements, in 
which are imbedded various important organs, such as the 
glands of the skin and their ducts, hairs, bloodvessels, and 
nerves. This connective tissue occurs as a dense felt-work, 
formed by bundles of fibres, which divide and cross each 
other repeatedly. Each bundle is formed of fine fibrils that 
yield gelatin, and are held together by an albuminous fluid 
cement substance. This substance is also found between the 
bundles themselves, each of which probably possesses a 
hyaline sheath as well: acids or boiling cause the bundles 
to swell up. On account of the difference in density, the 
corium is said to be divided into two parts; the superficial 
is known as the papillary body, in which the bundles of 
connective tissue are very thin, less dense, and hence more 
transparent. Between the groups of bundles, or trabeculae, 
are spaces called lacuna;, which anastomose with one another 
by means of narrow channels. These lacuna; and channels 
form the lymph canalicular system, and contain flattened, 
nucleated, branched connective tissue corpuscles, the nucle- 
ated parts lying more particularly in the lacunae, while the 
branched processes extend into the channels. There are 
certain elevations on the surface of the corium, of various 
sizes and shapes, called papillae, between which are processes 
of the rete Malpighii. The largest are found on the palm 
of the hand and fingers. Some only contain vascular loops, 
others also nerve fibres and tactile corpuscles. A thin 
basement membrane lies between the corium and the rete 
Malpighii. 18 
ANATOMY AND PHYSIOLOGY. 
Subcutaneous Tissue. 
In the subcutaneous tissue the bundles of connective tissue 
are aggregated into larger groups, which do not interlace so 
markedly as in the corium. Owing to this arrangement of 
the tissue, it assumes a slightly lamellar-like appearance, 
but many groups of trabeculae run obliquely or even verti- 
cally, and thus continuous spaces are left between the groups 
of bundles. Connective tissue corpuscles line these spaces, 
and lie on the surface of the trabeculae in rows of unbranched, 
flat, endothelial cells. Bright fibrils of elastic tissue, that 
branch and anastomose to form networks, and vary in thick- 
ness, are found also on the surface of the trabeculae, in 
close relation to the corpuscles. In some situations subcu- 
taneous tissue contains considerable quantities of fat, and 
is then called the panniculus adiposus; other parts, such as 
the eyelids, ears, penis, and scrotum, are absolutely destitute 
of fat. A few migratory connective tissue cells lie in the 
spaces of the superficial part of the corium, and also in the 
subcutaneous tissue, very similar to plasma cells, large, 
coai’sely granular, and exhibiting only slight amoeboid move- 
ments. 
Large bloodvessels pass through the subcutaneous tissue, 
where they give off branches to the corium and the other 
organs. 
This tissue is composed of fat cells, which are arranged 
in groups to form lobules, and these again are aggregated 
into lobes. The cells are apparently spherical; each con- 
tains a fat globule, which occupies the bulk of the cell. 
The protoplasm of the cell is reduced to a thin wall, in one 
part of which is seen a more or less compressed nucleus. 
Between the fat cells there are flattened nucleated connec- 
tive tissue cells, and between the lobules there are septa of 
fibrous tissue, with similar but proportionately larger septa 
Adipose Tissue. SWEAT GLANDS. 
19 
between the lobes. Adipose tissue has characters in com- 
mon with gland tissue; thus to each lobe and lobule there 
is an afferent artery and one or more efferent veins, with a 
network of capillaries encircling the fat cells, either indi- 
vidually or in groups of two or three. 
A sweat gland is a tube, composed of a membrana pro- 
pria and of a lining epithelium, which consists of a single 
layer of columnar epithelial cells. The gland proper is 
Sweat Glands. 
Fig. 4. 
Transverse Section oe Sweat Gland. 
a, epithelium ; 6, muscular coat cut transversely ; c, nucleated membrana 
propria ; d, connective tissue. (Sangster.) 
situated in the subcutaneous tissue, and is formed by the 
convolution of the deep part of the tube. The duct passes 20 
ANATOMY AND PHYSIOLOGY. 
from the gland proper in an oblique and vertical dii’ection 
through the corium and epidermis to open on the surface. 
The epidermic portion is called the mouth of the duct; in 
it there is no membrana propria or special epithelium, and 
in consequence it is surrounded only by the cells of the 
epidermis. 
The duct is lined at the commencement by a continuation 
of the rete Malpighii, the cells of which are stratified, but 
gradually, as the deeper parts are reached, the epidermis is 
reduced, first to two layers of pavement cells and then to a 
single layer of short columnar cells, which at the lowest 
portion become elongated. 
The tube of the gland proper, in some parts of the body, 
contains a single layer of thin longitudinal uustriped mus- 
cle fibres, which is situated between the membrana propria 
and the columnar epithelial cells. The glands that have 
this muscular coat are usually larger in size than the variety 
without it, and are especially well developed on the volar 
side of the hand and foot, axillxe, scrotum, labile, and 
scalp. They also occur by the side of the smaller glands. 
The ceruminose glands of the external ear passage are of 
the same structure as the larger variety, with the addition 
of yellowish-brown pigment granules in the epithelial cells. 
Sweat glands occur on all parts of the surface, but are 
more numerous on the palms and soles. 
Sebaceous Glands. 
The sebaceous glands are situated in thecorium, and con- 
sist of gland substance and excretory ducts, which open 
usually at an acute angle into hair follicles, but occasionally 
upon the surface. The gland substance is composed of lob- 
ules, filled with polyhedral cells, which open into the ex- 
cretory ducts. A lobule is therefore a sac containing cells. 
The sac is a transparent and colorless nucleated membrane 
destitute of structure, aud the cells are epithelial cells, the SEBACEOUS GLANDS. 
21 
most external of which resemble those of the deeper layer 
of the rete Malpighii; some in the next layer contain drops 
of fat, whilst those in the centre of the sac are completely 
filled with the same substance. The cavity of the glands 
is occupied by fatty matter and the debris of the epithelial 
cells. The excretory duct consists of a transparent mem- 
Fig. 5. 
Sebaceous Gland. 
brane and an epithelial investment, the cells of which cor- 
respond to the external root sheath, so that a sebaceous gland 
is really a protrusion of a hair follicle. The larger glands 
nearly surround the hair follicle, and are composed of several 
lobules. There are no sebaceous glands on the palm, sole, 
dorsum of the third phalanges, or glans penis, and the largest 22 
ANATOMY AND PHYSIOLOGY. 
are found at the entrance of the nose, the lips, the labia ex- 
terna, and the scrotum. 
Hair Follicle. 
This is a depression in the corium which has a blind in- 
ferior dilatation and a funnel-shaped excretory duct. The 
Fig. 6. 
Transverse Section of Hair and Hair Follicle. 
neck is the contracted part below the duct where the seba- 
ceous follicle opens. The follicle itself consists of two parts: 
1. The hair sac. 
2. The root sheath. 
The hair sac consists of three layers,—external, middle, 
and internal. 
The external layer is composed of fibres of connective tis- 
sue which run parallel to the axis of the hair and join the 
fibres of the corium above, whilst below they encircle the 
dilated extremity of the follicle. 
The middle layer is formed of transverse fibres of connec- 
tive tissue, between which is a homogeneous, slightly granu- 
lar material that contains numerous rod-shaped, transversely 23 
HAIR FOLLICLE. 
arranged nuclei. This layer is highly contractile. Between 
these two layers are situated two or more longitudinal blood- 
vessels, which by their free anastomoses form a network 
around the follicle. The papilla of the hair protrudes into 
the cavity of the follicle, and is constituted of connective 
tissue fibres derived from this layer. The constricted por- 
tion of the papilla is the neck, and the thicker part the 
body, which has a conical extremity. The length is gen- 
erally double the breadth. 
The internal layer, thin and transparent, is a continuation 
of the basement membrane of the corium, and is called 
the vitreous membrane; the outer surface is smooth, whilst 
the inner is covered with prickles. 
The root sheath consists of two layers: 
1. The external root sheath. 
2. The internal root sheath. 
Tlie external root sheath is a continuation of therete Mal- 
pighii, which dips into the follicle, but terminates usually 
at a level with the apex of the papilla. The external layer 
of cells, viz., those that are in contact with the basement 
membi'ane, are columnar in shape, with nuclei at the inner 
extremity; the cells of the next layer are polyhedral, and 
the most internal are flattened. The sheath is thinnest at 
the neck of the follicle, but becomes thicker towards the 
bulb, where in the hairs of embryos and children small, 
simple or compound, budlike prolongations of the cells are 
seen. 
The internal root sheath consists of two layers : 
1. The outer or Henle’s layer. 
2. The inner or Huxley’s layer. 
1. The outer or Henle’s layer is a thin, transparent mem- 
brane, which commences at the neck of the follicle and ex- 24 
ANATOMY AND PHYSIOLOGY. 
tends as far as the external root sheath. The membrane is 
composed of oblong, non-nucleated, highly refractile scales 
in immediate contact with one another, which run parallel 
to the long axis of the hair. 
2. The inner or Huxley's layer consists of flattened, fusi- 
form, nucleated cells filled with small refractile granules. 
At the lower part of the follicle, and also towards the neck, 
the two layers are indistinguishable. The follicles of lanu- 
ginous hairs are so small that the relations between them 
and the sebaceous glands are reversed, and they appear 
merely appendages of the relatively large gland. 
Muscular Tissue. 
btnated muscular tissue is present in the skin of the face, 
where it terminates in the corium. 
A small involuntary muscle, called arredor pili, arises in 
the upper part of the corium, passes obliquely through it, 
and is inserted into the inner sheath of the hair follicle 
below the sebaceous gland; but some hair follicles have 
two muscles, which encircle the gland, and have a twofold 
action—to erect the hair and to compress the gland. There 
is, however, other involuntary muscular tissue in the corium, 
which runs either horizontally, as in the scrotum (dartos), 
or circularly, as in the nipple and in the areola around it. 
A hair is divided into the shaft, which projects beyond 
the skin, and the root, which lies imbedded in the hair 
follicle. The structure of a hair consists of cortical sub- 
stance, with addition, in some of the larger hairs, of a cen- 
tral medulla, composed of granular polyhedral cells. 
A cuticle of homogeneous, transparent, nou nucleated 
scales, overlapping one another at their margins, incloses 
the cortical part. The root, which terminates in the bulb, 
Hair. HAIR—NAILS. 
25 
surrounds a papilla projecting from the corium at the bot- 
tom of the follicle, and is composed of nucleated cells re- 
sembling the deeper cells of the rete Malpighii. The outer 
of these cells are flattened, and the inner are columnar in 
form and rest upon the surface of the papilla. In the root 
there is, besides the above-mentioned cuticle, another layer 
of flattened cells, which fits into spaces between these, and 
is continuous with Huxley’s layer. The cortical substance, 
which is colorless in gray hairs and contains various colored 
pigment granules in other hairs, is, in the main portion, 
composed of longitudinal fibres, which, towards the bulb, 
appear as fusiform cells with rod-shaped nuclei, and which, 
at the transition into the bulb, become shorter and shorter 
until the polyhedral cells constituting the bulb are reached. 
Hairs grow by the multiplication of the cells of the bulb 
lying next to the papilla. These new cells are gradually 
pushed outwards by the formation of yet newer cells, and 
become more fusiform as they leave the papilla. They also 
become more elongated, owing, perhaps, to the pressure of 
the internal root sheath. Hair are dissolved by strong so- 
lutions of potash. 
Nails. 
The nails are horny, elastic, transparent, concavo-convex 
laminae imbedded in the skin on the dorsal surface of the 
last phalanges, and are composed of nucleated epidermic 
cells firmly cemented together. They have an anterior, a 
posterior, and two lateral borders, an upper convex and a 
lower concave surface, the latter of which is situated on 
what is called the bed of the nail. This bed is formed by 
the rete Malpighii, the corium, and the subcutaneous tissue 
below it. 
The last contains no fat, and its fibres pass in separate 
bundles from the periosteum of the phalanges backwards to 
the posterior border or root of the nail. The anterior part 26 
ANATOMY AND PHYSIOLOGY. 
of the upper surface of the corium appears in ridges, con- 
sisting of parallel fibres of connective tissue, between which 
lie numerous fusiform cells, and the posterior part is covered 
with small papillae. 
These ridges and papillae contain loops of bloodvessels, 
which are connected with a coarse plexus in the corium. 
The rete Malpighii is much the same as in other parts, and 
is continuous with the root of the nail, but the stratum lu- 
cidum shows a distinct layer of granular cells. 
Bloodvessels. 
The large trunks of both arteries and veins are situated 
in the deeper parts of the subcutaneous tissue, forming a 
coarse plexus, and branches of varying length pass from the 
former through the mass of the corium to supply the various 
structures already described. The length of the branches 
depends upon the position of the organs to be supplied, and 
all of them terminate in capillary networks, from which the 
veins take their origin. There are several special capillary 
networks: 
1. For the papillary body, the papillae of which con- 
tain vascular loops. 
2. For the coiled tube of the sweat glands. 
3. For the hair follicles and the arrectores pili. 
4. For the sebaceous glands. 
5. For the adipose tissue. 
Nerves. 
Sensory nerves, composed of both medullated and non- 
medullated fibres, arise from trunks that accompany the 
larger bloodvessels in the subcutaneous tissue. The medul- 
lated fibres pass through the corium, and either end in the 
special terminal organs or become non-medullated, and form 
a subepithelial plexus, from which certain fibrils enter the NERVES. 
27 
rete Malpighii, where they branch and form a delicate ter- 
minal network lying in the intercellular spaces. In a simi- 
lar manner the nerves terminate in the outer root sheath of 
the hair follicle. The special terminal organs are : 
A. Pacinian corpuscles. 
B. End bulbs of Merkel. 
c. Tactile or Meissner’s corpuscles. 
A. Pacinian Corpuscles.—These corpuscles, which are ob- 
long, elliptical, or pointed, consist of a number of capsules 
arranged concentrically around a central elongated clear 
Fig. 7. 
a, vascular; b, nervous papilla; c, bloodvessel; d, medullated nerve fibre; e, 
tactile corpuscle; /, transversely divided medullated nerve fibres. (After Biesia- 
decki.) 
mass. Each capsule is composed of a hyaline ground mem- 
brane, probably elastic, in which are imbedded fine con- 
nective tissue fibres, that lie transversely, and on its inner 28 
ANATOMY AND PHYSIOLOGY. 
surface is lined by an endothelial membrane, formed of a 
single layer of flattened nucleated cells. The corpuscles 
are connected with medullated nerve fibres, which form the 
stalk, and are found most frequently in the subcutaneous 
tissue of the volar side of the hand and foot. The central 
clear mass is the axis cylinder of the nerve fibre, which 
usually divides into two or more branches, that terminate 
in pear-shaped or irregular bodies, called buds, and are 
composed of a dense network of minute fibrils. In some 
instances the corpuscle appears to have a second stalk, which 
is really an artery, that ultimately divides into branches, 
that give rise to a capillary plexus between the capsules. 
B. End Bulbs of Merkel.—These are situated in the tissue 
of the papillae or amongst the epithelium, and occur as 
single large and slightly flattened transparent nucleated 
cells inclosed in a capsule of connective tissue, and are in 
direct connection with the medullated nerve fibres. 
c. Tactile Corpuscles.—These are oval bodies found in 
some of the papillae, more particularly at the ends of the 
fingers. They, like the end bulbs, consist of a capsule, 
which contains a soft core composed of several small cells, 
and the termination of a medullary nerve fibre. 
Lymphatics. 
The lymphatics of the skin are grouped into two systems, 
the superficial and the deep. 
The superficial resemble lymphatic capillaries, as their 
walls are composed of a single layer of endothelial plates. 
They form a network in the superficial part of the corium 
in immediate vicinity to the rete Malpighii and parallel to 
the surface, and into it branches of varying length enter 
from the papillae. 
The deep lymphatics also form a network, which lies in 
the subcutaneous tissue, but the meshes are larger and possess PHYSIOLOGY. 
29 
the character of tubes to a greater degree than in the super- 
flcial plexus. 
These two systems communicate by means of branches 
that are in immediate association with the bloodvessels. 
The adipose tissue contains numerous lymphatics. 
Physiology. 
The skin serves some more or less important services in 
the economy, such as secretion, absorption, and tactile per- 
ception. 
Secretion takes place in the form of perspiration by 
means of the sweat glands, which are continually carrying 
on their functions. 
Perspiration is a clear, colorless, acid fluid, with a dis- 
tinctive odor, that differs in various parts of the body. In 
a healthy man about thirty ounces is secreted in twenty- 
four hours, but this amount may be easily increased accord- 
ing to circumstances. For instance, more is secreted in 
summer than in winter, and more in consequence of exer- 
cise ; certain foods and drugs also increase the flow, while 
at times mental emotion does the same. The perspiration 
that is perceptible to the sight is called sensible, and the 
portion that evaporates insensible. Perspiration consists 
chiefly of water, the average amount of solids being 1.81 
per cent. 
Constituents of Solids. 
1. Sodium chloride and traces of other salts. 
2. Fatty acids, such as formic, acetic. 
3. Neutral fats and cholesterin. 
4. Ammonia (urea), and possibly other nitrogenous bodies. 
(Foster.) 
The amount of carbonic acid given off in twenty-four 
hours is from four to ten grams, and the oxygen that is 30 
ANATOMY AND PHYSIOLOGY. 
absorbed is rather less ; however, the chief substance lost is 
water. 
Animals that have been varnished soon lose heat, and die 
of some form of poisoning due to the absorption of some of 
the constituents of the perspiration. The skin has the 
power of absorbing, as is seen in the action on the system 
of certain drugs, like mercury and arsenic, after they have 
been well applied to the surfaces in a greasy form. The 
body also increases in weight by prolonged immersion in 
fluids. 
For a description of the laws concerning the sense of 
touch the student is referred to the textbooks of Phys- 
iology. 31 
MORBID ANATOMY. 
CHAPTER II. 
MORBID ANATOMY. 
The morbid processes which take place in the skin show 
themselves on its surface as certain discolorations, elevations, 
etc. These have received the name of the primary lesions. 
Enumerated, they are as follows: 
1. Macule. 
2. Papule. 
3. Tubercle. 
4. Wheal. 
5. Vesicle. 
6. Bulla. 
7. Pustule. 
Hebra’s definitions are: 
1. Macule.—Any change in the normal color of the skin, 
arising from disease, and not uniformly distributed over the 
whole surface of the body. 
2. Papule.—Any morbid change in the skin which forms 
a solid projection above the surface, in size between a millet 
seed and a lentil, and containing within it no fluid. 
3. Tubercle.—Any solid swelling of the skin, caused by 
disease, which contains no fluid, is as large as a lentil, bean, 
or hazelnut, and covered with epidermis. 
4. Wheal.—A solid form of eruption slightly raised above 
the surface of the skin, of which the superficial area greatly 
exceeds the thickness. 
5. Vesicle.—An elevation of the horny layer of the epi- 
dermis by transparent or milky fluid, corresponding in size 
to papules. 
6. Bulla.—An elevation of the epidermis, in size between 32 
MORBID ANATOMY. 
a lentil and a goose’s egg, containing transparent or yellow 
purulent fluid. 
7. Pustule.—A small abscess, covered only with epidermis. 
The process of ordinary inflammation of the skin is the 
sole mode of production of such lesions as the wheal and 
bulla, and is also the commonest cause of the other primary 
lesions. 
In considering inflammation of the skin, it is necessary 
to bear in mind a few facts as to its anatomy. There is the 
deep plexus of vessels lying close beneath the level of the 
hair follicles, giving off branches, which in their turn break 
up to form anastomotic networks round the follicle and sweat 
glands. From it also communicating branches pass upwards 
to join the superficial plexus. The latter is situated be- 
neath the papillae, which are freely supplied with branches 
from it. Owing to this distribution of bloodvessels in the 
skin, the papillary body, the hair follicles, and the glands 
are the most vascular parts of the integument, and as such 
are the first to give evidence of the inflammatory process. 
Thus during the early stages of inflammation the dilata- 
tion of the vessels and the increased blood flow give rise to 
hyperaemia of the part, which becomes visible through the 
epidermis. The surface becomes red, and inflammatory 
macules are produced, which, according to their shape and 
distribution, constitute the eruptions known in this country 
as rashes. 
Examples.—Roseola, measles, erythema. 
When the inflammatory process is confined to a minute 
area, as round the orifice of a hair follicle, and when in ad- 
dition to the hyperaemia, there is a further stage of inflam- 
mation present, viz., exudation into the substance of the pa- 
pillae, the inflammatory papule is formed. 
Examples.—Lichen, papular stage of eczema. MORBID ANATOMY. 
33 
If the above condition extends to an area larger than that 
of a lentil, it is termed an inflammatory tubercle. 
Example.—Erythema tuberculatum. 
A similar state produces the wheal, but the inflammatory 
oedema of the papillary body is quite peculiar. The pro- 
cess is very acute, and the exudation readily reabsorbed ; so 
that wheals are characterized by their transitory duration. 
In size they are, if discrete, about as large as the finger- 
nail, or somewhat smaller, but may become much larger by 
confluence. They vary in color according to circumstances, 
but for the most part are usually violet-red. The presence, 
however, of the exuded fluid sometimes forces the blood 
from the vessels, and the wheal then becomes white. As 
this first takes place in the centre, it is not unusual to see 
white wheals with red margins. Wheals are generally ir- 
regular in outline. The process which gives rise to them is 
neurotic in origin, probably causes vaso-motor spasm. 
In the lesions hitherto considered the inflammatory exu- 
dation has not advanced beyond the true skin. In the 
vesicle, however, the serum transudes the boundary line be- 
tween the rete mucosum and the papillm, and making its 
way in the intercellular spaces, pushes the moist Malpighian 
cells asunder, and finally upheaves the horny layer of the 
epidermis. According to the extent of the area of epider- 
mis raised by the exuded serum, a vesicle or bulla results. 
Examples.—Vesicles,in herpes, vesicular stage of eczema; 
bullrn, in pemphigus. 
The transition from the vesicle to the pustule is merely 
the passage of the inflammatory process from a simple se- 
rous exudation to one accompanied by migration of leuco- 
cytes. Thus the fluid of vesicles is often seen to become 
milky, and afterwards straw-colored, as the serum becomes 
richer in cells. 
Example.—Impetiginous eczema. 34 
MORBID ANATOMY. 
Sometimes the inflammatory process subsides rapidly after 
having given rise to one or more of the primary lesions, 
such as papules and vesicles, and generally leaves behind 
it vestiges which may be traced for some time afterwards. 
Whether the inflammation be transitory, whether it per- 
sists and becomes chronic, or is so by its nature from the 
beginning, certain secondary changes are set up in the tis- 
sues. As is well known, the epidermis derives its nourish- 
ment from the papillary body ; consequently, congestion of 
the latter structure leads to a disturbance of nutrition of 
the epidermic cells; they do not pass through their chemi- 
cal and physical changes, and are prematurely shed in larger 
or smaller masses as flakes or branlike scales. This is known 
as desquamation. It accompanies almost every inflamma- 
tory process, whether it be one which is of passing duration, 
as in measles, or whether it be chronic, as in psoriasis. 
The next secondary change in the tissues resulting from 
inflammation is excessive deposit in the pigmentary layer 
of the epidermis, causing more or less brownish staining of 
the part, especially common in chronic inflammations. 
This change is known as pigmentation. There is another 
variety, not so permanent, which may accompany acute in- 
flammatory conditions, and probably arises from the changes 
taking place in the exuded coloring matter of the blood, 
analogous to those seen in bruises. 
An example of the first variety of pigmentation is well 
seen in chronic eczema, and of the second in some forms of 
old-standing urticaria. 
A third change results from the increase in the cellular 
elements in the true skin, whether they be migrants from 
the blood or proliferated from the connective tissue corpus- 
cles already existing in the part. It seems that they ulti- 
mately lead, by a process of fibrillation, to au increase of 
fibrous tissue. Thus the corium and subcutaneous tissue 
become hypertrophied. The fold of skin thus affected is MORBID ANATOMY. 
35 
pinched up with difficulty from the subjacent tissues, and, 
on being compared with a fold of sound skin, the increase 
in substance is at once apparent. 
This infiltration of the skin is well marked in chronic 
eczema. It is always accompanied by pigmentation and 
desquamation. 
There are certain changes, some of which affect the prim- 
ary lesions themselves, which have received the name of sec- 
ondary lesions ; they are : 
1. Scale. 
2. Excoriation. 
3. Crust. 
4. Fissure. 
5. Scar. 
The scale (squama) has already been discussed in con- 
nection with the process of desquamation. 
The excoriation (excoriatio) is produced by the exposure 
of the moist rete by the removal of the horny layers of the 
epidermis. This happens when vesicles burst, or are rup- 
tured by the violence of scratching or rubbing. It is not 
uncommon to see whole areas denuded of horny epidermis 
and exuding drops of serum from the exposed rete. This 
exudation soaks into linen in contact with the part and stiff- 
ens it, or it dries on the surface and gives rise to the sec- 
ondary lesion known as the crust (crusta). 
According to the character of the discharge crusts vary 
in appearance. Simple serous exudation gives rise to gray- 
ish leathery crusts; when there is pus the crusts are yellow, 
and may be brown, or even black, owing to a mixture of 
blood with the exudation. 
The crusts that form on the head and face often have a 
peculiar honeylike appearance, due to the presence of seba- 
ceous matter. Sometimes the affected surface, after having 
ceased to exude and commenced to desquamate, again be- 
comes moist; the crusts and scales thus formed alternately, 
remaining adherent, are called lamellated crusts. 36 
MORBID ANATOMY. 
Crusts are best seen in eczema. 
The fissure (rhagas) is nothing more than a crack in the 
skin. It may extend only to the epidermis, but more fre- 
quently involves the corium. Fissures occur in skin which 
is rendered brittle by infiltration, and especially in parts 
which are subjected to much movement, such as the hands 
and flexures of joints. 
The scar (cicatrix) replaces lost tissue. Scars indicate 
that the inflammatory process has been of the gangrenous 
variety—that is to say, it has been so severe that the cell 
production in the papillary body has caused strangulation 
of the vessels and consequent death of the part. 
This variety of inflammation is characteristic of the dis- 
ease variola, but it may occur spontaneously or as a result 
of continued irritation of the part in other affections— 
herpes, for example. Scars are white, smooth, devoid of 
hair follicles or glands. The appearance of a single scar 
furnishes no information as to its cause. 
It has been shown how the process of ordinary inflamma- 
tion of the skin may produce the so-called primary and 
secondary lesions, howT its severity may cause loss of tissue, 
and how, when chronic, it leads to more or less permanent 
changes in the tissues. 
Although the primary lesions, for the most part, corre- 
spond to certain types of inflammation, they cannot be re- 
garded in any other light than that of evidencing so many 
stages in the inflammatory process, and as such they natu- 
rally pass from one into the other. Thus a disease which 
is generally characterized by the development of macules 
may present tubercles, or even bull*, from the fact that an 
inflammation, which ordinarily stops at simple hypersemia, 
has passed into one accompanied by exudation. Again, the 
eczematous inflammation commences in a papular eruption. 
Here it may cease; but more frequently the papules de- 
velop into vesicles, and these perhaps later on into pustules. MORBID ANATOMY. 
37 
A want of appreciation of the manner in which one type 
of inflammation passes imperceptibly into another has led 
to much confusion in dermatology. 
There are certain specific inflammations of the skin, 
associated with diathetic conditions, such as syphilis, struma, 
and leprosy. These inflammations all commence in the 
substance of the true skin as small rounded cells, which are 
deposited in groups in the spaces of a fine recticulum, and 
are richly supplied with delicately-walled bloodvessels. 
From the great similarity of these deposits to ordinary 
granulation tissue, Virchow includes them all under the 
head of granulation growths. The deposits give rise to 
elevations on the surface, which, according to their size, are 
termed papules or tubercles ; or they may be so superficial 
and diffuse as to appear like a simple macule. After a time 
the disturbance of the nutrition of the epidermis causes 
desquamation, and the tubercles are seen to be covered with 
scales. Unless interfered with by treatment, the tendency 
of these deposits of new growth is to increase until a point 
is reached at which their proper nutrition can no longer be 
maintained ; they then break down and ulcerate ; as they 
heal cicatrices are left, the result of the destruction of tissue 
which perishes with the new growth. 
Some other modes of production of the primary lesions 
must now be briefly noticed. 
A macule is defined as “ any change in the normal color 
of the skin.” Besides the inflammatory macule we must 
include the discoloration caused by the escape of the color- 
ing matter of the blood into the surrounding tissue, as seen 
in purpura. These purpuric macules are distinguished from 
the inflammatory by the fact that the color does not dis- 
appear on pressure. Occasionally one variety passes into 
another. Small dotlike purpuric macules are called pete- 
chise. When once the coloring matter of the blood has 
entered the tissues, the part undergoes a characteristic series 38 
MORBID ANATOMY. 
of changes in color, as seen in bruises. There are white 
macules, due to absence of pigment in the skin, as in leu- 
coderma, and brown, due to excessive deposit of pigment, 
as in liver-spot and freckle, or to parasitic growth, as in 
tinea versicolor. 
Papules arise from many causes besides that already 
pointed out as resulting from inflammatory cedema of the 
papilla?. There are, for instance, the papules arising from 
minute lupus or syphilitic deposit in the corium. They are 
also formed by a heapiug up of the epidermis at the mouth 
of the hair follicle (lichen pilaris). There are conditions 
of the sebaceous glands which lead to the production of 
papules, as when they degenerate and form little white solid 
bodies protruding above the level of the skin, especially in 
the neighborhood of the eyelids {milium). 
A very important mode of forming papules is seen in 
lichen ruber, in which an overgrowth of the cells of the 
external root sheath of the hair is said to take place, and 
ultimately produces the flat-topped, umbilicated papule. 
There are also other less important varieties of papules. 
All that applies to the papule may be said of the tubercle, 
the distinction between them being only the very artificial 
one of size. Tubercles either result from deposits of new 
growths (syphilis, lupus), or from a further development of 
smaller papules, as in the variety of erythema multiforme, 
known as erythema tuberculatum. 
The wheal has already been discussed. Besides the vesicle 
of ordinary inflammation, which is best seen in eczema, it 
is said that there is another variety, produced in connection 
with the sweat duct in the condition known as sudamina. 
Vesicles which occur in situations where the epidermis is 
thick, as on the hands, acquire a peculiar sodden appear- 
ance at their margins, and are now known as the sago-grain 
vesicles. 
Under the head of pustule must be included the catarrhal MORBID ANATOMY. 
39 
pustule, which often occurs as a further development of the 
vesicle, and also those suppurations round the hair follicles 
which result in small abscesses. Although the latter com- 
mence deep in the substance of the corium, the pus makes 
its way to the surface, and they ultimately appear as minute 
abscesses covered only with epidermis (acne). 
The inflammatory bulla is seen in pemphigus. Other 
conditions give rise to the formation of bullte, but chiefly 
as the result of accident (erysipelas, erythema multiforme). 
What may be termed false bullse, as sometimes seen on the 
hands, are produced by the confluence of vesicles. 
The foregoing remarks on the general pathology of the 
skin will serve to show that for purposes of diagnosis the so- 
called primary lesions are, according to their definition, 
wholly useless: 
First, because they may be caused by totally distinct con- 
ditions. 
Secondly, because they may change as the process which 
gives rise to them becomes modified. 40 
CLASSIFICATION. 
CHAPTER III. 
CLASSIFICA TION. 
Nearly every author who has written on skin diseases 
has suggested a new method of classification, based on some 
theory of supposed utility. The first system of any import- 
ance was founded by Willan, whose idea was to class the 
diseases under the heads of the more important external 
manifestations; thus he employed nine orders, each named 
after some particular symptom of an eruption, without pay- 
ing any regard to the general character of the disease. For 
instance, varicella, herpes, and eczema are included in the 
order vesiculse. 
The next classification to be noticed is that of the French 
school, which is called the natural system, because the 
nature of the disease, and not the symptoms, forms its basis. 
This was introduced by Alibert, and modified later by 
Hardy, but has not been used to any great extent in this 
country. 
The anatomical system was proposed by Erasmus Wilson, 
who grouped skin diseases into four principal classes: 
1. Affections of the corium. 
2. Of the sudoriparous glands. 
3. Of the sebiparous glands. 
4. Of the hair and follicles. 
These classes are divided into several sub classes. 
The classification introduced by Hebra, and most fre- 
quently made use of in this country and in America, is 
founded on anatomico-pathological principles. He defines 
twelve classes: TIIE SKIN PROPER. 
41 
1. Hypersemise cutanese. 
2. Ansemise cutanese. 
3. Anomalies of the cutaneous glands. 
4. Exudations. 
5. Hsemorrhagise cutanese. 
6. Hypertrophise. 
7. Atrophise. 
8. Neoplasmata. 
9. Pseudoplasmata. 
10. Ulcerationes. 
11. Parasites. 
12. Neuroses. 
Classification by cause would undoubtedly be the best, if 
sufficiently correct information could always be obtained; 
but in the present state of our knowledge of the subject 
such a plan is only partially possible. However, it will be 
seen that the last two classes in the following system are 
classified on this principle. 
The system in this-work is, in the first place, somewhat 
similar to Erasmus Wilson’s in having two anatomical 
divisions; and, further, with certain slight modifications it 
resembles Hebra’s in subdividing them into pathological 
classes. 
Division I.—DISEASES OF THE SKIN PROPER. 
Class I.—Exudatioxks. 
1. Scarlatina. 
2. Morbilli. 
3. Rotheln. 
4. Variola. 
5. Varicella. 
6. Vaccinia. 
7. Typhus. 
8. Enteric. 
9. Diphtheria. 
Sub-class A.—Induced by Infection or Contagion. 
10. Equinia. 
11. Malignant pustule. 
12.. Verruca necrogenica. 
13. Frambcesia. 
14. Erysipelas. 
15. Septicsemic rashes. 
16. Surgical rash. 
17. Syphilis. 42 
CLASSIFICATION. 
Sub-class B.—Of Internal or Local Origin. 
1. Erythema,. . 
2. Roseola. 
3. Urticaria. 
4. Pellagra. 
Simplex, lseve, fugax, in- 
tertrigo, multiforme, no- 
dosum. 
Erythematous, . 
1. Lichen,. . . 
2. Prurigo, . . 
f Simplex. 
Ruber and planus. 
[ Scrofulosorum. 
Papular, . . . 
' Of Hebra. 
Infantum, of Hutchinson. 
L Recurrens, 
Vesicular and 
bullous, . . . 
1. Herpes,. . . 
f Febrilis. 
Gestationis. 
[ Iris. 
2. Pemphigus, . 
Vulgaris. 
Foliaceus. 
1. Eczema, . . 
Simplex. 
Rubra. 
Varieties (local). 
Eczematous and 
pustular, . . 
2. Impetigo contagiosa (porrigo). 
1. Pityriasis rubra. 
2. Psoriasis. 
3. Pityriasis. 
Squamous, 
1. Furunculous. 
2. Anthrax. 
3. Delhi boil. 
4. Ulcers (varieties). 
Phlegmonous and ulcerative, . 
Hypersemhe, 
Ansemiae, 
Haemorrhagise,. . . 
Class II.—Vascular. 
Purpura simplex. 
“ rheumatica. 
“ hsemorrhagica. 
Scorbutus. 
Class III.—Neuroses. 
Zoster. 
Cheiro-pompholyx. 
Pruritus. 
Dystrophia cutis. THE SKIN PROPER. 
43 
Class IV■—Hypertrophies. 
1. Ephelis, lentigo. 
2. Melanoderma. 
3. Morbus Addisonii. 
4. Chloasma uterinum. 
Pigmentary,. 
Epidermis and papillae, Ichthyosis, xeroderma. 
1. Morphaea. 
2. Scleroderma. 
3. Sclerema neonatorum. 
4. Elephantiasis arabum. 
5. Elephantiasis teleangiectodes. 
6. Dermatolysis. 
Connective tissue, 
Class V.—Atrophia. 
Pigmentary, 
f 1. Albinismus. 
[ 2. Leucoderma. 
Connective tissue, Atropia cutis. 
Class VI.—Xeopl AS.M AT A. 
Sub-class A.—Benign. 
Papillomatous, 
1. Clavus. 
2. Tylosis. 
3. Verruca. 
4. Cornua. 
Of connective tissue, 
1. Keloid. 
2. Fibroma. 
3. Xanthoma. 
1. Lupus, . . 
Vulgaris. 
Erythematosus. 
Of granulation tissue, 
2. Rhinoscleroma. 
Of bloodvessels, 
1. Naevus. 
2. Angioma. 
Of lymphatics, Lymphangioma cutis. 
Sub-class B.—Malignant. 
1. Lepra, . . 
2. Carcinoma. 
3. Epithelioma. 
4. Ulcus rodens. 
5. Sarcoma. 
Maculosa. 
Tuberosa. 
Anaesthetica. 44 
CLASSIFICATION. 
Division II.—DISEASES OF THE APPENDAGES OF 
THE SKIN. 
Subdivision A.—Of the Sebaceous Glands. 
1. Seborrhoea. 
2. Acne punctata,. . . . 
3. Acne vulgaris. 
4. Acne sycosis. 
5. Acne rosacea. 
6. Molluscum contagiosum. 
(Nigra (comedo). 
( Alba (milium). 
Subdivision B.—Of the Sweat Glands. 
1. Hyperidrosis. 
2. Anidrosis. 
3. Bromidrosis. 
4. Chromidrosis. 
5. Sudamina. 
Subdivision C —Of the Hair. 
1. Hirsuties. 
2. Lichen pilaris. 
3. Nsevus pilosus. 
4. Canities. 
5. Alopecia. 
6. Alopecia areata. 
7. Tricliorexis nodosa. 
Subdivision D.—Of Nails. 
1. Onychia. 
2. Onychogryphosis. 
3. Onychauxis. 
4. Onychatrophia. 
5. In general diseases. 45 
THE APPENDAGES OF THE SKIN. 
Class A.—Parasitic Affections. 
1. Pediculosis, . . . 
Corporis. 
Capitis. 
Pubis. 
Animal, 
2. Scabies. 
3. Eruptions from fleas, etc. 
1. Tinea tonsurans. 
2. Kerion. 
3. Tinea sycosis. 
4. Tinea circinata. 
5. Eczema marginatum. 
6. Tinea versicolor. 
7. Tinea favosa. 
Vegetable, 
Class B.— 
-Eruptions Produced by Drugs. 
It will be noticed that although, in the main, we have 
followed Hebra, yet there are certain alterations in arrange- 
ment, due chiefly to the more recent researches in pathol- 
ogy. Much assistance has been gained from Dr. Bulkley’s 
article on the subject in the “Archives of Dermatology” 
for April, 1879, and many of his suggestions and names 
have been adopted. 46 
CLASS I.—EXUDATIONES. 
Division I.—DISEASES OF THE SKIN PROPER. 
CHAPTER IV. 
Class I.—Exudationes. 
Sub-class A.—Induced by Infection or Contagion. 
SCABLA TINA —MORE ILL I—It 6 TURIN. 
Acute Infectious Diseases. 
The acute infectious diseases agree in certain broad fea- 
tures. As a rule, each occurs but once in the history of an 
individual, one attack protecting the patient from a subse- 
quent attack if he be exposed to the virus. 
They all run an acute course, and are characterized, first, 
by an incubation period, or period of latency, from the time 
when the poison is received to the appearance of the first 
symptom of the disease ; secondly, by the presence of symp- 
toms of constitutional disturbance ; and, thirdly, during 
some period of the disease by the existence of an eruption 
on the skin. 
Each of these diseases reproduces itself in any susceptible 
person exposed to its poison, and never causes any of the 
other acute infectious diseases. 
Varieties of the same disease, however, do not necessa- 
rily produce the same variety, for these modifications are 
due not to any special properties of the poison, but to some 
condition in the constitution of the person who receives it. 
Although some epidemics are known to be more fatal 
than others, the difference between them is due not to any SCARLATINA. 
47 
special virulence of the disease, but depends altogether on 
the condition of the community into which the disease is in- 
troduced. Occasionally it is found that the members of a 
family are all attacked by a very severe form of scarlatina, 
contracted from the same person, but this occurrence must 
not be regarded as a proof of anything but a special sus- 
ceptibility of the family to the influence of the disease. 
When large numbers of persons are attacked, as in the 
case of schools, wdiere family susceptibility can be elimi- 
nated, it is not found that the character of the disease is 
the same in all cases, although it may be derived from the 
same source. 
Finally, it must be pointed out that, having regard to the 
infectiousuess of the diseases in this category, their early 
recognition is a matter of great importance, in order that 
persons suffering from them may be isolated and the neces- 
sary steps be taken to disinfect the articles they have in- 
fected. 
Scarlatina—Scarlet Fever. 
Definition.—Scarlatina is an acute infectious disease char- 
acterized by the presence of a red rash on the body and ex- 
tremities, and of redness and swelling of the fauces, accom- 
panied by symptoms of constitutional disturbance. 
Symptoms.—Between twenty-four hours and seven or 
eight days after the reception of the poison the patient is 
attacked by shivering, vomiting, headache, and sore throat. 
The soreness of the throat rapidly increases, and from twelve 
to thirty-six hours after the beginning of the constitutional 
symptoms a rash commences to appear on the chest, neck, 
and wrists, whence it may extend over the whole body. 
The rash is generally at its height about the third or fourth 
day of the disease, then begins to fade, and disappears in 
about a week or ten days. This disappearance is followed 
by desquamation of the cuticle, which generally begins in 48 
CLASS I. EXUDATIONES. 
the latter part of the second week, but may commence as 
the rash fades or not until the end of the sixth week. Des- 
quamation occurs over the whole body, particularly on the 
hands and feet, and is by no means limited to the site of the 
eruption. 
During the continuance of the rash the condition of the 
fauces is characteristic; the whole mucous membrane is 
highly injected, the papillae of the soft palate are bright 
red and prominent, and the whole of the parts are more or 
less swollen. Occasionally ulceration of the tonsils takes 
place, and the glands of the neck are nearly always some- 
what enlarged, and sometimes suppurate. The tongue at an 
early stage of the fever is covered with a white fur, through 
which the papillae, which have become red and swollen, 
show themselves, particularly at the edges, thus giving the 
strawberry appearance well known as a symptom of the 
disease. Later on, as the fever subsides and as the rash 
fades, the tongue commences to desquamate, the fur is grad- 
ually removed, leaving it of a bright-red color, with its pa- 
pillae considerably enlarged, and gradually the bright red- 
ness fades to a normal hue, the papillae cease to be swollen, 
and it recovers its usual appearance. 
From the first symptoms of the disease the temperature 
is higher than normal, and becomes still higher on each sub- 
sequent day until the third or fourth day, when a tempera- 
ture of 103° to 104° is reached, the evening temperature 
being usually higher than the morning by abuut a degree. 
At the end of a week the temperature gradually falls, and by 
about the tenth or fourteenth day has again become normal. 
The pulse is considerably quickened, especially at night, 
when in adults 120 pulsations often occur in the minute. 
During the course of the disease the patient suffers from pain 
in the throat, particularly in swallowing ; he has severe 
headache, and frequently some delirium. At the height of 
the fever albumen is often present in the urine, but disap- SCARLATINA. 
49 
pears as the fever subsides ; at a later stage, however, es- 
pecially about the end of the third week, there is a tendency 
for it to reappear. 
These are the symptoms of an average attack of scarla- 
tina, but it must be borne in mind that they are liable to 
considerable modification—that the rash may be absent, or 
may appear only in a few dark patches or as a bright efflor- 
escence over the whole body; that the constitutional dis- 
turbance may be almost absent or may be of the severest char- 
acter ; that the condition of the throat varies with the se- 
verity of the attack from a simple injection to a condition 
ending in sloughing of tonsils, uvula, and cervical glands; 
and that the delirium may be altogether absent, or present 
at night only in a mild form or in the most violent type. 
It is now necessary to describe more particularly the vari- 
eties of rash which are present in the different forms of scar- 
latina. 
In an attack of average severity the rash first appears 
on the chest and neck as minute red points, which are slightly 
raised, the skin intervening between them being of the nor- 
mal color. Later on they become brighter, and the redness 
which is at first limited to them extends over the interven- 
ing skin. If examined carefully, they can still be distin- 
guished by the fact that they are redder than the surround- 
ing skin. At this stage the skin is found to be rough oil 
passing the hand over it. As the rash becomes more fully 
developed the identity of the red points is lost in the gen- 
eral hypersemia ; but this stage is not always reached, and 
in the milder form of scarlatina this identity is not lost until 
the rash commences to fade, while in some rarer forms the 
eruption does not become confluent during its whole course. 
The distance between the spots varies in different parts of 
the body. On the chest, neck, and face they are so close as 
usually to become confluent, while on the wrists, backs of 
the hands, and dorsum of the feet they are farther apart, 50 
CLASS I.—EXUD ATIONES. 
and more frequently remain separate than when situated on 
the chest and neck. In some cases, the intense hypersemia 
of the red spots causes minute vesicles to be formed at these 
points. These vesicles last but twenty-four or forty-eight 
hours, and when they dry up the skin desquamates freely. 
In the most severe forms of scarlatina an entirely differ- 
ent eruption is present. Instead of bright-red points appear- 
ing there is at once an escape of coloring matter from the 
capillaries into the superficial layers of the skin. This hap- 
pens within twenty-four or thirty-six hours from the first 
symptom. A purple mottled appearance is thus produced, 
which but partially fades on pressure. There is slight gen- 
eral hypersemia of the skin, but the rash is of a dusky red, 
which betokens an unfavorable termination. Accompanying 
this form in children there is the most intense restlessness 
and partial unconsciousness, while in adults complete con- 
sciousness sometimes remains, lint there is constant vomiting 
of brown liquid from the stomach, a feeble, rapid, and com- 
pressible pulse, and a sense of extreme prostration. Between 
this and the milder forms of scarlatina there is every gra- 
dation, but it may be accepted generally that the tendency 
to haemorrhage and the dusky color of the rash is an indi- 
cation of a severe form of the disease. In the most severe 
forms the tongue is spongy; later it becomes dry, glazed, 
and red, and finally cracks and bleeds. 
The temperature in the haemorrhagic form is not aj vyays 
specially not reaching above 103°; buFrtschipf 
characteristic is irregularity, a considerable fall often pre- 
ceding the fatal termination, .while in the death agony it 
rises, and even after death continues to rise. 
Occasionally later in the disease, even as long as a month 
after the first symptom, the patient again suffers from sore 
throat, the fauces again become swollen and injected, albu- 
men appears in the urine, and a rash once more is developed 
on the chest. This varies much in appearance, but usually SCARLATINA. 
51 
begins as a number of minute red points, which are soon 
lost in a general hyperaemia. The rash lasts sometimes but 
twelve hours, sometimes two or three days, and is, in all 
probability, due to some septic condition. 
During desquamation an occasional simple injection oc- 
curs on the chest, without the presence of any constitutional 
symptoms. It is not uncommon, also, during convalescence, 
to find the legs covered with a mottled rash, which does not 
fade on pressure, due to the escape of blood coloring matter 
into the surrounding tissue. This lasts but a few days, and 
is also not attended by any constitutional symptoms. 
Finally, it must be remembered that in all these rashes 
there is no tendency to oedema of the skin, except occasion- 
ally slight fulness or puffiness about the eyes, and that, with 
the exception of those specially mentioned, all fade on pres- 
sure. 
Diagnosis.—Care is often required in the diagnosis of 
scarlatina, although in an attack of moderate severity its 
symptoms are sufficiently well marked to make its separa- 
tion from other diseases a simple matter. It will not be 
necessary to refer to all the symptoms already described, 
but it will be sufficient to poiut out that at any period of 
the rash the disease may be recognized not only by the 
character of the eruption, but by the sore throat, the in- 
jected fauces, the strawberry character of the tongue, the 
pyrexia, and the constitutional symptoms. 
In the most severe form, when no rash is present, the 
diagnosis of scarlatina is almost an impossibility. Vomit- 
ing and high temperature* succeeded by restlessness, de- 
lirium, and coma, are symptoms which are rather suggestive 
of poisoning than of a specific fever; but, as a rule, cases 
such as these do not occur singly, and other cases of less 
severity occurring immediately afterwards in members of 
the same family often throw light upon the first case. 
In the haemorrhagic forms the same difficulty also exists, 52 
CLASS I.—EXUDATIONES. 
but to a less degree, for in them the condition of the throat 
is often sufficient to aid the diagnosis. 
From the haemorrhagic form of variola,—the disease for 
which it is likely to be mistaken during small-pox epidem- 
ics,—it may be distinguished, first, by the implication of 
the throat; secondly, by the absence of pain in the back in 
scarlatina, an almost constant symptom of variola; and, 
thirdly, by the absence of the abortive papules and vesicles 
which can usually be found among the li£emorrhages in the 
latter. 
From roseola it may be distinguished, first, by the smaller 
size of the red points in the rash of scarlatina, and by the 
fact that in scarlatina the skin intervening between these 
points soon becomes injected. The condition of the throat 
and tongue, as well as the presence of pyrexia, makes the 
diagnosis between the erythemata and scarlatina a simple 
matter. Between a very mild form of scarlatina, in which 
the space intervening between the red points does not be- 
come injected, in which the temperature is but slightly 
raised and the throat but little affected, and roseola there 
is often much difficulty in diagnosis; but it must be noted 
that in scarlatina a larger extent of the soft palate and 
fauces are injected than in roseola, and that the enlarge- 
ment of the papillae of the tongue covers a larger surface 
than in the latter disease; moreover, the papules of roseola 
are more raised than the red points of scarlatina. 
The accompanying table (p. 53) shows the distinctive 
symptoms of scarlatina, measles, and rotheln. 
Prognosis.—The termination of a case of scarlatina can, 
as a rule, be correctly predicted after the rash has existed 
for twenty-four hours. Until this time a guarded opinion 
should always be given. When the rash is fully developed 
and of a bright-red color; when the throat affection is char- 
acterized more by injection than by swelling of tonsils and 
enlargement of cervical glands; when the pulse is not in- SCARLATINA. 
53 
Rash, 
Scarlatina. 
Consists of minute red points 
close together on a bright-red 
hypenemic ground. 
First appears on chest, neck, 
and face. 
Appears after about twenty- 
four hours’ illness. 
Attended by marked injection 
of fauces, increase of tempera- 
ture, strawberry tongue, slight 
suffusion of eyes. 
Followed by desquamation of 
skin in large flakes. 
Glands of throat enlai’ged. 
Measles. 
Consists of papules of larger 
size, arranged somewhat in cres- 
centic manner on a white ground 
of normal skin. 
First appears on forehead and 
face, and extends downwards. 
Appears after about seventy- 
two hours’ illness. 
Only slight sore throat and but 
little injection, high temperature, 
furred tongue, papillae sometimes 
enlarged, but to a less extent than 
in scarlatina. 
Marked coryza. 
Occasionally by desquamation 
of skin in very small scales. 
Glands, as a rule, not enlarged. 
Rotheln. 
Consists of slightly raised 
patches, varying in size, but usu- 
ally about the size of a pea. 
The skin intervening between 
the spots is normal in color or 
very slightly reddened, but later 
on the patches occasionally be- 
come confluent. 
First appears on chest. 
Appears first, or is preceded 
for a few hours by slight catarrh. 
Fauces injected, but less so 
than in scarlatina. Tempera- 
ture slightly increased. Tongue 
furred. 
No desquamation, or only in 
the shape of small scales. 
Glands enlarged at different 
portions of body, and especially at 
back of the sterno-mastoid muscle. 54 
CLASS I. — EXUDATIONES. 
creased in adults to above 120 at night, recovery may be 
expected. When, however, the rash is badly developed and 
of a dark color or haemorrhagic, the pulse very rapid, and 
a tendency for the temperature to be very irregular, the 
mortality is very high. 
In giving an opinion on the probable termination of a 
case of scarlatina, it should be borne in mind that the mor- 
tality is inversely proportionate to the age of the patient, 
children of two or three years of age dying in much larger 
proportion than those older. It may also be noted that 
rickety children, as a rule, have much more severe attacks 
than others, amd. that they are more liable to suffer from 
severe throat affection and suppuration of glands. 
Morbid Anatomy (abridged from Klein’s “ Report to the 
Privy Council”).—In scarlatina the morbid changes which 
take place in the skin are mainly those of hypertemia and 
slight exudation, with consequent nutritive changes in the 
epidermic layers. 
1. The rete Malpighii, as a whole, is thickened, its cells 
separated by more or less fluid effusion, and leucocytes to a 
considerable extent are present. In some of the cells the 
nuclei are seen to be enlarged and constricted or double, in- 
dicating fission of the rete cells. 
2. In later stages the rete is less thickened, but here and 
there local thickenings of the stratum lucidum, the cells of 
which are full of granules, and partial loosening of the stra- 
tum corneum are found, preceding the separation of large 
masses by desquamation. In the hair follicles the epithe- 
lium of the external root sheath is often thickened, has its 
nuclei dividing, and contains some scattered leucocytes. 
The inner root sheath is also thickened, more nucleated 
and granular. The epithelium of the sweat glands shows 
signs of germination, and is sometimes found loose in 
the tubes, having been detached by inflammatory exuda- 
tion, which sometimes contains blood. Occasionally in S. MORBILLI. 
55 
maligna haemorrhages occur into both the cuticle and the 
corium. The corium in early stages presents signs of inflam- 
matory oedema, its papillae are enlarged, the lymphatics and 
bloodvessels well filled, and leucocytes present in abundance. 
In the bloodvessels there is multiplication of the endothe- 
lial nuclei and of the muscle cells in the walls of the ar- 
terioles. 
Treatment.—Inasmuch as scarlatina is an acute disease 
running a rapid course, the treatment consists in putting the 
patient under circumstances most favorable to his recovery. 
Thus a well-ventilated room of moderate temperature, the 
careful regulation of diet,—which should consist simply of 
milk, beef tea, etc., during the pyrexial period,—attention 
to the bowels, and, if necessary, in severe cases, when the 
strength is failing, the administration of stimulants, are as 
a rule sufficient. sleeplessness, when present, 
are best treated with chloral hydrate and bromide of potas- 
sium. The frequent sponging of the body with water, vine- 
gar, etc., is extremely useful. Severe pyrexia should be 
treated with cold baths. The patient should remain in bed 
for three weeks from the beginning of the disease, with a 
view to preventing kindey complication. Albumen, after 
two or three weeks’ illness, should be constantly looked for, 
and the treatment regulated accordingly. 
Morbilli—Measles. 
Definition.—Measles is an acute infectious disease char- 
acterized by the production of an eruption of red papules, 
accompanied by symptoms of coryza and general constitu- 
tional disturbance. 
Symptoms.—From ten to fourteen days after the reception 
of the poison the patient becomes ill and feverish, shivers, 
sometimes vomits, and complains of headache. The skin 
becomes dry and hot, the tongue coated with white fur, 56 
CLASS I.—EXUDATIONES. 
through which a few large papillae may show themselves ; 
the eyes become suffused, the eyelids swollen, the fauces in- 
jected, and sneezing, pain in the frontal sinuses, and all the 
symptoms of a severe catarrh appear. The temperature 
rapidly increases, the pulse is quickened, and the rash ap- 
pears on the fourth day, first on the forehead and face, aud 
thence extends over the rest of the body and extremities, 
about one or perhaps two days being occupied in its com- 
plete development. 
As the rash makes its appearance the face becomes more 
swollen, the coryza increases, aud an exacerbation of the 
constitutional symptoms, together with some amount of 
bronchitis, nearly always appears. After the rash has ex- 
isted for two or three days it gradually fades, and the con- 
stitutional symptoms subside. 
The rash first presents itself as a number of small red spots 
irregularly scattered over the skin, which rapidly become 
raised, forming dark-red colored papules from to \ of an 
inch in diameter. 
On the face especially, and on all parts of the body where 
the papules ai’e closely aggregated together, they coalesce 
and form patches of various sizes and of a crescentic shape; 
as the rash fades a temporary staining of the skin remains, 
which disappears after some days. The rash hides on pres- 
sure, but at once reappears on the removal of the finger, 
and its disappearance is often followed by desquamation of 
the skin in small scales. 
Several varieties of the rash are described. 
1. Morbilli Leaves.—In this variety healthy skin inter- 
venes between the maculae, which are but slightly raised. 
2. Morbilli Papulosi.—The papules are more raised and of 
a dark-red color ; they are situated at the mouth of hair 
follicles, and closely resemble the papules of small-pox. 
3. Morbilli Vesiculosi.—The mouths of the hair follicles 
are filled with fluid, aud small vesicles are thus produced. MORBILLI. 
57 
4. Morbilli Confluentes.—Occur when the maculte are 
crowded so closely together that they coalesce and no 
healthy skin intervenes between them. 
5. Morbilli Hcmiorrhagici.—This form of rash results from 
haemorrhage into the maculae, which of course do not then 
fade on pressure. 
Diagnosis.—There are four diseases for which measles may 
at first sight be mistaken,—scarlatina, rotheln, roseola, and 
variola. 
The following table will show the difference between these 
diseases in the early stages; at a later stage the difference 
in the appearance of the rashes become more marked, the 
different constitutional symptoms more fully developed, and 
the diagnosis consequently easier : 
Morbilli. 
Rash appears on 
the fourth day. 
Slight sore throat 
Tongue furred, few 
papillae enlarged. 
Severe catarrhal 
symptoms. 
Scarlatina. 
Rash appears on 
the second day. 
Considerable sore 
throat and injection 
of fauces. Tongue 
furred, many papil- 
lae enlarged. 
No catarrh. 
Rotiieln. 
Rash appears on 
the first day. 
Slight sore throat. 
Tongue furred; pa- 
pillae slightly en- 
larged, chiefly at 
edges. 
Slight catarrh. 
Roseola. 
Rash appears on the first day. 
Slight sore throat. Tongue 
very slightly furred, only few pa- 
pillfe enlarged at edges. 
No catarrh. 
Variola. 
Hash appears on the third day. 
Slight sore throat. Tongue 
furred, papilhe not enlarged. 
Suffusion of eyes only. 
Severe lumbar pain. 
Prognosis.—Usually favorable, but at times dangerous, 
owing to the long complication. 
Morbid Anatomy.—On examining the measles eruption in 58 
CLASS I. — EXUDATIONES. 
its earliest stages, we find usually slight hyperaemia round 
the orifice of a sebaceous follicle, with slight swelling from 
effusion of plasma. Occasionally swelling alone is present, 
and more rarely the hyperaemia only. Round the minute 
hyperaemic papule thus formed (often with a hair in its 
centre) a roseolar patch, due to hyperaemia of the papillary 
body, soon appears. Slight exudation of plasma, with a 
few corpuscles, usually follows, and causes elevation of the 
papule itself. The pale brownish stain seen after the fad- 
ing of the rash is due to changes in the escaped red cor- 
puscles, and is deeper in proportion to the intensity of the 
previous congestion. 
During the process of retrogression single or multiple 
reddish points, minute extravasations, may occur on the site 
of previous spots, or the haemorrhages may appear more dif- 
fusely over the whole spot and have definite margins. These 
are due to local weakness of the bloodvessels, allowing an 
easy escape of red corpuscles. 
Occasionally the extravasations take place at the height 
of the rash, and remain after the papules have faded. Mi- 
nute vesicles sometimes are seen in the centre of the spots, 
but they are met with chiefly in cases where profuse sweat- 
ing is present; they are probably sudamina. 
Treatment.—This consists in putting the patient on a proper 
regimen and paying careful attention to the bowels, etc. 
The lung complication may require the administration of 
an emetic and the application of warm poultices to the chest. 
Local treatment of the rash is not required, but sponging 
the body with aromatic vinegar and water is useful in al- 
laying irritation. 
Rotiieln—German Measles. 
Definition.—Rotheln is an acute infectious disease char- 
acterized by an eruption of red blotches on the skin, and ROTHELN. 
59 
attended by slight sore throat, slight coryza, and but little 
constitutional disturbance. 
