VENEREAL D1SEASES. PART I. 
VENEREAL DISEASES 
There are three diseases communicated in sexual contact which are called venereal diseases: 
they are gonorrhoea, the chancroidal ulcer, and syphilis. The first two are essentially of venereal 
origin ; the third, syphilis, in the majority of cases is contracted in coitus, but it is also communi- 
cated in ways wholly unconnected with the venereal act. Besides these three diseases and their 
sequelze, there are many other affections of the genitals of both sexes which by custom have come 
to be described in treatises on venereal diseases. 
Gonorrhoea and chancroid are purely local affections unattended with systemic poisoning, 
while syphilis is a chronic infectious disease which may involve all of the tissues and organs of 
the body. 
The origin of gonorrhoea is usually in some irritating pus or secretion, and is by some thought 
to depend primarily upon a micro-organism. 
Until a few years ago the doctrine was held that the chancroidal ulcer was the result of a 
specific pus or virus handed down from one patient to another; but to-day most of the 
practical syphilographers are no longer of that opinion. Rejecting the theoretical reasoning 
of earlier years and drawing their conclusions from close clinical study and extended exper- 
imentation, they have demonstrated the fact that the 'chancroidal ulcer is not necessarily the 
direct descendant of a similar lesion, but that it may thus originate by direct transmission, and 
also may be developed de novo from simple inflammatory pus and from pus arising from active 
syphilitic lesions which have been irritated, flhese facts effectually dispose of the dogma that 
chancroids owe their origin to a specific virus. 
Syphilis is derived from the secretion of an active lesion or from the blood of one previously 
syphilitic ; it is also transmitted by heredity. Its poison is sui generis, and not comparable to that 
of any other disease. It is claimed by some to originate in a bacillus, but the evidence thus far 
offered is far from convincing. Based upon the assumption that chancroid and syphilis were the 
products of two distinct poisons or viri, a doctrine called the "doctrine of dualism " was introduced 
into the study of venereal diseases, and it held sway for many years. We now know that there is 
no such pathological entity as a specific chancroidal virus, but that there is an undoubted syphilitic 
virus, or materies morbi; hence the terms "dualistic theory" and "dualism" in venereal diseases 
are no longer tenable, and the sooner they are forgotten the better. 
To recapitulate : Gonorrhoea is a non-specific inflammation ; the chancroidal ulcer is not the 
product of a definite and specific virus ; syphilis is indubitably caused by a distinct virus ; it is 
therefore the only truly specific venereal disease. GONORRHCEA IN THE MALE. 
Gonorrhcea is an acute, non-specific, purulent, highly contagious inflammation of the male or 
female urethra, and is much more common in men than in women. I he disease has been variously 
known under the names urethritis, blennorrhagia, chaudepisse, and the clap, but in medicine the 
term gonorrhcea is very generally employed, though etymologically incorrect. Though the primary 
habitat of gonorrhoea is the urethra, it is sometimes conveyed by contagion to the mucous mem- 
branes of the eye and rectum. It is very doubtful whether, as claimed by some, gonorrhoea ever 
attacks the nose and the mouth. 
Symptoms.-The symptoms of gonorrhoea in the male begin sometimes as early as the end of 
the first and as late as the sixth day of contagion. Cases in which the appearance is said to be 
delayed for ten days or two weeks are those in which the early symptoms are so mild that they are 
overlooked, or in which an old form of inflammation in the deeper portions of the urethra has 
undergone irritation, which slowly passed into inflammation. The first symptoms are a slight heat 
and a tickling or itching sensation, sometimes at first not unpleasant, at the orifice of the urethra, 
which is slightly reddened and glazed, and perhaps covered with a small quantity of colorless mucus, 
which may or may not glue the lips of the meatus together. This condition very soon becomes more 
intense, the redness becomes deeper and extends in a disk form around the meatus, which assumes 
a pouting appearance, and from which oozes or may be pressed a thin, milky fluid which consists 
of mucus and lymphoid cells. At this time a decided smarting and burning sensation is felt in the 
fossa navicularis, particularly during urination. This may be called the first or congestive stage 
of gonorrhoea, which lasts from one even to four or five days. At the end of this time the second or 
inflammatory stage begins. At this time the orifice of the urethra will be very red, and with it the 
whole glans swollen. In some cases oedema forms about the fraenum, which in subjects having 
long and tight prepuces may be so great as to produce phimosis, as is shown in Fig. 11 of Plate I 
Or if the prepuce is short, particularly if it is tight at the orifice, paraphimosis may be produced, as 
shown in Fig. i, Plate II. Frequently the oedema involves the whole organ, which is then greatly 
increased in size and distorted in shape. At this time the discharge is very copious, of a deep- 
green color, and perhaps tinged with blood. (See Fig. i, Plate I.) Coincidently, there is much 
pain and tenderness in the end of the penis, particularly in the fossa navicularis. Very frequently 
patients thus afflicted complain very early of uneasy sensations in the loins and of more or less 
tenderness of the lymphatic ganglia in the groin. Urination becomes exceedingly painful along 
the whole length of the pendulous urethra, and often in its deeper portions. Such is the severity 
of the hot, burning pain that patients dread to empty their bladders. Two causes are given for 
this pain during urination : First, the irritation of the urinary salts ; second, the forced distension 
by the stream of the inflamed and sensitive canal. In the graphic language of my late colleague, 
Dr. Bumstead : " During the act the patient involuntarily relaxes the abdominal walls, holds his 
breath, and keeps the diaphragm elevated, in order to diminish the pressure on the bladder and 
lessen the size and force o/ the stream of urine. In consequence also of the urethra being con- Part I 
Plate I 
Fig 2 
Fig. 3. 
Fig.l 
Fig .4 
Fig 5 
Fig.c 
Fig.8 
Fig. 9 
Fig .10 
Fig.7 
Fig .11 
LEA BROTHERS & CO. PUB LISHE RS . PHILADE LPHIA . 
1 ACUTE GONORRHOEA IN THE MALE . 
3 ABSCESS OF VULVO-VAGINAL GLAND 
5 GONORRHOEAL 0RCH1-EPIDIDYMITIS 
7. SUPPURATIVE ORCHITIS WITH HERNIA TESTES 
9. LYMPHANGITIS FROM ACUTE GONORRHOEA 
2 .ACUTE GONORRHOEA IN THE FEMALE . 
4 . GONORRHOEAL EPIDIDYMITIS . 
6 . ACUTE VAGINITIS . 
8 APPEARANCE OF HERNIA TESTES . 
10. PHLEGMONOUS ABSCESS OF CORPUS SPONGIOSUM 
11.PHIMOSIS COMPLICATING ACUTE GONORRHOEA. GONORRHCEA IN THE MALE. 
21 
tracted, and more or less obstructed by the discharge, the stream is forked or otherwise irregular." 
In the full development of the second or inflammatory stage there is often more or less systemic 
disturbance. Such patients may have a mild or pronounced fever, accompanied with chilliness, 
acceleration of the pulse, malaise and want of appetite, more or less thirst, and not uncommonly 
mental depression. This category of symptoms usually lasts two or three days. The glans penis 
is much swollen and red, the penis tender and painful, and the urethra in its whole length has a 
cord-like and knotted feel. Uneasy aching and dragging pains and tenderness are felt in the peri- 
neum at the root of the penis, in the groin, testes, and loins. At this time the sufferings of the 
patient are increased by painful and persistent nocturnal erections or by chordee, in which the penis 
is bent downward in the shape of a bow. Chordee is due to oedematous infiltration of the corpus 
spongiosum, which becomes less extensible than the corpus cavernosum. As a result, when in erec- 
tion the cavernous bodies undergo extension they are drawn downward by the thickened and 
unyielding spongy body. Hilton thinks that in erection there is a sudden spasm of the vaso-motor 
muscles of the penis caused by irritation of the branches of the pudic nerve which go to the urethra, 
and that erections are caused by excito-motor action upon the spinal cord, which during sleep is not 
under the control of the brain. I have often seen Dr. Bumstead in his lectures illustrate the mech- 
anism of chordee by gluing a piece of tape along the surface of an india-rubber condom and then 
distending it with his breath. Patients should always be warned that in case of chordee no vio- 
lence should be done to the organ by forcibly straightening it or "breaking the cord," since severe 
hemorrhage may result or a lesion of continuity made which will almost inevitably terminate in 
stricture. Very often in the acute stage of gonorrhoea, owing to the intensity of the inflammation 
and congestion, hemorrhage mild or severe may occur. In the majority of cases it is of no import- 
ance, and sometimes even seems to be beneficial; in somewhat rare cases, however, it is very free, 
and patients tell extravagant stories of the amount of blood which they have lost. 
In the acute stage of gonorrhoea, particularly in its period of full development and toward 
its decline, various complications may arise, such as epididymitis, orchi-epididymitis, periurethral 
abscess, lymphangitis, adenitis, etc., which will be considered later on. 
The second or inflammatory stage of gonorrhoea varies in different cases, and lasts from one 
to three weeks. Its duration is influenced by the patient's docility and amenability to treatment, by 
his occupation, by extremes of heat and cold, and by his habits and constitutional peculiarities. 
The third or stage of decline is noticeable in the marked decrease in the uneasy and painful 
sensations, in the gradual subsidence of the redness and swelling, and in the partial or entire 
cessation of the pain in urination. Nocturnal erections and chordee may persist, but they are 
usually much less painful. The glans penis resumes its natural size and color, and the pouting 
lips of the meatus subside and become normal. Coincidently, the discharge becomes less green 
and profuse, and, reaching a condition of muco-pus, disappears. The duration of the third stage 
depends almost entirely on treatment and on the fidelity with which the patient cares for himself. 
It may be a week or several weeks. The tendency of gonorrhoea during the inflammatory stage 
is to extend backward toward the bulbo-membranous junction, and then to remain in a subacute, 
indolent condition. This may be determined by mild pressure from the scrotum toward the glans, 
when no discharge shows itself, but beginning at the perineum causes one or more drops of dis- 
charge to appear. 
As a rule, the first attack of gonorrhoea is more severe than succeeding ones, in which the 
symptoms often are mild irritation, slight if any swelling, and discharge. Many cases are seen in 
which the discharge is the first symptom noticed, and, with its exception, the patient suffers little 
or no discomfort. The conclusion is obvious that in gonorrhoea, as in all inflammatory processes, 
the morbid action may be acute and severe or subacute and mild. 
There is a peculiar form of gonorrhoea which is occasionally seen early in the secondary stage VENEREAL DISEASES. 
22 
of syphilis. It may occur in cases in which the initial, seated on the glands or prepuce, has not 
yet healed, in cases in which it has healed, and yet again in cases in which an extra-genital chancre 
had existed. In these rather exceptional cases long after the last coitus a more or less severe 
gonorrhoea begins, in some of which I have seen as much suffering as is experienced in a virgin case 
of gonorrhoea ; it may also occur in different degrees of mildness, e\ en to the production of a 
sufficient mucus to glue the lips of the meatus together. Specific medication fails to give relief 
in the very severe cases, and the usual methods of treatment must be employed. The trouble 
disappears spontaneously in mild cases. 
In those rather exceptional cases in which the syphilitic chancre is seated in the urethra one 
or more inches from the meatus, a discharge usually occurs, which may be serous or sero-purulent. 
It is commonly scant in quantity and unaccompanied by unpleasant symptoms, except perhaps at 
the time of the explosion of the general manifestations of the disease, when an exacerbation may 
occur. 
Chancroids within the urethra give rise to considerable discharge, which is usually thinner 
than that of gonorrhoea and of a rusty color. 
Under the title of dry or bastard gonorrhoea an inflamed condition of the urethral mucous 
membrane, with little if any discharge except perhaps a small quantity of mucus, has been 
described. In many instances the condition is symptomatic of old inflammatory changes in the 
deep urethra which have undergone mild exacerbation, while in others it may be due to sex- 
ual excesses and to the irritant action of the urine heavily laden with urates and oxalate of 
lime. 
In some cases of herpes progenitalis, particularly those in which the vesicles are seated near 
the meatus, the urethra may be found to be reddened, rather sensitive, and covered with a small 
quantity of mucus. 
Balanitis, particularly when due to congenital phimosis, may be accompanied by a mild form 
of inflammation of the mucous membrane of the meatus and fossa naviculans. The passage of 
a calculus and manipulations with urethral instruments sometimes are followed by gonorrhoea, 
which is usually mild and ephemeral. 
Etiology. I wo of the most important questions in the study of gonorrhoea are its cause 
and origin. So much often depends upon a clear understanding of how a given case of gonor- 
rhoea originated that an explicit exposition of the subject is demanded. In clinical practice gonor- 
rhoea in the male is sometimes derived from a female thus suffering, but such cases are much less 
numerous than those in which it arises from other sources. Ricord's proposition, that women fre- 
quently give gonorrhoea without having it themselves, may, I think, be unreservedly accepted as an 
axiom, and its importance cannot be over-estimated. Of it Fournier says: "The result of my 
investigation convinces me that the opinion of Ricord is the only one which can be accepted as 
conforming to the facts of daily observation. It seems to me, however, that it falls below the 
truth. In my opinion he should have said most frequently.' " Fournier further thinks that to one 
case in which gonorrhoea originates in gonorrhoeal pus there are three which have a different origin. 
My own experience has demonstrated clearly to me that such a mode of origin is even less 
frequent. My own statistics of some years ago of thirty men affected with true gonorrhoea, in 
but five did I find gonorrhoea in the women with whom they had cohabited. 
By far the majority of cases of this disease originate in coitus with a woman suffering from 
some form of muco-purulent or purulent discharge from the genital tract. A consideration of 
the frequency of these discharges in the female explains the great frequency of gonorrhoea in the 
male. They may come from the cavity or the neck of the uterus, from a swollen and exulcerated 
cervix, from the vagina and vulva, and from the vulvo-vaginal glands. The gonorrhoea which 
originates in these discharges may be mild in character or of great severity and obstinacy. My GONORRHOEA IN THE MALE. 
23 
experience fully accords with that of Dr. Bumstead, who said that some of the most obstinate cases 
he had ever met with had a leucorrhoeal origin. 
Coitus just before, during, and after menstruation is very frequently followed by gonorrhoea, 
which is usually of a severe type. Many authors speak of the severity of the affection thus 
acquired, and Diday dignifies it by the name " urethrorrhoea." Certain it is that the course of 
such a gonorrhoea may be as severe and protracted as it is when it originates from acute gon- 
orrhoeal pus. In this manner many husbands who have for years cohabited with their wives with 
impunity have contracted the disease, and the. same often occurs in the unmarried. 
Gonorrhoea sometimes occurs under peculiar circumstances, which are clearly given by Dr. 
Bumstead, who says: "I am constantly meeting with cases in which one or more men have cohab- 
ited with impunity with a woman, both before and after the time when she has occasioned gonor- 
rhoea in another person, or less frequently in which the same man, after visiting a woman for a 
long period with safety, is attacked with gonorrhoea without any disease appearing in her, and after 
recovery resumes his intercourse with her and experiences no further trouble. The frequency 
of such cases leaves no doubt in my mind that gonorrhoea is often due to accidental causes and 
not to direct contagion." My own experience is fully in accord with that of my late colleague. 
Though husbands somewhat exceptionally contract gonorrhoea from wives free from the dis- 
ease, in the vast majority of cases, though their partners suffer from uterine and vaginal dis- 
charges, they escape. The same is often true as to the lover and mistress. The most rational 
explanation of this immunity of the males is that frequent exposure to the irritant secretions has 
produced what the French term acclimation or accoutumance. Thus it is that with married women 
and in unsanctified cohabitation the favored but luckless lover often comes to grief for the want 
of this indefinite but none the less real factor in the case-namely, acclimation. A clear and 
positive statement of this fact will often spare an innocent person the suspicion or accusation of 
having gonorrhoea and of communicating it. 
Fournier tritely remarks that a man gives himself the gonorrhoea oftener than he receives it. 
I think that in many cases this is true. We very frequently see married and unmarried men with 
an urethral discharge which originates in some old and latent lesions of some portion of the urethra 
which under certain conditions have become inflamed. These lesions may be of a triHing or 
severe character, such as local thickening, a slight stenosis of the canal, stricture, granulations, and 
polypoid growths. It can be readily understood that men with urethrae thus damaged are prone, 
the proper causes existing, to gonorrhoea, whether or not the females are suffering from a discharge. 
These causes are sexual excess, high living, the abuse of stimulants, and prolonged horseback 
riding. Ricord's recipe for contracting gonorrhoea is graphic, comprehensive, and suggestive. 
He says : " Select some woman of a pale, lymphatic temperament-a blonde is better than a 
brunette-and the more whites she has the better. Take her out to dine; order oysters first, 
and don't forget asparagus afterward. Drink often and freely: white wines, champagne, coffee, 
liqueurs,-they are all good. After dinner dance a while, and have your friend dance with you. 
Get well heated during the evening, and quench your thirst without stint with beer. At night 
play your part valiantly: two or three times would not be too much, but more would be better. 
The next morning do not forget to take a prolonged hot bath ; moreover, do not omit an injec- 
tion. This programme having been conscientiously followed out, if you don't have a clap, some 
good deity must have saved you." 
Though it has been claimed that intense and prolonged sexual excitement without completion 
of the act has been followed by gonorrhoea, it is rational to suppose that in such a case there was 
pre-existent damage to the urethra. 
It is also claimed that gonorrhoea may arise de novo in persons suffering from a gouty or rheu- 
matic state of the system, as well as in those of very full habit. 1 have seen many such cases in 24 
VENEREAL D/SEASES. 
which patients thus explained the origin of the discharge, and in many of them I have clearly 
demonstrated the presence of pre-existent urethral lesions. In this same category, I firmly believe, 
belong those cases in which gonorrhoea is said to have been set up by the use of arsenic, canthar- 
ides, the terebinthinates, and asparagus. The origin of gonorrhoea in these states of the system 
and in these irritants has often been proposed and accepted in order not to bring up compromis- 
ing reminiscences. Long-continued masturbation causes congestion of the mucous membrane 
of the deeper portions of the urethra, the evidence of which is often seen in redness and 
scanty mucus in the pendulous portion. Such cases are very prone to develop gonorrhoea 
from excess in venery and in consequence of irritating substances in the urine. 
1 think that as regards man it may be broadly stated as an axiom that in many instances he 
contracts gonorrhoea from an irritating secretion of the female genito-urinary tract, and that in 
others the leaven of the disease exists in himself in the form of some urethral lesion, which under 
sufficient stimulation becomes active and pus-producing. 
The facts thus far adduced I think clearly and unmistakably prove that gonorrhoea is not a 
specific or virulent disease, but one which has its origin in muco-pus and pus from various sources ; 
further, that it is a disease prone to leave greater or less damage to the urethra, which focus or 
foci are readily irritated by various causes. The great severity of some cases and the compara- 
tive mildness of others may not always be readily explained, but the facts connected with them 
will no doubt warrant the opinion that gonorrhoea, like all inflammations of mucous membranes, 
may be of two types, the severe and the mild. 
In addition to the facts offered by clinical observation, there are those of experimentation 
which have been made by numerous observers independently during a period of nearly a hundred 
years. Reliable observations show that well-marked gonorrhoea has been produced in virgin sub- 
jects by the following agents : Pus from various forms of ophthalmia many times, from abscesses, 
and from infantile leucorrhcea caused by worms in the rectum ; pus from an urethra inflamed by a 
mechanical irritant, and from the urethra the seat of inflammation produced by unskilful use of 
the sound ; pus derived from severe stimulation of uterine catarrh with ammonia, from the muco- 
purulent sputum of bronchitis ; pus experimentally produced in the urethra of a woman, and laud- 
able pus from an abscess. Besides these agents, undoubted gonorrhoea has been caused by the 
injection of irritant and caustic drugs, such as ammonia. 
Considering, now, this whole subject, the summing up of my late colleague is admirably clear, 
comprehensive, and convincing: " I he inferences from what has now been said of the etiology of 
gonorrhoea, relative to its nature, are so obvious that they require little more than mere mention. 
If in a large proportion of cases the disease can be traced to no other cause than leucorrhcea, 
the menstrual fluid, to excessive coitus, intercourse under circumstances of special excitement, 
inattention to cleanliness, the abuse of stimulants, etc., and if, when thus originating, it is undistin- 
guishable either by its symptoms, course, complications, or termination, from the same affection 
due to contagion, it is evident that it should be ranked among the ordinary catarrhal inflammations 
of mucous membranes ; or, in other words, that it is a simple urethritis, the connection of which 
with sexual intercourse is a merely accidental, or at all events not a necessary, circumstance." 
If further proof were necessary in the denial of a specific origin of gonorrhoea, it can be 
furnished in the analogical evidence offered by muco-purulent conjunctivitis, which is the true 
analogue of gonorrhoea. It originates in simple secretions, and gives rise to a secretion which is 
indefinitely contagious. 
The etiology of gonorrhoea is frequently an important question in domestic relations, and often 
upon its correct understanding the happiness, harmony, and well-being of families are dependent.1 
1 I am accustomed, in my lectures, to illustrate the baneful effect of the theory that gonorrhoea is always due to a specific virus by 
the details of one of a number of very sad cases which have come under my observation: A married man, twenty-six years old, GONORRH CEA IN THE MALE. 
25 
In the year 1879, Neisser first described a micro-organism in the pus of gonorrhoea, which he 
called the micrococcus gonorrhoea. It was claimed by him, and by Bokai, Bockhart, Aufrecht, Leis- 
tekow, Eklund, and others, that this microbe was found only in gonorrhoeal pus from the urethra, 
vagina, and conjunctiva ; that it was peculiar in size, shape, and mode of reproduction ; and that it 
was the pathogenic micro-organism of gonorrhoea. In support of this claim cases were reported in 
which gonorrhoea was said to have been produced by the introduction of the microbe derived from 
culture-fluids into the urethra of a number of men. In 1885, Bumm showed that in gonorrhoeal 
pus there are at least five species of microbes to be found, and that previous experimenters had 
not used proper methods of culture for the reproduction of the true gonococcus, and that they had 
reproduced those having no pathogenic power. After many experiments, Bumm was able to cul- 
tivate the true gonococcus, and he introduced some of the second culture into the urethra of a 
woman whose genito-urinary system was proven to be free from the micro-organism. Three days 
after the inoculation pain on urination was felt and gonococci were found in the epithelium of the 
urethra. A typical gonorrhoea of three weeks' duration followed, during which the gonococci were 
found in the urethral discharge. This experiment, though striking in its results, was not accepted 
as conclusive by prominent bacteriologists, who claimed that, "notwithstanding the fact that no pus- 
cells were found in the culture upon microscopical examination, we cannot entirely put aside the 
objection that perhaps the cocci in the urethral discharge were simply carried over, especially as 
the transference upon the artificial culture-medium was made with relatively large masses." To 
meet this objection, in the second edition of his book, published in 1887, Bumm records a second 
case, in which the vehicle of inoculation was derived from the twentieth culture of the secretion of 
purulent conjunctivitis. Some of this was placed in the urethra of a woman, which soon became 
inflamed and painful and the seat of a characteristic discharge in which gonococci were found. 
Bumm further shows that the gonococcus is prone to invade the epithelium and the deeper 
tissues. 
These experiments seem to show that in gonorrhoeal pus a number of micro-organisms or 
cocci are to be found, and that it is probable that the pathogenic microbe is the one called by 
returned after a month's absence and cohabited with his wife. In two days he noticed the usual symptoms of acute gonorrhoea, and 
consulted a physician, who informed him that he was suffering from that disease. To the patient's remark that he had only had con- 
nection with his own wife, the physician replied that gonorrhoea came from gonorrhoea-ergo, the wife had that disorder. The patient 
being incredulous, the physician fortified his position by quoting from the work of a prominent author from whose teachings he had 
gained his belief. Such was the patient's anger and disgust that he immediately confronted his wife, who was at the full table of a 
large boarding-house, and in vile and blasphemous language accused her of infidelity and of giving him a foul disease. Amid shame 
and distress of mind the wife indignantly spurned the charge, but to no effect. The husband left the house and went elsewhere, but 
took occasion to inform his wife's relatives of the state of affairs. At this time a second visit to the physician resulted in a more 
positive asseveration of his opinion. Such was the desperate state of affairs that the husband consulted a lawyer with a view of get- 
ting a divorce. At this juncture the wife's brother insisted that her husband should accompany her to my office, with the view of set- 
tling the matter. It was a memorable interview with the sullen and angry husband and the indignant and outraged wife. The hus- 
band's first question was, Could a man contract gonorrhoea from a wife who was not thus affected ? To which I replied, emphatically, 
Yes. I then went over with him the various sources of origin of gonorrhoea, and instanced cases which I had met in which ground- 
less suspicions had been entertained between husband and wife. When I came to inquire into the circumstances of hi§ case, I 
learned that his wife had some time previously been the subject of an operation upon the uterus, and that she suffered from leu- 
corrhoea. This was sufficient to clear her of all suspicion; but when I mentioned the fact that menstrual fluid sometimes caused 
severe gonorrhoea, the wife eagerly and triumphantly said to him that he had forced her on that night to have intercourse in spite 
of her waning menstruation. The husband was chagrined and humiliated. Later on, domestic happiness was restored. 
A still sadder case was published in an old trench work on venereal diseases : A young man, after having lived with a young 
girl for some years, married her. Some months after he was compelled to take a journey of some distance, and while travelling was 
attacked with gonorrhoea. He consulted a physician, and informed him that he had never had connection with any woman but his 
wife. The physician laughed and made a sarcastic reply. Some days after, when the testicle swelled, the latter informed him that 
if his wife was virtuous he must have had " une affaire " with other women. The young man wrote to his wife an indignant and 
passionate letter and blew out his brains. The unfortunate woman, who was found to be free from disease, miscarried and died. 26 
VENEREAL E/SEASES. 
Bumm the gonococcus.1 It is a significant fact that all of Bumm's cultures have been made from 
the pus of conjunctivitis. The constancy with which micrococci are found in gonorrhoeal pus shows 
that its existence is more than a coincidence. Though so much has been written on this subject, 
very much more is necessary, particularly in the way of clinical investigation, and in the compara- 
tive study on a large scale of specimens of gonorrhoeal pus and of the secretions from which they 
were derived in contagion, before the subject can be put upon a plane of certainty, and before it 
can be affirmed that the vehicles of contagion of gonorrhoea must of necessity and invariably con- 
tain the gonococcus. 
It is well to remember that other observers have claimed that they have found this micro-organ- 
ism in pus from abscesses and various portions of the body, and in the saliva, and that De Amici 
states that he found the identical micrococcus in the pus from an urethra artificially inflamed with 
injections of ammonia. As we shall see farther on, the microbian theory of the origin of gonor- 
rhoea has been productive of very little improvement in therapeutics. Certainly, we are unable 
to-day, in the discursive and unsettled condition of the question of micro-organisms, to say that there 
is a specific gonorrhoeal pus, and that it contains a specific micro-organism. 
The lesions produced by gonorrhoea in the urethra vary according to its severity, extent, and 
duration. In many cases the red and swollen membrane resumes its normal color and suppleness. 
During the intensity of the process a thickened and excoriated condition may be seen with the 
endoscope, which, unless resolution takes place, may end in stenosis of the canal and a granular 
condition of the mucous membrane. Very often in cases of persistent gleet this thickened, red- 
dened, and granular appearance of the urethral membrane may be seen dotted with spots of more 
or less well-marked exulceration, lhe stenosis of the canal in gonorrhoea is due to hyperaemia, 
oedema, and cell-exudation, which at first are limited to the mucous membrane ; later on, they may 
extend to the deep submucous tissues, and there give rise to the development of new fibrous and 
connective tissues which compose strictures. 
The small warty growths or polypi which are not infrequently seen in the urethra are 
undoubtedly caused by localized hyperplasia of the papillae. 
In many cases of chronic gonorrhoea the endoscope reveals only a slight thickening and red- 
1 Allen in an interesting article (" Practical Observations on the Gonococcus," Joitrn. of Cut. and Gen. Ur. Diseases, March, 
1887) thus describes the method he employs, which was first proposed by Roux, of identifying the microbe: " A drop of pus is spread 
into a thin layer by pressing between two glass slides, and allowed to dry in the air. A drop of a solution of methyl blue in aniline- 
water is now placed upon it for a moment, and washed off with a stream from a wash-bottle; a few drops of Gram's iodo-iodide 
liquid is then poured on and allowed to remain for several minutes. This fixes the color in the micro-organisms in general. Gram's 
liquid is now washed off, and while the specimen is still wet a cover-glass is placed upon it, and it is examined with an oil immersion- 
lens. If micro-organisms resembling the gonococcus are found, we proceed to test them by decolorization. The cover-glass is 
removed, and the specimen treated with absolute alcohol until the color is as completely removed as possible. The cover-glass is 
replaced and the specimen again examined, when all gonococci will be found to have disappeared. All other organisms, however, 
which may have been present will be distinctly visible. If desirable, the pus-cells may be brought out again by applying a solution 
of eosin. By this method we have been able to exclude all cases which would have been of necessity left doubtful without some con- 
firming test." This method, unfortunately, seems to be on the principle of " now you see it, and now you don't see it." 
Under a low power the gonococcus looks like fine grains of gunpowder, but under a higher power it is seen to be divided into 
two unequal halves, which when stained show a colorless dividing-line. Very often four of these segments are seen together, and 
seem to show that the micro-organism is reproduced by fission. Unfortunately, at present it seems that our knowledge of the morpho- 
logical characters of true gonococcus is not clear and sharply drawn, for Bumm says that later and more extended observations have 
convinced him that the biscuit form is not specific for the gonococcus, which is possessed by a considerable number of micro-organ- 
isms, which consist of two hemispherical halves separated by a fissure, and thus resemble the gonococcus. 
From the foregoing, which is an impartial presentation of this subject, it is obvious that much has yet to be learned as to the 
origin, differentiation, life-history, and morphology of this microbe before we can make positive assertions as to its being the sole 
pathogenic agent in gonorrhoea. GONORRHOEA IN THE MALE. 
27 
ness of the mucous membrane, which is covered with bluish-white flakes or scales, which are con- 
stantly cast off. 1 hese are the so-called gonorrhoeal threads, and are shown by the microscope to 
be composed of epithelial cells and lymphoid cells held together by mucine. They are usu- 
ally seen at the period of decline of the discharge and for some time afterward, and their pres- 
ence indicates a low grade of persistent inflammation. I have seen cases, however, in which they 
were present in the urine long after the discharge had ceased, and in which the endoscope showed 
absolutely no abnormality of the urethral mucous membrane. 
Modes of Contagion.-In the vast majority of cases gonorrhoea is communicated by direct con- 
tagion in coitus, but it is possible that it may be contracted by mediate contagion. The time-worn 
explanation of the origin of the trouble by contact with a foul privy may possibly be true in some 
very exceptional cases ; but, as a rule, it may be looked upon as a euphemism to be used in the 
case of some clerical, venerable, or married transgressor. In the cases reported, in which one 
member of a family has gonorrhoea, and in which several others, particularly young girls, are thus 
attacked, it is probable that contagion takes place by means of towels or that through carelessness 
the pus is transferred to their genitals. 
Diagnosis.-Commonly, the diagnosis of gonorrhoea is made by the patient before the phy- 
sician is consulted. In some instances, however, a correct conclusion is not reached at the first con- 
sultation. Some cases of balanitis, in which the prepuce is rather tight, resemble gonorrhoea, for 
the reason that besides the discharge the meatus may be red and swollen, and perhaps there is 
slight uneasiness in urination. Retraction of the foreskin and cleansing of the parts will permit 
a thorough examination, and then the diagnosis can be readily made. In those cases of balanitis 
in which the preputial orifice is very small, even of pinhole size, more difficulty may be experienced. 
By means of intrapreputial injections the discharge may be removed ; the parts then being dried, 
slight pressure upon the urethra from behind forward will reveal the presence or absence of pus 
in the canal. 
When the initial lesion of syphilis is developed on or within the lips of the meatus, a slight 
mucous discharge is present, and doubt as to its nature may exist up to the period when the diag- 
nosis of chancre is made. I he initial lesion may occur at one or more inches down the canal, 
and give rise to a discharge which is usually sero-purulent and scanty. Such patients complain 
of a localized uneasiness and impediment to urination, and examination reveals a circumscribed 
thickening of the corpus spongiosum. In these cases the endoscope affords much aid. 
Gummatous infiltration occurs at any part of the pendulous urethra, and a scanty sero-puru- 
lent discharge accompanies its development. The absence of inflammatory symptoms, the local- 
ization of the lesion, and the history of the patient are usually sufficient for a correct if perhaps 
rather delayed diagnosis. 
The mucous fluid which exudes from the meatus when the seat of herpes progenitalis and the 
presence of vesicles establish the case as not one of gonorrhoea. 
The pus of chancroids of the meatus is of a rusty-brown color, differing markedly from that 
of gonorrhoea. 
Prognosis.-In general, the prognosis of gonorrhoea is good, and a cure may be promised in 
from three to four or six weeks. The disease is commonly very obstinate when acquired before 
puberty, particularly in scrofulous and tuberculous subjects. In plethoric persons, in high livers, 
and those addicted to drink, in rheumatic and gouty subjects, gonorrhoea is frequently very per- 
sistent. In those who are overworked, the subjects of mental worry, and those of neuropathic 
tendency, the disease is often very tedious. 
As a rule, gonorrhoea limited to the pendulous urethra runs a favorable course. Instances 
have occurred, however, in which rupture of the corpus spongiosum, the seat of chordee, has been 
followed by pyaemia and death. 28 
VENEREAL DISEASES. 
The dictum that gonorrhoea, though apparently cured, lurks in some portion of the genito- 
urinary tract is far too dogmatic. Many men have had gonorrhoea, and have never after observed 
a symptom, subjective or objective, of the affection. 
In many cases its tendency to creep backward to the bulbo-membranous junction is followed 
by implication of other portions of the genito-urinary tract. Epididymitis and orchi-epididymitis 
of gonorrhoeal origin are not uncommonly the leaven upon which tuberculosis of the testes is 
developed. 1 have seen instances of chronic inflammation of, and discharges from, the urethra in 
tuberculous subjects, in which I satisfied myself that the simple inflammation had resulted in local 
tuberculosis. As a sequela of gonorrhoea, abscess, follicular and parenchymatous, of the prostate 
is not very uncommon, and may result in pyaemia and death. Gonorrhoeal inflammation of the 
prostate is not infrequently the starting-point of tuberculosis of that organ, and similar changes in 
the cord may lead to involvement of the seminal vesicles. Cystitis as a result of gonorrhoea is not 
uncommon in the acute and chronic form ; in the former the prognosis, ordinary prudence and 
precaution being observed, is good; the latter is often persistent, and may be followed by 
extension of the disease to the prostate, ureters, and kidneys. 
Pyelitis and pyelo-nephritis of gonorrhoeal origin are now recognized as of not uncommon 
occurrence, and it is probable that the majority of the cases of tuberculosis of the genito-urinary 
tract in the male have had their origin in chronic gonorrhoea. 
Peritonitis and subperitoneal phlegmon are rare complications of gonorrhoea, due to exten- 
sion of the inflammation to the peritoneum and s.ubperitoneal connective tissue by extension from 
the vas deferens, seminal vesicles, prostate, bladder, and ureters. 
Gonorrhoeal rheumatism is a painful and obstinate affection, which may be cured or it may 
lead to deformity, cachexia, and invalidism. Its supervention during an attack of gonorrhoea 
should always cause a guarded prognosis. 
Though it has been claimed that paraplegia may result from gonorrhoea, the details of the 
illustrative cases do not clearly and sharply define cause and effect. 
Prophylaxis.- L hough many injections have been vaunted as preventives of gonorrhoea, they 
are all of doubtful value, and are commonly used to the verge of irritation. Scrupulous cleanliness 
after coitus is the most reliable prophylactic measure. 
Treatment.- I he treatment of gonorrhoea varies according to the stage of the disease and 
the condition of the patient. 
In former years authorities recommended an abortive treatment, but such are its uncertainties 
and dangers that it is now scarcely ever used. Some patients, for urgent reasons, sometimes insist 
upon a trial to abort their gonorrhoea, tor such cases injections of a solution of nitrate of silver, 
one grain to the ounce of water, used every three or four hours, may be tried. Stronger solutions 
should not be used. 1 he intention is to produce a substitutive inflammation, which, it is claimed, 
is more easy of cure than the gonorrhoeal inflammation. Since these injections must be used early 
in the first stage of the disease, at which period cases are not frequently seen, their sphere of use- 
fulness under any circumstances is very limited. Strong solutions of nitrate of silver have been 
known to cause violent inflammation of the whole penis, and even the formation of abscess. 
When a case is seen in the first stage the most rational treatment is to prescribe rest, a brisk 
cathartic, a moderate and very plain diet, to render the urine alkaline, and to envelop the penis in 
old linen moistened with cold water or lead-water. 
Treatment of the Acute Stage.-The most important measure in this stage is absolute rest, 
preferably in the recumbent position, but the majority of patients are unwilling to thus submit. 
The great advantages to be attained, however, should be thoroughly explained to them. Taking 
cases, therefore, as we find them, they should be enjoined to walk and exercise as little as possible, 
to spare themselves in every way, to avoid muscular exertion, to ride rather than walk, to sit rather GONORRHCEA IN THE MALE. 
29 
than stand, and to lie down as often and as long as possible. In very bad cases, in which the inflam- 
mation is so active that a patient is forced to seek the recumbent position, it is well to apply cool- 
ing lotions on lint to the organ or to employ the very useful cold-water coil of Dr. Otis. For all 
itinerant cases in the second stage a nicely-fitting and comfortable suspensory bandage should be 
ordered at once. 
Careful attention to diet is an important consideration. It should be light and plain and in 
moderate quantity. All highly-seasoned foods, salads, gravies, soups, and condiments should be 
absolutely interdicted. Coffee, beer, alcoholic liquors, and asparagus should be avoided. The 
utmost cleanliness should be recommended, and the patient warned of the very contagious nature 
of his discharge, particularly as affecting the eyes. All sexual excitement must be sedulously 
avoided, and the patient should be warned against lascivious thoughts. 
Much care is necessary in adapting dressings to the penis for the purpose of catching the dis- 
charge. Patients should be warned not to place pieces of lint or cotton over the urethral orifice, 
nor to use stockings or bags at the bottom of which a bird's-nest-shaped wad of cotton is placed, 
since by all of these procedures the pus is injuriously kept against the meatus and glans. India- 
rubber condoms are also objectionable. The most cleanly and efficient method of dressing the 
penis is that recommended by Dr. J. W. White, which I have used many years. A piece of old 
linen or muslin or two thicknesses of absorbent gauze about four inches square, in the centre of 
which is a small oval aperture, is slipped over the exposed glans behind the corona, and the pre- 
puce is then pushed forward. From its orifice the linen protrudes and catches all of the secretion. 
If the patient has no foreskin to thus hold the bandage, a piece of linen or gauze four inches by six 
may be wound around the whole penis, and there retained by means of a small piece of adhesive 
plaster. India-rubber bands and tape bandages exert injurious pressure. If practicable, the penis 
may be suspended by means of the under-clothes along the fold of the groin. The utmost care 
and delicacy must be observed in handling the organ : squeezing to cause pus to exude is very 
harmful, and pressure of any kind must be avoided. 
During the acuteness of the attack purgation at intervals of three or four days is very essen- 
tial. For this purpose two to four compound cathartic pills or ten grains each of calomel and 
supercarbonate of soda taken at night are excellent. Saline cathartics and the natural cathartic 
waters are to be avoided, since much of the sulphate of magnesia passes off in the urine and irri- 
tates the urethra. 
In the acute or inflammatory stage of gonorrhoea injections and oleo-resins are contraindicated. 
The chief object of therapeutics is to render the urine alkaline, bland, and as little irritating as pos- 
sible. For this purpose there is no better remedy than the bicarbonate of potassa. In general, 
the following prescription may be used : 
B. Potassae bicarbonatis, 5j; 
Syr. aurantii corticis, §ij; 
Aquae, £vj. M. 
Dose for an adult, one tablespoonful in a wineglass of water three times a day an hour after 
eating. 
In very acute cases I have used for many years the following prescription, containing hyoscy- 
amus, which acts beneficially as a sedative to the genito-urinary tract: 
B. Potassae bicarbonatis, ~j; 
Tr. hyoscyami, gss< • 
Aquae, zviij. M. 
To be taken in the same manner as the foregoing prescription. The citrate and acetate of potassa 
may also be remembered and used in the same proportions. 30 
VENEREAL DISEASES. 
Flaxseed, sassafras-pith and slippery-elm teas, and gum-arabic and barley waters, pleasantly 
flavored, may be taken as beverages. They are regarded as beneficial by many physicians, and 
patients sometimes think that they render urination less painful. Under any circumstances they 
are harmless. Vichy, Apollinaris, Poland, Bethesda, and soda waters are pleasant and suitable 
drinks, and to them may be added a few grains of supercarbonate of soda. 
Locally, the most important measure is the immersion of the penis in very hot water for fully 
ten minutes every two or three hours, by which means the pain and soreness are relieved and the 
redness and swelling reduced. A small quantity of laudanum and of bicarbonate of soda may 
often be with benefit added to the hot water. In the early days of the inflammatory stage baths at 
a temperature of 96° or 98° Fahr, are of much benefit in tending to produce a comfortable night's 
sleep. If possible, the whole body should be immersed ; if not, the hip-bath may be used. Immer- 
sion of the penis in very hot water during urination is often productive of amelioration of the pain. 
For the prevention of erections and chordee, besides the observance of a rigid hygiene, the 
patient must retire early and sleep on a hair mattress with light bed-clothes. It is always well, if 
possible, to avoid the use of anodynes, and much benefit has been derived, in my experience, from 
the use of the following injection in cases of persistent nocturnal erections and chordee : 
R. Liq. morphiae Magendie, gij; - 
Cocaine muriat., gr. vj-viij; 
Aquae, 3iv. M. 
Of this one or two drachms may be carefully and slowly thrown into the urethra, and there retained 
for fully five minutes, just before retiring. Or the following may be used in the same way: 
R. Extracti opii aquos, • 
Aquae, *iVe m, and filter. 
Signa: injection. 
For immediate use any cold body, such as a flatiron, may be applied to the perineum and the 
under surface of the urethra, or cold-water affusions may be tried. Owing to idiosyncrasy, cold 
is not beneficial in some cases, while hot-water immersions are very efficacious. I have seen much 
relief in some very severe cases of chordee by the use of the following prescription : 
R. Chloroformi, gj j 
Tr. belladonnas, gss • 
Liniment, saponis, giiss. M. 
A small quantity of this may be applied over the affected part on lint or cotton, and there kept for 
some time. I have also seen benefit in severe cases by allowing sulphuric ether to evaporate from 
a strip of old linen wound around the penis. Care must be exercised that the chloroform and 
ether vapors do not reach the head of the penis. 
In those cases in which there is much malaise, nervousness, and worriment, when hyoscyamus 
fails, laudanum in doses of two or three drops in a small quantity of water, taken three, four, or 
five times a day, is productive of a sense of comparative comfort during the day and of sleep at 
night. Besides being nauseous and irritating to the stomach, camphor has proved a very unre- 
liable remedy in my hands. 
In many cases, besides the erections and chordee, there is considerable vesical irritation, with 
frequent and imperious desire to urinate, together, perhaps, with pain in the perineum, loins, scro- 
tum, and groins. In such cases the laudanum, as just advised, may be used or suppositories may 
be ordered, as follows : 
R. Morphiae sulphatis, gr. ij; 
Ext. belladonnae, gr. iij; 
Ol. theobromae, q. s. GONORRHOEA IN THE MALE. 
To make suppositories no. iv. One of these may be introduced into the rectum just on retiring, 
and a second during the night if necessary. Digitalis and lupuline are not uniformly reliable, and 
gelsemium in potent doses is sometimes dangerous from its depressing action upon the heart. 
In many cases calm sleep may be induced by using the following combination, which is not fol- 
lowed by unpleasant after-effects: 
B. Potassii bromidi, 0xvj ; 
Chloral hydrat., gr. Ixxx; 
Liq. morphise Magendie, gtt. Ixxx ; 
Syr. simplicis, 
Aquae, oj- M. 
Dose, one teaspoonful in a little water on retiring, and it may be repeated during the night if neces- 
sary. In some cases, owing to tolerance, the quantity of all of the active agents may be suitably 
increased. Bromide of potassium alone proves of much benefit in the milder order of cases. 
Physicians must use the utmost caution in giving anodynes in gonorrhoea ; they must be given in 
the smallest doses and repeated as seldom as possible, and discontinued at the earliest moment 
upon the relief of the urgent symptoms. 
The tendency of gonorrhoea being toward disturbance of the nervous system and debility, 
much circumspection is required in preventing them. Purgation must not be pushed to the extent 
of weakening the patient, and if signs of falling away show themselves, a rather more liberal diet 
should be allowed so soon as admissible. If patients remain in-doors, they should be allowed a 
daily ride in the open air. 
Free drinkers suffering from acute gonorrhoea often complain bitterly of the loss of their accus- 
tomed stimulant, and even show physical evidences of it. Such cases may be benefited and placated 
by giving them from a half to one drachm of the fluid extract of coca at the periods of depression. 
Such is the restraint enforced upon patients that it is well to allow them to smoke with moderation 
during an attack of gonorrhoea. 
As the acute symptoms subside, with the redness and swelling growing less, the discharge less 
copious, whiter, and thinner, and a diminution of general and local discomfort, a modification of 
treatment is necessary. The first measure usually indicated is the use of exceedingly mild injec- 
tions. These should at first consist of very warm water thrown into the urethra at the time of 
each immersion and after urination. It is well to have about half a pint of hot water, and into it 
put about one drachm of supercarbonate of soda or of powdered borax, and to throw this gently, 
without any force, into the canal as far as it will go, using several syringefuls at each time. Five 
grains of the aqueous extract of opium in a drachm of water may be added. If it is found that 
these injections are well borne and beneficial, their efficacy may be increased by the careful addi- 
tion of some stimulant, such as sulphate of zinc one grain to the ounce of water, or of carbolic 
acid two drops to the same quantity. 
Under favorable circumstances, and in the continued decline of the second or inflammatory 
stage, various internal remedies, chiefly copaiba, cubebs, sandalwood oil, and kava-kava, may be 
used with or without the alkali, and stronger injections may be ordered. Much judgment and 
tact is required at this stage in adapting the local and internal stimulation. I am accustomed to 
begin with the addition of thirty grains of cubebs in capsule form to each dose of the alkaline 
mixture already spoken of, and to discontinue, if possible, the tincture of hyoscyamus. Improve- 
ment being noted, the dose of cubebs may be increased to one drachm, care being taken that the 
pure and fresh powder is obtained. The most noticeable effect of this will be the marked diminu- 
tion of the discharge and of the uneasy symptoms, particularly during urination. At this period 
also kava-kava may very often be of much benefit. It may be taken in the form of fluid extract, 
in doses of thirty to sixty drops, with the alkaline mixture. 32 
VENEREAL DISEASES. 
With the full establishment of the stage of decline the treatment should be more active, and 
injections then play an important part. The patient should be properly informed as to their use. 
Urination should take place shortly or just before the injection is used. The glans penis being 
exposed by the retraction of the prepuce and carefully dried, the orifice of the syringe should be 
introduced gently into the urethra, and there held while the thumb and fore finger of the left hand 
compress the lips around it by lateral pressure. The patient should either stand up or sit at the 
edge of the bed or of a chair, and with the syringe, in position and the penis at an angle of about 
forty-five degrees, the piston is slowly and carefully forced down by the fore finger of the right 
hand. If carefully done, none of the injection is lost. Using a syringe holding three or four 
drachms, the urethra will be felt to be much distended. Allowing the first injection to remain a 
minute or two, it should be followed by a second one, and then, while the fore finger and thumb of 
the left hand compress the meatus, the fore finger of the right hand may be passed up and down 
the urethra in order that the injection may reach its whole surface. Where mild injections are 
used no ill effects follow their introduction into the deep urethra, and pressure of the canal at the 
perineum with the idea of stopping their further entrance is wholly unnecessary. In the conserva- 
tive manner that injections are now employed the objections formerly urged against their use are 
no longer valid. 
It is important that the patient should be provided with a suitable syringe, easy of use and 
adjustment. Those made of india-rubber are excellent, particularly the one called Sigmund's 
syringe, with a bluntly conical nozzle, also the No. i, A., and even the india-rubber ear syringe. 
Druggists also keep glass syringes, which are very good and inexpensive, but the objection to 
them is their frailty. A very useful syringe has been devised by Balmanno Squire, made of glass 
and rubber and provided with a cap which prevents the escape of the injection and allows the 
patient to carry it with him ready for use. The object to be attained in all syringes is a short 
rather blunt end which will fit the meatus and act as an obturator, and a piston easily worked. 
Very many drugs have been employed as injections for gonorrhoea, and their action is both 
stimulant and astringent. It is a safe rule to always use mild injections which cause no uneasiness. 
To this end it is well to begin with a minimum strength and to feel one's way carefully in increas- 
ing, and never to go to the point of causing discomfort. What we may term idiosyncrasies as to 
injections are very common ; therefore it is necessary to have an extensive armamentarium. Injec- 
tions beneficial to one may fail with another. 
My late colleague, Dr. Bumstead, in his lectures was eloquent in the praise of acetate of zinc, 
and frequently ordered it in very dilute form, combined with opium, toward the close of the second 
stage. In general, solutions containing one grain to the ounce of water may be employed at first, 
and gradually increased until three grains are reached. The sulphate of zinc may also be used in 
similar proportions combined with some preparation of opium, preferably Magendie's solution, as 
follows : 
R. Zinci sulphatis, gp. yj ad viij; 
Liq. Magendie, • 
Glycerinae, • 
Aquae, q. s. ad §iv. M. 
A combination of sulphate of zinc and acetate of lead forms a very excellent injection, as 
follows : 
R. Zinci sulphat., 
Plumbi acetat., gr. vj ad xij ; 
Ext. opii aq., • 
Aquae, gvj. M. 
This with tincture of catechu and wine of opium is said to be the composition of the injection GONORRHCEA IN THE MALE. 
33 
Bru which has such favor with the laity. The efficacy of both of the foregoing injections may be 
increased in some cases by the addition of calamine or of subnitrate of bismuth. Kaolin, or clay 
earth, and silicate of soda may also be used. The subnitrate of bismuth may often be of benefit 
when used in the following- combination : 
o 
R. Bismuth, subnit., 5ij; 
Tr. catechu, 
Vin. opii., dd. gij : 
Glycerinae, 5ss; 
Aquae, ad 3vj. M. To be well shaken. 
The following imitation of the Bru injection was proposed by Dr. Bumstead: 
R. Zinci sulph., gr. xv ; 
Plumbi acetat., gr. xxx; 
Ext. krameriae fl., 
Tr. opii, da. jjiij ; 
Aquse, ad svj. M. 
It is my custom to prescribe this injection, using eight ounces of water instead of six. It is then 
often of much benefit. 
The following injections were employed by Ricord, and are much improved by using a larger 
quantity of rose-water than is directed : 
R. Zinci sulphatis, 
Plumbi acetatis, ad. gr. xxx ; 
Aquae rosae, gvj. M. 
R. Zinci sulphatis, gr. xv ; 
Plumbi acetatis, gr. xxx; 
Tr. catechu, 
Vin. opii, ad. gj; 
Aquae rosae, gvj. M. 
According to Dr. J. W. White, the following prescription was held in high favor by the late 
Dr. Maury : 
R. Tr. matico, 
Tr. catechu, aa. gj; 
Ext. opii, gr. Xv ; 
Plumbi acet., gr. xij; 
Glycerinae, £Ss; 
Aquae rosae, *vss. M. 
In cases where changes are necessary injections of sulphocarbolate of zinc, of sulphate of cop- 
per, and of alum, from one to two grains to the ounce of water, may be prescribed. 
The vegetable astringents may also be employed, the chief of which are tannin, hydrastin, and 
aromatic wine, dannin may be used dissolved in water in the proportion of one to three grains to 
the ounce. I he fluid hydrastis may be used, mixed with water 3j or 3ij to Siv, or the muriate of 
hydrastin half to one grain to the ounce of water. In many obstinate cases the following has 
proved beneficial in my hands: 
R. Vini. aromat., 
Glycerinae, aa. £ss; 
Aquae, gvij. M. 
In many obstinate cases of gonorrhoea in the third stage permanganate of potassium is of 
benefit if properly used. It should first be employed in the proportion of half a grain to the ounce VENEREAL DISEASES. 
34 
of water, and the strength increased as required. It is rarely necessary to go beyond a strength 
of two grains to the ounce. 
In similar cases nitrate of silver is often of much value, but it should always be used with the 
utmost caution. One grain of the salt to eight ounces of distilled water may be carefully injected 
at first, and the strength reduced or increased according to results. The following prescription is 
often of service, subject to the just-mentioned modifications : 
B. Argenti nitrat., gr. j; 
Ext. bellad., gr. vj; 
Glycerin®, gss; 
Aquae, ad §viij. M. 
The liquor hydrargyri pernitratis and chloride of zinc have been employed in injections for 
gonorrhoea, but in my hands they have never been productive of striking results. When used, 
they should be ordered in a state of large dilution, and if continued the quantity should be cau- 
tiously increased. 
In the third stage much benefit may be derived from deep-seated retrojections. These are 
of two kinds : first, those for cases in which the inflammation is in some portion of the pendulous 
urethra anterior to the compressor urethrae muscle ; second, for gonorrhoea seated beyond this mus- 
cle in the deep portion of the urethra. I he utmost care and delicacy must be observed in admin- 
istering these injections, which should be given, if possible, by the physician himself or a trained 
assistant or nurse, or by the patient, who has been thoroughly taught how to use them. They 
should never be used where active inflammation exists, since the instrument employed may then 
wound the inflamed mucous membrane. In general, the soft gum velvet catheter, of sizes from 8 
to 12, English scale, is very useful, but when obtainable the retrojection syringe of Dunham, which 
is really a bougie a boule with open calibre, and with minute holes directed backward in the bulb- 
ous end, may be employed. I he instrument should be passed back to the bulbous portion of the 
urethra. The liquids injected may be simply very mild salt and water, quite warm water, or warm 
or hot aqueous solutions of bichloride of mercury (i : 40,000) or of permanganate of potassium, 
half to one grain to eight ounces of water, these should be slowly thrown into the urethra by 
means of the ordinary india-rubber hand syringe holding four ounces. These irrigations which 
flow out alongside of the catheter should be used once or perhaps twice a day, the patient stand- 
ing during the operation, having previously emptied his bladder. By this method the bulbous por- 
tion of the urethra, where gonorrhoea is so prone to lurk, may be thoroughly medicated. 
In those rather rare cases in which gonorrhoea extends and localizes itself beyond the com- 
pressor urethrae muscle, called catarrh of the neck of the bladder, it is necessary to use the velvet 
catheter in its full length, the curved catheter of Mercier, or the very useful catheter of Ultzmann. 
The instrument should be slowly introduced, care being taken by delicate manipulation to overcome 
any resistance offered by the compressor urethrae muscle. The object to be attained is the lodg- 
ment of the eye of the catheter in the membranous portion of the urethra. If the injection flows 
out by the side of the catheter, it is evident that the end of the instrument is in front of the com- 
pressor urethrae muscle. If on removal of the syringe the fluid escapes from the catheter, it may 
be concluded that its end is in the cavity of the bladder. If, however, no fluid escapes from the 
catheter, it is certain that the eye of the instrument is in the deeper portion of the membranous 
urethra, and that the injected fluid will bathe those parts and flow into the bladder. The sensations 
of the patient should be the guide as to the amount of fluid to be used. In some cases several 
ounces are well borne ; in others discomfort and tenesmus are caused by a small quantity. For 
cases which tolerate large quantities of fluid the ordinary fountain syringe may be used. In this 
class of cases care as to hygiene and internal treatment, particularly with balsamics, is indis- 
pensable. GONORRHOEA OF THE MALE. 
35 
In very chronic cases of deep urethral inflammation much benefit often follows the instillation 
of two or three drops of a solution of nitrate of silver, 20 grains to the ounce of water. T his may 
be done by means of my own deep urethral syringe, by Ultzmann's syringe, or by Keyes' modifica- 
tion of the latter. It is important to locate the end of the syringe in the deep membranous and 
prostatic urethra. Such injections should not be repeated oftener than every five or seven days, 
and during their use the hygiene of the patient must be carefully guarded. 
What is termed the "modern treatment of urethritis" is the outcome of a method proposed 
by Dr. H. H. Curtis in 1883, which consisted in prolonged retrojections of hot water into the 
urethra. This method was modified by Dr. W. S. Halsted, and later by Dr. S. O. Vanderpoel, 
under the influence of the microbian theory of the origin of the disease, by the use of a solution 
of the bichloride of mercury. This treatment has been extensively used by Dr. G. E. Brewer at 
the Roosevelt Hospital, who has much improved its methods of administration. Solutions of 
bichloride of mercury, 1 part to 40,000 or 60,000 of water, are employed. The patient having 
urinated, a double-current hard-rubber nozzle is firmly placed in the meatus, and the fluid contained 
in a bottle placed on an elevation is allowed to run into and distend the urethra, from one to two 
quarts being used. This treatment is applicable for inflammation in any part of the canal in front 
of the bulb. 
For the region of the bulb and for deeper portions of the urethra an apparatus consisting of 
a tin pail, beneath which is a platform for a Bunsen's burner or an alcohol lamp, is used. The pail 
is connected by means of a long rubber tube with a good-sized flexible catheter. The whole is 
then suspended from above by means of a pulley. The catheter is passed about five inches into 
the urethra, and the hot medicated fluid started, the heat being gradually raised until tolerance is 
reached. About two quarts of fluid are injected, and the operation is repeated twice a day. The 
results claimed for this treatment hardly warrant its general adoption, considering the time and 
trouble incident to its use. It may be used in hospitals and dispensaries, but its application is, for 
obvious reasons, limited in private practice. Dr. Brewer claims that in private practice the results 
are more favorable, and that in thirty cases recovery took place within two weeks. Should further 
and more extended experience confirm this claim, the treatment will no doubt be largely adopted. 
My own experience with deep retrojections of hot water, of solutions of bichloride of mercury, and 
of carbolic acid has convinced me that in many cases much benefit is produced, and that in some 
pain and temporary injury have resulted, brom a careful consideration of the subject, I feel con- 
fident that this method will never supplant the older ones-that it will not be accepted as a routine 
treatment, but rather as an adjuvant for occasional use in connection with the classical methods. I 
have been much astonished at the absence of bad results at the Roosevelt Hospital, where the 
catheter has been introduced into acutely-inflamed urethrae. The experience thus gained was 
wholly at variance with the traditional dread of such interference. 
Internal Medication in Gonorrhoea.-There are three principal drugs used internally in the 
treatment of gonorrhoea, which are called anti-blennorrhagics : they are oil of sandalwood, balsam 
of copaiba, and cubebs. Besides these there are a number of minor drugs which are occasionally 
used. 
It is perhaps necessary to repeat the caution that these agents are contraindicated in the acute 
stage of the disease, and of benefit in the subacute and chronic state. It is claimed by some 
French authorities that they should not be administered until the discharge is thoroughly mucoid in 
character. My experience has taught me that their effect is better if used at a time when the dis- 
charge is still purulent, but not copious, and when the general symptoms have ceased to be dis- 
tressing. In a general way, it may be stated that their use may be begun at about the tenth or 
fourteenth day of the acute stage, unless it is very active and persistent. 
Oleum santali or oil of sandalwood is a thick, yellowish liquid of a pungent, aromatic odor, of 36 
VENEREAL DISEASES. 
which the close is from twenty to thirty drops three times daily. It may be taken upon loaf sugar, 
in the form of capsules, and as an emulsion. Owing to its cost, it should not, as a rule, be pre- 
scribed for poor patients. In the form of capsules it is extensively employed and constitutes one 
of our best remedies. The capsules are made by many firms, and some are good, while others are 
bad either from adulteration or from the substitution of some other volatile aromatic oils, such as 
those of cinnamon, wintergreen, and white cedar, for the oil of sandalwood. It is the duty of the 
physician to assure himself that his patient gets the genuine article, which is always kept by the 
best druggists.1 I have been especially pleased with the Javaresse capsules made in London, and 
have been disappointed in a French brand which is now much advertised in this country. In using 
this remedy as early as possible, it is well to begin with a small rather than the full dose. Of cap- 
sules containing five drops of the oil one may be given three times a day, or of those containing 
ten drops one twice a day. If well borne and beneficial, the dose may be cautiously increased, 
until if the case requires it sixty drops are taken daily, divided into three or four doses. It has 
been claimed that capsules of oil of sandalwood, taken an hour and a half after eating, pass undis- 
solved through the stomach, and are acted upon in the intestines during their period of digestion, 
and that in this way unpleasant gastric symptoms are avoided. I have seen many patients in whom 
immunity to these troubles was attributed to this method of taking the drug, and I always recom- 
mend it. While some patients can take the oil on sugar, many cannot; its use by this method is 
therefore limited. It is always well to administer an alkali at the time or soon after the inges- 
tion of the sandalwood oil when given in capsule form or on sugar, since its emulsification is thus 
increased. For this purpose the solution of bicarbonate of potassa already spoken of may be 
used, or if inconvenient Vichy water with supercarbonate of soda in very moderate quantity may 
be taken. W hen for any reason, such as expense or repugnance, capsules cannot be used, an 
emulsion will prove of benefit, of which the following is a good formula: 
R. 01. santal., fluid., vj to ~x. 
Liq. potassse, gvj . 
Mucilaginis acaciae, xjss . 
Aquae menth. pip., q s> ad giv 
M., with careful trituration. Dose, one teaspoonful three or four times a day with two tablespoon- 
fuls of water. 
1 he drawbacks to the use of sandalwood oil, such as gastric derangement and acid eructations, 
intestinal irritation with pain and diarrhoea, and pain and uneasiness in the regions of the kidneys 
and loins, need not of necessity cause its discontinuance. It is well to reduce the dose, lengthen 
the intervals, and to adopt measures to prevent and relieve the gastro-intestinal irritation. When, 
however, the latter is persistent the use of the drug must abandoned. 
I have at present under treatment a case in which a copious general but superficial erythema 
was caused by the ingestion of oil of sandalwood. 
Balsam of copaiba may also be given in the treatment of gonorrhoea toward the decline of the 
acute stage, in general about the tenth or fourteenth day. Its use, like that of sandalwood oil, 
should be begun tentatively in a rather small dose, and if proper it should be increased. Its action 
is diuretic and stimulating to the renal circulation. Ricord's experiment, in which copaiba was 
administered to a patient having gonorrhoea and a urethral fistula, in which the posterior portion 
was much benefited while the anterior portion was unaffected until the urine was allowed to pass 
through it, shows clearly that this drug has a marked effect upon the mucous membrane of this 
canal. The chief contraindications to its use, besides its nauseous taste-which can be overcome- 
1 The capsules manufactured by Hazard & Co., Caswell, Massey & Co., Frazer & Co., and by Fougera are perfectly pure and 
reliable. GONORRHOEA IN THE MALE. 
37 
are gastro-intestinal derangements. To avoid these as far as possible, the diet should be very 
plain and sparing, and the drug should be taken an hour and a half after eating, and shortly after a 
' small quantity of Vichy or other alkaline water, with a few grains of supercarbonate of soda, may 
be swallowed. The dose must then be reduced to a minimum of efficiency, and gradually and 
cautiously increased. In this way, by judgment and tact, the remedy may be persisted with. The 
not infrequent supervention of the copaiba rash or erythema demands the immediate discontinuance 
of the drug. For promptness of cure cases require the largest doses possible, without ill effects, 
in order that the urine may be constantly and copiously charged with its stimulating and healing 
qualities. Much idiosyncrasy among patients is observed in taking copaiba : some are unable to 
take any but small doses, while others bear large ones with impunity. In general, the dose is from 
one to three drachms in divided portions daily. Copaiba is most commonly administered in cap- 
sule form, and it must be confessed that those of French manufacture are by far the best. It is 
somewhat disappointing that in the present period of great advancement in pharmacy American 
firms are unable to compete with their French rivals. 
It is well to begin with a dose of one ten-drop copaiba capsule three times a day at the 
period already indicated. If well borne, two three times a day may be given, always an hour or 
an hour and a half after meals, and, if possible, followed by a scant draught of alkaline water. 
Should the obstinacy of the case demand it, the use of the drug not being contraindicated, the 
dose may be increased to three capsules three or four times a day. 
Copaiba is largely used in the form of emulsion, particularly in hospitals and dispensaries. 
In this country the following formula, known under the name of the La Fayette mixture, is exten- 
sively used: 
B. Bals, copaibae, 5j; 
Liq. potassae, gij; 
Ext. glycyrrhizae, §ss; 
Spts. aether nitrosi, 5j; 
Syrup, acaciae, 5vj ; 
01. gaultheriae, gtt. xvj. 
Mix the copaiba and liquor potassae and the extract of liquorice and sweet spirits of nitre separately, 
and then add the other ingredients. The dose is from one to four teaspoonfuls three times a day. 
The following useful formula is given by Mr. Milton in his classical work on gonorrhoea: 
B. Copaibas bals., 
Liq. potassae, aa. jiij 
Mucilag. acaciae, 5j; 
Aq. menth. viridis, q. s. ad 5vj. M. 
Dose, one ounce three times daily. 
The following prescription is of benefit in cases of delicate stomach: 
B. Copaibae bals., 51J; 
Magnesiae, 5j; 
01. menth. piperitae, gtt. xx; 
Pulv. cubebae, 
Bismuthi subnitrat., aa. 
M. and divide into pills of five grains each, and coat with sugar. Dose, three to six pills, three 
times a day. 
At my clinic at the New York Hospital, in addition to the La Fayette mixture, we use the 
following prescription, which was obtained by my assistant, Dr. R. H. Greene, in Boston, with 
beneficial results. As a specimen of polypharmacy it is a marvel, and, though of a brown color, 
it is called mistura viridis, in honor of its sponsor. Its formula is as follows : 38 
VENEREAL DISEASES. 
R. Syrupi tolutani, 
Mucilag. tragacanth., 
Aquae calcis, 
Aquae camphorae, 
Aquae menth. pip., da. 3j; 
Ol. santal. flav., 
Bals, copaibae, 
* Ext. sarzae. comp., da. 3-ss; 
01. sabinae, 
Ol. conii, ad. gj; 
Ol. cubebae, 
Ext. ergotae fluid., dd. jjiss. M. 
Dose, one or two teaspoonfuls three times a day with a little water. 
Cubebs in the form of powder, fluid extract, or oleoresin is a remedy of much value, and is 
capable of extended use in the treatment of gonorrhoea. Like copaiba and oil of sandalwood, its 
use may be begun at the stage of decline. It seldom causes gastro-intestinal disturbance, and 
sometimes exerts a beneficial action upon the stomach, especially when dyspepsia exists. It is of 
especial importance that the powder should be fresh and that the fluid extract and oleoresin should 
be well made and pure. The dose of powdered cubebs is from fifteen to thirty grains, and even a 
drachm, three times a day. It may be given in combination with the supercarbonate of soda or 
with finely-pulverized bicarbonate of potassa. It can be taken mixed with a small quantity of 
water, since its flavor is very evanescent, or it may be administered in capsule form or by means 
of wafers. The dose of the fluid extract is from twenty to sixty drops three times a day, half an 
hour or an hour after eating. I he following combination has been useful in many cases in my 
practice : 
R. Fl. ext. cubebae, • *j; 
Liq. potassae, 
Spts. aether nitros., aa. giv; 
Syr. tolutani, ga M. 
Dose, one to two teaspoonfuls three or four times a day. 
In combination with eucalyptus, cubebs is often of much benefit in chronic gonorrhoea, as 
follows: 
R. Fl. ext. cubebae, 
Fl. ext. eucalypti, ad. §j; 
Liq. potassae, ?ss ■ 
Syr. tolutani, gjss. M. 
Dose, one or two teaspoonfuls three or four times a day. 
Though useful in some chronic cases, the oleoresin of cubebs is less commonly used than the 
other preparations. It may be given in ten to twenty drops or in capsular form. The following 
is an excellent formula: 
R. Ol. cubebae, gtt. clx-cccxx; 
Liq. potassae, 
Mucil. acaciae, gSs. ; 
Spts. lavand. comp., giss. ; 
Syr. tolutani, ad gij. M. 
One teaspoonful three or four times a day, with a little water. 
Cubebs in combination with copaiba may be used in the form of capsules, preferably those 
made in France, of which the dose is from one to three capsules three times a day. Pastes or 
electuaries composed of these drugs with supercarbonate of soda, with or without oil of sandal- 
wood and a suitable flavoring, may be used in the form of pills or of a bolus. GONORRHOEA IN THE MALE. 
39 
All patients for whom oil of sandalwood, copaiba, and cubebs are prescribed should be warned 
that their odor may be perceptible in the breath and in the urine. 
As already mentioned, the fluid extracts of kava-kava and eucalyptus are often of benefit in 
chronic gonorrhoea and in the subacute stage of gonorrhoeal cystitis. I heir dose is from twenty to 
sixty drops in water three times a day. 
Gurjun balsam in doses of thirty drops three times a day has proved beneficial in the hands 
of Vidal and Mauriac, and from a limited experience Berkeley Hill thinks it is worthy of more 
extensive trial, especially in hospitals, on account of its cheapness. 
Turpentine in capsule form or in the pearls of Clertan, in somewhat exceptional cases of 
chronic urethral discharge and in chronic gonorrhoeal cystitis is of much benefit. 
In their anxiety for cure physicians and patients are sometimes led to over-medication and to 
the too persistent use of injections. It is good practice always, when medicines and injections 
seem to have lost their benefit, particularly in cases where the stomach and general health are 
impaired, to stop for a time the use of both and to watch the case. With injections especially it is 
often noticed that up to a certaip time they are of benefit, and that then they fail. The truth is, 
that they often act as direct irritants. Very frequently in such cases, particularly where debility 
exists, an iron-and-quinine tonic will improve the patient's nutrition, and the discharge will cease 
spontaneously. By carefully watching the case the physician will be able to determine whether it 
is necessary to resume the anti-blennorrhagic or the use of the injection, which should always be 
mild. 
In very many cases of obstinate chronic gonorrhoea much benefit will be produced by the pas- 
sage of sounds. This procedure should always be begun with the greatest caution, and the instru- 
ment should be introduced with the utmost delicacy. In the vast majority of cases sounds should 
not be resorted to earlier than the sixth or eighth week of the existence of the discharge. Then 
one not larger than size No. 12, English scale, should be employed, allowing it to remain at first 
only two or three seconds in the canal. 1 he operation should not be essayed if the patient has to 
be in active movement, and should be preferably done at night. If discomfort is not caused, and 
if the discharge is not increased, the introduction of a sound one or two sizes larger may be tried 
again in about five or six days. Results being favorable, this treatment with gradual increase- 
aided perhaps by anti-blennorrhagics or mild injections, may be continued at the intervals stated, 
or even longer ones, until the urethra no longer gives indications of a stenosed condition and the 
patient is free from discharge and discomfort. This same method should be applied with all of its 
details in those cases in which the discharge is kept up by an old stricture. 
In contradistinction to what we may call the over-zealous patient is that not infrequently 
observed individual who at the period of decline or cessation of his discharge becomes careless, 
even reckless, and indulges in excesses in drink and venery. The result is apt to be serious, 
since the exacerbation or relapse is not commonly confined, as at first, to the fossa navicularis, but 
may involve the whole urethra as far as the bulb, and even beyond. Such patients demand the 
utmost care and watchfulness, lest the testicles, prostate, and bladder become involved. They 
should be put at absolute rest in the recumbent position, and treated upon the lines already laid 
down. As soon as possible judicious deep urethral local medication should be instituted. 
There is a class of cases not infrequently seen in which a slight discharge remains, and for 
which no other explanation can be given than hyperaemia of the deep urethra due to prolonged 
continence. Such patients frequently suffer from recurring nocturnal emissions, coincidently with 
which the discharge is increased. For their relief there is but one remedy, which is coitus, which 
should be guardedly performed and at sufficiently long intervals. Such cases require great tact 
and prudence on the part of the physician in order to procure benefit and avoid harm. The 40 
VENEREAL D/SEASES. 
results of this sexual hygiene are often very auspicious. Since all pus from the urethra is liable 
to be of a contagious nature, the physician must give his patient explicit directions as to such 
prompt and copious irrigation, perhaps with a medicated fluid, as will protect the wife or mistress 
from all harm. 
Treatment of Hemorrhage.-As a rule, hemorrhage during gonorrhoea is of trifling character, 
and seemingly is beneficial. When it is excessive the patient should be put on his back and the 
cold-water coil applied. This failing, a gum-elastic bougie, sufficiently large to distend the canal, 
should be retained in the urethra and careful compression applied to the perineum and under sur- 
face of the penis. If in urgent cases solutions of persulphate of iron are used, care should be 
taken that they are not too strong. 
COMPLICATIONS OF GONORRHCEA IN THE MALE. 
Epididymitis and Orchi-epididymitis.-The most frequent complication of gonorrhoea is 
inflammation of the epididymis, which may be limited to that part or may also involve the testicle. 
The former is called epididymitis, and the latter orchi-epididymitis, and both are known under 
the title swelled testicle. Various explanations,1 such as sympathy, reHex action, and metastasis, 
have been given as to the origin of the affection ; all of which are vague. In some cases the 
inflammation seems to increase by continuity of tissue from the deep portions of the urethra 
through the ejaculatory duct to the testis. 
Swelled testicle is rarely seen within the first two weeks of the existence of gonorrhoea, and 
when its onset is thus seemingly precocious it is generally in cases in which the disease began in 
foci of chronic and subacute inflammation seated in the deep urethra. Statistics show that from 
the third until after the sixth week the liability to this complication increases, that it is of very fre- 
quent occurrence after that time, and that there is danger as late as the third month. Cases have 
been reported in which the testicular inflammation began several days before the appearance of 
the urethral discharge, the probable explanation of which is that a deep-seated chronic urethral 
inflammation was the starting-point of both. Strictures of the urethra and chronic deep-seated 
inflammation of the canal frequently cause epididymitis. 
Symptoms.-Before the onset of the affection proper the urethral discharge ceases and 
patients complain of varying symptoms. In some a pain in the groin along a portion or the 
whole of the spermatic cord is experienced ; in others it is seated within the pelvis, and is some- 
times described as reaching to the kidney ; in other cases patients experience a sense of weight 
and uneasiness in the scrotum, and not infrequently they say that a jarring motion caused pain in 
testis itself and called their attention to the trouble. In general, there are no premonitory con- 
stitutional symptoms, but as the intensity of the inflammation increases a chill and fever of various 
1 Reynaud's suggestion is interesting in this connection. He says: "When one reflects on this fact, so remarkable and so 
frequently observed, the suppression of a blennorrhagic discharge at the moment of the appearance of an orchitis; when one 
especially reflects that there is no direct communication, vascular or nervous, between the urethra and the testicle,-one finds himself 
forcibly led to think that there exists between the two organs a nervous arc of which the centre is the cord, from whence the irrita- 
tion of one reacts on the capillary circulation of the other. In the cases which occupy us the two extremities of the nervous arc are 
closely approximated." 
Paget also speaks as follows: " I do not know how it can be explained, except by disturbance of the exercise of the nervous force 
in the testicle, which disturbance was excited by the transference from the morbidly-affected nerves of the primary seat of irritation in 
the urethra." 
McBride's views also are interesting: "We are all familiar with the common fact that irritation of the orifice of the duct of a 
gland excites it to greatly increased action-that it becomes congested; and such a process may occur in the testicle when the ejacula- 
tory ducts are involved in an inflammation of the prostatic portion of the urethra. Both views are probably correct, the reflex action 
occurring in some cases, most probably those which begin acutely, while the cases which are chronic in progress and origin most often 
originate from extension of the inflammation from the urethra by continuity of tissue." GONORRHOEA IN THE MALE. 
41 
deo-rees, with malaise, want of appetite, great thirst, a frequent desire to urinate, and perhaps con- 
stipation, may supervene. As a rule, the systemic reaction is not great, but in very severe cases, 
and particularly those in which the spermatic cord and vas deferens are involved, there may be 
well-marked fever with all of its concomitants. In some rare cases there are nausea and vomiting. 
The invasion of the affection may be prompt or slow. Many patients walk and attend to their 
duties with mild and bearable discomfort for one or more days before they are forced to assume 
the recumbent position. In other cases, particularly those in which one or more exciting causes 
are active, the affection is well under way and the patient on his back within twenty-four hours. 
Early examination of a case shows that the epididymis, with perhaps the cord, is swollen and pain- 
ful and that the scrotum over it is somewhat reddened. In some cases the pain and swelling are 
confined to die globus minor or tail of die epididymis, which becomes of die size of a hickory-nut, 
and the affection may thus be limited : usually, however, die body and globus major or head of the 
organ are promptly involved. Then a large tumor is found seated superiorly and posteriorly to 
the testis, and die furrow which naturally exists between that organ and die epididymis may be pres- 
ent or it may be obliterated. The shape of the tumor varies in different cases. The epididymis, 
becoming enlarged, may cover the testis like a cap, or it may grow longitudinally and form a 
semilunar tumor, which rests on the testis like a crest on a helmet, the head of die appendage 
reaching well forward and the tail well upward. There is also usually more or less lateral expan- 
sion of it Pressure on the testis in such a case usually causes no pain, but when the swollen epidi- 
dymis is held between the thumb and forefinger die patient winces or cries out. Coincidently with 
this inflammation, die scrotum on the affected side becomes of a deep, even purplish red, and 
tense Pain is at this time severe and continuous, with paroxysms at night. Slight motion tends 
to increase the patient's sufferings, and pressure even of die bed-clothes causes agony. Coinci- 
dent involvement of the cord is attended with a still greater amount of pain. In these very severe 
cases the testicle is also, as a rule, the seat of inflammation. When the epididymis alone is 
inflamed the swelling is very considerable, but when it and the testes are involved, it is great, so 
that a tumor of the size of a small fist is formed. The testis will be found to be very painful and 
tender and a much larger area of the scrotum will become inflamed, thickened, and of a deep 
red While at first there was only moderate and localized adhesion of the upper portion of the 
organ to the scrotal wall, when orchi-epididymitis is present there is adhesion of a large surface 
corresponding to the size of the swollen testicle. In proportion as the testicular inflammation is 
great the tunica vaginalis becomes affected and the seat of serous effusion, by which the size of the 
tumor is materially increased. With this concomitant the acme of the inflammation may be said to 
be reached. The appearances of epididymitis of the right side are well shown in Fig. 4, Plate I., 
in which the red and tense integument contrasts with the normal and wrinkled surface of the left 
side Orchi-epididymitis is shown in Fig. 5 of the same plate as a round, prominent swelling 
tapering toward the inguinal ring, and covered with red, tense skin, over which are engorged 
blood-vessels. 
In its full height swelled testicle consists of inflammation of the epididymis, of the testis proper, 
of the tunica vaginalis, which is the seat of effusion, and of exudative oedema of the subscrotal con- 
nective tissue and of the scrotal wall, with perhaps inflammation of more or less of the cord. At 
this time it is difficult to detect the hydrocele unless the effusion is very copious. As a rule, well- 
marked swelled testicle reaches its acme within forty-eight or seventy-two hours. Much depends 
in these cases upon the vigor and efficiency of the treatment, which may prevent the affection from 
reaching the point of full development, and which will usually superinduce the stage of decline. 
Swelled testicle may exist in a severe form from one to five days in untreated cases, when sub- 
sidence of the inflammation begins. In carefully-treated cases the intensity of the symptoms need 
not last longer than twenty-four or thirty-six hours. The first symptom of improvement is ameliora- 42 
VENEREAL E/SEASES. 
tion of the pain, and soon it is noticed that the patient can move in bed with more freedom than 
before. The redness and oedema of the scrotum become less, and its adhesion gradually passes 
away, and the swelled organ becomes smaller and can be more freely manipulated. At this 
time the general health of the patient will improve ; he will lose his anxious look, drink less of 
fluids, and ask for food. As a rule, the course of swelled testicle in bad cases occupies from ten 
to fourteen days, during which time the patient will have been confined to his bed. At the end of 
this time, though he may go about, he is far from well, and should be looked after with the most 
careful attention. Unless removed by tapping, the hydrocele remains for a long period, and while 
it does the testis remains swollen and tender. When there is no hydrocele the testis is found to grad- 
ually become smaller and softer, and soon the line of demarcation between it and the epididymis 
can be made out. During this period of involution the epididymis also grows smaller, but much 
more slowly, and for longer or shorter periods it is found to be enlarged and indurated. Its con- 
tinuance in this state is governed largely by the duration and intensity of the inflammation. With 
the oedema of the part there is cell-exudation, and the future of the case depends on the extent 
and severity of this morbid condition. So rapid and complete is the involution of the swelling of 
the epididymis in some cases that it seems scarcely credible ; in others it is slow, occupying several 
months ; while in others permanent enlargement and induration is left. In severe cases-luckily, 
not common-the testis, tunica vaginalis, epididymis, and vas deferens are left in a state of indu- 
ration and chronic subacute inflammation. 
During an acute attack of swelled testicle the sufferings of the patient, as in gonorrhoea, are 
sometimes increased by the occurrence of nocturnal emissions. 
As a rule, the first attack of swelled testicle is the most severe, and it renders the patient 
liable to relapses. The affection is usually unilateral, though rarely both testes are involved. 
Exceptionally, inflammation of one organ is followed by that of its fellow, and is called see-saw 
epididymitis, the epididymite a bascule of Ricord. 
Much gradation in intensity is observed in swelled testicle. Some patients simply complain 
of a little uneasiness and heaviness in the scrotum, and the surgeon is the first to find the epidid- 
ymis more or less enlarged. Other patients present more marked subjective symptoms, with 
moderate epididymitis and often involvement of the testicle, yet by means of medicinal applica- 
tions and with the support of a suspensory they are able to go about with moderate freedom. Res- 
olution of the inflammation also varies considerably in different subjects. In some cases with very 
little care the testis soon returns to its normal state, while in others it is slow. 
In a normal testis little difficulty is experienced in determining the extent and localization of 
the inflammation, but it must be remembered that exceptionally there exist malpositions of the 
epididymis, when confusion may occur. The most common form of malposition is where the 
epididymis is placed anterior to the body of the testis, in which the features observed in the 
normal testis would be reversed. I hen it may be seated on one side, either external or inter- 
nal, in which event the diagnosis need not be difficult. In the third variety the epididymis and vas 
deferens are attached superiorly, the long axis of the testis being in the antero-posterior direction. 
In a fourth variety the epididymis and vas deferens form a loop or sling from before backward 
around the testis. It is always important to make a correct diagnosis of the position of the parts, 
particularly if puncture of the tunica vaginalis is decided upon. It is a good rule to find the vas 
deferens high up in the scrotum, and if practicable trace it downward between the tips of the 
thumb and fore finger. 
Sometimes, even when the epididymis is normally placed, its weight and bulk are so much 
increased by inflammation that it falls downward and forward with the testis above it. Examina- 
tion then reveals the tail of the epididymis anteriorly and the head posteriorly, the organ hanging 
antero-posteriorly in the scrotum. GONORRHCEA IN THE MALE. 
43 
Gonorrhoeal inflammation, when it attacks an undescended or misplaced testis, has frequently 
been unrecognized. Berkeley Hill speaks of the case of a young man suffering from gonorrhoea, 
obstinate constipation, stercoraceous vomiting, fever, and great abdominal tenderness, particularly 
in the left iliac region. The right testis was found in the scrotum, but the left one could not be 
discovered. After death, from peritonitis, a small inflamed testis was found close to the internal 
ring. Undescended testis in the inguinal canal need offer no diagnostic difficulty. Ricord mistook 
a perineal swelling for abscess of Cowper's gland, but examination of the scrotum showed absence 
of one testis, and a diagnosis of misplaced and inflamed testis was made. Gosselin reported the 
rare occurrence of gonorrhoea attacking the epididymis seated in the scrotum while the testis was 
retained in the inguinal canal, in which the first diagnosis was epiplocele. 
Statistics seem to show that swelled testicle occurs more frequently on the left than on the 
right side, presumably, according to some authors, from the fact that men usually "dress" on this 
side. As to the frequency with which different tissues of the testis are attacked, the statistics of 
Sigmund show that in 1342 cases of swelled testicle the epididymis alone was involved in 61 ; the 
epididymis and tunica vaginalis in 856; the epididymis and cord in 108 ; and these three parts 
together in 317. 
Gonorrhoeal inflammation of the spermatic cord, without involvement of the corresponding 
testis, is a rather rare complication. In the three cases which I have seen, there was a fusiform 
or cylindrical swelling of the size of one s finger or of a sausage, beginning at the external ring 
and ending near the epididymis. I he overlying skin was hot, red, rather oedematous, and not 
freely movable over the inflamed cord. There was moderate fever in two cases, and the pain was 
severe ; in the third case the febrile symptoms were well marked, and the patient vomited and was 
much constipated. These symptoms, in addition to which the patient said that he first experienced 
pain after prolonged coughing, led my house-surgeon to think the case was one of hernia. The 
existence of a discharge led to inquiries, which settled the diagnosis. 
Gonorrhoeal inflammation of the vas deferens alone is of rare occurrence. Gosselin reported 
a case in which the swelling began below the external ring and extended to the level of the head 
of the epididymis. It was of the size of a hickory-nut, hard and painful, and from it a cord of the 
size of a goosequill stretched to the tail of the epididymis. Above the tumor the vessel was hard 
and cord-like. 
Induration of the epididymis may exist without impairment of the function of the testis. In 
some cases so copious and dense is the proliferation of cellular tissue that constriction, even to 
the extent of obliteration of the vasa efferentia, is produced, rendering the testis sterile. This is 
especially to be feared when the globus minor is involved, since at this point the tubes unite into 
one, whereas at the globus major there is a multitude of minute efferent vessels, some of which 
may escape. Unilateral induration of the globus minor may cause obliteration of the deferent 
duct and sterility of one testis. When it occurs on both sides, absolute sterility may be produced, 
but, as a rule, such patients have their usual sexual desires and their erections and ejaculations are 
complete. Their semen, however, is entirely wanting in spermatozoa. Further, the size and con- 
sistency of the testes remain as before, and atrophy is very rarely produced. It has been observed 
that in auspicious cases treatment has more or less perfectly removed the induration, and that 
then spermatozoa have again been found in the semen. 
Atrophy of the testes has been known to occur in a few cases following orchi-epididymitis, 
and hypertrophy is not very uncommon, particularly in subjects who have had repeated attacks of 
the affection. 
Abscess of the testis is a not frequent complication of gonorrhoeal orchi-epididymitis, the focus 
of the trouble being usually in the epididymis. It should be promptly opened and the wound 
treated antiseptically, otherwise fistulae and fungous growths are liable to form. It does not, of 44 
VENEREAL DISEASES. 
necessity, follow that the vas deferens will be occluded. Cysts in the epididymis sometimes follow 
swelled testis, and are sometimes the seat of acute pain, and may be mistaken for circumscribed 
abscesses. 
Abscess of the body of the testis somewhat rarely occurs during gonorrhoeal orchi-epididy- 
mitis. An incision should be made as soon as fluctuation is discovered. In some cases the wound 
heals and the integrity of the organ seemingly remains. In other cases a hernia of the testis tis- 
sues occurs, and protrudes as a fungous mass from the opening in the scrotal walls. This condition 
is shown in Figs. 7 and 8 of Plate I. Such cases require prompt castration. 
Chronic hydrocele is frequently caused by swelled testicle. Vetault thinks that the effusion is 
due to congestion of the vessels of the tunica vaginalis, caused by presence of the indurated tissue 
in the head of the epididymis. It is also probable that the acute inflammation during gonorrhcea 
leaves a tendency in these vessels to engorgement and consequent effusion of serum. 
Gangrene of the scrotum is a somewhat rare complication of swelled testicle ; and of it I have 
seen two cases-one in a diabetic patient, and the second in a man suffering from Bright's disease. 
It usually begins at a dependent portion of the sac as a black spot, which spreads and destroys 
more or less of the walls, laying bare the testis or testes, which, however, are not invaded. After 
the cessation of the gangrene the parts usually heal and cover the testes again, unless the destruc- 
tion has been very extensive. 
Neuralgia is a not uncommon sequela of swelled testicle. It may exist as a slightly painful 
sensitiveness in the organ and along the cord, particularly on pressure or during active motion, or 
as a distinct dull pain subject to irregular and fugitive paroxysms. Usually, in these cases the 
epididymis is found to be enlarged and very sensitive. It is commonly seen in weak, sickly sub- 
jects, particularly those of neuropathic tendency, and subjects given to worry and fretting. 
Reflex neuralgias, first fully described by Mauriac, are not infrequent complications and 
sequelae of swelled testicle. The pain is generally unilateral and confined to the territory supplied 
by the lumbar and sacral nerves of the affected side, but may cross the median line and extend in 
various directions. Spinal pain, seated at the junction of the lumbar and sacral plexuses, is some- 
times complained of, and it may be bilateral and more severe on the unaffected side. Deep-seated 
pain, as if in the kidneys, extending from the ribs to the sacrum, pains radiating from the lower 
part of the lumbar portion of the cord and radiating upon the abdomen and lower extremity, and 
a sense of a constriction encircling the body under the level of the umbilicus, are also sometimes 
experienced. Pains and vague unpleasant sensations are felt at spots along the intercostal nerves 
and in the course of their distribution. 
The pains affecting the leg are not uncommon, and they may be seated in the anterior crural 
or posteriorly in the sciatic nerve, fl he pains in the anterior crural nerve involve the anterior 
aspect of the thigh as far as the knee, rarely below that, though Mauriac says that the internal 
saphenous nerves may be the seat of pain. I he pains in the sciatic nerve are referred to the 
sciatic notch, from which they may extend forward to the great trochanter or downward to the 
popliteal space. In many cases they are limited to the buttocks and postero-external portion of the 
thigh. The pains may be of a neuralgic character, continuous or with exacerbations, sometimes 
of a fulminating character, and remissions, or may exist as more or less extensive hyperaesthesia of 
all those parts supplied by the lumbar and sacral nerves and their branches. 
The intensity of these pains sometimes amounts to agony, and they cause insomnia, nervous 
excitement, and prostration and emaciation : they may last several days or several months, but in 
the end they cease. It is frequently observed that a relapse of the orchi-epididymitis is accom- 
panied or followed by some neuralgic manifestations. Such morbid phenomena emphasize the 
necessity of careful and intelligent treatment of the testicular lesion. 
Patients who have suffered from epididymitis, particularly those in whom relapses have been GONORRHCEA IN THE MALE. 
45 
frequent and whose epididymes are thickened, are prone to engorgement and gummatous infiltration 
of these parts if they subsequently contract syphilis. The same tendency is observed in cases in 
which the testis proper has been inflamed during gonorrhoea. Chronically inflamed and indurated 
epididymes sometimes become the seat of caseous degeneration, and in sickly, scrofulous,, and 
tuberculous subjects tuberculosis may attack them. 
Causes of Epididymitis.-Gonorrhoea being the predisposing cause, various exciting causes 
are often the starting-points of the trouble. These are the early use of strong injections, par- 
ticularly when used to abort the disease ; indulgence in alcoholic stimulants ; and sexual excite- 
ment, with or without coitus, since men, either from lust or with a mistaken idea that they may thus 
rid themselves of their trouble, often have connection while suffering from gonorrhoea. In the major- 
ity of cases, walking, activity in business, dancing, and riding, particularly on horseback, are the 
immediate causes. My own impression in several cases was that the testis became inflamed in 
consequence of its not being held up by a suspensory bandage. Passage of sounds and catheters 
toward the decline of gonorrhoea is frequently followed by epididymitis. A similar procedure in 
the chronic and remote stage of gonorrhoea, or when stricture of the urethra exists, is often fol- 
lowed by a mild and ephemeral epididymitis or orchi-epididymitis. 
Diagnosis. Commonly, no difficulty is experienced in the diagnosis of swelled testicle, since 
the history of the case and the nature of the lesion are so clear. In those rare cases of acute 
hydrocele doubt might exist, but it would be soon dispelled by a consideration of the history of the 
case and an examination of the parts. Swelled testicle, with redness and oedema of the scrotum, 
is said to have been mistaken for erysipelas of that pouch. Such an error will rarely occur, and 
with ordinary care will be promptly found out. Haematocele of the tunica vaginalis may at first 
resemble gonorrhoeal swelled testicle, but the history of traumatism will settle the question. The 
same remarks apply to orchitis of traumatic origin. 
In orchi-epididymitis, or epididymitis accompanied by inflammation of the cord as far as the 
external ring, a mistaken diagnosis of hernia may be made, particularly when there is much fever, 
with constipation and vomiting, as sometimes occurs. The error need not be of long duration, 
since in the scrotal lesion there is a history of gonorrhoea, while in hernia there is usually a history 
of a fugitive or permanent tumor in the groin, and perhaps of antecedent inflammation or strangula- 
tion of the hernial sac. 
Epididymitis of a misplaced or undescended testis sometimes is difficult of recognition. In 
such cases the history of an urethral discharge should cause suspicion, when the examination of the 
scrotum will show absence of one testis. It must be remembered that the testis may be retained 
within the abdominal cavity, in the inguinal canal, and that it may be found in the perineum. 
In all cases it is of importance to assure one's self of the relation of the epididymis to 
the testis since puncture of the tunica vaginalis is so frequently necessary. It is important to 
ascertain whether inversion of the epididymis is present, since puncture under these circum- 
stances might wound or destroy the vas deferens. In swelled testicle the seat of inversion the 
tumor is long antero-posteriorly, with the epididymis well forward and the testis under and rather 
behind it. 
In cases of inflammation of the spermatic cord it is well to seek the vas deferens as it leaves 
the tail of the epididymis, and trace it until it will be found to be lost in the swollen meshes of the 
cord since it may not be possible to examine it as it escapes from the canal. The diagnosis of 
these cases is more difficult when the portion of the cord between the external and internal rings 
is also swollen. 
Inflammation of the vas deferens may be made out by tracing the canal in the upper portions 
of the cord and passing the finger-tips downward until the morbid part is reached. 
Prognosis. The prognosis of swelled testicle from gonorrhoea is, in the main, good, since 46 
VENEREAL DISEASES. 
more or less complete resolution generally occurs. It depends, however, largely upon the prompt- 
ness and efficiency of the treatment and on the nature of the patient. Careless habits, intolerance 
of restraint, and poor fibre tend to make the prognosis more serious. The occurrence of the vari- 
ous structural complications already detailed, and the supervention of the various neuralgias, of 
course make the condition more serious. The fecundity of a man is not imperilled by induration 
of one epididymis and the occlusion of its vas deferens, but the occlusion of both of these ducts 
renders him sterile. Though his procreative power is lost, his ability to copulate remains. The 
question of the sterility of a man often becomes an important factor in domestic relations. It must 
not be stated with absolute positiveness that when no spermatozoa are found in the semen a man 
is absolutely sterile, since it may be that there is present a temporary stenosis due to exudation, 
and for the reason that under treatment resolution of the infiltration may be produced. It is only 
in cases where the semen examined over long periods is found to be wanting in spermatozoa that 
the existence of absolute sterility may be asserted. 
The prognosis is always better when the lesion is seated in the head of the epididymis, and 
correspondingly worse when in the tail, since in that the spermatic vessels have converged to form 
over the vas deferens. Since relapses of epididymitis frequently have their origin in chronic sub- 
acute, deep-seated urethral inflammation, their occurrence will suggest the necessity of the removal 
of the cause. 
Treatment.-Absolute rest in bed is the first indication in the treatment of gonorrhoeal epididy- 
mitis. During the premonitory stage the sooner the patient takes to his bed the better for him. 
The next indication is to place the swollen organ in a position of rest and comfort; and for this the 
suspensory bandage is generally useless. A number of excellent procedures are at our command. 
The simplest is to form an immovable platform or shelf on which the organ may rest. This may 
be done with india-rubber adhesive plaster; and, though regarded as dirty and objectionable by 
some, it by a little trouble can be made cleanly and serviceable. A sufficiently long strip of adhe- 
sive plaster, three to five inches wide, is placed across the thighs of the recumbent patient so high 
up that its superior border touches his perineum, whose scrotum for the moment has been carefully 
lifted toward the body. While sufficient adhesive surface is applied to the thighs, that portion of 
the plaster which forms the bridge between them may be covered with gutta-percha tissue, which, 
being folded under, adheres to the adhesive plaster. We have thus a water-proof platform or 
bridge upon which the scrotum may be placed. The objection that this application involves the 
immobility of the patient has no weight, for he is better off in that condition. 
The next method of fixing the testes is to take the heel of a good-sized firm stocking, upon 
one end of which two pieces of tape, seated about one inch apart, are securely sewn, while on 
the other end two similar pieces of tape are sewn about three inches apart. A waistband having 
been put in place, the suspensory is applied to the scrotum with the two tapes, which are nearer 
together underneath, each one of which should be passed outward and upward over the thigh and 
pinned on the waistband at about the anterior superior spine of the ilium. The remaining or supe- 
rior tapes are brought up on each side of the penis and fastened to the waistband in the median line. 
The third efficient method requires a soft linen or silk handkerchief, which should be folded 
diagonally so as to form a triangle, in the centre of the base of which two pieces of tape are to be 
sewn. Having placed a firm waistband around the body just above the iliac crests, the scrotum is 
elevated and the centre of the base of the handkerchief triangle is placed in accord with the raphe 
of the scrotum. The tapes are carried around the thighs on either side, and are secured to the 
waistband near the iliac crests. Having thus rendered the bandage firm, the two outer ends of the 
handkerchief are brought upward along the folds of the groin and secured to the waist-bandage, 
while the apex of the handkerchief triangle is brought upward in the median line, and also secured to 
the band. By these means the testes may be kept at rest and any form of application may be used. GONORRHCEA IN THE MALE. 
47 
The next indication is to administer a brisk cathartic in the form of pills or a powder of from 
five to ten grains of calomel and bicarbonate of soda. The diet must be mild and sparing, prefer- 
ably of milk or of toast and weak tea. In the acute stage anorexia is very common, and the thirst 
is great, for which Vichy, Apollinaris, Poland, and Bethesda waters are very good. Little internal 
medication is necessary, though the mixture of bicarbonate of potassa with tincture of hyoscyamus, 
spoken of in the treatment of the acute stage of gonorrhoea, may be given. In nausea and sick- 
ness of the stomach medicine is not beneficial. 
For the relief of pain, particularly at night, some preparation of opium may be used in the 
form of pill, suppository, or hypodermic injection. The resulting constipation should be attended 
to I have found pulsatilla a very uncertain remedy in acute and painful swelled testicle, but in the 
chronic stage of the affection I am under the impression that it has been of benefit. 
In general a strong lead-and-opium wash, perhaps combined with muriate of ammonia, and 
applied to the organ properly fixed on old linen or lint, is a most efficient and reliable remedy. At 
the onset of the affection ice guardedly applied may be tried. Small pieces may be placed in a 
bladder or in the india-rubber bag made for the purpose, and these should be placed on the testes, 
upon which several layers of linen or lint had been already laid. A little experimentation will soon 
determine how much intervening linen is necessary to produce benefit and avoid pain. In some 
cases this treatment, when thus used, is attended with amelioration of the patient's sufferings and 
a decrease in the intensity of the inflammation. In other cases, however, it cannot be borne. Its 
range of usefulness is not great. 
While some patients are benefited by cold applications, others require hot ones, the best of 
which are poultices of slippery elm or flaxseed, with which may be incorporated, in the proportion 
of eight to one, fine chewing tobacco, or, of sixteen to one, of hyoscyamus, belladonna, or digita- 
lis leaves Should these narcotics produce exhaustion, sickness of the stomach, or other patho- 
logical effects, they must be abandoned. Dr. Bumstead thought well of the following, applied on 
lint to the scrotum : 
B. Ext. belladonnas, gij; 
Glycerinae, §ss; 
Aqua, 5j- M. 
Also this • 
B. Pulv. opii., 3'j > 
Glycerina, 5j- M. 
When these prescriptions are used the scrotum must be enveloped in gutta-percha tissue or oil 
silk. 
The following ointment is often of service when spread thickly on lint : 
B. Pulv. opii, 3'j 5 
Pulv. camph., 5ss; 
Vaseline, 5j- M 
Strapping of the testicle is never appropriate in the acute stage, though it may be beneficial 
in some cases of chronic swelled testicle. It is much less commonly employed now than formerly, 
owing to the fact that it is difficult of application, is not cleanly, loosens quickly, and often gives 
rise to fissures and inflammation of the skin. Considerations of cost narrow its usefulness to 
hospital and dispensary practice. The scrotum must be smoothly shaved before the plaster is 
applied Mercurial, belladonna, or the plain rubber adhesive plaster may be used in strips of 
three-quarters of an inch in width. A better method of pressure to the enlarged testis is 
that recommended by Corbett, the object of which is to envelop the organ after the manner 
that a football is covered with leather. For this purpose oval india-rubber bulbs of various 48 
VENEREAL DISEASES. 
sizes, such as are found in the spray apparatuses, may be used. The upper part is cut off 
and forms the neck, around the free margin of which may be sewn lead wire divided into two 
or three segments, by which means suppleness is retained and injurious pressure of the cord 
is prevented. The bulb is then cut lengthwise, and into the holes pierced on each side of the 
cut surfaces silk cord may be adjusted like laces in a corset. As the testis grows smaller, more 
and more of the bulb may be cut away, and thus the holes become placed farther back and further 
pressure is made. It is well to first envelop the testis in a layer of absorbent cotton, and, if indi- 
cated, ointments may be spread on it. 
Another method is the following, recommended by Escalier, which is a modification of the sus- 
pensory of Langlebert. The testis is grasped and around its upper portion a ring of adhesive 
plaster is fixed, and covered over with a piece of silk handkerchief over which is a thick layer of 
absorbent cotton, and over that again a layer of gutta-percha tissue. Then over the whole strips 
of adhesive plaster are passed in a circular manner, so that the ends may be drawn more or less 
tightly before being fixed. About every twenty-four hours it is necessary to tighten the adhesive 
strips. Removal of fluid from the tunica vaginalis is necessary in all cases before compression is 
applied. 
In those severe cases in which the testis is also inflamed, together with serous effusion in the 
tunica vaginalis, prompt puncture of this sac is urgently called for, and is commonly followed by 
marked relief of the pain and tension in the organ. It is well to employ a small straight bistoury, 
and to make a number of minute punctures well down into the cavity of the tunica vaginalis, over 
its median and most rounded portion, taking care that the tunica albuginea is not wounded. When 
practicable, withdrawal of the fluid by the hypodermic syringe may be done. The older surgeons, 
particularly French and English, advocated incisions fully six-tenths of an inch into the parenchyma 
of the testis. Such procedures were frequently followed by hernia of the testis substance and 
atrophy of the organ, and should not be resorted to. 
Various other applications have been used with reported benefit, but they are only suitable to 
the declining stage of the epididymitis. Painting the scrotum with a 40 per cent, solution of 
nitrate of silver may in some cases cause resolution. I have seen marked benefit in the subacute 
stage from the use of an ointment of iodoform one drachm to the ounce, and I have seen it fail dis- 
mally. Similar proportions of iodoform and glycerin spread on lint and covered with oil silk may 
also be used. 
In cases of swelled testicle in which the engorgement is very great a number of leeches 
according to the powers of resistance of the patient may be applied to the groin as far down as 
the scrotum, but not on it. Relief is rarely afforded unless at least six leeches are used. 
Neuralgia of the testis requires appropriate general treatment, notably tonics with quinine, 
when the malarious or a debilitated condition is present. The inflammatory foci in the urethra 
demand active but conservative measures. Locally, belladonna or opium ointment, perhaps com- 
bined with iodide of lead in the proportions of one ounce and one drachm, may be used. Continu- 
ous mild pressure sometimes gives marked relief, for which purpose the india-rubber adhesive plas- 
ter may be used or mercurial plaster spread upon buckskin. 
Gonorrhoeal Ophthalmia.-Gonorrhoeal ophthalmia is happily a rare complication of gonor- 
rhoea, occurring, according to statistics, 59 times in 37,034 cases of eye diseases, but probably in 
rather greater frequency in the course of gonorrhoea. It is a violent, and often destructive, inflam- 
mation, resembling, but more intense than, purulent conjunctivitis. It is caused by the transfer- 
rence of pus from the urethra, from the opposite eye previously affected, or from the eye of another 
person similarly attacked. In children it is known as ophthalmia neonatorum, and originates in conta- 
gion from the leucorrhoeal discharge of the mother. It is seen in young girls suffering from vaginitis 
and vulvitis, and men suffering from gonorrhoea have been known to thus inoculate themselves by GONORRHCEA IN THE MALE. 
49 
washing their eyes with their urine. Though gonorrhoeal ophthalmia is thought to arise mainly 
from gonorrhoeal pus alone, all forms of urethral and vaginal pus should be regarded as dangerous. 
The pus of balanitis and of abscesses, though said to be innocuous to the eyes, should never be 
carelessly brought in contact with them, such is the danger of contagion in every form of purulent 
secretion. 
This form of ophthalmia is said to be more common in men than in women, for the reason, 
probably, that gonorrhoea is so much more frequent in the former than in the latter, and perhaps 
because, as a rule, women are more cleanly in their habits than men. It may occur in the acute 
stage of gonorrhoea, but it is generally seen during the declining stage. It may be confined to one 
eye, or may later on attack the other one. 
Gonorrhoeal pus is said to retain its contagious properties for sixty hours after it has become 
dried in the sun, and to be contagious when diluted with one hundred parts of water. 
Symptoms.-The first symptoms, which usually begin in a few hours or as late as thirty hours 
after contagion, are an itching sensation at the margin of the lids, as if caused by a foreign body, 
soon followed by increased lachrymation, a gumming of the ciliae together, and collection of little 
masses of mucus at the inner canthus. The watery secretion soon becomes mucoid and very 
shortly purulent. A conjunctivitis, mild at first and limited to the lids, but later on of a severe type 
involving the ocular mucous membrane, which is elevated above the sclerotic coat, is then seen. 
All of the conjunctival surface is then of a very deep-red color, much swollen, producing eversion 
of the lids, and roughened from distension of the papillae. The intense chemosis of the conjunc- 
tiva bulbi is well shown in Fig. 4, Plate I., in which the red, swollen, and infiltrated membrane sur- 
rounds the cornea like a pad. At this time the secretion is purulent and profuse, and much red- 
ness and oedema of the integument of the lids is present, as seen in Fig. 3, Plate I. The follow- 
ing account of gonorrhoeal ophthalmia by my late colleague, who to his many attainments added 
that of an accomplished ophthalmologist, is inimitably graphic : " An attack of gonorrhoeal ophthalmia 
is so rapid in its progress that the early symptoms just now described may have passed away before 
the first visit of the surgeon, who is often called to see his patient only after the full development 
of the disease. He probably finds him sitting up, his head bent forward, his chin resting on his 
breast, and his handkerchief applied to his cheek to absorb the discharge, which irritates the sur- 
face upon which it flows. The eyelids are swollen, especially the upper, which slightly overlaps 
the lower, and is of a reddish or even dusky hue. The patient states that he is unable to open 
the eye. His inability to do so is caused less by an intolerance of light than by the mechanical 
obstruction which the swelling of the lids occasions, and by the pain which is excited by any friction 
of the inflamed surfaces upon each other. 
"The surgeon now moistens the edges of the lids with a rag dipped in warm water in order 
to facilitate their separation, and proceeds with his examination. In his attempt to open the eye he 
is careful not to make pressure upon the globe, in order to avoid giving unnecessary pain, and also 
lest the cornea, if already ulcerated, may be ruptured .and the contents of the globe escape. With 
one finger just below the eye he slides the integument downward over the malar bone, and thus 
everts the lower lid, the upper lid being elevated by a similar manoeuvre with the other finger of 
the same hand applied below the edge of the orbit; or, again, he may expose the globe by seizing 
the lashes and margin of the upper lid with the thumb and finger, and drawing the lid forward and 
upward. All this may be accomplished with the left hand, the right being free to wipe away the 
discharge or to make applications to the eye. 
"As soon as the lids are separated a quantity of thick yellowish pus wells up between them 
and partially obstructs the view ; the swollen palpebral conjunctiva, compressed by the spasmodic 
action of the orbicularis muscle, may also project in folds. The collection of matter is now 
removed with a soft moist sponge or rag, and the surface of the ocular conjunctiva exposed. This 50 
VENEREAL DISEASES. 
membrane is found to be of a uniform red color, with the vessels undistinguishable from each 
other, and elevated above the sclerotica by an effusion of serum and fibrin in the cellular tissue 
beneath it. This swelling of the conjunctiva is seen to terminate at the margin of a central depres- 
sion occupying the position of the cornea and filled with a collection of the less fluid constituents 
of the puriform discharge, which may at first be mistaken for the debris of a disorganized cornea. 
On removing this matter, however, the latter structure may still be found clear and transparent at 
the bottom of the depression, where it is overlapped by the swollen conjunctiva. In less fortunate 
cases it may have become hazy from infiltration of pus between its layers, or ulceration may have 
commenced. If an ulcer is not evident on first inspection, it may be discovered at the margin of 
the cornea by gently pushing to one side the overlapping fold of the conjunctiva. Meanwhile, the 
secretion of pus is constantly going on, and requires repeated removal. It is astonishing to 
observe how large a quantity of this fluid can be secreted by so limited a surface. It has been 
estimated at more than three ounces per day in some cases." 
The amount of pain occasioned by this disease varies in different cases. During the develop- 
ment and acme of the inflammation it is generally severe. It is described by the patient as a sensa- 
tion of burning heat and tension in the eyeball, radiating to the brow and the temple. The system 
at large sympathizes with the local disease. For a time there may be general febrile excitement, 
but symptoms of depression soon appear; the pulse becomes rapid and irritable, the skin cold and 
clammy, and the patient anxious and nervous. This depression of the vital powers is not invariably 
met with, but is the most frequent condition of the patient after the disease has continued for a few 
days ; and it may appear even at an earlier period when the health has been previously impaired 
from any cause. Notwithstanding the severity of the symptoms, resolution is still possible. Under 
proper care and treatment the inflammatory action may abate and the tissues recover their normal 
condition, leaving the eye as sound as before the attack. So fortunate a result is more to be hoped 
for than confidently anticipated. 
Prognosis.-The prognosis is always grave, especially so when both eyes are attacked. If 
treatment is instituted at an early period, the chances of the patient are best. If ulceration of the 
cornea has taken place, they are bad. It generally begins at the corneal margin, either super- 
ficially or deeply, and may creep around or may advance toward the centre. Sometimes the whole 
cornea is extruded and the contents of the eye escape. An eye has been known to be thus 
destroyed within twenty-four hours, and even in a single night. The escape of the contents of 
the globe often gives the patient hope that he is recovering, whereas his sight is gone. 
According to the extent and situation of the ulceration the eye is more or less permanently 
injured. When superficial and marginal, the resulting opacity of the cornea may not interfere with 
the sight, which may be impaired if the leucoma is central. Perforation of the anterior chamber 
and prolapse of the iris, when partial, may also be remedied by art; but when the whole or the 
larger part of the cornea has sloughed away, and the prolapsed iris has become covered with a 
dense layer of fibrin, forming an extensive staphyloma, the case is hopeless. 
Trachoma or exuberant granulations of the palpebral and bulbar conjunctiva often follow 
gonorrhoeal ophthalmia, and are sometimes of much annoyance to the patient and resistant to 
treatment. Frequently a tendency to hyperaemia of the external ocular tissues from slight irrita- 
tion is observed over long periods. 
Diagnosis.-So much do severe cases of purulent ophthalmia resemble those of the gonor- 
rhoeal form that a diagnosis is often impossible, owing to the meagreness of the history. Any 
intense form of ophthalmia, whatever may be its origin, must be looked upon in as serious a light 
as that due to gonorrhoea. 
Treatment. The first indication in treatment is to procure a skilled, kind, and trusty female 
nurse, and preferably two-one for the day, the other for the night-who should be in constant GONORRH(EA IN THE MALE. 
51 
attendance. She should, at the outset, be thoroughly impressed with the gravity of the case, 
instructed as to her duties, and shown the technique of opening the eye and removing the pus. 
She must be warned of the intense contagiousness of the secretions, must be directed to keep her 
hands and nails in a thoroughly aseptic condition, and she should provide herself with a pair of 
protective concave spectacles having a diameter of two inches. In case one eye only is affected, 
the other one should be covered with cotton wool strapped down with adhesive plaster, over which 
a solution of gutta-percha is painted. In young subjects it is well to secure the hands. 
If seen before inflammation has fully developed, four to six leeches may be applied at the 
external canthus or to the mucous membrane of the corresponding nostril, or if not at hand cups 
may be used on the temples. The character of the inflammation being manifest, a careful, con- 
tinuous, and energetic treatment must be followed. Constant application of cold is then absolutely 
required. This is accomplished by means of small pieces of linen of a single thickness, which, 
when thoroughly chilled upon a piece of ice, should be laid over the eye, and replaced by another 
every two or three minutes in very intense cases. These pieces of linen should be burned imme- 
diately after use. The further treatment of the case should be as follows, after the manner pro- 
posed by my colleague, Dr. J. A. Andrews, which has been productive of excellent results at 
Charity Hospital: When the inflammation is fully established the indications are to wash away 
the pus in the most perfect manner as soon as possible, and to render the conjunctival surface as 
nearly as possible aseptic. For this purpose a saturated solution of boracic acid is necessary. This 
may be used by means of Andrews' irrigator No. 2, made by Ford of New York, or by means of a 
piece of fine rubber tubing attached to a fountain syringe, and allowed to flow with the utmost gen- 
tleness. These irrigations must be repeated as often as necessary. Then, from the beginning of 
the disease, a 2 per cent, solution of nitrate of silver should be dropped, rather than brushed, into 
the eye, since it is then distributed by the movement of the eyelids. The more vascular and swol- 
len the conjunctiva, the more frequent should be these instillations, which may be made from three 
to four times daily, according to indications. Instillations of a four-grains-to-the-ounce-of-water 
solution of atropine may be used also at intervals during the severity of the attack. As improve- 
ment takes place, the use of the solution of nitrate of silver should be more infrequent until it is 
finally dropped. 
If chemosis has taken place, the ocular conjunctiva and subjacent connective tissue should be 
divided by means of blunt scissors, and in case the eversion of the lids is not complete, the outer 
commissure should be freely divided, together with the canthal ligament, for the inflamed surfaces 
must be in such a condition that they can be thoroughly treated. Excessive oedema of the lids 
interfering with the opening of the eye may be relieved by minute punctures of the skin. After 
the subsidence of the acute symptoms the nitrate-of-silver solution, which toward the end has been 
used much less frequently than at first, may be replaced by a solution of sulphate of zinc, as 
follows : 
R. Zinci sulphatis, gr. ij; 
Glycerinae, 31J > 
Vin. opii, 3j; 
Aquse, 5V- M. 
This may be instilled into the eye by means of a glass-and-rubber dropping-tube. 
Should ulcer of the cornea occur, the pupil should at once be dilated with atropine solution and 
vigorous but prudent measures adopted. 
The granular condition of the conjunctiva should be treated by the application of a piece of 
sulphate of copper to the surface every second or third day. 
(For further operative treatment of the sequelae of gonorrhoeal ophthalmia see Bumstead and 
Taylor on Venereal Diseases, and the various textbooks on diseases of the eye.) 52 
VENEREAL DISEASES. 
Patients suffering from gonorrhoeal ophthalmia should occupy a large, well-ventilated room, 
which should be moderately, not wholly, darkened, and they should be placed exclusively in the 
care of the surgeon and the nurse or nurses. At the onset of the disease a brisk aperient, even a 
cathartic, may be given, which should be repeated as necessary, care being taken that the patient's 
strength is not impaired by it. A mild diet, gruels and light broths, may be taken. Should evi- 
dences of malnutrition and debility appear, with weak and irritable pulse, more nutritious food of 
the most digestible character must be given, together with tonics and perhaps ale, porter, milk 
punch, etc. It must be remembered that the vitality of the corneal tissue is very low, and that its 
destruction may be hastened by an impoverished state of the system. 
Convalescence is much hastened by change of air, particularly in the mountains. It is some- 
times astonishing to observe how rapidly the nutrition of the patient increases, and how quickly the 
trachoma and conjunctival congestion disappear, under the influence of country air. 
Lymphangitis.-Inflammation of the lymphatics of the penis occurs not infrequently as a 
complication of gonorrhoea. It usually begins during the acute stage, in the lymphatic radicles 
of the glans and prepuce. These parts become red and, swollen, and from them red lines run 
along the dorsum of the penis toward the groin. They are the seat of itching, burning, and 
pain, which is felt along the lymphatic vessels, which to the touch are cord-like, hard, and knotted. 
In these cases painful erections are frequent. 
Very often lymphangitis may simply reach this condition of moderate swelling of the end of 
the penis, with red knotted cords along its dorsum, accompanied by pain on pressure over the sus- 
pensory ligament and tenderness of the inguinal ganglia, and then pass away in a few days. In 
other cases it becomes more intense, the whole penis becoming very painful, red, swollen, and oede- 
matous, even to an enormous size, and frequently twisted into curious shapes, together with pain- 
ful engorgement of the inguinal ganglia. Such are the pain and discomfort that the patient is often 
forced to assume the recumbent position. 
There is also an aphlegmasic form of lymphangitis sometimes seen as a complication of gon- 
orrhoea, called by Fournier lymphangite a froid, and shown in Fig. 9, Plate I. Along the dorsum of 
the penis are white beaded lines which to the touch appear like indolent indurated cords. They thus 
remain for days or several weeks, and are liable to be mistaken for the lymphangitis of syphilis. 
Occasionally, the lymphatics of only a portion of the penis, such as that near the fraenum or 
on one side or part of one side, are involved and cause the penis to assume queer shapes. 
Lymphangitis may lead to phimosis, paraphimosis, and adenitis, and, per contra, may result 
from phimosis and inflammatory paraphimosis. As a rule, resolution occurs within a short period 
under treatment and with the decline of the gonorrhoea. Suppuration and abscess, particularly in 
the prepuce and in the course of the lymphatics, occur sometimes. I he concomitant adenitis may 
lead to suppuration also. 
In the severe cases, besides the violent pain in the penis and tenderness in the ganglia, mictu- 
rition is difficult and painful, and erections are excruciating. Fever, chilliness, malaise, want of appe- 
tite vary according to the severity of the affection. 
The causes of gonorrhoeal lymphangitis are strong injections during the acute stage and even 
later, want of cleanliness, irritating dressings, and applications of caustics, the backing up of the dis- 
charge against the glans and meatus by retentive pledgets of lint or cotton, sexual intercourse, 
alcoholic excess, traumatism, and the pressure of tightly-fitting trousers. 
Diagnosis.-Lymphangitis from gonorrhoea usually offers no difficulty in diagnosis, since cause 
and effect are generally known to the patients themselves. It is said to have been mistaken for 
dorsal phlebitis, which is very rare, is usually unaccompanied by gonorrhoea, has its origin in some 
decomposing animal matter carried by the fingers, is of much quicker invasion, and is accompanied 
by greater and more active swelling. In phlebitis the indurated lymphatic cords are not present. GONORRHCEA IN THE MALE. 
53 
Treatment.-The supervention of lymphangitis during gonorrhoea should render the recum- 
bent position obligatory. The genitals should be well immersed in hot water very frequently, and 
particular care should be given to cleansing the prepuce and glans and to the prompt and thorough 
escape of pus. The genitals should be put on a crural platform of adhesive plaster, as advi-sed in 
the treatment of swelled testicle, and iced water and cooling lotions of lead and opium or of 
muriate of ammonia and laudanum, and perhaps the cold-water coil, applied. Hip baths and full 
baths are also of benefit. The gonorrhoea should be treated as already directed. 
Abscesses should be opened promptly and treated with thorough antisepsis. 
Abscess of the Corpus Spongiosum.-Under this head two affections are included: first, 
inflammation of the follicles of Morgagni, which open into the urethra ; second, suppurative inflam- 
mation of the connective tissue beneath the corpus spongiosum. They occur in the acute and 
chronic stages of gonorrhoea. 
The follicular abscesses have their origin in purulent inflammation of the mucous follicles. At 
first a minute round or oval tumor is felt in the lower portion of the urethra, which rapidly becomes 
of the size of a pea, sometimes bilobed and attached by a thin pedicle, which consists of its thick- 
ened and obliterated duct. These tumors are usually circumscribed, movable, hard, and not very 
sensitive. They may be multiple or single. As they increase in size they contract adhesions with 
the integument and become the seat of fluctuation. Their course is usually chronic, like that of 
wens, but occasionally they are of acute development. After remaining in an indolent condition 
they have been known to be attacked by acute inflammation. They may open spontaneously and 
give rise to blind fistulae, since they do not open into the urethra. 
They require to be cut down upon and thoroughly enucleated. 
Periurethral Phlegmon.-This affection is met with during acute gonorrhoea, particularly in 
patients who have injudiciously indulged in excessive coitus and alcoholics or who have used strong 
injections. It occurs in some persons with each gonorrhoea. Its most frequent site is on either or 
both sides of the fraenum, and less commonly as far as the peno-scrotal angle. Their origin is at 
first rather insidious. Phlegmons near the fraenum appear at first like small round, circumscribed, 
not very painful tumors. As they increase they cause redness and distension of the mucous mem- 
brane and pain, with perhaps some impediment to urination. 
Periurethral abscesses near the peno-scrotal angle may be seated laterally or in the median 
line, as shown in Fig. io, Plate I. They vary in size, and may extend from the perineum to the 
peno-scrotal angle, and sometimes as far as the penis itself. The skin over these swellings retains 
its normal color until the maturity of the abscess. They invariably terminate, sooner or later, in 
suppuration. Their course often is very chronic. 
Treatment.-Incision should be made into the abscesses near the fraenum, and their walls 
should, if possible, be enucleated, since they sometimes subside after opening into blind culs-de-sac 
which discharge pus. 
Abscesses at the peno-scrotal angle should be opened at the first sign of fluctuation, since by 
that procedure the urethra is less likely to be opened into by it. Urethral fistulae not uncommonly 
follow this variety of abscess, and are only cured by radical surgical measures. All operations, 
even minor ones, on these parts should be done with thorough asepsis and antisepsis. 
Adenitis.-Slight tenderness and swelling of the ganglia of one or both groins is very common 
in the acute and subacute stages of gonorrhoea, and is usually of short duration. It commonly fol- 
lows lymphangitis of the penis, but is seen in cases where there is neither tenderness nor swelling 
in the lymphatic vessels. As a rule, only one ganglion of one side is attacked, but several ganglia 
may be involved, and even all of them on both sides. The attention of the patient is called to pain in 
the groin on walking or stooping over, and examination reveals a small oval, painful, movable tumor. 
Under favorable circumstances resolution promptly takes place ; otherwise, the tumor increases in 54 
VENEREAL DISEASES. 
size and becomes attached to the skin, which is reddened and the seat of pain. Even in this condi- 
tion resolution may be produced by energetic treatment; suppuration, however, may ensue. In 
scrofulous subjects ganglia inflamed and indurated from gonorrhoea may run a very chronic course ; 
the periganglionic connective tissue becomes inflamed, and later on the seat of suppuration. The 
overlying skin becomes thickened, much elevated, and of a dull purplish color, and pierced by sev- 
eral openings having thin, undermined edges, from which a thin pus exudes. This is termed the 
strumous suppurating bubo, which is shown in Fig. 6, Plate II. Such buboes may have their origin 
in irritation otherwise than gonorrhoeal, and in traumatism. 
Buboes of the variety above described are also called sympathetic and simple. It was formerly, 
and is indeed to-day, claimed by some that this sympathetic action is unaccompanied with the lodg- 
ment of irritative matter in the ganglia. To my mind, this idea is entirely erroneous, as it is my 
firm belief that no lymphatic ganglion becomes inflamed unless some product of inflammation is 
carried into it by its afferent vessels or its structure is injured by traumatism. In gonorrhoea pus- 
cells are undoubtedly the materies morbi. The etiological relation of the gonococcus in these cases 
is yet to be determined. 
Treatment.-In the mild, particularly the monoganglionic, cases the recumbent position, with 
the application of ice-water or ice-bags or solutions of muriate of ammonia, usually produces prompt 
resolution. The severe or polyganglionic cases should be similarly treated, perhaps with the addi- 
tion of a few leeches. This failing, active blistering may be tried. Some cases with tendency to 
indolent engorgement of the ganglia are brought to speedy resolution by the intraganglionic injec- 
tion of a few drops of a 5 per cent, watery solution of carbolic acid. When it is evident that sup- 
puration is inevitable, it should be hastened by the application of hot poultices. Then the parts 
may be incised, the debris of the ganglia curetted, and the wound treated antiseptically. The 
so-called strumous buboes call for prompt and efficient surgical treatment. A long incision should 
be made in their whole length in the direction of the groin, the ganglia should be scraped out 
thoroughly, together with as much inflamed tissue as possible, and the superabundant purplish 
integument should be cut away. The parts should be thoroughly irrigated, dusted with iodoform, 
stuffed with gauze, and held by a bandage. GONORRHCEA IN THE FEMALE. 
Gonorrhcea in the Female is much less frequently seen than in the male, and usually runs a 
much less definite course. There being so much more surface of mucous membrane in the genito- 
urinary tracts of the female than of the male, there is a corresponding complexity in the situation 
and course of the disease. 
The comparative rarity of gonorrhoea in women is undoubtedly due to the fact that coitus is 
usually impossible for a male suffering from the acute disease, and also that subacute and chronic 
discharges are generally washed from the urethra by the stream of urine. Then, again, such is 
the thickness of the epithelium of the vulva, and so copiously is it covered with sebaceous matter, 
that its susceptibility to contagion is not very great. 
Gonorrhoea in the female generally results from direct contagion from gonorrhoeal pus, but 
not infrequently it is caused by sexual excesses in subjects suffering from a pre-existing simple 
inflammation of some portion of the genital apparatus. The violent use of instruments of various 
kinds in women addicted to masturbation, and uncleanliness, are also factors sometimes observed. 
The muco-purulent discharge of pregnant women not uncommonly becomes intensified after deliv- 
ery, owing to various causes, and with its concomitant symptoms in every respect resembles true 
gonorrhoea. I he presence of vegetations about the vulva is not infrequently seen to be the start- 
ing-point of a purulent inflammation of the female genitalia which presents all the features of gon- 
orrhoea, even to its contagiousness. I have repeatedly seen women who previous to the outbreak 
of secondary syphilitic manifestations have suffered from a muco-purulent discharge of mild charac- 
ter in whom what appeared to be true gonorrhoea was developed without any other exciting cause. 
In like manner, the exanthemata have been known to cause a mild chronic leucorrhoea to be trans- 
formed into an acute purulent inflammation possessing contagious properties. Not uncommonly, 
women come for advice for acute purulent inflammation of some part of their genital tract whose 
onlv explanation is that they have taken cold, not infrequently by sitting on a cold stone. Then, 
again, in excessively hot weather women suffering from leucorrhoea, and being forced to travel long 
distances during which their usual vaginal irrigations have been impossible, are sometimes affected 
with an acute purulent inflammation in every particular resembling gonorrhcea. 
Young girls are not uncommonly attacked by inflammation of the vulva, and perhaps of the 
vagina, sometimes due to taking cold, again from the presence of ascarides in the rectum, and also 
from uncleanliness, and even from masturbation. Then, again, cases are not infrequent in which 
one or two little girls are found to be suffering, presumably from gonorrhoea, in which there is no 
evidence whatever of direct contagion, though some female members of the family may have gon- 
orrhoea. Though they very rarely confess to the act, it is very probable that the pus is conveyed 
from the elder's genitals by the finger of one or the other. I have seen several such cases in which 
the assumption of mediate contagion by means of towels was warranted. These acute genital 
inflammations in young children very often involve medico-legal problems. Their discovery by the 
parents or guardians not uncommonly causes a suspicion of rape, and very many innocent men 
55 VENEREAL R/SEASES. 
56 
have been thus accused who have simply fondled or caressed the girls. Since the medical man is 
usually the judge in these cases, it behoves him to speak in the most guarded manner, and to 
calmly and reflectively investigate the case in the light of what is known as to the origin of acute 
inflammation of the female genitalia. 
There are many underlying constitutional conditions which act as predisposing causes to gon- 
orrhoea in the female. The first is a natural inherent vulnerability of the mucous membranes gen- 
erally, as shown in the tendency to catarrh and acute inflammations, which is seen in a marked 
degree in many women without any general pathological condition to account for it. It is shown in 
the tendencies to bronchitis, to gastro-enteritis, and to inflammations of the genito-urinary tract. 
Then, again, anaemic, chlorotic subjects, and persons debilitated by any cause, are thus prone to 
inflammation. Scrofulous subjects likewise are subject to chronic and acute inflammation of 
these parts. 
The course of gonorrhoea is much more regular in men than in women, for the reason that in 
the latter there are so many parts in which it may begin. Thus, it may attack the vulva, and there, 
in favorable cases, run its course and end, or it may extend to the urethra and to the vagina, and 
from there to the parts above. My experience teaches me that cases of gonorrhoea in women may 
be divided for purposes of clinical description as follows : First, those in which it is limited to the 
vulva; second, those in which it involves the vulva and urethra ; third, those in which the vulva, 
urethra, and lower portion of the vagina are affected ; and fourth, those in which all of the outer 
genitalia are invaded, together with the vagina and more or less of the mucous membrane lining 
the uterus and perhaps Fallopian tubes. 
In the majority of cases gonorrhoea begins in the external genitalia, either in the vulva or at the 
introitus vaginae. Commonly, the affection of the urethra is due to extension of the inflammation 
either from the vulva or the vagina, since the urethra is not much involved in coitus ; but somewhat 
exceptionally its commencement is found to have been in that canal, and from it the neighboring 
parts may or may not have been invaded. 
In rather rare cases the affection begins in the vagina, usually high up in the posterior or 
anterior fornix, and from this extends into the uterus or downward to the external parts. In 
other cases it begins in the form of a patch on some portion of the vaginal wall, usually the 
posterior. 
In many cases of gonorrhoea in women the history of the period of invasion is very obscure. 
In some the sudden onset of the affection in a previously healthy woman, in a woman recently 
married, or in a woman having had but a single intercourse may give positive clues as to the early 
stage of the disease. In very many cases, however, the patient gives the history of having suffered 
for a long period with chronic leucorrhcea, and of having experienced an exacerbation, and exam- 
ination reveals acute inflammation of the external and perhaps internal genitalia. 
In woman we rarely see the orderly course of gonorrhoea as we see it in men, for the reason 
that the complex condition of her genital organs offers new areas for invasion, predisposes her to 
local congestions, and also largely for the reason that, as a rule, women are not as attentive in 
following treatment as men are, and are prone to relax their care when they experience slight 
improvement. It is for this reason, mainly, that gonorrhoea is so persistent in their sex. 
Symptoms of Gonorrhoea of the Vulva.-Gonorrhoea may originate primarily in the vulva, or 
it may be caused by contact with gonorrhoeal pus from the vagina and parts above. It begins with 
a sensation of itching, soon followed by intense burning. At first the secretion is mucoid and in 
excess of the normal fluid of the parts ; it then becomes muco-purulent, and finally of a glairy 
purulent character. Examination usually shows, particularly in hospitals and dispensaries, and 
often in private practice, matting of the hairs on the mons Veneris and of the hairs of the labia 
majora in the form of little tufts. Upon separation the greater and lesser labia are seen to be very GONORRHOEA IN THE FEMALE. 
57 
red, much swollen, with more or less superficially eroded spots in the reflections of the mucous 
membrane. The whole surface is bathed with a creamy pus which stains and stiffens the drawers 
and back portion of the chemise in spots. Perhaps there may be erythematous or even eczema- 
tous patches on the upper and inner coapted surfaces of the thighs from the irritation of the dis- 
charge which has flowed over them, and may even irritate the anus. In uncleanly subjects the 
retention and decomposition of the discharge gives rise to a characteristic nauseating and disgust- 
ing odor. When the inflamed surfaces have been carefully bathed numerous minute follicular ele- 
vations, many perhaps superficially eroded, may be seen, mostly on the labia minora, but also on 
the labia majora. Unless appropriate treatment is instituted, the swelling becomes very great, the 
eroded surfaces become larger and coalesce, and in consequence of the oedema and pain examina- 
tion of the urethra and vulva is very difficult. In cases of long labia minora the swelling is some- 
times so great, and the constriction offered by the labia majora is so firm, that strangulation seems 
imminent. This condition has been considered by some authors as analogous to paraphimosis in 
the male, while others think that acute vulvitis is the analogue of balanitis and balano-posthitis. 
The inflammatory process may be thus intense, and yet limited to the vulva ; and although the 
urethral and vaginal orifices are red and inflamed, these canals may yet be unaffected. Thus it is 
that urination is excruciatingly painful, particularly when the urine runs over the vestibule, vagina, 
orifice, and fourchette, and that digital or instrumental examination is rendered impossible. 
Taking all its features into consideration, gonorrhoea of the vulva of the severe form is a dis- 
tressingly painful affection. Its heat, attendant itching, and burning give rise to erotic desires, even 
to nymphomania, while handling or manipulation of the parts or sexual intercourse is utterly impos- 
sible. Not uncommonly, the irritation of the anal orifice by the escaping discharge gives rise to 
tenesmus, diarrhoea, and even incontinence of the rectum. Such patients are frequently forced to 
assume the recumbent position, since sitting and walking are attended by increased pain. Occa- 
sionally malaise with mild fever is noticed. Implication of the urethra is very common in these 
cases, unless efficient treatment is promptly instituted, and the patient's sufferings are thereby cor- 
respondingly increased. 
Arising as it does from aborted and perhaps violent attempts at coitus, in rape, in mediate 
contagion from gonorrhoeal pus, from catching cold, and from the decomposition of pre-existent 
mild discharges from want of cleanliness, the date of the onset of vulvar gonorrhoea is very often 
clearly marked, fl he evolution of the affection is prompt and rapid, and but one or two days may 
elapse from the time of the commencement of the premonitory pruritic burning sensation to its 
full development. The course is entirely dependent upon the efficiency and vigor of treat- 
ment. 
Luckily, there are many cases of a milder form of this affection, and to the latter some authors 
apply the term "simple vulvitis," while they call the severe form "gonorrhoeal vulvitis." In like 
manner, they recognize a simple and a gonorrhoeal or specific vaginitis. The tendency of the present 
day is to claim that the so-called specific forms of inflammation are caused by the gonococcus, and 
that the simple form is simply hyperaemia with exudation. The more conservative-and, to my 
mind, correct-explanation of these cases of varied intensity is that many of the severe ones are 
caused by gonorrhoeal pus, and that others are due to exacerbations taking place upon parts pre- 
viously the seat of mild inflammation. I repeatedly see cases in private and public practice in 
which the severity of the symptoms and of the concomitants is such that the most ardent advocate 
of a specific germ inflammation would unhesitatingly pronounce them to be truly gonorrhoeal, in 
which there is absolutely no history of contagion, but which are really instances of an acute 
inflammation engrafted upon a mild form. While, therefore, for medico-legal reasons it is import- 
ant to make a distinction between the mild forms of vulvitis and the severer-or, as we term them, 
gonorrhoealforms, in clinical practice we must recognize the well-attested fact that they are often 58 
VENEREAL D/SEASES. 
mutually interdependent. The dogmatic statement that pus from the genitals of the female con- 
taining the gonococcus is undoubtedly due to gonorrhoeal contagion is from its positiveness and 
seeming simplicity so plausible that it may come to be widely accepted ; indeed, a recent French 
author, Aubert,1 says that the existence of the microbe is known to lawyers, and that in cases of 
rape they inquire, " Have the gonococci been looked for?" In the present far from satisfactory 
state of our knowledge of the origin, habitats, and life-history of this micro-organism I am firmly 
convinced that medical men are not warranted in boldly saying that, owing to its presence in the 
pus of vulvitis or vaginitis, the disease must have been contracted from a person suffering from 
gonorrhoea, nor are they justified in stating that a gonorrhoeal discharge containing the gonococcus 
in the male is derived from true gonorrhoea in the female. In the one case the liberty of a man 
may be put in jeopardy, while in the other an innocent woman may be falsely accused. If the 
microbe is the materies morbi of gonorrhoeal inflammation, it even then does not follow that in all 
cases its presence in the vulva is undoubtedly due to contagion from a man or woman suffering 
from gonorrhoea. Many cases give a distinct history of a subacute vulvitis, sometimes very mild, 
which has undergone exacerbation, and then appears to be truly gonorrhoeal. May it not be that 
the previous inflammation has rendered the parts favorable to the development of the gonococcus, 
and that the latter has in some unexplained way become lodged upon them, since we do not know 
" whence it comes nor whither it goes " ? 
Gonorrhoea of the Urethra.-Gonorrhoea limited to the urethra, though rare, is sometimes 
seen in women in the acute and chronic forms. In the majority of cases, however, it is due to the 
extension of the inflammatory process from the vagina or vulva. The symptoms cf urethral gon- 
orrhoea in the female show themselves promptly after the impure coitus, and resemble the disease 
in the male more closely than any other form. The woman usually first complains of a tingling 
or itching sensation in the urethra during and a short time after urination. Cases, however, are 
rarely, if ever, seen by the surgeon until the disease is well marked in character. Then the mea- 
tus is found to be swollen and red and around it a halo of inflammation. A thick, decidedly green- 
ish pus is seen to be lodged within it, and the finger being introduced into the vagina and its tip 
being pressed from behind forward over the course of the urethra, causes several drops to exude. 
(See Fig. 2, Plate I.) This procedure causes pain and uneasiness to the patient, and reveals to the 
surgeon the fact that the canal is swollen. While in men the affection is limited at first to the dis- 
tal end of the urethra, in the female the whole length of the canal is involved to the neck of the 
bladder. For this reason the desire to make water is more frequent in gonorrhoea of women than 
of men. Such are the pain, scalding, and strangury that women often delay urination until much 
tension exists in the bladder. When the latter organ is also inflamed, they are unable to hold 
their water. Hysterical and neurotic females seemingly suffer more than others, and in some 
instances they have coexistent rectal tenesmus. 
In its full development gonorrhoea of the female urethra shows itself by much redness and 
swelling of the meatus and of the regions of the clitoris and vestibule. The discharge is quite 
copious, and the reddened surfaces are more or less superficially eroded. Patients say that when 
a few drops of urine lodge on these surfaces the sensation is that of scalding water. In favorable 
cases the affection is limited to the urethra and parts around it, but often, from ignorance of the 
nature of the trouble or from carelessness or improper treatment, it involves more surface, and we 
usually find the vulva and introitus vaginae also acutely inflamed. 
The tendency of the affection, untreated, is to remain in an acute condition from two to three 
weeks, and then to gradually decline. Perhaps the vulvitis and vaginitis may subside and the ure- 
thra appear to be normal, but the patient will complain of burning during urination, and pressure 
on the urethra will cause a thick creamy pus to exude. This condition may exist for months and 
1 Lyon medical, Feb., 1888. GONORRHCEA IN THE FEMALE. 
59 
even years. It gives rise to localized excoriations of the urethral mucous membrane, which may 
be but slightly thickened, producing slight stenosis of the canal, or the latter may be so much swol- 
len as to present a papillomatous condition. Very commonly warty growths or caruncles of the 
meatus have followed urethral gonorrhoea in the female. 
Localized excoriated patches and segments of the urethra the seat of hyperplasia, both attended 
with uneasiness in the canal and desire for and pain on urination, are sometimes seen in adult and 
older females who give no history of an antecedent gonorrhoea. 
Gonorrhoea of the Vagina may be local or general, acute or chronic. Very commonly, 
little can be learned of its onset, since it is liable to occur in women the subjects of uterine or 
vaginal leucorrhoea. Then, again, women, as a rule, are less communicative and truthful regard- 
ing their amours than men are ; consequently, the date and source of contagion are always with 
difficulty, and many times are never, ascertained. Carelessness of the person, and the indifference 
which comes to many women about vaginal discharges, very frequently tend to prevent the surgeon 
obtaining a satisfactory history of the case. 
When seen early the vagina affected with gonorrhoea presents a dry red surface, which is the 
seat of a sensation of heat. Very soon a mucoid fluid is seen, which soon becomes muco-purulent. 
In its fully-developed stage the secretion of vaginal gonorrhoea is a pus of considerable consistence 
and of a milky color, due to the admixture of large quantities of epithelial scales. 
When gonorrhoea of the vagina is due to the extension of the inflammation from the external 
genitalia, it is attended with all of the symptoms incident to the latter, together with a sense of 
burning heat which is referred by patients as deep down in the pelvis. The vaginal orifice and 
carunculae myrtiformes are reddened, swollen, and eroded, and constantly bathed with pus. In 
the cases under consideration, if treatment is adopted promptly, only a small portion of the lower 
vagina may be involved. Untreated, however, the tendency of the disease is to become firmly 
fixed and chronic, and to localize itself in the upper parts of the vagina, particularly in its posterior 
fornix or Douglas' cul-de-sac. In some cases it is found to attack the anterior fornix, and in others 
both recesses, anterior and posterior to the uterus. 
Acute gonorrhoea originating in the vagina proper is sometimes seen to involve its lower third, 
but may occur at any part, particularly on its posterior aspect. When severe and extensive, it gives 
rise to great suffering in the form of a continuous burning pain in the pelvis, which is much aggra- 
vated by motion, walking, and even by sitting down. So great is the swelling of the vaginal ori- 
fice, and such is the tenderness, that the introduction of the finger or of an instrument is impossi- 
ble, and patients beg that the nozzle of the syringe shall not be inserted, and if at all a very small 
one. When the acute stage is fully developed, the sufferings of the patient are often further 
increased by the extension of the disease to the urethra and vulva. Under these circumstances 
her condition is often pitiable, as may well be imagined from the extent of surface involved. The 
duration of the acute stage is very variable, and depends largely upon the efficacy of treatment 
and upon the regularity with which it is followed. In general, a week or ten days elapse before 
topical treatment can be instituted in the vaginal canal. Then much can be done, provided the 
woman can be kept in bed and properly attended to. But women thus afflicted are, as a rule, 
careless patients, and, though the gravity of their case be pictured to them in the clearest manner, 
they in very many instances backslide. Then, again, the recurrence of the menstrual epoch, with its 
engorgement of the genito-urinary tract and sometimes its irritating secretion, is often a very seri- 
ous setback. In private and dispensary practice we constantly see these patients reach a subacute 
condition and then they disappear, and even in the hospital they often consider themselves well 
and demand their discharge long before the surgeon deems it prudent. 
Subacute gonorrhoeal vaginitis is seen in two principal forms-the one limited to the lower 
segment of the tube, and usually rather more severe on its posterior wall; the other and more 60 
VENEREAL DISEASES. 
frequent one in the cul-de-sac behind the uterus. Besides these, the affection may be seen to be 
seated anterior to the uterus and in the middle third of the vagina. When occurring in the lower 
two-thirds of the vagina, the membrane is found to be red, swollen, in places eroded, thrown into 
large folds, and bathed with pus. When low down, the introitus vaginae and the tissues immedi- 
ately around it are more or less inflamed. 
Gonorrhoea of the posterior vagina or Douglas' cul-de-sac is of not infrequent occurrence, 
and is of especial interest, since the disease in its subacute and chronic stages shows a tendency to 
settle there almost as well marked as it does to creep back to the bulbo-membranous junction in 
the man. In this position it is very liable to escape detection unless carefully looked for. To this 
end, the best opportunity for a thorough examination is offered by the genu-pectoral position, 
though very often, from feelings of delicacy, we cannot insist upon it. The next best position is 
that of Sims, with his own speculum, but it is inferior, in my experience, to the genu-pectoral posi- 
tion. In the latter Sims' speculum may be used or one made of thin nickel-plated iron, such as is 
found in the shops. Thus exposed, the mucous membrane is seen to be of a deep red, cedematous, 
and more or less excoriated and covered with copious creamy greenish pus mixed with glairy 
mucus. In most cases there is coexistent inflammation of the os uteri in the form of a deep-red, 
easily-bleeding, inflammatory areola, and from it a muco-purulent plug may hang. In some cases 
the gonorrhoeal inflammation extends only as far as the os internum, but in others the uterine 
cavity is affected. From these it may extend to the Fallopian tubes ;x there lurk for long periods, 
producing salpinx, pyosalpinx, and all of their sequelae. It may also involve the bladder. San- 
ger estimates that fully one-ninth of all gynecological cases are the result of gonorrhoea. When 
the inflammation in these cases comes to involve the body of the uterus, they may be classed as 
gynecological, since they then usually fall into the hands of specialists in women's diseases. 
Besides the cases of gonorrhoea of the vagina, which, from the sudden onset of the affection 
and from its violent nature, are regarded as due to direct contagion, we frequently see vaginitis-or, 
as it is of late years termed, elytritis-develop in persons subject to cervical and corporeal endo- 
metritis and chronic subacute inflammation of the vagina. The history of the beginning of the 
trouble is usually very vague, though in some cases excessive and unnatural coitus and uncleanli- 
ness seem to be the existing causes. Morbid constitutional conditions also tend to intensify this 
inflammation. 
Elytritis or vaginitis of more or less severity occurs in the young, middle-aged, and old in less 
severe form than that already described. This variety is termed by authors simple elytritis or 
vaginitis, and Martineau says that it can be differentiated from the severe forms by the fact that in 
the latter the secretion is acid in reaction, while in the former it is alkaline. The clinical descrip- 
tion of the severe form has been given, and it is only necessary to say that in every feature the 
mild affection is much less severe. In these mild cases, however, exacerbations may be observed, 
and the affection may become as severe as those of gonorrhoeal origin. Perhaps2 in these cases 
1 According to Sanger, all cases of salpinx are either of gonorrhoeal, syphilitic, tubercular, or actinomycotic origin. 
3 Bumm (Deutsche med. Wochenschrift, Dec. 8, 1887) thinks that many writers exaggerate the consequences of neglected gon- 
orrhoea in women. He propounds the theory of mixed or compound infections in women. Reasoning on the hypothesis that the 
bacteria of pneumonia destroy the epithelial lining of the pulmonary alveoli, and cause an exudation which forms a cultivating 
medium for the bacillus tuberculosis and pyogenic micro-organisms which result in phthisis and abscess of the lungs, he thinks that 
the o-onococcus likewise acts upon the female genital mucous membranes, and produces a suitable culture-ground for other organisms 
which do not attack them in the healthy state. Bumm is convinced that the gonococcus only involves mucous membranes, and that 
for this reason women suffering from gonorrhoea are not attacked by pelvic cellulitis. The latter, he thinks, is due to compound infec- 
tion since in two cases of the trouble complicated by abscess he found large quantities of the staphylococcus aureus in the pus. He 
thinks that the micro-organism penetrated the erosions in the cervix, and were carried by the lymphatics into the connective tissue of 
the pelvis. 
Bumm also states that the further the inflammation extends from the vagina, the less are the chances for compound infection, GONORRHCEA IN THE FEMALE. 
61 
also the exacerbation may be clue to the invasion of some micro-organism, since we know that the 
vulva and vagina are true incubators of all forms of bacterial growth. Elytritis or vaginitis is 
shown in Fig. 6, Plate I. 
Abscess of the vulvo-vaginal glands may occur as a complication of mild and of gonorrhoeal 
vaginitis, and may be of the acute or chronic form. The inflammation may be limited at first to 
the duct of the glands, or the body of the latter may be involved. Frequently, inflammation of the 
duct causes stenosis of its lumen and consequent abscess. This is very frequently seen in brides 
or in girls after the first sexual intercourse. A redness and swelling of the vulva and vagina are 
set up commonly with more or less mucoid secretion, and from them the duct is invaded. In 
acute gonorrhoeal vulvitis or vaginitis these bodies are also frequently attacked. The symptoms 
are at first of a mild character. The patient feels an uneasiness on one side of the vagina, and 
and that in gonorrhoea of the uterus there are usually few germs besides the gonococcus, and that in the tubes the latter alone is 
usually found. In the tubes the specific action of this microbe may be seen in the form of purulent inflammation of the mucous 
membrane only, the connective tissue not being invaded. He is under the impression that the escape of gonorrhoeal pus from the 
tubes into the peritoneal cavity is not followed by suppurative peritonitis, but that a circumscribed adhesive inflammation is set up 
which seals up the tube, and that the woman may suffer afterward from chronic pyosalpinx. Should pyogenic micrococci be pres- 
ent in the pus, Bumm thinks that purulent peritonitis and death might ensue. As in man gonorrhoeal epididymitis may be followed 
by tuberculosis of the organ, so in the woman, according to Bumm, may the tubes the seat of gonorrhoea be attacked by tuberculosis, 
both cases being instances of " mixed gonorrhoeal infections." 
In his book, already alluded to (see foot-note on Etiology of Gonorrhoea in the Male, p. 26), Bumm was at least sceptical as to 
Kammerer's assertion that he found the gonococcus in the effusion of gonorrhoeal rheumatism, and now says that he found in the 
synovial fluid of a joint the seat of gonorrhoeal rheumatism true pyogenic cocci. This also he regards as an instance of mixed infec- 
tion, in which the gonococcus prepared the way in the urethra for the entry of the pus-producing germs. 
Clear and convincing as these statements seem to be, the fact remains that the etiological relation of the gonococcus to gonor- 
rhoea is not yet made out with precision. Thus, Lustgarten and Mannaberg ( Vierteljahresschrift fur Dermatologic zind Syphilis, p. 
905, 1887), of Kaposi's clinic in Vienna, state that by means of a sterilized platinum spoon they removed the secretion from a normal 
urethra, and that in it they found various forms of bacteria, and among them one morphologically identical with the bacillus tubercu- 
losis, and another a diplococcus seemingly identical with the gonococcus. 
Conrad of Berne (British Med. Journal, Oct. 17, 1887, P- §54) has tried to solve the question as to whether it is possible to dif- 
ferentiate a gonorrhoeal affection of the. female genitals from a non-gonorrhoeal one by means of the microscopic examination of secre- 
tions and cultivation experiments. He gathered with much care and at different times the secretions of acute purulent or mucoid 
catarrh of the vagina, womb, or urethra from cases which had from time to time recurred with exacerbations, and submitted them to 
bacterioscopic examinations with the assistance of three experienced bacteriologists. Sixty cases of supposed gonorrhoea were thus 
studied, and only in five recent and two chronic cases was the gonococcus found, though numerous bacilli and cocci were seen. Con- 
rad reaches the following conclusions: 1. The detection of the gonococcus succeeds more easily in men than in women. It is so 
because the latter (a) experience comparatively less discomfort from acute gonorrhoea where the microbe is most frequently demon- 
strated ; (£) they generally seek medical advice and help later than men ; (c) as a rule they pass water before undergoing a gyneco- 
logical examination, and thus wash away or dilute their urethral discharge ; (d} they sometimes come to be examined only after some 
treatment by injections or other local means. It is possible also that detection becomes more difficult in consequence of gonococci 
bcin-T destroyed by micro-organisms of other species, which often grow luxuriantly in discharge of genital mucous membranes. 
2. While in recent cases of female gonorrhoea Neisser's gonococcus may be almost always detected, it cannot possibly be found in 
many chronic cases. 3. Hence both acute and chronic gonorrhoeal affections may be present in women in spite of our inability to 
demonstrate the pathogenic microbe in a given case. If so, the gonococcus may have only a limited diagnostic value, the practitioner 
bein" often compelled to rely only on etiological and clinical facts. Emmert, a colleague of Conrad, drew attention to the fact that 
the genuine habitat of the gonococcus appeared to be the discharge of the urethra, and not of the vagina, since when the microbe was 
found in the former, artificial inoculation of the vaginal mucous membrane almost invariably produced gonorrhoeal vaginitis, while 
inoculation of the vaginal discharge from a gonorrhoeal woman in the vagina of a healthy one had no effect. 
Sahli another of Conrad's colleagues, also thought that the gonococcus very often could not be demonstrated in the gonorrhoeal 
pus of women, and states that he was unable to detect it in a patient with a profuse purulent vaginal discharge who had recently been 
infected by a man with typical gonorrhoea and with masses of cocci in his urethral discharge. Only some extra-cellular diplococci 
were discovered in the woman. Sahli ascribes the difficulties in finding the gonococci in the female to the possibility of their being 
crowded out by other vaginal micro-organisms of non-pathogenic and half-pathogenic varieties; by which he means microbes which 
give rise to pathological processes only when they are present in considerable numbers or when the system is already weakened by 
any cause. 62 
VENEREAL DISEASES. 
examination reveals a small round, movable tumor, best felt at the vulvo-vaginal angle a little 
below the middle of the orifice. The swelling increases quite rapidly, and shows itself in redness 
and tension of the mucous membrane. Besides the great tenderness of the parts, there is a con- 
tinuous throbbing pain of great severity, so that only comparative ease can be gained by the 
recumbent position. (See Plate 1. Fig. 3.) In some cases the abscess bursts spontaneously, and 
in others an incision is necessary. There is a remarkable proneness in these abscesses to recur- 
rence, due to irritations of varied kinds of the adjacent parts. For this reason it is often necessary 
to exsect the gland and its duct. 
Inflammation of the loose cellular tissue around the vulvo-vaginal gland, with abscess forma- 
tion, is a not unfrequent concomitant of abscess of the gland itself. 
The duct of the vulvo-vaginal gland may also be the seat of chronic inflammation, and by press- 
ing the body of the organ against the ramus of the ischium a few drops of muco-pus are seen to 
exude. This little operation is sometimes known to old prostitutes, who endeavor to conceal the 
trouble by expression previous to examination by the surgeon. 
Then, again, the gland itself may become the seat of chronic inflammation, so that its walls 
become thickened and hardened until a round movable tumor of the size of a nutmeg is formed. 
Such a gland gives rise to few symptoms, except an occasional discharge of muco-pus, and may 
thus exist for years unless removed by operation. 
Bumm thinks that in cases in which suppuration occurs in the vulvo-vaginal glands there has 
been invasion of the parts by pyogenic staphylococci, but that in those in which there is cystic 
degeneration of their walls there has been entry of gonorrhoeal pus. 
Ino-uinal adenitis is sometimes observed in a complication of gonorrhoea in the female. Usu- 
o 
ally, it is of the resolutive variety, and subsides upon assuming the recumbent position and the use 
of cold compresses. In some cases hard, indolent enlargement of one or more ganglia is produced, 
which may thus remain indefinitely or later become the seat of abscess. 
Chronic gonorrhoea in the female is very often due to the localization of the process in one or 
more of the follicles of the vulva. What are known as Skene's glands are thus frequently affected. 
These bodies lie on each side of the meatus, and their ducts, which are quite long, pass upward and 
open on each side of the median line just below the clitoris. They are often the seat of a low grade 
of chronic inflammation lasting months and even years, which shows itself by a muco-purulent 
fluid which escapes from them from time to time. This inflammation, which often passes unrecog- 
nized, may be the seat of exacerbations either just before or after the menstrual epoch, in conse- 
quence of vulvitis and vaginitis, from sexual excess, masturbation and the use of instruments, and 
from uncleanliness. 
The smaller periurethral follicles and those studding the vestibule, and less commonly those 
opening on the fourchette, may also be the seat of a similar chronic inflammation and give rise to 
a muco-purulent or purulent fluid. They also are liable to exacerbations, and sometimes form small 
but painful abscesses. 
It is undoubtedly true, as claimed by several authors, that pus escaping from these chronically- 
inflamed glands and follicles often gives rise to gonorrhoea in man. Owing to the difficulty at times 
experienced in causing the exudation of the pus during examination by the surgeon, these local- 
ized foci of gonorrhoea very often are not recognized. 
The methods of treating these forms of gonorrhoeal vulvar and vaginal folliculitis is to slit up 
the follicles, expose their inner surfaces, touch them with pure carbolic acid, dust them with iodo- 
form, and then stuff them with absorbent gauze. Irrigations of the vagina and ablutions of the 
vulva must also be made. 
Diagnosis. Since microscopic examinations have not clearly shown the presence of the gon- 
ococcus in all cases and all forms of severe or gonorrhoeal inflammation of the external female GONORRHCEA IN THE FEMALE. 
63 
genitalia, we cannot as yet accept the postulate that those cases in which the microbe is found are 
truly gonorrhoeal in nature, and that those in which it is absent are of simple character. Clinically, 
we are warranted in asserting that the severer order of cases produces a pus possessing contagious 
properties, and that the secretion of the mild and chronic cases is not always contagious in charac- 
ter, but that we can never say when contagiousness ends nor when secretions are truly simple in 
their nature. Further and comparative study of the habitats and life-history of the various micro- 
bes found in the vulva and vagina may yet clear up what is to-day obscure and unsettled. 
Cseri1 examined the vaginal secretions of twenty-six children from three to ten years of 
age suffering from various chronic diseases, and arrived at the following conclusions: 1. Catar- 
rhal vulvo-vaginitis of children is infectious. 2. The secretion contains a well-marked path- 
ological coccus. 3. The contagiousness of the secretion is very active. 4. The spreading of 
the affection occurs by means of towels, bath-tubs, closets, instruments, and through the 
nurses themselves. 
Treatment of Gonorrhcea in the Female.-In the treatment of gonorrhoea in the female the 
prime essentials are scrupulous cleanliness and constant care as to details. The patient should be 
made to clearly understand the gravity of the disease and its tendency to further extension and to 
localize itself in the recesses and crypts of the genitalia ; and she should be urged to continue under 
observation until she is pronounced cured by the surgeon. It is the duty of the latter to make 
thorough and painstaking examinations of the whole genito-urinary tract, and to acquaint himself 
with the full extent of the disease. 
In acute cases the recumbent position should be insisted upon. The diet should be of the 
simplest character, and preferably of milk. A brisk cathartic may be given, and throughout the 
course of the disease one or more full movements of the bowels should occur each day. For this 
purpose the Hunyadi-Janos water is excellent. 
For gonorrhoea of the vulva, with all of its painful accompaniments in the acute stage, very 
hot sitz-baths, repeated four or more times daily if possible, should be used, taking care that the 
water is brought into free contact with the whole surface affected. Very often the itching and burn- 
ing are much allayed by affusions of hot alkaline solutions (powd. borax or supercarbonate of soda, 
3ij to water 3xxxij), to which may be added two to four drachms of wine of opium or laudanum. 
Then a lotion as follows may be employed : 
B. Pulv. boracis, gj. 
Liq. plumbi subacetatis, giss ; 
Ext. opii aquos, • 
Aquae, gvj. M. 
With this may be saturated pledgets of lint or of absorbent gauze, which should be carefully and 
thoroughly applied to the surfaces in order to keep them apart, and renewed very frequently, 
since they soon become saturated with pus. So soon as the vulvar orifice will permit the long tube 
of a Davidson's or fountain syringe should be introduced as far as it will go, and several copious 
injections of very hot alkaline water should be made every day. As the inflammation declines it 
may be necessary to paint the parts to their smallest recesses with a solution of nitrate of silver, 
thirty grains to the ounce of water, followed by ablutions with a solution of common salt. After a 
very hot sitz-bath the lead-opium-and-borax lotion may again be applied. In twenty-four hours after 
this application to the old or the young much improvement will be noted in the lessened oedema and 
redness and in a less painful condition. Then a 1 per cent, solution of alum, with laudanum, may 
be used, and later on the parts may be dusted with subnitrate of bismuth or powdered boracic acid 
on a pledget of lint or absorbent gauze. 
1 Wien. med. Wochenschrift, 22, 1885. 64 
VENEREAL DISEASES. 
Vulvar gonorrhoea is very frequently, sooner or later, accompanied with implication of the 
urethra and increase in the patient's sufferings. The solution of bicarbonate of potassa with 
hyoscyamus recommended for acute gonorrhoea of the male may be given in order to relieve the 
urine of its acidity, and diluent drinks, such as flaxseed and slippery-elm and barley-water, may be 
drank ad libitum. As soon as the inflammation in the urethra has somewhat subsided by use of 
the foregoing measures suitable for the acute stage of vulvitis, intra-urethral injections of very hot 
water or hot flaxseed tea, frequently made by means of any recurrent syringe or catheter, or pre- 
ferably by means of Skene's reflux catheter, may be used. As the inflammation subsides, intra- 
urethral injections of hot water, containing carbolic acid in the proportion of one-half of i per cent., 
are very beneficial. In many instances where the pain on urination is very great the instillation 
into the urethra by means of a small cylindrical dropping-pipe of a solution of opium in glycerin, 
or of cocaine muriate in glycerin and water, is followed by marked relief. As the urethral lesion 
further declines, a 2 per cent, solution of nitrate of silver may be injected as far down the urethra 
as possible, since it is commonly involved in its whole length ; or a thirty-grain-to-the-ounce solu- 
tion of nitrate of silver may be carefully and sparingly applied by means of a cotton-holder, facili- 
tated either by the endoscope or by the fenestrated forceps of Dr. H. M. Sims. 
It is only in the subacute and chronic stages that antiblennorrhagics are to be used, and then in 
rather smaller doses than in the male. (See section on Gonorrhoea in the Male.) In some cases 
these agents produce marked relief in the symptoms and a lessening of the discharge, and, again, 
they seem to be of no benefit at all; from which it follows that local measures are always the most 
certain. 
It is necessary to repeat that in chronic urethral and vulvar gonorrhoea in women the patients 
are apt to be careless and indifferent in the stage of decline, which, added to the setbacks incident 
to menstruation, tends to perpetuate their trouble. At this time the surgeon should accentuate his 
injunctions to follow treatment, to be as quiet as possible in every way, and to abstain from any 
errors in eating and drinking. 
Of the use of a 2 per cent, solution of thallium, recommended by Goll and others, I am at 
present unable to speak. 
Gonorrhoea of the lower part of the vagina, which is commonly accompanied with the same 
affection of the vulva and perhaps of the urethra, should be treated on the principles already given. 
As soon as the acute symptoms subside, copious irrigations of very hot water well into the canal 
should be made. Then, as soon as the irritability of the parts will permit, the surgeon should make 
a thorough examination, having at his command a perfect light, natural or artificial. In my judg- 
ment, the genu-pectoral position, though objectionable to patients by reasons of delicacy of feeling 
and of its uncomfortableness, is by far the best to obtain a thorough view of the whole vagina, 
including the cervix uteri and the posterior and the anterior fornix vaginae. The blade of a Sims 
speculum carefully introduced elevates the posterior vaginal wall, and free inspection is possible. 
Where the surgeon works without the aid of an assistant the adjustment to the Sims speculum 
devised by Dr. Cleveland may be used, with much help. When the very acute symptoms of gon- 
orrhoeal vaginitis have begun to subside, the inflamed surfaces may be carefully and thoroughly 
cleansed by means of a cotton-holder. Then the whole surface may be gently and sparingly 
touched with a thirty-grain-to-the-ounce solution of nitrate of silver, after which the canal should be 
thoroughly irrigated with hot water to which a little common salt has been added. Another and 
less commendable and precise way of applying the nitrate-of-silver solution is to pass a Ferguson's 
speculum so as to encircle the cervix uteri, which is touched with the solution on a cotton-holder. 
Then one or two drachms of it are poured into the speculum, when, on withdrawal with a rotary 
motion the solution will come in contact with the vaginal walls. After this application, which 
should be thoroughly made in the posterior and in the anterior fornix, and also to the uterus, GONORRHCEA IN THE FEMALE. 
65 
usually as far as the os internum, the vagina should be thoroughly tamponed. Should the exigen- 
cies of the case demand it, pure clay may be applied to the roof and sides of the vagina, and held 
in place with an absorbent cotton tampon or with Poster's tampon of wicking. Currier, in some 
interesting articles upon the treatment of gonorrhoea in the female, claims that benefit will some- 
times follow the application by means of the tampon of a mixture of subnitrate of bismuth and 
glycerin, one drachm to the ounce. In this I think, from experience, that as regards many cases he 
is perfectly right, though my preference is for a mixture containing double the quantity of bismuth. 
In my experience, tampons made of absorbent gauze are preferable to those of absorbent cotton, 
since they absorb more freely and do not give rise to the unpleasant and sometimes painful sensa- 
tions caused by the bolus of cotton. In many cases the nitrate-of-silver solution having been applied 
once or twice, much benefit will follow the deposition deep into the vagina of a considerable amount 
of powdered boracic acid, which must be retained by the gauze tampon. Whatever form of 
tampon is used, it should be removed with great care every twenty-four hours, and then copious 
hot-water injections should be made. The frequency and strength of the nitrate-of-silver applica- 
tions should be governed by the progress of the case. Usually, several days should elapse before 
a second is made, and if the patient is under control two or three are enough. 
It is well to bear in mind that vaginal injections may be given, the patient lying on her back 
with her hips elevated, either by means of a Davidson or a fountain syringe, or by Dr. Foster's 
excellent vaginal douche. 
In chronic vaginitis extract of Pinus canadensis may be used on tampons. 
As in the gonorrhoea of men, so in that of women, the parasiticide effects of irrigations of 
bichloride of mercury have proved either unsatisfactory or valueless. They are only admissible in 
the chronic stage in any form or case, and should be used very hot and of a strength at first 
of i : 40,000, which may, if well borne, be increased. 
Schwartz of Halle, believing that the annihilation of the gonococcus means the cure of gon- 
orrhoea, recommends the following heroic antiparasiticide treatment: The vagina and vulva are 
thoroughly cleansed with a 1 : 1000 solution of the bichloride. Then by means of a Simon or 
Bozeman speculum all of the parts are swabbed, with the utmost care, with cotton-wool saturated 
with a 1 per cent, bichloride solution, taking care to rub off the superficial layers of the epithelium 
and to reach the folds of the introitus vaginae. I hen the vulva and vagina are dusted with iodo- 
form, which to be effective should be rubbed in, and then the vagina must be packed with iodoform 
gauze, which should remain three days, at the end of which the process should be repeated. 
Another tampon of iodoform gauze is then inserted, and allowed to remain five days, upon 
the removal of which, during eight or fourteen days, copious irrigations of the vagina with subli- 
mate solution, 1 : 2000, should be employed. It is stated that after the second tampon the vagina 
is red and raw and the seat of a copious purulent discharge. While it is claimed that in Germany 
marked benefit has followed this method of treatment, I think that its employment should be much 
modified in the reduction of the solutions of the sublimate. It is well known that continuous irri- 
gation of the vagina with a solution 1 : 5000 is commonly attended in a short time with irritation, 
which also sometimes affects the hands of the nurse or surgeon. Then, again, many persons are 
subject to the iodoform idiosyncrasy, and the application of the drug causes violent local reaction 
and sometimes systemic poisoning. Therefore it should never be put recklessly in large quantities 
into any cavity, natural or artificial. I think, however, that with modifications and toning down 
Schwartz's treatment may be of benefit. PHIMOSIS. 
Phimosis is that condition of the prepuce which prevents its retraction and exposure of the 
glans. It may be congenital or acquired. . 
The morbid conditions giving rise to congenital phimosis are-first, the narrowing, sometimes 
entire occlusion, of the preputial orifice ; second, a straitness and narrowness of the prepuce 
itself; and, third, shortness of the fraenum. To these may be added, in the acquired form, redun- 
dance of the prepuce. The orifice of the prepuce may be as small as a pin's head, when it may 
offer an impediment to urination and prevent inspection of the meatus, and as large as the diameter 
of a pea. Not infrequently boys who have not suffered from phimosis in their youth, do so later 
on, owing to the growth of the glans penis and to the concomitant imperfect development of the 
prepuce. 
In most cases of congenital phimosis there are adhesions between the mucous membrane and 
the glans. These may be thin, small, but numerous, and easily broken up, or they may be exten- 
sive and firm, even to the complete adherence of the whole prepuce and the glans. A case is 
reported in which the prepuce was attached to the margin of the meatus and formed a tubular pro- 
longation of the urethra nearly an inch long. Redness, heat, and perhaps superficial ulceration, 
often result from contact of the urine and want of cleanliness. These conditions in their turn may 
lead to cicatricial stenosis of the orifice. 
Congenital phimosis, well shown in Fig. 2, Plate II., gives rise to balanitis, heat, itching, even 
pain, in the head of the penis, and a consequent erethism of the genitals, with frequent erections, 
symptoms pointing to stone in the bladder, lascivious dreams, seminal emissions, and incontinence 
of urine, especially at night. Such subjects are often addicted to masturbation. As they grow older 
there is in many an arrest of development of the penis, and sometimes of the testes. When puberty 
is reached any or all of the foregoing symptoms may exist, and such subjects often complain of too 
speedy ejaculations and a not full and complete enjoyment of sexual intercourse. At and beyond 
puberty phimosis may give rise to congestion and inflammation of the membranous and prostatic por- 
tions of the urethra, and these foci of inflammation may be the cause of a persistent form of epididy- 
mitis. I have seen several cases of ephemeral stenosis, and some of true stricture, of the urethra, 
which were undoubtedly due to inflammation caused by reflex action of phimosis. While prolonged 
masturbation alone may lead to hyperaemia and stricture in the deep urethra, this practice in subjects 
of well-developed phimosis, congenital or acquired, inevitably leads to these morbid conditions. 
In early life, as remote effects of phimosis, it has been conclusively shown that nervous dis- 
turbances, incoordination of muscles of locomotion and of speech, hyperaesthesia, amblyopia, and 
hypochondriasis have been produced. 
It must be remembered, however, that there are many cases of phimosis which are not attended 
by any of the foregoing symptoms, direct or remote. At puberty, however, phimosis always gives 
rise to unpleasant symptoms, such as balanitis, balano-posthitis, interference with erections and 
66 Plate II 
Part I 
Fig.l 
Fig 2 
Fig. 3 
Fig .4 
Fife .6 
Fig 5 
Fig. 8 
Fig 7 
LEA BROTHERS & CO. PUBLISHERS . PHI LADELPHIA 
1 PARAPHIMOSIS FROM GONORRHOEA 2 . CONGENITAL PHIMOSIS . 
3. GONORRHOEAL OPHTHALMIA . 4 . INTENSE CHEMOSIS IN GONORRHOEAL OPHTHALMIA . 
5. SIMPLE PARAPHIMOSIS 6 . SUPPURATING BUBOES,STRUMOUS . 
7. INDOLENT ADENITIS FROM SYPHILIDE . 8 . VEGETATIONS OF GLANS PENIS . Z'/ZZA/OSZS. 
67 
the sexual act, and perhaps the deep urethral changes already spoken of. At this period, partic- 
ularly, it is a prolific cause of masturbation and of a morbid desire for coitus. 
At puberty the irritation caused by phimosis often results in the development of vegetations or 
warts, and in later life, as a consequence of it, cancer of the penis is liable to occur. In tropical 
countries elephantiasis of the penis frequently begins in a phimotic prepuce. 
I he morbid process in phimosis of all forms may be simply inflammatory oedema, or this con- 
dition plus simple or specific cell-infiltration. 
Acquired or accidental phimosis may exist in a prepuce normally rather small, but capable of 
thorough retraction, or in one which in the normal state passes readily backward and forward over 
the glans. The causes of it are want of cleanliness, the decomposition of diabetic urine, excessive 
venery, perhaps increased by the abuse of stimulants, gonorrhoea, herpes preputialis, eczema, chan- 
croids, and hard chancres. Traumatism and compression of tightly-fitting pantaloons are also causes 
I he symptoms vary in severity and in the nature of their concomitants according to the cause 
Phimosis resulting from uncleanliness and excessive venery presents nothing characteristic 
The prepuce is red and inflamed, and there is more or less balanitis. It is usually an ephemeral 
trouble and readily amenable to local remedies. Phimosis complicating gonorrhoea is often a trou- 
blesome concomitant, since it interferes so much with the treatment of that affection. There is 
commonly much redness and swelling, and it often produces curious deformities of the oro-an as 
shown in Fig. n, Plate I., in which the prepuce is curved upward. Sometimes the intensity of the 
inflammation is seated in the prepuce near the fraenum, which becomes swollen and turned inward 
giving the appearance of a pouting chin. Then, again, the whole extent of the foreskin may be 
involved, in which case the distal end of the penis becomes greatly swollen and comes to resemble 
a miniature Indian club. In all of these cases there is a purulent urethral discharge. Phimosis 
caused by herpes progenitalis consists of redness and oedema of the distal end of the penis 
together with vesicles. 
Gangrene is a rather uncommon complication of the simple forms of inflammatory phimosis, 
excepting when due to traumatism and diabetes ; it is not rare in the severer forms. 
Chancroidal phimosis and that form due to syphilitic lesions will be described under their 
respective heads. 
Cicatricial phimosis belongs to the category of the acquired affections. Cicatrices frequently 
follow fissures and ulceration which have been produced by forcible retraction. A fibroid preputial 
ring is not uncommonly seen in cases of phimotic prepuce. Recurrent herpes preputialis may cause 
stenosis of the orifice, either from scars or infiltration. From puberty to old age recurrent balanitis 
even in persons having roomy foreskins and of cleanly habits, sometimes leads to increase and indu- 
ration of the subpreputial connective tissue, and converts that appendage into a rather resistant cyl- 
inder which is with difficulty retracted. Chancroidal ulcers, particularly those seated on the free muco- 
cutaneous surfaces of the prepuce, are prone to produce this condition, which frequently exists in a 
severe, even dangerous, form, when much hyperaemia and oedema accompanies the lesions on the 
inner surface of this covering in the coronal fossa or upon the glans. The induration and oedema 
accompanying hard chancres are frequent and potent causes of phimosis. A chronic indurative 
oedema, resulting from the long-continued existence of primary and secondary syphilitic lesions, 
often gives rise to a condition in which it is either impossible to retract the prepuce or it is done 
with the utmost difficulty and the production of painful fissures. In late syphilis sclerosis of the 
prepuce and glans, alone or combined, sometimes causes well-developed phimosis. 
Treatment.-In many cases of congenital phimosis relief may often be obtained by gradual 
dilatation with Nelaton's or other dilating forceps. The operation should, if practicable, be repeated 
every day or two, and performed with the utmost care, so as not to draw blood, tear the tissues or 
cause pain. While this operation may be of benefit, the more radical cure by circumcision is by 68 
VENEREAL N/SEASES. 
far preferable. Slitting up the prepuce on the dorsum, in whole or in part, should never, if pos- 
sible, be done, since good results do not commonly follow. Very little more trouble is involved in 
the operation for circumcision, and the cure then is perfect. Dr. Bumstead's suggestion, that "it 
would be well for the future comfort of individuals if fathers would inquire into and attend to this 
matter as they approach adult age," should be widely heeded. Indeed, such attention to hygiene 
is very often urgently called for in infantile life. In children having long foreskins, when an 
operation is impracticable the utmost attention should be paid to cleanliness, particularly in remov- 
ing sebaceous matter and in preventing lodgment of the urine. Acute inflammatory phimosis is 
not uncommon in children, and should be treated by copious intrapreputial injections of very warm 
water followed by a mild solution of carbolic acid or of boracic acid or of lead-water. 
In inflammatory phimosis the recumbent position should be insisted upon, and a light diet and 
a brisk cathartic ordered. Copious intrapreputial injections of hot water, followed by a i per cent 
solution of carbolic acid, should be made every two or three hours. If the preputial orifice is too 
small to admit of the nozzle of a syringe, it may be enlarged by the careful use of Nelaton's for- 
ceps or by means of a sponge tent. 
Injections may be made by various syringes : the one invented by me is of especial benefit 
The nozzle, which is made of india-rubber, is about two inches long and flat, and on its rounded 
end are several holes, and it may, if desired, be used with a fountain syringe. 
Whatever fluid is used, it is necessary to see that it reaches all of the intrapreputial cavity 
especially behind the glans. 
While the patient remains recumbent it is well to keep the penis elevated and enveloped in 
old linen saturated either with ice-water, a solution of muriate of ammonia, or a lead-and-opium 
wash. The cold-water coil may be necessary in very severe cases. 
Leeches should never be used to the penis ; they may be of benefit if a sufficient number are 
applied to the groins. 
As soon as retraction of the prepuce is possible lint or old linen soaked in lead-and-opium 
wash must be placed between it and the glans, and treatment followed as given in the section on 
Balanitis. 
Phimosis from gonorrhoea needs active and continuous treatment in addition to that of the 
acute stage of the discharge. Intrapreputial injections, very hot, frequently made, and large in 
quantity, of one part of the bichloride of mercury to from 10,000 to 30,000 of water, or of a satu- 
rated solution of boracic acid, or of a 1 per cent, solution of carbolic acid in water, should be employed 
The penis should be kept in an elevated position ; care must be taken to catch and remove the dis- 
charge, and lead-and-opium wash, ice-water, or the cold-water coil used in the acute stage 
Circumcision should be performed as soon as possible in cases of chronic phimosis, cicatricial 
phimosis, and phimosis complicated by intrapreputial vegetations. 
The treatment of phimosis complicated by chancroids or by indurated chancres is described 
under the appropriate heads. Part I 
Plate VI 
Fi&.l. 
Fi£ 3 
1 . HERPES PROGENITALIS . 2. HERPES VULVAE . 
3 . VEGETATIONS OE THE SKIN. 4 .CONDYLOMATA LATA 
LEA BROTHERS & CO. PUBLISHERS , PHILADELPHIA PARAPHIMOSIS. 
Paraphimosis is that condition of the penis in which the prepuce, retracted behind the corona, 
cannot be pushed forward over the glans. 
It is found in boys who, perhaps for curiosity and with some force, have retracted the prepuce 
for the first time ; in persons who have a long foreskin and narrow preputial orifice ; in those who 
have a long, straight, and more or less tight foreskin ; in patients who have a short frcenum ; in 
those who have short and rather tight foreskins habitually worn over, and only partially covering, 
the glans ; in those having short, not abundant, foreskins worn behind the glans ; and, finally, in 
those whose foreskin is in perfect proportion to the glans. 
The causes of paraphimosis are, primarily, the more or less developed malformations ; secondly, 
inflammation causing constriction, balanitis, balano-posthitis, excessive coitus, perhaps increased by 
alcoholic excess ; coitus with a woman having a small vulvar orifice ; traumatism, gonorrhoea, ecze- 
ma, lymphangitis ; the retraction of a phimotic prepuce the seat of intrapreputial vegetations ; chan- 
croids and hard chancres. It is seen in all grades of mildness, in which it is reducible, and in all 
stages of severity, in which reduction is more or less difficult, and even impossible without operation 
or incision. 
The mechanism of paraphimosis is very simple. Retraction of the tight preputial orifice 
behind the glans leaves a fold or ring of mucous membrane just behind and continuous with it, 
and which ceases at a more or less deep furrow, and beyond this furrow is a swollen ring or fold 
of integument. The ring of mucous membrane is the inner surface of the prepuce ; the furrow is 
formed by the orifice of the prepuce, at the bottom of which it acts as a constricting ring, while the 
cutaneous fold or ring beyond is the external layer of the prepuce. In this condition inflammation 
begins and increases. The glans becomes swollen and red, even purplish, in color; the mucous 
collar of the penis becomes red and oedematous ; the constricting preputial ring strangulates the 
parts more and more as they become swollen ; and the cutaneous ring or collar beyond it also 
becomes more red and oedematous. In such a case, if relief is not obtained, the condition of 
affairs becomes worse. Besides the engorged glans, the chief swelling is seated under and just 
behind it on each side of the fraenum. When seen quite early this chin-like protrusion of mucous 
membrane is found to be filled with serous effusion. As time goes on. this is replaced by fibrinous 
exudation, and this chin-like body becomes hard and resisting. Coincidently with this the strangu- 
lation of the glans is greater; the mucous membrane pad behind it is more red, swollen, and infil- 
trated ; the constricting ring is correspondingly smaller ; the cutaneous ring of prepuce behind it 
more swollen. In this state the penis often becomes twisted in spiral and other peculiar forms, some- 
times to the point of strangulation, such as are shown in Figs, i and 5 of Plate II. In conditions 
thus seemingly desperate the parts may thus remain, and become permanently fixed by cell-exuda- 
tion. Generally, however, nature intervenes, if art is withheld, and the constricting ring is attacked 
by ulceration or gangrene ; in which case a longitudinal fissure forms along the dorsum in the 
mucous layer of the prepuce, and a corresponding one in the cutaneous portion. These increase, 
69 70 
VENEREAL E/SEASES. 
fuse, involve the preputial ring, and end by forming an ulcer seated transversely to the axis of the 
penis and behind the glans. Constriction is then ended, the patient's suffering relieved, but much 
oedema and disgorgement may remain. In somewhat exceptional cases there are two points of 
strangulation-the one at the preputial orifice or ring, the other in the mucous membrane at the 
base of the corona glandis, and largely due to the excessive engorgement of the part. Then in 
other cases the retraction of the prepuce is incomplete, and the orifice or ring only slips back 
behind, and not beyond, the corona, where it is firmly held, and with difficulty reduced except by 
operation. 
Gangrene, however, may occur under these circumstances, and may result in the destruction 
of more or less of the integument or glans, may involve the urethra, may perforate a blood-vessel, 
cause intense suppurative inflammation, and lead to erysipelas, phlebitis, and lymphangitis. 
In those cases in which reduction is accomplished early little if any disfigurement is left. 
When only the phimotic ring has been cut, on the subsequent pushing forward of the prepuce 
over the glans a median cut on its upper border is seen. When the exigencies of the case have 
necessitated an incision through the reflected mucous layer, the preputial orifice, and the tegument- 
ary layer of the prepuce, on the cessation of the inflammation and the reduction of the foreskin it 
will present the same lateral dog's ears as are seen when the dorsal incision is practised in phimosis. 
Not infrequently, the treatment having been delayed, the retracted portions of the prepuce become 
adherent to the corpora cavernosa, and its under portion forms a prominent chin or subpreputial 
frill of firm structure, which protrudes from the region of the fraenum forward. 
These are the sequelae in the preputial covering in the simple inflammatory forms of paraphi- 
mosis now under consideration. We shall find others when we consider the affection complicated 
by chancroids and hard chancres. 
Prognosis.-The prognosis in paraphimosis depends entirely upon the stage of the trouble 
when first seen. If the surgeon is consulted early, reduction can be accomplished without difficulty. 
If later, when strangulation has taken place, various sequelae, from the dorsal ulcer or gangrenous 
spot to more extended gangrene and destruction of the integument and perhaps portions of the 
glans and urethra, lymphangitis, phlebitis, and erysipelas, may occur. Such structural effects as 
scars of the prepuce and the beard at the fraenum may be removed by subsequent operation. 
Treatment.-The first procedure necessary in a case of paraphimosis is to thoroughly wash 
the penis in warm soapsuds, followed by affusion of a 2 per cent, watery solution of carbolic acid, 
since a phimotic condition is produced by reduction, and cleanliness will hasten resolution. Immer- 
sion in very hot water is of benefit when practicable. When there is much pain and in nervous, 
fidgety subjects a few whiffs of chloroform to induce very slight narcosis, or even the full effects of 
ether, may be necessary. Sometimes the recumbent position, with elevation of the penis in a cyl- 
inder of pasteboard, and a brisk cathartic, followed by a hot sitzbath, will often lessen the oedema 
and render the surgeon's duty much easier. It is always well to knead the parts and to press out 
as much as possible of the serum. A little olive oil or vaseline may be smeared in the balano- 
preputial furrow, but not on the glans, since it then causes the operator's fingers to slip. In those 
cases in which the mucous membrane of the region of the fraenum is translucent and much serum 
is seen, multiple punctures, followed by gentle pressure by the hand around the head of the penis, 
will always be followed by benefit. 
Several methods of reduction may be employed. A simple plan is to make a ring of the fore- 
finger and thumb of the left hand, which firmly encircles the penis behind the constriction ; at the 
same time that this hand is drawn forward, the glans, grasped by the fingers of the right hand, 
and at the same time compressed and elongated, is pushed backward, and reduction may follow. 
Another method is to take the penis behind the constriction between the index and middle fingers 
of both hands, and, making firm traction while the thumbs crowd down upon it, knead and press PARAPHIMOSIS. 
71 
the dorsum and base of the glans backward. Still another method, occasionally successful, is to 
strap the glans with a half-inch Martin's bandage, push the retracted prepuce forward, and then 
gently extricate the rubber. 
Compression of the glans by forceps of any kind usually fails. Should all of these efforts fail, 
operative procedures are necessary. 
In many cases incision of the constricting band is sufficient to relieve the parts. Since in most 
cases this is seated in the furrows already described, a curved bistoury may be introduced on its 
outer edge, well down under and through it, taking care not to wound the corpora cavernosa. If 
the swelling is such that the curved bistoury cannot be introduced beneath the band, a thin straight 
one may be used. This should be introduced at right angles to the penis at the outer edge of 
the constriction, and a number of firm but not deep cuts should be made, the operator being 
slow and deliberate in his movements, with the point of the instrument until the band is felt 
to give way. 
In some cases it is necessary to incise the mucous membrane and skin in the line with the 
incisions already spoken of. When this is done, it is well to inquire as to the natural length of the 
prepuce, and to make the incisions in conformity with the facts ascertained. Another rule is to 
take the length of the glans as the guide, and make the incision as long as that. As a result of 
this procedure the patient subsequently has the so-called dog's-ear prepuce, which requires a further 
. operation to complete the circumcision. 
When the constriction exists just behind the glans, it is sometimes with difficulty made out, 
and much care must be observed to cut it alone. HERPES PROGENITALIS. 
Herpes progenitalis, by some incorrectly called "herpes preputialis," is a mildly inflamma- 
tory affection consisting of one or more vesicles or groups of vesicles. It occurs in both sexes, 
but is not quite as frequent in the female as it is in the male sex. In men it occurs most com- 
monly on the inner surface of the prepuce, in the sulcus behind the corona, on each side of 
the fraenum, on the lips of the meatus, on the free margin of the prepuce, and upon the integu- 
ment of the penis. In general, the vesicles are unilaterally placed, though they may be symmet- 
rically developed, or those seated on one half of the organ may encroach on the other half. 
In women herpes progenitalis occurs on the inner aspect of the labia majora, on all parts of 
the labia minora, on the vestibule and prepuce of the clitoris, and occasionally on the outer surface 
of the labia majora and on the mons Veneris. I have seen two cases in which herpes of the 
whole labium majus was accompanied with herpes zoster of the crural, external cutaneous, and 
small sciatic nerves of the same side. 
The evolution of the affection may occur without any prodromal symptoms whatever: some- 
times it is antedated by various neuralgic phenomena, but in most cases there are slight burning, 
heat, and itching just before the outbreak. In nervous and chlorotic women an intense pruritus 
often begins with, and lasts during, the attack. 
The eruption may consist of a single vesicle or it may consist of a group closely packed, or, 
again, of a number of scattered vesicles, usually following the course of a nerve. The first mor- 
bid change observed is a red spot, which is soon the seat of vesicles. These lesions may be of 
the size of a pin's head or of the diameter of a line, and are rounded, translucent vesicles contain- 
ing clear serum. When seated on the mucous membrane they, owing to the succulence of the 
parts and thinness of the epidermis, soon rupture ; but when seated on the skin they remain intact 
for some days, and unless scratched their contents become turbid and dry into a brownish scab. 
Herpetic vesicles seated at the margin of the prepuce and on the outer rim of the labia minora, 
particularly when they are long, may be almost wholly obscured by the inflammatory oedema 
which the laxity of these tissues sometimes favors. Rupture of the vesicle leaves a shallow exul- 
ceration corresponding in size to the vesicle. Its floor is at first of a deep rosy-red, with a finely 
uneven surface, and its edges sharply cut as if punched out, and sometimes undermined, but not, 
as a rule, to the same extent as in chancroid. When there is a group of vesicles, they fuse 
together and rupture, forming a patch which has been described as having a polycyclical outline. 
(See Figs, i and 2 of Plate VI.) This is comparable to the outline presented by two pieces of 
three-leaf clover placed base to base, which then has a festooned margin formed by segments of 
circles. Early in their evolution the vesicles are surrounded by a well-marked redness, the tend- 
ency of which is to gradually decline until a mere hyperaemic rim remains. 
Usually, the vesicles heal in a few days ; in some cases they are very persistent, and in others 
they become ulcerated and undistinguishable from true chancroids. In this state their secretion is 
sometimes auto-inoculable, and in some cases the cause of buboes. When seated on an inflamed 
72 HERPES PROGENITALIS. 
73 
prepuce and irritated by decomposed smegma or gonorrhoeal pus, herpes progenitalis occasionally 
assumes a more or less destructive tendency. I have very frequently seen vesicles become covered 
with a thin blackish crust, and thus remain indolent with no tendency to healing. 
When fully developed, there is usually an amelioration or subsidence of the itching, heat, or 
burning, but somewhat exceptionally the excoriated surfaces are exquisitely sensitive, and the 
patient shrinks from the slightest touch of them. Uncomplicated cases last from a few days to 
two weeks. 
Under the name neuralgic herpes Mauriac first described an affection of considerable gravity 
in which, besides the eruption, there is a coexistent neuralgia of various branches of the sacral 
plexus. He cites the case of a man who for eleven days previously had felt a slight sensation of 
heat in the prepuce, and was suddenly attacked by a severe pricking and itching in the part. 
Mere pressure of the clothes became insupportable, and the pain was so intense that sleep was 
impossible. Four or five days later he was attacked by darting pains down the leg and in the peri- 
neum, buttocks, and scrotum. Anaesthesia alternated with hyperesthesia made the patient's suf- 
ferings nearly unbearable. Two years later the patient had another attack, only one vesicle being 
present, during which he suffered from boring pains, neuralgia of the urethra, and disturbances of 
sensibility. In a second case observed by Mauriac, forty-eight hours preceding the appearance of 
a single vesicle paroxysmal pains radiated through the penis and perineum, and subsequently darted 
up and down the leg. A short time after a vesicle appeared at the orifice of the meatus, accom- 
panied by hypersesthesia of the urethra, painful micturition, and pain in the bladder. 
In my experience, herpes progenitalis is not infrequently preceded or accompanied with neur- 
algia of some part of the male genito-urinary apparatus. I have seen several cases of vesicles 
seated on either lip of the meatus attended with neuralgia of the bladder and urethra. The canal 
itself was of a deep-red color, and was bathed with a scanty mucous secretion, in which no pus- 
cells could be detected. The affection usually lasts a week, and is painful during the first few 
days. I have also seen several cases in which pain on the side of the scrotum corresponding to 
the situation of the vesicles on the penis, of a burning and exquisitely sensitive character, was 
experienced during the existence of the herpetic eruption. 
The following well-marked case of neuralgic herpes was for a long time under my care: A 
man thirty-five years old, thin and pale, but of average good health, whose father and whose sisters 
had been for years subject to sciatica and other neuralgias, had since his fifteenth year suffered 
from sciatica, which during a period of twenty years had returned every three months. The 
attacks were usually preceded by gastric disturbance. The pain began just above the knee, and 
extended upward to the gluteal region. In a few days he experienced a sensation of heat and 
burning on the side of the penis corresponding to the sciatica, followed promptly by a group of 
vesicles which was painful. There was burning in the urethra, strangury, and pain on the same 
side of the scrotum as the sciatica. In seven out of ten attacks of sciatica herpes progenitalis 
was present. 
This affection is peculiarly prone to relapse at longer or shorter intervals, occasionally with 
distinct periodicity. In exceptional cases there are swelling and pain in the inguinal ganglia of the 
corresponding side. Sometimes, when the vesicles become much inflamed and ulcerated, sup- 
purating buboes occur. I have several times seen this happen in syphilitic subjects, and have 
been led to think that most authors are too positive in asserting that these glands possess an 
immunity in herpes progenitalis. 
This affection is peculiar to adults as late as middle life, and is rarely if ever seen in old 
persons. 
Etiology.-Various constitutional conditions-neurotic, gouty, rheumatic, and plethoric-were 
formerly regarded as the causes of herpes progenitalis, but their influence, if such exists is simply 74 
J/ENEEEAL D/SEASES. 
that of greater or less predisposition. Extended clinical observation has shown that local determin- 
ing conditions are, as a rule, the existing causes of the affection. These may be briefly stated as any 
or all congestions and inflammations, ephemeral or long continued, of various grades affecting one, 
several, or all portions of the genito-urinary tracts of both sexes. Thus, following balanitis, par- 
ticularly when resulting from phimosis, gonorrhoea, chancroids, and hard chancres, especially in 
severe instances, herpes progenitalis frequently appears. In patients subject to strictures-par- 
ticularly when deep seated-and to lesions at the neck of the bladder, herpes is often known to 
occur, commonly at or following an exacerbation. I have seen recurring herpes appear coinci- 
dently with renewed inflammation in a man suffering from chronic epididymitis. In like manner, 
long-continued turgescence of the penis from any cause may be followed by the appearance of the 
affection. 
As predisposing causes to herpes progenitalis in the male, uncleanliness and decomposition of 
the sebaceous matter, excessive venery, and over-indulgence in alcoholics, hot weather, obesity, and 
plethora, are frequently noted. The neuropathic condition may act as an underlying predispos- 
ing cause. 
In women, as in men, congestions and inflammations, ephemeral or long continued, are always 
the underlying causes of herpes progenitalis. Prostitutes are those who suffer in greatest number 
from this affection, due, undoubtedly, to the very frequent irritation of their genital apparatus in 
coitus. Many years ago I saw, weekly, large numbers of pceuella publics, and observed a goodly 
proportion thus affected. Such is its frequency among these women that Unna calls it the "voca- 
tion disease." Violence to the female genitals, in rape and from excessive size of the penis, and 
in masturbation, particularly when large and firm substitutes for the penis are employed, often pro- 
duce herpes of the parts. Vulvitis, vaginitis simple or severe, are frequently the forerunners of 
the affection. Congestion of the pelvic organs, menstruation, dysmenorrhoea, pelvic cellulitis, 
metritis, inflammation of the ovaries, and endometritis are likewise occasional excitants of the 
affection. As in men, so in women, herpes progenitalis is seen in early and late adult life, and 
found to relapse in the same exasperating manner. 
It is probable that in all cases of herpes progenitalis disturbance occurs in the nervous arc 
which exists between the genital apparatus and the spinal cord, and that irritation is transmitted 
from the external or deep portions of the genital apparatus backward to the spinal nerve-centres, 
and from these conveyed to some portion or portions of the penis, vulva, or mons Veneris. Clin- 
ically, many cases of herpes preputialis present features of similarity to herpes zoster, even to the 
point of being coexistent with it. 
Diagnosis.-Usually, the diagnosis of herpes of the genitalia is readily made, but when exul- 
cerated the vesicles may closely resemble chancroid or hard chancre. As a rule, the sensations 
of heat, itching, and burning, the superficial character of the lesion, its less profuse secretion, and 
scarcely undermined edges will establish the diagnosis, which may be strengthened by the history 
of relapses. Further, the very frequent unilateral position and peculiar groupings of the herpes 
vesicles are important diagnostic aids, while in some cases the arrangement of these lesions in the 
course of a nerve points undoubtedly to their nature. 
Both in its solitary and multiform conditions herpes zoster may resemble the syphilitic chancre 
in its early and erosive stage. There are probably more errors made by mistaking this as yet 
undeveloped initial lesion for herpes than there are about any other form of the hard chancre. 
The surface of the chancrous erosion is of a deeper and duller red color, even coppery, and its 
floor is smooth and shining, without any small granulations. Its areola is very slight and of a 
dull-red color, and there is a general absence of inflammation about the whole lesion. Leloir 
emphasizes the fact that pressure between the thumb and fore finger of a chancrous erosion will 
fail to cause a drop of serum to exude from its surface, while if similarly treated an herpetic vesi- HERPES PROGENITALIS. 
75 
cle gives issue to repeated drops. It is a good rule to be always guarded in the diagnosis of these 
minute lesions, particularly in cases in which there is absence of the prodromal and accompanying 
symptoms of herpes, and especially when the lesion seems particularly insignificant. In like man- 
ner, a clear history of antecedent herpes should not embolden the surgeon to speak too confidently 
of the simple character of its successor. A group of chancrous erosions constitutes what is called 
the multiple herpetiform chancre, which is liable to be mistaken for a cluster of herpetic vesicles. 
Besides the points of difference already given concerning a single erosion, in its multiform condi- 
tion the diagnostic points insisted upon by Fournier may afford much aid. Patches of chancrous 
erosions assume a round or oval outline or irregularly round or oval shape. Herpes progenitalis, 
on the contrary, has the polycyclic form, with its festooned and segments-of-circles-like margins, due 
to the fusion of a group of round vesicles. 
Treatment.- I he first indication is to remove irritation or inflammation from the external and 
internal parts of the male or female genital apparatus. If any abnormality of the prepuce exists 
as an exciting cause, circumcision should be performed, since benefit is produced in the vast major- 
ity of cases. Any deep-seated urethral trouble or affection of any of the accessory parts of the 
genital tract should receive appropriate treatment. All sources of irritation of the penis should be 
avoided, and frequent ablutions in hot water made. Any coexisting dyscrasia, gouty, rheumatic, 
neurotic, or plethoric, should receive proper attention. Sexual, alcoholic, and dietetic excesses 
should be interdicted. 
In women, as' far as possible, irritations, congestions, and inflammations should be avoided 
or removed by appropriate treatment, and the frequent use of douches of hot water should be 
insisted upon. 1 he health of the patient should be considered, and any deviation from the normal 
attended to. 
Locally, many agents may be employed. For irritable herpes in either sex the lead-and-opium 
wash is often very soothing. Very often the persistent neuralgic and burning pains require for 
their relief very careful but thorough cauterization with carbolic acid, solutions of nitrate of silver 
(60 grains to the ounce of water), or perhaps with fuming nitric acid, after which the lead-and- 
opium wash may be applied. As an adjuvant in these cases frequent immersions in very hot water 
are very soothing. Boracic acid and iodoform, alone or in combination, are frequently of benefit 
where a tendency to ulceration exists. Iodoform and glycerin, or in ointment form mixed with 
vaseline (i drachm to the ounce), very frequently is beneficial in relieving the neuralgia and 
promoting healing. 
A solution of the bichloride of mercury (i : 3000) or of carbolic acid (2 per cent, to the ounce 
of water) may be found useful. 
The following formulas may also be tried: 
R. Argenti nitrat., gr.ij; 
Ext. bellad., gr. x; 
Aquae, 3j. M. 
R. Zinci sulphat., gr. vj; 
Spts. lavandulae, 3ss; 
Glycerinae, 5iss; 
Aquae, ad 5j. M. 
All solutions should be carefully applied to the parts on lint or absorbent cotton. Calomel, 
oxide of zinc, subnitrate of bismuth, starch, lycopodium, and Venetian talc may be used during the 
stage of healing as dusting powders. VEGETATIONS. 
Vegetations are papillary new growths formed by hypertrophy of the papillse, increase in the 
capillaries, and hyperplasia of connective tissue. They are known under various names, the chief 
ones being-venereal warts, pointed warts, moist warts, fig warts, cauliflower excrescences, pointed 
condyloma, verruca acuminata, verruca vegetantes, condyloma acuminata, spitze condylom, and 
vegetatione dermique. It is important to remember that these names are applied to vegetations 
alone which are simple new growths, and that the term "condyloma latum" is given to certain 
papillary growths of syphilitic origin. 
Vegetations are not, in the majority of cases, of venereal origin, though their most frequent 
sites of development are on or in the neighborhood of the genitals of both sexes, particularly in 
persons who have had gonorrhoea, chancroids, and syphilis, and in pregnant women. Their growth 
is induced and favored on mucous surfaces and at the junction of the skin and mucous membrane, 
and on thin delicate skin, by uncleanliness, by the decomposition of sweat and of sebaceous mat- 
ter, and by the presence of gonorrhoeal and other kinds of pus. For clearness of description, 
vegetations may be divided into two well-marked classes : first, the soft, succulent warts of the 
mucous membranes and muco-cutaneous junctions ; second, the harder and firmer warts which 
appear on the skin, particularly near the genitals, since here the two factors of the growth, heat 
and moisture, exist. 
The soft warts or vegetations are found in the male upon the corona, in the sulcus behind it, 
and on the inner surface of the prepuce, particularly near the fraenum. They also are found around 
or within the orifice of the meatus, rarely to the depth of nearly an inch, and on the edge of the pre- 
puce. In women they commonly develop upon the fourchette, around the entrance of the vagina, 
and within it as far as the uterus, and upon the inner surface of the labia minora and majora. 
From the genitals in either sex they may spread to neighboring regions. 
Vegetations begin as minute reddened erosions of the mucous membrane, which very soon 
come to look like pinhead-sized, finely granular papules. In this state I have known them to be 
mistaken for incipient hard chancres. From this insignificant-looking lesion growths even of vast 
size spring. When the parts are moist and little attention is paid to cleanliness, they grow rapidly 
and exuberantly, but where the parts are dried they grow slowly and show less tendency to periph- 
eral development. The close coaptation of parts, with their greater inaccessibility to care and 
their increased secretions, also favors rapid growth. The pinhead-sized warts already described 
grow in height and in breadth and form vegetations of various shapes. They may be rounded and 
sessile or pedunculated or Indian-club and mushroom-shaped, in which conditions they vary in size 
from a pea to a raspberry. Or, instead of growing in breadth when from the formation of the 
parts they are subjected to lateral pressure, they grow to a length of an inch and more ; and 
separated they look like so many thin red spears with smooth sides, jutting out and radiating in vari- 
76 VEGETATIONS. 
77 
ous directions. This form, like the blossoms of thyme, which was called by the older writers achro- 
thymion, is seen chiefly around the introitus vaginae, and, springing from the balano-preputial fur- 
row in subjects having a roomy prepuce, and from the region of the fraenum, has been called the 
verruca digitata, or finger-like wart. The exuberant development of warts of the sessile and 
pedunculated or club-shaped forms may result in new growths of enormous size, which are called 
fungating masses and cauliflower excrescences. 
lhe color of vegetations varies in different subjects and at different times. It may be of the 
deep red of the cock's comb or of a purplish red, and when rather small it may be but slightly 
more pink than the mucous membrane upon which they are seated. Their surface is covered with 
minute mammillated warty elevations, resembling those of the strawberry or raspberry. A very 
clear idea may be gained of the appearance of vegetations from inspection of Fig. 8, Plate II. 
On mucous surfaces, particularly when covered, as by the prepuce, or in close coaptation, as in 
the vulva, vegetations are attended by a sticky mucoid secretion which rapidly undergoes decom- 
position and gives rise to a penetrating and sickening odor. In the male they are frequently the 
cause of balanitis when seated upon the prepuce near the fraenum or in the sulcus glandis, and 
when about the meatus a purulent discharge may be produced. Likewise in the female a well- 
marked purulent vulvitis or vaginitis is sometimes caused by vegetations, and often aggravated 
by uncleanliness. 
Carious annoying and injurious mechanical con- 
ditions are sometimes caused by vegetations in both 
male and female. Men having the various malforma- 
tions of the prepuce, such as smallness of the orifice, 
straitness and tightness and redundancy, and those in 
whom the fraenum is short, upon the development of 
warts on these parts are very liable to phimosis. This 
complicated condition is often accompanied by much 
inflammatory action and with a copious flow of pus. 
Warts thus concealed under the prepuce, the condi- 
tions being so favorable, grow rapidly, sometimes push- 
ing forward and out of the preputial orifice, and again upward, causing gangrene and perforation 
of the prepuce, as seen in Fig. i, in which it will be seen that the meatus is covered with these 
growths. When seated about the fraenum they first 
cause difficulties in retracting the foreskin, and later 
on phimosis with all of its concomitant uncleanliness. 
The flow of urine and the ejaculation of semen are 
often rendered difficult by vegetations around the 
urethra and at the fraenum, and coitus is frequently 
rendered impossible. 
In women, vegetations at the meatus and in 
the vestibule very often give rise to irritation, burn- 
ing, and a discharge, and sometimes a frequent desire 
to pass water, and they may act as an impediment 
to urination. In the vulva and around the introitus 
vaginae, besides these inflammatory accompaniments, 
when small they interfere with the introduction of 
specula and with coitus, and when excessively large, as seen in Fig. 2, they impede urination and 
effectually block up the vaginal orifice. Cure of such cases often involves partial stenosis of the 
the orifice. The lot of women thus afflicted is indeed a sorry one, and those in whom the growth 
Fig. i. 
Vegetations causing Perforation of Prepuce. 
Fig. 2. 
Vegetations of the Vulva. 78 
VEGETATIONS. 
of vegetations has extended around the anus further suffer from irritation, spasmodic contractions, 
and pain and difficulty of defecation. 
These soft, succulent vegetations sometimes, when irritated or subjected to traumatism, 
become very much inflamed, and even gangrenous, and in the inflamed condition have been 
regarded as exuberant epitheliomata. Long-continued irritation has been known to transform 
these growths into true epithelioma in both male and female. 
The hard or corneous warts, or venereal warts of the skin, may exist alone or form the 
successive crops of soft ones which begin on mucous surfaces. They consist of small red sessile, 
rounded, or pointed tumors, quite firm in structure, of an area of a line or more, and of a height 
of two or more lines. Their features are well shown in Fig. 3, Plate VI., in marked contrast to 
the condylomata of syphilis. In structure they are similar to the soft ones, except that, owing to the 
nature of the skin, their epidermal covering is thicker, their papillae shorter, and the connective tis- 
sue more condensed. They occur on the penis, on the scrotum, in the crural folds, and about the 
anus in the male, and on the labia majora, inner surface of the thighs, on the perineum, and about 
the anus in women. Like those of the soft variety, they increase in great numbers, though more 
slowly. On coapted surfaces their epithelial covering may be rubbed off, and they then give issue 
to a sticky, fetid secretion which, mixed with sebum and sweat, is sometimes copious. Their further 
course is influenced by the conditions which surround them. If the parts are the seat of heat and 
moisture, especially if the patient is uncleanly, they grow and multiply indefinitely ; but if they 
occur on exposed surfaces, and particularly if they are carefully cleansed or dusted with absorbent 
powders, they may remain quiescent indefinitely. In like manner, the soft warts, when seated on 
parts which can be kept dry and are either exposed to the air or to the action of absorbent pow- 
ders, become hard and corneous and permanently lose their softness and succulence 
It is not at all uncommon to see vegetations in syphilitic subjects in the neighborhood of con- 
dylomata lata. 
Vegetations, especially of the soft kind, are mostly seen in subjects of from twelve years to 
adult life, and in the male and female in about equal proportions. As age advances they are 
less frequently observed, and in middle-aged and old persons they are harder, firmer, and sessile, 
less vascular, and fewer in numbers, most commonly resembling the chronic seed-warts of the 
hands. 
The view formerly held, that warts possess contagious properties, is now entertained by but 
few. That they show a great tendency in many subjects to growth, extension, and reproduction 
is explained by the existence of favorable conditions. When seen in a number of associates, male 
or female, their occurrence is simply a coincidence. 
Diagnosis.-So well marked are the features of fully-developed vegetations that their nature 
is readily recognized. When, however, they have undergone condensation and have become flat- 
tened, they may be mistaken for condylomata lata, especially when the latter have become hyper-' 
trophic. The latter usually have a clear syphilitic history, and are perhaps accompanied by other 
specific lesions, active or declining. Condylomata lata begin as small flat, papular, firmly-consist- 
ent formations, usually of slow growth at first, not very many in number, and may thus remain 
for a long time; whereas the vegetations or warts grow rapidly and present the cleanly-cut fea- 
tures already given. In many cases of chronic metamorphosed simple vegetations, so close is 
their resemblance to condylomata lata that their nature can only be determined by a pains- 
taking study of the case. 
Prognosis.-Though of simple nature, vegetations, from their great exuberance of growth, 
should never be slightingly regarded. Their frequent causation of acute purulent inflammation in 
both male and female, their tendency to induce phimosis, with gangrene and perforation of the 
prepuce, their interference with the functions of the female genito-urinary tract, and their liability VEGETATIONS. 
79 
when large to become gangrenous, should be borne in mind and explained to patients. 
Further, their inevitable growth and reproduction should not be forgotten. Then, again, par- 
ticularly in old subjects, they are prone to undergo malignant degeneration-in women earlier 
than men. It may be stated, without fear of contradiction, that a large proportion of the cases 
of epithelioma of the uterus and vagina and of the penis have begun in a seemingly insignif- 
icant wart. It is the duty of the surgeon to impress upon the patient the fact that as middle age 
approaches and increases warts on any portion of the body are menaces to his or her safety. This 
is particularly true as to the genital organs of both male and female. A male patient, having 
from any cause difficulty in retracting the prepuce with warts around or beneath it, should be 
informed that they are especially prone at his time of life to undergo malignant degeneration. 
I reatment.-The indications for the treatment of vegetations are their complete removal and 
the prevention of their return. In every instance the immediate and accessory parts should be 
thoroughly washed or irrigated with solutions of carbolic acid (i : 100) or of the bichloride of mer- 
cury (i : 2000) ; then the surfaces and interstices of the warts should be thoroughly coated with an 
8 per cent, solution of muriate of cocaine. This being done, the surgeon's work can be more 
thoroughly and easily performed. After operations it is important that the parts should be kept 
dry and that coapted surfaces be kept separated. 
It may be stated as an axiom that surgical procedures for the removal of vegetations are much 
more rapid and effectual than caustics are. The latter, however, are useful under certain circum- 
stances. When the vegetations are small they are readily removed by the dermal curette or Volk- 
mann s spoon, the scraping being carried well to the level of the tissues, which, however, must 
not be wounded. A solution of persulphate or perchloride of iron should be carefully touched to 
the bleeding points, and the parts when dry quite firmly covered either with iodoform or absorbent 
gauze-never with watery solutions. Such is the tendency to recurrence of these growths that the 
cure cannot be considered complete until the surfaces are smooth. In cases of recurrence, before 
the little growths have reached much salience, the chloro-acetic acid, acetic acid, lactic acid, acid 
nitrate of mercury, nitric acid, the various solutions of iron just spoken of, and strong tincture of 
iodine may be employed. Bichloride of mercury, thirty grains to the ounce of collodion, or sali- 
cylic acid, one drachm to the ounce of the same fluid, are sometimes very effectual solutions lor 
small warts and those for which curetting is contraindicated. 
Sessile or pedunculated warts of an area of an inch or more may be readily removed by 
strangulation with a silk ligature. In some cases this object may be accomplished by the elas- 
tic ligature, using the ordinary small india-rubber bands fixed firmly around the base of the 
warts. 
Warts of larger area than an inch are best treated by the galvano-cautery loop, since these 
cases are the only ones in which this method of removal is really indicated. Their removal must 
be slowly and carefully effected with the least loss of blood. Their further treatment is similar to 
that of the small growths. 
In cases in which the warts are seated under a tight prepuce the utmost care should be 
observed that inflammation be not produced, since phimosis would inevitably occur and delay the 
cure. In many cases of both sexes, particularly when the lesions are very large and exuberant, 
I have repeatedly seen the most satisfactory results follow a preliminary treatment of immersing 
or bathing the parts for as much as an hour several times a day with water as hot as can be borne. 
I he warts grow smaller and more condensed, and are more readily tied, without the troublesome 
hemorrhage which is otherwise so constant. 
I he utmost care must be observed in removing vegetations about the meatus, and when pos- 
sible scraping or tying should be employed. When these means are impracticable the salicylic or 
bichloride collodion may be used very carefully. The idea is to simply remove the new growth and 80 
VENEREAL DISEASES. 
avoid damaging the parts and causing stricture of the meatus. As a rule, acids are contraindicated 
in this region. 
In cases where operative procedures are not admissible, whether owing to the size or situa- 
tion of the warts, it is well to apply freely to them, after the preliminary fomentations with very hot 
water, followed by washing with bichloride or carbolic solutions, equal parts of calomel and salicylic 
acid. At Charity Hospital I have cured many unpromising cases by this method. 
Bockhart1 speaks very highly of plumbum causticum in the treatment of vegetations. This 
preparation in a 33 per cent, solution of oxide of lead is a strong potash solution, and forms a 
grayish-green turbid mixture. It should be applied very carefully to the warts alone, the surround- 
ing parts being smeared with vaseline. In two cases thus treated by me the warts were promptly 
converted into black gummy masses, which fell off in a few days, leaving a slightly reddened sur- 
face. The agent is worthy of trial. 
Warts on the female genitals should be treated on the lines just indicated, care being taken 
that their removal be completed without damage to the tissues. When seated around the urethra 
or vaginal orifice several of the methods of removal may be necessary, the surgeon always aiming 
to preserve the lumen of these canals. When practicable, frequent copious injections of very hot 
solutions of the bichloride (1 : 2000 or 1 : 5000) should be used and the parts kept as dry as 
possible. 
The treatment of the hard vegetations of the skin has for its objects their evulsion or their 
absorption and withering. Very active measures are liable to cause dermatitis of the parts around 
the genitalia. If there are but few of them, they may be curetted and treated like the soft variety. 
If they are numerous, after careful cleansing of the whole surface and ablution with carbolic or 
bichloride solutions of the strength already mentioned, each maybe touched separately with the 
bichloride or salicylic collodion, and the parts kept dusted with subnitrate of bismuth, boracic acid, 
starch, or infant's powders. When these skin-warts have undergone desiccation and corneous 
degeneration, their removal is often difficult, and the following preparation will be found 
efficient: 
B. Acid, salicylic., 
Chrysarobin, ad. ; 
Collodion flex., 5j- M. 
They should be kept covered with this continually. 
After removal the surgeon should explain to the patient the conditions in which warts grow 
and luxuriate, with a view to prevent their recurrence. 
In persons beyond forty years of age persistent recurrence of an originally simple wart 
should always awaken suspicion of malignancy, and prompt and radical extirpation should be 
practised. 
1 Monatshefte fur Praktische Dermatologie, No. 4, 1888. BALAN ITIS. 
We apply the term "balanitis" to inflammation of the mucous membrane covering the glans 
penis, and "posthitis" to inflammation of the mucous lining of the prepuce. Either part may be 
affected separately, but when both surfaces are involved the affection is called " balano-posthitis." 
By many, however, the term balanitis is used to mean inflammation of the mucous membrane of 
either the glans or the prepuce, or both. 
I his affection is most commonly seen in persons having some abnormality of the prepuce, 
such as smallness of the orifice, straightness, tightness, redundancy, and shortness of the fraenum. 
It is also seen in persons having a normal penis, and in those whose prepuce is very short. In 
most cases it shows a tendency to relapse, and one attack predisposes toward subsequent ones. It 
exists in an acute and a chronic form, and in all degrees from mild to very severe. 
In its most simple form balanitis presents a very red, somewhat thickened surface, covered 
with a milky secretion emitting a penetrating and offensive odor. This condition is very amenable 
to treatment. 
Balanitis and balano-posthitis in a more advanced form present well-marked features. The 
glans and prepuce are swollen, and when the latter is retracted a mottled surface of shining white- 
ness, broken by deep-red superficial and irregular excoriations, is seen. In this case in some parts 
the epithelium still remains, and, having been macerated by the secretions, presents the whitish- 
pearly look spoken of, while in other parts it is cast off, and as a result the red excoriated patches 
are left. This is well shown in Fig. 19, Plate IX. 
In other cases, upon retracting the prepuce it is found that the glans or its covering, or both, 
are the seat of redness and swelling, and that their surface is covered with minute, closely-packed 
vesicles, which rupture promptly and give rise to excoriations. 
lhe foregoing, which we may call the simple forms of balanitis and balano-posthitis, may be 
promptly cured by appropriate medication. But should, for any reason, the irritating cause per- 
sist, a more severe form of the affection results. With the increase of the redness and swelling the 
excoriations give rise to exulceration, which may be superficial and covered with thin, soft green- 
ish crusts, as seen in Fig. 20, Plate IX., and which is called exulcerated balanitis or balano-posthitis. 
Under unfavorable circumstances these superficial lesions of continuity may become transformed 
into deeper ulcers. 
Balanitis is not infrequently seen in persons having a short prepuce, which tends to curl up in 
a. little bunch behind the corona glandis-a condition very often seen in those having hypospadias. 
In the coronal sulcus of these cases there is sometimes found a red raw, pus-secreting, narrow, 
transverse patch which is very obstinate and annoying. It usually originates in decomposition of 
he sebaceous matter, and shows a marked tendency to recur in consequence of very slight inat- 
tention to cleanliness. 
In the early stages of syphilis, coincidently with the erythematous or papular rash, balanitis is 
not uncommon in persons having long and tight foreskins, particularly if they are careless in the 
81 82 
VENEREAL D/SEASES. 
matter of cleanliness. With the erythematous syphilide one or more round or oval deep-red 
excoriations are developed, which, with the aid of uncleanliness, may invade the whole glans 
and prepuce. Mild and ephemeral in its course as this specific balanitis is in cleanly subjects, 
it may, owing to inattention, be followed by ulceration and diffuse thickening of the parts. 
Syphilitic papules upon the glans, and less commonly the prepuce, also owing to uncleanli- 
ness, very often develop into red exculcerated patches which may involve both surfaces in inflam- 
mation. It is not very infrequently seen that in early syphilis red patches and papules, both of 
which go on to cause balanitis, are developed without coexistent dermal rashes. 
These forms of balanitis in syphilitic subjects, unless properly cared for, are very persistent, , 
and are often followed by induration of the parts, and also, later on, by well-marked sclerosis. 
In some cases the subpreputial papules become much hypertrophied, and in others they are fol- 
lowed by the growth of simple vegetations. 
A diffuse inflammation of a subacute character, and infiltration into more or less of the sur- 
face of the glans and prepuce, are sometimes seen as the expression of the initial manifestation 
of syphilis. This so-called "infecting balano-posthitis " is soon followed by the enlargement of 
the inguinal ganglia, which, together with its subacute course, tends to point out its specific nature. 
In contradistinction to the foregoing acute forms of balanitis there are the chronic forms. In 
general, chronic balanitis is seen in persons beyond thirty years of age. It generally begins upon 
the glans and prepuce, which are usually in close coaptation owing to some abnormality. The 
inflammation is usually of a subacute character, and shows decided exacerbations and remissions. 
In this way the affection extends over years. If retraction of the prepuce is more or less possible, 
a somewhat reddened, thickened, and perhaps slightly excoriated surface is revealed. Owing to 
the thickness and less elasticity of the prepuce it rolls back, if at all, with difficulty, and in many 
instances this procedure is wholly prevented by the development of a fibroid ring at the preputial 
orifice. Such patients say that they have constant inconvenience with their penis, have much diffi- 
culty in cleansing the foreskin and glans, and have recurrences of tolerably mild inflammation. 
When examined from time to time a decided thickening of the epithelium is seen, together with 
considerable increase in the submucous connective tissue. The parts then have a bluish-white, 
milky-looking surface, which rarely becomes frankly red, owing to the fact that the blood-vessels 
have been narrowed by the general condensation of the mucous membrane. To the touch such a 
glans and foreskin feel firm, somewhat like wash-leather, and as time goes on turgescence of the 
end of the penis is never complete. Unless in such a case circumcision is performed, the growth 
of the epithelial covering of the glans increases and much diminishes its size, and very frequently 
it so compresses it that it levels the corona until it is continuous in line with the fossa. 
Not only are these cases distressing in the discomfort and suffering incident to the progress of 
the affection, but they are also attended with much gravity, since as years increase there is a decided 
tendency for them to undergo malignant degeneration. Upon this thickened epithelial covering 
excoriations form, which are often very difficult to heal, and should always be regarded in a serious 
light. Beginning thus as one or more excoriated patches, unless art intervenes very soon an ele- 
vation is seen which constantly increases, and later on shows signs of malignancy. This is one of 
the most common modes of development of cancer of the penis. 
Symptoms.-The symptoms of balanitis and balano-posthitis may be simply a slight itching or 
burning sensation, or a feeling of severe pain attended by much heat may be present. The end 
of the penis becomes very tender, even to a condition of erythism ; erections are painful, coitus 
frequently impossible, and urination attended with a burning sensation. A thin, milky, or a creamy 
purulent discharge is constant. 
Causes.-In most cases balanitis is due to uncleanliness, and results from the decomposition 
of the sebaceous matter which is formed by the glans seated in the mucous layer of the prepuce. BALAN/TIS. 
83 
Excess in coitus, coitus with a woman with a small vulvar orifice or with one suffering from leucor- 
rhoea, and masturbation are frequent causes. I he existence of vegetations under the prepuce is 
a frequent cause of balanitis, and the lodgment of gonorrhoeal pus in that position also causes it. 
In some cases the gonorrhoeal discharge excites inflammation at the preputial orifice, which extends 
to the prepuce and glans. Chancroidal pus and the secretions of primary and secondary syphilitic 
lesions, and these lesions themselves, are also prolific causes of balanitis. 
It is important to remember that persons suffering from diabetes are quite commonly attacked 
with balanitis or balano-posthitis, even though they may have no abnormality of the prepuce, owing 
to the decomposition of the urine. The supervention of this preputial affection in middle life with- 
out other assignable cause should lead to a suspicion of its diabetic origin. 
Complications.-While balanitis may result from phimosis, the latter may be produced by 
balanitis. Paraphimosis may also result from inflammation of the prepuce and glans. 
Lymphangitis of a mild or severe type is not at all infrequent in severe balano-posthitis, and is 
quite common when that affection is complicated with chancroids and various syphilitic lesions, also 
with gonorrhoea and vegetations. In mild cases the lymphatic vessels feel like cords under the 
foreskin. In severe cases the whole penis becomes of a deep red, greatly swollen, oedematous, 
and the seat of severe pain-a condition incorrectly called penitis. In these cases phlegmonous 
abscesses may form under the skin. Following lymphangitis of balanitic origin, inflammation of 
the inguinal ganglia, and even suppurating buboes, may result. 
Not infrequently, particularly in uncleanly persons, also in those debilitated by disease or 
excesses, gangrene of the prepuce occurs from balanitis. Owing to the inflammation of the parts 
and swelling of the glans, a black spot forms about the middle of the prepuce, and through the 
buttonhole-like opening which results, the glans protrudes. 
In cases of recurrent attacks of balanitis thickening of the submucous connective tissue is not 
at all uncommon. In some cases of acute balanitis well-defined, freely-movable, flat plates of 
thickened submucous tissue of various sizes and extent, which can be readily grasped between 
the thumb and forefinger, may be felt. I have frequently seen these plates of such firm structure 
and so sharply limited that they have been mistaken by my internes for hard chancres. Not 
uncommonly, after an attack of acute balano-posthitis, a semicircular ring of this thickened sub- 
mucous tissue is felt for some time behind the corona, and causes retraction to be less promptly 
performed than it is normally. 
In a phimotic prepuce, besides the thickening of the tissues, a fibroid ring is formed around 
its orifice in consequence of recurrent inflammation, and in it numerous troublesome radiating fis- 
sures may form. 
Phimosis ano paraphimosis as a result of balanitis have already been spoken of. By far the 
most serious complication and sequela of chronic balanitis in middle-aged and old persons is the 
tendency to hyperplasia of the epidermis of the glans and prepuce, which is so prone to lead to 
epitheliomatous degeneration. Adhesions of various sizes and possessing varying degrees of firm- 
ness are not infrequent in cases of phimosis complicated with balano-posthitis. 
V egetations as results of balanitis have been spoken of. 
Diagnosis.-In mild cases the diagnosis of balanitis is readily made upon retraction of the 
prepuce. However, when there is difficulty of retraction the case may be mistaken for gonor- 
rhoea. If the orifice of the prepuce is large enough to allow inspection of the meatus, the parts 
can be carefully wiped, and then, when pressure is made upon the under surface of the urethra if 
gonorrhoea is present, pus will exude from the meatus. If the urethra is found to be free from 
inflammation, pressure over the whole surface of the glans from behind forward will cause pus 
to escape from the preputial orifice. Besides these points of diagnosis, the subjective symp- 
toms will also be of assistance. VENEREAL DISEASES. 
84 
Herpes progenitalis, especially when, from any cause, accompanied with much hypersemia, may 
be at first mistaken for balanitis, but the history of the case may be of aid, and upon subsidence of 
the inflammation the sharply-limited margins of the vesicles will reveal the nature of the affection. 
The most difficult task, very often, in the diagnosis of balanitis is to determine whether or not 
chancroids or hard chancres lodged under the prepuce are at the bottom of the trouble. Chan- 
croidal ulcers may have been seen before the phimotic balanitis had developed, and then its origin 
is clear. But in many cases, from carelessness or ignorance, patients can give no history of a 
chancre or chancroid. Subpreputial chancroids are attended with much more severe and rapid 
inflammation than simple balano-posthitis. The pus becomes very copious, less thick and creamy 
than in the simple affection, and frequently of a rusty color. Soon the distal end of the penis 
becomes swollen, in shape like an Indian club, and of a dusky-red color, as is shown in Fig. 7, 
Plate III., and very frequently chancroids are developed by auto-inoculation around the preputial 
orifice, as seen in Fig. 8, Plate III. Then in chancroidal phimosis there is the early supervention 
of lymphangitis and of adenitis, both of which show a tendency to rapid destruction of the tissues. 
It should be borne in mind that in broken-down, starved, dissipated, and neglectful persons simple 
balano-posthitis may frequently become of such severity that the features of chancroidal phimosis 
seem present. 
Subpreputial hard chancres producing phimosis may be mistaken for simple balanitis. This 
complication, as a rule, is much less active in its nature than chancroidal phimosis. The affection 
increases slowly, usually with much less secretion of pus, it being at first very often a sero-pus. 
The oedema increases slowly, is more aphlegmasic, or less red, but rather firmer. The diagnosis 
is usually soon cleared up by the development of the indurated ganglia in the groin, and perhaps 
by the induration of the lymphatics of the penis. In very many cases it is possible, upon careful 
palpation, to determine the presence of a well-defined induration under the prepuce. It must be 
remembered that subpreputial vegetations also grow slowly, produce phimotic balano-posthitis, and 
feel like hard chancres under the prepuce. The secretion accompanying them is profuse and of a 
disgusting odor, the inflammatory reaction is rather late in appearing, and the lymphangitis and 
adenitis are less common and of a more inflammatory nature than in the phimotic balanitis of hard 
chancre. 
It is sometimes a difficult question to decide whether in a given case phimotic balanitis is 
caused by chancroids or vegetations, and sometimes only after incision of the prepuce. 
Prognosis.-In general, the prognosis of balanitis is good. When due to chancroids, besides 
the destruction of the prepuce and glans-and perhaps of the urethra-which is so liable to occur 
unless proper treatment is instituted, chancroidal ulceration in the lymphatics and chancroidal 
buboes may result. Hemorrhage also is very common and often very persistent, and phagedena 
may be produced. Balanitis from hard chancres may result in more or less destruction of the 
prepuce and glans, compression of the urethra, and phagedena. 
Balanitis and balano-posthitis caused by early syphilitic lesions are easily cured if early recog- 
nized and properly cared for. 
The balano-posthitis of elderly persons, with its epithelial hyperplasia, is the source of great 
annoyance from the discomfort produced and the hindrance to proper cleanliness, and is of posi- 
tive danger in the tendency which it engrafts to epitheliomatous degeneration of the prepuce, 
glans, and penis. 
Treatment.-Mild cases of balanitis are readily relieved by the retraction of the prepuce, 
cleanliness, and the interposition of lint soaked in plain water. But various lotions also may be 
used. When there is much excoriation a one-grain-to-the-ounce-of-water solution of nitrate of silver 
is often very efficacious, or two grains of alum to the ounce of water may be used. Solutions of 
lead are particularly useful when there is much inflammation ; thus: Pa pt I 
Plate III 
Fig. S 
Fig 4 
Fig.] 
Fig 2. 
Fig 5. 
Fig.7. 
Fig. 6 
Fig.8. 
Fig. 9 
1 • CHANCROID OF FREE BORDER OF PREPUCE . 2 . CHANCROID OF PREPUCE 
3- CHANCROID OF GUANS AND PREPUCE,ULCUS ELEVATUM . 4 . SUPERFICIAL SERPIGINOUS CHANCROID OF GLANS 
5. MULTIPLE CHANCROIDS,SOME COALESCED . 6 . CHANCROID OF FRAENUM WITH SLIGHT PARAPHIMOSIS. 
7 . INTRA PREPUTIAL CHANCROIDS COMPLICATED WITH PHIMOSIS AND GANGRENE . 8 . CHANCROIDS ON FREE MARGIN OF PHIMOTIC PREPUCE . 
9- GANGRENOUS PERFORATION OF PREPUCE FROM CHANCROIDS . 10. PARAPHIMOSIS COMPLICATED WITH CHANCROIDS . 
LEA & CO. PUBLISHERS .PHILADELPHIA BALANITIS. 
85 
R. Liq. plumbi subacetat., Sss-gj; 
Aquae, §iv. M. 
To this may be added either one drachm of laudanum or two drachms of wine of opium. 
In like manner the following prescriptions may be of much service : 
R. Acid, boracic., 
Acid, tannici, dd. jss; 
Aquae, §iv. M. 
R. Liq. sodae chlorinatae, gij; 
Aquae, 'vj. M. 
R. Zinci sulphat., gr. vj; 
Spts. lavandulae comp., 
Vin. opii, dd. ; 
Aquae, 5iv. M. 
The aromatic wine of the Pharmacopoeia is a pleasant and efficacious application, used by 
means of lint or absorbent cotton. 
Balanitis resulting from early syphilitic lesions is much benefited by the use of black wash or 
yellow wash. 
A solution of bichloride of mercury (i : 2000 of water) is often very beneficial. When excoria- 
tions are present, after superficial pencilling with a solution of nitrate of silver (10 grains to the 
ounce of water), the surface may be dusted with iodoform, and then a little film of perfumed 
absorbent cotton placed over it. Boracic acid, calomel, and subnitrate of bismuth may also be 
used, particularly toward the decline of the affection. 
Salves should not be used, and poultices should be strictly prohibited, since they do no good 
and cause oedema. 
Copious and frequent ablutions of the parts should be practised several times a day, and 
when there is any tendency to phimosis frequent injections of hot water slightly alkalinized by 
borax, or a mild solution of alum, or dilute lead-water, or a solution of bichloride of mercury 
(1 . 2000-5000) or of carbolic acid (1 : 200), should frequently be made as directed in the treat- 
ment of phimosis. 
lhe penis should be kept from hanging down by appropriate bandaging, and, as far as pos- 
sible, the recumbent position should be assumed. 
When phimosis, congenital or acquired, exists, circumcision should be advised. The treat- 
ment of balanitis complicated by chancroids, hard- chancres, and vegetations is given under the 
appropriate heads. THE CHANCROID OR SOFT CHANCRE. 
Such is the general acceptance of the term "chancroid" or "soft chancre" in this country, in 
contradistinction to the hard chancre or initial lesion of syphilis, that it is well to retain it. It is 
also known as the simple and the non-infecting chancre, the local contagious ulcer of the genitals, 
as chancrelle by Diday and his followers, and as chancre by the Germans. 
In order to clearly understand the nature of the chancroid, it is necessary to take a short retro- 
spective glance at the history of the venereal diseases. Prior to 1852, though the two forms of 
chancre, the soft and the hard, were recognized clinically, they were both regarded as due to the 
same poison or virus, and it was held that according to idiosyncrasy or the condition of the consti- 
tution of the bearer in some cases systemic infection occurred, while in others the lesion remained 
local and the system at large escaped. In 1852, however, Bassereau after prolonged study and 
observation arrived at the conclusion, as a result of numerous confrontations of persons who 
had cohabited and who presented similar sores, that there was a marked difference in the then 
so-called poisons from which chancroidal infection and syphilitic infection originated. Bassereau's 
arguments, being so clear and convincing, so simplified a previously obscure question that they were 
soon generally accepted, and later on they received Ricord's emphatic endorsement. From this 
time on the labors particularly of the French school were directed toward bolstering up the doc- 
trine of two poisons or viruses, or, as it came to be called, the doctrine of dualism. This, then, 
was simplicity itself, and seemingly all-convincing and infallible-namely, one poison for syphilis, 
another for chancroid ; therefore there were two specific venereal poisons, while gonorrhoea, the 
third great variety of venereal disease, was due to various morbid secretions. The stability of 
this doctrine of dualism depended upon the sharpness and precision of differentiating these two 
poisons and their results. With syphilis there was little trouble, since its virus and its sequelae 
stood out in such bold relief. But with chancroid it was different, and no end of theories were 
offered, all having as their object the making it as well defined a morbid poison or entity as syph- 
ilis. While matter enough to make volumes has been written upon chancroid in the past, to-day 
clear and intelligible ideas may be given in sentences where pages were formerly required. There 
is no more striking illustration in medicine than is offered in the history of chancroid of diffuseness 
and uncertainty of description when the disease was largely the subject of speculation and theory, 
and of terseness and lucidity when simple, plain facts regarding it, unbiassed and unobscured by 
theory, are given. To-day the history of chancroid may be amply given in a modest pamphlet, while 
years ago a portly volume was necessary. 
Within the past fifteen years more particularly, and dating back as far as twenty-five years, 
observations and experiments by various authorities have been made with a view of determining 
the nature of the chancroid. Slowly and surely have facts accumulated, so that to-day among pro- 
gressive syphilographers the view that the chancroidal ulcer is due to a distinct virus is generally 
given up. 
86 THE CHANCROID OR SOFT CHANCRE. 
87 
Next to Bassereau's era of light, that which was inaugurated in 1876, in which Dr. Bumstead 
and myself claimed (I state the fact with all modesty) that there was then sufficient proof that the 
chancroid is not due to a distinct poison or virus, and that it may be developed under certain cir- 
cumstances de novo, is in my judgment the most important in the history of syphilography. From 
that eventful day, in which, at the International Medical Congress, Dr. Bumstead's paper was read 
with my corroborative results, reached independently of him, and when no other person assented 
to the view, which by all present was regarded as false and almost sacrilegious, the more enlight- 
ened view of the nature of the chancroid has gradually gained ground. We felt that a false doc- 
trine like the following, which is presented by an American author, should, if possible, be demol- 
ished : " Chancroid is an affection perpetuated only by contagion ; sexual intercourse is not essen- 
tial. \\ henever upon the human body a chancroid is found, there has been deposited pus from 
another chancroid under conditions favorable to its absorption. No amount of sexual excess, no 
degree of uncleanliness, no irritation, traumatic or chemical, however prolonged, no simple or poi- 
sonous ulceration from other specific sources (syphilis, cancer, glanders, etc.),-nothing, in short, 
can produce chancroids except chancroid (chancroidal bubo included). So that, as Fournier puts 
it, if all patients in the world with chancroid would avoid contact with others until their malady 
got well, the disease would cease from off the face of the earth." The fallacy of these sweeping 
assertions will be clearly brought out after a presentation of certain general facts concerning chan- 
croid. 
The chancroid is a local contagious ulcer of the genitals, inflammatory in its nature and very 
destructive in its course. It never under any circumstances leads to syphilis nor any form of sys- 
temic infection. Its action is purely local to the parts upon which it develops and to the lymphatic 
vessels and ganglia in immediate anatomical association with those parts. Under certain circum- 
stances chancroid becomes serpiginous, creeping from its original focus and attacking and destroy- 
lng parts beyond, or, beginning in a chancroidal bubo, it runs a chronic, deeply destructive course 
over the pudenda, thighs, and abdominal walls, and in very severe cases ends in death. Like gon- 
orrhoea, chancroid is in the vast majority of cases an essentially venereal disease, having its origin 
in sexual contact and its lesions being sharply limited to the genitalia. The vehicle of contagion 
of the chancroid in clinical practice is the secretion of a chancroid, of chancroidal lymphangitis, of 
a chancroidal bubo, or of a serpiginous chancroidal ulcer. Besides these secretions, inflamma- 
tory pus and pus resulting from active irritation of syphilitic lesions are also capable of producing 
chancroidal ulcers de novo, the person from whom the contagion is derived being perhaps free from 
actual chancroids at the time. This statement will receive further explanation a little later on. 
Experiments have shown that the contagious property of chancroidal pus is contained in the 
corpuscles, since its filtered serum has been found to produce no reaction upon the tissues. Upon 
this fact the hypothesis has been based that chancroid remains a local disease, for the reason that 
its pus-cells are confined to the nearest lymphatic ganglia and do not enter the circulation. This 
may be taken as a fair specimen of the indiscriminate generalizations which have been indulged in 
regarding these ulcers. As far as is known to-day, chancroidal pus presents under the microscope 
the same appearance as ordinary pus. 
A marked peculiarity of the chancroid is its amenability to reproduction upon its bearer. This 
may be demonstrated by experimental inoculations by means of minute superficial incisions or 
abrasions, and is very commonly seen in auto-inoculations, particularly in women. Our knowledge 
of the inoculative power of the chancroid, and of the varying vulnerability of the skin thereto, 
largely depends upon the experience of those who years ago practised syphilization for the cure 
of syphilis, using therefor chancroidal pus and pus derived from irritated syphilitic lesions. It was 
proved that these forms of pus produced ulcers having all the characteristics of chancroids in a VENEREAL DISEASES. 
88 
long series, but that in time their power seemed to wane, since only aborted pustules were pro- 
duced. The natural inference from the facts as observed was that auto-inoculations with chan- 
croidal pus gradually decreased in activity with the increased repetition of the process. After a 
period of quiescence tissues which had failed to respond to the irritant action again became sus- 
ceptible to the influence of chancrous pus. The practical application of this fact is that a man or 
woman may have an indefinite number of chancroids during life. 
Various statements have been made as to the durability of chancroidal pus when transferred 
from the body. Thus, Ricord says that he kept it in sealed tubes for seventeen days, and then 
found it active, and Sperino claims that by means of a lancet upon which this secretion had dried 
seven months later he produced chancroids, lhe late Prof. Boeck of Christiania, whose expe- 
rience in chancroidal inoculations was greater than that of any man before or since his day, assured 
me that chancroidal pus lost its irritant qualities in a few days after drying ; and I personally saw 
my late colleague, Dr. Bumstead, fail at Charity Hospital to make successful inoculations with 
chancroidal pus which had been dried on glass slips for twenty-four hours. When greatly diluted 
in water this form of pus loses its power, which is probably destroyed in any menstruum in which 
its corpuscles become disintegrated. 
According to general testimony, chancroidal ulcers may be transmitted by inoculation to the 
lower animals. This fact, first evolved during the period of obscurity of the chancroid, is pertinent 
in emphasizing a point of difference between it and syphilis, which is not communicable to animals, 
but it is no longer essential or of any practical value. 
Modes of Contagion.-Chancroidal contagion takes place most commonly by actual contact, 
the pus being transferred from one person to another in the act of coitus or in some other inti- 
mate mode of direct transfer. This method is called "direct contagion." What is known as 
"mediate contagion," in which the poison is transferred by means of the fingers, by towels, uten- 
sils, and instruments, may also occur, but much less frequently. 
It is probable that chancroidal inoculation in many instances takes place by means of more or 
less well-marked erosions, abrasions, tears, and rents in the mucous membrane, and even on the 
surface of herpetic vesicles. It is also fair to assume that the balano-preputial mucous membrane, 
with its delicate epithelium and its rich and very superficial capillary system, especially as it is 
subject to the heat, moisture, and maceration incident to the nature and structure of the parts, may 
be eroded by the irritating pus and become the seat of chancroids. Clinical observation certainly 
warrants the view that this secretion may lodge in the ducts of the sebaceous follicles, and there 
produce ulceration. The impunity with which surgeons whose fingers are intact handle chancroids 
and their sequelae proves that the epidermis of the skin is to an extent impervious to the action of 
its pus. It is important to remember, however, that we frequently see on uncleanly patients chan- 
croidal pus escape from the genitals and remain a more or less long time upon the integument, and 
there produce typical ulcers in the hair-follicles. In this case also it is fair to assume that contagion 
has taken place through the irritant action of the pus in the follicular openings. It is very prob- 
able that prolonged lodgment of chancroidal pus upon the fingers, particularly in the region of the 
sulcus of the nail, would be followed by ulceration. 
While in syphilis mediate contagion is quite common, in chancroid it is quite rare. Instances 
in which patients have transferred chancroids by means of their fingers or nails to other portions 
of the body through scratching or other modes of transference have occurred in my experience 
as well as in that of others. I have also seen chancroidal contagion result from the carelessness 
of a surgeon in the operation of circumcision, and a simple bubo converted into one of the chan- 
croidal variety by the surgeon operating upon it without having cleaned his bistoury with which he 
had just incised a chancroidal bubo. 
Chancroidal pus smeared upon a water-closet seat might possibly be transferred to the THE CHANCROID OR SOFT CHANCRE. 
89 
genitalia or peri-genital region of another, though I have never seen or heard of such a coin- 
cidence. 
Many years ago I had under my care a man who inoculated an incised wound of the brow 
with chancroidal pus from his penis by means of his fingers, which was converted into a typical 
very destructive chancroidal ulcer.1 
Occasionally we see men suffering from chancroid who have cohabited with women upon whose 
genitals no ulceration can be discovered ; and the explanation of the case formerly very generally 
accepted was that in the vagina chancroidal pus had been deposited by one man and taken up 
in coitus by a second one, who became contaminated, while the woman thus freed from the pus 
escaped. The case related by Ricord in which during a husband's short absence his friend, suffer- 
ing from chancroids, had connection with his wife, who shortly after cohabited with her husband, 
who contracted chancroids, while she escaped, is so full in detail as to be convincing. As a corol- 
lary of this coincidence the case of Puche is interesting. A man on his wedding-day had coitus 
with a woman suffering from chancroid, and later on with his wife. Having neglected washing his 
long foreskin after the impure coitus, the chancroidal pus was transferred to his wife's genitals, 
and she contracted chancroids, while he escaped. Further, the possibility that the vagina may 
thus be the means of mediate contagion, the woman escaping, has been very clearly proved by the 
experiments of Cullerier and Tarnowsky. The practical inference from the fact is that the epithe- 
lial lining of the vagina, being quite thick, is resistant to the action of chancroidal pus, and that if 
removed within a few hours, either by the friction of coitus or by irrigation, contagion will not 
take place. 
Frequency.-The collated experience of those who see large numbers of cases of venereal 
diseases goes to prove that the frequency of occurrence of chancroid is largely dependent upon 
the class of cases observed. Years ago I examined at short intervals large numbers of puellcz 
publics in our down-town wards, and among them found many cases of chancroid, while in a more 
select grade of the profession up town, where 1 also had opportunities of examination, I found a 
large proportion of hard chancre and few chancroids. In like manner, at Charity Hospital I see 
more chancroids than hard chancres, while in private practice the reverse obtains. I his expe- 
rience is in direct accord with that of Fournier, who says "that the simple chancre which is com- 
mon in the lower classes becomes rarer and rarer relatively to the syphilitic chancre in proportion 
as we rise in the social scale." Fournier explains this condition by assuming that men of the 
lower classes mostly cohabit with old prostitutes long ago syphilitic, and then only subject to chan- 
croid, while among the upper classes younger women, who are just acquiring or have just acquired 
their experience in syphilis, are the ones in demand. 
\\ hen we come to consider farther on the origin of the chancroid, we shall find that it is 
derived, not only from actual lesions, but also from inflammatory pus in syphilitic and non-syphilitic 
subjects ; and it will be shown that the matter of cleanliness plays a most important part in its 
propagation. 
Mauriac has shown that in Paris during the reign of the Commune the ratio of chancroids was 
much increased, and that in the years succeeding the Franco-Prussian War it was much diminished. 
In earlier days, when the ambition of syphilographers, particularly those of the French school, was to establish sharply-drawn 
lines between chancroid and syphilis, it was claimed that while the initial syphilitic lesion was rather common about the head and face, 
the chancroidal ulcer was not found there, and that the tissues of these parts possessed an immunity against its influence. Though at 
hist a number of doubtful and unsatisfactory cases were brought forward in opposition to this view, later on experimental inoculations 
made by Puche Rollet, Bassereau, Huebbenet, and Melchior Robert, and a number of indisputable cases of chancroidal inoculation, 
clearly proved that the supposed immunity was a myth, and the question of the cephalic chancroid died out. As a clinical curiosity 
the lesion is interesting. The controversy concerning it brought out very clearly the fact that the vast majority of cases of venereal 
ulcer upon the head and face are of syphilitic origin. 
My experience fully convinced me of the very destructive action of chancroidal pus about the face. 90 
VENEREAL DISEASES. 
The logical explanation of this is that during the unbridled license of the Commune vice and 
uncleanliness went hand in hand, but later on, when law and order prevailed, a more moral and 
sanitary status existed. Thus, during the past twenty years I have seen in dispensary and in 
hospital practice what we may term little epidemics of chancroid follow the influx of foreign immi- 
grants, particularly Italians and Hungarians. 
Compared with gonorrhoea, chancroid is less common, though of more frequent occurrence 
than syphilis. 
Clinical History.-Sources of Chancroidal Contagion.-In the light of our present knowledge 
it may be positively affirmed that chancroid, like gonorrhoea, is not caused by a distinct virus, as 
was formerly claimed. As from its intensity and great contagiousness gonorrhoea was and is con- 
sidered by some a virulent disease, so is the chancroid regarded by some authors as due to a dis- 
tinct and specific virus, as has already been stated, simply because its action is very destructive 
and the power of inoculation and auto-inoculation resides in its pus. In no other features does it 
resemble a virulent or infectious disease, and it differs most widely from them in the fact that their 
virulence and infective qualities increase and multiply as the disease progresses, while the activity 
of chancroidal ulceration, which is always local, is greatest in its early stages, and shows a tendency 
to gradually grow less until its inoculative power is lost. 
The basis of our knowledge of the nature of the chancroidal ulcer is experimental inoculations 
and clinical observations. Experimental inoculations with a view of determining whether there is 
a true chancroidal virus have been made during the past thirty years, but it is really during the past 
fifteen years that our knowledge has been broadened and sharply formulated. 
Early experimenters found that when actively irritated primary and secondary syphilitic lesions 
gave forth a pus which was inoculable on its bearers in an indefinite series in the form of ulcers 
which in no way whatever differed from chancroids. Later on, it was demonstrated that in syphil- 
itic women inoculated with their own vaginal secretions ulcers identical with chancroids and capa- 
ble of reinoculation through a number of generations were formed. By these experiments it was 
proved that active irritation of primary and secondary syphilitic lesions altered their appearance 
and their secretion, and that, as a result of the latter, ulcers resembling chancroids were produced. 
The fact that the skin and mucous membrane in early syphilis are peculiarly susceptible to irrita- 
tion and inflammation was considered in this connection as perhaps an underlying cause of the 
development of the seemingly true chancroids. Thus far, science was only warranted in assuming 
that chancroids were derivatives of irritated early syphilitic lesions developed in syphilitic subjects. 
To prove that this occurred in non-syphilitics without the transmission of syphilitic contagion to 
them was then the crucial test. 1 his missing link in the chain of evidence was luckily supplied in 
the experiments of Bidenkap and Gjor of Christiania. Bidenkap's case was that of a non-syphil- 
itic woman suffering from gonorrhoea, who inoculated herself with the pus derived through several 
generations from an initial syphilitic lesion, with the result of producing a sore identical with a chan- 
croid which itself was accidentally auto-inoculated with success. A year and a half later the woman 
contracted syphilis. Gjor's cases are equally clear and satisfactory. They are three in number, in 
which non-syphilitic women inoculated themselves with pus derived from irritated mucous patches, 
with the result of producing upon themselves chancroids. All of these women were kept under 
observation long enough to show that they had not contracted syphilis. 
The conclusions warranted by these observations and experiments were- 
1. That irritation of syphilitic lesions, particularly the early ones, gave rise to a destructive 
form of pus which by auto-inoculation produced ulcers identical in all characteristics with chan- 
croids. 
2. That this pus inoculated upon subjects virgin to syphilis produced ulcers unmistakably chan- 
croidal and inoculable in a series like chancroids. THE CHANCROID OR SOFT CHANCRE. 
9i 
3- That this form of pus, though very irritating and destructive, did not contain the germs of 
syphilis. 
Clear and convincing as this evidence was, it could be urged against it that it was experi- 
mental and not clinical-an objection certainly more sentimental than real. It so happened that in 
March, 1870, an undoubted and incontrovertible case of chancroidal contagion from irritated lesions 
resembling chancroids in a syphilitic subject came under my observation. This important case 
is as follows : A man syphilitic in 1869 came in March, 1870, with a papular syphilide of body and 
acute gonorrhoea. A few days later he came with a group of unruptured herpetic vesicles on the 
under surface of the prepuce, which he feared were chancroids, although he had not had coitus in 
three weeks. During the following week his gonorrhoea remained active, and at the end of that 
time I found that the herpetic vesicles presented the appearance of firm, oval, typical chancroids, 
lhe gonorrhoeal pus had flowed over the vesicles owing to his carelessness, and had thus trans- 
formed them. A few days later, his gonorrhoea being on the decline, while intoxicated he had con- 
nection with his wife, who about ten days later came to me with five or six typical chancroids on 
the fourchette and inner aspect of the labia minora. The wife also was negligent, and her chan- 
croids became large and deep, and she had a typical chancroidal bubo. Two years later she 
contracted syphilis from a lover. The husband also suffered from an unmistakable chancroidal 
bubo. 
In this case gonorrhoeal pus in a syphilitic subject transforms herpetic vesicles into true chan- 
croids, which are communicated to a non-syphilitic woman as chancroids without syphilitic infection, 
thus confirming clinically the results of experimental inoculations. I have several times during the 
past fifteen years traced, chancroids in men Xo purulent and muco-purulent genital discharges from 
women in the secondary stage of syphilis. It can be safely asserted that any observer may obtain 
similar results if he will take the pains to follow up to their origin a series of cases of chancroids 
in the male. 
Thus far, we have seen that beyond question chancroids may originate in the products of 
active inflammation in syphilitic subjects, and we are warranted in stating the postulate that these 
ulcers are rather remotely derivatives of syphilis. But experimental inoculations have been pushed 
farther by such authorities as Pick, Reder, Kraus, Vidal, Wigglesworth, Finger, and others, who 
ha\ e proved that ulcers in all respects like chancroids may result from inoculations with the secre- 
tion of tartar-emetic pustules, the pus of impetigo, ecthyma, lupus, zoster, pemphigus, scabies, 
acne, eczema, and of chronic ulcers of the lecj. 
An essential to this full production of chancroidal ulceration is the intensity of the inflamma- 
tion, which in many instances was induced by artificial irritation, particularly by drugs. The ulcers, 
besides having all of the characteristics of chancroids, were, like them, inoculable and auto-inocu- 
lable in a series of generations. 
ith this further evidence before us the truth of the assertion already made in these pages, 
that chancroid does not depend upon a specific virus ofi its own, and that it may be generated de novo, 
is clearly brought forth. 
We, then, are in a position to go farther and to cover the whole ground in asserting that 
while the chancroid may be-and very commonly is-derived from a previous chancroid, a chancroidal 
bubo, or a chancroidal lymphangitis, it also may originate in the pus derived from irritated lesions of 
syphilis, and from irritated simple lesions in syphilitic subjects, and in simple pus, particularly when 
originating in active or intensely irritated lesions? 
I recently had the opportunity of observing a case in which chancroids originated in the pus of a simple but much irritated 
ulceration, which is very instructive: A healthy young man free from syphilis and gonorrhoea came to me with a rosary-like series of 
seven chancroids in the balano-preputial sulcus. He was surprised at the information that he had chancroids, and asserted that he 
was positive that the woman with whom he had cohabited had no such trouble; to which I readily assented, and I explained to him VENEREAL DISEASES. 
92 
With this disposal of the question of the virulence of chancroid, the assertion already quoted, 
that "if all the patients in the world with chancroid would avoid contact with others until their 
malady got well, the disease would cease from off the face of the earth," is at least amusing. 
Experimental studies in pus-inoculations show that the intensity of the destructive action of 
the secretion depends largely on the degree of irritation to which the producing lesion is subjected, 
and that its unknown quality, which has wrongly been called "virulence," is really due to that. A 
common-sense view of the course of these destructive ulcers of the genitals does away with the 
necessity of assuming a subtle virulent action as being possessed by them. Of all parts of the 
human frame, the genital organs are those most prone to irritation. In them the circulation in 
capillaries and sinuses is very abundant. They are the seat of frequently-recurring congestions 
with or without coitus, and are largely under the control of the mental emotions. Their conforma- 
tion is such that unless kept continually and scrupulously clean inflammations are sure to occur. 
What wonder, then, that ulceration is severe upon these exuberant regions ! Then we have as 
accessories such constitutional conditions as malnutrition and debility in varied forms, in which it is 
well known that inflammation is severe, and that potent factor in all inflammatory processes 
namely, alcohol-to which in clinical practice I am assured, by long observation, much of the 
chronicity and destructiveness of the chancroid is due. Alcohol in many cases is to clinical chan- 
croids what tartar emetic and savin powder were to experimental chancroids. It is also well to 
remember that in plethoric subjects the intensity of chancroids is usually well marked. 
Though our knowledge of the origin and nature of the chancroid is thus satisfactory and clear, 
I am convinced that much more light will be thrown upon them when we come to know more about 
the origin, habitats, and life-history of pyogenic microbes. 
Appearances of the Chancroid.-Chancroidal ulcers have no period of incubation, since the 
destructive action of the pus begins at once, and the resulting lesion is apparent as soon as the mor- 
bid action penetrates beneath the epithelium. Thus, when this layer is thick, the appearance of 
the chancroid may be delayed, and very often some time elapses during which the pus is entering a 
follicle. Constitutional conditions in many cases influence the rapidity of development. Chan- 
croids on mucous surfaces develop much more quickly than upon the integument. Abrasions, 
excoriations, and fissures in the mucous membrane afford favorable doors of entry, and upon them 
chancroids develop with great promptness. In general, inflammatory action is very apparent within 
twenty-four hours after the implantation of the pus on mucous membranes, and within forty-eight 
hours in general the pustular nature of the lesion can be readily made out. In other cases the 
progress may be slower, and three or four days may elapse before the chancroid pustule is fully 
formed. These statements are based on the results of experimental inoculation, and are in the 
main correct. The statements of patients sometimes place the appearance of chancroids after 
connection at much longer intervals, but they are so liable to errors of observation, and often are 
so careless of their persons, that very little credit can be placed on them. The surgeon very 
how chancroids might originate. Examination of the young woman, who was free from syphilis, on the following day showed that 
her genitals were free from disease, but that in the os uteri there was a deep fissure covered with a highly-ulcerated surface and sur- 
rounded by much hyperaemia. From this lesion a profuse brownish gelatinous pus escaped. The woman gave the following story : 
Seven years before she had a child, and has since thought that she was not quite right in the womb, having exacerbations and remis- 
sions of leucorrhoea. Four weeks before she was obliged to go to bed in consequence of what was called peritonitis. Three weeks 
later, one day, after getting out of the sick bed, her lover, who had been such, and her only one, for years, and she resumed their 
amorous embraces in a very vigorous manner, supplemented with unlimited wine; the result of which was the chancroids in himself 
and much pelvic pain in his consort. The leucorrhceal discharge, previously innocuous to this man, when irritated by excesses, 
perhaps also owing in a measure to her condition of debility, became active and destructive. I carefully elminated every source 
of error. 
Cases like this show how much unhappiness and suffering may be caused in social relations by the unjust accusations emanating 
from physicians who are believers in the virulent origin of the chancroid. THE CHANCROID OR SOFT CHANCRE. 
93 
often can form a more correct idea from the size and number of the lesions than he can from the 
patient's story. 
By the aid of experimental inoculations and of clinical observation we are able to give a very 
clear description of the early appearances and course of the chancroid. In its course there are 
three stages, the active, the stationary, and the reparative. 
Upon mucous membranes the very first sign of a chancroid is a minute yellow spot surrounded 
by a halo of intense redness, which shades off into the surrounding pink color. If not ruptured, 
the yellow central spot grows larger and higher, and very soon a typical conical-shaped pustule is 
formed. Upon the integument the same yellow spot and red halo are present, and the pustular 
condition may be present or may be replaced by an ulceration. 
In most cases on mucous membranes chancroids very early lose their epithelial dome, which 
constitutes the pustule, and the typical ulcer is then seen. 
I he outline of a chancroid is usually either round or oval, according to the conformation of 
the parts upon which it is seated ; but when developed upon a fissure or abrasion it may be linear 
or irregular. Irregularity of outline also results from the coalescence of a number of chancroids. 
On the prepuce and in the sulcus they are circular ; about the fraenum they frequently are oval; 
when developed partly on the glans and partly on the prepuce they are irregular, for the reason 
that the ulcerative process is more active on the former than on the latter. Chancroids at the 
orifice of the prepuce and at the anus have a tendency to follow the radiating fissures peculiar to 
these parts. A comprehensive idea of the outline of chancroids may be gained by a survey of 
Plates III. and IV. 
\\ hatever the shape of the chancroid, the edges are sharply cut and abrupt, as if punched 
out. The whole thickness of the epithelium is destroyed, and it can be seen that though cleanly 
cut, as is the resulting lesion, the edges of it are slightly undermined in some cases to such an 
extent that the tips of a probe can be carried circumferentially around the ulcer and under it. 
This feature of undermined edge is due to the fact that the soft subepithelial tissues are less resist- 
ant than the more horny epithelium. In addition to the undermined condition, the edges are fre- 
quently minutely uneven or jagged, as best seen by a magnifying-glass, showing that the destruc- 
tive action takes place by minute radiating processes. Around the edge of the chancroid is an 
areola of redness which varies in depth and width according to the stage of the inflammation. 
This red halo extends pari passu with the ulcer. The floor of the latter is peculiarly uneven and 
worm-eaten in appearance, and in its early stage covered with a light yellowish pellicle composed 
of disorganized tissues and pus. With the growth of the ulcer this film becomes thicker and 
forms a pseudo-membranous layer, which is shown with admirable fidelity in Fig. 6 of Plate III. 
I his membranous pellicle covering the chancroid is thrown into little uneven mammillations, which 
correspond to the minute rugosities which cover the surface of the ulcer. 
The secretion of chancroids is in the active stage quite abundant, and, while purulent, the pus 
differs from that of gonorrhoea. It is thinner in quality and usually of a brownish or rusty-brown 
tint, due to the admixture of small quantities of blood. This chancroidal pus under the microscope 
is found to consist of pus-globules, red corpuscles, and the detritus of tissues. 