Symptoms.—After an incubation period, usually of about 
fourteen days, an eruption of oval or round spots, of a lighter 
red color than those of scarlatina or measles, appears on 
the chest, afterwards extending over the rest of the body, 
which vary in size from a pin’s head to a threepenny piece. 
If the spots be large they are generally irregular in their 
shape; if small, they are more crowded together, and give 
an appearance more resembling scarlatina. The spots are 
generally discrete, but the rash is more often confluent on 
the face than on any other part of the body. The rash 
lasts about two days, and then fades, leaving a slight brown 
stain, which gradually dies away; it is rarely followed by 
desquamation, and, if at all, only in the form of minute 
scales. In rare cases the spots have been known to become 
vesicular. The constitutional symptoms which accompany 
the appearance of the rash are chiefly those of catarrh, and 
occur at the same time as the rash, or precede it by less than 
twelve hours, and not by some days, as in measles. The 
fauces are somewhat injected, and the tonsils may be even 
slightly swollen. The tongue is coated with white fur, 
through which a few large papillae can be seen, more often 
at the tip than elsewhere. An important symptom which 
accompanies the others is the tendency of the lymphatic 
glands to become enlarged, which is more constantly the 
case in the neck, especially in those situated behind the 
sterno-mastoid muscle, but the glands of other parts of the 
body are not always exempt. Increase of temperature is 
rare in rotheln, or is limited to the first few hours of the 
disease. 
Diagnosis.—Rotheln may be confounded with three other 
affections,— scarlatina, morbilli, and roseola. The chief 
characteristic points between rotheln and scarlet fever and 
measles are shown on p. 53 under the head of Scarlatina ; 60 
CLASS I.—EXUDATIONES. 
from roseola it can be best distinguished by the absence of 
coryza in the latter disease, and by the glandular enlarge- 
ment which occurs in the former. See also table, p. 57. 
Prognosis is always favorable. 
Morbid Anatomy.—The light-red spots are due to capil- 
lary hvpersemia of the papillary layer, which very rarely 
goes on to slight exudation into the rete Malpighii, causing 
slight elevation of the spots. As they fade a very faint 
and transient pigmentation may remain, and minute epi- 
dermic flakes may be shed. The vesicles occasionally seen 
on the back are probably miliaria. 
Treatment.—No special treatment is required. VARIOLA. 
61 
CHAPTER V. 
Class I.—Exudationes—continued. 
VARIOLA— VARICELLA- VA CCINIA. 
Variola—Small-pox. 
Definition.—An acute infectious disease characterized by 
the existence of a rash, which passes through the successive 
stages of papules, vesicles, and pustules, accompanied by 
symptoms of considerable constitutional disturbance. 
Symptoms.—On the fourteenth day after the reception of 
the poison, headache, nausea, feverishness, severe lumbar 
pain, and general malaise are experienced. After forty- 
eight hours—that is, on the third day of the disease—an 
eruption of red papules appears on the face, especially its 
upper part, and on the wrists, then extends over the chest 
and back and the limbs generally; about two days are 
occupied in the gradual appearance of the rash. 
The actual site of the spots is round a hair follicle or the 
orifice of sebaceous or sweat glands. The papules are fre- 
quently arranged in threes and fives in a crescent shape, 
two crescents often coming together to form a circle. A 
few hours after the first appearance of a red spot it gradu- 
ally becomes elevated, increases in size, assumes a dark-red 
color, and is hard or “shotty ” to the touch ; on the third 
day of the eruption the summit of the elevation becomes 
vesicular, and gradually, as the whole elevation takes this 62 
CLASS I. — EXUDATIONES. 
character, the summit becomes depressed, till on the fourth 
or fifth day of the eruption an umbilicated vesicle is formed, 
containing clear fluid. All the vesicles are not, however, 
umbilicated, this condition apparently depending on their 
being formed round the opening of a hair follicle. The 
contents of the vesicles gradually become more turbid, and 
by about the sixth day of the eruption become pustular. 
The base of the pustule then becomes hard, and the whole 
of the skin, especially about the face, becomes oedematous. 
About the eighth or ninth day of the eruption the pustules, 
which in the meantime have largely lost their umbilication, 
burst, and crusts or scales form on the surface. After a 
variable time, of from a few days to five or six weeks, the 
crusts are shed, and a depressed purple stain alone remains 
to indicate the position of the former pustule ; from this a 
succession of fine scales are frequently shed. The color 
may persist for some weeks, but gradually fades, and the 
depression contracts, leaving a cicatrix, the well-known 
“pitting” of small-pox. 
If the pustules have been numerous the skin of the face 
rarely recovers its normal pink, transparent appearance, 
but remains permanently of a uniform pasty white color. 
During convalescence small abscesses frequently form in 
the skin, chiefly on the thighs and legs. 
During the whole course of the disease the constitutional 
symptoms are severe. The temperature is increased to 
about 104°, 105° Fahrenheit, the tongue is covered with 
thick creamy fur, severe pains in the head and limbs, and 
especially in the back, are constantly present, while deliri- 
um, sometimes of the most violent character, and intense 
itching of the skin during the whole course of the eruption, 
prevent sleep, which is much required. As the crusts are 
formed the fever decreases until the temperature becomes 
normal. The severity of the constitutional symptoms de- VARIOLA. 
63 
pends altogether on the amount of rash. It has been stated 
that considerable variation exists in the different forms of 
small-pox; these will now be described. 
1. Variola Discreta.—The pustules remain separate from 
each other during the whole course of the disease. 
2. Variola Serni-confluens.—A few pustules run together 
on the face. 
3. Variola Confiuens.—The pustules run together all over 
the body. 
4. Variola Corymbosa. — The pustules are arranged in 
groups, the skin surrounding which is free from eruptiou. 
This is a rare and fatal form of the disease. 
5. Variola Hemorrhagica.—In this, the most severe form 
of variola, there is a bruised appearance. 
The character of the bruises is such that it would be im- 
possible to distinguish them from those produced by blows. 
But at the same time there is haemorrhage beneath the con- 
junctiva, and bleeding from nearly all the mucous mem- 
branes of the body. In this form, although there is great 
prostration, the mind is clear. The tongue is thickly cov- 
ered with white fur, and the lumbar pain is severe. Often 
the attack is fatal before the appearance of the rash, but 
if not the papules appear rather as small haemorrhages into 
the skin with ill-defined margins. 
If the vesicular stage be reached the vesicles have irreg- 
ular margins, which are obscured by the haemorrhage, and 
the fluid which they contain becomes black from the pres- 
ence of coloring matter from the blood. 
The characteristic papules of small-pox may be preceded 
by a petechial rash. This consists of a quantity of minute 
petechise, closely aggregated together, which do not fade on 
pressure; their most frequent site is the lower part of the 
abdomen and the inner side of the thighs, the axillae, the 
upper part of the arms, and the skin over the clavicle. 64 
CLASS I. — EXUDATIONES. 
The whole of the surface affected presents a dark and 
mottled appearance. 
This rash must not be confounded with the true variola 
hsemorrhagica; often, however, the two are combined, and 
in these cases dark-purple or rather blue bruises appear 
among the petechise; if there be no bruises—that is, if the 
rash be purely petechial and not haemorrhagic—the petechise 
in a few days gradually fade, and are replaced by the true 
papules of variola, which appear while the petechise are 
still present. Sometimes the papules are preceded by a 
hypersemia of the skin, which may be diffuse or in separate 
spots, and the disease then presents an appearance closely 
resembling scarlatina, which is sometimes called variola 
roseola. The site of this rash is not limited, as in the pete- 
chial variety, but may occur over the chest and arms. It 
is not uncommon to see the roseolous and petechial rashes 
combined in the same individual, but they more often ap- 
pear separately ; both usually commence on the second day 
of the disease. 
Finally, it must be remembered that small-pox often 
occurs in persons who have been previously vaccinated, 
and that under these circumstances the course of the disease 
is greatly modified. The successive stages of development 
of the rash are more rapidly completed, the rash is far less 
abundant, and the constitutional symptoms are less marked. 
Diagnosis.—The diagnosis of variola in the early stage 
is not so easy as in the latter. 
The roseolous rash may be mistaken during the first forty- 
eight hours both for scarlatina and roseola. Other symp- 
toms, arranged in the following table, assist even at this 
early period in distinguishing between these diseases. VARIOLA. 
65 
Symptoms during First Forty-eight Hours. 
Variola. 
Very slight sore 
throat. 
Tongue furred. 
Papillae not en- 
larged. 
Eash of short dura- 
tion. 
Severe pains in 
back. 
Pyrexia and consti- 
tutional symptoms. 
SCARLATINA. 
Severe sore throat. 
Tongue furred. 
Papillae enlarged. 
Eash may last some 
days. 
No marked pains 
in back. 
Pyrexia and con- 
stitutional symptoms. 
Eoseola. 
Very slight sore 
throat; redness lim- 
ited to edge of soft 
palate. 
Tongue slightly 
furred. 
Papillae enlarged 
only at edges. 
Kash of short dura- 
tion. 
No marked pains 
in back. 
Pyrexia and con- 
stitutional symptoms 
subside with appear- 
ance of rash. 
On the third day, when the papular rash is appearing, it 
may be mistaken for measles, but it must be remembered 
that the rash appears on the third day in small-pox, and 
on the fourth day in measles, and that in the latter the 
chief constitutional symptom is coryza, whereas in the 
former there is only slight suffusion of the eyes and the 
usually well-marked lumbar pain. In a few hours the 
characteristic feeling of shotty papules, observable in pass- 
ing the hand over the rash, makes the diagnosis of small- 
pox more simple. 
A not uncommon mistake is to confuse acne, when accom- 
panied by a pyrexial attack, with small-pox. Simple as 
the diagnosis apparently is, the two diseases are occasionally 
confounded, and it is well, therefore, to point out that the 
date of the appearance of the acne and the absence of the 
special constitutional symptoms of small-pox must be borne 
in mind. The same rule will enable small-pox to be dis- 66 
CLASS I. — EXUDA#IONES. 
tinguished from a secondary papulo-vesicular syphilide, for 
which it has sometimes been mistaken. 
At a later stage the vesicles of small-pox present an ap- 
pearance which prevents the disease being mistaken for any 
but varicella. Here, however, it should be remembered 
that the varicella rash appears on the second day, and in a 
few hours becomes vesicular, while in variola the date both 
of the appearance and vesiculation of the rash is later. 
The small, round, watery appearance of the varicella vesicle, 
its almost invariable freedom from umbilication, its ten- 
dency to appear in successive crops, scattered not in twos 
and threes but irregularly, renders the diagnosis anything 
but difficult. 
Prognosis.—This will depend largely on the character of 
the rash. 
The haemorrhagic form is always fatal. The presence of 
the roseolar or petechial rash is not prognostic of anything 
special. The amount of rash is a most important sign, the 
danger depending directly on the amount. The discrete 
variety is not usually fatal, the mortality being about two 
or three per cent, among the unvaccinated. In semi-con- 
fluent small-pox'* the mortality is about twice that of the 
discrete. 
In variola confluens among the unvaccinated about half 
die. In the pustular haemorrhagic form, where there is 
darkening of the vesicles, or if the vesicles be badly devel- 
oped, the mortality is even higher. Age- is also an im- 
portant element, the mortality being much greater among 
the very young and old than among persons of middle age. 
Morbid Anatomy.—In the first stage the variola spots 
consist merely of localized hyperaemic patches, in which 
there is slight serous infiltration of the papillae. 
In the papular stage the greater part of the little hard 
swelling is due to an increase in the thickness of the cells VARIOLA. 
67 
of the stratum lucidum, which undergo swelling and seg- 
mentation. 
In the vesicular stage it is seen, on examining sections 
under the microscope, that the pock presents a chambered 
structure, most marked in its upper portion. It probably 
arises, according to Rindfleisch, through the serous infiltra- 
tion of the epidermis not raising the horny layer en masse, 
as in a simple vesicle, but forcing its way gradually in be- 
tween the lamellae. It thus pushes asunder and displaces 
them from a horizontal to an oblique or vertical position. 
The fine filaments seen in the lower part of the vesicle may 
possibly be the remains of the cementing substance of the 
epidermis. The umbilicus seen in the centre of many of 
the vesicles is usually obviously due to the presence of hair 
follicles or the ducts of sweat or sebaceous glands, the tissues 
of which, being more resistant, act as bridles holding down 
the centre of the pock. It is not met with in every vesicle, 
and usually disappears at the stage of suppuration. 
In the suppurative stage the papillary layer and the sub- 
jacent part of the corium are richly infiltrated with leuco- 
cytes, which escape freely into the vesicle. When mature, 
the umbilicus and most of the septa in*the centre have 
melted away, and the pock consists of a somewhat irregular 
cavity filled with pus, mingled with epithelial debris. 
In the process of drying up, or scabbing, the hypersemia 
and exudation diminish; the rete cells at the margins and 
base of the pustule begin to cornify, and gradually form a 
fresh horny layer, which covers the papillse, denuded, but 
not destroyed, and forms a closed capsule round the little 
pus mass ; this dries up and is cast off. In some cases, 
however, the exudation of leucocytes, being excessive, sepa- 
rates the fibres of the papillse widely, and pressing on the 
vessels cuts off their blood supply and produces necrosis. 
Hence the base of the pock is formed by a pale slough, 
which has to be cast off by the suppuration around it. The 68 
CLASS I. — EXUD ATIONES. 
tissue thus destroyed is replaced by grauulations, which heal 
by second intention and leave a permanent scar. 
In variola hsemorrhagica the haemorrhages affect all the 
layers of the skin, and often the subcutaneous tissue also; 
they are probably due to transudation of corpuscles rather 
than to rupture of vessels, as no morbid condition has been 
detected in the latter. The haemorrhages proceed not from 
the capillary plexuses round the hair follicles and glands, 
but from the loops in the papillae at their apices or in their 
substance, as well as in the subjacent cutis. 
During the stage of desiccation, since the centre of the 
pustule begins to dry up before the margin, an umbilicus is 
again formed even in pocks where it was at first absent. 
Treatment.—This consists in putting the patient upon a 
suitable diet, placing him in a well-ventilated room, attend- 
ing to his bowels, seeing that he gets sufficient sleep, and, 
when necessary, administering stimulants. With a view to 
prevent pitting, many applications and methods have been 
used; solution of nitrate of silver, carbolic acid solutions, 
painting with collodion, powdering with fuller’s earth, prick- 
ing and emptying the vesicles, have all in turn been re- 
sorted to without any favorable result. 
The application of oil to the surface is, however, useful 
in allaying the intense itching which accompanies the rash, 
and care should be taken to prevent the patient wounding 
the vesicles by scratching. 
When the scabs form, if they be large, they will often 
retain pus; they should then be softened with a poultice 
and removed. Abscesses should be opened early. 
V aricella—Chicken-pox. 
Definition.—Varicella is an acute infectious disease, char- 
acterized by the production on the body of small round 
vesicles, appearing in successive crops. These dry up and 
form scabs, which fall off, sometimes leaving cicatrices. VARICELLA. 
69 
Symptoms.—About a fortnight after the reception of the 
poison a crop of small roseolar papules, varying in number 
from a dozen or so to several hundred, appear first on the 
upper part of the body,—usually the face,—and are scat- 
tered irregularly over the surface, but not in twos and threes, 
as in variola. Within a few hours the papules become ve- 
sicular, and the rash is then usually described as having at 
this period the appearance of having been produced by a 
number of small drops of scalding water thrown on the 
skin. 
The vesicles are of small size, usually less than one-fifth 
of an inch in diameter, filled with clear fluid, giving them 
a bright, glistening appearance, and seldom have a central 
depression. After twenty-four hours the vesicles become 
slightly turbid, and at the end of two or three days are 
covered with scabs. Later these separate, occasionally leav- 
ing pitting of the skin. On the first day of the rash about 
a dozen or fifteen vesicles appear, on the second day there 
may be as many as 100 to 150, and successive outbreaks 
occur during the first four or five nights. The rash is never 
confluent, but occasionally two vesicles may coalesce. 
The eruption is generally attended with considerable 
itching and some constitutional disturbance, which is never 
severe. The temperature rarely rises above 100° Fahren- 
heit. The constitutional symptoms seldom precede the rash 
by more than a few hours, and usually occur simultane- 
ously with it. 
Diagnosis.—There is only one disease for which varicella 
can ever be mistaken, and that is variola. The differences 
between the eruptions will be found on p. 66. It may be 
well to mention that a vesicular syphilide has been occa- 
sionally mistaken for varicella, but to distinguish the two 
diseases it will only be necessary to point out that the 
syphilitic eruption rarely appears without other syphilides 70 
CLASS I. EXUDATIONES. 
being present. The history and course of the two affections 
will serve to confirm the diagnosis. 
Prognosis.—Favorable. 
Morbid Anatomy.—On a small roseolar papule, due to 
superficial hypersemia of the cutis, a small loculated vesicle 
soon forms. On examining this microscopically the cells 
of the upper layer of the rete are fouud filled with numer- 
ous refracting globules, scattered through the protoplasm 
and undergoing vesicular transformation. These cells, open- 
ing into one another, give rise to an irregularly loculated 
cavity, situated between the horny and the deeper layers of 
the rete, containing serous fluid, in which leucocytes and 
multinucleate epidermic cells float. As the cells undergo 
fatty degeneration, the clear serous fluid soon becomes tur- 
bid, and is absorbed, leaving a small brownish crust. On 
the separation of the scab there is left merely a slight de- 
pressed stain, which fades in time, leaving no trace unless 
suppuration and superficial ulceration of the papillary layer 
have taken place. 
Treatment.—No specific treatment is required ; the con- 
stitutional symptoms may be treated on general principles. 
The irritation of the skin is relieved by the application of 
oil. If suppuration occurs beneath the scab, the pus should 
be set free by poulticing. 
Vaccinia—Vaccination. 
Definition.—An acute infectious vesicular disease of the 
cow, communicable to man, and which has the effect of pro- 
tecting the latter from attacks of small-pox. 
Symptoms.—With the disease in the cow we have here no 
concern, and therefore shall only describe the rash produced 
in the human subject by the inoculation of the cow-pox in 
a person who has not previously been vaccinated. If a 
puncture be made in the skin of such a person with a lan- VACCINIA. 
71 
cet, and the vaccine matter be inserted with care, after two 
days, during which nothing appreciable occurs, a papular 
elevation is produced. On the fifth or sixth day this be- 
comes a pearl-colored vesicle of a round or oval form, de- 
pressed in the centre and with its edges raised. On the 
eighth day the vesicle is more distended, but the depression 
in the centre still remains. On the seventh or eighth day 
a red ring is formed round the vesicle, which may be two 
or three inches in diameter. The redness fades on pressure, 
but the area is harder and more tender than the surround- 
ing skin. About the tenth day the redness begins to dis- 
appear, and the lymph in the vesicle is seen to become thick 
and purulent, while the umbilication is less marked. At 
the end of a fortnight a scab forms, which remains adherent 
till about the end of the third week, when it falls off, leav- 
ing in its place a somewhat circular depression, which is 
foveated. These pits correspond with the cells of the vesi- 
cles. The cicatrix contracts somewhat, but otherwise, as a 
rule, remains for life. 
Two o* three days after the operation considerable itch- 
ing of the part is experienced, and about the seventh or 
eighth day there is usually, especially in young children, 
some amount of constitutional disturbance, such as shiver- 
ing, loss of appetite, and general malaise. At this period 
the temperature is somewhat slightly increased ; sometimes 
also the axillary glands become enlarged. 
Although this is the course of by far the majority of the 
cases of vaccination, some are, from time to time, found 
which do not run through quite the same symptoms as 
described above. Thus, occasionally a rose rash (roseola 
vaccinia) makes its appearance between the third and eigh- 
teenth day after inoculation, commencing most often in the 
neighborhood of the irritation and extending over other 
parts of the body. This rash consists of very slightly raised 
spots of a red color, varying in size from a quarter of an 72 
CLASS r. — EXUDATIONES. 
inch to three or four inches in diameter. It lasts but a day 
or two, and is not followed by desquamation or deposit of 
pigment. 
In Variola vaccinia herpetica a crop of vesicles appears 
on the third day after the operation, and is preceded by an 
attack of shivering. They soon burst; the fluid which 
escapes irritates the adjoining skiu, and an eczematous 
condition of the part is produced, the skin becoming hard 
and oedematous. Intense itching accompanies this outbreak, 
and the axillary glands often become enlarged. 
In Variola vaccinia bullosa a bulla of variable size, with a 
red edge, takes the place of the ordinary vesicle. It con- 
tains a clear liquid, which soon escapes, leaving a crust, 
which is shed without producing a scar, unless ulceration 
takes place, when the cicatrix is of considerable size. 
In Variola vaccinia jurunculosa red tubercles are formed, 
which subsequently suppurate. 
Occasionally Erysipelas appears about the seventh to the 
tenth day round the vesicle, and spreads over the arm. It 
does not differ from ordinary erysipelas, and is accompanied 
by oedema, pain, and considerable constitutional disturbance. 
In some cases the pustules, instead of drying up and form- 
ing scabs, burst, and ulceration takes place. The ulcers 
are attended by itching, pain, and constitutional disturb- 
ance. This condition rarely results from lymph which has 
passed through the human subject, but occurs more fre- 
quently after inoculation direct from the cow. 
But one other variety has to be described,—that in which 
perfect vesicles are never developed, but scabbing occurs 
after a little fluid has been formed. It may be well also 
to mention that revacciuation produces vesicles the typical 
characters of which are less marked, appearing earlier and 
running a more rapid course than in primary vaccination. 
Vaccino-syphilis will be noticed under “ Syphilis,” p. 114. 
Prognosis.—A favorable result always follows vaccina- VACCINIA. 
73 
tion, except in the rare cases when erysipelas occurs among 
young children. 
Morbid Anatomy.—The structure of the vaccinal exan- 
them, in its successive stages of papule, vesicle, and pus- 
tule, is much the same as in variola. 
The umbilicus of the vesicle is formed at the point of 
puncture, and is said to be due to the inflammation excited 
by the scratch, causing adhesion of the corium and epider- 
mis, so that the subsequent serous effusion separates the cu- 
ticle around the band thus formed. The vesicle is locu- 
lated, and, like that of variola, its umbilicus may disap- 
pear when suppuration sets in. Scabbing takes place in 
the centre and extends to the margin of the pock. 
Treatment.—Vaccination requires but little treatment. 
The vesicles should be carefully protected from injury, and 
oil should be applied to allay the itching. On the eighth 
day, if the vesicles be much distended, a few punctures into 
them is useful to relieve tension. If there should be any 
tendency to retention of pus or ulceration beneath the scabs, 
they should be removed by a poultice, and the wound treated 
according to the rules for treating ulcers. If the erythema 
be great, or if erysipelas occur, the arm should be kept in 
a sling and lotio plumbi should be applied to the part. 
Finally, it should be borne in mind that lymph should 
never be taken, for the purpose of vaccination, from any 
but a perfect vesicle, with a proper areola, in the person of 
a healthy child vaccinated for the first time. 74 
CLASS I. EXUDATIONES. 
CHAPTER VI. 
Class T. —Exudationes—continued. 
TYPHUS—ENTERIC—DIPHTHERIA. 
Typhus Fever. 
Definition.—Typhus is an acute infectious disease char- 
acterized by the production of a mottled rash, which be- 
comes petechial, aud which is accompanied by considerable 
constitutional disturbance. 
Symptoms.—Thirteen or fourteen days after the reception 
of typhus poison there is a sense of chilliness and headache, 
accompanied occasionally by vomiting, and general pyrexial 
symptoms. On the third day, more often on the fourth or 
fifth, the mulberry rash of typhus makes its appearance. 
The rash can be described as consisting of two parts. The 
one which is simply an indistinct dark mottling appears as 
if it were a little distance beneath the surface of the skin, 
and is described as the “ subcuticular ” mottling. The other 
consists of a quantity of small purple maculae scattered 
over the surface of the skin, aud appear to be altogether on 
the surface. When they first appear they are very slightly 
raised, but in a few hours become perfectly flat. The sub- 
cuticular mottling may exist by itself, but the maculae are 
usually present as well. The rash is fully developed in less 
than forty-eight hours from its commencement, and no rash 
is ever produced after this period. For the first few days 
the spots fade on pressure, but later on a yellow stain is left, 
and still later pressure produces no effect on the spot, which 
has then become petechial; the petechise remain, appearing TYPHUS FEVER. 
75 
like minute hemorrhages, and often last as long as three 
weeks, but the mottling disappears earlier. The rash ap- 
pears first on the wrist, upper part and sides of abdomen, 
and about the edges of the axillae; later it gradually ex- 
tends over the whole abdomen and chest. The constitu- 
tional symptoms steadily increase, especially the delirium, 
which is often of a violent character. The tongue, which 
is first coated with white fur, becomes dry, brown, and some- 
times black, and great difficulty is experienced in protrud- 
ing it, on account of sordes collecting about the mouth. 
Later the tongue begins to moisten at the edges, and the ap- 
petite rapidly returns, even before the tongue has cleaned. 
During the whole course of disease the temperature is 
raised constantly to 104° or 105° Fahr. The maximum 
temperature is usually reached on the fourth day, when a 
slight fall takes place; a further fall occurs about the sev- 
enth day, and although at the beginning of the second week 
it is slightly lower than during the first, it rises until the 
crisis occurs. This takes place generally between the twelfth 
and seventeenth days. The temperature then falls rapidly, 
and becomes normal within three or four days of the crisis, 
unless some complication be present. 
Occasionally erysipelas and glandular swellings, especi- 
ally of the parotid, occur during the course of the fever. 
Diagnosis.—Typhus is frequently mistaken for brain dis- 
ease, pneumonia, measles, and enteric fever. In the first 
two it is only necessary to point out that no rash exists; 
from measles, however, the diagnosis is not always an easy 
matter. In both the rashes appear on the same day, but 
differ in certain essential particulars (see table). 
The diagnosis of typhus from enteric fever is a perfectly 
easy matter, and a mistake should never be made between 
these two diseases (see table). 
Prognosis.—The chances of recovery depend altogether 
upon age. The young nearly always recover, while among 76 
CLASS I. EXUDATIONES. 
Enteric. 
Commences insidiously. 
Rash at end of first week. 
Group of lenticular ro- 
seolous papules. 
Rash appears in suc- 
cessive crops, each spot 
lasting two or three days. 
No petechise. 
Diarrhoea common. 
Full, tender abdomen. 
Flushed cheeks, glisten- 
ing eyes. 
Typhus. 
Commences suddenly. 
Rash on fourth or fifth 
day. 
Dark, mottled, non-ele- 
vated rash. 
Rash fully developed in 
forty-eight hours. 
Rash becomes petechial. 
Diarrhoea less common 
than in enteric. 
Flat abdomen. 
Heavy, dull expression 
of face. 
Measles. 
Rash commonly present 
on face. 
Maculae often coalesce 
and are raised. 
Subcuticular mottling 
not present. 
Coryza. 
Typhus. 
Rash not very often 
present on the face. 
Maeulaj smaller than 
measles, separate from 
each other, and not raised. 
Subcuticular mottling 
present. 
Suffusion of eyes, but 
no coryza. ENTERIC FEVER. 
77 
those of middle or advanced life the mortality is very high. 
Fat, heavy persons are more likely to die than those who are 
more spare. A large amount of rash, which soon becomes 
petechial, especially if it be of a dark color, an absence of 
fall of temperature at some period during the first week, a 
sudden rise of temperature during the third week, a very 
rapid pulse, much delirium, coma, convulsions, and suppres- 
sion of urine, are all unfavorable signs. 
Morbid Anatomy.—The rash of typhus is due to superfi- 
cial hypersemia of the cutis, but, as exudation is absent, the 
spots remain on a level with the rest of the skin. At a 
later stage the darkening of the spots is produced by the 
escape of red corpuscles from the vessels, and actual pete- 
chia sometimes form. These subsequently undergo the 
same changes as purpuric spots. 
Treatment.—This should be regulated on general princi- 
ples. 
Enteric or Typhoid Fever. 
Definition.—Enteric or typhoid fever is an acute infec- 
tious disease characterized by swelling and subsequent ul- 
ceration of the Peyer’s and solitary glands of the ileum, 
usually accompanied by successive crops of rose-coloi'ed 
papules, chiefly on the abdomen, together with abdominal 
symptoms and considerable constitutional disturbance. 
Symptoms.—From ten to sixteen days after the reception of 
the poison, headache, chilliness, and occasionally shivering, 
followed by a little delirium, are experienced. With these 
symptoms there is increased temperature, a furred tongue, 
and sometimes diarrhoea, or more often irregularity of the 
bowels, a few days of constipation being followed by purg- 
ing. On the seventh, or from that to the twelfth day, in 
cases where a rash is present, a crop of rose-colored papules, 
from half a line to two lines in diameter, make their ap- 78 
CLASS I. EXUD ATIONES. 
pearance ou the abdomen, chest, and back. These are 
slightly elevated, and disappear on pressure, but reappear 
the moment the finger is removed. There number varies 
from two or three to a hundred or so, but usually not more 
than about half a dozen are present at a time. Each crop 
lasts from three to six days, and is usually followed by sub- 
sequent crops. When the papules fade, no discoloration of 
the skin remains, and the rash is never permanent. The 
duration of the rash is from one to three weeks, but occasion- 
ally recurs at a later date if there is a relapse. 
During the course of the disease the abdomen becomes 
prominent, and often tympanitic and tender on pressure, 
especially in the right iliac fossa, where it often produces 
gurgling. 
The constitutional symptoms increase in severity after 
the first week, and sometimes the delirium is violent in 
character. The tongue becomes drier as the fever pro- 
gresses, and towards the latter part of the second week is 
dry, very red, and glazed. Diarrhoea becomes a more com- 
mon symptom in the second week, and is sometimes very 
severe. The stools are liquid and of a yellow-ochre color. 
If allowed to stand, the more solid portion settles to the 
bottom, and is then found to consist of shreds of undigested 
food mixed with sloughs and debris from the ulcers in the 
intestines. Often they contain a little blood. In some cases 
severe haemorrhage occurs from the ulcers, and the stool 
then consists almost wholly of blood. 
At a later stage of the fever the ulceration of the intes- 
tinal glands occasionally extends through the peritoneum, 
and perforation of the intestines, with its accompaniments 
of extravasatiou into the peritoneal cavity and consequent 
peritonitis, results. The temperature in enteric fever is 
always increased during the first-week ; it rises higher and 
higher until a temperature of 104° Fahr. is frequently ENTERIC FEVER. 
79 
reached. The morning temperature is lower than the even- 
ing, and during the second and third week this is main- 
tained. Later, however, usually in the third week, as the 
recovery begins, the difference between the morning and 
evening temperature is much more marked. Occasionally 
a sudden fall of temperature takes place, due usually to 
haemorrhage from the bowel; but if any rise be observed, 
it is due to some complication, often of the lung. The pulse 
is always increased in enteric fever, often 120 at night, but 
less frequent in the morning. 
In the mild cases the patient begins to recover at the 
latter part of the second week, and in more severe cases at 
a later date. Convalescence is always slow. Among the 
complications are haemorrhage from the intestine, perfora- 
tion of intestine, peritonitis, and pneumonia. 
Occasionally two or three days before the lenticular spots 
make their appearance they are pi’eceded by a scarlet rash, 
which spreads over the whole body. It is a mere tempo- 
rary hypersemia, and fades on pressure. 
In rare cases pefechise and purpuric spots occur during 
the course of the fever; they are in no way associated with 
the lenticular spots. 
Taches bleudtres are sometimes observed. They consist of 
blue patches, from two or three to eight lines in diameter, of 
irregular shape, usually separate, but sometimes coalescing. 
They are not raised, and give an appearance somewhat 
resembling the typhus spots, but they do not pass through 
the same changes as the latter. They are usually situated 
on the abdomen, thighs, and back. 
Sudamiua frequently occur, and are followed by desqua- 
mation. 
Diagnosis.—The diagnosis of enteric fever is usually not 
a difficult matter. The high temperature, the prominent 
abdomen, the dry red tongue, the diarrhoea, and, when 80 
CLASS I. — EXUD ATIONES. 
present, the lenticular spots, conclusively point out the dis- 
ease. It can be recognized by the flushed cheeks, glistening 
eyes, and parched lips, which contrast strongly with the 
heavy, dull, leaden appearance of typhus, and by other 
symptoms, w'hich are given in a tabular form on p. 76. 
Prognosis.—Young children rarely die of enteric fever, 
but as age progresses mortality increases. A very high 
temperature which is not attended with morning remissions, 
much diarrhoea, haemorrhage, tympanitis, delirium of a 
violent character, much muscular tremor, are unfavorable 
indications. The amount of rash is not prognostic of a 
favorable or unfavorable termination. 
Morbid Anatomy.—The enteric papule begins as a small, 
circumscribed pink spot, due to hypenemia of the papillary 
layer. In a day or two it becomes slightly raised, owing 
to the exudation of plasma into the papillse and rete, and 
-in some cases a minute vesicle, due to further collection of 
serum, forms at its apex. As the spot fades the plasma is 
absorbed, and the faint brown stain left by it soon disap- 
pears. The anatomy of the taches bleudtres has not been 
investigated. 
Treatment.—Considerable care is necessary in the treat- 
ment of enteric fever. The patient should not be permitted 
to leave his bed until convalescence has well advanced, 
should be fed on fluids only, and should be given no vege- 
table food. The diarrhoea should be carefully controlled, 
and constipation treated by enemata. 
For tympanitis, peritonitis, etc., opium is the best remedy. 
Haemorrhage should be treated with astringents and ice. 
Finally it may be stated that antipyretic treatment, both 
by cold bathing and the administration of quinine, has 
proved very successful on the Continent and in England 
when it has been systematically carried out. DIPHTHERIA. 
81 
Diphtheria. 
Definition.—Diphtheria is an acute infectious disease in 
which there is a tendency to the formation of false mem- 
brane on mucous and abraded surfaces, chiefly of the fauces 
and respiratory tract, accompanied by considerable consti- 
tutional disturbance. 
Symptoms.—After an incubation period, which varies 
greatly, but which is probably from twenty-four hours to 
ten days, shivering and vomiting set in, and the temperature 
becomes increased. The throat becomes sore, and there is 
some amount of stiffness about the neck. The fauces be- 
come of a dark-red color, the tonsils swollen, and at the 
end of two days from the beginning of the disease a quan- 
tity of minute white points appear on the surface of one or 
both sides of the fauces. As these spots increase in number, 
they coalesce and form a thick yellowish-white membrane. 
This sometimes consists of a single piece, but is often scat- 
tered over the surface in separate patches. The cervical 
glands become enlarged, the tongue coated with white or 
brown fur, the pulse and temperature increased, and the 
urine albuminous. 
In the next stage the membrane separates, often leaving 
unhealthy sloughing ulcers. 
In this stage recovery may take place, or death may 
result from exhaustion ; during any period of the illness 
asphyxia, resulting from the production of false membrane 
in the larynx or bronchial tubes, may be fatal. In the 
course of the disease a roseolous rash may appear over the 
body. This is not different from the roseola which appears 
with other acute diseases. 
Convalescence after diphtheria is very slow ; often paral- 
ysis of groups of the muscles shows itself within six months 
from the beginning of the attack. 
Diagnosis.—Diphtheria may be confounded with (a) scar- 82 
CLASS I. — EXUDATIONES. 
latina, (6) tonsillitis, (c) herpetic sore throat. The points 
of difference between these diseases is shown in the follow- 
ing table: 
Diphtheria. 
Throat of deep red, which is 
not uniformly distributed. 
Patches of thick yellow mem- 
brane on any portion of fauces. 
Tonsils unequally swollen. 
Tongue coated with white fur. 
Scarlatina. 
Throat of bright red, which is 
uniformly distributed. 
Large white, thin, irregularly 
shaped exudations on fauces. 
Both tonsils equally swollen. 
Tongue furred, with large pap- 
illae. 
Herpetic Sore Throat. 
Throat less red than in scarla- 
tina or diphtheria. 
Small white points on tonsils. 
Tonsils unequally swollen. 
Tongue furred. 
Tonsillitis. 
Throat less red than in scarla- 
tina or diphtheria. 
Small, thin, yellow exudation 
points over surface of tonsils. 
Tonsils unequally swollen. 
Tongue furred. 
Prognosis.—Diphtheria, under any circumstances, is a 
disease in which a guarded prognosis should be given. 
During the whole course of the disease symptoms may arise 
which are the precursors of a fatal termination. 
Those cases are most serious which occur in young chil- 
dren, when there is a tendency to extension of the mem- 
brane, when an alteration in the voice betokens affection of 
the larynx, or when the powers of the patient begin to fail 
early. 
Morbid Anatomy.—The diphtheritic poison, as it affects 
the mucous membrane, may give rise to two degrees of 
morbid changes: 
1. The catarrhal stage, representing affection of the epi- 
thelial layers only, the disease not undergoing any further 
development. DIPHTHERIA. 
83 
2. The fibrinous stage, where, either with or soon after 
the catarrhal stage, there sets in an exudation of plasma, 
which gives rise to a fibrinous pseudo-membraDe. 
In the catarrhal stage, on making a section through the 
grayish-white, slightly raised patch, the epithelial layer is 
not obviously thickened, and the grayish change extends 
only here and there into its substance. Numerous masses 
of micrococci are found on and in the superficial epithelial 
layers, forming somewhat flattened deposits. From these, 
processes of micrococci extend down into the rete Malpighii, 
spreading out here and there into roundish aggregations or 
colonies. The rete cells themselves are swollen, and have 
their nuclei more distinct. v 
Leucocytes next invade the diseased patch more and 
more, filling up all the space in the epithelium not already 
occupied by micrococci. Mingled with them there are large 
young cells, three or four times the size of leucocytes, and 
some inultinuclear cells. This cellular or purulent infiltra- 
tion helps to check the extension downward of the fungoid 
growth, and finally leads to the casting off of the patch of 
epithelium. 
In the fibrinous stage, either soon after the appearance of 
the fungoid growth or after some pus formation, an exud- 
ation of plasma into the epithelial and subepithelial tissues 
lifts up the portion already infiltrated with micrococci, 
forming a thick false membrane, which soon undergoes 
necrosis. The surface consists of broken-down flakes and 
masses of epithelium, filled with micrococci, while in the 
deeper layers are loosened cells variously altered in shape 
and disintegrating, inclosed in a meshwork of fibrin fila- 
ments, with at first a few scattered leucocytes. Subsequent 
exudations of fibrin lift up the layers and thicken the fibres 
previously formed, giving the mass an amyloid appearance, 
and, on microscopic examination, the fibres are found to be 
fine in the subepithelial layers, becoming gradually coarser 84 
CLASS I. — EXUDATIONES. 
as the surface is approached. After twenty-four to forty- 
eight hours the rupture of the capillaries in the papillary 
layer gives rise to slight haemorrhages, which are surrounded 
and shut off by subsequent fibrinous exudation. The cords 
of micrococci, extending gradually downwards towards the 
subepithelial layers, are thus being constantly pushed off 
towards the surface; but as the exudative process slackens, 
some of them extend into the lymphatic spaces of the tissue, 
filling them and the lymphatic vessels as well. 
As the exudation of plasma finally ceases, the purulent 
infiltration forms a line of demarcation, and with the in- 
creased secretion from the mucous glands either floats off 
the membrane en masse or checks the downward growth of 
the micrococci from the latter, which then slowly breaks 
down on the surface and is washed away. 
Treatment.—The removal of the false membrane is of no 
avail; antiseptic applications are, however, very useful, and 
the patient’s powers should be most carefully supported. 
The internal administration of the tincture of the perchlo- 
ride of iron is valuable, both for its local action as an an- 
tiseptic and for its hsematemic properties. If the larynx 
becomes affected, and there be much local obstruction to 
breathing, tracheotomy should be at once resorted to, for it 
is of no use to wait until the patient’s powers are almost 
exhausted. The operation is itself a trivial one, and should 
therefore not be postponed. EQUINIA. 
85 
CHAPTER VII. 
Class I.—Exudationes—continued. 
Equinia—Pustula Maligna—Verruca Necrogenica—Framboesia— 
Erysipelas—Septicsemic Rashes—Surgical Rash. 
Equinia—Glanders—Farcy. 
Definition.—An acute infectious disease of the horse, ass, 
or mule, communicable to man by inoculation of a wound 
or abraded surface, and it is said by the prolonged contact 
of infected matter with the unbroken skin or mucous mem- 
branes, or by inhalation of air impregnated with the poison- 
ous particles. It produces severe constitutional symptoms, 
and usually a pustular rash. 
Symptoms.—The disease as it occurs in animals need not 
be discussed, except to remark that there is no essential 
difference between glanders and farcy. They are both 
caused by the same virus, both equally contagious, and 
differ only in certain clinical and anatomical details. The 
“farcy buds” are merely one of the manifestations of 
“glanders,” as a gumma or tubercular syphilide is of syph- 
ilis. According to the course and duration of the disease, 
an acute, subacute, and chronic form of glanders may be 
described. In acute glanders, after an incubation period of 
three to five days, or even of two or three weeks, malaise, 
loss of appetite, and obscure pains in the joints and muscles 
of the extremities are experienced. At the same time the 
skin round the wound or excoriation which has been inocu- 
lated becomes red, painful, and slimy; the lymphatics and 86 
CLASS I. EXUDATIONES. 
glands become enlarged, red, and painful, and there is often 
an erysipelatous redness or cellulitis extending for a con- 
siderable distance round. The ulcer enlarges, its base and 
sides become corroded and grayish-white, with a foul dis- 
charge ; there is great prostration, with severe pain in the 
joints and muscles, and high fever is often present. Rigors 
are rare unless the disease is complicated with septicaemia. 
If the attack be produced by inhalation of the poison, it 
commences with general symptoms only, and the first defi- 
nite sign is the eruption. This consists of red spots,—at 
first small papules, but soon enlarging into little indurated 
tubercles about the size of a pea,—scattered over the face 
and more or less over the rest of the body. Pustules, and 
occasionally vesicles, soon form on their apices, burst, and 
leave foul ulcers. Sometimes larger nodules—farcy buds— 
at first form along the course of the lymphatics of the skin 
and subcutaneous tissue, but soon break down and suppu- 
rate, leaving deep irregular ulcers with sloughing surfaces. 
Similar nodules and abscesses in the intermuscular tissue, 
and suppuration in and around the joints, are often met 
with, also haemorrhages into the swellings. In the affection 
of the mucous membranes, especially of the nose, either at 
the beginning, if the disease has been inoculated there, or 
after the previous phenomena, there is severe pain and 
swelling with a mucous discharge, clear and viscid at first, 
but later brownish, offensive, and sanguineous. Tumors 
and ulcers may be found in the nose. Severe cough, pain 
in the chest, and expectoration of matter resembling the 
nasal discharge mark the implication of the lungs with the 
diseased growths. The pulse is small and frequent, head- 
ache is often severe, and delirium is not uncommon. 
In subacute glanders the symptoms are, on the whole, the 
same, only less intense and more protracted. The pain and 
the retarded suppuration caused by the ulcers usually pro- 
duce a condition of hectic. EQUINIA. 
87 
In chronic glanders there is, as in the acute forms, at first 
redness and swelling round the inoculated spot, with inflam- 
mation of the lymphatics, glandular enlargement, and some 
fever. The general symptoms subside for a time, but the 
ulcers go on slowly spreading in some places, healing in 
others. After a time nodular tumors or farcy buds, red 
spots, and pustules may arise, producing abscesses and ul- 
cers on the skin, in the muscles, joints, and viscera. The 
nasal and other mucous membranes become affected, as in 
the acute form, and tubercles or ulcers about the larynx 
give rise to hoarseness or sudden oedema of the glottis. 
Bronchitis and pneumonia are frequently met with. 
The fever may be high if there is much suppuration and 
rapid formation of abscesses, or may assume a hectic type. 
Even in the event of a favorable course recovery is very 
slow, and often incomplete ; the abscesses and ulcers grad- 
ually heal, the nasal discharge lessens and finally ceases, 
and the gastric and respiratory symptoms disappear. It is 
necessary to add that at any time the chronic variety may 
become acute and rapidly fatal. 
Diagnosis.—The inoculation wound may be at first mis- 
taken for the result of cadaveric poisoning, but is distin- 
guished when the rash, nasal affection, and other symptoms 
set in. When acquired by inhalation, or where no wound 
is present, the early symptoms may lead to confusion with 
enteric fever if there is much pyrexia, malaise, headache, 
and delirium, or with rheumatic fever if the joint and mus- 
cular pains predominate. The appearance of the rash and 
nasal complication soon makes the diagnosis clear. 
The papules may at first resemble those of variola, but 
they are larger and not “ shotty they soon develop into 
pustules and ulcers, instead of drying up into scabs ; and 
abscesses, usually absent in variola, are almost constant in 
glanders. 
Chronic glanders may be mistaken for syphilis ; the his- 88 
CLASS I. — EXUD ATIONES. 
tory of contact with horses or persons suffering from the 
former, and the absence of the usual signs of the latter, 
will suffice to distinguish between the two diseases. 
Prognosis.—Acute glanders is nearly always fatal, usually 
in seven or ten days from the onset of the attack. In the 
subacute forms of the disease death does not occur till 
after the second or third week, and about twenty-five per 
cent, recover. 
In the chronic form the usual duration is about four 
months, and fifty per cent, recover. 
Morbid Anatomy.—In acute glanders the cutaneous and 
nasal tubercles—farcy buds—so often met with in the horse, 
are frequently absent in man, and the morbid changes re- 
semble those of pyaemia. As regards the skin, there are 
found, after death, scattered over the body, especially on 
the face and extremities, the red spots observable during 
life, with vesicles or pustules in some places and abscesses 
or ulcers in others. The vesicles containing caseo-purulent 
or bloody fluid have often a gray sloughy base. In the 
small cutaneous abscesses the pus is often of a viscid nature, 
and mixed with blood and shreds of tissue. (Edema, ery- 
sipelatous or phlegmonous changes, may also be present in 
the surrounding skin. The cutaneous nodules or tubercles 
are found to consist of localized deposits of small round 
cells in the sub-papillary layer of the corium, which at a 
later stage give rise to infiltration of the papillae with leuco- 
cytes. The papillae being thus disorganized, pus collects 
beneath the epidermis, forming a small abscess, which on 
bursting leaves a foul ulcer. 
In the internal organs, such as in the mucous membranes 
of the nose, pharynx, and trachea, in the lungs, muscles, 
bones, and abdominal viscera, nodules, ulcers, abscesses, 
and haemorrhages are frequently found. 
Treatment.—No treatment is of any avail in the acute 
forms of the disease. In the chronic little can be done pustula maligna. 
89 
beyond keeping up the strength with a liberal and stimu- 
lating diet. 
Pustula Maligna—Malignant Pustule. 
Definition.—A disease produced by the poison of animals 
suffering from charbon, characterized by the formation of a 
pustule, by subsequent gaugrene, and by severe constitu- 
tional disturbance. 
Symptoms.—It first appears as a small dark-red patch, on 
which an elevation soon grows ; a small pustule forms on 
this and bursts. The inflamed area rapidly extends, be- 
coming hard, and sloughs. Symptoms of severe constitu- 
tional disturbance accompany the local affection, and death 
frequently takes place in four or five days from the begin- 
ning of the disease. It is produced in man by direct con- 
tact with the diseased animal, but there is also some evi- 
dence that it can be conveyed by flies. 
Diagnosis.—There is no disease for which malignant 
pustule can be mistaken. 
Prognosis.—Usually fatal. 
Morbid Anatomy.—Sections of the developing malignant 
pustule show that the central black spot is produced by 
haemorrhage into tissue which has already undergone gan- 
grene. There is acute inflammatory oedema around, and as 
the process of haemorrhage and gangrene spreads gradually 
from the centre, we get finally the fully developed dark-red 
or blackish spot covered with a vesicle containing blood- 
stained purulent fluid. The pustule is usually surrounded 
by extensive phlegmonous inflammation of the adjacent 
skin and’ subcutaneous tissue. The haemorrhagic infiltra- 
tion is seen to extend deeply into the substance of the 
corium, sending out reddish radiating branched processes. 
There is also more or less scattered haemorrhage in the 
oedematous tissue, and in the corium in isolated patches. 90 
CLASS I. EXUDATIONES. 
The fluid of the vesicle contains enormous quantities of 
slender, rod-shaped bacteria (Bacillus anthracis) aggregated 
in masses in the substance of the rete. As the disease ad- 
vances they infiltrate the papillae, hair follicles, sebaceous 
glands, and the deeper layers of the corium, finally making 
their way into the blood and infecting the body generally. 
An excess of leucocytes and plasma is present in the corium 
and papillae. These bacilli have been cultivated out of the 
body, and after several generations had been obtained were 
found to produce anthrax when introduced into the bodies 
of animals. 
Treatment.—In an early stage destruction of the affected 
part by caustics, or its entire removal by the knife, is ad- 
visable. If this be impossible, warm poultices should be 
applied, and attention should be directed to sustaining the 
patient’s powers. 
Verruca Necrogenica. 
Definition.—A disease occurring among those who are 
engaged as butchers or in making post-mortem examina- 
tions, and consisting of warts produced by infection from 
dead animal matter. 
Symptoms.—The warts consist simply of patches of mor- 
bid growths, having somewhat the appearace of epithelial 
cancer. 
Diagnosis.—The occupation of the patient readily enables 
the character of these growths to be recognized. 
Prognosis.—They have a tendency to recur, but are other- 
wise innocent. 
Treatment.—Removal by the knife or by caustics. 
Fr ambcesi a—Y AWS. 
Definition.—A contagious disease of the West Indies and 
Africa, rarely seen in this country, characterized by the ERYSIPELAS. 
91 
appearance of a pustular eruption, which is replaced by a 
series of ulcers and attended by considerable constitutional 
disturbance. 
Symptoms.—It commences with feverishness, and soon 
after small papules are produced, which are most numerous 
on the face and the extremities, and gradually grow until 
they reach the size of a sixpence. At the end of a few 
days a pustule forms on the elevation, and bursts, leaving a 
thick crust, beneath which ulceration takes place; on this 
ulcer large granulations grow, giving an appearance which 
has been compared to a raspberry, but eventually these 
cicatrize and heal. This condition may go on for months, 
during which successive crops of the pustules may be pro- 
duced. The constitutional symptoms are feverishness, sore 
throat, and sometimes dropsy. 
Diagnosis.—There is no disease for which this can be 
mistaken. 
Morbid Anatomy.—The morbid changes have not been 
investigated. 
Treatment.—No specific treatment is known; the ulcers 
must be treated with stimulating applications, aud the 
strength must be kept up with stimulants and a generous 
diet. 
Erysipelas. 
Definition.—An acute contagious disease, characterized 
by the production of a local inflammatory condition of the 
skin, and attended with symptoms of constitutional disturb- 
ance. 
Symptoms.—There is still room for doubt whether an or- 
dinary inflammation of the skin of itself can become ery- 
sipelatous, or whether a specific contagion is required for 
the production of the disease. It is certain, however, that 
wherever there is abrasion of the surface, the skin at this 
point is likely to be attacked by erysipelas if the patient be 92 
CLASS I. EXUDATIONES. 
exposed to unhealthy conditions—such, for instance, as a 
current of air escaping from a foul water-closet, or contact 
with decomposing matter. When once generated, the in- 
flammation spreads by extension to contiguous surfaces, and 
is easily conveyed by the hands of the attendants to other 
patients. It is the opinion of some that two forms of this 
disease exist,—viz., a traumatic and an idiopathic erysipe- 
las,—and that the latter is not communicable. Evidence 
on this is, however, unsatisfactory ; the belief probably arises 
from the fact that in hospitals the so-called idiopathic va- 
riety is usually treated in medical and not surgical wards, 
and that the patients therefore present no broken or ab- 
sorbent surface for the reception of the poison. 
The disease usually commences with a feeling of chilli- 
ness, headache, and often with vomiting. The tongue be- 
comes furred, the pulse rapid, the temperature rises, and in 
severe cases the vomiting remains constant. There is a 
sensation of pain and itching at the seat of inflammation. 
When the part is first attacked the skin becomes red, 
shining, and slightly swollen, but the redness disappears 
temporarily on pressure. As the disease extends to the 
surrounding parts, the skin becomes of a darker red and 
the swelling increases, and at the end of about three days 
the redness may fade and the swelling subside, while the 
cuticle over the part desquamates. 
In some cases the cuticle is raised into vesicles.or bullae, 
giving rise to the different varieties of erysipelas, to be de- 
scribed as follows: 
Erysipelas Vesiculosum.—While the inflammatory condi- 
tion exists, a crop of small vesicles appears on the affected 
surface, which last a day or two, then burst, and leave small 
brown scabs. 
Erysipelas Bullosum.—In this form, in which there is con- 
siderable swelling of the part after the inflammation has ERYSIPELAS. 
93 
existed a few days, bullse appear, which last a few days and 
then burst, leaving scabs. 
Erysipelas Fustulosum.—The contents of the vesicles or 
bullse become purulent. 
Erysipelas Orustosum.—Simply a later stage of the former, 
characterized by the crusts which are formed (Hebra). 
Erysipelas Fugax.—The variety in which the inflamma- 
tion moves from place to place, and is of short duration in 
each locality. In some cases the inflammation passes through 
some or even all the forms just mentioned above. In the 
majority of instances the area of redness is bounded by a 
well-defined line; but this is not always present, aud it is 
sometimes difficult to determine the exact point where the 
inflammation ends and the healthy skin begins. The ex- 
tent of surface covered is also very variable, being in some 
cases very limited, in others extending over the greater 
part or whole of the body, but the latter condition is very 
rare. The locality of the inflammation, to some extent, 
affects the course of the disease. Thus in erysipelas faciei 
there is considerable oedema of the skin over the orbits, 
cheeks, and lips. This does not extend beyond the forehead, 
nor laterally beyond the ears; the rest of the surface is red 
but not swollen. The attack may be limited to one side of 
the face, but it usually extends to both, although its start- 
ing-point is on one side. It frequently arises from local 
breach of surface, due to some previously existing disease, 
such as otorrhoea, decayed tooth, or some skin eruption, such 
as eczema. 
This variety is attended with considerable constitutional 
disturbance, often delirium. Other varieties of erysipelas 
are usually mentioned, being named after the parts of the 
body attacked; there is little to be said about them beyond 
the fact that the amount of swelling varies according to the 
denseness of the part. In those cases where the swelling is 94 
CLASS I. — EXUDATIONES. 
great, suppuration and sloughing often result, preceded by 
a dark-purple appearance of the skin. 
Diagnosis.—The local inflammation in erysipelas is dis- 
tinguished from the more extended rashes of the acute 
specific diseases ; from erythema it may be recognized by 
the absence of symptoms of constitutional disturbance, of 
swelling, and of desquamation in the latter, as well as by 
the rapidity with which the erythemata pass through their 
various stages. 
Prognosis.—This depends upon the constitutional symp- 
toms and the condition of health of the patieut at the time 
when attacked. If the fever be high, if there be much de- 
lirium, if vomiting be constant, or if there be signs of ex- 
haustion, the opinion must be guarded, as a fatal issue may 
occur rapidly. The facial variety is the most serious on 
account of brain complications. Iu the majority of cases 
recovery takes place. 
Morbid Anatomy.—On cutting through the thickened and 
somewhat indurated portion of skin, the surface of the 
section shows the corium thickened, gelatinous-looking, and 
juicy, merging into the subcutaneous fatty tissue, with which 
it is in a manner blended. From the cut surface a sero- 
fibrinous fluid, containing leucocytes and a few red corpus- 
cles, exudes. 
Thin sections, under the microscope, show an abundant 
effusion of leucocytes throughout the whole of the affected 
tissue. The bloodvessels especially are surrounded by thick 
cords of accumulated leucocytes, most marked in the mar- 
ginal spreading part, where there are comparatively few 
connective tissue spaces. Towards the centre the leucocytes 
are more diffusely spread, and are present in great numbers 
in and around the lymph spaces and lymphatic vessels. 
The endothelium of the latter is often swollen and granular, 
and sometimes is found desquamating. The epidermis, as 
well as the sweat and sebaceous glands and the hair folli- SEPTICEMIC RASHES. 
95 
cles, becomes similarly affected with sero-fibrinous and cellu- 
lar infiltration. The epidermic cells, especially those of the 
upper layer of the rete, are swollen, and as serum transudes, 
it gradually separates the layers in the stratum lucidum 
and produces vesicles or bullse. As the inflammatory pro- 
cess extends to the subdermic tissue, the fat cells, the blood 
and lymphatic vessels, become surrounded by lines of effused 
leucocytes. During the subsidence of the process the epi- 
dermis, owing to the alteration of the cells of the stratum 
lucidum having interfered with the conversion of their pro- 
toplasm into keratin, desquamates, and the degeneration 
and gradual absorption of the effused white and red corpus- 
cles gives rise to a reddish-brown stain. 
Treatment.—At the onset of the attack a brisk purgative 
is necessary; and, indeed, during the whole course of the 
disease attention must be paid to the bowels. Iron in some 
form, and in large doses, is the most useful drug to be 
given. Locally, the application of cold to the part is agree- 
able, and is probably of benefit; dusting with flour may 
be tried. Hebra recommends the application of mercurial 
ointment. Care should be taken to remove scabs retaining 
pus by means of poultices; suppuration should be treated 
with free incisions. It it believed by some that a super- 
ficial erysipelas in an early stage can be localized by draw- 
ing a ring round the affected part with a stick of caustic, 
but in practice this is often found to fail. 
Septicemic Rashes. 
Definition.—Rashes occurring during septicaemia. 
Symptoms.—During the septicsemic condition it is not 
uncommon to find rashes develop. They may appear as a 
simple hyperaemia, or consist of slightly raised patches or 
papules, which may be distinct from each other or may be 
confluent. The skin intervening between the papules may 96 
CLASS I. EXUDATIONES. 
be normal in appearance or may be more or less injected. 
The papules, as a rule, fade on pressure, but return to their 
previous condition as soon as the finger is removed. Some- 
times haemorrhages take place from the edges of the papules, 
and give rise to a mottled appearauce of the skiu ; these, of 
course, are not affected by pressure. In some cases, in ad- 
dition to this rash, a quantity of vesicles or bullae form, but 
these seem to be due to some neurotic condition, and more 
often follow an injury to the spinal cord. The papular rash 
usually first shows itself on the backs of the hands, wrists, 
the olecranon, and patella ; on the chest and abdomen the 
patches frequently are larger than on the extremities. The 
appearance of the rash is always, for a variable time, pre- 
ceded by considerable constitutional disturbance, in nearly 
every case commencing with a severe rigor. The tempera- 
ture is much increased, and the usual symptoms of septicae- 
mia are present. These rashes may occur at any time when 
the patient is suffering from septicaemia. 
Prognosis.—This is almost always unfavorable. 
Treatment.—No local treatment is requix-ed. 
Occasionally, a few days after an operation, a roseolar 
rash appears over the body, attended with sore throat, high 
temperature, and other constitutional symptoms. Although 
mention of the affection has not been made under Scarlatina, 
there are many who believe it to be identical with this dis- 
ease. The symptoms,, it is true, have not been distinguished 
from those of scarlatina, to which it bears the closest re- 
semblance, but sufficient evidence to prove their identity 
has not yet been adduced. 
Surgical Rash. SYPHILIS. 
97 
CHAPTER VIII. 
Class I.—Exudationes—continued. 
SYPHILIS-INFANTILE SYPHILIS— VACCINO- 
SYPIIILIS. 
Syphilis—Pox. 
Definition.—A chronic iufectious disease, produced by 
contagion or by inheritance from an affected parent, char- 
acterized by a train of definite symptoms, occurring in a 
definite order. According to Hutchinson it is a prolonged 
exanthem ; hence the position it occupies in this classifica- 
tion. 
Symptoms.—Inoculation of the virus is followed by an in- 
terval during which no signs are manifested of its presence. 
This is the incubation period. 