1 he underlying bed, as it may be called, of chancroids should always be attentively studied. 
It usually consists of ordinary inflammatory oedema, and is felt between the thumb and finger as a 
mass firm in consistence midway between ordinary oedema and a furuncle. It is yielding to firm 
pressure, though not doughy, but has not the dense consistency of the true hard chancre. The 
oedematous infiltration of the chancroid is not very sharply limited, but becomes gradually lost in 
the surroundincr tissues. 
o 
In the typical hard chancre the induration, on the other hand, is condensed and sharply cir- 
cumscribed. This symptom, to a certain degree important in the diagnosis of the chancroid, is 94 
VENEREAL DISEASES. 
often much obscured by injudicious cauterization, particularly when the solid stick of nitrate of 
silver is vigorously used, and also when chromic acid, pure sulphuric acid, and indeed any very 
caustic application, is made. A similar misleading hardness is very often felt after active cauteriza- 
tion of herpetic vesicles, abrasions, fissures, and vegetations. 
The duration of the period of activity of chancroid is so variable that it is really indefinite. 
It is influenced largely by the intelligence and efficiency of the treatment, the care and attention 
of the patient, and by his general condition and modes of life. Alcoholic indulgence is a prolific 
cause of chronicity and activity of chancroidal ulceration, and plethora tends to increase it. A 
very active life, much walking, and physical exercise likewise tend to perpetuate the existence of 
these sores. 
In general, chancroids exist in an active condition from two to four weeks, but they may be 
arrested sooner by treatment or they may thus continue for indefinite periods. The amount of 
destruction of tissues varies in different cases, in different localities, and in varying conditions. On 
the integument the ulceration is slow, and there is not the marked tendency to extension that there 
is on mucous membranes. In some instances the ulceration extends quite superficially over con- 
siderable surface, as seen on the glans penis pictured in Fig. 4, Plate III. Then, again, the ulcera- 
tion grows in extent by the fusion of a number of chancroids, as depicted in Figs. 3 and 5 of Plate 
III., in which it will be seen that a large portion of the balano-preputial surface has been invaded. 
In Fig. 6 the activity of the ulceration has been such as to undermine the fraenum, and thus several 
chancroids have become united into one large one. Another condition in which chancroidal ulcera- 
tion is always exceedingly destructive is shown in Figs. 7 and 9 of Plate III., in which subpreputial 
chancroids in one (Fig. 7) has produced great deformity of the organ, with much subpreputial 
destruction, with evidence of beginning gangrene in the prepuce itself, while in Fig. 9 gangrene 
of the prepuce has actually occurred and the ulcerated glans is seen beneath. Then, in Fig 14, 
Plate VII.-placed there to show side by side characteristic chancroidal ulcers with typical hard chan- 
cres-an active chancroid is seen complicated by the development of other chancroids in the course 
of the lymphatics-called bubonulus, a feature first described by Nisbet. 
The so-called stationary period of chancroids exists in many cases, owing to the apathy and 
inattention of the patient; and these circumstances have proved to us that after a varying time 
the intensity of the ulceration in chancroids passes into a stage of quiescence, in which there is no 
marked tendency to destruction, and on the other hand none to repair. Chancroids, such as shown 
in Figs. 3, 5, and 6 of Plate III., and in Figs. 2, 5, and 7 of Plate IV., might, all irritating influences 
being at a minimum, thus remain for several weeks. This aphlegmasic condition may readily give 
place to exacerbation of the destructive action. 
The stage of repair of chancroids is indicated by a number of changes in all of the features 
of the ulcer. Perhaps the most noticeable one is a diminution of the inflammatory areola and a 
subsidence of the underlying oedematous infiltration. Then the grayish-yellow well-marked pseudo- 
membranous layer begins to disappear, and as it does healthy pink granulations spring up over 
more or less of the surface and the unhealthy pus begins to become laudable. The undermined 
edges lose their deep redness and gradually disappear, and the ulcer becomes saucer-shaped. 
Coincidently with this, healthy granulations make their way over the whole surface and push 
upward, gradually becoming even with the parts around. Then, a delicate filamentous ring 
of epithelium begins at the place of the undermined edge, and gradually increases in width, 
at the same time closing over the site of former ulceration, until, in the end, full cicatrization 
is accomplished. In cases where the sores have been quite large points of cicatrization spring up 
in the centre, enlarge, fuse together, and meet the circumferential healing ring. These minute 
surface-spots of healing are well described by my late colleague, Dr. Bumstead, as follows: 
" Macerated by the discharge, it (the spot) has a whitish look and resembles a fragment of lint Plate IV 
Part 1 
Fit. 2 
Fig .4 
Fig.l 
Fig. S 
Fig. 6 
Fig 5 
Fig.7 
Fig. 8 
LEA BROTHERS Sc CO. PUB LISHERS . PHILADELPHIA 
1 . CHANCROID OF1 VULVA AND ANUS . 2 . CHANCROID OF ANUS OF A WOMAN . 
3 . CHANCROID OF ANUS AND PERINAEUM OF A MAN . 4 . EXPERIMENTAL AUTO-INOCULATION WITH PUS OF FIGURE 3 . 
5 . FOLLECULEN CHANCROIDS OF VULVA AND ANUS . 6 . CHANCROIDS FROM AUTO-INOCULATION THROUGH COAPTATION OF LABIA MAJORA 
7 . CHANCROIDS OF VULVA IN ACTIVE STAGE . 8 . CHANCROIDS OF OS UTERI . THE CHANCROID OR SOFT CHANCRE. 
95 
which has not been removed at the last dressing; but at subsequent visits of the patient it is 
found to be still present, gradually increasing in size until it becomes continuous at some portion 
of its periphery with the margin of the sore, and it thus contributes toward the final closure of the 
wound." 
A remarkable feature of the chancroidal ulcer is its tendency, even in the reparative stage, to 
retrogress and assume all of the attributes of activity. In such cases, however, there is usually 
some well-defined cause for the exacerbation, such as carelessness, and particularly uncleanliness, 
sexual intercourse, or alcoholic excesses. A sore which has seemingly become of simple nature 
rapidly takes on all of the chancroidal features, even to great destructiveness. This possible 
accident should always be remembered by the surgeon in holding his patient well in hand, even 
when the latter regards himself as virtually well. The possibility of contagion in the advanced 
reparative stage of chancroid should always be impressed upon the patient. With thorough cica- 
trization the chancroid is annihilated ; without fresh contagion there is no relapse, such as we often 
see in true chancre. 
Scars left by chancroids vary according to the size, depth, and situation of the ulcers, and are 
trifling or severe in proportion to the extent of the destructive process. They may be superficial, 
thin, and smooth, or they may be thick and deep, uneven, and traversed by fibrous bands of various 
sizes. At the margin of the prepuce following a chancroid, as seen in most marked form in Fig. i, 
and less so in big. 8, Plate III., they are usually hard and fibrous and produce more or less of phi- 
mosis. When superficial, but extensive, as when following a chancroid on the glans, as in Fig. 4, 
Plate III., they are thin and smooth. Extensive chancroids of the balano-preputial furrow, as shown 
m Figs. 3 and 5 of Plate HI., are usually followed by much destruction, as shown in a semilunar 
depression in the corona, and an uneven fibrous cicatrix, often adherent to the corpora cavernosa. 
Chancroids of the fraenum of the extent shown in Fig. 6, Plate III., commonly result in a well- 
marked scar and more or less deformity. Chancroids producing phimosis and paraphimosis are 
followed by much destruction of tissue and by firm fibrous scars of varying shapes. 
Scat of the Chancroid.-In the male the chancroid is most commonly found in the sulcus 
e in tie glans; on the inner surface of the prepuce; on and near the fourchette, particularly 
on the fossae on each side of it; on the lips of the meatus and within the urethra ; upon the sheath 
of the penis , on the glans ; and, usually by auto-inoculation on the scrotum and thighs, pubes 
nd anus. They occur on the finger by contagion from genital sores, and upon the face by means 
the fingers, and within the anus from pederasty-seen in Fig. 3, Plate IV. In women they are 
und at the introitus vaginae ; on the fourchette and vestibule, and on the clitoris ; on the labia 
nora, within the vagina (rather rarely) ; on the os uteri; on the labia majora, and by auto-inocu- 
on on the integument of the latter bodies ; upon the perineum, inner surface of the thighs ; on 
t ie hypogastrium, and around the margin of, and within, the anus. 
Varying Features of Chancroidal Ulcers.-The most simple form of chancroid is very shallow ; 
tie undermining of the edges is very slight, and the worm-eaten unevenness of the base very deli- 
This condition may really be but the early stage of the ulcer, and appropriate treatment 
very soon brings about the reparative stage. 
A form called by Clerc the "exulcerous chancroid" is occasionally seen. The sore is shallow 
and saucer-shaped, and the punched-out, sharply-cut edges are wanting. The floor is rather smooth 
and covered with a grayish-yellow film, and from it much pus escapes. The two foregoing varieties 
are stages of development rather than different forms. 
Upon surfaces where mucous membranes and integument meet, and upon the mucous mem- 
brane lining the labia majora, and on the skin in the region of the genitals, rounded conical eleva- 
tions surmounted with a minute pustule are sometimes seen. The pustule increases in size, and 
forms an ulcer which presents a crater-like appearance, as sometimes seen in acne indurate as is 96 
EENEEEAL E/SEASES. > 
shown in Figs. 5 and 6 of Plate IV. This lesion is called the follicular or acneform chancroid, and 
results from the destructive action of the pus, beginning in the hair- or sebaceous follicles and 
accompanied by much inflammatory swelling. 
What is termed the ecthymatous chancroid is always met with upon the integument, particu- 
larly upon the penis and those parts of the genitals of both sexes which are not macerated with 
perspiration or which are not in coaptation. I his variety of chancroid resembles in many of its 
features chancroidal ulcers produced by inoculation. It begins as a small red spot, commonly 
around a hair-follicle, which increases rather slowly, with a small, more or less perfectly formed, 
pustule in its centre. As the redness extends the pustule flattens down into a blackish-green crust, 
and thus may attain an area of nearly half an inch before its nature is suspected by the patient. 
Removal of the crust reveals a typical chancroidal ulcer, with the exception that the sharply-punched 
out and undermined edges are thicker, as they are composed of epidermis ; the floor is deeper, 
corresponding to the thickness of the skin ; and the base more markedly uneven and worm-eaten. 
The ulcer is usually slow in its course, and secretes not a large amount of pus, which constantly 
dries into a crust. Upon the penis or on the outer surface of the labia majora this chancroid is 
sometimes accompanied with lymphangitis and adenitis. It is well shown after the removal of 
crusts in Fig. 14, Plate VII. 
In some cases of chancroids, particularly when they are seated upon the prepuce near the 
sulcus glandis and upon the labia minora, or on any part, in short, in which, owing to its conforma- 
tion, irritation is apt to be severe, the bed, as we may call the underlying tissues, is sometimes the 
seat of more than usual oedema and cell-infiltration. The result is, that the chancroid is elevated 
above the surrounding plane, and it is then called the ulcus elevatum. In like manner, there is a 
syphilitic elevated ulcer. The salience of the ulcus elevatum is by some authors incorrectly said to 
be due to exuberant granulations, whereas inspection will show the typical chancroidal surface, 
with usually less undermining of the edges of the ulcer. A quite good idea of the ulcus elevatum 
may be obtained from inspection of Fig. 3, Plate III., especially of those chancroids on the extreme 
left just over the fore finger. 
These ulcers, showing a tendency to extend rather superficially over more or less surface, are 
called serpiginous chancroids. In my judgment this formidable adjective is rather too loosely used, 
particularly by French writers. Por instance, the coalesced and moderately active chancroids 
depicted in Fig. 4 Plate III. were called by Cullerier " serpiginous," when there is really no evi- 
dence of very unusual destruction. The term should be applied to cases which show progressive 
extension, where the lesion creeps over much surface. Such cases perhaps deserve this designa- 
tion. (See Fig. 7, Plate IV.) In America we, for the most part, reserve the term "serpiginous 
chancroid" to a chronic, more or less deeply destructive ulcer which usually has its beginning in a 
chancroidal bubo. These ulcers, happily rare, have a deep, irregular, fungating surface covered 
with a rather thick, uneven, variegated, brownish-red, and grayish-green slough or membrane, and 
a sanious pus, and having thick bluish-red, undermined, and often everted edges, extend irregularly 
over the abdomen and thighs to the parts beyond, destroying more or less of the whole thickness 
of the skin, most rebellious to treatment, lasting months, years, and a lifetime, and often ending in 
death from exhaustion or from perforation of the abdominal walls and peritonitis. 
What is termed phagedenic chancroid is an example of the most serious complication of the 
local contagious ulcer. Phagedena is a rather infrequent complication of both chancroid and hard 
chancre, and, in my experience, occurs more frequently in the course of an initial lesion than in 
that of the chancroid. For its production no special virus is required. It originates in local causes, 
such as neglect of treatment and improper treatment of chancroids, or where they are so situated 
that it is difficult to thoroughly irrigate them, as in chancroidal phimosis. Poverty, insufficient 
food, alcohol, and a crowded condition, as sometimes occurs in hospitals, in camps, and in emigrant- Plate V 
Part 1 
Fig. 8 
Fig .4 
Fig.l 
LEA BROTHERS & CO. PUB LISHE RS , PHILADELPHIA 
1 . CHANCROIDAL BUBO SERPIGINOUS . 2 CHANCROIDAL BUBO. 
3. CHANCROID WITH ULCERATION OF LYMPHATIC OF DORSUM OF PENIS AND SUPPURATING BUBO . 
4 . LARGE HARD CHANCRE OF PREPUCE COMPLICATED WITH ULCERATION AND SUPPURATING BUBO OF LEFT SIDE . THE CHANCROID OR SOFT CHANCRE. 
97 
ships, are predisposing causes to it. It is seen in two forms-the sloughing or gangrenous and 
the serpiginous. In sloughing chancroid the ulcer becomes swollen and surrounded by a deep 
bluish-red areola, and its floor becomes a gangrenous slough which secretes a foul brown sanies. 
In this condition it increases in area and in depth. 
Serpiginous phagedena is similar in its appearance, but has a tendency to extend more super- 
ficially. Ihese cases are always attended by severe local pains and a general and severe consti- 
tutional condition. The patient looks anxious and haggard, has no appetite, emaciates rapidly, and 
in unfavorable instances dies. The course of the affection is sometimes rather slow, and in others 
very rapid. In some cases a diphtheritic membrane forms over the sore, while the destructive 
action goes on beneath. 
The course of chancroidal phagedena presents many features which point to a bacterial infec- 
tion complicating the chancroidal ulceration. 
Chancroidal Lymphangitis and Bubo.-Inflammation of the lymphatics is a not very 
frequent complication of the chancroid. It is sometimes seen as heat, redness, pain, and a cord- 
like condition of these vessels on either side of the penis, corresponding to the chancre. This con- 
dition may end in inflammation of the inguinal ganglia and its own subsidence, or it may go on to 
the formation of chancroids along the sides of the penis, and even at its root, low down on the 
pubes, as seen in Fig. 14, Plate VII., and in Fig. 3, Plate V. In some cases, besides chancroidal 
ulcers along the lymphatics, there is a similar form of bubo. 
Chancroidal Bubo.-During the active stage especially, but also in the stationary, and even 
in the reparative, stage of chancroids an actively destructive bubo may form, usually upon the 
same side as the chancroid, but sometimes, where the lymphatics have crossed, as exceptionally 
occurs, from one side to another, on the opposite side. This bubo commonly affects several gan- 
glia, and is then termed " polyganglionic," and when one only is involved it is called " monogan- 
glionic. ' The patient first experiences pain usually in the centre of the groin, where a small 
tumor is formed. The early symptoms are similar in the simple inflammatory and in the chan- 
croidal bubo. The painful lump increases in size, and over it the integument becomes red. Loco- 
motion is consequently difficult or impossible. Two morbid processes then go on. In the first 
place, within the ganglia the destruction of tissue peculiar to chancroids takes place, while around 
them ordinary phlegmonous inflammation occurs in the connective tissue. In some instances the 
bubo-abscess does not open until after the periganglionic abscess has perforated the integument. 
In others the enclosed chancroidal abscess bursts through the capsule of the ganglia and converts 
the whole into a characteristic bubo called virulent, in the meaning of the term given in my 
description of these ulcers. In strict fact, the syphilitic bubo is the only virulent one. W ith the 
irruption of the chancroidal pus the pain is much more severe, and the progress toward perfora- 
tion of the overlying integument much more rapid. While in most instances chancroidally affected 
ganglia fuse together and form one large abscess-cavity, in exceptional cases they remain separate 
and show themselves upon the skin as separate lesions, between which very often there are fistu- 
lous passages. A typical chancroidal bubo of a not severely destructive type is shown in Fig. 2, 
I late V., on the right-hand side, in which the grayish-green surface, thickened, red, and everted 
edges, surrounded by a diffuse areola of a reddish-purple color, are well shown. On the left side 
the four black spots show where the chancroidal pus has perforated the different ganglia, while the 
surrounding ulcerated surface is still the seat of simple inflammation, not as yet having been 
affected by the ganglionic pus. 
In Fig. 1 of Plate V. is very graphically shown a typical chancroidal bubo in its actively pro- 
gressive stage. The whole integument corresponding to the bubo-abscess is destroyed ; the sur- 
face is fungating, of a greenish-red and blackish-brown color in parts, with ulcerated, undermined 
and everted edges, surrounded by a very red areola. Such a bubo under unfavorable circum- 98 
VENEREAL DISEASES. 
stances inevitably goes on to extensive destruction, superficially involving the whole thickness of 
the skin, and going deeper into the softer tissues, often laying bare the fascia and the muscles, 
and sometimes eroding the vessels. I have seen perforation of the peritoneum and death in these 
cases. This very formidable course of the chancroidal bubo is happily not common, and is seen 
much less frequently now than formerly, when our knowledge of its treatment was not as com- 
plete. 
The chancroidal bubo in some instances heals in so far as that the bubo-cavity is nearly filled 
up, leaving an ulcer as deep as, or perhaps rather deeper than, the whole thickness of the skin ; 
and here the reparative process may end. Peripheral extension of the ulcer may be indefinite in 
extent and time, and as a result we have what I have already spoken of as a serpiginous chancroid, 
which very rarely originates in an ulcer on the genitals. 
As a general rule, suppurating buboes only follow chancroids ; and this feature has consider- 
able diagnostic significance. Exceptionally, however, suppurating adenitis is a complication of the 
hard chancre, as is well shown in Fig. 4, Plate V., in which the red line of the lymphatic can be 
seen crossing the dorsum of the penis to the left groin, where the reddened skin shows that 
abscess-formation has taken place in several ganglia. This complication of the hard chancre is 
usually seen when from any reason, such as irritation, inaccessibility, and uncleanliness, the ulcer 
becomes very destructive or phagedenic. It is probably an accessory phenomenon grafted upon 
the initial lesion, owing to the lodgment of some pyogenic microbe. 
Phimosis is one of the most common complications of chancroid, and is always to be feared 
in subpreputial lesions, even if the prepuce is normally roomy. Where any abnormality of this 
cutaneous covering exists, this complication is especially to be feared. 
Chancroids seated in and behind the sulcus glandis are particularly liable to be attended with 
much oedema, which results in phimosis. Lesions situated near the framum are also especially 
liable to be attended by much swelling and consecutive phimosis. In like manner, chancroids 
upon the inner layer of the prepuce are sometimes attended by swelling and this complication. 
Wherever the existing lesions may be situated, chancroidal phimosis is always a formidable com- 
plication, and one much to be avoided. (See Figs. 7 and 9, Plate III.) 
Chancroids upon the free margin of the prepuce may also cause phimosis, as shown in Fig. 8, 
Plate III. This, although a much less dangerous form than the phimosis resulting from intrapre- 
putial chancroids, may become, unless promptly and efficiently treated, a very severe one from 
extension of the ulceration inward. Chancroids upon the cutaneous layer of the prepuce may 
also give rise to phimosis. The complications of chancroidal phimosis are lymphangitis, ulcerative 
and gangrenous perforation of the prepuce, destruction of the glans and urethra, and burrowing 
upward between the integument and the corpora cavernosa, with subsequent deformity. Hemor- 
rhage, mild and even alarming in character, is not an infrequent complication of chancroidal 
phimosis. 
Paraphimosis complicated by chancroids is commonly a sequela of chancroidal phimosis, and 
is usually produced in the vigorous and sometimes frenzied efforts of the patient to retract the pre- 
puce in order to get at his ulcers. These lesions may be seated upon any of the parts just men- 
tioned, but are commonly confined to the mucous membrane, unless the cutaneous portion has 
been contaminated by auto-inoculation. Fig. 10 of Plate III. shows a very typical instance of chan- 
croidal paraphimosis. The original ulcers in and behind the sulcus glandis have contaminated the 
more resistant preputial membrane on the dorsum, while on the side a chancroid near the frse- 
num has produced a corresponding lateral chancroid on the glans. The deep sulcus between the 
mucous membrane of the prepuce and the skin shows the spot where, deep down, the free margin 
of the prepuce is situated and forms the constricting ring. On the left side, behind this sulcus on 
the skin, is a chancroid which has been produced by auto-inoculation from the lateral formerly Pa rt 1 
Plate VII. 
Fig.l 
Fig 2 
Fig. 8. 
Fig .4 
Fig 5. 
Fig.6- 
Fit" 
Fig .8. 
1& a 
Fig .11 
Fig.lO. 
Fi&.lE. 
Fig 14 
Fig 13 
I • INDURATED CHANCRES OF PREPUCE AND SKIN OF PENIS . 2. MULTIPLE INDURATED CHANCRES . 
3 • INDURATED CHANCRE OF PREPUCE AND CLANS . 4. INDURATED CHANCRE WITH MOLECULAR GANGRENE AND CEDEMA . 
5 • INDURATED CHANCRE OF PREPUCE . 6. INDURATED CHANCRE OF THE MEATUS EXTENDING INTO THE URETHRA . 
7 INDURATED CHANCRE WITH MOLECULAR GANGRENE AND OEDEMA . 8. INDURATED CHANCRE OF MEATUS . 
9 INDURATED CHANCRE OF PREPUCE . 10.INDURATED CHANCRE OF MEATUS . 
II ■ INDURATED CHANCRE WITH PERSISTENT INDURATION . 12.INDURATED CHANCRE OF PREPUCE WITH ROSEOLOUS SPOTS OF THE NEIGHBORING PARTS . 
13 • INDURATED CHANCRE WITH MOLECULAR GANGRENE AND CEDEMA . 14. A SERIES OF CHANCROIDS IN THE COURSE GF THE LYMPHATICS . 
LEA BROTHERS & CO.PUBLISHERS .PHILADELPHIA THE CHANCROID OR SOFT CHANCRE. 
99 
intrapreputial chancroids. The queer shape is strikingly characteristic, though in many cases it is 
on the corkscrew order. There is great tendency in these cases to hard oedema of the end of the 
penis and to lymphangitis. 
Diagnosis.-In various stages the chancroid may be mistaken for herpes progenitalis, exulce- 
rated balanitis, ulcerated fissures and abrasions, hard chancres, mucous patches, ulcerating syph- 
ilides, and epithelioma. 
When a number of herpetic vesicles are grouped on the genitals with their polycyclic outline, 
their shallow and not much ulcerated surface, with the history of antecedent pains, their diagnosis 
is easy. In cases in which there is much inflammation a doubt may exist, but while ulcerous her- 
pes may extend deeper into the tissues, it does not, as a rule, like chancroid, extend peripherally 
by ulceration. Herpetic vesicles coalesce because they are so closely grouped ; chancroids coalesce 
by peripheral extension and fusion into each other. A single herpetic vesicle may be mistaken for 
a chancroid, but observation of its course for a day or two will settle the question of its nature, 
lhe crucial test of auto-inoculation of the secretions will in the case of chancroid be followed 
by a similar lesion, whereas failure would follow in the case of herpes progenitalis. It must be 
remembered, however, that in uncleanly persons, in those whose vesicles have been injudiciously 
cauterized, in persons of poor fibre, in plethoric subjects, and those given to drink, herpes pro- 
genitalis often takes on features identical with those of chancroids. 
Exulcerated balanitis is commonly very readily recognized. Its lesions begin in patches much 
larger than chancroidal ulcers, usually with a history of inattention to cleanliness or of phimosis, 
and their edges are not undermined, nor are their surfaces ulcerated or worm-eaten, but rather 
smooth and velvety. 
Very frequently, patients, particularly men, are much exercised over traumatic fissures and 
abrasions. When much inflammation is present a reserved diagnosis may be made, but cooling 
applications will cure the simple lesion, whereas the chancroid will be only slightly improved. 
W ater dressings and time will make the diagnosis between a simple lesion, a chancroid, or a hard 
chancre, the last of which these seemingly simple lesions often prove to be. 
Mucous patches may in a measure resemble chancroids if very much irritated, but it is an 
exceeding rarity to see them present and of the appearance of the chancroid. Usually their mode 
of development, size, situation, their well-marked salience, their configuration, peculiar color, and 
their coexistence with a history of syphilis or with syphilitic lesions, point out their specific nature. 
It must be remembered that about the genitals of both sexes mucous patches and condylomata 
lata, an hypertrophied form of the former, are often much irritated and give issue to an irritant 
pus which is auto-inoculable. In this connection a study of Figs. 6, 7, and 11 of Plate VIII. is 
important. 
In old syphilitics, both male and female, particularly those who are cachectic or broken down 
by dissipation, ulcers having all of the characters of chancroids, but of greater depth, are not 
uncommonly seen. I hey have a soft base, are very often multiple, particularly in women, very 
.sluggish in their course, usually unaccompanied by ganglionic reaction, but attended by a profuse 
purulent secretion. In some instances I have seen their pus produce other similar ulcers by auto- 
inoculation, and I have seen several cases in which their secretion produced undoubted chancroids 
in coitus. I hese ulcers in women are commonly attended with much oedema and cell-infiltration, 
and may exist months and years. They in somewhat rare cases become phagedenic. In men, 
though occasionally very chronic, they are less formidable. 
It is scarcely conceivable that chancroid can be mistaken for epithelioma, yet my colleague, 
Dr. Bumstead, saw in consultation a case in which this accident occurred. When it is considered 
that cancer and epithelioma do not begin as ulcers, but as small nodules and warty growths, par- 
ticularly on parts the seat of antecedent chronic irritation, the diagnosis seems very easy. IOO 
VENEREAL E/SEASES. 
Prognosis.-In the majority of cases the prognosis of chancroids is good. When intel- 
ligent and efficient treatment is instituted early, the affection is soon cured. Carelessness of 
the patient, dissipated habits, and excessive physical exercise render a prognosis less positive 
and assuring. 
When phimosis or paraphimosis is present the outlook is more grave, since, unless the patient 
can be put under perfect control on his back, the progress of the case will be inevitably bad, and 
may result in more or less loss of tissue and deformity of the penis, may be complicated by severe 
hemorrhage, or result in phagedena or gangrene. Lymphangitis and buboes may be produced, 
which may lay a patient up for a long time, besides entailing upon him much suffering and misery. 
In such cases the immunity to systemic infection enjoyed by the patient is a source of much com- 
fort to him. Chancroids of the meatus and urethra under unfavorable circumstances result in 
stricture. 
In women the prognosis of chancroids is less favorable, even in mild cases, than in men. The 
difficulties of properly treating them, unless they will remain in bed under the care of a nurse or 
in a hospital, are very great. The conformation of their parts, the presence of normal and abnor- 
mal secretions, the setbacks caused by menstruation, and difficulty of retaining properly the dress- 
ings,-all tend to prolong the course of the ulcers. Further, women as a rule are not docile 
patients. 
Young surgeons are prone to fear phagedena in the course of chancroids. This formidable 
complication is usually not to be feared early in the course of these lesions. I have in private 
practice never seen it begin in an uncomplicated young chancroid, though in armies, jails, and 
emigrant vessels, and among the squalid poor and drunkards, it often begins quite early. There 
is usually, in these cases, a history of injudicious treatment, particularly in the way of improper 
cauterization, an absence of treatment, and inattention on the part of the patient, or of inacces- 
sibility of the ulcers in consequence of complications, such as phimosis and paraphimosis. The 
presence of complications should always render the prognosis more guarded, particularly in per- 
sons of poor fibre and in those given to drink. 
Treatment.-The most sensible and efficient prophylactic measure is thorough cleansing of 
the genitals in every fold and recess. In the treatment of chancroid it is important to know what 
not to do-namely, not to give mercury and treat the case as one of syphilis, which is the custom of 
many practitioners ; not to employ the curette as an abortive or curative means ; not to cauterize inju- 
diciously ; not to use ointments and fatty preparations ; and never to resort to excision. Nothing but 
harm can follow any of these procedures. 
Cauterization of chancroids has for its object their destruction and their transformation into 
simple lesions. To-day this treatment is not largely followed, owing to the tendency, which 
has increased within the past fifteen years, to limit it to certain cases. The agents now mostly 
used are nitric acid and carbolic acid. Carbosulphuric paste, Vienna paste, Canquoin's paste, 
acid nitrate of mercury, chloride of zinc, and solutions of caustic potassa, are deservedly pass- 
ing into oblivion. 
It is of prime importance that patients suffering from chancroids should be as quiet as pos- 
sible-that they should rest at every opportunity, should not attempt severe muscular exercise 
nor walk, jump, dance, nor ride on horseback. Care should be taken that friction and pressure 
of the penis be avoided. Alcoholics should be uncompromisingly interdicted, and plain digestible 
food taken. 
The most rigid attention to cleanliness is necessary during the existence of chancroids. 
Destructive cauterization is only applicable for chancroids in the early stage and before the 
ulcers become complicated by much oedema. Before using it-in fact, before making any appli- 
cation to chancroids-the ulcers and the surrounding parts should be thoroughly cleansed with THE CHANCROID OR SOFT CHANCRE. 
101 
soap and water, and then well irrigated with a solution of bichloride of mercury (i : 2000). No 
chancroid should be thus treated which cannot be thoroughly exposed and afterward carefully 
dressed. 1 he technique of applying the acid-and in most cases liquid carbolic acid answers 
every purpose-is very simple. The surface of the ulcer must be carefully dried, and then the 
acid thoroughly applied by means of a bit of absorbent cotton wound around the end of a wooden 
toothpick. Care must be taken that the undermined edge is thoroughly touched, but that none 
of the liquid escapes on the surrounding parts. Some authors recommend that the application of 
carbolic acid shall be preliminary to that of nitric acid, the former playing the role of an analgesic. 
In the vast majority of cases within the lines already indicated this double cauterization is wholly 
unnecessary. Such is the evanescent character of the pain produced by carbolic acid, which is 
soon followed by a sensation of coolness and numbness, that patients make scarcely any complaint 
from its use. 
\\ hen the chancroidal film at the floor of the ulcer is rather thick, it may be necessary to 
use the stronger caustic, nitric acid, which may be done in the manner just indicated ; but it is 
always well to first apply an 8 per cent, solution of muriate of cocaine. By this means the patient 
suffers no pain, and the surgeon may be more thorough in his application. There is no necessity 
for the use of a long glass stopper or of a glass rod in applying nitric acid, since it can be done 
much more perfectly with the absorbent cotton on the end of a wooden toothpick. It is usually 
veil for a few hours after these caustic applications to apply water dressing or lead-water on lint. 
I he actual cautery and Paquelin's thermo-cautery are very efficient destructive agents, but 
their use is greatly restricted in consequence of the dread inspired in the mind of the patient 
by them. I hough the parts may be thoroughly benumbed by cocaine, few patients can avoid 
shrinking when they see the incandescent wire or cauterizer. 
A word of warning is necessary against the use of the stick nitrate of silver, which unfortu- 
nately is largely used by the laity and many physicians, not only for chancroids, but also for simple 
fissures, erosions, and herpetic vesicles. This agent irritates, while it does not destroy ; it intensi- 
fies the patient's sufferings, obscures the nature of the lesion, rendering diagnosis impossible, and 
produces so much inflammatory oedema in a lesion and around it that it is frequently mistaken 
for a hard chancre. Its use is to be emphatically condemned. 
In this connection it is well to emphasize the fact that mercurial ointment is especially baneful 
to chancroids, particularly in their active stage, during which any fatty application is productive 
only of mischief. 
Treatment Subsequent to Cauterization.-Such is the superficial action of carbolic acid when 
delicately applied that under proper conditions no inflammatory reaction is to be feared. With 
nitric acid, on the contrary, unless temporary water or lead-water dressings are used, there is a 
danger of producing subchancroidal and circumferential oedema and cell-infiltration. This is a 
complication much to be avoided, since it inevitably retards the cure. It is also very necessary in 
any case where several chancroids, or even one large one, have been cauterized that the patient 
should remain in the recumbent position from a half to a whole day. 
For chancroids upon the glans and prepuce and in the vulva the interposition of pledgets of 
lint or of absorbent cotton is necessary. Whatever application is used, these should be changed 
at short intervals, and directly destroyed, preferably by fire. Care must be exercised that the 
parts be not wounded in changing dressings. In addition, patients should be instructed to very 
carefully wash the parts, using a little bunch of absorbent cotton with soap and warm water, and 
then thoroughly immerse them in a sublimate solution (1 : 2000). For women too much insistence 
upon cleanliness is not possible, since they, even the most cleanly of them, are liable to be derelict. 
They should be instructed to thoroughly and copiously irrigate the vagina several times daily with 
a mild and hot alkaline solution, followed by a hot solution of sublimate (1 : 5000). 102 
VENEREAL DISEASES. 
The most efficient all-around application to chancroids is iodoform, since it is an undoubted 
promoter of healthy granulations and a local sedative. It should only be employed in the form 
of an impalpable powder, either pure or in combination with some bland and absorbent pow- 
der, such as subnitrate of bismuth, starch, magnesia, boracic acid, or powdered sugar of milk. 
Its odor is its great drawback, but even in private practice the expedients of the patient or sur- 
geon may be such that its use does not compromise the former. Various essential oils are mixed 
with it, but, after all, coumarin, the active principle of Tonka beans, is yet the best disguise. Pow- 
dered roasted coffee also is good. When used in powder form the ulcerated surface should be 
fully but not copiously dusted with it, and over it a thickness of perfumed lint or absorbent 
cotton may be placed. It may be employed suspended in sulphuric ether (3ss-5j to 5j) or in sim- 
ilar proportions in glycerin, 5ij, aq. 5vj. I. have been unfavorably impressed by its use when com- 
bined with vaseline and other fatty bases. 
It is important to remember that the action of iodoform is that of producing healthy granula- 
tions, and that when this has been effected its use should be suspended, since upon granulating 
surfaces it often acts by even impeding healing. Further, from these surfaces it is liable to be 
absorbed and produce toxic effects upon the skin and system at large. The conclusion, therefore, 
warranted is that iodoform should be suspended when chancroids take on a granulating surface? 
It has been claimed that iodol, a preparation containing a large percentage of iodine, is equally 
as efficient as iodoform, and has the advantage of being odorless. Unfortunately, our hopes have 
not been realized, since this agent is frequently found wanting in test cases. When there is a mod- 
erate amount of ulceration its action is fairly as good as that of many old remedies. 
In like manner, the subiodide of bismuth was vaunted as the substitute for iodoform. In my 
hands chancroids have crept on, leaving this substance as a deep red crust over the ulcer, while it 
was very annoying to the patient by reason of the staining of his under-linen. 
Within the past five years I have used with advantage salicylic acid, which is odorless and does 
not stain the linen. It, however, is not invariably reliable like iodoform. For ordinary chancroids 
and ulcerated herpes progenitalis, five grains of the acid suspended in an ounce of water is a good 
lotion. Combined with subnitrate of bismuth, 1 : 4 or 1 : 8, salicylic acid may be used even when 
chancroids are active. 
Recent experience with resorcin and pyrogallol has convinced me that they are not equally 
as reliable as iodoform. In many cases they act fairly well, but they are powerless in arresting 
serpiginous chancroids. 
In the cicatrizing or reparative stage of chancroids much progress is often made by judicious 
applications of a solution of nitrate of silver, 10 : 20 grains to the ounce, made every few days. 
The following lotions are also useful in many cases: 
R. Zinci sulph., gr . 
Spts. lavand. comp., ; 
Aquae, giv. M 
R. Argenti nitrat., gr j . 
Aquae, . giv M 
R. Liq. sodae chlorinatae, . 
Aquae, jyj 
R. Acid, boracic., 
Aquae, giv M 
R. Vini aromat., zj. 
A(lu3e' giij.' M. 
1 See my paper " On the Toxic Effects of Iodoform, Cutaneous and Systemic," New York Medical Journal, Oct. i 1887 Plate VIII 
Part I 
Fig 2'. 
Fig. 8. 
Fig .4 
Fig.5. 
Fig.6. 
Fig.7. 
Fig.8. 
m.io 
Fig. 9. 
Fig.n. 
I INDURATED CHANCRE OF LEFT LABIUM MINUS. 2 .MULTIPLE INDURATED CHANCRES OF VULVA WITH SUPERFICIAL GANGRENE AND HARD CEDEMA OF THE SUBJACENT TISSUES- 
3 INDURATED CHANCRE OF THE HYPOGASTRIC REGION . 4. INDURATED CHANCRE OF LABIUM MINUS . 
5- INDURATED CHANCRE OF LABIUM MAJOR AND CHANCROIDS . 6 . MUCOUS PATCHES OR CONDYLOMATA LATA OF PENIS AND SCROTUM 
7 • CONFLUENT MUCOUS PATCHES OF THE LABIA MAJORA AND ANUS . 8 . MUCOUS PATCHES OF THE FAUCES 
9- MUCOUS PATCHES OF TONGUE . 10. MUCOUS PATCH OR TOE . 
II ■ CONFLUENT MUCOUS PATCH OF CERVIX UTERI . .12. INDURATED CHAN CREPT)F BASE OF.NIPPLE . 
LEA BROTHERS & CO. PUBLISHERS .PHILADELPHIA THE CHANCROID OR SOFT CHANCRE. 
103 
The seat of chancroids materially modifies the method of treatment. For those lesions under 
the prepuce dry powders may be used, and great care must be taken to avoid oedema, for that 
brings in its train phimosis and paraphimosis, two very annoying and serious complications. On 
the integument watery applications may be used, or powders covered over with lint moistened in 
water. 
At the fraenum chancroids are prone to become the seat of oedema, to hemorrhage, to eat 
through the base of the bridle itself. Therefore they require especial care, particularly as oedema 
at this region is always followed by phimosis, even if the prepuce is ample. 
Chancroids at the margin of or within the urethra must also be carefully treated, and it is well 
to depend on iodoform alone, since cauterization is so liable to produce oedema and even result 
in stricture. 
Chancroids under the prepuce must be treated after the manner of phimosis, plus that of 
destructive ulceration. Subpreputial injections of hot (i : 2000) sublimate solution or of carbolic 
acid and water (1 ; 150) should be used very often by means of my flat syringe nozzle, taking care 
to get the irrigating liquid well behind the glans. Then iodoform suspended in glycerin and water 
should be introduced. It is better in all cases to anticipate gangrene, and if the progress in treat- 
ment is not perfectly satisfactory to make two lateral incisions into the prepuce as far back as the 
glans, which will place all of the affected parts at the disposal of the surgeon. Fears of inoculation 
of the incisions need give the surgeon no disquietude. 
In paraphimosis complicated with chancroids it is well to refrain from cutting if possible ; but 
if the constriction tends to produce strangulation, the encircling band at the bottom of the sulcus 
must be cut as directed in the section on Paraphimosis. 
Chancroids in women demand the utmost attention to cleanliness, very much prudence and 
care in cauterization, and thorough and frequent dressings. Their surfaces should be kept free 
from all discharges, and all coapting parts should be separated. In like manner, chancroids of the 
anus must not be injudiciously cauterized; they should be carefully dressed, the parts being 
separated. Attention should be paid that the stools be rendered liquid in consistence. 
Since the era of violent and indiscriminate cauterization has departed and iodoform has come 
into use, the ravages of serpiginous chancroids, phagedena, and gangrene are much less common 
and less severe than formerly. 
The treatment of serpiginous chancroids should be both local and general. Wherever there 
is debility, it is to be combated with nutritious food, tonics, and, if necessary, stimulants. Locally, 
after prolonged immersions of the parts in water as hot as can be borne and irrigations with 
1 : 2000 hot sublimate solutions, the surface may be touched with nitric acid or bromide and gly- 
cerin (1 : 8), care being taken that the ulcerating furrow at the edge be thoroughly covered. The 
whole may be temporarily covered with lint or absorbent cotton moistened with dilute Labarraque's 
solution, 1 : 10 of water. After this iodoform may be applied quite freely, and the whole surface 
covered with absorbent or iodoform gauze, over which is a layer of gutta-percha tissue. While 
this treatment is usually successful, cases do occur which tax the resources of the surgeon and 
call in play all manner of therapeutical expedients in the way of remedies and methods of appli- 
cation. 
Phagedenic chancroids, commonly seen in neglected cases, in ulceration in inaccessible places, 
and those injudiciously cauterized, and occurring mostly in unhealthy subjects, require the most 
careful attention to diet, hygiene, and surroundings. The vital powers must be sustained by tonics 
and stimulants, and opium must be given to relieve the pain and quiet the nervous anxiety of the 
sufferer. The next essential is to determine whether syphilis is a factor in the process, since in 
proportion as that diathesis is active in such cases, so is mercury beneficial ; whereas it is posi- 
tively injurious in simple phagedenic chancroids. I have never seen any benefit result from the use VENEREAL DISEASES. 
104 
of the potassio-tartrate of iron, which Ricord used to call the "born enemy of phagedena." In this 
complication of the chancroid the dermal curette may be employed with benefit to remove debris 
of tissue, sloughs, and pultaceous matter from the surface and edges. Then the whole surface 
may be thoroughly but carefully touched with nitric acid, with the bromine solution (i : 3) of gly- 
cerin, or with the actual cautery, care being exercised that the surrounding parts are not injured. 
Phagedena complicating chancroidal phimosis necessitates incisions sufficiently extensive to allow 
the parts to be reached. In addition to this direct medication, the most important measure is the 
immersion of the body in a hot sitz-bath (98° to 102° Fahr.) for from eight to twelve hours a day, 
care being taken that the comfort of the patient is attended to in every particular. I have seen in 
my hospital practice the most salutary results from this treatment in very unpromising cases in 
which the destructive action ceased and reparative action began in from two to thirteen days. 
Where the phagedena attacks the distal portion of the penis, irrigations of hot water, of hot 
sublimate solution (1 : 2000) by means of a spray syringe for several hours a day, have proved 
very efficacious in my hands. When healthy granulations appear the surfaces may be dressed 
with balsam of Peru and covered with absorbent gauze. 
It is important to remember that many cases of bubo accompanying chancroids are simply 
inflammatory in nature, and that only a certain proportion (one-third to one-half) are of the 
destructive nature warranting the term chancroidal. It is well, therefore, at first to resort to the 
usual methods of aborting buboes, such as cold and rest, counter-irritation by tincture of iodine, blis- 
ters, strong solutions of nitrate of silver, and compression in the hope of resolution. These failing, 
as soon as fluctuation is felt the abscess must be opened by means of incision in its whole length 
in the line of Poupart's ligament. The abscess-cavity should then be thoroughly irrigated with 
hot sublimate (1 : 2000), all of its recesses dusted sparingly with iodoform stuffed with absorbent 
gauze, over which is placed a pad of iodoform gauze, a peat-bag, or oakum pad held in place by 
a spica bandage. On removal twenty-four hours after, the curette may be employed, if necessary, 
to remove debris of broken-down ganglia and connective tissue, and the parts again irrigated and 
dressed as before. So soon as healthy granulations appear the iodoform (always to be sparingly 
used) should be discontinued, and balsam of Peru substituted. I he pressure exercised by the 
packing and by the bandage is most salutary. SYPHILIS. 
Syphilis is a chronic infectious disease originating in certain secretions containing organized 
matter which is reproduced indefinitely in the human body. In this manner it profoundly affects 
the whole organism, and is therefore classed as a constitutional disease. It enters the system by 
means of the blood-vessels and lymphatics, attacks primarily the connective tissue framework of 
the whole body, and in that way may in its course affect every tissue and organ. It is character- 
ized by the development of an inflammatory process of rather low grade, and by the formation of a 
low form of cell-growth called granulation-tissue. It is by some claimed to be due primarily to a 
micro-organism, though the existence of this so-called bacillus of syphilis is as yet not at all clearly 
demonstrated, and is doubted by many. Syphilis is, by those observers who claim a microbian ori- 
gin, considered to belong to the class of infectious granulomas. It never originates de novo, but 
mxariably results from the specific virus of syphilis, and is therefore by some called a virulent 
disease. 
Syphilis exists in two well-marked forms, both the results of the same virus : the one termed 
acquired, in which a morbid secretion of a syphilitic person is implanted upon some portion of 
the body of a healthy person, and there gains entrance ; and "hereditary," where it is transmitted 
om a mother or father, in whom the diathesis is active, to her or his progeny. These two forms 
of syphilis, the acquired and the hereditary, though they possess between them many points of 
esemblance in the nature and evolution of their lesions, in the peculiarities and localities of devel- 
pment, and in their contagiousness, differ markedly in their mode of onset and course ; hence they 
must be studied separately. 
Acquired syphilis always begins at the point of local infection, and nothing can be truer than 
the axiom, No chancre, no syphilis. 
Various clinical facts and the results of microscopical examination of the initial chancre go to 
prove that, certainly in its very early stages, syphilis, like cancer, is a local affection confined to the 
original infection-focus or to the lymphatics in immediate association. While it is difficult to say 
when further progress is made by the disease, it is safe to assert that the date of general infection 
about coincident with that of the evolution of the secondary manifestations. 
As a very general rule, one attack of syphilis confers upon the patient an immunity to subse- 
quent infection, in this way resembling the acute infectious diseases, such as smallpox, scarlet fever, 
and measles. But, as we sometimes see second infections of these acute forms, so in the very 
chronic infectious disease syphilis do we see undoubted second attacks. There are about forty 
authentic cases of this accident on record, and I have seen four undoubted ones, two of which are 
now under observation. 
For simplicity of description the course of syphilis is, following Ricord, divided into three stages 
the primary, secondary, and tertiary. This division assumes that after the expiration of the pro- 
dromal and quite regular primary period, in the secondary stage the superficial structures alone 
are involved, and that in the tertiary stage the deeper ones are attacked. That this uniformity of 
105 VENEREAL DISEASES. 
106 
evolution is pursued in many cases cannot be denied, yet there are so many in which the so-called 
tertiary lesions are seen, as we say, precociously in the secondary period, and some in which 
lesions peculiar to the secondary period occur in the tertiary stage, that it is evident that this chro- 
nological division of syphilis must at an early day be modified or changed. In the mean time, 
without laying down arbitrary divisions, we must define as closely as possible the chronological 
limits between the secondary and tertiary stages, and then consider in detail the various exceptions 
to them as they arise. Such a course tends toward accuracy of observation and study. 
The primary stage of syphilis begins with the act of infection, in which the virus is deposited 
upon some portion of the body, genital or extra-genital. In the vast majority of cases no evidence 
of this accident is seen, and, owing to various causes, such as promiscuousness of sexual contact, 
indifference, and failure of memory, in many cases no precise data can be obtained concerning it. 
From the date of infection a period of time elapses before any visible manifestation of syphilis 
shows itself, which is called the first period of incubation. Clinical observations and experimental 
inoculations enable us to say that the duration of this period may be as short as ten days and as 
long as seventy days. I myself have seen undoubted instances of sixty and seventy days' pri- 
mary incubation. In general, however, the average will be found to be between twelve and 
twenty-one days. At the expiration of this time the hard chancre or initial lesion of syphilis 
shows itself. 
With the appearance of the hard chancre the second period of incubation of syphilis begins, 
but not the secondary stage of the disease. This period is rather more regular than the first 
period of incubation, and lasts usually about forty or forty-five days, sometimes as long as sixty, 
and very exceptionally seventy days. Cases of longer incubation than just stated should be 
received with much caution and the elements of fallibility carefully probed. The length of the 
secondary period of incubation may, to a certain extent, be modified by influences which may 
govern the circulation, such as heat and alcoholics. In general, in hot weather the end of the 
secondary period comes quite promptly, while in cold weather it may be delayed. 
The morbid phenomena observed during this period of incubation are the development and 
growth of the initial lesion or chancre, and the enlargement of the inguinal ganglia in immediate 
anatomical connection, which become appreciable sometimes as early as the fifth day, but usually 
from the seventh to the tenth. In some cases there is an induration of the lymphatic vessels lead- 
ing from the chancre to the ganglia. This lymphatic hyperplasia goes on slowly and painlessly 
until the ganglia become much enlarged. These two periods of incubation, the primary and the 
secondary, constitute the first or primary stage of syphilis, which may occupy in its evolution from 
sixty to ninety days, rarely longer. 
With the expiration of the second period of incubation, or that of local manifestations, the 
secondary period of syphilis, or, as it is called, the period of general or constitutional manifestations, 
begins. In this period, as a rule, the lesions are superficial, and confined largely to the skin 
and mucous membrane, consisting of erythematous papular and pustular rashes. The duration 
of the secondary period of syphilis cannot be definitely stated, since it depends largely upon 
the condition of the constitution and the habits of the patient, and also upon the fidelity with 
which he follows treatment. In the vast majority of cases-certainly in those in which there 
is no organic trouble-syphilis proves a very tractable and curable disease, provided patients 
will follow treatment in a careful and systematic manner during a sufficient period of time 
If this is done, the disease may end with the secondary stage, the patient thereafter remaining 
healthy. 
The tertiary stage of syphilis is seen to-day in America much less frequently than formerly, 
owing very largely to our improved ideas in treatment. Indeed, if cases of tertiary syphilis are 
critically, but in an unbiased manner, examined, it will be found that in the majority the long- SYPHILIS. 
io/ 
drawn-out course of the disease is, in most instances, due to neglect of or indifference to treatment, 
or to the baneful effects of alcohol. 
Still, we must recognize that there is a tertiary period of syphilis following, without sharp lines 
of demarcation, the secondary period, and in it the lesions are more profound and destructive. 
I he secretion of the hard chancre is invariably contagious ; the secretions of secondary lesions 
and the blood, and very probably the lymph, during the secondary period are equally contagious ; 
and, although it is claimed that this property is not possessed by the secretions of tertiary lesions, 
such is the doubt on the subject that it is well to fear their noxiousness as much as we do that of 
their predecessors. 
I he physiological secretions of syphilitic subjects, such as the tears, milk, and saliva, are abso- 
lutely innocuous when they are free from admixture with primary and secondary secretions and 
from blood. 
lhe semen of a syphilitic man is incapable of conveying the disease when laid upon a mucous 
or cutaneous surface, and, though many cases of this form of infection are reported, none of them 
will stand scrutiny. When this semen fecundates the female ovum, however, it may transmit to 
the resulting offspring the modified form of syphilis called hereditary. 
Syphilis originating in vaccination is communicated either through admixture of blood with the 
lymph or some organized syphilitic matter which escapes from the base of the vesicle. This state- 
ment is in accord with the known laws of syphilitic infection, and is not in the least invalidated by 
the assertions occurring in the histories of many cases of vaccinal syphilis, in which it is stated that 
only pure lymph, without blood or any admixture, was used. 
Gonorrhoeal and leucorrhceal discharges in persons actively syphilitic have been shown by 
experimental and clinical observation to produce in others chancroidal ulcers, as has been 
shown in the section on the origin of the chancroid. Such secretions are none the less to 
be avoided. 
Vthicles of the Syphilitic Virus.-The initial lesion of syphilis has its origin- 
1. In the secretion of, and organized matter derived from, a previous hard chancre or initial 
lesion ; 
2. In the secretions of the secondary lesions of syphilis, whether of the skin or of the mucous 
membranes : that of mucous patches and condylomata lata has been shown to be especially con- 
tagious ; 
3. In the blood of persons in the active stage of syphilis : the lymph also may communicate 
the disease. 
Modes of Syphilitic Infection.-Such is the bland, unirritating character of the various infect- 
ing secretions of syphilis that it is very probable a door of entry, such as a fissure, an abrasion, or 
other denuded surface, perhaps so small as not to be visible, is generally necessary for their intro- 
duction. It is claimed, however-and no doubt reasonably-that the virus may penetrate the thin, 
soft, and moist epithelium of mucous membranes. Clinical facts show clearly that it may penetrate 
into the orifices of the mucous follicles, and in them take root. 
Syphilis is conveyed in direct and mediate infection in the same manner as the chancroid, 
though instances of the latter mode are more frequent than in chancroid. 
Syphilis is classed as a venereal disease mainly by tradition, and also from the fact that a 
certain proportion of cases originate in the venereal act. It is really the least venereal of all 
of the three great venereal diseases, since, in addition to the genital organs of both sexes, the 
mouth, the breast, the anal region, the head, and, in fact, all portions of the body, serve as ports 
of entry. 
Direct infection occurs most frequently from the genitals of one person to those of another, 
and also in unnatural practices, often between persons of the same sex ; in the anus ; in the 108 
VENEREAL DISEASES. 
mouth, involving sometimes the lips, the gums, the tongue, and the tonsils ; and in the fold between 
the breast and the side of the chest. 
Mouth-to-mouth infection is far from uncommon among families, between lovers, from babe to 
wet-nurse, and from nurse to babe. 
Women are infected on the nipple or breast by husbands and lovers, and I have seen two men 
who were infected on the nipple by women. Men also are infected on the penis from the mouths 
of both women and men, as I have myself seen. 
Surgeons and midwives are frequently infected upon the finger with syphilis by contact with 
the secretions of their patients, chiefly from the genital organs. Dentists also contract the disease 
while operating in mouths the seat of mucous patches, and numerous cases have been reported in 
which syphilis was communicated by bites from persons having these lesions in their mouths. Not 
only does this mode of infection occur during brawls and fights, but also in exuberant embraces 
between the sexes. I have now under my care a lady with a hard chancre on the under part of 
her chin, who was playfully bitten there by a syphilitic lover, and a gentleman similarly affected 
who was thus bitten in an amorous encounter with a puella publica. 
In ritual circumcision syphilis may be conveyed either by the mouth of the operator or by his 
instruments. 
A singular mode of transmission of syphilis is said to occur in Roumania.' It is the custom 
there to attribute all affections of the eyes to foreign bodies, for the relief of which there is a class 
of women called leeching oculists who suck or cleanse the eyelids with their tongue. One of these 
women, having mucous patches in her mouth, conveyed the disease to many persons. 
Mediate contagion is that form in which the syphilitic virus present from any cause upon any 
substance or article is through it communicated to a healthy person. The agent of infection may 
be a cigar, a pipe, a toothbrush, drinking utensils, knives, forks, spoons, razors, towels, children's 
toys, nursing-bottles, babies' rubber rings, sponges, bandages, surgical and cupping instruments, lead- 
pencils, and speaking-trumpets. Many instances have been reported of the transmission of syphilis 
by means of the Eustachian catheter and by the vaccination scarificator. Among glassblowers the 
passing the pipes used in the trade from one to another has been a frequent means of conveying 
syphilis. Tatooing has long been recognized as a source of syphilitic infection, and Maury and 
Dulles reported fifteen cases originating in one man who had mucous patches in his mouth. Cases 
have been reported in which syphilis was communicated to healthy persons through biting off thread 
first bitten by an infected man. In the operation of skin-grafting also the disease has been known 
to be communicated to a healthy person by means of a graft taken from a person suffering from 
secondary syphilis. 
The general substitution of bovine for humanized vaccine virus has rendered the question of 
vaccinal syphilis almost a dead issue in this country. When transmitted in vaccination, the vehicles 
of contagion are either blood or organized material from the base of the sore. 
Syphilis is precisely the same disease whether it originates in a primary or a secondary 
lesion. 
The initial lesion of syphilis-also called chancre in contradistinction to chancroid, hard, indu- 
rated, infecting, Hunterian chancre, initial sclerosis, primitive or initial neoplasm, and primary 
syphilitic ulcer has its origin, as before stated, in the secretions of either primary or secondary 
specific lesions, and appears after the lapse of time which we have called the first period of incu- 
bation. As a general rule, but a single lesion is seen in this, differing from the multiple character 
of the chancroid. Exceptionally, there are several initial chancres, usually upon one region, very 
1 La France medicale, Feb. 7, 1888. Pari ] 
Plate IX 
Fig. 2.- 
Fife. 3 
Fife .4. 
Fife 6 
Fife. 5.' 
Fife. 8. 
Fife. 9. 
Fife .13 
Fife ,12. 
Fig .16. 
Fig .17. 
Fife .18 
Fife .19, 
4 Fife 20 
'• •NDURATED CHANCRE OF UPPER EYELID . 2. SUPERFICIAL INDURATED CHANCRE OF FOREHEAD . 3 INDURATED CHANCRE OF LOWER EYELID . 
4-INDURATED CHANCRE OF TONGUE . 5. INDURATED CHANCRE OF UPPER EYELID . 6. INDURATED CHANCRE OF UPPER LIP. 
7-CONDITION OF FINGER IN STAGE OF REPAIR OF FIGURE 10 . 8. INDURATED CHANCRE OF FINGER . 9. INDURATED CHANCRE OF NIPPLE . 
10 INDURATED CHANCRE OF FINGER . 11.INDURATED CHANCRE OF PULP OF FINGER. 12. INDURATED CHANCRE OF FINGER IN STAGE OFREPAIR 
13-INDURATED CHANCRE OF UPPER LIP. 14.INDURATED CHANCRE OF FINGER. 15.INDURATED CHANCRE OF TONGUE. 
16 INDURATED CHANCRE OF PUBES . 17. INDURATED CHANCRE OF CHIN . 18.INDURATED CHANCRE OF SCROTUM,PARCHMENT-LIKE 
19.SIMPLE BALAN0-POSTHITIS . 20.BALAN0 POSTHITIS WITH SUPERFICIAL ULCERATION . 
LEA BROTHERS & CO PUBLISHERS , PHILADELPHIA : SYPHILIS. 
109 
rarely seated on different regions ; in which case they are due to separate inoculations, and not, as 
with the chancroid, to auto-inoculations. 1 he penis, the female genitals, and the breast are the 
three regions upon which multiple hard chancres are most frequently found. Inspection of Plates 
VII., VIII., and IX. shows twenty fig- 
ures of hard chancres, in but five of 
which is the lesion multiple, though in 
the wood-cut Fig. 3 multiple indurated 
chancres, nine in number, are pictured 
on the breast. In Figs. 1, 2, and 4 of 
Plate VII. are multiple chancres of the 
penis shown, in two of which there are 
two of these lesions, and in one six- 
an exceptional number, though a case 
has been reported in which there were 
nineteen. In Fig. 2, Plate VIII., multiple 
chancres of the vulva are shown, and in 
Pig. 18, Plate IX., are two chancres of the scrotum. These figures-five cases of multiple chan- 
cres in twenty-nine cases of hard chancre-show a much larger proportion than is observed in 
practice. 
Hard chancres seated on the sexual organs are called genital, and those found elsewhere upon 
the body extra-genital, chancres. 
In the male, chancres are found most frequently on the prepuce, particularly near and in the 
sulcus, on the prepuce and glans, near the fraenum, on the lips of the meatus, one or both, some- 
times upon the glans, upon the skin of the penis, at the peno-scrotal angle, and in the urethral 
canal. Upon the scrotum they are not absolutely rare, and are found upon the lips, tongue, ton- 
sils, on the end of the nose, at the entrance to the nares, on the eyelid, forehead, ears, fingers, 
pubes, breast, leg, and foot. 
In the female, they are found upon the labia majora and minora, most commonly at the introi- 
tus vaginae, fourchette, vestibule, clitoris and meatus, uterus, vaginal walls quite rarely, and in or 
near the anus. Extra-genital chancres in the female are not uncommonly found on the lips, 
tongue, tonsils, and face, upon the breast either upon the nipple or on the areola, upon the pubes 
and buttocks, and elsewhere on the body. 
Appearances and Characteristics of the Initial Lesion.-It is of great importance in the matter 
of diagnosis and of prophylaxis that the infectious nature of the initial lesion should be recognized 
very early, since, owing to its seemingly trifling character, its bearers are often not deterred from 
coitus, and infection is thereby spread. 
I here are four conditions under which syphilitic chancres appear at their very beginning. 
These are-first, the chancrous erosion, which may be single or multiple ; second, the silvery spot; 
third, the dry papule ; and fourth, the umbilicated papule or follicular chancre. 
lhe chancrous erosion, by far the most common form of development, begins as a minute, 
sharply-rounded, excoriated spot, the surface of which is neither elevated nor depressed, but 
appears simply like an erosion of the epithelial cells. The color is a sombre red, which later on 
becomes a coppery red. The spot assumes a round or oval outline, has a smooth, polished sur- 
face destitute of granulations, and gives forth a scanty serous secretion. 
While, in general, we find but one such erosion, exceptionally there are five, and as many as 
fourteen may be present. This form is the multiple herpetiform chancres of Dubuc. They have 
a diameter of a line or less, are grouped together at first in a discrete manner, present all of the 
appearances of a solitary chancrous erosion, and usually, as they grow older, coalesce and form 
Fig- 3- 
Multiple Indurated Chancres of Breast. I IO 
VENEREAL DISEASES. 
one chancre, and rather exceptionally remain separate. The smooth, shining surface is decidedly 
different from that of herpetic vesicles, and they further are unaccompanied with the itching and 
burning of herpes. The firm texture of the syphilitic lesions, though they readily bleed, does not 
give issue, as claimed by Leloir, to serum upon pressure, as the vesicles of herpes do. 
Solitary or multiple chancrous erosions are mostly seen on the mucous membrane of the pre- 
puce and on either side of the fraenum. 
The silvery spot as the initial symptom of the syphilitic chancre, first described by me, pre- 
sents well-marked appearances. It generally occurs on the glans and at the meatus, and at first as 
if a pinhead-sized spot of mucous membrane had been touched with nitrate of silver or carbolic 
acid. With a magnifying-glass there is no evident change other than the peculiar staining of the 
superficial epidermal cells. The silvery lesion increases slowly but visibly from day to day, and 
preserves its integrity of surface until it reaches an area of about a line, when, coincidently with 
the subjacent induration which has been simultaneously developing, and which has slowly raised 
it up into salience, it disappears, and is replaced by a smooth, shiny surface peculiar to hard 
chancre. 
The dry papule-papule seche of Lanceraux-is usually found upon the glans or prepuce when 
they are not in coaptation, and consequently always in a dry condition. It is, as a rule, solitary 
and is not uncommonly seen on persons who have been circumcised, and is also found on the 
integument of the penis, about the pubes, on the thighs, and elsewhere upon the body. This form 
of the initial lesion begins as a small dull red spot which increases in area as it grows to a height 
of from a half to one line, and even higher. Its evolution is slow and aphlegmasic, and when 
fully developed it resembles somewhat a not very scaly papule or patch of psoriasis, but of denser 
consistence. Its surface is flat or slightly convex, its color a brownish red, and it may or may not 
have a faint inflammatory halo. It may be accompanied by hardening of the lymphatics, and later on 
by enlargement of the neighboring ganglia. It may thus run its course, and subside gradually into 
a deeply-pigmented macule, or it may become exulcerous on its surface. A modification of this form 
of the initial lesion has been described as diphtheroid of the glans-an incorrect term, since neither 
in appearance nor course does the lesion at all resemble diphtheritic membrane. It consists of 
patches of a glistening grayish-white color, presenting a sensation to the fingers something like 
that of wet chamois-skin. The lesion is slightly salient, and involves the superficial tissues of the 
glands, and sometimes of the prepuce, and has sharply-defined borders, and gives rise to no secre- 
tion from its surface. It may involve more or less of the glans, and is sometimes continuous with 
an indurated nodule of the prepuce. 
The umbilicated papule or follicular chancre is a rare form of the initial lesion. I have seen 
four well-marked cases of it. It begins as a small pinkish elevation of the size of a milium, with a 
minute depression in the centre which grows slowly and assumes the appearance of a tumor of 
molluscum sebaceum. Further increase takes place until a pea-sized tumor is formed. As the 
lesion grows the central depression becomes broader and deeper, until in its full development the 
chancre is cup-shaped and as if set in the mucous membrane, with the free borders markedly ele- 
vated. It is firmly indurated, sharply circumscribed, the deeply concave surface smooth, glossy, of 
a deep red, and exulcerated. In two cases the lymphatic vessels, enlarged to the calibre of a 
goosequill, extended along the penis, and the shape of the lesion could be compared to a minia- 
ture flute. In this form of chancre it seems that the syphilitic material enters the follicle, and then 
gives rise to cell-increase, shown in the appearances above described. 
Beginning in either of the foregoing forms, the syphilitic chancre-which is really a neoplasm 
or a nodule of greater or less size composed of new and lowly-organized form of tissueorows 
quite slowly in an aphlegmasic manner, without the usual accompaniments of inflammation. This 
newly-organized tissue forms an indurated mass or nodule under and around the sore, which is SYPHILIS. 
111 
sharply circumscribed, hard, firm, and resistant; hence the term primary induration. This indura- 
tion is sometimes hard and cartilaginous, even ligneous, particularly when seated in the mucous 
and submucous tissues, and often when in the skin and subcutaneous tissues. When it is devel- 
oped in the superficial portions of the mucous membrane it forms a thin flat, circumscribed plate 
of hardened tissue, called parchment induration. In very exceptional cases the induration is devel- 
oped around the circumference of the sore, like a ring, and is then called annular. I hen, again, 
particularly around the introitus vaginae, vestibule, and fourchette, and also sometimes on the 
integument, the initial syphilitic neoplasm lacks the typical density, firmness, and sharp demarca- 
tion. In these cases induration is said to be absent-a statement which is not accurate, since the 
newly-organized cells are there, as in the typical initial sclerosis, but they are not so copious and 
densely packed as to form a sharply-defined nodule. This condition often leads to doubts and 
errors in diagnosis. The common-sense view of the case is this : that induration as a symptom of 
syphilis is, like all symptoms in medicine, liable to great variations in degree and intensity, being 
severe in many cases and of varying degrees of mildness in others. Though well-marked indura- 
tion may not be present in these rather less common cases, the young syphilitic cells are there, 
though not in such a condition of plentitude that they can be recognized by the tactile sense 
of man. 
I he secretion of the syphilitic chancre is serous in character, and its sero-purulence or puru- 
lence is due to adventitious causes, such as irritants of various kinds. There is every reason to 
believe that much of the destructive metamorphosis of chancres is engrafted upon them by pyo- 
genic microbes. Indeed, in many instances we see not only syphilitic infection from a chancre, but 
also pyogenic infection. The immaturity of the newly-organized cells renders their existence 
precarious, and in consequence we frequently see on the surface of chancres molecular decay 
or gangrene. This form of decay also has its origin in the strangulation of the capillaries by 
the closely-packed new cells, the result of which is necrosis limited to the parts supplied, d his 
strangulation of the vessels is an important factor in the phagedena which sometimes attacks hard 
chancres. 
The duration of the initial lesion of syphilis is very variable, and depends largely upon the 
extent and density of the new growth. In some cases it is so slight and insignificant that it comes 
and goes without its presence having been known or without leaving a trace. This anomaly is 
sometimes seen in women, less commonly in men. The tissue forming the primary nodule, being 
of unstable nature, is peculiarly susceptible to the action of mercury, under which it can often be 
seen, as it were, to melt away. So that if the chancre, as it often does, lasts until the evolution 
of secondary lesions, it usually disappears quite rapidly under the influence of systematic treat- 
ment. But in some cases it is very voluminous and persistent, and may exist for months. Those 
old-time and oft-quoted cases in which it is said to have lasted years were in all probability instances 
of fibroid cicatrices resulting from chancres. I have seen many of these which had been regarded 
as persistent and permanent indurations, whereas the syphilitic neoplasm had vanished years before 
and was replaced by firm fibrous tissues. 
We are in a position now to consider the chancre in its various phases of full development, 
which can be satisfactorily done by studying Plates VII., VIII., and IX. In Figs, i and 5 of Plate 
VII. is well shown the shining, translucent, slightly greenish film, somewhat pultaceous in nature, 
seated on the hard base with the circumscribed redness. This appearance, first described by Clerc, 
is very characteristic, and a remembrance of the fact that variations in the thickness and color, 
both lighter and darker, are seen in chancres, will be of much aid to the student. Compare the 
surfaces of these chancres with those of chancroids, and mark the radical differences in them and 
in their surroundings. 
Figs. 7 and 9 of Plate VII. are admirable examples of chancres the seat of superficial molec- 112 
VENEREAL DISEASES. 
ular degeneration : mark the fact that no pus is present, but, on the contrary, a scanty serum is 
found. Fig. 2, Plate VIL, shows well multiple chancres, the large posterior one in the middle 
line being of the same character as Figs. 1 and 5, while the others show evidence of desiccation 
of their secretion and the formation of crusts from exposure to the air. Figs. 6, 8, and 10 show 
the irregular, somewhat uneven, chancres of the meatus, which are always characteristically indu- 
rated. Further evidence of molecular gangrene is shown in Figs. 3, 4, and 13 of Plate VII., which 
portray characteristic hard chancres. In Figs. 3, 12, and 13 of Plate VII. persistent induration is 
well pictured. 
It is a difficult task to reproduce the appearances of the chancre in women when situated on 
prominent portions of their genitals, and it is almost impossible to do so when they are seated 
deep in the vulva. Figs. 1, 2, and 4 show chancres much indurated, with superficial molecular 
gangrene. In the female sex, as already stated, in the deeper portions induration may be slight 
and intangible ; hence a guarded diagnosis should always be made in the case of a subacute and 
persistently active lesion, particularly if there is very little ulceration. The condition of the 
inguinal ganglia is often of much aid in these cases. 
Fig. 12 of Plate VIII., and all of the figures of Plate IX., illustrate extra-genital chancres. Of 
Plate IX., Figs. 1, 3, and 5 illustrate chancres of the lids, which may be thus localized or may extend 
to the conjunctiva, and even may be limited to that membrane. Though markedly indurated, these 
chancres are not sharply defined. They become more or less irritated and ulcerated, and thus they 
lose the typical characteristics. Their localization, their firmness, their comparative sharpness of 
demarcation, and perhaps their history, will point to their nature, while hardness of the ante-auric- 
ular, and later of the post-auricular, ganglia will confirm it. Figs. 2, 4, 6, 13, and 17 of Plate IX. 
illustrate chancres about the head, which on examination always present the syphilitic characters, 
and such lesions are always accompanied by indolent, painless enlargement of the ganglia in imme- 
diate association, and later on of those of the whole region. 
Chancres of the nipple and areola are well shown in Fig. 12 of Plate VIII. and Fig. 9 of Plate 
IX., and in wood-cut Figs. 3, 4, and 5. They occur in the form of the chancrous erosion (see 
wood-cut Fig. 3) in the ecthymatous 
form, as the indurated ulcer and the 
indurated fissure, of which there may 
be several. The chancre may be seated 
on the nipple itself, as in Fig. 9, Plate 
IX., or it may be situated at its base on 
the areola, as shown in Fig. 12, Plate 
VIII., or in wood-cut Fig. 4. In general, 
these chancres are rather depressed 
than elevated, and show a tendency 
to ulceration. This feature is shown in wood-cut Fig. 5, in which it has by mild phagedenic 
action encircled the nipple in the shape of a horse-shoe. The induration of chancres in this local- 
ity is usually not sharply limited. In these cases the lymphatics running from the breasts to the 
axillae are often much enlarged and hardened. When seated in the nipple these chancres are often 
the seat of much pain. 
Chancres of the lips are shown in Figs. 6 and 13, Plate IX. They occur on either the upper 
or the lower lip. They usually begin as a small excoriation or as a fissure, and are generally at 
first regarded by the laity as "cold sores" or "cracks." They quite rapidly increase, and with 
their growth the submaxillary and ante-auricular ganglia become enlarged and harden. Great 
variation in size is observed in chancres of the lips: in some cases they are small and superficial, 
in others deep and extensive, sometimes reaching enormous sizes, as shown in Fig 13, Plate IX., 
Fig. 4. 
Chancre of the Breast. SYPHILIS. 
TI3 
in which the whole upper lip is involved. When large, they occasion much trouble and distress to 
the patient, and they are fertile sources of infection to relatives and friends. 
Chancres of the tongue are shown in Figs. 4 and 15, Plate IX. ; they are usually seen in the 
form of a nodule or fissure attended with well-marked induration. At an early date they cause 
much disquietude in the minds of pa- 
tients, who fear they are cancerous, 
lheir appearance, usually in persons 
prior to the fortieth year of age, their 
induration, and the early implication of 
the submaxillary ganglia, are the most 
reliable points of diagnosis. 
Chancres of the fingers are shown 
in Figs. 8, 10, 12, and 14, Plate IX. 
they begin on the side of the nail at 
its end and on the tip of the finger, 
also on the integument of the pha- 
langes. Chancres about the end of 
usually do not present well- 
marked hardness. I hey show a decided tendency to exuberant development, as seen in Fig. 14, 
I late IX., and often appear like fungating, cauliflower-looking masses of a deep-red or purplish- 
red color. I hey are commonly, in this situation, the seat of severe pain, and in many instances 
inflammatory lymphangitis and epitrochlear and axillary adenitis are caused by them. They are 
sometimes attended with severe constitutional disturbance, even with a typhoid condition. Pig. 
12, 1 late IX., shows one of these fungous chancres in its reparative stage, while Figs. 7 and 10 
show the ultimate destruction produced by them, which is often greater than is here shown. Fig. 
8 shows an indolent chancre over the last phalangeal joint of the thumb. The excessive danger 
of these chancres of the finger in surgeons and nurses is shown in the case reported by Bardinet, 
in which a nurse infected a number of parturient women, from whom fully a hundred, old and 
young, became syphilitic. 
Chancres of the forehead, chin, pubes, and scrotum are shown in Figs. 2, 16, 17, and 18. 
These lesions are indolent in their course, more or less ulcerated and uneven, sometimes covered 
with a crust, surrounded by a dull-red inflammatory areola, and are soon accompanied by subacute 
adenitis of the neighboring ganglia. In these positions they seldom show a tendency to phagedena. 
It is, in general, a good rule to entertain a suspicion of syphilis in every case of small indolent 
ulcer about the head, genital or perigenital regions, and, we may also add, about the breast. 
Induration of the Ganglia and Lymphatics.-In every case of hard chancre the neighboring 
ganglia become indolently enlarged, and in many instances the lymphatic vessels are involved in a 
similar change. I he enlargement is sometimes appreciable as early as the fifth day after the 
appearance of the sore, and, as a rule, between the seventh and the tenth days. In rather excep- 
tional cases well-marked induration may not be felt until the fourteenth day, rarely later. At first, 
it is usually more pronounced on the same side as the chancre. Later on, both sides are involved, 
though the enlargement is sometimes unilateral. The hardness of the ganglia is peculiar in its 
density and painlessness. They are freely movable, and feel under the skin like almonds or little 
round tumors, which do not usually adhere to one another or to the overlying integument. 
Sometimes one ganglion becomes much larger than the rest, and exceptionally a number become 
blended into an indolent mass. Suppuration rarely occurs. (See Fig. 7, Plate II.) The follow- 
ing table, compiled by Fournier, gives at a glance the situation of the chancre and that of the lym- 
phatic ganglia at first involved : 
Fig. 5. 
Indurated Chancre of Base of Nipple (ulcerative). 114 
EENEEEAE DISEASES. 
Seat of the Chancre. 
Chancres of the genital organs-i. e. of the penis, 
the scrotum, the labia majora and minora, the four- 
chette, the meatus urinarius, the urethra, the entrance 
of the vagina, etc. 
Perigenital chancres (those of the perineum, the 
genito-crural folds, the mons Veneris, the thighs, 
the buttocks, etc.). 
Chancres of the anus and the margin of the anus. 
Chancres of the lips and of the chin. 
Chancres of the tongue. 
Chancres of the eyelids. 
Chancres of the fingers. 
Chancres of the arm. 
Chancres of the breast. 
Chancres of the uterine neck. 
Corresponding Indolent Adenitis in the- 
Inguinal ganglia. 
Inguinal ganglia. 
Inguinal ganglia. 
The submaxillary ganglia. 
The subhyoidian ganglia. 
The preauricular ganglia. 
The epitrochlear and the axillary ganglia. 
The axillary ganglion. 
1 he axillary ganglia, and sometimes the subpec- 
toral ganglia. 
Theoretically, the pelvic ganglia. Generally 
nothing is found in the groins; exceptionally an 
inguinal bubo. 
The varying features of the chancroid and hard chancre having been so fully illustrated by 
the chromo-lithographic figures and emphasized in the text, it unnecessary to present a table of 
differential diagnosis. It is necessary to remember that the chancroid in its early stages may be so 
superficial that it might be mistaken for a chancre, and that from various causes later on it may 
have an inflammatory indurated base, and thus simulate a syphilitic lesion. The syphilitic chan- 
cre may lack its appreciably hard base, and have a rather uneven surface from various causes, and 
then may be regarded as a chancroid, or later on its surface may become covered with a pultaceous 
membrane, and then simulate an indolent chancroid. 
A patient may in coitus contract chancre and chancroid, the latter appearing promptly without 
incubation. If the resulting chancroid is not healed by the time that the syphilitic lesion begins to 
develop, the latter is modified as to its appearance by having an ulcerated surface similar to chan- 
croid. This is the so-called mixed chancre, which is simply an accident, a coincidence. There is 
not, as has been claimed, any pathological relation between the two processes-no more than there 
would be if a man were wounded in the face, from which he first derived a black eye, and later on 
developed a hard chancre on the same spot. 
Treatment of the Hard Chancre.-It is now generally conceded that we possess no means 
of preventing the development of the initial lesion of syphilis, since all forms of cauterization and 
radical excision at the moment of the discovery of the lesion, and even within a few hours after the 
infecting coitus, have signally failed. Cases in which it is claimed that syphilis has thus been 
aborted are undoubtedly those in which a chancroid has been regarded as a chancre. 
As the hard chancre is a localized neoplasm indicative of constitutional infection, and not, 
like the chancroid, a localized destructive process, it logically follows that cauterization is wholly 
inadmissible. The first indication in treatment is to keep the lesion and parts around scrupulously 
clean, to protect the chancre from irritation, and to keep it constantly covered. When seen early, 
water dressing on lint is all that is necessary for a chancre. Caustics at this period are particularly 
contraindicated, since they produce inflammatory oedema. In the early periods of the syphilitic 
chancre any of the lotions recommended for chancroid on page 102 may be used. Within the 
past two years I have used largely a solution of bichloride of mercury, 1 : 1000 or 2000, for these 
lesions. At least twice a day the penis should be washed with soap and water, and then immersed 
in this solution, which also must be applied on lint or absorbent cotton continuously to the chancre ; 
tJic dressing should be changed zuithout fail every two hours. Much of the destructive action of hard SYPHILIS. 
115 
chancres is due to micro-organisms, which lodge upon their surface ; and many of these lesions, 
besides being the seat of syphilitic infection, are also the focus of pyogenic infection, as seen in 
the development of suppurating buboes and in the course of chancres of the fingers. 
When molecular destruction or suppurative action takes place in the chancre, iodoform or 
calomel and bismuth in equal parts may be dusted on its surface, or the black wash or the yellow 
wash may be applied. When induration is copious and persistent, mercurial ointment may be 
applied on lint. Should the induration impair the function of a part, such as the eye, mouth, or 
meatus, mercurial treatment should be commenced at once. In the case of a pultaceous film or 
membrane persisting on the surface of the chancre, carbolic acid or nitric acid should be carefully 
and sparingly applied. 
As the chancre commonly remains until the period of constitutional manifestations, its subse- 
. quent treatment becomes a part of the general disease. PART II. 
SYPHILIS. 
(Continued.) 
Evolution of the Secondary Period.-During the two periods of incubation which constitute 
the primary stage of syphilis, which lasts on an average from fifty-five to seventy days, the mani- 
fest lesions are the chancre with its lymphatic complications. 
There is a remarkable variation in the amount of systemic disturbance at the beginning of the 
secondary period, when it is thought that the disease really becomes constitutional, though it is 
probable that for some time previously the various morbid processes have been maturing. In 
many subjects no deviation whatever from the healthy standard is observed to mark the com- 
mencement of the secondary stage, and the dermal lesions are the only evidences of syphilis. 
In others, however, particularly in women, much and varied constitutional disturbance takes 
place. 
Perhaps the most constant morbid symptom is fever, which, though absent in many cases, 
is present in most in varying degrees of intensity. In some cases there is an elevation of tem- 
perature of from one to three degrees, commonly with a corresponding mild nocturnal exacerbation. 
In other cases the febrile movement is well marked, the morning temperature being from ioi° to 
102° Fahr., and in the evening 104° Fahr., and in rather exceptional instances higher, even to 107° 
Fahr., particularly in women. This fever maybe continuous, intermittent, remittent, and irregular. 
It may cease spontaneously, but is markedly under the influence of mercurials. It is often seen to 
be correspondingly severe coincidently with a very profuse and extensive exanthem, particularly 
of the erythematous variety. In many cases a mild rise of temperature appears coincidently with 
a relapse of secondary manifestations, especially when the latter are severe. In the intermittent 
and remittent forms of syphilitic fever, though there is no chill, patients complain of a chilly feel- 
ing toward evening, which is accompanied by a feeling of lassitude, soreness of the whole body, 
and headache. The subsequent sweat, which is not constant, amounts to a slight moisture, but in 
some instances is quite well marked. In cachectic subjects and in those who are early attacked 
with cerebral symptoms this fever sometimes assumes a typhoidal type. Besides the elevation 
of temperature there is a corresponding acceleration of the pulse, and the respiration ratio is 
increased. I he tissue metamorphoses are present in proportion to the intensity of the fever. 
Various neuralgic pains are also complained of by patients, the peculiarity of which is their 
quite constant occurrence toward dark and at night. Headache, mostly nocturnal in character or 
continuous, with paroxysms toward night, is a very constant symptom. It exists in various degrees 
of intensity, from a mild and endurable form to one in which the patient's sufferings are agonizing, 
in which he or she is tortured by pain during the night, and prostrate, worn-out, and suffering dur- 
ing the day, when the pain may not wholly cease. Neuralgic pains affecting the cranial nerves, the 
fifth in particular, also seated in the intercostal nerves, in the sciatic and its branches, and in the 
anterior crural, are not uncommon. Persons, who have previously suffered from neuralgia of any 
part are especially liable to exacerbations during the eruptive stage of syphilis, and, in fact, at any 
time during the activity of the diathesis. 
117 118 
VENEREAL DISEASES. 
Insomnia is a symptom sometimes complained of by syphilitic patients, who can give no 
reason for it whatever, since in many cases there is no physical suffering. It is peculiar in the fact 
that it is not readily influenced by soporifics, but gradually ceases with the disappearance of the 
exanthematic symptoms under mercurial treatment. 
In some exceptional cases, particularly in women, a mild and temporary aberration of the 
mind is observed in the form of emotional disturbances, hallucinations, delusions, and morbid 
impulses. Pains in the muscles and joints simulating rheumatism and occurring at night are 
most constant at the evolution of, and during, the secondary period. 
The tendency to anaemia in early secondary syphilis is in many cases well marked. The 
diminished nutritive qualities of the blood and the impairment of the nutrition of the tissues are 
shown in the pale, sallow, and emaciated facies, in the palpitations and the small thready pulse 
and shortness of breath, in the want of appetite and energy, and in the nervousness and restless- 
ness and apprehensiveness and great languor amounting often to dejection. 
While in most cases this formidable combination of symptoms is gradually dispelled by 
treatment, and a healthy tone, mental and physical, is restored, in many, particularly in persons 
of poor fibre, in those suffering from visceral diseases and from adynamic conditions and other 
morbid states of the system, this cachexia and asthenia may persist, and require the most intel- 
ligent management, therapeutical, hygienic, and climatic, to successfully combat it. 
Relapses of anaemia, cachexia, and asthenia are common during the whole course of 
the infection. 
During the secondary stage of syphilis a peculiar susceptibility of the skin and mucous 
membranes to irritation and inflammation is quite constantly observed. It is seen in the reac- 
tion caused by cuts, abrasions, burns, and incised wounds. In this stage gonorrhoea is often seen 
to become very virulent, and its pus auto-inoculable. Herpetic vesicles readily become inflamed 
and present the appearances of chancroids. 
Various forms of pus and muco-pus when inoculated give rise to ulcers having all the attri- 
butes of chancroids. (See Source and Origin of the Chancroid.) Infiltrations of the skin are pro- 
duced by causes otherwise trivial, and wounds, bruises, and ulcers are frequently complicated by 
infiltrated areas. 
During the secondary period, particularly in women, certain changes are sometimes ob- 
served in the sensibility of the skin. This condition, which consists in loss of the sense of touch, 
of heat or cold, and of the perception of pain, is called "analgesia." It is mostly found 
upon the backs of the hands and forearms, also on similar aspects of the feet and ankles, and, 
in exceptional cases, it exists over the whole body. I have seen it in both the male and the 
female. 
The course of syphilis is remarkably uncertain, and is seen in all degrees of mildness and in 
every form of severity. Constitutional peculiarities, habits, and surroundings are at the bottom of 
this morbid action. Some patients suffer very mildly from syphilis, even when they do not follow 
treatment, while others, again, are sorely punished. The benignity of syphilis in America which is 
claimed by some authors is dependent upon our more minute knowledge of the disease, upon 
improved methods of treatment, and upon our improved hygienic conditions and better food-sup- 
ply than is obtained in some older countries. Take away these powerful factors for good, and 
syphilis would in a few years be equally as malignant as it was years ago. In the majority of cases 
patients otherwise healthy experience very little trouble from syphilis, provided they pursue a proper 
treatment for a sufficient length of time, avoid alcoholics, husband their strength, and exercise watch- 
fulness of their general well-being. It is said that patients of light complexion and reddish hair 
suffer more severely than those of dark complexion-a statement which is in the main correct. 
But although the epithelial tissues and the integument of these patients are so frequentlyand we SYPHILIS. 
119 
may perhaps say persistently-attacked, the prognosis, in the long run, is good if their bodies are 
otherwise sound and their habits exemplary. 
In youth and old age syphilis is especially severe. As regards youth, this statement must be 
thus modified : in young children suffering from hereditary syphilis the disease is, as a rule, severe 
and even deadly ; but in the acquired form of syphilis of children there is really no remarkable 
malignancy. In old age syphilis is always a grave disease. Its stages are peculiar in the number, 
severity, and even malignancy of its lesions and coexistent systemic disturbance. In them tertiary 
lesions are prone to appear, and the disease intensifies morbid conditions, hereditary or acquired, 
visceral or nervous. 
I he existence of scrofula, tuberculosis, neuropathic conditions, rheumatism, gout, scorbutus, 
the hemorrhagic diathesis, and visceral diseases renders the prognosis of syphilis more grave. 
Alcoholic addiction is always a most serious complication of syphilis. 
SYPHILIDES. 
General Considerations.-The term " syphilides " is applied to the various lesions of the 
skin symptomatic of syphilis in preference to the term " syphilodermata," which, besides being 
inexact, is decidedly not euphonious. Syphilitic eruptions appear during the course of the disease, 
both early and late. They embrace all forms of eruption, from erythema to nodular infiltration, 
d hey are the result of hypersemia and cell-increase ; the hyperaemic eruptions being, as a rule, 
peculiar to the early periods, while those composed of cell-infiltration appear later and very late 
in the disease. 1 he infiltrating cells belong to the class of granulation tissue. The most simple 
forms of infiltration lesions are papules, which appear in early and intermediary periods, while the 
niore advanced lesions, tubercles, as a rule, appear later. 
dhe dermal lesions of syphilis are in many respects similar to those of simple origin, consist- 
ing of erythema, papules, pustules, vesicles, bullae, and tubercles or nodes. 
This correspondence between simple and syphilitic skin lesions leads to the use of the terms, 
following the classification of Willan, of syphilitic lichen for papular eruptions ; syphilitic impetigo, 
eczema, and psoriasis for pustular and scaly rashes ; and syphilitic lupus for tubercular eruptions. 
Nothing but inexactitude and uncertainty can result from such a nomenclature. We shall use the 
simple, practical, and exact division as follows : erythematous, papular, pustular, pustulo-ulcerative, 
and vesicular syphilides among secondary lesions, and tubercular, bullous, tuberculo-ulcerative, and 
gummatous among the late or tertiary lesions. A minute knowledge of the syphilides requires, 
as a groundwork, much familiarity with simple eruptions. 
lhe syphilides present certain peculiarities and undergo various morphological changes. In 
their course they exhibit a chronicity and absence of inflammation which are in marked contrast with 
those of simple eruptions. Though, exceptionally, the erythematous and papular syphilides appear 
with a brusque and rapid onset, and with considerable systemic reaction, they soon subside into the 
subacute and .aphlegmasic condition peculiar to them. 
Absence of itching, irritation, and pain is the rule with syphilitic eruptions. In some cases of 
early and acute evolution the erythematous and papular rashes may be attended with a mild and 
ephemeral pruritus. Early rashes on the scalp sometimes itch moderately, as they also may on the 
legs and forearms. It must be remembered that a pruritic condition of the skin from internal and 
external causes may coexist with syphilitic eruptions. Pain may accompany the tubercular or gum- 
matous syphilides when developed in the course of a nerve, or it may follow the cicatrices of these 
lesions which compress a nerve or nerve-filament. 
Owing to these causes their chronicity, their tendency to relapse and to the changes which VENEREAL DISEASES. 
I 20 
the lesions of syphilis undergo, polymorphism or the simultaneous occurrence of several orders 
of lesions, is very frequently observed, particularly in the early, but also in the late, stage. 
The color of the syphilides is less frankly red than that of simple eruptions, and varies 
from a pinkish-red to a deep brownish-red or coppery color, or to the hue of the lean of ham. 
When, exceptionally, the red of syphilitic eruptions is at first well marked, it very soon becomes 
less intense and more subdued. Early erythematous and papular syphilides may be rendered 
temporarily pale by pressure, but later on, owing to pigmentary changes, the color is unaffected. 
These pigmentary changes, though very frequent in syphilis, are also observed in such simple 
eruptions as lichen planus, dermatitis, eczema-in fact, in any eruption which runs a chronic 
course. 
The early eruptions of syphilis most commonly resemble the exanthemata in their general 
and symmetrical distribution. Relapses, particularly of the erythematous and papular syphilides, 
are less extensive and are prone to appear symmetrically on certain regions and to assume a circu- 
lar form. This is especially noticeable upon the neck, on the forearms, near joints, and also on the 
anterior surface of the legs. 
Such is the belief in the infallibility of mercury in the cure of syphilitic eruptions that it has 
been considered as the test of their diagnosis. The facts are, that the early and infiltrative lesions 
are very amenable to the influence of mercury, particularly when given before they are old, but 
when they become chronic, scaly, ulcerative, and more or less cicatricial, they are very often 
rebellious. 
Syphilitic eruptions, besides their essential physiognomy, show a tendency to peculiar localiza- 
tion. The secondary lesions appear in scattered form on the scalp, at its margin on the forehead, 
and at the nucha, on the ala nasi, at the angle of the mouth, about the anus and genitals, around 
the umbilicus, upon the palms and soles, around the nails, on the nates, between the toes, and par- 
ticularly on the extremities near joints on both flexor and extensor surfaces. As the disease grows 
old the eruptions, which at first were general and symmetrical, show a tendency to become localized 
on certain regions symmetrically, and later on to become unsymmetrical. 
The course, polymorphous changes, and sequelae of the syphilides will be considered sepa- 
rately with each variety. 
THE ERYTHEMATOUS SYPHILIDE. 
This eruption has been called syphilitic erythema, syphilitic roseola, macular syphilide, syphilis 
cutanea maculosa, syphiloderma erythematosum, all of which names are more or less faulty or objec- 
tionable. The application of the term macular to this syphilide is positively wrong, since it conveys 
the idea that it is composed of macules, whereas it is really formed of erythematous spots, which 
later on may become macules or stains. Consequently, if we admit a macular syphilide, which is 
irrational and unnecessary, the term may apply to an old erythematous eruption, and equally to 
the pigmented sequelae of any other form of syphilide. 
The erythematous syphilide is usually the earliest and most constant dermal lesion of the diath- 
esis. It probably exists in all cases of syphilis, and is sometimes first recognized either by rea- 
son of limited distribution or of its very faint development. It commonly constitutes the whole 
eruption, but often coexists, even at the invasion of the disease, with papules and even 
pustules. 
The lesions composing the eruption consist of round or oval and irregular spots of hyperaemia, 
varying in diameter from a line to one-third or one-half of an inch. At first their color is usually 
of a very delicate pink, so light in some cases that the eruption looks like a very faint mottling of 
the skin. In others it is even less perceptible, and can only be seen by exposure of the parts to Plate X 
Part II 
LEA BROTHERS 8c CO. PUB LISHERS , PH ILADE LPHIA 
ERYTHEMATOUS SYPHILIDE. SYPHILIS. 
121 
cold air or water, and it becomes lost in the subsequent hyperaemic reaction. In outline the spots 
may be sharply marginated or ill-defined. They are not appreciably elevated, and at first not cov- 
ered with scales. In this form we constantly see a mixture of pea-sized spots with those having a 
diameter of a third of an inch. 
In marked contrast to this very subdued form of the erythematous syphilide, which is well shown 
in Fig. i, Plate X., is the more intense form, which is also frequently seen, and which is pictured in 
Fig. 2, Plate X. In this variety the eruption begins as pinkish or rosy spots, which quite rapidly 
become darker until a rather deep pinkish red is observed. (See Fig. 2, Plate X.) The spots are, 
as a rule, of a diameter of one-third or one-half an inch, presenting considerable uniformity, and 
often dotted with pinhead-sized punctae of deeper red, corresponding to the orifices of the seba- 
ceous and perspiratory glands, where it is probable that the hyperaemia is more intense. In this 
variety there is no elevation of surface, the spots are sharply marginated, and very soon become 
covered with minute scales. 
There is a third form of the erythematous syphilide, not at all uncommon, but which has not 
been clearly described. It consists of small well-marked subdued-red spots, having a blotchy or 
irregular outline, oftentimes gradually lost in the surrounding skin, and averaging from two to 
four lines in diameter. These spots, besides being readily seen, are as easily felt as very minute 
little rough prominences of the skin. The lesion is, though elevated, not at all papular, and close 
inspection shows that its salience is due to the marked localized hyperaemia, particularly around 
the follicles. This eruption has an individuality of its own, is wholly different from the roseole 
papuleuse of the French, comes out with tolerable promptness, and is seen in its most characteristic 
form on the anterior aspect of the trunk, less so on the back, limbs, and face, where its so-called 
elevation is less marked. It is blotchy, persistent in its course, becomes scaly quite early, and 
on its decline subsides into small pigmented spots. 
In their course these three clinical forms of the erythematous syphilide present considerable 
variation. 
The pale rose or pinkish eruption, which so often escapes detection, is usually of ephemeral 
duration. I he spots rarely become elevated, and more rarely the seat of scaling, and they dis- 
appear as they appeared, suddenly and quickly. It is not uncommon to see this eruption in its 
subdued form coexist with well-defined erythematous spots on the face, forehead, and the flexor 
surfaces of the arms. While, in general, the concomitant systemic disturbance is mild, very often it 
is severe with this rash. 
The second or more hyperaemic form of the erythematous syphilide usually appears by prompt 
and comparatively rapid invasion, and is often accompanied by marked elevation of temperature, 
malaise, rheumatoid pains, and neuralgias. The irregularly and generally distributed spots are at 
first of a grayish red, which soon assumes the purplish tint shown in Fig. 2, Plate X. Very often 
with this deepening of color punctae of even deeper hue appear at the orifices of follicles. Again, 
at these follicular openings circumscribed cell-increase occurs, forming very minute papules, which 
has given to the eruption the name roseole piquetee or granular roseola. In some cases, usually 
in only a certain number of spots, there is, besides the hyperaemia, moderate cell-increase into the 
papillae, producing a slight salience of the lesions-a condition called roseole papuleuse and roseola 
ur tic ata. 
I his form of the erythematous syphilide is peculiar for its chronicity, since the purplish spots 
remain unchanged for weeks, and perhaps as long as three months, fl hen they gradually become 
grayish brown, then coppery, and finally a yellowish buff, when they disappear, the process of invo- 
lution sometimes occupying several months. More or less desquamation is often observed in this 
syphlide from its period of development to its decline. 
The faint and the dark forms of this eruption may consist of numerous closely-packed and 122 
VENEREAL D/SEASES. 
generally-distributed spots or a more or less sparse eruption. In some cases, particularly of the 
dark spots, coalescence into patches of a number is seen, chiefly about the joints or on parts sub- 
jected to pressure and irritation. 
The tendency is well marked in all forms of the erythematous syphilide to appear first in the 
region of the umbilicus and on the hypogastrium, and from there they invade, in some cases slowly 
and in others quite rapidly, the whole trunk and extremities, showing preference for, but not being 
confined to, the flexor aspects, and very often localized and persistent on the palms and soles, 
where they very commonly form small and large, discrete and confluent, scaling patches, and often 
on the thorax, following the obliquity of the ribs. The face, chiefly the forehead and the cheeks, 
are also frequently invaded, while in many instances the eruption is seen on the hairy scalp, where 
it is commonly accompanied with alopecia. About the neck, chiefly at the hairy margin, it is also 
seen, and very often in quite large patches, owing to irritation of the collar or clothes. Physical 
exertion, hot baths, high temperature, acute mental emotions, and alcoholic stimulants are occasional 
causes of the abnormally rapid evolution of this syphilide. The more or less active circulation of 
'the patient has a marked influence on the intensity or mildness of the specific erythema. 
In its course the punctate form of the erythematous syphilide is frequently as chronic as the 
purplish form. The red and slight central elevations slowly subside with desquamation until the 
whole patch is no longer salient, and the dull red gradually turns into a coppery hue, and from that 
to a yellowish buff, until it is finally lost. 
In some cases, more especially those in which the eruption lasts quite long, and in which treat- 
ment has not been active, it is not uncommon to see a more or less copious papular syphilide devel- 
oped among the patches of erythema, or perhaps grouped in certain regions, near joints, or about 
the head. 
Relapses of the erythematous syphilide are not uncommon, but they present the peculiarity 
that the second rash does not follow immediately or soon after the first, which is, as a rule, fol- 
lowed by one of the papular or pustular order, but later 
on, at periods of from four to six months to a year and a 
half in very exceptional cases. Many instances of what 
seem to be true relapses of this syphilide are caused by 
accidental systemic disturbances, produced by changes 
of the season, nervous excitement, and alcoholic indulg- 
ence. I have many times observed this coincidence, the 
nature of which it is important to determine, owing to 
the disquieting effect upon the mind of the patient of 
the thougnt that his disease has returned to its original 
form. 
While it is not common, it certainly is not exceptional 
to see a generalized erythematous syphilide appear as a 
relapse. It is uncommon, however, to see the deeply hy- 
peraemic purplish form of the syphilide thus reappear. 
By far the most common form of relapse is a symmet- 
rical and less copious and extensive eruption, and limited 
to certain regions, such as the anterior aspect of the 
trunk, the forearms,near the joints, the wrists particularly, 
the thighs and buttocks, and about the forehead, nose, mouth, and chin. In these somewhat 
sparse and localized relapses the erythematous syphilide shows a marked tendency to assume 
the circular or ringed form, which is rarely seen in first exanthems, and is well shown in 
Fig. 6, in which the somewhat unusual feature is portrayed of rings forming within larger 
Fig. 6. 
Circular or Ringed Erythematous Syphilide. SYPHILIS. 
123 
rings. I have seen two instances of rather late-relapsing erythematous syphilide in which, at 
the flexor surface of the elbows and in the popliteal spaces, the eruption formed difluse patches 
over which were scattered a number of perfect disks of unaffected skin varying in diameter from 
one-third of an inch to one inch. 
In most cases of relapse there is an absence of the combination of severe systemic symptoms so 
often observed with the first eruption. The temperature may be normal, slightly raised, or much 
elevated. Being the most prominent of the early manifestations, this syphilide is always associated 
with a greater or less number of other lesions, a constant one being the chancre. Erythema of 
the fauces, erythematous patches excoriated by reason of coaptation of surface, papules on hairy 
parts, pustules, condylomata lata, alopecia, and affections of the nails are frequent concomitants ; 
to which may be added iritis and periostitis. 
Diagnosis.-In its hyperaemic stage the erythematous syphilide may be mistaken for rubeola, 
scarlatina, or the erythemata from copaiba, sandal-wood oil, and other drugs. I he mode of inva- 
sion-which is rarely as markedly acute as that of the exanthemata and of drug eruptions-the 
absence of the high fever, the catarrhal and conjunctival and gastric symptoms of the simple exan- 
thems, the circumscribed and indolent character of the rash, the history of the case, the concomit- 
ant lesions and symptoms, will readily indicate its syphilitic origin. Should a mistake occur, the 
persistence of the syphilitic rash is in such marked contrast with the evanescent course of the 
exanthemata and drug eruptions that the error would soon be corrected. 
Pityriasis versicolor is frequently mistaken for the pigmentary stains of the erythematous and 
other syphilides. In the parasitic eruption the patches are very large and also very small, whereas 
in the syphilitic pigmentation there is greater uniformity of small patches. Pityriasis or tinea 
versicolor begins about the sternal region, and from there spreads over the trunk, quite rarely 
to the extremities, neck, and most rarely to the face. It is also at times pruritic. Its patches 
may be removed by brisk friction, and its scales under the microscope show the microsporon 
furfur. 
The rings of this syphilide are permanent, and show no tendency to increase, and the enclosed 
skin is unaffected ; while those of tinea tonsurans enlarge gradually, enclose areas of scaling, 
slightly brownish skin, and are more scaly. In the scales of the parasitic eruption the tricophvton 
tonsurans is found. 
ERYTHEMA OF MUCOUS MEMBRANES; MUCOUS PATCHES AND 
CONDYLOMATA LATA. 
The mucous membranes are involved during the whole course of syphilis, particularly in its 
earliest period, by several of the morbid changes similar to those of the skin-namely, the ery- 
thema and the cell-infiltrations. The eruptions thus produced have points of resemblance with 
those of the skin, but they are much modified by moisture, friction, and irritations to which mucous 
membranes are constantly subjected. 
d he first and most constant erythema is that of the fauces or uvula and roof of the mouth. 
It may consist of simple redness of the surface, without any thickening, or of a redness with 
oedema of the parts. A more advanced form is that in which, in addition to the erythema, the 
surface of the mucous membrane has a milky appearance, as if lightly touched with a mild solu- 
tion of nitrate of silver or of carbolic acid. This opaline condition in syphilis is not developed in 
an unbroken patch, but scattered all over these surfaces are patches of superficial erosion of 
various shapes, as shown in Fig. 8, Plate VIII. This opaline erythema may be limited to the pos- 
terior wall of the pharynx, and may also involve the tonsils and just fringe the borders of the VENEREAL DISEASES. 
124 
pharynx. It also extends to the soft palate and the roof of the mouth, either on one or both 
sides ; and it is there absolutely diagnostic of syphilis, since in no other disease do we find the 
peculiar combination of milky-looking and superficially eroded and deep-red patches, unilateral 
and bilateral. 
Erythema in spots of varying size is seen on the glans and prepuce, in the vulva, and in the 
nose. The eruption is readily cured, but is prone to return, and necessitates the avoidance of all 
sources of irritation, the most strict attention to cleanliness, and, where possible, the separation of 
opposed surfaces. It is usually accompanied by a quite profuse mucoid secretion. 
Mucous patches, also termed mucous papules-so called from their surfaces resembling mu- 
cous membranes-are flat or moderately convex slight elevations, sometimes even being of the 
skin-level, of varying size, having a color from a grayish-pink to a decidedly rosy tint. They are 
found about the genitals and anus, on the inside of the cheeks, particularly at the angle of the 
mouth, on the lips, tongue, uvula, tonsils, at the opening of the nares, on the palpebral conjunc- 
tivae, at the umbilicus and the base of the nails, on the os uteri, and between the toes. In men they 
are found most frequently in the mouth and around the anus, while in women they are most com- 
mon upon the vulva. 
Mucous patches begin in small red spots, which grow quite rapidly until they attain an area of 
from one-third of an inch to one inch in diameter, having an oval or round outline according to the 
conformation of the parts upon which they appear. As they grow in size they become more or 
less salient, and from them a sticky, turbid, mucoid secretion escapes, which may dry into dirty 
crusts, but which always emits a peculiarly sickening odor. Usually, a number of these lesions 
are observed on a given locality, as is well shown in Figs. 6 and 7, Plate VIII., in which corre- 
sponding patches are seen on the under part of the penis and the scrotum on which it rests, and on 
the labia majora. This multiple character of these lesions is not due to auto-inoculation, but to the 
local irritation which exists equally on both surfaces. 
These lesions are peculiarly obstinate and prone to return so long as their determining causes, 
such as uncleanliness, irritating liquids, and close coaptation of parts, are operative. 
Mucous patches begin as erythematous spots which become the seat of cell-infiltration into the 
papillae, and thus these circumscribed hyperplasias are formed. The term "mucous patch" is 
reserved to these lesions when they are slightly salient and until they reach an elevation of not 
more than a line. Beyond that stage they often increase, by exuberance of cell-development, until 
they become quite prominent papulo-tubercles, when they are called condylomata. In some cases, 
however, they become ulcerated and reach the skin-level or even lower. 
Condylomata lata, or broad condylomata, are exuberant and exaggerated mucous patches, 
having the same pathological nature. They are pathognomonic expressions of the syphilitic diath- 
esis, and must not be confounded with the simple corneous and papillary cell-growths which are 
called vegetations. The clinical features of condylomata lata are well shown in Fig. 4, Plate VI., 
and can be satisfactorily contrasted with simple vegetations, shown in Fig. 3 of same plate. (See 
section on Vegetations.) These syphilitic lesions are round or oval, with a tendency to coalesce, 
are sharply marginated by abrupt steep borders, and have a more or less granular, mammillated 
surface, somewhat suggestive of a strawberry. Their color is a rosy red to a grayish or lilac red. 
Like mucous patches, they are accompanied with a mucoid, foul-smelling secretion, and they 
are also the cause, when seated on the glans penis or in the vulva, of a discharge resembling 
pronorrhoea. 
o 
Their course is indefinite and wholly governed by the circumstances which surround them and 
by treatment, to which they, like well-developed mucous patches, are slowly amenable. When 
much neglected on the penis and vulva, they in time form large, firm, exuberant cauliflower-looking 
masses, which have nothing of a syphilitic physiognomy, and are commonly mistaken for enormous 3art 1 
Fig.l. 
SMALL MILIARY PAPULAR SYPHILIDE. 
1. of Back. 2, of Face. 
LEA BROTHERS & CO. PUBLISHERS PHI LADE LPHIA 
Xate X 
Fig, 2. SYPHILIS. 
125 
vegetations, which in strict truth they are. Under these circumstances they are liable to undergo 
cancerous degeneration. 
Upon whatever part situated, about the mouth, nose, eye, anus, penis, and vulva, mucous 
patches and condylomata lata more or less seriously interfere with their functions. 
They are often accompanied by engorgement of the ganglia in immediate connection with 
the region upon which they are developed. The treatment of these lesions will be given with that 
of the syphilides. 
THE PAPULAR SYPHILIDES. 
Papular syphilides are formed by circumscribed cell-infiltrations into the papillae and rete 
mucosum. There are two well-defined varieties-the conical or miliary, and the lenticular or 
flat. 
The miliary papular syphilide is divided into two varieties-the small and the large. lhe 
small papules may be of the size of a pin's head, and even three or four times as large. 
I hey are conical or rounded, sometimes slightly umbilicated, elevations of the skin of a deep 
pinkish-red or of a dull coppery-red color. They present the marked peculiarity of appearing in 
groups or in the form of circles and segments of circles, or shaped like the letter S ; both of which 
appearances are well shown in Plate XL, Figs, i and 2, and in the latter iritis is shown. 1 he 
arrangement of the eruption usually differs somewhat according to the time of its development. 
When it appears very early, it is copiously scattered over the body, particularly on the face, with 
considerable interpapillary hyperaemia. A later evolution is peculiar in the fact that the circular 
and grouped tendency is more pronounced, so that even to the later months of the secondary 
period we see this syphilide in these forms usually much less copiously than earlier, and localized 
in certain regions. 
lhe small miliary papular syphilide usually begins about the face, and from there invades the 
whole body.1 Its evolution, particularly when early, is usually quite prompt-in some instances so 
much so that it may be called acute. Later on it may be slow, even chronic, in appearing, and 
there often is not the uniformity of size of small papules, but an intermixture of some large ones. 
I he morbid process composing this syphilide is really a specific folliculitis ; in other words, the 
lesions consist of infiltrations around sebaceous and hair-follicles. Such is usually the density of 
the papule tissue that this syphilide is peculiarly chronic and persistent, remaining unchanged, 
except perhaps showing a slight desquamation, for long periods. When large surfaces are 
invaded by this syphilide, passage of the hand over them gives a rough sensation, something like 
that of a nutmeg-grater or of sand-paper. Being essentially a follicular lesion, it is seen in 
copious development about the face and back, upon the anterior surface of the thorax, and on the 
outer aspects of the legs and arms. On the face and sternal region, in cases where the papules 
are very numerous and closely packed, they often run together into patches and become covered 
with thin, adhesive, sometimes excessive and greenish-white, scales, in which case the syphilitic 
1 Salsotto Di una forma non anchora descritta di Sifilide cutanea," Giornale Italiano della Malat. Venerei e della Pelle, 1887, 
P- 257) describes a form of syphilitic eruption peculiar to the early period and first year of infection, limited to the face, cheeks, alae 
nasi, lips, most commonly to the labio-nasal fold and mento-labial sulcus, which he thinks has not been described before. This syph- 
ilide consists of small-sized miliary and lenticular papules of a coppery color. They are seated in the above-mentioned folds, 
arranged in lines following those of the skin, and they may coalesce. The papules soon become covered with scales, which fall 
and are soon replaced. This desquamation continues until the syphilide, which is of relatively long duration, disappears and leaves 
coppery pigmentations. 
Salsotto calls the eruption " papulo-squamous syphilide of the face," and says that he never saw it in the male sex. In five hun- 
dred cases of syphilis he observed this form fifty-three times. Age, constitution, and color of skin of the patients have no causative 
influence. Salsotto thinks that this is a peculiar form of eruption, and not a variety of the classical papulo-squamous syphilides. 126 
VENEREAL E/SEASES. 
physiognomy of the eruption is lost and it appears like a psoriasis, or sometimes a seborrhoea, of 
this region. During the chronic course this syphilide gradually passes from the dull and even 
bright red to the coppery hue, and very often assumes a deep, dull purplish-coppery color. Not 
infrequently a minute quantity of pus is formed at the apex of a greater or less number of papules, 
when it becomes a-nice question to decide whether it is a case of papular or pustular syphilide. 
This condition is admirably shown in Fig. i, Plate XIV., from which, though it represents a small 
pustular syphilide, a very clear idea of the densely-packed form of the small miliary eruption may 
be gained, both as to size and shape of the lesions and to their color. Even when the general 
disease is being actively treated, these lesions are peculiarly chronic, and if left alone they remain 
indefinitely, preserving their salience and giving forth a scanty branny desquamation. They slowly 
subside, reach the skin-level in deep purplish-brown or dark-brown spots, which in many instances 
go on to marked atrophy. After several months they become small, whitish, depressed cicatrices, 
which are indelible. Iritis, neuralgia, cephalalgia, rheumatoid pains, and alopecia are not infre- 
quent concomitants. 
The diagnosis of the small miliary papular syphilide is quite easy in the early stage, and usu- 
ally in all stages, provided the whole body is examined. It may be mistaken for the punctate 
form of psoriasis, for lichen pilaris and lichen planus. In most cases a history of syphilis may be 
obtained, or the presence of other symptoms, active or passive, will point to its nature. In psori- 
asis the active growth of the papules and the early appearance of silvery imbricated scales will 
usually point to their nature. Lichen pilaris is developed mostly on the outer aspects of the 
extremities as disseminated minute follicular papules, many of skin color, and none tinted like 
those of syphilis nor peculiarly grouped-shows no tendency to invade the face, is more or less 
pruritic, and lacks a syphilitic history. Lichen planus is rarely such an extensive eruption, shows a 
predilection for the flexor surfaces, especially near the wrists and near the ankles, has larger Hat 
umbilicated papules, and is decidedly pruritic. 
The large miliary papular syphilide is a much less common eruption than the preceding, of 
which it not infrequently forms a part. The papules are of the size of a line in area or of a split 
pea. They are of conical, sometimes rounded, shape, of a deep-red or coppery hue, and not as 
often tinged with purple as their smaller fellows. I hey are rarely seen in large numbers, and 
most rarely constitute a general eruption, and then always as a rather late relapse. They are 
most profuse on the back, buttocks, the anterior portions of the thighs, and the face and back of 
the neck. They are sometimes seen also in not large numbers with the erythematous syphilide. 
They are scattered irregularly and often unsymmetrically, and show no tendency to close grouping 
or to form circles or segments of circles. They often become pustulated and degenerate into 
ulcers. They are more amenable to treatment than the small papules, and, though they very 
often subside into deep coppery, rusty-iron-tinted stains, they do not, as a rule, produce atrophic 
spots. 
This syphilide may be mistaken for acne indurata, which usually begins before puberty, has 
not such uniformity of lesions nor a syphilitic history, is more hyperaemic, and more abundant about 
the face and shoulders. In many, especially very chronic, cases, however, the color of the simple 
lesions resembles very much that of the syphilitic papules. Mercurial treatment will cause the 
specific lesions to disappear, and fails to affect the simple ones. 
THE LENTICULAR OR FLAT PAPULAR SYPHILIDE. 
There are two varieties of this syphilide-the small and the large. The small papular syph- 
ilide very commonly appears as a general eruption, sometimes being the first secondary manifesta- Part 11 
Plate XII 
LEA BROTHERS & CO. PUB L.ISHE RS , PH I LADE LPHIA 
LARGE FLAT PAPULAR SYPHILIDE AND 
INDURATED CHANCRE OF PUBES. 127 
SYPHILIS. 
tion upon the skin. The large papules are rarely seen as the first general eruption, most com- 
monly in sparse and scattered form with the erythematous syphilide or with the small papular 
variety, or even with the pustular syphilides. It also is seen as a rather late general rash. 
The small flat papular syphilide begins as rosy-red spots which reach a diameter of one-eighth 
to one-fourth of an inch and an elevation of from one-third to one-half a line. I hey are of round 
or oval shape, sharply marginated, surrounded with a slight red areola, and of a fiat rounded and 
sometimes umbilicated surface. They never show any anatomical 
connection with the follicles, but about the thorax often follow the 
line of obliquity of the ribs. The early general eruptions are, like 
those of the erythematous syphilide, scattered symmetrically over 
the body, as is shown in Plate XII. and in wood-cut Fig. 7, and the 
papules show no tendency to fuse together. In relapses, which are 
not uncommon with this syphilide, the papules are less numerous, 
are prone to appear symmetrically on certain regions, and also to 
assume a circular form. 
The sites upon which the papules first appear are about the 
shoulders, along the sides of the thorax, about the back of the 
neck, on the forehead, along the margin of the hairy scalp, where 
they form what has been called the corona Veneris, and upon the 
face, particularly in the central portions about the nose and mouth. 
Commonly, the extremities are invaded after the trunk and the 
head, and in early exanthems on both surfaces, flexor and extensor. 
In very many cases the supra- and infraclavicular regions are 
spared, but the rest of the trunk is well covered. The papules 
also appear on the palms and the soles, less copiously on the dor- 
sum of the hands and feet. On the gluteal regions they are usually 
very copious, and they are also found on the mons Veneris and 
groins. In somewhat rare cases these papules appear in great 
profusion about the face, often attended with marked hypertemia, 
when they cause a peculiar leonine expression which has been fan- 
cifully called syphilitic leontiasis-a condition which is also produced 
in even a more marked degree by later tubercular eruptions. 
I he color of these syphilitic papules is subject to much varia- 
tion in consequence of their situation and the conditions of the 
patient s circulation. Being at first of a rosy or pinkish red, they 
gradually become darker and have a coppery tint, such as is well 
shown in Plate XII. This deepening of color comes on earlier and 
is usually more pronounced upon the face, the forehead especially, 
and the legs. It is not uncommon to see the papules remain 
unchanged for a few weeks on the trunk. Very often they can 
scarcely be said to have any characteristic color, but look like pale-yellowish elevations of cell- 
infiltration, without hyperaemia, particularly in persons of very thin skin and poor circulation. On 
the legs they often take on a purplish color, and become surrounded by a well-marked areola of 
the same tint, owing to effusion or stasis. In somewhat rare cases these papules upon the face, 
particularly near the median line, are of the same tint as the skin, though they are generally ac- 
companied by those which are colored. Upon parts where the sebaceous glands are numerous this 
syphilide, with either small or large papules, becomes covered with a thin yellowish crust formed 
of epidermal scales and sebaceous matter. After a short duration the surfaces of the small papu- 
Fig. 7. 
Papular Syphilide in the Negro. 128 
VENEREAL DISEASES. 
lar syphilides become slightly roughened from the presence of small adherent scales, which are 
larger and more copious on regions where the epidermis is thick. The amount of scaling 
increases with the chronicity of the papules, and may later on become the most noticeable fea- 
ture of these lesions. 
These papules never present that firmness of consistence peculiar to the miliary varieties. 
In broken-down and cachectic subjects the epidermal covering of these papules is thrown off, 
and is replaced by a dirty-white thin membrane which covers a superficially ulcerated surface. 
Relapses of this syphilide are very common, but it is rare to see them in the extensive and 
generalized form. Commonly, there are a goodly number of these papules scattered over the 
Fig. 8. 
Fig. 9 
Papular Syphilide of Scalp. 
Papular Syphilide of Chin, Rhagades of Angles of Mouth. 
body and extremities, often intermixed with a much less abundance of large Hat papules. Then, 
again, we see tendencies for the syphilide to relapse in certain localities, as the head and face. On 
the vertex they may be seen in the median line, as shown in wood-cut Fig. 8. also on other parts 
of the scalp and the back of the neck. I he small miliary papular 
and the thematous syphihdes are also prone to appear in this 
region with the first eruption or with relapses. All of them are 
prone to produce more or less extensive and troublesome alo- 
pecia. These syphilides are sometimes the cause of even well- 
marked pruritus in this region. About the nose and chin also 
this syphilide is prone to appear in relapse, or thus limited in a 
rather late rash. In these regions the lesions are often of a semi- 
globular and even irregular shape in a sparse distribution, as 
shown in wood-cut Fig. 9, in which, at the angles of the mouth, 
the tendency of the papular syphilides to become rather hyper- 
trophic and superficially exulcerated is very well shown. This 
tendency is most marked at the junctions of skin and mucous 
membranes, at the nares, behind the ears, at the scrotum, penis, 
vulva, anus, and umbilicus, on the glans and prepuce, between 
the toes, and on all portions of the body where two layers of skin 
are in close coaptation. 
Relapses of this syphilide are also found very frequently near joints, rather more copiously 
than on the other portions of the extremities, and near them, particularly, they are prone to 
assume the shapes of circles, segments of circles, and crescentic lines. About the penis and 
Fig. io. 
Papular Syphilide in Circles and Encrusted. Part II 
Plate XIII 
Fi&.l'- 
W2. 
5. 
Fig.S. 
LEA BROTHERS & CO. PLJB LISHERS , PHILADELPHIA 
1 • ERYTHEMATOUS AND SCALING SYPHILIDE OF PALM . 2 . ULCERATING SYPHILIDE OF PALM . 
3.BULLOUS SYPHILIDE OF PALM . 4. SYPHILITIC PERIONYCHIA OF HAND . 
5. SYPHILITIC PERIONYCHIA OF FEET . SYPHILIS. 
129 
scrotum these papules also may assume the circular form, and here, owing to the moisture of the 
parts, they often become covered with adherent crusts composed of much epithelium and some 
sero-pus. 1 his complication of the flat papular syphilide, which is also seen near the gluteal fis- 
sure, under the breast, and near the axillae, is well pictured in wood-cut Fig. io. In the majority 
of cases the circles produced by the various forms of 
papular syphilides are due to the development of 
papules in the shape of rings and segments of rings, 
and are completed by the fusion of these lesions 
together ; in which case the enclosed areas of skin 
are unaffected. More exceptionally, the papules 
increase at their margin by a ringed elevation, and 
thus extend, the skin healing in the centre while the 
morbid process gradually covers more surface. This 
phenomenon is well portrayed in wood-cut Fig. n, 
which shows the well-marked scaling rings with the 
enclosed dull-red and desquamating areas. A rather 
exceptional feature is shown in the figures on the neck 
and under the jaw, in which circles are enclosed within 
larger circles. In this case new lesions began after 
the first ones had become circles, and followed the 
course of their predecessors. 
I he small flat papular syphilide is seen to attack 
the palms and soles with almost as much frequency 
as the erythematous eruption. I he papules maybe distributed over the whole palm and upon 
the fingers, as shown in Fig. i, Plate XIII., or they may be sparsely grouped in the central hol- 
low, with a few scattered outlying ones, or they may show a tendency to the formation 
of more or less complete circles. In 
these regions and upon the soles of 
the feet these papules are prone to 
become seated in a chronic form, when 
they lose all individuality and give rise 
to a patchy or expansive Scaling and 
thickened affection of the skin. Wood- 
cut Fig. 12 shows the general distribu- 
tion of the scaling patches of the palm 
following the flat papular syphilide, in 
marked contrast to the appearance of 
psoriasis and eczema of these parts. 
In the negro, as I first pointed 
yphilitic papules sometimes are of snow-white color, as shown in Fig. 8, the original of which 
e subject of my paper. The white color is probably due to the cell-infiltration, which 
es the pigment-cells of the rete mucosum. In many cases the pathological appearance is 
absent, and the papules are of a coal-black color in true negroes, and rather dark in mulattoes. 
The resolution of this syphilide in its uncomplicated form is accomplished by the absorption 
of the new cells, which is always materially hastened by the action of mercury. The papules 
gradually subside and flatten until pigment-spots red or coppery in hue are left. Tfie pigmentation 
disappears gradually, and remains longest on the lower extremities. 
FIG. II. 
Circinate and Scaling Form of Papular Syphilide. 
Fig. 12. 
Squamous Syphilide of Palm. 
1 "On a Peculiarity of the Papular Syphilide of the Negro," Am. Journal of Dermat. and Syphilography, 1873, P- 107. VENEREAL DISEASES. 
130 
In most cases atrophic changes do not follow the flat syphilitic papules, though when they are 
very chronic, especially about the face, small spots of atrophy are left. 
The mode of invasion of this syphilide is usually subacute, and is often accelerated by excess- 
ive heat, alcoholic drinks, and hot baths. A period of a week or two, and sometimes longer, is 
required for its full evolution. The copiousness of the eruption is very variable, being well marked 
in first rashes, even to the point of nearly covering the whole surface of the body, while in relapses 
it is more or less sparse. In the latter forms new papules may appear for one or two months. 
Relapses may be expected at any time within two years after infection if treatment is not 
followed, and sometimes later. 
The concomitant lesions and symptoms of this syphilide, when the first rash, are mucous 
patches and condylomata lata of the mouth, throat, genitals, and anus, general adenopathy, alo- 
pecia, cephalalgia, neuralgias, rheumatoid pains, and iritis. 
Diagnosis.-Such are the marked appearances of this syphilide as a general eruption, with its 
history and concomitant symptoms, that the diagnosis is usually very easily made. When, however, 
it exists in a sparse and localized form, particularly when the papules are of varying sizes and more 
or less scaly, a semblance to psoriasis is offered. The papules and patches of this latter affection are 
essentially scaly, silvery, and imbricated. It usually begins before puberty, and its history is that 
of a repetition of precisely similar lesions, and sometimes of heredity. In syphilis the history of 
some or all of the primary or secondary lesions and symptoms may usually be obtained, and the fact 
may be elicited that previous eruptions presented different peculiarities. In syphilis repetition of 
precisely the same dermal lesions is not common. In the ringed form of the small flat papular 
syphilide its tendency to be localized near joints, its history, and the coincident appearance of 
lesions of the mucous membranes, will generally point to its origin. 
THE LARGE FLAT PAPULAR SYPHILIDE. 
The large flat syphilitic papules are exaggerations of the smaller ones, being from one-quar- 
ter to one-half, and even an inch, in diameter. They are round or oval, sharply marginated, hav- 
ing a flat surface, with sometimes a sloping depression in the centre. They appear as minute 
spots, which increase in area and in height, which is usually about one line or less. They vary in 
color, being of a rosy-red, a sombre coppery^red, and even of a purplish-brown color. 
This syphilide rather rarely appears as the first secondary eruption, and is then very often 
mingled with the erythematous syphilide, with which it sometimes appears in limited numbers. It 
is usually a much more sparse eruption than the small flat variety, and does not show the tendency 
of the latter to become grouped in the form of circles. It is found on the forehead, face, nucha, 
shoulders, back, anterior aspect of trunk, over the inguinal and gluteal regions, and over the 
extremities on the flexor aspects, and particularly near joints. It is found on the palms and 
soles, and near and on muco-cutaneous junctions, where it is prone to assume the appearance 
of condylomata lata. Friction or irritation causes these papules to increase very much in 
area. 
This syphilide belongs to the middle and late portions of the secondary stage, rather than the 
early ones ; and for this reason it is called by the French an intermediary eruption. It may occur 
quite late in syphilis, even in the third year, and is seen to coexist with well-marked tertiary lesions. 
It may relapse several times, but commonly this occurs in the progressively sparse forms, so that 
there may be less than a dozen of these lesions on the whole body. When they thus appear very 
late, they often attain an area of more than an inch, with a corresponding deep-seated condition 
and marked elevation, when they reach the dignity of being called papulo-tubercles. These SYPHILIS. 
i3i 
large papules undergo metamorphoses similar to those of the small ones. Their surfaces may 
become covered with a dirty false membrane ; they may be the seat of ulceration ; they may form 
scaling patches and by peripheral extension form distinct rings, as shown in wood-cut Fig. II. In 
rare cases they grow in area, while from their surfaces papillomatous growths, due to inflammatory 
hypertrophy of the papillae, shoot up and form what has been called the verrucous or vegetating 
syphilides. This phenomenon is mostly observed upon the scalp, face, shoulders, gluteal regions, 
and genitals. The papules sometimes reach an elevation of two or three lines, and even more, 
and they give issue to a foul-smelling secretion. This transformation is also seen in condylomata 
lata, in syphilitic tubercles, and upon the surfaces of healing gummatous or tubercular syphilitic 
ulcers. 
When near parts the seat of moisture or in coaptation these papules become superficially 
eroded. 
The tendency of the large flat papular syphilide is to remain in an indolent condition and to 
become chronic scaling or ulcerated patches. Under treatment the papules slowly subside, accom- 
panied by more or less desquamation, until pigmented spots are left. Sometimes the centre of the 
papule is absorbed first, and a scaling rino- is left for a short time. 
The concomitants of this syphilide when it appears early are those of the exanthematic stage. 
Later on it may coexist with pustular eruptions of the hairy parts, iritis, nodes of flat and long 
bones, alopecia, onychia, perionychia, condylomata, and cachexia, and when very late with tertiary 
lesions. 
Prognosis.-The early appearance of this syphilide is indicative of an active and proliferative 
state of the disease. Its frequent relapse is an undoubted proof of the gravity of the case. 
Diagnosis.- This form of syphilide is usually very readily diagnosticated when it appears 
early and coincidently with other syphilitic, symptoms. Later on, it may be mistaken for psoriasis, 
particularly if the patches are scaly. A consideration of the facts given in the diagnosis of the 
small flat papular syphilide will be of service in determining the nature of the larger papules. 
SYPHILITIC ONYCHIA AND PERIONYCHIA. 
In syphilitic onychia the morbid process begins in the nail itself; in perionychia it begins in 
the soft tissues around the nail, and then involves it. Both affections run a chronic course and are 
more or less destructive. They are peculiar to the first and second years of syphilis, but may 
occur at later periods. 
In syphilitic onychia the nail becomes lustreless, of a dull-yellow or bluish-yellow color, thick- 
ened, cracked at the free margin, friable, and brittle. Its surface becomes rough and seamed with 
longitudinal fissures, which allow dirt to accumulate. The surrounding skin becomes thickened, 
cracked, and scaling. More or less of the nail is thus involved. 
In the early secondary stage separation of the nail to a more or less extent may begin at the 
free border and extend toward the base. In some cases the morbid process consists of a narrow 
linear separation ; in others more or all of the nail becomes separated. As this detachment occurs 
the nail changes color into a greenish-brown or bluish-black color. When the separation is par- 
tial the newly-growing nail from the base pushes forward and covers the part left bare. One or 
more nails, even all of them, may thus be affected, those of the hands more commonly than those 
of the feet. 
Perionychia syphilitica is seen in two forms : first, that in which the lesion begins around the 
margin of the nail ; second, where the integument of the distal phalanx becomes infiltrated and 
inflamed, and as a result the nail is secondarily involved. 132 
VENEREAL DISEASES. 
The affection usually begins as papule or pustule, or as a fissure, which is imitated on either 
the lateral borders of the nail or at the basal sulcus. Ulceration then begins which affects the 
nutrition of the nail and loosens it. If this process is limited to one border or to a portion of the 
border of the nail, if arrested early only a limited destruction is produced. If, however, the mor- 
bid process begins at the basal sulcus, the ulceration burrows under the lunula, and then may 
involve the whole matrix. In any case the nail is wholly destroyed, whereas if the ulceration 
begins on the side, and even involves considerable surface, the nail will be soon replaced, since 
the base and lunula then remain intact. 
If the base of the nail is wholly destroyed by ulceration, a new one is not formed, and the 
matrix becomes covered with cicatricial tissue. When the distal part of the matrix has been fully 
destroyed, the nail reaches as far as that, and there stops. 
Ulcerative perionychia may begin under the free margin of the nail, and gradually destroy the 
matrix as far as the base. 
Diffuse perionychia, well shown in Figs. 4 and 5, Plate XIII., begins usually painlessly during 
the active stages of syphilis as a redness of the distal portions of the fingers. The affected por- 
tions gradually become of a sombre coppery red and swollen and bulbous, sometimes in shape like 
an Indian club. When the inflammation and infiltration are advanced, the nutrition of the nails is 
affected, and they die rapidly as if struck by a blight. This rapid necrosis is peculiar to this form 
of perionychia. The nail first loses its color, which becomes dull and dark ; its lateral attachments 
become loosened, and its whole surface is undermined and ulcerated, and a foul-smelling pus 
escapes from beneath it. Then the nail becomes blackish-green, uneven, and puckered. With 
the onset of the nail affection severe pain begins, which renders the fingers useless and the toes 
an impediment to locomotion. If any portion of the nail remains imbedded-and some usually 
does-it acts as a foreign body and keeps up the pain and ulceration. In these cases inflammation 
of the lymphatics and axillary glands, with fever, malaise, and much suffering, may supervene. 
When the dead nail is removed and treatment instituted, the swelling begins to subside and the 
matrix to heal, and unless the destruction has been too great, a new nail, at first rather imperfect, 
is formed. 
In the treatment of these nail affections internal medication is of prime importance, while 
local applications are also required. For the dry onychia careful trimming and filing are necessary, 
with the prevention of irritation. For the ulcerative form careful washings and the application, if 
necessary, of a mild caustic, followed by iodoform, are essential. 
For diffuse perionychia the first indication is the total removal of the nail and its spiculze. 
When much inflammation is present, hot-water immersions, followed by the application of lead- 
and-opium wash, are required. Then iodoform may be carefully dusted over the morbid surface, 
which may be covered with absorbent cotton and the finger gently bandaged. Equal parts of 
mercurial and zinc ointments, with extract of belladonna, may be used in addition. 
THE PUSTULAR SYPHILIDES. 
These eruptions are less common than the preceding ones, and may appear both early and 
late in the course of syphilis, in a mild and ephemeral and in a severe form. 
In size the pustules may be as small as a pin's head or as large as a ten-cent piece. They 
are conical, globose, flat, sometimes umbilicated, of round or oval outline, and usually surrounded 
with more or less bright-red or copper-colored areola. Under some pustules there is considerable 
cell-infiltration ; under others the thickening is not very perceptible. These lesions begin as true 
pustules, or as papules which shortly become pustules. The pustular syphilide may be very 'art I 
Fife.1. 
SMALL PUSTULAR OR ACNE - FORM SYPH1LIDE. 
1. of4 Back. 2, of face and Chest, with indurated Chancre of Lip. 3. of Arm 
Fig. 3. 
Fig. 2. 
LEA BROTHERS & CO PUB LiS H E RS . PH I LADE LPHIA 
Fate XIV SYPHILIS. 
133 
copious and involve the whole body, as shown in Fig. i, Plate XIV., or less copiously, though 
generally distributed, as seen in Fig. 2 of the same plate. Again, they may be sparse and limited 
to certain regions. Regions copiously supplied with hair and sebaceous follicles are the ones 
most commonly invaded by these eruptions. The pustules are usually symmetrically distributed, 
either in a grouped or scattered form. The early and extensive eruptions of these syphilides 
appear and develop promptly, the later and more sparse ones in a subacute and chronic manner. 
In general, the pus of these lesions dries quickly into crusts, which vary in shape according to 
that of the pustules. They may be conical or flat, round, oval, or horseshoe-shaped. 
Pustules may simply leave pigmentations, and even cicatrices. 
The Small Pustular or Acneform Syphilide.-This syphilide attacks the hair and seba- 
ceous follicles, and consists of papulo-pustules. Its lesions are of the size of pinheads and 
larger, usually conical, sometimes rounded, and decidedly elevated. It very frequently forms the 
whole eruption, but is often accompanied by miliary papules, large conical pustules, and erythe- 
matous patches. 
Its evolution early in the secondary stage is often attended with marked systemic disturbances 
and very high fever. Its mode of invasion is rapid in the early months of syphilis, when the rash 
is commonly very copious, and subacute in subsequent eruptions. The maturity of the pustules 
occurs within forty-eight hours in the rapid cases, but it is more slowly reached in the subacute 
ones. Very often in cases of very rapid development the lesions are papular for a day or two, 
and then a minute quantity of pus begins to form on their apices. In the subacute and chronic 
eruptions the lesions are less numerous, more localized, and show a tendency to appear in groups. 
The acute eruption is shown in Fig. 1, Plate XIV., and the subacute in Figs. 2 and 3. In Fig. 1 
it will be noticed that each pustule remains separate, and that little or no coalescence is seen. 
There is also no tendency of the minute pustules to become ulcerated. In Figs. 2 and 3 the 
appearances of these pustules in relapses or second eruptions are well shown. Some of the pus- 
tules, especially where pressure is liable to be exerted, have become enlarged and encrusted. I he 
distribution of the pustules on the scalp, over the forehead, on the inner third of the face, chiefly 
at the nose, mouth, and chin, is most characteristic. The little groups of pustules, accompanied 
by much hyperaemia on the outer aspect of the arm in Fig. 3, are typical in appearance. On the 
upper lip of the woman pictured in Fig. 2 is an extensive hard chancre. 
I he color of the base and areola of pustules is at first a bright red, later a dull brownish- 
red or coppery, and on the lip it may be tinged with purple from stasis. As a rule, the papulo- 
pustules remain intact, they rarely becoming ulcerated and fusing together, as other forms of 
pustules do. After a longer or shorter time the little masses of pus at the apices of the lesions 
become of a brown or greenish-brown color, dry, and fall off, leaving papular lesions, which 
give the skin a hard, warty feel. The papules desquamate, subside slowly, and finally leave 
pigmented spots. 
Relapses of the syphilide are prone to occur in groups of from twenty to thirty pustules, 
which are scattered over the face, trunk, and extremities. Late in the secondary period small 
groups of pustules may occur scattered over the face, sometimes in ringed form, and during the 
whole period they sometimes relapse upon the scalp. 
I his form of pustular syphilide in early eruptions begins about the face, scalp, back of the 
neck, and shoulders, whence it spreads, becoming very copious over the whole back, the scapular 
regions especially, also on the sternal regions and on the outer aspects of the extremities. 
I he course of this syphilide is especially chronic, usually lasting several months. Owing to 
its chronicity and the density of structure of its lesions it is very often followed by cicatrices 
which destroy the follicles. For this reason the alopecia of the scalp produced by it is usually 
permanent. 134 
VENEREAL DISEASES. 
The p rognosis of this syphilide is less favorable than that of the other early forms. The 
eruption is more persistent and destructive and the constitutional reaction greater. 
When it appears early this syphilide is usually accompanied by the lesions and symptoms 
peculiar to that stage. Later on, iritis, nervous phenomena, and bone lesions are frequent 
concomitants. 
Diagnosis.-The early eruption of this syphilide, with its sudden onset, general distribution, 
its history, and its concomitant lesions and symptoms, is so well marked that its nature is recog- 
nized at once. Later and more sparse eruptions may be mistaken for acne. The latter simple 
affection begins about puberty on the face, and later on the back, never in the scalp, consists of 
papules, pustules, and comedones, and is lacking in a syphilitic history and other specific symptoms 
and lesions. 
THE LARGE PUSTULAR OR IMPETIGO-FORM SYPHILIDE. 
This syphilide is less common than the preceding variety, and consists of pustules of the size 
of a pea, and even of greater area. The eruption resembles simple impetigo somewhat in the 
appearance of the pustules, in their grouping, in their tendency to coalesce, and in their crusting. 
In general, however, the syphilitic pustules are larger and flatter than those of impetigo ; hence 
the resemblance is often more imaginary than real, 
This eruption may be said never to occur as the initial secondary rash, but it usually follows 
the early ones at longer or shorter intervals from the middle of the first and as late as the second 
or third year. Like all the early syphilides, the eruption of this form is more copious in the early 
months, and more sparse and localized at later periods. The pustules have a perifollicular origin 
in most instances ; hence the syphilide is most constant and exuberant on parts where the seba- 
ceous and hair-follicles are most numerous. 
The pustules begin as red spots which rapidly become elevated by yellow subepidermal pus. 
They are in shape round and oval, decidedly elevated, acuminate, globose, and sometimes distinctly 
umbilicated, particularly as they begin to desiccate. Over bony prominences and parts subject to 
pressure and friction they increase much in area. In Fig. i, Plate XV-, the large pustular syph- 
ilide is admirably portrayed in its period of full development. The quite uniform large size of the 
very salient pustules is well shown, together with their well-marked areola. The copiousness of 
the eruption points to the fact of its early evolution. Its situation upon the forehead and scalp, 
generally over the face, neck, and upper part of the trunk, is typical. The large pustules are 
seated where the suspenders or clothes press more tightly than elsewhere. The various shapes, 
round, oval, conical, globular, and umbilicated, are well shown. 
After the maturity of the pustules they promptly begin to wither, and soon flatten down into 
light or dull-greenish or brownish-green and brown casts, and as they then increase more or less 
in area, those which are near one another may fuse together. They thus occur in irregular and 
round groups ; sometimes the outer ones fuse and form circles enclosing an encrusted or red area 
of skin. 
The encrusted stage of this syphilide is well shown on the back in Fig. 2, Plate XV., in which 
the varying shades of green are well marked, with the uneven flat surfaces of the papules, their lim- 
ited coppery-red areola, depicted. About the middle of this picture, among a group of crusts, two 
pustules may be seen fused together; which feature is often much more extensive. On the top 
of the shoulders the crusts are of a deep brownish-green, due to admixture of minute quantities of 
blood exuded by pressure. The sparse and localized distribution of this syphilide in Fig. 2 is 
indicative of a relapse or of late evolution. A comparison of Plates XIV. and XV. will show very 
clearly the varying characteristics of the large and small conical pustular syphilides. Dart I 
Fig 2. 
LARGE PUSTULAR OR IMPETIGO - FORM SYPHILIDE 
1. of' Face 2. of Back . 
LEA BROTHERS & CO. PUB LI S H E R S . PH I LADE LPHIA . 
Fife.l 
Plate XV SYPHILIS. 
135 
The ulceration under the crusts is usually superficial, and not active. In unhealthy subjects 
the pustules become active ulcers, which increase peripherally while they heal in the centre, they 
thus increase in a serpiginous and superficial manner, until they may cover large portions of the 
integument. In some cases a deeper serpiginous ulceration takes place. Thus it is that this syph- 
ilide is one of the foci of the two forms of serpiginous syphilide. The ulceration may extend in 
depth rather than in area, and destroy much tissue, as is sometimes seen on the scalp, where they 
may become vegetating, in the beard, and upon the nose. In cachectic, dissipated, and poorly- 
nourished subjects this syphilide in its entirety is prone to undergo exacerbations, by which, owing 
to the extent and depth of the many ulcers and to the concomitant systemic condition, a malignant 
form of syphilis is developed. 
I he course of this syphilide is generally chronic and rather exceptionally rapid. It may 
appear as a quite copious eruption, and thus end, or it may begin in a generalized sparse form 
and from time to time be increased by the appearance of new pustules. 
1 his syphilide is rarely found in combination with the erythematous syphilide, except as a 
relapse, but in a sparse form it is sometimes a concomitant of the papular syphilides and of lesions 
common to the late secondary, and even the tertiary, period. 
Prognosis.-This depends upon the extent and malignancy of the eruption and on the state 
of the health of the patient. Careful local treatment and hygiene are necessary. 
Diagnosis.-The absence of acuteness of invasion, and the inflammatory accompaniments, 
neat and itching, differentiate this eruption very clearly from simple impetigo. The presence of 
concomitant lesions or their sequelae and the history of the case will generally establish their syph- 
ilitic origin. 
THE ECTHYMA-FORM SYPHILIDE. 
I his syphilide may appear quite early in secondary stages, when, as a rule, it is superficial in 
character, and at later periods, when it may be deeply ulcerative. The lesions of the early periods 
begin as small red elevations of the skin, which in a few days become conical or rounded pustules 
from one to three lines in area. They continually, but usually not rapidly, increase in size, while 
their purulent contents become dry, greenish-brown, and even black, crusts from the admixture 
of dirt or the presence of small quantities of blood. The process of extension is attended with a 
flattening and perhaps central depression in the crusts. In Fig. i, Plate XVI., newly-formed and 
forming crusts are well shown of a greenish and greenish-brown color. On the lower part of the 
figure are eight pustules of small size, which show well the purulent origin of the lesions. In 
f igs. 2 and 3 the brownish-green, even blackish-brown, color of the crusts is faithfully presented. 
I his syphilide is usually attended with a well-marked pink-red and dark-red areola, but it is less 
active, inflammatory, and pronounced than it is in simple ecthyma. Beginning as a purplish-red, it 
soon reaches the deep coppery-red hue seen in Figs. 2 and 3. 
1 he superficial ecthyma-form syphilide begins in a more or less sparse form about the face 
and neck, particularly near the margin of the hair, and from there it spreads most copiously over 
the back, legs, or on the anterior surface of the trunk, on the gluteal and inguinal regions, and on 
the outer aspects of the arms and legs, usually being more profuse on the upper than on the lower 
extremities. The whole eruption may appear promptly within a week or ten days, and perhaps be 
attended with fever and malaise, or it may be developed in crops at short intervals, the whole evo- 
lution sometimes occupying several months. As a rule, the earlier the appearance of the eruption 
the more copious and extensive will it be, and versa. The pustules may be scattered in an 
isolated manner or grouped together, sometimes in the shape of circles and parts of circles. In VENEREAL DISEASES. 
136 
late appearances this syphilide may be unsymmetrical and limited to one or more regions. In Fig. 
2 the peculiarity of this syphilide to form into kidney-shaped crusts is well shown, particularly in 
the lesion above the elbow and that nearest the wrist. This metamorphosis of the pustules is 
sometimes even more pronounced, and semblances of a horseshoe are formed. The course of the 
pustules can be well traced on the outer and lower edges of the figure. In Fig. 3 the tendency 
sometimes seen in this syphilide for the crusts to become conical is quite well shown in the larger 
ones. This feature will be further dwelt on in the section on the rupial syphilide. An inspection 
of all the figures shows that the lesions are distinctly pustular from the first. The deep variety 
of the ecthyma-form syphilide is simply an exaggeration in all respects of the preceding. The pus- 
tules begin on a more infiltrated base, ulceration is more extensive and deeper, and the crusts 
become firmer and thicker and very rapidly of a brownish-black color. When lifted off, usually 
with some little force, a grayish-red ulcerated surface covered with an unhealthy coppery-red glu- 
tinous pus is seen. The surrounding areola is of a deep coppery red. The situations of develop- 
ment of this variety are similar to those of the superficial form. The lesions are usually less 
numerous, more localized, and even more chronic. They may remain isolated or several may 
coalesce. 
The evolution of the deep ecthyma-form syphilide is usually very slow, appearing in crops of 
from two to a dozen pustules, and extending over months or a year. In some cases it is accom- 
panied by extreme cachexia and fever of a remittent type, while in others the systemic symptoms 
are not severe. 
The superficial eruption usually leaves pigmented spots, while the deep variety very often is 
followed by well-marked and usually thin cicatrices, which are at first of a coppery color, and in 
time become of a glistening white. 
The prognosis of this syphilide depends largely upon the severity of the systemic condition, 
which, as has been shown, may be mild or severe. The presence of so many encrusted lesions 
gives rise to much discomfort, and at last they leave temporary spots of disfigurement, and even 
indelible cicatrices. The persistent appearance of new crops of pustules influences the prognosis 
unfavorably. 
The diagnosis of this syphilide is usually not difficult. It is well to bear in mind that the sub- 
acute aphlegmasic evolution of the syphilitic eruptions is in marked contrast with the inflammatory 
course and pruritic condition of simple ecthyma. The latter is usually seen most copiously on the 
legs and sparsely on the arms, rarely upon the trunk, particularly in broken-down and dissipated 
subjects. Persons suffering from pediculosis frequently have an ecthymatous eruption about the 
legs, which is usually accompanied with other pronounced symptoms and lesions of this affection, 
a consideration of which soon settles its origin. Part 11 
Plate XVI 
Fi§. 3. 
Fig .1 
Fig. 2. 
LEA BROTHERS & CO. PUBLISHERS , PHILADELPHIA 
ECTHYMA-FORM SYPH1LIDE. 
1 &: 2 , of Arms . 3, of Back . PART III. 
RUPIA OR RUPIAL SYPHILIDE. 
The term rupia, which signifies dirt, is applied to an eruption consisting of ulcers upon which 
laminated crusts are formed. In strict accuracy, rupia is more properly the sequela of the various 
pustular syphilides, since any of the latter may assume the features of rupia. It is for this reason 
that we see this form of syphilide both early and late in the course of the disease, both as a quite 
copious and also as a sparse eruption. Its presence is pathognomonic of more or less severe syph- 
ilitic infection, and it is commonly accompanied by cachexia and febrile movement. 
Rupia may appear precociously within the first half year of infection, within two years, and 
several years later, and exceptionally very late in the course of the disease. It is seen in two 
forms : first, that in which the crusts are small, numerous, and more or less symmetrically placed 
over the body, and occurring in the secondary period of syphilis ; and second, that in which the 
crusts are larger, less numerous, more localized, and often unsymmetrical, in which the evolution 
is late. Rupia thus in many respects has the characteristics of both secondary and tertiary 
lesions. 
It begins as a pustule, which soon flattens into a dry, greenish-brown crust. Under this crust 
infiltiation and ulceration occur, which extend beyond its margins, and from which pus is secreted, 
which on becoming dry forms another and slightly larger layer of crust. Then, as the ulceration 
extends in area, further laminae of crusts, each slightly larger than its predecessor, are formed, 
until in the end a conical laminated crust results, as is shown in Fig. 3, Plate XVI., and Fig. 1, 
I late XVII. In general, the pus secreted by these ulcers is thick and scanty, and, being formed 
slowly, it dries quickly, and as a consequence considerable time is occupied in the formation of a 
typical crust, which is usually quite adherent. In some cases, however, the pus is more copious 
and more fluid, and the crusts seem to swim upon it, are less adherent, and they develop much 
more rapidly. Thus we find these lesions varying in size from a half inch to one and two inches, 
and even to six inches, in diameter. 
Rupial crusts are conical, laminated, dry, firm, and of a brownish-black color, like a dirty oys- 
ter-shell. I he ulceration underneath them may be quite superficial or decidedly deep, surrounded 
by a well-defined, slightly undermined margin of deep-red or coppery-red skin, having an unhealthy, 
smooth, grayish-red surface covered with pus. 
In general, the early rupial lesions develop quite promptly by a continuous or even intermit- 
tent course, while the late ones are very slow in their evolution, occupying many months. 
1 he early or small rupial eruption usually begins in the pustules of the large pustular syph- 
ilide or in those of the ecthyma-form syphilide, and is really an intensification of these eruptions. 
It does not follow, however, that in a given case all of the lesions will become rupial, since it is 
very commonly seen that some wither, while others increase. An excellent illustration of the 
ecthyma-form syphilide in the process of becoming rupial is shown in Fig. 3, Plate XVI., in which 
the various gradations of the crusts are very noticeable, In Fig. 2 of the same plate the tendency 
of a few of the crusts to become rupial is also shown. 
137 138 
VENEREAL DISEASES. 
This eruption is prone to appear upon the face, on the outer and inner surfaces of the extrem- 
ities, and upon the trunk, particularly upon the back. 1 he crusts are most frequently seen on the 
forehead, near the nose, mouth, and on the chin. 1 he eruption may thus be limited to one region, 
as shown in Fig. 2, Plate XVII., in which are depicted many pustules, some in process of desicca- 
tion, and rupial crusts of various sizes, the largest being on the lower lip, and, as is common in this 
region and upon the nose, chin, and in the beard, being of rather exceptional size and of irregular 
shape. In other cases the forearms, and even the trunk, may be affected, and sometimes all of the 
regions previously mentioned may be the seat of rupia. It is rare to see the eruption limited to 
the lower extremities. While in general rupial crusts retain their own individuality, they some- 
times coalesce and form horseshoe and other irregular shapes. 
The mode of evolution of the syphilide is usually by successive crops, which may appear on a 
certain region or may extend to other parts. I his eruption usually leaves cicatrices of various 
degrees. 
The large form of rupia is usually quite sharply limited in its area of development, as well as 
in the number of its lesions, and its course is more chronic and more aphlegmasic than that of the 
small variety. It occurs most constantly upon the face, on the scalp, trunk, and upper extremities ; 
also upon the buttocks and lower extremities. It may be symmetrically or unsymmetrically dis- 
tributed, and may be limited to one encrusted ulcer or there may be as many as twenty or thirty. 
The lesions usually appear singly or in small number, and they grow slowly and painlessly. Their 
course is markedly irregular, some being developed with comparative rapidity and reaching an area 
of one inch within one or two months, while in the evolution of others six or more months may 
elapse. Having reached a diameter of about an inch, further increase is usually accomplished 
quite slowly. 
The ulceration, which is really the essential lesion, in the large form of rupia is usually quite 
deep, involving one half and even more of the thickness of the derma, and has a smooth, unhealthy, 
grayish-red surface, with a sharp, undermined margin of a deep-red color. 
The large rupial eruption is well shown in Fig. 1, Plate XVII., in which the lesions are quite 
numerous. The laminated crusts are well shown, particularly on the forearm, while on the arm 
near the elbow the surface is more rugose and irregular, owing undoubtedly to the frequent move- 
ments of this part. 
After removal of these crusts thinner ones may form until treatment produces healthy granu- 
lation and healing. Not very infrequently, even in untreated cases, healing begins spontaneously 
under the crust, which may be thrown off by the profuse granulations. The latter feature may 
occur even in cases while under treatment. Upon the healing of the ulcer a deep-red, thickened, 
glazed spot is left, which slowly becomes thinner, sinks down more or less below the skin-level, 
becomes slowly blanched, until in the end, which may occupy weeks, months, or years, a white, 
shining, depressed cicatrix surrounded by a pigmented border, and perhaps traversed by fibrous 
bands or the seat of minute follicular depressions, is left. 
The prognosis of rupia should be guardedly made, since the systemic condition is usually that 
of more or less pronounced cachexia. Coexistence of visceral affections renders it more grave. 
Early precocious and extensive eruptions call for careful hygiene and treatment. Such cases are 
not necessarily fatal, nor are they always indicative of permanent ill-health or invalidism, since 
they are amenable to judicious and energetic medication, local and general. 
The large form of rupia is usually indicative of a profound and lasting infection and gready 
impaired nutrition, and calls for the most watchful and judicious treatment. 
Especially upon the face and extremities these ulcers cause annoyance and suffering. 
No difficulty in diagnosis can occur, since no simple eruption resembles rupia. Part III 
Plate XVII 
Fig 3. 
Fig.2. 
Fig.L 
LEA BROTHERS & CO PUB LISHERS . PHILADELPH IA 
1. Rupial Syphilide of'Arm . 2. of Face 
3. Ulcerating Tubercular Syphilide in form of Zona. RUPIA OR RUP1AL SYPHILIDE. 
139 
THE BULLOUS SYPHILIDE. 
There is a form of syphilide in which the pustules resemble those of variola and varicella, and 
sometimes become so large that they look like blebs. This eruption is much less common than 
the other pustular syphilides, and follows the various other rashes. It begins as red spots, which 
are soon replaced by superficial pustules whose epithelial covering is very thin, and which have a 
tendency to spread out, attain considerable area, and become umbilicated, though they may retain 
a globular shape and look like bullae. They are found usually on regions where the epidermis is 
thin and delicate, and they show no tendency to develop around follicles. They grow slowly, some- 
times coalesce, pursue an indolent course, become dry and puckered, and form greenish-brown 
crusts. I hese lesions may be scattered over the body or grouped in regions, such as the forehead 
and face, on the anterior surfaces of the extremities, particularly the upper ones, and sometimes 
upon the palms and the soles. On account of the large size of the pustules this eruption was 
called pemphigus syphiliticus by French writers. It is this latitude in the definition of the word 
pustule " which has caused so much confusion in syphilography, and which has given rise to the 
view that the bullous syphilide, which is quite common in hereditary syphilis, is also of rather fre- 
quent occurrence in the acquired disease. 
Ihe true bullous syphilide is decidedly rare in acquired syphilis, and occurs usually late in its 
course in cachectic subjects and in those reduced by dissipation, want, and hunger, and in the 
victims of visceral disease. 
Ihe eruption begins by the effusion of serum beneath the epidermis, by which in a week or 
two a bulla is formed. Its course is slow and its distribution sparse and discrete. I he serum 
very soon becomes turbid and milky, and then purulent. It may dry and form a greenish-brown 
crust, or the walls of the bulla may rupture and an ulcerated surface may be left. In Fig. 5 of 
I late XIII. this syphilide, occurring on the wrist and palmar surface of the hand and fingers, is 
well shown. Ihe ruptured bullse have left shreds of epidermis which partially cover the deep cop- 
pery-red, superficially ulcerated surface, which is surrounded by a characteristic narrow deep-red 
areola. I he process of development of the bullse can be traced from the small to the large 
lesions. 
Ihe resulting ulcers may be superficial and may heal rapidly, or they may become deep, 
destructive, and even gangrenous. This syphilide when mild may not leave cicatrices ; when 
severe more or less destruction of the skin is produced. 
THE GUMMATOUS SYPHILIDES. 
There are two forms of the gummatous syphilides: first, the early secondary or precocious 
gummata, and second, those appearing late in the course of the disease and called tertiary. 
lhe early gummata present many of the characteristics of the secondary lesions, while the 
late form possesses those of the tertiary period. 
I here are three distinct varieties of the early or precocious gummata-a generalized, a local- 
ized, and a neurotic variety. 
Ihe generalized form appears as early as the eighth week of infection and at any time during 
the first and early parts of the second year, the rule being that the earlier the date of its appear- 
ance the more extensive is the eruption and the more numerous the lesions. It begins in the form 
of small circumscribed swellings under the skin, usually unattended with pain and only perceptible 
to the touch. In a short time they become adherent to the skin, and then they appear like bright- VENEREAL DISEASES. 
140 
red spots, which are frequently looked upon as blind boils. Thus early they are found to be round 
or oval tumors of the size of a bean deeply set in the skin. They grow quite rapidly, and within 
ten days may attain an area of an inch or inch and a half. A slower growth is also seen. As they 
increase in size their red color becomes more sombre, and perhaps coppery. When fully devel- 
oped they present a quite firm structure, and may be said to be in the stage of condensation. 
Their course is usually quite constant and without much variation. As they grow older their red 
color becomes more coppery, and they gradually grow softer in structure, as if they were perme- 
ated with fluid. This may be called the stage of softening, which varies in degree in different 
cases. In some tumors there is simply a soft, yielding condition of the tissues ; in others, what 
appears to be true fluctuation may be felt. To the inexperienced these tumors in the latter case 
may giye imPressi°n °f abscesses and suggest the use of the knife, which, however, should not 
be used, since absorption may occur even in this stage of liquefaction of the gummy infiltration. 
Under favorable circumstances these lesions do not go on to ulceration, and they are then said to 
belong to the resolutive variety of this early form of gummata. Then the tumors gradually lose 
the slight convex elevation which they had attained, and slowly flatten out, while they gradually melt 
away from their outer edge, their color fading pari passu until a pigment-spot is left which is most 
persistent upon the legs. Slight or severe cicatrices may also be left. The period of development 
of these tumors usually occupies from ten days to two weeks, but after that their duration is vari- 
able. Under careful treatment they may promptly retrogress, and may without it remain in an 
indolent condition in the second stage indefinitely. 
This eruption is prone to appear symmetrically over the body, at first in a crop of goodly 
number, which may be increased by successive smaller ones at shorter or longer intervals. Some- 
times, even when the general eruption is copious, medication is very efficient in the control of 
this syphilide, and new crops may be prevented if treatment is instituted promptly. The arms, 
forearms, the scapular regions, perhaps the back, the anterior surface of the trunk, the gluteal 
regions, thighs, and legs, mostly on the anterior and outer aspects, are the parts usually invaded. 
On the legs these tumors frequently take on inflammatory action when complicated with varicose 
veins, with oedema, chronic eczema, dermatitis, erysipelas, and pediculosis. 
In some cases the resolutive tendency in this eruption is not observed, but a necrobiotic action 
soon appears. The stage of condensation is then quite short and softening begins early. The 
centre of the tumors assumes a dark-red color in one or in several spots, and distinct fluctuation 
is soon made out. Then slight ulceration begins, usually in several places, corresponding to the 
follicular openings, and very soon the epidermal roof of the tumor melts away, and an unhealthy 
ulcer with a slightly fungating greenish-red floor, covered with a sanious pus, and surrounded by a 
thickened deep-red, undermined, and more or less everted edge, is seen. As a rule, however, these 
precocious gummatous ulcers are more superficial than the tertiary ones ; their floor is less deep, 
their edges less undermined and everted, and their whole appearance indicates that the destruction 
is less profound. The further course of these ulcers is largely dependent upon local and internal 
medication, without which it may be indefinite. 
The concomitant symptoms of this generalized early gummatous eruption are those of the 
secondary period of syphilis. It frequently follows, and even coexists with, the generalized sec- 
ondary rashes. There is usually much accompanying systemic reaction, cachexia, malaise, and dis- 
turbance of the nervous system. 
The localized form of early gummata appears somewhat later than the preceding one ; that is, 
at about the fifth month and within the first year of infection, and perhaps later. The difference 
between the two is mainly that of degree and extent of development of the lesions. Like the first 
variety, the evolution of the tumors is aphlegmasic, but a little more indolent and insidious ; in 
short, partaking to a certain extent of the characteristics of both the very early secondary and ter- RUPIA OR RUPIAL SYPHILIDE. 
141 
tiary gummata. The tumors present the same appearance, except that they are larger and per- 
haps not quite as salient as those of the first variety. The regions of the head and face, pharyn- 
geal walls and mouth, the forearms and legs, are the ones upon which the eruption usually appears, 
though it sometimes is seen upon the trunk, arms, and thighs. 1 he stages of condensation and 
softening are observed in the course of these tumors, which may become absorbed or may break 
down into ulcers which are larger and more pronounced in their features than the earlier ones. 
I he eruption is usually symmetrical in the early months of syphilis, and it shows a progressive 
tendency to unsymmetrical development as it appears later in the disease. 
I hese two forms of gummata are found in aged persons, in those given to alcoholic excesses, 
in subjects of strumous tendency, and those debilitated by any exhausting cause or adynamic influ- 
ence, such as visceral diseases, fevers, pneumonia, diphtheria, chronic malaria, want and squalor, 
and in persons of poor fibre. 
I he neurotic form of the early gummata has a marked individuality of its own, and presents 
points of resemblance to erythema nodosum. In the very early months of syphilis, either in the 
stationary period of an early syphilide or at its decline, generally preceded or accompanied by 
severe neuralgic symptoms involving the facial or cranial, intercostal, anterior crural, or any cuta- 
neous nerve, by cephalalgia continuous or nocturnal, by rheumatoid pains in the muscles or joints, 
and by malaise and debility, this eruption makes its appearance with more or less promptitude and 
develops quite rapidly. In some instances so acute is the invasion that in a week we may find 
fully-developed tumors an inch or two long, but in general their evolution is rather less rapid. In 
addition to the neuralgic phenomena, local pains on the sites of the lesions or on the whole terri- 
tory or limb on which they are developed are complained of. These pains may be continuous or 
intermittent, and in some instances are as excruciating as in severe herpes zoster. They are 
described as flashing, burning, lancinating, and are sometimes said to resemble those of an abscess. 
In some instances the patient's sufferings are less after the evolution of the syphilide, but in most 
cases the tumors are so painful that patients shrink with terror from their palpation. There is also 
a moderate febrile movement, an evening temperature of ioo° or ioi° Fahr., and in very severe 
cases as high as 104° ; emaciation, want of appetite, and all their concomitant symptoms. The 
seats of predilection are the forearms and legs, but the tumors may appear on the shoulders, arms, 
thighs, chest, and trunk. As a result of the pain and swelling in the arms and legs there are more 
or less discomfort, stiffness, impairment of motion, even to the extent of pseudo-paralysis. 
1 he eruption consists of two orders of lesions : first, oval or round tumors, or irregular plaques 
from fusion of tumors ; second, tumors or nodosities seated in the subcutaneous tissues, and at 
first freely movable under the skin and fasciae, and later on adherent by both their upper and lower 
surfaces. 
lhe cutaneous tumors begin by infiltration in the deeper portions of the skin and its con- 
tiguous connective tissue. When first seen they are in bright-red and rather sharply circumscribed 
spots, which soon form round or oval swellings, slightly raised and convex. In some cases the 
bright-red color rapidly becomes darkened until a blackish-red or decidedly ecchymotic appearance 
is seen, while in others it is of a deep bright-red similar to that of erythema nodosum. In some 
cases, again, the red centre pales and becomes the color of white wax or of a billiard ball, while 
the deep-red border or areola remains in various stages of intensity, consisting of a commingling 
or play of colors, such as we see following a bruise or erythema nodosum. In many cases resolu- 
tion takes place ; in others the stage of softening may end in ulceration. The resulting ulcers 
present all the characters of the late gummata, except that they are rather more superficial. Their 
subsequent course is usually chronic and aphlegmasic. In some cases general inflammation and 
swelling attack a limb or the seat of these lesions, and the patient's suffering is thereby much 
increased. Commonly, these tumors or ulcers remain separate, but sometimes they increase and 142 
VENEREAL DISEASES. 
coalesce. They are, as a rule, symmetrically placed. The resulting cicatrices are usually slight 
and superficial. 
Late or tertiary gummata are peculiar to more advanced stages of syphilis, and are, like the pre- 
ceding lesions, true circumscribed tumors. I his eruption is generally composed of a limited num- 
ber of lesions whose invasion is slow, painless, and aphlegmasic, and which are symmetrically or 
unsymmetrically placed. It is particularly prone to appear upon parts where the connective tis- 
sues are loose and abundant. It may be limited to the connective tissue, and on invading the skin it 
usually ulcerates. When subcutaneous the lesions are called gummous or gummatous tumors, and 
when they involve the skin in ulceration they are called gummatous ulcers. This syphilide, there- 
fore, has three stages-of tumefaction, of ulceration, and of repair. It begins as small pea-sized, 
movable, painless nodules under the skin, which grow quite slowly. As they increase in area they 
contract adhesions with the skin and over bony surfaces and in parts where the connective tissue is 
scanty with the periosteum and fasciae. I hey possess a well-marked firmness of structure, are 
quite resistant to pressure, less elastic than fatty tumors, and not as firm as scirrhus. The super- 
ficial growth of these nodules is attended with reddening of the skin, which, as infiltration goes on, 
becomes of a deep coppery-red, much thickened, and less supple. The resulting lesions are tuber- 
cular infiltrations into the skin and connective tissue, or true gummy tumors, which are more or 
less convex and usually surrounded by an inflammatory areola of greater or less breadth. Gummy 
tumors may be of the size of a pea, a hickory-nut, or have a diameter of several inches. They 
show a marked tendency to develop in groups near together, and, while each may remain isolated, 
they frequently fuse together into large patches, as is well shown in Fig. 4, Plate XVIII., as occur- 
ring upon the buttocks, where the connective tissue is very abundant. 
Gummy tumors may remain in the stage of tumefaction for weeks or months, and under treat- 
ment undergo resolution. As a rule, however, they soon undergo degeneration in either of two 
ways: first, ulceration may occur at one or more points on the cutaneous surface, and extend to 
the whole lesion, or the subcutaneous new growth may soften and cause ulceration in the overlying 
skin. Various stages of fluctuation are felt in these softening tumors. In many instances the 
symptom is deceptive, and a premature incision gives vent to a thick bloody fluid and reveals a 
softened necrotic mass, but no abscess-cavity. True fluctuation, however, may be felt later on, and 
a cavity containing a thick, viscid, gummy fluid resulting from the disintegration of the tumor is 
found. Surgical interference is not usually required. 
The resulting gummatous ulcer is in shape similar to the tumor, round or oval or horseshoe- 
shaped, gyrate, or irregular, from the fusion together of these lesions. In Fig. 1, Plate XVIII., a 
typical small gummy ulcer upon the knee is well shown : a larger one on the shoulder is pictured 
in big. 2 ; in Fig. 3 a characteristic horseshoe-shaped ulcer from fusion of three primary ones is 
depicted, while in Fig. 4 an admirable illustration of diffuse gyrate and irregular gummy ulcers is 
given, brom a study of these pictures all of the clinical features of gummatous ulceration may be 
gleaned. It is necessary to remember that the precocious gummatous ulcers resemble these later 
ones in most of their features. 
The floor of gummatous ulcers is very uneven, of a reddish-green, sometimes greenish-black, 
color, and bathed with a sanious, very fetid pus. The edges are thickened, sharply cut, and per- 
pendicular, as if punched out, red, sometimes more or less everted, and surrounded by an extensive 
areola of hyperaemia. The course of these ulcers varies according to the care they receive. They 
often remain in an indolent condition for months, and cause much oedema of the surrounding parts. 
Groups of ulcers may be found connected by narrow bands of reddened and detached skin, whose 
nutrition is but feebly sustained by the superficial vessels, as shown in Fig. 4, Plate XVIII., on the 
left side, and which sooner or later melt away. 
The depth of these ulcers depends largely upon the thickness of the connective tissue and the Part I|] 
Plate XV111 
Hfc.l. 
Fig. 2. 
Fi^. S. 
Fit; .4 
LEA BROTHERS & CO. PUBLISHERS .PHILADELPHIA 
GUMMOUS SYPH1LIDE. 
1.of Knee. 2. of Shoulder. 3.of Ankle. 
4 , of Hut locks . RUPIA OR RUPIAL SYPHILIDE. 
143 
extent of the infiltration. Over bony surfaces, such as the ulnae, clavicles, cranial bones, and the 
anterior surfaces of the tibiae, they ar.e comparatively shallow, as they are near joints, as shown in 
bigs, i, 2, and 3, Plate XVIII. Upon the walls of the body, arms, and thighs, and more especially 
upon the gluteal regions, they are often very deep, in very fat persons in these localities being fully 
three inches below the skin-level. In some cases they expose the surface of muscles, and they may 
even invade the intermuscular septa. 
Reparative action is seen in the development of healthy granulations upon the foul surface of 
the ulcer, in the cicatrization, beginning usually at the margin, and in the fading of the hyperaemic 
areola. I he cicatrices differ according to the situation and depth of the destructive process. In 
some cases they are thin and parchment-like ; in others they are rough from the presence of fib- 
rous bands and nodules. Their deep purplish-red or coppery-red color gradually and very slowly 
fades from their centre outward until a dead-white, and perhaps glistening, hue is left. 
I he gummatous syphilide may appear on the scalp, the face, and the neck. It is prone to 
attack the extremities near the joints, and is found on the posterior aspect of the trunk more fre- 
quently than on the anterior, very often on the gluteal regions, very rarely on the lower part of the 
abdomen, and never on the palms or the soles. 
I hese ulcers may take on a serpiginous course, and may become converted into the serpig- 
inous syphilide ; they may become phagedenic or even gangrenous. They may be complicated 
by erysipelas, particularly when seated on the head or the extremities, and their healing thereby is 
often much accelerated. They frequently induce upon the legs severe and chronic oedema, which 
may give rise to a condition similar to elephantiasis Arabum. 
Gummy tumors and ulcers, when seated on the upper and lower extremities, sometimes 
involve the cutaneous nerves and cause neuralgias and various other disturbances of sensibility. 
Prognosis.- I he appearance of gummata very early in the secondary stage is indicative of an 
active condition of infection and a lowered vitality, and calls for prompt and efficient treatment. 
lertiary gummatous lesions show that the diathesis is still active and that infiltrations in vari- 
ous portions of the body are to be feared. Besides the local danger incident to these lesions, the 
general systemic condition is usually not favorable. The presence of a gummy infiltration into any 
part points to the necessity of thorough and prolonged treatment. 
Diagnosis.- I he early generalized form of gummata is usually readily recognized, since its 
characteristics are well marked and the infection is so recent that other symptoms are present or 
a history is readily obtained. The little tumors have been diagnosticated as "blind boils," and 
they may sometimes present some of the painful and inflammatory symptoms of furuncles. 
1 he localized form is also readily recognized, especially when the lesions are symmetrically placed, 
hen there are few of them, limited to certain regions, doubt as to their nature may arise, which can 
usually be dispelled by the history of the case and of the existence of some active or declining specific 
lesion elsewhere. It is important to bear in mind that upon the regions of the head, face, mouth, 
pharynx, and the upper and lower extremities these lesions are prone to develop. 
I he neurotic gummata may at first be mistaken for erythema nodosum, but usually there is a 
history of recent infection or there are some other signs of syphilis. In general, the systemic con- 
dition in the specific affection is rather more aphlegmasic than that of the simple trouble, though 
the nervous symptoms are usually more severe in the former than in the latter. Should doubt 
exist in the mind of the surgeon early in the history of the eruption as its evolution progresses, 
with the history of the case before him, with its much more chronic and aphlegmasic course, and 
its rebelliousness to simple treatment, it will soon be dispelled. 
The diagnosis of late gummata is to be made in the state of tumor and of ulceration. As a 
movable subcutaneous tumor a gumma may be mistaken for a fibrous, a sarcomatous, or a fatty 
tumor, an enlarged ganglion, or a bursa the seat of chronic inflammation. Very often but little 144 
VENEREAL DISEASES. 
help can be gained by palpation, and the diagnosis will be made by the history of the case, the 
possible presence of some other lesion or some syphilitic sequela, by the absence of pain, and by 
the situation of the tumor or tumors. Tumor-like or diffuse infiltrations about the face, in the 
mouth, in the female breast, about the genitals, near joints, and in parts where the connective 
tissues are abundant, should always, when doubt exists, be first subjected to specific treatment, 
which has frequently caused the absorption of growths for which the knife had been advised. 
Patients while taking the iodide of potassium, particularly in large doses and for a consider- 
able time, are sometimes attacked by subcutaneous nodules or tumors which may be mistaken for 
gummata, but which will disappear quite promptly upon discontinuing the drug. 
In both the stage of tumefaction and of ulceration, gummata about the face may be mistaken 
for lupus, the evolution of which usually occurs before puberty, while its seat is in the derma rather 
than in the subcutaneous tissues. (For further particulars see section on Lupus.) 
THE TUBERCULAR SYPHILIDE. 
This syphilide is really an exaggeration of the large conical and flat papular syphilides, and is 
peculiar in the manifold changes which the tubercles undergo. It consists of deeply-seated, cir- 
cumscribed, and sometimes diffuse infiltrations into the whole thickness of the derma, whereas the 
infiltrations composing the papular syphilides are seated more superficially in that tissue. The 
line of demarcation, however, cannot in every case be determined, and we then apply the term 
" papulo-tubercles " to lesions which are more than papules and less in structure than tubercles. 
While the papular syphilides, though peculiar to the secondary period, may appear rather late in 
the disease, so the tubercular syphilides, though belonging to the tertiary period, may exception- 
ally be developed more or less early in the secondary stage. 
The non-ulcerative or resolutive tubercular syphilide is seen in two well-marked forms-first, 
as sharply-defined conical or rounded tubercles, and second, as more or less elevated, flat, sharply- 
circumscribed, and often scaly patches. These lesions do not, as a rule, ulcerate, but disappear by 
fatty degeneration and interstitial absorption. 
The conical or rounded tubercles vary in size from a diameter of one-third of an inch to an 
inch or more. The small ones are comparable to a split pea seated deeply in the derma, while the 
larger ones may be likened to a split marble and a split walnut similarly placed. These lesions 
begin as pinkish, and even deep red, non-inflammatory spots, which increase slowly in depth and 
area until a decidedly rounded or conical elevation is reached, when the sharply-defined tubercle is 
the result. The small tubercles retain their rounded or conical elevated state for considerable 
periods, while the larger ones become flatter and seemingly, but not actually, less salient. When 
fully formed they have a pinkish-red, a coppery- or brownish-red, and even a crimson-red, color. 
Their appearance on the face is well shown in many of the outlying tubercles in Fig. i, Plate XIX. 
On this region they usually have a smooth, shining surface, with little and perhaps no scaling, 
whereas when developed where the epidermis is thick their surface is often quite copiously covered 
with good-sized quite adherent scales. This appearance is portrayed in Fig. 2, Plate XIX. 
When appearing in the secondary period, or, as we may say, precociously, this syphilide, 
usually invades the whole body in the same symmetrical manner as the large papular syphilide 
in a more or less copious and disseminated eruption. In its normal evolution it shows a tendency 
to attack certain regions, perhaps being limited to one or invading several. The sites of predilec- 
tion are the face ; the forehead ; the scalp ; the back of the neck ; the shoulders and scapular 
regions ; the thorax, particularly on its posterior aspect; the gluteal regions ; the limbs, more 
commonly on the outer aspects and near the elbows and knees, occasionally about the wrists or Plate XIX 
Part 111 
Fi|.2. 
LEA BROTHERS & CO PUBLISHERS . PHIL.ADELPHI A 
TUBERCULAR SYPHILIDE N0N-ULCERAT1VE. 
1 , of Face 2, of Arm . TUBERCULAR SYPHILIDE. 
145 
the back of the hands, and rather exceptionally on the palms and soles. When thus developed 
upon certain regions the tubercular syphilide shows a tendency to the grouped arrangement of its 
lesions, in some cases circular, and again irregular. Upon the forehead, where it is frequently 
seen, it often forms an irregularly triangular group, with the apex at the glabella and the base near 
the margin of the scalp, along which it also shows' a tendency to develop in the shape of a semi- 
circular band or corona, thus resembling an early and frequent distribution of the syphilitic papule 
which is called the corona Veneris. It also appears in a scattered or irregularly grouped form over 
the forehead, particularly toward the median line. On the face the tubercles usually appear first 
about the alae nasi, and from there spread outward upon the cheeks and upward over the forehead, 
t pon the face, as well as upon the forehead, the tubercles show a marked tendency to appear in 
successive crops, usually at the margins, and perhaps at a distance beyond the original patch. 
1 hey may be scattered without any particular order or may appear in a more or less circular 
arrangement. 
I he irregular and circular grouping of recurring crops of tubercles is well shown in Fig. i, 
Plate XIX. On the right cheek the circle of lesions is tolerably perfect, and the merging of 
the upper circle on the cheek with the smaller one jutting from the lip gives the festooned 
appearance so characteristic of this syphilide under these circumstances. On the forehead the 
tubercles are distributed without order. While, in general, atrophy takes place in the old and 
central tubercles, as is well shown in the patch on the right cheek of Fig. I, Plate XIX., rather 
exceptionally new tubercles appear on the exact sites of previous ones. We then have the picture 
of a ring of tubercles enclosing an area which is undergoing atrophic changes, while upon it new 
and well-formed lesions also appear. When the tubercles are very numerous and hypertrophic 
upon the face, a peculiar leonine expression is given to it which has been termed by some authors 
"syphilitic leontiasis." This same feature is sometimes observed in the course of the papular 
syphilides under similar circumstances. 
Another somewhat exceptional feature in the course of this syphilide is observed upon the 
face, nose, and forehead. One or more tubercles fuse together into a patch which increases quite 
rapidly all along its whole margin. As this tubercular infiltration increases and extends at its 
periphery, atrophy and absorption take place in its enclosed area ; the result is that the lesion is 
transformed into a circle or ring composed of a distinctly 
elevated margin or rim enclosing a somewhat but seem- 
lngiy quite depressed central patch, which gradually loses 
its deep-red or brownish-red color, and is finally converted 
into a more or less perfectly atrophied tissue. When the 
process is rapid, the resulting destruction of the skin is 
usually slight, but when it is slow marked atrophy is, as 
a rule, produced. When this peculiarity of course attends 
tubercles seated about the nose, butterfly-shaped patches, 
the body being formed by the nose itself and the wings 
on the cheeks, may result, the whole presenting points of 
resemblance to lupus erythematosus. In wood-cut Fig. 
!3 this annular development of the tubercular syphilide is , 
admirably shown as occurring upon the forehead, the upper 
lip, and the lower part of the cheek, the elevated rim being 
the focus of the syphilitic new growth, while the enclosed area is cicatricial. 
In big. 14 a tubercular patch is shown which has resulted from the fusion of a number of 
tubercles, and which is covered with a thin greenish-brown crust. The peculiar encrusted state 
of this syphilide is seen not infrequently about the face and on parts rich in sebaceous glands. 
Fig. 13. 
Tubercular Syphilide of Face, annular and 
serpiginous. 146 
VENEREAL D/SEASES. 
The crusts are composed of epidermal cells and dried sebaceous matter, and are not, as might be 
suspected from cursory examination, due to ulceration. When this syphilide is developed upon 
hairy parts its surface is less smooth than elsewhere, and very often it becomes vegetating or pap- 
illomatous in character. 
On the body the non-ulcerative tubercular syphilide pursues, as a rule, a similar course to that 
observed on the face. It may be developed in the shape of circles or segments of circles, figures- 
of-eight, serpentine lines, and kidney-shaped patches, more 
especially on the shoulder and near the elbows and knees. 
In many cases a group of tubercles fuses into a patch which is 
slowly but continuously enlarged by the development of new 
tubercles at its margin and by its own extension. This fea- 
ture is clearly shown in Fig. 2, Plate XIX., in a patch nine 
inches long and six inches wide, seated on the elbow, with 
new tubercles constantly forming at its periphery. In this 
region, as also about the knees and upon the palms and 
soles, scaling is a constant concomitant symptom. Besides 
this mode of extension by the development of outlying tuber- 
cles, these lesions, particularly on the trunk, frequently fuse 
into a patch which grows by its whole border or by portions 
of it, and thus comes to have crescentic and often festooned margins. In this way it often involves 
vast areas of skin, atrophy taking place in the central portions, while the infiltration goes relent- 
lessly on. This creeping course of the eruption has, in the past, led observers to term it "serpig- 
inous syphilide," but I think that the latter term should be reserved to a creeping ulcerative syph- 
ilide, for reasons to be given. It is not unusual to see more or less of the body and extremities 
invaded by this eruption without one particle of ulceration. In some cases, however, owing to 
traumatism, slight ulceration may occur. Then, again, owing to external and internal causes, 
particularly those of a debilitating nature, this quondam resolutive syphilide becomes more or less 
ulcerative and changed in appearance. 
The second form of this syphilide is rather less frequent than the first, and consists of flat, 
sharply-circumscribed patches which are deeply seated in the derma. It begins as small red spots 
which increase at first quite rapidly, until they attain an area of one or two inches, or even more 
than that. An excellent idea is conveyed of this form of eruption by wood-cut Fig. 15. The 
tubercles are usually not much elevated, are sharply marginated, and commonly look like patches 
of thickened and reddened skin covered with a greater or less quantity of imbricated scales. The 
color of the lesions is of a deep red, a coppery red, or sometimes a red bordering upon purple. 
The surrounding areola is usually narrow and of various shades of red. The individual lesions 
run an aphlegmasic and chronic course. They are exceptionally developed in the shape of 
circles, and may, particularly when irritated, fuse together into large and diffuse patches, which 
are usually accompanied by decided hyperaemia. This is frequently seen upon the legs. In some 
cases tubercles increase at their margin and undergo atrophy in their centres. Atrophic changes 
in the middle of tubercles are usually seen after they have reached a diameter of an inch. Sev- 
eral or many tubercles may undergo ulceration, and not infrequently does this occur upon parts 
subjected to friction and pressure. In general, this form of tubercular syphilide is more prone 
to degeneration than the first variety. Upon part? where the circulation is very active or where 
there are many sebaceous follicles colloid degeneration may occur. 
The earlier the evolution of this syphilide the more copious and disseminated is the eruption. 
At later periods it is more localized and the tubercles less numerous. Its course is very slow, 
occupying weeks, months, and years. This syphilide shows a marked tendency to relapse, and is 
Fig. 14. 
Tubercular Syphilide of Face, in parts covered 
with crusts. 
_ € TUBERCULAR SYPHILIDE. 
147 
somewhat peculiar among its congeners in the fact 
that it retains its own individuality for such long 
periods. 
The atrophic spots left after absorption of the 
tubercles are usually sharply defined, at first of a 
dark-brown color, which gradually gives way to a 
dull-white tint. A ring of pigmentation often re- 
mains around an atrophic cicatrix for a long time. 
The concomitants of this syphilide when occur- 
ring early are perionychia, alopecia, iritis, cerebral af 
fections, testicular lesions, and condylomata. Later 
on it may coexist with cachexia or osseous periosteal 
and visceral lesions. 
Diagnosis.-Such is the clearly-marked appear- 
ance of this syphilide that errors in diagnosis should 
be very rare. Upon the face an eruption of conical 
tubercles in groups or patches might be mistaken for 
lupus. The tubercles of the latter are less regular 
m outline, not circularly grouped, and pinkish rather 
than brownish-red in color, frequently studded with 
colloid masses, and very prone to ulceration. With 
the specific lesion there is usually a history of infec- 
tion or of antecedent lesions, or a coexistence of 
other specific lesions or their sequelae or symptoms. 
Lupus usually begins before puberty. A perusal 
of the section on Lupus erythematosus will enable 
the reader to quite readily differentiate that affec- 
tion from the specific eruption. 
I ubercles of leprosy may resemble those of 
syphilis sometimes very closely. They, however, 
are almost always accompanied by patches of white 
anaesthetic skin, by nerve-swellings, perversions of 
sensation, nodular infiltrations, and ulceration ; and, 
moreover, there is commonly a history of the dis- 
ease. 
1 he second form of the tubercular syphilide 
may be mistaken for psoriasis, but care in the study 
of the history of the case will usually put the ob- 
server right. Besides its syphilitic history, and fre- 
quently the presence of sequelae of other specific 
lesions, the tubercular syphilide is peculiar in the 
lact that atrophic changes are very soon noticed in 
the centre of the lesions, and that some of them, 
few or many, may undergo ulceration. These features are not observed in psoriasis. 
Fig. 15. 
Generalized Tubercular Syphilide, resembling psoriasis. 148 
££N£££AL D/S£AS£S. 
THE ULCERATIVE SYPHILIDES, EARLY AND LATE. 
Besides the impetigoform and ecthymaform syphilides, which sometimes show a tendency to 
active ulceration, there are a number of syphilitic ulcerative eruptions which may appear early or in 
the secondary period, and which are called "malignant precocious syphilides." They vary in the 
copiousness and extent of the lesions and in their duration. These eruptions may thus begin in a 
malign and destructive manner, or the ulcerative tendency may be engrafted on syphilides papular 
or pustular which began without any malignancy. As a general rule, some excessively debilitating 
influence or lowered state of nutrition is the cause of the activity of the syphilitic poison. Alco- 
holism is a prolific source of malignant syphilis. 
In Fig. 2, Plate XXL, is well shown an early ulcerating syphilide of extensive development 
and destructive character. The starting-point of the eruption is seated in the numerous small, 
scattered pustules, which rapidly form ulcers which become covered with thick crusts-a condition 
indicative of rapid destruction, and copious pus-formation. In the lower portion of the figure a large 
patch of skin is seen much infiltrated and breaking down into ulceration, and all over it may be 
seen small pustules which are rapidly becoming encrusted. Such an ensemble is always a symptom 
of an active and destructive eruption. The red margin or framework around these crusts shows 
a soft inflammatory and infiltrated condition of the skin, which has in itself the elements of decay, 
and which melts away before the extending ulceration. 
In Fig. 3, Plate XVII., is well shown another form, not at all uncommon, of early ulcerative 
syphilide. The original lesion in this case also is a pustule, which serves as a focus of syphilitic 
inflammation and infiltration, which is promptly attacked by destructive ulceration. In the upper 
part of the figure a horseshoe-shaped ulcer partly encrusted is well shown-a feature very com- 
monly met with in these early and malign eruptions. Toward the umbilicus is a large typical 
ulcer in the active stage, and a larger one already encrusted. In this case the unilateral develop- 
ment of the eruption, following the lines of obliquity of the ribs, and thus resembling in a measure 
herpes zoster-a feature not very commonly observed-is well shown. 
I have recently had under my care a syphilitic patient whose lesions resembled in a marked 
degree those pictured in Fig. 3, Plate XVII. In this connection it is interesting to note that 
Falcone1 recently reported the case of a man having a chancre on the right side of the corona 
glandis, with corresponding inguinal adenitis, pustules in the scalp, and an erythematous syphilide 
upon the right half of the body, with scaling papular lesions of the right palm and sole, and no 
manifestations upon the skin or mucous membranes of the left side. 
These early syphilitic ulcers are quite deep, have sharply-cut, somewhat undermined edges, 
and secrete a foul pus. They are prone to appear upon the scalp, the face, the trunk, particularly 
its upper and posterior portions, and the extremities more copiously on their external surfaces, 
and usually involve several regions and sometimes the whole body. They appear in crops or as 
a general eruption, and do not, as a rule, show a tendency to a circular distribution. 
A more pronounced form than the foregoing of early malignant syphilide has been called 
by French writers syphilide tuber culo-crzistacee ulcer euse. It begins as small pea-sized, deep-red 
tubercles, which rapidly undergo degeneration, forming ulcers which are as sharply cut as if 
punched out; have foul necrotic surfaces ; secrete a disgusting pus ; and become covered with 
crusts similar to those pictured in Fig. 2, Plate XXL This eruption is prone to appear upon the 
face and scalp, the upper extremities, the trunk, and sometimes involves the whole body. It often 
produces great ravages upon the head by the fusion of a number of lesions, and over the body it 
' " Un caso di Sifilide constituzionale con manifestazioni cutanee in una sola meta del corpo," Giornale Italiano delle in 
Malattie Veneree e delle Pelle, p. 139, 1887. Pari 111 
Plate XX 
Fig.2. 
SERPIGINOUS TUBERCULAR SYPHILIDE. 
1, of' Back . 2, of' Arm . 
LEA BROTHERS & CO. PUB LIS HE RS ,PHILADE LPHIA THE ULCERATIVE SYPHILIDES. 
149 
frequently leaves disfiguring cicatrices. This syphilide may appear promptly or slowly, in crops 
or as an extensive eruption. Its course is persistent and chronic. 
A more severe form of early destructive syphilide, but one happily not common, has been 
called by the French tuber culo-ulcereuse gangreneuse. It appears in broken-down subjects as round, 
dark-colored tubercles which become the seat of a black central slough, from which rapidly destruc- 
tive ulceration proceeds. The resulting ulcers are deep, have a foul brownish-red necrotic, uneven 
surface, thick everted edges, and a fetid secretion. Around each lesion is a broad, deep-red, 
inflammatory areola of similar appearance, but much thicker, deeper in color, and more elevated, 
than is seen surrounding the crusts in big. 2, Plate XXI. 
The invasion of this syphilide is rapid, the lesions appearing on region after region in suc- 
cessive crops, perhaps very active at first, and then more sluggish in their course. In very bad 
cases an uninterrupted, rapidly destructive course is observed, which certain French authors have 
called galloping. The sites of election are the face, scalp, upper extremities, and also the trunk 
and lower limbs. 
In these cases of precocious malignant syphilides emaciation and exhaustion coexist in pro- 
portion to the destructive action and extent of territory invaded. In many cases a fever of 
typhoidal type is present. Visceral diseases frequently arise and lead to death, which is usually 
from exhaustion. 
The late ulcerating tubercular syphilides are more chronic in their course, more local- 
ized in their distribution, and less destructively active than the foregoing eruptions. 
Either of the varieties of the resolutive tubercular syphilide may at any time during their 
course become the seat of ulceration. In general, the destructive process which thus overtakes 
this usually dry form of eruption is caused by lowering of the nutrition of the patient from any 
cause or from traumatism. Owing to pressure, friction, blows, or irritants of any kind, one or 
more tubercles may become inflamed, soften, melt away, and be replaced by ulcers which involve 
a portion or the whole of the original lesion. These ulcers have sharply-cut, perhaps undermined, 
edges, a smooth foul surface, a thick, viscid, ill-smelling pus, and are surrounded by a red infiltrated 
areola. In somewhat rare cases all of the lesions undergo this necrobiotic action. The mode of 
invasion may be rapid or slow, but the subsequent course of the ulcers is chronic and aphlegmasic. 
Epon healing, cicatrices similar in all respects to those of the dry tubercles are left. 
Ulcerating Tubercular Syphilide.-In marked contrast to the resolutive-or, as we may 
also term it, the dry tubercular-syphilide is that not uncommon form of tubercular eruption in 
which there is an evidently inherent tendency to ulceration. When this eruption appears early in 
syphilis it is usually in the form of scattered round or oval tubercles, averaging an inch or more 
in diameter, symmetrically placed over more or less of the body. Very soon one or more puru- 
lent points are seen in the lesions, which coalesce and form greenish-brown crusts, under which an 
ulcerating surface exists. This destructive action may involve the whole tubercle or may be lim- 
ited to a portion of it. In this way more or less of an extensive eruption may undergo decay, or 
those of one or more regions may be thus attacked. The ulcers remain in an indolent and chronic 
condition, and finally leave well-marked scars. 
Later in the disease this syphilide shows a tendency to less extensive distribution, to less 
copiousness of its lesions, and to develop in the scalp, about the face, on the shoulders or scapular 
regions, over the buttocks, and near the large joints of the extremities. The distribution of the 
eruption may be symmetrical or the reverse. The ulcerating tubercles may be grouped, scattered, 
°r in circular form ; they may remain in a discrete state or become fused together and form 
ulcers of various shapes pathognomonic of syphilis, such as horseshoe, reniform, figure-of-eight, 
or serpentine. 
Late forms of the ulcerating tubercular syphilide present certain well-marked characteristics. 150 
VENEREAL DISEASES. 
Ihey are developed usually on the face, on the scalp, on the outer aspects of the arms and fore- 
arms, over the sacrum, on the gluteal and inguinal regions, and about the knees. The pre-existing 
infiltration in these cases is either in the shape of a few or perhaps many quite large, deep-seated, 
and not sharply-defined tubercles, which by peripheral extension fuse into an irregular patch of a 
deep, dull, and even purplish-red color, cold in appearance and devoid of inflammatory features. 
The resulting patch or patches have irregular outlines, an uneven, hillocky surface, and are rarely 
surrounded by an inflammatory areola. Perhaps very early in the discrete tubercular stage, or 
even after the full development of a well-marked patch, degenerative changes are seen in the form 
of yellowish purulent points scattered over the lesions. These points may remain in an inactive 
state or may increase in size and turn into brownish-green crusts. The resulting condition is a 
tubercular patch of infiltration studded with points of ulceration. These ulcerous foci may remain 
stationary, as many as six or eight being seen in a patch three or four inches in diameter, or they 
may fuse and convert the whole morbid tissue into ulceration. In general, the tuberculous infil- 
trated patch remains, but is destroyed in places by ulcers which come and go, and which in the end 
may have invaded its whole extent or only a portion. Thus we very often find a decidedly uneven 
surface studded with round, oval, or irregular depressions which have been the seat of ulcers. 
Under treatment the infiltration may be absorbed, and in the end cicatrices mark the sites of the 
ulcers, whereas a purplish-red pigmentation remains over those portions of the infiltration which 
had not fallen into decay. 
This syphilide is peculiarly amenable to proper treatment. 
THE SERPIGINOUS SYPHILIDES. 
We apply the term serpiginous to a chronic, more or less destructive, syphilide which by its 
ulcerative process creeps over large surfaces of the integument. Though other syphilides, such 
as the pustular, ulcerating, and tubercular, sometimes show a tendency to extend in a serpiginous 
manner, such a course is only an accidental feature in their history ; they should not be denomi- 
nated serpiginous syphilides. This term, therefore, should be reserved for those lesions whose 
essential course is in ulcerating at their periphery while they heal in their centre. 
There are two quite well-marked forms of the serpiginous syphilide, the superficial and the 
deep-the first being peculiar to quite early periods of syphilis, sometimes even being precocious 
in its evolution ; the second being in all respects a late manifestation, appearing as early as the 
second and as late as the fifteenth year. 
The superficial serpiginous syphilide begins as a papule which falls into ulceration, as a pus- 
tule, generally of the impetigoform, the variolaform, or ecthymaform syphilides, as a scratch, a 
bruise, or a fissure, which becomes irritated and encrusted. In its early stage the eruption has no 
distinctive characteristic ; it simply appears like a superficial round or oval ulceration covered over 
with a thin, not very adherent, flat crust. This patch, treatment not being adopted, extends until 
it reaches an area of one or two inches. At this time the ulceration increases in activity at the 
margin, while in the centre granulations which have formed under the crust become in a short time 
glazed ; the central crust then falls, leaving an islet of cicatrization surrounded by a furrow of 
ulceration, outside of which is a deep-red areola of varying width. The serpiginous syphilide 
is then fully developed. The color of the crust at first is of a yellowish-green, which gradually 
deepens into a greenish-brown or black. The ulceration goes on slowly at the margin of the 
patch, being more or less covered with a rim of incrustation, the formation of which keeps pace 
with the destructive process. While these changes are taking place at the periphery healing of 
the enclosed surface goes on pari passu, so that the width of the ring of crust is steadily main- SERPIGINOUS SYPHILIDES. 
151 
tamed. The centre of the healed surface then becomes blanched, while the outlying portions of 
it still remain of a dull-red color. This blanching process also usually keeps pace with the periph- 
eral ulceration and central healing surface. When healing begins in the marginal furrow, the 
crusts become harder, drier, and darker, and are noticeably more salient than before by reason 
of their being lifted up by the newly-formed granulations. When they fall off or are removed, 
they expose an exulcerated ring, which may or may not be slightly depressed below the skin- 
level. At this time careful cauterization with a solution of nitrate of silver will soon produce 
a cure. 
When small, the ulcer generally increases throughout its whole periphery, preserving its 
round or oval shape ; and this may be the case even when it becomes quite large, as is shown in 
wood-cut Fig. 16, in which the serpiginous syphilide, having begun upon the shoulder, has gone 
upward on the neck, forward to the clavicular region, and downward on the back, progressing in 
all directions with equal rapidity. Very commonly, however, it increases at one or more segments 
of the circle, and thus it becomes reniform, oval, or irregular and festooned, as is well shown in 
Figs, i and 2 of Plate XX. The extension of the ulcer is largely influenced by the tissues in 
which it is seated. Thus on the inner surface of the forearm and on the legs it creeps up and 
down much more rapidly than it does on the outer aspect. On the face, where this syphilide is 
somewhat infrequently found, its ulcers are of a quite uniform round shape. On the trunk irreg- 
ularly oval lesions are usually observed, seated in the line of obliquity of the ribs. In an interest- 
ing case1 reported by me the lesion was in the shape of a parallelogram. 
This syphilide may last a few or many months, and even years. In many cases the ultimate 
destruction of the skin is decidedly slight, very superficial atrophy having been produced even 
after a protracted course. 
The deep serpiginous syphilide originates in one of the late or tertiary lesions, such as a 
tubercle, a deep ecthymaform pustule, or an ulcerating gumma. From any of these deep-seated, 
necrobiotic tubercular foci there is soon developed a deep, sharply-cut, active ulcer with under- 
mined edges and a coextensive crust. This ulcer increases in size more or less rapidly until it 
covers an area of two or three inches, when similar changes to those in the first variety take place. 
The crust falls from the cicatriform centre, but remain intact at the margin of the patch in the 
shape of a ring of less than an inch in breadth. Under this encrusted ring the morbid changes 
peculiar to the syphilide take place. The underlying ulcerating ring consists of a furrow from 
half an inch to one inch wide and one or two lines deep. It has a foul grayish-red floor and a 
sharply-cut, slightly-everted, and undermined edge, which is of a deep-red color, and extends as an 
areola more or less beyond into healthy tissue. In its early stage the destructive process in this 
ulcerating furrow is continuous and active, while later on it may be quiescent in certain segments, 
where granulations may form. Over the more active segments greenish-brown or dark brownish- 
black crusts may form, which may be on or below the level of the skin, as is well shown in Fig. i, 
I late XX. When healing is progressing, however, the crusts become hard, dry, and adherent, 
and decidedly elevated, owing to the fact that granulations have filled up the ulcerating furrow and 
lifted them up, as is well shown in Fig. 2, Plate XX., and wood-cut Fig. 16. Stated in few words, 
the nature of the morbid process in the serpiginous tubercular syphilide is a proliferation, at its 
margin in the everted lip of integument, of the peculiar granulation-cells of syphilis, which is 
rapidly followed by ulceration, which exists in the enclosed furrow and within the ring of ulcer- 
ation ; healing takes place synchronously within this circle, and keeps pace with the outlying ulcer- 
ation. It is a good example of simultaneous new growth and decay. 1 he extension of this syphi- 
lide is always in the manner described, and never by the breaking down of outlying, sharply-lim- 
ited tubercles, as occurs in the non-ulcerative and ulcerative tubercular syphilides. In some cases 
1 Journal of Cutaneous and Genito-urinary Diseases, June, 1887- 152 
VENEREAL DISEASES. 
papular and pustular lesions are found beyond the periphery of the syphilide: they are usually, 
however, due to the irritation of the secretion of the ulceration or to traumatism. 
lhe cicatrices left by this syphilide vary considerably in their appearance. Upon the continu- 
ity of the limbs and on the anterior aspect of the abdomen they are usually thin and smooth, while 
those seated near or over joints are uneven, 
traversed by fibrous bands, and often firmly 
condensed with the subcutaneous tissues. 
These scars, like those of all deep ulcer- 
ating syphilides, are not uncommonly the 
seat of false keloid, particularly when near 
joints. The existence of dense fibrous 
bands and of cicatricial keloid near joints 
often produces deformity and even fixation 
of a limb. 
The color of the scars is at first a dull 
deep red, which slowly becomes pale from 
the centre outward. In very large scars 
pigmentation may remain for several years. 
The serpiginous syphilides of both vari- 
eties are peculiar in the fact that periods of 
activity and latency are very constant in their course. Such, however, is their persistency that a 
cure cannot be said to have resulted until every portion, even the most minute, of the ulcerating 
ring is thoroughly cicatrized. Relapses may occur by ulceration of the cicatrix, which may be local 
or general. This relapsing ulceration has none of the peculiarities of the original serpiginous 
lesion. It is usually caused by traumatism, in consequence of lowered nutrition, or by the disturb- 
ances resulting from alcoholic indulgence. 
The course of this syphilide is always slow, chronic, and aphlegmasic, usually lasting months, 
and sometimes years. It may or may not be accompanied by cachexia. It is sometimes seen in 
subjects who seem otherwise perfectly healthy. The deep serpiginous syphilide may appear as 
early as the second and as late as the fifteenth year of infection. It is prone to develop upon the 
continuity of the limbs, mostly on their anterior aspect; about the shoulder, from which it may 
attack the neck ; upon the back, where it is sometimes of vast extent, as shown in Fig. i, Plate 
XX. ; and upon the anterior aspect of the trunk. While its occurrence is not rare, it is not 
common. 
Prognosis.-In the majority of cases the general health is not seriously impaired by the 
existence of the syphilide. In those cases in which there is cachexia the health may be 
restored by appropriate treatment, provided there are no visceral complications. Such are 
the slow, painless course of the lesion and its usual comparatively dry and encrusted condition 
that in many cases it soon ceases to cause annoyance unless it is near a joint. The possibility 
of the local destruction, with the subsequent cicatrix and perhaps fibrous bands, renders the 
prognosis in most cases not good. Energetic and persistent treatment, however, will promptly 
effect a cure. 
Diagnosis.-The serpiginous syphilides may possibly be mistaken for serpiginous lupus and 
serpiginous chancroid. Such, however, is the clearly-marked physiognomy of the lesion, very 
often supported by a history of syphilis, that a diagnosis is seldom difficult. Lupus usually begins 
in early life and chiefly attacks the face. Its ulcerations are less definite, regular in distribution, 
and sharply cut than those of syphilis. The lupoid ulcerations are covered by light-yellow or 
bluish-brown crusts scattered among surfaces of cicatrization which are always uneven and fibrous. 
Fig. 17. 
Serpiginous Syphilide of Neck and Back. Plate XXI 
1. Pigmentary Syphilitic . 2. Precocious Tubercular Syphilitic . 
Fig.l. 
Fig. 2. 
LEA BROTHERS & CO PUBLISHERS PHILADELPHIA 
Part 11 THE PIGMENTARY SYPHILIDE. 
153 
Intermingled among these typical lupus lesions are red tubercles of various sizes and shapes, 
vxl h?h are also seen to appear beyond the outer margin of the affection. 
A serpiginous chancroid usually has such a clear history of origin in a chancroid on the 
ge ntals or of a chancroidal bubo that a mistake in diagnosis can hardly occur. (See p. 96, and 
al 'O Plate V.) 
THE PIGMENTARY SYPHILIDE. 
Jnder the title " pigmentary syphilide " French, Italian, and American observers have 
described a peculiar chromatogenous affection consisting of more or less brown or yellowish- 
brown spots or patches appearing in the early months of syphilis as primordial lesions, and not 
as secondary discolorations. Of late years this form of eruption has been recognized in Ger- 
many, and it is to be regretted that German authors have contributed much confusion to syphil- 
ography by confounding discolorations secondary to the erythematous and papular syphilides with 
pigmentary anomalies which are essentially primary in their nature. 
d he descriptions here given are chiefly based upon observations made in America by myself, 
with the light of the published experience of foreign observers. 
1 he primordial pigmentary anomalies due to syphilis consist essentially in a hyper-pigmenta- 
tion which may in whole or in part be replaced by a corresponding loss of color or leucodermatous 
condition. 
I he pigmentary syphilide is seen under three well-marked and quite distinct conditions : 
1. In the form of spots or patches of various size. 
2. As a diffuse pigmentation which may soon become the seat of patchy leucodermatous 
changes. 
3. In an abnormal distribution of the pigment of the skin, in which, owing to the crowding 
out of the pigment in places, they become whiter, while the parts invaded become darker. In this 
form there is really no actual excess of pigment. 
The pigmentary syphilide in the form of spots consists of round or oval patches with either 
sharply-marked borders or with ill-defined and jagged margins, of a light yellowish-brown or of a 
pronounced brown color, which is unaffected by pressure and the conditions of the circulation. 
In some cases of very delicate white skin the spots are so faint and indistinct that they can only be 
seen in a strong light, and sometimes require to be observed in an oblique direction. Again, in 
persons of a dark skin they may present difficulties of detection. In Fig. 1 of Plate XXL is well 
shown a marked case of this form of pigmentary syphilide in which the spots may be said to have 
reached the acme of hyper-pigmentation. The case was under my observation for several months, 
during which I saw many minute pinhead-sized spots increase in size until they reached an area as 
large as any depicted in the figure. 
The patches vary considerably in size-from that of a pea to an area of an inch or more, and 
exceptionally as large as the palm. They are usually discrete and rather sparsely scattered, but 
often occur in considerable numbers, when they may become confluent. They are neither elevated 
nor scaly, and the lanugo of the regions is, as a rule, unaltered. In this form it is the rule to see 
the hyper-pigmentation evenly distributed and sharply limited, and very exceptionally to see an 
areola of deeper pigmentation. In most cases the intervening skin is unaffected, though it some- 
times looks whiter than natural from the marked contrast with the pigmented spots. The latter 
may remain in an indolent condition for weeks or months, particularly in cold weather, or they may 
gradually wither and fade and leave no trace. Again, they may disappear by the development of 
a leucodermatous ring around each patch, which extends centripetally until it absorbs all the excess- 154 
VENEREAL E/SEASES. 
ive pigmentation and leaves a corresponding pigmentless area. This decolorizing process may 
attack several, many, or all of the spots. In the latter case a pseudo-leucoderma is produced ; and 
if the case is only seen at that stage, I can well understand that its observer might come to the 
conclusion that the essential lesion was an atrophy of pigment, and not primarily a hyper-pigmen- 
tation. In some cases of secondary leucodermatous involvement a pinhead-sized brown macule is 
left in the centre of the spot. The pigmentless condition of the skin may last several weeks or 
months, but gradually the normal color returns. In those cases in which there is simply gradual 
absorption of the excessive pigment the normal color of the skin returns pari passu. 
The second form of the pigmentary syphilide is far more common than the first. More or 
less slowly the part invaded, usually the neck, becomes in a greater or less extent of a dull dirty- 
brown color. The affection usually begins on the sides of the neck or on the back of it, and from 
there it spreads until it involves almost if not all of its surface. From the neck it extends ante- 
riorly over the breasts, and posteriorly for a short distance down the centre of the back. The 
color varies in different cases : in some it is of a light cafe-azi-lait color, while in others it is of a 
light, and again even of a pronounced brown, tint. In many and mild cases the brownish discolor- 
ation passes unnoticed, or it is ascribed to the action of the sun or the friction of the clothes ; in 
others, however, it is soon discovered, and often attributed to uncleanliness. When a goodly-sized 
patch or patches, say of the size of one's palm, become discolored, a number (sometimes few, 
sometimes many) of minute round, oval, irregular and even linear, white spots may be seen scat- 
tered without order over the affected surfaces. These white spots usually grow slowly in size, and 
are soon distinctly noticeable. Very often a patient is ignorant of any trouble until she is told 
that her neck is getting white. The spots are sometimes distinctly whiter than the normal skin, at 
other times of normal skin color, though they usually strike the observer as being whiter than 
normal, owing to the pronounced dark background. They may or may not be sharply marginated, 
in some cases the line of demarcation being sharp, in others rather indistinct. Sometimes quite 
rapidly, and again rather slowly, these patches grow in size until the appearance resembling leuco- 
derma is very striking. As they increase they frequently fuse together, and less and less is seen 
of the pigmentation. Very often a condition is produced which may be compared to lace with 
large meshes, the interstices being formed of the white spots and the strands of the lace being 
formed by the, as yet, unabsorbed round, gyrate, oval, and irregular pigment-lines or bands. In 
the end these remnants of the hyper-pigmentation disappear, and in the course of several months 
the parts become normal again. 
In the study of these cases during the activity of the process I have sometimes seen very mild 
and ephemeral hypercemia, which would have escaped superficial observation, and the question is 
yet unsettled in my mind whether there is not a mild form of congestion which precedes the hyper- 
pigmentation. My studies of these cases in this country cause me to marvel at the emphatic state- 
ments of some German authors, who say that the process of depigmentation occurs in previously 
unaltered skin, and who unequivocally call the affection leucoderma. I have at the present time 
under my care at Charity Hospital two well-marked cases in which it has been distinctly seen that 
shortly after the invasion of the dark patches white spots began to appear, and I have seen the 
same process in many other cases. Such is the uniformity in the course of this form of the pig- 
mentary syphilide that I can hardly understand how two opinions are held. 
The third form of this specific chromatogenous affection is the least common of all. Its mode 
of invasion is slow, like the rest, aphlegmasic, and uncertain. In it there seems to be no actual 
hyper-pigmentation. The natural color of the skin in spots of irregular size and shape becomes 
white, while their margins become dark ; and as the blanched spots grow in size their brownish 
framework becomes more pronounced. It seems to be essentially a displacement of pigment. In 
my experience this form is usually confined to the sides of the neck, and does not, as a rule, HEREDITARY SYPHILIS. 
155 
involve the whole surface. Its progress is slow, and from its evolution until the skin again 
becomes normal several months may elapse. 
1 his affection appears early or late in the secondary period, and may or may not coexist with 
other syphilitic manifestations. It may appear as early as the second or third month of the diath- 
esis, usually at the sixth month, and during the second and even third years. It is most frequently 
seen in persons up to the age of thirty-five, and it is extremely rare to see it in older persons. It is 
in the vast majority of cases seen in young girls from fifteen to twenty-five years of age. It is a 
rather uncommon manifestation in the male sex. 
It is most commonly found on the neck, especially its lateral portions. It is less frequently 
seen on the face (forehead more frequently), and may be seen on the trunk, especially its upper 
and lower portions, where the skin is thin and fine, and on chiefly the upper parts of the extrem- 
ities, especially their inner and flexor surfaces. It must be distinctly remembered, however, that 
elsewhere than on the neck pigmentations and subsequent leucodermatous1 spots not very uncom- 
monly follow the erythematous and papular syphilides, and that such secondary processes are not 
by any means the pigmentary syphilide. 
I his syphilide is seemingly uninfluenced by mercurial treatment, systemic or local. In the 
fight of the history of most cases, and of the striking character of the discolorations, a diagnosis 
is usually very easy. It is well to bear in mind that chloasma, leucoderma, tinea versicolor, the pig- 
mentation caused by scratching, and the spots of increase or loss of pigment caused by psoriasis, 
and some erythemata may present features resembling the chromatogenous disturbance induced 
by syphilis. 
HEREDITARY SYPHILIS. 
Hereditary syphilis, less correctly called "infantile and congenital," is that form in which the 
disease is transmitted in utero to the offspring from one or from both parents. As a rule, the 
transmission ends with the second generation, but rare cases have been observed in which it is 
pretty conclusively shown that syphilis may be transmitted to the third generation. 
Hereditary syphilis in its course differs in very many respects from the acquired form, to 
which, however, it has some points of resemblance. Unlike the acquired disease, in the inherited 
form there is not the initial lesion with its periods of incubation, nor is its evolution as regularly 
typical as that of the former. 
Hereditary syphilis is severe and deadly in proportion to the activity of the virus in the parent 
or parents of the affected child. When both parents are in the active stage of syphilis, abortion 
usually occurs, or a child profoundly syphilitic is produced and soon dies. As a cause of death in 
infants hereditary syphilis has always been a powerful factor. The immature and rapidly-growing 
organism of the embryo is profoundly influenced by the poison. In general, though not always, 
the severity of the disease in the offspring decreases with each succeeding child. Further, the 
chances of life in the child increase with its age, and are usually much better when it reaches six 
ruonths or one year or more of age. 
I here is an absence of precise statement on the part of some authors as to the date of 
appearance of hereditary syphilis, their words giving the impression that it may be as late as the 
first or second year or even later. The consensus of opinion of most syphilographers is, however, 
that the symptoms appear usually within the first three weeks of life, and sometimes even at birth. 
My own opinion is strong in favor of the view that some evidences of the disease, mild and insig- 
nificant perhaps, or even severe, show themselves before the end of the third month. 
1 See observation by me on " Leucodermatous Spots following Syphilitic Roseola," Archives of Dermatology, p. 118, January, 1/ENEEEAL D7SEASES. 
156 
The lesions of hereditary syphilis are found in every organ and tissue of the body, and they 
are, as a rule, more hyperaemic and active than those of the acquired form. The early manifesta- 
tions are generally and symmetrically distributed, while those of later dates may be localized and 
unsymmetrical. 
Vesicular and bulbous syphilides, so rare in the acquired form, are not infrequently seen in 
hereditary syphilis, in which rupia is most uncommon. The nasal mucous membrane, which in the 
acquired disease is, if at all, involved at a quite late period, is, as a rule, affected early and in a 
somewhat characteristic manner in hereditary syphilis. Gummatous infiltrations and visceral affec- 
tions are common and severe in tainted infants. 
As a rule, hereditary syphilis shows itself in a tangible form before puberty. There has been a 
craze of late years for hunting up and publishing cases of late hereditary syphilis, many of which are 
far-fetched and of doubtful authenticity. It is a good rule to consider as evidences of hereditary 
syphilis lesions of more or less typical appearance and character which have appeared before the 
eighteenth or twentieth year, more especially where there is corroborative evidence, and to look 
with caution akin to suspicion upon anomalous lesions which appear in the adult, and for the want 
of a more precise name are called "late manifestations of hereditary syphilis." It is an undoubted 
fact, however, that specific lesions sometimes appear after long periods of latency. 
It is claimed that an hereditary taint gives a more or less complete immunity from the acquired 
disease, but much further evidence is wanting on the subject. 
It may be stated as an axiom that syphilis is transmitted to the child as syphilis, and not in the 
form of scrofula, rickets, tuberculosis, and phthisis. The cachexia incident to hereditary syphilis 
may cause a predisposition toward these and other adynamic conditions. Certain late hereditarily 
syphilitic lesions may present points of resemblance to lupus, but there is no pathological link 
between the two diseases. 
It is now admitted by nearly all practical syphilographers that syphilis of the infant may be 
derived from the father alone, the mother remaining free from the disease. Instances of paternal 
infection are far more common than was at one time supposed. The transmission of the disease 
from the mother alone is conceded by all observers, while the fact is incontestable that both parents 
together may convey it to their offspring. The semen of a syphilitic man, though containing sperm- 
cells capable of originating the disease in the embryo, does not possess infectious qualities for the 
mother, since it never, under any circumstances, when unmixed with specific pathological products, 
gives rise to the initial lesion. 
Abortions resulting from syphilis occur usually about the sixth month or later, in somewhat 
rare cases earlier. An aborted syphilitic foetus is generally in a macerated condition, perhaps 
more or less denuded of epithelium, of a livid or purple color, or covered with pustules or bullae. 
Stillborn children may not present visible evidence of the disease. As a quite general rule, syph- 
ilitic children which come to term are at birth seemingly plump and healthy, and only begin to 
wither and show evidence of the taint at the end of the first month, and sometimes later. Usually 
the early evolution of specific lesions is indicative of a virulent type of the disease. 
The prognosis of hereditary syphilis is never of a reassuring kind. It depends largely upon 
the condition of the parent or parents at time of procreation, and upon the extent and intensity 
of the lesions, since, besides the manifestations upon the skin and mucous membranes, patholog- 
ical changes may exist in the bones of the skull, in the brain and spinal cord, in the lungs, liver, 
spleen, kidneys, and intestines, any or all of which may lead to death. Further, a condition of 
marasmus is not at all uncommon, and intractable gastro-intestinal disorders are prone to develop. 
The usual first symptom of the disease is an inflammatory thickening of the nasal mucous 
membrane, the symptom of which the snuffles is very prominent and often distressing. Then a 
rapidly-increasing emaciation begins, by which the subcutaneous fat is removed, leaving the skin THE ERYTHEMATOUS SYPHILIDE. 
157 
wrinkled, of an earthy sallowness, and seemingly too large for the skeleton. The skin is drawn 
firmly over the bones of the head, hands, and feet. Coincidently, the lesions of the skin appear 
at first chiefly near mucous outlets and on parts covered with clothes and on those in coaptation. 
In this miserable condition the child comes to have a senile, worried, and anxious expression of 
countenance, and is said to resemble a little old man. The combination of symptoms expressive 
of hereditary syphilis in the very young is as follows : The old-man look, bullous and pustular 
eruptions (perhaps), deep and persistent erythema of the buttocks, neck, palms, and soles (and 
also of other parts), snuffles, laryngitis mucosa, enlarged lymphatic ganglia, fissures at mouth and 
anus, and swellings of the bones, particularly of the long ones at their diaphyso-epiphysial junctions. 
1 he eruptions of hereditary syphilis are the erythematous syphilide ; the papular syphilides 
of the skin and mucous membranes ; the vesicular, pustular, bullous, tubercular, and gummatous 
syphilides. The face of a syphilitic child with fissures of the lips and ulceration near the right ala 
nasi is depicted in Fig. 4, Plate XXIII. 
THE ERYTHEMATOUS SYPHILIDE. 
I his eruption is usually the most frequent, and, with the exception of the bullous, the earliest 
of the hereditary forms. It is generally accompanied by roseola or mucous patches of the mouth, 
and sometimes condylomata lata of the anus. 
The erythematous syphilide begins on the lower part of the abdomen *or on parts covered 
with the diaper as minute round or oval pink spots, which at first pale upon pressure. It rapidly 
extends to the trunk, legs, upper extremities, and face. The spots vary very much in size, from a 
third of an inch to even an inch in diameter. As they increase in size their hue becomes darker, 
and may even reach a coppery tint. In Fig. 1, Plate XXII., this syphilide is well depicted in its 
full development upon the buttocks and legs. As a rule, the spots or patches are not elevated, 
though, owing to the intensity of the disease or irritation, more or less slight salience may occur. 
As they grow old and darker they become slightly scaly. 
About the head, chin, neck, around the buttocks and axillae this syphilide sometimes appears in 
extensive and diffuse patches, as is shown in Fig. 2, Plate XXII. In this condition a well-marked, 
but of course superficial, infiltration may be observed, which renders the skin rather less supple 
and elastic-a condition which may become so pronounced about the mouth, eyes, buttocks, hands, 
and feet that fissures may appear in the lines of motion. 
Early crops of this syphilide do not show a tendency to the circular form which is sometimes 
seen in later ones. 
While in most cases this eruption is so pronounced in character that it is strikingly noticeable, 
it may be so faint and evanescent as to escape observation. 
THE PAPULAR SYPHILIDE AND CONDYLOMATA LATA. 
1 his syphilide is rarely if ever of the small conical form, as seen in the acquired disease, but 
is made up of quite large flat or plano-convex papules. It may appear as the first eruption or 
intermingled with the erythematous rash. Again, it may coexist with three or four varieties of 
syphilides. The papular syphilide of infants is well shown in Fig. 3, Plate XXII., and in Fig. 3, 
Plate XXIII. In the former the size, shape, color, and mode of distribution of the papules are 
clearly shown in what may be termed their mild form. The lesions are round or oval, of a dull-red 
verging on a coppery tint, and only slightly prominent; they are, in fact, the erythematous syphilide 158 
VENEREAL DISEASES. 
plus some moderate exudation and cell-infiltration. They show in this figure (3, Plate XXII.) a 
tendency to confluence, which is not at all uncommon in the infant, though very rare in the adult, 
except as the result of irritative pressure. 
In Fig. 3 of Plate XXIII. these papules are well shown in their full development, verging even 
upon hypertrophy. They are essentially the same lesions as those just spoken of, except that they 
are the seat of greater cell-proliferation and exudation. The same tendency to grouping and fusion 
is here observed. 
In wood-cut Fig. 17 is well shown the facies of a child with papular and ulcerative syphilides 
and fissures of the lips. Here also the peculiar grouping and coalescence of the lesions is 
observed; and, further, it may be noted that, 
owing to irritation of the secretions of the mouth 
and nose and friction, some of the papules have 
become ulcerated. This tendency to ulceration 
of papules is very marked in hereditary syphilis, 
especially near mucous outlets and on parts sub- 
ject to irritation and friction. The condition is 
admirably shown in Fig. 1, Plate XXIII., which 
presents a striking diagnostic picture. This ne- 
crobiotic tendency of the papules must be remem- 
bered as the opposite of the condition of their 
hypertrophy, already spoken of. 
As a rule, the distribution of the first crop 
of papules is exceedingly irregular, but later 
eruptions often show a decided tendency to as- 
sume circular forms. This feature is shown in a 
striking manner in Fig. 2, Plate XXIII., in which 
many of the papules have become covered with 
a copious epidermal proliferation almost as well 
marked as in psoriasis, while others on the outer 
part of the right cheek have become covered with 
crusts formed of dried sero-pus and epidermis. 
This combination of conditions is diagnostic of inherited syphilis. 
Condylomata lata are hypertrophied and superficially exulcerated papules, and are found in 
the folds of the skin or at the junction of mucous and cutaneous surfaces. There may be one, 
several, or many. They are of round, oval, or irregular shape from coalescence, markedly salient, 
of a grayish or lilac-pink or dark-red color. Their surface is flat or plano-convex, more or less 
exulcerated, perhaps fissured, and from them a scanty viscid, offensive, and highly contagious 
secretion escapes. 
These lesions are among the earliest, the most obstinate, and most constant of the hereditary 
diatheses. They are seen about the anus and also the mouth associated with buccal mucous patches, 
behind the ears, and between the fingers and toes. When left untreated or irritated from neglect 
or want of cleanliness, they prove especially obstinate and prone to exuberant growth. They are 
much more amenable to local than to constitutional treatment. 
Mucous patches are in reality immature condylomata lata, they being the result of hyperaemia 
and moderate cell-increase and exudation in mucous membranes. They are very prone to appear 
in the mouth and at its angles, and in the nares and larynx. 
Fig. 17. 
Face of Syphilitic Child, with papular and ulcerative syphilides and 
fissures of the lips.  
Part II 
HEREDITARY SYPHILI DE. 
I. f-.'i yl IwiiialoiiH Syphilidv in pulches. ? ! lil'I'u nn !■: i-yl I mm n I nun Hyp! id idn -i I'upiilti i- Syphilidn 
Fi|. 8 
LEA BROTHERS & CO. PL'BLISHEFIS .PHILADELPHIA 
Plate XXI THE BULLOUS SYPHILIDE. 
159 
THE BULLOUS SYPHILIDE. 
I his syphilide, though rare in hereditary syphilis, is so very rarely seen in the acquired disease 
that it may be considered almost as the sole appanage of the hereditary form. 
I his eruption is the most precocious of all the syphilides of hereditary origin. It appears 
either within a day or two or a week after birth, usually within, and not commonly after, the first 
month, and very often found on macerated and aborted children in the sixth or seventh month 
of gestation. Its development is as rapid as its appearance is precocious. In many cases it is 
confined to the palms and the soles, as is shown in Figs. 14, 15, 16, and 17 of Plate XXIII.; 
in others it may also be found usually less characteristically developed on the limbs, particularly 
the lower ones, the trunk, and the face. Upon the palms and soles it reaches its fullest develop- 
ment, and there we find various-sized bullae, the contents of which have often in twenty-four hours 
changed from a sero-purulent to a purulent fluid. The lesions are seated upon a hyperaemic sur- 
face, often of a violaceous or purple tint, and again of a deep coppery-red hue. Elsewhere upon 
the body this tinted background may be wanting, and there is usually to be seen a more or less 
extensive coppery-red areola surrounding the lesions, which in these localities are not, as a rule, 
of as well-marked bullous character as are those of the hands and the feet; indeed, they are often 
more nearly pustular in nature. 
1 his syphilide usually appears in one outburst, and in those cases in which there are several 
crops they appear promptly and with only short intervals between them. The lesions of later 
eruptions are usually not as fully and characteristically developed 
as those of the first outburst. 
The course of the bullae is variable. They commonly grow 
m size and coalesce. They may become desiccated and wither, 
leaving a deep-red but healed epidermis, or they may become the 
seat of ulcerations which are of various degrees of severity, from 
the mild and superficial to the deep destructive, malignant form. 
The bullous syphilide is usually the expression of a profound 
infection, and is usually accompanied by visceral lesions. Its prog- 
nosis is therefore always bad. I have seen two cases in which 
recovery took place, and Neumann reports one case. 
The vesicular syphilide is almost always associated with 
the bullous eruption, and is really a dwarfed form of the latter. 
The vesicles are small, round, and conical, discrete or aggregated, 
and their transparent serum rapidly turns into pus. The sites of 
election are the face about the chin and mouth, the hypogastrium, 
the nates, the forearms, and the thighs. 
The pustular syphilide may exist as an individual eruption or as a part of a bullous exan- 
them. The pustules are small, conical, seated on sharply marginated, red, infiltrated bases. They 
run an indolent course, sometimes drying into crusts, and again giving rise to troublesome ulcers. 
They may remain separate or become confluent, especially about the mouth and on the buttocks. 
At early periods the eruption is copious and symmetrically and generally distributed ; later on it 
shows a tendency to sparseness and limitation. The lesions may leave no permanent trace or 
may give rise to scars. 
The tubercular syphilide is much rarer in the hereditary than in the acquired disease, and 
is even more prone to ulceration than in the latter form. Its clinical characteristics are those of the 
dry and ulcerative forms of the acquired disease, except that there is more commonly an accom- 
Fig. i8. 
Extensive Destruction of Face. 160 
VENEREAL DISEASES. 
panying hyperaemia and evidence of more inflammatory action. This syphilide may appear as 
early as the sixth month or several years after birth. It is mostly found on the head and 
extremities. 
Gummatous infiltrations are not uncommon on the skin of the face and extremities and 
mucous membranes, particularly of the mouth and larynx. In wood-cut Fig. 18 are depicted 
the ravages of this syphilide into the skin and mucous membrane, together with specific lesions 
of the bones. 
AFFECTIONS OF THE NAILS. 
There are two forms of onychia due to hereditary syphilis-the ulcerative or perionychia, and 
the malnutritive, due to the impairment of the nutrition of these structures. 
The description of the perionychia of acquired syphilis, already given, will in the main suffice 
for that of the hereditary disease. In the latter, however, the morbid process most commonly 
begins in a papule, pustule, or fissure in the fold of skin surrounding the nail. 
In Figs, io, n, 12, and 13 are well shown the conditions of malnutrition and imperfect devel- 
opment so often seen in these afflicted children. There are no salient diagnostic features about 
them, and similar conditions are sometimes seen in the course of non-specific epidermal and 
dermal affections. The nails are rough, lustreless, striated longitudinally or transversely, much 
thickened, brittle, friable, and they constantly catch dirt. With proper care and treatment, and 
with the improvement of the system, they may gradually become less deformed and perhaps 
perfect. Left uncared for, they remain as dwarfed, immature, and unsightly deformities. 
THE TEETH IN HEREDITARY SYPHILIS. 
There are certain malformations of the permanent teeth in hereditary syphilis which are 
known as Hutchinson's teeth or "test teeth." In his description, now classical, Mr. Hutchinson 
says: " By far the most reliable amongst the objective symptoms is the state of the permanent 
teeth if the patient be of age to show them. Although the temporary teeth often, indeed usually, 
present some peculiarities in syphilitic children of which a trained observer may avail himself, yet 
they show nothing which is pathognomonic and nothing which I dare describe as worthy of general 
reliance. The central upper incisors of the second set are the test teeth, and the surgeon not thor- 
oughly conversant with the various and very common forms of dental malformation will avoid 
much risk of error if he restrict his attention to this pair. In syphilitic patients these teeth are 
usually short and narrow, with a broad vertical notch in the edges and their corners rounded off. 
Horizontal notches or furrows are often seen, but they, as a rule, have nothing to do with syphilis. 
If the question be put, Are teeth of the type described pathognomonic of hereditary taint? I 
answer unreservedly that when well characterized I believe they are. I have met with many cases 
in which the type in question was so slightly marked that it served only to suggest suspicion, and 
by no means to remove doubt; but I have never seen it well characterized without having reason 
to believe that the inference to which it pointed was well founded." Figs. 6, 7, 8, and 9 show 
typical malformations. The tooth in Fig. 5 has been only very recently cut, and some small spines 
are seen occupying the notch, which in a short time would be broken away, leaving a state resem- 
bling that shown in Fig. 6, which is typical. Fig. 8 shows an exceedingly well-characterized set of 
syphilitic teeth, the central incisors being dwarfed and notched, while the lateral ones are of normal 
size, and of the right canine the apex is replaced by a notch, in the centre of which is a small Pari Hl 
Plate XXIII 
W5. 
Fife.7. 
Pig .11' 
pi|10. j 
Fife 12. 
Fi| 14 
Fig 15 
Fig 3 
HEREDITARY SYPHILIS. 
LEA BROTHERS & CO. PUB LIS HERS , PHILADE LPHIA 
'■MOIST PAPULAR SYPHILIDE. 
2 PAPULAR SYPHILIDE IN CIRCLES. 
3 PAPULAR SYPHILIDE IN GROUPS . 
4- FACIES OF SYPHILITIC INFANT WITH FISSURES OF 
LIPS AND ULCERATION NEAR NOSE . 
5,6,7,8, 9 .SYPHILITIC TEETH. 
10,11,12,13 . NAILS OP HEREDITARY SYPHILIS 
14,15 . BULLOUS SYPHILIDE OF PALM 
16,'17 . BULLOUS SYPHILIDE OF SOLE . TREATMENT OF SYPHILIS. 
161 
tubercle. In Fig. 5 the teeth are much less typical in their length and narrowness than are those 
of the other figures. 
It must be remembered, however, that these malformations are far from common, and that 
children hereditarily syphilitic may have sound teeth. The symptoms thus presented should 
receive due weight in the study of a case ; but if much doubt should exist it would be well to seek 
for further corroborative evidence of antecedent inherited disease. 
AFFECTIONS OF THE BONES. 
The bones are variously and often extensively affected in hereditary syphilis. In the early 
months of life the most constant morbid change is at the junction of the diaphyses with the epiph- 
yses of the long bones, though the small bones of the fingers and toes are often attacked. At later 
periods the tendency of the disease is to involve the shafts of the long bones and also the flat 
bones. The morbid process at the diaphyso-epiphysial junction is called osteo- 
chondritis, while that of the long and flat bones is either proliferating or gum- 
matous periostitis and osteitis. Either of these morbid changes may end in 
necrosis, in gelatiniform atrophy resembling dry caries (Parrot), in hypertro- 
phy, or in osteophytic outgrowths. 
Osteochondritis is of not infrequent occurrence, and its presence is of 
considerable diagnostic value. It shows itself in the form of fusiform and 
ring-shaped swellings at the ends of the long bones, chiefly those of the fore- 
arm, the leg, arm, and the thigh. These swellings may undergo degeneration 
in whole or in part, and give rise to deep ulcers. In some cases the new tis- 
sue softens and melts, causing separation of the epiphyses from the shafts. 
Periostitis is observed in older children, from the fourth or fifth year as 
late as the fifteenth. It is often the seeming outcome of the child's use of its 
limbs, upper and lower. Usually, the greater part of the shaft is involved, the 
tibia and ulna being especially liable to it. In wood-cut Fig. 19 are presented 
the appearances of hereditary syphilis in a young girl whose development has 
been arrested and the tibiae and ulnae the seat of periostitis which had become 
attacked with superficial necrosis. Periostitis, particularly of the tibiae, very 
often leads to elongation of the bone and its bending with the arc outward-a 
condition described as sabre-shaped (Fournier). 
I he skull-bones are not infrequently the seat of gummatous periostitis, which undergoes 
degeneration and leads to much destruction of the bone and skin. 
lhe swellings of the phalanges are not uncommon in the hereditary disease, nor indeed in the 
acquired form, and are called dactylitis syphilitica. The bones become rounded, fusiform, and 
acorn-shaped. The affection runs a chronic course, and may end in resolution, in necrosis, or in 
thinning, and even elongation, of the bone. 
Fig. 19. 
Extensive Bone Disease and 
Lack of Development. 
TREATMENT OF SYPHILIS. 
It is now generally conceded that the expectant or symptomatic methods of treating syphilis 
have been tried and found wanting, and that, being a chronic disease, it requires a prolonged and 
systematic treatment. In the light of our present knowledge most practical syphilographei s and 
physicians are in favor of a course of treatment lasting from two to three or four years not, how- 162 
EENEEEAL DISEASES. 
ever, a continuous course of medicine, but rather a series of courses employed at intervals during 
these years according to the indications of each case. In general, in patients of fair average 
health with a proper attention to hygiene, two years or two years and a half of careful and pro- 
gressive treatment are sufficient to cure them of their disease, as shown by entire absence of any 
further signs of it whatever and by the power of the patient to procreate healthy children. An 
experience extending over many years in the observation of a vast number of patients has con- 
vinced me of the truthfulness of this statement. The requirements for such future immunity are 
a good state of health, the docility of the patient to his physician, and a treatment begun suffi- 
ciently early and carried on in a watchful, painstaking, and thorough manner. The duties of the 
physician and patient are reciprocal. Though in very many cases such hopes may be held out to 
the person infected with syphilis, it must be remembered that in persons of poor fibre, or those 
suffering from any visceral affection or who have previously suffered from rheumatism or gout, 
malaria, or from any adynamic influence, and particularly persons addicted to alcoholic indulgence, 
a longer time is required and a usually less favorable outlook should be promised. 
The first duty of the physician is to acquaint his patient with the gravity of his case, to place 
clearly before his mind the fact that a serious ordeal is before him-that the ensuing two, three, or 
four years are really the most critically momentous ones in his whole life, and that his future health 
and happiness, and those of his family, hinge upon his care of himself during this trying epoch. 
With intelligent zeal on his (or her) part, this period may be passed with little or perhaps no dis- 
comfort whatever, whereas carelessness and negligence will be fraught with suffering, disfigure- 
ment, and perhaps permanent impairment of health, or may even result in death. 
Besides its lesions proper, syphilis tends to produce in the economy anaemia, cachexia, and 
even a condition of marasmus. Therefore, the hygiene and surroundings of the patient must be 
as nearly as possible perfect. Such patients require fresh air, plain, wholesome food, and, as far as 
possible, a life of peace and contentment. While all excesses should be sedulously avoided, all 
influences exhausting physically or irritating or depressing mentally should be removed. The 
daily regimen should be carefully looked after, and regularity of hours for food, business, and 
sleep should be observed. The changes of the seasons should be accompanied with appropriate 
clothing and the utmost precaution taken against catching cold. The condition of the digestion 
and the gastro-intestinal functions should be conserved, and during treatment especially all sexual 
excesses and lowering tendencies should be avoided. 
While the physician should thus impress his patient with the gravity of his condition, he should 
also constantly hold out to him that most consoling hope that he will in the end be free from his 
disease. While some patients are light-hearted, and even indifferent to their physical condition, 
others, however-happily not many-show a tendency to a depression of spirits and melancholy 
concerning their disease which is termed syphilophobia-a most distressing state of mind both 
for the patient and his physician. Such cases should be treated with constant encouragement and 
kindness mingled with firmness. 
The methodical treatment of syphilis should begin at the time of the evolution of the second- 
ary manifestations in the vast majority of cases. As a rule, no good is produced by beginning- 
treatment prior to this time, since it only tends to render the course of the disease less orderly, 
very often leaves the existence of syphilis in a state of doubt, does not prevent, but may perhaps 
retard, secondary manifestations, while it certainly does not in any way lessen their severity. Clin- 
ical and pathological facts show us that syphilis is not fully mature until the date of the evolution 
of the secondary manifestations. At this time the newly-formed young round infecting cells are 
proliferated in vast quantities, and are thrown into the general circulation, and through that carried 
to the skin and viscera. Then syphilis may be said to be ripe. Now we further know, by induc- 
tive reasoning and observation, that the one sovereign remedy for early syphilis-namely, mercury TREATMENT OF SYPHILIS. 
163 
-acts by destroying and rendering fit for that absorption this young nascent infectious tissue. 
This is the sum and substance of its action. It is in no sense whatever a true tonic, and when, 
owing to its administration, the strength and forces are increased, nutrition improved, or the weight 
of the body increased, it is in consequence of its depurative action in ridding the economy of these 
cells, which, scattered throughout the viscera, lead to impairments of functions, to disturbances of 
nutrition, and to emaciation. Is it not, therefore, illogical and irrational to introduce this essen- 
tially catalytic agent into the economy before the materies morbi has been developed ? The greater 
number of practical thinking men who have studied this question on a large scale have reached the 
conclusion that the proper time to begin the systemic and systematic treatment of syphilis is at the 
time when the disease is ripe by reason of the infection of the economy by the actively nascent new 
growths. The abortive treatment of syphilis both in the primary and secondary stages is plausible 
in theory, but nugatory in practice. It sometimes happens, however, that certain exigencies render 
the adoption of early systemic treatment necessary or imperative. These may be stated as follows : 
1. Where the initial lesion from its size, depth, or extent causes much pain and discomfort or 
interferes with the function of parts, or from activity of ulceration threatens to destroy them (glans, 
clitoris, urethra, fingers, eyes, nose, lips, tongue, tonsils, breast, and anus). 
2. In certain of those cases where from its situation the chancre may lead to infection of others, 
such as the fingers in surgeons and midwives, nipples in wet-nurses, chancres on the tongues of 
infants and on the lips of young, careless, and thoughtless persons. 
3. When the enlargement of the lymphatic ganglia is excessive and causes inconvenience and 
impairment of locomotion or movement of the arms, or produces much discomfort and disfigure- 
ment (neck and submaxillary region, elbows, and groins). 
4. In all cases where chancres are complicated with a pyogenic (perhaps microbian) infection 
attended with, pain, fever, and perhaps typhoidal symptoms (chiefly on the fingers). 
5. In cases where married or sexual relations render the early disappearance of the chancre 
imperative. 
6. Where the extreme anxiety or unreasonable impatience of the bearer renders it impera- 
tively necessary. 
7. In those somewhat exceptional cases in which severe cephalalgia, neuralgia, pains in bones, 
joints, and fasciae are precocious. 
Among the vast number of remedies which have been vaunted in the cure of syphilis, mercury 
for the early stages and in compound form for later stages is the only one which has stood the test 
of time. Owing to various causes (chief of which is its intelligent use by medical men) this agent 
no longer has a bad reputation with the laity ; it has ceased to be a popular bugbear, and we sel- 
dom now hear at least the better class of patients express the fear that their teeth and bones will 
decay, that their hair will fall out, and that other imaginary ills will overtake them from its use. A 
more general and correct idea of the course of syphilis has taught the public that the disease, and 
not the remedy, is the cause of these troubles. Success in the treatment of syphilis has followed 
the intelligent and painstaking use of this great remedy, and progress has been mainly in the direc- 
tion of the most eligible and efficient preparations and in the modification of administration and the 
attenuation of the quantity given. 
Conceding, therefore, that mercury is the great and salutary agent in the treatment of this 
troublesome and oftentimes dangerous disease, we must add to this postulate the statement that 
even when administered in the most careful and watchful manner it is in some cases (happily, 
rather exceptional) attended with certain unpleasant phenomena-namely, stomatitis and saliva- 
tion, gastric and gastro-intestinal disturbances, and impairment of the nutrition of the body and 
depression of the vital forces. In the majority of cases these conditions act only as temporary 
drawbacks, and they can be obviated or dissipated by forethought, tact, and skill. Let us consider 164 
VENEREAL DISEASES. 
them briefly. Ptyalism is in general a condition which can be prevented and aborted by care and 
watchfulness. It is true that its invasion is sudden and severe in some cases, particularly where 
blue pill, calomel, or even the gray powder, is given in small and oft-repeated doses, and where 
inunctions are employed. But the knowledge of the possibility of this accident under these con- 
ditions enables one to guard against it. In general, the preparations now used cause this accident 
very rarely, not usually in a sudden outburst, and severe cases are to-day almost unheard of. 
Ptyalism (stomatitis and salivation) need have no terrors for the conservative surgeon. 
Gastro-intestinal irritation is rather more frequently observed, particularly in weakly subjects 
or those with poor digestion. In most cases it can be overcome and a tolerance of the mercurial 
preparation established by care in attenuating the dose, in preparing by antacids, stomachics, and 
tonics the condition of the stomach, by the use of very digestible food, by the avoidance of alco- 
holic and malt liquors, and by supplementing the drug with some mild sedative remedy, such as 
opium (always, however, with extreme caution and in minute quantity, for fear of inducing addic- 
tion to it) or hyoscyamus. By these means gastro-intestinal intolerance may be overcome. 
Profound nutritional disturbance in consequence of taking mercury is seen, on the whole, very 
rarely. This condition shows itself in debility and emaciation, with or without diarrhoea or gastric 
trouble. In most cases watchfulness, care, and skill serve to overcome it in a short time. In very 
rare cases so pronounced is the condition that the use of mercury seems entirely out of the ques- 
tion ; in which event recourse may be had to hypodermic injections, to inunctions (both very cau- 
tiously), or to some preparation of iodine. 
The advantages of the use of mercury being so great, and the drawbacks in the aggregate so 
small and usually so readily avoidable or removable, it remains to be determined how to properly 
employ it. 
In the treatment of syphilis mercury is given by the mouth (stomach ingestion), by inunction, 
by fumigation, and by hypodermic injection. 
As a routine treatment medication by the mouth is the one most used, and, as a rule, best 
suited to the habits and tastes of patients in this country, though the other methods are constantly 
employed as auxiliaries and as methods of utility and emergency. 
In assuming the charge of a case of syphilis the surgeon must not be influenced in the slight- 
est degree by the dicta of those observers who divide the disease into two great classes-the mild 
and the severe-and base their therapeutics on that assumption. There are no precise data in the 
early stages by which a mild or severe course may be positively predicted, consequently all cases 
require an active, vigilant, painstaking, and conservative treatment. As time goes on the indica- 
tions for greater or less activity of dosage will be very clear. 
The remedy which has proved most efficacious and manageable, particularly in this country 
and France, is the green iodide of mercury; and it may be said without fear of contradiction that 
if the surgeon knows how to handle this agent well, he need have little care as to whether from 
time to time a new preparation of mercury is invented and exploited. As an all-around agent this 
particular one has stood the test of time ; those who have used it for many years have entire 
confidence in it, and those who commence its use are speedily prejudiced in its favor. 
The necessity for an active, energetic treatment being conceded, the next questions are how 
to use the therapeutic agent and for how long. Let us, for the sake of clearness, consider the last 
question. Whereas in former years mercury was given in large, even enormous, doses, it was only 
thought necessary to use it for a limited period, say of six months or a year. Now we use it in 
smaller doses and for long periods. 
The duty of the surgeon being to care for a patient during two and a half, and even three or 
four, years, he must so administer the remedy that its action is constant and its result curative. 
Like all drugs, mercury when given for long periods loses its efficacy and influence over the syph- TREATMENT OF SYPHILIS. 
165 
ilitic diathesis and its lesions. A condition of tolerance is induced by the continuous ingestion of 
the drug, and after a time it ceases wholly to be a therapeutic agent, and often to have any effect, 
and certainly none which is beneficial. Further, in syphilitics (I will not say what it does in dogs, 
rabbits, or other objects of experimentation) it very commonly produces a condition of anaemia and 
debility (often even when the body is fat and flabby), and perhaps a low grade of gastro-intestinal 
irritation. I constantly see patients who come of their own accord or are sent by their physicians 
who have been treated continuously, and without any intermission, for one, two, or more years with 
mercury, and who still have some syphilitic lesion which refuses to disappear-perhaps dermal, 
osseous, or articular, or even cerebro-spinal or visceral. These patients, and very often their phy- 
sicians, cannot understand why it is that a treatment so constant and energetic, and in most cases 
so conscientiously administered, should be productive of such unsatisfactory results. The answer 
to the question is very clear and simple. They had used mercury long after it had ceased to be a 
therapeutic agent, long after it had lost its influence over the syphilitic diathesis ; and, strange to 
say, some had escaped without serious injury, but in others the chances of cure had been mate- 
rially jeopardized or rendered very remote. I have seen, during a period of many years of obser- 
vation, so much annoyance, so much trouble, misery, and even disaster, result from this method of 
using this incomparable remedy, and have become so convinced of the seriousness of the subject, 
that I feel that I must raise my voice against it as being an irrational and even mischievous treat- 
ment-a perversion of one of the greatest therapeutical blessings which we possess. 
At the commencement of mercurial treatment it is important that the condition of the mouth, 
gums, and teeth should be examined and all abnormalities removed. The condition of the stom- 
ach also requires attention. Then a pill containing one-fourth or one-fifth of a grain of the green 
iodide of mercury may be ordered, to be taken three times a day. For this purpose the gelatin- 
coated pills of our prominent druggists or the tablet triturates may be prescribed in preference to 
certain French sugar-coated granules, which are frequently so hard that they are insoluble in the 
stomach. A favorite prescription with me is the following: 
R. Hydrarg. protoiodidi, gr. vj-vij; 
Ferri et quiniae cit., 3'ss.; 
Ext. hyoscyami, gr. vj. M. 
Ft. pil. xxx. 
My experience and observation teach me that those cases of syphilis do the best that are 
vigilantly and energetically treated from the date of secondary manifestations for two and even 
three months. In my judgment this period is the crucial one in the history of the case, and 
according as the disease is thoroughly modified and acted upon at this time, so are the chances 
for future immunity proportionately great. It seems to me very probable that much of the late 
rebelliousness, and even malignancy, of syphilis is due to the fact that the newly-formed infecting 
granulation-cells and the concomitant subacute inflammation induce in tissues and organs, par- 
ticularly delicate ones, structural and nutritive changes which predispose them to subsequent 
low grades of inflammation and cell-increase, besides a tendency to a repetition of the essential 
syphilitic process. We see this malign and subtle influence in the cerebro-spinal centres, in the 
tissues of the eye, in the viscera, and in the skin. I his condition may be classed as a predispo- 
sition engrafted by syphilis to future cell-changes, hypertrophic or degenerative. The practical 
lessons to be drawn from the well-known clinical facts barely outlined here are that e\ ery effort 
should be made to destroy the young, rapidly-proliferating cells of the active diathesis, to remove 
them as quickly as possible from the parenchyma of organs and tissues before they shall ha\ e had 
time to induce these subtle but often most dangerous structural changes. Very many of the cases 
which are spoken of as not doing well under a systematic mercurial course are those in which the 166 
VENEREAL DISEASES. 
disease has not been profoundly and persistently acted upon in the early months. In proportion 
as a systematic and vigorous mercurial course is entered upon late, so is it more and more heavily 
weighted in its action. Mercurial treatment covering the first two or three months of the disease 
is, in my judgment, far more salutary and effective than a course extending over six or eight 
months instituted later on. 
In general, it will be found in adults that three-fifths of a grain of the green iodide are not 
sufficient to make a perceptible impression on the lesions. It, however, is a good dose to begin 
with. By it the tolerance of the drug may be gauged and its remedial action estimated. It may 
with benefit be increased to four-fifths of a grain, and even a grain, daily, slowly or abruptly. In 
the vast majority of cases one grain or one and a half or two grains of the drug daily, in divided 
doses, will be amply sufficient. Should the severity of the symptoms and intensity of the diathesis 
not be modified by these doses, it is well not to increase them, but to substitute the inunction method 
or hypodermic injections, and thus spare the stomach. In uncomplicated cases such a profound 
effect is usually produced by an eight or twelve weeks' course that the medicine may be stopped. 
Then it is well to allow three, four, or six weeks to elapse without the administration of mercury, in 
which interval tonics or even the iodide of potassium may be given. Then the mercurial should 
again be used, since the system will once more be virgin to its influence, and its effects will be 
heightened. After eight weeks or even more of watchful energetic medication another cessation 
of the mercurial influence should be observed for a month or six weeks, when again it may be 
renewed. In this way a series of successive and efficient treatments are kept up, and the drug is 
held well in hand, producing therapeutical effects and not degenerating either into a toxic or an 
inert agent. The moral effect of the discontinuance of the ingestion of the drug upon the 
patient is very great and salutary. Patients weary at the seemingly interminable dosing of the 
continuous treatment, which is often irksome and sorely trying. In the intervals of repose they 
cease to consider themselves sick, and have the opportunity of judging of their condition when 
freed from drugs. 
In cases, particularly uncomplicated ones, treated from the beginning there are usually no 
perceptible secondary or tertiary stages. The secondary stage is entered upon, the disease is 
systematically attacked, and, excepting perhaps a few ephemeral and trifling manifestations upon 
the skin or mucous membranes (and they are largely produced by extraneous irritation, friction, 
coaptation of parts, and want of cleanliness, smoking, etc.), he (or she) sees no further develop- 
ments. The treatment, however, should be kept up for the specified periods. 
In untreated and insufficiently treated cases we find the merging of the lesions into the ter- 
tiary type, and then the indication is to combine a mercurial preparation with the iodide of potas- 
sium, commonly called the mixed treatment. Blue pill, gray powder, and calomel are deservedly 
passing into disuse. They are even to-day looked upon as promptly efficient agents, but they can 
always with advantage be replaced by mercurial inunctions or hypodermic injections. The blue 
pill has never commended itself to my favor. When it is given in small doses it does nothing 
whatever, hence is considered so mild ; and when it is given in sufficient quantity one never knows 
how soon severe salivation may be induced. The person who takes it is in continual jeopardy. 
So is it with calomel. 
The tannate of mercury was devised and vaunted as being efficacious without producing 
gastro-intestinal irritation. My experience with it is quite large, and I have found it to be an 
active drug, sometimes, however, possessing irritant qualities. The stated dose, one grain thrice 
daily, has been proved at my clinic too large. It should be given in doses of half a grain three 
times daily, and increased if necessary. The carbolate, salicylate, and alaninate of mercury are 
recent additions to our armamentarium. 
The following combinations are of much value : TREATMENT OF SYPHILIS. 
167 
B. Hydrarg. biniodidi gr. j-ij 
Potassii iodidi, 3ss-5j > 
Syr. aurantii cort., 5>'j j 
Aquae, 5j- M. 
One teaspoonful three times a day, an hour after eating, in a wineglass of water. 
B. Hyd. bichlor., gr. i-ij-iij; 
Potassii iodidi, 5ss-3vj~oj 5 
Tr. cinch, comp., giiiss. 
Aquae, §ss. 
To be taken in the same manner as the foregoing. 
When the lesions are of the brain, spinal cord, viscera, bones, or the connective tissue, the 
iodide of potassium or of sodium may be used alone or in combination with the inunction method. 
(For further particulars as to the use of the preparations of iodine see Bumstead and Taylor, 
pp. 875-882.) 
Vegetable and ferruginous tonics, preparations of the hypophosphites, cod-liver oil, pepton- 
izing agents, and all remedies tending to increase the strength and improve nutrition should be 
employed in combination with the specific medication. As an adjuvant tonic erythroxylon coca has 
proved a very valuable agent in my hands. It is best given in the form of fluid extract, but, unfor- 
tunately, many of the extracts in the market are inert. One of the most trustworthy preparations 
is that known as " the Mariani," which is really a fluid extract. The following are useful formulae : 
B. Fl. ext. erythrox. coca?, 5ij; 
Tr. cinch, comp., 
Tr. gent, comp., dd. §j. M. 
1 wo teaspoonfuls in a wineglass of water three times a day, after meals. 
B. Fl. ext. erythrox. cocse, §ij; 
Tinct. gent, comp., 
Tinct. cinch, comp.. dd. ; 
Elix. calisayse, 51V. M. 
One tablespoonful three times a day in water, after meals. 
Zittman's decoction may be used in late and obstinate lesions. 
The inunction treatment is really so valuable and so widely efficient that it is a pity that its use 
is restricted by its tiresomeness and the dirtiness of its application. 
I he agents used are mercurial ointment and the oleate of mercury, preferably of the strength 
of 20 per cent. In spite of its odor and uncleanliness, such is its unvarying efficiency that my 
preference is strongly in favor of the blue ointment. (For full particulars of the method of using 
inunctions see Bumstead and Taylor On Venereal Diseases, p. 861.) 
Hypodermic injection in syphilis constitutes a treatment of utility and emergency. It can 
never be used as a routine treatment, for the reason that there is not sufficient extent of tissue on 
the body to fulfil its requirements. Then, again, the transitory or more or less permanent sore- 
ness and tenderness left by the injections, the indurated plaques and nodules, and deep abscesses, 
are powerful contraindications. 
1 his treatment may be employed in the secondary stage, where other treatments are contra- 
indicated, since it combines the advantages of smallness of dose, rapidity of action, and the absence 
of the local and systemic drawbacks incident to stomach ingestion of mercury. 
An experience of twenty years with this treatment has convinced me that the best preparation 
is the bichloride of mercury in doses of one-eighth to one-twelfth of a grain dissolved in ten drops VENEREAL E/SEASES. 
168 
of water. All sorts of fanciful preparations have been proposed for the injections, looking toward 
absorbability and absence of local reaction (see Bumstead and Taylor, pp. 862-866), but they have, 
as a rule, been more appreciated by their introducers than by others. The injections should be 
made every day or every second or third day, according to indications, with the observance of 
thorough antisepsis and great care and slowness in the performance of the operation. 
The revival of Scarenzio's method of calomel injections, which I saw tried in Charity Hos- 
pital in 1866 by my late associate, Dr. Bumstead, and found wanting, has not, to my knowledge, 
extended in a practical manner to this country. These injections (the vehicle being oil or gly- 
cerin), as practised by the advocates of to-day, are made usually deep into the muscles or connec- 
tive tissues. The idea is to establish reservoirs of mercury in various portions of the body from 
which from time to time minute quantities of this beneficent drug may escape and pass into the 
circulation. Seeing that in many cases, notwithstanding the. careful elaborateness of the tech- 
nique, the injected spots become the seats of abscess, the treatment often degenerates into the 
establishment of scattered pus-producing foci in the body. 
Mercurial fumigation is an efficient method of treatment, but one of utility or emergency. 
(For full particulars regarding its administration see Bumstead and Taylor, pp. 857-860.) 
TREATMENT OF HEREDITARY SYPHILIS. 
The fact of the birth of a syphilitic child emphasizes the necessity of thorough and systematic 
treatment of one or both parents. A pregnant woman known to be syphilitic should at once be 
placed under a most careful but rigorous treatment, preferably of mercury and iodide of potas- 
sium. The treatment of syphilitic infants is attended by many drawbacks. Gastro-intestinal irrita- 
bility, and even intolerance, very often contraindicate medication by the mouth, while the excessive 
delicacy of the skin very often precludes the use of inunctions. For children, as for adults, the 
green iodide of mercury is very efficient: it may be given in doses of one-twentieth of a grain, and 
increased to one-tenth, mixed with sugar of milk or subnitrate of bismuth, and suspended in a little 
water, thrice daily. I have seen this agent combined with lactate of iron in one-grain doses work 
very well. Where they can be used inunctions of mercurial ointment or of the io per cent, oleate 
of mercury, in quantities of ten to thirty grains, administered every other day, should be employed. 
Little if any reliance can be placed on treatment directed to the child through its nurse. 
The gray powder may sometimes be found useful. Though the bichloride of mercury in 
minute and oft-repeated doses, largely diluted with water and given with the milk or alone, has 
been very highly recommended, I have never seen it do good, and have often observed gastro- 
intestinal intolerance. 
Osseous and articular lesions, affections of the brain and viscera, are best treated with a com- 
bination of mercury and iodide of potassium, as given on page 167, beginning with three-drop 
doses, well diluted, thrice daily, and gradually increasing for children about three months old. 
Hereditary syphilis requires a systematic, long-continued treatment on the same general plan as 
that appropriate to the acquired form. 
Iodide of iron is not in any sense an antisyphilitic remedy ; it is simply an adjuvant tonic. 
Local Treatment of the Syphilides.-Much aid is often afforded by direct treatment of the 
syphilitic lesions. I shall give a number of formulae which I have used in private practice, at the 
hospital, and at my clinic. 
The erythematous syphilide may sometimes remain persistently on exposed portions of the 
body, and be both disfiguring and compromising. In such cases mercurial fumigations are often 
of much value. The following ointments may also be used: TREATMENT OF SYPHILIS. 
169 
B. Hydrarg. precip. alb., gr. xvj; 
Ung. aq. rosae, §j- M. 
B. Hydrarg. precip. rub., gr. xx; 
Pulv. camph., gr. x; 
Ung. aq. rosse, 5j. M. 
B. Hyd. bichloridi, gr. j-ij; 
Acid, carbol., gr. x; 
Ung. zinci oxid., §j. M. 
B. Ung. hydrarg. fort., gij ; 
Pulv. camph., gr. x; 
Ung. zinci oxid., §j. M. 
B. Oleate hydrarg., 20-10, ; 
Bals. Peru., 3j j 
Ung. simpl. or vaseline, £j. M. 
In very obstinate cases the following may be kept on as continuously as possible : 
B. Ung. hydrarg. fort., 
Ung. zinci oxid., ad. ,$j; 
Pulv. camph., gr. xx. M. 
These ointments should be rubbed into the skin as vigorously as possible without producing 
dermatitis. 
lhe following lotion may be used upon the face: 
B. Hydrarg. bichlor., gr. ij-iv; 
Ammon, muriat., gr. x; 
Aq. coloniensis, giij ; 
Glycerinae, 5ij; 
Aquae, ad §iv. M. 
It may be freely sponged on the parts or lint soaked with it may be applied to them. 
I he persistent forms of the papular syphilides may be removed by full baths composed of 
corrosive sublimate 5j to 3iv, with an equal quantity of muriate of ammonia in thirty gallons of 
very warm water. Papular syphilides of the palms and soles should be promptly attacked by an 
ointment composed of equal parts of mercurial ointment and vaseline. Where there are many 
papules, and much concomitant infiltration of the parts, the following ointments should be used : 
B. Ung. hydrarg. fort., > 
Bals. Peru., 5U j 
Ung. simpl. or vaseline, 5'ss> M. 
B. Ung. hydrarg. fort., 5'J 5 
01. cadini vel 
Betulae albae, 5j > 
Vaseline, 5J- 
B. Ung. hydrarg. nitratis, 3'J > 
Ung. aq. rosae, > 
Bals. Peru., oj- 
B. Hyd. submuriat., Sss-gj; 
Acid, carbolici, Sr- xx > 
Ung. aq. rosae, 5J- 170 
VENEREAL DISEASES. 