Occasionally a slight redness indicates some local irrita- 
tion at the point where the poison was introduced, which, 
however, speedily subsides, and, uuless the chancroidal virus 
has been mixed with that of syphilis, nothing as a rule is 
seen. 
The primary sore makes its appearance between the four- 
teenth and thirtieth day after exposure to contagion. It 
is doubtful whether a shorter period than ten days ever 
elapsed between infection and development of the chancre; 
on the other hand, it is unsafe to decide that syphilis has 
not been contracted because six weeks have not passed since 
the last known risk was incurred. 
It is usual to divide the manifestations of syphilis into 
three classes or stages,—primary, secondary, and tertiary. 98 
CLASS I. EXUDATIONES. 
The following table shows the period to which the chief 
symptoms and lesions are usually referred : 
Primary. 
Local Phenomena. 
The chancre. 
Induration of the 
chancre. 
Induration of near 
glands. 
Secondary. 
Constitutional 
Phenomena. 
Induration of remote 
glands. 
Pyrexia. 
Sore throat. 
Pain in limbs, etc. 
Alopecia. 
Iritis. 
Sypliilides: 
Roseola. 
Lichen. 
Psoriasis. 
Acne. 
Vesicles. 
Condvlomata. 
Mucous tubercles. 
Tertiary. 
Remote Phenomena. 
Arterial system: 
Aneurism. 
Nervous system: 
Paralysis, etc. 
Respiratory system: 
Ulceration of lar- 
ynx. 
Phthisis. 
Osseous system: 
Caries, etc. 
Liver 
Periosteum 
Testicle 
Cellular 
tissue 
Gummata. 
Late sypliilides: 
Rupia. 
Impetigo. 
Ecthyma. 
Tubercles. 
Lupus. 
Ulcers. 
Mr. Hutchinson has made the following convenient divi- 
sion of the course of the disease: 
A. Incubation.—From “ exposure ” to induration of chan- 
cre and neighboring glands; rarely less than ten days or 
more than six weeks ; usually from three to five weeks. 
B. Development.—From induration to appearance of rash, 
sore throat, and fever; two to four weeks. SYTHILIS. 
99 
C. Excinthem Stage.—So-called secondary symptoms. Very 
variable in extent, and dependent much on treatment; may 
exist for two years from infection, or even more. 
d. Post-exanthem Stage.—A period of latency ; sometimes 
with occasional relapses. 
E. Tertiary Stage.—Period of “ remote sequelae.” Symp- 
toms proper to this stage rarely occur before six months 
from infection, or they may never manifest themselves at 
all. They may appear at any time throughout life, and 
are specially prone to do so when the patient is exposed to 
depresssing influences, such as long, exhausting illness or 
privation. 
The primary sore, or chancre,—the initial lesion of syph- 
ilis,—may present a great variety of appearances; it may 
exist by itself, or be complicated by the presence of a so- 
called “soft chancre,” thus constituting a “ mixed ” sore. 
It is rare to find more thau one true chanrce upon the same 
individual; yet exceptions to the rule are at times met with, 
notably in vaccino-syphilis. The seat of the sore is always 
at the point of inoculation ; hence in the majority of cases 
it makes its appearance on some part of the genitals. It 
may, however, be accidentally produced on the fingers, eye- 
lid, tonsils, lip, tongue, navel, or anus. The most typical 
though by no means the most common form of primary 
sore is the “ true Hunterian chancre.” This commences as 
a small, almost painless papule, dusky red in color, and 
slowly increases in size till it attains the proportions of a 
tubercle; when fully developed its dimensions vary from 
the size of a split pea to that of a sixpence ; its outline, 
usually circular, may be modified by its situation: for in- 
stance, on the finger it may creep round the nail. After 
this, ulceration takes place upon the summit, with the forma- 
tion of a grayish slough, often compared to moist wash- 
leather. The secretion is slight in amount, and consists of 100 
CLASS I. EXUD ATIONES. 
serum and epithelial dehris, not of true pus. By the re- 
moval of successive sloughs the ulcer gradually deepens, and 
an excavated or crater-shaped depression is produced. Soon 
after the appearance of the chancre—generally within a 
week—a peculiar induration may be observed in the edges, 
base, and for a little distance in the surrounding tissues. 
It is of a tough consistency, much resembling cartilage and 
harder than ordinary inflammatory effusion, and is due to 
the presence of fibro-plastic elements, which infiltrate the 
layers of the coriura and subcutaneous tissue. This condi- 
tion, which to the touch feels like a coin or ring, may per- 
sist for some time after complete cicatrization of the sore, 
but finally disappears by a process of fatty degeneration. 
It is most typical in parts where the connective tissue is 
abundant, such as the prepuce. 
A far more common form of chancre is first noticed as a 
mere abrasion of the cuticle, which, instead of healing, 
increases in size, becomes slightly eroded, or in some cases 
elevated, is covered by a scanty nou-purulent secretion, 
undergoes induration, and finally heals with little or no 
contraction of tissue. In another variety a simple crack 
or fissure, which at first presents no appearance indicative 
of syphilis, obstinately refuses to heal, becomes indurated, 
and is followed by signs of constitutional infection. The 
amount of inflammation accompanying a primary sore 
varies much ; it is generally slight, but when irritation is 
set up by caustics it may become excessive, and in delicate 
subjects may result in destructive phagedenic process. The 
duration of a primary sore is seldom less than two weeks 
and rarely more than three months. 
Indolent enlargement of the glands nearest to the sore is 
usually observed within a week from the first appearance 
of the pimple or abrasion, but is attended with little or no 
pain. Suppuration occurs only in rare instances, where 
there has been much irritation of the primary soi'e. SYPHILIS. 
101 
Secondary Symptoms.—At a variable period after inocu- 
lation—generally between the eighth and eleventh week— 
signs of constitutional infection make their appearance. 
The primary sore by this time may have healed, but this is 
by no means the rule; and even in cases where the ulcer 
has disappeared the hard mass of induration will be easily 
felt. The first constitutional symptom is fever, which usually 
precedes the appearance of the rash on the body by twenty- 
four hours; it is not always well marked, and is said by 
Fournier to be more common in women than in men. In 
spite of the elevation of temperature there is, according to 
some, a craving appetite peculiar to this stage. The other 
symptoms are severe neuralgic headache, worse at night; 
great pain in the limbs, more especially in the joints; en- 
largement of the lymphatic glands throughout the system, 
particularly those of the occiput and axilla; sore throat; 
and an eruption on the skin. The sore throat may com- 
mence as a simple erythema, but soon small shallow ulcers 
are seen scattered over the tonsils, root of the tongue, and 
upper part of the pharynx. Following the classification, 
and to a great extent the description, of Baumler, we may 
divide the phenomena as seen on the skin into the following 
groups: 
I. Circumscribed hypersemia with but slight infiltration— 
muscular syphilide; roseola. 
II. Marked infiltration of the papillary body. 
A. In the form of papules—papular syphilide. 
b. In large patches—squamous syphilide. 
On mucous membranes, or at favorable points on the 
cutis—moist papules (condylomata lata). 
III. Especial implication of the immediate vicinity of the 
follicles (hair and sebaceous). 102 
CLASS I. — EXUDATIONES. 
A. Simple infiltration with scanty or no exudation in the 
follicles—lichenous syphilide. 
b. With acute suppuration in the follicle—acne syphi- 
litica. 
C. Exudation into small, markedly infiltrated groups of 
follicles with rapid formation of crusts—impetigo syphilitica. 
IV. Infiltration with sub-epithelial suppuration and su- 
perficial ulceration—pustular syphilide (pemphigus syphi- 
liticus, ecthyma syphiliticum, rupia syphilitica). 
V. Infiltration with disintegration to a considerable depth 
(gummous)—tubercular syphilide. 
Macular Syphilide—Roseola Syphilitica. 
This form of the exanthem is the first and most common. 
It consists of rose-colored spots of a roundish or irregular 
shape, varying in size from a pin’s head to that of a pea, 
disappearing on pressure and coming out in crops. The 
site varies with the severity of the attack. Sometimes but 
few spots are to be found on the chest, and in other cases 
the whole body may be covered. As a rule the eruption, 
if not treated, lasts for Aveeks, when it gradually fades, 
leaving slight coppery stains, which ultimately disappear. 
Occasionally roseola syphilitica relapses, when the spots 
differ somewhat from their original character, being paler 
in color, fewer in number, and very often assuming an an- 
nular form. 
Papular Syphilide. 
When a case has been neglected this form of syphilide is 
often the first to appear, but it may be developed from the 
preceding variety. The papules vary in size from a grain 
of wheat to a pea, and are at first red in color, gradually 
becoming darker. They are hard and usually smooth, but 
occasionally covered with small scales. The eruption may SYPHILIS. 
103 
occur on any part of the skin, but its favorite sites are the 
borders of the scalp, the forehead,—where it forms a band 
called the corona veneris,—on the palms and soles, on the 
back of the neck, either in depressions or wrinkles, or on 
the flexor surfaces of the joints. If the papules are situ- 
ated on the moister parts, such as the female genitals, or 
about the anus, or beneath the breasts, they may resemble 
the characters of condylomata. Relapses may take place 
late in the disease, when the papules are arranged in an 
annular form, often attacking unsymmetrically the palms 
and soles. The papules persist for a longer or a shorter 
period, according to circumstances, and finally disappear, 
leaving a deeply pigmented stain. 
Moist papules, or condylomata lata, are found on the 
mucous membranes as well as on the parts already men- 
tioned, in the form of superficial white spots, in which there 
are abrasions of the membranes and a circumscribed thick- 
ening of the epithelium. They thus resemble the effect 
produced by nitrate of silver. The condylomata at times, 
and especially on the surface, will ulcerate, when the con- 
dylomatous ulcer is produced, but more frequently they 
spread rapidly, owing to the contagion of the secretion, and 
then appear in large masses. 
Squamous Syphilide. 
This form of syphilide arises either from a gradual en- 
largement of a single papule or from the coalescence of 
several papules, when the infiltration is excessive, causing 
desquamation on the surface. The appearance is somewhat 
that of common psoriasis, but the scabs are dirty in color, 
quite different to the white transparent scales of the common 
disease. It may .occur on any part of the body, but when, 
as is often the case, it appears late, it may show itself as a 
single patch of crescentic outline. 104 
CLASS I. — EXUD ATIONES. 
Lichen Syphiliticus. 
Occurs in the form of papules, which closely resemble 
simple milium, and consist of hard granules, like gum, 
found in the epidermis, which, when scooped out, leave 
small pits. They are at first red, but gradually become 
yellow, and are situated in groups of a dozen or more. 
When the inflammatory process that gives rise to them is 
severe, vesicles, or even pustules, may result. 
Acne Syphilitica. 
In all respects, with perhaps the addition of a slightly 
coppery areola, this variety resembles acne vulgaris. The 
situation of the disease is the same in both, and the only 
point which can assist in the diagnosis is the presence of 
other syphilides on the skin. If the acne spots become 
pustular, with the rapid formation of crusts, syphilitic im- 
petigo is produced. 
Pemphigus Syphiliticus. 
Occasionally vesicles, large enough to deserve the title of 
bullae, are seen, chiefly on the hands, and to them Baumler 
has given this name. It is most common in hereditary 
syphilis. 
Ecthyma is oue of the later eruptions, occurring in the 
tertiary stage. It is unsymmetrical, altogether irregular, 
and characterized by pustules situated on inflamed bases. 
The pustules are caused by an infiltration into the epider- 
mis of a fluid that rapidly becomes purulent. They soon 
burst, and so produce ulcers, which extend at the edges in 
a serpiginous manner, and when healed leave scars that 
may be pigmented. 
Ecthyma Syphiliticum. SYPHILIS. 
105 
Rupia. 
This is the severest form of the pustular variety. It con- 
mences as a hard papule, which softens in the centre into a 
deepseated pustule, which soon dries, and forms a conical- 
shaped scab, having the appearance of a limpid shell. 
When the scab falls off a foul circular ulcer is left, that ul- 
timately circatrizes, leaving a permanent scar. It usually 
begins on the face, and extends to other parts of the body, 
chiefly the extremities. Rupia is generally unsymmetrical, 
and therefore a tertiary symptom, but in badly nourished 
persons it may occur comparatively early in the disease. 
Tubercular Syphilide. 
Tubercles are described as hard, flat, elevated bodies of 
a copper color, which usually attack the face, tongue, penis, 
and limbs late in the disease. They commence as small 
papules, which enlarge and become scaly or scabby on the 
surface. Beneath the scales ulceration may take place. 
Tertiary Symptoms.—Under the head of secondary symp- 
toms all the syphilodermata have been briefly mentioned, 
it being impossible to divide them correctly into secondary 
and tertiary manifestations, because the numerous excep- 
tions to the rule destroy the rule itself. The truth is, that 
all these varieties may occur more or less at the same time, 
or that they may overlap each other in such a way as to in- 
terfere with the conventional arrangement into fixed periods. 
Still it is useful, clinically, to retain the three divisions ; 
and, more than that, there are certain general characters 
connected with the tertiary stage which help us to decide 
whether a symptom is a remote sequela or one of the acute 
phenomena of the disease. 
Certain characteristics of the tertiary stage: 106 
CLASS I. — EXUDATIONES. 
1. Great obstinacy in healing and proneness to recur. 
2. General absence of symmetry. 
3. Invasions of deep organs and tissues as well as the su- 
perficial. 
The late syphilides are most commonly of the pustular 
or tubercular type. The term syphilitic lupus is applied 
to a tubercular syphilide of the face, resulting in severe ul- 
ceration and extensive destruction of the bones and tissues ; 
the name is ill-chosen, as it is apt to cause confusion with 
lupus vulgaris, which is not syphilitic. Ulcers are very 
common in this stage, and may arise as a result of boils, 
pustules, or tubercles. They are usually circular, with 
well-defined edges, looking as if they had been punched out 
with an instrument. They spread slowly, and destroy the 
deeper tissues in the process. A list of the other tertiary 
lesions has been given at the commencement of the chapter, 
and it is not within the scope of this work to do more than 
mention them. 
Diagnosis.—The primary sore, or true chancre, has to be 
distinguished from the non-syphilitic chancre, or chancroid. 
The following are the chief points to be considered in de- 
ciding between them : 
1. Site.—It is extremely rare for the non-infecting sore 
to exist upon any part except the genitals. The true chan- 
cre, though affecting the same locality, may be found else- 
where. 
2. Number.—The soft sore has a tendency to multiplic- 
ity. The chancre, or hard sore, is usually solitary. 
3. Time of Appearance.—The soft sore nearly always ap- 
pears within three days of contagion. The hard rarely 
shows itself before the tenth day. 
4. Induration.—Yery slightly marked in a soft sore that 
has not been treated by caustics; well defined and carti- 
laginous in a chancre. SYPHILIS. 
107 
5. Secretion.—The soft sore secretes pure pus; the hard 
chancre, serum and epithelial debris. 
6. Bubo.—The bubo resulting from a soft sore has a ten- 
dency to swell, be painful, and suppurate. The whole group 
of glands become glued together, and cannot be moved un- 
der the skin, whereas in the case of a true chancre the 
glands rarely suppurate unless the sore is irritated, or unless 
it takes on a phagedsenic character. The ganglia become 
hard, are not glued together, remain freely movable under 
the skin, and are only slightly tender. 
Herpes prseputialis is sometimes mistaken for a chancre, 
but this mistake can only occur after the rupture of the 
vesicles, when the ulcer that is left resembles the “ simple 
abrasion ” of primary syphilis. The history of a crop of 
vesicles, the smarting pain, the absence of induration, the 
date of appearance, and the rapid subsidence uuder simple 
treatment, are the main points to note in forming a diag- 
nosis. 
Syphilides, or Syphilo-dermatci. 
The general characteristics of skin eruptions due to syph- 
ilis are: 
1. Tendency to present several types simultaneously. 
The macular, papular, and squamous forms constantly occur 
together, and may present every variety of intermediate 
stage. 
2. A tint generally compared to “ copper ” or “ raw ham,” 
and especially well marked in inveterate eruptions. 
3. The general color of the skin becomes yellow or earthy, 
implying the presence of a special cachexia. 
4. Less itching than non-specific eruptions. 
5. Tendency to leave brown stains, and to produce other 
pigmentary changes, such as leucoderma. 
6. A disposition on the part of the ulcerative forms to 
spread in a characteristic serpiginous manner. 108 
CLASS I. — EXUDATIONES. 
7. A tendency to attack the parts of the body not usually 
affected by the non-syphilitic eruptions, such as the flexor 
surfaces of the limbs, the palms, and soles. 
Squamous syphilide, or syphilitic psoriasis, presents the 
following peculiarities: 
1. The production of scales is less profuse than in com- 
mon psoriasis. 
2. The white, glistening appearance of the patches is 
less marked, and there is a tendency to an ulcerative condi- 
tion with the formation of dirty-colored scabs. 
3. The inner sides of the arms and thighs suffer more 
than the elbows and knees. 
4. A decided tendency to affect palms and soles. 
Syphilitic Iritis.—The lymph effused is seen in the form 
of patches or beads, especially at the margin of the iris, 
instead of appearing as a film covering the whole organ. 
There is also less pain than is the case with the traumatic 
and rheumatic varieties. 
Syphilis of the Tongue, as a result of a gumma which 
has broken down, produces an obstinate, ragged ulcer, 
which has often the appearance of cancer. The history 
and the presence of other symptoms of syphilis will assist 
the diagnosis, while the scrapings, placed under the micro- 
scope, would indicate the presence or absence of the char- 
acteristic elements. Erichsen says: “The syphilitic ulcer is 
elongated, irregular, and does not rapidly extend .... 
while the cancerous ulcer is of a more circular shape, has 
hard eroded edges, and spreads with great rapidity.” Syph- 
ilis and cancer may both produce a hard, non-ulcerating 
tubercle in the tongue, but here, in addition to the history, 
we must bear in mind that cancer usually attacks the tip 
and edges, while syphilis affects the deep substance, of the 
organ. (Erichsen.) SYPHILIS. 
109 
Prognosis.—The prognosis as regards absolute cure in a 
case of syphilis is most uncertain. It is true that many 
patients, after one or two attacks of secondary symptoms, 
if properly treated and of sound constitution in other re- 
spects, may never again be troubled by any manifestations 
of the disease. It is also, no doubt, true that the chance of 
immunity from fresh symptoms increases with the time that 
has elapsed since the disappearance of the last. Still, it is 
never safe to announce that we have seen the last of it. 
Any depressing influence, any severe illness, great priva- 
tion, or overwork may excite the disease to renewed activ- 
ity: Cases in which syphilis has reappeared after an ap- 
parent quiescence of twenty years are by no means rare. 
The important question, When may a man marry who has 
had syphilis? is one which ought to be considered under the 
head of prognosis. Much might be said upon the subject, 
but it will be sufficient here to assert that it is absolutely 
unsafe to marry until all constitutional signs of the disease 
have disappeared for at least twelve months. With the 
exception of infantile syphilis, which often destroys the child 
within a few months, it is only as a result of old-standing 
tertiary mischief that the disease is ever fatal. 
Morbid Anatomy.—On examining under the microscope 
a hard chancre which has become fully developed, an infil- 
tration of small round cells will be observed throughout the 
whole substance of the corium or mucous membrane, im- 
bedded in an amorphous or slightly granular substance, and 
specially numerous around the bloodvessels, the walls of 
which are usually somewhat thickened and contain numer- 
ous round cells. As the cellular infiltration extends into 
the rete Malpighii, it produces impaired nutrition of the 
epidermis and subsequent scaling. In the later stages the 
conversion of the exuded cells into connective tissue main- 
tains the induration, especially in the marginal part of the 
chancre. 110 
CLASS I. — EXUDATIONES. 
The roseolar syphilide consists in a mere localized hyper- 
jemia of the papillary layer, going on gradually to slight 
effusion of plasma, with accumulation of cells around the 
capillaries and a slight increase of nuclei in their walls. 
In the papular syphilide the papillary layer is the seat of 
a cellular infiltration, identical in appearance with that of 
the hard chancre. The epidermis covering the little nodules 
becomes thinned or scaly, and occasionally a very slight 
subepithelial exudation gives rise to a shallow vesicle. 
In “mucous tubercles” the same essential changes take 
place, but under the influence of warmth and moisture the 
papillary body hypertrophies, and the epidermis being 
macerated, a molecular ulceration of the exposed papillae 
occurs. “Mucous tubercles” that are kept dry assume the 
appearance of ordinary papular syphilides. 
The squamous syphilide, due to the enlargement of a 
syphilitic papule or to the coalescence of several, presents 
similar anatomical changes. 
In the simplest cases of lichenous syphilide there is an 
infiltration of small round cells just outside the hair and 
sebaceous follicles, combined with hypenemia of the follicu- 
lar plexus. In more acute cases there is slight exudation 
into the follicles, forming minute discrete vesico-pustules, 
which soon dry up, and, falling off, leave small dark, de- 
pressed, slowly-fading scars. 
Occasionally the intervening skin between the papules 
becomes affected, and the papillary layer being infiltrated, 
the little group of lichenous spots becomes converted into a 
scaly eruption. 
If the process be still more acute, leading to suppuration 
in and round the follicles, the acneiform syphilide is pro- 
duced; and if the skin intervening between the follicles 
becomes affected, an aggregation of closely-packed pustules 
on an inflamed base is formed, which soon becomes covered SYPHILIS. 
111 
with a greenish-yellow granular crust, producing the im- 
petiginous syphilid e. 
In the vesicular and bullous syphilides the serous effusion 
into the epidermis, separating the cells of the stratum luci- 
dum, gives rise to vesicles, the contents of which, often tur- 
bid and blood-stained from the first, soon become purulent. 
The crusts formed by the drying up of the contents leave 
only a slight scar on falling off. If the base of the vesicle 
becomes red and inflamed, and the rete with the papillary 
layer be more or less destroyed, the so-called edhymatous 
syphilide is produced. Owing to the loss of tone, the scars 
left after separation of- the scabs and healing of the ulcers 
are depressed, and often deeply pigmented. 
By an extension of the infiltration round the periphery 
of the scab, successive layers are added from below, and a 
conical prominence, seated on a purplish-red ulcerated sur- 
face, is gradually formed, termed the rupial syphilide. 
In the tubercular syphilides there is a formation of gum- 
mata in the substance of the true skin. In the deeper lay- 
ers of the corium there are seen small nodules, grayish-red 
and homogeneous on section, and merging gradually into 
the surrounding tissue, so that they cannot be enucleated. 
Microscopically they consist of masses of round cells 
closely aggregated together in a meshwork of fine fibres. 
The marginal portions in older nodules, and the whole mass 
in the younger ones, are pretty freely supplied with vessels; 
but in process of growth these get gradually obliterated in 
the centre, which then undergoes mucous or caseous degen- 
eration. The margin, on the other hand, may undergo 
condensation from partial conversion of the round cells into 
spindle cells and connective tissue. As the nodule extends 
towards the surface, the swelling, which at first has pre- 
sented the appearance of a colorless papule, becomes redder, 
and, slowly involving the papillary layer, causes irritative 
changes in the epidermis. These may result in desquama- 112 
CLASS I.—EXUD ATIONES. 
tion only, or, by the exudation of a little serum, in the 
formation of a thin yellowish crust. Sometimes, also, a 
vesicle is formed, which dries up to produce a crust, beneath 
which ulceration of the tubercle slowly takes place. If the 
tubei'cle be large and softened in the centre, when it reaches 
the skin a bluish-gray furuncle-like body is formed, which 
on bursting discharges a yellowdsh material, and in conse- 
quence a deep, slowly-spreading ulcer is produced. 
Infantile or Inherited Syphilis. 
A child may inherit syphilis from either parent, but in 
the majority of cases the mischief may be traced to the 
father. This arises from the fact that a woman whose con- 
stitution is infected at the time of conception, or becomes so 
during gestation, is particularly liable to abort. When de- 
livery takes place at full term, the child rarely survives it 
more than a few weeks. It should be mentioned here that 
some deny the possibility of direct contamination of the 
foetus by the father, and maintain that the mother is always 
intermediately infected. Nothing is known with certainty 
of the means by which the disease is transmitted, but it is 
certain that the placenta not uncommonly shows traces of 
the malady. (Virchow.) 
Infantile syphilis may either appear at or soon after birth, 
or may not give any signs of its presence till several weeks 
have elapsed. The former cases are the more serious, and 
usually terminate fatally. They are characterized by a 
bullous or pustular eruption, which never appears later 
than the first week. The first seat is generally on the palms 
and soles, spreading thence to the trunk, limbs, and occa- 
sionally to the face. Dirty-red, circular spots, of variable 
size, are first seen, and effusion beneath the cuticle converts 
these into blebs, which after a time rupture and produce 
unhealthy excoriations, obstinately resisting treatment. SYPHILIS. 
113 
Fresh crops of blebs appear, some of which at times attack 
the mouth and nose. The nails fall off, and finally the 
child becomes a mass of ulcerating sores, and succumbs in 
less than a month. The name pemphigus neonatorum was 
applied to this form of the disease before its nature was un- 
derstood, but it is more correct to call it pemphigus syphil- 
iticus. 
In the more numerous class of cases the child may be 
apparently healthy at birth, or merely somewhat undersized. 
After a period, varying from a fortnight to two months, it 
becomes emaciated, delicate, and irritable; the skin is 
shrivelled, rough, dry, and of a peculiar earthy color. 
Mucous tubercles, accompanied by catarrh of the nasal 
mucous membrane, make their appearance, and give rise to 
much swelling and profuse thin secretion. The character- 
istic noise produced by the child’s efforts fo remove the 
obstacle to respiration has obtained for this symptom the 
name of “ the s?vuffles.” At about the same time as the 
coryza an eruption appears, usually commencing about the 
anus and buttock, whence it may extend to any or every 
part of the surface, more especially over the face. Macules, 
papules, and scaly patches, in varying proportions, make up 
a rash of a mixed character, which it is impossible to refer 
to any one form. The color, however, presents the copper 
tint of syphilis. 
Condylomata about the anus cause much trouble, and 
“rhagades” are found in that situation, and about the 
mouth, where they leave scars. 
In addition to these symptoms the infant usually suffers 
from severe diarrhoea, stomatitis, and loss of flesh and hair, 
and in consequence assumes the aspect of an old man. At 
the end of twelve months, if properly treated, all these 
symptoms subside. Tertiary manifestations make their 
appearance between the ages of four and fourteen. As in 
the adult, they appear in the bones and deeper tissues as 114 
CLASS. I.—EXUDATIONES. 
well as in certain eruptions, such as rupia and ecthyma. 
Besides these there are certain lesions which are specially 
characteristic of the inherited form of the disease. 
A. Cloudiness and opacity of the cornea, known as “in- 
terstitial keratitis.” 
B. Certain changes in the teeth, probably the result of 
early stomatitis. These changes are most marked in the 
permanent set, but may be observed to a less extent in the 
milk teeth. The incisors, especially those of the upper jaw, 
suffer most, the median being first attacked. They are 
small in size and pegged, rapidly wear away, and pre- 
sent a notch in the centre of the edge and a wide interval 
between them. The canines suffer, but to a less extent. 
(Hutchinson.) 
c. Depression of the nasal cartilages produces the re- 
markable flattening of the bridge of the nose. 
D. Less common than any of the preceding is an enlarge- 
ment of the lower end of the humerus and sternal end of 
the clavicle. 
Vaccin o-Syphilis. 
The series of carefully observed cases reported by Mr. 
Hutchinson in this country, and the report by Dr. Pacchi- 
otti, of Turin, who was specially employed to observe an 
outbreak of the disease in the Rivalta valley in 1861, leave 
no doubt that syphilis is occasionally produced in healthy 
persons by careless vaccination with lymph taken from in- 
fected children. Under these circumstances the disease 
runs precisely the same course and exhibits the same symp- 
toms as when inoculation takes place in other ways. 
Treatment. 
Primary Sore.—There is considerable doubt whether any 
good is gained by the vigorous cauterization of the primary SYPHILIS. 
115 
sore, which is so strongly recommended by some surgeons ; 
at all events, if the plan is adopted, it must be done early 
and with the strongest form of caustic, such as pure nitric 
acid. The usual and best local application is black wash. 
When a case is decided to be one of syphilis, no time should 
be lost in giving the antidote, which is undoubtedly mer- 
cury. Some authorities recommend waiting till the secon- 
dary symptoms have shown themselves before using the 
remedy, but it is better to try and lessen their severity by 
its early use. 
In administering the drug we may select from a large 
number of methods, of which the following are the most 
important: 
A. By the Mouth.—One drachm of the solution of corro- 
sive sublimate three times a day; four or five grains of blue 
pill, with a little opium, night and morning; one grain of 
the green iodide three times a day, or five grains of Plum- 
mer’s pill as often, as the best preparations to be used. 
b. By the Rectum.—Bryant advises the use of mercurial 
suppositories. 
c. By Hypodermic Injection.—Four grains of the per- 
chloride in an ounce of water; fifteen minims for a dose. 
D. By Vapor Baths.—Using from ten to thirty grains of 
calomel for each bath. 
E. By Inunction.—A drachm of mercurial ointment may 
be rubbed into the axillae or groin night and morning. 
Two or more of the preceding modes may be used to- 
gether, and it is sometimes an advantage to vary during the 
treatment the mode of administering the drug. In a mer- 
curial course attention should be paid to the following points: 
1. Avoid profuse salivation. The gums must be care- 
fully watched, the teeth being cleansed twice or three times 
daily with an aromatic or astringent wash. 116 
CLASS I. — EXUDATIONES. 
2. Warn the patient against catching cold. 
3. Continue the treatment for some time after the disap- 
pearance of the symptoms, and discontinue the use of the 
drug gradually rather than suddenly. 
4. Give a simple and nutritious diet, with a moderate 
amount of good wine and beer. Avoid fruits of all kinds. 
5. Stop the use of the drug, or give it very cautiously, if 
the patient is cachectic, and substitute for it iron, cod-liver 
oil, and other tonics. 
Secondary Symptoms.—They should be treated on a sim- 
ilar plan—that is, by the administration of mercury, if it 
has not been already commenced during the primary stage. 
Ulcers in the mouth and throat should be lightly touched 
with nitrate of silver or with a solution of perchloride of 
mercury. 
Condylomata about the anus, etc., are best treated by 
dusting them with calomel. 
Tertiary Symptoms.—Mercury by the mouth, with only a 
few exceptions, should be avoided in this stage, especially 
when the deeper tissues are involved. In its place the drug 
to be relied upon is iodide of potassium, which should be 
given in full doses of ten to thirty grains three times a day. 
Gummatous deposits in the skin should be treated locally, 
by means of mercury ointment, or the oleate of mercury. 
In this stage good food, wine, change of air, and general 
tonics are of great importance. 
Infantile syphilis must be treated by mercury. The usual 
modes of administering it are by the mouth, in the form of 
one or two grains of gray powder, night and morning, or 
by the inunction of mercurial ointment, wdiich is most easily 
applied on the child’s abdominal binder. ERYTHEMATA. 
117 
CHAPTER IX. 
Class I.—Exudatioxes—continued. 
Sub-class B.— Of Internal or Local Origin. 
1. ERYTHEMATOUS GROUP. 
Erythema simplex, lseve, fugax, intertrigo; multiforme, including 
papulatum, tuberculatum; annulare, iris, gyratum—Erythema 
nodosum—Roseola—Urticaria—Pellagra. 
Definition.—The erythemata are characterized by the ex- 
istence on the skin of dusky-red, slightly raised patches of 
various sizes, which occasionally vesicate, run an acute course, 
and are attended with little or no constitutional disturb- 
ance. 
Symptoms.—When the patches first appear, they are sur- 
rounded by a hypersemic zone, which prevents their margin 
being clearly defined ; at the end of a few hours this zone 
disappears without leaving any pigment, and the erythema- 
tous papules can be distinctly recognized. After lasting a 
few days the papules fade, and are usually followed by des- 
quamation, which is limited to the site of the eruption. In 
some cases, during the height of eruption, a small vesicle or 
bulla may be produced. There is no itching, and but little, 
if any, constitutional disturbance. The papules are most 
frequently found on the back of the hands and the dorsum 
of the feet, where, as a rule, they commence even when they 
extend to other parts of the body. They occur less often 
on the arms and legs, and seldom extend to the face and 
Erythemata. 118 
CLASS I. EXUDATIONES. 
trunk of the body, never without implicating the limbs. 
A large number of varieties of this rash have been described 
by different writers, depending on differences noticeable in 
the character of the eruption itself, in its site, and in the 
amount of constitutional disturbance it produces. 
With one exception, to be afterwards mentioned, they are 
attended by but little if any increase of temperature; in- 
deed, but for the appearance of the rash there is nothing in 
the patient’s condition, either local or constitutional, which 
would attract attention to the disease. They all agree 
in the rash being unilateral ; when the trunk is implicated, 
both sides of the body are affected at the same time. The 
duration of the disease varies greatly, and it often has a 
tendency to return to parts which have been attacked in the 
first instance, and from which the eruption has already 
faded. 
Erythema Iceve occurs as the result of venous obstruction, 
and is a mere hypersetnia of the skin ; it frequently is a 
consequence of some general condition, such as dropsy, and 
is more often seen on the legs. The redness is preceded by 
oedema of the skin, and may not progress further than the 
stage of hypersetnia, but occasionally bullae form on the sur- 
face. 
Erythema fug ax is a simple hvpersemia of the skin, which 
is due to gastric disturbance or local irritation. It consists 
of patches of redness of irregular shape, which appear in 
different parts of the body, frequently on the face and up- 
per part of the trunk. The patches are of very short 
duration, come and go rapidly, and in most cases itch and 
tingle while present. 
Although these diseases are usually described as erythe- 
tnata, it is doubtful whether they should not, as Hebra sug- 
gests, he excluded on the ground that they are only hyper- 
se mise of the skin. 
Erythema intertrigo is a local erythema, produced by the ERYTHEMATA. 
119 
friction of opposed surfaces of the skin, and occurs in fat 
persons, more particularly children. It soon becomes moist, 
when it assumes the nature of eczema, under which head it 
will be again noticed. 
Of the other varieties described by different writers, such 
as Wilson, Rayer, and Fuchs, only those included by Hebra 
under the name of erythema multiforme will be noticed. 
Hebra looks upon these varieties as merely different stages 
of development of the same eruption : thus E. papulatum 
and E. tuberculatum differ from each other simply in the 
size of the patch, in the former being about the size of a 
pin’s head or larger, in the latter about the size of a four- 
penny piece. They occur generally on the backs of the 
hands and feet, and occasionally extend to the arms and 
legs, and rarely to the face and body. In both forms they 
are of a dusky-red or violet color, and when they first make 
their appearance are surrounded by a zone of redness, 
which lasts but a few hours. At the end of three or four 
days they fade, occasionally leaving a temporary yellow 
stain, due to escape of coloring matter of the blood into the 
skin. A slight desquamation follows the fading of the pap- 
ules. The papules are succeeded by others, but the whole 
course of the eruption is limited to a few days. The young 
are most frequently affected by this form of erythema, most 
often in the spring and autumn of the year. A difference 
of opinion exists as to which sex is most frequently attacked. 
Erythema annulare results when the erythematous patch 
begins to fade in its centre, leaving a red ring surrounding 
a pale surface. 
Erythema iris is produced when a second or third ring is 
formed outside the inner, due to a fading of the redness in 
the circumference of the patch. In this, as in all varieties, 
vesication may take place. 
Erythema (jyratum is said to occur when portions of the 
rings of E. iris fade, and in consequence of several patches 120 
CLASS I. EXUDATIONES. 
being close the rings run together, forming a serpentine 
eruption. 
The circular form of erythema differs only from the pap- 
ular in the appearance of the eruption. They present 
themselves on the same parts of the body, last but a few 
days,—never beyond a month,—and cause almost no con- 
stitutional disturbance. 
Erythema Nodosum. 
This variety of erythema differs widely from the preced- 
ing forms in the character of the eruption,—in its site, in 
its symptoms,—and, in fact, it is not a skin disease at all. It 
consists of oval swellings, at first hard, but at a later stage 
soft, from a half to four or five inches in length. At the 
commencement the swellings are pale red, but gradually be- 
come of a dark-red or violet color. After a few days, as 
the color fades, it is replaced by a yellow discoloration, 
which persists for some time after the disappearance of the 
swelling. These swellings occur in crops of rarely less than 
a dozen in number, most frequently on the front of the lower 
extremities, but are by no means limited to this site. A 
second, sometimes even a third, crop makes its appearance, 
invading parts which in the first attack have escaped, and 
thus the eruption extends over other parts of‘the body. 
This form of erythema is not attended by any itching, but 
is characterized by considerable pain at the seat of eruption, 
and great general debility, ansemia, and gastric disturb- 
ance. 
Diagnosis.—Simple erythema can only be confounded 
with prurigo, from which, however, it can be distinguished 
by the extreme itching and blood crusts of the latter, 
and by the limitation of the rash of prurigo to the back and 
extensor surfaces of the arms and legs; while erythema 
attacks the anterior surface as well. The varieties of ery- ERYTHEMA NODOSUM. 
121 
thema multiforme can hardly be mistaken for any other 
disease, with the exception, perhaps, of the gyrate form, 
which may be taken for ringworm of the body. The rapid- 
ity of the appearance and disappearance of the former, and 
the absence of microscopical evidence, are points to guide 
us in our diagnosis. 
Erythema nodosum can be readily distinguished from all 
other eruptions by the tenderness of the patches, the pain 
they occasion, and by the constitutional and gastric symp- 
toms which accompany it, as well as by the gradual altera- 
tion in color from day to day, resembling a bruise. 
Prognosis.—Always favorable, although the period of 
duration varies. Death after E. Iseve results not from the 
erythema, but from the disease during which it occurs. The 
length of an attack of E. nodosum depends on the number 
of crops which appear; five or six weeks is, however, an 
outside limit. Like the rest of the erythemata, the symp- 
toms disappear spontaneously. 
Morbid Anatomy.—The changes in the skin may be due 
to— 
1. Simple hypersemia of the superficial layer of the cutis. 
2. Hypersemia followed by exudation. 
The former exists in E. simplex and E. intertrigo. 
On examining the affected portion of the skin with a 
simple lens, magnifying about twenty diameters, a great 
number of minute red dots are seen, which are the tops of 
the capillary loops in the papillse, especially in the region 
of the hair follicles. As the turgescence of the minute 
vessels passes off readily, no morbid appearances are to be 
found after death. 
In the latter condition, in addition to the simple hyperse- 
mia of the papillary layer, there is exudation of plasma, of 
pale and then of red corpuscles, according to the severity 
of the process, followed often by various secondary inflam- 122 
CLASS I. EXUDATIONES. 
matory changes. In E. papulatum, following on the hy- 
persemia, there is slight effusion of plasma in the substance 
of the papillary layer, giving rise to slight elevation of the 
little spots. An excess of serum, transuding into the epi- 
dermis, and collecting in the stratum lucidum, may give 
rise to minute vesicles. In E. nodosum a number of pale, 
together with a few red, corpuscles, as well as a large amount 
of plasma, are effused. The exudation pressing on the ves- 
sels, gives rise, as in a wheal, to the pallor in the centre of 
the patch, and the breaking-down and pigmentary changes 
in the red corpuscles produce the purplish, greenish, and 
yellow discoloration in the same way as in a fading bruise. 
Treatment.—In the treatment of E. laeve every care should 
be taken to assist the circulation of the part; the limb 
should be raised, carefully supported, and warm fomenta- 
tions applied. Often acupuncture by means of Southey’s 
trocars becomes necessary to relieve the oedema. Bathing 
the part with an astringent lotion is recommended. 
In E. fugax the diet should be carefully regulated. Often 
this eruption is due to the use of soap, which should of 
course be avoided. Local treatment is unnecessary, not 
only in this form but in all the varieties of erythema, on 
account of the short duration of the eruptiou. In E. inter- 
trigo attention should be paid to keeping the part dry and 
clean; a weak tar lotion is of use. The constitutional treat- 
ment of all the erythemata should consist in regulating the 
bowels and in the subsequent administration of acid and 
bitter tonics. 
Roseola. 
Much difference of opinion exists among dermatologists 
concerning the diseases usually classed under this heading. 
Willan has described, under the name of roseola, a variety 
of rashes which are not recognized by all writers, and Hebra 
especially doubts their existence. There may be some diffi- ROSEOLA 
123 
culty in agreeing with Willan in the correctness of describ- 
ing as separate affections R. infantilis, R. sestiva, R. autum- 
nalis, R. annulata, but we shall mention a rash under the 
name of roseola which is by no means limited to one period 
of the year. A roseolous rash, occurring in association with 
some of the acute infectious diseases, has been described 
under the head of these diseases. 
Definition.—Roseola is an acute disease characterized by 
the production on the body of small rose-colored papules, 
and attended by very slight constitutional symptoms, which 
make their appearance at the same time as the rash. 
Symptoms.—The rash consists of minute red and slightly 
elevated spots, scattered over the chest and neck, less often 
extending over the face and arms. They disappear tem- 
porarily on pressure, last but a few days, and fade, leaving 
a discoloration of the skin, but are sometimes followed by 
slight desquamation. Feverishness, headache, and occa- 
sionally vomiting are present at the commencement of the 
rash. 
The constitutional symptoms are, however, slight; the 
temperature is seldom as high as 102° Fahr., and more often 
only just above normal. The fauces are frequently a little 
injected, but the redness does not extend beyond the edge 
of the soft palate, and the tonsils are not swollen. The 
tongue is slightly furred, and the papillse along its edge are 
often prominent. 
Diagnosis.—Roseola is often mistaken for scarlatina, and 
the diagnosis between the two affections is frequently a 
matter of considerable difficulty. They differ in the fact 
that the papules in the former are more widely separated 
from each other than those in the latter, and the skin inter- 
vening between the papules does not become red in roseola, 
as it does in scarlatina. The constitutional symptoms in 
roseola appear at the same time as the rash, while in scar- 
latina they precede it. Roseola is not infectious, and occurs 124 
CLASS I. EXUDATIONES. 
more frequently among young women and children than 
other persons. Also see table, p. 57. 
Prognosis.—Roseola always ends in recovery in a few 
days. 
Morbid Anatomy.—The changes are the same as in the 
milder forms of erythema, the processes usually stopping 
short at hypersemia only, but sometimes going on to slight 
exudation of plasma. The vascular plexuses round the 
hair follicles, sweat and sebaceous glands, are the regions 
specially involved. 
Treatment.—Nothing is required beyond rest for a day 
or two. 
Urticaria—Nettle Rash. 
Definition.—A disease the chief symptoms of which is the 
production of wheals on the skin, causing great irritation, 
usually unattended by any constitutional symptoms, but 
sometimes by fever, pain in the epigastrium, and headache. 
Symptoms.—The eruption makes its appearance at the 
same time as any constitutional symptoms which exist, and 
consist of a quantity of wheals. These vary greatly in size, 
in quantity, in shape, and in color; but the difference in 
the variation in color is due to their being in different 
stages of development. As a rule they appear first as red 
elevations, which increase in size, becoming white in the 
centre with red margins. They may occur on any part of 
the body, and although each individual wheal does not last 
many hours, a succession may make their appearance for 
weeks or months. They ai'e accompanied by a severe itch- 
ing or stinging sensation of the part, and constitutional 
symptoms may or may not be present. 
In some individuals a condition of skin exists which may 
fairly be considered to result from an urticarial diathesis. 
Several forms of urticaria are recognized. 
Urticaria Febrilis.—In this form the eruption is preceded URTICARIA. 
125 
by shivering, headache, furred tongue, and vomiting. Soon 
a number-of slightly raised wheals appear over the greater 
proportion of the body, and usually begin on the wrists and 
neck. These come and go rapidly, and the itching is in- 
tolerable, so much so that it is impossible not to rub or 
scratch them. Wherever the skin is touched fresh wheals 
appear, till in this way the surface is more or less covered. 
From the scratching the skin becomes excoriated, but des- 
quamation does not occur at any time. The irritation is 
always worse at night. 
Urticaria conferta is a chronic variety of the disease in 
which the wheals are abundant but limited to one or two 
localities. 
Urticaria evanida is also a chronic form, in which the 
wheals come and go rapidly. 
Urticaria perstans is a variety in which the eruption con- 
tinues without changing for some weeks, and may perhaps 
be the same form which has been well called by Dr. Alfred 
Sangster Urticaria pigmentosa, in which the wheals last for 
years, leaving a deposit of pigment, which causes a mottled 
appearance on the skin. 
Urticaria tuberosa is rarely seen ; in it the wheals are of 
a larger size than in the others, and it occurs in persons of 
weak constitution. 
Urticaria miliaris, U. vesicularis, U. bidlosa, are described 
and so called because vesicles or bullie form on the surface 
of the wheal. They are extremely rare. 
In Urticaria papidosa the wheals are so small as to re- 
sembles papules. Hebra says that they increase in size, 
but later in the disease diminish again. 
Diagnosis.—Urticaria is easily distinguished from the 
erythemata by the more diffused character of the eruption 
and the difference in the site, by the absence of local irri- 
tation in erythema, by the urticarial wheals being white in 
the centre with red margins, and more raised than the ery- 126 
CLASS I. EXUDATIONES. 
thematous patches; from measles and scarlatina by the 
absence of coryza and sore throat in urticaria, and its low- 
ness of temperature, and by the different courses these dis- 
eases run ; from erythema nodosum by the presence of 
itching in urticaria and heat and pain in the former. 
The ease by which the rash is excited in certain varieties 
of urticaria by the slightest irritation of the skin is often a 
useful diagnostic sign. 
Urticaria often arises from the ingestion of some special 
article of food, such as mussels, oysters, cucumber, mush- 
rooms, etc., and even cold water ; but in many persons it 
arises without any apparent cause. It is undoubtedly 
affected by season, in some being worse in cold than in hot 
weather. The young are more liable to it than the old, and 
it is occasionally associated with irregularities of menstrua- 
tion, pregnancy, the presence of parasites in the alimentary 
canal, and arises very frequently from the irritation caused 
by the bites of fleas, bugs, etc. 
Prognosis.—Urticaria is not a fatal disease. As a rule 
an attack passes off' in a few7 days, but it may be extremely 
obstinate and resist all forms of treatment. 
Morbid Anatomy.—On examining a vertical section of an 
urticarial wheal we find the connective tissue bundles of the 
corium separated by effused plasma. The capillaries and 
small vessels are dilated, especially in the marginal zone of 
the wheal, full of blood, and surrounded by lines of effused 
leucocytes, which are present in larger numbers than nor- 
mal throughout the whole corium. The lymphatics of the 
skin are widely dilated and full of lymph. In some cases 
escape of red corpuscles by transudation, or actual rupture 
of the vessels, gives rise to pigmentary and other color 
changes in the wheal. 
Each wheal usually corresponds with the area of distri- 
bution of a terminal arteriole, and is supposed to be pro- 
duced by paralysis of the vasomotor nerves supplying the PELLAGRA. 
127 
branch ; but opinions differ as to the way in which this can 
give rise to exudation. 
Treatment.—If a cause, either internal or external, can 
be found for its existence, it should be at once removed. 
In acute urticaria it is well to begin with an emetic or 
purgative, or both. In both acute and chronic forms it is 
important to diet the patient carefully, paying particular 
attention to avoid his having indigestible food, salt meat, 
pork, etc. The bowels should be regulated, and the patient 
kept cool. With a view to allay irritation, sponging the 
skin with cold water should be adopted. Saline baths and 
lotions are useless, but washing with w'eak vinegar is agree- 
able, and should be persisted in if the irritation be severe. 
Aconite has been given internally with doubtful benefit, 
but arsenic is certainly of value in some of the more per- 
sistent forms of the disease. 
Pellagra—Italian Leprosy. 
Definition.—Pellagra is a serious disease, occurring en- 
demically in Northern Italy and Southern France, one of 
its chief characteristics being an erythema of the skin. 
This appears on those parts of the body most exposed to 
the sun, such as the hands and arms, neck and chest. 
Women suffer from it on the face, owing to the fact that 
their head dresses do not protect them from the sun’s rays, 
while among men, whose faces are screened by large hats, 
this part is more rarely affected. 
Symptoms.—It commences as a mere erythema of the skin, 
which is accompanied by a sense of irritation. During the 
winter this subsides, but a deposit of more or less pigment 
remains. Vesication does not occur, but the erythema is 
followed by desquamation. On the return of the summer 
the erythema again makes its appearance, and each year 
the skin is left more stained with pigment. At first the 128 
CLASS I. EXUD ATIONES. 
patient simply complains of lassitude, but gradually be- 
comes melancholic; later on suffers from marked cerebral 
symptoms, which terminate in insanity. 
Prognosis.—The length of the disease—that is, from first 
symptom to death—varies from a few to ten or twelve 
years, usually about five. Although it generally proves 
fatal, this is not always the case ; but even when recovery 
takes place it is only partial. Complete restoration to health 
is rare. 
The causes of pellagra are not well understood. It is a 
disease altogether confined to the poor, and to those who 
work in the sun. It has been attributed to the character 
of the food which these people eat, and has been thought 
to he associated with maize, their chief article of diet. In 
the damp seasons maize is attacked with a parasitic fungus, 
wdiich is supposed by Bellardine to be the origin of pellagra. 
When maize is supplemented by other food, as in the large 
towns, the disease does not exist. Pellagra is not conta- 
gious, nor is there any evidence that it is hereditary, al- 
though members of the same family who are exposed to 
the same conditions are often attacked with it together. 
Treatment.—The treatment of the local inflammation is 
simple. Protection from the rays of the sun always leads 
to a subsidence of the symptoms. As has been explained, 
a nourishing and varied diet in the early stages of the dis- 
ease will often restore the patient to health. LICHEN. 
129 
CHAPTER X. 
Class I.—Exudationes—continued. 
2. PAPULAR GROUP. 
Lichen simplex, ruber, planus, marginatus, scrofulosorum—Prurigo 
—Prurigo Infantum—Relapsing Prurigo. 
Lichen. 
Under the title of lichen a considerable number of dis- 
eases have been described, many of them presenting appear- 
ances which differ very widely from each other. Willati 
includes not only those conditions which will shortly be 
described, but others which differ in their course as well as 
in their appearance; thus “ Lichen pilaris ” of Willan is 
more fitly described as a disease of the hair follicles, and is 
apparently the disease which Devergie called Pityriasis 
pilaris, while the Lichen agrius and Lichen tropicus of 
Willan are believed by Hebra to be varieties of eczema. 
Hebra, indeed, objects to AVillan’s Lichen simplex, on the 
ground that it is an acute disease of the skin, but in the 
following account L. simplex will be retained for the reasou 
that, with this exception, its appearance and course are such 
as necessitate its association with the other forms which are 
accepted by Hebra as true lichens. We shall therefore 
limit ourselves to describing three forms,—L. simplex, L. 
ruber of Hebra or L. planus of Wilson, and L. marginatus, 
including scrofulosorum. 
Definition.—Lichen may be defined as a papular disease 
of the skin, with more or less local irritation. 130 
CLASS I. — EXUDATIONES. 
Lichen Simplex. 
Lichen simplex is characterized by a group of minute pap- 
ules, that appear more frequently on the back of the neck 
and upper extremities, but often on other parts of the body. 
The papules are acuminated and of a red color, and last a 
variable time, usually about five or six days. They gradu- 
ally disappear, and are followed by trifling desquamation. 
Occasionally slight signs of constitutional disturbance accom- 
pany the local symptoms, such as feverishness and headache. 
Locally an itching or tingling sensation is present at the 
site of the eruption. 
Lichen Ruber (Hebra), Lichen Planus (Wilton), 
Lichen Psoriasis (Hutchinson). 
Lichen ruber of Hebra is comparatively rare in this 
country. Hebra describes it as “ an eruption of miliary 
papules which are at first distinct from one another, and 
covered with thin scales.” The papules remain the same 
size during the whole course of the disease. Successive 
crops of the eruption appear, and thus the papules become 
aggregated together; eventually they are so closely placed 
that they come in contact with each other, and in this way 
are formed “ continuous patches of variable size and shape, 
red, infiltrated, and covered with scales.” As the disease 
progresses the patches extend over different parts of the body, 
the skin becomes greatly thickened, and when this condi- 
tion exists over joints their movement is interfered with. 
Frequently in the folds of the skin over the joints of the 
fingers fissures occur and extend into the corium, becoming 
filled with black crusts of blood. The natural lines and 
wrinkles about the face disappear, the nails become either 
greatly thickened, brittle, and of a yellowish-brown, or thin LICHEN. 
131 
and of a light color. The hair of the head, pubes, and ax- 
i 11 as is never affected. This variety itches but little. 
Under the names of Lichen planus and Lichen psoriasis 
Wilson and Hutchinson describe diseases which are proba- 
bly the same as the Lichen ruber of Hebra. Mr. Hutch- 
inson, in his “Lectures on Clinical Surgery,” 1879, says: 
“ Under slightly different names Hebra and Wilson have 
independently described this disease, and have agreed most 
closely as to all its main features.” 
This disease usually presents itself in the form of patches 
of a round or oval shape, or running in lines, and consists 
of an aggregation of small round flat-topped papules, some 
of which may have a minute central depression, which is 
the opening of a hair follicle. In the earlier stages of the 
disease the papules are more scattered, but as the eruption 
develops they increase .in number, and have a tendency to 
become confluent, often forming patches resembling common 
psoriasis ; this, however, never results from the increase in 
size of the individual papules. The papules are of a livid red, 
or violet tint, and each is covered with a small thin scale. 
Often the eruption has at first sight an appearance like 
herpes, which on closer observation is found to be due to 
the shiny character of the scales. The patches never are 
moist, and have no tendency to become ezcematous ; but 
they are aggravated by such forms of local irritation as 
tight garters. The rash is usually symmetrical, is first no- 
ticed on the limbs, but subsequently extends to the trunk, 
and in many cases attacks the tongue. It is occasionally 
accompanied by scaliness of the palms and soles. Itch- 
ing is nearly always a constant symptom, and when pres- 
ent is very severe. The pruriginous condition resulting 
from the scratching often changes the character of the 
eruption. A tendency to constant relapses characterizes 
this variety, and a history of previous attacks is often an 
important aid to diagnosis. Persons affected with this dis- 132 
CLASS I. EXUDATIONES. 
ease are generally about forty years of age, and are very 
rarely under twenty. As a rule there is little or no con- 
stitutional disturbance, but the general health may suffer 
as a result of repeated attacks. 
Lichen Scrofulosorum, Lichen Circumscriptus, 
Lichen Marginatus. 
Although Hebra describes under the name of L. scrofu- 
losorum a variety of lichen which he believes to occur 
only in scrofulous subjects, there is reason to doubt whether 
the limitation thus indicated is altogether advisable ; at all 
events, in this country we are accustomed to see cases which 
answer generally to this description, occurring also in others 
than scrofulous persons, and differing in certain characteris- 
tics to be mentioned hereafter. 
In Hebra’s variety all the papules appear about the same 
time in groups; they may vary greatly in color, from that 
of the normal skin to a deep brownish-red. The shape of 
the groups is usually circular. The papules undergo no 
change, and are attended by but little local irritation. The 
eruption differs in its site from the other forms of lichen in 
being usually confined to the trunk and seldom attacking 
the limbs. 
The English forms of Lichen scrofulosorum,—viz., L. cir- 
cumscriptus and L. marginatus,—occur, as has already been 
pointed out, in persons who cannot be called scrofulous. 
The papules are grouped together in rings or patches, and 
a tendency to the former is very common. On the outer 
side of the rings the skin is normal, but within the circle 
is often slightly yellow, whilst the papules themselves are 
usually red. The eruption grows by extension of the rings, 
which as they increase in size meet other rings, and the pap- 
ules disappearing at the point of contact, the so-called gy- 
rate variety is produced. As the papules fade the skin is LICHEN. 
133 
left stained with pigment. The usual site of this form of 
lichen is the back and chest. Some amount of itching is 
always present, which is aggravated by flannel vests. 
Diagnosis.—The lichenous eruptions have to be distin- 
guished from each other, from psoriasis, eczema, pityriasis 
rubra, tinea tonsurans, and pityriasis versicolor. 
In the early stage it must be noticed that while lichen 
ruber begins with the development of red papules, which 
are scattered on any part of the body, but usually on the 
limbs, and are surmounted by small scales, the papules of 
lichen marginatus are of a lighter color, are collected to- 
gether in groups or rings, and appear more frequently on 
the trunk. Psoriasis begins with the formation of minute 
papules covered with white shining scales, situated mostly 
on the extensor surfaces of the limbs, and not aggregated 
together. Eczema begins with an eruption of small papules 
and vesicles, the latter containing clear fluid. The papules 
are never scaly, and are scattered irregularly, usually on the 
flexor surfaces of the limbs. 
Later lichen ruber appears as red patches, consisting of 
aggregated papules, covered with thin scales. The patches 
never become moist. In lichen scrofulosorum and margin- 
atus the papules appear in groups, that fade in the centre. 
In the more advanced stage of psoriasis large patches are 
formed by the coalescence of the original small spots 
through growth at their periphery ; they are all covered 
with white glistening, transparent scales, and in eczema the 
oozing from the surface gives rise to crusts, which are a 
most important diagnostic sign. 
Pityriasis rubra at this stage can be diagnosed by the ab- 
sence of infiltration, and by the fact that it extends uni- 
formly over the greater part of the surface of the body. 
In the most advanced stage the eruption of lichen ruber 
consists of red patches covered with thin scales, the indi- 
vidual papules having disappeared. The skin is thickeued, 134 
CLASS I.—EXUDATIONES. 
and the nails are affected. Lichen scrofulosorum never at- 
tacks the whole surface in the same manner as lichen ruber, 
and patches or rings rarely become scaly. 
In the most advanced stage psoriasis can be distinguished 
from lichen ruber by the smaller amount of surface affected, 
and by the fact that healthy skin intervenes between the 
patches ; from lichen marginatus it can be easily diagnosed 
by the tendency of the rash in the latter to form rings with 
simply stained skin in the centre. Old-standing eczema 
can always be recognized by the crusts. 
The eruption of pityriasis rubra can only be confounded 
with that of lichen ruber in the late stage, and can be dis- 
tinguished from it by the absence of infiltration of the skin 
and severe constitutional symptoms of the former. 
Lichen marginatus may be mistaken for ringworm of the 
body, but a microscopic examination of some of the epider- 
mis will at once settle the doubt; the same disease may also 
bear some resemblance to pityriasis versicolor, but this can 
only occur when the rash is fading, and can be easily dis- 
tinguished in the same way. 
Prognosis.—There is comparatively little danger attend- 
ing the lichenous diseases seen in this country, although 
some of them are very intractable, and last a long time on 
account of frequent relapses. 
Morbid Anatomy—Lichen Ruber.—On examining vertical 
sections of skin affected with lichen ruber, the epidermis is 
seen to be thickened aud dried, especially on the hands and 
feet, but thin and scaly on other parts. The corium is also 
thickened and denser than normal, if the case is of old 
standing. The hypersemia seen in life disappears after 
death. Under the microscope thin sections of the papules 
when first formed show merely enlargement of the root 
sheath at the base of the hair follicle, with numerous nodu- 
lar outgrowths from it into the corium. Later the upper 
part of the root sheath may become enlarged, being, accord- LICHEN. 
135 
ing to Hebra, pointed towards the hair follicle and expanded 
above, forming a series of concentric funnel-shaped envelopes 
round the hair. In the fully developed papules changes are 
found in other portions of the skin. The epidermis is thick- 
ened, and the rete Malpighii contains small round cells. 
The papillee are enlarged, contain more round cells than 
normal, and have their fibrous tissue increased. The ves- 
sels in the papillary body and corium are enlarged and 
surrounded by small rouud cells. The root sheaths of the 
hair are thickened, as described above, and the arrectores 
pili are usually hypertrophied. The sebaceous and sweat 
glands do not seem to be primarily affected, but undergo 
degenerative changes as the disease progresses. 