These ointments should be rubbed into the skin well, and if possible retained by gloves, those 
of India rubber by preference. 
In cases of much infiltration with hyperaemia the following are very beneficial: 
R. Ung. hydrarg. fort., 31'j; 
Ung. diachyli, 5j; 
Bals. Peru., 3j. M. 
R. Hyd. submur., 3j; 
Acid, carbolici, gr. xx ; 
Ung. diachyli, 5j. M. 
Chronic scaling papular syphilides of the body may be removed by using- 
R. Chrysarobin, gr. x-xx; 
Vaseline, • §j. M. 
To be used after a warm alkaline bath, and care being taken to protect the eyes and perhaps the 
face. 
Chronic scaling syphilides of the palms and soles may be benefited by the following: 
R. Acid, salicylic., Sss-^j; 
Ung. diachyli, §j. M. 
R. Acid, salicylic., sj; 
Chrysarobin, £ss; 
Ung. aq. rosae or vaseline, gj. M. 
Local scaling patches may be removed by- 
R. Acid, salicylic., gj; 
Chrysarobin, 3ss; 
Collodion flex., §j. M. 
To be painted on occasionally. 
Hypertrophic papules and condylomata lata may be washed with one part of Labarraque's 
solution and eight parts of water, and then dusted with calomel; or, after careful cleansing, they 
may be sprinkled with- 
R. Acid, salicylic., gj; 
Cretae praecip., gj. M. 
or, 
R. Acid, salicylic., 5j; 
Acid, boracic., siij; 
Cretae praecip., gj. M. 
R. Acid, boracic., 
lodoformi, aa. §ss. M. 
R. Acid, salicylic., sj; 
lodoformi, gij; 
Cretae praecip., §j. M. 
In the stage of decline the following is excellent: 
R. Acid, salicylic., 3j; 
lodoformi, gij; 
Collodion, §j. M. 
Ulcers left by early and late syphilides should be carefully washed and cleansed, and if possible 
immersed in very hot water, and then dusted with iodoform or iodoform and precipitated chalk in TREATMENT OF SYPHILIS. 
171 
equal quantities. When large surfaces of ulceration are present affusions of a warm- or hot-water 
solution of bichloride of mercury (gr. j to oxxxij) should be applied. It may be necessary to 
touch each ulcer with a solution of nitrate of silver (gr. x-xx to sj aq.) or with equal parts of 
carbolic acid and glycerin. 
Serpiginous ulcerations require constant care and perhaps frequent mild cauterization of the 
ulcerating periphery. Iodoform may be used with advantage, but if the surface is large the sur- 
geon must be on the lookout for toxic symptoms. The following lotion may be applied: 
B. Hydrarg. bichloridi, gr. viij; 
Aquae, gxvj-gxxiv. M. 
Or these ointments: 
B. Ung. hydrarg. fort., 3>ij-3vj 5 
Ung. zinci oxid., 
Ung. diachyli, dd. sj. M. 
B. Ung. hydrarg. nitratis, gij; 
Bals. Peru., 3j; 
Ung. aq. rosae, 5j. M. 
Gummatous ulcers require much care and attention. When there is a foul, uneven necrotic- 
base the careful application of (a) caustic potassa oij, water 5j, or of a sixty-grain-to-the-ounce- 
of-water solution of nitrate of silver, or (r) equal parts of carbolic acid and glycerin, should be 
made as often as necessary. Then the surfaces may be dusted with iodoform or with- 
B. lodoformi, 5ij ; 
Bismuth, subnit., 3j. M. 
Sterilized sand may also be advantageously employed, particularly in very deep and extensive 
ulcers, after carefully and sparingly dusting them with iodoform. 
In some cases I have seen a healthy surface induced by the following : 
B. Acid, salicylic. 5ij ; 
lodoformi, 5vj ; 
Bismuth, subnit. or sterilized sand, 51'j. M. 
In all cases of ulceration rest and the recumbent position should be ordered ; the parts after 
any application should be covered with some antiseptic dressing, and the whole carefully and firmly 
bandaged. DISEASES OF THE SKIN. PARI' I V. 
DISEASES OF THE SKIN. 
It is important for the student or practitioner desiring to acquire a knowledge of Skin 
Diseases to be impressed, at the outset, with the fact that these diseases intimately belong to 
the general domain of medicine and surgery, and that they should not be studied in a narrow 
and special manner, but rather in the broad light of pathology and medicine. It is one of the 
important signs of a more perfect system of dermatology that to-day the morbid changes in the 
skin are almost universally admitted to be in very many instances more or less intimately asso- 
ciated with, and perhaps we may say the expression of, deranged systemic conditions. From its 
structure, its situation, from the conditions which surround and react upon it, the skin is frequently 
the seat of irritation and inflammation ; and varied as these externally caused affections are, they 
have as congeners eruptions which are etiologically related to visceral diseases, septic poisoning, 
hereditary and acquired morbid and diathetic conditions, nervous affections, and gastro-intes- 
tinal disorders. Certain articles of food will be found to be the occasion of morbid outbreaks 
upon the skin, and a long list of drugs will be given, the ingestion of which is frequently found 
to produce the most varied dermal lesions. A well-marked group of skin affections are caused 
by microscopic vegetable parasites, and a number of minute animal parasites produce more or 
less severe ravages upon the skin. Then, again, certain skin diseases are due to some hereditary 
or acquired morbid conditions inherent in the structure of the skin itself. 
Painstaking study and observation soon familiarize the student with the dermal affections of 
external origin. His chief source of embarrassment will be in establishing an etiological cause 
or factor for cases in which external irritation plays no part. It is a good rule in all inflamma- 
tory local, and even general, affections of the skin to first eliminate external causes as factors 
in the case. Then the way is clear for inquiry and search for an internal cause ; and the suc- 
cess of the practitioner will depend on his acumen, broad and intimate knowledge of medicine, 
his powers of observation, and the retentiveness of his memory in dermal affections. It is these 
cases which call into service his knowledge of physical diagnosis, the physiology and pathology 
of the circulation, of the relation of the nervous system to diseases of organs and tissues, of the 
reaction of affections of the nervous system upon the skin, of the correlation of nervous sympa- 
thies, of simple and obscure morbid states, of infectious diseases local and general, of the vicissi- 
tudes of age and sex, of morbid conditions resulting from changes of the season, from climatic 
and telluric influences, and from food and drink, of the deviations of health due to race and race- 
intermingling, and, finally, of the conditions known under the head of heredity. In short, 
for a man to be a thorough practical dermatologist he must be an educated and ad\ anced 
physician. 
d he special requirements in the study of diseases of the skin are first, a fair, common- 
sense, not too minute and technical knowledge of the anatomy of the skin and of its appendages, 
if possible gained from a good teacher; second, a clear and practical understanding of inflam- 
mation, and a knowledge of hyperaemia, anaemia, and hemorrhage, of hypertrophy and atrophy, 
175 176 
DISEASES OF THE SKIN. 
of new growths, and of the microscopic appearances of the animal and vegetable parasites. 
Until the student is well grounded in the clinical history and diagnosis of skin diseases he 
should not delve too deeply into the mysteries of their pathological anatomy. Such study has 
much to commend it, but it should always be secondary and supplementary to practical obser- 
vation and therapeutics. 
Certain general rules should govern the student in the observation of cases. The physiog- 
nomy and build of the patient, his temperament and habits of life, and his medical history, often 
present points of much importance. Frequently, much information may be obtained from the 
history of the patient's family and kinsfolk antecedent and present. Then a patient's occupa- 
tion often exerts a local or general influence upon him, and very often from this source informa- 
tion of much practical value is gained. Then the eruption must be carefully studied and analyzed. 
Its seat, extent, intensity, and general physiognomy must be considered, and whether it is a first 
invasion or a relapse should be noted. Very often patients themselves can give important 
information as to their trouble, its origin, its amenability to treatment, the conditions causing its 
extension, relapses, the effects of season, climate, diet, etc. 
The patient should be examined by daylight in a comfortable room, and all of the eruption, 
present or past, should be scrutinized. In the examination of females the utmost delicacy, care, 
and tact should be employed. Even when a general examination of the body is necessary it can, 
and should, always be done in a manner which will not shock or trouble the most sensitive and 
delicate patients. This delicacy of examination should be followed in public as well as in private 
practice. 
The objective signs of diseases of the skin are those which are visible to the eye. These 
embrace two orders of lesions-the one called the primary lesions ; the other, the secondary 
lesions. Of these two orders of morbid change in the skin all eruptions are composed. It is an 
absolute essential, therefore, that the student should have a thorough knowledge of them, since 
they are to dermatology what the alphabet is to words and language. Some eruptions, simple in 
appearance, consist of but one primary lesion and of the one or more secondary lesions which 
result from it. Then, others are more complex, and consist of several primary lesions and of their 
secondary metamorphoses. Careful observation of the evolution, life-history, peculiarities of situ- 
ation, and tendency to become grouped or remain sparse, and of the mode of retrogression, of these 
various lesions and of the peculiarities of their secondary changes, is necessary in order to be a 
skilled dermatologist. 
In any given case it is always a good rule to seek out the most recent portion of the eruption, 
learn its lesion or lesions, and then build upon the results. Conversely, it is, as a rule, not well 
to form opinions upon the mature eruptions, but to reach them by induction. Thus it is that 
while in the majority of cases the diagnosis of an eruption is made at the first examination, in 
some a second or third inspection is necessary. 
The primary lesions of the skin are eight in number, as follows: i, the erythematous spot; 
2, the papule ; 3, the tubercle ; 4, the vesicle ; 5, the pustule ; 6, the bulla or bleb ; 7, the wheal; 
and 8, the tumor. 
The secondary lesions are seven in number, as follows: 1, the scale; 2, the excoriation; 3, 
the fissure ; 4, the ulcer; 5, the crust; 6, the cicatrix ; and 7, the macule or pigmentation. 
The subjective symptoms of diseases of the skin are, first, those which pertain to the sys- 
temic condition of the patient, such as fever, malaise, debility, marasmus, nervous disturbances, 
and gastro-intestinal disorders ; and, second, those inherent in the skin itself-namely anaesthesia, 
analgesia, hyperaesthesia, itching, burning, a sense of crawling or formication and of the pricking 
of pins. In some diseases of the skin subjective symptoms are either wholly absent or of very 
slight character, while in others they are more or less severe. DISEASES OF THE SKIN. 
177 
The description of skin diseases necessitates a varied and expressive vocabulary. It is well, 
therefore, to become familiar with the more commonly-employed words. Care should always be 
taken to use only terse, simple, and graphic words, and to eliminate those which in former years 
tended to retard the study of dermatology by their length, inexact character, obscurity, and redund- 
ancy. Thus, acuminate signifies pointed at the apex ; aggregated, grouped or collected in patches; 
annular, in form of a ring; circinate, of circular outline ; diffuse, irregularly scattered ; discrete, 
isolated from each other; erythematous, having a red hue; exulcerans, superficial ulceration; 
fibrosus, composed of fibrous tissue ; figuratus, having a figured appearance ; foliaceous, in the 
form of leaves ; guttatus, of the size of a drop of water ; gyrate, having a serrated or wavy out- 
line ; hiemalis, developed in winter ; lenticular, of the size of a bean or lentil; madidans, weeping, 
oozing; marginatus, of defined margin ; melanotic, of brown, black, or blackish-blue color; mili- 
ary, of the size of a millet-seed ; multiformis, consisting of several types of elementary lesions ; 
nodosus, in form of nodes ; nummular, in shape of coin ; polymorphous, in many forms ; prurig- 
inous, itching ; punctate, in points ; serpiginous, creeping; universalis, involving the whole body; 
versicolor, of various shades of color ; vulgaris, applied to simple or common forms. 
Lesions of the skin may be limited to a small portion of a region or regions, or may involve 
the whole body. They may be symmetrically placed or occur only on one side. They very fre- 
quently follow the lines and furrows of the skin, the lines of obliquity of the ribs, and the course 
of cutaneous nerves. In these groupings they present various forms of figure and outline, some- 
times circular, again in the form of rings and of segments of circles and serpentine lines, and 
sometimes concentric rings are formed. 
Some affections of the skin show a predilection to develop upon certain parts ; thus, the ery- 
themata are prone to appear on the backs of the hands and face ; eczema on flexor aspects, where 
the epidermis is thin and delicate ; psoriasis on extensor surfaces, where it is thick and abundant; 
acne on the face and back ; the various form of lupus chiefly on the face ; and the syphilides on the 
face, at the margin of the hairy scalp, frontal and occipital, and in the region of the joints. PRIMARY LESIONS. 
THE ERYTHEMATOUS SPOT. 
The erythematous spot is the most elementary of all skin-lesions, and is due to hyperaemia of 
the superficial capillaries of the cutis. There are two forms-the active and the passive, the former 
being much more frequent, and always at its beginning of a bright-red color, while the latter or 
passive, resulting as it does from mechanical impediment to the circulation or to extravasation of 
blood, is of a deep-red, even bluish, tint. Erythematous eruptions, which are composed of these 
spots in greater or less extent and intensity, are the expressions of the most varied pathological 
conditions, from slight gastric disorder and from the ingestion of certain drugs to specific and septic 
infection. According as their determining cause is acute or subacute, so is the mode of evolution of 
the erythemata. In most instances their invasion is prompt, their extension and involution rapid. 
The color of erythematous spots varies from a pale rose-red to a deep and even coppery red. 
Their sizes are most diverse, varying from that of a pinhead to that of a nail and of the palm 
of the hand, and in some cases consisting of large patches or sheets of eruption covering whole 
regions. Some authors call the small spots roseola, and class the large patches as erythema. 
Their shape is subject to much variation. In general, they are round or oval, but frequently 
they develop into irregular gyrate patches consisting of groups and segments of circles, serpentine 
lines, and figures-of-eight. The spots and patches are generally sharply marginated, and sometimes 
fade in the centre while they increase at the periphery. 
Many erythematous spots are not at all elevated, while others, of greater intensity and longer 
duration, present more or less salience, owing to the fact that exudation and perhaps cell-changes 
have taken place in the skin. In many instances papules, tubercles, nodes, vesicles, and bullae are 
present as complications of active severe erythemata. 
The more evanescent erythematous eruptions occasion no appreciable thickening of the skin, 
whereas the more active ones are often attended with considerable swelling, even with the forma- 
tion of deeply-seated and prominent nodes. 
Itching and burning are constant symptoms of most erythemata, together with greater or less 
systemic reaction. Marked features of the erythematous spots of syphilis are the slow aphleg- 
masic development, the indolent course, and the absence of itching in uncomplicated cases. 
The date of the process of involution varies very much in the different forms of erythema, 
and depends largely upon the continuance of the exciting cause. As a rule, it is prompt and rapid, 
but in many instances is delayed. The appearances presented are the fading away of the redness 
into reddish-brown, greenish-yellow, and copper-colored spots ; all of which eventually disappear, 
often accompanied with slight desquamation. 
The more florid young erythematous spots disappear momentarily under pressure ; the older 
ones and those of passive origin do not present this feature. 
Erythematous spots due to external irritating agents and to the coaptation of surfaces vary in 
size, intensity, and duration according to their cause. All portions of the body may be the seat 
of erythematous spots: some are more prone to develop upon the hands and face, while others 
show a predilection to the trunk and limbs. 
PAPULES. 
These lesions occur in so many forms of eruption, in so many varieties of shape, color, size, 
etc., and undergo such varied morphological changes, that an accurate knowledge of them is 
essential. 
178 PRIMARY LESIONS. 
179 
Willan and the older dermatologists placed all papular eruptions under the title of lichen ; but 
to-day this term is restricted to the affections known as lichen planus, lichen ruber, and lichen 
scrofulosus, since in these the papular element is the essential and constant feature of the eruption. 
All other papular efflorescences are more or less inconstant in character and show great mutability 
of form, shape, and structure. Thus, eczema includes a lichenoid or papular variety, and there 
are papular forms of erythema and of the syphilides. None of these should be considered under 
the general head Lichen. 
The term papule is applied to superficial, solid, quite firm, slightly compressible inflammatory 
elevations of the skin, varying in size between a pinhead or a millet- or mustard-seed and a lentil; 
hence the terms miliary and lenticular papules. When these lesions reach a larger size than one- 
quarter or perhaps one-third of an inch, they are called tubercles. 
The color of papules varies much in different diseases and in their different stages. They 
may be of the normal hue of the skin, as in urticaria and prurigo ; of a yellowish-red color, as in 
lichen scrofulosus ; of all shades of red, as in eczema, acne, and psoriasis ; of a violaceous or red- 
dish-blue color, as in lichen planus ; or of a dull red or coppery hue, as in the papular syphilides. 
1 heir outline may be round, oval, or angular, and they may be conical or acuminated, flat, 
umbilicated, and semiglobular. 
They are all more or less elevated above the level of the skin-in some cases slightly so, in 
others presenting marked salience. Thus, the prurigo papules are often scarcely visible, and fre- 
quently their presence can only be determined by passing the tip of the finger quite firmly over the 
affected parts, when the faintest sensation of undulation is felt. The papules of eczema are fre- 
quently not much elevated, and rarely as prominent as those of erythema papulatum, while those 
of acne, lichen scrofulosus, psoriasis, lichen planus, and of syphilis consist of well-marked eleva- 
tions varying between one-quarter of a line and one-eighth of an inch. 
The evolution of papular eruptions is acute, subacute, and chronic. In erythema and in 
many cases of eczema the development of the papules is very rapid, the whole eruption being 
promptly developed. In other instances successive crops appear. The growth of the papules of 
lichen planus, lichen ruber, and lichen scrofulosus is subacute, and a series of crops appears before 
the eruption is at its period of full development. Likewise, the evolution of syphilitic papules is 
slow and in crops, and relapses are frequent. 
All parts of the body may be the seat of papules, though certain forms show a tendency to 
develop on certain regions. Thus, the papules of acne are generally confined to the face and back ; 
those of eczema appear upon the flexor surfaces of the limbs, the face, and the trunk ; those of 
psoriasis upon the extensor surfaces and parts whose epidermal layers are thick ; while those of ery- 
thema show a marked tendency for the backs of the hands and feet, arms, legs, face, and upper 
portions of the body. 1 he papules of lichen planus are commonly found on the flexor and exten- 
sor surfaces of the wrists, on the forearms, legs, knees, thighs, and chest, while those of lichen 
scrofulosus are generally met with on the trunk, and less frequently on the limbs. 1 he various 
forms of syphilitic papules are developed over the whole body, those of the early stage being quite 
general and symmetrical, while those of later appearance show tendencies to develop upon the 
face, near joints, and upon the palms of the hands. 
I he arrangement of the distribution of papules is most varied, though generally symmetrical, 
d hey may be scattered over a region in a discrete manner, or they may be aggregated in groups, 
or they may be so numerous that they are confluent. 
All papules undergo more or less varied morphological changes at an earlier or later date : 
those of lichen planus, lichen ruber, and lichen scrofulosus, however, retain their individuality 
longer than any others. Thus, the papules of erythema soon form irregular patches or circles and 
segments of circles, while those of eczema in most cases soon become vesicles or pustules or are 180 
DISEASES OF THE SKIN. 
lost in a scaling or oozing surface. In acne, papules are usually present with pustules, and com- 
monly become the seat of pustulation ; while the papular form of urticaria, the lichen urticatus of 
the older writers, develops either into large wheals or into erythematous patches. The miliary 
papules of syphilis are prone to become papulo-pustular and even pustular; while the larger and 
flatter forms of papular syphilide show a tendency to become squamous, to fuse together in the 
forms of circles and segments, of figures-of-eight and gyrate and serpentine lines ; to increase at 
their periphery and heal in their centre, and thus form rings, or to lose their epidermal covering 
and become converted into moist papules, the so-called mucous patches of the skin, or to break 
down into ulcers. 
Papules are, as a rule, accompanied by more or less desquamation. Those of erythema, acne, 
and urticaria in their decline are slightly scaly, while those of psoriasis always increase into scaling 
surfaces. Uncomplicated eczematous papules are always more or less scaly, while those of lichen 
planus, though covered with a thick layer of epidermis, rarely show exfoliation. The scales of 
lichen scrofulosus are small and scanty. Though epidermal proliferation is only secondary to the 
formation of syphilitic papules, it frequently becomes a prominent feature. It may be stated that, 
as a rule, all scaling syphilides begin in the papular form, the exception being the tubercular form. 
While it is common to find whole eruptions composed of papular elements, not infrequently there are 
present erythematous spots, vesicles, papulo-pustules, pustules, ulcerations, tubercles, and nodes. 
After a variable duration papules undergo involution, which may be rapid or prolonged accord- 
ing to the nature of the exudation or cell-proliferation composing them. This process shows itself 
first in a diminution in the color of the lesions, and then their gradual subsidence until the skin- 
level is reached. They leave spots of varied color, from a light red to a deep coppery tint, and 
from a yellowish-green to a purplish-blue. Remaining longest on the legs, in time these maculae 
fade away, and in most cases leave a normal skin ; in some absence of normal pigmentation is 
observed as a sequela, and with the syphilitic papules there is sometimes atrophy. 
Papular eruptions may be unattended by any sensory disturbance, or may be accompanied by 
heat, tension, and burning, and by itching of various degrees of intensity. 
The pathological changes observed in the formation of papules are varied. Certain of them 
are due to exudation into the papillary layer of the skin and increase of epidermis ; others to vary- 
ing degrees of hyperaemia, exudation, and cell-infiltration into the Malpighian layer or rete and into 
the papillae ; while others are caused by perifollicular hyperaemia and cell-increase, and inflam- 
matory changes in the papillae and upper layers of the corium. The papules of syphilis, like all 
of its neoplasms, are of a specific nature, thus differing from all their congeners, and are due to a 
lowly-organized cell-infiltration of quite sharp limitation into the papillae and upper layers of the 
corium and into the perifollicular papillae. 
In marked contrast to the foregoing, which may be termed true papules, are a number of 
lesions of more chronic and acute character, to which the term papule is applied. They are the 
following: 
1. Minute conical papules of the size of a pinhead or of a mustard-seed seated around the 
orifices of hair-follicles and enclosing a more or less twisted hair. They are of the color of the 
skin or of a brown tint, and present a rough sensation like that of a nutmeg-grater. They are 
prone to appear on the legs and forearms and in locations where hairs are abundant. This lesion 
is the lichen pilaris of Willan and the keratosis pilaris of modern authors. The lesion consists of 
concentric laminae of epidermal scales. 
2. Minute white or yellowish-white elevations of the skin of the forehead, cheeks, and chin, 
having very small black spots at their apices. These are due to retention in the sebaceous 
glands of hard and altered sebum, and are called comedones. 
3. Small millet-sized pale-yellowish papules, found about the eyes, penis, and scrotum, and i8i 
PRIMARY LESIONS. 
called milium or grutum. They consist of a fibrous capsule enclosing epidermal cells, and are 
probably due to fibroid degeneration of one or more lobules of sebaceous glands. 
4. Smaller or larger circumscribed hemorrhages into the rete mucosum, giving rise to papu- 
lation, and termed lichen lividus and purpura urticans. 
5. Chronic hypertrophy of the papillae and epidermis, as seen in some cases of chronic 
eczema, particularly of the legs, in elephantiasis Arabum, syphilitic condylomata and tubercles, 
framboesia, and in some cases of ichthyosis. 
6. Small flesh-colored conical elevations caused by spasm of the muscles of the skin, push- 
ing the follicles upward, and called cutis anserina or goose-flesh. 
TUBERCLES. 
The term tubercle, as used in dermatology, is applied to a variety of firm, circumscribed 
elevations of the skin which are larger than papules and smaller than tumors. Assuming that 
a diameter of one-third of an inch is the limit to which the term papules is applicable, tubercles 
may be said to have a diameter of from one-third of an inch to an inch, and even more. 
Besides in their more extensive area, tubercles also differ from papules in their greater depth ; 
thus, while the anatomical changes which constitute the smaller lesion are situated in the upper 
strata of the derma, those forming the tubercle involve both the superficial and deep layers of 
that tissue. In every sense, therefore, they are exaggerated papules. 
Tubercles of the skin may be divided into four well-defined classes, as follows : 
1. Those due to inflammatory exudation and cell-proliferation, examples of which are seen 
in erythema multiforme and some cases of erythema nodosum, in ringworm of the beard, and 
in acne indurata. 
2. Tubercles formed by connective-tissue new growths, such as molluscum sebaceum, 
molluscum fibrosum, keloid, morphoea xanthoma, neuroma and scleroderma, and lymph- 
angioma. 
3. Those caused by the development of granulation tissue, as found in lupus, syphilis, 
and leprosy. 
4. Tubercles composed of malignant new growths-epithelial cancer, carcinoma, scirrhus, and 
the various forms of sarcoma. 
Lesions due to such widely different pathological processes present equally varied features 
of growth, development, and decline. 
The inflammatory tubercles of the erythemata, being simply monster papules, present a 
similar life-history to that of their smaller congeners, and differ only in their rather longer 
period of retrogression. The tubercles of acne begin as papules or papulo-pustules, and con- 
sist of round or oval circumscribed masses or nodules seated deeply in the skin, having a rounded 
or convex red or brownish-red surface. They are frequently the seat of pustulation. 
The tubercles sometimes seen in tinea trichophytina barbae consist of quite firm, round, 
oval, or irregular, deeply-seated swellings or nodules, which present marked elevations of the 
skin. Their well-marked convex surface is of a red or a dull-red color, often obscured by scales 
and studded by diseased hairs. The course of the tubercles of acne and ringworm of the beard 
is very chronic, and their involution is rapid or slow according to the activity and efficiency of 
treatment. 
In these inflammatory exudative diseases the tubercles sometimes grow to such a size that 
the term nodule more correctly describes them. 
The tubercles of molluscum sebaceum are frequently called little tumors. They are of 
pinkish hue or of the normal color of the skin, and often present a minute depression at their 182 
DISEASES OF THE SKIN. 
apex. They vary in size from that of a good-sized shot to that of a pea, and even of a grape. 
Their course is very chronic, and they may later on become the seat of degenerative changes. 
The lesions of molluscum fibrosum are sometimes so small that the term papule is applicable, 
and, while in most instances they are of such a size that they may be called tubercles, very 
frequently by increased growth they form tumors. Very often the choice of terms becomes a 
puzzling question. 
The tubercles of keloid vary in size according to their age ; beginning as papules, they 
increase until in some cases they form tumors. Their growth is peculiar in the fact that besides 
peripheral extension they increase in area by the development of outshoots. 
The tubercles of neuroma are allied in nature to fibroma molluscum, and are simply fibroma- 
tous tumors developed in the continuity of a nerve. They are round or oval, circumscribed, and 
movable under the skin, and sometimes the seat of pain. Morphoea xanthoma and scleroderma 
are classed as tubercular diseases, more from the fact that they are essentially infiltrations of the 
whole derma than from their presenting tubercular elevations. The case may be best stated by 
saying that, pathologically, they belong to the group of connective-tissue infiltrations, the most 
prominent of which present well-marked tubercles, and that the extent and diffusion of the new 
growths composing them are such that they usually do not rise much above the level of the skin. 
Their tubercular nature is determined by pinching and palpation. 
The tubercles of lymph-angioma are slightly-elevated, compressible, round or oval lesions, 
having a smooth flat surface, and of a normal or brownish-red hue. They may be mistaken for 
the large flat syphilitic papule or tubercle. They present a pearly-white, translucent tissue com- 
posed of hypertrophied lymph-vessels and fibrous tissue. They are considered by Von Reckling- 
hausen to belong to the family of connective-tissue new growths. 
The tubercles of lupus present so many different appearances and such a variety of features 
that description of them is reserved to the chapter treating of the whole subject. 
Syphilitic tubercles, being monster papules, present much the same course as the smaller 
lesions. They are of firm consistence, more or less elevated, of a deep-red or coppery hue, fre- 
quently the seat of scaling; they show tendencies to appear on certain regions, to remain indolent 
or increase peripherally, to undergo varied morphological changes, and may coexist with other 
syphilitic lesions more or less superficial. A full description is given in the section treating of the 
syphilides. 
The tubercles of lupus are usually followed by a loss of tissue ; those of syphilis, being in 
many cases amenable to treatment, may be absorbed without disfigurement. 
Tubercles composed of malignant new growths are of varied character and appearance, and 
must be studied by themselves. Those of epithelioma are commonly found upon the face in the 
region of the eye, upon the lips and in the pharynx, and on the tongue. They may be developed 
upon other portions of the body, owing to irritation of any lesion from a wart to an ulcer. They 
are most commonly met with in persons beyond forty years of age. 
Scirrhous tubercles rarely remain in that stage, but go on to the formation of tumors, and are 
usually found on the breast. 
Sarcomatous tubercles begin as subcutaneous nodules, which soon contract adhesions with the 
skin, and then appear as bright-red or brownish-red circumscribed conical and rounded elevations, 
of which there may be few or many, and showing a tendency to coalesce. They may increase 
in number over the whole body, and often attack the viscera. Their tubercular stage passes into 
that of tumor. Melanotic sarcoma tubercles have a similar clinical history, but have a deep-blue 
color. PRIMARY LESIONS. 
183 
VESICLES. 
Vesicles are elevations of the epidermis containing a serous fluid. In shape they are conical, 
semiglobular, and umbilicated, and in outline round, oval, and irregular. Their color varies accord- 
mg to the condition of their contents, being at first clear and pellucid, and later on more or less 
turbid. They vary in size from a millet-seed to a lentil, in this corresponding to papules. When 
vesicles consist of but one chamber or locule they are called simple, and when they are formed of 
several they are termed compound or multilocular. In proportion as the distending fluid is copious 
or scanty, so are the vesicles tense or flaccid and of uneven surface. Their consistence varies with 
the thickness of their epidermal dome : those in which this is thick are firm ; those in which it is 
thin are the reverse. They are called superficial when developed in the epidermis or between that 
structure and the mucous layer of the skin, and deep-seated when developed in the latter stratum, 
d hey are caused by serous exudation from the vessels of the papillae or from the retention of sweat. 
They are always the result of inflammation or hyperaemia in varying degrees. In the majority of 
vesicles the effusion passes between the cells of the mucous layer and reaches the corneous layer, 
which it uplifts ; while in sudamina the vesicles are formed in the corneous layer. The exuded 
fluid is of alkaline reaction. 
Vesicles are usually ephemeral in their course, existing only a few hours or days, and undergo 
various changes. They may burst and leave a raw surface, or, their contents being absorbed, 
they may dry up and fall off as scales ; the exuded fluid may become turbid from the admixture of 
lymphoid cells, and then they become pustules ; or they may be the seat of hemorrhage. 
The vesicles of herpes zoster and of sudamina, miliaria, and varicella are more stable than 
those of other diseases, and may remain intact for several days. Those of eczema, impetigo 
herpetiformis, dermatitis herpetiformis, impetigo contagiosa, very rapidly undergo change. 
Vesicles usually occur in a grouped or aggregated form, rarely singly, and are seated on a 
more or less inflamed surface, sudamina excepted. They occur upon all portions of the body- 
upon the flexor surfaces and in the course of the nerves-and may be developed on parts where 
the epidermis is thick-namely, the palms of the hands, the sacral and gluteal regions, and else- 
where. 
The term vesico-pustules is applied to vesicles containing a moderately turbid fluid, and they 
are really border-line lesions between vesicles and pustules. 
More or less severe subjective symptoms precede and accompany the formation of vesicles, 
such as itching and burning and neuralgic pains. 
PUSTULES. 
Pustules are circumscribed elevations of the skin containing pus, originating as such or by 
transition from vesicles. They vary in size from a millet-seed to an area of half an inch and more. 
I hey are conical, Hat, semiglobular, and umbilicated in shape, and in outline round, oval, and 
irregular. They appear singly scattered over the body, in groups, and in the form of rings. In 
color they are of varying shades of yellow, sometimes bluish from the admixture of blood. I hey 
are seated upon a more or less red and elevated, and even indurated, areola, thus presenting vary- 
ing conditions of salience. Lesions resulting from transition from vesicles are called vesico-pus- 
tules, and papules which become pustular at their apex are called papulo-pustulcs. 
Pustules have their origin in the mucous and papillary layers of the skin, in sebaceous glands, 
and around follicles. The pathological conditions causing them are the most varied, from external 
irritation to septic and specific infection. Thus it is that pustules vary so much in their mode of 
evolution, size, shape, duration, and involution. They may consist of but one chamber, or they 184 
DISEASES OF THE SKIN. 
may be multilocular. They pursue a most varied course. Some begin promptly to wither and 
become encrusted, others remain indolent for a time ; some break down into more or less deep 
ulcers, while others may extend peripherally and then become desiccated and form crusts ; and 
yet, again, some may increase in size and assume the appearance of bullae filled with pus. The 
more superficial and ephemeral pustules leave no structural change in the skin ; those involving 
the deeper layers of the derma and of long duration may cause atrophy. 
Pustules are found in acne, eczema, ecthyma, impetigo, impetigo contagiosa, variola, scabies, 
sycosis, syphilis, septic infection, and are caused by the ingestion of such drugs as iodide and bro- 
mide of potassium, salicylic acid, arsenic, and frequently result from the application of drugs, such 
as mustard, tartar emetic, mercurial ointment, arsenic, bichloride of mercury, iodoform, prepara- 
tions of tar, minute insects, and poisonous shrubs and vines. Their origins being so numerous 
and different, their significance and prognosis must be based upon them. 
The subjective symptoms of pustules differ with their cause. There may be slight itching and 
burning, and again these symptoms may be very severe. In syphilis, pustules rarely give rise to 
any irritation, except when developed upon the scalp or when from any cause the evolution of the 
rash is acute, and then slight pruritus may be present for a short time. In general, the itching 
and burning have a great influence upon the course of pustules, since they cause scratching and 
rubbing, which in their turn cause the extension of the inflammatory process. 
BULL/E OR BLEBS. 
Bullae are essentially monster vesicles, and are elevations of the epidermis varying in size 
between a lentil and a moderate-sized potato. Their mode of development and structure is the 
same as those of vesicles. While the latter show a tendency to uniformity of size, bullae have no 
standard, large and small ones being found irregularly mixed. In shape they are round, oval, and 
irregular. When fully developed they consist of unilocular, much-elevated blebs or blisters, tense 
from the pressure of the enclosed fluid, or flaccid when the serum is scanty, of a yellow straw 
color, and surrounded by an inflammatory areola. Their walls are firm, and spontaneous rupture 
does not always occur. Sooner or later the enclosed fluid changes to a turbid white, and perhaps 
to a yellow, and in some cases there is admixture of blood. Bullae occur upon all portions of the 
body. There may be but few or many. They may be scattered in a discrete manner or collected 
in groups. Their mode of appearance may be acute, subacute, or chronic. 
There are various modes of involution of these lesions : some become desiccated and form 
flat adherent crusts ; others rupture, leaving a raw surface covered with shreds of epidermis ; others 
degenerate into ulcers and become encrusted ; while in some their contents become inspissated and 
form a soft yellowish cohesive mass which is composed largely of pus-cells covering a reddened 
raw surface. 
Bullae are found in pemphigus, erythema multiforme, erysipelas, some forms of herpes, 
dermatitis herpetiformis, in the course of pneumonia and septic infections, in syphilis-very 
rarely in the acquired form, and more frequently in the hereditary disease-as a result of the 
toxic action of drugs and external irritants and vesicants, and in leprosy. 
Lesions are not infrequently met with which are neither vesicles nor bullae, and are called 
small bullae. They are seen in some cases of herpes, in erythema multiforme, in hydroa, and 
in one form of dermatitis herpetiformis. 
Itching and burning of various degrees may accompany the development of bullae. When 
the lesions are few in number there may be scarcely any sensory disturbance ; in the more acute 
and extensive eruptions the symptoms are often severe. PRIMARY LESIONS. 
i85 
WHEALS. 
Wheals are solid elevations of the skin of ephemeral duration, varying in size from one- 
half of an inch to four, and even six, inches in diameter. At their invasion they present a 
central portion whiter than the normal skin surrounded by a red areola, but they soon take 
on a dull deep-red and sometimes purplish hue. They are oval and irregular in shape, and 
sometimes form band-like and serpentine lines. In some cases wheals increase at their periph- 
ery and heal in the centre, and then coalesce and form gyrate patches. They vary in eleva- 
tion very much ; many wheals are raised about two or three lines above the surface, others less 
than an inch, and in exceptional cases they reach a prominence of an inch and a third. They 
give to the epidermis at their maturity a shining, tense appearance, which is of short duration. 
It is not uncommon to see minute pellucid vesicles upon the surface of wheals, and even bullae 
in some exceptional cases. While, in general, wheals are evanescent in their course, coming 
and going without leaving any traces in one or a few days, sometimes they show a tendency to 
remain stationary for one or more weeks as hard, elevated lumps. They occur, therefore, in 
an acute and a chronic form, in the former large surfaces of the skin of the body, forearms, face, 
and legs being symmetrically attacked ; in the latter the wheals show a tendency to localization 
on the upper and lower limbs, and often are unsymmetrical. The erythematous spot which is 
always found following wheals is usually of a pale-red color, in some instances of a deep-red, 
and in cases in which hemorrhage has been a complication of deep shades of purplish blue. 
I hese deeper maculations may be rather slow to disappear, particularly about the legs. In 
rather rare and chronic cases more or less permanent coppery pigmentation may be left on 
the sites of wheals, as seen in urticaria pigmentosum. 
I hese lesions are formed by a rapid exudation of serum into the upper layers of the skin. 
I heir whitish centre is caused by irritation and contraction of the capillaries, and represents the 
skin in a condition of spasm ; this is accompanied by peripheral dilatation of the capillaries and 
prompt effusion of serum. The result is a wheal. 
Wheals may be caused by such external irritants as the sting of a nettle or by minute insects 
and animal parasites, or they may be the result of gastro-intestinal irritations of various kinds and 
degrees. 
I he etiology of chronic forms of wheals is somewhat obscure. 
Eruptions of wheals seem correlated to those of erythema multiforme. I he subjective 
symptoms accompanying their evolution are very various. In most instances there are mild 
fever, malaise, and loss of appetite, while exceptionally we find these symptoms very intense and 
accompanied by delirium and cerebral hyperaemia. The affected regions are the seat of intense 
itching and burning. The chronic form is sometimes the expression of a rheumatic condition or 
an accompanying feature of flatulent acid dyspepsia. 
Wheals are also called pomphi, urticae, and quaddeln. 
TUMORS. 
Tumors of the skin vary in size between a hickory-nut or walnut and a goose's egg, or 
between a man's fist and an infant's head. In their essential elements they differ from each other 
as widely as they do in size. They are formed either superficially in the skin, in the deep layers 
of the derma and connective tissue, and in the appendages of the skin. They are of various 
shapes-semiglobular, sessile, pedunculated, and angular. Their elevation varies from a slight 
salience, in which the tumor can only be made out by palpation, to an inch or several inches. In 
outline they are round, oval, and irregular, and in color of the normal hue of the skin, of all shades 186 
DISEASES OF THE SKIN. 
of red, blue, purple, black, and brown. Their surfaces may be smooth, uneven, papillated, and 
lobulated. 
These tumors may be divided as follows : 
1. Those composed of epidermal hyperplasia of a benign character, the so-called cutaneous 
horns peculiar to the face, hands, and glans penis. 
2. Those caused by exudative inflammatory changes, as sometimes seen in erythema nodosum, 
in giant urticaria, and in the ephemeral subcutaneous nodules. 
3. Degenerations of sebaceous glands, constituting wens. 
4. Connective-tissue increase, as in molluscum fibrosum, elephantiasis Arabum, and lymph- 
angio-fibroma. 
5. Hypertrophy of fatty and muscular tissues-lipoma and myoma. 
6. Tumors due to abnormal development of capillaries, veins, and arteries. 
7. Those formed of enlarged lymphatic glands, as in syphilis, scrofula, tuberculosis, glan- 
ders, Hodgkins' disease, and prurigo. 
8. Granulomatous tumors, such as lupus hypertrophicus and the gummy tumors or gummata 
of syphilis and dense and diffuse syphilitic infiltrations into the face, lips, penis, and labia majora 
and minora. 
9. Tumors formed of simple inflammatory tissue upon the nose, as in some cases of rosacea. 
10. Tumors of rhino-scleroma, whose seat is upon the nose, and whose pathology is said to 
be a dense infiltration of small round cells, regarded by Kaposi as small-celled sarcoma. 
11. Malignant tumors of all kinds which belong to the domain of surgery. 
All of these lesions have modes of development peculiar to themselves, and their course and 
decline are equally varied. Some are amenable to internal treatment, but the majority require for 
their removal some form of surgical procedure. SECONDARY LESIONS. 
SQUAMA OR SCALES. 
Scales are collections of epidermis due to hyperaemia, inflammation, and infiltration, and also 
to a congenital hypertrophic condition of the skin. Most scales consist of simple effete epidermal 
cells, and others are permeated with minute globules of fat and called fatty cells. The former are 
due to abnormally rapid proliferation, while in the latter the natural evolution into horny cells does 
not take place. They may be small like bran or meal, in flakes of the size of one's hand and 
larger, and may, when shed from the fingers, be cylindrical. They vary in thickness from that of 
tissue-paper to several lines, and are more or less adherent to the parts beneath. They may be 
soft and friable or dry and harsh. In color they are white, yellow, greenish-brown, and black. 
I hey may be limited to one or more regions or may be shed from the whole body. Scaling in 
which the particles are bran-like is termed furfuraceous desquamation, while in the flake form it is 
called membranaceous desquamation. In psoriasis, from the fact that the scales lie upon each other 
like tiles on a roof, they are called imbricated. 
Scales are formed in all inflammatory affections of the skin-the erythemata and exanthemata, 
seborrhoea, pityriasis simplex, capitis, rosea, versicolor, and rubra ; in psoriasis, ringworm, favus, 
lichen ruber, lichen planus, keratosis pilaris, syphilis, lupus, lupus erythematosus ; and in ichthyosis 
due to a congenital morbid condition of the skin. 
EXCORIATIONS. 
Excoriations are superficial losses of the epidermis due to scratching, friction, coaptation of 
parts, and to external irritants. While the majority are superficial and only involve the epidermis 
or mucous layer, they are sometimes so deep as to damage the true skin. The former on healing 
may leave no scar ; the latter may be followed by scars. The size, depth, and extent of excoria- 
tions depend primarily on the force, persistence, and duration of the exciting cause, and second- 
arily upon the condition of the skin itself, which is more vulnerable in a state of inflammation and 
of impaired nutrition, and in plethoric persons and those indulging in too stimulating food and 
alcoholic and malt liquors. 
Excoriations of the skin are found in the shape of large and small patches caused by friction, 
slight wounds, coaptation of surfaces, and by irritants of various kinds, and in the form of scratch- 
marks, which is the most common of all. Scratch-marks may be punctiform and grouped, or 
m the form of lines or streaks of red raw skin, from which a bloody serum oozes and forms 
adherent crusts. 
Excoriations are found in the diseases in which itching is severe, such as eczema, dermatitis 
from external and internal causes, lichen planus, pruritus cutaneus, prurigo, pediculosis, and 
scabies, and in the course of jaundice, Bright's disease, diabetes, and certain nervous affections. 
Their etiology can be arrived at by intelligent investigation. Those found in pediculosis are 
peculiar in their tendency to be more numerous and extensive on certain portions of the body, 
and to be interspersed with minute blood-crusts, which are of material aid in diagnosis. Unlike 
the excoriations of pediculosis, which are long and thin, those of scabies are smaller, shorter, 
and more grouped, and are found in the regions upon which the latter disease is prone to 
develop. 
187 188 
DISEASES OF THE SKIN. 
Scratching, when long continued, leads to more severe changes in the skin, such as infiltra- 
tion, thickening, and pigmentation, while excoriations not infrequently give rise to pustules 
and ulcers. 
Much aid in diagnosis is afforded by a study of the shape, extent, configuration, localization, 
and other concomitants of excoriations. In most cases it is well to seek carefully for the external 
cause, and, failing in that, to seek for internal causes. 
FISSURES OR RHAGADES. 
Fissures are linear cracks in inflamed, infiltrated, and inelastic skin, either limited to the 
epidermis or involving the skin more or less deeply. They are short or long, superficial or 
deep, narrow or broad, straight or wavy, and have a raw or pus-secreting surface. They occur 
about the face at the angles of the mouth and eyes, in the labio-nasal sulcus, at the part where 
the ear joins the scalp ; on the neck, at the flexures of joints ; on the tips of the fingers and 
around the nails ; on the palms and soles, upon the tongue, and around the anus. Their most 
common seat is in the natural furrows of the skin, in parts subject to motion and tension, but 
they may occur elsewhere. They are found in eczema, scabies, the various forms of dermatitis, 
lichen ruber and lichen planus, seborrhcea of the face, lupus, lupus erythematosus ; in dryness 
of the skin from heat, cold, and soap ; and may be due to chemical or mechanical irritants. 
Fissures are painful and interfere with the movements and the functions of surfaces, parts, or 
members. 
ULCERS. 
Ulcers of the skin are solutions of continuity with tendency to extension, resulting from 
suppuration or the breaking down of inflammatory exudations and of infiltrations, and are 
accompanied by secretion and perhaps covered with crusts. In size they vary greatly from 
that of a mustard-seed to vast areas involving a region or a limb. Their shape may be round, 
oval, reniform, annular, semicircular, gyrate, and serpentine. In depth they involve the epi- 
dermis and mucous layer, and even the whole cutis, and they may attack the connective tissue 
and subjacent structures. Since they originate in so many different conditions, their appearances 
are very varied. 
In dermatological practice ulcers may be divided into three groups: first, those resulting 
from inflammatory action beginning in the skin itself; second, those due to traumatic causes; 
and third, those which follow the breaking down of neoplastic infiltrations. 
In the first or inflammatory group we find ulcerations following some of the exanthemata, 
the erythemata, herpes zoster and progenitalis, erysipelas, furuncles, carbuncle, pemphigus, 
eczema, purpura, scurvy, and those occurring in any adynamic condition of the system. 
In the second group belong ulcerations resulting from causes operating from without, such 
as mechanical, medicinal, and chemical irritants and escharotics, morbid discharges, scratches, 
stings of insects and parasites, bruises, wounds, continued pressure, and extravasations of 
blood from violence. In this group belong certain endemic lesions known as perforating ulcer 
of the feet, the Aleppo boil, Delhi boil, and Biskra bouton ; also the ulcers found in the feigned 
diseases of the skin, which are always caused by escharotics. Chancroidal ulcers also come 
under this category, since they are caused by certain forms of pus and irritant discharges. 
The third group, embracing ulcers which result from the degeneration of neoplastic infiltra- 
tions, are those occurring in tuberculosis, scrofulous inflammations, syphilitic papules, pustules, 
and infiltrations, lupus, leprosy, and epithelioma. SECONDARY LESIONS. 
189 
Ulcers have peculiarities of seat, and present various surfaces, bases, edges, and areolae. 
Their secretions may be sero-pus, pus, or the latter mingled with the detritus of tissues. Each 
form of ulcer must be studied separately. 
Various names are given to ulcers. Those of simple nature and mild form are termed 
healthy or healing ulcers, Those which do not show a tendency to heal are variously called 
the weak, the indolent, callous, or chronic ulcers: irritable and inflamed and hemorrhagic 
ulcers belong to this category. Under the head of malignant ulcers we find the phagedenic 
and sloughing or gangrenous ulcers, the serpiginous chancroidal ulcers, the ulcerating and 
serpiginous syphilides, and the rodent ulcers. The varying features of these ulcers will be 
described with each subject. 
CRUSTS. 
Crusts are masses of dried exudation consisting of serum, pus, blood, and fluids due to the 
liquefaction of inflammatory and neoplastic products, separately or intermingled. Being second- 
ary in their nature to excoriations and ulcers, they vary much in size and shape. They may be 
small or large, very thin or very thick, and their surfaces may be flat, conical, globose, mammil- 
lated, and uneven. They are more or less firmly adherent to the morbid surfaces beneath. 
Crusts from an oozing serous surface are large, light, thin, friable, and yellow. Those formed 
from pustules are of varying shades of yellowish green, and those in which blood is intermingled 
of a red or reddish-black color. The crusts of syphilis result from pustules and the decay of 
papules and tubercles. They are as peculiar in shape as these lesions are, and of a deep 
brownish-black color, resembling the dirt attached to oyster-shells. In the rupial syphilide the 
crusts are conical, and consist of lamellae which are caused by peripheral increase of the subjacent 
ulceration. I he original crust is small and firmly seated ; the destructive process going on beyond 
its margin forms an encrusted layer beneath it, and thus in the end very high conical crusts 
may be formed. 
Crusts observed in lupus are of a dark color, but rather more bluish than those of syphilis, 
and they are very irregular in outline and shape. In many instances a diagnosis between the 
encrusted lesions of syphilis and those of lupus is very difficult, and can be arrived at only by a 
study of the history of the case and of the concomitant lesions. 
d he crusts of epithelioma, sarcoma, and carcinoma have no distinctive characters. In favus 
the fungus forms round and figure-of-eight yellowish-green umbilicated crusts seated on a red- 
dened skin. 
d he term lamellated crusts is applied to lesions composed of strata of epidermis and sebum. 
SCARS OR CICATRICES. 
Scars are new formations of fibrous tissue thinly covered with epidermis, following the 
destruction of the corium by ulceration, gangrene, and atrophy. 1 hey are thin or thick, smooth 
or uneven, puckered and traversed by fibrous bands, and sometimes studded with minute depres- 
sions corresponding to the seat of destroyed follicles. They may be on a level with the skin, 
depressed, or elevated, and therefore are termed the simple, the atrophic, and the hypertrophic 
scars. They may be movable or adherent to the parts beneath, frequently are sharply mar- 
ginated, and again fuse imperceptibly with the surrounding skin. In their early stages they are 
of various shades of red and brown, but they gradually become blanched, and then present a 
pearly, glistening appearance. Some scars have a permanent pigmented areola ; others are sur- 
rounded by normal skin. Though scars are permanent deformities, they frequently undergo 190 
DISEASES OF THE SKIN. 
change by contraction, by atrophy, and by hypertrophy. In their early stages they are moder- 
ately compressible, but later on they become firm and unyielding. 
Scars result from injuries-burns, scalds, caustics, incised wounds-ulceration, gangrene, 
and from the absorption of neoplastic growths without ulceration. They bear relation, as to size 
and shape, to the lesions causing them. 
The majority of scars offer no certain points of diagnosis, though many by their number, out- 
line, size, characteristics, and location present facts of assistance. Thus, following ecthyma, acne, 
variola, furuncles, and herpes zoster numerous small scars form : in ecthyma, scattered chiefly over 
the limbs ; in acne, on the face and back ; in variola, over the face ; and in herpes zoster, grouped 
along the course of some cutaneous nerves. The scars of lupus are generally found about the 
face, more exceptionally on the hands, arms, and legs, and are large and of irregular outline, 
uneven in surface, pinkish red in color, and not numerous. Those of the early syphilitic lesions, 
such as papules and pustules, are small, numerous, and found on the face, extremities, and trunk, 
with a tendency to grouping and to localization near joints. The scars from syphilitic tubercles and 
deep ulcers are large, round, oval, kidney-shaped, and of gyrate outline, due to a serpiginous 
course or to the fusion of a number of figure-of-eight-shaped lesions. They are more numer- 
ous than in lupus, as a rule smoother in surface, and of a deep coppery color more or less 
permanent. They frequently become hypertrophic and the seat of dense fibrous bands, par- 
ticularly when near joints. In many instances seemingly formidable elevated and knobbed 
scars in syphilis undergo involution until a depressed cicatrix is left. The hypertrophic cicatrix 
has been observed to grow peripherally, and it is most commonly found on parts rich in con- 
nective tissue. It sometimes presents points of great resemblance to true keloid, but is less 
permanent. 
Scars are usually indolent and painless, but exceptionally they are the seat of slight, even 
severe and agonizing, pain, sometimes nocturnal in character. 
In scars there is an absence of nerves, sebaceous and sweat glands, and hair-follicles, but 
blood-vessels and lymphatics are present. 
MACULES OR PIGMENTATIONS. 
Macules are pigmented spots or discolorations of the skin of various sizes, shapes, colors, 
nature, and origin. They are always the secondary result of a previous morbid process. In 
color they are white, gray, of the various shades of red, yellow, green, blue, brown, and black. 
They vary in size from a pinhead and a silver dollar to that of the palm of the hand, and some- 
times are of vast proportions, occupying more or less of the surface of the body. They are 
round, oval, irregular, circinate, gyrate, and in the form of lines and serpentine bands. The 
majority of discolorations are permanent; others are of a more or less prolonged duration. 
The various forms of macules or discolorations may be arranged in the following groups : 
1. Red, dull-red, and reddish-blue spots, resulting from hyperaemia, are found in simple 
erythema, erythema multiforme and nodosum, acne, urticaria, the various forms of dermatitis, 
herpes, psoriasis, lichen planus and ruber, eczema, impetigo, impetigo contagiosa and her- 
petiformis, pemphigus, and the more superficial lesions of syphilis. Their tendency is to grad- 
ual fading. 
2. The pale, waxy color of anaemia, chlorosis, and following severe hemorrhages, and the 
yellow and yellowish-brown pigmentations of jaundice and cirrhosis. These conditions are 
more or less amenable to treatment. 
3. The white spots due to a deficiency of pigment, as seen in leucoderma, vitiligo, albinis- SECOND ALY LESIONS. 
191 
mus, following psoriasis, and sometimes the early syphilitic lesions (erythema and papules), and 
leprosy, all of which are permanent. 
4. The brown, coppery-red, and black spots and patches due to excess of pigment, found in 
lentigo, chloasma, Addison's disease, in urticaria pigmentosa, lichen ruber and planus (sometimes), 
xeroderma pigmentosum, and leprosy ; following deep lesions of syphilis ; in diffuse form on the 
scrotum, penis, and labia majora, on the areolae of the breast, on the linea alba of pregnant women ; 
following scabies and pediculosis corporis, and in argyria from the deposition of nitrate of silver 
in the tissues. Many of those hyperpigmentations are permanent, and all are of long duration. 
5. I he yellow, yellowish-green, and purple-red spots or patches, due to effusion of blood into 
the skin, caused by traumatism, stasis, impediments to and defective circulation, and altered con- 
dition of the blood and capillaries. These are found in bruises, congestions of the face and ears, 
hands and feet, accompanying varicose veins, cirrhosis, scurvy, and purpura. In the latter disease 
the small spots are called petechiae ; those in the form of striae, vibices ; and those involving large 
surfaces, ecchymoses. Most of these spots are of temporary duration ; those resulting from 
impairment of the circulation are permanent. 
6. I he pink, red, purple, and purplish-black spots of flat naevi. Their color does not disap- 
pear on pressure, and, although exceptionally the mildest forms fade away, the majority are 
permanent. 
Macules have been classed by previous authors with erythema and ranked as primary lesions. 
Such an arrangement has always seemed to me to be incorrect, for the reasons given. CLASSIFICATION. 
The study of diseases of the skin is much aided by a classification. Since most of the 
recent classifications are based upon etiology or pathological anatomy, and as these branches of 
the subject are not in state of certainty and perfection, it follows that there is not a perfect 
classification. The trouble is, that there are too many, for almost every author thinks that 
it is incumbent upon him to elaborate one or more. The following classification emanates 
from the American Dermatological Association, and, although it has its shortcomings, it also 
has its good points : 
Class I. Disorders of the Glands. 
1. Of the Sweat-Glands. 
Hyperidrosis. 
Miliaria crystallina. 
Anidrosis. 
Bromidrosis. 
Chromidrosis. 
2. Of the Sebaceous Glands. 
Seborrhoea : a. oleosa; b. sicca. 
Comedo. 
Cyst: a. Milium; b. Wen. 
Molluscum sebaceum. 
Diminished secretion. 
Class II. Inflammations. 
Exanthemata. 
Erythema simplex. 
Erythema multiforme : a. papulosum ; b. bullosum ; c. 
nodosum. 
Urticaria. 
* Dermatitis : a. traumatica; b. venenata ; c. calorica. 
Erysipelas. 
Furuncle. 
Anthrax. 
Phlegmona diffusa. 
Pustula maligna. 
Herpes : a. facialis ; b. progenitalis. 
Herpes zoster. 
Psoriasis. 
Pityriasis rubra. 
Lichen : a. planus ; b. ruber. 
Eczema: <z. erythematosum; b. papulosum ; c. vesicu- 
losum ; d. madidans ; e. pustulosum ; f rubrum ; 
g. squamosum. 
Prurigo. 
' Acne. 
Impetigo. 
Impetigo contagiosa. 
Impetigo herpetiformis. 
Ecthyma. 
Pemphigus. 
* Indicating affections not properly included under other titles of this 
class. 
Class III. Hemorrhages. 
Purpura: a. simplex ; b. hasmorrhagica. 
Class IV. Hypertrophies. 
1. Of Pigment. 
Lentigo. 
Chloasma : a. locale ; b. universale. 
2. Of Epidermal and Papillary Layers. 
Keratosis : a. pilaris; b. senilis. 
Callositas. 
Clavus. 
Cornu cutaneum. 
Verruca. 
Verruca necrogenica. 
Xerosis. 
Ichthyosis. 
Of nail. 
Hirsuties. 
3. Of Connective Tissue. 
Scleroderma. 
Sclerema neonatorum. 
Morphcea. 
Elephantiasis Arabum. 
Rosacea : a. erythematosa; b. hypertrophica. 
Frambcesia. 
Class V. Atrophies. 
1. Of Pigment. 
Leucoderma. 
Albinismus. 
Vitiligo. 
Canities. 
2. Of Hair. 
Alopecia. 
Alopecia areata. 
Alopecia furfuracea. 
Atrophia pilorum propria. 
3. Of Nail. 
4. Of Cutis. 
Atrophia senilis. 
Atrophia maculosa et striata. 
192 CLASSI FI CA TION. 
193 
Class VI. New Growths. 
1. Of Connective Tissue. 
Keloid. 
Cicatrix. 
Fibroma. 
Neuroma. 
Xanthoma. 
2. Of Vessels. 
Angioma. 
Angioma pigmentosum et atrophicum. 
Angioma cavernosum. 
Lymphangioma. 
3. Of Granulation Tissue. 
Rhino-scleroma. 
Lupus erythematosus. 
Lupus vulgaris. 
Scrofuloderma. 
Syphiloderma : a. erythematosum ; b. papulosum ; c. 
pustulosum ; d. tuberculosum ; e. gummatosum. 
Lepra: a. tuberosa; b. maculosa; c. anaesthetica. 
Carcinoma. 
Sarcoma. 
Class VII. Ulcers. 
Class VIII. Neuroses. 
Hyperaesthesia : a. pruritus ; b. dermatalgia. 
Anaesthesia. 
Class IX. Parasitic Affections. 
1. Vegetable. 
Tinea favosa. 
Tinea trichophytina: a. circinata; b. tonsurans; c. 
sycosis. 
Tinea versicolor. 
2. Animal. 
Scabies. 
Pediculosis capillitii. 
Pediculosis corporis. 
Pediculosis pubis. 
It is impossible to follow this order, seriatim, but the general scheme will pervade the 
work. ERYTHEMA. 
The erythematous eruptions belong to the group of hyperemias of the skin. They may be 
divided into four classes: first, those due to external irritation ; second, those caused by sys- 
temic disturbance of a more or less definite character ; third, those due to the action of specific 
poisons in the system, showing themselves upon the skin ; and fourth, those due to the ingestion 
of certain drugs. The eruptions of the first variety are termed idiopathic erythemata, while those 
of the second, third, and fourth classes are called symptomatic erythemata. 
d he eruptions due to local irritation are named erythema simplex. They consist of a 
more or less intense and extensive hyperaemia of the skin according to the strength, length 
of time of application, and extent of the irritant, and may fade away or may go on to pap- 
ulation, vesiculation, and even to pustulation and the formation of bullae. It is important to 
remember that the primary lesion is erythema, and that the papules, vesicles, etc. are simply 
secondary to that process. 
The simple or idiopathic erythemata are caused by heat, cold, pressure of garments, trusses, 
bandages, crutches, etc., by close coaptation of cutaneous surfaces (intertrigo), by irritating dis- 
charges, by the toxic action of drugs used externally, and by woollens and friction. 
All of the foregoing erythemata are called active hyperaemias, in contradistinction to the 
passive forms, which are simply local congestions due either to stasis or to some impediment to 
the circulation. 
1 he symptomatic erythemata are, first, those which are described under the general title of 
erythema multiforme; second, those of syphilis, the exanthemata, eruptions occurring in the 
course of adynamic fevers, diphtheria, rheumatism, and cholera; and third, those due to the 
toxic action of drugs taken by the stomach and by hypodermic injection. The drugs which 
most frequently cause erythematous eruptions are belladonna, quinine, and preparations of cin- 
chona, chloral, iodoform, opium and its derivatives, antipyrine, copaiba, cubebs, stramonium, 
iodide of potassium, and guaiac. So frequently are more or less severe and generalized erythe- 
matous eruptions caused by the ingestion of drugs that it is well in every case to make inquiry 
at once as to whether the patient has taken medicine of any kind. 
The symptomatic erythemata are undoubtedly of angio-neuritic origin. The matcries morbi 
or toxic agent acts upon the brain-centres, and the irritation is from them transmitted to the 
nerves and vessels of the skin. 
195 ERYTHEMA MULTI FORME. 
The term erythema multiforme is used to designate a group of erythematous eruptions which 
have strongly-marked characteristics, run a somewhat erratic course, and in their evolution some- 
times assume the features of the vesicular, pustular, and bullous eruptions. Their mode of inva- 
sion is prompt, but less so than that of the drug eruptions and of the exanthemata, and their 
extension is sometimes very rapid, and again moderately so. A peculiarity frequently noticed is 
the development of successive crops. These eruptions always invade symmetrical regions, most 
frequently the dorsal surface of the hands and feet, less so the forearms and legs and the face and 
trunk, the upper portion of which is the part most commonly attacked. Wherever else erythema 
multiforme may appear, it will invariably be found upon the hands. 
It begins as small red spots, which quite rapidly increase in area and become salient above 
the level of the skin. In a few hours patches of a diameter of half an inch are seen grouped 
together, as yet not coalesced, and covering the backs of the hands as far as the wrists. For the 
first day or two the color of the patches is of a bright red, but from that time on it becomes 
deeper, and gradually passes into a dull purplish and violaceous hue. Coincidently with the 
deepening of the color the patches become appreciably raised and thickened, and are then true 
papules. While at first these are often surrounded by a well-marked red areola, the latter grad- 
ually fades away in cases of discrete eruption, and ends by forming a faint red ring around each 
papule. In this state the eruption is termed erythema papidatum. Examination proves, how- 
ever, that the morbid process differs from the more superficial erythemata in the fact that the 
inflammatory process is greater and that exudative or plastic changes have taken place in the 
lesions. It is from this fact that Hebra, who did so much to simplify our knowledge of these 
eruptions, gave them the name of erythema exudativum multiforme. In those cases where the 
inflammatory process continues in the papules these lesions become larger, more elevated, solid, 
and oedematous ; the eruption is called erythema tuberczdatum. We frequently see these papules 
and tubercles constituting the eruption. 
While in many cases erythema multiforme is of a mild type and ends at the papular and 
tubercular stages, in others it increases in intensity and spreads from the hands and feet to other 
regions of the body. In these severe cases further changes take place in the lesions. Sometimes 
the papules and tubercles fuse together and form large patches of oedematous hyperaemia. In 
other cases, where the lesions are discretely placed-that is, separated from one another-each 
papule or tubercle increases at its margin, while the centre becomes less red and oedematous. 
We have then what is called erythema annulare; in other words, the hyperaemic process goes on 
to the formation of rings, which are usually of the dull purplish-red color. While these rings are 
forming, two changes may take place: either the enclosed area of skin becomes less red, 
inflamed, or thickened, or new patches of erythema may develop in their centre, which may only 
reach the papular or tubercular stage, or which may even go on to the formation of rings. Then 
we find larger rings enclosing smaller ones. The extension of these rings often brings them in 
196 Part IV 
Plate XXIV 
LEA BROTHERS & CO. PUB LIS HE RS . PHILADELPHIA 
ERYTHEMA MULTIFORME ERYTHEMA. 
197 
contact with each other, and as a result there are one or more irregular patches of serpentine 
lines, figures-of-eight, circles, and segments of circles. The various forms of erythema multi- 
forme from the papular to the ringed condition are well shown in the plate. 
The term erythema marginatum, which is sometimes used, applies to cases in which the ery- 
thematous circles have a sharply-defined border. 
In addition to these phases of development, erythema multiforme is often the seat of changes 
of more intense and varied character. Patches of papular and tubercular erythema may become 
the seat of vesicles, pustules, and bullae. Such cases are of severe character, and the inflamma- 
tory processes are very active. Not infrequently, during the evolution of the hyperaemic rings 
one or more circles of vesicles may appear at their outer margin or within them. The eruption 
then presents a marked appearance, due to the multiformity of the lesions and to the peculiar 
play of colors. This form has been termed erythema iris. The wood-cut represents a central 
papule surrounded by circles of hyperaemia and of vesicles. 
Fig. 19 
Erythema iris. 
Having reached its full development perhaps in one or even in successive crops, erythema 
multiforme quite rapidly fades away. The patches, rings, and serpentine lines grow less red and 
elevated, and disappear, leaving a slight and ephemeral pigmentation, and usually mild des- 
quamation. 
I he duration of the eruption varies considerably. In some cases it lasts about a week, while 
m others it occupies four, and even six, weeks in its evolution. 
Erythema multiforme is peculiar in the fact that it appears mostly in the spring and the fall ; 
the months of April and May and October and November are specified by Hebra as those in 
which it is most commonly observed. 
I he subjective symptoms are sometimes absent, and are never of a very severe character. 
In some cases patients complain of malaria, debility, rheumatoid pains, and, as they term it, bilious- 
ness. I hey are rarely confined to bed. In some severe cases there is an elevation of tempera- 
ture of a few degrees, and I have heard such patients complain of an ephemeral chilliness. In 
most cases there is moderate pruritus and a burning sensation, while in exceptional ones these 
symptoms are so severe that they cause great discomfort. A sense of tension and stiffness of the 
parts is often experienced. Solstier and C. Boeck have seen cases in which inflammation of the 
pharynx preceded the eruption. 
Etiology.-We know very little as to the cause of erythema multiforme, and we are in the 
dark as to the reason of its appearance at certain seasons. My experience has led me to think 
that in most instances gastro-intestinal irritation-which is a somewhat vague term-is in some 198 
DISEASES OF THE SKIN. 
way the cause. Then, again, I have seen its development follow strong mental emotions, and 
also seemingly result from errors of diet. The somewhat infrequent coincidence of the eruptions 
with pain and moderate swelling of the joints has given rise to the suspicion that it is allied to 
purpura rheumatica. Numerous instances have been reported, and I have seen cases myself in 
which erythema multiforme appeared in the early and exanthematic stage of syphilis. The opinion 
of most observers is to the effect that there is no etiological relation between the specific diseases 
and the erythema. Cases of syphilis thus complicated have, as a rule, been of rather a severe 
form. Years ago I frequently saw erythema multiforme in newly-arrived female immigrants, 
mostly of Irish birth. Opinions differ as to which sex is most frequently attacked. In my 
experience, young and adult females are in the majority, with a fair representation of 
males. 
Diagnosis.-So characteristic are the mode of evolution and appearances of erythema multi- 
forme that usually its nature will be recognized at once. In the papular form it might be mis- 
taken for eczema papulatum, but the site of the eruption, its peculiar color, the absence of the 
tendency to exfoliation and oozing, and the mildness of the itching, clearly diagnosticate it from 
that affection. In the ringed form it might be mistaken, chiefly owing to its dull color, for the 
circinate erythematous and circinate papular syphilides. The promptness and acuteness of inva- 
sion, the site, and the mild local symptoms of the simple eruption differ from the slow aphleg- 
masic development of the specific eruption which is prone to develop upon the face, neck, and 
extremities near joints. Further, the absence of a syphilitic history will settle all doubts. 
Prognosis.-The prognosis is usually good, since the tendency of the eruption is to spontan- 
eous involution. It is well to inform patients of their liability to relapses. 
Treatment.-The internal treatment should be largely symptomatic. In general, a brisk 
cathartic, such as from five to ten grains each of calomel and supercarbonate of soda, given at 
night and followed in the morning by one or two wineglasses of Hunyadi Janos water, will almost 
always be of benefit. Further treatment, in most cases, should consist of a diuretic and aperient 
mixture, as follows: Potassae acetatis, sj ; Sal Rochelle, 3ij ; Aquae, sviij. Dose, one tablespoonful 
in a wineglass of water three times a day an hour after eating. Should the patient present any 
symptom referable to the gastro-intestinal canal, it should receive prompt attention. It is of the 
utmost importance to regulate the diet to a plain and easily digestible standard, to cause the avoid- 
ance of coffee, malt liquors, alcoholics, and stimulating condiments. Malaria, debility, and rheu- 
matism as complications call for appropriate treatment. 
Local applications are not frequently needed. Those most efficient are lead-water with or 
without the addition of laudanum, cold water, water and alcohol in equal parts, spirits of min- 
dererus and alcohol equal parts, and carbolic acid thirty drops to eight ounces of water. Oint- 
ments are rarely needed, but the simple lead ointment, preferably made of one drachm of Gou- 
lard's extract to an ounce of vaseline, and a freshly made oxide-of-zinc ointment, may be borne 
in mind. Starch, infant's powder, and lycopodium may be used for dusting the surfaces. In 
cases of annoying pruritus, fifteen grains of camphor added to either of the foregoing powders 
may prove beneficial. 3art IV 
ERYTHEMA NODOSUM 
LEA BFjOTHEffS & CO. PUB LIS HE RS . PHILADELPHIA 
Plate XXV ERYTHEMA NODOSUM. 
Erythema nodosum is a disease presenting well-marked features and characterized by the 
formation of erythematous nodules in the skin. It begins in both an acute and a subacute manner. 
A short time prior to the appearance of the eruption the patient usually complains of loss of appe- 
tite and impairment of digestion, weakness, and frequently sleeplessness and chilliness, and suf- 
fers from a fever which is usually mild, but sometimes pronounced in character. The eruption 
begins in two ways : first, as small nutmeg-sized erythematous nodules or tubercles occupying the 
whole thickness of the skin, and in number perhaps less than a dozen ; second, as small-sized, 
movable nodules seated in the deeper portions of the skin, which is at that time not hyperaemic. 
The cutaneous nodules are usually seen over bony surfaces, such as the anterior aspect of the 
tibia and the outer aspect of the ulna, in both of which positions the subcutaneous connective 
tissue is not abundant. The subcutaneous nodules are found in parts where the connective 
tissue is thick, such as near the shoulder-joint, on the arms, and on the thighs. The nodules 
very soon invade the upper portions of the skin and take on their hyperaemic color. When 
first seen the nodules of erythema nodosum are round, pale-red, slightly elevated spots. They 
usually occur in groups, and are always symmetrically placed. They most commonly begin on 
the anterior surface of the legs, as is well shown in Fig. i, Plate XXV., and in many cases the 
eruption is confined to that region. In others the forearms on their outer aspects are attacked, 
and from these foci the eruption may, in somewhat rare instances, invade the thighs, arms, upper 
portion of the trunk and neck, and very rarely the face. Several times I have seen it symmetri- 
cally developed upon, and confined to, the anterior aspect of the shoulder-joint. In many cases 
each nodule retains its own individuality, and does not fuse with those near it; in others, the 
central ones of a large group fuse together, forming a large expanse surrounded by smaller 
nodules at the periphery. In some severe cases the limbs become oedematous in the region which 
is the seat of the eruption. In other and rare cases the erythematous nodules are developed 
in the line of the lymphatics-a fact which has given color to the hypothesis that the disease is 
allied in its nature to lymphangitis. 
In size the nodules of erythema nodosum vary from that of a nutmeg to that of an egg, and 
even larger. Usually, a few nodules appear symmetrically placed, and are followed by others in 
greater or less numbers. Thus it is that in most instances the evolution of the disease is by 
successive crops of the skin lesions. I have seen cases, however, in which the whole eruption 
appeared at once. In its full development the appearances of erythema nodosum are well shown 
in Plate XXV., illustrating the case of a girl aged seventeen. It will be seen to consist of groups 
of red elevated tubercles. Beginning as rosy-red spots, these nodules or tubercles increase in 
area, and as they do so they become elevated, and thus they grow to full development. With the 
extension of area is observed a well-marked conical salience of each nodule. As a rule, the 
lesions are quite sharply marginated, and not surrounded by an inflammatory areola. They 
come then to form elevated round and oval tumors of various sizes, covered with tense glistening 
199 200 
DISEASES OF THE SKIN. 
and reddened epidermis. In some instances earlier, and in others later, changes in their color and 
consistence begin to be observed. The rosy hue, particularly at the margins of the lesions, 
becomes deeper, and gradually passes into a purplish or violaceous tint. Then we see that their 
central portion has become lighter, and frequently assumes a dull-yellow color, something like that 
of chamois-skin. The combination thus presented of the enclosed yellow or yellowish-green area 
surrounded by a ring of variegated purple or violaceous color, and the gradual fading of this play 
of colors, frequently gives the lesions the appearance of old bruises. It was this process of meta- 
morphosis which led the old writers to call this disease dermatitis contusiformis. When fully devel- 
oped, the nodule of erythema nodosum has a quite firm consistence, rather less, however, than 
that of the furuncle. This may appropriately be termed "the stage of condensation," which is 
of variable length, usually only a few days. Then, coincidently with the changes in color just 
described, the nodules seem, we may say, to melt down, and in a short time to present a deceptive 
sense of fluctuation. This maybe called "the stage of softening." Should a person unfamiliar 
with the disease see a case in which there was but one lesion on each leg in the stage of softening, 
I can well understand how he could mistake it for an abscess. I once saw a young surgeon thus 
err, and observed that his free longitudinal incisions only gave vent to some thick black blood and 
revealed tissues which seemed infiltrated with that fluid. There need never be fear of abscess- 
formation, since these lesions always undergo spontaneous involution. The time required for 
the absorption of these inflammatory tubercles varies considerably. In some acute cases a 
nodule or nodules will appear promptly and disappear within a week or ten days. In the cases 
in which the lesions are extensive and scattered, usually several weeks elapse before they have 
disappeared. Sometimes new crops appear as the old ones are undergoing involution, and in 
these cases the process of absorption is slow. Then there are cases-usually those in which the 
lesions are limited in number-in which their development is very slow, and they run an indolent 
course of a month or even more. It very frequently happens that considerable time elapses 
before the skin resumes its normal color and loses the hypersensitiveness which follows this 
eruption. 
Besides the constitutional symptoms already mentioned, the evolution of erythema nodosum 
is attended with certain symptoms produced by the lesions themselves. The eruption never itches, 
but is accompanied by a burning pain. Patients complain that the nodules are exquisitely sore 
and painful, and they shrink from the slightest touch. The limbs become more or less stiff, and 
locomotion is often accomplished with difficulty and discomfort. 
This affection is found in the young and middle-aged, and also in old persons, and in females 
more frequently than in males. Some authors state that it, like erythema multiforme, is peculiar 
to the spring and fall months. I have failed to convince myself of this cyclical development. 
Etiology.-We are unable to state the exact cause of this curious affection, other than that 
it is usually the concomitant of a cachectic or adynamic condition. I have noted its appearance 
in cases of chronic bronchitis, in acute pneumonia, in both acute and chronic rheumatism, in old 
and cachectic syphilitics, particularly women, and also in the course of Bright's disease. Uffel- 
mann and Dehme have seen severe forms of the eruption in young persons coming from tuber- 
culous families. Though not a common disease, it can scarcely be called a rare one. The 
dermatologist, I think, sees it rather less frequently than the disciple of general medicine. 
Diagnosis.-So strongly marked are the characters of erythema nodosum that one at all 
familiar with it can scarcely make a mistake in diagnosis. In its early stage, if developed upon 
the face, it might be mistaken for erysipelas, but the error would soon be discovered in the dif- 
ference in the course of the eruption. In the declining stage, with the lesions presenting the 
sombre red and yellowish-green hue and painful symptoms, it is often mistaken for bruises, but 
even here the error is soon cleared up by the course of the disease, usually by the fact of its sym- ERYTHEMA NODOSUM. 
201 
metrical development on various parts of the body. When once seen or where attention has 
been called to the fact, the error of mistaking the softened nodules for abscesses certainly will 
not be made. 
There is a form of precocious gummatous eruption-which is rather infrequently seen in 
the early months and within the first year of syphilitic infection-which presents marked points of 
resemblance to erythema nodosum. In the syphilitic affection we find severe and excruciating 
local and regional neuralgic pains of a continuous or intermittent character, and a well-marked 
febrile condition. There is usually a history of recent syphilitic infection, and often the concomi- 
tance of active or declining lesions. The syphilitic eruption may begin as abruptly as the simple 
form, but its further course is much less acute. The specific nodules not infrequently undergo 
degeneration and form ulcers. With these points in mind, an error in diagnosis will not be 
long held. 
Prognosis.-The prognosis is usually good as regards the eruption, since it ends in sponta- 
neous recovery in from one to six weeks. It is well to remember that the eruption often comes 
out in successive crops, and that instances of relapse are not infrequent. 
Treatment.-Very little can be said in a direct way on this subject, since we do not know the 
nature of the eruption. Each case must be treated according as the general condition present, 
and possibly the concomitant affections, may indicate the line of treatment which belongs to gen- 
eral medicine. It is unnecessary here to enumerate again the varied affections of which this erup- 
tion is so often a complication. Much benefit to the painful joint-symptoms may sometimes be 
derived from the internal use of salicylate of soda or some other salicyl preparation. It is doubt- 
ful whether they have any influence upon the eruption. 
Locally, much relief may be obtained from warm applications, and also from cold ones, the 
first giving relief in one case, and the last in others. Dusting powders and ointments are rarely 
found to be of benefit. As cooling lotions, equal parts of vinegar and water, an aqueous solution 
of muriate of ammonia (sij to 5vj), alcohol and water in equal parts, spiritus mindererus and 
alcohol in equal parts, a calamine lotion (sij to water siv), and lead-water or lead-and-opium wash, 
may be remembered. In some cases in the declining stage gentle continuous pressure by means 
of the roller bandage is of much benefit and support. I have also seen good results follow the 
application of flexible collodion. ECZEMA. 
Eczema is a chronic, sometimes acute, inflammation of the skin manifesting itself in redness 
and thickening, which is often the seat of papules, vesicles, and pustules, alone or in combination. 
Its chronicity and intensity are usually so great that polymorphous changes are observed during 
its course. 
Much confusion has been caused in the past by over-elaboration in the description of many 
so-called different kinds of eczema, and by the tiresome details of the results of experimental 
irritation of the skin. There is no difficulty in a clear understanding of eczema in all of its 
phases, provided the facts of pathological anatomy are not made too technical and exhaustive. 
Stated in a simple, plain manner, eczema is an inflammation of the skin, with all of the vas- 
cular engorgement which the name carries with it, attended with redness, thickening, heat, and 
pruritus. This constitutes erythematous eczema, which may be taken as the prototype of all forms 
of the disease, since it is present in nearly all of them in the early stage. It is admirably shown 
in Fig. i of Plate XXVI. 
Let us see, in a general way, what takes place in the eczematous process. As a result of the 
intense hyperaemia there is swelling of the papillary and mucous layers of the cutis, due to exuda- 
tion and cell-infiltration. The result is a tolerably even reddened surface and a thickened skin, or 
eczema erythematosum. Should the inflammation continue and increase, the exudation and cell- 
infiltration into the papillae would be greater, and the surface of the skin would then become 
covered with papules, and a papular eczema would be formed. 
Taking, again, erythematous eczema as the basis, we can trace out still other conditions to 
which it is liable. The inflammation being severe, serous exudation takes place from the vessels 
of the papillae, pushes upward between the cells of the mucous layer, and uplifts the epidermis in 
the form of globose or conical vesicles. The result is a vesicular eczema. 
If, owing to any cause, the serous exudation carries with it pus or lymphoid cells, pustules 
instead of vesicles are formed, and the condition is named pustular eczema. 
These, therefore, may be called the primary forms of eczema-the erythematous, papular, 
vesicular, and pustular. They may exist alone or in combination, in various forms of grouping 
with each other, as is well shown in Fig. 2, Plate XXVI. 
All of these forms of eczema undergo secondary changes. The erythematous form becomes 
the seat of scaling, and then is termed eczema squamosum. Owing to inelasticity of the eczema- 
tous skin, and its enforced motion, particularly at the arms, angles of the mouth, and joints, fis- 
sures frequently form in it, and then we have what has been called eczema rimosum or fissum, as 
shown in Fig. 21, of the arms of a young man. Sometimes the inflammation is so great, and 
perhaps aided by the patient's scratching, that the epidermis is cast off in eczema erythematosum, 
and a raw oozing surface is left, and the condition is then called eczema rubrum or madidans- 
weeping or oozing eczema. This form of eczema, however, most commonly develops from the 
vesicular and pustular forms, in which the primary lesions are soon destroyed, their epithelial cov- 
202 Part IV 
Plate XXVI 
LEA BROTHERS Sc CO. PUBLISHERS . PHILADELPHIA 
ECZEMA 
1 . Eryt hemal osum . 2 . Papulatum , vesiculosum, 
squamosum el impeli^inosum. ECZEMA. 
203 
enng being unable to resist the disintegrating effects of the secretions, and often being rubbed off 
by scratching. 
I he crusts of eczema rubrum are uneven, yellow, and gummy, and frequently dark from the 
admixture of blood and dirt. They are composed of the liquefied cells of the mucous layer, 
which give to eczematous exudations their peculiar stickiness of serum and of epithelium. In 
Fig. 21. 
Eczema rimosum. 
contrast to these there are dirty, dark-green crusts, formed of dried pus, seated on a reddened, 
inflamed, superficially ulcerated base, as in eczema rubrum, which give to the affection the name 
eczema zmpetiginodes. 
Both eczema rubrum and eczema impetiginodes are well illustrated in Plate XXVII. Figs, 
i and 2. The appearance of the varicose veins in Fig. 2 is suggestive of a very common cause 
of eczema of the leg. About the face impetiginous eczema often assumes peculiar forms of 
distribution, such as is shown in Fig. 22. This is the impetigo figurata of the older writers. 
d he tendency of eczema being to chronicity, to exacerbations, and to relapses, profound changes 
are frequently produced in the affected areas of skin. This is 
more particularly the case with the face and the extremities. 
Frequent and long-continued attacks of eczema of the hands 
often produce a thickened scaling condition ; the skin is thickened, 
infiltrated, inelastic, and scaling, and frequently the seat of fissures. 
While in many cases the intensity of the morbid process is greatest 
upon the palmar surface of the hand, in others the whole member is 
involved. In Fig. 23 is shown chronic infiltrated eczema of the 
back of the hand. The skin is harsh, dry, and thick, its natural 
lines of motion are greatly enlarged, and the surface is covered in 
parts with scales. This may be taken as a fair illustration of this 
form of eczema, which is modified in appearance according to the 
condition of the parts involved. 
About the feet and legs there is frequently found lichenoid 
eczema, or eczema verrucosum, which the French describe as hypertrophic lichen. It is well 
shown in Fig. 24, and it is really a sequel to, rather than an essential of, eczema. It will be 
seen that the whole leg is swollen, and about the ankle the seat of papillomatous growths, which 
are due to hypertrophy of the papillae and epidermis. Frequently ulceration coexists. There is 
also much increase in the subcutaneous connective tissues. 
It is necessary to study in detail the chief classical features of the various forms-or, more 
correctly speaking, phases-of eczema. 
Erythematous eczema begins either in punctiform or diffuse redness, most commonly on 
the face, neck, and genitals. It is sometimes acute and ephemeral, and frequently chronic. It is 
Fig. 22. 
Eczema impetiginodes (figuratum). 204 
DISEASES OE THE SKIN. 
chiefly seen in persons of either sex beyond thirty-five years of age, and especially in old people. 
Beginning as a slight and superficial hyperaemia unless aborted, it goes on to swelling and infiltra- 
tion. Its surface soon becomes rough and harsh and covered with small more or less adherent 
Fig. 23. 
Indurated Eczema. 
scales. Its common tendency is to merge into scaling eczema, rather than vesicular, pustular, etc. 
The surface of erythematous eczema, like that of other forms, is not often uniformly red, but is 
darker in points, particularly around the follicular openings and in 
spots which are subject to irritation. Its color varies between a yel- 
lowish and a deep, even purplish, red. It may involve the whole 
face or portions thereof. When, as seen in Fig. i of Plate XXVI., 
the face and forehead are attacked, there is a marked distortion of 
the features, and their natural lines and furrows become deepened 
and more prominent. Frequently there is much oedema under the 
eyes and a bloodshot condition and very often severe conjunctivitis. 
Erythematous eczema appears upon the face in varying degrees 
of severity and extent. It is sometimes localized to the forehead, 
under the eyes, around the mouth and ears. It is usually an intract- 
able affection, and is much aggravated by heat, cold, and scratching 
caused by its intense itching and burning. This form of eczema fre- 
quently undergoes exacerbations, caused by indulgence in highly-sea- 
soned, indigestible food, alcoholics, and by constipation. Exacerba- 
tions and remissions are observed in nearly all cases. Erythematous eczema of the scrotum and 
penis is usually chronic and rather intractable, and accompanied by marked thickening of the 
tissues, oedema, and exaggeration of its surface lines. ECZEMA. 
205 
This, like all forms of eczema occurring about the face, neck, and genitalia of both sexes, 
gives rise to a swelling and often tenderness of the lymphatic ganglia of the vicinity. 
Papular eczema was considered by the older writers a form of lichen. It begins by the 
appearance of small round flat or acuminate papules, varying in size from a pinhead to a line, 
and even larger. Their color is subject to much variation, being of all shades from a very light 
to a deep, even bluish, red. They occur irregularly, scattered most commonly over the flexor 
surfaces of the arms, thighs, and trunk, or grouped in patches, and rarely on the face and hands. 
I he papular element of the eruption is usually the predominant one, but frequently there are more 
or less perfect vesicles in combination. Sometimes a group or groups of eczematous papules fuse 
together and form nummular infiltrated patches of scaling or of weeping eczema. In many cases 
there is no hyperaemia of the skin between the papules. 
Papular eczema is peculiarly obstinate and persistent, exacerbations and relapses being very 
common. Itching is a constant and distressing symptom, and the course of the disease is usually 
much aggravated and prolonged by the patient's vigorous scratching. This, like all forms of 
chronic eczema, is frequently complicated with small abscesses and furuncles. 
Papular eczema is frequently seen in persons beyond the age of twenty-five who are addicted 
to alcoholic excesses, to the indulgence of the pleasures of the table, and to irregular modes of 
life. It is also seen in persons suffering from uric-acid diathesis, in old men who have led fast 
lives, and in those exposed to the vicissitudes of cold climates. 
Vesicular eczema begins as small or large, usually ill-defined, patch or patches of redness of 
the skin, accompanied with much itching and burning, which is soon followed by the appearance of 
myriads of small discretely and irregularly placed or closely-grouped, sometimes confluent, vesicles 
of the size of a pin-point to a mustard-seed, and not much elevated. On parts where the epi- 
dermis is thick a vesicular eruption may readily be mistaken for the papular form. Not infre- 
quently it is necessary to examine a patch of vesicular eczema in an oblique light in order to 
clearly make out the appearance of the lesions. Usually there is much accompanying swelling ; so 
much so that some cases warrant the term eczema oedema to sum. The heat, itching, and burning 
cause much suffering, which is usually in a measure allayed by the rupture of the vesicles. The 
vesicles of eczema are more ephemeral than any others. 
1 he course of vesicular eczema varies very considerably. In some cases the eruption appears 
promptly ; the exudation dries into crusts and soon disappears, and may or may not be followed by 
relapses. Then, again, the vesicles may remain intact for a day or two, and in consequence of 
scratching and friction may be replaced by a weeping surface, which is termed eczema rubrum, or, 
should it become covered with crusts, eczema impetiginosum. 
Patches of eczema present a diffuse redness interspersed with punctate spots of deeper red, 
which are said to be due to an intensification of the inflammation at the follicular openings. 
Vesicular eczema frequently exists in a well-defined eruption, or it may be accompanied with 
papules, vesicles, and pustules. When it becomes chronic it frequently merges into the infiltrated 
form. It may involve large or small surfaces, and is prone to appear upon the face, neck, trunk, 
and upper extremities, particularly on flexor surfaces and near joints. In very acute cases the 
eruption may be unsymmetrically distributed, but in older cases it is commonly symmetrical. 
Pustular eczema, also called eczema impetiginosum, the impetigo of older writers, does not, as 
the rule, exist as a separate form, but rather as a part of a polymorphous eczema, or as the intensi- 
fication of the vesicular and sometimes papular varieties. Much confusion has been caused by 
writers applying the term indiscriminately to eczema rubrum when covered with dark-green puru- 
lent crusts. The term should be confined to those cases of eczema in which pustules develop on 
inflamed surfaces as the initial lesion. 
The pustules of eczema are large and more resistant than vesicles, and grouped in a discrete 206 
DISEASES OF THE SKIN. 
or confluent manner in patches of varying size. They preserve their form for longer or shorter 
periods, and when ruptured give rise to quite firm and solid crusts of a dark-green color seated 
on a red and excoriated surface. Usually the secretion of pus is copious, and crusts cast off are 
rapidly replaced, or the thickness of the old ones is so increased that they become very prominent. 
Pustular eczema is attended with infiltration in proportion to its chronicity. 
This form of eczema is prone to appear on the scalp and face, often at the orifice of follicles, 
and frequently in peculiarly figurate shapes. It is most frequently found upon children of the 
strumous and tubercular diatheses, and in those whose nutrition is of low grade, both infants and 
young persons. It is frequently an intractable form of eruption, but is not usually attended with 
such distressing local symptoms as are the vesicular and papular forms. It is sometimes observed 
that a large patch or patches of this eruption cause scarcely any itching and discomfort. It is fre- 
quently produced upon the head and neck by lice. 
The secondary forms of eczema also need separate descriptions. 
Eczema rubrum may result from any primary form of eczema which has gone on to the ooz- 
ing stage. Its prominent characteristics are its red, inflammatory, weeping surface of infiltrated 
skin, covered more or less completely with sero-purulent crusts, sometimes mixed with blood and 
varying in color from a yellowish-green to a greenish-brown. The raw surface of this form of 
eczema is formed by the basal layers of the epithelium. The surface exudation is not at all con- 
tinuous, but rather intermittent, and is dependent on the condition of the circulation and on the 
amount of movement and friction the parts are subjected to. Thus it is that crusts may remain 
for several days or they may be frequently replaced. In some cases, particularly about the face 
of children, the exudative process lifts up the superficial layers of the epidermis in large flakes, 
in which case the crusts are composed of epidermal cells and dried sero-pus. 
Eczema rubrum occurs most frequently in the very young and the old in the form of extensive 
patches, usually seated on the face or the legs. In smaller patches it is found at the flexures of 
the joints and upon parts in coaptation, under the breasts, in and about the groin, and in the 
gluteal fold. Its course is chronic, and it is rebellious to treatment. It is frequently, on the legs, 
complicated with varicose veins, and from its chronicity is sometimes the forerunner of eczema 
verrucosum. 
Eczema squamosum, or scaling eczema, is in reality the declining stage of all of the primary 
forms of eczema, the erythematous and papular in particular. It is noticeable for the fact that in 
many cases it retains its scaling form without undergoing further metamorphosis. In general, it 
presents a dry, harsh, red, infiltrated, and desquamating surface, but its appearances may be very 
varied. The color may be of a yellowish-red or red, and is usually not uniform, and frequently 
punctate. It may consist of thickened skin of yellow color covered with adherent scales, and may, 
particularly on the hands, be nearly of the normal skin color. It consist of patches of various 
sizes and irregular shape. The amount of desquamation is greatest where the epidermis is thick- 
est, and the induration and infiltration are most marked in parts where the connective tissue is 
most abundant. 
Squamous eczema may occur upon any portion of the body, but in its individual form it is 
most commonly seen about the forehead and scalp, about the face and ears, upon the trunk, and 
upon upper extremities, more commonly on the flexor surfaces near joints, and upon the palms 
and soles. It is not uncommon to see one or more symmetrical or unsymmetrical patches of per- 
sistent scaling eczema about the legs in persons beyond thirty years as a sequela of some primary 
form of the affection. 
This form of eczema is found in old persons and those toward middle life. It is of chronic 
duration, lasting months or years, and liable to frequent and sudden exacerbations and remis- Dart IV 
/. ECZEMA RUBRUM ET IM PETIGI NOSUM . e ECZEMA RUB RUM 
Fi£.l. 
Fi£.2. 
LEA BROTHERS & CO. PUBLISHERS. PHI LADE LPH 1A 
Plate XXVII ECZEMA. 
207 
sions. lhe age of the patient, the condition of health, his habits, occupation, and surroundings, 
together with the season and the climate, have an important influence on the affection. 
The scales may be small and branny or in flakes of various sizes. 
Eczema rimosum is the term applied to patches of the erythematous, papular, pustular, or 
scaly varieties which are traversed by fissures. They appear upon parts where motion or traction 
of the skin is great, and the cracks generally occupy the surface lines and furrows of the skin, d he 
most simple form of eczema rimosum is seen in chapped hands, but about the face, mouth, ears, 
anus, and joints it is frequently severe and distressing. 
Eczema verrucosum vel papillomatosum is really a sequela of eczema, and consists in a 
general thickening of the skin and subcutaneous tissues. It is peculiarly obstinate to treatment 
and frequently a permanent deformity. 
With the foregoing description in mind the reader can gain a clear and comprehensive under- 
standing of eczema in its varied changes and modifications by a systematic study of the colored 
plates and wood-cuts. The prototype, erythematous eczema, is admirably shown in the colored 
big. i of Plate XXVI. The redness, diffuse and punctate, the thickening of the skin, and the 
exaggeration of its folds, are clearly portrayed. In Fig. 2 of Plate XXVI. the polymorphous 
character of eczema is graphically shown. Above the elbow there are scattered papules, and just 
below it a slightly reddened, scaly surface ; then about the middle of the forearm is a considerable 
group of vesicles, which are rather more visible and prominent than it is one's good fortune to see 
very often. I hen toward the wrist are patches of dark incrustation, due to the rupture of a mass 
of pustules, and small portions of reddened and inflamed skin, which represent eczema rubrum. 
Then upon the fingers and palms a severe form of scaling eczema is shown. 
Eczema impetiginosum can be well studied upon the head of the child, Fig. 1, Plate XXVII., 
while in Fig. 2 of the same plate the appearances of eczema rubrum are naturally shown. 
Carrying in mind the picture of eczema squamosum near the elbow in Fig. 2, Plate XXVI., 
an intelligent idea of eczema rimosum may be gained by a study of Fig. 21 (wood-cut). 
1 he peculiar shapes sometimes assumed by eczema impetiginodes about the face are admir- 
ably represented in the wood-cut, Pig. 22. 
The chronic infiltrated form of eczema is admirably shown in wood-cut, big. 23. 
These comprise all of the primary and secondary forms of eczema. 
The wood-cut, big. 24, representing eczema verrucosum vel papillomatosum, clearly illustrates 
the condition of general enlargement, with the thickening of the skin and subcutaneous tissues, 
and the development of warty excrescences. 
Acute eczema, in the sense of rapid appearance and equally prompt decline, is not common. 
This term is usually applied to cases in which the invasion is very sudden and the individual symp- 
toms of the eruption well marked. Such a beginning, however, is not commonly followed by 
rapid subsidence ; yet it must be remembered that there are cases in which the duration of 
eczema is short-lived. Eczema is rarely acute in the manner of the erythemata, exanthemata, 
erysipelas, etc. However quickly it may come, it leaves- slowly. For these reasons it is more 
correct to speak of the invasion of eczema as being acute or chronic, rather than to div ide it into 
the two forms, acute and chronic. 
Owing to the fact that eczema is sometimes attended with surface exudation, it is by some 
writers denominated a catarrhal inflammation-a term which is unnecessary and improper. The 
hypersecretion of a mucous membrane is not, in any way, comparable to the sero-cellular fluid of 
eczema, which is the result of breaking down and liquefaction of the cells of the rete mucosum. 
Exaggeration of function of the muciparous glands, with hyperaemia of the mucous membrane, is 
a. radically different process from the intense and chronic inflammation of the skin of eczema. 208 
DISEASES OF THE SKIN. 
finally, in very many cases of the latter affection there is no surface-exudation whatever at any 
period. 
Eczema of the face, as a rule symmetrically developed, may involve much surface or may 
be of limited extent, and may be acute or slow in its onset. In general, the non-hairy parts are 
more frequently attacked than the hairy ones. 
Acute eczema of the face is usually of the erythematous or vesicular form, and sometimes, 
about the forehead, of the papular variety. Pustular eczema is not infrequently seen here, par- 
ticularly in children, and eczema rubrum is not uncommon. The redness and swelling are intense, 
and the burning and itching very severe. A diagnosis of erysipelas in these cases is frequently 
made. In this manner the face, forehead, and even scalp, may be attacked. Eczema of the 
scalp is usually of the pustular and impetiginous, sometimes of the scaling, varieties, and may 
extend backward toward the nucha or forward to the face. Upon hairy parts the exudations, 
which usually contain sebaceous matter, form thick crusts, which mat the hairs together, remain 
for a long time, and often emit an offensive odor. This form of eczema is frequently caused by 
pediculi. 
Eczema limited to the cheeks is not infrequent; but it is rare to see the affection confined to 
the forehead unless due to local irritation. In general eczema of the face the eyelids become 
swollen, and perhaps closed, and there may be much hyperaemia of the conjunctiva. 
In a chronic scaling and fissured form eczema, perhaps without much infiltration, may exist 
upon the upper lids, at the labio-nasal sulcus, at the angle of junction and behind the ears, and 
around the mouth. In rather rare cases the nose alone is the seat of eczema, which may 
cause temporary stenosis of the orifices, and likewise the upper lips may become affected 
from irritating nasal discharges. 
Eczema of the auricles may be acute and general or chronic and local, and frequently the 
hearing is impaired in consequence of the swelling from the inward extension of the affection. 
Eczema of the head and face is very persistent, undergoes exacerbations and incomplete 
remissions, and shows great tendency to relapses. Eczema of the face is prone to develop in 
middle life and in the aged. 
Eczema of the hands and feet is of both acute and subacute invasion. It may exist alone 
or in conjunction with the affection elsewhere, upon the face, legs, genitals, and trunk, and, though 
usually symmetrically developed, one member alone may be attacked. In the acute form redness 
and swelling are rapidly accompanied by vesiculation, which upon the palms, owing to the thick- 
ness and resistance of the epidermis, may go on to the formation of bullae. On the backs of the 
hands and on the fingers, their palmar surfaces excepted, vesicles and papules are primarily seen ; 
a raw, oozing surface is left by the rupture of these lesions. More or less immobility of the 
fingers and discomfort result from the swelling. The tendency of the affection is to chronicity, 
and the parts to become less red, markedly thickened, traversed by deep lines and perhaps 
fissures, and the seat of scaling, which upon the palms may be at first in large and quite thick 
flakes. This condition is liable to exacerbations. 
Not uncommonly, the affection may be limited to a part of the palm, to the ends of or the 
dorsum of the fingers, and to the backs of the hands, in which cases it is usually due to some 
local irritant, such as soap and water, cold, and some agent used in the various trades. Chapped 
hands are examples of fissured eczema. In chronic eczema of the fingers the nails are usually 
involved. 
Eczema of the feet may be limited to the toes or may involve the whole appendage. The 
chronic condition is similar to that of the hand, except that the morbid parts become macerated 
by the perspiration, and a variegated red, raw, and fissured surface, covered with thick epidermal 
shreds and flakes, is seen. Locomotion is either impaired or impossible. ECZEMA. 
209 
Eczema of the genitals usually begins acutely, and has a tendency to pass into a chronic 
condition. The penis and scrotum, together or separately, may be affected, and the vulva and 
surrounding parts. In both sexes the acute stage is attended with redness, swelling, and vesi- 
culation and the formation of crusts. Eczema of the penis appears promptly, and quickly 
develops into the chronic stage. Upon the dorsum it assumes the thickened and fissured 
form, and on the under surface it is raw and oozing. The prepuce and glans are not 
involved, but phimosis is frequently caused by the thickening of the cutaneous layer of the pre- 
puce, which cannot be retracted, as a result of which balanitis is often set up. In severe chronic 
cases much deformity to the organ is produced. Acutely-developed eczema of the penis should 
always cause a suspicion of scabies. 
Eczema of the scrotum may remain in the red, thickened, and encrusted oozing state for a 
time, and then pass into the chronic condition, in which the tissues are red, hard, thickened, and 
traversed by numerous deep furrows. The elasticity and mobility of the sac are much impaired. 
In some cases the coapting surfaces of the thighs are also attacked. 
Eczema of the vulva is attended by much redness and swelling, and soon passes into the 
weeping and oozing stage. Beginning about the labia majora, it attacks the whole vulva, and may 
spread to the rrions Veneris and thighs. A vaginitis frequently is caused, the discharge of which 
increases the eczema. 
Eczema of the genitals in both sexes is a very distressing affection, and patients suffer much 
from the itching and burning, which are attended with exacerbations. The consequent scratching 
and rubbing increase the trouble. It is observed in young adults, in persons of middle life, and 
in the aged. 
In diabetic subjects of both sexes eczema of the genitals may originate in the irritation of the 
tissues from the decomposition of the urine. In the male, balanitis is caused, which spreads to the 
penis, and in the female the trouble begins in the vulva, and from this may invade the surround- 
ing tissues. Phis form of eczema is peculiarly persistent. Irritating uterine and vaginal dis- 
charges sometimes cause vulvitis, from which eczema of the surrounding parts is developed. 
I regnancy frequently tends to aggravate eczema of these parts. 
Eczema of the genitals, being in most instances of local origin, is confined to those regions ; 
it may coexist- with or be followed by the affection seated elsewhere. 
Eczema of the anus usually begins as an erythema, attended with intense and spasmodic 
pruritus. If unrelieved, thickening of the skin and mucous membrane is produced, together with 
inelasticity, the result being the formation of fissures. Examination of the anal orifice reveals a 
more or less deep red, infiltrated, and perhaps excoriated condition of the parts, which are 
seamed by deep radiating fissures, which spread outward like a fan. Frequently the lower portion 
of the rectum is secondarily attacked with inflammation, and from it mucus, pus, and blood 
escape. 
A mild form of eczema of the anus occurs in children from irritation of secretions, diarrhoea, 
and uncleanliness, which is usually amenable to treatment. In severe cases prolapse of the 
rectum is produced. In the adult and in middle and old age eczema of the anus is commonly 
a persistent and intractable affection. It is frequently attended with the most intense suffering 
from the itching and burning and the interference with the function of the anus. It sometimes 
has its origin in the frenzied scratching and rubbing caused by pruritus ani. 
In most instances of eczema of the anus the affection is confined to that region. 
Eczema of the trunk may be local or general. An extensive papular eczema is fre- 
quently found here, as well as the weeping and scaling forms. 
Eczema of the nipples and breast, commonly found in women, is, as a rule, symmetrical. 
It usually begins in the nipple, which becomes red, much swollen, raw, and very painful. Crusting DISEASES OE THE SKIN 
2 IO 
and fissuration soon occur, and the affection may invade the breast in a disk-like patch. With the 
swelling of the surrounding parts the nipple comes to look like a flattened knob. The affection 
consists usually of the encrusted, oozing, and fissured forms. It is frequently complicated by 
cedema of the connective tissues and abscesses. Pain and itching are constant symptoms. 
Eczema of the nipple and areola is, as a rule, found in women under forty years of age 
during lactation, pregnancy, or with scabies. Beyond the fortieth year and the climacteric period 
a peculiar form of cancer, presenting features resembling eczema, is liable to attack these parts. 
This affection is known as Paget's disease of the nipple. In it the affected surface is bright red, 
raw, and granular when the crusts have been removed, whereas in eczema there is less rawness 
and more of a punctiform redness. In the malignant affection there is moderate surface indura- 
tion, which is absent in the simple one. An elevated marginated edge limits the cancerous affec- 
tion, while eczema shades off imperceptibly. Though eczema of the nipple and areola is rebel- 
lious to treatment, it is curable, whereas the cancerous affection requires the knife. 
Eczema of the umbilicus occurs in the encrusted, thickened, and oozing forms. It is usu- 
ally caused by a want of cleanliness and by the decomposition of epithelial and sebaceous matter in 
very fat persons, in whom the navel is quite deep. It spreads peripherally in a disk form, rarely 
involving much surface, and usually being unaccompanied by eczema of other parts. It is a rather 
intractable affection, owing to the continual friction and the difficulty in applying remedies. 
The term eczema intertrigo has been applied to the affection when it occurs upon portions of 
the skin in coaptation with each other, such as under the breasts, in the folds of the groin in fleshy 
persons, and between the scrotum and thighs. 
Eczema of the joints is usually confined to the flexor surfaces, and is symmetrically placed. 
Beginning as an erythematous eruption, it soon reaches the thickened and scaly stage, and is 
prone to be traversed with fissures. In some instances external irritation sets up eczema at but one 
joint, and it is then unsymmetrical. Hebra's statement, that it is rare for one axilla alone to be 
attacked, and that when the bends of the elbows are affected the popliteal spaces are likewise 
involved, and the wrists coincidently with the ankles, is frequently verified in practice. 
Eczema in these places is for obvious reasons very obstinate to treatment. Impairment of 
function of the extremities is quite constant. 
Eczema of the legs may be symmetrical or the reverse, is usually of the weeping, sometimes 
of the scaling, variety, and is commonly seen in persons beyond thirty years of age. The depend- 
ent position of these members acts as a predisposing cause to inflammation, and a varicose condi- 
tion of the veins is in many instances the starting-point of eczema. The irritation of garters, the 
friction of clothes and bandages, the improper treatment of ulcers, cuts, bruises, and boils, are 
also frequent causes of it. In some cases scratching, perhaps caused by the bites and stings of 
insects on the legs, is followed by eczema. Not infrequently, the cedema of Bright's disease is 
thus attacked. (The clinical picture of eczema rubrum of the legs is admirably portrayed in Fig. 
2 of Plate XXVII., in which varicosity of the internal saphenous vein is well shown.) 
1 his form of eczema is for many reasons very intractable, and is frequently complicated by 
the appearance of ulcers, which are commonly of considerable size. Many sequelae result from it. 
There may be permanent pigmentation, a thickened and scaling state of the skin, or it may be left 
permanently swollen and warty, as shown in the wood-cut, Fig. 24. 
Eczema of infants and young children is very common and intractable. It is generally 
of the vesicular, pustular, and weeping forms, but from its chronicity it may terminate in eczema 
squamosum. It may last months or years, or perhaps for a lifetime. It usually begins about the 
head or face. Frequently a small scaling patch of seborrhoea of the scalp is converted by assidu- 
ous washing and friction into eczema, which spreads over the face to the neck and may involve 
other portions. Then, again, symmetrical itching spots occur on each cheek, and scratching and ECZEMA. 
2 I I 
irritation cause them to spread. In a less numerous class of cases the affection begins about the 
trunk and buttocks from some local cause, and later on the head may be involved. After the head 
and face, the forearms, backs of the hands, the axillae, the trunk generally in patches, the pudendal 
regions, and the popliteal spaces are prone to be attacked. Universal eczema is very rare in 
children. Unna's division of eczema of children is a good one, but its scope should be increased. 
He distinguishes a nervous eczema of dentition, a tuberculous eczema, and a seborrhoeal eczema. 
Io these should be added eczema depending upon gastro-intestinal disorders and malassimilation. 
Unna thinks that a localization near the eyes, nose, mouth, or ears, complicated with phlyctenular 
keratitis, scrofulous rhinitis, otorrhoea, or a large vesicular type of eczema, with oedema and gen- 
eralized swelling of the glands and with slight itching, are characteristic of tuberculous eczema. 
I he reflex irritation of dentition undoubtedly acts as an exciting cause of the affection, which is 
graphically described by Unna as follows: If the neighborhood of the eyes, the nose, and the mouth 
is free, so that the eczema surrounds the face like a mask cut in the middle, we may have to deal 
with an eczema of dentition or with a seborrhoeal eczema. The first appears upon an entirely 
sound skin, usually about the middle of the cheeks, and then upon the forehead in quite a sym- 
metrical manner, and almost always at the same time upon the radial side of the backs of the 
hands and upon the wrists, itches intensely, and the itching is the more pronounced the stronger 
the child and the more healthy and sound the epidermis. It depends entirely upon reflex irritation, 
and especially that produced by the process of dentition, and disappears, often coincidently with 
the eruption of a few teeth, as quickly as it came, probably to reappear in a few days. It resem- 
bles herpes zoster in that groups of isolated well-formed vesicles suddenly make their appearance 
upon a reddened base, but differs from it in its decided symmetry and its tendency to repeated 
recurrence. 
Unna thinks that the scaly condition of the scalp so often seen in infants, and termed 
seborrhoea, is really a marked form of eczema. This often spreads over the ears, forehead, and 
cheeks after it has taken on a moist form, and, without attacking the neighborhood of the eyes, 
jumps over to the eyelashes. It further spreads upon the shoulders and upper arm in the form 
of dry scaly or fatty plaques. The itching is less than in dentition, but more than in the tubercu- 
lous form. It sometimes extends to the genitals, legs, and back. 
Eczema occurring in children suffering from gastro-intestinal irritation, due to improper and 
insufficently nutritious food, is generally accompanied by emaciation and debility, is prone to 
extend, is very itching and persistent. (An excellent illustration of weeping and impetiginous 
eczema in the infant is given in Fig. i, Plate XIV.) 
Etiology.-Local irritation and constitutional conditions are the main causes of eczema, but 
these are often largely supplemented by an inherent tendency in the nerves and blood-vessels and 
cells of the skin to hyperaemia and hyperplasia, which is more pronounced in some subjects than 
in others. In very many cases local irritation is the sole cause, brom its exposed condition and 
great extent the skin is liable to many and varied sources of irritation. Heat and cold and the 
changes of the seasons are prolific causes of eczema. The injudicious use of soap and water, the 
employment of baths of salt water and sulphur-water and of various medicated baths, frequently 
give rise to it. Barkeepers, cooks, dyers, shoemakers, grocers, druggists, masons, washerwomen 
and those employed in laundries, spinners, weavers, and oystermen are often attacked by eczema 
developed by irritating causes incident to their occupations. 
Rough and colored underwear, gloves, stockings (particularly those colored by some prepara- 
tion of arsenic or aniline), trusses, corsets, belts, braces, garters, rings, earrings, bracelets, plasters, 
poultices, liniments, and counter-irritants are in many case the cause of eczema more or less 
local or general; to which may be added chemical irritants, alkalies, acids, croton oil, solutions of 
bichloride of mercury and of carbolic acid, iodoform, mercurial ointment, tartar emetic, arnica, DISEASES OF THE SKIN. 
212 
and very many plants and shrubs and animal parasites. Scratching also belongs to this category, 
and perspiration, particularly upon parts of the skin in contact, is a common source of the affec- 
tion. Cases of eczema have been known to follow the exanthemata, the erythemata, vaccina- 
tion, and impetigo contagiosa. Varicose veins of the legs and of the vagina and rectum are 
frequent causes of eczema. 
In assigning constitutional conditions as causes of this affection it must be remembered that 
it is impossible to establish between them and the skin affection the definite intimate and unvary- 
ing relationship which is observed between the various poisons of measles, scarlatina, etc. and 
their dermal rashes. The knowledge that in certain conditions of the system eczema may occur 
is based on experience, observation, and induction. We are unable, however, to clearly establish 
the relations of the pathological conditions to the eruption, and are frequently confronted with the 
fact that in precisely similar morbid states no dermal affection is observed. The attempt to prove 
that a number of distinct morbid conditions or diatheses is at the root of eczema and of allied skin 
diseases has resulted in failure. 
As a general rule, impaired nutrition may be looked upon as a predisposing cause of eczema. 
In persons suffering from the various forms of dyspepsia, from the uric-acid diathesis, and from 
nervous debility eczema is very often seen. Likewise, diabetes, Bright's disease, and jaundice 
have eczema as a frequent concomitant. The disorders of menstruation have been cited as 
causes, but it is probable that the resulting cachexia plays the essential part. During the course 
of pregnancy eczema has been observed, frequently with each recurrence of that state, so that a 
fair reason is given for the assumption of a causal relation in some cases. Scrofula and tuber- 
culosis may be causes of eczema, from the fact that in them there is a predisposition to hyperaemia 
and cell-change from very slight causes. Many undoubted instances have been observed in which 
profound mental shock has been the starting-point of eczema, particularly when seated on the face. 
Rheumatism and gout, with their allied condition of malassimilation, are frequently the prominent 
morbid conditions of persons suffering also from eczema. Their etiological relations, however, are 
very difficult to establish. The plethoric condition is one favorable for the development of eczema, 
and the indulgence in too hearty and too stimulating food, combined with excess in the use of 
spirituous or fermented liquors, is constantly observed to be followed by the appearance of that 
affection. Improper and insufficient food may tend toward its production. Constipation as a 
cause of eczema, if it exists at all, acts through its impairment of the system at large. The 
reflex influence of dentition in causing eczema, though formerly denied, is now quite gen- 
erally conceded. Eruptions of eczema have been known to alternate with attacks of asthma 
and with acute and chronic bronchitis and diarrhoea. 
In all cases of eczema in which the local cause is not clearly made out it is a good rule to 
interrogate the patient as to the condition of his or her health, and to treat in an appropriate way 
whatever deviation may exist. 
Even when uninfluenced by any underlying pathological state, eczema has a tendency to 
induce a morbid condition in the skin, and it may be safely asserted that, especially in a severe form 
and localized to one or more spots, and in even large areas, it engrafts a tissue-tendency therein 
to subsequent similar attacks, and also that the affection of one part of the skin predisposes to a 
greater or less degree the whole of the integument to the same morbid process, which is mani- 
fested either by its direct extension from the original focus or foci, or by beginning spontaneously 
at a point or points more or less remote. 
So many strong and unquestioned facts exist showing the hereditary transmission of eczema 
that the belief in it is fully warranted. The view is further strengthened by the results of experi- 
mentation, which have shown that tissue-changes in the skin and nervous system, and even induced 
deformities, may be transmitted from parent to offspring. The integument of a person who has ECZEMA. 
213 
long been the victim of eczema undergoes a certain modification, consisting in a tendency of the 
blood-vessels to hyperaemia and of the cells to hyperplasia. Why should not this condition be 
handed down, as well as tissue-changes the result of experiment, and in the same manner that 
moles, warts, and naevi are? The attempts to explain the heredity of eczema by the transmission 
of diatheses, and upon the basis of humoral pathology, have been as fruitless as those made to 
prove its dependence upon the so-called dartrous, herpetic, rheumatic, and arthritic diatheses. 
Eczema is more common in persons of light complexion and thin skin than in dark subjects 
having harder skins. It affects the young and the aged and those intermediate in years. The 
soft, rapidly-growing cells of the child, with their great vascularity, and the aged and feeble cells 
and impaired blood-supply of old persons, are undoubtedly the underlying causes of eczema in 
these extremes of life. 
Some authors contend that eczema is contagious, while the majority hold an opposite view. 
Instances frequently occur in which facts point to contagion as the starting-point of eczema, and 
patients frequently assert that they caught the affection from a person similarly affected. It is 
probable that in these cases similar conditions and modes of life produce the coincidence. 
Prognosis.- I he prognosis in most cases of eczema, notwithstanding its chronicity and tend- 
ency to relapse, is good, and may be based upon a variety of considerations. The fact that an 
eruption of eczema is present for the first time is more reassuring than in the case of a relapse. 
The duration of the eruption is also to be considered. If the history and appearances show a 
chronic much-infiltrated condition, it is reasonable to suppose that the cure will be somewhat pro- 
tracted. In most instances small patches of eczema are much more amenable to treatment than 
larger ones, and in general it may be said the more extensive the surface and the more intense the 
morbid process, the more delayed will be the cure. The situation of the eruption also must be 
considered. About the head and face eczema is particularly obstinate, whether diffuse or local- 
ized, and tends to lurk indefinitely on the scalp, on the cheeks, about the eyes, nose, mouth, and 
ears. Upon the neck likewise it is generally very chronic. Upon the region of the joints it is 
often troublesome, but curable, and when it attacks the scrotum, perineum, and anus it is very per- 
sistent and prone to relapse. Eczema of the legs shows a remarkable chronicity, and about the 
fingers and hands it is very obstinate. Eczema seated upon two opposing surfaces of skin 
requires much care to remove it. 
The stage of the eruption always has a bearing upon prognosis, and frequently presents 
points of interest as to the course the eruption has pursued. An eczema in the scaling or infil- 
trated stage is, all things considered, more quickly cured than when in the erythematous, papular, 
and weeping condition. 
The occupation of the patient must also be considered, since in many instances the skin affec- 
tion is directly or indirectly the outcome of it. 
Then, again, the health and habits of the patient have a most important bearing upon the 
course of eczema. Lowered vitality, poor fibre, and coexisting visceral diseases tend to render 
the course of eczema more chronic and persistent. A patient thus suffering is more readily cured 
if he is not addicted to alcoholic stimulants and fermented liquors than he is if he indulges in them. 
Eczema is peculiarly obstinate in persons who indulge too heartily in food, particularly when it is 
rich and highly seasoned. 
The age of the patient also has a bearing on prognosis, since in the young and the old eczema 
is very obstinate. 
Very often much information is gained in cases of relapse by the history and course of former 
attacks. 
The form of the eruption also has a decided bearing upon prognosis. Papular eczema is dis- 
tressingly persistent; the erythematous scaling and oozing forms are often obstinate ; whereas 214 
DISEASES OF THE SKIN 
vesicular eczema very commonly appears promptly and does not last long. The existence of 
eczema in various forms upon different parts of the body renders prognosis less assuring. 
Eczema unsymmetrically distributed is usually more readily cured than when it is symmetrical, 
and the prognosis is better where one region is involved than if several are. 
A history of eczema in parents and blood-relations should have its weight in forming an 
opinion of a case. 
It is commonly seen that patients having a thin, delicate skin and of light complexion are very 
prone to eczema and to its chronicity. 
Climate and the weather have notable influence upon the course and causation of eczema. 
Cold weather particularly is followed by exacerbations and relapses, which also may result from 
extreme heat. 
Diagnosis.-Owing to its polymorphous character, and frequently from its location, the diag- 
nosis of eczema is sometimes difficult. In general, however, it may be readily arrived at. To this 
end the following features should be kept in mind: i, the peculiar punctate redness of the erup- 
tion ; 2, its infiltration ; 3, its exudation and crusts ; and 4, its itching and burning sensations. 
These symptoms in varying degrees are always of much value, and are usually supplemented by 
the history of the case and perhaps by the existence of a previous similar eruption and by facts 
relating to it. Eczema may be mistaken for the following diseases : 
Erythema, particularly of the face, sometimes presents points of resemblance to eczema. Its 
invasion and progress are more prompt, its redness is deeper and more blotchy, and it is accom- 
panied by a burning sensation rather than by itching. The peculiar infiltration, exudation, and 
crusts of eczema are wanting. Its decline is usually rapid. 
Erysipelas of the face may be mistaken for the vesicular stage of eczema, but the doubt is 
soon cleared up. Erysipelas has a tendency to begin about the nose, to spread peripherally, to 
present a deep pink tint, a tension of the skin, and subcutaneous oedema, and frequently the 
formation of bullae is observed,-all of which features are different from eczema. In erysipelas 
there are fever and often much systemic reaction. 
Herpes may at first be mistaken for vesicular eczema, but its prodromal neuralgia, its group- 
ing, and its situation in the course of cutaneous nerves soon settle the diagnosis. 
Scabies may be incorrectly diagnosticated as eczema, and in chronic cases the diagnosis is 
often not easy. Frequently a history of contagion may be obtained, or the microscopic examina- 
tion of the crusts shows evidence of acari. The existence of an eruption between the fingers, 
upon the flexor aspect of the wrist, upon the nipples, penis, hands, umbilicus, the lower part of 
the abdomen, about the buttocks, and upon parts of the body where pressure is exerted, should 
lead to a suspicion of scabies. Irregular isolation of papules and cuniculi are features of the 
latter affection. 
Seborrhcea, particularly of the hairy parts, presents many features of resemblance to eczema. 
In the former the scales are thin, abundant, and greasy, and seated on a red extensive, uniform sur- 
face, and there is no infiltration. 
Lichen planus might be mistaken for papular eczema, but its extreme chronicity, the charac- 
teristic appearance, site, and course of its papules, present points of marked contrast. 
Tinea circinata may somewhat resemble scaling eczema. Its sharp margination, its tendency 
to circular and gyrate outline, its want of infiltration, are important points of diagnosis which can 
always be definitely made by microscopic examination of the scales. 
Pityriasis rubra presents a uniform red surface without much infiltration, is accompanied by 
profuse lamellar desquamation, and constantly ends in death. It is readily diagnosticated from 
eczema. 
Psoriasis of the scalp is frequently mistaken for squamous eczema, and a diagnosis is arrived at ECZEMA. 
21.5 
by the history of the case and the appearance of concomitant lesions in other localities. Chronic 
scaly patches of eczema sometimes resemble psoriasis. They are usually less scaly and less 
sharply marginated, and frequently a history of exudation is given. The itching and burning 
of eczema are rarely present in uncomplicated cases of psoriasis. The tendency of the latter 
affection to invade the extensor surfaces and the regions of the elbows and knees is in marked 
contrast with the course of eczema, which is prone to attack the flexor aspects and parts where 
the epidermis is thin. 
Urticaria, particularly when the wheals are small and ephemeral or in the form of papules, 
may, when not seen in the early stage, be mistaken for papular eczema. Even intelligent patients 
are frequently unable to give a clear idea of the manner of invasion of this affection. Like papu- 
lar eczema, it is obstinate and prone to relapse. 
Syphilitic eruptions in the encrusted and scaly stage may be mistaken for eczema. The his- 
tory of the case, the presence of concomitant lesions or their sequelae, and the absence of itching, 
are always points of importance in the specific eruptions. Pustular syphilides of the scalp and 
beard may come to resemble impetiginous eczema. The large and small papular syphilides, when 
irritated, lose their peculiar features and look like eczema. This is particularly to be observed 
about the mouth, axillae, in parts subject to contact, and about the genitalia and anus. Eczema of 
the palms and soles very commonly is mistaken for the scaling stage of the papular syphilides of 
these parts. I he history of the case, with their different modes of invasion, is important. In syph- 
ilis there is usually a coincidence of other lesions or their sequelae, and a history of the affection 
beginning as isolated papules scattered in the palm of the hand, which have grown and fused 
together. Pruritus is very rare in uncomplicated cases of syphilis. 
I REatment.-In a large proportion of cases of eczema internal medication is not required, 
since the disease will often yield to local measures. It is well in all cases, however, to look into 
the condition of the patient's health, and to ascertain his habits, modes of life, and the require- 
ments of his occupation. In the eczema of acute invasion the diet of the patient should be of the 
simplest and most digestible character, and sparing in quantity. Active purgation by means of 
cathartics, preferably the compound cathartic pills or a powder composed of calomel and super- 
carbonate of soda, in proper dose for the age and strength of the patient, is usually called for and 
of benefit. 1 hen a diuretic aperient may be given, as follows : 
B. Potassge acetat., ; 
Sodge et potassge tartrat., 5ij; 
Aquge, oviij. M. 
Dose, one tablespoonful in a wineglass of water three or four times a day, an hour apart from 
meals. Should further purgation be rendered necessary by the severity of the affection, the Ger- 
man bitter waters, Hunyadi Janos and Victoria, may be administered. Their chief ingredient is 
the sulphate of magnesium, and patients take them with much less reluctance than they would 
artificial solutions of Epsom salts. The moral effect of taking a natural water has much influ- 
ence upon patients. 
I hough eczema is far from being constantly a disease of debility, there are many cases of it 
in which the assimilation and nutrition are below par. In all such cases in cachectic persons, in 
those of strumous tendency and of poor fibre, in women subjected to over-lactation, appropriate 
medication with careful attention to diet and hygiene should be instituted. 
Not infrequently, eczema, particularly in a relapsing form, is seen in subjects of dyspepsia of 
various kinds, and its treatment requires much care in the management of the diet and hygiene of 
the patient, and in adapting appropriate medication. Much aid is thus given to local applications. 
In some cases of nervous debility, in persons who live under mental strain from business 216 
DISEASES OF THE SKIN. 
cares or worry and anxiety, eczema may be very obstinate, and can only be cured by judicious 
treatment and watchful care of the patient, supplemented by local remedies. 
In subjects of gout and rheumatism suffering from eczema the principles of general medicine 
are to be followed, and their cutaneous lesions treated locally according to indications. The salicy- 
lates and alkalies are often of benefit in such cases. 
Eczema occurring in persons addicted to high living and the constant use of alcoholics and 
fermented liquors requires the exercise of a judicious and persistent hygiene. Such cases need 
purgation at frequent intervals, and are benefited by the aperient diuretic mixture already men- 
tioned. I have seen benefit in such subjects from the use of salicylic acid or salicylate of soda. 
This same treatment and hygiene is indicated in cases of eczema in persons of the so-called uric- 
acid diathesis, in whom thorough oxidation of the products of metamorphosis of the tissues does not 
take place. In these cases very frequently much general and local benefit follows the alternating 
use of chlorate of potassium and dilute nitric acid, by which large quantities of oxygen are sup- 
plied to the system. The dilute nitric acid should be given in doses of from fifteen to thirty drops 
in an ounce of water half an hour before meals, and followed by from ten to twenty grains of the 
chlorate of potassium, dissolved in two ounces of water, an hour after meals. I have seen much 
benefit from this treatment in adults and persons further advanced in life. 
Eczema occurring in persons suffering from diabetes, Bright's disease, and other visceral affec- 
tions is usually very persistent and requires an appropriate system of constitutional treatment. 
Though there is no specific for eczema, nor any one drug suitable for general or routine use, 
there are several which in proper cases are of benefit. The alkalies have a wide range of use in 
eczema, particularly in plethoric subjects, in those given to high living and addicted to drink, and 
those who suffer from an acid dyspepsia. My preference is in favor of the citrate or acetate of 
potassa in appropriate doses, dissolved in plenty of water and taken an hour or longer after meals. 
Supercarbonate of soda in Vichy water may be remembered. Arsenic is an agent capable of doing 
much harm, and in certain cases much good. Its use is contraindicated in all cases of acute inva- 
sion and in those in which there is gastric or intestinal irritation or intolerance. This agent is of 
benefit in the superficial chronic forms of the disease, particularly those in which the scaling pro- 
cess is well marked ; and, conversely, it is of little if any use in chronic infiltrated eczema. In 
eczematous persons of neurotic tendency, in those suffering from malaria, it is at once a tonic and 
a remedy which favorably affects the skin affection. In some chronic cases of erythematous eczema 
of the face it will be found of benefit. Eczema affecting the hands and fingers symmetrically, and 
occurring in limited, rather superficial, patches over the body, is often favorably influenced by 
this remedy. With the internal use of arsenic vigorous but careful local treatment should be 
combined. 
Fowler's solution, and arsenious acid and arseniate of soda in pills or in tablets, are the most 
prominent and reliable preparations. They should not be used in a routine way, but intelligently, 
carefully, and persistently. Having determined that the agent is indicated in a given case, the 
condition of the stomach and bowels must be considered, and if necessary a preparatory treat- 
ment should be adopted. It is generally well to clear the gastro-intestinal canal by purgatives and 
aperients before administering the remedy. Then a fair medium dose may be given, dissolved in 
or followed by plenty of water, an hour and a half after eating. The effect is to be watched, and 
if benefit is seen and tolerance exists, the dose may be slowly but gradually increased. Taking 
Fowler's solution as a sample, for an adult five drops may be given three times a day. This, all 
things being considered, may be increased by one drop at each dose every three or five days, and 
thus pushed until in some cases fifteen-drop doses may be reached. In all cases the stomach and 
bowels must be watched, as well as the conjunctiva and soft tissues around the eyes and the hands 
and the feet. Any evidence of injurious action must be noted and the dose of the remedy reduced. ECZEMA. 
217 
The supervention of these symptoms does not of necessity imply the discontinuance of the agent. 
In these cases the tact and intelligence of the practitioner will be displayed in modifying and adapt- 
ing the further use of the drug. The object is to get its physiological effect without any patho- 
logical drawbacks. Preparations of arsenic may be given in or with bitter infusions, to which 
may be added a mild carminative, such as ginger or peppermint. In many cases of eczema, 
particularly those complicated with rheumatism, suboxidation, and in old persons arsenic in combi- 
nation with one of the alkaline salts already mentioned, are of much benefit. 