Lichen Scrofulosorum.—On examining thin sections of the 
small papules at an early stage, the tissue round the vessels 
of the sebaceous and hair follicles affected is found to con- 
tain numerous leucocytes. This infiltration gradually ex- 
tends upwards, and in the fully developed papules not only 
the follicular wall but the papillae rouud the orifice of the 
hair follicle are filled with small round cells. In the later 
stages the exudation invades the hair follicle and sebaceous 
glands, and masses of cells are found between the root 
sheath and the follicular wall, in the substance of the root 
sheath itself, and in the rete Malpighii around the orifice 
of the follicle. 
Treatment.—The treatment of licheu must be both local 
and constitutional. With regard to the former, the chief 
aim must be to allay the irritation, so as to afford rest, to 
remove all sources of irritation, such as flannel, and to ap- 
ply soothing lotions and ointments composed of such drugs 
as hydrocyanic acid and weak preparations of tar. It is 
also necessary to pay great attention to cleanliness. In 
lichen scrofulosorum the local application of cod-liver oil is 
stated by Hebra to be of great value, but in applying this 
remedy care should be taken to keep it in constant contact 136 
CLASS I. EXUDATIONES. 
with the skin. As regards internal remedies for lichen ru- 
ber or planus, there are no drugs so valuable as the various 
preparations of arsenic, but to produce any good result they 
must be taken in full doses and continued for a long period. 
It must be borne in mind that the use of this remedy must 
not be abandoned during the intervals of apparent cure, but 
must be continued with a view to prevent a relapse. If 
there is any proof of a scrofulous habit, cod-liver oil and 
iron must be given. 
Prurigo. 
Definition.—Prurigo is a chronic papular disease of the 
skin, accompanied by intense irritation. 
Symptoms.—The severe form of this disease described by 
Ilebra as seen on the Continent is happily very rare in this 
country, only one or two cases having been reported. 
The milder conditions known in England are prurigo 
mitis, occurring among children, and the relapsing prurigo 
of Hutchinson. Inasmuch as the prurigo of Hebra has 
many peculiarities in which it differs from the disease we 
understand by the same name, a short resume of Hebra’s 
description will therefore first be noticed. 
Prurigo of Hebra.—The eruption first appears in the 
shape of subepidermic papules of the size of hemp seeds; 
they are but slightly elevated above the surface, of the same 
color as normal skin, and are recognized more by the touch 
than the sight. They are always isolated, and may come 
out on all parts of the body, but, however severe, leave in- 
tervals of healthy skin. They are attended by intense itch- 
ing, which causes the patient to scratch, giving rise to ex- 
coriations of the surface and the formation of small blood 
crusts on their summits. After this has lasted for some 
time the whole of the skin affected becomes hard, brawny, 
and darker in color, owing to the deposit of pigment. As 
the disease progresses the normal furrows of the skin are PRURIGO. 
137 
seen to become deeper and farther apart; this is especially 
observable on the backs of the hands, the fingers, and the 
wrists. To the more severe form, which lasts the whole of 
life, the name of prurigo ferox is given. The parts most 
frequently attacked are the front and back of the chest, the 
whole of the back, loins, abdomen, and particularly the 
extensor surfaces of the limbs. The rash is less commonly 
present on the arms and thighs than on the forearms and 
legs, and on the whole more often attacks the lower than 
the upper extremities. Even in the most severe forms the 
flexor surfaces of the joints, the genitals, scalp, and face 
escape. Frequently eczema is produced as the result of the 
irritation, and in consequence the lymphatic glands become 
enlarged. Although the disease is never absolutely cured, 
at times the symptoms are so mitigated that it appears to 
have disappeared. Weather apparently has some effect on 
its intensity, for it is always more severe in cold than in 
warm seasons. Prurigo is not congenital, but nearly always 
commences soon after birth. 
Prurigo Mitis.—Prurigo, as wTe understand it, is, as com- 
pared with the above disease, a simple malady. Although 
the objective symptoms in both varieties resemble each 
other, the English disease does not run such a protracted, 
course as the German, and is in fact limited almost entirely 
to early life. The'delicate skin of infants is usually in the 
first instance irritated by some local cause, such as flannel 
or the bites of parasites; as a result a papular eruption, 
together with some amount of urticaria, is developed, chiefly 
on the back and the extensor surfaces of the limbs. This 
is accompanied by severe itching, and wrhen the child is old 
enough to .scratch blood crusts are formed, which constitute 
an important characteristic of the disease. On passing the 
hand over the back the whole skin feels rough like a nut- 
meg grater. 
Prurigo mitis usually occurs in delicate and badly-nour- 138 
CLASS I. EXUDATIONES. 
ished children, and is certainly more common among the 
poor, probably owing to their being more exposed to the 
causes above mentioned. The disease does not usually last 
longer than a few years, and is rarely seen in persons above 
the age of ten years. 
Mr. Hutchinson has recently paid considerable attention 
to the prurigo of infants, and has made several important 
and interesting observations on its causation. He points 
out that there is considerable difference in the appearances 
of the ordinary eruption, which depends on the size of the 
papules and the amount of urticaria accompanying them, 
in some cases the papules being “hard, rough, and dry, like 
a nutmeg grater, while in other cases they are of larger 
size, like half-developed wheals of urticaria, with perhaps 
even some tendency to vesication,” and that there are be- 
sides two other distinct varieties to be distinguished. In 
one of these positive vesication takes place, and the palms 
and soles are affected. The history of the case leads to the 
belief that the child has in the first instance suffered from- 
varicella. He states that it is not uncommon to find that 
the skin eruption commenced with a sudden outbreak of 
disease, which rapidly changed its character, and that, in- 
asmuch as abortive varicella undoubtedly occurs, the first 
outbreak was probably due to this disease, which was not 
then recognized. 
The ordinary prurigo eruption begins more gradually 
and varies in severity, being better in winter and worse in 
summer, and is due to the irritation produced by fleas or 
other parasites, which are more abundant in the warm than 
in the cold weather. 
A pruriginous condition of skin may, however, also be 
induced by varicella or vaccination, which is not developed 
until the skin is subsequently irritated by fleabites or some 
other local cause. 
Prurigo may therefore be produced in one of three ways: PRURIGO. 
139 
1st. By the local irritation of fleas, or by wearing flannel, 
etc. 
2d. By these local causes acting on a skin which has 
been previously made susceptible to their influence by a 
previous attack of varicella or vaccination. 
3d. By the direct irritation of varicella itself without 
the intervention of any other exciting cause. 
Relapsing Prurigo.—This disease, first described by Hutch- 
inson, differs from the other forms of prurigo,—first in the 
age at which it occurs, having a tendency to commence 
about puberty; and secondly, in the color of the papules, 
which are in this variety red. Together with the papular 
rash, which attacks most frequently the face, neck, and 
upper extremities, there is often an erythematous blush. 
Sometimes the rash leaves scars. Relapsing prurigo is 
attended with less itching than is the case in the other 
varieties, and does not produce the same hardness of skin 
as in Hebra’s prurigo; its distribution is the same as in the 
latter, inasmuch as it never attacks the palms, soles, genitals, 
or flexures of the joints. 
Diagnosis.—Prurigo may under some circumstances be 
mistaken for scabies, phthiriasis, eczema, urticaria, pruritus, 
and erythema. 
From scabies it may be distinguished by the different 
sites of the two diseases. The presence of the rash on the 
genitals and on the flexures of the joints will serve to 
eliminate prurigo. If a burrow can be discovered and the 
acarus produced, the diagnosis is of course easily settled ; 
besides, pustules and constant itching are points in favor of 
scabies. 
From pediculosis it may be diagnosed by the absence of 
pediculi. 
From eczema it is often difficult to distinguish it, espe- 
cially when the two diseases are combined. The character 140 
CLASS I. EXUDATIONES. 
of the skin near the eruption assists the diagnosis, the red- 
dening which accompanies eczema being entirely absent in 
prurigo. The scattered eruption, the blood crusts, and the 
tendency of the papules to bleed in prurigo are points of 
difference from eczema. 
From urticaria and pruritus it can be recognized by the 
absence of papules in these two diseases. 
From erythema (see Chapter IX, p. 120). 
Prognosis.—The prognosis of Hebra’s variety is unfavor- 
able, and although the patient may live for years, his life 
is made utterly miserable by the intense itching. The pru- 
rigo of infants, due to a local cause, is curable when the 
cause is removed, but the duration of the disease is often 
protracted. The relapsing prurigo of Hutchinson is always 
a most obstinate form, lasting, in consequence of so many 
relapses, for years. 
Morbid Anatomy. — On microscopic examination the 
changes found in Hebra’s variety are described as follows: 
The epidermis is thickened considerably, especially in the 
rete Malpighii, where numerous small round cells are found. 
The papillary layer shows the papillae enlarged, full of 
young cells, and their vascular loops dilated. Leucocytes 
are also found pretty freely scattered in the hair papilla and 
bulb, the root sheath, and in the corium around the follicle. 
In chronic cases spindle-shaped cells are found in the 
corium, and especially round the vessels. 
Treatment.—Beyond attempting to alleviate the patient’s 
condition by attending to his general health and procuring 
sleep, nothing can be done to cure the variety described by 
Hebra. Since prurigo of children is often due to a local 
cause, this must be sought for and carefully removed ; 
children, as a rule, outgrow prurigo, but considerable relief 
can be obtained from the use of tar baths, consisting of twro 
or three or more teaspoonfuls of liquor carbonis detergens PRURIGO. 
141 
to a gallon of warm water. In such a bath the child should 
be kept for at least half an hour twice a day, and in the 
interval should be well anointed with a soothing ointment. 
For cachectic or strumous children cod-liver oil and steel 
wine should be prescribed. In the relapsing variety arsenic 
is of value. 142 
CLASS I. — EXUDATIONES. 
CHAPTER XI. 
Class I.—Extjdationes—continued. 
3. VESICULAR AND BULLOUS GROUP. 
Herpes febrilis, gestationis, iris—Hydroa—Pemphigus vulgaris, 
foliaceus. 
Herpes. 
Definition.—Herpes is an acute vesicular disease of the 
skin, which runs a rapid course and is accompanied by local 
irritation and sometimes by symptoms of constitutional dis- 
turbance. 
Of the many varieties usually mentioned under this title 
only three are important enough to need special description : 
herpes febrilis, herpes gestationis, and herpes iris. 
Symptoms.—Herpes febrilis may be described as a neurotic 
disease, and commonly occurs as a symptom of catarrh or of 
pneumonia, but may be due to any condition producing a 
rigor, such as the passing of a catheter. Whatever may be 
its cause, it always appears to be produced through the 
influence of the nervous system, and in all its forms the 
temperature is slightly increased, and the patient complains 
of headache and malaise. The eruption often precedes any 
constitutional symptom, and may occur on almost any part 
of the body, but its most common sites are the lips, tonsils, 
uvula, mucous membrane of the mouth, palate, and more 
rarely the face, ears, and tongue. 
The eruption appears in groups, and lasts about seven or 
eight days. It consists of small papules, which become HERPES. 
143 
vesicular aud which contaiu a clear fluid. After lasting 
two or three days this fluid becomes turbid, and is generally 
absorbed, though in some instances the vesicle bursts and 
crusts are formed. The vesicles themselves are situated on 
inflamed bases, and an itching or burning sensation always 
accompanies, and sometimes precedes by a few hours, the 
appearance of the eruption. 
When herpes occurs on the lips, the vesicles are few in 
number, and rapidly coalesce and dry up into scabs; but 
when it appears on the mucous membrane of the mouth, 
they soon burst and leave a superficial ulceration. Again, 
when the vesicles form on the tonsils, uvula, or soft palate, 
they also burst, but leave white patches on the mucous 
membrane, which are liable to be mistaken for diphtheria, 
and this mistake is rendered more probable by a swelling 
of the tonsils, which is occasionally seen at the same time. 
Although this disease usually occurs in isolated cases, a 
whole family is sometimes found to be attacked by it. 
As a sub-variety of herpes febrilis may be mentioned 
herpes progenbalis, in which the vesicles are developed on 
the prepuce, glaus, or dorsum of the penis in the male, 
and on the labia or mons veneris in the female. These 
vesicles are generally few in number and form scabs, which 
last but a short time and then drop off, leaving healthy 
skin ; when, however, the vesicles are broken by scratching, 
small superficial ulcers result, which soon dry up and scab; 
and, further, it must be noticed that when there is much 
induration of the part, it is difficult to distinguish the her- 
petic ulcer from the syphilitic chancre. Frequently, also, 
there is some amount of swelling, and the appearance of the 
eruption is often preceded by pain. 
Herpes gestationis occurs in pregnant or parturient women, 
but is rarely seen in England. It has been recently de- 
scribed by Liveing and Bulkley. The rash is not purely 
vesicular, but consists of papules and vesicles of various 144 
CLASS I. — EXUDATIONES. 
sizes, from a pea to a bean, which appear in groups over 
the body, chiefly on the extremities. The eruption is pre- 
ceded by and accompanied with severe itching, which con- 
tinues after its disappearance, and by slight symptoms of 
constitutional disturbance and considerable pains in the 
limbs. Pigmentation is often left after the eruption disap- 
pears. This variety lasts some weeks, aud is often prolonged 
by relapses. 
Herpes iris, described by Willan as a separate variety, is 
characterized by the arrangement of the vesicles in rings 
round a single vesicle, and two or even three rings may be 
seen outside each other. They do not make their appear- 
ance simultaneously, but in successive circles, and those 
vesicles nearest the centre often subside during the growth 
of fresh vesicles at the periphery. It must not, however, be 
expected in herpes iris that all the vesicles are to be found 
arranged in this orbicular manner; it is sufficient to char- 
acterize the disease if some only are arranged in rings, whilst 
others appear in irregular crops; and it must be noticed 
also that, though they are usually discrete, they may coa- 
lesce and form bullse. The disease itself lasts a variable 
time, usually from one to four weeks, according to the num- 
ber of rings formed, and is not accompanied by any con- 
stitutional symptoms. Hebra points out the tendency of 
herpes and erythema to behave in a similar manner in pro- 
ducing multiform varieties, and that herpes circiuatus re- 
sults from herpes iris in the same way that erythema iris 
results from erythema annulare. The erythematous and 
herpetic rashes select the same sites, for they both occur 
most frequently on the backs of the hands and feet, at times 
on the limbs, in some instances as high as the arms or thighs, 
but hardly ever on the trunk. Hebra, indeed, goes so far 
as to say that, taking into consideration the similarity of 
the mode of development, the course and the seat of the two HYDROA. 
145 
diseases, he is tempted to regard them as modifications of 
one and the same disease. 
Diagnosis.—Herpes is not likely to be mistaken for any 
other disease, for the vesicles are larger than in eczema, and 
do not spread from the periphery, and are smaller than in 
pemphigus. The inflamed bases on which the vesicles are 
seated, the rapid course of the disease, and the sense of irri- 
tation which accompanies it, are sufficiently marked char- 
acteristics to prevent mistakes. 
Prognosis.—The prognosis is always favorable, although 
the disease is occasionally protracted in the ringed variety. 
Morbid Anatomy.—The morbid appearances are identical 
with those found in pemphigus, and are therefore included 
in the description of the latter disease. 
Treatment.—No local or constitutional treatment is known 
to affect the course of the disease. 
Hydroa. 
Definition.—In addition to these varieties of herpes, some 
mention must be made of a rare disease of a kindred nature, 
termed hydroa by Bazin, who divides it into vesicular hy- 
droa, vacciniform hydroa, and bullous hydroa. It is defined 
as a chronic disease of the skin, occurring in arthritic sub- 
jects, and characterized by groups of vesicles or bullae. 
Symptoms.—Vesicular hydroa first appears as small, l'ound, 
deep-red spots, with well-defined edges, varying in size from 
a lentil to a threepenny piece, and sometimes surrounded by 
a rose-colored area. The next day a vesicle forms in the 
centre of the spot, filled with a transparent yellow fluid, 
which in a day or two is absorbed from the centre, when 
the vesicle itself becomes a black scab. 
Sometimes, especially during the cold weather, the fluid 
in the vesicle is so rapidly absorbed that there is only to be 
seen a white or yellow macula, formed by loose epidermis 146 
CLASS I. — EXUDATIONES. 
in the centre of a red disk. The eruption is usually accom- 
panied by no symptoms of constitutional disturbance except 
feverishness. It generally makes its appearance on the 
backs of the hands, wrists, and front of the knees, but is 
occasionally found on the mouth, or even on the conjunc- 
tivse. However, in the former case it does not occur on the 
mucous membrane till the third day, and then it is sur- 
rounded by a violet areola and scabs earlier. 
Each outburst of vesicles lasts about four or five days, 
but, as they are constantly repeated, the disease usually 
continues for about three or four weeks, and even then re- 
lapses sometimes occur. Vesicular hydroa is a disease pecu- 
liar to gouty subjects of both sexes, from twenty to thirty 
years of age, but generally attacks men. It is most com- 
mon in spring and autumn, cold and variations in tempera- 
ture having a marked influence on its appearance and course. 
Vacciniform hydroa and bullous hydroa differ from the 
variety described in that the vesicles of the former disease 
become umbilicated, and in the latter meet and form bulla*. 
Pempiiigus. 
Definition.—Pemphigus is characterized by the appear- 
ance of bullae in successive crops, terminating either in the 
absorption of the fluid, or in bursting and giving rise to the 
formation of ulcers. 
Symptoms.—This disease differs according to the size, po- 
sition, and behavior of the bullae and subsequent ulcers, but 
may be divided into two chief varieties,—pemphigus vul- 
garis and pemphigus foliaceus, but the latter is rare. 
Pemphigus vulgaris includes those forms which are most 
frequently seen, and consists of two or three small bullae 
situated on slightly inflamed bases, which increase very 
rapidly until they cover a surface of about two inches in 
diameter. They are white, tense, and generally oval or PEMPHIGUS. 
147 
round, but may lose their shape by becoming confluent. 
The fluid in the bullse is at first clear and alkaline, but in 
a short time becomes turbid and acid. A bulla may ter- 
minate by absorption of its fluid, when nothing but the 
dried-up cuticle remains, or it may burst, when it leaves 
an ulcerated surface, more or less covered with crusts. A 
dark stain remains for some time to mark the site of a 
bulla, and as the disease has a tendency to appear in suc- 
cessive crops, the skin gradually becomes more and more 
stained. The bullse may be scattered irregularly over the 
body, or may be grouped together in circles or semicircles, 
from the circumference of which fresh bullse grow at the 
same time as those in the centre disappear. In other but 
rare cases red patches of skin are found, in which the bullse 
are badly defined or even absent. All parts of the surface 
may be attacked with pemphigus, even the vagina and the 
rectum, but the head, palms, and soles are almost always 
exempt. At the conclusion of the disease the skin becomes 
dry, and desquamation, often over a larger area than the 
actual site of the eruption, takes place. As a rule consti- 
tutional symptoms are not severe, depending solely on the 
amount of the eruption, but when the bullse are of large 
size, and crops rapidly succeed each other, the itching be- 
comes intolerable. 
Pemphigus foliaceus differs from the preceding variety in 
color, situation, and character of the blebs. The bullse are 
of a red or yellow tint, and the vessels of the base can be 
seen through the fluid, which in this variety is small in 
quantity and does not distend the bulla. Around the first- 
formed bullse others are developed, which eventually coa- 
lesce, while the fluid escapes and leaves crusts, the appear- 
ance of which is compared by Cazenave to that of flaky 
pie-crust. Although this condition is at first limited in area, 
it gradually spreads over the surface; and as there is no 
disposition for the part originally attacked to heal, a large 148 
CLASS I. EXUDATIONES. 
portion of skin becomes affected, from which the smell is 
most offensive. The.constitutional disturbance is slight at 
the commencement, but as the disease progresses feverish- 
ness, sleeplessness, and diarrhoea set in, and the patient 
finally succumbs. 
Diagnosis.—Pemphigus is liable at all times to be mis- 
taken for any disease in which vesicles or bullae occur. 
From erysipelas it may be distinguished by the extent of 
the inflamed surface and the defined margin of the former, 
while the latter has only a narrow areola around the vesicle, 
and by the fact that the constitutional-symptoms which are 
characteristic of erysipelas do not occur in pemphigus. 
From eczema simplex it may be distinguished by the 
smaller size of the vesicle in the former, and from scabies 
by absence of the burrows. Pemphigus foliaceus often pre- 
sents great similarity to eczema rubrum, but the marked 
marasmus, pigmentation, and freedom from fibrous thicken- 
ing of the skin in the former are the chief points of diag- 
nosis between them. 
Prognosis.—This is favorable if the eruption is limited to 
a small area, and if there be but few bullae; but when they 
extend over a large surface, as in pemphigus foliaceus, death 
is the almost invariable result. 
Morbid Anatomy.—Microscopic examination of the vesicles 
or bullae shows the papillae infiltrated with young cells, 
which extend also into the rete Malpighii in great numbers, 
and the capillaries are filled with blood. The sero-fibrinous 
exudation, escaping from the papillary layer, causes a sep- 
aration of the epidermic layers; and as the fluid collects 
more abundantly opposite the apices of the papillae, small 
columns of cells, elongated or variously altered in shape, 
give the vesicle a loculated appearance. A very abundant 
exudation, as in pemphigus, causes the cells to assume a 
spindle-shaped appearance, and finally the trabeculae give 
way, leaving traces in the shape of delicate filaments TEMPHIGUS. 
149 
attached to the roof and floor of the vesicle. The fluid in 
pemphigus consists at first of clear serum, in which numer- 
ous pale and only a few red corpuscles are found, but as 
the leucocytes soon undergo fatty degeneration, the contents 
assume an opalescent and then a more purulent appearance. 
Occasionally a large mixture of red corpuscles gives the 
serum a distinct sanguineous character. 
Treatment.—This consists in improving the general con- 
dition, while local applications appear to exercise no influ- 
ence on the coui’se of the disease. A generous and nour- 
ishing diet is necessary, and for medicine arsenic in full and 
repeated doses is as important as quinine is in ague. Much 
relief also is afforded by frequent bathing, removing the 
crusts, and keeping the ulcers clean. 
Little, however, can be done in pemphigus foliaceus but 
to combat the symptoms as they arise. 150 
CLASS I. EXUDATIONES. 
CHAPTER XII. 
Class I.—Exudationes—continued. 
4. ECZEMATOUS AND PUSTULAR GROUP. 
Eczema simplex, Acute: Eczema erythematosum, squamosum, papu- 
latum, vesiculosum, pustulosum, fissum seu rimosum, rubrum— 
Ecthyma, Chronic: Eczema capillitii, faciei, articulorum, ma- 
nuum et pedum, crurale, genitale, corporis—Intertrigo—Porrigo 
or Impetigo contagiosa. 
Eczema—Moist Tetter. 
Definition.—Eczema is an acute inflammatory disease of 
the skin, characterized by an erythematous papulo-vesicular 
or pustular eruption, which usually gives rise to a moist, 
reddened surface, and from which a serous discharge that 
stiffens linen exudes freely. In the latter stages it takes the 
form of a dull-red or brownish surface covered with scales. 
A sensation of burning or marked itching accompanies it. 
Symptoms.—The eruption may present various appear- 
ances, as the disease, instead of going through the typical 
course above indicated, may stop short at any one of the 
stages mentioned, or may pass over or abbreviate some of 
them and then remain stationary. In this way, instead of 
the red, excoriated, weeping surface most commonly seen, a 
condition which is almost entirely erythematous, papular, 
vesicular, pustular, or squamous, may be met with, and, 
according as one or other condition is most prominent, sev- 
eral varieties have been described/ 
Various secondary changes may affect the portion of skin ECZEMA. 
151 
suffering from eczema. Infiltration of the cutis and sub- 
cutaneous tissue, cracks and fissures, abundant pus forma- 
tion, superficial ulceration, and the production of scabs are 
some of the phenomena most frequently met with. Scratch- 
ing, in consequence of the intense itching, often excites a 
renewed attack, and contributes materially to the extension 
and persistence of the eruption. Eczema may occur with- 
out any obvious cause in persons otherwise healthy; it may 
be excited by various local irritants, chemical, mechanical, 
thermal, etc.; it may affect those who are gouty, syphilitic, 
or strumous, and in some instances it may be hereditary. 
Digestive, uterine, and nervous disorders may predispose 
to or aggravate an attack of eczema, and should be taken 
into account in the treatment. 
According to its course and duration, eczema may be 
divided into the acute and the chronic type, the latter being 
far the most commonly met with ; but local varieties, differ- 
ing in appearance according to their site, require special 
description. Eczema occurs in males more frequently than 
in females; of 6708 cases recorded by Hebra, McCall 
Anderson, and others, 4467 were males, and only 2331 
females. 
Acute eczema is characterized by the occurrence of inflam- 
matory redness and swelling of the skin, followed usually 
within forty-eight hours by the eruption of numerous minute 
vesicles containing clear yellowish serum, and accompanied 
with a sensation of burning and tension. Within a week 
the vesicles either dry up and desquamate or burst, leaving 
red oozing points, or rapidly become pustular, giving rise, 
from desiccation, to thin brownish or yellow crusts, which 
in separating leave a reddish scaly surface, that itches 
slightly. A feeling of chilliness or slight pyrexia is usually 
the only constitutional symptom, and within a fortnight the 
whole eruption may disappear. More frequently, however, 
fresh crops are seen, either round the first or on different 152 
CLASS I. — EXUDATIONES. 
parts of the body, attended by severe itching, which causes 
violent scratching and produces excoriations. Successive 
acute attacks may thus prolong the disease, or it may pass 
into a chronic form. 
According to situation, the appearances vary somewhat. 
On the face the redness and oedema of the skin are well 
marked, and may resemble erysipelas; the surface is, how- 
ever, irregular and granulated, not uniformly smooth and 
shiny, as in the latter, and the disease is very prone to re- 
lapse and become chronic. On the hands and feet the 
eruption appears as a collection of smally watery vesicles, 
with swelling and little or no redness at first, but they soon 
coalesce, and later on dry up; pain and tension are severe 
if the disease is extensive, but give place to itching as the 
eruption subsides. On the genitals swelling and redness 
form the main phenomena, the vesicles being usually small. 
Hebra states that in the male, while the penis remains dry 
and the vesicles rarely exceed a pin’s point in size, on the 
scrotum they are larger, and on bursting give rise to an 
abundant discharge. 
Repeated attacks usually cause the disease to become 
chronic. 
Universal acute eczema is a rare variety, attended, ac- 
cording to Hebra, with but little constitutional disturbance 
besides a feeling of great chilliness. Different appearances 
are presented by the eruption, according to its site. On the 
face it produces the changes already described, on the trunk 
it resembles scarlatina which is beginning to desquamate, on 
the flexures,of the limbs vesicles and raw weeping surfaces 
are more common, while on the scalp the abundant scabs 
which are produced by the secretion from the vesicles, and 
retained by the hair, form a foul-smelling, offensive-looking 
mass. 
Chronic eczema presents appearances of the same nature 
as those met with in the acute disease,—viz., papules, vesi- ECZEMA. 
153 
cles, pustules, crusts, and extensive red, moist, and weeping, 
or dry scaly surfaces. 
The frequent relapses and the persistence of the disease 
cause a more abundant serous discharge, and the prolonged 
infiltration of the skin often gives rise to hypertrophy of the 
papillary body, with sclerosis of the cutis and subdermic 
tissues. 
According as one or other lesion predominates, we may 
have eczema erytliewwtosum, with simple inflammatory red- 
ness of the skin, followed by desquamation ; eczema squa- 
mosum (often described as pityriasis rubra), with abundant 
formation of scabs on a reddened, infiltrated basis, with 
little or no discharge; eczema papulosum (frequently termed 
lichen eczematodes, etc.), with an eruption of small red ag- 
gregated papules; eczema vesiculosum, the vesicles being 
either small and rapidly bursting, or larger and by conflu- 
ence forming bullae where the skin is thick and dense, as on 
the hands and feet; eczema pustulosum, where, either from 
the beginning or soon after their appearance, the vesicles 
become pustular, and, drying up, give rise to brownish, yel- 
lowish, or black crusts, conditions which have been raised 
to the rank of a new and separate disease under the name 
of impetigo contagiosa; eczemafissum seu rimosum, where 
numerous cracks of varying depth in an erythematous dry 
or moist surface occur in places where the skin is normally 
thrown into folds; and eczema rubrum, where the red, infil- 
trated, excoriated surface, usually discharging profusely, is 
well developed. This last form is accompanied by severe 
burning heat, and later on by intense itching; constitu- 
tional symptoms—fever, headache, and digestive derange- 
ment—are well marked, and the surface presents numerous 
bright-red points of hypersemia, from which fluid keeps con- 
tinually exuding, like the drops of water on the surface of 
salt butter (Hutchinson). The disease described as ecthyma 
consists of an eruption of large flattened pustules on a red, 154 
CLASS I. — EXUDATIONES. 
indurated, slightly raised base, giving rise frequently to 
dark-brown, dense crusts, and unhealthy, sloughy ulcers ; it 
is merely a form of pustular eczema occurring in debilitated 
cachectic persons living under bad hygienic conditions. 
Of the local varieties of chronic eczema the following 
will now be described : 
1. Eczema capillitii. 
2. Eczema faciei. 
3. Eczema articulorum. 
4. Eczema mauuum et pedum. 
5. Eczema crurale. 
6. Eczema genitale. 
7. Eczema corporis. 
1. Eczema Capillitii.—In eczema of the scalp, owing to the 
presence of the hair, which becomes glued together by the 
sero-purulent discharge, a dense matted crust may be pro- 
duced if the disease is left to run its course unchecked, until 
the entire scalp is affected. Pus, mingled with sebaceous se- 
cretion from the numerous glands, forms beneath the crusts, 
and pediculi, their ova, and even maggots may find a rest- 
ing-place in the filthy, stinking mass. When occurring in 
discrete spots and in clean people the discharge and crusts 
are constantly removed, and the disease is easily recognized. 
In the later stages, when the crusts have separated and 
the discharge is less in quantity, a red, infiltrated surface 
covered with numerous scales adherent to the hairs is seen. 
This variety is usually pustular, occurs most often in 
children, and may persist for years if neglected. Subcuta- 
neous abscesses and glandular enlargements are not unfre- 
quently met with, especially in strumous children. In 
chronic cases there is some loss of hair, speedily renewed, 
however, when the disease is cured, except in neglected cases 
where profuse suppuration under the scabs has destroyed 
the hair follicles. ECZEMA. 
155 
2. Eczema Faciei.—Eczema of the face, when it affects the 
hairy parts, resembles the former variety in the liability 
to the production of shallow pustules with a hair passing 
through them, which dry up and form yellow, greenish, or 
brown crusts. On removal they leave a red, moist, or scaly 
surface. In chronic cases the hair follicles become more 
deeply involved, as in sycosis; the skin is dusky red and 
thickened, and permanent alopecia is apt to follow, from the 
destruction of the hair bulbs. Pain and burning heat, with 
later on some itching, accompany the eruption. 
Eczema of the eyelashes, or tinea tarsi, frequently con- 
founded with inflammation of the Meibomian glands, is 
merely a local eczema implicating the hair follicles and 
glands, and is always accompanied by itching. Redness, 
swelling, and excoriations, and scabbing of the margins of 
the lids, with partial or complete loss of the eyelashes, m'ay 
be produced by it. 
Eczema of the nostrils usually terminates in the formation 
of a thick scab, which felts together the margins and blocks 
up the orifice. The continual pus formation under it causes 
often an erysipelatous swelling of the mucous membrane or 
skin of the nose. 
On the smooth parts of the face eczema is usually sym- 
metrical, unless produced by purely local causes. 
Eczema of the ears may occur merely as a moist fissure 
at the reflection of the auricle from the mastoid process, or 
as a weeping or crusted red surface at the back of the auri- 
cle, on the lobule, or elsewhere. The skin is prone to exces- 
sive swelling and discharge, which either drips away con- 
stantly or dries up, forming stalactiform crusts. Hearing, 
always somewhat impaired, is made much worse when the 
meatus is affected and blocked up more or less completely 
by crusts and ceruminous discharge. 
Eczema of the lips may present either a red, scaly, infil- 156 
CLASS I. EXUDATIONES. 
trated or a moist surface. There is often marked oedema, 
with painful fissures or large yellow crusts. 
On the cheeks and forehead large yellow crusts, looking 
like dried honey,—which gained for the disease in this 
site the names of crusta lactea and melitagra flavescens,— 
are most commonly seen. 
3. Eczema articulorum occurs on the flexor surfaces of 
the limbs, and leads to slight contraction, with great pain on 
moving the subjacent joint. The skin, red, much infiltrated, 
and oozing or crusted, is traversed by numerous fissures, 
following the lines of the normal folds of skin, causing the 
application of the name eczema fendille. Eczema rubrum 
occurs most frequently in these situations. 
4. Eczema Manuum et Pedum.—The fissured variety of 
eczema is here most common, especially on the palms and 
soles, where the skin presents a dry, inelastic, thickened ap- 
pearance, itches considerably, and is traversed by numer- 
ous deep, paiuful fissures. The vesicular form, with large 
blebs, pustules, crusts, or moist surfaces, may also occur. 
Local irritants—water, sugar, lime, soda, soap, dyes, etc.— 
are the most common causes of eczema restricted to the 
hands or feet; hence the so-called “ grocer’s itch,” “ baker’s 
itch,” etc., are merely local varieties of eczema. 
5. Eczema crurale is often modified, and its typical fea- 
tures concealed, by conditions peculiar to its site, such as 
varicose veins, ulcers, scars, pigment patches, and oedema, 
leading to chronic dermatitis. 
The disease hence arises sometimes around a varicose 
ulcer or scar, sometimes on a pigmented patch, and at others 
the oedema appears as if secondary to the skiu affection ; 
but in all cases eczema, whether as simplex, rubrum, or 
squamosum, is easily recoguized. 
6. Eczema geaitale, occurring in the chronic form, affects 
in the male the scrotum and penis either together or sepa- 
rately. On the penis it appears as raised red transverse ECZEMA. 
157 
lines ; on the dorsum it is most marked when the skin is 
stretched, with a moister red area on the under surface, of 
the organ. Though itching is severe, and induces much 
scratching and excoriation, there is but little discharge. 
On the scrotum it may occur as an abraded red surface, com- 
paratively free from infiltration, or as an irregular fissured 
or greatly hypertrophied elephantoid mass in inveterate 
cases, exuding an abundant sticky discharge, which, as it 
decomposes and dries up, becomes extremely offensive. 
On the female genitals the disease affects the labia majora 
chiefly, and may extend to the nymphse and vulva or to the 
adjacent parts of the thigh and abdomen, and takes usually 
the form of eczema rubrum. When affecting the mucous 
membrane it causes an abundant blennorrhagic discharge, 
resembling that of gonorrhoea, and there is usually much 
burning and itching. Appearing about the anus, it leads 
to the formation of painful itching fissures in the direction 
of the normal radiating folds of skin. There is often slight 
prolapsus aui, and the discharge is abundant and offensive. 
7. Eczema corporis, presenting the general characters of 
the disease as described on p. 151, has some special pecu- 
liarities when it attacks the navel and nipples. The nipple 
and the adjacent areola are denuded of epidermis, red, swol- 
len, moist, and painful; and crusts may form, under which 
either healing goes on or increased secretion, which oozes 
under or through the scab, and is accompanied by severe 
itching and pain. It may spread gradually to the sur- 
rounding skin, and is very obstinate; but, once cured, it 
leaves but little permanent damage behind. 
On the umbilicus it takes either the ordinary form of 
eczema rubrum or impetiginosum, or that of an oedematous 
projecting red surface denuded of epidermis, and discharg- 
ing freely or covered with a yellowish or greenish-brown 
scab. 
Eczema intertrigo occurs in the axillae, between the nates, 158 
CLASS I. EXUDATIONES. 
between the mammae and chest, and in other places where 
folds of skin secrete much moisture and rub together, and 
appears as a moist, red, and tender surface, sometimes slightly 
excoriated. 
The so-called eczema marginatum, formerly held to be a 
special variety of eczema, has now been shown to be merely 
one of the manifestations of ringworm of the body. 
Diagnosis.—Eczema in one or other of its forms may 
sometimes be mistaken for the following diseases : erythema, 
erysipelas, lichen ruber, herpes febrilis, miliaria, scabies, 
pemphigus foliaceus, psoriasis, pityriasis rubra. 
In erythema the smooth isolated spots which generally 
appear on the backs of the hands, the sharply defined edges, 
the absence usually of vesicles, discharge, and crusts, and 
the slightness of subjective symptoms, form a ready means 
of separation from eczema erythematosum or papulatum, 
which have a rough—often vesiculate—surface shading off 
into the surrounding skin. 
Erysipelas is separated from acute eczema by the marked 
pyrexia, which begins usually with rigors, by the smooth 
surface with well-defined edge, and the rapid spreading of 
the patches, by the affection of the lymphatics, and the 
greater severity of the burning heat and pain. Erysipelas 
may, however, supervene on an attack of eczema. 
Lichen ruber, which in aggregated patches may resemble 
eczema papulatum or squamosum, never becomes at any 
stage vesicular, and the isolated, flat-topped, shiny, solid 
papules that are found round the margin of the patch are 
quite characteristic. 
Herpes febrilis, which occurs most commonly on the lips 
and prepuce, is distinguished from eczema of the same parts 
by the larger size and longer duration of the vesicles, and 
the absence of infiltration and itching. The vesicles dry up 
in a few days, and are not succeeded by fresh crops," as in 
eczema. ECZEMA. 
159 
Miliaria differs from eczema in the fact that the vesicles 
occur in groups, usually on the abdomen and thorax, in the 
course of some febrile disorder. The eruption is of short 
duration, and is unattended by itching. In eczema, on the 
other hand, there is little or no constitutional disturbance, the 
vesicles are aggregated on a red base, there is marked itch- 
ing, and the disease tends to become chronic. 
In scabies the vesicles, pustules, and scabs which are pro- 
duced by the irritation of the parasite, or the itching and 
scratching that it excites, are undistiuguishable from those 
of eczema. Careful examination will usually show near the 
pustules the little dark lines of the burrows, with a terminal 
dilatation from which the acarus can often be extracted. 
The appearance of the disease on the hands and feet, wrists 
and abdomen, is also a suspicious circumstance. 
Pemphigus foliaceus presents an appearance that is often 
difficult to distinguish from general eczema which discharges 
only slightly and is becoming scaly. The peculiar cachexia, 
the diarrhoea and marked weakness, and the pigmentation 
of the skin, together with the tendency of pemphigus folia- 
ceus to begin on the front of the trunk, contrast markedly 
with the absence of cachexia and pigmentation, the itching 
and the tendency to infiltration and sclerosis of the skin, in 
eczema. 
The condition known as eczema squamosum may some- 
times be mistaken for psoriasis. The latter affects mainly 
the extensor surfaces instead of the flexors, as in eczema. 
The scales, thick, adherent, and silvery, are seated on ab- 
ruptly defined, dark-red patches, while in eczema the scales 
are thin, loose, not silvery, and the bright-red patches 
merge more gradually into the adjacent skin. Psoriasis is 
dry throughout, while chronic eczema always discharges at 
one period of its existence. 
Pityriasis rubra, regarded by some as merely a variety of 
eczema, differs, according to McCall Anderson, in the uni- 160 
CLASS I. EXUDATIONES. 
form redness and defined margin of the eruption, extending 
gradually to cover the whole surface, in the rapid exfolia- 
tion of large scales, in the burning heat and comparatively 
slight itching, and in the absence of any considerable in- 
filtration, while the punctate appearance of the skin, the 
papules, vesicles, and crusts are quite wanting. 
Eczema of the hands and feet may, by the confluence of 
several vesicles under the thick palmar cuticle,acquire bullae, 
which resemble those of pemphigus. Small vesicles and a 
definite eczematous eruption are usually present in the 
neighborhood, and prevent the possibility of error. 
Both psoriasis and a tertiary squamous syphilide affecting 
the palms and soles may be indistinguishable from eczema, 
and only the discovery of evidences of these diseases on other 
parts of the body can determine the diagnosis. 
The diagnosis of the principal diseases of the scalp is 
given in the following table. ECZEMA. 
161 
DIFFERENTIAL DIAGNOSIS BETWEEN ECZEMA 
CAPITIS AND SEBORRHCEA, PSORIASIS, VESICO-PUSTULAR SYPHILIDE, TINEA TONSURANS, 
AND FAVUS OF THE SCALP. 
ECZEMA. 
SEBORRHCEA. 
PSORIASIS. 
SYPHILIDE. 
TINEA TONSURANS. 
FAVUS. 
1. Most frequent in 
children, in the debili- 
tated or strumous. 
1. Usually in adults. 
1. Most often in 
healthy persons, rarely 
in strumous. 
1. Usually in adults 
only. 
1. Frequent in chil- 
dren. 
1. No special prone- 
ness in strumous. 
2. Often attacks the 
2. Crusts are thin, 
2. Eruption usually 
2. In small patches 
2. Patches usually 
2. Round, dry, sul- 
whole scalp. Ulcers, if 
oily, can be kneaded 
white, scaly, and sil- 
usually; often deep 
circular, deficient in 
phur yellow, cup- 
any, superficial; crusts 
into masses; consist 
very; dry from onset 
ulcers with sloughy 
hair; crusts, etc., not 
shaped crusts, pene- 
thick, yellowish, brit- 
tle; pus, epithelium, 
and granular matter. 
Seated on red, infil- 
trated, moist, often ex- 
coriated surface, which 
shades off gradually 
into healthy skin and 
itcbes excessively. 
3. Syphilitic history 
and phenomena ODly 
accidental, if present 
at all. 
chiefly of sebum and 
epithelium on a smooth, 
oily surface; not, or 
oniv slightly, red, and 
nou-excoriated or infil- 
trated ; itching only 
slight. 
3. Usually no specific 
phenomena. 
and throughout course; 
red base, only slightly 
infiltrated, and itching 
only slight. 
3. Usually no specific 
history. 
bases. 
3. Usually a history 
of primary syphilis, 
and presence of alo- 
pecia, nocturnal 
pains, etc. 
necessarily present; 
itching slight. 
trated by dull brittle 
hairs, with abrupt 
edges and often bald 
patches. 
4. Distinct eczema 
4. Usually only slight, 
4. Well-marked scaly 
4. Syphilides, squa- 
4. Ringworm of 
4. Cupped yellow 
often on other parts 
oily crusting on lace 
patches, usually pres- 
mous, pustular, tu- 
bodyftinea circinata) 
crusts may be found 
of body, on flexor sur- 
faces or behind the 
ears. 
near scalp. 
ent on extensor sur- 
faces of elbows and 
knees. 
berctilar, etc., with 
coppery color, usu- 
ally present on body. 
often present. 
on hairy parts of the 
body. 
5. Hair healthy, oe- 
5. Hairs often drop 
5. Hairs only slightly 
5. Hairs fall out 
5. Hairs twisted, 
5. Hairs dull, dry, 
casionally falling out; 
no parasite. 
out. 
affected. 
freely, and incurable 
alopecia may result. 
thickened, whitish, 
broken off short, 
easily extracted; fill- 
ed with trichophy- 
ton tonsurans. 
brittle, easily ex- 
tracted, loaded with 
achorion Schonleinii. 
6. Non-contagious. 
6. Non-contagious. 
6. Non-contagious. 
6. Communicable 
by inoculation, which 
produces a hard 
chancre, followed by 
constitutional symp- 
toms. 
6. Contagious. 
6. Contagious. 162 
CLASS I.—EXUDATIONES. 
Prognosis.—In itself the disease alone is never fatal. An 
ordinary attack of acute eczema runs through its various 
stages and subsides, leaving little or no trace within a week 
or ten days. Fresh crops of eruption arising near the 
original patch, or on distant parts of the body, may appear 
in succession, and prolong the disease for many weeks, 
verging gradually into the chronic form. The latter, with 
alternations, retrogressions, and relapses, may persist for 
months or even years. 
Among the local varieties of chronic eczema the more 
limited the area of the patch the more obstinately does it 
persist in spite of treatment. 
Morbid Anatomy.—Microscopic examination shows that 
the papular and vesicular stages are produced as follows : 
Abundant transudation of plasma and cells gives rise to an 
enlargement and elongation of the papillae, which contain 
numerous leucocytes. Biesiadecki describes a numerous 
plexus of spindle-shaped cells between the ordinary rete 
elements which they inclose in their meshes. The cells of 
the stratum lucidum next enlarge and burst, and fluid col- 
lecting between the rete and horny layers produces a vesicle 
containing serum and leucocytes. The vascular plexuses 
of the papillary layer, and of the hair and gland follicles, 
are hypersemic. In chronic cases there is more or less cell 
infiltration of the cutis, most dense around the vessels, 
which gradually extends down into the subcutaneous tissues, 
and, by the production of spindle cells and new-formed 
fibrous tissue around the fat cells and capillaries, causes a 
sclerosis of the skin resembling that met with in elephan- 
tiasis. The columnar rete cells contain brown pigment, and 
in the coriuin thin strands of pigment mark the sites of 
obliterated vessels. 
Treatment.—In the constitutional treatment the main in- 
dications are—first, to remove or modify any condition 
which predisposes to the occurrence of the disease; and, ECZEMA. 
163 
' secondly, to give sufficient nutritious, easily digested food, 
and to forbid the use of stimulants. 
Hence the action of the bowels must be regulated by 
occasional doses of the aperient mineral waters, such as 
Carlsbad or Hunyadi Janos. Gouty symptoms must be 
combated by colchicum and alkalies, and for strumous chil- 
dren cod-liver oil and iron is required. 
In the acute forms antimony is of the greatest value, and, 
according to Dr. Cheadle, often does good when all other 
remedies fail. It should be given in doses of T'3 to of a 
grain two or three times a day. In the chronic forms ar- 
senic, iron, quinine, and strychnine are of use as tonics, but 
none of them have any specific action on the disease. 
In local treatment the indications are: 
1. To use sedatives only, or mild unirritating applications 
during the acute stages, or in acute exacerbations of the 
chronic form. 
2. To remove thoroughly all scales or scabs before apply- 
ing local remedies. 
In the stage of heat and tension dressing with simple cold 
soft water, or with a lead and opium lotion, is the best 
remedy to apply, but soap of all kinds should be avoided- 
Dusting powders of starch, oxide of zinc, or chalk may be 
tried. Crusts should be removed by softening them with 
oil or a bread-and-water poultice, and then scraping them 
off gently. After cleaning the part with oatmeal paste, or 
with simple water, the surface is ready for local applica- 
tions. The best are mild solutions of tar or weak prepara- 
tions of mercury; of the former the most convenient form 
is Wright’s liquor carbonis detergens. It is an alcoholic 
solution of coal tar, and mixes well with water; 3\j to the 
eight ounces of water is the strength which should be used 
at first, and should be gradually increased if the lotion is 164 
CLASS I. EXUDATIONES. 
borne Avithout pain or smarting. The following prescription 
from the Pharmacopoeia of the Skin Hospital, Blaekfriars, 
is of considerable Aralue in allaying the itching and pre- 
venting the formation of fresh scabs : 
R. Acetate of lead, ...... grs. x 
Oxide of zinc, grs. xx 
Calomel, . . grs. x 
Citrine ointment, grs. xx 
Palm oil, 3ss. 
Benzoated lard to, 
In the chronic, inveterate, and localized varieties blister- 
ing in successive small portions may be tried, or the vigorous 
application of Hebra’s spirituus saponatus alkalinus. Tar, 
or various forms of it and substances got from it, are most- 
useful in the scaly forms of eczema ; but if used at all in 
the acute stages it should be with great caution, as they are 
apt to produce fresh outbreaks of the disease. The sub- 
stance itself, oil of cade, ol. rusci, or ol. fagi, may either be 
applied pure, or in ointments containing 1 to 8 or 12 parts. 
In eczema capitis, after removing scabs by oil, poultices, 
and Avashing, the following ointment may be applied with 
advantage : 
Bisulphuret of mercury, grs. vi 
Bed precipitate, grs. vi 
Creasote, rrgij 
Lard or vaseline, o.) 
(Skin Hospital.) 
Eczema faciei.—After cutting short the hair and removing 
the scabs, an ointment of oleate of-bismuth or zinc, one 
part to two of vaseline, should be applied on lint, and re- 
tained in position by a flannel mask. 
Eczema in the ears should be treated by removal of the ECZEMA. 
165 
crusts, and by brushing out the meatus cautiously with a 
potash solution—5 to 10 grains to the ounce. 
Eczema of the eyelids, or tinea tarsi, should be treated by 
removal of the crusts, epilation, and the application of one 
of the mild mercurial ointments before mentioned. 
In eczema manuum et pedum wrap the affected part with 
strips of lint covered with zinc ointment, and apply some 
tar or other stimulant when the fissures are healed. Vul- 
canized india-rubber gloves, as recommended by Dr. McCall 
Anderson, are of considerable value when the cuticle is 
very thick and hard. 
In eczema of the legs, after removing the crusts and dress- 
ing the ulcers with a weak tar or lead and opium lotion, 
strap the limbs with stout plaster, or better still with Mar- 
tin’s elastic bandage. 
In eczema of the genitals, bathing with water, and dress- 
ing with a glycerin lotion, such as— 
Glycerin, i^xxiv 
Oil of bitter almonds, Ttj>ss. 
Water to, g j 
Diluted with 1 to 3 parts of water. (Skin Hospital.) 
in the day, and well smearing the part just before bedtime 
with the following ointment, will tend to remove the disease : 
Acetate of lead, ...... grs. x 
Liq. carbonis detergens, or xv 
Y aseline, gj 
Eczema intertrigo requires little treatment beyond washing 
with soft water and the use of some dusting powder of vase- 
line, together with the careful separation of the parts by 
means of soft lint. 
In eczema of the nipple painting with tiucture of catechu 
is useful after the removal of the crusts, and in very obsti- 166 
CLASS I. — EXUDATIONES. 
nate cases Hebra recommends the thorough application of 
a strong potash solution as a last resource. 
Porrigo—Impetigo Contagiosa. 
Definition.—A local disease of the skin, communicable by 
inoculation, excited most commonly by accidental irritation, 
and characterized by an eruption of flat vesicles, which 
rapidly change into pustules and dry into yellow friable 
crusts. 
Symptoms.—From scratching or from any accidental irri- 
tation of the skin there arises, usually on the face or head, 
but sometimes on the hands, an eruption of isolated small 
vesicles, which soon become pustular and then dry into 
yellow scabs. These scabs vary in size from a split pea to 
a shilling, and appear as if “ stuck on,” since there is no 
inflammatory areola around them. Dr. Tilbury Fox, who 
first distinguished the disease as a separate affection, states 
that the eruption is generally preceded by a slight pyrexia, 
and by malaise and sensations of chilliness; also that it is 
accompanied by severe itching, which is particularly trou- 
blesome at night. 
On removing the scabs a reddened base secreting a 
gummy, purulent fluid, which does not stiffen linen like 
that of eczema, is seen, and as the disease abates the scabs 
fall off from the erythematous base and the red spots grad- 
ually fade. 
When the head is affected the posterior cervical glands 
are apt to enlarge, and if the disease be neglected pediculi 
may be present among the scabs. The disease is spread 
from one part of the body to another, and from one person 
to another, by the direct inoculation of the pus. 
Diagnosis.—The eruption of discrete vesicles, which soon 
become pustules and scabs, the absence of serous discharge 
and the presence of pus, the inoculability, the contagious- PORRIGO. 
167 
ness and the slight pyrexia which precedes it, are the points 
which are supposed to separate porrigo from eczema. 
Prognosis.—The disease runs an acute course, and usually 
lasts about a fortnight. It maybe prolonged by successive 
eruptions, but is never dangerous to life. 
Morbid Anatomy.—The conditions met with resemble those 
of eczema. Fungous elements have been found in the crusts, 
but not in the contents of the vesicles, so that they are prob- 
ably accidental. 
Treatment. —The removal of the scabs by oiling and poul- 
tices, and the subsequent application of a mild mercurial 
ointment, or a carbolic acid lotion (1 in 20), to destroy the 
infective character of the pus, are the remedies that are 
needed to effect a cure. 168 
CLASS I. — EXUDATIONES. 
CHAPTER XIII. 
Class I.—Exudation es—continued. 
5. SQUAMOUS GROUP. 
Pityriasis rubra—Psoriasis vulgaris—Pityriasis. 
Pityriasis Rubra. 
Definition.—Pityriasis rubra is a chronic scaly disease, 
characterized by an intense reddening of the skin, which 
soon extends over the whole body, but which is not accom- 
panied by any infiltration or thickening. 
Symptoms.—Pityriasis rubra is a somewhat rare disease. 
Its chief characteristic is an intense reddening of the skin, 
which gradually extends over the whole surface, but fades 
on pressure. There is no infiltration or thickening of the 
reddened area, but the affected part is covered with loose 
scales of epidermis, which are shed in enormous quantities, 
often in large flakes, and the nails become opaque and ir- 
regular. 
The reddening is much increased by heat, while cold, ou 
the other hand, gives it a blue tint. At a late stage of the 
disease the color becomes lighter and of a yellow or brown 
hue, which fades after death, when the skin resumes its 
normal appearance. At no time is the itching at all severe, 
and constitutional symptoms are for a long time absent; 
but in the later stages of the disease the skin becomes ex- 
tremely tender, the appetite becomes impaired, and the body 
emaciated, until death results. PITYRIASIS RUBRA. 
169 
The above description applies to the disease first sepa- 
rated from other affections by Hebra. It is right to men- 
tion, however, that several modern observers are of the 
opinion that it is merely an abnormal form of eczema, in 
which there is little or no exudation. Hutchinson believes 
that the essential features of the disease are “its occurrence 
in healthy persons, its proneness to become universal, and 
its non-amenability to treatment.” “If, then, a person in 
good health should, without obvious cause, become the sub- 
ject of a skin disease which should spread rapidly and very 
widely, involving the whole surface, and this eruption should 
prove to be uninfluenced by treatment, I would not care 
much whether the skin was dry or moist, whether it began 
as vesicles, papules, or erythematous patches, whether it 
were pruriginous or not. Such a malady would be proba- 
bly, so far as causes are concerned, a close ally of pityriasis 
rubra” (“Clinical Lectures,” 1879). The hard and fast 
lines drawn by Hebra, which would exclude from the cate- 
gory of pityriasis rubra all cases which do not conform ex- 
actly to the above description, cannot be sustained in prac- 
tice, because cases differing somewhat from the typical form 
of pityriasis rubra, both in the character and the severity 
of the eruption and in the nature of their course, are not 
unfrequently met with. 
Diagnosis.—From psoriasis and lichen ruber it may be 
at once separated by the absence of any infiltration, while 
the intense reddening of the surface enables it to be distin- 
guished from pityriasis simplex or ichthyosis. The absence 
of moisture marks a difference from all varieties of eczema, 
and, further, the large extent of surface involved, the ten- 
derness of the skin, and the absence of the characteristic 
papules definitely separate it from eczema squamosum, 
which is, moreover, essentially a local affection, while pityr- 
iasis rapidly becomes general. 
Lupus erythematosus is said by Hebra to resemble pityr- 170 
CLASS I. — EXUDATIONES. 
iasis rubra both in the reddening of the skin and the pro- 
duction of epithelial scales, but the former is limited to the 
face, and is attended with “enlargement of the mouths of 
the hair sacs and sebaceous glauds, which are also plugged 
with masses of hardened sebum.” 
Prognosis.—The prognosis in this disease is very unfavor- 
able, and the majority of cases terminate fatally. 
Morbid Anatomy.■—In early stages the microscopic ex- 
amination shows little besides scaling of the horny layer, 
with moderate serous and cellular infiltration of the rete 
and of the papillary layer. In other cases there is marked 
atrophy of the whole skin, the rete and the papillary layer 
are atropied, the horny layer thin and scaly, the connective 
tissue fibres of the corium thickened, and elastic fibres more 
numerous. There is also considerable deposit of pigment, 
and the hair follicles, sweat and sebaceous glands are much 
wasted. 
Treatment.—No treatment has been found of any mate- 
rial use in checking the course of this disease, but the em- 
ployment of tepid baths and the application of oil and 
emollient ointments is recommended by Hebra. 
Psoriasis Vulgaris. 
Definition.—Psoriasis is a chronic disease of the skin, 
characterized by the production of white silvery scales on 
hypersemic bases. 
Symptoms.—The eruption begins with congestion of the 
papillae of the skin, giving rise to an increased production 
of epidermic cells in the form of a quantity of minute ele- 
vations, which increase in size, and are separated from each 
other by healthy skin. When these are of the size of pins’ 
heads, the name psoriasis punctata is given to the eruption; 
as they develop they have the appearance of drops of mor- 
tar, and it is then known as psoriasis guttata; a further in- PSORIASIS VULGARIS. 
171 
crease by growth of the periphery brings them to the size 
of coins, when the rash is described as psoriasis nummularis. 
While the patches first formed in this way develop in size, 
others are continually beginning, until patches of all sizes 
are to be seen. These patches of diseased skin have a ten- 
dency to heal in their centres, while extension takes place 
at their margins, and as a result rings are formed, the cir- 
cumferences of which vary in thickness according to the 
size of the patches, since the healing process in the centre 
takes place more rapidly than the growth at the margins. 
To this variety the name of psoriasis circinata or lepra is 
usually given. Frequently two rings come in contact with 
each other at the edges, thus forming the figure 8; or three 
rings will meet, producing a trefoil. Often, however, the 
circles are not complete, and as a result a quantity of wavy 
lines are formed. This variety is known as psoriasis gxyrala 
or figurata. The rings never overlap each other, each pre- 
senting an impenetrable barrier to the extension of contigu- 
ous rings. The name of psoriasis universalis is given to the 
eruption when the patches increase in size, coalesce, and 
cover the whole of the body. This is very rarely met with, 
and even when it does occur a considerable portion of 
healthy skin remains unattacked and intervenes between 
the diseased patches. When the thickening of the skin 
and the growth of epidermic cells is very marked, the erup- 
tion is called psoriasis inveterata. A further form has been 
described by McCall Anderson under the name of 
rupioides, owing to the special prominence of the patches, 
which are usually larger than in psoriasis guttata. “The 
accumulation of the epidermis takes place to an unusual 
extent, so that on many of the patches it assumes the shape 
of large conical crusts marked by concentric rings.” When 
the crusts are removed no ulceration remains, but “ a slightly 
elevated dusky-red surface is exposed to view, which some- 
times bleeds a very little.” 172 
CLASS I. — EXUDATIONES. 
Although when psoriasis first appears there is little dis- 
coloration of the skin, it soon becomes raised and of a 
marked red color, which as time goes on grows darker. At 
a later stage the scales are shed, leaving the red patches 
still raised but bare. At a further period, when the disease 
commences to heal, the patch becomes less and less elevated, 
and the color lighter and lighter, till eventually the erup- 
tion fades, leaving the skin perfectly normal and not stained 
with pigment. 
Psoriasis, as a rule, is attended by some amount of local 
irritation, and the scratching which results leads to the 
formation of small blood crusts. Hebra has pointed out 
that these will always be found on the edge of the patch as 
well as in its centre, and states that the older patches only 
itch at their margins, and concludes therefore that the itch- 
ing only occurs while the eruption is growing. 
Psoriasis may occur on any part of the body, but the tips 
of the elbows, the fronts of the knees, and the head are es- 
pecially liable to be affected. It may be limited to the knees 
and elbows without attacking other parts, but if the rest of 
the body is implicated these regions are but rarely exempt. 
When the head is attacked, the eruption extends beyond 
the part covered with hair and forms a ring round the fore- 
head and ears. Often the disease penetrates into the mea- 
tus of the ear, and thus produces deafness. Psoriasis is 
never seen on the mucous membranes or the red margins of 
lips, and but rarely on the palms and soles. The nails are 
sometimes subjected to the action of the disease, and then 
become thick, friable, and of a brown color. 