Eczema occurring in debilitated, cachectic, scrofulous, and tuberculous subjects requires a care- 
fully adapted tonic treatment. In such cases the use of quinine must be very guarded, since we 
know that this drug is potent in causing dermal congestion. Preparations of iron are of especial 
value, while the stomachic effect of infusions of quassia and columbo-root has an excellent sup- 
plementary influence. In many cases the combination of a preparation of iron with an alkali is of 
much benefit. The following formula will be found useful: 
B. Ferri et quiniae sulph., 0iv; 
Potassse citratis, §j; 
Syr. aurantii corticis, 51'j ; 
Aquae, §vj. M. 
Dose, one tablespoonful, with a little water, three times a day, after eating. Citrate of iron may 
also be used in this combination in the same doses. Palatable and digestible preparations of 
cod-liver oil are also useful adjuvants to treatment. 
Iodide of potassium is of doubtful value in any case, and is of positive injury in many. 
d he treatment of eczema in infants requires much care, intelligence, and patience. In very 
many cases healthy children become the victims of this disease through the persistent and inju- 
dicious use of soap and water and by means of irritating under-garments. Cleanliness is a prime 
essential in the old and the young, yet in infants it is often attained at a severe cost. The young, 
soft, rapidly-growing cells and active circulation of infants predispose their tissues, the skin par- 
ticularly, to inflammation ; hence they are especially vulnerable. Many a mother or nurse has 
unconsciously been responsible for a long and severe attack of eczema in an infant by the too 
active washing and rubbing of a slight patch of seborrhoea of the scalp. In the same way, the 
energetic washing and cleansing of transient erythemas about the joints, armpits, and buttocks 
have often been the starting-point of the affection. This subject of the hygiene of the skin in 
infants is of great importance, and should always be remembered. 
Very often the intensity of the itching is such that the nervous system is disturbed, the 
general health impaired, and insomnia is produced. Besides local treatment, internal medication is 
urgently called for. In such cases opium and its derivatives, and chloral, are contraindicated, 
chiefly by reason of their tendency to produce dermal congestion, while gelsemium is at best an 
uncertain and often a dangerous remedy. Bromide of potassium and of sodium in proper quan- 
tity are of much value under these circumstances, administered at night in divided doses. I have 
seen good results in several cases of adults from the use of urethan, given in divided doses of 
twenty to thirty and forty grains each, every two hours for two or three doses. 1 here are no 
bad effects following the gentle and refreshing sleep thus induced. 
Local Treatment.-Such is the polymorphous character of eczema that routine local treatment 
cannot be followed, It is necessary to determine the stage of the eruption, and also to consider 
the peculiarities of the region or regions attacked. The success of the physician largely depends 
upon his aptness in clearly recognizing the indications for treatment and his skill in adapting reme- 
dies for the case. 
Erythematous eczema of acute invasion, with its heat, redness, and swelling, calls for cooling 
and sedative applications. Fatty and tarry preparations are entirely contraindicated. With the DISEASES OF THE SKIN 
218 
institution of the appropriate constitutional treatment already given, the first care should be to put 
the parts at perfect rest, whether they be the face, extremities, or trunk, to remove from them all 
pressure, and to secure them from the friction and rubbing of the clothes. In very many cases of 
acute erythematous, and in some of the papular and vesicular, varieties, the most efficient agent 
of relief is very hot water, which should be applied at intervals with a sponge, using slight pressure 
and followed by the application of pieces of old linen or of lint frequently dipped in the same. 
To this hot water may be added laudanum, one ounce to two quarts, or carbolic acid in the 
proportion of i : 200. In some cases the addition of a small quantity of supercarbonate of soda 
or of powdered borax is beneficial. Usually, the necessity for hot water is not of long duration, 
and it may then be replaced by cooling lotions. Each case of eczema is a law to itself, and hot 
applications will be found to be soothing in one, while cold ones will be in another. The idio- 
syncrasy is very soon found out. The cooling lotions found most useful are the ordinary lead- 
water, lead-and-opium wash, and black wash. Carbolic acid in the proportion of thirty to sixty 
drops to the pint is often effective, and is sometimes improved by the addition of a drachm of 
powdered borax. The following combination I have repeatedly seen to produce the most happy 
results in erythematous, acute papular, and vesicular eczema: 
R. Acidi carbolici, jjj or ; 
Tr. opii, |j; 
Spts. camphorse, 3 ij; 
Bismuthi subnit., giij; 
Aquae, gxvj. M. 
The calamine lotion (oij to 3viij of water) and subnitrate of bismuth in the same proportion, and 
in the same vehicle, are often of benefit. All lotions should be applied on old linen lint or 
absorbent gauze, which should be spread out smoothly, frequently moistened, and not cov- 
ered with oil silk or gutta-percha tissue in the majority of cases. 
In those cases of acute invasion and of much severity of symptoms our armamentarium is 
further increased by the various absorbent powders. In this category there are starch, infant's 
powders, lycopodium, Venetian talc, and oleate of zinc in powder. The following combination has 
long been used in acute eczema and in the erythemata with much benefit: 
R. Zinci oxidi, £ss; 
Pulv. amyli, 3j; 
Pulv. camphorae, M. 
It should be carefully prepared and sifted. 
All of the various powders may be made still more soothing by the addition of such drugs as 
stramonium, hyoscyamus, and cannabis indica after the manner proposed by Dr. Faithful. The 
fluid extract is to be dropped in proper quantity over the powder, which must be triturated for a 
sufficient time and then sifted. 
Generally, powders may be applied by means of a puff, but in cases where two coapted sur- 
faces are attacked they should be thickly dusted on soft lint and then carefully put in place. In 
very severe cases Unna's powder-bags may be used. These are made of cambric or thin muslin 
and partly filled with any absorbent powder, and then they should be transversely stitched in 
several places in order to prevent the shifting of the powder. They may be made of any size or 
shape as the case requires. Movement of the body causes the exudation of the powder. Such 
applications should be carefully watched and renewed. Though hot water is in many cases of 
great benefit in the acute forms of eczema, washing of the parts with water or with soap and water 
usually aggravates the disease. In nearly all cases in the early and in the subacute stage the use ECZEMA. 
219 
of water is contraindicated, since much irritation is caused by it. It is always a good rule to 
mix a small quantity of bay rum or of alcohol with the water used to cleanse parts in the neigh- 
borhood of a patch of eczema. 
With the subsidence of the acute and the inauguration of the subacute condition in eczema 
the indications for treatment are altered. In the subacute state-which, by the way, implies much 
and persistent inflammation and suffering-ointments prove of great service. These applications, 
to be of benefit, must be freshly made of pure ingredients and triturated until all sharp particles 
are reduced to an impalpable powder. Much of the success of the practitioner will depend on 
his care and watchfulness of the quality of the ointments used. The most generally useful oint- 
ment in eczema is that composed of oxide of zinc one drachm, and one ounce of cold cream or 
vaseline or simple cerate. Its odor, not its efficacy, may be enhanced by the addition of a few 
drops of tincture of benzoin. Very frequently the addition of from ten to twenty grains of finely 
powdered camphor to the ounce of zinc ointment is of much benefit in relieving the pruritus. Of 
late years the oleate of zinc in the form of powder has been substituted for the oxide and, by some 
superiority is claimed. One of the most useful preparations lately devised is called Lassar's 
paste. It is made as follows : 
R. Zinci oxidi, 
Pulv. amyli, dd, gij; 
Vaseline, §ss. M. 
To this is added 2 per cent, of carbolic acid. The virtues of this combination may be increased by 
the addition of powdered camphor. This ointment or paste has more body than the oxide-of-zinc 
ointment, and a sufficient coating can be applied without the tendency to melt observed in the 
latter. Glycerole of starch has been recommended as a remedy for subacute eczema, and may be 
considered a part of our armamentarium. Boracic-acid ointment, containing one drachm of the 
salt to an ounce of cold cream or vaseline, and boroglyceride in similar proportions and combi- 
nations, are very excellent applications of a soothing nature. 
Diachylon ointment is one of the most important applications we have in dermatology: it is 
useful in very many cases and many phases of subacute eczema. It may be prepared according 
to the Pharmacopoeia, or by melting one part of oil of sweet almonds with two parts of freshly- 
made lead plaster (R. W. Taylor), or equal parts of lead plaster and vaseline (H. G. Piffard). 
However made, diachylon ointment is unstable and prone to rancidity. To be of benefit, it 
must be perfectly fresh and very carefully prepared of pure ingredients. In many cases it may 
be used alone, and again a combination of equal parts of oxide-of-zinc ointment and diachylon 
ointment is very beneficial. Hebra combined balsam of Peru with diachylon ointment, and it will 
frequently prove of much service when slight stimulation is necessary. 
Lead ointment, made of carbonate of lead one drachm to cold cream or vaseline one ounce, 
is sometimes of service, and in the practice of a friend I have seen good results follow the use of 
a combination of the ordinary white lead paint one drachm to the ounce of a fatty preparation. 
I he officinal lead ointment may be remembered as well as the subnitrate of bismuth in the propor- 
tion of one drachm to an ounce of ointment. Besides camphor and balsam of Peru as adjuvants 
to allay pruritus in ointments, any of the foregoing may be combined with varying quantities of 
thymol, stramonium, or belladonna ointment, with a view to increase their soothing effects. 
In the declining stages of eczema, particularly when the surface is dry, an ointment composed 
of from thirty to sixty grains of calomel to the ounce of cold cream or vaseline is often of marked 
benefit. This remedy may also be combined in similar proportions with zinc ointment in subacute 
and chronic cases. White precipitate in proportion of from five to fifteen grains to the ounce ol 
ointment is frequently of benefit in subacute forms, particularly upon hairy parts. 
Within a few years sulphur has been recommended by Unna in combination with zinc oint- 220 
DISEASES OF THE SKIN. 
ment in moist eczema, but principally in the scaly and encrusted stages. In these varieties also 
ointments containing from i to 3 or 4 per cent, of chrysarobin, or pyrogallol, may be used. 
Though resorcin has been much vaunted as a reducing agent in chronic scaling and thickened 
eczema, it is at best an uncertain and unsatisfactory remedy. Ichthyol, which has been so bril- 
liantly exploited by Unna, has not, in this country, proved beneficial and satisfactory in the treat- 
ment of eczema. Salicylic acid, in proportion of from 2 to 6 per cent, with a fatty medium, is very 
frequently of great benefit in chronic scaling eczema. In cases where there is much epidermal 
hypertrophy of the feet, hands, or limbs the application of this ointment enveloped with gutta- 
percha tissue will often be followed by great benefit. 
Care in application is an essential to success in the use of ointments. The fatty agent should 
be smoothly and tolerably thickly spread on linen or lint and applied evenly over the affected parts. 
When necessary, suitable retentive bandages may be used, employing slight pressure, which, if 
well borne, acts well as a mild stimulant. In some cases ointments may be advantageously rubbed 
in with the tip of the finger, using slight pressure. In recesses of the skin, such as the nose, ear, 
umbilicus, and anus, they should be applied by means of a camel's-hair brush or of a pledget of 
cotton wound around a wooden toothpick. The frequency of renewal of ointments depends on 
the sensations of the patient and on the amount of exudation. In general, an application once in 
eight or twelve hours is sufficient. 
The compound salicylated plaster of Klotz is very useful in some cases of moist and in many 
of the scaling fissured and infiltrated forms. The formula is as follows: 
B. Emplast. diachyli simplicis, 
Emplast. saponati, dd, 40 parts; 
Petrolati, or vaseline, 15 parts; 
Acid salicylic, 5 parts. M. 
This should be quite thickly spread on lint or old linen and applied to the parts. 
In addition to the ointments of sulphur, salicylic acid, etc., whose action consists largely in 
reducing the scaliness and infiltration of eczema, we must not lose sight of those valuable old-time 
applications known as the tarry preparations, since there is a tendency at present to set them aside. 
Heretofore we have chiefly considered the remedies which are of benefit in relieving the inflamma- 
tion and soothing the suffering in eczema. The next consideration is the relief of the thickening 
and induration of the skin which so constantly accompany the eczematous process. In this the 
art and skill of the practitioner are often much taxed. The cardinal points in the treatment of sub- 
acute and chronic eczema are determination of the time for, and the regulation of the amount of, the 
stimulation necessary. It must always be remembered that so long as any thickening remains in an 
eczematous patch, the affection is not cured. In dry scaling, papular eczema of the head, face, and 
extremities, with induration, much benefit will follow brisk frictions made once or twice a day with 
the simple tincture of green soap mixed with a little water, which is made as follows: 
B. Saponis viridis, ; 
Alcohol, §iv; 
Ol. lavandulge, gss. M. and filter. 
This preparation is also called spiritus saponatus alkalinus, and care must be exercised that it is not 
confounded with the officinal soap liniment. After this application, occupying five or ten minutes, 
the parts may be covered with either the zinc ointment or Lassar's paste or diachylon ointment, each 
ounce being mixed with one drachm of pure oil of cade or of genuine oil of white birch. In this 
way the stimulant action is maintained, provided it is grateful to the patient. In case more stimu- 
lation is required, frictions may be made with the compound tincture of green soap, made as 
follows: ECZEMA. 
22 1 
R. 01. cadini, 
Saponis viridis, 
Alcohol, ad. ; 
01. lavandulae, 3j. M. 
Sig. Tinctura saponis viridis composita. Besides dissipating the induration, the tarry preparations 
are of great benefit in relieving pruritus. It must be remembered that they are contraindicated in 
the acute and moist forms of the disease. These two tinctures are of especial value in subacute 
and chronic eczema, in which also the pure oil of cade or oil of white birch (Ol. Rusci vel Ol. betu- 
lae albae) may be used. These occasional applications may be made by means of a flannel pad or 
a small brush. 
Not infrequently, the stimulation offered by these remedies is insufficient, and then we are 
forced to resort to cantharidal collodion and acetum cantharidis and solutions of caustic potash or 
soda. The preparations of cantharides are applicable to the more superficial and local indurations, 
and must be carefully applied to the morbid parts only. The solutions of potash and soda may be 
made of various strengths, from ten to sixty, and even one hundred and twenty, grains of either 
of these caustics to one ounce of water. These solutions must be carefully but firmly rubbed into 
the morbid patch by means of a flannel pad or small brush until the epidermis is denuded and a 
raw, weeping surface is left. This may be dressed with a soothing ointment or lotion, and for 
several hours a gummy fluid, looking like glue, will exude. Perhaps one such application, followed 
when the acute symptoms have subsided by an astringent and tarry ointment, may effect a cure. 
Very often several applications of the potash or soda solutions are necessary, and care must be 
exercised in properly adjusting the intervals. 
Much improvement has been made during the last decade in the treatment of eczema by means 
of permanent dressings, which have the decided advantages of being cleanly, easy of application, 
of being stable and durable, comfortable, and remarkably curative, exercising a mild, uniform 
pressure which exsanguinates the blood-vessels. 
The gelatin jelly of Pick and the glycerin-and-gelatin jelly of Unna are capable of much 
good in a restricted class of cases of eczema in the late stage of the moist form, in the scaling, 
fissured, indurated, and papular forms. The following formula has worked well in my hands: 
R. Gelatin, §ss; 
Glycerinse, 
Aquae, da. giij. M. with gentle heat over a water-bath. 
I o this may be added oxide of zinc, carbolic acid, camphor, chrysarobin, pyrogallol, salicylic acid, 
calomel, or white precipitate in appropriate quantities. When used, the jelly should be liquefied, 
and then painted evenly and sufficiently thickly over the morbid surface with a soft broad brush, 
and the whole covered over with tissue-paper. In a few days the coating becomes loose, and should 
be carefully removed, and, if necessary, reapplied. 
Unna's salve-mulls are also excellent permanent applications in eczema. Their basis is ben- 
zoated suet and lard spread on and well incorporated into the meshes of one or both sides of mull 
undressed muslin. In this ointment may be incorporated oxide of zinc or any of the agents 
already mentioned. The mull can be cut of any size desired, and is quite adherent. 
The gutta-percha plaster mulls, also devised by Unna, are very useful in a more limited field 
than the salve-mulls. Their main difference is that on one side they are covered with a layer of 
gutta-percha. They are of use when maceration of the epidermis is necessary. India-rubber plas- 
ters, containing oxide of zinc, white precipitate, chrysarobin, and pyrogallol, have been made by 
Seabury and Johnson for Dr. Stellwagon. I have used them considerably, and find that they are 
contraindicated in all but very chronic cases in which there is much scaling and induration. Such DISEASES OF THE SKIN. 
222 
is their impermeability that even the oxide-of-zinc plaster has caused much suffering in subacute 
aggravated papular eczema. 
In some forms of scaling and infiltrated eczema much benefit will follow the application of 
flexible collodion or traumaticin (a mixture of gutta-percha and chloroform), combined with the oil 
of cade or the oil of white birch in the proportion of one ounce of the former to one drachm of 
the tarry oil. This method of permanent application is the forerunner of all of the existing ones 
now in use, and I trust that it will not be considered immodest if I state that it originated with 
myself many years ago, and was published in Seguin's Series of American Clinical Lectures' Be- 
sides the tarry oils, powders of various kinds can be mixed with the collodion or traumaticin. 
It should never be forgotten in the treatment of eczema that the removal of crusts and scales 
is a necessary step in the treatment. Crusts should be thoroughly soaked with sweet or almond 
oil, and then removed with great care. In case they are thick and very adherent, a cold starch 
poultice, with the addition of boracic acid or of a few drops of carbolic acid, may be applied. In 
very obstinate cases hot bread-and-water poultices, with boracic acid, may be necessary. 
Scales and epidermal thickenings are best treated by covering the parts with linen soaked 
either in a dilute solution of potassa or soda or in a solution of salicylic acid, and then thoroughly 
enveloped with gutta-percha tissue. 
Cases of obstinately recurring eczema are not rare, and are peculiarly intractable. Dr. H. Rad- 
cliffe Crocker has proposed a novel mode of treatment for such cases, consisting in counter-irrita- 
tion over the vaso-motor centres, using cantharidal collodion as the agent. According to the 
position of the eruption the counter-irritant is applied. If it is on the face, the blister should be 
applied behind the ears ; if on the face and forearms, on the nape of the neck ; if about the geni- 
tals or legs, over the lumbar enlargement; and if only one leg is affected, it should be placed over 
the great sciatic nerve. Repetition of the applications may be made according to indications. 
In the treatment of eczema, particularly when large surfaces are involved and the eruption is 
much disseminated, and also in some cases of the severe oozing form with much pruritus, warm and 
cool baths may often be of benefit. No rule can be laid down as to their exact temperature ; there- 
fore it is well to try them first at about 98° Fahr., and according as they are beneficial increase or 
diminish the heat. In some cases they aggravate the eruption and the patient's sufferings. Bran, 
starch, supercarbonate of soda, and powdered borax may be added with much benefit. 
Treatment of Eczema of the Face.-Eczema of the face is commonly of the erythematous, 
pustular, and perhaps vesicular forms. In the acute stage powders, lotions, or hot water may be 
necessary, to be followed by the use of zinc ointment and camphor, Lassar's paste with carbolic 
acid, and camphor and diachylon ointment. Ointments containing oxide of zinc should never be 
used upon hairy surfaces or upon the palms or the soles. In case the affection is confined to the 
hairy parts, calomel ointment or a mild white precipitate ointment may be used. Strips of salve- 
mull may be cut to fit the parts and kept in place. With the subsidence of the acute symptoms the 
stimulant treatment must be carefully begun, in which cases the tarry preparations are very often 
useful. 
Treatment of Eczema of the Nostrils.-Eczema of the nostrils is seen chiefly in scrofulous 
children, in persons suffering from nasal catarrh, and may exist as an extension of a patch on the 
nose or upper lip. Besides appropriate internal medication for such children and measures for the 
relief of the rhinitis, careful local treatment is necessary. In the inflamed state one nostril at a 
time is to be plugged with absorbent cotton saturated with diachylon ointment, combined with bal- 
sam of Peru or camphor; and this should be changed every few hours. To reduce infiltration 
very light touchings with liquor potassae, or with equal parts of carbolic acid and glycerin, may be 
employed. In the chronic state calomel ointment or a mild white precipitate or citrine ointment, 
1 " The Treatment of Eczema," by R. W. Taylor, M. D., November, 1876. ECZEMA. 
223 
perhaps combined with a small quantity of one of the tarry liquids, is efficacious. As Kiesselbach, 
Moldenhauer, and Hardaway have pointed out, there are two affections of these parts which have 
been classed as eczema. The first is eczema, as just spoken of; the second is an inflammation of the 
vibrissae which is really a folliculitis. For the latter affection Hardaway, besides appropriate gen- 
eral treatment, advises the following ointment, first proposed by Van Harlingen : 
B. Squire's1 glycerol, plumbi subacetat., 3ss ; 
Glycerini, gjss; 
Ung. aq. rosae, §j; 
Cerse albae, q. s. M. 
in inveterate and relapsing cases Hardaway thinks that the follicles should be destroyed by 
electrolysis. 
Schmiegelow and Bacon recommend the following treatment, based upon the hypothesis that 
the affection is caused by the lodgment of micrococci in the follicles: small pieces of cotton-wool 
are soaked in an aqueous solution of corrosive sublimate, i : 1000, or, if too irritating, i : 2000. One 
nostril at a time is thus treated, the tampon being large enough to quite fill it. This should remain 
two hours, and the other nostril should be similarly treated. If irritation is produced, an ointment 
of one part of boracic acid to ten of vaseline should be used. 
Treatment of Eczema of the Ears.-In the early and acute stages the usual treatment by zinc, 
lead, or diachylon ointment is indicated. In the chronic stage much attention to details is required. 
Crusts must be removed by soaking with glycerin or olive oil, and the canal should be cleared if 
possible. Ablution of the parts and syringing of them with warm bran- or barley-water are often 
very beneficial. To relieve infiltration, liquor potassa, equal parts of carbolic acid and glycerin, 
and aqueous solutions of nitrate of silver, thirty to sixty grains to the ounce, may be used. The 
utmost care should be taken to apply but a small quantity of these liquids and to avoid touching 
the ear-drum. A camel's-hair pencil or absorbent cotton fixed upon a wooden toothpick may be 
employed. Following this stimulation, diachylon ointment with balsam of Peru or one of the tarry 
oils may be applied. Calomel ointment and a mild white-precipitate or yellow-oxide-of-mercury 
ointment will often be of benefit. Permanency of dressing is important in the late stages of the 
affection. 
Treatment of Eczema of the Scalp.-This is usually of the pustular or scaly form, and the 
subacute and chronic stages are soon reached. The prime necessity is the removal of crusts. 
Then a mild ointment of either white or red precipitate, five grains to the ounce, or the calomel 
ointment, each of them combined with 2 to 5 per cent, of camphor and carbolic acid, must be 
thoroughly rubbed in twice or even three times daily. The tarry oils may be added as the 
inflammatory symptoms subside. This same method is indicated on the hairy parts of the face, 
where in many cases epilation is necessary. 
Treatment of Eczema of the Eyelids.-Eczema of the eyelids is frequently seen in children of 
the poorer classes and in the scrofulous. An ointment composed of three grains of red precipi- 
tate to one ounce of cold cream or vaseline should be carefully applied several times daily. In 
cases in which there are minute follicular abscesses the hairs must be pulled out and the parts 
1 The formula is as follows : 
B. Acetate of lead, 5 parts ; 
Litharge, 3% parts; 
Glycerin, 20 Parts bY weight. 
Mix and expose to a temperature of 350° Fahr, and filter through a hot-water funnel. The resulting liquid contains 129 grains of 
the subacetate of lead to the ounce. This liquid may be combined with cold cream, simple ointment, or vaseline in the proportion 
of one drachm to the ounce, and is often beneficial in acute vesicular, papular, and oozing eczema. 224 
DISEASES OF THE SKIN. 
cleansed, and touched carefully with a 50 per cent, solution of carbolic acid, or a solution of 
nitrate of silver (30 grains to water sj), after which the ointment may be applied. 
Treatment of Eczema of the Lips.-Eczema of the lips is frequently seen in children and 
young people of poor fibre, and is usually of the fissured form. Owing to the mobility of the 
parts and the moisture which covers them, eczema in this region is very persistent. Acetum 
cantharidis or weak solutions of caustic potassa may be applied every day or two, and the parts 
then smeared with a zinc ointment or Lassar's paste containing thymol or camphor. 
Treatment of Eczema of the Hands and Feet.-In the acute stages the various cooling lotions 
may be applied, followed by diachylon or calomel ointment, with camphor or some tarry oil. If 
the fingers are involved, each one must be separately bandaged. In the chronic indurated condi- 
tion stimulation with the compound tincture of green soap may be employed, followed by the 
application of diachylon ointment or of a mild salicylic salve-mull. Where the induration is exces- 
sive the solutions of potassa and soda are the most efficient remedies, and they should be carefully 
and thoroughly used, and followed by cooling remedies for a time, and then by the application of 
diachylon ointment, to which, as soon as indicated, balsam of Peru or the tarry oils should be 
added. In some cases the epidermal hypertrophy is so great that it is necessary to swathe the 
parts in linen saturated with a mild alkaline solution (caustic potassa or soda one drachm to water 
one pint), and the whole then enveloped in gutta-percha tissue. 
In many cases of chronic eczema of the hands it will be necessary to wear india-rubber gloves. 
Care should be observed that the hands are not irritated by soap and water. Cleanliness may be 
attained by gentle wiping with a cloth wet with diluted alcohol or bay rum. 
Treatment of Eczema of the Genitals.-Eczema of the penis and scrotum usually passes quickly 
into the thickened and weeping or scaling and fissured stage. Very often immersion of the parts 
in very hot water, with bran and borax, is of marked benefit. Diachylon ointment with camphor 
may then be applied, or one composed of black oxide of mercury one drachm to simple ointment 
or cold cream, one ounce with camphor, is often of much benefit. Care must be used in apply- 
ing tarry preparations to these parts. Every point of hygienic technique must be employed in 
these cases. When chronic dense infiltration is present, the strong caustic solutions must be used 
with great care, and followed each time by the alkaline bran bath, after which the parts are to be 
enveloped in lint spread with diachylon ointment. In women vaginal discharges must be cured 
or prevented from touching the affected surfaces, which must be kept apart. Alkaline and bran 
baths, followed by cooling lotions, and later by diachylon ointment with camphor or thymol, may 
be used. 
Treatment of Eczema of the Amts.-Eczema in this locality soon becomes of the indurated and 
fissured variety. Care of the diet, attention to the condition of the bowels, and the most scrupu- 
lous cleanliness are the first essentials. Hot water with borax and bran may be used as a douche 
or as a bath once or twice a day. Equal parts of diachylon and zinc ointments, with at first balsam 
of Peru or powdered camphor, may be kept constantly on the parts by means of a wad of absorb- 
ent cotton. Later on the tarry preparations may be added. In some cases, so persistent is the 
induration, strong caustic applications are required in the manner already indicated. Carbolic acid, 
vinegar and water, liquor picis alkalinus (tar, 5ij ; potassae caustic, 5j ; aq. 3j. M.) in diluted form, 
and tinctura saponis viridis composita, may be used as the occasion requires to relieve the terrible 
itching. Much care and persistency are necessary to effect a cure. 
Treatment of Eczema of the Umbilicus.-The parts should be thoroughly relieved of crusts 
and secretions, and diachylon ointment with tar or carbolic acid applied on cotton pushed firmly 
but carefully to the bottom of the recess. In some cases further stimulation is necessary. A cure 
depends wholly on the thoroughness of the treatment and on the constancy of the application. 
Treatment of Eczema of the Breast.-When eczema of the breast is due to scabies, an appro- ECZEMA. 
225 
pnate treatment will usually effect a cure quite promptly. In many cases, however, the affection 
becomes well developed in the indurated and scaling or oozing forms. In these stimulation with 
carbolic acid, strong solutions of nitrate of silver, and potassa solutions are frequently necessary. 
I hey should be applied thoroughly and with great care, and proper attention must be paid to the 
subsequent soothing treatment. Then the diachylon ointment with some stimulant adjuvant may 
be used. Care should be taken to keep the ointment on continuously and to avoid friction and 
pressure of the parts. 
Treatment of Eczema of the Joints.-Absolute rest is the prime necessity in the treatment of 
eczema of the joints. The acute stage is to be treated in the usual manner. Later on, diachylon 
ointment, zinc salve-mull, and zinc ointment may be used. Occasional frictions with the compound 
tincture of green soap tend to allay itching and reduce infiltration. Permanency, smoothness, and 
exact adaptation of the various applications are very essential. When it is possible, bandaging 
of the parts is of much benefit, by reason of the pressure exerted. Eczema of the axillae is fre- 
quently complicated with abscesses and inflammation of the lymphatic ganglia, which should be 
treated according to the indications. 
Treatment of Eczema of the Legs.-In the erythematous papular and vesicular stages the 
parts should be put at rest and anointed with zinc ointment combined with camphor or carbolic 
acid. In the later weeping, scaling, and infiltrated condition which eczema is prone to assume in 
these localities, equal parts of zinc and diachylon ointments may be used, combined with balsam of 
Peru, camphor, or carbolic acid. This should be spread on lint and smoothly applied, and then the 
leg should be bandaged from the foot to the knee. In chronic eczema of the leg, particularly when 
Ary or scaling, the glycerin-gelatin jelly, combined with oxide of zinc and camphor, is often of 
much benefit. In many cases the india-rubber bandage either spirally applied or in cylinder form 
is of service, while in others it causes an aggravation of the affection. Old infiltrations about the 
legs should be properly stimulated with the alkaline solutions, care being taken to keep the patient 
°n his back during the treatment. Ulcers, which so frequently accompany eczema of the legs, 
should be treated according to the indications which they present. 
Treatment of Eczema of Infants.-The first indication is to put the child in a perfect state of 
health and hygiene and to remove from it all possible sources of irritation. The cure depends 
upon the perfection and adjustment of the dressings. The various astringent and soothing oint- 
ments must be used in the much-inflamed and oozing states. As the affection passes into a sub- 
acute condition, stimulation is necessary, which should always be guardedly used in young subjects. 
It is obvious that the tarry preparations, camphor, carbolic acid, chrysarobin, etc., should be used 
m much less strength than in the adult. In young subjects the great difficulty of treatment is the 
retention of the applications, and in them the fixed dressings already spoken of are indicated. 
In children, as in adults, the object of the physician should be to produce as rapid a cure of 
eczema as possible. The old idea, that the rapid drying up of eruptions is followed by morbid 
metastasis elsewhere, is no longer held by authorities of experience. As a corollary of this prop- 
osition, the fallacious and mischievous idea held by many that eczema in an infant is a benefit, and 
that it will get well either after dentition or after a given age is reached, needs but be mentioned 
to be strongly condemned. ACNE. 
Acne is a chronic inflammation of the sebaceous glands of the face, neck, chest, and back, 
peculiar to young persons, male and female. It may occur in girls earlier than in boys-as a rule, 
at or about puberty, but in some cases later. It appears in a mild form as a slight blemish, and 
also in such severity as to be disfiguring. Between these extremes, however, there are many 
degrees. Its distribution is commonly bilateral, but its lesions are not, as a rule, symmetrically 
placed nor grouped with any regularity or uniformity, but in a characteristic disseminated manner. 
An acne eruption is commonly polymorphous, consisting of papules, pustules, and tubercles, with 
perhaps more or less perifollicular hyperaemia.. Its lesions coexist in all stages of development, 
evolution, and decline by reason of the chronicity of the disease and the constant appearance of 
new crops. The number of the lesions is very variable : sometimes these are few, sometimes 
more, and again there are many. The want of uniformity of the disease is further shown by the 
variation in the number of lesions in the succeeding crops. 
In general it is a chronic affection, lasting months or years, though it may develop in the acute 
form. Its sites of election are the forehead, cheeks, and chin, though it may appear on the sub- 
maxillary regions and the neck. It is also found upon the chest, and principally upon the upper 
portion of the back, less frequently on the lower portion. It also may be found upon the trunk 
and extremities, where hair or sebaceous follicles are most numerous, but never on the palms and 
soles. While it is not uncommon to see the coexistence of acne upon the face and trunk, it does 
not, as a rule, exist upon the latter region while the face remains unaffected. 
Much redundancy in the nomenclature of acne has been indulged in, and its study has been 
correspondingly rendered more difficult. The simplest division of the disease is into acne simplex, 
in which papules and tubercles are present together, and acne indurata, in which one or both of 
these lesions have become much hypertrophied. We very commonly see cases of acne in which 
all of the lesions are papular, and again those in which pustules predominate over papules ; but 
they are essentially similar cases, nevertheless. 
Acne simplex consists of papules varying in size from a hempseed to a pea, any or all of 
which may become pustular. The papules are of a bright-red color, conical or rounded, some hav- 
ing a sharply-defined outline with a slight surrounding redness, while others are not thus clearly 
marginated. Some papules have at their summits blackish punctae caused by dirt in the follicular 
opening-a condition which has given rise to the term "acne punctata." These papules may 
remain in an indolent condition for some time, or they may even quite rapidly increase in size. In 
most cases there is no uniformity in the course of their growth. From this cause and from the 
recurrence of crops it happens that in a case of full development there is an intermingling of 
lesions of varied sizes. This form of the disease is known as "acne papulosa." With the growth 
of the papules a change is very commonly noticed in their apices, which become capped with a 
minute quantity of pus, and they are then really papulo-pustules. In this condition the affection 
is called "acne pustulosa." There is no rule as to the time of this pustular change: it may be 
seen in pinhead-sized lesions and those as large as a pea. The amount of pustulation varies very 
226 Part IV 
Plate XXVIII 
LEA BROTHERS & CO. PUBLISHERS . PHILADELPHIA 
ACNE. ACNE. 
227 
considerably: in some cases it is small and superficial, in others quite deep and copious. The pus 
when in small quantity dries in a short time into minute crusts ; when in large amount it remains 
in the interior of the follicle, which is transformed into an abscess-cavity. These pustular lesions 
are round or conical, commonly surrounded by a well-marked inflammatory areola, and sometimes 
by a zone of exudative infiltration. The pustulating process of acne lesions is usually quite acute 
in its course, though it may take place quite slowly. 
In many cases a more or less patchy, or even a diffuse, hyperaemia complicates cases of acne, 
which has been by some called "acne rosacea it is in reality hyperaemic acne, and wholly differ- 
ent from rosacea, which we shall find consists of new connective-tissue growth, together with 
enlargement of the capillaries. 
In Plate XXVIII. is well shown an ordinary case of acne in which pustulation is quite general. 
Its lesions are perhaps more than ordinarily numerous, but its distribution is typically shown all 
over the forehead, particularly at the base of the nose, on the cheeks, alae nasi, and chin. Over 
the temporal region the little black-headed red papules portray in a clear manner acne punc- 
tata, while elsewhere on the face perfectly white papules with little black apices are to be seen, 
which are not inflammatory growths, but rather sebaceous follicles distended and plugged with 
immature sebum, while their orifices have become receptacles for dirt. Under the eyes are a 
number of white flat papules without any appearance of apex or dirt point, which are called 
"milium. 1 his lesion is supposed to be caused by cell-changes in the walls of the glands, which 
by increased bulk come to look like a papule. 
Histological studies have shown that in ordinary acne the inflammatory changes are chiefly in 
the walls of the sebaceous follicles, and also in the perifollicular tissue. In proportion as this 
exudative inflammation progresses beyond the follicle, the papules increase in size and depth 
until they become nodules or tubercles ; which gives rise to the name "acne hypertrophica." It is, 
however, more commonly called "acne indurata." In this form the lesions are mostly of large 
size, being either papulo-tubercles or tubercles more or less of which become at their apices pus- 
tular. fl hey are round or oval in shape, firm in structure, and sharply marginated, though perhaps 
surrounded by an inflammatory areola. Their color is of a deep-red or of a brownish- or even 
purplish-red tint. They run a very chronic course, and then slowly subside and wither, leaving for 
the most part cicatrices which may be smooth and depressed, studded with depressions, or irregular 
and even elevated. This condition has been called "acne atrophica." Cicatricial keloid very fre- 
quently attacks these scars, which sometimes disfigure the face, and especially the back, in a most 
marked manner. 
The symptoms of acne are usually, when present, of a very mild character, and very often there 
are none. Moderate heat and itching may be complained of at the time of evolution of the lesions 
or at later periods, particularly when the circulation is much accelerated. Very often patients com- 
plain of a tenderness or soreness of the face, which, however, in many cases, is caused by picking 
the lesions with the finger-nails or other means of irritation. 
Such drugs taken internally as the iodides and bromides sometimes give rise to acne, while 
others, such as tarry preparations, chrysarobin, certain dyestuffs, and mercurial ointments, applied 
externally, produce the same result. These forms have been designated "acne artificialis." 
Etiology.-Our knowledge of the causes of acne is in a very unsettled state. It is probable 
that the predisposing cause, which exists at puberty in both sexes, is the functional activity of the 
sebaceous glands which is coincident with the various developmental changes which then occur. It 
has not been proven that acne is dependent upon more or less serious disorders of menstruation, 
since it is as often seen in those in whom this function is perfectly performed as in those in whom 
it is not. Some cases, however, become worse or have new crops at or about the menstrual epoch. 
I hough I have inquired into the matter, I have never been able to convince myself that acne is, in 228 
DISEASES OF THE SKIN. 
any way, even remote, caused by masturbation, as is maintained by some authors and so commonly 
believed by the laity. The occurrence is simply a coincidence. There seems, however, good 
ground for considering cachexia, chloro-anaemia, struma, tuberculosis, and general adynamic con- 
ditions as etiological factors in the development of acne-much stronger, by the way, than there is 
for considering the affection thus induced worthy of a special name, acne cachecticorum. Whether 
gastric disorders are really the essential causes of acne I am far from certain, but there can be no 
doubt that they exercise much influence in keeping the disease active and perhaps in causing new 
crops. Constipation has been stated as an efficient and not infrequent cause of the affection, which 
is often improved by attention to the function of the bowel. The coincidence of rebellious acne 
with uterine, ovarian, and severe menstrual disorders in older females has led to their acceptance 
by some physicians as definite etiological factors. At least it may be said that they often exercise 
a decided influence for the worse in the course of the disease, though it is far from proven that 
they gave rise to it primarily. 
It is a good rule in all cases of acne to question the patient as to his (or her) health, and to 
consider any deviations from it as possible factors in its causation or perpetuation the removal of 
which should be a part of the treatment. In like manner should all functional inactivities and 
derangements be regarded. 
Under the general head of reflex irritations, which at one time were regarded by many as the 
essential cause of acne, it is well to remember that Sherwell has stated that urethral irritation and 
inflammation may cause it, and that he has cured this disease when these troubles coexisted simply 
by the passage of sounds. 
While most of the foregoing may be considered as more or less remotely contributing causes, 
the most we can say of positive causes is that persons having thick, uneven, and often dirty-looking 
skin, with evidence of imperfect circulation and often epithelial overgrowth, are especially predis- 
posed to acne. So, also, however, are very many persons having seemingly perfect skin. Though, 
perhaps, there are more cases of the disease in blonde and not very dark-haired persons than in 
brunettes, it cannot be considered a disease peculiar to the former class, since brunettes are often 
thus affected, and even very sorely. 
Perhaps the most tangible evidence of the cause of acne is in the fact that in many, if not in 
all, instances the origin of the disease is in the minute epithelial plug which, being retained in the 
sebaceous duct, acts as a foreign body and causes inflammation of the gland proper. The pivotal 
questions are: What causes the inflammation which precedes the formation of the plug ? and why is 
it so prone to appear at certain times of life ? Heat and cold may exercise an influence on exposed 
parts. Uncleanliness would seem to be a very rational explanation of the origin of some cases, 
though it is out of the question in very many. External applications and cosmetics might reason- 
ably be supposed to be prolific causes of acne, yet among the vast number who use them how really 
few there are that are thus attacked ! The omnipotent and omnipresent microbes might also rea- 
sonably seem to be in these cases the morbific agents, and perhaps may yet be proven to bear at 
least some relation to acne. When we know really so little it may seem unkind to taunt with igno- 
rance those who think that they "know it all," but it will certainly be conceded by scientific men 
that such statements as "certain conditions may be justly charged," et cet., "the relation is espe- 
cially intimate," "such and such symptoms are not infrequent in those suffering from acne," "such 
a condition tends to produce acne," et cet.-are really the barest platitudes. 
In the so-called acne artificialis the etiological factor is usually easy to find. Preparations of 
iodine and bromine take first rank as internal agents. Tar, chrysarobin, and dyestuffs act as 
external causes, while blacksmiths, flax-spinners, and persons who work in petroleum and its 
derivatives are especially liable to acne produced by the irritant particles incident to their daily 
toil. ACNE. 
229 
Diagnosis.-In the majority of cases the configuration of the eruption, its sites, its mode of 
development, its history and course, and the age of the patient affected are so clear that a diag- 
nosis is usually easy. The acne of iodine and bromine may present some difficulties by reason 
of their possible extent, intensity, and perhaps copiousness, but the history of the case will clear 
away doubt. So will it be xyidi acne induced by external irritants. 
I hose pustular syphilides which have a sebaceous glandular origin may be mistaken for acne, 
but their tendency to become clustered about the nose, mouth, and chin and the scalp-margin, the 
coexistence of other specific lesions, and a history of syphilis, will soon determine their nature. 
Prognosis.-This must depend upon the extent and duration of the eruption, the condition 
of the patient, and the zeal with which treatment is followed. Many cases are very obstinate ; 
others yield after a diligent treatment, while some are promptly cured. 
Treatment.-As has been already incidentally remarked, all morbid conditions, diatheses, 
functional and organic diseases should receive due attention in the estimate of the case, and as 
far as possible cured or relieved. Certain writers have indulged in what may be termed hair- 
splitting over-elaboration in the recital of the occult, vague, irrelevant, and oftentimes visionary 
symptoms which they give as causes of acne. A patient with this disease should have an equal 
chance with that of one afflicted with any form of skin disease, and the more he is treated on the 
broad lines of general medicine and pathology, and the less he is suspected of mysterious diath- 
eses or blood-states, the better is it for him. Plethora and anaemia are indicative of their thera- 
peutical needs; cachexia, struma, chronic gastro-intestinal disorders, functional trouble of the 
menses, uterine and ovarian troubles, all claim the respectful attention of the physician. Care as 
to diet, habits of life, the avoidance of all excesses, all physical and mental disturbances, should be 
considered. A well-regulated hygiene should be the background of treatment. In very many 
cases an alkaline treatment is of decided benefit, for which the following mixture is to be com- 
mended : 
B. Potassae acetatis, 5j; 
Syr. zingiberis, §j; 
Aquae, ad £viij. M. 
One tablespoonful three times a day in a wineglass of water an hour after meals. 
Very often the following prescription, which I have used largely in private and public practice, 
is productive of benefit as an antacid and mild aperient: 
B. Potassae acetatis, ; 
Sodae et potassae tart., §ij; 
Syr. zingiberis, 5j; 
Aquae, ad M. 
I o be used in the same manner as the preceding. 
In addition to the alkaline treatment arsenic may be of service. It may be given in five-drop 
doses with the first prescription or in the following combination : 
B. Liq. arsen. Fowlerii, gtt. Ixxx ; 
Potassae citrat., §j; 
Syr. aurantii, 5j; 
Aquae, ad §viij. M. 
One tablespoonful three times a day half an hour after meals in a wineglass of water. 
In general terms, the alkaline diuretic effect is beneficial in cases complicated with hyperaemia. 
In the more subacute and chronic cases arsenic is frequently indicated. It must be used cautiously 
and persistently, with a view to beneficial action and the avoidance of its usual drawbacks. It must 
he stated, howrever, that in many cases it has no effect whatever. The fluid extract of ergot has 230 
DISEASES OF THE SKIN. 
been highly praised by my friend Dr. Denslow, and from it I think I have seen some benefit derived. 
Sulphide of calcium, given with the view of preventing suppuration, is one of the many drugs which 
are recommended by a few. It is at best of doubtful value, and often an unpleasant remedy for the 
stomach and bad for the breath. I have seen patients who have swallowed pounds of glycerin in 
the most approved methods of dosage, but they have kept their acne. The trouble with many 
remedies is that those who vaunt them are not always accurate and impartial observers, and they 
see in them benefits which others are unable to produce or obtain. The effects of the natural 
course of the disease, as well as those resulting from external medication, are very often not con- 
sidered as factors in these therapeutical observations. In addition to the remedies mentioned it 
may not be amiss to state that the whole therapeutic armamentarium is at the command of the 
zealous physician who has cases of acne in charge. 
The local treatment of acne carries with it the most scrupulous attention to cleanliness and 
the avoidance of all possible sources of irritation. The occurrence of the pathological plugs 
carries with it a weight of responsibility. If epithelium, dirt, and sluggish circulation cause these 
agents of inflammation, care should be exercised that the two former are not permitted to form, 
and that the latter should receive appropriate care. 
The parts should be carefully washed and protected, using bland soaps or the simple tincture 
of green soap. As a prophylactic the parts may be bathed with a solution of the bichloride of 
mercury (i : 2000-5000) once or twice a day after washing. 
To cause absorption of acne-nodules and relief of hyperaemia sopping the face with very hot 
water once or twice a day is often of much benefit. To the water may be added a little powdered 
borax. A soft linen pad is the best agent of application, and each spot should be cared for by 
dipping the pad in the hot water and then applying it to the skin quite firmly for several minutes. 
Soap frictions in combination with hot-water soppings are means of much value in the treatment 
of acne. As local applications there is a vast array of lotions and ointments. It is with acne as 
with all diseases difficult to cure, the most varied and the most comprehensive armamentarium is 
formed. 
In simple papular acne the following lotions may be used: 
B. Sulphuris loti, giij; 
Spts. camphorse, 3iij; 
Sodae biborat., 3j ; ( 
Glycerinae, §ss; 
Aq. rosae, ad §iv. M. 
B. Hyd. bichloridi, gr. ij-iv; 
Ammon, muriat., gr. iij-vj ;• 
Aquae coloniensis, gij; 
Aqtiae, ad giv. M. 
Where there is concomitant hyperaemia, or where soap frictions and hot-water applications 
cause suffusion of the face, the following lotions are serviceable : 
B. Calaminae, ; 
Acid, hydrocyan, dil., 
Aquae, giv. M. 
B. Bismuth, subnit., 3'd ; 
Spts. cam ph., gij; 
Aquae, §iv. M. 
B. Zinci oxidi, giij; 
Aq. laurocerasi, §iv. M. ACNE. 
231 
All of these lotions should, after brisk agitation, be sopped on the parts. 
Sulphuret of potassium is sometimes beneficial, though its odor is extremely unpleasant. It 
may be used as a lotion as follows : 
B. Potassii sulphuret., jj; 
Spts. cam ph., gij; 
Aquae, §iv. M. 
An ointment of the strength of a drachm to the ounce may also be of benefit. 
Other ointments may be mentioned as worthy of trial: 
B. Sulphuris loti, gj; 
Pulv. camph., gr. x; 
Ung. aq. rosae, M. 
B. Hydrarg. precip. rub., gr. vj-x; 
Spts. camphorae, gss; 
Vaseline. 5j. M. 
B. Hydrarg. precip. alb., gr. x; 
Bals. Peru., 5j; 
Vaseline, §j. M. 
B. Hydrarg. bichloridi., gr. j ; 
Acid, carbol., gr. x-xvj; 
Ung. aq. rosae, gj. M. 
B. Zinci iodidi, gr. vj; 
Vaseline, §j. M. 
B. Sulphuris iodidi, gr. v-viij; 
Vaseline, 5j. M. 
Chrysarobin is occasionally found to be beneficial in causing the absorption ot acne lesions. 
It should not be used (at least at first) in stronger proportion than three grains to the ounce of 
ointment, and care should be taken to avoid the eyes. 
Mechanical treatment, though mentioned rather late, is of prime importance in the treat- 
ment of acne. All comedones should be thoroughly evacuated by means of a watch-key pressed 
firmly and vertically down over their apices or by Piffard's, Clover's, or I?ox's evacuators. As 
soon as pustulation is noticed the lesions should be punctured well down into their substance 
with a small bistoury or with a Kaposi's acne-lancet. Indeed, where the lesions are of firm 
structure or accompanied by hyperaemia, much good is done by quite deep vertical incisions. 
When the lesions are very numerous much benefit often results from careful but efficient 
curetting. 
Acne indurata is oftentimes most rebellious, and requires active measures. Each nodule may 
be very carefully touched with equal parts of carbolic acid and glycerin, with a solution of the acid 
nitrate of mercury (i : 4 of water), or even with cantharidal collodion, care always being taken to 
prevent inflammatory reaction. The following compound may also be used, as advised by Fox: 
B. Chrysarobin, 3ss; 
Acid, salicylic., ,"j; 
Collodion flex., 5j. M. 
Each lesion should be carefully painted as often as the film left by the liquid is cast off. DISEASES OF THE SKIN. 
232 
Moderate stimulation may be applied to indolent lesions by the following, which must be care- 
fully handled : 
B. Potassse fusae, gr. x; 
Thymol., gr. xx; 
Glycerinae, jij; 
Aquae, §iv. M. 
Resorcin in ointment-form of a strength of ten to thirty grains and upward to the ounce may 
sometimes be of marked benefit. 
Unna speaks highly of the following prescriptions: 
B. Ung. zinci oxid., 5ij+3v'jl 
Sulphur, praecip., giiss; 
Terrae siliciae, 5j. M. intime. 
Sig. sulphur paste. 
This should be smeared on the skin at night, and washed off in the morning, when the parts may 
be lightly covered with the following: 
B. Resorcin, gr. xxx-lxxv; 
Glycerinae, gtt. xv; 
Aq. flor, aurantii, £v ; 
Alcohol, 5ij+5iv. M. 
Or the following may be used : 
B. Ung. zinci oxid., 5>j+5v> 
Resorcin, 
French chalk, da. giiss. M. 
To be applied at night, and the next day the following may be used lightly on the face : 
B. Hydrarg. bichloridi, gr. j-ij; 
Glycerinae, gtt. xv; 
Aq. flor, aurantii, gv; 
Alcohol, M. 
Unna further makes a strong claim for the value of ichthyol in acne. His prescriptions are: 
B. Ammon, sulfo-ichthyolici, gr. xlv ; 
Aquae destillat., 
Glycerinae, 
Dextrini, dd. 51'iss. M. with gentle heat. 
To be smeared on the skin at night, and during the day a mild bichloride-of-mercury lotion should 
be applied. 
The following he calls ichthyol-sublimate paste : 
B. Ung. zinci oxidi, jv ; 
Boli albae, 
Acidi sulfo-ichthyolici, da. gr. Ixxv ; 
Hydrargyri bichloridi, gr. j. M. 
To be applied at night, and washed off in the morning with ichthyol soap. 
For obvious reasons, applications must be made mostly at night and discontinued during the 
day. It is well, therefore, that such care be taken of the skin during the daytime as will prevent a 
condition of tension and dryness or of irritation, for which purpose a thin film of zinc ointment is 
often very good. PSORIASIS. 
Psoriasis is a chronic inflammatory affection of the skin manifesting itself by circumscribed, 
thickened, reddened, somewhat elevated patches, covered with adherent scales. It is essentially 
a dry affection, presenting in the main a remarkable uniformity of type-form. It varies very much 
m the extent of development, its lesions being in some cases very sparse and in others very copi- 
ous, with intermediate degrees. It is, in general, an affection of slow evolution, but exceptionally 
it appears with much rapidity. In some cases the rapid development of the first crop of lesions is 
followed by subsequent slowly-appearing ones. Its distribution in its early stages is always sym- 
metrical, but sparse and unsymmetrical patches may appear later on. Its sites of election are in 
general those parts where the epidermis is thick, such as the extensor surfaces. It shows a predi- 
lection for the apices of the elbows and knees and continuous surfaces. It is also found upon the 
scalp and the trunk, particularly upon the back. In some cases the elbows and forearms are 
involved, together with the knees and legs. It is rather rare, however, to see it on the lower 
extremities while the upper ones remain free. The palms and the soles are not infrequently 
attacked, and in some cases the nails are involved, as a rule by extension of the affection from the 
fingers. 
In cases of extensive eruption the flexor surfaces are also involved, but the patches on them 
are less markedly scaly. As a rule, the development of scales in psoriasis depends on the thick- 
ness of the epithelium of the parts attacked. There is usually less epidermal overgrowth in chil- 
dren and females than in adult males. 
The mucous membranes in psoriasis are unaffected. The extent of skin involved varies in 
different cases and according to the chronicity of the affection. In its characteristic form the erup- 
tion consists of small or large patches scattered more or less copiously over the body, which by 
their increase may be quite extensively covered. Universal psoriasis is not seen in this country. 
It is in no sense a contagious affection, though there is abundant evidence that it frequently 
results from hereditary transmission. Though psoriasis has frequently been observed in patients 
whose parents had more or less remotely suffered from syphilis, there are really no data upon 
which to found a claim of causal relationship. 
Psoriasis begins as small red spots, in greater or less number, at the orifices of follicles, sudor- 
iparous, hair, or sebaceous, which are soon covered with a thin silvery scale, or it may first show 
itself as pinhead-sized, thin, slightly adherent scales which cover red spots. In this stage the 
affection is called psoriasis punctata. 
Either slowly or quite rapidly these punctae increase in area to the size of a split pea, when, 
from the resemblance of the lesions to drops of mortar, it is called psoriasis guttata. By still fur- 
ther peripheral growth, disks, mostly of round, oval, or even irregular outline, of one or two inches 
in diameter, are formed, which give the name of psoriasis nummularis (Lat. numma, coin) to the 
eruption. By the growth of these patches, and by their consequent fusion, large extents of surface 
become involved, to which the term psoriasis diffusa is given. The latter form, when very obsti- 
nate to treatment, is called psoriasis inveterata. McCall Anderson first described a peculiar feature 
233 234 
DISEASES OF THE SKIN. 
of psoriasis in the stage between psoriasis guttata and nummularis which he terms psoriasis rupi- 
oides, in which the accumulation of epidermis is unusually great, so that many of the patches become 
covered with conical crusts marked by concentric rings resembling limpet-shells, and possessing a 
likeness (but no relation, however) to rupia. 
The commencing lesion in psoriasis is a pinkish-red point at a follicular orifice, which is 
scarcely if at all raised above the normal level of the skin. As the peripheral growth increases 
elevation of a moderate degree is seen in the patches, which are very aptly described by Radcliffe 
Crocker as slightly-raised plateaus of skin covered with lamellar scales. The patches or disks of 
psoriasis are sharply marginated, each one, as a rule, jutting up abruptly and vertically from the 
skin surface. They are generally surrounded by a thin red areola. Their surfaces are more or 
less abundantly covered with whitish, silvery-white, or grayish-white, glistening, imbricated scales. 
The white color is said to be due to the presence of air between the scales, the roughened surface 
of which is a ready nidus for dirt, by which the color of the patch may be much modified. Removal 
of a scale-crust reveals a reddened surface dotted over with minute bleeding points, the apices of 
enlarged papillae. 
As the patches grow in area their color usually changes from the original rosy pink to a red, 
which may be bright or of a dull brownish hue. As a rule, psoriasis on the legs is darker in color 
than it is on the upper extremities. 
With the growth of the patches a decided thickening in the texture of the skin takes place, 
which is the result of inflammation consecutive to the psoriatic process. This infiltration may exist 
in varying degrees about the body, being particularly well marked on the lower extremities, and on 
the upper ones where the epidermis is thick ; in fact, on any part where the affection has been 
intense and chronic. The loss of elasticity of the skin consequent upon this infiltrated condition 
is sometimes very troublesome. 
In somewhat rare cases spontaneous involution takes place in psoriasis, in which event the 
epidermal increase ceases, the scale crusts become smaller and less adherent, and then fall off, 
leaving a reddened surface which loses its elevation, and, after a period of fine desquamation, 
becomes normal. 
In the usual course of the disease, when a patch reaches a diameter of an inch or a little more, 
involution begins in its centre, which sinks down, becomes less and less scaly, until a morbid ring 
is left, enclosing more or less healthy skin. This has been called psoriasis circinata, p. annulata, 
and p. orbicularis. It not infrequently happens that coincidently with this central involution of the 
disease it becomes active in its ringed shape. The scaly rings increase in size, while the enclosed 
skin keeps pace in healing. As the rings grow larger they often fuse together and form patches 
with a festooned outline or figure-of-eight shape, and in some cases, owing to healing in one por- 
tion of the ring, segments of circles are left. The width of the morbid rings is subject to much 
variation, being sometimes seen in a marked degree, and again in the shape of wavy lines. It is 
not at all uncommon to see this form, psoriasis gyrata, coexist with diffuse patches. Where the 
latter are present, involution usually begins in their centre in one or more spots, and spreads 
peripherally until the affection is effaced. 
In Plate XXIX. psoriasis is portrayed in a very graphic manner. The intensity of the erup- 
tion is centred at its favorite region, the elbow, from which it has extended up and down the arm, 
while it also involves the anterior and lateral portions of the chest. Upon the arms the masses of 
grayish-white imbricated scales are very prominent, and it is seen that the tendency of the patches 
is to coalesce without having undergone central retrogression. An exuberance of epidermal 
growth indicates activity of inflammation, which precludes central involution. Upon the chest- 
walls the scaliness is much less marked, for the reason that there the epidermis is thin. On the 
infraclavicular region the red raw spots reveal the sites of removed scale-crusts. Part IV 
PSORIASIS 
LEA BROTHERS & CO - PUB LIS HE RS . PHILADELPHIA 
Plate XXIX PSORIASIS. 
235 
A very characteristic picture of psoriasis is given in Fig. i, Plate XXX., though less pro- 
nounced than that of Plate XXIX. The most striking feature is the diffuse scaling patch on the 
forearm, made up of little clusters of very white, thin, adherent scales. On the arm and upper 
forearm the psoriasis rings are of characteristic appearance, while on the back of the hand and on 
the arm are a number of spots which are termed psoriasis guttata. Thus in Plate XXIX. psoriasis 
nummularis is clearly shown, and in Plate XXX. psoriasis guttata, circinata, and diffusa are por- 
trayed. In Plate XXIX. the deep dull-red color of 
the eruption so often seen is well shown, whereas in 
Fig. i, Plate XXX., the not uncommon rosy-pink 
background is very striking. The conical scale-crusts 
resembling limpet-shells found in psoriasis rupioides 
are well delineated in wood-cut Fig. 25. 
Psoriasis of the palms and soles may be patchy 
or diffuse. It may involve the palm or the sole in a 
uniform manner, as shown in Fig. 2, Plate XXX., in 
which there is considerable uniformity in the amount 
of scaling, or in a localized and patchy manner, as is 
represented in wood-cut Fig. 26. It may again ap- 
pear on these parts in the guttate form, sparsely scat- 
tered. Psoriasis on the hands and feet, elbows and 
knees, is, owing to their movement, often accompa- 
nied with painful fissures. 
The nails of the fingers and toes may be affected 
in psoriasis, usually by extension of the affection from the hands or the feet. One or more, and 
even all, of these appendages may be thus attacked. The nail loses its natural polish and becomes 
dry and rough, thickened, opaque, of brownish tint, and very brittle, especially on the free ends. 
Fig. 25. 
Psoriasis Rupioides. 
Fig. 26. 
Psoriasis of Palm. 
Longitudinal and transverse furrows, as shown in wood-cut Fig. 27, may form on them and 
harbor dirt, which adds to the disfigurement. Again, in some cases the whole structure of the nail 
ls lost in a rough, gnarled, hillocky, and unsightly surface, as is shown in wood-cut Fig. 28. 
Psoriasis of the palms and soles is very persistent, and may linger long after the affection has 
disappeared from other parts. Psoriasis of the nails is little less than a calamity to those who 
suffer from it. If under constant care these appendages are finally brought back to a state bor- 236 
DISEASES OF THE SKIN. 
dering on health, they are for a long time imperfect and functionless. In bad and neglected cases 
unsightly and permanent deformities result. 
Psoriasis of the scalp is usually of the diffuse form, and shows itself by hyperaemia of the skin, 
upon which are seated more or less adherent, thin, light-brown or dirty-white crusts. As a rule, 
there is not much concomitant fall of hair. 
Psoriasis very uncommonly attacks the face, and very rarely in a diffuse manner. The ears, 
however, are sometimes affected, even deeply in the 
auditory meatus, when deafness may result from the 
accumulation of scales. 
Though a wealth of Latin terms has been ex- 
pended upon psoriasis, it must be remembered that 
there is really but one disease. The adjectives punc- 
tata, guttata, nummularis, annulata, diffusa, and gy- 
rata have been handed down from our forefathers in 
dermatology, and because they are expressive of 
stages of development of the disease, and are not, 
like many dermatological terms, more or less mislead- 
ing and superfluous, we retain them as aids to precise 
expression. 
The evolution of psoriasis, as a rule, is wholly 
unattended with any general or systemic reaction, 
fever, malaise, or pain. It is in no sense an itching 
affection, like eczema. At its inception there may be 
very often a little heat and pruritus observed, partic- 
ularly in warm weather or when the circulation is 
accelerated. In exceptional cases of severe and acute invasion, where there is much heat, redness, 
and swelling, the itching and burning may be severe. When, however, the disease subsides into 
its accustomed chronic course, it becomes aphlegmasic and is borne by its sufferers with remark- 
Fig. 27. 
Psoriasis of Nails. 
Fig. 28. 
Psoriasis of Nails and of Dorsum of Hand. 
able equanimity. New crops may be attended with some pruritus, which may appear at any time, 
due to plethora or to gastric irritation. Fissures about joints and in lines of motion are often very 
painful, particularly on the hands and feet and behind the cars. Plate XXX 
Fig.l. 
7, Psoriasis of Arm . 2. Psoriasis of Palm 
2. 
LEA BROTHERS & CO. PUBLISHERS . PHILADELPHIA . 
Dart IV PSORIASIS. 
237 
The course of psoriasis is, as already stated, very chronic, occupying sometimes months, and 
even years. It has periods of quiescence and of spontaneous involution, of exacerbations of 
greater or less extent and intensity, and of remissions. It may attack the patient once or twice 
a year, usually in the spring and fall, or its appearance may occur at varying intervals of one or 
more years. 
Psoriasis usually begins from the tenth or twelfth year up to the thirtieth. It is occasionally 
seen in young children, even under two years of age, and it is rather exceptional to see its first 
development after the fortieth year. 
Chronic psoriasis of extensive form in persons addicted to alcoholic excesses, and in those 
afflicted with gout, sometimes becomes so intense that it loses its characteristic physiognomy and 
comes to look like pityriasis rubra or dermatitis exfoliativa. 
After its disappearance psoriasis may leave pigmented and pigmentless spots, though in most 
cases no disturbance in the color of the skin is produced by it. Upon the trunk and arms whitish 
patches of a transitory character are sometimes seen, while upon the legs brown discolorations are 
not very uncommon. An interesting case has been reported by Dr. J. C. White of verrucous 
growths following psoriasis, which later on became the seat of epithelioma. 
Etiology.-Our knowledge of the causes of psoriasis is not at all precise, though we do 
know, from the fact that it arises under so many different conditions, that there is no underlying 
psoriatic diathesis. There is a striking unanimity of opinion among authors in considering hered- 
ity as the primordial cause, though in many cases this possible factor is difficult to prove. So 
many well-attested cases, however, have occurred of seeming hereditary transmission that the 
inference is warranted that the structural defects of the skin peculiar to the disease may be thus 
handed down. We observe this inheritance in children from parents and grandparents, and in 
those whose uncles and aunts are similarly afflicted. One or more members of a family may thus 
suffer, and usually there is no apparent reason why some of the family possess an immunity to it. 
The dictum of Hebra, that psoriasis is a disease of the healthy, is in a great measure true. 
The majority of psoriatic patients seem otherwise in perfect health, as is often conceded by those 
who see a diathesis in every case of skin disease. On the other hand, we do see the disease in 
persons whose health is below par, and again we observe its evolution brought out or favored by 
ill health. 
In those exceptional cases in which the disease appears within a few years after birth it is very 
often impossible to fix upon a rational etiological factor ; and the same may be said of many cases 
in which the evolution is before or about puberty. In these classes of cases vaccination, the exan- 
themata, and any conditions producing pronounced and generalized cutaneous hyperaemia may, 
and often do, call forth an attack of psoriasis. Later in life we admit at least as predisposing 
factors in the disease mental emotion, impoverishment of the system, and what may be compre- 
hensively termed the " gouty state." In most of these cases it is very probable that a condition 
of psoriasis recognized, or unrecognized by reason of its limited and undeveloped character, was 
the leaven upon which these influences acted. It is very doubtful whether a case of psoriasis is 
thus developed de novo. 
Abnormal mental conditions, such as anxiety, worry, grief, and fear, may act as predisposing 
causes. Pregnancy, and especially lactation, have been noted by many to bring out an attack of 
psoriasis. Anaemia-in fact, all adynamic states-may also be placed in this category. 1 he gouty 
vice, with its allied rheumatic state, and the condition of suboxidation are beyond doubt very often, 
in persons of middle age, potent excitants of a dormant psoriasis. I can hardly look upon them 
as essential causes. 
In some cases the seasons, particularly spring and fall, seem to have an influence on the devefi 
opment of psoriasis. 238 
DISEASES OF THE SKIN. 
Gower states that in three cases of epilepsy treated by powdered borax he saw psoriasis 
develop. Lang, supported by Wolff and Weyl, unhesitatingly ascribes the origin of the disease 
to a micro-organism, and Lassar claims that he produced a similar disease in rabbits by inoculation 
with the detritus taken from a psoriatic man. 
Prognosis.-My studies have convinced me that the dictum "once psoriatic, always so," is 
far too dogmatic. In proportion as psoriasis is treated early and effectively, so 'does the skin lose 
its tendency to its peculiar morbid changes. I have seen so many cases of children and young 
persons who have been quickly relieved of their early outbreaks, and have then ceased to suffer 
from this disease, that I am convinced that its inveterate character in most cases is due to the bad 
tendency engrafted upon the skin by profound and prolonged attacks in early life. 
Even in inveterate psoriasis there is seldom any impairment of the health. Such patients 
look well, and, .in spite of the extent of skin covered with thickened scaly patches, seem well, and 
make no complaint except of their cutaneous trouble. 
We are frequently asked of the propriety of marriage for males and females suffering from 
psoriasis, and of its bearing upon the offspring. A subject having oft-repeated and extensive 
eruptions, particularly if they are of hereditary origin and of very early appearance, will in all 
probability give birth to children similarly affected. When, however, the attack or attacks are 
mild and of not frequent recurrence, and where the hereditary taint is not well marked, there are 
chances of the escape of the offspring. In no case can it be positively predicted that hereditary 
transmission will occur. 
Diagnosis.-As a rule, there is no difficulty in the diagnosis of psoriasis, but in certain condi- 
tions of its lesions and in certain localities it may resemble scaling eczema, scaling papular and 
tubercular syphilides, lichen planus, ringworm, seborrhoeal eczema, and lupus erythematosus. 
Scaling eczema may resemble psoriasis about the head, and when in marginate patches about 
the body. It is never as scaly as psoriasis, nor are its scales as bright and pearly; it is much more 
itchy, very often moist, at least at times has a tendency to multiformity of lesions, and very often a 
characteristic history. It is usually less sharply marginated and generally much more infiltrated. 
The clinical history of the scaling papular and tubercular syphilides has already been given, 
with pictures of them, the remembrance of which will usually be sufficient for the reader. In 
some cases, however, grave doubts may exist as to the syphilitic or non-syphilitic nature of a 
given scaling eruption. In such cases their history must be carefully probed, and evidence of 
other syphilitic lesions, present and past, must be looked for. Failing a history of syphilis, the 
inference is that the case is one of psoriasis. The early evolution of the latter disease, its recur- 
rence always in the same form, a history of its heredity, and its subacute inflammatory nature, are 
points to be considered. 
Lichen planus has such a marked individuality that it will rarely be mistaken for psoriasis, 
except where its papules are large and very scaly or where they have (very exceptionally indeed) 
fused together (wrists, abdomen, and legs) into patches which have become covered with horny 
scales. In such cases examination elsewhere on the body will, as a very general rule, reveal pap- 
ules of all sizes, round, angular, star-shaped, slightly scaly, and deep-red or violaceous in color, 
which show no tendency to spread into patches, which is the usual outcome of psoriatic lesions. 
Ringworm is usually less inflammatory than psoriasis, never so characteristically scaly, and 
shows no predilection for the elbows, knees, palms, and soles, but always involves the hair in mal- 
nutrition. Its scales are contagious by inoculation, those of psoriasis are not. 
Seborrhoeal eczema is commonly found upon the scalp and on the face, particularly where the 
sebaceous follicles are numerous and large-localities which are not very commonly attacked by 
psoriasis. Then, again, the sternal and interscapular regions are frequently invaded, as well as 
other portions of the body. The patches of this disease are different from psoriasis ; they are PSOL/AS/S. 
239 
usually not large, round, oval, irregular, bow-shaped, and serpentine. They are of a yellowish-red 
rather than of a deep tint, are less infiltrated, much less scaly, and the scales are thin, flaky, and 
not very adherent. Like psoriasis, however, seborrhoeal eczema sometimes clears up in the centre 
and spreads at the periphery. 
Lupus erythematosus is so constantly localized on the face, is as a rule a chronic affection of 
slow course, presenting crescentic patches covered with small adherent yellow scales and follicular 
epidermal plugs, that it can hardly be mistaken for psoriasis by any one even of limited experience. 
Treatment.-It must be confessed that the internal treatment of psoriasis is based largely upon 
empirical considerations. In those cases in which, owing to the youth of the patient, no underlying 
morbid state is discoverable, it is well to use arsenic, since it is the one remedy which very often 
produces marked effects in this disease. Even in the traditional healthy psoriatic patient this rem- 
edy should always be used, provided the hyperaemia of the patches is not great. Its chief benefit 
is seen in those cases in which the patches are of a pink or rosy-pink color, and it is often of posi- 
tive harm in cases of very deep-colored lesions. 1 he general rules for the use of the drug should 
be followed. The age of the patient, the idiosyncrasies, state of the stomach and bowels, should 
all be considered. Beginning with a moderately full dose, the remedy should be held well in hand 
and increased, diminished, or suspended according to indications. To obtain its therapeutic effects 
arsenic must, as a rule, be pushed to a condition of tolerance. 1 his being induced, if the outcome 
looks hopeful its use may be continued ; if not, it must be abandoned. 
In many cases, particularly of the gouty kind, alkalies are very beneficial. They act by their 
antacid effect, their renal stimulation, and by reducing cutaneous hyperaemia. They should always 
be remembered in middle-aged and old subjects, and may often be combined with arsenic to the 
advantage of the patient. Not infrequently the mixture of acetate of potassa and Rochelle salt 
(see sections on Eczema and Acne) will be found useful. 
Gouty and rheumatic subjects, as well as those who suffer from suboxidation, should receive 
careful directions as to diet, avoidance of alcoholics, and all conditions which tend to produce a 
crisis in their system. By this means much relief may be obtained and relapses delayed or pre- 
vented. 
All psoriatic persons suffering from any source of debility should, by means of therapeutics 
and careful hygiene, be put upon, as near as possible, a plane of health. Each case should be care- 
fully analyzed and all deviations from the normal standard of health should be promptly corrected. 
Carbolic acid, administered in one-half and one-grain doses three or four times a day, has been 
beneficial in Kaposi's practice. Chrysarobin in doses beginning with one-sixth of a grain and 
increased to (where tolerated) one grain, three times a day, given in powder or pill form, has been 
recommended by Napier. Haslund, Greve, and Boeck of Denmark and Norway claim excellent 
results from the use of good-sized doses of iodide of potassium. I have used it according to their 
methods without the slightest result other than diuresis. 
Cod-liver oil, preparations of iron, syrups of the hypophosphites, and phosphorous compounds 
may be very useful in cases where they are indicated. 
Local Treatment.-The rationale of the local treatment of psoriasis is, after the partial or 
complete removal of the scales, to produce a decided stimulation of the morbid areas, while we 
carefully avoid causing inflammation of the skin. A large number of remedies are beneficial to 
this end, though they are by no means specifics. In the use of these agents the physician must 
combine energy with caution, and he should never order very active stimulation until he is certain 
that the patient can rest long enough for reaction to occur. then, again, the nature of the parts 
to be stimulated should be taken into consideration, and especial caution exercised about the head, 
face, and neck, about parts related to lymphatic ganglia, the feet and hands, and the region of joints, 
elbows and knees especially. The vast majority of psoriatics are ambulant patients, whose duties 240 
DISEASES OF THE SKIN. 
and necessities preclude the possibility of laying up, hence the directions for treatment should be 
in accord with the requirements of their daily life. Then, again, the age, sex, constitutional pecu- 
liarities, delicacy of skin, tendency to dermal inflammation, and the inveterate or mild nature of the 
eruption should be duly considered, and the activity of treatment correspondingly adapted. The 
methods of application and all necessary precautions concerning the use of remedies must be fully 
explained to the patient and the object to be attained clearly brought to his mind. 
The first necessity in treatment is the removal of the scales, which act as barriers to any appli- 
cation. The simplest means of doing this is by the warm alkaline bath (sal soda or borax, i to 2 
pounds ; water, 30 galls., ioo°-i io° Fahr.), prolonged for half an hour, or if necessary much longer. 
When the scales are very thick and adherent brisk inunctions of olive oil or liquid vaseline before 
the bath are often very efficacious, or soap inunctions may be previously employed. For this pur- 
pose the green soap is excellent. It should be rubbed well and liberally into the whole surface, 
and then followed by the bath. Afterward the medicated application may be used. Wet packing 
for very extensive cases is very excellent if well done. Turkish baths also may be used, omitting 
the cold plunge wind-up. Sulphur waters, natural and artificial, and thermal waters generally, have 
no particular effect, and certainly no greater benefit than hot alkaline water. Local maceration 
may be accomplished by swathing the parts in wet linen and then covering them well with oil silk 
or gutta-percha tissue. On limited spaces, all things being propitious, plasters of green soap may 
be allowed to remain one or more hours, and their macerating powers may be much enhanced by 
laying over them a wet towel and over that a thickness of oil silk or gutta-percha tissue. The 
tincture saponis kalinus (see Treatment of Eczema) is a remedy of very extended application in 
this preparatory treatment. In some cases scouring the parts with sand- or pumice-stone soap by 
means of a flannel pad with quite firm and vigorous friction is productive of good. In all cases it 
is well to avoid making the skin too raw, since it will then ill bear further stimulation. 
After active treatment at night it is well to lubricate the parts during the day with a small 
quantity of some bland oil or ointment, otherwise tightness and tension of the skin may be com- 
plained of and fissures may be produced. The various agents will now be considered seriatim. 
Tarry preparations have taken-and will, in spite of their odor, hold-the front rank in the list 
of local remedies for psoriasis. New remedies which are to supplant them come and oftentimes 
go, but they stay. The simplest tarry preparation is the tar ointment, which is often very efficient. 
Then there are the oil of cade and the oil of white birch, both of which are most valuable agents. 
Oil of cade (ol. cadini) and olive oil or liquid vaseline in equal parts or even more diluted will 
often be found of great service. Like all tarry preparations, this one should be well rubbed into 
the skin by means of an appropriately stiff brush or a flannel pad. In general, once or twice a 
day is sufficient for these frictions. Oil of white birch (ol. betulae albae vel ol. rusci) is thought by 
some to be more active than the oil of cade. Like the latter, it may be used in its purity in severe 
cases, but is best used in combination with a bland oil. The compound tincture of green soap 
(green soap, oil of cade, and alcohol equal parts, with a few drops of oil of lavender) is a most excel- 
lent preparation for large and small patches of psoriasis. It may be rubbed into the skin on going 
to bed, after a hot alkaline bath, due precaution being taken for the spotless bed-linen. Ordinary 
soap-and-water bathing is required in the morning, or the tinctura saponis kalinus, followed by a 
zephyr-like application of sweet oil or vaseline, may be used. My friend Dr. F. B. Greenough 
recommends the following excellent combination for private practice: 
B. Ol. cadini, 
Glycerinae, 
Alcohol, da. 5j. 
In using tar in any form on extensive surfaces a strict lookout must be kept for its possible PS0PP4SIS. 
241 
toxic effects, cerebral, gastric, and urinary. Dermatitis of all degrees may be produced by it, and 
when used on surfaces rich in hair- and sebaceous follicles a troublesome tar acne may be induced. 
Such accidents call for the suspension of the use of the drug. 
Mercurial ointments, composed of the white precipitate, the red precipitate, and the yellow 
oxide, are often of much benefit in limited and not pronounced cases. These drugs may be used 
in the proportion of one scruple to thirty-grains-to-the-ounce-of ointment basis for adults, and in 
smaller quantity for children and women. 1 hey may often with benefit be combined with a tarry 
oil. Citrine ointment and blue ointment appropriately diluted may also be used. 
Rochard's ointment is a decided stimulant, and deserves a place in dermatology. Its formula 
is- 
R. lodini, gr. vij; 
Calomel, 9j; 
Ung. simpl., §ij. M. intime. 
Chrysarobin was once thought to be an agent which would replace the tars, but it has not 
done so. It is, however, a very efficient remedy within certain limitations. It must always be 
used in the most circumspect manner, since even when used in mild degree it is liable to produce 
severe dermatitis. Then, again, it badly discolors the hair and the nails, and permanently ruins 
the patient's linen. When used about the face it bestows a complexion of an Indian upon its 
employer, and is prone to produce a low grade of persistent conjunctivitis. It may be employed 
as an ointment, at first of very mild strength (5 or 10 grains to the ounce of fatty base), and it 
will rarely be necessary to use it stronger than one drachm to the*ounce, and then always with 
caution, by reason of fear of dermatitis. It very curiously leaves the morbid patches much whiter 
than usual, while the surrounding healthy areas are more or less pigmented. It may be used on 
localized patches, but not over joints, in combination with salicylic acid and collodion (see p. 231) 
or traumaticin. 
Pyrogallol is of benefit in some cases of sparse nummular psoriasis. I have for years occa- 
sionally used it in combination with collodion and traumaticin (sj to ,sj) with satisfactory results. 
In some cases the addition of one-half or an equal quantity of salicylic acid has aided in the prompt 
involution of the patches. Its use in the form of ointment is contraindicated by its disfiguring 
discolorations and by reason of the danger of its absorption and the occurrence of grave £oxic 
disturbances. 
Salicylic acid is beneficial in those cases where there is such a tendency to hyperaemia that 
much headway is not made by the traditional stimulating agents. It is best used in combination 
with diachylon ointment (3ss-3j to §j). (See Treatment of Eczema.) Klotz's salicylated plaster 
and Unna's salicylic muslin plaster should be borne in mind in this connection. 
Sulphur ointments, particularly in cases where the scaling is not profuse and the skin-infiltra- 
tion well marked, are very often most gratifying applications, used in the proportion of one or two 
drachms to the ounce of ointment. I he old-time Vleminckz's solution is deserving of a place in 
our memory, since it may very often be used in hospital practice with very good results. Its 
formula is as follows: 
R. Calcis vivae, Sxvj; 
Sulphur, £xxxij; 
Water, lb. xx. M. and boil to 12 pounds. 
It may be used in full strength or diluted, but always with a view to possible dermatitis. A paste 
of equal parts of sulphur and tar is sometimes very efficient. 
Wilkinson's ointment in the following modified formula may be found useful: 242 
DISEASES OF THE SKIN. 
B. Sulphuris sublimatis, 
01. cadini, ad. giv; 
Saponis viridis, 
Vaseline, dd. §j; 
Cretae praecip., giiss; 
01. lavandulae, jss. M. 
It should be spread on lint and retained with a roller bandage. 
Naphthol (3ss-sij to sj ung.) has been highly praised by Kaposi, who once regarded it as the 
successor to the tars. It has not proved to be an eminently efficient agent in the hands of others. 
Thymol is much thought of by Radcliffe Crocker in the ointment form (gr. xv-siij to 3j), and 
may be found useful in the mild and sparse class of cases. 
Acetum cantharidis is capable of limited application in cases where a not large amount of 
surface is involved. 
Anthrarobin, recently introduced by Lieberman as a substitute for chrysarobin and pyrogallol 
because of its deoxidizing powers, is a yellowish-white granular powder, slightly soluble in chlo- 
roform and ether, and readily so in alcohol and alkaline solutions. Behrend claims good results 
from its use in psoriasis. In the wards of Charity Hospital it has been used by Bronson during 
the past few months in a io per cent, ointment or vaseline. In eight cases of extensive psoriasis 
apparent cure was produced in about a month, though in one case a slight relapse was noted. 
Bronson found that the staining produced by anthrarobin was deeper than that of chrysarobin, but 
he did not observe that marked tendency to its diffusion upon the surrounding parts inevitable to 
the use of the latter. Little or no irritation is caused by a io per cent, ointment, but one of 20 per 
cent, caused a slight smarting sensation. It was not found to possess antipruritic properties. Both 
Bronson and Morrow 1 expressed themselves in a guarded manner as to the action of the drug, 
which they consider to be limited and localized, and not essentially different from that of others 
of its class. 
1 Transactions of the American Dermatological Association, Sept., 1888. FAVUS (TINEA FAVOSA). 
Favus, also called tinea favosa, belongs to a class of skin diseases caused by vegetable para- 
sites, which also includes tinea tricophytina and tinea versicolor. These diseases are peculiar in 
the fact that no doubt exists as to their cause. 
Favus is a contagious disease manifesting itself upon the scalp, the integument, and in the 
nails by cup-shaped yellow and greenish-yellow crusts, which are composed of a microscopic fungus 
and epithelial cells. It is not a common disease in America, but is frequently met with in some 
parts of Europe. 
In the majority of cases favus begins on the scalp, and there presents a very characteristic 
clinical history. 
Favus of the scalp usually begins in a very insignificant manner, and in most cases has become 
quite firmly fixed before it is recognized and brought to the notice of the physician. It begins in 
one or several spots, grouped or scattered, and at first looks like little yellow flat papules seated 
around hairs, sometimes presenting a strong resemblance to pustules. At this early stage each 
spot may be surrounded by a disk-like areola of red and scaly skin. From this 
speck-like lesion the favus cup, scutula, or godet is formed, and a conglomera- 
tion of these cups composes the eruption. The mechanism of a favus cup is 
as follows : The fungus lodges in the orifice of the hair-follicle, and then devel- 
ops around the shaft of the hair beneath the epidermis. In this funnel-shaped 
depression there is not a very favorable chance for exuberant growth, for the 
reason that here the epidermis is well bound down. The fungus therefore infil- 
trates the hair-shaft and grows downward in its follicle, as is shown in wood-cut 
Fig. 29. It thus results that there is not a conical uplifting of the epidermis. 
Owing to its exuberance of growth the parasite rapidly increases in a centrif- 
ugal manner. Around the original point of contagion it increases in ringed 
shape in the meshes of the superficial epidermis. At the orifice of the fol- 
licle, the epidermis being firmly bound down, the fungus cannot push it up, but 
with each stage of its peripheral growth it increases in quantity by concentric 
layers, while the centre remains firmly fastened. Thus it is that in the end we 
find the peculiar cup-shaped crusts, which may be as large as split peas or as 
silver five-cent pieces. The cup shape of the lesion therefore depends on the 
resistance of the tissues at its centre and the soft yielding character of the epi- 
thelial cells beyond. In its fully-formed state the favus cup is of a sulphur or 
golden-yellow color, which may later on become decidedly greenish in hue, as is shown in Plate 
XXXI. It must be borne in mind that the fungus grows as an infiltration in the upper layers of 
the epidermis, a thin film of which always covers the surface of each cup or scutula. In some 
instances for a short time, and in others for a long time, the favus lesion may not be very much 
elevated above the level of the skin, and in that case its epidermal covering is continuous with that 
of the territory beyond it. Sooner or later, however, the cup begins to rise slowly, and as it does 
Fig. 29. 
Hair Infiltrated with 
Achorion Schonleinii. 
243 244 
DISEASES OF THE SKIN. 
so the epidermis around its margin cracks and gives way. Then the lesion becomes distinctly 
elevated to the extent of a line or even to three times that height. At this time a small probe 
may be passed around such a cup, and it will be found that it is held in place by its centre, where 
one or two hairs can almost always be seen transfixing its structure. The convex portion of the 
lesion is imbedded in the deep layers of the epidermis. The coalescence of a group of these 
lesions forms a patch, which, as a rule, has a festooned and gyrate outline. The tendency of the 
disease is not to spread peripherally from one or two foci, and thus involve the whole scalp, but by 
the development of a number of irregularly scattered patches, which increase in area and from 
which detached fungous elements escape and lodge in other hair-follicles. Thus it happens that 
we see little clumps of normal hair and skin surrounded by the favus lesion, and thus it is that 
amid a group of hairs a number will often appear healthy, for the reason that their follicles are not 
invaded. The structure of the hairs is soon very much affected. They become dull, lustreless, 
brittle, often split longitudinally, and finally they fall off. Changes also take place in the appear- 
ance of the crusts, which show a remarkable tendency to remain upon the skin. In their older 
portions they become bleached, the yellow or greenish hue being gradually lost and a dirty-white 
color being left. Then, again, from the lodgment of dirt and from the escape of blood from 
scratching (very often in consequence of coexisting pediculi) they often come to look of a dark- 
brown color. Removal of the crusts at an early stage reveals a seemingly healthy scalp or one 
only slightly red and scaly. In a few weeks the yellow spots reappear, and in the course of time 
the disease is as bad as ever, such is the persistence of the fungus in the follicles. 
Favus runs a slow, chronic course, lasting years and even a lifetime. It has periods of activity 
and of quiescence of varying lengths. During attacks of severe illness it remains stationary. In 
some exceptional cases, however, it disappears, seemingly spontaneously. It usually begins in 
early life, but no age has an immunity from its ravages. Its development is attended with mild or 
active pruritus, and perhaps a sense of heat, and during its course the patient complains at inter- 
vals of its itching and of a feeling of fulness and tension. It has no influence on the health. 
From their earliest appearance the cups are dry and crumble at slight pressure. They give forth 
a mouldy, mousy odor, which is one of the characteristics of the disease. 
The ultimate effect of favus on the scalp is to convert it into a smooth, shiny, parchment-like 
membrane of cicatrization and atrophy. These profound changes are largely brought about by the 
mechanical pressure of the favus cups upon the rete and hair-papillae. The latter structures are 
killed outright, and permanent alopecia results. Pressure upon the rete causes its absorption. 
The result is that the skin becomes a layer of fibrous tissue covered with epithelium. 
Removal of a favus cup early in the disease reveals a corresponding depression, which may 
be obliterated by the growth of cells from below. In very chronic cases pustules and small abscess 
formations may occur on the margins of and scattered among favus patches. 
Favus of the skin of the body, which may exist alone or in conjunction with the scalp affec- 
tion, occurs on parts covered with lanugo and on parts where there are no hair-follicles, such as 
the palms and soles and glans penis. On these surfaces it begins as a small red scaly spot, which 
increases at its periphery by a distinctly marginated and very slightly elevated border. Very soon 
minute yellow punctae may be seen, which on superficial examination might pass as pustules, as I 
have seen occur. These punctae increase in size after the manner of, but much more rapidly than, 
the favus lesions of the scalp. They are, moreover, rather more salient than on the latter region. 
Wood-cut Fig. 30 gives a very clear idea of what McCall Anderson terms favus epidermidis. The 
characteristic cups in the centre of an oval red scaly patch with well-defined outline are clearly 
shown. On the skin elsewhere than the scalp favus shows a decided tendency to centrifugal 
increase, after the manner of ringworm, and very often there is a greater or less clearing up of 
the central portions of the patch. This increase of the affection in the circinate form is well shown Part IV 
Plate XXXI 
LEA BROTHERS & CO. PUB MSHE RS , PHIL.ADE LPHIA 
TINEA FAVOSA. FAWS (F/NEA FAVOSA). 
245 
in wood-cut Fig. 31 upon the palm of a patient who was under the care of Dr. G. T. Jackson. In 
this case the acute and rapid course peculiar to favus on the body and extremities was well shown. 
Favus of the nail is a rather rare affection, and involves one or more of these appendages. 
Ihe fungus may burrow beneath the free edge, and from 
there infiltrate the nail and the subungual tissues. When 
fully developed its yellow color may be seen shining through 
the nail, which later on may be more or less eroded by it; or 
it may lodge in the sulcus around the nail, and from there ex- 
tend. In some cases no evidence pointing to the favus origin 
of the nail affection is visible to the eye. These structures be- 
come of a dull, dirty-white color, deeply striated longitudinally 
and perhaps split, thick on their ends and very brittle. 
In the majority of cases favus is not an extensive erup- 
tion. If developed on the scalp, it may attack its entirety or 
portions of it. Upon the body it is more amenable to treat- 
ment, and consequently rarely covers large areas. The col- 
ored picture of Plate XXXI. represents an unusually exten- 
sive eruption, only one example of which have I seen. Kaposi 
has reported a case of universal favus in a man who also suf- 
ered from chronic diarrhoea, from which he died. At the 
autopsy ulcers were found in the stomach and large intestine, 
and in the false membrane which covered the stomach ulcers 
the favus fungus was said to have been found. 
Diagnosis.-In its full development the appearances of favus are so strikingly characteristic 
that its nature can be readily perceived. In chronic cases obscured by filth and dirt, and where 
the crusts have lost their outline and have become of a dirty-white color, the mistake of regarding 
Fig. 30. 
Favus of the Skin. 
Fig. 31. 
Favus of Hand. 
them as cases of chronic eczema or psoriasis might be made. But the history of the case, the loca- 
tion of the eruption, and its odor upon a close scrutiny point to its parasitic nature, which can be 
determined at once by the microscope. 
Etiology.- I he morbid factor in favus is the microscopic organism known as the Achorion 
Schbnleinii (for details of which see Hebra's textbook). This parasite is usually caught by 
young children from cats, who in their turn acquire it from mice. From children it is transferred 246 
DISEASES OF THE SKIN. 
to older persons. It may also be derived from rabbits, dogs, horses, and oxen. The extent of 
contagion observed is very variable. In some families there may be no cases beyond the one ; in 
others there may be several ; and exceptionally many relatives and friends are attacked. 
Prognosis.- Though contagious, favus is communicable in a less degree than ringworm. It is 
probable that the cohesiveness of its crusts prevents to a certain extent the diffusion of their spores 
through the air. Contagion in general takes place by contact or by the transference of the para- 
site from one person to another or from one region to another. 
When the disease has existed for a long time and taken a firm hold of the parts, particularly 
of the scalp, the prognosis is not good. Favus of the epidermis is a readily curable affection, while 
that of the nails is very persistent and prone to produce deformity. In general, a good outlook 
may be promised for those cases which are treated early and with much energy and persistency. 
Treatment.-Success in the treatment of favus can only be obtained by constant and ener- 
getic measures, with care as to all details. First clip the hairs off short, and then remove the 
crusts, which may be done by soaking them with olive oil or liquid vaseline to which 3 per cent, 
of carbolic acid has been added. After rubbing a goodly quantity on the surface (the operator 
always being careful of contagion by the fingers) strips of canton flannel or lint may be bound on, 
and over them a tightly-fitting cotton cap may be tied. After one or two applications the free sur- 
face of the scalp will be revealed. Then a thorough and systematic course of epilation must be 
begun, using forceps which have a square edge. This operation may be rendered more expedi- 
tious, and scarcely at all painful, by rubbing firmly into the parts a cocaine ointment (gr. x to lano- 
lin gr. c). The seances of epilation maybe daily if possible. Every hair must be removed, taking 
a few at a time. Kaposi recommends the use of such a flat surface as the edge of a paper-knife 
(or of a druggist's spatula) with which to grasp by the thumb a lot of hairs, when the morbid 
ones will come away with a slight pulling motion, while the healthy ones will remain. After each 
epilation the following lotion may be well rubbed into the scalp by means of a large bushy oamel's- 
hair pencil: 
B. Hydrarg. bichlor., gr. viij ; 
Aq. coloniensis, jij; 
Alcohol, 80 per cent., ad §iv. M. 
Care should be taken to cause this liquid to permeate the follicular openings. 
It must be remembered that weeks, and even months, may be required in bad cases, and that 
the certainty of the thorough destruction of the parasite cannot be confidently stated until several 
weeks or two or three months have elapsed without the appearance of its redevelopment. The 
moral courage of the patient and physician is sorely tried by these cases. 
Little can be said in favor, and much in condemnation, of the calotte and of the Burgundy 
pitch stick as means of epilation. They are brutal in their operation, and not effective of good 
results. 
Dr. H. J. Reynolds claims good results from a method of treatment which is as simple as it is 
ingenious. He applies a sponge attached to the positive pole of a battery and saturated with an 
antiparasitic lotion (1 per cent, aqueous solution of the bichloride of mercury preferred) over the 
morbid parts, while the negative pole is applied at some distance away. The liquid is thus made 
to penetrate more deeply by the aid of the electric stimulus. Dr. Reynolds claims that he has 
obtained good results in favus and other parasitic affections by this means, which is so readily 
employed. A strong solution of hyposulphite of soda (siij, aq. siv) may be used. 
Favus of the epidermis may be painted with tincture of iodine, with collodion and corrosive 
sublimate (gr. ij to 5j), with a 5 per cent, chrysarobin ointment, or with a sulphur and carbolic acid 
ointment (siss, gtt. xx, vaseline sj). PART V. 
PEDICULOSIS. 
A number of animal parasites or epizoa affect the human skin, and produce on it a great 
variety of morbid changes. The chief of these minute animals are the three varieties of lice, the 
Acarus scabiei, the flea, the sand-flea, the bedbug, the Filaria Medinensis or Guinea-worm, the 
harvest-bug, and the wood-tick. 
Pediculosis or morbus pedicularis is found in three different and well-marked forms : pedicu- 
losis capitis, caused by the Pediculus capitis; pediculosis pubis, by the Pediculus pubis; and 
pediculosis corporis, by the Pediculus vestimentorum. The results upon the human integument 
of the irritation of these parasites is eczematous inflammation in any or all of its protean forms. 
Pediculosis capitis is mostly seen among the poorer and less scrupulously clean classes : it 
affects chiefly young subjects, less commonly older persons, and more frequently females or 
males with long and thick hair, which offers a favorable nest for the parasite. 
The top of the head and the occipital region are the parts primarily attacked, and the disease 
is always most marked within their area. 
The clinical history of cases of pediculosis capitis, or lice of the head, is in the main quite 
uniform and the appearances very striking. The subjective symptom, itching, is usually first 
noticed or complained of, though in many instances in young children, in girls, and even in older 
persons, its true import is unappreciated. A superficial or cursory examination in cases of 
moderate severity will frequently reveal nothing, for the reason that the morbid changes take 
place on the scalp itself, at the very roots of the hairs, and that the arrangement of the hair covers 
these conditions up. In old and neglected cases, however, evidence of the disease is seen on the 
superficial portions of the hair. Itching of the scalp in a patient, particularly a young one, should 
always cause the physician to thoroughly examine its surface. In a case of pediculosis capitis when 
the hairs are separated a number of phenomena present themselves. In the first place, a most 
unpleasant odor is usually promptly noted, and a greater or less matting of the hairs at their roots 
and for a distance beyond is seen. Where the lice are abundant, they are there revealed in ant- 
like activity, but in many cases they must be sought for with a little care. The sight of a louse on 
the head always settles the diagnosis. Besides the lice, we find always at the roots of the hair, 
where they are nurtured by the natural heat and protected by the mass of the hair, the nits in 
numbers of one to three or more. 1 he scalp is then seen to present manifold lesions. In recent 
cases there may be only a little patchy redness, with papulation and perhaps a little pustulation. 
In well-marked cases the lesions are striking in appearance. The scalp is raw, oozing, and even 
bleeding, and covered without regularity with large papules and pustules. Crusts of recent forma- 
tion and soft in consistence are mingled with older and harder ones having a dark, dirty-green or 
greenish-brown color. They are made up of serum, pus, and even of blood, and form around 
247 248 
DISEASES OE THE SKIN. 
little masses of hair, which they convert into tufts. In old and severe cases so much thickened 
does the scalp become, particularly around the hair-follicles, that a rough granular, even vege- 
tating, surface is produced, which gave rise in ancient dermatology to the term porrigo gramdata. 
As a result of the irritation of the scalp the post-cervical ganglia become enlarged, sometimes 
moderately, but even to a marked degree, tumors of the size of a hickory-nut being produced. 
It is not uncommon to see sparse eczematous efflorescences occur concomitantly with pedicu- 
losis capitis. This eczematous complication is mainly due to scratching and the transference of the 
pus and sero-pus from the head to the other parts. It is seen all over the face, generally in scat- 
tered form, over the ears, and very frequently down the back of the neck in a state of waning 
progression. There may be only patches of redness with papulation, or there may be a multi- 
formity of lesions-erythema, papules, pustules, and crusts. The association of a sparse ecze- 
matous eruption on the ears, face, and back of the neck, with a tendency to scratch the head, 
should always lead to an examination of the scalp, which in most cases will be found to be the 
focus of the mischief. 
The severity of the disease, as a rule, depends upon the number and the fecundity of the 
parasites. Some people, however, seem to suffer more than others by reason of the delicacy of 
their integument, and in them a few pediculi will produce infinite mischief. Then, again, we some- 
times see swarms of these vermin upon a scalp, and only a very moderate amount of inflammatory 
reaction. Mothers frequently say that a particular child seems very prone to the ravages of lice, 
while its brothers or sisters are scarcely if at all affected, all the children seemingly living under 
similar conditions. 
Lice are usually transferred from head to head in children while at school or at play. From 
them the disease may spread into the family, and older persons may become affected. The affec- 
tion in children is frequently overlooked, owing to the delicacy of feeling of the parents or guardians, 
who cease to comb and cleanse the sore spots out of a foolish regard for the patient's outcries. The 
result is that the parasites increase in numbers, while the disease 
grows worse. Some young females who thus become affected very 
often so arrange their hair and its ornamentation that evidences of 
lice are entirely concealed, while the affection keeps on apace. Males 
usually have not this means of hiding their trouble. Persons confined 
by chronic illness, particularly those having long hair, not uncom- 
monly become affected with lice, which may remain for a long time 
undisturbed out of a false regard for the sufferer's comfort. 
It must be borne in mind, especially by young practitioners, 
that all cases of eczema of the scalp and neck are not of necessity 
caused by pediculi, though the suspicion of such an origin is generally warranted 
in young subjects, and especially in females with long hair. Then, again, it is well 
to remember that many cases of eczema of the scalp become complicated with 
pediculosis, since a fertile feeding-ground is offered. 
Etiology.-In general, the Pediculus capitis is the original and exciting cause 
of the eruption. Little can be said of predisposing causes other than that some 
patients' skin reacts much more readily to the pedicular irritation than others. In 
all cases the scratching induced by the parasite is an important factor in the inten- 
sity and extent of the disease. It is beyond doubt that the scattered spots of 
eczema about the cheeks, nostrils, chin, ears, and perhaps on the neck, are caused 
by particles of pus transferred by the finger-nails. 
Description of the Pediculus capitis.-The head-louse is of a brownish-gray color, though it is 
said to vary with that of its host, and is sometimes difficult of detection ; of an oval shape, about 
Fig. 32. 
Fig. 33. 
Pediculus capitis, 
male. 
Hair with ova of the 
Pediculus capitis. PEDICULOSIS. 
249 
two mm. long and one mm. broad. It has a triangular-shaped head, a thorax, and an abdomen, 
brom the head two antennae spring, one from each side, anterior to the eyes. From each side of 
the thorax three legs, with stout hairy claws, spring. The female is larger than the male, which is 
provided with a conical-shaped penis seated on its back. The vagina of the female is placed in the 
last abdominal segment, on its ventral surface. In copulation, therefore, the female is above the 
male. 
The ova or nits are oval in shape, and glued to the hair by a cylindrical sheath of chitine, the 
oldest one being nearest the scalp, and the later ones above the first, as shown in Fig. 33. 
Prognosis.-This is usually good, provided intelligent and painstaking treatment is followed. 
Observance on the part of the parent, guardian, or patient of the physician's directions will soon 
result in cure. Sometimes an eczematous condition and tendency resulting from severe pediculosis 
capitis remains long after the disappearance of the lice, and requires persistent energetic treat- 
ment. 
Treatment.-The treatment of pediculosis capitis varies in its simplicity according to the 
severity of the case. In many cases the existence of lice is made out before much dermal irritation 
has been produced, and their destruction is readily accomplished by saturating the scalp with tinc- 
ture of larkspur {Delphinium staphisagria} or with the following lotions : 
R. Hydrarg. bichloridi, gr. i-ij; 
Aq. coloniensis, gij; 
Aquae, 3iv. M. 
R. Acid, carbolici, 5j~3'j i 
Glycerinae, gss; 
Aquae, ad £viij. M. 
These lotions should be well rubbed into the roots of the hairs and along their whole continuity, 
since then the pediculi and ova are both destroyed. After allowing either of the lotions or the 
tincture of larkspur to remain on the scalp for several hours, the head may be shampooed with 
soap and water and an alkali, and then the fine-tooth comb should be made to traverse all of the 
hairs, care being taken that the scalp be not wounded. Used properly, the fine-tooth comb is a 
valuable adjunct to the treatment. 
In those cases in which the pediculi are few in number a cure may be effected without cutting 
the hair. In the case of boys there is usually no objection to its removal, but with girls it should 
be spared if possible. It may be practicable to remove only the affected portions, and to spare 
enough superficial hair to cover the head. Should, however, the parasites not be entirely 
destroyed, the scalp must be cleared. 
In dispensary, hospital, and perhaps in private practice crude petroleum is a remedy of uniform 
reliability. It is far preferable to benzine, kerosene, and other coal-oil products, which often pro- 
duce anaesthesia and analgesia of the skin, and even dermatitis. The crude petroleum should be 
freely but very carefully sopped on the surface, as well as made to permeate the hairs. The parts, 
being allowed to thus macerate several hours, may be shampooed and perhaps combed. Two or 
three such applications are usually sufficient. 
The following ointments may also be used : 
P. Pulv. staph isagriae, jij; 
Bals. Peru., gij; 
Ung. aq. rosae, 5j. M. 
R. Naphthol, sj-^ij; 
Vaseline, §j. M. DISEASES OF THE SKIN. 
250 
The cases most difficult to treat are those in which there is eczema superadded. For the 
relief of these it is well to proceed vigorously with the destruction of the lice with petroleum, and 
then apply such ointments as the following : 
R. Hydrarg. precip. alb., gr. xij; 
Bals. Peru., 3j; 
Vaseline, M. 
R. Hyd. sub. mur., gr. xx; 
Acid, carbolici, gtt. x ; 
Ung. aq. rosse, %j. M. 
Very often a persistent eczema remains which requires appropriate treatment. 
For the removal of the ova, vinegar and water, acetic acid and water (5j-3ij-3iv), borax and 
water, solutions of carbolic acid (i to 5 per cent.), alcohol and water (1 : 8), may be employed, 
attention being paid to the subsequent shampoo. 
PEDICULOSIS PUBIS. 
Pediculosis pubis is most commonly observed in adults, and is usually conveyed in sexual 
contact. It is a very common affection, and is seen in the better classes of patients, male and 
female, as well as in the lowest of them. The parasite is called the crab-louse, Pediculus pubis. 
Though its habitat is in most cases upon the pubic and hypogastric regions, the insects are often 
found upon the sternal regions, in the axillae, upon and among the eyelashes and eyelids, in the 
beard, and even upon the temporal region. They are also not infrequently found, especially in 
hairy men, on the thighs and even on the legs. In some of these cases the lice have reached these 
distant parts by migration, in others by transference by means of the fingers and nails. 
In the majority of cases the attention of the patient is at first called to the trouble by an itch- 
ing and crawling sensation about the pubes. It is not uncommon to see a few crab-lice cause 
much uneasiness in a patient, and then again we encounter persons who have large numbers of 
them upon them which had been there for long periods, and yet they had given them very little 
discomfort and caused them no uneasiness of mind. 
In general, the lesions produced by this variety of pediculus are very mild, erythema and 
scratch-marks only being seen. In severe cases inflammation of the hair-follicles, pustules, and 
eczema may be induced. Persistent itching at the pubes should always awaken suspicion and 
cause an examination of the parts. The lice, if present, will be seen for 
the most part seated firmly on the skin, attached by a hair, as minute 
light-brown spots. Some may be seen clinging only to the hairs, amongst 
which the minute ova or nits and the reddish, brick-colored excrement of 
the insect may be present. The cause being recognized, a cure can be 
promptly produced. 
The crab-louse is smaller than the other two forms of pediculi. The 
shape of its body has been compared to a shield, and its head to that of 
a violin. Its thorax and abdomen are continuous, and from each side of 
the former three stout, strong legs spring, at the end of which are a 
number of hooks which resemble the claws of a crab. It is much more 
slothful than its congeners, and remains with its head buried in a follicle while it holds on to the 
hairs with its claws. Thus it is that it resists dislodgment, and sometimes retains its grasp until 
the whole length of the hair has been traversed. 
Fig. 34. 
Pediculus pubis. PEDICULOSIS. 
251 
1 reatment.-Mercurial ointment is a remedy in high repute among the laity high and low, 
and well deserves its fame as a parasiticide. Its tendency, however, to cause follicular congestion, 
and even severe eczema, is so marked that its use should be restricted to cases of emergency. If 
it is used, it should be with a sparing hand and with great care. As an all-round remedy there is 
none superior to the tincture of larkspur-seeds. This can be freely and repeatedly applied with- 
out fear of consequent dermatitis. The stavesacre ointment spoken of in the treatment of 
pediculosis capitis may be used, but for obvious reasons fatty preparations are objectionable 
upon parts affected by this louse. 
The following lotion is very efficient and pleasant, and when carefully, even though quite 
freely, used, productive of no bad results : 
B. Hyd. bichloridi, gr j+ij+iv; 
Aq. colon., gij; 
Aquse, §iv. M. 
I he strength of the lotion should be in proportion to the extent and intensity of the louse 
colonization. 
The following lotions are also beneficial, and may be remembered in the cases of females : 
B. Acid, acetic., 5ss ; 
Aq. colon, sj; 
Aquae, ad gviij. M. 
B. Acid, carbolici, 3j"5'j 5 
Spts. camph., §ss; 
Glycerinae, 3vj; 
Aquae, ad gviij. M. 
It is sometimes necessary to clip the hair close to the skin of persons thus affected. In all 
cases, after maceration with a lotion for one or more hours, a hot alkaline bath should be employed 
and fresh under-linen should be put on. Chloroform and sulphuric ether in lotion and spray form 
have been recommended, but, besides their manifest disadvantages, they sometimes fail to kill the 
lice. Eczema secondary to pediculosis pubis should receive appropriate treatment. 
PEDICULOSIS CORPORIS. 
Pediculosis corporis is caused by a parasite which resembles the Pediculus capitis, which 
ensconces itself in the coarse meshes of the under-clothing and in the seams thereof. It is occa- 
sionally seen meandering over the integument, but when thus sought for is rarely found. The 
ravages of this insect, and the consequent suffering, are caused by the insertion of its proboscis 
into a follicle, from which it draws blood for its sustenance. Following this procedure, a minute 
quantity of blood escapes, and usually dries and forms a little crust at the punctured point. 
The clinical appearances presented by pediculosis corporis are in the main quite well marked, 
and are observed in varying degrees, according to the number and extent of distribution of the 
lice. In some mild cases the patient simply complains of a moderate itching or of crawling sensa- 
tions, which may not have caused sufficient scratching to induce excoriations. Examination of such 
a case will usually show the presence of a few or many of the little pinhead-sized, reddish-black 
blood-crusts already spoken of as of such diagnostic import. It very often happens in these cases, 
as well as in the severe ones, that the itching is not confined to the parts attacked by the parasite, 
but exists elsewhere, perhaps quite remotely, being caused by reflex action. 
Where scratching is severe and long continued, scratch-marks or excoriations are seen, and 252 
DISEASES OF THE SKIN. 
they possess a modified diagnostic value. These lesions, usually caused by the nails or some stiff 
instrument, such as a brush or comb, are for the most part linear in shape, of varying length, 
usually narrow, and sometimes presenting a raw surface, or again are covered with blood-crusts. 
Coexisting with the minute blood-crusts and scratch-marks there are usually to be seen, always 
irregularly placed and scattered, papules of various sizes, which have been torn by scratching, and 
which usually develop upon the sites of wheals which are caused by the irritability of the skin and 
by its wounding by the nails. Diffuse and patchy erythema are also commingled. Very many 
cases are constituted by the conglomeration of the foregoing lesions. Such an one is well por- 
trayed in Plate XXXIL The subject is an old man, upon whose shoulders, nucha, neck, arms, 
and sides we see the combination of minute blood-crusts, torn papules, wheals, and linear excoria- 
tions. The picture is typical. 
We frequently see, however, instances of greater change in the integument, particularly in 
old subjects. Dermatitis, eczema, pustules, furuncles, abscesses, ulcers, rupial-looking eruptions 
are often superadded, and mingled with the less severe forms of lesion already enumerated. As 
a result of chronic pediculosis corporis the texture of the skin becomes harsh, dry, and more or 
less brown, and sometimes almost black in color. This is particularly the case in the aged, whose 
skins are generally the seat of senile atrophy. 
Pediculosis corporis is usually met with in middle-aged and old persons, but also is seen in the 
young. As a rule, it is a disease of poverty, filth, and squalor, though we do meet with it among 
cleanly and well-to-do people. It usually begins about the shoulders, over the clavicles and nucha, 
and upon the neck and upper arms. Dogmatic rules of diagnosis are difficult to make, and when 
made are frequently found to be more or less incorrect. In general terms, however, it may be 
stated of pediculosis corporis that it begins, and at first becomes intense, in the regions already 
named in contradistinction to scabies, which usually centres itself, when developed, upon the trunk 
between the line of the umbilicus and the thighs. Since the tendency of both is to extend, this 
regional point of diagnosis may soon be lost. 
The Pcdiculus corporis vel vestimentorum consists of a head, thorax, and abdomen. P'rom 
the head an antenna springs on each side, while from each side of the thorax three hairy claws jut 
out. It is of a light brownish-gray color, and is sometimes rendered darker in hue 
by absorbed blood. These lice are usually active in their habits and are capable 
of great fecundity. 
Diagnosis.-In all cases the louse is the objective point, and its discovery 
settles the diagnosis. The main difficulty is in eliminating from pediculosis cor- 
poris cases of pruritus cutaneus of internal origin. As a rule, the diagnostic 
points already brought out and the history of the case are sufficient, but in 
doubtful cases the question can only be settled by the discovery of the louse. 
Treatment.-The first essential in treatment is to thoroughly sterilize the 
clothes of the patient and his bed-linen. Failure to do this means the perpetuation 
of the disease. To this end, these fabrics should be either ironed, boiled, or baked 
at a temperature high enough to destroy the lice and not to ruin the clothes. 
The patient should use hot alkaline baths, with copious soap frictions. The skin may with 
benefit be rubbed With balsam Peru ointment (sij to vaseline 3j), or a mild carbolic-acid lotion, or 
vinegar and water, perhaps with the addition of a little Cologne-water, may be sopped on. 
Dermatitis and eczema secondary to the pedicular irritation should be carefully attended to 
until fully cured. Very often, particularly in old persons, a persistent pruritus follows pediculosis 
corporis, and it should be especially looked after by care as to diet, by the avoidance of alcoholic 
and malt liquors, by attention to the digestion and the bowels, the avoidance of irritating under- 
wear, and by the use of antipruritic remedies, aqueous or greasy. 
Fig. 35. 
Pediculus corporis, 
female. Part V 
Plate XXXII 
LEA BROTHERS & CO. PUBLISHERS PHILADELPHIA 
PEDICULOSIS CORPORIS. ERYTHEMA FACEI AND EPHEMERAL 
ERYTHEMATA. 
Besides the exudative erythemata, E. multiforme and E. nodosum, already described, there 
are a number of hyperaemic eruptions due to external and internal causes, and described under 
the general name erythema simplex, which have an individuality of their own and merit a separate 
description. 
The simplest forms of erythema are those resulting from external irritation of the skin. They 
consist of small or large patches of hyperaemia, which may vary in tint between a slight pinkish 
blush and a purplish red. These patches vary in size with the extent of the active irritant, and 
their density of color is largely dependent upon the intensity of that factor. 
Erythema from cold may be of active and fugitive character, and is seen chiefly upon the head, 
face, and hands of persons who have been in a low temperature. It consists of moderate hyper- 
aemia without exudation, and tends to disappear rapidly. 
A chronic and persistent erythema of the face and hands is observed in persons whose occu- 
pations cause them to be much out of doors, especially those exposed to high winds-drivers and 
seafaring men. This erythema is usually accompanied by pigmentation, and perhaps by enlarge- 
ment of the capillaries, of the face. Pressure causes the redness to disappear momentarily. Frost- 
bite and chilblains are merely intensifications of these conditions. 
Erythema from heat is usually observed upon exposed parts, but may be present on any por- 
tion of the body. It varies in intensity with the degree and continuance of the high temperature. 
It may be mild and ephemeral or severe and persistent. Long-continued exposure to high tem- 
perature (sun's rays or artificial heat) results in true inflammation of the skin. 
Traumatic erythema is that form which results from any damage done to the skin by external 
agencies. Coaptation of cutaneous surfaces very frequently causes erythema, sometimes mild and 
transitory, and again severe and distressing, the skin becoming very red and excoriated and exuding 
a gummy secretion. This has been called erythema intertrigo, and also intertrigo, and is usually 
readily cured by the interposition of powders on lint or linen between the morbid surfaces. 
Under this same head, traumatic erythema, is included the hyperaemia which results from irri- 
tating discharges, from woollen and colored underwear, and from friction. In addition to these 
causes, traumatic erythemata are set up by the toxic action of drugs applied to the skin and by 
articles of trade-sugar, flour, dyestuff, etc. To this category also belong erythemata resulting 
from the pressure of clothes, trusses, crutches, orthopaedic apparatuses, and bandages of various 
kinds. 
In all of these cutaneous hyperaemias relief promptly follows the removal of the source of 
irritation. 
kinds 
SYMPTOMATIC ERYTHEMATA. 
The most common forms of symptomatic erythema are those due to the ingestion of drugs. 
The volume of evidence as to the toxic action of drugs now accumulated has much simplified our 
253 254 
DISEASES OE THE SKIN. 
knowledge of the erythematous eruptions. Erythema resulting from drug ingestion is usually of 
sudden invasion, rapid evolution, and correspondingly quick decline when the drug is discontinued. 
The erythematous eruptions thus induced may be circumscribed or diffuse, and vary from a pale 
red even to a deep purplish tint. They may consist only of hyperaemia, but in intense cases 
papules, vesicles, pustules, and bullae may be concomitant features of the morbid process. There 
is usually more or less systemic disturbance, with cerebral hyperaemia, accelerated pulse, rise of 
temperature, nervousness, and malaise. They are all attended with burning, itching, and tension 
of the skin. It is a good rule in practice in all cases of suddenly-appearing erythema to inquire 
into the probability of poisoning from the ingestion of drugs. 
The eruptions of belladonna are usually quite deep, and there is diffuse hyperaemia of the 
face, fauces, neck, and perhaps the upper extremities. 
Quinine and cinchona preparations sometimes give rise to very intense and extensive ery- 
thema. In some cases the redness may be limited to the face and hands, and in others it may 
involve large portions of the body. Besides these mild and circumscribed cases, I have seen a 
generalized eruption from small doses of quinine as severe as is seen in scarlet fever, together 
with marked systemic reaction, and followed by profuse universal desquamation, the epidermis of 
the fingers and toes, palms and soles, being shed in its entirety. Not infrequently urticaria, either 
alone or in conjunction with erythema, has been seen to be caused by quinine, which also has been 
known to produce an erythematous and bullous eruption. 
The eruptions caused by chloral are seen in two forms : first, the erythema caused by a single 
dose, which is of rapid development and of speedy decline ; and second, a more pronounced and 
chronic form of erythema, with perhaps exudation, papules, and vesicles, and seen in persons who 
are addicted to the use of the drug. 
Erythema from iodoform ingestion may be of the papular or diffuse form. It is sometimes 
mild and quite transient, and again severe and attended with exudative changes-papules, vesicles, 
and bullae. It may eventuate in cutaneous hemorrhage. 
Erythema from opium is usually superficial in its character, attended with much pruritus, 
mostly limited to the face and not very often in large patches. In hypodermic use morphine is 
sometimes, by accident, thrown into a vein, whereupon the face and body become the seat of intense 
pricking, burning, and itching sensations, and very often the alarming symptoms are followed by 
severe erythema, even with the production of much oedema of the face and hands. 
Antipyrine erythema is neither of uncommon occurrence nor is it rare. It is usually of abrupt 
invasion and of a bright-red color, and undergoes speedy involution. 
Very many other drugs cause cutaneous hyperaemia, some of which also produce true derma- 
titis and will be considered later on. 
The erythemata of syphilis have been fully described. Those produced by the exanthemata 
are treated of at length in the textbooks on medicine, and only require mention here. So also it 
may be said of the circumscribed pink spots of typhoid fever, the larger, deeper, and petechial 
spots of typhus fever and cerebro-spinal meningitis, and the more diffuse erythemata of rheuma- 
tism, cholera, and pyaemic infection, and of the circumscribed erythema of diphtheria. 
Prominent among the symptomatic erythemata is that form which the older writers called ery- 
thema fugax. This eruption is symptomatic of many internal causes-some well known, others 
obscure. In Plate XXXIII. is shown the face of a woman affected by erythema fugax of the face 
in its period of full development. This form of erythema is very commonly thus limited to the 
face, especially the cheeks, as seen in the picture. It may also attack the region of the nose, the 
eyelids, the ears, and the lips and the chin. It sometimes remains stationary, and again shows a 
tendency to metastasis, chiefly to the hands, forearms, and upper portions of the trunk and neck. 
The patches are of red color of very varying degrees ; they are hot, tense, itchy, more or less Part V 
Plate XXXIH 
LEA BROTHERS & CO. PUB LISHE RS . PHILADE LPHI A 
ERYTHEMA FACE1. SYMPTOMATIC ERYTHEMATA. 
255 
swollen (sometimes markedly so), and sometimes the seat of pain. The affection usually develops 
very quickly, being preceded with an itchy and burning feeling ; may last a few hours or even less, 
or may last a day. It sometimes appears every day, again with great irregularity, and in somewhat 
exceptional cases with marked periodicity, especially in malarious regions or in those subject to 
malaria. 
Erythema fugax may attack the region of the eyes, which may become closed from the result- 
ing oedema, or by it the lips may be much swollen ; and sometimes the tongue is coincidently 
affected in a similar manner. In somewhat rare cases much hyperaemia and swelling of the 
pharynx is observed, and evidence of bronchial congestion may be present, together with dis- 
tressing dyspnoea. 
I he morbid conditions which cause this ephemeral form of erythema are very varied. In 
many cases the ingestion of certain articles of food is followed by an attack, and this and certain 
other considerations, to be spoken of later, give weight to the view of the at least occasional rela- 
tionship or interdependence of this eruption with urticaria and acute circumscribed oedema. 
Disorders of digestion and the varied morbid conditions of the gastro-intestinal canal are very 
often complicated by attacks of evanescent erythema. The neuropathic condition sometimes seems 
to favor its development. 
Menstrual troubles have been noted to coexist with or perhaps underlie erythema fugax. 
Amenorrhoea and this form of erythema have been noted to coexist so frequently that a causal 
relationship has been claimed. Under the title "erythema menstruale " cases have been reported 
m which erythema of the face has coexisted with the decline and suppression of the menses. Such 
cases are evidences of disorders of the circulation rather than, as claimed by some writers, 
instances of vicarious menstruation. 
Under the most varied morbid conditions, chronic, subacute, and acute, of the brain and spinal 
cord, of the lungs, liver, and kidneys, fevers, and under the influence of strong mental emotions, 
erythema fugax may arise. 
1 he hectic flush of phthisis may be taken as the most dangerous form of erythema fugax, 
while blushes caused by any of the emotions are varieties of the simplest origin. 
Diagnosis.-Attention to the clinical points already brought out will usually lead to a recogni- 
tion of the nature, and perhaps the cause, of erythema fugax. Very often the history of the case 
and of the antecedent condition of the patient will be sufficient. 
Prognosis.-Removal of the cause of the mild forms of cases will result in cure, brequently- 
recurring attacks of erythema fugax should lead the physician to examine the patient in the most 
thorough manner as to his habits, his food, the condition of his health and of each viscus ; to exam- 
ine his urine ; to inquire as to antecedent disease and regarding hereditary tendencies. 
1 REatment.-Local treatment should consist of the various powders, lotions, and perhaps 
ointments, already mentioned in the sections on erythema and eczema. Removal of the cause of 
the trouble is the main indication. ERYTHEMA CIRCINATUM, HERPES IRIS, 
AND ERYTHEMA SERPENS. 
In the section entitled "Erythema multiforme" the clinical history of the papular and tuber- 
cular stages of that protean disease is brought out. It now remains to trace the clinical relation- 
ship between erythema multiforme-and especially its annular form-and certain vesicular and 
bullous affections termed herpes iris. As has already been explained (see page 196 ct seq.), the 
lesions of papular and tubercular erythema may at their margins increase in intensity, while more 
or less involution takes place in their centre. The erythematous rings thus formed, called ery- 
thema annulatum and e. circinatum, may increase in size until large surfaces are covered, and they 
may run together and form gyrate patches. Beginning thus as a bright-red papule, it usually 
becomes deeper in hue until a purplish red may be present. As the lesion increases in its ringed 
form the central patch may become blanched and scaly, and may remain of a light-red or even of 
a purplish hue. In some cases, in more or less of the rings, new inflammation begins, and rings 
within the larger ones, as many as one, two, or three, may be developed. Usually the course of the 
disease is so rapid that very great changes of color are observed from day to day. It is not at all 
uncommon in these cases to see a purplish-red eruption of to-day become a yellowish-red to-mor- 
row. This form of erythema in the greater number of cases forms the connecting link between the 
eruptions which are fundamentally erythematous and those which, besides their erythematous back- 
ground, are also vesicular and even bullous in their nature. This form of ringed erythema is well 
shown in Plate XXXIV., in which the rings are in the declining yellowish-red stage, having been 
of a deep-red color the day before the picture was taken. In the present instance there is a 
whitish centre surrounded by the redness which ends in the rings. In many cases a decided play 
of colors may be seen, such as a yellowish central patch with a red surface up to the ringed margin, 
or a purple centre with variegated redness beyond it. In the course of some of these lesions the 
various tints of fading cutaneous hemorrhage are seen. These varieties have been called erythema 
iris. In rather exceptional cases true hemorrhage takes place within the rings. 
If the tip of the finger is passed over these circles, a sensation of firmness due to the inflam- 
matory exudation is felt. In some cases, though the rings are papular in nature, the appearances 
are so illusive that one is led to think that they are composed of vesicles. In somewhat exceptional 
cases rings of vesicles form around lesions thus far advanced (see Plate XXXIV.), and may even 
develop within the circles, either irregularly placed or in the ringed form. This feature then seems 
to be an exacerbation of the trouble. In general, however, the vesicular element of the disease 
shows itself earlier in the modes now to be described. 
My experience and study have convinced me that there are three modes of development of 
erythema vel herpes iris. In the first the disease begins as patches of erythema, perhaps markedly 
annular or perhaps of irregular shape. At the margin of one or few or many of these lesions 
vesicles form, perhaps in the shape of a ring or scattered irregularly around its periphery; or there 
may be one or many vesicles seated without order on the surface of the patch. When seated at 
the margin of the erythematous disk there may be only one or two vesicles, or they may be so 
numerous that circles or portions thereof are present. These vesicles vary in size from a line to 
half an inch in diameter, and are of round or oval shape. They are firm in structure, contain a 
256 Dart V 
ERYTHEMA CIRCINATUM 
ihahca 111 bli11 g 11 <a i j i <a h Iris. 
LEA BROTHERS & CO PUBLISHERS PHILADELPHIA 
Plate XXXIV erythema circinatum, herpes iris, and erythema serpens. 
257 
yellowish serum which soon becomes cloudy, and they often give evidence of being multilocular 
from the fusion of many original vesicles. In the form thus described there is usually a prepon- 
derance of erythema over vesiculation; indeed, in many instances very few vesicles are to be seen. 
I he second form begins as a minute bright-red spot attended with heat and itching. Very 
soon a distinct vesicle is seen surrounded by a red areola. This lesion grows peripherally, and 
does not reach much elevation (one half to one line). As it increases at its margin with its con- 
stant red halo, it becomes depressed in its centre, which may turn pale or remain of various shades 
of red, even of purplish hue. There is then simply a vesicular ring enclosing perhaps an erythe- 
matous disk and surrounded by hyperaemia. Around the margin of this ring a more or less com- 
plete circle (or circles) of vesicles of tolerably uniform size develops, and it is encircled with red- 
ness. In this way new vesicular lesions may form until a large patch is produced. In the enclosed 
area the morbid process may cease, or inflammation may again start up, and even hemorrhage 
may occur. As a result of this acute inflammation, often occurring by spurts, there is produced a 
variegation of colors which prompted the older dermatologists to use the term "iris" to these 
conditions. 
I he third mode of development is a modification of the second. Upon the primordial red 
spot a bulla forms, and very soon a more or less perfect ring of vesicles is developed upon its 
circumferential red areola. This ring may be followed by the appearance of other external rings, 
or new ones may occur within pre-existing rings ; or, again, vesicles, and even bullae, may form in 
irregular fashion toward the centres of the patches. In some cases the further extension of the 
disease is not by vesiculation, but by spreading erythematous patches or by red rings of exudation, 
such as are seen in Fig. 34. In some cases the rings of vesicles and bullae are quite accurately 
formed, but in many there is an absence of mathematical precision, and the general effect upon the 
mind of the observer is that the lesions show a tendency to an annular development rather than 
to the formation of well-defined circles. 
W hile many examples of the last two modes of development show a vesicular and bullous 
element in all of the lesions, it is not at all uncommon to see these features conjointly with true 
erythematous patches. 
In general, the evolution of these eruptions is rapid and their involution prompt. The usual 
signs of subsiding, hyperaemia and inflammation, are seen. Sometimes, however, ulceration over- 
taxes these lesions. In most cases the vesicles (which are generally deeply seated) dry, wither, 
and leave slightly pigmented scaly surfaces, which soon become of normal appearance. 
I he most common sites of these eruptions are the face, particularly about the eyes and mouth, 
the backs of the wrists and hands, and the insteps. The neck, the outer aspects of the arms- 
sometimes the flexor surfaces-the palms, and the soles may also be affected, while the trunk is 
rarely invaded. Not infrequently the mouth, tongue, and the pharynx are coincidently the seat of 
hyperaemia and perhaps of vesiculation. 
These eruptions are often seen to occur several times in the same patient, perhaps at quite 
uniformly stated intervals or at certain seasons, or again without any regularity. 
(For diagnosis, prognosis, and treatment see page 198.) 
ERYTHEMA SERPENS. 
Erythema serpens is a hyperaemic affection so sharply marked that it merits a separate 
description. This affection, known to older writers as erythema migrans, has been clearly 
described by Morrant Baker, and has within two years been rechristened erysipeloid by Rosen- 
bach, who has shown that it originates in a microbe. It is therefore a local infectious disease, 
derived from some putrefactive secretion of dead animals or from the contamination of some 258 
DISEASES OE THE SKIN. 
traumatic lesion (usually insignificant) by harmful matter, such as dirt, dyestuff, pus, and ichor. 
It is not contagious from one person to another. It is met with in handlers of hides, taxidermists, 
butchers, cooks, fish-dealers, oyster-openers, poultry-venders, attaches of dissecting-rooms and 
dead-houses, dealers in cheese, and in surgeons. 
Erythema serpens begins about the fingers or the hands, commonly near the nails or knuckles, 
and also upon the feet, as a fissure, an abrasion, or a cut, which is usually visible during its entire 
course. Around this minute primary lesion a round or irregular-shaped pink spot forms, and from 
this focus the disease is developed. In some cases the extension begins immediately ; in others 
the focal spot remains in a slightly painful and indolent condition for a day or two. The original 
pink or red zone of inflammation then extends slowly and with distinct margination in its whole 
extent. There is usually no exudative thickening of the skin and no raised circumferential ring, 
the hyperaemia being decidedly superficial. In some cases there is mild puffiness of the fingers, 
and a consequent indisposition upon the part of the patient to move them. As the affection 
extends the morbid surface becomes mottled or blotchy from the intermingling of pink, pinkish- 
red, and even violaceous hues. In this way the disease may creep over a considerable extent of 
integument, occupying in its course from one to six weeks. The decline may be rapid or rather 
slow, and is noticeable in the cessation of its extension and of the concomitant discomfort, and in 
the fading away of the redness. Such symptoms of septic infection as redness of the lymphatics, 
enlargement of the ganglia, and phlebitis are scarcely ever seen in erythema serpens, and where 
present are very mild and ephemeral. 
The early symptoms vary in a marked degree. Some patients complain of a slight local sore- 
ness ; others of a burning, tingling, and even shooting and throbbing pain, which may be localized 
or may extend to parts beyond. Some patients seem indifferent to the disease ; others are ner- 
vous, worried, and apprehensive. In some cases, so slight and insignificant is the infecting lesion 
and the erythema, that one is incredulous of the patient's story of his suffering. There is usually 
no systemic reaction, but in severe cases mild fever, malaise, and a general condition of nervous- 
ness and worry may exist. 
The marked variation in the course of erythema serpens would seem to indicate that it 
originates in more than one septic agent, and that perhaps idiosyncrasy is an accessory factor. 
In some of the mild cases no history of contamination with decomposing animal matter can be 
obtained, and we are forced to conclude that the disease results from what Morrant Baker calls 
"harmful matter," no end of which may come in contact with the fingers and the hands especially, 
and in a more limited manner with the feet. 
The relation of the putrefactive secretions of dead animal matter is so well established as an 
etiological factor in erythema serpens or erysipeloid as to be beyond doubt. Rosenbach's observa- 
tions have proved that the essential septic agent is a microbe, the exact nature of which is yet to 
be determined. It is very probable that the severe cases of erythema serpens are those derived 
directly from septic and putrefactive fluids. 
• The prognosis of this affection is, in the majority of cases, favorable. Sooner or later the 
disease will cease and leave no sequelae. Lymphangitis, phlebitis, and swelling and abscess of 
ganglia are so rare that they are almost unknown. 
Treatment.-The first essential is thorough antisepsis, and then the parts should be put at 
rest. To this end they should be well washed with soap and hot water, and then freely bathed 
with a watery solution of the bichloride of mercury (1-2 : 5000). Lead-and-opium wash, a satu- 
rated solution of boric acid, or a 2 per cent, solution of carbolic acid in water, or Thiersch's solu- 
tion, may be kept on the parts constantly by means of absorbent gauze. Saline diuretics may be 
given, a plain, simple diet enforced, and the bromides or morphine may be administered if the 
exigencies of the case demand them. Part V 
Plate XXXV 
LEA BROTHERS & CO. PUBLISHERS , PHILADELPHIA . 
TINEA vel PITYRIASIS VERSICOLOR. TINEA VERSICOLOR. 
I inea versicolor is the mildest of all the vegetable parasitic diseases of the skin : it affects 
only the superficial layers of the epidermis, and is mostly confined to parts covered with clothing. 
It is also called pityriasis versicolor and chromophytosis. 
I his disease begins, in the great majority of cases, upon the chest, chiefly over the sternum, 
and is rarely seen elsewhere upon the body without being found on this classic site. It first 
shows itself as minute light, fawn-colored punctae or spots, which close examination shows have 
a follicular origin. These little lesions are scattered without regularity over the parts affected, 
lheir growth is moderately rapid, and is more so in persons who perspire freely. As the punctae 
grow they assume the shape of round and oval patches. These latter continue to increase, and 
often merge into one another and become lost in an expanse of morbid epidermis. In this way 
large surfaces become covered, the larger patches themselves increasing peripherally, while new 
spots are forming more or less distantly from their borders. Thus in practice we see the eruption 
in various phases. Sometimes there are many small spots discretely and irregularly scattered, or, 
again, a few large spots are surrounded by a number of smaller ones. No tendency to symmet- 
rical distribution is observed. In some cases large expanses of tissue are covered by the eruption, 
as is shown in Fig. 35, where it is in greater profusion over the sides of the trunk than over the 
sternum. When the eruption consists of very large patches surrounded by numerous small ones, 
it has been compared to a map which shows large surfaces or continents and smaller ones which 
are supposed to represent islands. 
I he color of tinea versicolor varies between a light-fawn and a deep-brown, or even blackish, 
tint. Upon very light and delicate integument it is much less pronounced than upon a dark one. 
In general, sparse and limited eruptions are lighter in color than compact and extensive ones. 
The tint presented in Plate XXXV. may be said to be well marked and even fully developed. 
In general, there is scarcely any elevation of this eruption, but in some cases on oblique view 
a slightly-marked salience may be noted. The eruption in any form is sharply marginated, and is 
not surrounded by inflammatory areolae. It gives forth branny scales, sometimes in profusion, and 
again in minute quantity. It does not attack the hairs or the nails. 
I he site of most constant election is the sternal region, and from there it usually spreads or is 
transferred elsewhere upon the body. It not uncommonly extends over the thorax anteriorly, 
laterally, and posteriorly, when it is prone to settle between and over the scapulae. It is also found 
over the abdomen and hypogastric region, and I have seen it exist by extension upon the thighs. 
Crocker has seen it upon the popliteal spaces. It is usually, however, limited to the upper and 
chiefly inner portions of the thighs. It somewhat rarely extends up the neck, chiefly on the lateral 
aspects, and limited to the region covered with the collar or neck-gear. I have seen it extend from 
under the lower jaw up to the ears, and then jut forward to the malar prominences. Biart has 
seen it on the face proper, and Payne found it in the beard and scalp. As a rule, it is confined to 
the upper parts of the arm, but it may invade the forearm as far down as the wrists, as I have 
several times seen. It sometimes occurs in an annular and serpiginous form. 
This disease is usually seen just before puberty, and occurs at any time up to old age. It is 
most frequently met with in early adult and middle life, in both males and females in about equal 
proportion. 
259 260 
DISEASES OF THE SKIN. 
The symptoms of tinea versicolor vary within considerable limits. In some cases no complaint 
is made even when the eruption is very extensive. In others pruritus of a mild or tolerably severe 
degree is complained of. Usually the itching is more severe when the weather is hot, when the 
circulation is increased by any cause, or when the patient wears coarse flannel. 
The course of the disease is essentially chronic, lasting months and years. Patients some- 
times tell us that the eruption disappears spontaneously, or that it becomes much less extensive 
and then increases again, or that it comes and goes with hot weather. In general, however, it 
comes to stay. It is the least contagious as it is the least irritative of all vegetable parasitic affec- 
tions. Instances of well-defined contagion no doubt are frequently met with, but then, again, hus- 
bands and wives frequently give evidence that they have not contracted it the one from the other, 
and the same has been observed in the cases of bedfellows, male and female. One can but mar- 
vel at Lancereaux's statement that he became infected by scales taken from a patient for micro- 
scopic purposes, and that he afterward infected his wife. 
Etiology.-The cause of the disease can readily be determined in a simple and expeditious 
manner. A few of the scales should be placed on a glass slide, and upon them a minute quantity 
of equal parts of glycerin and liquor potassa should be dropped, and over this a cover-glass 
placed. Under the microscope (400 to 500 diameters) the Microsporon furfur of Eichstedt will 
then be readily seen. This micro-organism consists of spores and mycelium, the former in colonies 
or clusters, the latter arranged in a most inextricable confusion of interlacement. The appearance 
of the parasite is well shown in wood-cut Fig. 36. It was once claimed that consumptive persons 
were especially prone to the disease. This much, however, 
qan be said-that many persons having chest affections, with 
more or less sweating of the intermammary region, present 
tinea versicolor. The disease occurs so commonly in the sick 
as well as in the healthy that it cannot be classed as the sole 
appanage of either. It seems, however, much more luxuri- 
ant and persistent in some patients than in others. 
Diagnosis.-Since the parasite may be so readily dis- 
covered even by persons not skilled in the use of the micro- 
scope, there need be no difficulty in determining the nature 
of the disease. 
It may be mistaken for chloasma on superficial exam- 
ination, but the evident seat of the disease in the epidermis, 
its peculiar scaliness, its sites of development, its subjective 
symptoms, and indeed its whole physiognomy, are so clearly 
marked that its nature is readily recognized. (See section 
on Chloasma.) 
By the laity tinea versicolor is frequently looked upon 
as an evidence of hepatic derangement, and many a physician 
has brought a case to me thinking that it was syphilitic in 
nature. The maculations following the erythematous syph- 
ilide are never in great sheets like tinea versicolor; they are 
small, patchy, less uniform in surface and outline, less scaly 
at all, are not confined to the regions of the parasitic disease, and are accompanied by a history 
f syphilis or by the presence of other lesions. 
Tinea versicolor has been mistaken for the macular form of lepra, but such an error can 
ardly exist long. In all cases of doubt the microscope is of unfailing guidance. 
Prognosis.-Such is the mild, non-inflammatory course of the disease that even when exten- 
Fig. 36. 
Microsporon furfur: a, principal group of spores, 
forming a rounded mass; b, small groups of spores; 
c, filaments of mycelium, formed of long, brilliant 
curved articulations. X 400. TINEA VERSICOLOR. 
261 
sive it occasions very little real discomfort. It is none the less persistent, however, and demands 
continuous energetic treatment for its destruction. When it has nearly disappeared it is prone to 
begin again : left alone, it may remain indefinitely. 
Treatment.-The keynote in the treatment of tinea versicolor is the thorough maceration of 
the epidermis, by which the parasite may be more or less completely removed, and in consequence 
of which remedial agents become directly active. To this end hot baths, with copious and vigor- 
ous soap inunctions or local bathing, are absolutely essential. To the local or general baths alkalies 
(borax and sal soda) may be added with a free hand, but not in sufficient quantity to cause irrita- 
tion. Indeed, in adapting all methods of treatment, while the destruction of the parasite is held 
prominently in mind, great care must be exercised that dermatitis is not produced. 
Brisk frictions of the affected surfaces with the green soap by means of a flannel pad or nail- 
brush should be made perhaps every day or less frequently, and then the part well immersed and 
washed in hot water. In stubborn cases soap frictions, with the addition of powdered pumice-stone, 
may be used to rub off the epidermis and dislodge the parasite. 
V arious lotions may then be of benefit, of which the following are noteworthy: 
R. Sodae hyposulphitis, 3>ij; 
Aquae, §iv. M. 
R. Acid, sulphurosi, 
Glycerinae, ad. giss; 
Aquae, £ij. M. 
R. Hyd. bichloridi, gr. iv+vj; 
Ammon, mur., 5ss; 
Aquae, §iv. M. 
For limited patches, with care : 
R. Acidi acet., 
Aq. coloniensis, ; 
Aquae, ad §viij. M. 
Chiefly for the pruritus. 
Ointments have been recommended for the treatment of tinea versicolor, chiefly those com- 
posed of chrysarobin, pyrogallol, thymol, and sulphur. There can be no doubt of their efficacy 
m many cases, but they are objectionable as being difficult of application and by reason of their 
greasiness, of their odor, and of their staining properties. 
Since the parasite is harbored in the patient's under-wear, and from that often proves a source 
of reinfection, it follows that great care should be taken to thoroughly sterilize all under-garments 
worn. To this end thorough boiling is the best means. After each seance of treatment only 
newly-washed and well-ironed under-wear should be put on. TINEA TONSURANS. 
There are three principal varieties of ringworm included under the term tinea tricophytina or 
tricophytosis, produced by the fungus Tricophyton tonsurans: they are tinea tonsurans, ringworm 
of the scalp ; tinea sycosis, ringworm of the beard ; and tinea circinata, ringworm of the body. 
All three affections have a special and distinctive clinical history and require varying modifications 
of treatment. Some authors make a further subdivision by including ringworm of the thighs, tinea 
tricophytina cruris, which really belongs to ringworm of the body, and ringworm of the nails, tinea 
tricophytina unguium, which is simply a very rare accidental complication of any form of ringworm. 
Fhe inflammatory conditions produced by the Tricophyton tonsurans are more severe than those of 
tinea versicolor, and less destructive than those of favus. 
RINGWORM OF THE SCALP. 
Ringworm of the scalp is a chronic, very contagious affection, resulting from the irritation of 
the fungus Tricophyton tonsurans upon the root-sheaths of the hairs and epidermis of the head. It 
usually begins in an insignificant manner, and is commonly quite well under way before its nature 
is recognized. Children, who are almost the only subjects of the disease, may complain of slight 
pruritus of the scalp or their attendants may notice upon that region one or more scurfy patches. 
Such a history calls for minute examination by the physician, which should always be made in clear 
sunlight, perhaps with the aid of a lens of moderate magnifying powers, and with such an arrange- 
ment of the hairs as will admit of full and accurate inspection. 
In the early stages of the disease one, a few, or many reddish-brown scaly spots may be seen 
irregularly scattered, without the slightest tendency to symmetry, over the scalp. These little spots, 
varying in size between a split pea and a quarter of a dollar, are in general quite sharply margin- 
ated, slightly or decidedly elevated, and surrounded by a growth of normal hair. Over the surface 
of the patches the hairs may be broken off short at the skin-level, or they may jut up like stumps, 
stubble, or cut grass for a length of one to three or four lines. In general, these features are most 
readily seen upon children whose hair is dark, and are sometimes not very striking in light-colored 
children. Since the correctness of the diagnosis largely depends upon the condition of the hairs, 
these structures must be carefully examined. They will be found to be thicker, more swollen than 
normally, dull and lustreless in hue, rough in structure, and very readily broken, the resulting frac- 
ture being irregular. It may happen that a few long hairs are left on a patch, and then the distal 
portion will be healthy, while that within half an inch of the scalp will present the appearance 
already described. Such a combination of dull, reddish, scaly patches on the scalp with unhealthy 
hairs is always pathognomonic of ringworm. The condition of the hairs is unvarying; that of the 
scalp may deviate from the type-form already described. Thus the color may not be perceptibly 
changed from normal; it may be of a dull-gray tint, without any tendency to redness, or it may 
be of a dull grayish-brown hue. Then, again, the redness may be very well marked, and may 
approach a purplish tint. The appearances shown in Plate XXXVI. are very characteristic of a 
recent and active attack of ringworm of the scalp. 
262 Part V 
Plate XXXVI 
LEA BROTHERS & CO. PUBLISHERS .PHILADELPHIA. 
KERION AND RINGWORM OF HEAD. 7TNEA T0NSC7TANS. 
263 
lhe diseased patches increase slowly or rapidly in size, accentuating their original round or 
oval shape, becoming irregular in outline or gyrate from the fusion of two or more. In many 
cases the scaly surfaces are of themselves tolerably smooth ; in others minute papulation resem- 
bling goose-flesh, the flesh of a plucked fowl, and certain coarse files may be seen. This condition 
is due to epidermal increase at the orifice of the hair-follicles around the stumps, and presents a 
miniature resemblance to small tree-shoots banked around with earth. Throughout the whole 
course of scalp ringworm mild epithelial desquamation usually goes on. 
lhe elevation of the skin varies in different cases and at different periods. At first the skin 
may be so swollen and puffed that decided salience is seen, or the elevation may be slight, and 
often is unappreciable, especially in chronic cases. 
I he studies of competent observers have proved that the activity of the fungus is spent on 
the epithelial cells, and that it has no tendency to primarily involve the mucous layer and the 
deeper layers of the skin. In the greater number of cases, therefore, the disease runs its course 
in a chronic non-inflammatory condition, presenting the typical phases already described. We 
occasionally meet cases in which the scurfy condition of the skin is soon lost, and in which the 
eruption is composed of smooth white (sometimes markedly so), shining patches of skin, from 
which stumps are absent and on which there are usually prominently open follicular orifices. 
Such cases are often mistaken for alopecia areata, and in the absence of the classical history of 
ringworm the diagnosis is difficult until the fungus is found, and that is generally on hairs beyond 
the patches. 
In somewhat exceptional cases the parasite, as it so commonly does, burrows deep into the 
hair-follicle, and there involves the epithelial structures of the hair-sheaths in hypertrophy and 
inflammation, which latter process extends to surrounding and deeper tissues. Wethen see a new 
order of phenomena. What is known in dermatology as tinea kerion is a more or less acute 
inflammation of the hair and sebaceous follicles, due to the Tricophyton tonsurans. In kerion the 
scalp is much swollen, presents a boggy sensation, even to a misleading but moderate sense of 
fluctuation ; so much so in two instances that I have seen young men prepare to incise the parts. 
Usually there is much less stump-growth than in simple ringworm, and the hair-follicles present 
a honeycomb appearance, swollen and everted, and give issue to a gluey, honey-like fluid, some- 
times in surprising quantity. Upon the vertex and the left side of the head of the child in Plate 
XXXVI. are two characteristic patches of kerion which presented a pulpy, boggy sensation to the 
finger, and by their color and elevation contrasted sharply with the smaller patches of ringworm. 
Some authors speak of the occasional occurrence of vesicles in scalp ringworm. I must say 
that I have seen lesions which, with great imaginative powers and a willing credulousness, might be 
considered to be vesicles, but which were really cedematous papules or granular elevations, but 
not strictly true vesicles. On the contrary, in some severe and neglected cases we sometimes see 
well-marked pustules, particularly in combination with papules, or, as I may say, a mildly papillo- 
matous condition of the scalp, with more or less oozing, which might on cursory examination be 
mistaken for eczema. In these cases there is usually much tendency to incrustation, which may 
further obscure their nature. 
The occurrence of scattered patches of ringworm on the face, neck, and hands, and even on 
the body, is not at all uncommon in tinea tonsurans. 
I he course of ringworm of the scalp may be very acute or very chronic. Some children 
seem to offer a fertile field for the proliferation of the Tricophyton tonsurans, which seems to gallop 
over large extents of scalp surface. In other cases (and in general the greater number) the 
course of the affection is rather slow. The original patches increase in area a froid, and new ones 
may appear and act likewise. In some cases the affection is more rapid on some portions of the 
scalp than others. 264 
DISEASES OF THE SKIN. 
This disease attacks both rich and poor without preference, and, as a general rule, 
shows no marked luxuriance even in the weakly and sickly subjects. It is the most obsti- 
nate form of ringworm seen in children, owing to the burrowing of the fungus in the 
inaccessible skin-follicles. 
Etiology.-The infecting agent in all forms of ringworm is the Tricophyton tonsurans, which, 
besides attacking the human race, is also found upon the lower animals-horses, cows, oxen, and 
dogs in particular. It luxuriates only in epithelial 
tissues. 
This parasite is readily seen under the micro- 
scope with a glass magnifying from 100 to 500 diam- 
eters. To this end the hairs and epithelial scales 
must be soaked for a few moments in a minute 
quantity of equal parts of liquor potassae and gly- 
cerin. It consists of conidia or spores and myce- 
lium. (See wood-cut Fig. 37.) 
This fungus is conveyed from the infected to 
healthy children at school and at home by direct 
contact or through the medium of the fingers, caps, 
or other head-gear, combs, brushes, towels, etc. Older 
children may be infected by handling or contact with 
a diseased animal. This form of contagion is not 
at all uncommon in subjects near or beyond puberty. 
Though very young children do not show a marked susceptibility to scalp ringworm, older 
ones certainly do, and seem to lose this morbid tendency as they grow to maturity. Various 
theories are offered to explain why the scalps of some children afford such a favorable nidus 
to this fungus, while others are less susceptible ; all of which, though plausible, are far from 
convincing. Conditions of moisture and humidity of the atmosphere are favorable to the 
luxuriant growth of the Tricophyton tonsurans. It is an interesting question as to whether the 
great prevalence of scalp ringworm in England is in any measure due to its damp climate. 
Diagnosis.-The recognition of ringworm of the scalp usually presents no difficulties. This 
is especially true when the disease exists in its typical state. When complicated by folliculitis and 
dermatitis, as observed in kerion, eczema or pediculosis capitis might be suggested. But a study 
of the history, together with microscopic examination of the hair-stumps and epithelial scales, will 
soon settle the question. In its chronic scaly stage appearances resembling pityriasis capitis might 
be noted, and the diagnosis may possibly only be made by the discovery of a diseased hair and 
the fungous elements within it. Usually, however, the patchy character of the eruption, even in 
the reparative stage, is diagnostic of ringworm. Sometimes the bald white spots of ringworm 
suggest alopecia areata to the mind of the physician : a study of the case and the employment of 
the microscope will soon put an end to doubt. It is hard to conceive of a case of psoriasis of the 
scalp being mistaken for ringworm, yet such a blunder has been made. The rule should be to 
consider the history of the case, look elsewhere for patches of psoriasis (elbows and knees), and 
to use the microscope. 
The reddish scaly patches early in the course of the disease might suggest a commencing 
attack of favus, which time and the microscope would soon determine. 
Prognosis.-Though destruction of the skin and alopecia are not common in uncomplicated 
ringworm of the scalp, these sequelae are to be feared in aggravated cases. The tendency of the 
disease to chronicity, to auto-infection, and the infection of others renders it a very formidable one. 
Though it, of itself, does not impair the nutrition of a patient or cause him much suffering, the 
Fig. 37. 
Tricophyton tonsurans : a, spores; b, b, mycelium composed of 
short stems; c, c, mycelium composed of long transparent 
stems; d, epidermic scales. TINEA TONSURANS. 
265 
seclusion and ostracism which it often entails have a prejudicial influence upon his or her health 
and morale. It is a serious trouble, too, when it gets into a family of children ; and it has been 
truly said that it is little less than a calamity when it gains a firm foothold in a school or public 
institution for children. In general, the earlier the treatment is instituted, the quicker does the 
cure follow, and, conversely, the longer the disease exists, the more difficult and delayed is the 
cure. 
Much responsibility rests upon the physician in pronouncing a case of ringworm cured. 
Children thus affected should be kept from school and from playing and romping with relatives 
and companions. In families, in boarding-schools, in protectories, and correctional institutions, 
such children should be segregated from the rest, though their health should not be allowed to 
become impaired by confinement and want of exercise. Proper precautions should be taken to 
prevent the spread of the contagion, and all possible safeguards adopted to protect the healthy 
ones, particularly in epidemics among large numbers of children. 
It must be remembered that one diseased hair remaining upon the head of a child may be the 
cause of a second and severe attack of ringworm. Careful examination should be made, and no 
case should be pronounced cured until all hairs are, seen to be healthy, and until there are no 
longer any scaly patches even of small size and of apparent insignificance. 
Such is the persistence of ringworm of the scalp that in cases diligently treated, when cure is 
anticipated, examination reveals isolated stumps scattered irregularly and more or less copiously 
over the head. I he experience gained in the management of a few cases of scalp ringworm will 
in general make the physician both alert and skilled in the recognition of these diseased stumps. 
It is always a good rule to withhold the assurance of cure until all hairs are seemingly normal 
in lustre and suppleness. Such are the striking appearances of diseased hairs that their recog- 
nition is not difficult to a trained observer. A person lacking this training should resort very 
frequently to the microscope for aid. In this connection it is well to emphasize the fact that 
diseased stumps sometimes break off, and the orifices of the follicles look like little dots or 
points of a dirty brownish or black color. The existence of these peculiar punctae is always 
a bar to a verdict of cure. 
I REatment.-The difficulty in the treatment and cure of scalp ringworm is well attested in 
the infinite variety of remedies which have been used and recommended. Since applications which 
are deemed almost specific in their action sometimes fail, it is fitting that the physician should have 
at his command all available remedies which have proved beneficial even in limited degrees. With 
a wealthy armamentarium at his command he can select a remedy which will be suitable for each 
case. 
I he chief reason of the difficulty in treating ringworm of the scalp lies in the fact that the 
ungus tends to lodge deep in the hair-follicles, where it is difficult to get at. Then, again, the 
ricophyton tonsurans itself is tenacious of life, and the remedies used in its destruction must not 
be too severe, otherwise the tissues and appendages in which it luxuriates will also be destroyed. 
1 his factor of inaccessibility and the persistence of vitality of the parasite always confronts us. 
Iheie aie yet still other conditions to be considered. The skin of young children is always prone 
to react badly under stimulation, and in treating such the inherent tendency to severe inflammation 
must always be borne in mind. And, further, in children of older growth, as in very young 
ones, there frequently exists a marked tendency to dermatitis and eczema, which will act as a draw- 
back to active stimulation. Nothing can be more annoying to all parties and cure-delaying than 
the occurrence of abscess or dermatitis during the treatment of ringworm. Therefore, while the 
physician must employ energetic remedies, he must exercise a temperate hand and always keep a 
sharp lookout for possible complications of an inflammatory nature. He must bear in mind that 
injuriously severe remedies may cause the destruction of the hair-papillae, which means subsequent 266 
DISEASES OF THE SKIN. 
baldness, and that unsightly scars are perennial reminders of unskilled efforts. This watchfulness 
is all the more necessary in cases where a large extent of surface is involved, for in them the 
incautious use of stimulating and antiparasitic remedies may be followed by annoying or distress- 
ing results. Having selected the remedy deemed suitable to a given case, the physician must see 
that it is used intelligently, with patience and perseverance, until its efficacy or failure is estab- 
lished. To determine this question time is necessary, and a remedy known to be of benefit in 
such cases should not be precipitately abandoned. Much of the unsuccess in the treatment of 
scalp ringworm is due to a want of sufficient patience and to a vacillating policy on the part of the 
medical attendant. On the other hand, the parents and guardians should be thoroughly impressed 
with the difficulty of cure, the chronicity and tendency to exacerbations and relapses in these cases, 
for they are often prone to impatience and to become unreasonable, and to take the children from 
one medical man to another ; in which event the cure is usually delayed indefinitely. 
The first essential in the treatment of scalp ringworm is the cutting of the hair to a length of 
one-half or three-quarters of an inch. In boys this procedure should always be insisted upon, and 
it should be resorted to in cases of girls where the diseased patches are multiple or where there are 
isolated and disseminated stumps. Then the scalp should be thoroughly shampooed and the hair 
well washed with a 2 or 3 per cent, watery carbolic solution, or with a saturated solution of boracic 
acid, or the following solutions should be kept on hand and used daily as often as requisite : 
R. Hydrarg. bichloridi, gr. i-ij; 
Ammon, murat., 5ss; 
Aq. coloniensis, £ij; 
Aquae, ad £viij. M. 
R. Acid, acetic., 5ss+5j; 
Aq. coloniensis, Jjij; 
Aquae, ad gviij. M. 
R. Acid, boracic., 3j~5'j > 
Ether, sulphurici, ; 
Spts. vini rect., ad §vj. M. 
This is the lotion proposed by Carafy, who thinks that alcohol has greater penetrative power into 
the hair-follicles than water. 
These lotions can hardly be considered as parasiticides proper, since their function is chiefly 
to sterilize the as yet unaffected scalp and hair. They are, however, none the less necessary, and 
are efficient. 
Having the morbid patches freely accessible to view and manipulation, a careful and well- 
regulated course of epilation should be begun, using forceps with broad flat blades and with a 
spring not sufficiently strong to tire the user. 
Sopping each spot with very hot alkaline 
water or the inunction of carbolic vaseline 
(5 per cent.) tends very much to aid the 
ready extraction of the hairs. This epilation 
should be done by firmly grasping one or 
'more hairs by the forceps and making traction in the line of their growth. This should be 
performed in a systematic manner over a given part, and not at random. Sometimes the 
brittleness of the hairs is so marked that they break off at the skin-level, in which case epila- 
tion must be delayed, but it should again be essayed just as soon as the stumps have 
become sufficiently firm. > 
In recent cases, where the patches are limited in number and area, a cure is often effected by 
Fig. 38. 
Epilating Forceps. TINEA TONSURANS. 
267 
comparatively mild means. To this end the affected parts may be painted with tincture of iodine 
or with the following: 
R. Tr. iodini, gij; 
Collodion flex., 5j. M. 
Ora solution of bichloride of mercury in water, two to four grains to the ounce, may be used. A 
number of years ago 1 proposed for this condition the following combination : 
R. Hyd. bichloridi, gr. ij+iv; 
Tr. benzoini comp., gj. M. 
this, like the iodine preparation, should be painted on the spots daily. It is not only of much 
benefit in many cases of early scalp ringworm, but also is worthy of extended use in the chronic 
scaly stage. The tincture of benzoin forms a protective coating of the skin, and keeps the para- 
siticide in a state of constant application. Besides this necessary feature, this liquid, as well as col- 
lodion, liquor guttae-perchae (traumaticin), undoubtedly acts by preventing the access of oxygen, so 
necessary to the growth of the fungus. 
In the early stage of ringworm of the' scalp various ointments may be used, always with due 
attention to their strength, which, it may be stated in general terms, should vary according to the 
indications of each case. These ointments may be composed of boracic acid, bichloride of mer- 
cury, yellow oxide of mercury, red and white precipitates, white precipitate and sulphur, calomel 
and carbolic acid, iodine and salicylic acid, or citrine ointment may be used more or less reduced. 
I hese same remedies may also be remembered in the more chronic and obstinate cases. For 
these especially the following combination may be used, according to the lines already indicated : 
R. Chrysarobin, 
Acid, salicylic., da. 5j; 
Collodion flex., ,yj. M. 
Or io per cent, of chrysarobin suspended in liquor guttae-perchae, traumaticin. The latter combi- 
nation proved most efficacious in the hands of Dr. W. T. Alexander in an epidemic of scalp ring- 
worm in one of the institutions for children in New York. Dr. Alexander in his paper brings out 
clearly the important fact that the retentive and impenetrable dressing thus produced was especially 
beneficial in mitigating the arduous labor and care on the part of nurses ; which is an important 
consideration in afflicted families, and especially so in institutions where there are large numbers 
of children. The stability of the covering of the patches is beneficial to the patients, and efficiently 
prophylactic to those with whom they may be forced to come in contact. Chrysarobin is so objec- 
tionable in the ointment form, by reason of its tendency to stain and disfigure the patient and his 
clothes, that its use is contraindicated. Moreover, it is prone when thus employed to produce 
severe dermatitis. In suspension with collodion or traumaticin its staining qualities are not present, 
though it may produce dermatitis, which should always be expected and guarded against by its 
very careful use. 
lhe oleate of mercury is held in high esteem by Dr. J. V. Shoemaker in the treatment of 
scalp ringworm, and his testimony, as well as that of others, places the remedy among those most 
axailable for chronic and rebellious cases. It may be employed according to the indications in 
ointment of vaseline or cold cream of varying strengths (5 to 30 per cent.). Like all ointments, 
it should be gently but firmly rubbed into each patch, and, if productive of undue redness, cooling 
lotions should be applied. This same expedient must be observed in the use of all remedies upon 
the scalp. 
I he oleate of copper is also looked upon as a very efficient remedy by Dr. Shoemaker, and 
recently Dr. H. W. Blanc of New Orleans has published excellent results in the treatment of 268 
DISEASES OE THE SKIN. 
twenty-seven boys of an orphanage from its employment. The formula of the latter was as 
follows: 
R. Cupri oleate, ; 
Vaseline (vel lanolin), 5j. M. 
Not only is it claimed that this remedy is antiparasitic, but that it is also soothing ; so much so 
that it is not contraindicated in cases complicated with inflammation and kerion. 
In the treatment of ringworm of the scalp, as well as in favus, it is well to remember the 
method of Dr. H. J. Reynolds (see page 248). 
Old and persistent patches of scalp ringworm may require energetic stimulation, always 
employed with great caution as to strength and frequency of use. To this end it is well to 
remember Coster's paint (iodine, 3j-5ij ; oil tar, sj), acetum cantharidis, carbolic acid in combina- 
tion with glycerin, cantharidal collodion, strong tincture of iodine, and citrine ointment. The fol- 
lowing prescriptions will often be found of much service in this class of cases: 
R. Sulphuris sublim., oj+S'j > 
Vaseline, sj- M. 
R. Hydrarg. precip. alb., gr. x+xx; 
Sulphuris loti, 5jd3ij ; 
Ung. aq. rosae, 3j. M. 
R. Sulphur, sublim., 3j_3'j j 
Potassae subcarb. 5ss~3j; 
Ung. simpl., §j. M. 
R. Acid, carbolici, gr. xx-xxx; 
Sulphur, loti, 3j+3U 1 
Vaseline, §j. M. 
R. Ung. hydrarg. nitratis, 3j+3ij; 
01. cadini, gj; 
Ung. aq. rosae, ,5j. M. 
R. Hydrarg. sulph. flav. jjj; 
Acid, carbolici, gtt. x+xx; 
Ung. aq. rosae, gj. M. 
R. Hydrarg. bichloridi, gr. j-ij-iij; 
Ammon, mur., , ; 
Bals. Peru., 5j; 
Vaseline, §j. M. 
Within recent years much discussion has taken place regarding the propriety of the use of 
croton oil in the treatment of scalp ringworm. Since blisters act by causing active inflammation 
in follicles and its extension to the morbid epidermal tissues, it follows that their use in chronic 
rebellious cases is decidedly indicated within proper limits. Thus may be used the various strong 
remedies already enumerated. In this category croton oil naturally belongs, and the experience 
of many observers goes to prove that, properly used, it is a very valuable adjunct treatment, and 
that, carelessly used, it is a remedy fruitful of harm. Dr. Alder Smith is one of the authors who 
place great reliance on this drug, and I shall give his method of using it in his own words, which 
are, I think, judicious and conservative. He says : "In some inveterate cases, which have resisted 
the action of parasiticides, when all the patches have disappeared and the disease has passed into 
the disseminated variety, I believe the best chance of a cure is to subject the entire scalp to a very 
close examination with a lens, and to place, by aid of a very fine sable brush, a minute drop of TINEA TONSURANS. 
269 
croton oil wherever the isolated stumps or black spots may be seen. (A case where black dots 
are observed is the one most difficult to cure.) If there are only a limited number, die oil can be 
pressed into the follicles by running the point of a very fine blunted gold pin into them by the side 
of the diseased stumps. The oil usually causes a pustule, and the loosened stump comes out with 
the discharge, and can afterward be removed with the forceps." 
In this connection it is well to remember that electrolysis has been found beneficial in these 
and analogous cases by Hardaway and others. 
1 he treatment of kerion is simply that of scalp ringworm plus much inflammation. Epilation 
should be thoroughly employed ; the follicles may be touched with carbolic acid and glycerin in 
equal parts, and a bland antiparasiticide ointment should be kept constantly on the surface. In 
like manner cases complicated with dermatitis and eczema should be dealt with. 
I he latest remedy for the various forms of ringworm is the tincture of Siegesbeckia orientalis, 
which has been recommended by Dr. J. Hutchinson1 of Glasgow, Scotland. Siegesbeckia orientalis 
is a shrub, the green portions of which have a great reputation in the treatment of lesions of the 
skin in the Mauritius. A tincture of this shrub was used by Hutchinson in equal proportion with 
glycerin, and was well rubbed into the ringworm patches night and morning. The drug is said to 
act as a stimulant and a parasiticide. By its use the morbid areas become broken up into a num- 
ber of smaller patches, with intervening sound skin. By the continued use of the tincture the 
small patches in time gradually disappear, and leave small erythematous blushes, which fade away 
in a day or two. It is said that with this treatment epilation is unnecessary. On the other hand, 
it is stated that Hallopeau2 has tried this remedy in the St. Louis Hospital in Paris, and found it 
completely inefficacious. Hallopeau prefers a method of treatment used by Vidal, which consists 
in the application both morning and evening to the diseased patches, which had previously been 
shaven, of a layer of vaseline which is covered with an impermeable dressing. It is said that 
Lailler modified this method by adding to the vaseline i per cent, of iodine. Improvement takes 
place quite rapidly, although, it is significantly remarked, a complete cure requires months. 
1 British Med. Journal, June 25, 1887. 
2 Journal of Cutaneous and Genito-urinary Diseases, Jan., 1889, p. 36. PITYRIASIS RUBRA. 
Pityriasis rubra is an inflammatory affection of the skin having a distinct individuality and 
characterized by a diffuse, perhaps general, redness of great intensity, attended with profuse and 
constant exfoliation of the epidermis in small and large flakes. During its evolution papules, 
vesicles, pustules, and bullae and crusts are never seen ; hence the affection is not the chronic and 
scaling stage of eczema. Since its development is in large expanses of morbid tissue, from which 
epidermic lamellae are freely shed, and not in the form of discrete disks covered with imbricated 
scales, it is evidently not related to psoriasis. It, however, must be said that in chronic psoriasis, 
especially in drunkards and in persons of rheumatic and gouty habit, a generalized exfoliating red- 
ness of the skin sometimes supervenes, which might be, and has been wrongly, called pityriasis 
rubra. The affection, moreover, is not the chronic stage of pemphigus foliaceus, nor has it any 
relation to the generalized exfoliative dermatitis, resembling scarlet fever, which is caused, in some 
persons, by the ingestion of quinine. Further, it is not clinically related to the various and often 
anomalous forms of localized and more or less generalized desquamative inflammations of the skin, 
which are in most cases much less severe and of decidedly shorter duration than pityriasis rubra. 
Clinical observation has shown that the disease pityriasis rubra of Devergie, and particularly 
of Hebra, presents such a striking physiognomy and so sharply marked a clinical history that it is 
hard to understand why any doubt of its distinct individuality should be for a moment entertained. 
Being a very rare disease, some authors have described it at second hand, and I can readily under- 
stand why persons who have not had the opportunity of studying its course are led to think that 
the primary and secondary scaling affections already mentioned belong in the same group as pity- 
riasis rubra. My studies have firmly convinced me that we should unhesitatingly accept pityriasis 
rubra as a separate disease, and then leave it alone. The efforts made during the past ten or 
twelve years by various authors to establish a generalization and to prove a correlation between it 
and the various scaling affections mentioned have been productive of nothing but uncertainty and 
confusion. The facts, I think, are these : Pityriasis rubra is a disease sui generis, and the other 
extensive scaling diseases are of a different nature and course, and in no way akin to it. Real 
progress will be made by a systematic and analytical study of the last-mentioned group of cases 
by endeavoring to arrange them in clinical divisions and by well-directed investigations into their 
etiology. In the light of our present knowledge I think that the following division of general des- 
quamating affections, which was proposed by Dr. Buchanan Baxter, commends itself for its sim- 
plicity, and offers a rational basis for further investigation : 
1. Exfoliative dermatitis supervening on eczematous affections ; 
2. Exfoliative dermatitis supervening on psoriasis ; 
3. Exfoliative dermatitis supervening on pemphigus ; 
4. Cases of primary exfoliative dermatitis. 
Of pityriasis rubra I have seen three well-marked cases, and from their study, and from an 
attentive reading of classical dermatological works, I am able to present its clinical history. 
Pityriasis rubra is very rarely seen in its commencing stage, but there is a concurrence of 
opinion among authorities that it first appears on the anterior surface of the trunk, in the axillse 
270 Part V 
Plate XXXVII 
LEA BROTHERS & CO PUBLISHERS, PHILADELPHIA 
PITYRIASIS RUBRA. PITYRIASIS RUBRA. 
271 
and upon the inner surface of the arms near the joints, and in the folds of the groin. It begins as 
a red spot or spots, which slowly increase in area, but never show any elevation nor the sharply- 
marginated condition of the erythemata. Being at first of a bright pinkish-red tint, the color 
increases in intensity as the disease becomes diffused over large surfaces. When it is fully 
developed the skin is of an intensely red hue, and it may become of a deep brownish- or brick- 
red, such as is very accurately depicted in Plate XXXVIL Upon this morbid surface none of the 
primary lesions of the skin, except erythema, are seen ; but early in the course of the disease the 
excessive exfoliation of the plates of epidermis begins, and continues more or less unintermit- 
tently. At first the scales are small and thin, but as the disease gains ground and becomes inten- 
sified, small plates or flakes of affected epidermis are replaced by larger ones ; and so the disease 
goes on with the incessant reproduction of this exfoliation of epidermis. In some parts, such as 
the face and the back of the hands, the scales are usually smaller than elsewhere. Upon the 
body and extremities they may be very large. There is, however, even in these places, often a 
marked commingling of large and small flakes. These epidermal exfoliations are of a dull-gray 
color, as is well shown in Plate XXXVIL, and may be as thin as tissue-paper or three or four 
times that thickness. They are usually loosely adherent, and as a rule curl up on their edges until 
they are detached in their whole extent. The epidermis of the palms and soles have been known 
to escape with little thickening, but these sites are also the seat of much very thick and quite 
adherent exfoliation, such as is well shown in Figs. 2 and 3 of Plate XXXVIL Scales from these 
parts are sometimes so thick that they can be split up in layers. It is not uncommon to observe 
this disease in the condition depicted in Fig. 1 of the plate, in which only the intense redness is 
seen. Pressure with the finger-tips dissipates this deep color for an instant, during which a yellow- 
ish-white tint may be seen. Such a deep-red surface may remain without marked scaling for one 
or several days, but the exfoliation, for a time thus inactive, commonly begins again with activity. 
Upon the legs, particularly in persons who stand or walk much, a purplish tinge may be superadded. 
When the hands and feet are involved the nutrition of the nails is much affected. These structures 
become thick, rough, easily broken, striated, and of a dull-brown color (see Figs. 1, 2, and 3 of 
Plate XXXVIL). Early in the course of the disease there is scarcely any appreciable thickening of 
the skin, and this condition may exist for quite a long time. As time goes on, however, the inflam- 
mation in the upper parts of the cutis seems to grow deeper, and the whole tissue then becomes 
thickened and less elastic. This condition is usually most marked upon the extremities, where it 
leads to actual deformity and impairment of function. With the progressive thickening and less 
yielding condition of the skin a gradual loss of its subcutaneous connective tissues takes place. 
As these tissues are being absorbed the skin itself shrinks pari pass'll, until a more or less complete 
hidebound condition results. The effect of these changes is to so distort the fingers that they 
come to resemble talons and the nails to look like claws. Locomotion and acts of prehension are 
much impaired, and may become almost impossible. Fissures may occur near joints and on places 
subject to tension. The hairs, being of epidermal nature, also become affected. They grow thin, 
lustreless, and fall out. The mucous membranes are unaffected. 
1 he course of pityriasis is, as a rule, slow, and only exceptionally is it tolerably rapid. Months 
and years may be occupied in its extension. Its slow progress, however, is none the less sure, 
though we frequently see periods of quiescence, and we observe times when the exfoliation is at 
a standstill or at a minimum. Such a remission, however, is usually followed by a compensatory 
exacerbation. In this state years may pass, during which the patients may go about more or less 
comfortably, transact business, and, strange to say, complain very little of their lot. They suffer 
at first from a sense of heat of the skin and more or less pruritus, which, however, is never 
described as severe, nor is it productive of such an amount of scratching as to wound the skin. 
W hen fully developed the disease is attended with a marked sensation of chilliness, and such 212 
DISEASES OF THE SKIN. 
patients become unable to bear low degrees of cold. The latter tell marvellous stories of the quan- 
tity of scales which drop from them in standing or walking and while in bed. In general, a pint 
or a quart of scales may be collected in the morning from the bed of a patient in whom the disease 
is at its acme. In the eaily stages there may be an excessive secretion of sweat, but there is 
nothing akin to the plastic exudation of eczema observed during its course. Later on in the dis- 
ease the skin is markedly dry. In typical cases the affection extends from the crown of the head 
to the sole of the foot. In the later stages of the disease patients sometimes complain of hyper- 
aesthesia of the whole integument. 
Sooner or later, in very severe cases, the health of the patients, particularly of the older ones, 
show s signs of breaking up. I hey lose their appetite, their nutrition is impaired, they become 
nervous, sleepless, apprehensive, and despondent. I heir features become less mobile, they pre- 
sent a troubled and worried look, and they gradually lose their morale. In this state marasmus 
supervenes and leads to death. Kaposi has seen gangrenous spots develop upon a patient suffer- 
ing from this disease. In other cases, however, especially in middle-aged subjects, the course of 
the disease may be less disastrous. After a time it subsides more or less completely, and the 
patient may, even after a severe attack, return to health. The dictum that pityriasis is inevitably 
a deadly disease is far too dogmatic. Recovery may in some cases take place. 
I ityriasis rubra is a disease of the middle and late periods of life. It attacks both males and 
females perhaps the former in a greater proportion-and the rich as well as the poor. As a rule, 
there are no prodromal symptoms referable to the health. 
Eiioi,o(.\. Nothing positive can be stated as to the cause of this disease, though many 
h) potheses have been offered. It has been found in persons suffering from albuminuria and mild 
diabetes, tuberculosis of the lungs, brain, and intestines, in subjects who may be classed as deli- 
cate, and again in those in whom no deviation from health was appreciable. 
I aihology. H. Hebra has shown that in the early stages of the disease there is a moderate 
infiltration of the skin, which is later on the seat of absorption and atrophy. 
Diagnosis.-Such is the striking individuality of this disease and the uniformity of its type- 
form that it is hard to conceive how it can be mistaken. Should a case of generalized redness of 
the skin present itself, the first question to settle is whether it is primary or secondary to the dis- 
eases already mentioned. Intelligent questioning will soon settle this point. Acuteness of inva- 
sion, limitation of area, or a general exfoliation unattended with the well-marked redness of the 
skin in pityriasis rubra, are points to be considered in arriving at a diagnosis and in settling upon 
dermatitis exfoliativa. 
I reai men r. - I he indications for the treatment of pityriasis rubra are, in the main, such as 
general medicine dictates. Each case should be carefully examined as to the condition of health, 
the state of the various viscera, the condition of the nervous system, and the presence or 
absence of hereditary or acquired morbid conditions. Any derangement should receive proper 
attention. Arsenic has proved powerless, and carbolic acid is said to have been of benefit in one 
case. Alkaline diuretics may be of service in reducing cutaneous hyperemia. 
Locally, hot alkaline baths, even much prolonged, are decidedly indicated. Inunctions of any 
bland oil, such as almond, linseed, and cod-liver, may be productive of good in relieving hyper- 
aemia and preventing tension. DERMATITIS EXFOLIATIVA 
Fig. 39. 
Dermatitis Exfoliativa. 
It is impracticable in the present state of our knowledge to present a sharply systematic 
description of dermatitis exfoliativa, since there is not as yet a sufficient number of carefully 
69 273 274 
DISEASES OE THE SKIN 
recorded cases, and since the experience of most men has been limited to so few examples of the 
disease. The best that can be done is to give a fair resume of what we really know of the 
subject, and live in hope that observers in the future will carefully study and describe any cases 
they may see. 
The general exfoliative condition which sometimes follows eczema psoriasis and pemphigus 
(and perhaps lichen ruber) presents many points of resemblance and difference between them- 
selves, and it must be studied in connection with these diseases. It must be remembered also 
that more or less extensive, and perhaps rather persistent, inflammation of the skin, with profuse 
exfoliation, may follow the ingestion of certain drugs, notably quinine, bichromate of potassium, 
and chloral. The eruption of quinine may extend from head to foot, presenting a skin of as deep 
a color as in scarlet fever, with more or less profuse desquamation. It is important that all such 
observations of scaling drug-eruptions should be carefully reported. In black-and-white Fig. 39 
are shown the head and neck of a boy who suffered from generalized exfoliative dermatitis which 
had its origin in poisoning from handling Rhus venenata. For a time I was unable to satisfy my 
mind as to the cause of this extensive and persistent eruption. The history of the case, which 
was under my care in Charity Hospital, is briefly as follows : The patient was an American boy 
aged nineteen, whose family had suffered severely from lung troubles. Two months before his 
entry into the hospital he noticed a slight scaliness on his wrists, which soon extended to his face 
and chest. The skin was harsh and dry, but did not itch. Very soon the scaliness spread over 
the whole body. Then there was moderate thickening of the skin, which was not much reddened. 
The scales were copious, thin, small, and as large as the thumb-nail. Later on, moderate pig- 
mentation followed. There were no appearances of eczema. The epidermis on the palms and 
soles was much thickened. Under the influence of tonics with cod-liver oil and good food the 
eruption disappeared, and with it the emaciation which was so marked at the onset of the disease. 
During the summer of 1883 he remained at his home, and in the fall came back to the hospital, 
and brought with him some leaves of Rhus venenata. Having become very friendly with my 
orderly, he induced the latter to rub a small portion of the leaves over his first metacarpal inter- 
space of the left hand. This was done on the 1 ith of September. On the 15th he complained of 
itching and burning over the left deltoid muscle on the thigh and genital organs. The conjunc- 
tivae soon became reddened, and the skin of his whole body became covered with large red patches, 
resembling an erythema or the scarlatinal exanthem. The affection invaded the whole body, and 
its appearances are well shown in Fig. 39. There was marked thickening of the buccal mucous 
membrane, and the nails became thick and rough. In the first attack of this exfoliative dermatitis 
from rhus contact the patient was much emaciated, and the desquamation was very copious ; in the 
second attack his nutrition was excellent and the scaling was much less profuse. The first attack 
appeared two days after contact with the poisonous herb ; after the second experimental friction 
with it five days elapsed, and the dermal affection began at parts remote from the point of contact. 
All other possible causes of the skin inflammation were carefully looked for and eliminated. Part V 
Plate XXXVIII 
LEA BROTHERS & CO. PUBLISHERS . PHILADELPHIA 
IMPETIGO HERPETIFORMIS. IMPETIGO HERPETIFORMIS. 
In the year 1884, Duhring made a strong argument in favor of grouping under one title a 
number of rare and anomalous cases which in their course present multiform lesions, combine 
many of the prominent features of erythema, eczema, herpes, ecthyma, and pemphigus in whole 
or in part, and yet deviate from these classical type-forms of disease in many well-marked and 
striking features. To this vast scheme of generalization he gave the name "dermatitis herpeti- 
formis," and claimed that the same morbid process existed and manifested itself in this protean 
manner. The term "dermatitis" (largely objected to by many, but, unfortunately, not replaced 
by a better one) expressed the inflammatory condition of the skin, while the adjective "herpeti- 
formis" was intended to convey the idea of the tendency of all its lesions, particularly the pustular 
and vesicular, to be grouped together, to extend peripherally in the form of circles or segments 
thereof, and to undergo incrustation. 
While the existence of these curious cases is generally conceded, dermatologists have not 
shown an alacrity in fully accepting Duhring's far-reaching system, and have objected strongly to 
the use of the term "herpetiformis" as being suggestive of the course of certain vesicular dis- 
eases. It is claimed that the term is at best vague and misleading, and that it is inappropriate to 
use it to designate affections which combine pustules and bullae, and perhaps vesicles. Besides 
these objections to its nomenclature, the serious drawback to a convincing simplicity presents itself 
in the fact that we are wholly at sea as to the etiology of the disease, and that such markedly dif- 
ferent causes as nervous shock and septic infection are assigned as prominent etiological factors, 
together with many more which are very vague. 
I he truth of the matter is simply this : that while there is much in favor of thus group- 
ing these anomalous cases, before we can speak of them with scientific precision their number 
must be greatly augmented, and they must be carefully observed and recorded in all of their 
essentials. Dermatology, however, is much the debtor to Duhring. In this group of rare and 
anomalous diseases is included the one to which Hebra first gave prominence-namely, impetigo 
herpetiformis. 
1 his disease is seen mostly in pregnant women, though it is said by Duhring and Kaposi to 
occur in the male. It may appear at any time during pregnancy, usually after the third month. 
As a rule, there are well-marked prodromata, such as fever, chills, malaise, pain in the back, loss 
of appetite, and diarrhoea. In some cases a severe pruritus precedes and accompanies the evolu- 
tion of the affection. The eruption begins in a symmetrical manner as scattered bright-red spots 
upon the trunk anteriorly or posteriorly, the extremities, especially on the inner aspect of the 
thighs, the buttocks, near joints, on the face and scalp, palms and soles, and may affect the mucous 
membranes of the mouth and genital organs. Upon the erythematous spots small pinhead and 
millet-seed vesicles and pustules soon appear, which have a whitish-gray color. These pustules 
increase in number until round or oval groups are formed, and then the further extension of the 
affection is by circles of pustules around the original patches. In some cases bullae are also present. 
As the disease increases peripherally it dries into crusts in the centre, which are of a variegated 
yellow color. By the multiplication of these patches and their coalescence large extents of surface 
275 276 
DISEASES OE THE SKIN. 
are covered. A graphic picture of this disease is afforded by Plate XXXVIII. The case was 
that of a woman who was attacked in the fifth month of her eleventh pregnancy, when she was 
apparently healthy and well nourished. 
The disease runs a chronic subacute course, and is noticeable for its tendency to irregular out- 
bursts. As the disease grows old the crusts may become dry and fall off. and leave red or reddish- 
brown spots of varying size. This pigmentation is very constant, and usually exists in varying 
degrees of intensity. Not infrequently, owing to the severity and chronicity of the inflammation, 
the raw oozing surface left after the fall of the crusts undergoes such exudative changes that a 
vegetating raspberry-like condition of the skin is produced. 
Hebra thought that this disease was peculiar only to pregnant women, but later observations 
have proved this view incorrect. It is in most instances attended with a fatal result. Clinical 
examination has thrown little light upon its etiology, and post-mortem studies have had a negative 
result. It is thought by some to be of septic origin, though the details of many of the cases pre- 
sent no facts pointing to pus-infection as a cause. 
Such is the striking character of the eruption that a mistake in its diagnosis is hardly possible. 
Its treatment is in as unsatisfactory a state as its etiology. The main indications are to remedy 
any deviation from health and to relieve cutaneous hyperaemia. To this end warm alkaline baths 
may be used and the various emollient ointments already mentioned applied. PART VI. 
URTICARIA. 
Urticaria, also called "nettle-rash" and "hives," is an inflammatory affection of the skin 
symptomatic of varied external and internal causes, and characterized by the development of 
wheals, whose appearance and departure are usually alike sudden and capricious. 
Urticaria is met with in an acute and a chronic form, and, though it affects both sexes and 
persons of any age, it runs a somewhat different course in children than in adults. It is an affec- 
tion especially remarkable for its uncertain and evanescent course, and when uncomplicated leaves 
after it no trace of its existence. The eruption of wheals may be preceded by such prodromal 
symptoms as are termed by the laity "biliousness," or by fever and malaise and symptoms of gas- 
tric or gastro-intestinal irritation. In many cases, however, no systemic disturbance precedes the 
rash. The invasion of urticaria is usually sudden, involving the whole body, without predilection 
for any part in particular, in one outburst, or it is limited to certain portions, notably the face and 
limbs or those which are subjected to pressure or contact with the clothes. In many cases the 
evolution of the disease is by successive crops, by which, in the end, the whole body may be 
invaded. It sometimes suddenly disappears from one region and develops as conspicuously on 
another. It thus happens that in some cases the disease begins and ends within a few hours, 
while in others one or more days elapse during which crops of wheals appear. In the latter event 
more or less marked exacerbations and remissions may occur. In some acute cases well-marked 
and sometimes alarming swelling of the tongue, the mouth, and the throat coexist, which cause 
much suffering and anxiety. In still other cases a suffocative condition, resembling asthma, adds 
to the patient's sufferings. 
lhe constant symptoms of the invasion of urticaria are heat, burning, tension, stinging, ting- 
ling, pricking, and itching, which may be worse on the sites of the lesions, but which affect almost 
all if not the whole of the integument. The itching is usually so severe that patients cannot be 
restrained from scratching with such intensity, and even ferocity, that they wound the skin and 
thus aggravate the disease. It is often paroxysmal, sometimes observes periodicity, and is usually 
worse at night. These symptoms are often strikingly indicative of the capricious character of the 
disease, in the fact that patients complain that they rapidly change from one to the other. 
I he lesions of urticaria begin as diffuse or marginated red spots upon which wheals form 
which vary greatly in size, shape, and number. In acute attacks they are scattered irregularly and 
without symmetry over the body ; in chronic cases they may be symmetrically placed or the reverse, 
these lesions may be very minute, of the diameter of a line or two, of the size of a split pea or 
of the various silver coins, or they may be of mammoth proportions, such as the size of half an 
apple or of an inverted saucer, or even in extensive sheets. 
In general, the more copious the eruption, the smaller and more uniform are the wheals. 
These lesions are of a white or porcelain or slightly pinkish color, are firm in structure and sharply 
277 278 
DISEASES OF THE SKIN. 
defined in contour, slightly or markedly elevated, having flat, rounded, and perhaps centrally 
depressed surfaces, and surrounded by a thin pinkish-red areola. Sometimes there is a small, firm, 
white centre and an extensive red halo or a diffuse patch of redness studded with many small 
wheals. In shape the wheals are round, oval, reniform, semicircular, linear, band-like (exception- 
ally annular), in the form of serpentine lines, streaks and ridges, sometimes of grotesque and 
curious shapes, and often without regularity, owing to the pressure of garments upon the skin. A 
graphic representation of acute generalized urticaria is presented in Plate XXXIX., in which the 
multiform character of the wheals, as well as their general appearance, is well brought out. 
The older dermatologists used a plentiful supply of Latin adjectives and words to distinguish 
the subdivisions of urticaria and its peculiarities, which, though they convey a glamour of ripe 
scholarship, can very well be dispensed with. For instance, urticaria ephemera and u. evanida 
express the transient nature of the affection, and u. recidiva its tendency to relapse, and u. 
Persians its exceptionally chronic course; all of which conditions can be remembered without 
so much redundancy of nomenclature. 
In children and in some adults the wheals sometimes resemble papules, and are rather per- 
sistent in their course, and the condition is known as urticaria papulosa or lichen urticatus. Some- 
times so great is the congestion of the skin that true hemorrhage takes place into the wheals, and 
then we have what is termed urticaria hcemorrhagica or purpura urticans. Or when, from the 
abundance of serous affusion, a quantity escapes from the vessels of the cutis and pushes upward 
and forms vesicles or bullae on the surface of the wheals, a condition called ztrticaria vesiculosa or 
bullosa is produced. Or, again, owing to the large quantity of serum affused (usually in parts rich 
in loose connective tissue-eyes, mouth, penis, scrotum, hands and feet, and external genitals of 
the female), an cedematous, even a nodular, condition of the subdermal tissues complicates the affec- 
tion, and then it has been termed urticaria oedematosa and u. siibcutanea. 
As our knowledge of the clinical history of urticaria and its limitations is now quite extensive, 
and our understanding of the various pathological processes which take place in the skin more 
precise and systematic, the necessity for these Latin reminders is not great. Simplicity of nomen- 
clature is usually a guarantee of an intelligent knowledge of the nature of any disease. 
In some cases of urticaria such is the great irritability of the cutaneous nerves that wheals 
may be produced at will. Figures traced upon the skin with the finger-nails or with any sharp 
or blunt instrument will at first appear as red lines, which will immediately stand out in bold 
relief on the characteristic white structure of the wheals, as sharply as if cut out of marble by a 
sculptor, and surrounded by a thin, mild pink margin. In this way the impression of coins or of 
any article having an irregular surface may be reproduced upon the skin. This condition is 
known as factitious urticaria. It is often annoyingly persistent. This morbid state is sometimes 
seen in persons who, suffering in no way, can at will produce wheals by friction of the skin. 
Acute urticaria is characterized by the sudden appearance of a few or many wheals. In some 
cases there are from three or four to a dozen, in others one or several hundred. Usually the sys- 
temic reaction is in proportion to the number and extent of the lesions. In some cases, after a day 
or two of prodromal mild fever, malaise, and gastric disorder the invasion of the eruption is 
observed. In others the rash and the systemic disturbances appear synchronously. In some cases 
the prodromal symptoms seated in and peculiar to the skin itself precede by a few or many hours 
the invasion of the rash. In exceptional cases urticaria is preceded or ushered in by most alarm- 
ing symptoms. In the year 1873, during the autumn hog-killing season, there was an extensive 
epidemic of urticaria in the rural districts of New York which affected many persons, and espe- 
cially the older members of the communities. There was a severe prodromal stage of varying 
duration (twelve hours to two days), in which sometimes the symptoms were so severe that brain 
affections, and even apoplexy, seemed imminent. There were delirium, congestion of the head, Part VI 
Plate XXXIX 
LEA BROTHERS & CO PUBLISHERS .PHILADELPHIA 
URTICARIA. URTICARIA. 
279 
bounding pulse, and high fever, with all of the concomitants of such a condition. All of the alarm- 
ing symptoms subsided at the evolution of the wheals. 
In marked contrast with the foregoing classes of cases are those in which the patients seem- 
ingly have very little if any general systemic disturbance. They say of themselves that except for 
the rash they would be well. 
While in many cases urticaria leaves no trace of its existence, it is sometimes the starting- 
point of peculiar and multiform efflorescences. The wheals may promptly disappear, or upon 
their site erythematous patches may be left, or, again, each wheal may be followed by lesions which 
resemble in some particulars erythema papulatum and e. tuberculatum. More severe orders of 
lesions may accompany or follow urticaria-namely, vesicles, bullae, and blood-extravasations. 
Chronic Urticaria is more common in children than in adults. It is usually less extensive in 
its development than the acute form, and the lesions are less numerous. It is seen in persons 
otherwise healthy in a mild and oft-recurring form, causing moderate suffering, but no great anx- 
iety, and again in a severe and persistent form. Persons debilitated by any cause, particularly by 
alcoholism, by chronic gastric disorders, by prolonged lactation, and by a rheumatic tendency, sub- 
jects of neuropathic disorders and those suffering from visceral and uterine diseases,-in these 
subjects chronic urticaria is very often a serious malady by reason of the suffering it induces and 
the worry and loss of sleep caused by it. 
The urticarial wheals in the chronic form of the affection may be few or many-in some cases 
but one or two may be seen-and they are usually placed without any order and often unsymmet- 
rically. The lesions in this form are usually of large size, sometimes being true nodules as large 
as a walnut or even of the size of a potato. I had under prolonged observation a case of acid and 
flatulent dyspepsia in which large tumors of the size of an inverted saucer alternated with others 
as large as a hen's egg. This form of the affection has been called urticaria tuberosa, giant urti- 
caria, and ephemeral congestive tumors of the skin. The color of these lesions is of varying 
shades of red, but they may resemble in this particular the classical urticarial wheals. Sometimes 
they are the seat of hemorrhage. They present a tense brawny feel, and are attended with heat 
and burning sensations, Their duration may be limited to several hours or they may last one or 
two days. The site of these mammoth wheals is most commonly the extremities on the antero- 
external surfaces. They may be developed, however, about the face, on the scalp, near joints, and 
near the genital regions, producing much temporary deformity. 
Internal Urticaria.-Coincidently with an attack of urticaria, acute or chronic, we some- 
times observe a condition to which the term internal urticaria has been applied. The affection 
may show itself in redness and swelling of the mouth, tongue, and pharynx, or in the symptom of 
asthma, which some observers think depends upon a condition of the mucous membrane of the 
respiratory tracts similar to that of the skin. The disease shows itself in the oesophagus by the 
symptoms of pain and difficulty in swallowing, in the stomach by colic-pains, and in the intestines 
by eructations, vomiting, diarrhoea, and pain. Dyspnoea may be produced by the gastro-intestinal 
symptoms, without any pulmonary congestion. 
Acute Circumscribed Angio-neurotic Cutaneous CEdema.-Allied in nature to urticaria 
is the affection first described by Quincke under the title "acute circumscribed cutaneous oedema." 
This affection consists of swellings varying in size from a hickory-nut to a peach, formed by effusion 
into the subcutaneous cellular tissues, and also into the skin. It may exist in the form of large 
irregular patches several inches in diameter. The color of these oedematous tumors is very often 
that of the normal skin, and may be even somewhat blanched, waxy, or of a leaden tint, or it may 280 
DISEASES OF THE SKIN. 
be of a pink or reddish hue. The skin is stretched, and the tumors produce a sensation of ten- 
sion, with some burning feeling, but no well-marked pruritus. They have a doughy consistence 
rather than the firm brawny feel of mammoth urticaria. Their invasion is either very sudden or 
moderately so. In some cases a large tumor is formed in one or two hours ; then, again, an acute 
invasion is simply the prelude to a process of tumefaction which may occupy a day or more. They 
are sometimes decidedly migratory in their course, and, we may say, jump from one region to 
another. They last several hours, a day or several days, and then speedily vanish. They may 
wholly disappear, or they may recur at variable intervals, and sometimes with distinct periodicity, 
as was observed in a case reported by Matas, in which the invasion occurred daily between eight 
and eleven a. m. In other cases they have been known to recur both regularly and irregularly 
at intervals of a few days or several times a month, or at quite long intervals of one or several 
months, or even of several years. 
The most common site of these tumors is about the face, particularly near the eyes, on the 
lips, upper and lower, over the malar prominences, and also on the extremities, particularly near 
joints, and upon the hands and feet. Similar swellings may coincidently attack the pharynx and 
larynx. They are said to occur upon the trunk, and have been observed to exist coincidently with 
a classical urticarial outbreak. 
Acute circumscribed neurotic oedema occurs as early as the fourth and as late as the ninetieth 
year of life, but the observations thus far recorded would seem to warrant the opinion that it is 
rather more common between adult and middle age. 
Acute circumscribed oedema may occur with or without prodromal symptoms. In some 
instances bodily or mental fatigue has been ascribed as the cause of the affection. Matas's case 
was undoubtedly of malarial origin, as shown by its marked periodicity and its permanent cure by 
large doses of quinine. In some cases symptoms of varying severity, pointing to gastro-intestinal 
disturbances, acute or chronic, were noted, and Striibing is inclined to group these cases with those 
of oedema due to profound anaemia, in which there is increased irritability of the vaso-dilators. In 
two cases reported by Riehl there was no marked deviation from normal health, but the observa- 
tions of Striibing, Falcone, and Quincke go to show that hereditary influence is distinctly causative 
in acute circumscribed oedema. Osler thinks that there is a strongly-marked hereditary disposition 
to this trouble, and gives the history of a family in which it existed in five generations. 
Urticaria in children is very common, and often severe and markedly recurrent. It is 
mostly observed in badly-nourished subjects, particularly in those who are bottle-fed and badly 
fed, and who as a result suffer from flatulent and acid dyspepsia. In general, the urticarial wheals 
in young subjects are quite small, varying between papules and small tubercles. They appear 
chiefly on the extremities, sometimes on the trunk, and quite seldom upon the face. They may be 
few in number or quite numerous, and they may be limited to symmetrical regions or the reverse. 
They are attended with the usual symptoms of heat and pruritus, and may or may not be preceded 
or accompanied by systemic symptoms. In many cases they appear at night, and often great 
uncertainty exists in the mind of the child's attendant as to their origin, whether from some stomach 
trouble or whether they are the result of lice, bedbugs, or flea-bites (and in summer of mosquitoes). 
The examination of such a child in the daytime usually shows evidence of previous scratching or a 
number of scattered and perhaps torn papules, with here and there erythematous patches. With 
intelligent and painstaking care the physician will eliminate pediculi, bugs, fleas, and mosquitoes, 
and settle definitely upon capriciously or periodically recurring urticaria. Such is the tendency for 
this disease to become engrafted upon children, and to develop into severe and inveterate pruritic 
affections, that it is especially incumbent upon the physician to give each case his undivided atten- 
tion, to eliminate all sources of error, reach the truth, and then cure the disease and take such URTICARIA. 
281 
measures as will prevent its recurrence. To this end the diet and the gastro-intestinal system 
need especial attention. 
In some cases, however, large wheals are seen even in young children. I have seen a number 
of cases in which urticaria in infants was so intense that the wheals ran into patches which 
involved the arms, legs, and large portions of the trunk. Exceptionally in such cases marked 
effusion of blood takes place into the patches, which become of a purplish (even of a plum) color. 
It is not infrequent in these severe and extensive instances of urticaria in children to see mild, and 
even alarming, head symptoms, which I have known to raise in the minds of physicians a fear of 
impending acute meningitis. 
Urticaria pigmentosa is the name given to a rather rare and chronic form of the affection, 
which is followed by yellowish-brown or buff-colored pigmentations. This affection usually begins 
within the first six months or first year of life in the form of papules and tubercles from one quar- 
ter to one inch in diameter, which present the typical urticarial physiognomy. They may or may 
not be accompanied by mild or even severe systemic symptoms, but are usually attended with 
moderate burning and itching, but sometimes these symptoms are severe. 
This affection usually appears in crops of wheals at longer or shorter intervals and in small or 
quite large numbers. There is usually a concomitant state of hyperaesthesia of the skin, analogous 
to the factitious urticaria of adults, and wheals may be produced at will by friction, and often appear 
to be produced by emotional causes, such as crying. The sites of election of the eruption are the 
trunk, particularly the back (perhaps owing in a measure to the pressure of the body during sleep), 
upon the limbs, and also, less commonly, upon the palms and the soles. In some cases there is 
coexistent redness of the mouth and fauces. When developed, the wheals remain stationary 
for a few days ; then, or even sooner, their color becomes of a reddish tint, which still further 
deepens. 
After lasting one or two weeks the reddish tubercles gradually shrink, become withered, fade, 
and subside until they are no longer salient, and their sites are marked by spots or patches, many 
of which may have coalesced, and are of buff or of a light grayish-brown color. Liveing very 
graphically describes the eruption as "persistent tubercles and red, measly-looking patches mixed 
with yellowish pigment-spots resembling pityriasis (tinea) versicolor." The pigmentations are 
dependent upon increase of pigment in the rete and effusion of blood. 
According to our present knowledge, urticaria pigmentosa is observed in males more fre- 
quently than in females, and in subjects who are not particularly weak nor especially robust. It 
may last months or for years. 
Ephemeral and Persistent Nodes of the Skin.-There are two forms of swelling of the 
skin which are thought by many to be allied to urticaria, owing to the fact that they seem to be the 
acute and the chronic form of substantially the same affection, and also to the fact that the swell- 
ings of the first variety are peculiar in their rapid evolution and disappearance, and in their tend- 
ency to recurrence during a long period of time. 
These lesions are known as, first, ephemeral oedema of the gouty or ephemeral cutaneous nodes ; 
and second, rheumatismal cutaneous nodes or nodosities. 
Ephemeral cutaneous nodes or plaques usually appear very rapidly and without any symptoms, 
objective or subjective, though they may be more or less sensitive to pressure. They vary in size 
from a pea to a hazelnut or an almond, and may be of firm and elastic structure or may feel (par- 
ticularly when near joints) like little water-cushions. They are commonly sharply marginated, but 
may be of indeterminate outline, and perhaps may be made to glide under the fingers, or they may 
be adherent to the deep fibrous covering or to the skin, or to both of these structures. They may 282 
DISEASES OF THE SKIN. 
be sensibly, even markedly, salient, but may be so small that they would pass unobserved unless 
sought and found by palpation. They are found chiefly over superficial bones, near joints, and 
upon aponeuroses. The scalp, the face, forehead, the hands, and perhaps the feet, are the regions 
most commonly attacked. There may be one node, or there may be a few or many. They occur 
singly placed and grouped, with and without symmetrical distribution. Ordinarily, the growth of 
these lesions is rapid and complete in a few hours, or it may be much slower. Though their dis- 
appearance may be comparatively rapid, this process usually occupies from ten to twenty days. 
Their evolution is usually in successive crops, averaging from five to twenty days, though in some 
cases one or two nodes have been all that have appeared. These lesions may develop at any time, 
but it is thought by Brocq that they most commonly appear toward evening, and by Fereol during 
the hours of sleep. 
Duvaine and Fereol think that they are formed by an acute circumscribed oedema. Jaccoud 
and Besnier, on the other hand, hold the view that they are the result of infiltration and hyperpla- 
sia of connective-tissue elements ; which has been accepted as correct by Troisier and Brocq, who 
think that in addition there is serous exudation. 
Rheumatic Cutaneous Nodes.-In contradistinction to the foregoing are the lesions called rheu- 
matic cutaneous nodes, which are chiefly peculiar in their comparative chronicity. These lesions 
vary in size from that of a very small pea to that of an almond or hickory-nut. They are of rounded 
or oval outline, and are sharply defined. Their surfaces may be rounded, flatfish, or convex, their 
condition as to this feature being, as a rule, in keeping with the structure of the parts upon which 
they have been formed. They are usually not adherent to the skin, though they may in course of 
time become glued to it. They move more or less freely over the structure upon which they are 
seated, but may in time become adherent to it. The superlying skin may be of normal color, or 
it may be stretched and blanched. These nodes are of firm and elastic structure, but when old, 
particularly on parts subjected to motion and hard usage (hands and feet), they may become as 
dense and hard as cartilage. The structures upon which these nodes are found are the periosteum, 
pericranium, fasciae, aponeuroses, and tendons and near joints. The regions and organs most 
commonly the seat of them are the scalp (principally the frontal and occipital bone), the fingers 
and hands, wrist- and elbow-joint, and the knees, instep, and toes. 
These nodes may be painless or the seat of pain on pressure. About the fingers and joints 
they may give rise to uneasiness and slight pain. Troisier and Brocq reported a case of these 
nodes seated on the scalp in which their sensitiveness was so great that the patient could not bear 
to put his head on a pillow. They are usually isolated, very often unsymmetrical, and rarely con- 
fluent. In number they vary from one to a hundred. They commonly appear in small or large 
crops at irregular and uncertain intervals. 
The nodes may last several weeks or even many months, and it has been observed that when 
developed on parts subject to pressure and knocks (hands and feet) they may remain permanent 
and require extirpation. They are seen mostly in middle-aged and old subjects, though they may 
occur in the young. The rheumatic and arthritic conditions seem to be their underlying cause. 
They may be mistaken for exostoses and gummata. 
Barlow and Warner have described certain subcutaneous tumors which they found in infants 
suffering from chorea and rheumatism, which were of sizes varying from a grain of mustard to an 
almond, seated on the various subcutaneous fibrous tissues. In structure they were semi-trans- 
parent and looked like boiled sago-grains. 
Etiology.-Though we know very little as to the minute pathological mechanism involved in the 
causation of urticaria, except in the general term that it is a reflex neurotic condition attended with 
vaso-motor disturbance, we certainly do know a vast array of agents and conditions which more or 
less uniformly cause the disease. In short, our knowledge is largely based on observations of URTICARIA. 
283 
cause and effect. The causes of urticaria are, in a general way, of external and of internal origin. 
The external causes are, first, those of vegetable origin, such as the stings of nettles (urtica urens), 
irritation produced by various other stinging plants and by cowhage-down (mucuna pruriens), flax- 
seed (in poultices), turpentine, and capsicum ; second, those of the animal kingdom, particularly 
lice, fleas, bugs, mosquitoes, jelly-fish, caterpillars, bees, wasps, and leeches; third, those of 
mechanical origin, such as the scratching and friction of the skin, particularly in eczema, scabies, 
prurigo, and pruritus cutaneus, traumatism of varying kinds, puncture by the electrolytic needle, 
stings from whips and switches, and coarse and irritating under-garments, and medicinal and chem- 
ical irritants ; and, fourth, meteorological causes, notably cold (Munchmeyer), and sudden changes 
of temperature. Heat of the sun, heat from gas-lights, and the oppressive heat of confined rooms 
have been known to cause the disease. Heat engendered by heavy bed-clothing and salt sea-water 
are also known to be occasional active causes. 
The internal causes are, first, those which act upon the gastro-intestinal system, constituting 
the cases classed as tirticaria ab ingestis ; the most prominent and common of which are oysters, 
crabs, lobsters, mussels, and, in fact, all kinds of shellfish, pork, sausage, potted and canned meats, 
game, and cheese, in all of which poisonous ptomaines and leucomaines may exist, and also straw- 
berries, raspberries, peaches (though rarely), mushrooms, oatmeal, pastry, and various complex 
fancy dishes. To this category also belong various medicinal agents, taken internally, such as 
quinine, sulphate of cinchonidia, cinchona-bark, salicylic acid, salicylate of sodium, copaiba, cubebs, 
oil santal-wood, chloral, opium and its derivatives, santonine, hyoscyamus, iodide of potassium, 
iodoform, picrate of ammonium, antipyrine, and valerian. Intestinal worms are also frequently the 
cause of urticaria by irritation acting through the splanchnic nerves. 
Besides the foregoing, there are many internal causes which, in some subjects, produce urti- 
caria, but their exact mode of action is less clear. Thus, we see the disease in women having 
uterine and ovarian disorders, and observe its coincidence (sometimes cyclical) with menstruation 
and also as a concomitant of the menopause. Many persons who suffer from flatulent and acid 
dyspepsia have recurrent attacks of urticaria. Plethoric subjects, lithaemic patients, and those suf- 
fering from suboxidation may thus be affected. Urticaria has been frequently seen in locomotor 
ataxia and in neuropathic subjects, and to coexist and alternate with neuralgia and asthma. It is 
sometimes observed during the course of purpura, diabetes, albuminuria, rheumatism, jaundice, 
and fever and ague. 
According to Weiss, urticaria followed puncture of an echinococcus cyst in two patients, owing, 
he thought, to absorption of some of the contents of the cysts, since he never saw the affection 
follow puncture of other kinds of cysts. Debove injected on three occasions the filtered fluid of 
a hydatid cyst under the skin of the abdomen of three previously healthy subjects, in two of which 
urticaria was produced. These observations have convinced him that the urticaria in persons hav- 
ing this form of cyst results from auto-intoxication by absorption of the liquid. 
Urticaria resulting from mental emotions, such as shame, anger, fear, fright, worry, and trou- 
ble, is not at all uncommon, especially in excitable and nervous subjects. It is also occasionally 
seen, particularly its chronic and recurrent forms, in subjects in whom no etiological factor can be 
ascertained, such is their manifest state of health, and for which cases we invoke the aid of that 
vague term "idiosyncrasy" or the "mystery of the individuality" and predisposition, and console our- 
selves with the thought that some occult, inherent morbid condition of the vaso-motor nerves and 
centres exists. The fact that many if not all of the foregoing causes are inoperative in the pro- 
duction of urticaria in most cases lends weight to the view that in those in which they are operative 
there is in addition the underlying state of predisposition or idiosyncrasy of the system. The most 
striking instances of this are the cases of nettle-rash following certain articles of diet and the use 
of certain drugs. 284 
DISEASES OF THE SKIN. 
There is abundant clinical evidence to prove that persistent and recurrent urticaria, having its 
origin in some of the known external and internal causes, induces in the nerves and vessels of the 
skin a morbid impress, and engrafts upon it a tendency to the subsequent development of that 
disease, of eczema, erythematous rashes, and pruritic affections. This sequela of the disease is 
rather frequently seen in children, and Hebra's investigations show that prurigo may have its 
origin in early chronic urticaria. 
In infants and young children urticaria is usually the result of gastro-intestinal irritation and 
disorders, though it also may be developed by external irritants, chiefly of the animal kingdom. 
There can be no doubt that in young subjects the morbid condition of the skin, showing itself in 
an eczematous tendency and in chronic pruritic affections, is not uncommon as a sequela of per- 
sistent or recurrent urticarial attacks. 
Pathology.-The primary cause of urticarial wheals is the irritation of the sensory and vaso- 
motor nerves of the skin of peripheral or central origin, which results in the rapid exudation of 
serum in the substance of the papillae and uppermost layers. The white centre is indicative of the 
irritation and contraction of the capillaries, and represents the skin in a state of spasm. Around 
this morbid nucleus there is great capillary dilatation, from which prompt effusion of serum results. 
This exudative condition then acts upon the small blood-vessels of the morbid areas by compres- 
sion, and upon this the exsanguinated condition of the wheal depends. In this way we can ration- 
ally explain the white and bloodless centre of these lesions and the gradually fading redness of 
the exudation beyond it. In proportion as the exudation is prompt and rapid, so are the wheals 
whiter and firmer ; and when the morbid process is less rapid, they are of a pinkish or reddish 
tinge. This latter condition is owing to the fact that the pressure of the oedema is not sufficiently 
great to thoroughly exsanguinate the capillaries. Then, again, the thickness of the oedema plays 
a part in the whiteness and redness of the wheal. We are unable to say how much the choking 
of the lymph-vessels by lymph-clots, spoken of by Neumann, acts as a factor in the formation of 
the wheal, or whether it is a part of the morbid process. 
In this connection the observations of Auspitz are of interest. In addition to the facts adduced 
by Schlesinger and Goltz in proof that the medulla oblongata and the spinal cord are the seats of 
vaso-motor nerve-centres, Auspitz thinks that there may be ganglia seated immediately in the skin 
itself associated with and regulating the blood-current, and that,irritation of these may give rise to 
urticaria without any reflex transmission to the nerve-centres. Unna, who accepts these peripheral 
vascular ganglia, thinks that in them may reside a lasting predisposition to irritation and the result- 
ing phenomena which go to make up urticaria. 
Diagnosis.-So striking is the physiognomy of acute urticaria that its nature is at once mani- 
fest. The presence of undoubted wheals always puts the diagnosis at rest. When these lesions 
are of a pinkish color, or in their further development when they range between red and purplish- 
red colors, they may be mistaken at first for the papular or tubercular forms of erythema multi- 
forme. If the case, however, is investigated upon even a fair knowledge of the two affections, a 
diagnosis will soon be arrived at. It sometimes happens that sparsely-placed and persistent wheals 
upon the arms and legs and near joints when fading may suggest nodules of erythema nodosum 
to the mind of the observer: a little reflection will soon put him right. Urticaria, besides its pecu- 
liar features, always itches ; the erythemata cause burning sensations. Large plaques of urticaria 
upon the face may at first be regarded as erysipelas: the suggestion of such a possible error should 
lead the physician to a proper distinction of the trouble. 
Prognosis.-The usual outcome of acute urticaria is its rapid disappearance, and the avoid- 
ance of its cause, external or internal (then generally determined), usually ends the matter. When 
the disease shows a tendency to recurrence, the outlook is not always pleasant, and the facts call 
for careful examination as to the cause. Chronic urticaria can only be looked upon as a serious URTICARIA. 
285 
and perhaps grave condition, and calls for careful study on the part of the physician, and a rigid 
observance by the patient of the indications drawn from such an inquiry. The existence of urti- 
caria in infants and children should always claim proper recognition on the part of the physician, 
who, alive to the possible sad outcome of such cases, should do all in his power to cure and pre- 
vent the disease. The dermal sequelae of urticaria in the adult are more or less evanescent. The 
stains of urticaria pigmentosa require years to efface. 
Treatment.-The first indication in the treatment of urticaria is to clearly settle upon the 
cause, which, in the majority of cases, is readily accomplished. When the disease results from 
external causes, these may have ceased to exist when the case comes under observation. If any 
external cause is still operative, it should at once be removed. In all cases the patient should be 
put into the most thorough hygienic condition. Attention should be paid to the condition of his 
underwear, and if at all irritating it should be immediately removed. Perfect ventilation of the 
room should be ordered, none but the lightest bed-clothes should be allowed, and all extraneous 
sources of heat should be guarded against. 
Cases of urticaria originating in irritation of the gastro-intestinal canal require careful atten- 
tion to their cause, and upon the findings in each case the treatment must be adapted. In these 
particulars there is so much dissimilarity among cases, owing to cause, age, physical peculiarities, 
temperament, pre-existing morbid state, and habits, that each individual one requires a modification 
of the general scheme of medicine governing them as a class. The absolute essential in them all, 
however, is the prompt and thorough evacuation of the alimentary canal. To this end the judg- 
ment, tact, and experience of the physician must be bent. It is obvious that a cathartic suited to 
a child may not be proper for an adult, and that a thin, delicate person cannot be treated with the 
freedom in purgatives admissible in the case of a plethoric one. It would be a hopeless task to 
attempt to specify categorically the remedies necessary in all of these cases : such information is a 
part of a man's general medical culture, observation, and experience. In some cases such is the 
severity of the symptoms that the prompt action of an emetic is demanded, the nature of which is 
usually suggested by the case and its surroundings. In many cases Rochelle salts, Epsom salts, 
Hunyadi Janos water, and Saratoga waters may serve as prompt evacuants. Calomel and bicar- 
bonate of soda in suitable doses are of very great benefit in nearly all cases of urticaria ab ingestis. 
If possible, all food should be withheld during the attack, and moderate quantities of bland natural 
and artificial waters, properly cooled, should be taken. When food is permitted, it should be of 
the simplest and most digestible nature, and should not be allowed in large quantity. The stom- 
ach derangement which so often follows urticaria must be properly looked after, and treated 
according to the indications on the general principles of medicine. It is always well to guard 
patients who have passed through acute urticaria against all possible sources of irritation of the 
integument, as well as to impress upon them the noxiousness of the ingested cause. Avoidance 
for longer or shorter periods of alcoholic and fermented liquors, saccharine and starchy food, and 
fancy dishes should be counselled. 
Owing to the uncertainty in the etiology of chronic urticaria, its treatment, it must be con- 
fessed, is largely empirical, and in many cases is tedious and even disappointing. It is always 
very important to bear in mind that in most instances there exists what has been aptly termed a 
"bad habit" of the skin, that this structure is in a state of irritability, constantly ready for an 
explosion, and that its scrupulous hygienic care should form a very essential part of the manage- 
ment of the case. To this end, attention should be paid to the patient's underwear, which should 
be soft and unirritating ; directions should be given that irritation of the skin be not produced by 
baths at too hot a temperature, and that towels for friction be not used injuriously. Then the 
general hygiene, the diet, and the habits of the patient should be considered in the light of the 
facts elicited by the physician's examination ; all errors therein should be pointed out, and all pos- 286 
DISTASES OF THE SKIN. 
sible safeguards should be prominently brought to mind. Then the medical history should be 
patiently and carefully studied ; any concomitant morbid symptoms should be weighed and ana- 
lyzed ; the viscera should be interrogated and the secretions carefully examined. Whatever sys- 
temic disorder, aberration, or impairment of function or morbid condition, hereditary or acquired, 
that is ascertained should be considered the groundwork of treatment. In most cases alkaline 
diuretics are of great benefit in correcting acidity and in relieving cutaneous hyperaemia. The 
citrate and acetate of potassa, and even the liquor potassa, are often indicated in these cases, and 
in many the alkaline diuretic spoken of on page 215 is of great value. All cases attended with 
dyspepsia of any variety should be treated on the lines in them indicated. An underlying anaemia 
likewise should be treated appropriately, and change of air and scene ordered. 
In all of the foregoing cases, and in fact in every case of the disease, the function of the 
alimentary canal should be looked after, and constipation should always be remedied. In most 
cases an occasional dose of calomel and supercarbonate of soda, followed if necessary by a Seidlitz 
powder, Carlsbad salts, or a draught of Hunyadi water or of any good aperient mineral water, will 
prove of the greatest benefit. Should a distinct malarious condition be found (a proper patholog- 
ical significance being conceded to the word "malaria" and its current vagueness being avoided), 
the treatment should be largely hygienic and supplemented by quinine and the mineral acids, and 
perhaps with preparations of iron. 
The rheumatic and gouty states call for careful management and appropriate drugs, notably 
the acetate of potassa, the iodide of potassium, salicylate of soda, salicine, and colchicum. Chronic 
urticaria in persons suffering from lithaemia requires the careful regulation of the food, the habits, 
and the surroundings of the patient, a scrupulous attention to hygiene, and the ingestion of alkalies 
and perhaps the mineral acids. Patients of neuropathic tendency suffering from urticaria are nota- 
bly difficult ones to treat, and the management of them, as a rule, is attended with many cares 
and disappointments. They must be handled on the lines of practical medicine. 
For those cases in which the skill and acumen of the physician can find no tangible cause a 
number of remedies may be used. Atropia in doses of to of a grain, thrice daily, may be 
tried with all due caution as to its toxic effects. Tincture of belladonna also may be given in 
appropriate doses. Pick of Prague has seen cures from the use of pilocarpine, and salicylate of 
soda given empirically has been of benefit. In some of these cases of indefinite origin arsenic, 
given with care in progressive doses, may be useful. Bromide of potassium is much relied upon 
by many in this class of cases. It sometimes acts well in relieving the local symptoms, and it may 
be productive of a cure of the urticarial condition of the skin. It should be given in full doses 
and with watchful care. 
The local treatment of urticaria, acute or chronic, is of great importance, and, luckily, our 
armamentarium is very rich. In cases of acute general or extensive urticaria warm or hot alkaline 
(sal soda or borax) or bran baths should be given at once. The heat of the water should be 
graduated by the idiosyncrasy of the patient; but care should always be exercised that when there 
is evidence of much cerebral congestion the temperature should not be high. Jamieson thinks 
well of a bath containing two ounces of sulphuret of potassa, followed by friction with salicylic 
vaseline. As local applications alcohol and water, alcohol and vinegar, and Cologne-water and 
vinegar may be used by sopping on the surface and allowing them to evaporate. Sweet spirits of 
nitre, with or without the addition of an equal quantity of water, is very cooling. Lemon-juice is 
sometimes very grateful to the patient, and in an emergency sliced lemons may be rubbed over 
the morbid surfaces. The officinal spirit of mindererus has proved of value, and it may be with 
benefit combined with an equal quantity of alcohol. 
In many cases domestic remedies have to be relied upon. I have known much relief in many 
instances by using vinegar into which saleeratus had been sifted to the point of saturation, and then URTICARIA. 
287 
diluted with water to suit the case. Carron oil (linseed oil siv, aq. calcis 5xij) has proved of much 
benefit in the hands of the laity, and 1 once knew an old physician who practised in the country 
who placed great reliance upon the brine taken from the classical pork-barrel. 
The following prescriptions are capable of extended use: 
B. Sodii chloridi, §ss ; 
Aq. ammonias, 
Spts. camphorae, da. ; 
Aq., M. 
B. Chloroformi, £iss; 
Aq. coloniensis, §ij: 
Aquae, ad M. 
B. Sodae carbonat., gij; 
Succi conii, ; 
Aq. camphorae, 5vij. M. 
B. Sodae bicarb., jij; 
Acid, carbolici, 5ss; 
Aq. camphorae, £x. M. 
B. Pulv. boracis, Sij+S'ij; 
Acidi hydrocyanici dil., gij; 
Aq. rosae, Sviij. M. 
B. Acidi nitrici dil., Sss-Hjiij; 
Plumbi acet., gr. v+x; 
Aquae, 5vj. M. 
B. Zinci oxid., ijij; 
Spts. camphorae, giij; 
Liq. Goulardi, giss; 
Glycerinae, 5ss; 
Aq., £viij. M. 
Or Crocker's lotion : 
B. Calamine, gij; 
Zinci oxid., gss; 
Glycerinae, gr. xv; 
Aq. rosae, gj. M. 
B. Potassii cyanidi, gr. xvj+xxx; 
Aquae, gviij. M. 
For limited areas, and not about the face and mouth. 
The following formula by Jamieson is worthy of extended trial: 
B. Acidi carbolici, 3j; 
Glycerinae purae, gij; 
Spts. vini rect., giij; 
Aq. camphorae. M. 
The old-time lead-and-opium wash may be useful, or the following may be tried : 
B. Pulv. boracis, *ss; 
Liq. morph. Magendie, gss ; 
Aq. rosae, gviij. M. 
B. Liq. potassae, gjj • 
Zinci oxid., ; 
Aq. camphorae, oviij. M. 288 
DISEASES OF THE SKIN. 
1'he various powders may be used, such as starch, rice powder, toilet powders, flour, talc, and 
the combination of oxide of zinc, camphor, and starch (see page 218).. 
Menthol pencils, lump camphor, terebene, and listerine diluted in water may be of benefit in 
chronic and localized cases of urticaria. In this category belongs the mixture of syrupy consist- 
ence of equal parts of chloral and camphor, which may be used as a paint mixed with glycerin or 
in the form of an ointment (chloral camphor 3j ; ung. aq. rosae sj). In old and limited cases 
preparations of tar, the liquor carbonis detergens, the liquor picis alkalinus, mixed with an appro- 
priate quantity of water, may be of benefit; and it is well to remember that ichthyol dissolved in 
water (10-30 per cent.) has been found beneficial by Unna and others. Benzoic acid dissolved in 
alcohol may be tried. In some persistent cases the compound tincture of benzoin, collodion, and 
traumaticin, either alone or in combination with some antipruritic remedy, may be used as a paint 
to limited spots. In general, ointments are contraindicated, though some cases are benefited by 
gentle friction with camphorated oil, cold cream, vaseline, or lanolin. 
Benefit has been claimed on good authority from the application of the continuous current of 
electricity, the positive pole being placed at the top of the spine, and the negative pole low down 
in the same region. Change of air and scene may be recommended in chronic cases, which may 
be benefited by a sojourn at some of our American or at foreign spas. PEMPHIGUS. 
Pemphigus is a rare chronic, sometimes acute, inflammatory disease, manifesting itself in bullae 
which appear in successive crops, and which may be seated on the skin or mucous membranes. It 
is well, therefore, to speak of chronic and acute pemphigus and pemphigus foliaceus, since these 
forms possess various distinctive peculiarities. Certain variations in the course of the disease, due 
to age, idiosyncrasy, inherent and surrounding morbid conditions, and to the abnormal evolution 
of its lesions, and complications engrafted upon them, have led observers to recognize yet other 
subdivisions. While it is important to be familiar with all of the numerous and aberrant clinical 
features, we must, for clearness and sake of simplicity, be economical in our nomenclature. 
The whole body may be invaded by pemphigus, but it shows a preference for the limbs, per- 
haps more so for their articular portions. It is also found upon the face and the trunk. The 
palms and soles are commonly spared. The mucous membranes of the mouth, conjunctiva, female 
genitalia, and intestinal canal may be affected. 
The evolution of the bullae may be rapid, subacute, or decidedly slow. In general, large 
eruptions are noticeable for the rapidity of the appearance of the lesions, while in sparse ones the 
bullae usually develop slowly. The mode of appearance of pemphigus is, as a rule, by successive 
crops, which develop at long or short, and always irregular, intervals. These crops, when copious 
and sometimes when small, show a tolerable tendency to symmetrical distribution, but no uniform- 
ity or regularity of their arrangement whatever. There is also a noticeable want of uniformity in 
the size of the lesions, due largely to their successive development, but in a given synchronously 
developed crop they may vary greatly in size. It would seem that the morbid process is more act- 
ive in some persons than in others. In its course each lesion seems to act on its own account, and 
not in any conformity with the course of its fellows. Usually, the lesions are scattered without any 
order-near together, far apart, or grouped in large or small patches. The clustered condition is 
far from common. In some instances a central patch will seem to be the focus for the successive 
appearance of crops at its periphery, and in this way much integument may be invaded. The 
usual mode of extension of the disease is by progressive invasion of one territory after another. 
Sometimes two or more crops appear on one locality. 
Chronic Pemphigus, also called Pemphigus vulgaris.-The bullae of pemphigus usually 
appear as minute red spots, upon which vesicles form, which slowly or rapidly increase until the 
true bullae result. Around these lesions, when fully formed, a thin areola of varying redness may 
be seen. Occasionally, bullae spring up quite promptly on skin which is not in the least reddened. 
When fully formed a bulla is a typical water-blister. It is round, oval, reniform, or irregular in 
outline (chiefly from coalescence of two or more) ; its wall starts up abruptly at nearly right angles 
with the skin, and forms conical rounded or plano-convex eminences of varying heights. A very 
graphic picture of pemphigus with bullae of all 'sizes and forms is conveyed by Plate XL. The 
epidermal covering or roof of the bullae is usually thick, and sufficiently firm to hold their liquid 
contents even when considerable pressure is exerted upon them. These lesions present a per- 
fectly clear citrine or yellowish color, owing to the'translucency of the epidermic covering allowing 
2S9 290 
DISEASES OF THE SKIN. 
their serous contents to shine through it. When fully formed they are tense and quite firm and 
resistent to the pressure of the finger-tips. In some cases they rupture spontaneously or from 
traumatism. As they age they show signs of decay. Their contents gradually become turbid, 
milky, and perhaps yellowish-green, and less in quantity. Their walls become progressively with- 
ered, shrunken, and flaccid, until the epidermal roof flattens and sinks down upon the skin, which 
is at first red, raw, and oozing, but later on partly regains its normal condition. The scale-crusts 
are tolerably thin, but when mixed with pus are thick. For a time the skin on the site of bullae, 
after the fall of the scale-crust or scab, if pus has formed, remains somewhat thickened and pig- 
mented. Gradually, however, the deep-red, or purplish brownish-red, stains disappear, ahd in the 
end the skin may be healthy. 
Pemphigus, as a rule, does not cause scarring, but this complication may follow in some cases 
and under some circumstances. In these abnormal instances the bullae give rise directly or indi- 
rectly to ulcers. 
Burning and itching sensations of all grades of mildness and severity may precede or accom- 
pany the formation of the bullae. Usually, these symptoms are most severe early in the onset of 
the disease. In some cases inHammation of the lymphatics and ganglia of the involved or adjacent 
territory may complicate the disease. It is usually of ephemeral course. It is obvious that excoria- 
tions resulting from bullae are sore and painful. 
Varied systemic conditions are observed to precede or accompany pemphigus. As a general 
rule, systemic reaction is in proportion to the number, extent, and intensity of the efflorescences. 
In some cases, when the lesions are few, there is no appreciable disturbance of the health. In 
severe cases, however, there may be well-marked quite early prodromal symptoms, such as malaise, 
chilliness, want of appetite, weakness, gastro-intestinal irritation, sleeplessness, with mild or mod- 
erate febrile movements,-these symptoms in whole or in part are mostly seen in children and in 
old and feeble people. In some cases of the chronic form of pemphigus very few, if any, symp- 
toms may be observed coincidently with the evolution of the disease ; but as it gradually manifests 
itself by successive crops, the health slowly and steadily declines, until the patient succumbs, after 
periods of months or years, to marasmus and diarrhoea. Even in young persons pemphigus may 
run a severe course. This is especially the case in subjects debilitated by bad habits, vice, and 
disease, and those who have squalid surroundings and are denied good diet and intelligent hygiene. 
In such subjects the disease shows itself by the malign course of its lesions, which may become 
hemorrhagic and rapidly lead to deep and persistent ulcers, with progressive cachexia. The dis- 
ease when existing under these circumstances has been dignified with the names pemphigus malig- 
nus, p. cachecticus, and p. gangrenosus. Diphtheritic patches may form on pemphigus excoriations, 
which may be quite rarely attacked with gangrene. 
Acute Pemphigus-the existence of which was formerly denied-is now conceded to be a 
very rare cutaneous manifestation. Allen1 has lately reported a very satisfactory case, with a 
chromo-lithograph picture. I saw one case several years ago, and other observers have seen 
cases. This form of pemphigus is attended with prodromal symptoms of varying severity, and 
with a mild or well-marked fever, with its usual concomitants. Allen, by his studies, has been 
led to regard this disease as an eruptive fever or bullous exanthem. It is usually noticeable 
for the abundance of lesions and the rapidity of appearance of its crops after the initial acute 
evolution. It may or may not be accompanied by albuminuria. The disease may end promptly, 
may be somewhat protracted, or it may pass into the chronic form. 
In somewhat rare instances the disease may show itself by one or a few lesions localized to 
certain parts, such as the nose or ears, the fingers, ankles, wrists, or the toes and insteps, all of 
them distant from the centre of circulation. In these cases the lesions may be symmetrical or the 
1 Journal of Cutaneous and Genito-urinary Diseases, April, 1888. Part VI 
Plate XL 
LEA BROTHERS & CO. PUB LIS HERS , PHI LADE LPHIA 
PEMPHIGUS. PEMPHIGUS. 
291 
reverse. Pick recorded a case in which die lesions were limited to the right side. It is seen in 
young persons and in old and cachectic subjects. The Latin term for this form is pemphigus soli- 
tarius or p. locahs. 
In like manner, in those instances in which the itching is very severe and gives rise to worry 
and sleeplessness, and to all of the annoying and painful modifications and sequelae of the lesions, 
which have been much excoriated and very injuriously irritated, the term pemphigus pruriginosus 
has been applied. In these cases the dermal lesions become multiform ; excoriations, ulcerations, 
and wheals go to make up a lugubrious picture upon a patient whose vitality is sapped, whose 
nutrition is at low ebb, and in whom emaciation and suffering increase pari passu. These cases 
are simply those of chronic pemphigus, with certain very marked and distressing features. 
Neumann has described and figured a chronic and fatal form of pemphigus which he terms 
pemphigus vegetans. In this form erythema and bullae seated in the mouth and pharynx lead to 
molecular destruction and consequent inability to eat or swallow. In addition, the lesions run a 
peculiar course. The epidermal roof of the bullae is quickly thrown off, and on the excoriated sur- 
faces left inflammatory exudation takes place. These surfaces become elevated, more or less 
verrucous, even papillomatous, and perhaps may come to resemble condylomata, and then extend 
peripherally, perhaps in a serpiginous manner. Ulceration may attack the fungating growths or 
the interstices thereof, and from them a foul, viscid, and sanious fluid escapes. The seats of elec- 
tion of this eruption are the groins, the axillae, the hands, feet, and also the face. As the disease 
grows old, emaciation and exhaustion supervene, and the patient succumbs to diarrhoea and 
marasmus. 
Pemphigus foliaceus is a disease of striking peculiarities and of great rarity. It may begin 
after the manner of chronic generalized pemphigus, which becomes modified, or it may begin in 
the way peculiar to itself. In its course it seems to be a dermatitis which has a prodromal period 
of varying length of bullous efflorescence. It covers the whole body in its course, and spares 
nothing. The bullae of foliaceous pemphigus begin as small flaccid upliftings of the epidermis by 
a thin, turbid serum. Slowly or quite rapidly these flaccid and turbid bullae increase in area, 
though they rarely attain much more than two to four lines in elevation. Such is their flaccid con- 
dition that when the patient stands up the fluid gravitates in little bags to the lower part of the 
bullae. These lesions may coalesce or remain separate. In any event, they soon rupture, leaving 
a raw, oozing, unhealthy red surface, compared by Hebra to a superficial scald, more or less cov- 
ered with irregular-shaped epidermal crusts, and giving issue to a sero-pus which emits a sickening 
and disgusting odor of great penetrative power and persistency. The area of the disease slowly 
extends by the formation of the peculiar bullae. On sites where the bullous eruption is old a new 
order of phenomena may be noted. The bullous epidermal and pus crusts may remain for a time, 
adherent in greater or less extent, and covering the red raw surface. They then are shed more or 
less quickly, and from the morbid surfaces flakes of epidermis, thick or thin, are proliferated. 
These remain for a time adherent in whole or in part, and fall off, and are replaced by similar 
lamellae. By slow stages, occupying months or years, this complex morbid state of the skin 
extends until the whole body has been invaded. As a concomitant of it exudative changes take 
place in the skin, which becomes thickened, red, and perhaps slightly exuding. The condition 
then comes to resemble dermatitis exfoliativa, and the bullous element may become entirely absent. 
In the advanced stage of the disease the formation of scales varies at different periods, being 
sometimes remarkably active, and again correspondingly sluggish. These scales have been com- 
pared by Cazenave to flaky pie-crust. In the generalized state of the eruption variations in the 
character of the crusts may be noted. Upon some parts they may be thin, consisting wholly of 
immature epithelium, or they may be quite thick and composed of epithelium and serous exudation 292 
DISEASES OF THE SKIN. 
or serous pus. In like manner, the redness and thickening of the skin may not be uniform. 
About the joints of the extremities there is usually more thickening than elsewhere, and as a 
result these members are the seat of stiffness and tension which more or less prevents their 
motion, and usually leads to deep fissures. If the disease has not been ushered in and attended 
by systemic derangement, chills, malaise, and debility, conditions of ill-health are sooner or later 
observed in the majority of cases. The initial pruritus may cease, may exist in a moderate degree, 
or may persist, to the annoyance and great suffering of the patient. During the course of the 
disease there may or may not be elevation of temperature. As time goes on, emaciation, insom- 
nia, and a general break-up of the system usually occur, and the patient succumbs to some inter- 
current disease, such as pneumonia, typhoid fever, tuberculosis, or marasmus. In some cases, 
particularly in the young and in older and vigorous persons, a cure has been noted. Such a result 
is by universal testimony not common. The fact has been observed that pemphigus foliaceus has 
disappeared and seeming health restored, but it again became developed. 
Anomalous and Mixed Forms of Bullous Eruptions.-There are a number of affections 
which present lesions not strictly vesicular, nor yet fully bullous in nature, which are a source of 
much embarrassment in dermatological nomenclature. They are border-line cases, and are per- 
haps more correctly considered as allied to pemphigus than to any other affection. As distinctly 
separate from them, it is important to remember that erythema multiforme-especially erythema 
iris and herpes iris-is frequently complicated with the development of bullae, but in these cases 
the multiformity of the lesions present eliminates them from pemphigus. Then, in some cases of 
impetigo contagiosa, bullae (not, however, of the classical type) are sometimes seen in combination 
with vesicles and pustules, the so-called pemphigus acutus contagiosus adultorum of Pontoppidan, 
which will be described later. More or less typical bullous exanthems are produced by drugs, 
particularly the iodide of potassium, quinine, copaiba, and chloral. 
We must also consider in this connection the fact that in the various forms of dermatitis her- 
petiformis bullae are sometimes present in greater or less number with the other lesions, and that 
under this caption or some other one (yet to be originated, and with perhaps more precision), the 
various anomalous forms of bullous eruptions called herpes circinatus bullosus, pemphigus prurigi- 
nosus, herpes gestationis, pemphigus circinatus, herpes phlyctenodes, and impetigo herpetiformis 
will probably be included. 
Eliminating the foregoing eruptions, the full clinical history of which is yet to be written, and 
concerning the etiology of which we are almost in a hopeless state of ignorance, I think I shall do 
my duty best to my readers by quoting the words of the late Tilbury Fox, who was at once a 
trained clinician and a logical thinker. Having cleared the pathway of so much that is unknown 
and chaotic in the putative allies and congeners of pemphigus, it is well to remember that "there 
is a form of disease which seems to stand midway between herpes and pemphigus, the features of 
which ally it now to herpes, now to pemphigus. It may consist of solitary bullae seated on a red 
base and scattered over the body (hydroa vesiculeux of Bazin), or the bullae may be surrounded 
by small vesicles, or these two dispositions of the bullae may be seen in one and the same case, 
the eruption being localized to a certain part of the body, or generally distributed, and accompanied 
in severe cases by pyrexia and marked constitutional disturbance, when it is often the result, prob- 
ably, of malarial poisoning. The eruption may recur more or less periodically ; and, lastly, it may 
be complicated or followed by prurigo, and in that case will answer to the designation pemphigus 
pruriginosus." The foregoing is about all that can be said, in the present state of our knowledge, 
of those cases which are essentially vesiculo-bullous in nature, and appear clinically apart by them- 
selves, uncomplicated with any or all of the protean manifestations of the diseases above men- 
tioned, which the tendency now exists to classify under the title dermatitis herpetiformis. It will PEMPHIGUS. 
293 
thus be seen that the dermatologists of the future must of necessity be careful observers and 
logical reasoners, for they have a knotty and complex task before them. 
Pemphigus in Infants and Young Children -There is a form of pemphigus which attacks 
newly-born infants, and young children up to about the tenth year of life, which is similar in many 
particulars to the acute variety of older persons. In very young children the disease is most fre- 
quently seen in maternity hospitals and in lying-in asylums, and usually begins in an epidemic 
manner, and gradually dies away in the form of more or less rarely-occurring sporadic cases. It 
also occurs sporadically in families, and has been observed to follow quite persistently certain mid- 
wives in the course of their successive ministrations. It is very important that the existence and 
nature of this disease should be fully appreciated, since there is a seemingly natural tendency in 
the medical and lay mind to regard all such cases as of syphilitic origin. Let it, then, be definitely 
understood that there is a simple form of pemphigus in infants, and that it is in no way related to 
syphilis, and is entirely distinct in its nature and course from the bullous syphilides of the hereditary 
disease. 
Pemphigus in infants usually appears soon after birth, on the second day or as late as the tenth 
or fifteenth day. Its evolution may be even longer delayed, but this happens generally when the 
disease is in the full height of its epidemic form, and older children are attacked after a num- 
ber of very young ones have become affected. Much variation is observed in the severity of the 
systemic symptoms. In some cases no deviation from health is observed in the children before or 
during the eruption. In other cases it is observed that the child passes a restless night, cries as if 
in pain, seems nervous and fretful, refuses the breast, and is said by its mother or nurse to have 
been feverish. In the morning, when it is washed, one or more bullae are discovered, or several 
erythematous spots, with perhaps some slight elevation of the skin, may be seen. Perhaps in the 
greater number of cases the constitutional reaction shows itself gradually as the skin disease is 
developed. 
The lesions are, as a rule, typically bullous in their character. They are superficial in their 
nature, as if the serous effusion had taken place in the corneous layer, rather than under it, and 
upon the papillae and corium. Many of them look like quite superficial burns in the second 
degree. The bullae rise abruptly from the skin, reach an elevation of several lines to perhaps half 
an inch, are tense and somewhat resistant, and contain a light-yellow serum. They are of round, 
oval, linear, rectangular, irregular, and festooned shapes, and their ultimate outline is, as a rule, 
modified or moulded by the configuration and conformation of the parts upon which they are 
seated. They are surrounded by a thin areola of redness, which may be mild or pronounced, and 
which is in exceptional cases purplish when the bulla has been complicated with hemorrhage. In 
size the bullae may be as large as a pea or a horse-chestnut, and even larger. They form in from 
two to six hours, sometimes a longer time being consumed. Owing to the delicate structure of 
their epidermal envelope or roof they may rupture quickly, especially on parts subjected to pres- 
sure, and they not uncommonly fuse together. The whole body may be attacked by pemphigus 
neonatorum, though in general the palms and the soles may be spared. The most frequent sites 
are the neck, the face, the axillae, the arms and legs, the backs of the hands and the dorsum of the 
feet, the groins and gluteal regions. The mucous membrane of the mouth and throat may also be 
attacked. There is great disparity among cases as to the number of bullae present. It has been 
noted in some cases that but one or two of these lesions constituted the eruption, and that in 
others they were in numbers varying from a few to twenty or forty. 
Like the evolution of these lesions, their involution is usually prompt and rapid. They, as a 
rule, begin to pucker up, wither, and flatten within thirty-six to forty-eight hours. Before this time, 
however, the clearness of the contained fluid will have given place to turbidity, which may be slight DISEASES OF THE SKIN. 
294 
or well marked. In their period of decline a number of clinical features are observed. By drying 
up of their contents crusts formed of sero-pus and epidermis may form and cover superficially 
excoriated surfaces ; or the as yet unformed crusts may naturally or by violence fall off, and leave 
a raw, oozing surface ; or, thirdly, the resorption of the fluid may be slow, and pan passu a new 
epidermis forms, which is ready by the time that the residua of the withered bullae are cast off. 
Red spots are then left. In badly-nourished infants, and those whose mothers or nurses are indif- 
ferent or careless, and in those surrounded by poverty and squalor, ulceration of varying degrees 
of intensity may complicate the case. This accident has led some observers to concoct the names 
pemphigus neonatorum cachecticum and p. n. gangrenosum. It was observed by Hervieux but 
once in one hundred and fifty hospital cases. 
Pemphigus in infants runs its course by the development of successive crops of varying extent 
and number. These crops may appear day after day, or at longer but perhaps distinct intervals, 
one crop healing before another appears, or the successor just lapping over its predecessor in evo- 
lution. When markedly epidemic, pemphigus in infants may be complicated by a rather mild form 
of purulent conjunctivitis. In individual cases this disease may run its course in a week or ten 
days, or it may last a month or six weeks. Hervieux and others have seen epidemics last several 
months and followed by sporadic cases. In the very mild cases, as a rule, systemic reaction may 
be absent or very light. In persistent cases, however, if the morbid symptoms have not appeared 
early, they show themselves in the course of the disease in fever, diarrhoea, vomiting, refusal of 
food, emaciation, and a general woebegone state, which may end in death. Roeser states that he 
saw seven deaths in thirty-five cases, but these were in a hospital. The survival of infants seems 
to depend upon their ability to retain their powers of assimilation, and upon the care they receive 
from their mothers or wet-nurses. 
The etiology of pemphigus neonatorum is in a very unsatisfactory state, the truth being that 
we know very little concerning the cause of the disease. Many hypotheses have been offered to 
explain its origin, but none have appeared convincing. Heat, cold, foggy weather, the puerperal 
state, difficult and delayed labors, and sepsis have all been urged as causes. Dohrn of Marburg 
gives the history of a midwife in whose practice thirty-four children out of seventy-three were 
attacked with pemphigus within a few months. The eruption usually appeared at the end of the 
first week after birth, and was not attended with danger or suffering. Every hygienic precaution was 
taken, but the woman's ill-luck persisted. By Dohrn's advice she went away for a month's holiday, 
and on her return the first three children whom she attended escaped the disease, but the fourth, 
fifth, and seventh were promptly attacked. She went away again, then returned, and had a similar 
experience. This same development of the disease in the wake of a certain nurse has been 
observed by others. 
According to Roeser, when an epidemic is fully developed pemphigus may attack the strong 
or the weak, those born at full term or before it, infants well nourished and those badly nourished, 
sparing some and killing others without apparent reason. The fact that mothers are in good or 
bad health, that they have much or little milk, whether they have had hard or easy labors or puer- 
peral accidents, seems to have no essential bearing upon the disease. 
It must be remembered that individual cases of this eruption may occur in families, and that 
the clinical history already given applies to them as well as to hospital cases. 
In this connection I must call especial attention to the clinical features of the bullous syphilide 
which are given upon page 159. There need be no mistake in diagnosis in any case if the history 
is properly considered and all the clinical features carefully weighed. Though the simple form of 
pemphigus in infants may exceptionally appear upon the palms and the soles, a mistake in diag- 
nosis need not of necessity be made. The background of syphilitic bullae is of a diffuse deep-red 
color, perhaps coppery, and perhaps even violaceous. The lesions of syphilis are not frankly bul- PEMPHIGUS. 
295 
lous ; they are flatter, less tense, and more commonly contain pus. In the syphilitic eruption there 
is no uniformity of the lesions, but usually a diffuse and dark erythema, imperfect bullae in con- 
junction with pustules or coexisting with these, lesions on other parts, usually the legs and arms. 
Besides these essential clinical features there are usually other concomitants in cases of syphilis. 
Little more need be said regarding the pemphigus of older children, since its course is but 
a modification of the foregoing. Its invasion may be very prompt or rather slow. It may be pre- 
ceded or accompanied by fever, chills, malaise, and cerebral excitement. These symptoms, espe- 
cially the febrile movement, may persist and become severe and even grave during the course 
of the disease, which is by successive crops over the whole body. Two or three weeks, or even 
several weeks, may elapse during which the disease persists. The lesions may dry and wither, 
may form excoriations, or they may fall into ulceration. Recovery usually takes place quite slowly, 
but death sometimes ensues. As a rule, pemphigus in young children is seen among the poor and 
in debilitated subjects. It has been observed to follow pneumonia and bronchial affections, the 
exanthemata, particularly measles, and also eczema. It has been known to recur after the second 
attack of some of the foregoing diseases. In these cases it may assume a malignant, and even a 
hemorrhagic, form. In mild cases the temperature ranges about 102° Fahr., while in severe ones it 
rises much higher. Death is preceded by an adynamic state, usually with severe gastro-intestinal 
symptoms. 
Under thecaption of "Pemphigus" naturally belong a number of artificial bullous eruptions 
which deserve brief mention. T hese are, first, the bullte which result from the heat of the sun or 
from burns and scalds ; second, the bullae resulting with and without intent from drugs, principally 
cantharis, mustard, strong acids, and the cautery, in which category sometimes belong mystifying 
cases of feigned eruptions in hysterical women and malingerers ; third, the bullae found on the backs 
of sick people from prolonged decubitus and on surfaces irritated by injurious contact; and, fourth, 
the blisters seated on the heels, soles, toes, and fingers and elsewhere, due to pressure of some 
article worn by their bearer. 
Chemical analysis of the fluid of pemphigous bullae, with a view to throw light on the etiology 
or nature of the disease, has been attended with a negative result. Examination by the micro- 
scope has not given any uniformity of result, so that the best that can be said is that the bullae con- 
tain leucocytes, epithelial cells, fibrinous masses, and sometimes uric acid, urates, and phosphates. 
Some observers state that they have found micrococci and bacilli, but they have not demonstrated 
the fact that they were essential pathological factors. In like manner, the anatomy of the bulla 
is not described with uniform precision by the various observers who have studied it micro- 
scopically. 
Etiology.-Our knowledge of the causes of pemphigus are very obscure, so that it is far 
easier to speak of it with generality than with precision. T hough a microbian origin has been 
suggested, no facts connecting the disease with any micro-organism have been offered. Authors 
are at variance as to the influence of sex on its production, and the truth seems to be that each 
sex is about alike predisposed to the disease. It is certain that it is rather more common in chil- 
dren than in adults, and sufficient is known to warrant the conclusion that in some cases hereditary 
tendency may exist. In the skin of some persons there seems to abide a peculiar liability to the 
development of bullae on the slightest irritation ; but this seems to be simply a structural defect. 
During the course of various nervous affections and cerebral diseases, such as paralysis, sclerosis 
of the lateral columns of the cord, spinal meningitis, myelitis, progressive muscular atrophy, and 
following injury to nerves, bullous eruptions have been noted. In fact, they may be found when 
the nervous lesion is central or peripheral. Sangster and Mott have reported a case of pemphigus 
in a woman seventy-eight years old suffering from advanced degeneration of the kidneys, in which 
they found parenchymatous degeneration of the external cutaneous nerve, of the spinal ganglia, 296 
DISEASES OF THE SKIN. 
and of the posterior roots. These observations are in accord with those of Leloir and Jarisch, who 
also found coexisting central lesions. Clinical observation has shown that a number of morbid 
conditions preceded or accompanied pemphigus, such as the neuropathic state, melancholia, exhaus- 
tion, and adynamic states. Pemphigus has been known to complicate pregnancy and to coexist 
with severe menstrual, uterine, and ovarian affections. It has been known to complicate and fol- 
low pneumonia and bronchial affections and Bright's disease. I have seen it in chronic drunkards 
in whom no kidney lesions were discoverable. The inference is warranted that some cases seem 
to be dependent upon a septic cause, but much more precision of knowledge is necessary. Whether 
septic poisoning is at the root of many of the cases of pemphigus in children we do not know, 
though such an opinion is held by some. In many cases in children the disease is epidemic ; it 
also occurs sporadically, and we have no knowledge of its contagiousness. 
Diagnosis.-The recognition of pemphigus is commonly very easy in its earliest stages. It 
may, however, be confounded with erythema, urticaria, and herpes when they are complicated with 
bullous lesions. A careful study of the case and a comprehensive view of the course and evolu- 
tion of the lesions will soon set the observer right. It is necessary to remember that the foregoing 
affections are usually acute and ephemeral, and do not show in their evolution the persistency and 
intermittent character of pemphigus. In varicella the bullae coexist with papules and vesicles, and 
it is an acute febrile, rapidly-ending disease. The hereditary bullous syphilide has a marked dis- 
tinctness of history which has already been brought out. Certain pustular lesions of acquired 
syphilis may, by increase of their size and much elasticity of speech on the part of the observer, 
perhaps be termed pemphigus, but it is well to remember that true pemphigus never directly 
depends etiologically upon the syphilitic dyscrasia. I have seen-and many others no doubt have 
seen the same-severe chronic pemphigus in old syphilitics broken down by the persistence of that 
disease and by their bad habits, intensified in some instances by poverty and squalor; but 1 have 
never seen typical pemphigus lesions coexist with true general syphilitic lesions ; and we know 
how multiform the latter may be. (For further particulars the reader is referred to the sections 
on the Pustular Eruptions of Syphilis.) 
Pemphigus in its encrusted state may resemble eczema, impetigo contagiosa, and scabies ; and 
I think that the mere mention of the possibility of error in diagnosis in such cases should be suffi- 
cient to cause the young observer to picture in his mind the distinctive course of these diseases, 
and then he will speedily see light. In like manner, foliaceous pemphigus may come to resemble 
eczema rubrum and exfoliative dermatitis, but care, thought, and a moderate knowledge of these 
diseases are all that are necessary to dispel doubt. 
Prognosis.-In general, the prognosis of pemphigus is good in those cases in which there is 
little or no systemic reaction, in which the viscera are healthy and the general condition satisfactory, 
and in which there are few and not oft-recurring bullae. It is always to be guardedly given in old 
persons, in those suffering from chronic disease of the viscera, especially the kidneys, from nervous 
diseases, and in persons for a long time addicted to alcoholic and other excesses. In like manner, 
pemphigus in children, following in the wake of severe illness of varied kinds, is much modified 
for the worse by a resulting condition of debility. In very young children a cure largely depends 
upon the supply of good breast-milk and the general and special good care which the infant 
receives. Unless in epidemic form, pemphigus neonatorum is not attended with a high rate of 
mortality. 
Treatment.-The treatment of pemphigus should be largely on the lines of general medicine. 
Each case should be thoroughly investigated, and upon the facts elicited the medication should be 
based. In very many cases the disease is the accompaniment of various morbid conditions, the 
management of which depends upon the skill, training, and acumen of the physician. The gen- 
eral rule should be to restore, as far as possible, the balance of health ; and it would be tiresome to PEMPHIGUS. 
297 
enter into the labyrinth of pathological states underlying pemphigus. Where admissible, arsenic 
should be given in full and long-continued doses, since it is a remedy which has proved to be of 
benefit. Quinine, phosphorus, tonics in general, and cod-liver oil, may be used when indicated. In 
all chronic cases it is important to look well to the action of the kidneys. The diet and surround- 
ings of the patient should be carefully looked after. Local treatment is especially to be consid- 
ered. When the lesions are not numerous, they may be dressed with black wash and lead-and- 
opium wash applied on lint. Linseed oil and lime-water make a very soothing application. Various 
dusting powders may be employed, the formulae of which have been given in the sections on 
Eczema and Erythema. Oxide of zinc has been found to be a very good drying powder, and it is 
thought by Dr. Roswell Park of Buffalo to be equally as efficient as iodoform as an antiseptic. 
Subnitrate of bismuth also is an excellent application, either alone or in combination with starch. 
The following formulae also may be used: 
B. Zinci oxidi, §ss; 
Acid, carbol., gtt. xvj; 
Pulv. amyli, §iss. M. 
B. Hydronaphthol, 3j+3'j j 
Cretse prsecip., §ij. M. 
B. lodoformi, 
Acid, boracici, dd. i;ij; 
Pulv. amyli, §ij. M. 
B. lodoformi, 3j; 
Pulv. camphorae, gss; 
Pulv. amyli, gj. M. 
Great care should be taken that each bulla be protected with a small pad of absorbent cotton 
upon which a little of one of the foregoing powders should be dusted. 
It is especially important, when oozing takes place in the lesions, or excoriated surfaces 
are left, that thorough antiseptic precaution should be taken, since much of the ulceration and 
chronicity of the lesions is dependent upon the malign action of micro-organisms which settle upon 
the raw surfaces. To obviate this accident, bathing, local and general, with very dilute solutions 
of the bichloride of mercury is necessary, and great care as to cleanliness of the bed-linen is 
essential. In the excoriated and ulcerated state of pemphigus the various ointments recommended 
in eczema may be used. 
Baths of bichloride of mercury, of sulphuret of potassium, of sal soda, and of borax may be 
advantageously employed at temperatures deemed suitable for the case. In chronic pemphigus 
the continuous bath recommended by Hebra may be found useful ; for details of the technique of 
which see that author's handbook. 
Secretan reports an interesting case of a man one half of whose body was covered with pem- 
phigus, appearing in crops and attended with febrile movement. The condition being uninfluenced 
by the ordinary remedies, and the itching being severe and persistent, Secretan used compresses 
soaked in a i per cent, carbolic-acid watery solution. The result was that the disease was at once 
much improved and the itching instantly relieved. In the early part of this treatment the toxic 
effects of the carbolic acid caused a suspension of the application for some hours, or even for days. 
Cure took place in five weeks, owing, as the author thought, to the anti-microbian action of the 
acid. TINEA TRICOPHYTINA BARBAE 
Tinea tricophytina barbie-also called tinea sycosis, sycosis parasitica, barber's itch, and 
ringworm of the beard-is an affection of the hairy parts of the male face and neck, and originates 
in the same parasite as ringworm of the scalp. It is an affection subacute in its course, inveterate 
in its character, and productive of much discomfort and of present and perhaps future deformity. 
Though not common, it is far from rare in occurrence. It is met with chiefly between puberty and 
middle life, after which it is rarely observed. It affects all kinds and conditions of men, and there 
are no known facts to prove that any one is especially predisposed to it. 
Ringworm of the beard usually begins as a small red spot which is the seat of a moderate 
burning itching. It is usually found upon the submaxillary regions and around the neck, chiefly 
toward the middle line, but it also occurs upon the hairy portions of the face and on the chin and 
upper lip. In the very early stages of ringworm of the beard a number of morbid pictures are 
presented. In some cases the disease begins in the small superficial red spots already mentioned, 
which quite promptly increase in size, and when they have attained the area of a ten-cent piece or 
of a silver quarter they show their ringed character. This is well portrayed in Plate XLI. In 
front of the left ear is a well-marked, newly-appearing ring of red skin enclosing a whitish, scaly 
centre. From this condition it promptly extends until, owing to the configuration of the parts or 
from fusion with one or more of its fellows, a gyrate patch or patches result, as are well shown near 
the angle of the jaw and on the neck. In some cases-unfortunately, however, not common-the 
disease runs this mild course and shows this superficial tendency of development. Such cases, 
however, may later on become aggravated, and the disease may then attack the deeper structures. 
In other cases this form of ringworm is more severe from the start. In this event the patient first 
notices a deep red spot around a hair or several hairs, which shows a practised eye that a rather 
deep inflammatory process is going on. This spot grows apace in the typical ringed form, and 
when it has attained an area of about an inch consists of a distinctly elevated, perhaps papular, 
ring, of deep-red color, surrounding a thickened, less red, but scaly skin, the hairs and hair-follicles 
of which give evidence of morbid changes. In some of these more severe cases the circumfer- 
ential ring presents traces of vesiculation, and might pass on superficial observation as a ring of 
vesicles. If carefully inspected and punctured, it will be seen that the true vesicular process has 
not taken place, but that the epidermis has been slightly elevated, owing to the serum-soaked 
condition of the constantly-growing ring in which the development of the parasite is active and 
rapid. 
In contrasting the foregoing descriptions it will be seen that in the first the parasite involved 
and luxuriated in the epidermal layers, and in the second case involved the skin itself. 
Then, again, there is a third mode of behavior of the parasite. One or more red spots seated 
around hairs are seen. These grow rather slowly, but deeply, and soon become little conical, cir- 
cumscribed masses deeply seated in the skin and covered with a deep-red scaling epidermis. They 
may grow still larger, and come to form the nodular stage of ringworm of the beard now to be 
described. 
298 Part VI 
Plate XLI 
TINEA TRICHOPHYTINA BARBAE 
LEA BROTHERS & CO. PUBLISHERS , PHILADELPHIA TINEA TRICOPHYTINA BARBAE. 
299 
In most cases of this disease, whatever may have been its behavior in its early stage, the tend- 
ency of the fungus is to burrow down into the recesses of the hair-follicles, to cause them to 
inflame, and to involve the tissues around them-a process called perifolliculitis. The result of 
this deep process is to cause the nodular form-or, more properly, stage-of beard-ringworm. This 
nodular ringworm of the beard is seen in different conditions, which require systematic description. 
In the mildest form the disease consists in few or many little red elevated tubercles scattered 
over the beard and neck, which are not very deeply seated, and really occupy the thickness of the 
skin itself. These little tubercles may be red, scaly, and studded over with diseased hairs seated 
in inflammatory follicles which are the seat of 
pus or exudation. In more severe cases these 
tubercles are of larger size and involve the 
subcutaneous connective tissues in inflamma- 
tion, and they are then really nodules. In 
wood-cut Fig. 40 the small tubercles of 
beard-ringworm are well shown on the chin, 
while on the left submaxillary region and 
neck the characteristic nodules may be seen. 
These nodules may be few or many: they are 
usually found on both sides of the face, placed 
without order or symmetry, and are more or 
less salient, in a conical and rounded manner, 
according to their size. Their number in any 
case is indicative either of the primitive points 
of contagion or of the luxuriance of growth 
of the parasite and the extent of auto-inocula- 
tion, since the diseased scales or crusts of one 
tubercle may become lodged on the skin and 
beget many like it. These nodules then may 
be of the size of a pea, of a cherry, of a hick- 
ory-nut, or of a walnut, They grow more or 
less slowly, and fuse when close together. When a number of large nodules thus coalesce they 
form veritable tumors, which are more or less deeply seated and cause much disfigurement. It is 
not uncommon to see the tissues over and under the lower jaw so swollen, infiltrated, and dense 
that they cannot be pinched between the fingers, and in some cases so deep is the infiltration that 
the morbid tissues can hardly be moved or made to slide over the lower border of the under jaw. 
In some cases a number of separate large tumors, perhaps of varying size, are present. To the 
touch these nodules, when separate, are hard, firm, and tolerably well circumscribed, and when 
coalesced give to the tissues a peculiar resistant and brawny feel, like the rind of ham 
The surface appearances of nodular ringworm are very various. In some cases there is 
simply increased color of the skin, varying between a light pink and a dark even purple red, com- 
bined with considerable epidermal exfoliation and the presence of morbid hairs. In other cases 
the appearances are very different. The skin is smooth (though perhaps a little scaly), decidedly 
stretched, not much reddened, and slightly glossy, giving evidence of much subcutaneous inflam- 
matory exudation and the involvement of the hair-follicles and of the hairs. In another class of 
these nodular cases the appearances are strikingly different from the foregoing. Coincidentlv with 
the deep-seated process great structural changes take place in the corium itself. Minute swellings 
occur around the hair-follicles, which by exudation and pressure from beneath become very prom- 
inent : as this process grows in extent and intensity these little elevations then come to present a 
Fig. 40. 
Tinea tricophytina of Beard, nodular form. DISEASES OF THE SKIN. 
300 
warty or cauliflower appearance. Such a case then presents a marked picture of an uneven, 
verrucous, sometimes almost papillomatous surface, having, as we may say, a distinctly fleshy look, 
studded irregularly with broken-off hairs, with empty hair-follicles filled either with pus or serous 
exudation. The older dermatologists compared this warty, infiltrated condition of the skin in 
beard-ringworm to the soft part of the fig, and on the basis of that simile called it sycosis. 
In all cases the hairs are affected. They become dull, dry, lustreless, and easily fractured. 