Psoriasis of the scalp produces no changes either in the 
color or structure of the hair, although it causes it to be 
shed more freely than is naturally the case. 
Although much difference of opinion exists regarding the 
conditions that lead to the production of psoriasis, there is 
no reason for believing that climate, habits of life, special PSORIASIS VULGARIS. 
173 
occupations, exposure to cold, uncleanliness, diathesis, tem- 
perament, pregnancy, mental emotion, syphilis, gout or other 
diseases, or even sex, race, or age, have any influence on its 
origin. It is undoubtedly hereditary, and it is compara- 
tively rare to find psoriasis in one member of a family with- 
out finding it in another. 
Diagnosis.—Psoriasis may be confounded with seven dis- 
eases : 
1. Squamous syphilide (see Chap. VIII, p. 108). 
2. Lichen ruber (see Chap. X, p. 133). 
3. Eczema squamosum (see Chap. XII, p. 159). 
4. Pityriasis rubra (see p. 170). 
5. Pityriasis can be distinguished from psoriasis by the 
contrast of the thick white scales of the latter with the thin 
dark scales of the former, and by the absence of thicken- 
ing of the skin in pityriasis. 
6. Ichthyosis is easily recognized by the absence of the 
redness of the skin and the white silverlike scales peculiar 
to psoriasis, and by the fact of the disease affecting the 
whole surface and being congenital. 
7. Tinea circinata occasionally bears a rough resemblance 
to psoriasis, but it does not attack the knees and elbows, its 
scales are not silvery, and microscopic examination will en- 
able the parasite to be distinguished. 
Prognosis.—Psoriasis is not a fatal disease, but is exceed- 
ingly obstinate, though to some extent amenable to treat- 
ment, and it is liable to relapse. 
Morbid Anatomy.—Thin sections from a patch which has 
not lasted long show the epidermis much thickened, espe- 
cially the rete, which is soft and contain many leucocytes. 
The papillae also are infiltrated with numerous leucocytes, 
which fill up the connective-tissue meshwork, and the ves- 
sels are dilated, while their adventitia is thickened and loaded 
with cells. 174 
CLASS I. EXUDATIONES. 
Old patches often show thickening and induration of the 
whole corium, with vascular dilatation, serous and cellular 
infiltration, and some deposit of pigment in the branch cells 
as deep as the subcutaneous fatty tissue. 
In psoriasis inveterata the papillae on the back of the 
sacrum, and over the olecranon and upper part of the tibia, 
become enlarged and sclerosed, forming hard warty masses 
as in ichthyosis. The scales are made up of masses of cells 
from the stratum lucidum, which, as in other conditions 
producing inflammatory overgrowth, have not undergone 
the usual horny transformation, but have simply dried up 
and become pervaded with air. To this their friable con- 
sistency and their silvery color, as well as the readiness 
with which they separate from the hypersemic papillary 
layer, are due. 
Treatment.—The treatment of psoriasis consists in the 
use of constitutional and local remedies. Of the constitu- 
tional remedies no drug has proved of such service as ar- 
senic, which should be given in increasing doses until the 
eruption begins to disappear, and then continued in small 
quantities for a great length of time. 
The alkaline treatment has been said to be attended with 
success, but it is of doubtful value. It is given in the form 
of liquor potassae, in doses of twenty or thirty drops three 
times daily. McCall Anderson has seen much benefit de- 
rived from the use of carbonate of ammonia, which should 
be given in doses increasing from ten to forty grains. 
The internal administration of tar is also stated to be 
beneficial when other remedies fail, but it is by no means a 
drug to be relied upon.. 
The local treatment of psoriasis is most important, but 
though the employment of it without any internal remedy 
does remove the external appearance of the disease, a real 
cure is not effected on account of its liability to return. 
Both modes of ti’eatment should, therefore, be adopted at PITYRIASIS. 
175 
the same time, and the internal should be continued for a 
considerable period after the apparent cure. 
When the inflammation is excessive the continuous ap- 
plication of cold water is of great benefit in removing the 
scales and limiting their production. 
This may be carried out by means of baths or by local 
cold packing; the former should be done thoroughly by im- 
mersion of the whole body or one limb for many hours at 
a time. 
Before applying local remedies it is necessary first to en- 
deavor to remove the scales. This is best carried out by 
means of soft soap, and so effectual is this plan sometimes 
that no further application is required. 
Of local remedies those of a stimulating character are the 
most suitable, such as preparations of tar. The huile de 
cade, or common tar itself, or better still the liquor carbonis 
detergens, ought to be tried, but no drug has proved so suc- 
cessful in such a large proportion of cases as chrysophauic 
acid, which may be used in the form of an ointment con- 
sisting of ten to thirty grains of the acid to one ounce of 
vaseline or lard. Chrysophauic acid is the active principle 
of Goa powder, the Indian remedy for ringworm, and was 
first recommended in psoriasis by Mr. Balmanno Squire. 
The chief objection to this drug is the amount of irritation 
it produces, not so much in the .patch to which it has been 
applied, but in the neighboring skin. Sometimes this irri- 
tation is very severe, when the use of the remedy should be 
immediately suspended. 
Pityriasis. 
Definition.—Pityriasis is a chronic squamous disease of 
the skin, in which the scales are branny and are seated on 
a non-infiltrated surface. 
Symptoms.—The eruption consists of the production of a 
quantity of fine scales,, which are continually being shed and 176 
CLASS I. EXU D A TIONES. 
reproduced. The skin of the affected part may be slightly 
red, but there is no effusion into or thickening of the epi- 
dermic layer. There is but slight itching of the part, and, 
unless the skin be delicate, excoriations rarely result from 
scratching. Any portion of the body may be affected with 
pityriasis, but the most common sites are the hairy parts, 
more particularly the scalp. The ordinary condition, known 
as pityriasis capitis, has been shown by Hebra to be due to 
an increased secretion of the sebaceous glands, and is in no 
sense of the word a pityriasis. 
Diagnosis.—Pityriasis may be confouded with : 
1. Psoriasis (see p. 173). 
2. Tinea tonsurans. The only certain mode of diagnosis 
is by the use of the microscope, which show's the charac- 
teristic fungous elements in tinea; in addition, to the naked 
eye the hair is seen to be broken off short, and is easily 
extracted. 
Prognosis.—Pityriasis is a chronic and often intractable 
disease, but is never attended with any serious result. 
Treatment.—It is usually treated locally by the applica- 
tion of alkaline lotions. The best ai*e carbonate of potash, 
5j to the half pint; or liquor potassse, 3ij to 3 viij of water. 
Ointments containing either a little sulphur or mercury, or 
both combined, are useful. In very protracted cases arsenic 
may be tried. 177 
FURUNCULUS. 
CHAPTER XIV. 
Class I. —Exudationks—continued. 
6. PHLEGMONOUS AND ULCERATIVE GROUP. 
Furunculus—Anthrax—Delhi Boil—Ulcer. 
Furunculus—Boil. 
Definition.—A boil is an acute localized inflammation of 
tlie true skin, which usually terminates in necrosis and dis- 
charge hy suppuration of a central portion or “core.” 
Symptoms.—The ordinary follicular boil begins as a small, 
hard, painful spot in the true skin, which soon becomes red 
on the surface. Inflammatory swelling, heat, and pain 
rapidly occur, and in the course of a day or two a small 
subconical elevation, which throbs and is acutely sensitive, 
is produced. A minute yellow spot next appears at the 
apex of the swelling, the cuticle thins and ruptures,, and 
pus is gradually discharged from a small orifice. As the 
orifice enlarges, within it is seen a grayish or yellow slough, 
called the “core.” This becomes loosened and finally cast 
off, together with shreddy pus; and as the inflammatory 
redness and swelling subside, the little cavity fills up with 
granulations and heals, leaving a slightly depressed, often 
pigmented scar. 
In the “ blind ” or subcutaneous boil the starting-point is 
in the deeper layers of the cutis; the tumor is therefore less 
prominent, and pus i3 slower in reaching the surface. The 
process is, however, the same in both varieties. 
Boils are most frequently excited by local irritants, such 178 
CLASS I. EXUDATIONES. 
as the undue use of hydropathic bandages and poultices, or 
from post-mortem virus, etc.; but in* certain states of the 
system there appears to be a special predisposition to their 
occurrence. Persons suffering from diabetes or convalescent 
from acute diseases, especially enteric fever, seem specially 
liable to them. Though single boils cause little or no dis- 
turbance of the general system, yet when they are numerous 
and extensive, and occur in weakly and irritable individuals, 
there may be considerable fever. 
Diagnosis.—The circumscribed, painful swelling, going on 
to suppuration with the discharge of a “ core,” cannot well 
be mistaken for any other skin affection. 
Prognosis.—The course of a boil is usually towards re- 
covery after suppuration has set in, but occasionally it may 
disappear spontaneously, or under treatment, without break- 
ing. They are pi’one to recur, and successive crops may 
last for weeks. 
Morbid Anatomy.—This is included under Anthrax. 
Treatment.—In the early stage mercury with belladonna 
and glycerin, or the application of belladonna or soap 
plaster, is said to check the development of a boil. When 
more advanced, frequent poulticing, to relieve pain and to 
promote the discharge and separation of the sloughs, is the 
proper treatment. Yeast, in doses of a tablespoonful two 
or three times daily, is said to be of use in preventing fresh 
attacks; but the most appropriate internal remedies are 
quinine and iron or ammonia and bark. The diet should 
be generous and liberal, with a fair amount of beer and 
good port wine; and, in addition, change of air may be 
recommended. 
Anthrax—Carbuncle. 
Definition.—An acute localized inflammation of the true 
skin, differing from that in furunculus by the multiplicity 
of the cores and by the liability of the intervening skin ANTHRAX. 
179 
and the subjacent tissues to slough. The constitutional 
symptoms are usually severe. 
Symptoms.—Carbuncle begins as a flattened, slightly ele- 
vated swelling of the true skin, slightly red in color, and 
attended with severe pain and marked fever. Usually there 
are several points of intense inflammation, that lead to 
necrosis of the tissues and the formation of “ cores.” Con- 
siderable inflammatory infiltration surrounds the little nod- 
ule. As in a boil, suppuration soon commences; but, as 
the cores usually form only the superficial indications of 
more extensive subcutaneous sloughs, it has to continue a 
long time before they are separated, during which lymphan- 
gitis, cellulitis, and septic absorption, giving rise to pyaemia, 
may occur. 
Carbuncles appear most frequently on the nape of the 
neck, buttocks, and external surfaces of the limbs; they 
occasionally arise on the face and lips, in which situations 
the liability to phlebitis and fatal septicaemia is very great. 
They are usually solitary, but sometimes are multiple, and 
not infrequently a succession of them appears in different 
parts of the body. 
jDiagnosis.—Carbuncle can only be mistaken for a collec- 
tion of boils which have become confluent. The more in- 
tense pain and constitutional symptoms, the more extensive 
subcutaneous necrosis, and the greater proneness to slough- 
ing of the skin will serve to distinguish it. 
Prognosis.—Carbuncle, always an affection of serious im- 
port, is especially grave in those suffering from exhausting 
diseases or in a cachectic condition, however produced. The 
intense pain, causing sleeplessness, and the nervous exhaus- 
tion, the severe fever, the prolonged suppuration, with the 
special liability to septicaemia, in carbuncle of the face and 
lip, are all elements which intensify the danger in propor- 
tion as they are well marked. 
Morbid Anatomy.—Both of these affections, boil and car- 180 
CLASS I. — EXUDATIONES. 
buncle, may be considered together, the essential feature 
being the formation of necrosed masses of tissue, which are 
solitary in the former and form the “ core.” A carbuncle 
containing several “ cores” may be considered anatomically 
as formed by the confluence of several boils. The morbid 
anatomy has not been thoroughly made out; it is stated, 
however, that there is an acute inflammation either in the 
connective tissue passing from the base of a hair follicle 
down into the subcutaneous fatty tissue, or around one or 
more sebaceous glands, as the primary phenomenon. The 
hypersemia and abundant exudation of plasma into the 
loose subcutaneous tissue form the large swelling round the 
central spot. The accumulation of cells and plasma being 
excessive, the blood supply is either cut off* from the central 
core, or the vessels round become thrombosed, and in con- 
sequence the mass dies. A “ line of demarcation ” soon 
forms, and the “core” becomes loose and can be removed. 
In anthrax the process is the same; the “cores,” however, 
are multiple, there is much more oedema of the cellular tis- 
sue, and the intensity of the inflammation may cut off the 
blood supply from the intervening tissue, causing a grayish 
slough or black gangrenous mass. 
Treatment.—An abundant, nutritious, and easily-digested 
diet, with stimulants in proportion as the patient is depressed 
or debilitated, are essential parts of the general treatment. 
Iron and quinine, or ammonia and bark, as for boils, should 
be given. As measures of local treatment the free crucial 
incision, the subcutaneous incision of the nodule, and cau- 
terization with potassa fusa have been advised and practiced. 
In the early stages Hebra recommends the application of 
cold, by means of ice bladders, to check the extension of 
inflammation and subsequent suppuration. Poultices and 
warm poppy fomentations, with some antiseptic, such as 
carbolic acid or thymol, to lessen the risk of septic absorp- 
tion and to promote the separation of the sloughs, are un- DELHI BOIL. 
181 
doubtedly useful. These measures are probably quite as 
efficacious as the more active treatment mentioned above. 
Delhi Boil. 
Definition.—A chronic endemic disease met with in India, 
characterized by the production of a small flattened nodule, 
which undergoes slow ulceration and heals with loss of sub- 
stance, leaving a whitish, depressed scar. 
Symptoms.—Delhi boil is said to begin as a small reddish 
spot with a central papule, gradually enlargiug to form a 
smooth, reddish-brown, flattened nodule, which then begins 
to desquamate and ulcerate. Yellowish-white points, which 
are the altered hair and gland follicles, soon become covered 
with a thin scab, under which suppuration slowly goes on. 
An indolent sore, with hard edges and base of flabby granu- 
lations, is present under the scab. After lasting two or 
three months the sore usually begins to heal, and leaves a 
whitish, irregular scar. 
The disease attacks the exposed parts of the body, and 
does not seem materially to affect the general health. It is 
said to be communicable by inoculation. 
Morbid Anatomy.—This is described as follows: Micro- 
scopic examination of the papule, before ulceration has be- 
gun, shows the connective tissue of the corium infiltrated 
with masses of cells, oval or roundish in shape, yellowish- 
brown, and with one or more nuclei. The glands and pa- 
pillae appear to be destroyed by this growth, and the hair 
follicles become enlarged, while here and there these cystic 
dilatations are observed in the hairs themselves. After 
ulceration has commenced, in the purulent discharge pig- 
mented bodies, resembling the ova of distomata, are said 
sometimes to occur. 
Treatment.—Local treatment only is necessary, consisting 
in the thorough application of strong nitric acid if the nod- 182 
CLASS I. EXUDATIONES. 
ule be in an early stage, or of potassa fusa if an ulcer have 
formed, which converts the disease into a simple ulcer that 
soon heals. 
Ulcers. 
The following brief account of ulcers and their treatment 
has been contributed by Mr. Edmund Owen: 
An ulcer is well defined as being a solution of continuity 
with loss of substance. The common cause of ulceration of 
the skin is suppuration in the dermal connective tissue. 
The collecting pus, in its escape to the surface, destroys the 
superimposed dermal layer, and the epidermis, being thus 
deprived of its nutritive supply, dies and is shed. 
Now, whatever conditions interfere with the nutrition of 
the skin necessarily predispose to the formation of ulcers. 
Thus, when the function of the veins of the leg becomes 
impaired from a failure of the valves to check the down- 
ward fall of the blood, stagnation in, or rather congestion 
of, the cutaneous capillaries results, and from the distended 
vessels the serum oozes, so that the tissues become oedema- 
tous, pitting on pressure. 
In this sodden and unhealthy skin a comparatively slight 
irritation, or trivial injury, is frequently attended by lesions, 
troublesome out of all proportion. And thus the chafing of 
a badly-fitting boot, or the fretting of a dirty or rough stock- 
ing, or a knock against a stair, may determine the forma- 
tion of an ulcer, which will persistently refuse to yield to 
ordinary therapeutic measures. 
As a rule varicose ulcers are associated with eczema, an 
attack of eczema often preceding and determining their 
onset. 
Common-sense, with a little practice, will soon enable the 
student to select with great promptness the adjectives best 
describing the varicose ulcer, but the term “chronic” only 
too often denotes its chief characteristic. ULCERS. 
183 
The following is a list of the different kinds of ulcers 
usually met with: 
The healthy ulcer, which is circular and is generally cov- 
ered by a little thick pus; the granulations red and even 
with the surface of the part; the edge of the sore is covered 
by a slightly depressed, bluish-white film of new epidermis, 
which gradually loses itself in sound tissue. The treatment, 
whatever it may be, is evidently well chosen, for the sore is 
healing. 
The weak ulcer is covered by large and pale granulations, 
which are heaped up on the surface but are painless. The 
local treatment best adapted will be rest, aided by the pres- 
sure of a pad of dry lint and a bandage or strapping. 
Stimulating lotions may be of use, also resinous and other 
ointments. A change of application is often attended with 
such good results that the weak ulcer is converted into one 
of the preceding class. 
The indolent ulcer is gray and glazed, and is surrounded 
by an unyielding mass of tissue, which has been rendered 
thick and discolored from long-continued congestion. The 
discharge is thin, and often of a most foul odor. 
Blistering fluid applied around the margin may some- 
times effect much good by causing absorption of plastic 
deposit, but the poor and ill-fed can rarely submit to such 
treatment as out-patients. With in-patients two semi-ellip- 
tical incisions on the side of the sore will relieve much ten- 
sion and promote a healthy condition. 
The inflamed ulcer is recognized by placing over it, but 
not in contact with its raw and painful surface, the palm 
of the hand. The parts around are livid, hot, and tense. 
Poulticing affords great relief by diminishing the heat and 
pain. 
The phagedcenic or gangrenous ulcer is, as the former 
term implies, a sore which extends by eating its way into 
the neighboring skin. It shows no attempt at healing ; on 184 
CLASS I. — EXUDATIONES. 
the contrary, the discharge is thin and bloody, and the sur- 
rounding parts are livid and swollen. 
Opium given internally with quinine and acid, poultices 
and cleansing lotions, and the hot leg-bath will be required. 
The irritable ulcer is to be distinguished from the in- 
flamed ulcer by the absence of heat when the hand is held 
over it, as well as by the watery nature of the fluid thrown 
off from its surface. It is exceedingly painful, and its es- 
sential pathological character depends, according to Hilton, 
on the exposure of a nerve upon its surface. The exqui- 
sitely teuder spot is to be made out by searching over the 
granulations with a probe; the treatment will consist in the 
division of the twig above the spot indicated by the exam- 
ination. Opium and tonics may be required. 
Although the leg and ankle are the most frequent seats 
of ulcers, on account of the unfavorable influence with 
which the force of gravity continually acts upon the venous 
blood, still it is hardly necessary to remark that there may 
be other than varicose ulcers eveu on the surface of the 
lower extremity. Any part of the body may be the seat of 
an ulceration which is the result of the destructive influence 
of neoplastic deposits. Thus are begotten the tubercular, 
the lupoid, and the syphilitic ulcers. 
But to give a description of all these varieties of sore 
would be to write an essay on pathology, which, in the small 
space which can be devoted to the subject, is manifestly 
impossible. So we must content ourselves by concluding 
with a few general remarks which may be found of service 
to the student in his early practice. 
First, then, when ulcers are found in regions where one 
is not accustomed to see them, as upon the knee, calf, thigh, 
trunk, arm, or face, they are not uuf'requently of syphilitic 
origin. 
Of course the integument of these areas may be attacked 
by ulcers which are not the result of syphilis. But if the ULCERS. 
185 
sores are multiple, clean-cut, with rounded or crescentic 
margins, and appearing in successive crops, there is quite 
enough to justify the suspicion of the student, and even, it 
may be, to induce him to commence the treatment of the 
patient with the internal administration of iodide of potas- 
sium in full doses. But we will venture here to offer him 
two cautions,—firstly, not to place too much faith in what 
is known as a “ coppery stain ” about an ulcer; and, sec- 
ondly, not to conclude that, because an ulcer has healed 
whilst the iodide is being taken, therefore the sore was the 
result of a breaking down of a deposit left as the result of 
syphilitic infection. 
A last word concerning the treatment of those number- 
less ulcers which are the result of dilated veins. They occur 
chiefly in laundresses, ironers, hostlers, and others who stand 
much during the day, and who drink freely, whether of tea 
or beer. Rest is more easily enjoined than enforced ; but 
the amount of vascular fulness may be diminished by regu- 
lating the amount of fluid absorbed. The veins require 
support; but this cannot often be obtained in the shape of 
the costly elastic stocking, nor, if there be eczema present, 
could that useful aidfcbe tolerated, for the moisture from the 
vesicular eruption would soon render the webbing hard, 
irritating, and worse than useless. 
Martin’s india-rubber bandages are useful in some cases, 
but their application requires more care and manipulative 
skill than these patients usually possess, whilst their cost 
often puts them beyond the reach of most of these sufferers. 
Considerable success may be obtained by applying a piece 
of strapping firmly, but not too tightly, around the limb, 
above the ulcer and below the dilated veins, leaving the sore 
exposed for the application of lotions or ointments. Theory 
might perhaps suggest that such a method of treatment is 
unscientific, as it wTould offer another barrier to the easy 
return of the venous stream. But practice shows that the 186 
CLASS I.—BXUDATIONES. 
strapping so applied generally affords the greatest comfort 
by cutting off the weight of the downward-pressing column 
of venous blood, in the same way that the application of a 
truss affords relief in a bad case of varicocele. The strap- 
ping is best applied by the patient before he gets out of bed 
in the morning; its use may be dispensed with at night. 
In some cases of varicose eczema also the wearing of a garter 
below the knee affords great relief. HYPEREMIA. 
187 
CHAPTER XV. 
Class II.—Vascular Affections. 
Hyperaemia—Anaemia—Haemorrhages of the Skin—Purpura simplex, 
papulosa, rheumatica, haemorrhagica—Scorbutus—Haematidrosis. 
Ik the class of Vascular Affections of the Skin the sub- 
divisions Hypersemia, Anaemia, and Haemorrhages are in- 
cluded. 
In themselves the two first are of slight importance and 
do not endanger life ; but as the manifestations or symp- 
toms of graver conditions, or as the early stages of further 
changes in the skin, they require a more complete descrip- 
tion. Cutaneous haemorrhages are similarly of slight mo- 
ment if not symptomatic of variola, scarlatina, typhus, etc., 
and of the so-called purpura haemorrhagica, which is more 
properly a general vascular disease than one of the skin. 
Hyperemia. 
The hypersemic affections, characterized in general by an 
undue injection of blood into the capillaries, small veins, 
and arterioles of the superficial layer of the skin, fall con- 
veniently into the two subdivisions of active and passive. 
In the former of these the skin has usually a brighter 
red color, and the appearance is accompanied by a feeling 
of irritation, as of burning or itching, by moderate swell- 
ing, and sometimes by slight elevation of temperature; 
while in the latter the hue is more divid, the temperature 
lowered or only normal, and a feeling is experienced of 
numbness or even anaesthesia. The division between these 188 
CLASS II. — VASCULAR AFFECTIONS. 
two forms is merely one of convenience, as the active hy- 
penemia may culminate in the passive (congestion), or they 
may be present side by side on the same portion of skin, 
as in thrombosis or embolism, when the central part is in 
a state of congestion and the marginal in one of active 
hypersemia. 
Active hypercemia as defined presents varieties which may 
be classed under the two headings of: 
1. Traumatic, excited by irritants. 
2. Symptomatic, arising in the course of other diseases, 
probably under the influence of reflex irritation of the ner- 
vous system. 
The former are usually called erythemata, a term to which 
a special meaning has been already assigned (p. 117), and, 
as they are characterized chiefly by an increased vascularity, 
with little or no exudation, the more suitable name of hy- 
persemia will here be used. 
a. Hypercemia (erythema) viechanica arises on portions 
of skin exposed to undue pressure, rubbing, or scratching. 
It is usually transient, but if the irritant be repeatedly in 
action the skin is prone to become the seat of congestion or 
of inflammatory change, and the eruptions of exanthemata 
appear upon it with special brightness. 
b. Hypercemia calorica arises on parts exposed to the sun’s 
rays, or to winds, as a diffuse bright-red discoloration, which 
in time becomes darker and usually ends in brownish pig- 
mentation and slight desquamation. Transient degrees of 
heat, and either warm or cold baths, excite a fugitive 
hypersemia. 
c. Hypercemia ab acribu-s sen venenata is produced by the 
slight action of chemical irritants, the juice of certain 
plants, mustard, etc., and readily develops into exudation 
and inflammation if the cause be prolonged. HYPERiEMI A. 
189 
Symptomatic liypercemia may be excited by physical causes, 
such as anger, shame, etc.,—i. e., in the form of a blush or 
of a more diffuse and slighter injection—or it may arise in 
the course of dentition or gastric disturbances in infancy, 
when it has been termed erythema, roseola infantilis, stroph- 
ulus, etc., or vaccinia, variola, enteric fever, cholera, rheu- 
matism, and other diseases, when it has been variously 
named erythema or roseola vaccinia, etc. 
Passive liypercemia may be either general, under the in- 
fluence of heart or lung disease, causing mechanical con- 
gestion, or local, from pressure on the veins or deficient ar- 
terial vis a teryo. The two latter, which have been termed 
livedo mechanica and livedo calorica respectively by Hebra, 
will now be described. 
Livedo mechanica, arising under the influence of pressure 
from tight clothes, garters, varicose veins, etc., appears as 
a purplish-red, bluish, or grayish-black discoloration of the 
skin, disappearing under pressure, with slight swelling if 
there be no oedema. When the cause is removed it gradu- 
ally subsides. 
Livedo calorica is the name applied to the bluish-red or 
purplish tint seen on the nose, ears, etc., of persons exposed 
to the cold, and to the dark lines about half or three-quar- 
ters of an inch wide which form serpentine figures on the 
extremities and trunk. The latter are chiefly visible on the 
extremities, and, but less obviously, on the trunk, and though 
fading on pressure, disappear only when the patient is warm. 
Occasionally in the midst of the purplish background ver- 
milion-red patches are observable, varying in size from to 
i of an inch, and sometimes surrounded by a pale zone. 
If the action of cold be prolonged, it may in weakly, 
chlorotic persons give rise not only to congestion, but to ex- 
udation and an eczematous condition to which the name 
chilblain has been applied. 
Morbid Anatomy.—The active hypersemia leave little or 190 
CLASS II.—VASCULAR AFFECTIONS. 
no traces for examination after death beyond slight pig- 
mentation of the rete cells. The experiments of Auspitz 
lead him to a very probable explanation of the persistence 
after removing the ligature of the brown pigmentation sub- 
sequently left by the vermilion-colored spots noticed in pas- 
sive hypersemia. He ascribes it to the admixture with the 
transuded serum in the tissue of red corpuscles, which sub- 
sequently give rise to lisematoidin crystals and yellow or 
brown pigment. The pale streaks are due to the shutting 
off from the circulation of certain tracts of vessels which 
are empty or contain only clear serum, as in embolism, etc. 
Anaemia. 
Anaemia of the skin maybe general, as in chlorosis, after 
loss of blood, exhausting discharges, etc.; or local, under 
the influence of cold, undue action of local vasomotor nerves, 
pressure, etc. 
It is of importance only so far as it modifies the appear- 
ances of eruptions, and produces apparent retrogression in 
such as are characterized by hyperaemia. Thus the exan- 
thems of scarlatina and measles may fade if exposed to cold, 
or an old psoriasis be lost sight of after severe haemorrhage, 
only to reappear as the former vascularity of the skin re- 
turns. 
Treatment.—The application of cold water, spirit lotion, 
or lotio carbonis detergens, to relieve the burning and itch- 
ing in active hyperaemia, is all that is necessary. 
Haemorrhage of the Skin. 
A. Traumatic, . ... From wounds, bruises. 
Simplex. 
Papulosa. 
Rheumatica. 
Hsemorrliagica. 
1. Purpura, 
B. Symptomatic, . 
2. Scorbutus, 
3. Hsematidrosis. PURPURA. 
191 
Extravasations of blood in the skin take the form of: 
1. Petechice—round or irregular, bright or livid-red spots, 
not raised, varying from yg to y an inch in size, appearing 
as if splashed on the skin. 
2. Vibices—long streaks, either branching or parallel to 
one another. 
3. Ecchymoses—dark-red irregular patches, varying in 
diameter from 1 to 3 inches. 
They do not fade on pressure, but undergo a series of 
changes from red to brown, greenish, or yellow before they 
disappear. 
A. Traumatic.—The ordinary appearances of a bruise, or 
ecchymosis, produced, for instance, by a blow on the skin, 
and the minute petechise due to flea or bug bites, are fami- 
liar to every one. 
B. Symptomatic. 
Purpura. 
Definition.—Extravasation of blood occurring as puncta, 
petechise, vibices, or ecchymoses, either spontaneously or in 
the course of various diseases. 
Symptoms.—The following varieties have been described : 
a. Purpura simplex consists in the occurrence of numer- 
ous petechise, or vibices, irregularly scattered over the body, 
usually most markedly on the legs, where there is a ten- 
dency to symmetry of the eruption. The disease is said to 
occur in debilitated persons, but is attended by little or no 
subjective trouble, and is not dangerous to life. "When 
small papules appear between the haemorrhages the affection 
is termed purpura papulosa. 
b. Purpura rheumatica, or peliosis rheumatica, first de- 
scribed as a separate disease under the latter name by Schon- 
lein, is characterized by rheumatic pains in and about the 192 
CLASS II.—VASCULAR AFFECTIONS. 
joints, together with an appearance of a rash, which is at 
first erythematous but soon becomes haemorrhagic. Though 
provisionally classed with purpura, it ought rather to be 
considered a variety of erythema papulatum or nodosum, 
with which, according to Bazin and others, it is identical. 
According to Hebra it arises with dragging pains in the 
joints and some fever, followed in a few days by the erup- 
tion near the joints, or more especially on the abdomen and 
breast. The, spots, round and flat, are only slightly raised, 
gradually fade, with the usual changes of color, and dis- 
appear, without desquamation, in a week. 
The disease usually attacks strong and healthy persons 
between the ages of twenty and thirty, and more frequently 
males than females. It has never been seen in children or 
aged persons. 
c. Purpura hcemorrhagica is a severe constitutiual va- 
riety, in which the cutaneous extravasations are abundant 
and large, and accompanied by haemorrhages into various 
organs and from mucous surfaces. Marked anaemia and as- 
thenia are induced by the severe losses of blood, aud death 
is not an infrequent result. 
The so-called purpura fibrilis is usually only a purpuric 
rash that appears in the course of one of the acute infec- 
tious diseases. 
Diagnosis.—A petechial rash, not occurring in the course 
of one of the exanthemata, may be mistaken for: 
1. Fleabites. 2. Scurvy. 
Fleabites are most abundant Avhere the folds of the clothes 
are thick, as on the neck, wrists, waist, and ankles ; while 
purpura affects the lower limbs pre-eminently, and has no 
special predilection for other sites. It is also haemorrhagic 
from the beginning, and does not appear as a roseolar spot, 
or wheal, with a central red dot. PURPURA. 
193 
The following table will show the points of difference 
from scurvy. 
Scurvy. 
1. Is due to privation from 
vegetables and to depressing cir- 
cumstances, and is cured by lime 
juice and fruit. 
2. Affects usually many per- 
sons at the same time. 
3. The gums become spongy, 
the teeth loose, and painful subcu- 
taneous ecchymoses, prone to sup- 
puration, may occur. 
4. Is attended with great pros- 
tration and a peculiar dusky pal- 
lor of skin. 
5. Death occurs rarely from 
haemorrhage, usually from serous 
effusions or septicaemia. 
Purpura. 
1. Is not produced by want of 
vegetables, and lime juice has no 
influence on its course. 
2. Occurs sporadically. 
3. No affection of gums or 
painful ecchymoses. 
4. Prostration only propor- 
tionate to loss of blood; skin 
anaemic. 
5. Death results from asthenia 
or syncope, the result of haemor- 
rhage. 
Prognosis.—Purpura simplex and rheumatica are affec- 
tions of slight gravity, and as a rule tend towards sponta- 
neous recovery. Purpura hemorrhagica is serious in pro- 
portion to the amount of internal bleeding; it often resists 
treatment, and proves fatal by anemia and exhaustion or 
syncope. 
Morbid Anatomy.—The skin, after death, of a person who 
during life has had purpura shows— 
1. Recent hemorrhagic spots in the form of subarticular 
or interstitial puncta, or strie of a dark-purplish color. 
2. Small crusts of dark color, due to the drying up of the 
petechie. 
3. Brownish or yellowish stains, marking the position of 
former hemorrhages of which the fluid portions have be- 
come absorbed and the blood corpuscles more or less altered. 194 
CLASS II.—VASCULAR AFFECTIONS. 
In a section of a recent petechial spot, either in the fresh 
condition or after hardening, the effusion of blood is seen 
to be mainly limited to the papillary layer of the corium 
and the overlying rete Malpighii. On microscopic exami- 
nation blood corpuscles, the majority of which are more or 
less broken down, are seen surrounding the hair follicles, 
having apparently proceeded from the capillary network 
round the latter. Should the effusions take the form of 
vibices, the blood corpuscles are found in and around the 
papillae of the corium and in the rete, raising the horny 
layers of the epidermis as in a vesicle. 
Microscopic examination of the older spots shows the 
blood corpuscles broken down and converted into pigment, 
reddish-brown masses and granules of which are found 
lying in the meshes of the connective tissue of the corium, 
and sometimes staining the branched cells a brownish- 
yellow color. 
In the majority of cases of purpura simplex in which a 
microscopic examination of the blood capillaries has been 
made, no obvious morbid changes have been found. 
Dr. Wilson Fox described albuminoid or lardaceous 
changes in the capillaries in the vicinity of purpuric spots 
as traceable in some cases, and in the cutaneous haemor- 
rhages occurring in certain instances of phosphorus poison- 
ing acute fatty degeneration has been found in the arteri- 
oles and capillaries, to the rupture of which the extravasa- 
tions are ascribed. 
Where no alteration of the capillaries has taken place 
the escape of the red corpuscles is supposed to be due to 
simple diapedesis, the resistance of the capillary walls being 
so diminished as to allow the passage through them of red 
corpuscles when, from any slight exertion, as in standing, 
strain is thrown upon them. 
Treatment.—In the milder forms of purpura, rest in bed, 
nutritious diet, and tonics are all that is needed. SCORBUTUS. 
195 
In purpura haemorrhagica various drugs, chiefly metallic 
astringents and those which act on the bloodvessels, have 
been used; of these, tinctura ferri perchloridi, in doses of 
xx to xxx drops three times a day, either alone or with 
ergot and digitalis, gives the best results. 
Scorbutus—Scurvy. 
Definition.—Scurvy is a general disease of the body char- 
acterized by progressive ansemia, severe mental prostration 
and asthenia, impairment of nutrition and a tendency to 
the occurrence of haemorrhages from mucous membranes 
and into the skin, muscles, and viscera. It is due to priva- 
tion from, or an insufficient supply of, fresh vegetable food. 
Symptoms.—The patient presents at first a dirty, pallid, 
or earthy-looking complexion, accompanied by languor and 
malaise, mental apathy and depression, and rheumatic pains 
in the back and the muscles of the limbs. The gums swell, 
forming deep-red spongy masses round the teeth, which are 
prone to bleed and ulcerate, giving great fetor to the breath. 
The teeth may loosen and drop out. Petechise appear at 
first on the lower limbs, followed by ecchymoses and subcu- 
taneous extravasations, which spontaneously, or on slight 
irritation or injury, are liable to suppurate and give rise to 
unhealthy, painful, bleeding ulcers. Progressive anaemia, 
sudden syncope on slight exertion, sanguineous effusions into 
the pleura and pericardium, gangrene of the lungs, or diar- 
rhoea may lead to a fatal result. 
Diagnosis.—From purpura (see p. 193). 
Prognosis.—It is serious and often fatal if untreated. 
Death results most frequently from asthenia or sudden syn- 
cope. Cases of moderate severity almost always recover if 
fresh vegetables be added to the dietary. 
Morbid Anatomy.—The cutaneous changes resemble those 
met with in purpura, already described. 196 
CLASS II. VASCULAR AFFECTIONS. 
Treatment.—The essential point in the treatment is the 
restoration to the diet of vegetable food in the form of 
fruits, green vegetables, turnips, carrots, onions, lemon, or 
lime juice. 
The gum affection should be treated by antiseptic and 
astringent washes. The tendency to syncope should be 
averted by rest in bed, stimulants, and digitalis. 
Hasmatidrosis. 
Hsematidrosis, or “ bloody sweat,” is an affection of rare 
occurrence. It is a haemorrhage on the surface of the skin 
in parts where the cuticle is thin and delicate, and it is pro- 
duced by rupture of capillaries in the plexus round the 
mouths of the sweat ducts. 
The “stigmata” on the forehead, hands, and feet, stated 
to occur in the persons of religious fauatics, have proved in 
most cases, when submitted to a careful scientific examina- 
tion, to be fictitious. ZOSTER. 
197 
CHAPTER XVI. 
Class III.—Neuroses. 
Zoster—Cheiro-pompholyx—Pruritus—Dystrophia cutis. 
Zoster—Herpes Zoster—Shingles. 
Definition.—Zoster is a disease of acute and typical course 
and benign nature, characterized by the eruption of groups 
of vesicles or erythematous papules, which correspond in 
situation with the peripheral distribution of a cutaneous 
nerve—usually on one side of the body—and are produced 
through the influence of irritative lesions of the nervous 
system. 
Following the classification of Hebra, zoster is divided 
into the following varieties : 
1. Zoster capillitii. 
2. Zoster faciei. 
occipito-collaris. 
cervico-subclavicularis. 
4. Zoster cervico-brachialis. 
5. Zoster pectoralis. 
6. Zoster abdorainalis. 
7. Zoster femoralis. 
3. Zoster nuchse et colli 
Symptoms.—Usually after a few days, sometimes a few 
weeks, of neuralgic pains, either over the whole region which 
becomes subsequently affected, or at certain fixed spots cor- 
responding with points of division or emergence from the 
deeper tissues of cutaneous nerves, the eruption appears 198 
CLASS III. — NEUROSES. 
suddenly. It consists of an efflorescence of bright-red 
papules, about the size of millet seeds, on an erythematous 
surface, and is accompanied usually by a burning sensation. 
Within a few hours, or in a day or two, the papules become 
vesicles, from the size of a pin’s head to that of a pea, 
filled with a clear serous fluid; they are either quite isolated 
or closely aggregated, and sometimes by confluence form an 
irregular bulla. Successive crops of vesicles may prolong 
the eruptive stage for a week, but each series has all its 
vesicles at the same stage of development; thus one group 
may be papular, another vesicular, and a third already 
desiccated. 
After a day or two the contents of the vesicles become 
opaque and purulent; they then dry up, forming yellow 
scabs, which usually, about a fortnight after the onset of 
the affection,'fall off, leaving reddish-brown stained patches. 
Successive efflorescences may, however, prolong the total 
duration of the disease to three or four weeks, but they 
always appear upon adjacent portions of skin, never on that 
implicated by the first eruption. The vesicles may be few 
in number, and confined to a circumscribed area, or closely 
aggregated along the whole course of a nerve; in the latter 
case the pain and constitutional symptoms are somewhat 
severe, and the duration of the attack more prolonged. 
As zoster is not usually a fatal disease, cases in which the 
cause has been ascertained by autopsy are rare. Baren- 
sprung, Charcot, Wagner, Kaposi, and others have found 
as the most frequent cause haemorrhage and inflammation 
of the intervertebral or Gasserian ganglia. 
New growths, carcinomatous, tubercular, or purulent col- 
lections, causing irritation of the adjacent nerve trunks, or 
ganglia; traumatic lesions, causing irritation of the periph- 
eral, sensory, or mixed nerves, and meningitis; caries of the 
vertebrae or locomotor ataxy, causing irritation of the pos- 
terior roots—are frequently attended with eruptions of zos- ZOSTER. 
199 
ter. It has also been noticed after poisoning with carbonic 
oxide gas, and occasionally during the administration of 
arsenic (Hutchinson). Hebra and Kaposi, on whose de- 
scriptions this account is mainly based, consider as abnor- 
mal the following variations in the course and consequences 
of zoster: 
1. Cases in which some part or all of the eruption re- 
mains papular and aborts or forms bullse or pustules, the 
latter causing destruction of the dermis and giving rise to 
lasting cicatrices. 
2. Cases in which blood appears in the contents of the 
vesicles, or haemorrhagic infiltration of their bases occurs. 
In the latter the vesicles burst, the infiltrated tissue of their 
bases slowly necroses, and extremely painful ulcers, which 
take weeks or months to heal, and which leave permanent 
scars, are produced. 
3. Cases in which neuralgia does not abate with the 
efflorescence, but persists during aud long after the erup- 
tion. This is rare in the young, more common in the aged. 
4. Cases where muscular atrophy, anaesthesia, alopecia, 
or loss of teeth or atrophy of the alveolar process occurs 
after the zoster. 
5. Bilateral symmetrical zoster. 
Zoster usually occurs but ouce in a lifetime; it rarely 
passes the middle line before or behind, aud then only 
slightly; it appears at all ages and in both sexes; it affects 
either side of the body indifferently, being, according to 
statistics, slightly more common on the right. The groups 
of vesicles formed are, according to Hebra, always nearest 
the nervous centres, the subsequent crops lying more to- 
wards the periphery of the corresponding nerves. 
1. Zoster capillitii, best seen in bald persons, occurs on 
the scalp in the peripheral distribution of the supraorbital 
and great occipital nerves, and sometimes forms an arch 
over one parietal bone, terminating near the coronal suture. 200 
CLASS III. — NEUROSES. 
2. Zoster faciei presents the greatest variety of appear- 
ances. Groups of vesicles, limited accurately by the middle 
line, may appear on the forehead along the course of the 
supraorbital nerve; at the inner angle of the orbit and root 
of the nose along the supratrochlear; on the cheek, ala nasi, 
and lower eyelid along the infraorbital; and in the mouth, 
palate, and pharynx from implication of the palatine branches 
of the superior maxillary. Vesicles may appear on the gums, 
associated with violent toothache, loosening and loss of the 
teeth, and atrophy of the alveolar process when the supe- 
rior dental is affected. The eruption may also appear in 
the region of the auriculo-temporal, on the temple, pinna 
and meatus of the ear, on the chin, the mental branch, and 
on the side of the tongue in the course of the lingual. When 
the whole region of distribution of the ophthalmic branch 
of the fifth nerve is affected, in addition to the zoster fronta- 
lis, there are vesicles, very often haemorrhagic, on the nose 
and nasal mucous membrane, from affection of the infra- 
trochlear and ethmoidal twigs ; vesicles on the temple and 
malar prominence, from the zygomatic and lachrymal 
branches; and conjunctivitis, corneal ulcers, and iritis, from 
affection of the long root of the lenticular ganglion. Oph- 
thalmitis, thrombosis of the ophthalmic vein, septicaemia, 
death may thus result from zoster ophthalmicus. 
3. Zoster Nuchce et Colli.—The variety occipito-collaris 
presents vesicles on the back of the neck from the great 
and small occipital nerves, on the posterior surface of the 
pinna and lobule (great auricular), and on the side of the 
neck and beneath the chin. The variety cervico-subcla- 
vieularis occurs in the region of distribution of the ascend- 
ing and descending cutaneous branches of the cervical 
plexus, on the region of the neck below the scalp back as 
far as the shoulder, and downwards as far as the skin be- 
tween the clavicle and nipple. 
4. Zoster cervico-brachialis affects the brachial plexus, and ZOSTER. 
201 
presents groups of vesicles on botli sides of the arm and 
forearm as far as the little finger, and on the second and 
third intercostal spaces as far as the sternum. 
5. Zosterpedoralis occurs: 
a. As a continuous band of vesicles, occupying one to 
three intercostal spaces, running from the spine to the ster- 
num ; to this the terms zona and shingles were originally 
applied. The vesicles not unfrequently coalesce, and are 
sometimes haemorrhagic; in the latter case the pain is ex- 
cessive. 
b. As patches of vesicles, one usually near the spine, cor- 
responding to the hinder branches of the dorsal nerve ; one 
on the side of the thorax, where the twig of the intercostal 
nerve penetrates the muscles; and a third near the sternum, 
at the termination of the nerve. The spinal and sternal 
groups may pass the middle line about half an inch, and 
even in bilateral zoster the groups never coalesce to form a 
complete girdle, as the ends overlap. One group only may 
be present. 
The intense pain in the side and the dyspnoea may some- 
times lead to a suspicion of pleurisy. 
6. Zoster femoralis presents groups of vesicles, appearing 
usually first on the buttock, to which region they may be 
confined, or on the front or on the back of the thigh, and 
they may extend downwards to the ham or calf. On the 
penis zoster pudentalis, from affections of the pudic nerve, 
may occur, but is sharply restricted to one side of the organ 
(Kaposi). 
Diagnosis.—The sudden appearance, usually preceded by 
neuralgic pain, of a group of vesicles situated on the periph- 
eral distribution of a cutaneous nerve, and the course of the 
affection, are sufficient, even in abortive cases, to distinguish 
zoster from any other vesicular disease of the skin. 
Prognosis.—Zoster is a benign disease. An extensive 
efflorescence of the htemorrhagic form, with slow healing, 202 
CLASS III.—NEUROSES. 
painful ulcers, or severe neuralgia, may wear out an aged, 
weakly person, but death rarely results except from some 
intercurrent malady. 
Morbid Anatomy.—In the intervertebral ganglia undue 
vascularity of the surrounding fatty tissue of the ganglion 
itself and intracapsular haemorrhages have been found. 
Under the microscope the capillaries of the ganglion are 
found loaded with blood, the ganglion cells separated and 
destroyed by haemorrhage, and sometimes surrounded in- 
side their capsules, and numerous leucocytes are scattered 
throughout the tissue. When due to affections of the periph- 
eral nerves, at a distance from the ganglion, the condition 
is usually one of subacute neuritis. The nerve is grayish, 
slightly injected, thickened, adherent to its sheath and ad- 
jacent parts, and on microscopic examination an excess of 
spindle cells are found in it, causing granular degeneration 
of the medullary sheath and the axis cylinders. The vesi- 
cles present no essential difference from those of herpes 
febrilis or eczema. The acute neuritis of the peripheral 
nerves found by Haight near the vesicles resembles that 
met with in many other inflammations of the corium, and 
is not peculiar to zoster. 
Treatment.—No internal or local remedies have yet proved 
of the slightest use in cutting short an attack of zoster; all 
that remains to be done, therefore, is to palliate the severity 
of the symptoms, and to let the disease run its natural 
course, avoiding, as worse than useless, any attempt, by cau- 
terization or otherwise, to check the formation of the vesi- 
cles. Dusting with powder, and covering with cotton-wool 
and a bandage tcTprevent the clothes rubbing the vesicles, 
and, if ulcers form, dressing in the usual way, is all that is 
needed locally. Should the pain be intense, narcotics by 
the mouth, or better still hypodermically, ought to be used. 
The subsequent neuralgia, which is often severe in the aged, CIIEIRO-POMPIIOLYX. 
203 
is best treated by quinine and arsenic in full doses, and by 
the repeated application of the continuous current. 
CpiEiRO-roMPHOLYX (Hutchinson). 
Definition.—A disease of the skin characterized by the 
appearance of small clear vesicles or bullse on the hands, 
and sometimes on the feet, usually symmetrical, running a 
short course, and liable to constant relapses. 
Symptoms.—The disease, in its milder forms, is not very 
uncommon, but the more severe cases, in which large bullse 
are produced, are extremely rare. 
In persons of nervous temperament, when out of health 
or worried and depressed, the disease begins by burning and 
itching between and along the sides of the fingers, followed 
in a few hours, or on the next day, by the appearance of ir- 
regular groups of small, round, deepseated, flat-topped vesi- 
cles, containing clear serum, having no inflammatory areola 
around them, and resembling boiled sago grains. These 
vesicles usually dry up in a few days, and are followed by 
slight desquamation; in some more severe cases, however, 
they enlarge, and by their confluence produce bullse, which 
vary in size from a pin’s head to \ or of an inch in diam- 
eter, and are scattered over the whole palm or sole. They 
also dry up in a few days, and the cuticle subsequently des- 
quamates, but occasionally the bullse burst and then desic- 
cate, leaving red dry patches like psoriasis. The serum, at 
first clear, may become, if the bullse last a few days, opa- 
lescent and slightly yellowish, but never purulent, and it 
always remains alkaline. 
Frequently the nails are undermined and broken near 
the root. 
Diagnosis.—The rapid and symmetrical development, the 
short course and tendency to spontaneous cure, the lia- 
bility to recur, and its occurrence in those of nervous tern- 204 
CLASS III.—NEUROSES. 
perament and the worried and overworked, suffice to dis- 
tinguish it from eczema. 
The spontaneous cure and the absence of burrows sepa- 
rate it from scabies. 
It differs from sudamina in the fluid being alkaline,—not, 
as in sweat, acid from the beginning,—a fact which is against 
the theory of the dependence of the disease on obstruction of 
the sweat ducts. 
Prognosis.—The disease runs a favorable course in a few 
days, and is only troublesome through the itching and burn- 
ing sensation it excites and from its unsightly appearance. 
Treatment.—The application of lotio carbonis detergens 
(3ij to Jvj), of vaseline, or»of vaseline and liquor plumbi 
(ngxxx |j)} will usually relieve the itching. To combat 
the general nervous symptoms tonics may be given, of which 
iron, quinine, and uux vomica are the best, combined with 
change of air and rest. 
Pruritus. 
Definition.—Pruritus is a functional disorder of the skin, 
arising either spontaneously or as a symptom in the course 
of various diseases, attended with intense itching. The 
scratching which it induces may cause excoriations, eczema- 
tous or pustular eruptions, and other secondary changes in 
the skin. 
* 
Symptoms.—Pruritus itself is usually merely a symptom 
produced by : 
1. Local irritants, pediculi, acaria, ascarides in the rec- 
tum, etc. 
2. Constitutional conditions, such as jaundice, diabetes, 
intestinal, uterine, and genito-urinary disorders, senile de- 
cay of the skin, rheumatism, gout, etc. 
The chief varieties described are: PRURITUS. 
205 
a. Pruritus senilis, occurring in old people in association 
with atrophic changes in the skin. The itching, often in- 
tense, induces scratching, from which papules, excoriations, 
pustules, etc., result. It may be excited by pediculi cor- 
poris, in which case the marks of scratching are most dis- 
tinct on the neck and shoulders. 
b. Pruritus ani is a frequent and distressing accompani- 
ment of piles, gout, uterine and other disorders. 
c. Pruritus genitalium is most frequent in women, and is 
usually a symptom of local disease, eczema, etc., of utero- 
ovarian irritation, or of general diseases, such as diabetes 
and gout. 
Diagnosis.—The intense itching, unattended by special 
morbid changes beyond those that are the result of scratch- 
ing, suffices to distinguish it from other diseases of the skin. 
Prognosis.—Pruritus, though not fatal, is often obstinate, 
and causes great distress. 
Morbid Anatomy.—No special changes have been found 
in the skin or cutaneous nerves. 
Treatment.—The indications are: 
1. To remove or mitigate any local irritation exciting the 
affection, and to treat constitutional symptoms or diseases of 
adjacent organs. 
2. When no obvious causes can be found, to give tonics, 
iron, quinine, cod-liver oil, and locally to apply sedative 
lotions, such as lotio calaminse, lotio boracis with hydro- 
cyanic acid or dilute carbon is detergens. 
When the itching is general, alkaline baths often give 
great relief, after which an ointment of chloral camphor 
3ss. to vaseline §j may be used with advantage. Scratching 
must be strictly forbidden. 206 
CLASS III. — NEUROSES. 
Dystrophia Cutis. 
Definition.—Certain changes in the skin, other than zos- 
ter, usually of an atrophic, inflammatory, or gangrenous 
nature, which arise under the direct influence of lesions of 
the nervous system. 
Symptoms.—The appearance met with may be arranged 
under the heads: 
1. Atrophic or “glossy skin.” 
2. CEdematous. 
3. Eruptive, erythematous, papular, vesicular, or bullous. 
4. Ulcerative or gangrenous, “ acute bedsore.” 
1. “Glossy skin” is the term applied by Paget and Weir 
Mitchell to a peculiar condition, somewhat resembling scle- 
roderma, which supervenes after irritative lesions of the pe- 
ripheral nerves. It sometimes follows a clean cut, entirely 
dividing the nerve; but more commonly a partial division, 
contusion, laceration, or compression in a cicatrix, callus, 
etc., is the cause. The skin is smooth, pale, and anaemic, or 
pinkish and blotched, as if by chilblains, glossy, and its 
natural wrinkles effaced. The epidermis is often fissured, 
the nails are cracked and distorted, the hair is shed, and the 
sweat glands are atrophied, and their secretion diminished. 
The affected jjart is usually extremely tender and the seat 
of neuralgic pain, and its temperature is often lowered. 
2. OEdematous.—There is often slight oedema of the skin 
and subcutaneous parts in paralyzed limbs, which lasts for a 
considerable time, and gradually disappears as recovery 
takes place. Peculiar pale or slightly erythematous local- 
ized swelling of the skin and subcutaneous tissue, resem- 
bling chilblains, are also met with, appearing after neural- 
gic attacks at the sites of pain. They are sometimes de- 
scribed as urticarial, but are attended by intense shooting 
or burning pain, and not by itching. DYSTROPHIA CUTIS. 
207 
3. Eruptive.—The “lightning pains” of locomotor ataxy, 
and the neuralgic attacks met with in pachymeningitis, 
caries, or cancer of the vertebrae, and other affections in 
which there is compression and irritation of the posterior 
nerve roots, are often accompanied by an eruption on the 
painful points of skin, erythematous, papular, vesicular, 
pustular, or bullous in character. The patches correspond 
in situation, as in zoster, with the distribution of cutaneous 
nerves, and in their course and duration resemble that dis- 
ease. 
4. Ulcerative and gangrenous patches may occur as the 
sequelae of the last-mentioned changes, or as au independent 
form in the “ acute bedsore,” to which special attention has 
been directed by Charcot. This lesion, of grave and usually 
fatal import in the prognosis of cerebral or spinal diseases, 
appears, according to this authority, a few days, or occa- 
sionally only some hours, after the onset of the nerve 
symptoms, as an ei’ythematous patch of variable extent and 
irregular shape, seated, in spinal disease, over the sacrum, 
in cerebral usually on one of the buttocks. The color, at 
first light red, or somewhat bluish, fades on pressure, and 
in some spinal cases there is a phlegmonous-looking infil- 
tration, attended sometimes with anaesthesia, at other times 
with severe pain. After a day or two vesicles or bullae, 
containing clear brownish or sanguineous fluid, appear in 
the centre of the patch ; these soon burst, exposing a bright- 
red base, dotted with purplish black spots of cutaneous 
haemorrhage, which often extends as deep as the subcutane- 
ous tissue or muscles. The purple spots soon become con- 
fluent, necrose, and form a black slough surrounded by a 
margin of erythema. Patients rarely live long enough for 
the slough to be cast off, but in more chronic cases septi- 
caemia and gangrenous meningitis soon prove fatal. These 
patches appear even when the most scrupulous care is taken 208 
CLASS III. — NEUROSES. 
to avoid pressure or any irritation of the skin from the 
urine or feces. 
Diagnosis.—The occurrence of these phenomena in con- 
nection with severe diseases of the nervous system, their 
restriction to certain special sites, usually related to the 
cutaneous distribution of nerves, and the presence, before 
or throughout their course, of neuralgic pain, will clearly 
indicate their nature. 
Prognosis.—As these skin manifestations are merely symp- 
tomatic, their prognosis is that of the diseases in which they 
occur. 
“ Acute bedsore ” is, according to Charcot, an omen of a 
fatal result. 
Morbid Anatomy.—The cutaneous appearances in the 
erythematous, vesicular, and other eruptions are the same 
as those in the simple diseases. In “acute bedsore” there 
is an exudation into the whole corium, with leucocytes and 
plasma, resembling phlegmonous erysipelas, which is fol- 
lowed later on by lnemorrhagic infiltration aud gangrene. 
Treatment.—This falls beyond the scope of this work. In 
“acute bedsore” keeping the part clean, the frequent appli- 
cation of some antiseptic lotion or powder to diminish the 
risk of septicaemia, and poultices to promote the separation 
of the sloughs should be employed. EPHELIS AND LENTIGO. 
209 
CHAPTER XVII. 
Class IV.—HYPERTROPHIiE. 
Ephelis — Lentigo — Melanoderma — Morbus Addisonii—Chloasma 
uterinum — Ichthyosis — Xeroderma — Morphcea—Scleroderma 
—Sclerema neonatorum—Elephantiasis Araburn—Elephantiasis 
teleangiectodes—Dermatolysis. 
Pigmentary. 
1. Ephelis and Lentigo. 2. Melanoderma. 3. Morbus Addisonii. 
4. Chloasma uterinum. 
Ephelis and Lentigo—Freckles. 
Freckles are light or dark brown spots, varying in size 
from a pin’s head to a lentil, occurring on the skin of fair 
or red-haired people. They are found usually on the more 
exposed regions of the body, such as the face, neck, and 
backs of the hands and wrists, but appear also on other 
parts. They are greatly influenced by light, and are always 
darker in summer than in winter. Some doubt exists 
whether they can be produced by the sun’s rays, but there 
is reason to believe that many spots otherwise imperceptible 
are only then visible. Exposure of the limbs to heat will 
often produce a similar discoloration as the result of a de- 
posit of pigment in the rete. The appearance of the spots 
is entirely unattended by itching, or indeed any local or 
constitutional symptom. When the stains are larger, more 
persistent, and are not influenced by exposure to heat and 
cold, they are termed lentigines. 210 
CLASS IV. — HYPERTROPHIC. 
Melanoderma. 
This term includes all cases in which dark stains are pro- 
duced through some special condition of the body, such as 
pregnancy, intemperance, etc. 
Morbus Addisonii. 
In the course of this disease, which is an affection of the 
suprarenal capsules, a remarkable bronzing of the skin 
takes place. After the disease has been progressing for 
some time, the skin is noticed to be of a darker tint than 
normal, a change often attributed to jaundice. The upper 
part of the body is usually affected earlier than the lower, 
but the entire surface becomes eventually involved, the 
color becoming gradually darker, and—although the shades 
of color vary in different cases from a light to a dark brown 
—in the majority of fatal cases the color deepens markedly 
as death approaches. In parts where pigment is usually 
deposited, such as the axillae, flexor surfaces of joints, gen- 
itals, nipples, freckles, etc., the shades will be found to be 
of a darker brown, or even black, making the rest of the 
skin appear white by contrast. 
Chloasma Uterinum. 
This term is applied to the pigmentary deposits occurring 
in women suffering from uterine disease, or as a result of 
pregnancy. It usually appears in the form of crescentic 
patches on the forehead and below the hair. 
Epidermis and Papillae. 
Ichthyosis and Xeroderma. 
Definition.—Ichthyosis is a congenital hypertrophic dis- 
ease of the skin, characterized by increased growth of the ICHTHYOSIS AND XERODERMA. 
211 
papillary layer with thickening of the true skin and the 
production of masses of epidermic scales. 
Symptoms.—Some doubt exists whether ichthyosis is al- 
ways a congenital disease. The characteristic appearance 
of the skin is sometimes not developed until some years 
after birth ; it is, however, impossible to say that some ab- 
normal condition or tendency did not exist at birth, although 
it may not have become apparent until a later period, and 
this view is supported by the fact that ichthyosis is heredi- 
tary. 
There are many degrees of ichthyosis, ranging from a 
mere roughness of the skin to a condition resembling that 
of the skin of the shark. In a case of average severity the 
growth of the papillary layer is greatly increased, and the 
whole skin thickened. The natural furrows of the skin are, 
as the result of this growth, much deepened, and the surface 
is mapped out into polygonal tracts, presenting an appear- 
ance similar to a crocodile’s hide. Surmounting the ridges 
are collections of epidermic scales, which at first are limited 
in quantity, but as time progresses increase in size. Masses 
are formed in the centre of a patch, either thin and pearl- 
colored or of varying shades of color, from green to brown 
or black, and may also cover the enlarged papillae, forming 
projections from the surface. There is a complete absence 
of perspiration from the parts attacked with the disease, but 
the unaffected regions, such as the head, usually perspire 
freely. 
Ichthyosis simplex, or xeroderma, is the form most fre- 
quently met with. It usually becomes apparent in the 
child at about two years of age, when it is nothing more 
than a general roughness of the skin, especially marked 
over the knees and elbows. At a later period the epider- 
mis is shed in flakes and the general roughness is greatly 
increased, but certain regions, such as the inside of the ex- 
tremities and the palms and soles, differ from healthy skin 212 
CLASS IV. HYPERTROPHIC. 
only slightly, while the face is dry and furfuraceous. With 
the exception of these regions the skin is covered with the 
irregular-shaped patches above described, limited by the 
natural folds of the skin. On the knees and elbows, on the 
fronts of the ankles and margins of the axillae, and, indeed, 
on all parts exposed to friction, the masses become so thick 
and black from dirt that the disease is far more marked 
than on the other regions. 
Ichthyosis cornea occurs less frequently than the simple 
variety. It consists of a growth of hard, horny promi- 
nences, often standing out a quarter of an inch, which, 
being aggregated together, form patches somewhat resem- 
bling the condition found on the knees and elbows in 
ichthyosis simplex. They are believed to be due to an 
alteration of the lining of the sebaceous follicles into horny 
material. This first distends the follicle, and then passes 
through its orifice to the surface, where it protrudes. The 
exposed end is broken away, and with it a part of the ma- 
terial in the follicle, and a cup is thus left, which is again 
filled by further growth of the horny substance. When 
these are thrown off, the skin of the part is left in a normal 
condition. 
Diagnosis.—With the exception of psoriasis there is no 
disease for which ichthyosis could be mistaken. 
For diagnosis from psoriasis see Chapter XIII, p. 173. 
Prognosis.—Ichthyosis is a very intractable disease, but 
is never fatal. It can be somewhat benefited by remedies, 
but only temporarily. Occasionally, after a prolonged and 
severe general illness, the disease has been observed to dis- 
appear, and has not again returned. 
Morbid Anatomy.—Vertical sections show a dense ac- 
cumulation of horny epidermic cells, containing frequently 
a considerable quantity of fatty matter; the rete cells, es- 
pecially between the papillae, are more numerous and some- 
times pigmented, and the papillae themselves are greatly MORPHCEA. 
213 
enlarged and elongated, aud contain dilated vessels and 
numerous cells. In severe cases the hair follicles are more 
or less atrophied, the sweat and sebaceous glands are wasted, 
and there is induration and sclerosis of the corium and at- 
rophy of the adipose tissue. 
Treatment.—Any local application likely to soften and 
remove the accumulated epidermis is the proper treatment, 
and for this purpose alkaline lotions, and soaps of various 
kinds, the one recommended by Hebra being composed of 
iodide of sulphur, oil, glycerin, have been tried. Absolute 
cleanliness is most essential, and the constant and prolonged 
soaking of the body in water will often lead to a diminution 
of the ichthyotic condition. Various internal remedies have 
been tried, but with no benefit. 
Connective Tissue. 
1. Morphoea. 2. Scleroderma. 3. Sclerema neonatorum. 4. Ele- 
phantiasis Arabum. 5. Elephantiasis teleangiectodes. G. Der- 
matolysis. 
Morphcea—Addison’s Keloid. 
Definition.—Morphoea is a rare chronic affection of the 
skin, characterized by the occurrence—most often on the 
face—of roundish or oval pale-pink or ivory-colored 
patches, which are firm and inelastic, and therefore are not 
easily pinched up into folds. 
Symptoms.—Patches of one to three inches in diameter 
appear on the skin in the course of some cutaneous nerve, 
with a pale-yellowish or ivory like centre, smooth surface, 
and a well-defined violet or lilac-tinted margin. The co- 
rium, apparently dense and thickened, appears to be bound 
down to the subcutaneous tissue. A feeling of burning or 
tingling sometimes attends the development of the patches, 
and there may be slight pain on pressure, but usually no 
alteration in cutaneous sensibility. 214 
CLASS IV. — HYPERTROPHIC. 
When the patches appear on the face they are sharply 
limited by the middle line, and may occur in the area of 
distribution of the supraorbital nerve or other branches of 
the fifth, but on the trunk and limbs they are arranged in 
a somewhat similar manner as in herpes. Pigment is occa- 
sionally deposited in the skin around the patch, and its ab- 
sence or presence distinguishes the varieties morphoea alba 
and morphoea nigra. Owing to the infiltration and rigidity 
of the skin, the movements of the facial muscles and of the 
joints, when the skin of these parts is the seat of the disease, 
are much impaired, so that the fingers remain semiflexed 
and cannot be either bent or extended, and the expression 
of the face becomes stony and fixed, like that of a frozen 
corpse. The swTeat and sebaceous secretions, and the growth 
of hair on the hide-bound patches, are frequently deficient, 
and the temperature is usually 2° to 3° Fahr. lower than 
that of the healthy skin, but there is no special trophic 
change in the parts affected. 
The morphoea patches slowly extend, and having reached 
their acme may, in the course of years, gradually fade, and 
leave the skin perfectly normal or only slightly pigmented. 
However, occasionally sclerosis takes place, aud the thin, 
rigid skin acquires a shrunken, parchmentlike appearance, 
which has been termed morphoea atrophica. 
Diagnosis.—Patches of morphoea differ from leucoderma, 
which they resemble in color and definition, by the hard, 
infiltrated, and inelastic consistence of the affected skin. 
The pale patches of lepra maculosa differ from those of 
morphoea by being ansesthetic in their centre and usually 
symmetrical in their distribution, while the former disease 
is accompanied by affections of the nerves, cutaneous tuber- 
cles, etc., which never occur iu morphoea. 
Keloid can hardly be mistaken for morphoea, so forcible 
is the contrast between the raised, pinkish, clawlike nodule SCLERODERMA. 
215 
of the former and the level, pale, smooth patches of the 
latter. 
Prognosis.—Morphoea is never fatal. The disease in some 
cases tends slowdy towards involution, and the normal elas- 
tic condition of the skin is restored ; but when sclerosis and 
atrophy have occurred, permanent deformity is the result. 
Morbid Anatomy.—See Scleroderma. 
Treatment.—No local treatment has proved of any avail, 
but as general remedies tonics, such as iron, quinine, and 
cod-liver oil, are indicated if the case is complicated by 
anaemia or struma. 
Scleroderma—Scleriasis. 
Definition.—A rare disease of the skin, in which diffuse 
infiltrated and rigid areae are met with over comparatively 
large portions of the surface of the body. 
Symptoms.—Scleroderma begins most frequently on the 
back of the neck or upper extremities as a slightly raised 
brownish-red or pale waxy-colored patch, and may spread 
more or less rapidly over the face, arm, or even over the 
whole body, or it may take the form of long ribbonlike 
streaks or patches scattered over the body and limbs. As 
in morphoea, the skin is thickened, inelastic, and adherent 
to the deeper tissues, so that it cannot be pinched up, and 
feels both colder and dryer than the normal skin. Irregu- 
lar spots of pigment are sometimes met with on or round 
the patches." Sensibility is sometimes slightly impaired, 
and the temperature of the part is diminished 1° or 2° Fahr. 
The epidermis is normal, but may desquamate, and vesicles 
or other eruptions can appear upon it as on healthy skin. 
The secretions of the sweat and sebaceous glands are usu- 
ally, but not invariably, diminished. 
When scleroderma is first developed there is a slight local- 
ized raised swelling, produced by oedema in the subcutane- 216 
CLASS IY. HYPERTROPHIvE. 
ous tissue, pitting on pressure, and gradually becoming scle- 
rosed. But as the disease progresses the patches become 
level with or slightly depressed below the surface of the ad- 
jacent skin, and in the variety characterized by the presence 
of long bands the healthy skin rises on each side of them. 
The indurated patches subsequently, like those of morphcea, 
either undergo complete resolution or sclerosis and atrophy. 
The mucous membrane of the mouth, the tongue, and the 
pharynx sometimes present similar hard white patches. 
Patches of morphoea may precede or accompany the de- 
velopment of scleroderma, and the edge of a scleroderma- 
tous patch not unfrequently presents an appearance identi- 
cal with morphoea. The differences in form and color are 
comparatively unimportant in view of the resemblances in 
the rigid, infiltrated condition of the skin, the similarity, if 
not identity, of the anatomical changes, the chi'onic course 
ending in atrophy or resolution of the affected portions of 
skin, and the retention of the cutaneous sensibility observed 
in both affections. Hence morphoea and scleroderma, if not 
merely stages of the same disease, are certainly due to vari- 
ations in the intensity and exact localization of the same 
morbid process, and bear the same relation to one another as 
lupus erythematosus does to lupus vulgaris. In morphoea 
the unsymmetrical character of the patches, their abrupt 
limitation by the middle line, their arrangement along the 
course of cutaneous nerves, as in zoster, in lines or clusters, 
the occasional check to the development of the bones of a 
limb, and the slow course, unaffected by treatment, are points 
which strongly support the theory advocated by Mr. Hutch- 
inson, that, like zoster, the primary cause of the disease is 
an affection of the nervous system. 
When scleroderma attacks the face, the countenance be- 
comes fixed, the normal folds of the skin disappear, the lips 
and eyelids are rigid and sometimes everted, and the move- SCLERODERMA. 
217 
ments of the jaws and neck are interfered with, owing to 
the want of elasticity of the skin. 
In the extremities the firm, tendinous bands stiffen the 
joints, which then become semiflexed and almost immova- 
ble, and sometimes deepseated pains are left in the fasciae 
and bones. When atrophy of the skin has set in the sub- 
cutaneous tissue and muscles waste away, the thin, shriv- 
elled, smooth, and reddish band of pigmented cutis appears 
to be in direct contact with the bones, and the wasted limb 
has a dried-up, skeleton-like appearance, which is persistent. 
Diagnosis.—Morphcea differs from scleroderma in the 
form of its patches, which are round or oval and usually 
small, instead of being ribbonlike and covering a large 
area, and in their color, which is violet or lilac colored at 
its sharply defined margin, surrounded usually by a deeply 
pigmented ring, and yellowish in its central portion as com- 
pared with the pale white of scleroderma. 
Prognosis.—Like morphcea, scleroderma never causes 
death, though helplessness and great deformity may result 
from it. The patches occasionally undergo spontaneous 
resolution, and the skin resumes its normal character. 
Morbid Anatomy.—Sections of the skin in this disease 
show a general thickening and induration of the corium, 
which passes gradually into and is fused with the subcutane- 
ous fatty tissue. Microscopically examined, the epidermis 
is found to be normal, excepting that the rete cells contain 
some granular pigment. The papillae are unchanged in 
shape, but their connective tissue stroma is much more con- 
densed, and forms a narrow meshwork of condensed fibrous 
bundles. The connective tissue fibres of the corium are much 
thickened, form a compressed feltwork, and invade the sub- 
dermic fatty tissue, broad, dense bundles replacing the thin 
fibrils between groups of fat cells and compressing them 
firmly. Cords and networks of round and spindle cells are 
also found surrounding the fat cells. The vessels in many 218 
CLASS IV. — HYPERTROPHIC. 
places are narrowed and surrounded by round and spindle 
cells, but are not usually obliterated or deficient in number. 
Sebaceous and sweat glands and hair follicles are but little, 
if at all, altered, and the arrectores pilorum are distinct. 
In extreme cases the sclerotic changes extend throughout the 
subcutaneous tissue, which is much atrophied, even down to 
the fascia of the muscles, and there is considerable increase 
in number of the elastic fibres. 
The disease is considered to begin in the cellular deposits 
round the vessels, and in the stage of infiltration to spread 
thence in cords along the connective tissue bundles. As the 
cellular infiltration becomes converted into fibrous and 
elastic tissue the sclerosis of the skin observed in the latter 
stages is gradually developed. 
The anatomical changes in morphoea have not yet been 
completely investigated, but are probably analogous to those 
in scleroderma. 
Treatment.—No specific internal remedy or local treat- 
ment has any effect on the disease, but nutritious diet, good 
hygiene, and tonics are recommended. 
Sclerema Neonatorum. 
Definition.—An acute oedema and induration of tlie skin, 
occurring in young children. 
Symptoms.—The cause of this disease is not well under- 
stood, but it is believed, to be due to some alteration in the 
condition of the capillaries, resulting from some previously 
existing disease, such as affections of the intestines, lung, or 
brain, or some congenital defect. It may also result from 
impaired nutrition or syphilis. 
It commences with swelling of the lower extremities, fol- 
lowing oedema and induration of the skin of the part, which 
is itself tense, shining, pits on pressure, and of a red, white, 
or livid color. elephantiasis arabum. 
219 
After a time, varying from a few hours to two or three 
days, the swelling subsides, leaving the skin wrinkled ; some- 
times, however, the advanced stage of wrinkling of the skin 
is the first symptom, and is not preceded by the earlier stage 
of oedema. The general condition of the child is much al- 
tered, and it shows but few signs of vitality, while the tem- 
perature is lowered by two or three degrees. The disease 
gradually spreads upwards till the skin of the face is af- 
fected, when the features become immovable and neither the 
eyes nor mouth can be opened. The reduction of tempera- 
ture and the loss of vitality continue till death results after 
from two to ten days’ illness. 
Diagnosis.—This disease resembles no other. A local 
oedema cannot be mistaken for it for more than a few' hours, 
and the general condition then suffices to distinguish be- 
tween the two. 
Prognosis.—It is usually fatal. 
Morbid Anatomy.—Few changes have been found beyond 
a more or less oedematous infiltration of the whole skin and 
a rigid condition of the subcutaneous connective tissue. A 
slight increase of connective tissue in the deeper corium 
layer, and nodules and cords of embryonic tissue in the 
panniculus adiposus between the fat cells, have also been 
described by some authors. 
Treatment.—This consists in first removing the primary 
cause, when it can be ascertained, and afterwards in restor- 
ing, when possible, the circulation through the capillaries 
of the affected part. 
Elephantiasis Arabum 
Definition.—Elephantiasis Arabum is an enlargement of 
some part of the body, usually a limb, due to hypertrophy 
of the whole of the connective tissue, following an inflam- 
matory condition of the part. 220 
CLASS IY. — HYPERTROPHIC. 
Symptoms.—Under the name of elephantiasis several 
entirely distinct diseases have been included, and much con- 
fusion has resulted from the indiscriminate use of the word; 
thus, elephantiasis Graecorum is simply leprosy, and ele- 
phantiasis Italica is another name for pellagra. It is espe- 
cially common in hot climates, such as the west coast of 
Africa, Barbadoes, and Malabar. Its prevalence is not 
confined to any particular sex, age, or race, but various 
conditions have been suspected to be concerned in its eti- 
ology. It has been attributed to injuries of the veins and 
lymphatics, which have caused compression, and to lupus, 
and apparently with some reason to the gummata of syphilis. 
Elephantiasis Arabum begins with an erysipelatous inflam- 
mation of the skin, usually of the leg, which is accompanied 
with or preceded by feverishness and symptoms of general 
constitutional disturbance resembling intermittent fever. 
These symptoms gradually subside, but some amount of 
swelling of the skin remains. After a variable interval the 
inflammation of the skin, with redness, swelling, and pain, 
returns again, accompanied with or preceded by symptoms 
of constitutional disturbance. The same subsidence takes 
place, but the local effects last longer than in the previous 
attack, and leave a greater amount of permanent oedema- 
tous swelling behind them. These attacks are repeated from 
time to time during a series of years, and thus a gradual 
enlargement of the limb takes place until it has attained 
huge proportions. 
The skin is greatly thickened, shiny, stretched, and of a 
color varying from light brown to purple. Desquamation 
may be present, or the skin may be smooth and frequently 
fissured, when the natural furrows are greatly exaggerated, 
owing to the thickening of the skin, aud when the epidermis 
is heaped up and macerated by perspiration. The surface 
may be surmounted with tubercles, the result of growth of 
fibro-cellular tissue, or with large papillse, which may or ELEPHANTIASIS ARABUM. 
221 
may not be covered with epidermis. Sometimes the whole 
limb is covered with eczema, and occasionally the skin 
ulcerates, forming sores of varying size, from which a foul 
discharge exudes. Enlargement of the lymphatics causes 
them to stand up on the surface like vesicles, and when 
they burst or are punctured the milky lymph escapes. 
Each attack is accompanied by stabbing pains in the limb, 
but they are more severe at the beginning than at any sub- 
sequent period. Severe pain is, however, always felt if the 
limb be allowed to be in a dependent position for any length 
of time. Diminution of the sensibility of the surface also 
results from the disease. The enormous increase of the leg 
and foot when that part is affected causes the obliteration 
of the instep and upper part of the foot, and makes it re- 
semble the foot of an elephant, whence the peculiar name. 
Elephantiasis of the genitals differs slightly from that of 
any other part, and affects the scrotum, penis, labia, and 
clitoris. It commences “in the form of a hard kernel under 
the skin, usually at the bottom of the left side of the scro- 
tum.” From this point the disease spreads, and the skin 
over it becomes thickened and wrinkled, while the shape of 
the abdomen undergoes alteration. The penis is also in- 
creased in size, but lies partially imbedded in the enlarged 
scrotum. The skin of its lower surface is pushed forwards, 
and is only connected with the penis round the glans. The 
hypertrophied scrotum becomes covered with dilated lym- 
phatics, which at a later stage burst and permit lymph to 
exude. 
The regions usually affected are the lower extremities and 
the genitals, but the upper extremities and ears may also be 
the seats of the disease. 
Diagnosis.—Simple oedema is the only condition which 
bears the slightest resemblance to elephantiasis, but never 
leads to hypertrophy of the tissues. 222 
CLASS IV. — HYPERTROPHIC. 
Prognosis.—Elephantiasis may last a lifetime, and al- 
though it has no tendency to spontaneous recovery, it is, 
within limits, amenable to treatment. 
Morbid Anatomy.—Section of a limb affected with ele- 
phantiasis show the corium thickened and much indurated, 
the subcutaneous connective tissue greatly increased, in 
some parts dense and glistening, in others soft and gelatin- 
ous ; the muscles wasted, soft, and yellowish ; the fasciae, 
intermuscular tissue, and periosteum much thickened; and 
the bones hypertrophied, increased in both length and thick- 
ness, and presenting frequently irregular exostoses, which 
sometimes unite together adjacent bones. Caries and ne- 
crosis may also be present. A clear, yellowish, coagulable 
lymph exudes freely from the cut surface. The veins are 
dilated, and in places plugged by clots, and here and there 
may be observed irregular spaces filled with clear lymph. 
Microscopically examined the epidermis and papillary 
layer are seen to be raised into rugose, prominent masses, 
resembling ichthyosis. In these masses the epidermic horny 
layers are much thickened, the rete cells pigmented, and the 
papillae greatly increased in size. The corium bundles of 
connective tissue are increased in thickness, present a swollen, 
gelatinous, and glistening appearance, and are closely felted 
together. Fusiform and stellate cells are seen between 
them in places. The subcutaneous connective tissue is occa- 
sionally more than an inch thick, in some places dense and 
fibrous, and fused with the corium, in others soft and gelat- 
inous, consisting of loose areolar and embryonic connective 
tissue, pervaded with lymph, and in the latter case it merges 
into the fasciae and areolae, which themselves present similar 
changes. The muscles, from atrophy and fatty degenera- 
tion, become pale, and often seem to lose their true striated 
fibres, which are apparently replaced by fatty and granular 
debris, while the nerves are also compressed, indurated, and ELEPHANTIASIS ARABUM. 
223 
atrophied. The bloodvessels present their normal arrange- 
ment, except that they are more widely separated, owing to 
the increase of connective tissue. The veins, dilated and 
thickened in places, are sometimes thrombosed, and in later 
stages are indicated only by pigmented fibrous cords. The 
lymphatics are in places much dilated and form small cysts, 
the walls of which, though usually thickened, are sometimes 
thin and friable. The interstitial lymph spaces and cana- 
liculi are also enlarged, and here and there form cysts filled 
with clear yellow lymph or gelatinous embryonic connective 
tissue. 
When the lymphatics are ruptured they discharge abun- 
dantly, and the discharge, which consists of lymph or chylous 
fluid, has been found in some cases to contain filaria san- 
guinis hominis. The dilatations are ascribed by some au- 
thors to the irritation excited by these parasites and the 
obstruction caused by them in the lymph channels. 
The hair follicles, sweat and sebaceous glands, much elon- 
gated and widely separated, but otherwise little altered, in 
the early stages of the disease, becoming later compressed 
and atrophied. 
Treatment.—The first thing to be done is to allay the in- 
flammation by complete rest and, if possible, the elevation 
of the part affected, and by the application of warm poul- 
tices. After the inflammation has been reduced Hebra 
recommends the use of baths, poultices, and ointments to 
remove the accumulation of epidermis, and subsequently 
inunction with blue ointment. Bandages must next be 
applied to reduce the size of the limb, and Martin’s elastic 
bandage is probably the best for the purpose. Ligature of 
the main vessel of the limb has been recommended, but 
with such slight success as hardly to warrant its general 
adoption. 224 
CLASS IV. — HYPERTROPHIES. 
Elephantiasis Teleangiectodes. 
Definition.—This disease is closely related to elephantiasis 
Arabnm, but differs from it in that it may arise without any 
previous inflammation and is usually congenital. 
Symptoms.—This disease is either congenital or appears 
soon after birth, and is due to some obstruction of the lym- 
phatics. The skin of a limb becomes hypertrophied, and 
hangs down in rolls or flaps, which vary in color, owing to 
the enlargement of the vessels, but if pressure be steadily 
exerted on one of these flaps its size becomes considerably 
reduced. Although the thickening of the skin which hangs 
from the lower part of a limb produces an apparent increase 
in the size of the limb, the upper part has really wasted, 
and this atrophy is not confined to the skin, but includes the 
muscles and bones. After a time a quantity of vesicles 
appear, which may be arranged in groups or lines or may 
be scattered irregularly, and when these are ruptured the 
lymph which they contain exudes. 
Morbid Anatomy.—In elephantiasis teleangiectodes the 
essential morbid process is a new formation of connective 
tissue, at first embryonic, but later on dense and fibi'ous, in 
the subcutaneous tissue. The growths next present changes 
in the skin and subcutaneous tissue analogous to those in 
elephantiasis Arabum ; they are, however, pervaded by 
slits, gaps, and cysts filled with lymph, and by numerous 
bloodvessels, which are dilated, communicate freely, and 
sometimes become cavernous. 
Treatment.—Is identical with that suggested for elephan- 
tiasis Arabum. 
Dermatolysis. 
Definition.—Dermatolysis is a growth of the skin, caus- 
ing it to hang in folds. DERMATOLYSIS. 
225 
Symptoms.—The disease may occur in any part of the 
body, but according to Alibert it most frequently attacks 
the eyebrows, face, neck, abdomen, and labia, and is due 
to a pathological change in the skin, causing an increase of 
the fibro-cellular tissue. The skin hangs in folds, but no 
other symptom is present beyond some loss of sensibility in 
the part. 226 
CLASS v. — atrophia:. 
CHAPTER XVIII. 
Class V.—Atrophi.b. 
Albinismus—Leucoderma—Atrophia cutis. 
1. Albinismus. 2. Leucoderma. 
Pigmentary. 
Definition.—Albinismus is a congenital absence of pig- 
ment from the skin, hair, iris, and choroid, which may be 
either general or local. 
Persons suffering from general deficiency or absence of 
pigment are termed albinos. 
Symptoms.—In albinos the skin is dull white and of deli- 
cate texture, the hair is fine and yellowish or white, the iris 
is pink, and the choroid being devoid of the normal dark 
pigment, the pupil appears red instead of black. Persons 
thus affected are stated to be usually of delicate health, and 
their skins are more prone to suffer from exposure to heat 
and cold. 
The affection is more frequently met with in the tropics, 
and is more noticed in the dark races. 
In the partial form of the disease patches resembling leu- 
coderma are found scattered about the body, giving the 
person, if dark, a piebald appearance. 
Morbid Anatomy.—Microscopic examination of the skin 
of albinos shows absence of the normal pigment from the 
deeper rete cells. 
Treatment.—No treatment is of any avail. 
Albinismus. LEUCODERMA. 
227 
Leucoderma—White Leprosy. 
Definition.—A local deficiency or absence of pigment from 
the skin and hair, developed after birth and slowly spread- 
ing, but causing no constitutional disturbance. 
Symptoms.—Leucoderma begins by the appearance of one 
or more round white patches on various parts of the body, 
generally near brown moles or warts. The patch has a 
defined margin, bordered by a ring of excessive pigmenta- 
tion, which gradually merges in the healthy skin, and the 
hair on the patch is also white, but the affected skin in 
every respect except the absence of pigment presents no 
structural or functional difference from healthy skin. As 
the patches gradually enlarge they become oval, and by 
confluence form large pale tracts with convex margins 
bounded by deeply pigmented rings. As time goes on and 
the white patches spread, more and more of the skin is 
affected, till finally only a few brown patches with concave 
edges are left to represent the normal skin. The disease 
may originate at any age, but most frequently after pu- 
berty, and is almost always bilateral, though exact sym- 
metry is rarely found. 
Diagnosis.—The pale patches of lepra maculosa or lepra 
ansesthetica may be distinguished from those of leucoderma 
in that their edges are more shaded, the skin often infil- 
trated and anaesthetic in the centre as well as scarred, and 
that they often have a purplish raised hyperaesthetic border, 
whereas those of leucoderma have a sharply defined border 
and a dark pigmented ring. The structure and functions 
of the skin also in the latter are normal. 
The concave edges of the dark patches which represent 
normal skin will enable extensive leucoderma to be distin- 
guished from abnormal development of pigment in a healthy 
skin. 
Prognosis.—Leucoderma causes no pain or inconvenience 
to the person affected, but the white patches, though they 228 
CLASS V. — ATROPHIAS. 
sometimes become stationary, have no tendency to disappear 
spontaneously or under treatment. 
Morbid Anatomy.—The only change that has been de- 
tected is an absence of pigment from the deeper layers of 
the rete and from the hairs and their bulbs. 
Treatment.—No remedies have yet been found to remove 
the white patches. 
Of Connective Tissue. 
Atrophia Cutis. 
Atrophy of the skin, besides occurring as a result of vari- 
ous inflammatory affections or new growths of the skin, is 
met with as an independent disease, both in a general and 
a partial form. 
The first condition is usually a result of retrogressive or 
degenerative changes in old persons, and has been called 
senile atrophy. 
In it the skin becomes dry, wrinkled, rough, less supple, 
and more or less pigmented. The epidermis is smooth, or 
in places branny, the cutis and its papillae are thinned and 
wasted, and the subcutaneous fatty tissue is usually atro- 
phied. Hairs are scanty or wanting, and the sebaceous 
glands either atrophied or presenting degeneration in the 
form of milium granules. Anatomically the tissues may 
be found either in a condition which is mainly that of simple 
atrophy, or, in addition, more or less marked degenerative 
metamorphoses are present. 
In the former condition of simple atrophy the cuticle is 
thin and the papillae either wanting or projecting very 
slightly above the level of the corium. The corium meshes 
are thin, narrow, and contain few small corpuscles and very 
little interstitial fluid, while granular pigment, diffuse or in 
masses, is abundant. The fat cells are wasted, and contain 
vacuoles in places instead of oil globules. The vessels are 
thin, atrophied, and pigmented in some places, but varicose ATROPHIA CUTIS. 
229 
in others, and the hair follicles, though present, have their 
papilla? wasted and contain no hairs, or only their lanugin- 
ous filaments. 
In the degenerative conditions, in addition to the simple 
atrophy, the skin, in tracts of varying extent, becomes brit- 
tle and extremely thin, while its connective tissue bundles 
become converted into a vitreous or gelatinous mass, in 
which no vessels or nerves are visible. The hair and 
glandular follicles are also degenerated. The process is 
supposed to begin in the arterioles, like albuminoid degen- 
eration, and to spread thence to the other tissue. 
Partial atrophy of the shin is observed in the form of 
white scarlike parallel bauds, a half to two lines broad and 
several inches long, or in scattered round maculse, a quarter 
to two lines in diameter. 
The striae (linear atrophy') which are the most common 
have a glistening bluish-white appearance, and the skin 
forming them is unduly thin and depressed. They usually 
occur on the pelvic brim, the glutei, and the trochanters, 
and less frequently on the fronts of the thighs or the arms. 
Under the microscope the papillary layer is found atro- 
phied, the corium much thinned, with its bundles delicate 
and its vessels fewer in number, and the subcutaneous fatty 
tissue and appendages are wasted. 
The macula are much less frequently observed, but Dr. 
Liveing has found the following changes to occur in them : 
The spots, at first somewhat reddish, raised above the skin, 
hard and fibrous, passed on into the ordinary atrophic con- 
dition, appearing as discrete round or oval pitlike scars, 
covered by a thin membrane, and all about the size of a 
threepenny-piece. Finally a stage of contraction or oblit- 
eration sets in, and the spots become less apparent, as if 
encroached upon by the surrounding healthy tissues. Live- 
ing believes this disease to be allied to scleroderma aud 
morphoea, with which it has been several times associated. 230 
CLASS VI.—NEOPLASMATA. 
CHAPTER XIX. 
Class VI.—Neoplasmata. 
Sub-class A.—Benign. 
Clavus—Tylosis—Verruca—Cornu cutaneum—Keloid — Fibroma — 
Xanthoma—Lupns vulgaris—Lupus erythematosus—Iihinoscle- 
roma—Xsevus—Angioma—Lymphangioma. 
Papillomatous. 
1. Clavus and Tylosis. 2. Verruca. 3. Cornu cutaneum. 
Clavus and Tylosis. 
Definition.—Tylosis, or tyloma, is merely an undue ac- 
cumulation of horny epidermis, which appears usually on 
the extremities, on parts exposed to pressure. The thick- 
ened epidermis merges gradually on each side into the nor- 
mal, and there is little or no affection of the corium. 
Clavus, or “corn,” is the name applied to an epidermic 
accumulation, resembling that in tylosis, in the centre of 
which is a conical plug, the apex being situated on, and 
pressing down, the corium. 
Symptoms.—Tylosis causes usually little or no inconveni- 
ence, unless the accumulation be very thick and horny. 
Under these circumstances, when affecting the palm, it in- 
terferes much with the movements of the hand. When 
irritated, a vesicle may be formed, which spreads into a 
bulla, the fluid, on account of its long retention, becoming 
purulent, and thus a subepidermic abscess may be produced. 231 
CLAVUS AND TYLOSIS. 
The horny crust is loosened and cast off, leaving, after the 
ulcerated base heals, a perfectly normal surface. 
A “corn,” on the other hand, causes usually depression, 
and atrophy of the papillae beneath its “core,” and when 
pressed upon gives rise to severe pain. It is generally pro- 
duced by the pressure of a tight boot on the toes. When 
seated between the toes the maceration by retained moisture 
prevents it from assuming the horny character of the cal- 
losity, and hence this is the distinction between hard and 
soft corns. 
Morbid Anatomy.—Tylosis consists of an undue thicken- 
ing of the epithelium. The horny layers are increased in 
number and thickness, and the papillae are somewhat en- 
larged and more vascular. 
Sections through a corn show an epithelial accumulation 
and papillary hypertrophy identical with that in tylosis. 
In the centre of the patch, however, a conical epidermic 
plug is found, the layers of which are concave towards the 
free surface of the skin. The papillae beneath it, at first 
enlarged, are gradually atrophied as the growth deepens, 
which causes wasting of the corium and glands, till the core 
finally lies in a pit in the corium. 
Treatment.—Occasional rubbing down of the horny mass 
with a file is all that is needed in tylosis. When affecting 
the palm, dressing with lint soaked in liquor potassae and 
covered with oiled silk, and subsequent scraping away of 
the softened epidermis, restores mobility to the parts. 
Corns may be treated by placing a disk of felt plaster, 
with a hole in the centre, over them, so as to remove pres- 
sure. Dressing with liquor potassae or with strong nitric 
acid will often, after a time, cause the disappearance of the 
affection, and in obstinate cases excision of the corn, with 
the papillae from which it grows, may be necessary. 232 
CLASS VI.—NEOPLASMATA. 
Y ERRUC A—W ART. 
Definition.—A wart is a small excrescence of the skin, or 
mucous membrane near the junction with the skin, consist- 
ing of a localized hypertrophy of the papillse and the epi- 
dermis covering them. 
Symptoms.—Warts may be hard when exposed to the air 
on cutaneous surfaces, or soft when seated on mucous mem- 
branes, kept constantly moist by secretions; they may also 
be simple or compound, the latter being made up of a bunch 
of filiform papillae, usually pedunculate. Simple warts con- 
sist of a group of elongated papillae, surrounded by a com- 
mon epithelial envelope, the surface of which, however, usu- 
ally presents fissures marking the extent of each papilla. 
Hard warts, on the hands, body, and head, may appear 
suddenly in great numbers, and grow rapidly, and as they 
are also liable to involution and spontaneous disappearance, 
various quack remedies, “ charms,” etc., have been able to 
acquire an easy but somewhat doubtful reputation. 
Soft warts, or condylomata, are usually pointed, and are 
much softer and more vascular than the hard ; they occur 
.most often on the perinseum, round the anus, and on the 
genitals, oAving to the irritation of the gonorrhoeal discharge, 
syphilis, or decomposing sweat in persons of dirty habits. 
They have no tendency to spontaneous involution. 
Morbid Anatomy.—In the flat Avarts vertical sections 
shoAV merely an aggregation of hypertrophied, sometimes 
branched, papillae, the vessels of which are enlarged, and 
the epidermis covering them is much thickened. The co- 
lumnar cells of the rete are specially numerous, and fill up 
the interpapillary spaces. In the round, prominent, or coni- 
cal Avarts the hypertrophied, much-elongated papillse are 
still imbedded in a mass of thickened epithelium, which 
envelops them in a common sheath; but indications of the 
extent of each papilla are presented by numerous fine cracks, KELOID. 
233 
which split it up into polygonal arese, each corresponding 
to a papilla and its envelope. In the filiform warts the 
papillae, delicate and branched, have each a separate epi- 
dermic coat, and the little mass appears like a bundle of 
fine bristles. 
Treatment.—Hard warts, not showing any tendency to 
disappear, may be snipped off with curved scissors, and 
some styptic or cautery may be applied to the seat of at- 
tachment if there is any bleeding. If sessile, the repeated 
application of glacial acetic acid, of chromic or nitric acids 
or liquor potassse, will usually cause them to shrivel up. 
Condylomata may also be treated by excision and styptics 
if few in number. If numerous, they should be removed 
with Paquelin’s benzolin cautery. 
Cornu—Horn. 
Definition.—A cutaneous horn consists of a curved, coni- 
cal-ridged, brownish mass, and may be considered as a wart, 
the epidermis over which has a columnar structure and is 
closely compressed like that of the nails. 
Symptoms.—Horns usually occur on the head, but some- 
times on the penis, and they may be several inches long 
and spirally twisted. Occasionally they arise within a 
sebaceous follicle. Their growth is attended with little or 
no pain. 
Treatment.—Excision of the horn, with the portion of 
skin from which it grows, is the only effectual cure. 
1. Keloid. 2. Fibroma. 3. Xanthoma, 
Of Connective Tissue. 
Definition.—Keloid is a rare affection of the skin, con- 
sisting in the formation, spontaneously or in the seat of 
Keloid—Keloid of Alibert. 234 
CLASS VI.—NEOPLASMATA. 
former scars, of a firm nodular tumor, composed of hyper- 
trophied fibrous tissue, tender on pressure and sometimes 
attended with itching and tingling. 
Symptoms.—There is no essential difference between the 
“spontaneous” or “true” and the so-called “false” keloid, 
developed in cicatrices, and there is some doubt whether 
the “true” keloid of Alibert does not really arise in small, 
insignificant scars, the origin of which has been forgotten. 
The affection named keloid by Addison is identical with, 
and has been described under the head of, Morphoea. 
Keloid grows slowly as a rounded, oval, fusiform, or 
nodular patch, raised one or more lines above the surface 
of the skin, in which it appears imbedded. Occasionally it 
presents the shape of a stellate or radiating, latticelike for- 
mation, and sends out processes like the claws of a crab, 
which gradually subside in the surrounding skin. It is firm 
and elastic to the touch, has a smooth surface, is white, or 
occasionally pinkish, shiny, and marked by ramifying ves- 
sels. The surface is never scaly, and the tumor has no tern 
dency at any time to ulcerate or break down. Tenderness 
on pressure is usually present, and sometimes tingling, itch- 
ing, or burning. 
The growths occur as isolated patches on the sternum, 
mammae, sides of the trunk, or back ; they may be single, 
but are more frequently multiple, and sometimes are met 
with all over the body. The cicatricial variety may develop 
in scars, present in any situation, but it is said to be more 
common in the dark races in the scars left by flogging. It 
usually occurs in adults. Kaposi states that new patches 
arise as follows : 
“They consist, at the commencement, of brownish-red 
streaks of skin, with a pale-red or whitish lustre, of the size 
of oats or barleycorns, flat or already slightly elevated, 
communicating a sense of resistance, and are for the most 
part slightly painful on pressure. In the course of many KELOID. 
235 
mouths, or of years, the linear or streaky keloid increases 
in one or other direction, or in every superficial dimension, 
and thus assumes one of the characteristic shapes men- 
tioned above, with or without processes. At the same time 
it will have become somewhat thicker and more elevated.” 
Keloid, once fully developed, remains, as a rule, unal- 
tered for life ; in only a few cases has spontaneous involu- 
tion, or even complete disappearance of a single patch, been 
observed (Alibert and Hebra). 
Clinically, keloid arising in or round about a scar is in- 
distinguishable in its course and symptoms from the spon- 
taneous variety. 
Diagnosis.—A firm, whitish or pinkish, slightly elevated 
tumor in the skin, sending out clawlike processes, tender on 
pressure, growing slowly, and manifesting no tendency to 
degenerative changes, can only be a keloid or a hypertro- 
phied scar. In course and symptoms there is no valid mark 
of separation between the two, and microscopic examina- 
tion alone will complete the diagnosis. 
Prognosis.—Keloid does not affect the general health, 
and causes only slight inconvenience by the tenderness and 
occasional tingling. When removed by operation, it almost 
invariably recurs, and is then larger than the previous 
growth. 
Morbid Anatomy—Vertical sections of a “true” keloid 
tumor show a mass of dense white fibrous tissue, imbedded 
in the substance of the corium. 
Under the microscope the bundles of tissue composing it 
are seen to run parallel to the surface of the skin and to 
the long axis of the tumor. The epidermis, and papillae 
covering it, are normal, and the sebaceous and sweat glands, 
pushed aside at the margin, but not otherwise altered, may 
be strangulated and degenerated in the portion of corium 
above and below the nodule. Nuclei, spindle cells, and 
connective tissue corpuscles, almost wanting in the centre, 236 
CLASS VI. — NEOPLASMATA. 
are more abundant in the periphery, especially round the 
vessels which seem to form centres for the formation of the 
growth. 
In cicatricial keloid a nodule, of the same nature, is found 
imbedded in ordinary scar tissue, which forms a sort of cap- 
sule round it, and is covered by a layer of pigmented epi- 
thelium without papillae. 
In a hypertrophied scar the pigmented rete layer of the 
epidermis lies on a meshwork of irregularly interlacing 
fibrous bundles, the papillae being absent. Numerous round 
spindle and stellate cells and bloodvessels—some pervious 
while others are seen as fibrous, pigmented cord,—are 
present throughout. 
Treatment.—Any attempt to remove the tumor by exci- 
sion, caustics, or the actual cautery should be discouraged, 
on account of the speedy return and enlargement of the 
growth. The pain, if severe, should be mitigated by sub- 
cutaneous injection of morphia, or by an aconite ointment. 
Definition.—Small, sessile, pedunculate, usually multiple 
growths, arising in the superficial layers of the corium and 
of somewhat gelatinous structure. 
Symptoms.—The disease begins by the appearance of 
small, softish masses in the skin, most commonly on the 
chest, back, and neck, which grow slowly, and vary in size 
from a small shot to a large nut. From being at first ses- 
sile, as they enlarge they become more or less pedunculated, 
and sometimes even pendulous. They usually occur in 
adults, are covered with normal skin, and cause no pain or 
constitutional symptoms. 
Diagnosis.—The little soft, usually multiple, tumors are 
distinguished from molluscum contagiosum by the absence 
of a central umbilicus, and by the fact that they consist 
Fibroma—Molluscum Fibrosum. XANTHOMA. 
237 
of' solid tissue, and their contents cannot therefore be pressed 
out. 
Prognosis.—Fibroma is troublesome only on account of 
the deformity it causes; it is, as a rule, unattended with 
pain, and is in no way dangerous to life. 
Morbid Anatomy.—The little growths present a whitish 
centre and gelatinous margin, and on microscopic examina- 
tion are found to consist, in the centre, of young connective 
tissue, the meshes of which contain abundant serous fluid 
with some spindle and round cells, while the periphery may 
be composed of more or less mucoid tissue, with numerous 
branched and spindle cells. The growth, according to 
Rindfleisch, begins in the papillary layer. 
Treatment.—The only measure of any avail is the removal 
of the tumors by operation, which should only be under- 
taken if they cause considerable deformity, or if, by press- 
ing on nerves, they give rise to pain or inconvenience. If 
pendulous, a ligature may be used, or they may be snipped 
off with scissors. As numerous vessels enter their base, 
sharp bleeding may follow their removal by operation, but 
this can be usually stopped by pressure. 
Definition.—Xanthoma consists in the formation of yel- 
low or buff-colored, clearly defined patches in the skin, on 
a level with it or only slightly raised, and most frequently 
in association with prolonged jaundice. 
Symptoms.—Xanthoma occurs in adults, and about twice 
as frequently in women as in men. It may be localized and 
limited to the eyelids only, where it usually begins, or patches 
may be found scattered all over the surface of the body, in 
the mucous membranes, and in the sheaths of tendons. 
Two forms are described : 
Xanthoma—Xanthelasma—Vitiligoidea. 238 
CLASS VI.—NEOPLASMATA. 
1. Xanthoma planum. 2. Xanthoma tuberosum. 
1. Xanthoma planum begins, usually symmetrically, near 
the inuer cauthus, and extends slowly along both lids, es- 
pecially the upper one, spreading then over the adjacent 
part of the cheek where the skin is thin. The patches, of 
different sizes, and varying in color from yellowish-white to 
a faded huff or a chamois-leather tint, have sharply defined 
margins, a smooth surface level with the skin or raised into 
little tubercles at the edges. There is no difference in con- 
sistence or thickness between the affected and the healthy 
skin, and usually no subjective symptoms are present. 
2. Xanthoma tuberosum occurs as isolated nodules, or 
plaques, made up of aggregations of little tubercles, vary- 
ing in size from a millet seed to a grain of wheat, just slightly 
raised above the level of the skin. They occur hut rarely 
on the eyelids, more often on the cheeks and ears, hands 
and feet, and sometimes generally over the whole surface of 
the body. They can be pinched up with the skin, with 
which they are continuous, have a feeling of elasticity, and 
are attended with slight tenderness on pressure. On the 
palms and soles, however, they often cause severe pricking 
and burning pain, which interferes much with the use of 
the limb. Both forms of xanthoma not uufrequently oc- 
cur in the same individual. The patches, growing slowly 
by extension or by the formation of new marginal spots, 
reach their full development, and remain unaltered for the 
rest of life, undergoing no degenerative changes and causing 
no impairment of the general health. They have been ob- 
served in various diseases, and even in healthy persons, hut 
in a large number of cases—in 15 out 30 enumerated by 
Ivaposi—persisteUt jaundice has preceded or accompanied 
them. Whether, however, the jaundice—produced most fre- 
quently, according to Charcot, by hypertrophic cirrhosis—- 
is the cause of the skin affection, or whether both phenom- 
ena are due to some other factor, is as yet unsettled. LUPUS 
239 
Diagnosis.—Xanthoma may be mistaken for confluent 
masses of milium, especially on the eyelids. A superficial 
cut over the mass enables the milium granules to be easily 
squeezed out, whereas xanthoma, being imbedded in and con- 
tinuous with the healthy corium, cannot thus be enucleated. 
Prognosis.—Xanthoma is in no way dangerous to life, ex- 
erts no influence on the general health, and is annoying only 
from its unsightliness and from the pain when on the palms 
or soles. 
Morbid Anatomy.—Vertical sections show a pale-red sur- 
face, interspersed with yellow spots which cannot be squeezed 
out. Under the microscope the papillte and epidermis are 
almost normal, the only change being the deposit of much 
yellowish pigment in the rete cells and throughoutthe corium. 
In the cutis the yellow spots are made up of densely fibril- 
lated connective tissue, with more or less abundant stellate 
or roundish cells intermixed. The changes are most marked 
round the hair follicles and sebaceous glands. Pigment 
granules are scattered throughout, but the yellow color is 
due mainly to fat, which occurs as fine globules in the stel- 
late cells, or as a coarsely granular mass with some large 
globules between and in the connective tissue bundles. The 
change differs from atheroma, which it much resembles, in 
being an infiltration, and not a degeneration, of the new- 
formed connective tissue. 
Treatment.—The excision of the whole nodule down to 
the subcutaneous tissue, in such a place that the scar will not 
subsequently cause interference with the functions of the 
part, is the only remedy, 
1. Lupus vulgaris. 2. Lupus erythematosus, 3. Rhinoscleroma. 
Granulation Tissue Growths. 
Lupus. 
Definition,—A chronic, non-infectious disease, consisting 
in the deposit of pests of small round cells, irregularly 240 
CLASS VI.—NEOPLASMATA. 
placed ill the substance of the coriura, or more specially 
round the vessels in the plexuses of sweat and sebaceous 
glands. The deposits terminate either in interstitial ab- 
sorption or in breaking down and ulceration, and leave 
superficial scars. 
Symptoms.—Though various forms of lupus have been 
described under separate names, and the distinctions laid 
down are sufficiently marked in typical instances, the oc- 
currence, in practice, of various transitional forms, and the 
presence, occasionally, of two varieties in the same indi- 
vidual, tend to show that the different varieties of lupus 
are due, like those of eczema, merely to local peculiarities 
of site, and to degrees of development of one or other of 
the morbid phenomena met with in the disease. Thus in 
lupus vulgaris the cellular new growth is well marked, and 
may either be confined to the upper layer of the skin, or 
disseminated in nodules, or diffused through the whole thick- 
ness of the corium, while in lupus erythematosus the hyper- 
jemia of the plexus round the sebaceous glands is the main 
feature, the new growth being but small. 
Lupus vulgaris occurs at first as small reddish or yellow- 
ish-brown nodules—presenting an “apple-jelly” appear- 
ance—about the size of a pin’s head or shot, either diffusely 
scattered or aggregated closely in groups in the substance 
of the skin. They are not raised, and get paler, but do not 
disappear on pressure, and are covered by smooth epidermis. 
They may be quite superficial or deep in the substance of 
the corium, and enlarge slowly, new nodules appearing as 
the old reach their full development. The firm, transparent 
masses thus formed are painless, and often, by confluence, 
form flattened plaques, the size of a sixpence or larger, 
raised about a line above the level of the surface, irregular 
or smooth, and covered by shiny desquamating epithelium. 
By continued growth of the nodules projecting tubercles 
may be formed, and persist without change for a long time. LUPUS. 
241 
As the disease progresses either involution or ulceration 
may take place. In the former the tubercle becomes flaccid, 
the skin over it shrunken and wrinkled, and covered with 
white scales or scabs, which on falling off leave a central 
white, glistening, cicatricial depression, that is firm and con- 
tracts but little. In the latter the tubercle softens, disin- 
tegrates, and secretes pus, which dries up, forming thin yel- 
lowish or greenish crusts, resting on a depressed ulcer, with 
soft, defined edges and a red, smooth, bleeding base. As 
time goes on the skin between the granulations is more or 
less thoroughly destroyed, the tendons, fasciae, and other sub- 
cutaneous structures attacked, and an ulcer is formed with 
hard or undermined edges, and a base, covered with exu- 
berant or friable granulations, which heals but slowly after 
it may be weeks, months, or even years. But while retro- 
gression may be going on in one part, new nodules are con- 
stantly appearing in the margin of the patch, in skin pre- 
viously free, or even in cicatrices left by the healing pro- 
cess, and thus the disease is constantly spreading. By the 
contact and fusion of two or more circular patches a gyrate 
appearance is produced, known as lupus serpiginosus. When 
the disease is superficial, and shrivels up without ulceration, 
it is called lupus non-exedens ; when the growth forms prom- 
inent masses, lupus tuberculatus; lupus exedens and lupus 
exulcerans when ulceration has taken place ; and lupus ex- 
joliaceus when it is undergoing absorption with desquama- 
tion, and not sloughing. Lupus vulgaris arises most com- 
monly between the second and eighteenth years of life, and 
tends to disappear with advancing age, though relapses may 
occur at any period. It is rather more often met with in 
women than in men, is non-contagious, and though often and 
certainly associated with a strumous or phthisical diathesis, 
it does not appear to be hereditary. Lupus generally at- 
tacks the skin of the different parts of the body in the fol- 
lowing order: the cheeks, the nose, the ears, the wrists, and 242 
CLASS VI. NEOPLASMATA. 
the trunk. On the cheeks and nose it occurs usually as 
disseminated tubercles, which, after disappearance, leave 
the skin in a white, glistening, hairless condition, slightly 
pitted with scars. The mucous membrane of the mouth, 
nares, and fauces may be affected by extension of the dis- 
ease from the nose and cheeks, in the nose the extension of 
the granulation tissue inwards to the mucous membrane 
eroding, and often replacing, the cartilage, and subsequently 
breaking down and giving rise to loss of substance and seri*. 
ous deformity. On the extremities lupus is usually serpig- 
inous, though scattered spots may be found. The cica- 
trices which it produces may keep the elbows, knees, and 
fingers semiflexed and in a state of pseudo-anchylosis. In 
addition to this, lupus of the extremities is specially prone 
to erysipelas and lymphangitis, with occasional subcutane- 
ous abscesses, and to the occurrence of periostitis, caries, 
and necrosis of the bones. 
Lupus erythematosus begins usually as a reddish patch on 
the nose, with slightly irregular surface, followed soon by 
the development, on each cheek, of similar red patches. 
An erythematous spot, caused by heat or sunburn, or a 
small patch of eczema, may be the starting-point. On close 
examination the patches appear simply erythematous, and 
may come and go for some time before the disease becomes 
established, or they may be made up of an aggregation of 
slightly raised red spots, about the size of a pin’s head, 
which become pale on pressure, and often present a light 
greasy scale in the centre. They constitute, according to 
Kaposi, the “primary eruptive spots” of the affection, and 
each corresponds with the opening of a sebaceous follicle, 
the little scale, made up of epidermis and sebum, sending a 
small conical plug down into the duct of the gland. In 
severe cases, where the spots are closely aggregated, the 
scales become rapidly confluent, and form an irregular, 
closely adherent crust. When this has been softened by LUPUS. 
243 
oil and removed, numerous little processes, passing from its 
under surface into the follicles, can be seen, distinguishing 
it in the diagnosis from acute eczema. 
When the spots remain discrete, they spread gradually 
at the margin, which is red, slightly raised, and covered 
with scales and comedones, while the centre becomes pale, 
depressed, and pitted. 
In this way the patches join at the bridge of the nose, 
and the characteristic “butterfly” outline is produced, the 
portions on the cheeks representing the wings and that on 
the nose the body. Growing in this manner, the patches 
may spread to the scalp, or cover the whole side of the face, 
and new spots may develop on the ears, generally symmet- 
rically, leaving a band of healthy skin between them and 
the cheek. 
After persisting for a long time, often many years, the 
margins of the patch become paler, flatter, and gradually 
cease to grow, leaving a white superficial, slightly pitted 
scar, which may persist for the rest of life, or in process of 
time become almost imperceptible. Next to the cheeks, 
nose, and ears, the backs of the hands are most commonly 
affected, and it is rare for one hand only to suffer, the dis- 
ease here, as elsewhere, preserving its tendency to symmetry. 
In the disseminated and aggregated form (Kaposi) the 
individual spots do not spread at their margins as in the 
previously described or discoid variety, but run their course 
and cicatrize, leaving small pitted scars like those of acne 
or variola, and extension of the patches occurs by the de- 
velopment of new isolated spots in the adjacent tissue. 
Appearing first on the face, the patches may be confined to 
it or may spread thence to the scalp, neck, arms, and even 
the fingers and toes. At the onset the patch may be covered 
by an impetiginous scab, which, falling off after some days, 
exposes the primary eruptive spots. This form of lupus 
erythematosus is usually chronic, but may occur acutely, 244 
CLASS VI.—NEOPLASMATA. 
either primarily or supervening on the discoid or aggregated 
variety. Patches of densely aggregated spots appear first 
on the face, and in the course of a few days are followed by 
the eruption of hundreds of lupus spots all over the general 
surface. Other local and constitutional symptoms of some 
severity usually accompany the outburst. Of these Kaposi 
enumerates the following: 
1. Subcutaneous, painful, and tender nodules, of doughy 
consistency, covered at first by normal skin, which in two 
or three days, as the swelling begins to subside, present a 
crop of primary eruptive spots. 
2. Painful oedematous swellings of the skin and tissues 
round the joints of the hands and feet, and sometimes of 
the knee and elbow also, which, after some days, subside 
gradually with the development of spots of lupus erythema- 
tosus. 
3. Large, hard, painful swellings of the submaxillary 
and axillary, and more rarely the inguinal and parotid 
glands, subsiding with the development of the eruption 
usually within a few weeks. 
4. Erysipelas, or lymphangitis, only occurring chiefly in 
acute attacks in the parts affected by the painful subcuta- 
neous swellings, and on the face and ears. It may also 
arise, in chronic cases, even if no operation have been per- 
formed, lupus erythematosus being more liable to it than 
lupus vulgaris. It is usually a grave complication, and is 
frequently fatal. 
Diagnosis—Lugms Vulgaris.—The presence in the skin of 
the characteristic “apple-jelly” nodules is sufficient in itself 
for the diagnosis. Scabs, if present, should be removed by 
oiling, and if no spots are then discovered, waiting for a few 
weeks will usually enable the gradual development of newr 
nodules to be seen. LUPUS. 
245 
From syphilis, in the form of serpiginous ulceration, 
lupus differs by its slower course, shallower and less painful 
ulcers, clean, soft, red base of granulation tissue, and by the 
presence in most cases of “apple-jelly” spots near the 
ulcerating surface. The failure of specific syphilitic treat- 
ment is also an important aid to diagnosis. 
Epithelioma and rodent ulcer differ from it by reason of 
their greater hardness, by the induration of the margin, and 
by the fact that they never appear in childhood, and rarely 
till after thirty, whereas lupus, though it may recur later, 
usually appears for the first time in early life. 
From lupus erythematosus lupus vulgaris differs so much 
in appearance, in typical cases, that no mistake can be made. 
When the two forms occur in combination in the same in- 
dividual, the “apple-jelly ” spots of vulgaris, and the hyper- 
semic follicles, with thin scales and sebaceous plugs of the 
erythematous variety, can usually be recognized. 
Prognosis.—Lupus vulgaris affecting the skin is not in 
itself dangerous to life, although the attacks of erysipelas 
which occasionally complicate it may be serious. It some- 
times disappears spontaneously and never recurs, and the 
diseased patches of tissue can be destroyed by energetic 
treatment. It is difficult, however, to do this effectually 
without damaging the skin so deeply as to cause subsequent 
cicatricial contraction, and hence, after all attempts to re- 
move the diseased tissue alone, leaving the unaffected skin 
as little as possible damaged, the growth is prone to recur. 
Lupus erythematosus, except in the acute general form and 
when complicated with erysipelas, is also a benign disease. 
The discoid is more amenable to treatment than the ag- 
gregated form, and the growth, when once destroyed, is less 
likely to recur than in lupus vulgaris. 
Morbid Anatomy—Lupus Vulgaris.—According to Fried- 
lander and Thoma, whose observations have been confirmed 
in this country by Dr. Thin, lupus vulgaris begins by an 246 
CLASS VI. NEOPLASMATA. 
aggregation of small round cells in the adventitia of the 
vessels of the corium. Local enlargements of the cellular 
deposit produce the little, scattered, roundish nodules, ar- 
ranged like nests in fibrous loculi in the corium, composed 
of small young cells in a delicate fibrous network, per- 
meated by a few dilated capillaries, and containing some- 
times giant cells. The surrounding corium tissue'remains 
at first free from infiltration, but the small-celled gi’owth, 
extending along the vessels, reaches on one side the sub- 
papillary layer and papillae, and on the other the subcuta- 
neous connective tissue and fat. The cellular infiltration 
next diffuses itself from these foci, till the whole corium, 
from the papillae to the subcutaneous fat, is pervaded with 
small round cells, specially dense round the vessels, and 
hence accumulated thickly round the sweat glands, sebace- 
ous and hair follicles. The cells of the glands and hair 
follicles, at first swollen and granular, soon degenerate and 
finally become atrophied and destroyed. 
The rete Malpighii, at first normal, becomes later on 
thickened, and by the cellular infiltration, indistinguishable 
from the papillae, its cells are swollen, more granular, and 
proliferating, and numerous round cells are scattered 
amongst them. 
Fatty degeneration, breaking down of the cells, and ul- 
ceration of the growths next set in, but the process is a slow 
and superficial one, and the cells, in the deeper layers of an 
ulcerating spot, are frequently quite free from granules, and 
have distinct nuclei, while those on the surface are quite 
degenerated. Cicatrization finally occurs, and smooth scars 
result, from which the hair follicles and glands are absent. 
Lupus Erythematosus.—In sections of the early “primary 
eruptive spots” of the disease, the first changes which have 
been observed are dilatation of the vessels round the seba- 
ceous glands and hair follicles, with slight oedema, and, 
when the spots are superficial, similar appearances in the LUPUS. 
247 
adjacent papillae. In the next stage the connective tissue 
immediately around the glands is found thickly infiltrated 
with round cells, which extend into the corium and papillse, 
obscuring the connective tissue bundles and the boundary 
between rete and papillse; these, as atrophy begins, become 
cloudy, granular, and opaque, and begin to break down. 
The sweat glauds are also sometimes affected. 
Atrophy, or ulceration, with cicatrization being com- 
pleted, the hairs and glands are found degenerated, the 
connective tissue thickened, indurated, and obscured by 
fatty globules, and the atrophied bloodvessels may be indi- 
cated only by pigmented strands. The rete is thinned, the 
papillse absent, flattened, or wasted, and the whole corium 
is denser and has its meshes thickened. 
Occasionally the granulation tissue, instead of spreading 
in lines along the meshes of the corium, becomes aggregated 
in nests, producing nodules identical with those of lupus 
vulgaris. 
The painful nodes and swellings met with sometimes in 
acute outbreaks are due to inflammatory oedema of the skin 
and subcutaneous tissue. 
Treatment.—Under the head of general treatment, appli- 
cable to both lupus erythematosus and lupus vulgaris, the 
chief indications are—first, if the general health is lowered, 
to restore and maintain it by means of a nutritious diet, 
with a moderate amount of stimulants and tonics, such as 
iron, quinine, etc.; and, secondly, to combat and remove, 
as far as possible, any morbid diathesis, such as the strumous 
or tubercular, with cod-liver oil, phosphate of lime, and 
iodide of iron. It should, however, be clearly understood 
that the administration of these remedies will not by itself 
remove the diseases for which purpose local treatment must 
be adopted. 
In lupus erythematosus the local treatment consists in: 248 
CLASS VI. NEOPLASMATA. 
1. Removal of scales or crusts, if present. 
2. Application of soothing remedies when the disease is 
in the acute stage. 
3. Destruction of the new growth by mechanical or 
chemical means. 
1. The removal of all crusts or scales, by careful oiling 
and washing with soap and water, is essential as a prelimi- 
nary measure. 
2. Simple ointments, such as vaseline 3j with liq. plumbi 
oleate of zinc or bismuth 3>v to vaseline sj, zinc 
ointment, cold cream, cod-liver oil, sedative lotions contain- 
ing calamine, or glycerin and prussic acid, will be found 
useful. Mr. Hutchinson has seen great improvement follow 
the steady use of an ointment of liq. carbonis detergens 
to vaseline 3j. All conditions that may irritate the skin, 
such as the heat of the sun, wind, or excessive cold, should 
be avoided. 
3. For the destruction of the new growths, repeated mul- 
tiple puncture, or linear scarification, as first recommended 
by Mr. Balmanno Squire, proves often of great service, de- 
stroying the dilated vessels and a portion of the new growth, 
which is still further removed by the subsequent inflamma- 
tion. In very obstinate cases, where there is a more abun- 
dant formation of granulation tissue, scooping out the nod- 
ules with Volkmann’s spoon may be necessary. Numerous 
caustics have been used, of which the spiritus sapouatus 
alkalinus of Hebra is one of the best. It should be rubbed 
well into the patches with lint, removing all the scales. 
Crusts of dried-up blood and serum following the applica- 
tion should be removed by oiling, and the remedy used 
repeatedly till all traces of the disease have disappeared. 
Soft soap or liquor potassse may be applied in the same way. 
Acids, such as the acid nitrate of mercury or nitric acid, 
may also be used, but are less effective than alkalies, as, LUPUS. 
249 
owing to the fatty crusts, they often operate less upon the 
diseased parts than upon adjacent healthy tissue. Hebra’s 
arsenical paste is of value when other measures fail; its 
chief advantage is that it acts exclusively on the diseased 
tissue, and is not liable to cause toxic symptoms of absorp- 
tion. It should be spread on lint and reapplied every 
twenty-four hours for two or three days. The severe pain 
and oedema of the skin, arising under its use, usually sub- 
side in a few days, and the destroyed patches of growth 
desquamate, leaving small cavities, which soon heal. 
In lupus vulgaris the use of sedatives is also indicated, if 
there be much irritability or inflammation. 
The nodules of growth may be destroyed by (1) mechani- 
cal means, (2) the actual cautery, (3) chemical caustics. 
For the first purpose Squire’s linear scarification is suit- 
able, but only for the milder and more superficial forms of 
lupus, as it does not penetrate deep enough to destroy the 
little nests which lie in the substance of the corium. Mul- 
tiple puncture, by making with a small sharp-pointed knife 
numerous little stabs close to one another in the diseased 
nodules, frequently yields good results, especially when the 
nodules are small, isolated, and penetrate deeply into the 
true skin. Where the growth occurs in the form of a large 
plaque, it is necessary to remove it by means of Volkmaun’s 
spoon. The scraping should be done vigorously, and, as there 
is a marked difference between the soft, friable lupus tissue 
and the dense, fibrous corium, even on the face there need 
be no fear of doing it to excess. The edges of the patch 
especially should be thoroughly well scraped, and, after 
wiping the surface dry, any little masses of growth, lying 
in “pockets” of the corium, should be scooped out or cau- 
terized. When the crusts of dried blood and serum have 
separated, the patch will be found greatly diminished in 
size, and often entirely removed. The scrapings should be 250 
CLASS VI. — NEOPLASMATA. 
repeated from time to time till the growth is completely 
eradicated. 
The actual cautery, as the galvanic wire or cone, the 
benzolin cautery, or hot iron, may be used to destroy the 
growth, preferably when it occurs in confluent patches on 
the trunk and parts where scars are of little importance, 
and on the mucous membranes. The growth should be 
thoroughly ploughed up by the wire or cone, the resistance 
of the healthy tissue indicating when all the soft lupus de- 
posit has been traversed; oil should be subsequently applied, 
and should any reformation be observed after separation of 
the eschar and cicatrization, it should be again destroyed. 
Paquelin’s thermocautere is a most useful instrument for 
this purpose. 
Of chemical caustics, ITebra’s arsenical paste, applied in 
the same way as in lupus erythematosus, and nitrate of 
silver in points bored into the nodules, are the best appli- 
cations for disseminated patches. Potassa fusa, in stick or 
solution, or chloride of zinc paste, or acids, such as strong 
nitric acid, acid nitrate of mercury, or carbolic acid, are all 
valuable, and have been found efficacious in different cases. 
Riiinoscleroma. 
Definition.—A peculiar affection, of extremely chronic 
course, consisting in the formation, on the skin or mucous 
membrane around the anterior nares, of dense roundish 
tubercles, which have no tendency to ulcerate or undergo 
retrogression. 
Symptoms.—An abstract of the description of Kaposi, 
based on fifteen cases, is as follows: The tubercles, isolated 
or conglomerate, are either smooth, supple, and the same 
color as the normal skin, or bright or brownish-red and 
glossy. The epidermis over them is cracked and fissured, 
and from the rhagades a viscid secretion, drying into yel- RHINOSCLEROMA. 
251 
lovvish scabs, exudes. The nodules are somewhat elastic, 
seem cartilaginous to the touch, and are painful on pressure; 
they are imbedded in the skin, which is normal at their 
margins. 
The nodule, beginning slowly as a thickening and indu- 
ration of the skin on the septum or edge of one of the alee, 
extends gradually into the meatus, which it greatly narrows, 
to the cheek, and to the upper lip, and causes great de- 
formity. 
Diagnosis.—1. From a syphilitic gumma it is distin- 
guished by the extremely chronic course, absence of degen- 
eration or ulceration, obstinate resistance to treatment, and 
the peculiar localization and restriction of the disease. 
2. If the tumor be prominent, glistening, aud covered 
with dilated vessels, it can be diagnosed from keloid only 
by the history and by microscopical examination. 
Prognosis.—Though rhinoscleroma absolutely resists treat- 
ment, it is not fatal to life, and is not liable to grow rapidly, 
atfect the constitution, or undergo ulceration. The defor- 
mity and the obstruction to the nares are the chief incon- 
veniences arising from it. 
Morbid Anatomy.—According to Kaposi, who has de- 
scribed the disease at length, the nodule, which cuts easily, 
presents on section a pale-red, granular surface, bleeding 
moderately. Microscopically the epidermis is found normal, 
the papillae somewhat longer aud club-shaped, and their 
tissue and that of the corium replaced by a delicately fibril- 
lated, small-meshed network, inclosing numerous small 
round cells and pervaded by a few small vessels. The 
growth, which somewhat resembles lymphoid tissue, is most 
abundant in the papillary layer, but extends to the deeper 
layers of the corium, and sometimes even to the cartilage. 
The hair follicles and root sheaths imbedded in the growth 
are normal. 
Treatment.—Excision of the growth has hitherto been 252 
CLASS VI.—-NEOPLASM ATA. 
followed by recurrence, and all internal or local applica- 
tions fail to remove it. 
Of Vessels. 
1. Naevus. 2. Angioma. 
Nasvus. 
Definition.—Is a spot limited to one or other region of 
the body, light bluish or dark red in color, composed usually 
of dilated capillaries and veins, congenital or appearing 
shortly after birth. 
Symptoms.—Navi may be smooth and level with, or only 
slightly raised above, the general surface, or tuberculated, 
with irregular prominences on the surface. They may affect 
merely the superficial layers of the skin, or extend through- 
out its whole thickness, and even into the subcutaneous 
tissue. They can be emptied of blood by pressure, the 
superficial varieties becoming pale and the nodular loose 
and flaccid, but the blood soon returns on removing the 
compression, and they resume their normal tint. They 
occur most commonly on the face, scalp, and neck, but they 
may be met with on the arms and trunk, and but rarely on 
the lower extremities. 
Diagnosis.—Navi can only be mistaken, immediately 
after birth, for the small bruises caused by forceps, but an 
interval of a week will decide the question. 
Prognosis.—Navi tend to grow slowly, and when com- 
posed of large vessels and ulceration takes place, serious 
hamorrhage may be the result. 
Morbid Anatomy.—A navus consists of an aggregation 
of dilated bloodvessels, the walls of which are sometimes 
thickened, and the plexuses do not correspond with the 
normal meshwork of the part. 
Treatment.—No satisfactory mode of treating the super- 
ficial navi has been introduced, but those most usually em- LYMPHANGIOMA. 
253 
ployed are strong acids or the actual cautery. Both of these 
always leave a scar, but the latter is probably the best. 
Angioma. 
Definition.—A new growth composed of dilated vessels, 
closely applied to one another, arising usually in the sub- 
cutaneous tissue, and sometimes in the skin, and not con- 
genital. 
Symptoms.—Angiomata may arise as little slightly raised 
spots, of a bright-red color, resembling naevi, but differing 
from them in being developed in adult life instead of being 
congenital. When arising in the subcutaneous tissue, the 
skin, at first freely movable over them, becomes gradually 
involved, and they then appear as bluish-red tumors, much 
like nodular naevi. The growths may be single or multiple, 
and often cause pain from pressure on nerves. 
Morbid Anatomy.—Sections of the tumors show large 
roundish or oval spaces filled with blood, and limited by 
delicate connective-tissue trabeculae lined by an endothe- 
lium. A kind of capsule frequently surrounds the growth. 
Treatment.—If the size and situation be inconvenient, 
and haemorrhage and pain result, it may be enucleated. It 
does not usually recur. 
Lymphatic Tissue, New Growths. 
Lymphangioma. 
Tumors composed of dilated lymphatic vessels, or of 
lymphatic glands which have undergone cystic degenera- 
tion, are occasionally met with. As a rule they do not 
implicate the corium primarily, and belong to the domain 
of general surgery rather than to that of disease of the skin. 
In a case described by Kaposi, under the name of lymph- 
angioma tuberosum multiplex, hundreds of small, rounded, 254 
CLASS VI. — NEOPLASMATA. 
brownish, slightly raised nodules were found imbedded in 
the substance of the corium. They were about the size of 
lentils, became pale on pressure, and were slightly painful. 
On microscopic examination of an excised tubercle it was 
found to consist of circular or oval spaces, most numerous 
in the deeper layers of the corium, lined by endothelium, 
and identical in structure with dilated lymphatics. No 
changes were fouud in the bloodvessels or papillary layer, 
and, with the exception of pigmentation of the lower rete 
cells, the epidermis was normal. 
The tumors exercised no influence on the general health, 
gave rise to no subjective symptoms, and extended but 
slowly; they showed no tendency to involution, and re- 
mained unaffected by treatment. LEPRA. 
255 
CHAPTER XX. 
Sub-class B.—Malignant. 
Lepra maculosa, tuberosa, ansesthetica—Carcinoma—Epithelioma— 
Ulcus rodens—Sarcoma. 
Lepra—Leprosy. 
Definition.—A chronic constitutional disease, character- 
ized by the development of small-celled nodular growths in 
the skin, mucous membranes, and nerves. 
Symptoms.—Leprosy, formerly prevalent throughout the 
whole of Europe, and still occurring endemically on the 
west coast of Norway and on the shores of the Mediterra- 
nean, is now met with in this country only in sporadic cases. 
The persons attacked, or their immediate progenitors, have 
usually resided in countries where the disease is endemic, 
and the tendency to its development is hereditary. Opinions 
are still divided as to whether it is contagious; it is possi- 
ble, however, that the secretions of a person affected with 
the disease may at some period or other be capable of com- 
municating it to others. Though no primary lesion, analo- 
gous to the hard chancre of syphilis, is known to occur in 
leprosy, the disease frequently arises, and runs a typical 
course several years after the person attacked has left an 
infected locality, and though no morbid phenomena, resem- 
bling those of infantile syphilis, may be present at or soon 
after birth, in the children they may develop leprosy after 
an interval of many years, without ever having been ex- 
posed to the conditions supposed to give rise to it. Dr. 256 
CLASS VI. — NEOPLASMATA. 
Liveing is of opinion that many instances in which the dis- 
ease is thought to have arisen spontaneously in this country 
are possibly due to an untraceable hereditary taint. Mr. 
Hutchinson considers that a diet composed chiefly of fish 
favors the development of leprosy. 
The disease usually begins by a prodromal stage, absent 
or very slight in some cases, during which no characteristic 
symptoms of leprosy are present. Malaise, languor and 
depression, gastric disturbance, and sometimes slight shiv- 
ering and evening pyrexia, may last for months or even 
years. Finally, the phenomena peculiar to the disease 
make their appearance, and, according to the most promi- 
nent symptoms present, three varieties are described,—lepra 
maculosa, tuberosa, and ansesthetica. They differ in degree 
rather than in kind, and sometimes the characteristics of 
one variety are present together with those peculiar to 
another. 
Leprosy affects both sexes equally, and though most fre- 
quent in early adult life, it is met with at all ages. The 
macular and tubercular forms are the most common in 
temperate climates, while the anesthetic variety predomi- 
nates in the tropics. 
Lepra Maculosa. 
After a prodromal stage of varying duration, maculae, at 
first pale red and later dark brown or reddish-gray, appear 
on various parts of the surface. They are smooth, glisten- 
ing, flat, or only slightly elevated, present defined or some- 
what indistinct outlines, and vary from a half to three lines 
in diameter. The affected patches of skin, thickened, indu- 
rated, and somewhat tender on pressure, enlarge gradually 
at their margins, which are dark reddish-hrown in color, 
while at their centre they become paler. They are largest 
and most numerous on the trunk, limbs, and sometimes on LEPRA TUBEROSA. 
257 
the palms and soles also, but are less marked on the face. 
Occasionally, in the earlier stages of the disease, the patches 
undergo complete involution, leaving the skin normal in 
color, or white, smooth, and glistening. After existing in 
this form for years, during which the patches appear and 
disappear at intervals, with little or no constitutional dis- 
turbance, symptoms characteristic of the anaesthetic or tu- 
berous varieties become superadded, and the disease ass'umes 
graver features. 
Lepra Tuberosa. 
After a prodromal anrl a macular stage the smooth brown- 
ish infiltrated patches become more prominent, and cover a 
larger surface. Small round tubercles, varying in size from 
a shot to a small nut, next make their appearance in the 
centre of the macular elevations or in healthy skin. They 
are smooth or covered by fissured cuticle, reddish-brown in 
color, with ramifying vessels on the surface, and are firm 
and somewhat tender on pressure. The natural prominences 
of the skin and its furrows become exaggerated, and the face 
presents a prematurely aged, a sad, and morose expression. 
It is also broader and quadrangular in shape, brownish-red 
and glazed in appearance. The eyebrows are more promi- 
nent, and are bald except at their outer angles, and the 
nose, cheeks, chin, and lips are affected with several tuber- 
cles, which give them a thickened, irregular appearance, 
and produce a “pouting expression” of mouth, resembling 
that of a mulatto. This characteristic alteration of the 
whole countenance is termed “facies leontina.” 
Similar large infiltrated patches and aggregations of 
tubercles are met with on the body and extremities. The 
hands and feet become greatly deformed, t}ie nails are 
cracked and distorted, the hair and sebaceous glands on the 
patches and tubercles atrophy and disappear, and, owing to 
the pain and tenderness in the soles, walking becomes im- 258 
CLASS VI. — NEOPLASMATA. 
possible. Chronic oedema of the legs, producing a condition 
of elephantiasis, is usually met with in eases of long stand- 
ing. After some time the mucous membrane of the mouth, 
the pharynx, etc., are occupied by similar tubercles, which, 
like the rest, may, at the commencement of the disease, 
have undergone involution and atrophy, leaving roundish, 
depressed, and deeply pigmented patches, and in the later 
stages, becoming obstinate, may last, with little or no change, 
for years. They may also give rise to abscesses, which 
slowly discharge their contents, or on slight irritation un- 
dergo sloughing and ulceration, which, in the hands and 
feet, may cause necrosis of the bones or openings in the 
joints, and lead to the loss of fingers or toes. 
At this stage more or less fever, with rigors and severe 
depression, is usually present, and in acute cases the super- 
vention of pneumonia, pleurisy, diarrhoea, or other internal 
complications may rapidly prove fatal. In more chronic 
cases the above symptoms gradually recede, and there may 
be an interval of comparative comfort, during which the 
disease remains stationary or progresses only slowly. Re- 
curring periods of febrile exacerbations, with more extension 
and rapid development and ulceration of the tubercles, pro- 
gressively lower the general health, and may induce a con- 
dition of great prostration and marasmus, which ultimately 
causes death. Very frequently, however, after the disease 
in the tubercular form has lasted for some years, the symp- 
toms of anaesthetic leprosy may set in and gradually become 
predominant. 
Lepra Anaesthetica. 
After a prodromal stage, characterized frequently by the 
periodic appearance of bullae, resembling those of pemphi- 
gus, or sometimes of maculae, during which the general 
health presents little or no change, the anaesthetic variety 
becomes developed. Patches of variable extent and situa- LEPRA AN^ESTHETICA. 
259 
tion on normal skin, as well as on that which is the seat of 
macular infiltration or has been previously attacked by 
bullte, are found to be hypersesthetic. Any attempt, there- 
fore, to walk, grasp, or to use the hands excites painful 
or burning sensations or reflex spasmodic movements, and 
numbness and tingling in the extremities may also exist. 
Various subcutaneous nerves—the ulnar, radial, median, 
peroneal, etc.—present extremely painful nodular enlarge- 
ments. After a variable period the hypersesthetic parts 
gradually become less irritable, and ansesthesia commences 
in the previously sensitive patches or in places where some 
abnormal pigmentation has existed. A pinkish hyperses- 
thetic zone usually surrounds the ausestlietic area, in which 
sensibility to pain, to touch, to heat or cold, or to electricity, 
may be modified, and in the later stages wholly absent. 
During the course of the disease, as well as in the prodromal 
stage, bullse may appear. Atrophy of the skin and of the 
muscles supplied by the affected nerves next sets in, and in 
consequence various paralytic deformities of the hands and 
feet are produced. Constant chilliness is complained of, 
and the temperature of the body is much diminished. 
Either spontaneously or on slight irritation, of which there 
is no consciousness on account of the loss of sensation, ul- 
ceration of the skin takes place at the extremities, opening 
the joints and leading to the separation of one or more fin- 
gers or toes; hence this variety has been called lepra muti- 
lans. Necrosis and caries of the bones, and moist or dry 
gangrene of the extremities, attended with severe constitu- 
tional symptoms, are also liable to occur without obvious 
cause. Towards the termination of the disease marasmus, 
diarrhoea, or clonic and tetanic spasms set in, ultimately 
causing death. 
Diagnosis.—A well-marked attack of leprosy, with the 
characteristic pigmentation and appearance of face, cannot 
be confused with any other disease. In milder forms, how- 260 
CLASS VI. — NEOPLASMATA. 
ever, leprosy may be mistaken for pemphigus, leucoderma, 
lupus, or syphilis. 
The bullous eruption of leprosy differs from pemphigus 
in that the blebs are solitary or few in number, and usually 
associated with the anaesthetic patches. 
For diagnosis from leucoderma see p. 227. 
When the tubercles of leprosy are arranged in aggre- 
gated patches or in small nodules round a cicatricial centre, 
there is much resemblance to lupus. The firmer, more per- 
sistent character of the nodules, which are not soft and like 
“apple-jelly,” as in lupus, their tenderness on pressure, and 
the glistening, oily look of the infiltrated skin in leprosy 
are the chief points of diagnosis between them. 
At an early stage of the disease, if the maculae are small, 
pinkish, and fade on pressure, or present a small central tu- 
bercle, there is a resemblance to a papulo-macular syphilide. 
The spots of leprosy are, however, usually larger, even to 
the full size of the palm, an appearance never seen in syph- 
ilis ; they are more infiltrated and tender on pressure, are 
more persistent, and change to a dark-brown or white color, 
remaining smooth and shining instead of acquiring scales, 
crusts, etc., or forming serpiginous ulcers. The “ facies 
leontina ” is also characteristic of leprosy. 
Prognosis.—Leprosy, though usually chronic, is almost 
always a fatal disease, and only a few cases are recorded of 
complete recovery, most so-called cures being merely periods 
of remission, in which the symptoms remain in abeyance or 
undergo some retrogression, but after a longer or shorter 
period resume their former course. The tubercular form 
lasts a shorter time than the other varieties, its average dura- 
tion being eight or ten years, while anaesthetic leprosy may 
be prolonged -for twenty years. Occasionally tubercular 
leprosy, when once fully developed, runs an acute course, 
being attended with much fever and rapid evolution and 
disintegration of new tubercles, and then the disease pro- LEPRA AN2ESTHETICA. 
261 
gresses in a few months to a stage which it would usually 
have reached only after years. 
Morbid Anatomy.—Vertical sections through the cutane- 
ous nodules show reddish granular masses, limited by a 
fibrous capsule or shading off gradually into the corium, 
which extend sometimes close to the epidermis and at other 
times invade the subcutaneous tissue. Under the micro- 
scope they are seen to consist of small round or spindle- 
shaped cells, which in young uodules are most abundant 
round the thick-walled vessels and the plexuses of the sweat 
and sebaceous glands and of the hair follicles, while in the 
older ones they are densely aggregated, and lie in the deli- 
cate meshwork derived from the fibres of the corium. Their 
central parts contain no vessels ; the papillae are obliterated, 
the cuticle thinned, and the glands and hairs atrophied or 
degenerated, but a rich vascular network is formed in the 
margins. The cells of the new growth have distinct nuclei, 
and their protoplasm presents a somewhat cloudy “ground- 
glass ” appearance ; globules are found here and there, and 
the arrectores pilorum are said to be hypertrophied. A 
very slight cellular infiltration has been found in parts 
which presented the appearance of discoloration or pinkish 
maculae. 
The morbid changes in the nerves—neuritis leprosa—are 
as follows: At points exposed to pressure, or where the nerve 
is near the surface, its trunk presents fusiform enlargements, 
grayish or yellowish, semi-translucent, sometimes even brown 
or blackish in appearance, and it is much firmer than when 
normal. Transverse sections show the general nerve sheath 
unaltered, except that its vessels are slightly thickened. 
Beneath the funicular sheaths, which are usually somewhat 
thickened and in old-standing cases sclerosed, aggregation of 
small cells of the same nature as those composing the cuta- 
neous nodules are found, compressing the nerve fibrils and 
sending cords of cells in between them. More or less fatty 262 
CLASS VI. — NEOPLASMATA. 
degeneration and disintegration of the medullary sheaths, 
and in later stages complete atrophy of the nerve fibrils, 
next takes place, and the hypersesthesia at first produced by 
the irritation of the nerves owing to the growth gives place 
to anaesthesia as they become destroyed. In the affected 
portions of nerves, as well as the skin in which they are dis- 
tributed, Dr. Vandyke Carter has found roundish or oval 
brown pigmented bodies. Pigmentations and thickening 
of the vessels in the cerebral and spinal pia mater, as well 
as albuminous-looking deposits in the meninges and degen- 
erative changes in the spinal cord, have been described by 
Dauielssen and Boeck, but have not been met with by Dr. 
Carter in India. 
Treatment.—This must be directed to the improvement of 
the general health by nutritious diet, tonics, good hygienic 
conditions, cleanliness, exercise, and removal from districts 
where the disease is endemic. Internal remedies, of which 
many have from time to time been vaunted as specifics, have 
little or no influence on the general malady. Cod-liver oil, 
internally and by inunction, chaulmoogra oil or gurjun 
balsam applied in the same way, and the local stimulation 
of the deposits by the inunction of cashew oil, iodine, etc., 
are sometimes attended with benefit. Ulcers should be 
treated on general principles, and the hypersesthesia re- 
lieved by opiates. 
In the quiescent intervals galvanism is often useful in the 
treatment of paralysis and muscular atrophy. 
Carcinoma Cutis. 
Definition.—A malignant growth in the skin, composed 
of nests of cells contained in an alveolar stroma, occurring 
in the form of nodules, which spread by infiltration of the 
surrounding tissues, affect the adjacent lymphatic glands, CARCINOMA CUTIS. 
263 
recur after removal, and prove fatal by ulceration, cachexia, 
and exhaustion. 
Symptoms.—Carcinoma of the skin is usually secondary 
to the development of the disease in the organs ; it affects 
the cutis by continuous extension from the deeper parts, or 
occurs in the form of isolated nodules, usually multiple, be- 
ginning either in the subcutaneous connective tissue and 
soon involving the corium or arising primarily in the latter. 
Structurally it presents sometimes the characters of scir- 
rhus, sometimes those of encephaloid cancer. 
In scirrhus of the breast, as the disease extends towards 
the surface, the skin becomes adherent to the tumor, drawn 
in at the centre, indurated, and infiltrated. The margin is 
often raised into reddish-brown, elastic nodules, and similar 
masses may develop in the vicinity of, but not in visible 
continuity with, the primary growth. Occasionally, when 
scirrhus affects the liver or stomach, numerous small round- 
ish or oval, firm, and painful nodules may occur in the sub- 
stance of the corium, which present the same structure as 
the original mass. If life be sufficiently prolonged, like 
the nodules in scirrhus mammrn, they gradually extend to 
the surface, break down, and form excavated ulcers with 
everted indurated edges, a sloughy firm base, and foul ichor- 
ous discharge. 
Carcinoma encephaloides occurs sometimes primarily in 
the skin as a rare affection in old persons. Multiple nodu- 
lar masses of various sizes, most numerous on the face and 
hands and of a dark-red color, are present over the whole 
surface. They soon break down and acquire a greenish, 
firm crust or slough, producing excavated ulcers like those 
of scirrhus, which tend to spread in all directions. The 
lymphatic glands and internal organs are less liable to sec- 
ondary infection than in scirrhus. 
Diagnosis.—Multiple scirrhus nodules may be mistaken 
for those of fibroma; their hard, painful nature, their rapid 264 
CLASS VI. — NEOPLASMATA. 
growth and tendency to break down if life lasts long 
enough, the presence usually of a primary spot of disease 
in some other organ, and the microscopical structure of one 
of the nodules, will be sufficient for diagnosis. 
From gummata they are distinguished by the absence of 
a history or of other evidences of syphilis, by their great 
firmness, and by their structure. Encephaloid nodules, 
growing rapidly and forming ulcers with indurated everted 
edges, can hardly be mistaken for any other disease. 
' Prognosis. — Both forms of carcinoma are invariably 
fatal. 
Morbid Anatomy.—Scirrhus of the skin presents the same 
structure as in other organs of the body, and consists of 
nests of small roundish or polygonal cells contained in 
alveoli, the walls of which are comparatively thick and 
firm. At the edges of the tumor, the alveolar structure 
gradually passes into that of the normal tissue, which is 
very thickly infiltrated with round cells. In encephaloid 
the cells are larger, contain large round nuclei with clear 
protoplasm surrounding them, and the alveoli are composed 
of thin septa of connective tissue. The bloodvessels are 
larger and more freely distributed than in scirrhus; their 
walls are thin and cavernous, and dilatations and hemor- 
rhages are frequent. 
Treatment.—This can only be palliative. The strength 
should be supported by nutritious food and stimulants, the 
pain relieved by opiates, and the ulcers dressed with astrin- 
gent and antiseptic lotions. 
Epithelioma Cutis. 
Definition.—A malignant new growth of the skin, infil- 
trating the tissues and spreading along the lymphatics to 
the glands, characterized by a tendency to local recurrence 
after removal and by slight liability to the formation of the 
secondary growths in distant parts. EPITHELIOMA CUTIS. 
265 
Symptoms.—Epithelioma occurs but rarely under forty, 
and is most commonly met with on the lower lip, the ex- 
ternal genitals, and the face. It begins as small rounded, 
isolated or aggregated nodules imbedded in the substance 
of the skin, which in the course of months or years enlarge 
and form a roundish, buttonlike mass, raised slightly above 
the surface of the skin, with defined sloping edges and a 
smooth or somewhat irregular warty-looking surface. The 
little tumor is yellowish or brownish in color, and covered 
with ramifying vessels, is extremely hard, usually some- 
what painful, and, though at first freely movable, becomes 
at a later stage adherent to the deeper structures. The 
surface next desquamates, becomes excoriated, and is cov- 
ered with a thin, adherent, brownish scab in its centre, 
under which is found a reddish ulcer with a granular base 
and slight sticky secretion. The edges are prominent, 
everted, indurated, irregular, and often present little trans- 
lucent, rounded, vesicular-looking nodules towards their 
outer margin. Infiltration, followed by ulceration, goes on 
in all directions ; the neighboring lymphatic glands become 
enlarged, nodular, and indurated, and often break down to 
form malignant ulcers; and severe lancinating pains are 
usually present, with wasting and much prostration. On 
the scrotum the disease usually begins as an irregular, warty 
mass, frequently pigmented, which becomes excoriated on 
the surface, and then gives rise to sloughy ulcers. On the 
lip it often begins as a persistent fissure, covered by a thin 
scab, and at first without any induration of the surround- 
ing tissues; but the base gradually becomes hard, the mar- 
gins prominent and infiltrated, till a typical ulcer is finally 
produced. 
Diagnosis.—Epithelioma may be mistaken for syphilis, 
lupus, or a simple excoriated wart. The age, the previous 
history and course of the affection, the pain, which is usually 
greater than in syphilis, and occasionally the detection 266 
CLASS VT.—-NEOPLASM ATA. 
under the microscope of epithelial “globes” in the scrap- 
ings of the ulcers, will aid the diagnosis from syphilis, and 
when a hard, translucent edge or small, clear, marginal 
nodules are present the distinction is easy. 
For diagnosis from lupus see p. 245. 
An abraded wart cannot in many cases be distinguished 
from a commencing epithelioma, more especially since epi- 
thelioma not unfrequently attacks a wart which has lasted 
for some time. The persistence and the slowness of the 
ulcerated surface to heal point towards epithelioma. 
Prognosis.—In the early stages epithelioma, if completely 
destroyed, may not recur, but if considerable infiltration of 
the tissue and glandular affection have set in, the disease 
will return after excision or cauterization, and will ulti- 
mately prove fatal. 
Morbid Anatomy.—Vertical sections through a mass of 
epithelioma have a whitish, granular appearance, and are 
firm and friable. Under the microscope, at the margin of 
the growth the interpapillary processes of the rete are seen 
to be enlarged, much elongated, and pressing on the papillae, 
which, towards the centre portion of the growth, are re- 
duced to thin, fibrous septa. The epithelial cylinders, com- 
posed of spinous rete cells with a few scattered leucocytes, 
contain here and there rounded masses of flattened, lami- 
nated cells, resembling the transverse section of an onion, 
which are called the epidermic “globes” or “pearls.” They 
extend into the corium, which is more vascular and infil- 
trated with numerous small cells, denser near the epithe- 
lium. The bloodvessels, at first numerous in the connective- 
tissue processes between the epithelial cylinders, become 
gradually pressed upon and obliterated by them, which 
causes the superficial and older portions of the nodule to 
break down and ulcerate. In sections parallel to surface 
epithelial growths, as was first shown by Roster, are seen 
filling the lymphatics, and in this way the glands become ULCUS RODENS. 
267 
“ infected ” and the seats of secondary epithelial deposits. 
The sebaceous and sweat glands and the hair follicles in- 
volved in the growth show signs of epithelial proliferation, 
followed by degeneration, and are ultimately destroyed. 
Treatment.—A thorough removal of the growth by free 
excision or its complete destruction by caustics are the only 
measures which give any hope of a cure. 
As caustics, potassa fusa, Vienna paste, chloride of zinc, 
and Hebra’s arsenical paste are the most suitable. 
The disease in most cases recurs, and repeated operations 
or cauterizations, though they only temporarily check the 
progress of the disease, give some intervals of comparative 
comfort and prolong life. 
Ulcus Rodens. 
Rodent ulcer is considered by most Continental dermatol- 
ogists to be merely a variety of epithelioma, and several 
English observers have found the growth to. present the 
microscopic structure of the latter disease ; it presents, how- 
ever, certain clinical characters that require a separate 
description. 
Symptoms.—It begins as a small, smooth, pale papule or 
tubercle, situated usually on the upper half of the face; it 
gradually increases in size, and, after lasting perhaps for 
many years, commences to ulcerate. An ulcer, with hard, 
sinuous edges, often irregular in outline, and attended with* 
little or no pain, but extending gradually in depth and area, 
is thus produced. Its base is said to be not granulated, but 
smooth, glassy, and dull reddish-yellow in appearance, 
and as the margin extends cicatrization occasionally takes 
place in the centre. Slowly invading the deeper parts, 
ulceration may expose even the bones of the face, but there 
is never any secondary glandular infiltration, and the gen- 
eral health is little affected. It occurs in persons past mid- 
dle age, and usually in those advanced in life. 268 
CLASS VI. — NEOPLASMATA. 
Diagnosis.—The main differences from ordinary epithe- 
lioma consist in the extreme chronic, painless course, the 
absence of glandular infiltration and cachexia, the tendency 
in some cases to cicatrization, and the less marked liability 
to recurrence if the disease be once thoroughly destroyed. 
Treatment.—Complete destruction of the growth at an 
early stage by excision, by scraping, or by caustics, will 
often cure, and in all cases much retard the progress of the 
disease. 
Sarcoma Cutis. 
Definition.—Sarcoma of the skin is a rare affection, oc- 
curring primarily in the corium and subsequently to the 
origin of the disease in some other situation. 
Symptoms.—Small rounded reddish or bluish-brown nod- 
ules, varying in size from a small shot to a hazelnut, ap- 
pear at first on the feet or hands, and then scattered over 
the whole surface of the body. They are isolated, smooth, 
and elastic'to the touch, and in a late stage of the disease 
break down and slough. The disease occurs most frequently 
in males and in persons over forty years of age. 
Diagnosis.—It differs from carcinoma in beginning most 
commonly in the feet, in the absence of alveolar structure, 
and in the general freedom from implication of the lym- 
phatic glands. 
Prognosis.—Death usually occurs within two or three 
years from the commencement, probably owing to the ex- 
istence of similar tumors in the vital organs. 
Morbid Anatomy.—The nodules, when examined under 
the microscope, are seen to consist of round or spindle- 
shaped pigmented cells, traversed by thin-walled, cavernous 
vessels, and often presenting patches of Inemorrhagic infil- 
tration and degeneration. 
Treatment.—As in carcinoma of the skin, this can be only 
palliative. 269 
SEBORRHOEA. 
Division II.—DISEASES OF THE APPENDAGES OF THE 
SKIN. 
CHAPTER XXL 
Subdivision A.— Of the Sebaceous Glands. 
Seborrhoea, oleosa sicca, Ichthyosis sebacea neonatorum—Acne punc- 
tata, comedo, milium—Acne vulgaris—Acne sycosis—Acne ro- 
sacea—Molluscum contagiosum. 
Subdivision B.— Of the Sweat Glands. 
Hyperidrosis—Anidrosis—Bromidrosis—Chromidrosis—Sudamina. 
Subdivision A.— Of the Sebaceous Glands. 
Seborrhcea—Acne Sebacea. 
Definition.—Seborrhcea is a condition due to increased 
secretion of the sebaceous glands, in which the sebum mixed 
with dirt accumulates on otherwise healthy skin. 
Before describing the different varieties of seborrhcea it 
will be well to discuss briefly the composition of sebum and 
how it is produced. Kolliker shows that the sebaceous 
glands are constantly giving off' cells, which, when first 
formed at the bottom of the glands, are pale and only 
slightly granular, but which, when they are forced to the 
surface by the formation of fresh cells, become filled with a 
quantity of fat-granules. These granules at a later stage 
coalesce into a single globule, and the wall of the cell be- 
comes stronger and more horny. Seborrhcea consists in the 270 
DISEASES OF THE SEBACEOUS GLANDS. 
increased production of these oil-globules, and may be di- 
vided into three varieties—S. oleosa, S. sicca, and ichthyosis 
sebacea neonatorum. 
Symptoms.—Seborrhcea oleosa occurs usually between the 
ages of fifteen and twenty-five, and affects the cheeks, nose, 
and forehead. The exudation of oil from the sebaceous 
glands gives a greasy appearance to the skin, which next 
becomes dirty, owing to the liability of the oil to attract 
and absorb particles of dust and dirt floating in the air. 
When this condition has lasted for some time crusts are 
formed, which may vary greatly in color, and when they 
are raised small processes of sebum can be drawn from the 
follicles. When the disease occurs on hairy places the hair 
becomes matted, in consequence of which dirt adheres and 
vermin accumulate, constituting the condition known as 
plica Polonica. 
S. oleosa also occurs on the genitals of both sexes, and is 
known as smegma prceputii et clitoridis. When neglected it 
forms thin crusts, which in the male are situated on the 
glans penis beneath the prepuce, and in the female around 
the clitoris and in the neighboring grooves. If allowed to 
remain untouched for a long time, they cause severe local 
irritation and inflammation, a condition which may be mis- 
taken for gonorrhoea. Vernix caseosa is a name given by 
Hebra to a similar deposit over the whole body of new- 
born infants. 
Seborrhcea sicca is produced in a similar way to S. oleosa, 
but gives rise to the formation either of a dry, light-yellow 
crust or a branny coating to the skin. The regions most 
usually affected are the scalp and other hairy parts of the 
body. Scales of epidermis and dried sebum, which are con- 
stantly being formed and ought to be removed, are, owing 
to a want of cleanliness, allowed to accumulate in the hair, 
and are known as scurf. The affection does not last long 
without injuring the hair itself, which gradually falls off SEBORRIICE A. 
271 
and is replaced by badly developed hair till partial bald- 
ness is the result. When the disease is of long standing 
further changes take place in the scalp, and itching, which 
is absent in the earlier stage of the disease, may eventually 
arise from an eczematous condition of the skin. 
Ichthyosis sebacea neonatorum must not on account of its 
name be confused with true ichthyosis, but Hebra has thus 
termed the affection of new-born infants formerly known 
as ichthyosis congenita. The symptoms appear within a 
few hours of birth, when the skin presents a smooth, glossy, 
and somewhat purple appearance. It is also covered with 
a quantity of fissures, which are most numerous on the 
fingers and toes and over the flexures of the joints. The 
slightest movement causes pain, and in severe cases the 
child is unable to suck. 
Diagnosis.—S. oleosa may be mistaken for lupus ery- 
thematosus, but greater swelling and redness, more adherent 
scales, and a tendency to scar are found in the latter. 
S. sicca may be mistaken for three diseases when it attacks 
the scalp,—eczema, psoriasis, and ringworm. For the diag- 
nosis from the two former see table, p. 161. From ring- 
worm it may be distinguished by the history of the case, 
the absence of short broken hairs, the greater difficulty in 
extracting the hairs, and by aid of the microscope. 
Ichthyosis sebacea neonatorum may be distinguished from 
genuine ichthyosis by the fact that the former is local and 
not general. 
Prognosis.—This depends on the cause of the condition, 
for when it occurs in the course of a serious disease the 
prognosis is unfavorable, while under suitable treatment 
recovery is in ordinary cases usually rapid. 
Treatment.—Both local and constitutional means are used, 
but the former are the most important. In all varieties 
thorough cleanliness is necessary, and if crusts are formed 
they should be removed with oil, soft soap, or lard. After 272 
DISEASES OF THE SEBACEOUS GLANDS. 
removal of the crusts the part should be dressed with a 
slightly stimulating ointment, such as zinc, weak carbolic 
acid, or tar, and in S. sicca of the scalp a lotion of borax 
is useful. 
Internally tonics, such as arsenic, iron, and the mineral 
acids, should be administered in full and repeated doses. 
Acne Punctata. 
Definition.—A disease of the skin caused by the reten- 
tion of sebum in the ducts of the sebaceous glands and hair 
follicles. 
Acne punctata occurs in two forms, differing in color, 
which are therefore respectively called nigra and alba, but 
are usually known as comedo and milium. 
Symptoms.— Comedones usually occur between the ages of 
fourteen and twenty-five, and attack the face, chest, and 
back, in small black spots, which look, as Hebra suggests, 
like grains of gunpowder inserted into the skin. If one of 
these black spots be compressed between the nails, a long, 
wormlike body with a black head is forced out. The little 
mass thus ejected consists of retained sebum and the black 
head of dirt which has adhered to the cheesy material. 
The cavity from which the wormlike body is expressed is 
the neck of a hair follicle into which a sebaceous gland opens, 
and the wormlike appearance is caused by its shape. In the 
substance of the mass there is also, however, in some cases a 
living grub, which has nothing to do with the retention of 
the sebum and is quite as often found in normal glands. 
It is called the acarus folliculorum, and was first discovered 
by Henle in 1841. 
Milium appears in the same situations as comedones, and 
at the same time of life, but often terminates in an inflam- 
matory process, giving rise to acne vulgaris. It consists of 
a small swelling under the cuticle, which is caused by the ACNE PUNCTATA. 
273 
retention of sebum in the sebaceous gland and not in the 
neck of the hair follicle, and is white in color, owing to the 
impossibility of accumulating dirt, as in the comedones. 
Diagnosis.—These varieties of acne punctata can only be 
mistaken for acne vulgaris, but the absence of redness and 
other inflammatory signs in them is sufficiently character- 
istic. 
Prognosis.—It is perfectly harmless and easy to cure, but 
is liable to recur. 
Morbid Anatomy.—On incising the skin over one of the 
fine white granules in milium a small round body can be 
turned out with the point of a needle, which on compression 
breaks up into fine laminated scales. A thin vertical sec- 
tion examined with the microscope shows a mass of horny 
epithelial cells, surrounding frequently a central space filled 
with broken-down cells and fatty debris, and inclosed in a 
thin capsule of a finely fibrillated connective tissue. The 
whole mass consists of an altered sebaceous follicle, the cells 
of which, instead of undergoing fatty degeneration and al- 
teration into sebum, have become cornified. It is covered 
by the papillary layer of the corium, which has to be cut 
through in order to remove it. Frequently the little epi- 
dermic globule is fixed by a fine pedicle, consisting of an 
atrophied hair follicle, to the corium. 
Treatment.—For comedones thorough cleanliness and fric- 
tiou of the part affected is the best treatment. The plugs 
of sebum should be squeezed out by the finger nails or with 
a watch key, and a mild stimulating ointment containing a 
small quantity of sulphur or tar should be afterwards ap- 
plied. The skin over the little tumors in milium should be 
carefully divided and the mass squeezed out. Constitutional 
remedies are necessary in both conditions if any functional 
irregularity can be discovered. 274 
DISEASES OF THE SEBACEOUS GLANDS. 
Acne Vulgaris. 
Definition.—Acne vulgaris is a disease of the skin char- 
acterized by the appearance of nodules or pustules, caused 
by inflammation of the hair follicles and sebaceous glands. 
Symptoms.—It occurs in the same places as A. punctata 
and at the same time of life. It consists of comedones, 
which by their presence or by local irritation lead to an in- 
flammatory condition of the gland, producing raised red pim- 
ples, varying in size from a small seed to a pea. The disease 
is termed A. indurata if the inflammation extends deeply 
into the skin, and A. pustulosa if pus is formed. In the 
latter, after the pustule bursts or the retained matter is ex- 
pelled, the spot disappears, but a small shallow scar is left. 
If the disease attacks the forehead it is termed A. frontalis, 
and appears in the form of large papules, tubercles, or pus- 
tules, which leave scars when they are cured. At times, if 
the inflammation is severe, the disease resembles a boil. A 
severe form of A. vulgaris is produced by the local appli- 
cation of tar, and by the internal administration to sus- 
ceptible persons of such drugs as iodide and bromide of po- 
tassium. The usual theories as to the cause of A. vulgaris— 
excessive venery, or the too free use of alcohol or highly 
seasoned food—are very doubtful, and its true cause is a 
matter of uncertainty. However, it is common in the scrofu- 
lous and tubercular diathesis. 
Diagnosis.—Acne vulgaris is easily recognizable, but may 
be mistaken for small-pox in a certain stage (see p. 65) or 
for a syphilide. In the latter case some other syphilitic erup- 
tion at the same time is generally to be found (see A. syph- 
ilitica, p. 104). 
Prognosis.—Acne vulgaris is never fatal, though it pro- 
duces great annoyance to the individual, and in time the 
disease will disappear, for it rarely persists after twenty-five 
or twenty-six years of age. 
Morbid Anatomy.—In A. vulgaris the sebaceous plug, ACNE VULGARIS. 
275 
blocking the excretory duct of the gland, acts as a foreign 
body and excites inflammatory hypersemia, followed by se- 
rous exudation into and round the hair follicles and glands. 
If the plug be not removed, the further inflammation it ex- 
cites gives rise to pus formation in and round the sebaceous 
glands, surrounded by firm, painful, inflammatory indura- 
tion of the adjacent connective tissue, which subsequently 
becomes hypertrophied. In this way the hard tubercles of 
A. indurata are produced. The formation of pus is usually 
slight, and being at the closed extremity of the gland, is 
not near the surface but in the substance of the corium, and 
is therefore not usually seen until the nodule is incised or 
contents evacuated. When the pus is in excess or obvi- 
ously near the surface, the condition known as A. pustulosa 
is produced. 
Treatment.—The treatment should be both local and 
constitutional. Thorough sponging with hot water and fric- 
tion are of the greatest importance. The plugs of sebum 
should be removed by pressure, and the pus liberated by 
small incisions. Soaps containing free alkali are of value, 
and Hebra’s spiritus saponatus alkalinus is one of the best 
forms. The part should be well rubbed with it, but its use 
should not be prolonged over more than a few days on ac- 
count of the great irritation liable to be produced. It is 
well also to apply ointments containing a small quantity of 
sulphur and creasote, such as 
Sublimed sulphur, grs. xxx. 
White precipitate, ...... grs. x. 
iEthiops mineral, grs. x. 
Olive oil, 
Creasote, ........ tU?iv. 
Lard, to gix. 
—Skin Hospital; 
or lotions containing perchloride of mercury gr. £ or to 
the §j. While the pustules are forming it is well to touch 276 
DISEASES OF THE SEBACEOUS GLANDS. 
them lightly with acid nitrate of mercury, taking care that 
the fluid does not run on to the sound skin. 
The constitutional treatment should consist of such rem- 
edies as are calculated to maintain the general health by 
regulating the various functions of the body. The diet 
should be carefully attended to, and stimulants should be 
prohibited. 
Acne Sycosis—Acne Mentagra. 
Definition.—ITebra’s definition is “a disease of chronic 
course, non-contagious, attacking the hairy parts of the cu- 
taneous surface, and characterized by the development of 
papules and tubercles, continuous thickenings, and pustules 
of various sizes, all of these having invariably hairs passing 
through them.” 
Symptoms.—Acne sycosis consists of a chronic inflamma- 
tion and suppuration of the hair follicles, and therefore at- 
tacks only the hairy parts of the body, but the most usual 
site is the beard. The cause often suggested for A. sycosis 
is the use of blunt razors, but this is doubtful, since persons 
who never shave are liable to it. The pimples first appear 
like those of A. vulgaris, but with a hair passing through 
each of them, and as they get larger and assume the character 
of tubercles they may coalesce and form a thick, indurated 
mass, limited entirely to the hairy region and through 
which the hairs protrude. These hairs are easily extracted 
on account of the inflammation at their root, which itself ap- 
pears swollen. From the indurated mass pus oozes, which 
dries and forms thin yellow scabs, and when the eruption 
disappears cicatrices are left and the place remains bald. 
The disease is specially liable to follow attacks of eczema. 
Diagnosis.—A. sycosis may be mistaken for A. vulgaris, 
eczema, or a svphilide. From them it may be distinguished 
because it always attacks the hairy parts alone, and does 
not spread beyond them, because the hairs pierce the pus- ACNE ROSACEA. 
277 
tules or tubercles, and no similar eruptions are seen else- 
where. 
Prognosis.—The course is always tedious and the disease 
is difficult to cure, but it rarely terminates fatally unless 
erysipelas occurs as well. 
Morbid Anatomy.—This is very much the same as in A. 
indurata, but differs in the greater length of the hairs and 
their follicles, and in the greater depth to which they pene- 
trate the corium. The purulent foci, therefore, lie at a 
greater distance from the surface, and excite more severe 
inflammatory exudation into and hypertrophy of the tissues 
surrounding the follicles. Pus is also found outside the 
follicles and sebaceous glands and at the roots of the hairs, 
which are thus more or less completely destroyed. There 
is, however, no obstructing plug of sebum acting as a me- 
chanical irritant, as in A. vulgaris. 
Treatment.—This consists, in the first place, in epilating 
the hairs of the diseased parts and in shaving the rest of 
the patch, but to be of real service epilation should be com- 
menced as early as possible in the attack and should be 
continued as it spreads. The pustules should be pricked 
and the pus let out, and if the part is not very painful or 
inflamed they should be lightly touched with acid nitrate 
of mercury, but if it is tender cold-water rags covered with 
oil silk should be applied. As the disease becomes more 
chronic ointments and lotions similar to those recommended 
in A. vulgaris should be tried. Hebra strongly insists on 
the importance of regular shaving after the disease has 
been cured, to prevent its recurrence. 
Acne Rosacea. 
Definition.—A disease of the skin occurring on the face, 
and characterized by great hypenemia of the part and dila- 278 
DISEASES OF TIIE SEBACEOUS GLANDS. 
tation of the vessels, accompanied by hypertrophy of the 
fibrous elements and of the glands, which sometimes leads 
to the production of tumors. 
Symptoms.—A. rosacea is believed to be to some extent 
hereditary, and is certainly due to some condition affecting 
the general health. Indigestion, produced by excess of 
food or strong drinks, causes flushing of the face, which 
often terminates in this disease, and in women irregularities 
of menstruation must also be mentioned. It may appear 
at any time except during childhood, but generally in mid- 
dle or advanced life. 
A. rosacea is not in itself a disease of the sebaceous 
glands, although they are frequently among the tissues 
affected. It is always limited to the face, aud attacks in 
preference the nose, cheeks, forehead, and chin. It com- 
mences by an injection of the bloodvessels, leading to a 
reddening of the skin, which fades on pressure, and is in- 
creased greatly after a meal or on exposure to cold. This 
hypercemia of the part produces a burning or tingling sen- 
sation. The disease may stop at this stage or may be asso- 
ciated with other morbid changes, but when these are absent 
the nose is usually alone affected. With the reddening 
there may be a considerable increase in the amount of 
sebum secreted, which gives the part a very greasy appear- 
ance, or the sebaceous glands may be inflamed and filled 
with secretion and their ducts remain open. At a later 
stage round nodules form, and great hypertrophy of the 
part takes place, which, when the nose is attacked, causes 
great deformity. The nodules may be of varying shape 
and size, and sometimes hang from the nose in pendulous 
masses. 
The disease may persist or the redness may fade, and the 
tubercles either become absorbed or drop off, but extensive 
suppuration and ulceration never occurs. 
Diagnosis.—A. rosacea has to be distinguished from A. ACNE ROSACEA. 
279 
vulgaris, lupus erythematosus, and on the nose from frost- 
bite. 
From the first it may be recognized by the limitation of 
A. rosacea to the face, while A. vulgaris attacks the chest 
and back, and also because the inflammation in the former 
affects the skin between the acne spots and causes a tingling 
sensation. 
From lupus erythematosus A. rosacea can be distinguished 
by the absence of ulceration and of the scabs which are 
present in the former. 
From frostbite the early stage of A. rosacea is also dis- 
tinguished by the amount of swelling, and the dark-purple, 
shining appearance in frostbite contrasts with the bright- 
red and greasy appearance in A. rosacea. 
Prognosis.—It is never fatal, but is very obstinate, lasting 
sometimes for life. 
Morbid Anatomy.—The anatomy of A. rosacea cannot be 
clearly described, but there is no doubt that the disease be- 
gins with hypersemia of the part and increased growth of 
the fibrous and connective tissue, and that hypertrophy of 
the glands also takes place. 
Treatment.—Regulation of the diet, and, when necessary, 
of the menses, should be attended to before any good result 
can be expected from local treatment. The inunction of 
sulphur or iodide of sulphur ointment, the application of a 
weak solution of perchloride of mercury, or lightly touching 
the spots with acid nitrate of mercury, are the best forms 
of local treatment, but three or four days must frequently 
be allowed to intervene in order that the inflammation ex- 
cited by this treatment may have time to subside. 
In the mom severe form the local hypercemia is relieved 
by frequent multiple linear scarifications, and when any 
great deformity exists the complete removal of the tuber- 
cular excrescence is desirable. 280 
DISEASES OF THE SEBACEOUS GLANDS. 
Molluscum 'Contagiosum. 
Definition.—A contagious disease of the skin, affecting 
the sebaceous glands, leading to the blocking up of the duct 
and an increased growth of the gland, which becomes filled 
with a white, fatty, and granular substance. 
Symptoms.—The cause of the disease is unknown, but 
there is no doubt that it can be communicated from one 
person to another, although the mode has not been yet dis- 
covered. The disease appears first as a minute hard, white, 
shiny swelling, which gradually grows until it becomes as 
large as a hazelnut, but it is usually about the size of a pea. 
This little tumor, which may be sessile or pedunculated, is 
circular in form, with a flat top, having in its centre a small 
depression, which is the mouth of a sebaceous gland, and 
from which, when the tumor is squeezed, a soft, white, milky 
substance is forced. The tumors may occur singly or in 
scattered groups on the face, especially the eyelids, chest, 
arms, genitals, and on the breasts in women, and cause no 
pain, tenderness, or irritation, but occasionally producing, 
when inflamed, an ecthymatous pustule. As the tumors 
dry up, small horns or warts are sometimes left. The dis- 
ease is more common in children than in adults. 
Diagnosis.—It is easily recognized by the umbilication 
and ease with which the tumor can be emptied, and is not 
liable to be mistaken for any other disease. 
Morbid Anatomy.—The white material of which the tumor 
is composed is found to consist of granular and fatty matter 
with altered epithelium cells. On examining vertical sec- 
tions some of the tumors are seen to be composed of cystlike 
dilatations of sebaceous glands, filled with the products of 
the broken-down epithelial lining. Others present a lobu- 
lated structure, and microscopically are seen to be inclosed 
in fibrous capsules, which send delicate septa between the 
lobules. In each lobule there is first a layer of columnar HYPERIDROSIS. 
281 
cells next the fibrous wall, and then two or three layers of 
polygonal cells more or less infiltrated with fat-globules, 
whilst the centre is occupied by roundish or oval bodies, 
the so-called “molluscum corpuscles,” mixed with some 
fatty debris. These oval bodies, which were formerly sup- 
posed to be peculiar to molluscum, are merely epithelial 
cells that have undergone lardaceous or albuminoid degen- 
eration. 
The whole tumor is covered by the superficial portion of 
the corium, which is somewhat thinned and has its papillae 
flattened by the pressure of the subjacent growth. Its walls 
and base are surrounded by a network of fine vessels, which 
bleed when the tumor is snipped off. 
Treatment. — Treatment consists in making an incision 
across the tumor with a sharp knife and then squeezing out 
the contents. 
Subdivision B.—Of the Sweat Glands. 
Hyperidrosis. 
Definition.—A condition characterized by excessive sweat- 
ing, which may be general or local. 
Symptoms.—General sweating may occur in the course of 
any of the acute constitutional diseases, such as acute rheu- 
matism, when the whole surface of the body may be bathed 
in perspiration. 
Local sweating may affect the hands or feet, or one hand 
or foot, or even one-half of the body, and produces a 
sodden appearance, such as is seen after prolonged immer- 
sion in water. From the constant irritation of the sweat 
eczema may result. 
Treatment.—This should depend on the cause, internal 
remedies, such as belladonna, being required if the sweat- 
ing is general. Sponging with vinegar and water is useful 
to check the nightsweats in phthisis. Locally the part 282 
DISEASES of the sweat glands. 
should be constantly washed with yellow soap and water, 
and bathed with a lead or tannic acid lotion. 
Anidrosis. 
Definition-—A condition characterized by a deficiency of 
perspiration, and occurring as a result either of a constitu- 
tional disease or of an altered state of the skin, as in ich- 
thyosis. 
Bromidrosis. 
Definition.—A condition characterized by the odor of the 
perspiration. 
Symptoms.—This disease may be general or local. The 
former occurs usually in the course of some constitutional 
disease, when the smell differs according to the variety. 
Local bromidrosis is normally present in certain regions of 
the body, such as the axillae, perinseum, and feet, and it can 
therefore only be considered a disease when the smell is 
excessive. When the feet are affected the odor is at times 
so offensive that the person is unable to attend to his duties, 
though his general health is perfectly good. The perspira- 
tion is greatly increased above the normal, and is quickly 
absorbed by the socks, from which the smell arises, owing 
to rapid decomposition. 
Treatment.—Local bromidrosis is often very difficult to 
cure. Thorough cleanliness is essential; the part should be 
washed at least twice daily with plenty of soap, then dried 
aud powdered with starch or flour. Sea-water baths at 
night are of value in some cases, and so also is painting the 
whole part occasionally with iodine. In severe cases, when 
other measures fail, Hebra recommends the following plan, 
which he says “will invariably be attended with success:” 
“ A certain quantity of the simple diachylon plaster 
(emp. plumbi,emp. lithargyri) is to be melted over a gentle SUDAMINA. 
283 
fire, and an equal weight of linseed oil is then to be incor- 
porated with it, the product being stirred till a homogene- 
ous mass is produced, sufficiently adhesive not to crumble 
readily to pieces. This is then to be spread over a piece of 
linen measuring about a square foot. The foot of the pa- 
tient, having been first well washed and thoroughly dried, 
is now to be wrapped in the dressing thus prepared. Pled- 
gets of lint on which the same ointment has been spread 
are also to be introduced into the space between each pair 
of toes, to prevent their touching one another; and care 
must be taken that the foot is completely covered, and that 
the dressing is accurately in contact with the skin. When 
this has been done an ordinary sock or stocking may be put 
on the foot, and outside this a new shoe, which must be light 
and should not cover the dorsum of the foot. After twelve 
hours the dressing is to be removed ; the foot is then not 
to be washed, but must be rubbed with a dry cloth. The 
dressing is then to be renewed in the same way as before, 
and its application is afterwards to be repeated twice a day. 
This procedure must be continued for eight to twelve days, 
according to the severity of the case. ... In the course of 
a few days it will be found that a brownish-yeilow cuticle, 
about thick, is beginning to peel off from all those parts 
of the skin which were before affected with the disease, and 
that a healthy, clean, white surface of epidermis is exposed 
as this substance separates.” 
Chromidrosis. 
Definition.—A very rare condition in which the sweat is 
said to be colored. 
Sudamina—Miliaria. 
Definition.—An eruption of small transparent vesicles, 
chiefly on the abdomen, which contain sweat. 284 
DISEASES OF THE SWEAT GLANDS. 
Symptoms.—In the course of an acute disease, in which 
excessive sweating is a prominent feature, small transparent 
vesicles suddenly appear. At first sight they look like drops 
of water on the surface, but they are hard to the touch. 
The vesicles contain sweat, which is proved by analysis. 
When they burst an eczema may result from the irritation 
of the sweat. 
Treatment.—None is required, unless the disease is accom- 
panied by eczema, which should be treated accordingly. HIRSUTIES. 
285 
CHAPTER XXII. 
Subdivision C.— Of the Hair. 
Hirsuties — Lichen pilaris — Nsevus pilosus — Canities—Alopecia— 
Alopecia areata—Trichorexis nodosa. 
Onychia — Onycliogryphosis — Onychauxis — Onychatrophia — In 
General Diseases. 
Subdivision D.—Of the Nails. 
Subdivision C.—Of the Hair. 
Hirsuties. 
Hirsuties, or an excessive growth of hair on parts where 
normally only fine down occurs, may be either congenital or 
acquired. 
In the congenital variety the excessive growth may be 
either diffuse, covering the whole surface or a large portion 
of it, as in the so-called “ hairy men,” or localized to cer- 
tain smaller arese, as in moles or naevi. 
In the acquired variety large hairs, more or less numer- 
ous, develop in places generally covered only with lauugin- 
ous hairs, such as the upper lip or chin of women, the areola 
of the nipple, or on warts. The irritation of the skin by 
blisters or stimulating applications produces in some indi- 
viduals an abundant growth of long downy or bristly hairs. 
The process consists usually of an increase in number 
and a closer aggregation of the hairs, which are occasion- 
ally thick and bristly. The condition does not affect the 286 
DISEASES OF THE HAIR. 
general health, and is only troublesome in consequence of 
the disfigurement it produces. 
Treatment.—When the hairs are scanty and long, epila- 
tion is the best mode of removing them ; but when they 
are numerous, and are situated on the lip or chin of women, 
a depilatory paste, containing orpiment and slaked lime or 
sulphide of calcium, may be applied every three or four 
days. 
Lichen Pilaris. 
Lichen pilaris consists in the development of small pap- 
ular swellings around the hair follicles, and affects the ex- 
tensor surfaces of the limbs. On the outer side of the thighs, 
where they are most frequently observed, the skin feels 
rough and harsh to the touch. The papules, which are 
about the size of a pin’s head, are pale, or only slightly hy- 
persemic, and do not itch or cause any other subjective sen- 
sation. 
Morbid Anatomy.—The papules are due to epithelial 
debris accumulating in and blocking up the mouth of a 
hair follicle, with usually some exudation into and hyper- 
trophy of the connective tissue around the neck of the fol- 
licle. 
Treatment. —'This consists in washing the skin thoroughly 
with soap and water, frequent warm baths, and in the in- 
unction of vaseline or some simple ointment. 
Njevus Pilosus—Hairy Mole. 
Nsevus pilosus is the term applied to the brown pigmented 
patches, covered usually with long hairs, which are usually 
congenital. 
They are smooth and level with the surface, or only 
slightly raised, and consist of slight hypertrophy of the pa- 
pillary layer, in which and in the rete much brown or black ALOPECIA. 
287 
pigment is deposited, while the hairs are considerably hy- 
pertrophied. The patches are sometimes the starting-points 
of melanotic sarcomatous growths. 
Treatment.—They can be destroyed by blistering or with 
jJotassa fusa or other caustics, or by scraping with Volk- 
maim’s spoon. 
Canities. 
Canities is the term applied to the blanching of the hair, 
occurring normally as a gradual senile change or suddenly 
under the influence of severe mental emotions. The change 
begins at the root of the hair by a diminished formation of 
pigment, and a papilla which has once produced a gray hair 
does not usually form colored ones. The sudden alteration 
is ascribed to a development of air-bubbles in the substance 
of the hair shaft, which obscure the pigment present in the 
medullary portion. Sometimes canities occurs as a result 
of disease of the hair follicles, but after a time the hairs 
may become recolored. 
Alopecia—Baldness. 
Deficient growth of hair may be either congenital or ac- 
quired. The former is rare, and in it the hair is scanty and 
downy, or entirely absent from the scalp, but usually after 
a time the growth may become normal. Acquired baldness 
may result either as a senile change, when it is often pre- 
ceded by gravness of the hair with more or less atrophy of 
the skin, sebaceous glands, and hair follicles, or at a com- 
paratively early period as a sequel of one of the acute dis- 
eases, such as scarlatina, erysipelas, etc., or as a result of a 
local inflammatory process which affects the hair follicles and 
papillae, as in acute or chronic eczema, psoriasis, syphilis, 
favus, ringworm, etc. 
In alopecia senilis the skin, hair follicles, and glands are 
diminished in size and wasted,and only fine lanuginous hairs 288 
DISEASES OF THE HAIR. 
are produced. The change is a permanent one and not 
amenable to treatment. 
In premature alopecia, resulting from acute diseases, the 
baldness is usually temporary. In eczema, psoriasis, and 
other affections the shedding of the hair is analogous to tbe 
desquamation of the cuticle from the inflamed skin, and un- 
less the inflammation has been sufficiently severe to destroy 
the hair papillae, new hair, at first downy and afterwards 
normal, is reproduced. But where the follicles and papillae 
have been destroyed by suppuration and ulceration the bald- 
ness is permanent, and no treatment is of any avail. For 
the loss of hair after fevers tonics, generous diet, and a local 
stimulating lotion containing cantharides are the proper 
measures to be relied upon. 
Alopecia Areata. 
Definition.—An atrophic disease characterized by the sud- 
den loss of hair in ‘small roundish limited patches, which 
have a tendency to enlarge slowly. 
Symptoms.—The disease begins on the head or beard by 
the sudden loss of hair on a limited area. The hair comes 
out easily, and shows no signs of brittleness or any morbid 
change. Usually there is no sensation to indicate the posi- 
tion of the disease. The patches from which the hair has 
fallen are extremely smooth, white, and glistening, or pol- 
ished like a billiard ball, and on the same level with or 
slightly more depressed than the adjacent skin. The patches 
are most common on the scalp, but may occur on the eyebrows, 
cheeks, or other hairy parts of the body ; they are sharply 
limited and surrounded by healthy hair, growing luxuriantly. 
As the disease spreads the hairs at the margin of the patch 
become loose and easily fall out, and thus by the confluence 
of patches large irregular arete are formed. After a time 
the disease becomes spontaneously arrested, the smooth shiny ALOPECIA AREATA. 
289 
skin becomes marked by little prominences corresponding 
to the hair follicles, and thin hairs, at first white and downy, 
but afterwards stronger and darker, are slowly reproduced. 
In rare instances the hair never grows again, or only as fine, 
pale, or downy threads. 
Diagnosis.—The patches of alopecia areata are sometimes 
mistaken for tinea tonsurans, but the differences between the 
two diseases are so marked that the diagnosis is easy. In 
tinea tonsurans the patches are rarely bald, but are covered 
with short stubby hair, which comes out easily and under 
the microscope show's the fungoid character of the disease. 
The patches are also scaly, contrasting strongly wdth the 
perfectly smooth shiny patches of alopecia areata. 
Prognosis.—The disease, arising suddenly, like zoster and 
morphoea, runs a definite though prolonged course, and tends 
to spontaneous recovery. It is probably a neurosis, and due 
to some'nutritive lesion affecting the formation and growth 
of the hair. The occasional occurrence of alopecia areata on 
neuralgic patches is a fact somewhat in favor of this view. 
Morbid Anatomy.—No visible changes have been discov- 
ered in the cutis. The bulbs of the affected hairs are atro- 
phied, and a nodular swelling, due to the inversion of the 
root sheath on them, is sometimes seen near the end. The 
fungus described by Gruby, Bazin, and some others, and 
named microsporon Audouinii, has not been found by the 
majority of modern observers, and the cases described as 
alopecia areata by the first-named observers were probably 
only old-standing and severe forms of ringworm in which 
the hair had been completely destroyed. Inoculations from 
true alopecia areata have not produced any result (Dyce 
Duckworth). 
Treatment.—The spreading of the disease can sometimes 
be arrested, and the new growth of hair encouraged by se- 
vere blistering with acetum cantharidis or Burt’s vesicating 
fluid. The blistering should be repeated every fortnight. 290 
DISEASES OF TIIE NAILS. 
Internally iron, strychine, arsenic, and other nervine tonics 
are said to be of value; at all events they should be tried 
in conjunction with local stimulation. 
Trichorexis Nodosa. 
Triehorexis nodosa consists in the formation of little oval 
or round swellings on the hairs of the beard and mustache. 
The little nodes look like nits, but are seen under the micro- 
scope to be formed by a localized splitting and bulging of 
the hair itself, which presents somewhat the appearance 
of two brooms thrust into one another. No parasite is pres- 
ent, and the condition is ascribed by Beigel, who first de- 
scribed it, to the generation of gas in the medulla bursting 
the cortical substance of the hair. The affected hairs are 
not more easily extracted than normal hairs, but they break 
very readily at the nodes, leaving a frayed, brush like extrem- 
ity. The disease is very common and of little consequence. 
The treatment usually recommended is shaving, though the 
hairs are apt to split again when allowed to grow. 
Subdivision D.—Of the Nails. 
Onychia. 
Inflammation of the nails occurs after mechanical inju- 
ries to the matrix, such, for instance, as pressure on the 
edges of an hypertrophied toe nail (paronychia lateralis), 
or spontaneously after a slight scratch or tear of the skin 
about the fold round the nail. 
There is redness and swelling of the fold round the nail, 
most marked at the sides near each angle in “ ingrowing 
toe nail,” together with a deep-red discoloration of the ma- 
trix, attended with great tenderness on pressure and a sen- 
sation of heat and throbbing. The nail on its margin in 
idiopathic onychia becomes opaque, pus collects under it 
and under the cuticle of the fold, and the nail, becoming ONYCHOGRYPIIOSIS. 
291 
loosened in places, covers a sloughy, raw, tender surface, 
from which a brownish-red fluid exudes. Frequently the 
whole nail is shed, and after a slow process of healing a 
new nail forms, which is thin, rough, and brittle. In “in- 
growing toe nail” the inflammation and subsequent suppu- 
ration is limited to one or other angle of the nail and to 
the adjacent nail fold, from which exuberant tender granu- 
lations protrude. 
In acute onychia, or “whitlow,” there is often pyrexia 
and constitutional disturbance, and necrosis of the terminal 
phalanx, suppuration in the synovial sheaths', and cellulitis 
of the hand and arm may occur. 
Treatment.—“Ingrowing toe nail” in its milder forms 
may be well treated, as suggested by Dr. Tilbury Fox, by 
scraping the centre of the nail quite thin with a piece of 
glass and softening it with liquor potassse. The granula- 
tions should be touched with nitrate of silver from time to 
time. Should the disease be more advanced, the nail should 
be completely removed by operation. In acute onychia, or 
“whitlow,” poultices should be applied to the part, to pro- 
mote suppuration; dead skin or nail must be removed, and 
subsequently it should be dressed with astringent lotions. 
Internally tonics aud stimulants should be prescribed. 
Onychogryphosis. 
This is the term applied to a condition observed most 
frequently in the little and great toes, in which the central 
portion of the nail becomes converted into an irregular 
clawlike or horny growth, ridged and more opaque and 
brittle than the normal nail. It is due to the local hyper- 
trophy of the papillae of the matrix and of the nail bed in 
front of it, as a result of continued pressure. 
The papillae, sometimes two or three lines in length, pro- 
ject into the horny mass and form a tender, vascular core 292 
DISEASES OF THE NAILS. 
imbedded in greatly thickened epithelial layers, as seen in 
ichthyosis. 
Onychauxis. 
Onychauxis, or hypertrophy of the nail, assumes either 
the form of a lateral outgrowth which may press upon and 
irritate the adjacent folds of skin, causing the so-called 
“ingrowing toe nail,” or in the form of a somewhat chisel- 
shaped thickening of the nail, with the thick, broad part at 
the free border produced by hypertrophy of the papillse in 
the anterior part of the nail bed. 
The condition is analogous to tyloma, as onychogryphosis 
is to clavus. 
Treatment.—Both these forms of undue growth of nail 
substance can be treated by paring away the excess of horny 
substance by means of the knife, scissors, or pliers. Should 
the soft, vascular part be exposed, it should be divided and 
the bleeding spot rapidly cauterized. 
Onychatrophia. 
Absence or defective development of the nails occurs 
so*metitnes as a congenital condition, and frequently in as- 
sociation with absence of hair. The more common variety 
results from disease or destruction of the matrix or bed of 
the nail in the course of various local or general diseases, 
but most usually from injury. 
The changes met with in the nails as a result of general 
or local disease may be classed under the following heads: 
1. Acute.—Desquamative, in erysipelas, scarlatina, 
pityriasis rubra, and acute eczema. 
2. Chronic.—From severe diseases, such as enteric 
fever, pneumonia, peritonitis, etc. 
In General Diseases. IN GENERAL DISEASES. 
293 
3. In chronic eczema, psoriasis, and lichen ruber. 
4. As a result of parasitic growths in favus and tinea 
circinata. 
1. In acute eczema, erysipelas, scarlatina, and pityriasis 
rubra, the nails are sometimes shed as a consequence of the 
local hypertemia and exudation, the process being of the 
same nature as the desquamation of the cuticle. 
2. After severe diseases, such as enteric fever, pneumonia, 
and acute rheumatism, depressed transverse lines are often 
found on the nails during convalescence. The nail at these 
places is much thinner than normal, and often somewhat 
opaque and brittle. 
3. In chronic eczema, when the disease attacks the hands 
or feet, it may spread to the nails, causing them-at first to 
become pitted like the rind of an orange. Later they split 
longitudinally, at first slightly, when the dirt which fills 
the cracks makes them look like black lines, but widening 
as the disease progresses until the whole nail splits from 
end to end and finally is shed. 
In psoriasis the nails may become thickened, opaque, 
irregular, and darker in color. They are very brittle, short, 
fissured at their extremities, and present transverse cracks. 
In the bed and under the margin small spots of psoriasis 
may be seen in the early stages of the disease. 
In lichen ruber, in severe cases, the nails are opaque, 
rough, and brittle, sometimes thickened, and at other times 
thin and atrophied. 
4. In some cases of tinea tonsurans and of favus the nails 
become affected with the fungous growth. They are irregu- 
lar, thickened, and brittle, and in places are marked with 
yellowish spots and lines, in which the nail is more friable 
than normal and appears rotten. Under the microscope, 
after soaking in liquor potassse, scrapings show mycelium 
filaments and the spores of trichophyton or achorion. 294 
PARASITIC AFFECTIONS. 
CHAPTER XXIII. 
Class A.—Parasitic Affections. 
Sub-class A.—Animal. 
Pediculosis—Scabies—Eruptions produced by Fleas, Bugs, etc. 
Sub-class B.— Vegetable. 
Tinea tonsurans—Kerion—Tinea sycosis—Tinea circinata—Eczema 
marginatum—Tinea versicolor—Tinea favosa. 
Sub-class A.—Animal. 
Pediculosis—Phthiriasis, 
Definition.—A diseased condition of the skin produced 
by the attacks of lice. 
Symptoms.—Three species of lice infest the human body,— 
pediculus capitis, restricted to the hairy scalp; pediculvs 
pubis, found about the genitals, and occasionally on the 
margins of the eyelids, beard, and axillne; and pediculus 
corporis, or vestimenti, chiefly affecting the trunk. 
In pediculosis capitis, produced by the presence of pediculi 
capitis, the lice are found wandering about the roots of the 
hair, most abundantly on the occipital and temporal regions, 
and more frequently in women and children than in male 
adults. They excite intense itching by thrusting their pro- 
bosces into the hair follicles and sucking blood from the 
capillaries, and soon, owing to the scratching which results, 
excoriations, eczematous eruptions, and crusts appear. The PEDICULOSIS. 
295 
hair becomes matted, foul-smelliug, and covered with adhe- 
rent “ nits ” or ova ; the glands in the anterior triangle and 
at the back of the neck frequently swell and even suppu- 
rate, and excoriated spots and boils often appear on the 
nape of the neck. 
In pediculosis pubis, the crab lice, as they are termed from 
their shape, anchor themselves firmly to the roots of the 
pubic hairs, and by their sucking produce itching and fol- 
licular irritation, which excites scratching and thereby 
causes excoriations and eczema. The lice are seen as little 
grayish specks adhering to the bases of the hairs, and are 
mostly found in adults. 
Pediculosis corporis, occurring mostly in elderly persons, 
like the previous affection, is excited by lice, which, how- 
ever, are rarely visible on stripping the patient, as they in- 
habit and deposit their ova in the folds of the under-cloth- 
ing and the interstices of flannel garments worn next the 
skin. Thrusting their probosces into the hair follicles, they 
wound the capillaries and produce minute haemorrhagic 
specks, surrounded at first, like fleabites, by a hyperaemic 
zone. These spots are the seats of intense itching or creep- 
ing sensations. Violent scratching ensues; the cuticle is 
torn off over the parts affected, and excoriations are pro- 
duced, covered by scabs of dried blood. Papular, urtica- 
rial, eczematous, and furuncular or pustular eruptions are 
usually excited in the same way, and in old-standing cases 
the skin becomes deeply pigmented and covered with scabs, 
which are most numerous about the shoulders and the front 
of the chest beneath the clavicles. This eruption was 
formerly named prurigo senilis, and is not pathognomonic 
of pediculi in itself, being capable of production by any 
intense itching, but its restriction to certain sites and the 
presence of haemorrhagic puncta determine the diagnosis. 
Diagnosis.—In pediculosis capitis the presence of the 
“nits” or ova—small whitish, semi-translucent bodies—• 296 
PARASITIC AFFECTIONS. 
firmly adherent to the hairs, and the discovery of the para- 
sites near their roots or attaching to the comb, settles the 
question. 
In pediculosis pubis the parasites adhere to the roots of 
the hairs, and have the appearance of little grayish or 
brownish scales, which when pulled off with forceps often 
tear out the hair to which they cling. 
In pediculosis corporis the lice must be looked for on the 
folds of the under-clothing, about the junctions of the sleeves 
with the body, and under the collar of the shirt. The re- 
striction of the “ pruritic rash ” to the shoulders and infra- 
clavicular region, aud the presence of haemorrhagic puucta, 
may occasionally, when, from the under-clothing having 
recently been changed, no pediculi can be found thereon, 
lead to an accurate diagnosis. 
Prognosis.—Pediculi, if untreated, may increase and mul- 
tiply for years, causing eczema, pruritic eruptions, glandular 
enlargements, abscesses, etc. Under appropriate measures, 
however, they are readily exterminated, and the eruptions 
excited by them subside either spontaneously or under or- 
dinary treatment in a short time. 
Anatomy.—The pediculus belong to the class Insecta. Its 
head, which is small, is furnished with a delicate retractile 
proboscis, not usually discernible after death ; and it has a 
compressed thorax, six legs, and a somewhat flattened abdo- 
men. 
The pediculus capitis has a slender shape, and is gener- 
ally smaller than the other varieties; its abdomen is ovoid 
and terminates in a blunt cone. 
The pediculus corporis is much larger, averaging ¥th to 
§-th inch in length; its abdomen presents a terminal trian- 
gular notch. 
The pediculus pubis, the crab louse, is relatively much 
broader aud shorter than the other kinds ; its abdomen is 
nodulated, and the anterior pairs of its short stout legs are SCABIES. 
297 
provided with strong claws, with which it anchors itself 
firmly to the skin. 
Treatment.—The full-grown lice are easily destroyed by 
a carbolic lotion (1 to 20), or by the inunction of dilute 
ammonio-chloride, red precipitate ointment, oleate of mer- 
cury 5 per cent., or ung. hyd. c. sulph. As the ova are not 
readily attacked by these remedies, they must be applied 
for a week or ten days, so as to destroy the young lice as 
they become hatched. 
For pediculus pubis, ung. staphisagrise, scented with oil of 
lavender or roses, is a very valuable application. 
Pediculus corporis should be treated by warm baths, 
thorough change of clothing, and baking the old garments 
in a disinfecting oven at a temperature of 250°-300° Fahr., 
so as to destroy the lice or their ova. 
Itching may be mitigated by soothing alkaline or prussic 
acid and glycerin lotions, and any eczematous or other 
eruptions treated on general principles. 
Scabies—Itch. 
Definition.—A contagious disease of the skin, produced 
by the presence of the acarus scabiei in the epidermis. 
Symptoms.—Following the arrangement of Hebra, we may 
class the phenomena of scabies under three headings, viz.: 
1. Those arising directly from the presence of acari in 
the skin. 
2. Those which are the result of scratching. 
3. Those which are produced by the action of other irri- 
tants upon portions of skin affected by acari. 
1. Those directly due to the presence of acari in the skin. 
The full-growm female acarus after impregnation begins 
at once to work her way into the epidermis, and burrows 298 
PARASITIC AFFECTIONS. 
somewhat obliquely under the surface into the soft cells of 
the stratum lucidum or the rete, giving rise to a narrow* 
somewhat sinuous tunnel or cuniculus. The tunnel, whitish, 
and dotted here and there with darkish spots,—six or eight 
jn number, which are the deposited ova,—is somewhat dilated 
at its terminal extremity into a small roundish chamber, in 
which the acarus lies. At times the burrow is seen as a 
whitish line on the summit of a reddish ridge, and occa- 
sionally vesicles or pustules form near to or along the course 
of the cuniculus, but never involve its terminal chamber. 
At the extremities the burrows, which average ith of an 
inch in length, but which may vary from of an inch 
to two or three inches, are usually blackened by contact 
with staining materials, dirt, etc., on the trunk, penis, but- 
tocks, elbows, and knees, and in the skin of children ; while 
upon the hands of very cleanly people they are pale and 
not easily detected. In adults the disease most frequently 
attacks the interdigital webs and the thin skin on the flexor 
surface of the wrist; it also attacks the penis, hypogastrium, 
the buttocks, axillm or flexures of the elbows, mamrme, and 
inner ankles. In children the buttocks and feet are the 
chief seats of the disease, but any part of the body may 
become inoculated. The scalp and face are never impli- 
cated in adults, and only very rarely in children. The 
burrowing of the acarus is accompanied by itching, which 
is worse at night; and by the irritation of the parasite 
alone, as well as by the scratching it excites, urticarial, 
eczematous, pustular, or ecthymatous eruptions may be 
produced. 
2. As a result of scratching linear wheals, excoriated 
papules covered with black crusts of dried blood, vesicles, 
pustules, etc., are usually developed, forming a “pruritic 
rash” similar to that of pediculosis. It is always most 
marked on the front of the trunk and thighs, being limited 
to, or at all events most intense on, a space bounded by the SCABIES. 
299 
mammary line above and the knees below. The face is 
very seldom scratched, and the back to a less extent than 
the front of the trunk. 
3. If the skin affected with itch be exposed to pressure 
or friction, papules, tubercles, pustules, or crusts appear 
over the tubera ischii,—e. g., when persons sit on hard 
benches,—or they may present themselves on the tracts of 
skin indurated by crutches, trusses, belts, garters, or tight 
clothes. These nodules may or may not exhibit burrows 
on their summits. 
Diagnosis.—The diagnosis of scabies is based upon the 
history of contagion, usually to be elicited, the steady pro- 
gress of the affection, the presence of itching, aggravated 
at night, the particular site of the eruption, on the wrists 
and between the fingers most frequently in adults (unless 
parasiticide soaps be used), on the penis, hypogastrium, and 
mammae, or on the buttocks and feet, in infants, and by the 
discovery of cunieuli, from the terminal dilatations of which 
the acari can be extracted and examined microscopically. 
When, as in infants, the burrows cannot be easily distin- 
guished and crusts are abundant, the maceration of these 
with liquor potassae will often assist the discovery of full- 
grown or embryonic acari. 
Attention to these distinctive features will simplify the 
diagnosis of scabies, even though it should be complicated 
with pruritic, eczematous,'or ecthymatous eruptions. Pru- 
rigo of Hebra differs from scabies by the presence of hard, 
solid, fleshy papules, by its history, and by the greater 
severity of the itching. 
In pediculosis corporis, as in scabies, a “pruritic rash” 
may be present upon the trunk, but the absence of cunieuli 
in the skin will sufficiently distinguish the former from the 
latter. 
Prognosis.—Scabies is merely a local trouble; exerts no 
deteriorating influence on tire constitution even in inveterate 300 
PARASITIC AFFECTIONS. 
cases. It usually yields to parasiticides, and the eczema- 
tous eruptions excited by it and by the scratching subside 
under suitable treatment. 
Anatomy.—The adult female acarus scabiei is oval, about 
g0th to of an inch long by T^0th to ggth of an inch 
broad ; the dorsal surface is convex and armed with angular 
spines, while the ventral presents four pairs of legs, the two 
anterior of which have stalked suckers. In the male the 
third pair are furnished with fine setae, and the fourth with 
suckers. In the female both hinder pairs are provided with 
setae only, and, whereas the male wanders upon the surface, 
she burrows into the cuticle and deposits from twelve to 
twenty ova, from which are hatched six-legged embryos. 
These undergo several changes of skin, and acquire their 
fourth pair of legs after the first moulting. 
Treatment.—Give a warm bath, wash well with soap, 
thoroughly rub in some parasiticide ointment, containing 
as the essential ingredient grs. xx to $ss. of sulphur to §j 
of lard, scented with various aromatic oils; put on close- 
fitting flannel drawers and jerseys, so as to keep the oint- 
ment acting upon the skin; and repeat the bath and the 
washing at the end of forty-eight hours. If itching con- 
tinues after this, the same plan must be adopted again. 
Care must be taken not to use too strong preparations of 
sulphur, as they are apt to produce a severe eczematous 
condition. As a substitute balsam of Peru, or storax in the 
form of an ointment, may be tried. Sulphur vapor baths 
have been recommended, but they are not so efficacious as 
the other inodes of treatment. 
Eruptions produced by Fleas, Bugs, etc. 
The common flea, pulex ivritans, gives rise to a roseolar 
spot, sometimes slightly raised, with a central red punctual, 
and as the redness fades the centre remains as a red or dark- FUNGI. 
301 
colored petechia, lasting several days, and known as the 
purpura pulicosa. In some persons urticarial wheals or 
vesicles may result. 
The bed bug, acanthia lectularia, causes erythematous or 
urticarial spots, which itch much and are more persistent 
than fleabites. Though the redness fades in a day or so, 
a small itchy, indurated papule with central haemorrhagic 
punctum may last two or three days more. 
The harvest mite, leptus autumnalis, a minute reddish 
parasite, belonging, like the itch insect, to the class Arach- 
nida, imbeds itself in the skin, and causes a papular erup- 
tion with itching, intensified at night as the temperature 
of the body increases. The appearance lasts a week or ten 
days and then subsides. 
Gnats and mosquitoes, belonging to the genus Culex, and 
some kinds of midges also, cause erythematous or urticarial 
papules, and similar eruptions, which itch intensely, are 
excited in some persons by the hairs of a certain class of 
caterpillars. 
Treatment.—The itching may be allayed by the applica- 
tion of diluted sp. amm. aromat., of lot. carbonis detergens 
(3.j t° 3j)> or lot. hydrarg. perchlor. grs. ij to oj with the 
addition of trjjx to rrj?xij of dilute prussic acid in the ounce. 
Some authors, among them Hebra and Neumann, are of 
opinion that all skin diseases caused by the growth of fungi 
in the epidermis or appendages are due to one species of 
parasite, which present certain differences according to the 
conditions of the nidus in which it is found. It is more 
usual, however, to describe three different varieties of fungi, 
viz.: 
Sub-class B. — Vegetable. 
a. Trichophyton tonsurans. 
b. Microsporon furfur. 
c. Achorion Schoenleinii. 302 
PARASITIC AFFECTIONS. 
Trichophyton tonsurans, occurring in various parts of the 
body, gives rise to cutaneous affections, to which the term 
tinea with some qualifying adjective has usually been ap- 
plied. In the scalp it causes tinea tonsurans, the common 
ringworm, and kerion where prominent, boggy, honeycombed 
patches are present. On the hairy parts of the face it pro- 
duces tinea sycosis, on the body tinea circinata (herpes circi- 
natus, etc.), and the so-called eczema marginatum. The nails 
also occasionally become affected. The disease attacks all 
classes, the healthy and prosperous as well as the poor and 
debilitated. 
Definition.—A contagious disease of the scalp, caused by 
the presence of trichophyton tonsurans in the epidermis, 
the hairs, and their follicles. 
Symptoms.—Tinea tonsurans is met with most frequently 
in children, but is occasionally seen in adults. From the 
fact that persons who have suffered long from ringworm of 
the scalp in childhood frequently present patches of tinea 
versicolor when grown up, it has been supposed that the 
latter affection is due to a modification of the trichophyton, 
produced by the difference between the skin of an adult 
and that of a child. In the early stage, which rarely comes 
under observation, a small red, erythematous or slightly 
raised patch arises on some part of the hairy scalp, accom- 
panied by considerable itching. As the patch gradually 
enlarges, the redness and elevation of the centre subside, 
and a roundish ring with a bright-red l'aised margin, often 
presenting a crop of small vesicles (herpes circinatus), and 
a paler, rough, or scurfy-looking centre, is produced. If 
the rings be concentric, an eruption simulating erythema 
or herpes iris is produced. 
In the fully developed condition ringworm appears as a 
pale-brown or slaty-looking, roundish patch inch to 3 or 
Tinea Tonsurans—Ringworm of the Head. KERION. 
303 
4 inches in diameter), slightly elevated above the adjacent 
healthy scalp, and covered with short stubbly hairs £ inch 
long and small opaque branny scales. The hairs are thick, 
twisted, or hent, frayed at their extremities, have a dull- 
grayish look, and break off or fall out easily from their fol- 
licles, which are somewhat prominent. At this stage the 
brittleness, loss of color, and deformity of the stubbly hairs 
are marked features, and should always be looked for. In 
some instances the parasite excites an acute inflammation 
of the hair follicles, which become pustular, and as a con- 
sequence destruction of the papillse of the hairs and per- 
manent alopecia may follow. 
Eczema is sometimes produced, and the yellowish-green, 
brittle crusts which then form conceal the appearances of 
ringworm. 
Occasionally ringworm of the scalp becomes diffuse, and 
much resembles eczema capitis in the scaly stage. After 
lasting for a variable time ringworm begins to subside, and 
the patch is covered with fine scales and young hairs, which 
are apparently normal; or both skin and hairs may, on 
superficial observation, appear quite natural. Here and 
there, however, and chiefly at the margins of the patch, 
short, stubbly, discolored hairs can be found on careful ex- 
amination, and unless these are eradicated the disease is 
liable to relapse and to affect other persons. 
In a few cases smooth, hairless patches, resembling those 
of alopecia areata, are produced, which, according to Dr. 
Liveing, has led to the erroneous belief that there is a para- 
sitic disease (which has been called tinea decalvans) distinct, 
on the one hand, from tinea tonsurans, and on the other 
from alopecia areata. 
Kerion. 
This is a rare condition, in which one or more of the 
patches of ordinary ringworm becomes raised, tender, and 304 
PARASITIC AFFECTIONS. 
uneven ; small prominences, resembling inflamed hair folli- 
cles, soon appear, from which a viscid, honeylike secretion 
exudes, and the whole mass becomes what may be termed 
“ boggy ” to the touch. As a rule no pus is formed, but 
the hairs and their follicles are gradually destroyed, the 
result being permanent baldness. 
Tinea Sycosis. 
This variation is produced when the parasite attacks the 
hair of the beard and mustache, and extends into their 
deepseated follicles. The primary symptom, as in tinea 
tonsurans, is a red, scaly, and itching patch; the follicles 
next become indurated and tender, forming reddish, promi- 
nent tubercles, which suppurate ; the hairs become dull and 
brittle, and are easily extracted. When the pustules and 
small abscesses round the follicles burst, crusting takes 
place, but to a less extent than in eczema of the face. 
Tinea Circinata. 
This results from the development of trichophyton on the 
non-hairy parts of the body ; it appears most commonly on 
the face, neck, and trunk, and may or may not be accom- 
panied by patches of tinea tonsurans ; it also shows itself on 
the hands and arms of those attending to cases of ringworm 
of the scalp. Small reddish, somewhat raised, circular 
patches, covered with branny scales, and usually presenting 
a ring of minute vesicles at their margins, make their ap- 
pearance, and are commonly attended by marked itching. 
Fading in the centre, the patch gradually extends at the 
margins, which are usually vesicular (hence the name herpes 
circinatus), and forms “ fairy rings,” like those of other 
fungi. By the coalescence of these rings irregular circinate 
or gyrate bands are produced, the rings ceasing to extend 
and overlap where they blend, as if the material for their ECZEMA MARGINATUM. 
305 
further growth had been exhausted in spots already affected 
with the disease. T. circinata, when it reaches the scalp or 
hairy parts of the face, gives rise to T. tonsurans or T. 
sycosis, and is often found in isolated patches in persons 
affected with those diseases, or in those who have come in 
contact with them. 
Eczema Marginatum. 
Affecting the genitals, the inner sides of the thighs, and 
the buttocks, is merely a variety of tinea circinata occur- 
ring in parts where the abundant perspiration, warmth, and 
friction predispose the skin to inflammatory action. The 
red, elevated, and itching patches fade in the centre, leav- 
ing it deeply pigmented, and at the raised margins vesicles, 
pustules, excoriations, or crusts are met with. It spreads 
in the same way and presents the same fungus as T. circi- 
nata. In some cases the parasite may not be found, though 
the eczema which it has started persists. 
Diagnosis.—In T. tonsurans the round, scaly, itching 
patches on the scalp, the dull, brittle, or stubbly hairs, which 
are easily pulled out, and the reddish, spreading margin, 
while the centre is pale, are features which are diagnostic of 
the disease. When impetiginous crusts hide the whole 
patch, when smooth bald patches occur, when new hairs 
are growing and the disease is receding, or when it is in the 
early stage and appears as an erythematous or vesicular 
patch, ringworm may be mistaken for eczema of the scalp, 
alopecia areata, or erythema vesicans. When the entire 
scalp is affected, it is almost impossible to distinguish it from 
scaly eczema of the scalp. In all these cases, however, the 
detection of the parasite in the stubbly hairs, crusts, or 
scales, after maceration in liq. potassse, will clear up the 
difficulty. The frequent occurrence of T. circinata on other 
parts of the body, or the detection of dull, brittle, broken- 306 
PARASITIC AFFECTIONS. 
off or distorted, easily extracted hairs, will also help the 
diagnosis. 
Even to the naked eye the appearances of T. kerion are 
so peculiar that the nature of the affection can hardly be 
mistaken. In the early stages, where the puffy swelling 
may simulate a subcutaneous abscess, microscopical exam- 
ination of the loosened hairs settles the question. 
T. sycosis differs from eczema of the beard in the devel- 
opment of indurated tubercles and abscesses, the dull, brittle 
character of the hairs, which are readily extracted, the 
presence usually of T. circinata on other parts, and in the 
presence of trichophyton on microscopic examination. T. 
circinata and eczema marginatum may resemble some forms 
of erythema multiforme and of eczema respectively, but the 
spreading in “ fairy rings ” and the presence of the parasite 
are diagnostic. 
Prognosis. — Ringworm of the body is usually easily 
amenable to appropriate treatment, but on the hairy parts, 
on the other hand, it is extremely obstinate, persisting for 
months, and •sometimes for years, in spite of all remedies, 
and being liable to recur if the treatment have been left off 
too soon. The parasite does not endanger life, but is trou- 
blesome on account of the loss of hair it causes, the secon- 
dary inflammations it sometimes excites, and the marked 
contagiousness of the affection. 
Morbid Anatomy.—Examining under the microscope, after 
maceration for twenty-four hours in dilute liq. potassse, the 
dull, brittle hairs or the epidermic scales obtained by scrap- 
ing with a blunt knife a patch of tinea, fine mycelium fila- 
ments, made up of roundish or cylindrical segments, are 
seen running longitudinally throughout the hair, or forming 
a feltwork in and between the epidermic scales. Where 
the filaments reach the surface of the hair they give rise to 
globular aggregations (conidia), made up of minute round 
refracting bodies, the spores of the fungus, which measure ECZEMA MARGINATUM. 
307 
about in°h in diameter. Occasionally no filaments 
are met with, the hair presenting only collections of conidia 
and scattered spores on the surface and in its substance. 
Dr. F. Taylor, in examining vertical sections of a scalp 
affected with ringworm, found the following changes : In 
hairs slightly affected mycelium filaments only were found, 
running along the length of the hair, which was not altered 
in shape. The hair was in later stages obscured by a dense 
aggregation of spores in its follicle, and its substance, as 
far down as the upper part of the bulb, was destroyed, or 
replaced by mycelium threads. The hair papillae were never 
affected, and laterally the internal root sheath formed the 
outer boundai’y of the fungus growth, no traces of it being 
found in the outer root sheath, follicle walls, cutis, or epi- 
dermis. Only slight traces of inflammation were found 
round the hairs. 
Treatment.—In the different varieties of tinea produced 
by trichophyton attention must be directed to: 
1. The destruction of the parasite. 
2. The removal of any secondary inflammation which 
may have been caused by the parasite or the remedies em- 
ployed for its destruction. 
Where the disease is superficial, as in T. circinata and 
eczema marginatum, there is little or no difficulty in car- 
rying out the first indication. Lotions containing bichlo- 
ride of mercury (grs. ij ad 3j), sulphurous acid, or hypo- 
sulphite of soda (3j ad 3j), or the persistent inunction of 
dilute ammonio-chloride or nitrate of mercury ointments, 
or of oleate of mercury 5 per cent., are usually curative in 
a few weeks. Vaseline, oleate of zinc, or bismuth, etc., 
should be used subsequently if there is any eczema. 
In ringworm of the scalp or of the beard (T. sycosis) the 
main difficulty is to get the parasiticide brought into con- 
tact with all the mycelial filaments and spores, many of 308 
PAR\SlT*rC AFFECTIONS. 
which lie deep down in the hair follicles. Hence, though 
the superficial fungus growth is easily destroyed, and the dis- 
ease appears to be eradicated, much annoyance is caused by 
the recurrence of the affection, a few conidia which have 
eluded the poison being sufficient to start a fresh growth, 
and subsequently to infect other persons. 
The indications, therefore, for treatment are to : 
1. Remove as much as possible of the diseased hairs and 
epidermis. 
2. Use a parasiticide which will penetrate readily and 
deeply into the cuticle and hair follicles. 
3. Continue the treatment, more or less modified, for at 
least a month after all signs of the disease are gone. 
1. The hair over the diseased patch, and for i to inch 
round, or of the whole scalp, beard, etc., should be cut short 
with scissors, all crusts removed by oiling or poulticing, and 
the surface washed well with soft soap and water. Loose 
hairs and scales should be removed by rubbing, and in the 
case of T. sycosis by epilation, which, owing to the loosen- 
ing of the hairs, is here less painful than in eczema of the 
beard. Blistering by liq. epispasticus, acetum cantharidis 
glaciale, or Coster’s paint of iodine and oil of wood tar, is 
also useful for this purpose. 
2. A solution of bichloride of mercury in acetic acid 
(grs. vj to ,?iv), which has the combined advantages of pen- 
etrating deeply, of macerating the hair and epidermic tis- 
sues, and of blistering, is one of the best. It should be re- 
peated from time to time, and weak acid nitrate or ammo- 
nio-chloride of mercury ointments applied in the intervals 
to the irritated skin. 
3. After removing all the stubbly hairs, and when no 
further reproduction of the disease has appeared for some 
time after the last application of vesicants or of the mer- 
cury and acetic acid paint, weak ammonio-chloride of mer- TINEA VERSICOLOR. 
309 
cury ointment should be rubbed in twice a day for some 
time further, to guard against the possibility of some over- 
looked portion of fungus starting into fresh growth. 
Any eczema of the scalp thus excited should be treated 
in the usual way. 
Goa powder, or its active principle, chrysophanic acid, 
are useful only as irritants, and do not cure tinea tonsurans, 
though, like simple blistering, they may suffice to remove 
T. circinata. 
Any constitutional debility, strumous condition, etc., 
should be treated with cod-liver oil, tonics, and good food 
and hygiene, which, though unable to cure the disease, by 
improving the general health lessen the risk of eczema, etc. 
Cases of ringworm of the scalp are rarely cured within 
less than four to six months, and even with the most effi- 
cient and thorough treatment they may last for years. In 
public institutions and schools the separation of the patients 
and of their clothing, towels, etc., is necessary to check 
further spread of the disease. 
Tinea Versicolor—Chloasma—Pityriasis 
Versicolor. 
Definition.—A parasitic contagious disease, excited by 
the presence of microsporon furfur in the epidermis, usually 
occurring on the trunk as yellowish or pale buff-colored 
patches. 
Symptoms.—Tinea versicolor does not occur in childhood, 
and is hardly ever seen after fifty ; it is met with most fre- 
quently between the ages of puberty and forty. It is far 
less communicable than T. circinata, and usually attacks 
only those who have warm, easily-perspiring skins. Occur- 
ring chiefly on the front of the chest and abdomen, on parts 
covered by flannel garments, it may extend to the upper 310 
PARASITIC AFFECTIONS. 
arm or thigh, rarely affecting the face, scalp or leg, and 
never developing on the palmar and plantar surfaces. 
Small, roundish, slightly-reddened patches appear usu- 
ally symmetrically on the trunk, extending by a slightly 
raised and somewhat scaly margin. The patch soon be- 
comes pale yellow, fawn-colored, buff, or brownish in 
color, and unites with neighboring spots, forming irregular 
arese with detached roundish patches at the margin. Itch- 
ing, slight or absent in most cases, may sometimes be severe, 
and give rise to scratching and pruritic rashes. Occasion- 
ally the hair follicles become hypersemic, giving the patch 
an irregular, punctuated appearance; the pigmentary de- 
posit may be excessive, almost sooty black, the so-called 
pityriasis nigra; or urticarial or eczematous eruptions may 
be excited by the parasite. 
Diagnosis.—Tinea versicolor may be mistaken for a macu- 
lar syphilide, or for ordinary non-parasitic chloasma (me- 
lanoderma). 
The syphilide is usually accompanied by other specific 
eruptions, is preceded by roseola, sore throat, alopecia, etc., 
does not usually itch, occurs on the trunk, face, arms, and 
legs indiscriminately, and is of a brownish or coppery color. 
T. versicolor, though it may be met with in a syphilitic per- 
son, usually occurs per se; the patches frequently itch, oc- 
cur most frequently on the front of the trunk, and are of a 
pale-yellow or buff color. 
Spots of melanoderma are seen most often on exposed 
parts, rarely on the trunk ; they are perfectly smooth, not 
rough or branny, and itching is not met with. 
In all doubtful cases the discovery of the parasite (see 
morbid anatomy), on microscopic examination of the scales, 
will clear up the diagnosis. 
Prognosis.—In those who perspire freely and do not wash 
the body the disease is usually chronic, and may last for TINEA FAVOSA. 
311 
years. The parasite, affecting as a rule only the superficial 
layers of the cuticle, can easily be got rid of by treatment. 
Morbid Anatomy.—Microscopic examination of the scales 
scraped off from a patch of T. versicolor, and macerated in 
liq. potassse, shows a network of mycelium made up of branch- 
ing filaments, the segments of which are usually long and 
cylindrical, interspersed with roundish aggregations of large 
round spores, which look like bunches of grapes. The little 
hairs are more or less infiltrated and split up by the fungus, 
but the disease does not extend deeply into the epidermis 
or hair follicles. 
Treatment.—Cleanliness, frequent washing with soft soap, 
and the subsequent application of sulphurous acid (1 to 4) 
or hyposulphite of soda lotion (3j ad Sj), or the inunction 
of a mild mercurial ointment, easily cure the disease. No 
internal treatment is necessary. 
Tinea Favosa—Favus. 
Definition.—A contagious, chronic disease, excited by the 
presence of achorion Schoenleinii in the epidermis, hairs, and 
corium; met with most frequently on the scalp. 
Symptoms.—Favus, met with rarely in England, is much 
more common on the Continent, in Scotland, and in some 
parts of the United States, and, though contagious, attacks 
chiefly poor and dirty children. It begins on the scalp as 
an itching, reddish, scaly patch, resembling that of tinea 
tonsurans, the hairs on which are dull, but not so brittle as 
in ringworm. Small yellowish crusts, about the size of 
pins’ heads, next appear round isolated hairs, which pull 
out more easily with their bulbs entire, not broken off; the 
crusts (favi), convex at first, become, as they gradually 
enlarge, depressed and cup-shaped in the centre, and of a 
bright, sulphur-yellow color. Solitary favi may enlarge till 
they measure inch or more in diameter, or may become 312 
PARASITIC AFFECTIONS. 
confluent, and by admixture with epidermis, eczematous 
secretions, etc., form irregular crusts. The favi have a dis- 
agreeable, mousy odor, and when removed leave a depressed 
pit, which is excoriated or covered with smooth epithelium. 
In the later stages the typical cups disappear, and the sur- 
face resembles a scaly eczema capitis. Destruction of the 
hair follicles and permanent alopecia are frequent results 
of the disease. 
On the body erythematous patches or rings, resembling 
those of T. circinata, are occasionally met with; they sel- 
dom exceed inch in diameter, and have not the tendency 
to rapid extension seen in ringworm. 
It is essentially a chronic disease, lasting for many years, 
and, though contagious, does not seem so easily communi- 
cable as ringworm. 
It is more prone tc excite secondary inflammatory affec- 
tions than ringworm. 
In America domestic animals (cats, mice, etc.) are said 
frequently to transmit the disease to man. 
Diagnosis.—Favus, in the early erythematous stage, re- 
sembles ringworm, but the hairs are not so brittle, are not 
stubbly, and pull out with their bulb entire, instead of 
breaking off sharply. In the developed condition the 
mousy-smelling sulphur-yellow cups adherent to a hair in 
their centre are quite typical. In the later stages, when 
the cups have given way to whitish scales and flakes, or are 
covered over by impetiginous crusts, the discovery of the 
fungus under the microscope will distinguish favus from 
eczema in the scaly or moist and crusting stage. 
Prognosis.—The disease is very chronic, and, on account 
of its tendency to invade the deeper tissues, resists treat- 
ment even more obstinately than ringworm of the hairy 
parts. Permanent alopecia is frequently caused by it, and 
some observers believe that it exerts a lowering influence 
on the general health. T1SEA FAVOSA. 
313 
Morbid Anatomy.—Microscopic examination of a portion 
of favus crust inacerated in liq. potasste, and subsequently 
tinted with iodine solution, shows a mycelium made up of 
ovoidal segments, averaging inch in diameter, con- 
taining granules in their interior, and terminating in large 
rounded spores 3-gVg- inch in diameter with a distinct double 
contour. 
Vertical sections through a favus cup show the epidermis 
infiltrated with spores, micrococci, and fatty granules, most 
numerous at the margin. In the centi’e of the cup the dis- 
eased hairs, which have a mycelium running longitudinally 
and numerous collections of spores in their substance, are 
met with extending down to the bulbs. Beneath them, in 
favi to inch in diameter, mycelial filaments are found 
running into the corium substance at right angles to the 
surface for a more or less considerable distance; they ter- 
minate in chaplets of spores, which, with numerous leuco- 
cytes, are found in abundance between them. The chronic 
exudation, and in some cases the suppuration excited by 
this mycelial invasion, leads to gradual wasting of the 
affected corium, and is perhaps the cause of the depression 
and loss of hair. 
Treatment.—Epilation, advisable in ringworm, is here 
almost indispensable. The removal of crusts, blistering, 
and the application of the mercury and acetic acid paint, 
followed by hyposulphite of soda lotion or the inunction of 
ammonio-chloride of mercury, ung. sulph. co. (see p. 275), 
etc., must be persevered in for a long time. Tonics, cod- 
liver oil, good food, and hygiene are usually necessary. 314 
ERUPTIONS PRODUCED BY DRUGS. 
CHAPTER XXIV. 
Class B.—Eruptions produced by Drugs. 
External. 
Certain drugs, applied externally, excite eruptions of 
the skin. 
Some, such as mustard and turpentine, cause merely a 
moderate hypersemia, with but slight exudation, and are 
followed by branny or slight scaly desquamation and more 
or less lasting brown pigmentation. Others, such as croton 
oil, tartar emetic ointment, savin, or the juice of mezereon, 
excite an eczematous eruption, rapidly becoming pustular, 
and causing shallow ulcers, which heal, leaving whitish 
radiating scars, round the margin of which more or less 
brown pigment is usually developed. Mercurial and sul- 
phur ointment, soda and potash soaps, also excite local 
eczematous eruptions. 
Cantharides produces a vesicular or bullous eruption, and 
has been frequently used to simulate pemphigus. Arnica 
applied locally not unfrequently excites in the skin an 
erysipelatous inflammation, with considerable constitutional 
disturbance. 
Acne, due to blocking of the sebaceous glands and their 
subsequent inflammation, occasionally follows the external 
use of tar. 
Internal. 
Taken internally, belladonna or atropia, stramonium and 
byoscyamus, or their active principles, cause dilatation of INTERNAL. 
315 
the pupil, dryness of the tongue and raucous membranes, 
delirium,—often violent,—muscular paresis and picking at 
the bedclothes, and frequently a general hypersemic rash, 
most intense round the hair follicles and almost indistin- 
guishable from the eruption of scarlatina. 
Occasionally after the internal administration of quinine, 
or of anaesthetics, a patchy, hypersemic, or slightly raised 
eruption appears on pretty large arese of the face, neck, 
hands, and portions of the trunk. The patches are transi- 
tory, and it is a question whether some of them are really 
due to the drug or are merely erythema fugax, accidentally 
coinciding with its administration. 
Copaiba in some cases causes a rash, which at the onset 
resembles that of measles. Hypersemic, slightly raised 
patches, at first purplish-red and sometimes subsequently 
dark red or even hsemorrhagic in character, make their 
appearance on the face, trunk, and extremities. By con- 
fluence they may produce large plaques, or a diffuse paler 
reduess may surround the individual darker papules, which 
arise at first round the hair follicles. More or less severe 
pyrexia and anorexia, with dry, brown, furred tongue, and 
slight or severe prostration, may be met with. 
Under the administration internally of arsenic, a vesicu- 
lar, herpetic eruption, identical with that of zoster, some- 
times develops. 
Iodide of potassium or other salts of iodine taken inter- 
nally produce sometimes an acneiform, but more frequently 
a bullous, eruption. An erythematous raised base makes 
its appearance, on which numerous vesicles, gradually en- 
larging and by confluence producing a bulla, are developed. 
A purpuric eruption, varying in intensity from slight 
petechise on the legs to severe P. hsemorrhagica, is also 
occasionally excited. 
Bromide of potassium gives rise to hard tubercular swell 316 
ERUPTIONS PRODUCED BY DRUGS. 
ings, resembling acne, round the sebaceous and hair folli- 
cles, which occasionally run on into pustules, or definite 
furuncles are produced. The cessation of the drugs, and 
the application of local sedatives, with purgatives internally, 
is usually followed by the subsidence of the eruptions. INDEX. 
Acarus folliculorum, 272 
scabiei, 297 
Acne frontalis, 274 
indurata, 274 
mentagra, 276 
punctata, 272 
pustulosa, 274 
rosacea, 277 
sebacea, 269 
sycosis, 276 
syphilitica, 104 
vulgaris, 274 
treatment of, 275 
Active hyperaainia, 188 
Acute bedsore, 207 
eczema, 151 
infectious diseases, remarks on 
46 
Addison’s disease, 210 
keloid, 213 
Adipose tissue, anatomy of, 18 
Albinismus, 226 
Alibert’s keloid, 233 
Alopecia, 287 
areata, 288 
senilis, 287 
Anatomy of the skin, 13-29 
Anaemia, 190 
Anidrosis, 282 
Angioma, 253 
Anthrax, 178 
Atrophia cutis, 228 
Baldness, 287 
Bedsore, acute, 207 
Bloodvessels, anatomy of, 26 
Boil, 177 
treatment of, 178 
Bromidrosis, 283 
Bug, eruption from, 301 
Bulla, definition of, 31, 33, 38 
Canities, 287 
Carbuncle, 178 
treatment of, 180 
Carcinoma cutis, 202 
Chancre, 99 
Cheiro-pompholyx, 203 
Chicken-pox, 68 
Chilblain, 189 
Chloasma, 309 
uterinum, 210 
Chromidrosis, 283 
Chronic eczema, 152 
Cicatrix, definition of, 36 
C lav us, 230 
Classification 40-45 
Comedones. 272 
Condylomata, 103—113 
Corium, anatomy of, 17 
Corn, 233 
Cornu, 230 
Crab lice, 295 
Crust, definition of, 35 
Delhi boil, 181 
Dermatolysis, 224 
Diphtheria, 8 I 
Drugs, eruptions from, 314 
Dystrophia cutis, 206 
Eechymoses, 191 
Ecthyma syphilitica, 104 
Eczema, 150-165 
articulorum, 156 
capillitii, 154 
chronic, 152 
corporis. 157 
crurale, 156 
of the ears, 155 
erythematosum, 153 
of the eyelashes, 155 
faciei, 155 318 
INDEX. 
Eczema, fissum seu rimosum, 153 
genitale, 156 
intertrigo, 157 
of the lips, 155 
manuutn et pedum, 156 
marginatum, 158,305 
of the nails, 293 
of the nostrils, 155 
papulosum, 153 
pustulosurn, 153 
rubrum, 153 
squamosum, 153 
treatment of, 162 
vesiculosutn, 153 
Elephantiasis Arabum, 219 
teleangiectodes, 224 
End-bulbs, anatomy of, 28 
Enteric fever, 77 
Ephelis, 209 
Epidermis, anatomy of, 14 
Epithelioma cutis, 264 
Equinia, 85 
Erysipelas, 91 
Erythemata, 117 
Erythema annulare, 119 
fugax. I 18 
gyratuin, 119 
intertrigo, 118 
iris, 119 
laeve, 118 
nodosum, 120 
Excoriation, definition of, 35 
Farcy, 85 
Favus, 311 
Fibroma, 236 
Fissure, definition of, 36 
Flea, eruption from, 300 
Framboesia. 90 
Freckles, 209 
Furuncle, 177 
German measles, 58 
Glanders, 85 
Glossy skin, 206 
Hair, anatomy of, 24 
follicle, anatomy of, 22 
Hairy mole, 286 
Harvest mite, eruption from, 301 
Haematidrosis, 196 
Haemorrhage's into the skin, 190 
Herpes febrilis, 142 
gestationis, 143 
iris, 144 
zoster, 197 
Hirsuties, 285 
Horn. 238 
Hydros, 145 
Hyperaemia, 187 
ab acribus, 188 
calorica, 188 
mechanica. 188 
Hyperidrosis, 281 
Ichthyosis, 210 
sebacea neonatorum, 271 
Impetigo contagiosa, 166 
Infantile syphilis, 112 
Inherited syphilis, 112 
Intertrigo, 118, 157 
Italian lepros}’, 127 
Itch, 297 
Keloid, 233 
treatment of, 236 
Kerion, 303 
Lentigo, 209 
Lepra, 255 
anae-thetica, 258 
maculosa, 256 
tuberosa, 257 
Leprosy, 255 
Leucoderma, 227 
Lichen, 129 
circumscriptus, 132 
marginatus, 132 
pilaris, 286 
planus, 130 
psoriasis, 130 
ruber,,130 
scrofulosorum, 132 
simplex, 130 
syphiliticus, 104 
Livedo calorica, 189 
mechanica, 189 
Lupus erythematosus, 242 
treatment of, 247 
vulgaris, 240 
Lymphangioma, 253 
Lymphatics, anatomy of, 28 
Macule, definition of, 31, 32, 37 
Macular syphilide, 102 
Malignant pustule. 89 
Measles, 55 
Melanoderma, 210 
Milium, 272 
Milaria, 283 
Moist tetter, 150 
Molluscum contagiosum, 280 INDEX. 
319 
Molluscum fibrosum, 236 
Morbid anatomy, 31 
Morbilli, 55 
confluentes, 57 
hsemorrhagica, 57 
laeves, 56 
papulosi, 56 
vesieulosi, 56 
Morbus Addisonii, 210 
Morphoea, 213 
Muscular tissue, anatomy of, 24 
Naevus, 252 
pilosus, 286 
Nails, anatomy of, 25 
in general diseases, 292 
Nerves, anatomy of, 26 
Nettlerash, 124 
Onychatrophia, 292 
Onychauxis, 292 
Onychia, 290 
Onychogryphosis, 291 
Paccinian corpuscle, anatomy of, 
27 
Papular syphilide, 102 
Papule, definition of, 31, 32, 37 
Passive hyperaemia, 189 
Pediculosis, 294 
capitis, 294 
corporis, 295 
pubis, 296 
Peliosis hsemorrhagica, 191 
rheumatica, 191 
Pellagra, 127 
Pemphigus, 146 
foliaceus, 147 
syphiliticus, 104 . 
vulgaris, 146 
Petechias, 191 
Phthiriasis, 294 
Physiology of the skin, 29 
Pigmentation, definition of, 34 
Pityriasis, 175 
rubra, 168 
versicolor, 309 
Porrigo, 166 
Premature alopecia, 288 
Primary lesions, anatomy of, 31, 33 
Prurigo, 136 
of Ilebra, 136 
of infants, 137 
mitis, 137 
relapsing, 139 
Pruritus, 204 
Pruritus ani, 205 
genitalium, 205 
senilis. 205 
Psoriasis circinata, 171 
guttata, 169 
gyrata, 171 
inveterata, 171 
of the nails. 29:1 
nummularis, 171 
punctata, 169 
rupioides, 171 
treatment of, 174 
universalis, 171 
vulgaris, 169 
Purpura, 191 
rheumatica, 191 
simplex, 191 
Pustule, definition of, 62 
Pustula m»ligna, 89 
Relapsing prurigo, 139 
Rete Malpighii, anatomy of, 14 
Rhagas, definition of. 36 
Rhinosclerpma, 250 
Ringworm of the body, 304 
of the head, 302 
of the nails, 293 
treatment of, 307 
Rodent ulcer, 267 
Roseola, 122 
syphilitica, 102 
Rotheln, 58 
Rupia, 105 
Sarcoma cutis, 268 
Scabies, 297 
Scale, definition of, 35 
Scar, definition of, 36 
Scarlatina, 47 
Sclerema neonatorum, 218 
Scleriasis, 215 
Scleroderma, 215 
Scorbutus, 195 
Scurvy, 195 
Sebaceous glands, anatomy of, 20 
Seborrhoea, 269 
oleosa, 270 
sicca, 270 
Secondary lesions, anatomy of, 35, 
36 
syphilis, 100 
SepticEemic rashes, 95 
Shingles, 197 
Small-pox, 61 
Squamous syphilide, 103 
Subcutaneous tissue, anatomy of, 18 320 
INDEX. 
Sudamina, 283 
Surgical rash, 96 
Sweat, composition of, 29 
Sweat glands, anatomy of, I 9 
Sycosis (acne), 276 
(tinea), 304 
Syphilis, 97 
Syphilides, general characters of, 
107 
Syphilis of the tongue, 108 
Syphilitic iritis, 108 
Tactile corpuscles, anatomy of, 28 
Tertiary syphilis, 105 
Tinea circinata, 304 
favosa, 311- 
tarsi, 155 
tonsurans, 302 
versicolor, 309 
Traumatic haemorrhages, 191 
Trichorexis nodosa, 290 
Tubercles, definition of, 31, 32, 38 
Tubercular syphilide, 105 
Tylosis, 230 
Typhus fever, 74 
Ulcere, 182 
Ulcus rodens, 267 
Universal acute eczema, 152 
Urticaria, 124 
bullosa, 125 
conferta, 125 
evanida, 125 
febrilis, 124 
miliaris, 125 
papulosa, 125 
perstans, 125 
pigmentosa, 125 
tuberosa, 125 
vesicularis, 125 
I Vaccination, 70 
I Vaccinia, 70 
Vaccino-syphilis, 114 
Varicella, 68 % 
Variola. 61 
conflnens, 63 
corymbosa, 63 
discreta, 63 
bsemorrbagica, 63 
semiconfluens, 63 
Verruca, 232 
necrogenica, 90 
Vesicle, definition of, 31, 33, 39 
Vibices, 191 
Vitiligoidea, 237 
Wart, 232 
! Warts, treatment of, 233 
; Wbeal, definition of, 31, 33 
White leprosy, 227 
Xanthelasma, 237 
Xanthoma, 237 
planum, 238- 
tuberosum, 238 
Xeroderma, 211 
Yaws, 90 
Zoster, 197 
capillitii, 199 
cervico-brachialis, 200 
faciei, 200 
femoralis, 201 
nuchte et colli, 200 
pectoralis, 201 
pudentalis, 201 
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