They soon lose their hold on the follicle, and can be readily pulled out, and their roots are some- 
times seen to be covered with a whitish powder, which is really the parasitic fungus. All that has 
been said of the condition of the hair in scalp-ringworm applies to this disease. The follicles 
behave differently in each case and in various cases. Some of them may be simply swollen, scaly, 
and conical, showing only deep inflammatory exudation ; others may be the seat of pustulation or 
of serous exudation ; or others, again, so swollen as to be warty in appearance, as has been already 
described. There is no uniformity in the character of the crusts, of their size, or of their position. 
They may be present or they may be absent. They may be small or rather large, thin or thick, 
but never uniformly covering a part. They are usually quite adherent, and when lifted up reveal 
the typical fleshy surfaces. They are of various shades of yellow or greenish-brown, and, as a rule, 
emit an offensive odor. In some cases which have already been mentioned, however, they are 
wholly absent. I he amount of suppuration varies in different cases, perhaps owing to idiosyncrasy 
and perhaps to the activity of the fungus. In some cases a glairy, viscid fluid exudes from the fol- 
licles, which is comparable to that of kerion of the scalp. The surface discharge, therefore, may be 
slight or it may be copious. 
I'he irritation caused by the disease sometimes induces only mild pruritus and heat, but in 
many cases these symptoms, particularly in late stages of the disease, are so severe as to cause 
discomfort, suffering, and loss of sleep. 
Ringworm of the beard may last months or years, always goes from bad to worse, and never 
gets well spontaneously. It may be accompanied with ringworm of the body. Even under active 
treatment its involution is very slow, and often disappointing. 
It leaves after it a number of sequelae, the mildest of which is a 
scaly condition of the skin and an imperfect development of the 
hair, which requires great subsequent care as to its growth. In 
some cases the hair-follicles are entirely destroyed and perma- 
nent bald spots or patches are left. More or less scarring may 
result in very obstinate cases, particularly those too actively 
treated ; and so great is this that in some cases unsightly 
deformities are produced. Even in protracted cases no 
impairment of the health occurs, and in weakly subjects no 
amount of improved nutrition ameliorates the course of the 
disease. 
Etiology.-This disease is caused by the Tncofthyton 
tonsurans, which has been described in the section on ring- 
worm of the head. The morbid process is mainly a follicu- 
litis set up by the fungus in the hair-follicles, and this involves 
the tissues in inflammation which has been called perifolliculitis. 
There is also parasitic infiltration of the epidermis of the face, 
beard, and chin, and also of the hairs themselves. The manner 
of infiltration of the hair by the parasite is well shown in wood-cut Fig. 41, in one half of which 
the hair is represented as normal, and the other half as infected by the fungus. 
Ringworm of the beard is generally communicated by the barber to the patient. It is prob- 
Fig. 41. 
Hair from a Nodule of Ringworm of the Beard, TINEA TRICOPHYTINA BARBAE. 
301 
able that the vehicle of infection is the lather-brush, and not the razor. Careful inquiry by me into 
the origin of five cases which claimed one barber as the source of their ringworm elicited the fact 
that the cup and brush employed in shaving them had remained unused for several weeks, and that 
the brush had become mouldy. 1 he question left unsettled in these cases was, whether the para- 
sitic fungus had been left on these utensils or whether they had lodged there and had luxuriated 
and fructified. The disease may be contracted from a young subject or from older ones affected 
with ringworm of any part. In countries where kissing between men was or is the usual mode of 
greeting the mode of contagion was and is in some cases from man to man. Ringworm of the 
beard may result from auto-infection by the transference of the parasite from some part of the body 
to the beard by means of the fingers or of some utensil. Dr. Hyde states that he has treated a 
number of severe cases of ringworm of the beard which, he is convinced, originated in the process 
of shearing sheep having diseased pelts. I his form of ringworm, like that of the scalp, may be 
communicated by contact with domestic animals which are infected. 
Diagnosis.-The difficulty in the matter of diagnosis is generally to settle whether the affection 
is or is not of parasitic origin. In simple sycosis there is inflammation of the hair-follicles and of 
the perifollicular tissues, with a more or less free production of pus. There is no implication of the 
nutrition of the hair, which is usually seated firmly in the follicle and pulled out with a little force ; 
the reverse of which is observed in ringworm of the beard. In simple sycosis there is rarely if 
ever such nodular infiltration, and never the verrucous appearances so constant in the parasitic 
disease. In any case, intelligent care, supplemented with the aid of the microscope, will soon 
settle the diagnosis. 
Some severe cases of acne might be mistaken for ringworm of the beard, but a little consid- 
eration would soon put the physician right. 
Vegetating syphilides might be mistaken for this disease, but there is in them usually a history 
of syphilis and of other lesions, and the fact can be elicited that vegetating growths are really sec- 
ondary to typical syphilitic lesions. 
Prognosis.-The disease is highly contagious to the patient and those around him, and requires 
constant care as to prophylaxis. Its course is especially persistent, and it never ends spontaneously. 
The prognosis, therefore, hinges upon the correctness of the diagnosis and upon the energy and 
efficiency of the treatment. 
Treatment.-T he first indication is the removal as promptly as circumstances will permit of 
all the hairs from the affected area or areas. This should be done by means of the epilating for- 
ceps in the manner detailed in the treatment of scalp-ringworm. Much amelioration of the patient's 
sufferings will be produced by first thoroughly anointing the parts with some oily compound, and then 
freely bathing them with hot soapsuds, followed by hot-water soppings. The surface may then be 
painted with an 8 per cent, solution of muriate of cocaine, after which the physician's course will 
be practically unobstructed. It is well that all other parts should be shaved, and that they should 
be thoroughly washed with carbolic soap, and three or four times a day sopped with a solution of 
bichloride of mercury in water (i : 2000-3000). To the diseased patches it is well to apply the fol- 
lowing lotions after the preliminary treatment: 
B. Hydrarg. bichlor., gr. ij-f-iv; 
Spts. vini rect., §ij. M. 
B. Hydrarg. bichlor., gr. viij; 
Ammon, mur., gss; 
Chloroformi, §ss; 
Alcoholis, giss; 
Aquae. §ij. M. 302 
DISEASES OF THE SKIN. 
R. Sodae hyposulphitis, jiij; 
Alcoholis, 
Aquae, da. §ij. M. 
In using these lotions care should be taken that they are made to penetrate deeply into the fol- 
licles. To this end these structures should be thoroughly freed from all of the products of 
inflammation. 
The indications of the amelioration of the disease will be the lessened suffering of the patient; 
the absence of extension of the disease ; the subsidence of the nodules, which become smooth and 
lose their warty and deepened color, more movable, and less resistant. Much aid to the cure may 
result from the continuous application of various ointments during the intervals between the hot 
water and antiparasiticide macerations and the epilations. 
The following formula has proved of benefit in my practice : 
R. Hydrarg. submuriat., gr. xx+xl; 
Acid, carbol., gr. x-f-xx; 
Balsam. Peru., gj; 
Ung. aq. rosae, 5j. M. 
Likewise ointments containing the oleate of mercury and white precipitate may be used, as in the 
following formulae : 
R. Oleat. hydrarg., 3ij; 
Bals. Peru., 5j; 
Acid, carbolici, gtt. x-|-xx; 
Ung. simplicis, §j. M. 
R. Hydrarg. precip. alb., gr. x-|-xx; 
Thymol., gss; 
Vaselini, 3j. M. 
R. Hydrarg. sulph. flav., gss; 
Bals. Peru., 3j; 
Ung. sinipl., §j. M. 
These ointments should be spread upon lint and, if possible, applied to the parts by means of a 
bandage. Much aid in the cure results from an agreeable mild pressure exerted by means of the 
bandage. The treatment of the superficial scaly form of ringworm of the beard is essentially the 
same as that of ringworm of the body. 
The latest novelty in the treatment of ringworm of the beard is hydroxylamin, introduced 
by Eichoff1 of Elberfeld. This is an ammonia preparation of which one of the atoms of hydrogen 
is replaced by water. The chloride of this salt is in the form of colorless hygroscopic crystals, and 
proves to be a reducing agent of high power and very destructive to low organisms. Eichoff used 
this salt in the proportion of i : 1000 of a mixture of equal parts of alcohol and glycerin, three to 
five times a day, by means of a brush upon surfaces previously carefully washed with soap. He 
also found it beneficial in lupus and body-ringworm. It is a very powerful irritant, and must be 
used with much caution. 
1 Lancet, Feb. 9, 1889. TINEA CIRCINATA. 
Tinea circinata-incorrectly called herpes circinatus-is that form of ringworm which is 
found generally upon the body. It originates in the same fungus as ringworm of the scalp and 
of the beard. It is seen in young, middle-aged, and sometimes in old subjects, and may exist as a 
distinct morbid entity or as a concomitant of the other forms of ringworm. It is found in persons 
of all grades of health, and, though some individuals seem more susceptible to its development 
than others, we are ignorant of the reason thereof. It usually runs a chronic course, and, though 
in large eruptions some lesions may disappear spontaneously, the tendency of the disease is to 
spread and perpetuate its growth. Upon covered parts, coapted surfaces, regions studded with 
hair-follicles, and those upon which sweat is freely poured the disease shows a marked tendency to 
chronicity and luxuriant growth. 
Ringworm of the body begins as a pinkish or reddish scaly spot, which attracts attention chiefly 
by the slight itching it causes. This primordial spot quite quickly increases in size, and as it does 
so it becomes slightly elevated and distinctly marginated. When it reaches the size of a five- or 
a ten-cent silver piece its ringed character is very definitely pronounced. We then see a distinct, 
sharply-cut, marginated pink or reddish ring, not much but clearly elevated, sometimes papulated, 
and generally quite scaly, the scales being thin and branny. In some cases, upon parts where the 
epidermis is thin, a semblance to vesiculation may be seen in these rings, but the student must not 
think that he will find a true ring of vesicles. When quite small, the area within the rings is pinkish 
and scaly, but as the ring grows in size the tendency is for the central portions of the skin to return 
to a seemingly healthy condition. Thus, when rings are of one to three inches in diameter their cen- 
tral portion is of the normal skin color ; around it is a zone of pinkish or slightly brownish-red hue, 
which merges into the ring proper. In these cases, when central involution thus becomes complete, 
the tissues may be often reinfected with the parasite, and new rings may be formed within the orig- 
inal large ring. Arning says that he has seen four, and Unna three of these concentric rings. As 
the ringworm lesions grow they, when near each other, coalesce and form gyrate and serpentine lines. 
In general the round shape is preserved, but as the rings increase in size they may become oval or 
festooned, or even irregular, in outline. The configuration of the parts has much to do with the 
moulding of the shape of the ringworms. As these lesions grow quite old their sharpness of con- 
tour may be lost, and only a semblance of a ring may be left. 
In some cases the growth of the fungous elements in the epidermis is attended with more than 
a pink or reddish color, and the rings are of a brownish-red hue. This not common peculiarity has 
given rise to the term tinea circinata maculata. The simple fact of the case is that, coincident with 
the morbid process, abnormal pigmentation takes place in the rete Malpighii. 1 his variety of ring- 
worm may be quite acute and much disseminated. 
The course of ringworm varies under different circumstances and in different conditions. 
As a rule, the lesions at the onset increase with tolerable rapidity, showing the activity and luxu- 
riance of the fungus. In some persons their course is slow, in others more rapid. It is usually 
more active in warm than in cold weather. When large, the lesions may remain at a standstill for 
some time. Then, again, periods of activity and remission may be observed. The mode of evo- 
303 304 
DISEASES OE THE SKIN. 
lution of the disease is by successive crops, which appear in greater or less plentitude at long or 
short intervals, and are indicative of a continued series of reinfections with the fungus. The dis- 
ease may last months and even years, and is more readily curable in children, in whom it seems to 
increase in marked luxuriance. 
The lesions of ringworm are distributed without symmetry or orderly arrangement. There 
may be but one, a few, or many. In some cases one or more hundreds are seen on the body. 
They are not usually attended with much itching, though this symptom may be distressing in some 
persons, and may be accentuated when the circulation is increased by exercise or elevation of 
the temperature. All parts of the body may be attacked by ringworm, but it is especially prone 
to appear on the face, the neck, the hands, the inner surface of the arms, the trunk, the axillae, and 
on the thighs, groins, and nates. 
Tinea circinata cruris is the name given to ringworm when developed about the crural region 
and the genital organs. In these parts it runs a peculiar course, and is often complicated with 
eczematous efflorescences. It was this feature which led Hebra to call it eczema marginatum. 
Tinea tricophytina cruris, or ringworm of the groin, is commonly first seen as a circle or 
disk at that part of the thigh with which the scrotum is in contact. This rounded patch is red, per- 
haps very superficially excoriated, and ends in a sharply-defined, somewhat elevated, scaly margin. 
In other words, it is a typical patch of ringworm with more or less central hyperaemia. The descrip- 
tions given by some writers lead to the inference that in all cases of this affection there is much 
concomitant eczematous inflammation, whereas this is only true of perhaps the greater number 
of cases. For clearness of description it is well to remember that there are cases in which the 
appearances are very typ- 
ical of ringworm, and others 
in which this appearance is 
more or less masked by sec- 
ondary eczematous inflam- 
mation. In Plate XLII. Fig. 
2 is admirably delineated a 
case in which the disease pre- 
sented typical and uncompli- 
cated appearances. 1 he pa- 
tient was under the care 
of Mr. Jonathan Hutchinson 
when the picture was taken, 
and came to me several years 
after with a relapse similar in 
all respects to that delineated in Fig. 2. Similar lesions were found in the axillae, and the descrip- 
tions given here will apply with equal force to genito-crural and axillary ringworm. 1 he primor- 
dial ring increases in size, its advancing border being either thin and narrow, as shown in big. 2, 
Plate XLII., or much wider, even to the extent of half an inch. As this border grows larger it 
becomes festooned. It is usually of a pinkish-red color, more or less-but never markedly-ele- 
vated, quite scaly, and perhaps when large broken into segments. In general, it may be said that 
the morbid rings are rather wider than those depicted in Fig. 2. The disease progresses sometimes 
slowly, and again with astonishing rapidity, around and down the thigh perhaps to the knee, ovei 
the groin to the pubis, and it may invade the opposite thigh. It often passes backward around the 
crural region and up on the buttocks. In men it is usually seen in greater extent on the left side, 
where it, as a rule, originally begins, since most men "dress" on that side. When the original 
Fig. 42. 
Epidermis invaded by Tricophyton : a, inferior portion of the stratum corneum; b, superior portion of the 
rete. Both exhibit long mycelial threads, with few ramifications and a small number of spores. Part VI 
Plate XLII 
LEA BROTHERS & CO PUB L!SHE RS .PH! LADE LPHIA 
Land 2. Tinea Circinata of' body and inguinal regions. TINEA CIR CI NA TA. 
305 
'mgs become large, it is common to see the enclosed areas of skin become reinfected again, and 
the seat of circles or segments thereof, and perhaps of serpentine lines. As I have already said, 
this dry, scaly state of the eruption may exist during its whole course-especially is it so in women 
and it may be perhaps complicated with mild recurrent erythema in men. 
I he more severe form of genito-crural ringworm is shown in Fig. i, Plate XLIL, and is a 
composite affection, a commingling of the parasitic affection with eczema. In this form the advan- 
cing border is ot a deeper red, rather more elevated, perhaps scaly, and often the seat of papules, 
imperfect vesicles, with perhaps here and there a few pustules. In the enclosed area the skin may 
be more or less thickened, very often excoriated and oozing, generally is irregularly but quite 
deeply pigmented, and over it are scattered erythematous papules and perhaps tubercles, and 
sometimes vesicles and pustules,-all placed without definite arrangement. In the natural creases 
°f the skin painful fissures are frequently seen, and where the moisture is great at the fork of the 
thighs and around the anus the eczematous condition is often very severe, and sometimes compli- 
cated with large pustules and boils. Beyond the morbid margin the disease may show itself by 
outlying papules, red disks, or rings of more or less completeness ; which features show that auto- 
infection has occurred from lodgment of the morbid detritus upon these parts. The heat and mois- 
ture of the genito-crural and anal regions are the underlying causes of the luxuriance of the para- 
sitic growth, and the perpetuation of the disease may be aided by uncleanliness and the want of 
treatment. 
I his form of ringworm, as well as that of the axillae, is commonly attended with mild heat, 
burning, and pruritus, which may be severe, and is usually paroxysmal. Hebra thought that this 
affection was seen mostly in shoemakers and cavalrymen, but in America it is seen in males and 
females of all kinds and of all grades. It is generally a chronic affection, and is sometimes mark- 
edly limited in area, and again very extensive in its distribution. Its progress may be quite rapid 
or very slow, and its stay on the skin is often much prolonged by the appearance of new points of 
infection. It is especially severe and inveterate in warm countries, in persons who sit and sweat, 
and those seated for long periods on horseback. 
tiology.-Ringworm of the body is caused by the Tricophyton tonsurans. This fungus pene- 
trates the superficial corneous layers of the epidermis, and luxuriates in their midst. In severe 
nflammation the subjacent tissues are involved in the activity of the process. In wood-cut Fig. 
4- are well shown the microscopical appearances of the skin invaded by the trycophyton. 
In children body-ringworm either results from a similar condition existing on the scalp, or the 
infection is derived from another child or from some animal, such as sheep, dogs, horses, cows, and 
oxen. In older subjects it may be secondary to ringworm of the beard or may be contracted from 
some animal. Some persons, both young and old, seem more susceptible than others. It is often 
very difficult, and even impossible, to trace the source of infection in genito-crural regions, but in a 
imber of instances I have elicited proof of its origin in sexual contact. 
Diagnosis. In general, the clinical appearances of ringworm are so typical and striking that 
t e diagnosis is readily made. In all cases doubt can be immediately eliminated by the microscop- 
examinations of the scales placed in a drop of glycerin and liquor potassae. 
The red disk of tinea circinata may be mistaken for dry seborrhoea, in which the plaques are 
emeu ar. But the absence of follicular inflammation and of greasy epidermal crusts in ringworm, and 
e presence of the parasite in its scales, will promptly settle the question. In like manner, new, 
more commonly old and not much elevated, circular and ringed spots of psoriasis may be 
trikingly like ringworm, but the history of the case and the use of the microscope will always 
establish the distinction. Certain ringed erythematous and papular efflorescences of syphilis, 
ic i are not much elevated and are more or less scaly, may be regarded as ringworm ; and here, 
gain, the microscope and the history of the case usually clear away any doubt. 306 
DISEASES OF THE SKIN. 
Ringworm of the genito-crural regions may resemble the circular and marginate forms of the 
erythemata, but the situation and history of the former point to its nature, which can always be 
satisfactorily established by the microscope. In like manner, eczema, when developed in disk 
shape and scaly form, may come to look like ringworm, and here, again, the microscope and the 
history of the case help us out. 
Prognosis.-Ringworm of the body when limited in extent is readily curable, particularly in 
children, in whom its extension is often very rapid. In cases in which the disease is more or less 
generalized, the prognosis depends entirely upon the intelligent care and activity of treatment. 
Left alone, the disease does not cease to extend. In some limited spots spontaneous involu- 
tion of the affection may perhaps occur. This is sometimes seen in the case of one spot on a 
person. 
Treatment.-The indications for treatment are the destruction of the parasite and the pre- 
vention of auto-infection. In many cases of limited rings painting with tincture of iodine every 
day or two is sufficient, or the following may be used: 
R- Tr. iodini, 3j+3'j > 
Collodion flex., §j. M. 
R. Iodoform., 3j; 
Ether sulphur., gij; 
Collodion flex., 5j. M. 
The advantages of these applications consist in their anti-parasitic action, in their impermeability, 
and the consequent immunity to auto-infection which ensues ; and also in the prevention of the 
access of oxygen, so necessary for the growth of the fungus. I and others have found much 
benefit from a treatment proposed by myself some years ago. This consists in painting the parts 
every day or two with the following solution : 
R. Hydrarg. bichlor., gr. ij-J-iv; 
Tr. benzoin, co., M. 
The resulting film left on the skin is less thick and contracting than that left by collodion and 
traumaticin, consequently this preparation can be used on more extensive surfaces and near 
and over delicate parts, such as the axillae, the genito-crural and anal regions, and also on the 
neck and face. 
Genito-crural ringworm may require treatment by reason of its erythematous and eczematous 
complications. This should be conducted upon the lines already indicated in the treatment of the 
inflamed and moist states of the affections. Lassan's paste, oxide-of-zinc ointment, diachylon, and 
other ointments may be used in combination with the various parasiticide remedies. (For further 
details the reader is referred to the sections on the treatment of scalp ringworm and those on the 
treatment of the erythemata and of eczema.) Part V 
ECTHYMA 
LEA BFjOTHEnS & CO-PUBLISHEFfS .PHILADELPHIA 
Plate XL1I ECTHYMA. 
Ecthyma is an inflammatory affection, manifesting itself in a few or many large pustules, 
discretely placed or closely aggregated, seated upon a thickened base. In many cases it exists 
as a primary affection ; in others, however, it is developed secondarily to other affections of the 
skin. 
Ecthyma begins as small red spots, commonly seated around hair-follicles, in the centre of 
which a small yellow purulent point is seen. This initial pustule grows quite rapidly, and, as it 
does, extends in area rather than in height. The fully-formed lesions are well-marked round or 
oval pustules, varying from the size of a split pea to that of a quarter. They present a bright- 
yellow color, and are surrounded by a well-marked inflammatory areola. As the pustules become 
broad they dry and wither into crusts, which may be of a light or dark yellow, of various shades 
of green, or of a combination of these two colors, or they may be of a greenish- or reddish-black 
bom the admixture of dirt and of blood. These crusts are uneven in surface, slightly but dis- 
tinctly elevated, usually quite easily removed, and cover a suface which is simply excoriated or 
more or less decidedly ulcerated. In the former case the exposed ulcer of the skin is shallow, and 
m the latter depressed. In Plate LXIII. is very graphically portrayed an accurate picture of 
ecthyma. lhe course of the disease from the initial red spot, upon which the pustule soon forms, 
to the large and well-formed crusts is in it well 
shown and better than pen can depict. In this pic- 
ture the isolated and aggregated condition of the 
pustules is represented, and in wood-cut Fig. 43 the 
latter condition, with the tendency frequently ob- 
served to the fusion of pustules and the production 
of large irregular ulcers, is well brought out. As 
the crusts dry, healing takes place under them, 
and they fall off, leaving quite deep red spots. If 
alter the formation of the crust the underlying skin 
falls into ulceration, the size of the former increases 
in area and depth. 
Ecthyma usually appears in crops of pustules 
greater or less number. Each pustule reaches 
maturity in about a week, more or less, and then 
begins to dry and wither. It may fall off in a week 
r ten days, or it may remain on the skin for an indefinite period. Sometimes the crops follow one 
nother with much regularity and promptness, and again they may appear at intervals of several 
days or of weeks. 
his disease may be said to have an acute and a chronic mode of invasion. In some cases a 
fever accompanies the evolution of the eruption ; in others, and the greater number, there is 
systemic reaction. Heat and itching may precede and accompany the lesions, which later on 
cause a sensation of soreness. 
Fig. 43. 
VW ''WWW 
Ecthyma cachecticorum. 
307 308 
DISEASES OE THE SKIN. 
Ecthyma attacks the young and the old, and, as a rule, the anaemic and sickly, those poorly 
nourished and broken down by disease, vice, and poverty ; hence the term ecthyma cachectico- 
rum. Uncleanly habits favor the increase and severity of the affection. It is often seen to com- 
plicate pediculosis, scabies, and various erythematous and itching skin affections. 
Ecthyma is seen most commonly on the thighs, also upon the legs, arms, and the trunk. In 
most cases a rather persistent reddish-brown pigmentation is left on the sites of the lesions. In 
some cases and in some individual lesions scars of varying severity are produced. 
Etiology.-Lowered vitality from any and all causes seems to be the underlying cause of 
ecthyma. Recent observations seem to render it very probable that the disease is the result 
of infection by micro-organisms. Bockhart and others claim that the active morbific agent is 
the Staphylococcus pyogenes aureus and albus. Its origin and mode of infection are yet to be 
settled. It is certain that some persons are more susceptible to the disease than others, and it 
remains for future observation to determine how much idiosyncrasy has to do with its develop- 
ment. In some cases the extension of the disease, in part, by infection with the escaped pus is 
readily seen. 
Diagnosis.-Ecthyma may be mistaken for pustular eczema, impetigo contagiosa, impetigo her- 
petiformis, and certain encrusted pustular syphilides. The deeply-seated and decidedly inflamma- 
tory character of the lesions, and the site and mode of distribution of ecthyma, are sufficient to 
distinguish it from pustular eczema. Again, these features are in strong contrast to the more 
superficial character of the lesions of impetigo contagiosa, which, as a rule, begin and are often 
limited to the face. If the picture of impetigo herpetiformis is compared with that of ecthyma, the 
distinction can be made at once without the aid of differential diagnosis, for their resemblance is 
not at all striking. 
The most common error is to mistake ecthyma for the encrusted pustular syphilides. Where 
7 1 11 
doubt exists, and if the history of the case is not clearly in favor of the simple eruption, it is we 
to inquire into the existence of syphilis and to look for other specific lesions or their sequelae. In 
syphilis the crusts are usually thicker and darker, the underlying ulcers are deeper, and the sur 
rounding zone of infiltration is firmer and of a dull-brown or coppery hue. 
Prognosis.-Where the health can be re-established and care and attention given to the lesion, 
the prognosis is good ; contrariwise, it is not favorable. 
Treatment.-The indications for treatment are local and general. The health of the patient 
should be attentively considered, and all means, hygienic, medicinal, and climatic, should be 
employed to restore it. The knowledge of the condition will at once suggest to the mind of the 
physician the necessity of tonics, cod-liver oil, and nutritious food. Locally, much can be done by 
frequent washings of the parts, by alkaline baths, and by prompt removal of soiled bandages. 
Applications of carbolic-acid water (i or 2 : ioo) on lint or absorbent gauze are excellent, or mild 
bichloride solutions (i : 2000 or 5000) of water may be employed. The various ointments recom 
mended for the treatment of eczema and of pemphigus may be used ; for the formulae of which the 
reader is referred to the sections treating of those diseases. Part VI 
Plate XL1V 
Fig.lv. 
Fit • 2 
LEA BROTHERS & CO. PUBLISHERS , PHILADELPHIA. 
LUPUS ERYTHEMATOSUS 
1- of Face 2. of Hands, LUPUS ERYTHEMATOSUS. 
Lupus erythematosus is the name arbitrarily given to a chronic superficial infiltration of the 
skin of the face, and sometimes of the hands, manifesting itself either in circumscribed or in rather 
diffuse patches, and occurring more frequently in females than in males. It is also called lupus 
sebaceus, bat's-wing disease, and vespertilio. 
Lupus erythematosus usually begins upon some prominent part of the face, as the bridge of 
the nose, the cheeks under the eyes, the upper lip and chin, and the ear, chiefly on the lobule or 
at its junction with the cheek, also on the posterior portion of the ear and over the malar bone. 
It may also appear, but less commonly, upon the scalp and upon the forehead. In the greater 
number of cases the disease begins about the nose or on the territory immediately contiguous 
with it. 
Lupus erythematosus, as seen in America, appears as a primary lesion, consisting of cell-infil- 
tration around one or more sebaceous follicles, which may present two quite well-marked appear- 
ances. In the first we observe a small, pinkish-red, scaly papule, flat and with slight elevation, in 
the centre of which the orifice of the follicle may be seen to be simply thickened in its epidermal 
layers. This form is often strikingly suggestive of the punctate stage of psoriasis. In the 
second initial form of lupus erythematosus we find a small, flat, pink papule, less than or as large 
as a split pea, covered with a central yellowish sebaceous and sometimes greasy scale or crust, 
which is not readily detached ; and if removed, underneath it is seen a thin tapering, villus-like pro- 
cess which fits firmly into the small, patulous orifice of the sebaceous follicle. In some cases this 
crust is rounded or flat on its surface ; in others it is conical and comedo-like. A multiplication of 
these lesions constitutes the plugged-follicle symptom, which, without being an absolute essential to 
this disease, is very frequently found during its course. As a rule, quite slowly and almost insen- 
sibly these lesions grow in area, though they never attain a height of much more than a line. In 
some rather exceptional cases the peripheral growth is quite rapid at first, and then it becomes 
slow and chronic. In still more exceptional cases the rapid growth continues until one or more 
well-marked disks of infiltration are formed. 
I he original lesions increase at their periphery until they reach the size of a ten-cent piece or 
a silver quarter, and then the mature efflorescence may be said to be formed. It consists of a 
round or oval patch, at the margin of which is a more or less distinctly-elevated border, which is 
sharply defined. This border may vary in breadth, and often is not at all uniform in size, from one 
hall to one inch, is usually covered with small grayish or greenish adherent scales, and is frequently 
studded with plugged follicles, which are flat or conical. In some cases the border is covered with 
a more or less continuous crust, sometimes yellowish-green or dark-greenish in color, which covers 
the elevated infiltration beneath, and is bounded outside by a thin pinkish-red or violaceous margin, 
which shows the line of advance of the disease. This sebaceous and epidermal crust is firmly 
adherent, resists displacement with the nails, and when removed by considerable force underneath 
it are found numerous peg-like, tapering processes which correspond to dilated follicular openings. 
Besides the two foregoing appearances characteristic of the advancing border, it is sometimes seen 
as delineated in Plate XLIV. Fig. i. On the chin may be seen the primordial lesions, which on 
309 310 
DISEASES OF THE SKIN. 
the upper lip are further developed. On the left cheek a diffuse pinkish scaly thickened patch is 
seen, which ends by an abrupt margin which is not very much elevated above the normal plane of 
the skin, and which simply consists, like the whole patch, of thickened scaly skin. I hese patches 
may be pinkish, red, or even violaceous. Most authors assert that coincidently with the peripheral 
increase of the disease atrophic changes take place at the central portions of the patch. I his is 
true as to some cases, and not as to others. Figure i of Plate XLIV. represents a not infrequent 
example of the course of lupus erythematosus. The patch is of even plane, consists of super- 
ficially thickened skin, which to the touch is rather rough and dry, and is covered with small gray- 
ish-white, quite adherent scales. Close inspection may show the follicular nature of the trouble in 
the not very strikingly patulous orifices of these appendages, and perhaps in their closure by epi- 
dermal or epidermo-sebaceous scales. In some cases like the foregoing the plugged-follicle feature 
may be observed scattered over the patch. When the disease exists on hairy parts, such as the 
scalp and beard, the surface of the growing patch is usually quite uneven, owing to the prominence 
of the infiltrated hair-follicles. In the healed and cicatricial stage this uneven surface is also, as a 
rule, quite well marked. 
In many cases, however, atrophic changes begin when the affection is well under way, and 
increase pan passu with its evolution. Then we see a central depressed portion of skin, which at 
first is of some shade of pink or red, but which, as it gradually becomes thin, also becomes blanched, 
until in the end a thin, smooth, parchment-like whitish or mother-of-pearl cicatrix is formed. I hough, 
as a rule, we find these peculiar cicatrices in lupus erythematosus, we sometimes find them some 
what thickened and irregularly studded with minute quite deep round depressions, as if punched 
out, which correspond to the sites of infiltrated follicles which have undergone exceptional atrophy. 
I hen, again, the typical parchment-like cicatrix is not found, but one tolerably smooth, but quite 
thick and adherent to the much-thickened subcutaneous tissues. In the first case the scar can be 
readily pinched in folds between the fingers ; in the second, it is with difficulty, if at all, possible to 
grasp it in this manner. The central area of cicatrization-process is governed by no rules, and it 
differs materially in almost every case. In some patches of lupus erythematosus cicatrization begins 
when the lesion is of the size of a silver quarter or even less. In others it is much delayed, and 
may not show itself until the whole large patch is nearly, if not perfectly, complete. Many patches 
remain in full efflorescence for long periods before atrophic and cicatrizing changes begin. 1 his 
degenerative process may begin in one spot or in several, and may progress slowly or with toler 
able promptitude. 
Lupus erythematosus may thus continue until the whole face and adjacent parts are involved, 
or it may only attack a portion or portions of it. When under the influence of treatment, and in 
exceptional cases spontaneously, involution takes place, the disease ceases to extend, the margin 
sinks down gradually, loses its color, its scales, and its crusts, and then subsides into more or less 
perfectly-formed scar-tissue. Its course is slow and progressive, but periods of quiescence are 
observed in it. Sometimes without known cause its progress is quite active ; again, this feature 
seems to be due to elevation of temperature. 
I he marked tendency of the disease to appear on the nose, and from there spread to the 
cheeks, has led observers to compare the fully-formed eruption to the shape of a butterfly or of a 
bat, the patch on the nose representing the body and the patches on the cheeks the wings. 1 
fanciful simile is not at all constant, and, such is the erratic course of the disease and the absenc 
of symmetry in its development, that we often find an imperfect body, and wings not at all per ec 
in their arrangement. This is largely due to the fact that in most cases the disease begins in 
or more patches which form more or less regularly, and then fuse together into larger and 
course irregular patches. Exceptionally, the disease begins on the scalp, without implication of t 
face, and also under similar circumstances upon or about the ears ; but, as a quite general LUPUS ERYTHEMATOSUS. 
3i i 
these regions are invaded at a later date, or even synchronously with the attack on the face. 
In some cases the disease begins upon the forehead or on the cheeks at a distance from the 
nose. 
Lupus erythematosus of the hands and fingers has of late years been the subject of 
valuable papers by Hyde, Klotz, and Dumesnil. From a careful study of two cases and a consid- 
eration of the literature of the subject, I am led to think that the clinical appearances of this affec- 
tion when seated on these parts differ in no essential-if, indeed, any-particulars from those pre- 
sented by it on classical localities. It is of exceedingly rare occurrence, and is met with mostly in 
women. In the majority of the reported cases the affection began on the backs of the hands or 
fingers, and in a very few began upon or invaded the palmar surfaces. It is seen upon the feet, 
and when occurring upon the fingers and toes may present the appearance of chilblains. Both 
hands are noted as being involved about as frequently as one, and the one most used does not 
seem to have presented an especial predisposition to the affection. In the larger number of cases 
patches of lupus erythematosus of the face coexisted with similar lesions upon the hands, and in 
only a few cases were they found on the latter structures alone. This form of the disease usually 
begins about adult age, is very chronic in its course, and is rebellious to treatment. In very excep- 
tional cases the arm was affected together with the hand. 
Lupus erythematosus of the penis is of exceedingly rare occurrence, and presents no distinc- 
tive peculiarity in appearance, in course, or in its rebelliousness to treatment. Kaposi has described 
a form of lupus erythematosus having an acute invasion and course, which is complicated by more 
or less fever of a remittent type, by subcutaneous nodules of the size of hazelnuts or walnuts, by 
edematous, doughy, tubercular swellings about the smaller and larger joints, by aching, boring, 
deep-seated pains in the bones, chiefly the long ones, sometimes of a nocturnal character, and by 
submaxillary, axillary, and inguinal adenitis. I am not aware that any observer has seen this 
morbid combination as an evidence of aberrant lupus erythematosus in this country, but I have 
seen cases of syphilis and of iodide-of-potassium poisoning which would tally quite closely with 
Laposi s description. 
Hie symptoms of lupus erythematosus are burning and itching, which may be very mild or 
exceptionally very severe, especially upon exposure to heat or cold. In many cases little or no 
discomfort is induced. There are, to my mind, no general systemic symptoms which are pathol- 
ogically related to this disease of the skin. 
I his disease usually occurs about puberty, and in the female sex about twice as frequently as 
ln the male. It is sometimes seen earlier in life and rather exceptionally later. 
Etiology.-We know nothing of the underlying causes of lupus erythematosus. It may 
occur m strumous, cachectic, and debilitated subjects, and in those in whom no morbid condition 
can be made out. It is said to occur most frequently in persons of light skin and hair. It cer- 
tainly is sometimes seen in patients with patulous sebaceous glands and in those suffering from 
seborrhcea ; then, again, many subjects thus affected are not attacked by lupus erythematosus. I 
e seen a number of cases in which, every other cause being eliminated, there were reasonable 
grounds for believing that the disease owed its origin primarily to the injurious action of heat 
or cold. 
II 
e pathology of the disease may be stated as a small cell-infiltration around the sebaceous 
an hair-follicles, together with oedema, dilatation of vessels, and connective-tissue increase. 
Diagnosis. I he appearances of lupus erythematosus are usually so sharply marked that a 
gnosis is readily made. The seat of the eruption, its peculiar discoid or enlarged patches, and 
ts chionicity distinguish it from psoriasis and syphilis, both of which have a distinct history and 
sually other concomitant symptoms and lesions. The absence of tubercles, papules, and ulcera- 
eliminates it from lupus vulgaris. Perhaps in the early encrusted stage the appearances may 312 
DISEASES OF THE SKIN. 
resemble impetiginous eczema, but if such a diagnosis were made the chronic course of the disease 
would lead to its speedy abandonment. 
Prognosis.-Though in some cases spontaneous involution may occur, in general little hope 
can be entertained for such a fortuitous outcome. If proper treatment is regularly followed, the 
disease may be arrested and cured and the resulting deformity may be made less disfiguring. 
Treatment.-Nothing can be said of the certain influence of any drug, taken internally, upon 
this disease. It is obvious that any derangement of the health should be carefully attended to, 
with the hope that its restoration will act favorably upon the local lesions. Iodide of potassium 
and other preparations of iodine may be administered with the view (often vain) of causing absorp- 
tion of the newly-formed cells. 
Local treatment, however, is our main stay. For small patches the careful application oi car- 
bolic acid and the subsequent painting of the surface with collodion are sometimes very effective. 
This treatment, within judicious limits, may be used in moderately large patches. In using all 
remedies upon the face great caution must be exercised to avoid dermatitis. 
When much incrustation is present, it should be removed by oily inunctions and hot-water 
and-soap macerations. When the surface has been thus exposed, vigorous but careful frictions 
with the simple tincture of green soap or with the lather of green soap itself should be made every 
day or two, according to indications. The object to be attained is decided but not injurious stim 
ulation. If after any strong application to a patch of lupus erythematosus there is much redness 
and swelling, cooling lotions should be kept constantly on the parts until they disappear. In some 
cases-particularly those in which the sebaceous crusts are thick and tenacious, and in which the 
cell-infiltration is well marked, and more especially in those in which there is decided subcutaneous 
thickening-solutions of potash or soda may be used. These may be of the strength of one 01 
two drachms of the alkali to the ounce of water. They should be used with care and caution, 
applied with a piece of sponge or some absorbent cotton fixed to a small piece of woo , to t e 
morbid patch alone, and then washed off with equal parts of vinegar and water. These stimu a 
tions should be repeated as often as necessary, and in the intervals the patches should be kept con 
stantly covered with some mild stimulating and absorbent ointment spread upon lint or canton 
neL bor this purpose ointments of preparations of mercury, iodine, and sulphur are especial y 
indicated. If the parts are sensitive, belladonna or stramonium ointments may be used in com 
nation. I he simple and the compound tincture of iodine may be used as paints, and collodi 
mixed with salicylic acid, and perhaps with chrysarobin and pyrogallol, may be tried. Chromic aci . 
nitric acid, acetic acid, sulphuric-acid paste, chloride-of-zinc paste, Cosmi's paste (arsenious 
gr. xx, red sulphide of mercury gr. lx, benzoated lard sj), and the acid nitrate of mercury may 
be remembered ; and if the necessity for their use occurs great care and caution should be exer 
cised. In some cases erasion by the curette, multiple punctures, and linear scarifications may 
necessary, for the technique of which the reader is referred to the section upon the treatment o 
lupus vulgaris. HERPES ZOSTER. 
Herpes zoster, also called zona and shingles (a corruption of the Latin word cingulum, a girdle), 
is an acute inflammatory affection manifesting itself by the appearance of groups of vesicles along 
the course of the cutaneous branches of the fifth cranial and the various spinal nerves. In general, 
the onset of the skin lesions is preceded by sensory disturbances, which may begin one or several 
days or a few hours before them. This prodromal pain may be superficial or deep ; it may exist in 
the whole course of the nerve or nerves, or it may be limited to one or more spots. It is described 
as burning, cutting, throbbing, boring, lancinating, and pruritic. In some cases the pain and the 
eruption are coeval in development, and exceptionally there is no sensory disturbance. There may 
or may not be such concomitant systemic disturbances as fever, malaise, and gastro-intestinal irri- 
tation, or these may be very severe. The first cutaneous manifestation of zoster is a hyperaemic 
condition of the skin of the affected part, attended with heat, and upon this inflamed base vesicles 
promptly appear. These lesions are at first of the size of pins' heads, are grouped together indis- 
criminately, but are more or less isolated. As the vesicles increase in size and as new ones appear 
distinct patches of vesiculation are formed, In this way in the mature state of the affection we 
find large and small-sized vesicles and lesions which have been formed by the fusion of these ves- 
icles, and which may be called bullae, grouped together without order or arrangement upon an 
intensely red background. In general, the larger lesions are those which appear first and are 
seated toward the centre of the patch. Outlying vesicles, however, may attain a mammoth size. 
In structure herpetic vesicles are peculiar in the fact that they are firm, having thick epidermal 
roofs, well distended, often show a remarkable resistance, and may not rupture even if subjected 
to pressure or friction, differing markedly from those of eczema. They are round, oval in shape, 
globose, sometimes umbilicated and flat. They contain at first a yellow pellucid serum, which in a 
few days gradually becomes turbid from the admixture of leucocytes. In some cases, particularly 
m old persons or those broken in health, and when the inflammatory process has been very intense, 
effusion of blood may take place into the vesicles. 
I he evolution of zoster is, as a rule, by the appearance of crops of vesicles around and near 
the original site, which appear usually one after the other during three to six or seven days. Then 
a period of quiescence may follow, during which the local symptoms are commonly much less severe, 
and may subside, the vesicles become turbid, and in the course of a week or two dry into flaky 
crusts, which, though quite adherent, soon fall off and leave red spots. It is not infrequently 
noticed that in some portions of the eruption the lesions have not reached maturity, in which case 
we may find simply hyperaemic patches of skin or lesions which look like papules rather than ves- 
icles, or those in which their vesicular nature can only be determined by minute examination and 
even by deep puncture. They are then called aborted vesicles. The whole or a part of the erup- 
tion may be thus constituted. There is much variation in the number and size of the patches of 
vesicles . in some cases they are few and small, in others numerous and large. In the latter case 
they may be quite distinctly scattered or moderately close together, and they may even present 
semblances of definite anatomical arrangement. The accompanying hyperaemia may be mild or 
evere , it may consist of a narrow halo around the lesions or may form well-defined patchy back- 
313 3i4 
DISEASES OF THE SKIN. 
grounds. It is usually of a warm red color, and may verge upon deep red and purple. There is, 
however, no uniformity in a given case or in various cases in the outlines of these vesicular patches. 
They may be linear, figurate, round, oval, irregular, and sometimes present appearances suggestive 
of fern-leaves. 
Herpes zoster, in the vast majority of cases, appears on one side of the body only. In excep- 
tional ones it is developed upon both sides, though rarely on symmetrical regions except about the 
face. It has been seen to appear on both halves of the trunk, in most cases of which unsymmetrical 
nerves have been affected, so that a continuous girdle was not formed. In rather exceptional cases 
the body has been encircled in a symmetrical manner. Then, again, zoster affecting one side has 
coexisted with a similar eruption attacking the opposite half of the body, but seated on the head 
or the upper or lower extremity. 
As a rule, this disease appears but once in a lifetime, but to this many exceptions have been 
noted. Zosters about the face and genital organs are not at all uncommonly recurrent. In I late 
XLV. typical herpes zoster is seen on the right side of the patient to coexist with scars of a pre- 
vious attack. Second attacks, while far from common, cannot be said to be very uncommon, while 
subsequent ones are indeed rare. Kaposi, however, reports a case in which there were eleven 
attacks. 
The pain and burning in herpes zoster are usually less severe, and may even cease, when the 
eruption appears. Not infrequently, however, these morbid symptoms continue, and even increase, 
for shorter or longer periods. It is not uncommon to observe severe neuralgia remain long after 
the skin lesion has vanished. Then, again, analgesia, anaethesia, hyperaesthesia, pruritus limited 
or extensive, may follow in the wake of herpes zoster. Fall of hair, loss of teeth, and necrosis 
have been noted as sequelae. Paralysis may accompany or follow the eruption, and atrophy of 
the muscles may also be a sequela. In children, as a rule, the neuralgic symptoms are mild and 
ephemeral; in old subjects, anaemic and neurotic patients, particularly women, it is often the 
reverse. 
As a rule, the redness left by zoster gradually fades toward or in the third week of the 
disease. In some cases the vesicles lead to ulcerations which may be painful and persistent, 
requiring several weeks for healing. In old and broken-down persons and in neurotic subjects 
these ulcers may leave cicatrices, which are chiefly found upon the head and trunk, but also on t io 
extremities. In some cases, usually in aged subjects, gangrenous ulcers are produced by herpes 
zoster which are painful, difficult to heal, and productive of much suffering by their malign influ 
ence upon the health and nutrition. This accident has given rise to the term "herpes zoster gan 
grenosus," while a hemorrhagic complication of the vesicles has been called "herpes zoster haemor 
rhagicus." In the latter event unhealthy ulceration is not uncommon. As a result of these 
destructive concomitants more or less scarring of the skin is produced. It is obvious that v en 
complications exist, the course of the disease is prolonged, sometimes even for months. 
The most systematic division of herpes zoster has been made by Barensprung in accorclane 
with the place of origin and mode of distribution of its lesions. The different varieties may there 
fore be classed as follows : 
1. Zoster facialis, commonly confined to one-half of the face, occupies the surfaces of the sk 
and mucous membranes supplied by the fifth nerve. A form of it is z. labialis. 
2. Zoster occipito-collaris, in the distribution of the occipitalis minor, auriculans magnus, 
superficialis colli nerves, derived from the cervical plexus. 
3. Zoster cervico-subclavicularis corresponds to the descending (suprasternal, suprac avic 
supra-acromial) superficial branches of the cervical plexus. 
4. Zoster cervico-brachialis, due to a morbid condition of the brachial plexus, and may be 
ited to the arm or forearm or the hand, or involve all. HERPES ZOSTER. 
3i5 
5- Zoster dorso-pectoralis. In this form the affection begins over the spinal column, generally 
occupying a surface corresponding to three vertebrae : it spreads obliquely downward to the side 
of the chest, and thence passes, ascending slightly, to the sternum. The nerves concerned in this 
variety are the third to the seventh dorsal. 
6. Zoster dorso-abdominalis affects the lower part of the back, its upper limit being the 
eighth dorsal, its lower the first lumbar vertebra. It extends over the surface of the abdomen as 
far as the linea alba. 
7- Zoster lumbo-inguinalis begins in the lumbar region, and spreads horizontally forward to 
the linea alba, obliquely downward and forward to the mons Veneris and genital organs, and also 
downward to the skin of the gluteal region and outer surface of the thigh. It corresponds to 
branches of the upper lumbar nerves. 
8. Zoster lumbo-femoralis occupies the distribution of the external cutaneous, genito-crural, 
anterior crural, and obturator branches of the lumbar plexus. The wide cutaneous distribution of 
these nerves enables us to understand how extensive and severe this variety of herpes may some- 
times be. In other cases it is confined to the surface of the thigh, only certain branches of these 
nerves being then affected (z. femoralis). 
9- Zoster sacro-ischiadicus corresponds to the cutaneous supply of the sacral plexus. 
io. Zoster genitalis (herpes progenitalis et vulvae) is due to partial implication of these 
nerves. 
I he foregoing syllabus of the various forms of herpes zoster will form a trustworthy basis 
I 1 
Ior the study of all cases. It must not be supposed that thorough correspondence will be 
observed in all cases, since these nerves have 
numerous branches, any of which may be 
involved in the disease. 
Zoster of the face, corresponding to the 
branches of the fifth nerve, includes a number 
of forms. 
Zoster frontalis occurs in the distribution 
the supraorbital nerve upon the forehead 
nd scalp, and also upon the upper eyelid. It 
ls observed in the young and the old, is fre- 
9 ently attended with severe pain, sometimes 
hemorrhage, and the vesicles are not un- 
nionly the seat of ulceration, which leads to 
atricial atrophy of the skin. In wood-cut Fig. 
44 supraorbital zoster is well shown upon the fore- 
head, the eyelid, and the side of the nose, the 
jontal and trochlear branches of the fifth nerve 
emg involved. Hutchinson alludes to the rarity 
t e eruption affecting the lower eyelid or cheek 
the same time as the forehead, and says that he 
has seen it occur but once. 
tion wheter °PhthalmicUS is the title of the affec- 
tivitis k ,e mvO^ It *s a very painful affection, sometimes accompanied by conjunc- 
,j . it*5' iritis> and perhaps inflammation of all of the tissues of the eye. It may lead to 
destruction of the latter. 
are usuah Z°Ster facialis is found widely distributed or limited to one or two spots. The vesicles 
y ustered into small groups, but they may be very copious and form quite large patches. 
Fig. 44. 
Herpes Zoster of the Head, Frontal and Trochlear Branch of Fifth 
Nerve. 316 
DISEASES OE THE SKIN. 
It is usually unilateral, but many cases have been observed of the bilateral development of this 
form of zoster. I once saw a case in which there were two successive attacks of herpes of the 
trochlear branch of the fifth nerve, the vesicles being seated in a direct line an inch long on the 
right side of the nose. We frequently see a 
cluster of vesicles upon one side of the upper 
or lower lip, and we sometimes observe a coin- 
cident implication of the inferior portion of the 
nose. These have been called herpes labialis 
and h. nasalis. In wood-cut Fig. 45 groups of 
vesicles may be seen on the forehead, upper 
eyelid, ala nasi, cheek, and upper and lower 
lip, showing implication of the supraorbital 
and superior maxillary nerves. A general 
eruption scattered over the whole face is 
sometimes seen, and it not uncommonly oc 
curs more than once. It is attended with 
fever and malaise, and has been called herpes 
febrilis. It belongs to the zoster family. 
Herpes zoster, when the occipitalis major 
and minor nerves are involved, begins at 
the back of the neck, at the base of the 
skull, and passes forward in an arched form. 
It can scarcely be seen amid the hair, but is 
very perceptible in bald persons. Herpes occipito-collaris may involve the skin behind the eai, 
the ear itself, and the neck under the ear as far as the median line. 
Zoster cervico-brachialis may be limited to the neck and shoulder, in which case the acromia 
and clavicular nerves are involved or the upper extremity in whole or in part may be affected. 
is most commonly seen on the flexor, aspect of the limb, also on the extensor surface. It may 
limited to any portion of the arm, but it is rare to see it extend to the hands. In wood cut I ig 
46 is well shown a very extensive eruption of herpes brachialis observed by me, in which all of t * 
sensory branches of the brachial plexus below the clavicle, excepting the subscapular, were invo ve 
The groups of vesicles were seated on hyperaemic bases, and the structure of these lesions was v \ 
well marked upon the palms and the fingers to their tips. On the upper part of the chest wall 
eral groups of vesicles were seen, corresponding to the distribution of the anterior thoracic 
This form of zoster is seen in the young and the middle-aged, rarely in old persons. It is <3 
accompanied with severe neuralgia, which may persist for a long period, and may be folio a e y 
atrophy of the skin and of the muscles. 
The clinical appearances of zoster dorso-pectoralis, z. dorso-abdominalis, and z. lumbo 1 g 
nalis are in all essential particulars very similar. In all of them the vesicles may be in a mo 
less continuous semicircle from the spinous processes behind to the median line in front. 1 g 
eral, however, these eruptions consist of groups of large and small sizes scattered over t e 
of two, three, or four nerves. In general, these groups will be found first near the spine, e 
ing forward, at the angle of the ribs corresponding with a line drawn vertically from the axil 
within six to three inches of the median line. In some cases these groups are distinctly sef 
and in others there are intermediate strapvling vesicles, aborted vesicles, or red patches 
1 1 4-1 o rrFQ (I- 
rule, the eruption follows the line of obliquity of the ribs downward and forwar , an , 
ually bends upward from a line drawn from the nipple. In some cases the redness and ves . 
extend for a short distance beyond the median line upon the chest or abdomen of the othe 
Fig. 45. 
Herpes facialis (labialis). Pa rt VI 
Plate XLV 
LEA BROTHERS & CO. PUBLISHERS .PHILADELPHIA 
HERPES ZOSTER. HERPES ZOSTER. 
317 
In Plate XLV. are well shown the typical appearances of herpes zoster, and if they are clearly 
understood the reader will have little trouble in recognizing at a glance almost any case of zoster, 
whether seated on the trunk, head, or extremities. The central groups of small vesicles are very 
characteristic, and near them are large lesions of the bullous 
order which are formed by the coalescence of several vesicles. 
The large patch on the back consists of typical well-formed and 
fused vesicles, and above and a little external to it are two small 
groups seated on two upper nerves. The case, then, represents 
zoster of three mid-dorsal nerves. Anteriorly we see that the 
oblique direction of the two preceding patches is continued as far 
as the line of the nipple, and then the vesicular half belt turns 
gently up toward the middle line. In this anterior patch new and 
old and fused vesicles and those undergoing desiccation are min- 
gled without order or arrangement. The bright redness of some 
patches contrasts well with the deepening red of the anterior 
patch. The unusual feature of the case is the presence of large 
and small superficial scars, which show that the same nerves, 
and perhaps two lower ones, have been involved at an earlier 
date. With this description well impressed on the mind, and 
the facts contained in the syllabus on page 314 being remem- 
bered, all cases can be readily diagnosticated and the nerves 
affected clearly determined. 
When herpes zoster is seated near or upon territories sup- 
plied by lymphatic ganglia, the latter are often much enlarged 
and painful. 
The pathological conditions found in herpes zoster are, as 
first pointed out by Barensprung, certain changes in the nervous 
system. According to the testimony of a number of observers, 
the most essential changes are seated in the Gasserian and 
spinal ganglia. These are, in the main, redness and inflam- 
matory swelling and hemorrhage into the ganglia, and inflam- 
mation of the nerves and cell-infiltration into the neurolemma. 
While many observers content themselves with the lesion of 
the ganglia as the cause of zoster, Kaposi goes farther and 
says the latter may be due to a morbid condition in the region 
of the nerve, either at its origin or in the spinal ganglion or in 
the course of the nerve beyond the ganglion, and that the 
anatomical evolution of the disease follows the mode of ana- 
tomical involvement of the nerve-in other words, that the 
irritative causes may be peripheral in the nerve, in the ganglia, and in the spinal cord itself. 
Etiology.-Our knowledge is far from precise as to the causes of herpes zoster. There is 
an abundance of testimony in support of the view that a certain number of cases are of peripheral 
origin in some irritative lesion. Thus, blows, wounds, injuries to nerves, surgical operations, cica- 
trices, and inflammatory foci such as necrosis-sinuses have been recognized as the exciting causes 
of zoster. I have seen a well-marked case of zoster lumbo-inguinalis follow the irritation produced 
by an ill-fitting truss. 
Of late years Charcot has laid much stress upon the view, not entirely original with himself, 
that many nervous affections are due to or much modified by an inherited neuropathic tendency. 
Fig. 46. 
Herpes zoster involving all of the Sensory Branches 
of the Brachial Plexus below the Clavicle, ex- 
cepting the subscapular. 318 
DISEASES OF THE SKIN. 
This hypothesis has been accepted by Dreyfous1 as applying to this disease, who reports a case of 
brachial zoster in a man forty-two years old whose mother suffered from persistent tic douloureux 
and hysteria, and another of a woman aged fifty-two who had zoster in the course of the fifth nerve, 
and consequent facial paralysis, whose mother was demented, whose sisters were hysterical, and 
whose brother had sciatica. 
Exposure to cold, particularly in draughts, has very often been noted as the cause of zoster 
of the head or trunk. Sudden checking of the perspiration has also been stated as a cause. 
Arsenic, taken in a medicinal way, is thought to have caused the disease, and it is further claimed 
that carbonic-oxide poisoning has exerted a similar influence. 
Diagnosis.-The general physiognomy of herpes zoster is so markedly characteristic that it 
is hard to conceive how a mistake can be made in its recognition. In cases of aborted zoster the 
typical vesicular appearances might be wanting, but the history of the onset and the pain would 
point to its nature. 
Treatment.-Herpes zoster being essentially a self-limited disease, the origin of which is so 
often obscure, the treatment is necessarily largely symptomatic. Internal medication has been pro- 
ductive of very dubious results. It is well to bear in mind that phosphide of zinc is said to have 
been beneficial by some observers, and that quinine is regarded with favor by others. The truth 
is, that we have really no facts to warrant us in saying that any remedy (except narcotics) has con- 
trolled the pain or aborted the course of the eruption. Many physicians are willing on the least 
provocation to "see" beneficial effects of drugs which are really due to the natural evolution of 
the disease. 
Whenever the pain in herpes zoster is very severe it .is well to administer opium or morphine, 
either by the mouth or hypodermically. 
Locally, much can be done to allay suffering. In some cases cooling and anodyne lotions may 
be indicated and found beneficial. Various dusting powders, such as are used in eczema and the 
erythemata, may be of service. (See those sections.) 
Duhring speaks well of a lotion composed of one or two parts of the fluid extract of grindelia 
robusta to eight parts of water. Ointments containing opium, belladonna, and stramonium, though 
objectionable by reason of their greasy nature, have allayed pain and reduced cutaneous hyperaemia. 
Lotions or ointments of oil of peppermint, thymol, carbolic acid, camphor, chloral and camphor, 
may be used in some cases. White-lead paint, mixed with extra drier, is said by Daniel Lewis to 
have been beneficial in his practice. Warm fomentations and poultices containing poppy-heads, 
hops, belladonna, stramonium, and hyoscyamus-leaves have been productive of much comfort, par- 
ticularly in zoster of the fifth nerve and pectoral and thoracic zoster. The application of flannel 
wrung out in very hot water, and over which a little spirits of camphor or turpentine has been 
sprinkled, is a domestic remedy of value in some cases. Likewise hot-water bags and bottles may 
be remembered. In some cases cold applications are very grateful. Flexible collodion, mixed with 
morphine, camphor, iodoform, or belladonna, very often produces much comfort by its anodyne 
effect and protective nature. The muriate tincture of iron painted upon the patches of vesicles 
is much thought of by some authorities. 
lhe continuous and interrupted currents have been found beneficial in some cases, chiefly in 
the later pruritic, hyperaesthetic, and painful stages. They should be cautiously used at first, and 
their strength increased according to indications. It is doubtful whether electricity has any effect 
in abating herpes zoster. The further treatment of the sequelae of this disease should be based 
on general principles. 
1 La France medicale, Feb. 7, 1889. PART VII. 
SCABIES. 
Scabies, also called "the itch," is a contagious inflammatory disease of the skin, presenting a 
multiformity of lesions and having its origin in the animal parasite, the Acarus Scabiei, Sarcoptcs 
hominis, or itch-mite. In its course scabies may give rise to any or all the features of dermatitis, 
and even of eczema. It is, as its name indicates, an essentially pruritic disease, and its intensity 
is increased and its continuance largely established by the wounding of the skin incident to the 
scratching which its itching causes. In the main, it may be said to be a disease peculiar to poor, 
uncleanly, and filthy people, yet it is not uncommonly met with, particularly in America, in the 
middle, hard-working, and reasonably clean classes, and it is sometimes found in persons of the 
higher walks of life whose personal cleanliness is beyond question. 
Until a few years ago scabies was a rather uncommon disease in this country, but it has been 
noticed that in the various large cities and in some small communities there has been of late a 
remarkable increase in its prevalence. The reason of this is hard to explain, and I think that the 
remarks of my friend Dr. J. C. White1 upon this subject are worthy of quotation. He says : " It is 
impossible to find a satisfactory explanation of this great increase in the prevalence of scabies in 
this vicinity (Boston). Immigration has not been especially large in the past few years, nor has 
there been any noticeable change in the ways of living, or more intimate intercourse between 
various classes of society, which might possibly account for it. In European countries it is the close 
relations of barrack-life in the vast standing armies, the corresponding possibilities of bodily con- 
tact connected with apprentice-life, and the general disregard for personal cleanliness, which afford 
such facilities for the spread and continuance of the disease-conditions which, fortunately, do not 
exist in the United States. It is not impossible that the crowding of great numbers of operatives 
of both sexes in the large working establishments of our cities, and the multiplication of commer- 
cial travellers traversing all parts of the country-new features in our social life-may present 
more favoring chances for the development of the disease than formerly existed. The direct chan- 
nels of communication from individual to individual most commonly recognized are between school- 
mates, nurse and child, bedfellows, artisans, operatives, shop-girls, and through family intercourse 
and impure sexual contact." 
In order to present a clear and comprehensive description of scabies it is necessary, first, to 
sketch the natural history of the itch-mite and of its habits ; second, to describe the primary and 
secondary lesions which its irritating presence induces ; and, third, to speak of the various lesions 
and their transformations which result from the scratching caused by the pruritus incident to the 
disease. 
The parasite of scabies, Acarus Scabiei, Sarcopies hominis, or itch-mite, is usually found at the 
distal end of its burrow, beneath or within the epidermis, as a minute hemispherical yellowish-white 
1 " On the Increasing Prevalence of Scabies," Boston Medical and Surgical Journal, Feb. 14, 1889. 
319 320 
DISEASES OF THE SKIN. 
body just visible to the naked eye, but readily seen with the aid of an ordinary magnifying-glass. 
Extracted from its nest by means of a small bistoury or teasing-needle, it soon shows active motion 
when placed upon a smooth surface like that of the thumb-nail or of glass or porcelain. The female 
is the one generally found, and by some it is thought that she is the sole cause of the disease. A 
study of the minute anatomy of the acarus requires the use of the microscope with a magnifying 
lens of 50 to 100 diameters. The body is ovoid in shape, like a turtle, flat on its ventral and coni- 
cal on its dorsal surface, with two lateral indentations, a minute conical-shaped head, and eight 
Fig. 47. 
Fig. 48. 
Acarus Scabiei, female, dorsal aspect. 300 diameters. 
Acarus Scabiei, pregnant female, ventral aspect. 
five-jointed legs, the four anterior ones being short and teat-like, and the posterior ones thinner and 
provided with bristles. 1 he first and second pairs in both sexes have pedunculated suckers. On its 
dorsal surface transverse undulating minute furrows are found 
between semicircular rows of wedge-shaped scales, which allow 
the latter to glide over each other in the movements of the in- 
sect, as do the scales of a cuirass, as shown in wood-cut Fig. 47. 
I he under surface of the female acarus is shown in wood-cut 
big. 48, with its short crest in the anterior median portion leading 
to the first pair of legs, and its hind legs with long bristles. Across 
the surface undulating lines are seen, and toward the tail, just 
anterior to the genital cleft, a mature ovum may be distinguished. 
Careful and skilful examination reveals a digestive apparatus 
of stomach and intestines, and also ovaries. 
The male acarus is much smaller than the female (wood- 
cut Fig. 49), has suckers on the inner hind legs for copulating 
purposes, and well-developed genital organs seated in a horse- 
shoe-shaped framework. It is found on the soft skin near the 
burrows in which the female is nested and near the papules and 
vesicles. It is always found in less number than the females, 
and is less sedentary in its habits. Hebra tells with much naivete of finding a male acarus on top 
Acarus Scabiei, male, ventral aspect. SCABIES. 
321 
of a female, and while he is not positive that they were in the act of copulation, he thought that 
their relations were at least suspicious and worthy of pictorial display and record. No other 
observer has been so fortunate, and it is to be regretted that death overtook these interesting 
mites before Hebra could assure himself of their purpose. 
The mature female acarus when impregnated pierces the epidermis head first, burrows through 
it, and synchronously lays its eggs. The acarian furrow or 
burrow is well shown, with moderate enlargement, in 
wood-cut Fig. 50. At the top of the picture the female 
mite is seen at the blind end of the burrow, with the head 
toward the as yet uninvaded skin, and its tail toward the 
burrow. Its abdominal surface is in full view, and within 
the insect a mature ovum is seen. Behind it are twelve 
eggs and their envelopes, the distal embryo showing signs 
of developing anterior legs. Intermingled with the eggs 
are little black fecal masses. The female leaves the eggs 
behind her at the rate of one or two a day until from ten 
to twenty or even, as claimed by some, fifty are laid. 
Hebra, however, says that he never saw a burrow in which 
there were more than fourteen eggs, besides ten or twelve 
empty shells. As the eggs are viewed, placed in their long 
axis transversely to that of the burrow, their embryonal life 
is seen in increasing development as the orifice of the tube 
is reached, where one or more may be seen in a state 
near maturity. As the mites become mature and active 
they make their way out of the burrow. 
The embryo acarus is shown (wood-cut Fig. 51) on 
its abnormal surface to have six legs. It becomes active, 
breaks its shell, and emerges 
from the maternal burrow. 
It then forms a burrow of its 
own in the cuticle for the pur- 
pose of moulting. This proc- 
ess is said to occur several 
• 
times before maturity is reached. On this subject Hebra, whose work 
in this direction may be accepted as correct, says: "Every acarus 
passes through several changes of skin, during which it is in a state of 
rigidity, appears to be entirely devoid of feeling, and in fact looks 
exactly as if it were dead. It may, however, be known to be really 
moulting by the circumstance that the new parts can be seen through 
the old skin. Thus, behind the old one a fresh head is visible ; close 
to this, two fresh fore legs ; and near the old hind legs new ones. 
During its first change of skin the mite acquires four hind legs instead 
of two. This shows that it undergoes at least two moults, in the first 
of which it becomes eight-legged from having been six-legged ; while of course it has eight legs 
before as well as after the second change of skin." The mite is shown in its developmental con- 
dition after the second moulting in wood-cut Fig. 52. 
The mechanism and structure of the burrow are now to be considered. As soon as impreg- 
nated the itch-mite pierces the epidermis in an obliquely downward direction, toward the soft cells 
Fig. 50. 
Fig. 51. 
Burrow of Acarus Scabiei, on lumbar region. 
Larva of Acams Scabiei, with six legs; 
ventral aspect. 322 
DISEASES OE THE SKIN. 
of the rete, from the plasma of which it derives its nourishment. Once within the skin, the mite 
pushes on slowly, leaving its eggs behind it, to make room for which it must of necessity keep 
moving. The resulting passage or gallery, called the burrow or cuniculus, is in all respects a 
miniature mine, the 
point of entry being 
called the head and 
the blind extremity 
the tail. A sche- 
matic drawing of 
this is given in wood- 
cut Fig- 53- The 
oblique passage is 
well shown. At 
point I the orifice 
of the burrow and 
uplifted epidermis 
are shown ; at II the burrow is continued ; while at III is the some- 
what bulbous terminal end or tail, and in it the acarus. Owing to the 
irritation produced by the mite, inflammatory changes ensue, either 
at the head of or beneath the burrow. In wood-cut Fig. 54 section 
of a pustule seated in the upper part of the rete is shown, and over 
it, in a curved manner, runs a burrow. In wood-cut Fig. 55 the same condition is shown, with the 
burrow on the other side of the pustule. 
I'he naked-eye appearances of the burrow or cuniculus vary very much in different cases. In 
cleanly subjects it appears like a little white or pearly line of slight elevation of the epidermis, and 
sometimes it 
can be imitated 
by gently inser- 
ting a needle, 
and thus tun- 
nelling be- 
tween the up- 
permost layers 
of the epider- 
mis for a short distance; and on removal the uplift- 
ed tissues present an appearance similar to an 
acarian burrow. The epidermal roof has a white, 
glistening look, and along the continuity of the burrow very minute dilatations like a dotted line 
may sometimes be seen ; which seem to be spots where the acarus rested for a time and pressed the 
tissues out more widely than elsewhere. In some instances little dark spots, seated in the burrows, may 
be seen through the translucent epidermal roof: these are probably little masses of feces. Then, 
again, in careless subjects, and sometimes owing to accidental staining, the burrow appears much 
darker than the surrounding skin. Washing with soap and water shows that dust and dirt have 
become imbedded deeply in the epidermal scales forming the burrow. There are various shapes 
observed in these cuniculi. They may be straight, curving, serpentine, of a horseshoe form, like 
the letter S, and they may even form a right angle, or one burrow may cross another. They vary 
in length from one-eighth or one-sixteenth of an inch to an inch, and may even be longer. Their 
breadth is thread-like, and about equal to that of a pin or a needle, and their height, though per- 
Fig. 52. 
Fig. 53. 
* <7 Z/7/.V X ' 
Acarian Burrow obliquely piercing the epidermis, and ending above 
papillary layer of the cutis. 
Second Moulting of Acarus Scabiei, with 
eight legs, ventral aspect. 
Fjg. 54. 
Fig. 55. 
Same Section as portrayed in Fig. 54, viewed from 
the surface of the skin; acarus is seen below 
the pustule, P, and on the non-inflamed rete. 
Section of a Burrow through a Pustule, P, having penetrated the 
epidermis. SCABIES. 
323 
ceptible, is very slight. In these burrows we may sometimes be able to make out the head and tail 
quite clearly, and sometimes we cannot. When visible, the head or point of entry is rather wider 
than any other part, and perhaps more elevated. Occasionally it is seen to be distinctly fun- 
nel-shaped, however enlarged. In many cases a minute confused mass of scales is seen. The 
tail of the burrow where the acarus is lodged, and where it, unless removed by any means, dies, 
may present a decided salience compared with the height of the burrow, though it is most minute 
at the best, usually a mere dot, or it may in no way differ from the continuity of the canal. In some 
instances it may be seen that, owing to the irritation of the acarus, a vesicle or pustule has formed 
at the head of the burrow, and that under the latter inflammatory exudations have occurred. Then 
the burrow may lie upon the roof of the pustule or vesicle, or appear as a red line on the surface 
of the circumambient inflammation. .In some cases, particularly in regions where the epidermis is 
thin, the white burrow stands out in marked contrast upon a corresponding but rather larger red 
line of inflammatory elevation. In no case is the acarus found either in the juxta-cunicular vesicle, 
pustule, or bulla, since she always passes forward in order to place herself beyond danger and in 
quest of the nutritious juices of the rete. Again, the burrow is seen to jut out from the margin of 
a vesicle or pustule, sometimes in a straight line or in a curved manner, producing the appearance 
of a comma, or, as Hebra says, resembling a chemist's retort. Owing to various external agencies, 
these burrows are soon destroyed, and the red lines left by them are soon inextricably mixed with 
the concomitant lesions. From one to two weeks are occupied by the acarus in this tunnelling proc- 
ess. When the roof of the lesions has been worn or torn away, the appearance of a pin-scratch is 
presented, which is usually from one-sixth to half an inch in length. In this event the burrow is 
converted into a furrow, which can sometimes, by means of a magnifying-glass, be seen to have a 
beaded, jagged margin. 
The regions upon which burrows are most easily and commonly found are the interdigital 
spaces, the sides of the fingers, the inner surfaces of the wrists and near the styloid process of the 
ulna, the penis, the breasts-particularly near the nipple-the elbows and knees, the preaxillary 
folds, the ankles (particularly the inner ones in children), the dorsum of the feet and the inner 
middle portions of them, which merges into the sole. They are also found on males and females 
upon parts compressed by hat-bands, corsets, leather girdles, trusses, suspensories, and sometimes 
garters, particularly if they have caused epidermal hypertrophy. In shoemakers and tailors, in 
children, and in those who srt long during the day, they are found over the thickened skin of the 
buttocks where the ischial bones press the integument, upon the shoulders of porters, and over the 
ribs in weavers (Kaposi). 
Greenough1 has called attention to the fact that among the cases of scabies observed by him in 
America it is comparatively rare to find typical burrows ; and I think that the experience of most 
American observers is in accord with his. Whereas in London, Paris, and Vienna cuniculi are 
easily and commonly seen, in America the reverse obtains. Greenough ventures the suggestion 
that the comparatively greater cleanliness of habits of our population may perhaps be the cause. 
While, therefore, in a given case the presence of the acarian burrow, and especially of the 
itch-mite, is pathognomonic of scabies, the absence of this lesion does not prove that the disease 
is not caused by the Acarus Scabiei. As we shall see in the clinical part, there is an ensemble 
of lesions which go far in most cases to the establishment of the diagnosis. 
Besides the acarian burrows there are present, as essentially scabietic lesions, the smaller sub- 
epidermal nests of the newly-hatched mites. These are really minute pockets in the epidermis, 
and I am not aware that any observer has seen them present any shape or form at all typical of 
their nature. According to my observation, they are simply small, irregular-shaped papules or 
minute linear red elevations of the skin. 
1 " Clinical Notes on Scabies," Boston Med. and Surg. Journal, Sept. 23, 1886. 324 
DISEASES OE THE SKIN. 
In the encrusted form of scabies, seen mostly in children, and rarely if ever observed in its 
advanced and chronic form in this country, acari are found under the crusts among the soft tissue 
of the rete. In wood-cut Fig. 56 acari in various styles of development, eggs, and feces, are shown 
as they were taken from beneath a crust. When 
mature the male acarus does not burrow, and,, 
as he has not been seen wandering over the sur- 
face of the skin, it is fair to assume that he en- 
sconces himself in the crusts or exuviae, or per- 
haps in the papules. It will have been seen, 
therefore, that female acari burrow in the skin for 
purposes of nutrition and propagation, and that 
males do so during infantile growth only. 
Seeing that it requires from one to two or 
three weeks for the formation of a burrow, it fol- 
lows that other burrows can only be formed as fast as the new brood of mites is hatched. Then 
when the females are impregnated they in turn burrow and hatch out their young, which in their 
turn act in a similar manner. Thus it is that almost all cases of scabies begin in a small way by 
one or two or more burrows. The disease, therefore, at first increases rather slowly and in a lim- 
ited manner, but as the burrows become numerous it increases in intensity and in extent. 
The Clinical History of Scabies.-Scabies usually begins in a mild and perhaps insignif- 
icant manner, in the greater number of cases about the fingers, hands, or wrists. In some cases it 
is seen first upon the penis and upon the mamma, and soon upon the abdomen and legs. As a rule, 
however, these regions are attacked later than the hands. The patient first complains of a slight 
itching, usually between the fingers at their web. It may, however, be along the soft skin of the 
sides of the fingers or on the flexor surface of the wrist, and often near its ulnar side. It is not 
common to see scabies begin on the palm of the hand, though I have seen several cases in which it 
seemed that contagion took place on the ulnar border of the palm. As scabies usually begins by 
the implantation upon the skin of only a few mites, and as the female burrow is the main source 
of irritation, it follows that in the early stage of most cases the patient's sufferings are not acute ; 
hence he or she can give little precise information of its early stage, pays little attention to it, and 
only seeks medical relief later on when the lesions have become numerous and the pruritus is 
more or less distressing. 
In the early stages of scabies, as seen on and near the fingers and on parts where the skin is 
thin, we observe a number of small and perhaps large papules seated on a patchy, blotchy, diffuse, 
or linear erythematous surface, and perhaps we may be able to make out one or two cuniculi, and 
very often we may not. Such a picture would represent a young and very mild case of scabies, 
and it is rarely seen to last many days, since the tendency of the disease is toward an intensifica- 
tion of the inflammatory lesions and the invasion of the parts beyond. Then we note the appear- 
ance of vesicles, pustules, and even well-marked bullae. As these lesions come to sight they pre- 
sent no system of evolution whatever ; there is no seeming relation in point of development be- 
tween them. They all seem present at haphazard, and produce an indiscriminate jumble of primary 
and secondary lesions, such as we see in no other skin disease. As the lesions multiply and grow 
the skin may become the seat of wheals from scratching with the nails ; new papules are formed ; 
old and new papules are more or less torn and excoriated ; pustules and vesicles and bullae are 
ruptured ; and we have then a conglomeration of crusts, excoriations, fissures, superficial ulcera- 
tions, intermingled with papules, vesicles, and pustules, and seated on a thickened, reddened skin, 
-all commingled without the slightest tendency to order or symmetry. 
It is perhaps well to further describe individually the multiform parts of this chaotic picture. 
Fig. 56 
Crust of Scabies, showing acari in different periods of development, eggs, 
and feces. SCABIES. 
325 
In the erythema there is no tendency to gradual and orderly evolution ; it is pale and in lines and 
streaks here, blotchy and deep red there, and beyond it may be diffuse and accompanied by more 
or less, and often considerable, exudative oedema. The papules are in general small and rarely 
large ; they are conical or round, surrounded by redness, isolated and discrete, placed utterly with- 
out order, and in general more or less torn on their apices. The vesicles are of various sizes, 
usually tense and translucent, of decidedly inflammatory nature, isolated and sometimes grouped, 
usually discrete, and distributed without symmetry. The pustules are both small and large, conical 
or round, some torn, others encrusted, and mixed with the other lesions without any order. Bullae 
are usually less numerous, of decidedly inflammatory appearance, of irregular outline, and of 
various sizes. A correct idea may be gained of scabies by a study of the upper figure of Plate 
XLVI. Here we find the combination of vesicles, pustules, and bullae upon an inflamed skin. 
In the case represented the disease began in the interdigital spaces, and has spread over the 
dorsum of the hand and on the other parts of that organ. In the largest figure the deep ery- 
thema over the back of the hand is significant of the intense reaction caused by the disease. The 
lesions, as might be expected, are of the pustular and bullous classes, and can be seen to be 
scattered over the surfaces without any order or symmetry. On the forearm of the same figure 
the usual mode of extension of scabies is shown in the few isolated and irregularly-grouped pus- 
tules. A multiplication of these lesions and the development of its scabietic congeners means 
the material increase of the disease. 
In the right-hand lower figure the mode of extension of scabies is well shown in the scattered 
pustules and papules seated on the forearm. 
The increase of the disease is both by its extension and by the invasion of territory more or 
less contiguous to the seat or seats of its intensity, and by its development by contagion through 
the transference of the itch-mites to other parts by means of the fingers or the clothes. 
While the softer tissues of fingers, hands, wrists, and forearms may be said to be the more 
constant scabietic regions, scabies is often found elsewhere upon the body. It is important, in this 
connection, to remember that in some persons, particularly those who are exceedingly cleanly and 
given to scouring the hands with soap and water and brushes, in persons whose duties compel 
them to keep their hands in water for long periods (wash-women, scullery-women, men employed 
in baths, etc.), and in those who handle irritating powders and drugs, gravel, sand, lime, plaster, 
etc., scabies may get well of itself by reason of the death of the mites from these irritants. If in 
these cases the disease is present elsewhere on the body, a doubt as to its nature may be created 
in the mind of the physician by reason of the freedom of the hands. 
No stated rules can be laid down as to the mode of increase of the disease nor of the length 
of time required in its extension. It is essentially chronic in its course, and always lasts until all 
the mites are destroyed. The extent of the eruption and its duration, therefore, depend entirely 
upon the habits and occupation of the patient and upon the zeal and care of the treatment. In 
very many cases the lesions are so scattered and attended with so little suffering that the patient, 
in ignorance of their nature, does not seek medical advice. 
The most constant sites of election of scabies in adults, besides the upper extremities, are the an- 
terior surfaces of the axillae ; on the female breast, particularly toward and around the nipple; the penis ; 
and, in general terms, the territory on the anterior and lateral portions of the body corresponding 
with lines drawn across the breasts as far down as the middle ot the thighs or even the knees. The 
itch-mites on the trunk and lower extremities show the same preference for parts where the skin is 
soft and the epidermis is thin, for the obvious reason that their burrowing is there less impeded, 
and that they can more readily reach nutrient habitats. Ihus it is that in mild, and even in mod- 
erately severe cases, the eruption is most commonly seen on the anterior surfaces of the trunk and 
on the antero-interior aspects of the legs. As it becomes inveterate it extends laterally and back- 326 
DISEASES OF THE SKIN. 
ward on the trunk and outwardly on the thighs, and may involve the whole body except the head, 
which is never attacked except in infants. It may extend downward and involve the legs even as 
far as the web between the toes. In general, however, scabies is seen more frequently on the feet 
and legs in infants and young children than in adults. In many of these cases the disease is there 
implanted by their mothers or attendants, whose hands are affected, or it may be caused there by 
the infants' fingers in scratching or playing with their feet. The tightly-fitting drawers of children 
around the ankles have been noted to cause the disease to localize itself on those parts. 
So in the adult we find that scabietic persons, who wear bands, girdles, belts, trusses, garters, 
supporters, etc. present the disease in greater intensity under and near these appliances. 
As observed in America, scabies elsewhere than on the feet, hands, and arms usually does not 
present such a conglomeration of vesicles, vesico-papules, pustules, papulo-pustules, and bullae as 
it does on those classic regions. In these extra-brachial localities we find most commonly papules, 
papulo-vesicles, and pustules and papulo-pustules scattered indiscriminately, with no tendency what- 
ever to orderly grouping or arrangement or symmetry, upon a more or less patchy or blotchy ery- 
thematous, and often thickened, surface. Over the large flat surfaces of the trunk and legs we 
constantly see the results of violent scratching in the form of belts, papules, and tubercles of urti- 
caria mingled with resulting hyperaemia. If the reader will recall the clinical appearances of scabies 
as given when upon the hands, he can readily picture in his mind the aspect of the disease upon 
the body and legs, where, however, bullae and large pustules are not very common. 
As scabies becomes chronic and intense, two new orders of phenomena are engrafted upon it, 
which are due usually to the increasing depredations of the mites, to pressure upon the skin from 
without, to the severity of the scratching, and in many cases to the tendency inherent in the skin 
itself.to readily become inflamed. These phenomena are a thickened, deep-red, even purple, brawny 
condition of the skin from inflammatory exudation, which may be seen in broad or small patches, 
in streaks and bands, and in small tubercular formations ; . the appearance of crusts, large and small, 
of a greenish- and blackish-brown color ; and the development of encrusted ulcers like those of 
ecthyma and rupia. The thickened patches of skin are mostly seen on the hands and wrists, fore- 
arms, legs, and buttocks, under encircling girdles and belts, and upon the buttocks of those who 
sit during long hours-tailors, shoemakers, drivers, weavers, and others-and upon parts of the 
skin subjected to pressure either by the clothes or in the course of the patient's occupation. 
The scabietic lesions of the penis may be simply papules or vesico- or pustulo-papules. We 
occasionally see well-developed cuniculi on this organ. The various efflorescences are usually 
scattered without order or symmetry. It is not uncommon to see inflammatory nodular spots and 
patches upon this organ, together with the lesser developed lesions. In some cases, so great is the 
inflammatory infiltration that phimosis is induced. In yet others (particularly in very careless 
persons) ulcers may be seen which may be mistaken for chancroids. In some I have seen inflam- 
matory nodules on the free border of the prepuce which might by the uninitiated be mistaken for 
the initial syphilitic induration. Paraphimosis as a result of scabies is a somewhat infrequent 
complication, but the possibility of its occurrence should be borne in mind. 
As a result of the scabietic inflammation pigmentation of the skin very frequently follows. This 
is seen on any region where the disease has been severe and of long standing. It is most noticeable 
on parts where the skin is thin, particularly over the preaxillary regions, over the abdomen, breasts, 
and penis. This discoloration is of a dirty-brown hue, varying in intensity with the color of the 
skin of the patient, and is usually irregular in shape and outline, sometimes blotchy, at others 
patchy, and again diffuse and in sheets. It may remain for a long time. 
It may be stated, as a rule, that the constant skin lesions produced by the Acarus Scabiei be- 
long to the category of dermatitis. In some cases, however, a characteristic eczema is induced, 
the origin of which is often puzzling. In these cases careful examination should be made of the Part VII 
Plate XLV1 
LEA BROTHERS & CO. PUB LIS HE RS , PHI LADE LPHIA 
SCABIES SCABIES. 
327 
parts around the severe foci and of newly-appearing lesions, and generally the diagnosis may be 
arrived at by the discovery of the peculiar appearances presented by incipient scabies. 
Not only is eczema sometimes found upon the scabietic region, but it may also be seen elsewhere, 
as, for instance, upon the face and neck (particularly of children), and upon the legs and other portions 
of the body, which have become, as is not at all uncommon, the seat of a symptomatic pruritus. The 
presence of eczema or of lesions resulting from scratching upon the face and neck of a child or of 
an adult, presumably scabietic, therefore, does not exclude the diagnosis of scabies. 
European writers, particularly of previous decades, have described a severe form of encrusted 
eczematous scabies which they call scabies Norvegica or Norwegian itch. It is not seen in this country. 
The subjective symptom of scabies is itching, which seems to vary in severity in different 
cases. Some patients present large surfaces of eruption, and, strangely enough, complain very 
little ; others complain bitterly, and only have a limited eruption. As a rule, however, itching is 
the early and constant symptom of scabies. It is an itching pure and simple, and in uncomplicated 
cases is not attended with the burning sensations peculiar to eczema. It is probable that the pru- 
ritus of pediculosis is more severe than that of scabies, for there is ample proof that scabietic 
patients do not scratch with the persistency and ferocity of lousy persons, nor are the evidences of 
scratching as well marked in scabies as in pediculosis. The itching is commonly worse at night, 
particularly when the sufferer is warm in his bed. 
The course of scabies varies with each case, being slow in some, rapid in others. Left undis- 
turbed, the disease tends to extend over the body, the whole of which may in inveterate cases be 
involved. Usually, it begins in one region, mostly the hands, and from them extends up the arms, 
and it may be transferred by the fingers of the bearer to his or her body, and particularly to the 
genitals and the breast. It may be cured on one region and appear on another; and it must be 
borne distinctly in mind that it may be absent from the hands and present elsewhere upon the 
body. It has already been stated that scrupulous cleanliness and the irritating particles incident to 
certain trades, and immersion in soap and water, will often cure it upon the hands. 
Scabies is seen in all grades, from a few scattered papules to an extensive composite eruption. 
In some cases, where the treatment has been particularly vigorous and long continued on a part, 
scabietic eczema may be induced, which will always be perpetuated and rendered worse by its con- 
tinuance. It becomes a delicate and important question, therefore, to determine when scabies ends 
and eczema begins. 
It has been observed that during the course of the continued fevers, pneumonia, and in 
adynamic conditions scabies has remained, as we may say, in a dormant condition, and that when 
health was restored it became active. 
Scabies is found, for the most part, in childhood and early adult life, and in the middle-aged, 
and less frequently in old subjects. Greenough ventures the opinion-with which I am in entire 
accord-that it is probable that the harder and drier integument of old persons is less pleasant 
and less nutrient to the itch-mite than that of younger subjects. 
Experience and observation, particularly in this country, have shown that scabies is found 
among all classes of society. It is important for the young practitioners, and even the old ones, 
to remember that scabies may be found in the most cleanly and refined people, since the impres- 
sion is quite general that it is only seen in the poor and squalid. It is at present largely prevalent 
in the middle and working classes. It is obvious that careless and dirty people offer a more 
favorable habitat to the itch-mite than those who use soap and water freely and change their 
linen frequently. 
Etiology.-Though the Acarus Scabiei or Sarcoptes hominis is the essential cause of scabies, 
it must be remembered that eruptions almost if not wholly identical are produced by other varieties 
of the Sarcoptes derived from horses, dogs, cats, camels, sheep, and rabbits. It is well, therefore, 328 
DISEASES OF THE SKIN. 
in trying to establish the nature of a suspected case, not to be satisfied by simply inquiring as to 
whether the patient has come in contact with a person presumably scabietic, .but, such information 
failing, to ascertain what animal he has handled or been in contact with in any way. 
For the production of scabies it must be remembered that an impregnated female or a male 
and female acarus freely accessible to one another must find a habitat upon the skin, since the 
male does not burrow and soon dies. The transmission of the disease can only occur through 
direct personal contact. 
Among the young, scabies is contracted between nurse or mother and child, and between 
playmates and bedfellows. In older persons it is frequently communicated in sexual contact and 
by males or females sleeping together. Thus we find it among apprentices and clerks, among 
shop-girls and domestics, who occupy the same bed. In greater extent it is seen in large standing 
armies, in the navy, upon shipboard-in fact, in all large permanent gatherings of men. 
The observation has been frequently made that physicians who examine and handle scabietic 
patients very rarely become infected, and authentic cases of the transmission of the disease in 
handshaking are yet to be reported. Some persons seem especially prone to scabietic contagion, 
while others seem to have a greater or less immunity from its ravages. This is frequently well 
shown in certain families, in which among a number of scabietics one or more individuals mingle 
with them with impunity. 
The possibility of contagion by means of articles of clothing-gloves, underwear, etc.-and of 
bed-linen should not be forgotten. 
Diagnosis.-The clinical pictures of mild and severe cases of scabies are usually so clear and 
so sharply marked that an error of diagnosis need not be made by a person familiar with them. 
In any suspected case the discovery of the burrow-or, better yet, the acarus-conclusively 
settles the question. Very often a history of contagion, or of the existence of a similar disease in 
some relative, friend, co-worker, or bedfellow, may be obtained. 
About the hands and wrists and upon the preaxillary regions, upon the penis and breasts, the 
scattered and miscellaneous papules, vesicles (perhaps bullae), and pustules compose an eruption, 
without orderly grouping or symmetry, which is so characteristic that a mistake is hardly liable. It 
is necessary to bear in mind that vesicular and pustular eczema may be found in those regions, but 
that the latter has tolerably well-marked, orderly grouping, or, we may say, co-ordination of the 
lesions, which is never seen in scabies. 
Scabies upon the trunk and lower extremities may be mistaken for pediculosis, but a little 
knowledge, thought, and care will soon set things right. Pediculosis is caused by an insect which 
can be found without much difficulty ; it is mostly seen on the back and shoulders ; in a word, on 
the posterior part of the trunk and on the outer aspects of the legs-it never presents the ensemble 
of lesions seen in scabies-while the latter disease is prone to appear on the anterior portion of the 
trunk, between the nipples, and as far down as the junction of the lower with the middle third 
of the legs. 
It is well to remember that in children and some adults, where scabies consists of a few scat- 
tered papules over the trunk, the scratching induced may cause the appearance of wheals ; in which 
event a diagnosis of urticaria might wrongly be made. It may also be well to bear in mind that 
a pruritic eruption upon the body or legs of an old person, attended with scratch-marks, torn pap- 
ules, wheals, and perhaps ecthymatous crusts, is much more likely to be pediculosis corporis 
than scabies. 
Prognosis.-Scabies being a readily curable disease, the outlook is usually good in each case. 
Recent, mild, and circumscribed eruptions may be cured in a week or ten days ; more advanced 
and extensive eruptions require a longer time. 
Treatment.-The indications for treatment, which is purely external, are to destroy the itch- SCABIES. 
329 
mites, to cure the inflammatory changes which they have caused, and to use the most circumspect 
caution that the treatment adopted does not cause inflammation. To this end, while the physician 
must use judgment and discretion in adapting the strength of the medicament used, he must 
respect the delicacy of the integument of infants, children, women, and of some men, and treat them 
less heroically than he would individuals with a coarse and resistant skin. In addition to therapeu- 
tics, prophylaxis is an absolute essential, and such directions should be given that will secure the 
patient from subsequent auto-infection, and that will prevent him or her from contaminating others. 
Accordingly, the patient should be ordered to cease wearing his or her gloves until they are ironed 
or baked (it is preferable to throw them away), and all under-linen and bed-clothes should be thor- 
oughly washed or ironed or baked in an oven before they are put on again. 
The topical treatment of scabies should be in keeping with the site and extent of the eruption. 
If it is confined to the hands, its cure is usually simple and speedy. The best treatment preliminary 
to medication in all cases is thorough immersion of the parts in very warm water to which an alkali 
has been added, such as borax or sal soda. When the hands alone are involved, these soapsuds 
and alkaline immersions are readily made, but when the body is invaded difficulty in bathing is often 
experienced. It is not sufficient that the parts should be washed with hot alkaline water: they 
should be thoroughly immersed for at least half an hour, and better still for an hour. Perhaps the 
best method of procedure in cases of scabies of the arms, legs, and body is that used by Hardy, 
called the "quick cure," which I will give in full, and which should be carried out in all cases, as far 
as circumstances will allow, in its entirety or with modifications. I he first stage of the treatment 
lasts for twenty minutes, and consists in a general and thorough rubbing of the whole body, and 
especially of the diseased portions, with a thick lather of green soap or of a good quality of potash 
soft soap or some other good grade of soap. By this means the mites are dislodged from the sur- 
face of the skin, the cuniculi are rendered accessible to the parasiticide applications, and the ova 
may be.killed. The second stage of treatment consists of the bath. The water should, if possible, 
be kept at an elevated but agreeable temperature, and to each thirty gallons one pound or even 
more of borax, sal aeratus, or sal soda should be added. While under the water the body should 
be firmly but gently scrubbed with a brush. The third stage begins with the inunction into all 
scabietic parts of Hardy's modification of Helmerich's ointment, which is as follows: sulphur, 50 
parts ; subcarbonate of potassa, 25 parts ; and lard, 300 parts ; or any of the following ointments. 
It should always be remembered that upon the thorough inunction of the ointments the success of 
the treatment depends. Therefore, all care should be taken to make them penetrate papules, 
cuniculi, and all inflammatory lesions. Beneficial as Hardy's "quick cure" is, experience has 
proved that in most cases the patient was not freed from the disease by one of these composite 
treatments. In fact, several are necessary. 
In treatment, the aim being to kill the insect, we must endeavor to so adapt the strength of 
our remedies that we may attain this object and not cause or increase dermal inflammation. In 
children the integument is very delicate, and in some grown subjects it is prone to inflammation ; 
therefore we should handle them very carefully. Nothing so retards a cure as an intercurrent 
eczema caused by injudicious stimulation. It is a good rule in most cases to begin with a vigorous 
but carefully adapted onslaught, and then to attenuate the strength of the parasiticide remedy. 
Helmerich's ointment may be considered very strong, and is as follows: 
R. Flor, sulphuris, ; 
Potassae subcarb., 3j; 
Lard, oj. M. 
This may be used in severe cases where the skin is not fine and delicate. A milder ointment is 
the following: 330 
DISEASES OF THE SKIN. 
B. Lac sulphuris, 
Potassae subcarb., ; 
01. bergamot., gtt. xx ; 
Vaseline, §iv. M. 
At my New York Hospital Clinic and in private practice the following ointment has proved very 
efficacious : 
B. Flor, sulphuris, 
Naphthol., aa. giij; 
Bals. Peru., giij; 
Vaseline, M. 
In severe cases the quantities of the main ingredients may be increased. 
Kaposi's ointment is thus composed: 
B. Naphthol., 3j; 
Saponis viridis, Qx; 
Pulv. cretae, gij; 
Axungiae, 5vij. M. 
The following is the composition of Hebra's ointment: 
B. Flor, sulphuris, 
01. cadini, aa. £vj; 
Saponis viridis, 
Adi pis, a a. Oj; 
Cretae, M. 
A creasote ointment is often very efficient, since this agent is particularly destructive of the 
ova: 
B. Creosoti, gtt. xx+lx; 
Ung. zinci oxid., 3j. M. 
This may be used in cases where there is much eczema. 
Iodide of potassium in the proportion of thirty to sixty grains to the ounce of vaseline may 
prove of service. 
The following ointment is also capable of extended application : 
B. Sulphuris iodidi, gr. xv-f-xxx; 
Ung. aq. rosae, 3j. M. 
When the skin will bear it Wilkinson's ointment (see Treatment of Psoriasis) will often prove 
very curative. 
White's ointment is rather stronger than either of the foregoing, and is an excellent one : 
B. Flor, sulphuris, gij; 
Naphthol., gj; 
Bals. Peru., 
Vaseline, aa. £j. M. 
Balsam of Peru is a particularly valuable agent, and can be used widely in large or small pro- 
portion in ointment form, particularly when there is considerable inflammation. In some cases, 
where the scabietic lesions are not very copious and the inflammatory reaction severe, the follow- 
ing ointments, the strength of which may be increased or diminished, are of much value : 
B. Bals. Peru., gj; 
Ung. zinci oxidi, M. SCABIES. 
331 
JU Bals. Peru., 3j J 
Pulv. camph., gr. xvj; 
Liq. Goulard., gj; 
Ung. zinci oxid., §j. M. 
Styrax in the form of ointment may be used, but it is less pleasant than balsam Peru. 
Any of the foregoing ointments may be used : after proper immersion they should be well 
rubbed in. If the whole body is affected, every portion should thus be anointed on going to bed, 
care being observed to wear such old body-linen as will protect the bed-clothes. If the web of the 
hands is affected, brisk and thorough friction of the fingers and interdigital spaces should be made. 
So also all regions should be treated according to their peculiarities of conformation, the parts 
being washed with soap and water in the morning. When well administered for from three to six 
consecutive nights the treatment above given is usually curative. The patient will no longer suffer 
from pruritus, and the decline of the lesions will be manifest to the eye. Then it is well to wait 
and watch, and if the itching begins again and the inflammatory foci break out in renewed life, the 
treatment must be resumed. In many cases scabies is cured, and an eczema, sometimes of great 
persistency, is produced by prolonged treatment-a fact which cannot be too forcibly enunciated. 
In some cases the foregoing ointments, used cautiously, but energetically, may from the start cause 
redness and swelling which much discourage the patient. It is well then to administer the bath 
and apply the balsam Peru and oxide-of-zinc combination, and as soon as admissible begin again 
with the true antiscabietic remedies. 
For the treatment of the pruritus which accompanies and sometimes follows scabies, also that 
sympathetic itching of non-affected parts which is sometimes very distressing, the reader is referred 
to the section on the Treatment of Urticaria. 
Attention has been again called within a few years by Dolan 1 to the marked efficacy of sul- 
phide. of calcium in the form of watery solution. His formula for the parasiticide liquid is essen- 
tially that of VIemingkx's solution, as follows: flowers of sulphur, 100 parts ; quicklime, 200 parts ; 
and water, 1000 parts. This should be boiled, with occasional stirring, and kept in closed bottles. 
Fhe patient is first well soaked in a hot bath ; then he is painted over with this liquid by means of 
a rather stiff brush ; then he allows this mixture to remain on the skin for rather less than an hour ; 
and then he takes a second bath. By this treatment two or three baths and applications are said 
to produce a cure. It is important to remember that delicate skins cannot stand this treatment. 
It may be of service in jails, in tramp boarding-houses, and in correctional institutions. 
Radcliffe Crocker claims great success for the following treatment peculiar to the University 
College Hospital of London : "Four ounces of sulphide of potassium are dissolved in thirty gal- 
lons of water at a temperature of ioo° in a porcelain bath ; the patient soaks in this for a quarter 
of an hour. While he is taking the bath his clothes are put in a disinfecting oven. Three baths 
are generally ordered to make sure, but one or two are quite enough, as a rule." 
Little can be said in favor of sulphur baths in scabies, since they very often fail to kill the 
epizoa and ova, and produce much additional dermatitis. The same may be said of mercurial 
baths. 
1 "On the Use of Sulphide of Calcium in the Treatment of Scabies," British Med. Journal, Feb. 16, 1884. DYSIDROSIS OR POMPHOLYX. 
The term " dysidrosis " was applied by Tilbury Fox to an inflammatory, vesicular, and some- 
times bullous eruption seated upon the hands, feet, and face. Since, however, it has been shown 
that the disease is not intimately connected with a functional disturbance of the sweat-apparatus, 
the term dysidrosis, which Fox gave to it under the impression that it depended upon retention of 
sweat rapidly and freely secreted, will probably be replaced later on by that of pompholyx. It was 
called by Hutchinson cheiro-pompholyx. 
The eruption occurs in an acute and a chronic form, and may be limited to one region or 
invade several. It is usually symmetrically distributed, and may consist of many vesicles or bullae 
or it may be limited to a few. 
This disease is mostly seen in hot weather, though it may occur in winter, particularly in cooks 
or in persons who are exposed to strong heat. Upon the hands the eruption is found along the 
sides of the fingers, on the palms, and on the finger-tips. When it is extensive it may encroach 
upon or even invade the dorsal aspect of the fingers and of the hands. 
The essential lesion of this eruption consists in vesicles which are peculiar in that they are 
usually at first isolated and disseminated, and later are clustered and deeply imbedded in the skin, 
and give the appearance of boiled sago-grains, being very translucent in the centre and pearly in 
the minute ring which the play of light forms around it. Though this latter feature is seen, it is 
simply an illusion, since the contained fluid is clear and limpid. In Fig. 4, Plate XLVII., is por- 
trayed a group of these clustered vesicles. When the epidermis is thick they may present very 
little salience, but can be felt as little pinhead-sized lumps. When, however, the epidermis is thin, 
they soon become elevated into conical, globose, sometimes flat and umbilicated, lesions. In many 
instances a central follicular orifice may be very clearly seen, and sometimes a distinct depression 
is there seen. It was this feature which led Fox to conclude that the morbid process began in the 
sweat-glands, and that, egress being impossible, exudation occurred in the duct and around it. 
When the eruption is acute and well marked, such are the great number and size of the vesicles 
that bullas are produced, fl hese lesions are in this affection either mammoth vesicles or multiloc- 
ular lesions due to fusion of several large vesicles. The integrity of the vesicles may remain sev- 
eral days, and the same may be true of the bullae before they rupture. In sparse eruptions the 
vesicles may gradually dry up without ever becoming ruptured. 
In Figs. 2 and 3, Plate XLVIL, the appearances of a well-marked and advanced case of dys- 
idrosis are very graphically depicted. On the thumbs the large vesicles and bullae are very well 
shown, surrounded with considerable hyperaemia. In contrast to this exaggerated picture the 
appearance of the small-and we may almost say typical-vesicles on the inner side of the fore- 
finger of Fig. 2 is very instructive. In these three figures the clinical history of the disease as it 
occurs on the hands is well shown, and from them may be gleaned an idea of the appearances of 
the eruption when it occurs upon the face or the feet. On the middle, ring, and little fingers of 
Fig. 2 are well displayed the macerated condition of the epidermis which results from bursting of 
the vesicles. It will be seen to look sodden, like whitish soaked leather. 
According as the lesions are extensive and copious there is greater or less stiffness of the 
332 Plate XLV11 
Part VII 
LEA BROTHERS & CO. PUB LIS HE RS . PHILADELPHIA 
I. .\l 11 ia ri < i CrysI a 1 lin a . 2, - 3, d . Dvsidrosi s DYSIDROSIS OR POMPHOLYX. 
333 
hands and fingers. Movements are very difficult of accomplishment, and attended with more or 
less pain and discomfort. 
At the involution of the eruption a red, more or less superficially raw, usually glossy and 
scaly, surface is left. Very soon, however, the epidermis is replaced and the normal state is 
reached. In cases where there has been artificial irritation a secondary and accidental eczema 
may be produced. 
Upon the face the eruption is mostly seen in a sparse and disseminated form, but it may occur 
in a quite extensive and grouped manner and be attended with considerable swelling. 
On the feet much soreness is induced, and painful fissures may be formed. The vesicles, 
which at first were clear and translucent, may later on present a yellowish tint, but in uncompli- 
cated cases they have no sero-purulent contents at any time. 
The symptoms of dysidrosis vary within marked limits. As a rule, at the onset of the vesicles, 
a burning and itching sensation is felt, usually greatest upon the fingers and toes, less so upon the 
face. In some cases the whole affected member is the seat of these pruritic symptoms. So intense 
is the itching sometimes that a patient is forced to scratch until the vesicles are ruptured, and then 
he gets relief. 
Course.-The eruption may occur only on the hands, and then involve one or more fingers, 
or it may attack several fingers or the whole hand. On the face it may be limited to a few vesicles 
or there may be many. So is it on the feet. The eruption comes and goes, showing a decided 
tendency to relapse, particularly in hot weather. Uncertain as its onset is, its disappearance is 
usually rapid and spontaneous. It is always more or less symmetrical. When the vesicles are 
few in number, they may alternate in their evolution on either hand, thus preserving a symmetry 
which is at times not apparent. 
Etiology.-Most authorities are in accord in considering nervous debility as the underlying 
cause of this eruption. It has been found in the overworked, in persons whose nutrition is under- 
mined, and in those subject to worry and troubled with mental anxiety. It has been known to 
occur in subjects suffering from gastro-intestinal troubles, from plethora in those given to drink, 
and again in those whose health seemed normal. It is not, as a rule, found in young subjects, but 
mostly in those of adult and middle age. Crocker says that it is most common in young women 
of nervous temperament. It is seen in those who perspire very freely. 
Pathology.-It seems clear, from the investigations of Robinson, that the sweat-glands are 
not the essential factors of the eruption. Robinson says that the effusion comes from the papillary 
vessels, and, passing through and between the lower cells of the rete, collects in different situations 
in different vesicles. The fluid is alkaline or neutral, never acid. Crocker thinks that the disease 
is intimately connected with the sweat-apparatus. Though both Robinson and Crocker show that 
leucocytes are found in the effused fluid, clinically we see no sero-purulence in uncomplicated 
lesions. 
We occasionally see upon the face slowly, and sometimes quite rapidly, appearing vesicles, 
few or many, which present to the eyes in their course appearances which seem to point to their 
origin in occluded sweat-ducts. 
Diagnosis.-Usually the seat of the eruption, its clearly-marked clinical features, and its course 
are so sharply prominent that a mistake in diagnosis is not readily made. With the pictures given 
before the reader it is only necessary to remind him that eczema, herpes, and pemphigus may pre- 
sent somewhat similar features. Sudamina or miliaria is an essentially aphlegmasic trouble, and 
should not be confounded with dysidrosis. 
Prognosis.-The tendency of the disease is toward spontaneous cure, provided extraneous 
irritation is prevented and immobility of the parts maintained. I he liability to relapse, however, 
is well marked, and was observed to persist for thirty years in one case by Hutchinson. 334 
DISEASES OF THE SKIN. 
Treatment.-Much can be done to alleviate the suffering of the patient by cooling lotions and 
mild ointments, such as are given in the sections on Eczema and Urticaria. Soaking the members 
in very hot alkaline water may prove very beneficial. In general terms, it is necessary to find out 
the underlying morbid state if any exists, and to treat it according to its nature. Debility must be 
improved and digestive disturbances corrected. Plethora needs proper depletion, and alcoholic 
indulgence requires uncompromising interdiction. Robinson says that arsenic has a special effect 
in the cure of the disease ; therefore it is well to employ it in chronic cases in addition to the 
indicated treatment. MILIARIA CRYSTALLINA. 
Miliaria crystallin a, commonly called sudamina, is a non-inflammatory affection due to 
obstruction to the secretion of sweat, and attended with the production of minute or large clear, 
limpid vesicles. It is a condition which sometimes complicates febrile states, such as typhoid fever, 
acute rheumatism, pneumonia, scarlatina, and other diseases. It is frequently produced by hot 
baths and by hot poultices, and from the prolonged application of impermeable coverings such as 
rubber or oiled silk. It is said to result from severe muscular exercise in fat and feeble subjects. 
Miliaria crystallina is an eruption of minute miliary or rather larger-sized vesicles, conical 
or round, which have been compared to dewdrops, and from distension may become of the size of 
small peas. These vesicles may be isolated or closely packed together; they may be limited in 
extent or they may cover large surfaces, as in Tig. I, Plate XLVII. They usually show no tend- 
ency to coalesce, even when in close juxtaposition. They are sometimes seated seemingly beneath 
the most superficial layers of the epidermis, and have roof-coverings which, though quite resistant, 
are of very thin structure. Then, again, they are seated deeper in the epidermis, and are covered 
with a well-marked horny layer. These vesicles usually appear with remarkable promptitude as a 
complete eruption, and again they may show themselves more or less quickly or slowly in crops. 
Commonly there is no accompanying hyperaemia, though in some cases this condition may exist in 
a mild manner. Since the development and course of miliaria crystallina is aphlegmasic, little or 
no disturbance is experienced, though in some cases a mild burning or itching is complained of. 
Likewise, there being little tendency to scratch, the lesions do not, as a rule, become ruptured, but 
remain in an indolent condition until by gradual desiccation they disappear, leaving on their sites 
little scaly pinkish spots without redness. 
In some cases a vesicular outburst occurs, and in the course of a few days only a slightly scaly 
surface is left. In others the vesicles (particularly if deeply seated) remain for a week, and even 
longer, before they show signs of thorough disappearance. In still other cases the length of time of 
the eruption is extended by the development of new crops of vesicles on or around the original site. 
As a rule, miliaria crystallina occurs on those portions of the body where the skin is thin, such 
as the abdomen, the chest, the face, neck, and axillae. It may occur on the groins and extremities. 
It is well to remember that the sudamina rubra of the older authors is an inflammatory vesic- 
ular affection, known chiefly by the laity as prickly heat, and that the term sudamina alba is proper 
to miliaria crystallina when its vesicles have become milky in hue. 
Etiology.-The cause of the affection is excessive sweating in persons whose sweat-ducts 
have, from some occult reasons, become occluded. 
Diagnosis.-Such are the well-marked appearances and course of miliaria crystallina that its 
nature is always readily recognized. It must not, and should not, be mistaken for varicella. 
Prognosis.-The eruption usually has no pathognomonic significance. It comes quickly, and 
goes in like manner, and from it no prognostic data can be derived as to the outcome of the sys- 
temic disorder from which the patient may be suffering. 
Treatment.-This is very simple, consisting in the application of any bland fine powder, such 
as talc, starch, lycopodium, and the powders spoken of in the sections on Eczema, Urticaria, and 
Pemphigus. 
335 IMPETIGO CONTAGIOSA. 
Impetigo contagiosa is a contagious and auto-inoculable inflammatory disease of the skin, seen 
mostly in young children and sometimes in the form of quasi epidemics. 
It usually begins with mild systemic disturbance in the form of fever and chilliness and malaise. 
In many cases no general symptoms are to be observed, but in some, particularly in very young 
children, they may be quite well marked. 
In the great majority of cases the disease begins on the face about the mouth and chin, on the 
cheeks, alae nasi, near the eyes, and on the forehead. It may appear on the lips and in the nasal 
orifices. The primary lesion is a small vesicle which soon contains turbid serum and extends 
peripherally until a flat, sero-purulent, usually rather flaccid bulla is produced, which is surrounded 
by a more or less intense inflammatory areola. As this bullous lesion expands and flattens, the 
contained fluid dries pari passu, and in a few days a crust of the size of the lesion of a yellowish- 
green or straw color is produced. This crust is peculiar in the fact that it becomes dry and papery 
in consistence, rests upon the integument as if stuck on, and, becoming detached at its margins, 
tends to curl up, until it finally loses its hold and falls off. If such a crust is elevated, it will be 
seen that under it is a layer of thin sero-pus or of quite.viscid pus. The skin underneath is red, 
superficially excoriated, but not decidedly ulcerated. When after desiccation the crust falls, a pink- 
ish-red immature, shiny epithelium is left, which gradually becomes blanched and normal. The size 
of the completed bullae varies between the area of a split pea and of a three-cent silver piece. 
There is no tendency to uniformity in size, and though in shape the round or oval forms predomi- 
nate, these are often lost by the fusion of lesions and in consequence of the movements and the 
conformation of the parts, such as the nose, mouth, chin, and neck. In some cases, owing to dirt 
and to the irritation of picking, the sites of the crusts are transformed into troublesome ulcers. 
As a rule, the disease appears in crops, usually of small numbers, which may appear from day 
to day or at longer intervals. Thus it is that in some cases the eruption is fully out in three or four 
days, while in others the time is much prolonged. After the development of the eruption upon the 
face in this gradual manner it may be seen to attack the hands, the legs, the feet, and the abdomen, 
usually in successive limited outbursts. In the majority of cases in this country the severity of the 
disease is expended upon the face, and the spots of it which exist elsewhere are sparse and 
isolated. 
The extent of the eruption varies in different cases, being limited in some and more dis- 
tributed in others. In like manner, the number of the lesions varies within small and large limits. 
It follows, therefore, that in some cases the crusts are sparse and isolated, in others grouped and 
numerous. By the fusion of a number of lesions patches of various sizes and shapes are produced, 
d'he lymphatic ganglia in anatomical relation with parts the seat of contagious impetigo are usually 
more or less swollen and sometimes painful. It is not uncommon to see sparse vesico-pustules and 
bullae upon the hands and elsewhere on the bodies of persons who take care of children affected 
with this disease. A not uncommon site for the development of these lesions is the root of the 
nail, where they look like burns. In some cases it is observed that where a few children have 
impetigo contagiosa, one or more will present the disease in an abortive form, which warrants the 
336 Part VII 
Plate XLV1II 
2 . 
Fi£.l. 
LEA BROTHERS & CO. PUB LISHERS . PHILADELPHIA 
1.Impetigo Contagiosa. 
2. Eczema Inipe tigin ocl e s from Lice. IMPETIG O CO NT A GJ OSA. 
337 
suspicion that the bearers are less susceptible than their comrades. The disease is seen mostly in 
young children of the poorer classes, but also among well-to-do people. 
The symptoms are itching and burning sensations of varying degrees. 
Etiology.-During the past twenty years numerous fungi have been claimed as the cause of 
this disease, but, although it is probable from its contagious and auto-inoculable nature that it is of 
microbian origin, we cannot speak other than in general terms. The subject yet remains to be 
studied and elucidated. It has been claimed that the disease very often follows in the wake of 
vaccination, and then in all probability originates in the pus incident to that process. I have sev- 
eral times seen what appeared to me and to my clinical assistants as undoubtedly impetigo con- 
tagiosa upon the face and bodies of children who had suppurating surface wounds resulting from 
traumatism on the forehead, head, and hands. Careful study of these cases seemed to point to the 
pus of the wounds as the starting-point of the disease. 
Diagnosis.-If the reader will, with the aid of the text, study the appearances presented by 
Fig. i, Plate XLVIIL, he will, I think, gain such a knowledge of the affection as will help him to 
readily recognize it. He certainly will have no difficulty in uncomplicated cases. The age of the 
children, the development of the rash, the occasional clear history of contagion, and the site of the 
eruption will very often be of great aid in setting the physician right. Where the green encrusted 
patches exist upon the scalp as they are shown in Fig. 2, Plate XLVIIL, which are really those of 
pustular eczema from pediculi, a doubt may exist as to their nature. This can be removed by 
studying the newly-appearing lesions. If in this study what has been said of the course and appear- 
ance of pediculosis capitis and the course of contagious impetigo is borne in mind and contrasted, 
I think that the correct diagnosis will be readily arrived at. Pemphigus and herpes facialis may at 
some period of their course resemble contagious impetigo, but a little study will clear the doubt up. 
Treatment.-The first essential is the utmost cleanliness and the removal of crusts and pus. 
Washing the parts with carbolic soap and sponging them with carbolic acid and water (2 to 5 per 
cent.) are of prime importance. Remove the crusts as speedily and carefully as possible, cleanse 
the surface. antiseptically, and apply a white precipitate ointment (10 to 20 grs. to the ounce), a 
calomel ointment (3j-3j), or zinc ointment and bals. Peru. ERUPTIONS OF IODIC ORIGIN. 
The various preparations of iodine produce upon the skin all forms of inflammation. In addi- 
tion, as a result of their ingestion, we sometimes observe nodular masses under the skin, show- 
ing the implication of the connective tissues, and petechial spots and patches are thus produced 
which are due to change in the small vessels, and perhaps in the blood itself. There are, there- 
fore, the following forms of dermatitis caused by the ingestion of preparations of iodine, notably the 
iodide of potassium: erythematous, papular, papulo-pustular, urticarial, bullous, and tuberous. To 
these are to be added the subcutaneous nodular tumors and the petechial rash of iodic origin. 
The chief peculiarities of iodine eruptions is their sudden invasion, their tendency to localize 
themselves upon the face, neck, hands, and forearms, also on the back and legs less frequently, and 
to appear in polymorphous forms. They are generally accompanied at their onset, and even later, 
by mild or severe systemic symptoms, such as headache, chiefly frontal, lachrymation, rhinitis, neur- 
algic pains in the course of the branches of the fifth nerve and in the bones, mental and physical 
depression, and gastro-intestinal irritation. In general, all of these symptoms subside and clear off 
soon after the discontinuance of the drug. 
As a rule, iodine eruptions are symptomatic of an idiosyncrasy and intolerance of these agents. 
In some persons a small dose produces very marked disturbance ; in others large doses only pro- 
duce toxic effects. In some cases the idiosyncrasy may be overcome by steadily but cautiously 
pushing the drugs, but in others it remains for all time. It has been observed that intolerance to 
the iodides may exist at one period, and not be observed at a later one, owing perhaps to some 
temporary peculiarity of the constitution. It has been thought that impaired renal function, thus 
interfering with the natural elimination of the drug, has a decided influence in the production of 
toxic effects, cutaneous and systemic. 
Erythema.-The erythema from iodine ingestion is rarely seen as the sole dermal manifesta- 
tion, but is commonly accompanied by more severe lesions. Erythema and more or less oedema 
about the face, eyes, nose, mouth, hands, forearms, and sometimes the genitals, are not at all 
uncommon. These dermal changes are usually coincident with disturbance in the fifth nerve and 
in the mucous membranes of the eyes and the nose. The color of the erythema may be of a light 
pink or of a deep red, even of an ecchymosis, and the oedema may be slight or very well marked. 
This form of eruption is usually of rapid development and prompt in decline. Iodic eruptions of 
scarlatiniform appearance have been observed, and appearances of eczema rubrum have been 
simulated. 
Papular and papulo-pustular dermatitis of iodic origin, the so-called iodine acne, is very 
common. The lesions are small and large, with more or less surrounding hyperaemia. They are 
moderately firm in structure, and often feel like shot under the fingers. They are mingled without 
order and scattered without any regularity. They are of a bright-red color, which as they grow 
older becomes deeper. Papules are interspersed with lesions whose apices are capped with little 
masses of pus. They are seated upon the face and back, and less commonly on the arms and 
338 Part VII 
Plate XLIX 
Fi&.L 
Fig.2. 
LEA BROTHERS & CO. PUB LIS HE RS , PHIL.ADELPH 
1. Bui louts Eruption of Iodide of Potassium 
2. Bromide of Potassium Eruption. ERUPTIONS OF IODIC ORIGIN 
339 
legs. They appear in crops of large or small number, which continue to develop according to the 
length of time the drug is taken. In some cases a quite copious eruption appears suddenly. It 
may be not infrequently observed that iodine preparations engraft upon the skin a morbid tend- 
ency to inflame, which shows itself for quite long periods after the discontinuance of the drug. 
The clinical appearances warrant the opinion that the sebaceous, and perhaps the sweat-follicles, 
are the foci of this form of eruption. 
Urticaria.-A true urticaria is sometimes produced by the iodide of potassium. The wheals 
may be small or large, and usually resemble the type-form of the disease. I have in my service at 
Charity Hospital a woman upon whose face, neck, back of hands, and wrists a papular urticaria 
surmounted by small pellucid vesicles has been produced many times by doses of fifteen grains 
of the drug. It is not uncommon to find lesions resembling in all particulars papular and even 
tubercular erythema commingled without order with urticarial wheals. Other forms of dermal 
lesions may also be present. The wheals of iodic urticaria gradually become transformed into 
pink or red papules or tubercles, which either rapidly or slowly subside. 
The Bullous Eruption.-Of late years several observers-notably Hyde and Morrow- 
have published cases of this form of iodic eruption, and my own experience convinces me that it is 
of fairly common occurrence. The bullae are of various sizes, some, indeed, being vesicles and 
pustules, and but few being lesions of such fulness and symmetry of development as we see in pem- 
phigus. They usually are quite resistant, and retain their integrity for a number of days. A very 
good idea of a commencing iodic bullous eruption is given in Fig. i, Plate XLIX. In this plate all 
forms of lesion, from the small initial pustule without very much salience to the well-marked but 
not much elevated bulla, can be well seen. In some cases blebs as large as a pigeon's egg are 
formed ; in others, and rather exceptionally, the lesions are of large, even of mammoth, propor- 
tions, without any definite shape, and appear to be irregularly extensive upliftings of the epidermis 
with sero-pus. The bullae as usually found are round and oval in outline, globular in shape, and in 
their early stages sometimes show an evidence of umbilication. It thus happens that when a num- 
ber of shot-like papules and papulo-pustules are present upon the face, particularly when coexist- 
ent with more developed and umbilicated lesions, a marked semblance to variola is presented. 
This appearance is sometimes strengthened by the concomitant pains in the bones and pyrexia 
which may be present. In all cases of iodic bullae there are more or less diffuse inflammatory 
areolae present. The lesions are usually discrete, often closely packed, and sometimes by close 
contiguity they run together, though they each show a tendency to retain their own individuality. 
In general they flatten out by the drying of their contents, and leave red spots, and sometimes 
more or less profound cicatrices. Occasionally excoriated surfaces and ulcers are produced. In 
somewhat exceptional cases the lesions are found beyond the classic sites of this eruption-namely, 
the face, neck, and hands-and they then may be present upon the trunk, buttocks, thighs, and 
legs. I once saw a case of hemorrhagic bullae, due to the iodide of potassium, in which the lesions 
were well formed and sparsely scattered over the face, buttocks, arms, and legs. Strange to say, 
twenty years after this eruption a bullous exanthem without hemorrhage was produced again in 
the patient by the use of the drug. 
The peculiarities of this bullous rash, therefore, are its suddenness of invasion, its atypical 
lesions, and the coincidence of such multiform manifestations as papulo-pustules, vesicles, and pus- 
tules, together with blebs of various sizes and shapes. Cessation of the use of the drug is followed 
by prompt involution of the eruption, while its continuance may cause the appearance of still more 
lesions. In some cases, however, with this, as with other forms of eruption, after the first outburst 
the patient may take the drug with impunity. 340 
DISEASES OF THE SKIN. 
Dermatitis tuberosa.1-As a result of iodic intoxication tumor-like formations may be pro- 
duced which occur chiefly upon the face and hands, but also on other parts rich in sebaceous folli- 
cles. The name given this form of eruption by me, "dermatitis tuberosa," is both exact and sim- 
ple. In a case recently observed by me the following clinical features were noted, which give a 
clear idea of the affection. The appearances of the case are shown in wood-cut I7ig. 57. Upon 
the forehead, on the right temple, above 
and rather external to the right eye, upon 
the right cheek, and upon the neck are 
a number of perfectly-developed tumors, 
with several in the process of growth. 
Symmetrical lesions existed on the left 
side of the face and neck. These tumors, 
for such they really were, were of a deep- 
red color, mostly of round outline, some 
being somewhat oval, and varied in size 
from that of a three-cent silver piece to 
that of a quarter of a dollar. They were 
in structure both pedunculated and ses- 
sile. The large tumor over the temporal 
region was so much larger upon its sur- 
face than at its base that it could readily 
have been strangulated with a ligature. 
As it increased in growth it became so 
much more pedunculated that it presented 
the shape of a mushroom. The tumor on 
the side of the nose was of similar struc- 
ture. All the rest of the tumors had 
sharply defined vertical margins, and might 
truly be called sessile. Around all the 
tumors there was a red areola, so thin 
that it was very evident that the inflammatory process was sharply limited to the new growths. 
Palpation showed that in structure these tumors were soft, spongy, and non-resistant. The larger 
ones conveyed to the fingers a sensation of bogginess and of false fluctuation. Over the surface 
of the majority of these lesions there was a large number of minute cribriform, trumpet-shaped 
openings, from which a small quantity of pus could be made by pressure to exude. In the 
untreated condition this pus dried upon the surface of the tumors and formed crusts of various 
sizes. Upon the large temporal tumor about a dozen minute deep-yellow crusts may be seen 
depicted, each of which covers one of the trumpet-shaped openings spoken of. Upon the other 
tumors the effused pus has produced more or less encrusted coverings, which, being removed, 
reveal the typical cribriform openings. 
The foregoing description presents the essential features of this eruption in its untreated state. 
Applications of a watery or greasy nature removed the pus-encrustation, and permitted a further 
study of the lesions. Owing undoubtedly to the fact that from the necessities of the case the use 
of the toxic agent was kept up in increasing doses, the inflammatory action in the lesions persisted 
and they grew apace. They increased considerably in area, and reached a height, in some instances, 
of nearly half an inch, and in others, and the majority, of one-sixth of an inch. In general, a tumor 
became, as we may term it, fully developed in less than a week, after which, however, it might grow 
Fig. 57. 
Dermatitis tuberosa of Iodic Origin. 
1 See New York Medical 'Journal, Nov. 3, 1888. ERUPTIONS OF IODIC ORIGIN. 
34i 
larger. During the whole of its period of development the little cribriform openings leading to 
minute abscess-cavities in its body gave exit to pus. When the tumor became fully developed, 
however, this feature ceased almost entirely, the opening disappeared, and it is fair to assume that 
the minute abscess-cavities closed or became collapsed. From this time forth the secretion, if any 
was allowed to form, came from the surface of the tumors. At this time the surface of these 
lesions presented a uniform warty appearance comparable to that of simple venereal vegetations. 
It may be described as minutely mammillated or warty, but falling short of deserving the adjectives 
papillomatous, vegetating, or fungating. I can readily see, however, that, in the absence of treat- 
ment and with the continuance of the toxic iodic action, these tumors might have become exuber- 
antly papillomatous. 
Reaching, then, full development in about a week or ten days, these lesions showed a tend- 
ency to run a chronic, indolent, and aphlegmasic course. They caused no suffering, were trouble- 
some only in their disfigurement, and seemed to have come to stay. Under the use of equal parts 
of blue and zinc ointments they remained unchanged, but began to wither promptly when painted 
daily with a solution of perchloride of iron. Even under this treatment their subsidence was slow, 
and at the end of a month pigmented patches, decidedly but rather superficially atrophied, were left. 
These iodic tumors begin as localized congestive swellings of the skin in the form of round or 
oval patches. The two oval spots on the outer side of the right eyelid convey a good idea of their 
commencement. There may or may not be evidence of concomitant inflammation of the sebaceous 
follicles at first, but these structures, if present, become involved. The further growth of the 
tumor is in both area and height. The lesions as they appeared on the cheek looked at first like 
those of acne indurata, and, had they progressed no farther than the papulo-pustular or tuberculo- 
pustular stage, could with propriety have been called those of severe iodic acne. 
The local concomitant symptoms in this case were very mild, the patient simply complaining 
of slight pruritic heat. There was no systemic suffering, such as we so frequently see in cases of 
marked iodic intoxication. 
With the foregoing facts before us, I think that there can be no question as to the existence 
of a localized, circumscribed dermatitis of iodic origin to which the name dermatitis tuberosa applies 
perfectly. The inflammatory condition of the skin is evident, and its production of tuberous lesions 
has been, I think, clearly shown. The term acne anthracoide iodopotassique, which has been applied 
to it, is, in my judgment, too fanciful, and far, pathologically, from being precise. It is true that by 
an effort of the imagination a semblance between the openings in these tumors and those of anthrax 
or of anthracoid furuncles may be drawn, but here the likeness ends in every particular. Anthrax 
and its congeners are subcutaneous connective-tissue affections. The essential lesion in the morbid 
change in this iodic eruption is dermatitis, and the peculiar involvement of the sebaceous glands, 
with their cribriform openings and pus-crusts, are only secondary features of the process. The 
further development of the tumors into sessile and mushroom forms, presenting a moderately warty 
surface, gives striking evidence of exudation and cell-infiltration into the papillae cutis, and is the 
natural outcome of the inflammatory process. Still further hypertrophy may be observed, in which 
case the adjectives fungating, vegetating, or papillomatous may be applied in a qualifying sense. 
These vegetating lesions may assume quite large sizes, and care must be taken that they are 
not regarded as vegetating syphilides. They occur quite early on hairy parts (scalp and beard), 
and may attain very considerable area. In structure they are softer than syphilitic growths, and 
much more rapid in development. It is generally a good rule where one finds tuberous lesions in 
varying stages, together with vegetating lesions upon the scalp, face, neck, and hands, and also 
elsewhere, to suspect iodic intoxication, particularly if there is a history of sudden invasion. This 
clinical picture is almost pathognomonic. Upon the disappearance of these tuberous and vegetat- 
ing lesions scarring and atrophy may be left. 342 
DISEASES OF THE SKIN. 
Subcutaneous Nodular Tumors.-T hese lesions may result from iodic intoxication and be 
the sole morbid manifestation, or they may accompany one or more of the forms of eruption already 
described, for in this eruption we see the same peculiar tendency to multiformity of the lesions as 
in all iodic exanthems. 
Certain lesions due to iodine-poisoning resemble erythema nodosum. They appear quickly as 
small subcutaneous nodes, at first movable, but soon attached to the skin, which becomes red, 
tender and stretched. Their sites are on the legs and forearms, but also on other parts rich in 
connective tissue. Rapid in evolution, they are usually slow to go away. They undergo absorp- 
tion, and do not commonly fall into ulcers. They may reach the size of a walnut, may be few or 
multiple, and are usually symmetrically placed. They are sometimes particularly sore to the touch. 
Large circumscribed subcutaneous tumors of the size of a walnut or of an apple are some- 
times caused by the iodide of potassium. They, like the preceding form, are not usually of great 
firmness, but can be indented by the pressure of the finger. They appear quite promptly, but 
subside slowly, running a rather painful but aphlegmasic course. They usually coexist with other 
lesions. Elevation of temperature is not uncommon at the onset of these graver forms of iodic 
eruption. 
T he prognosis of all forms of iodic eruption is good, since the morbid processes usually abate 
on the cessation of the use of the drug. In the more severe forms of dermatitis of iodic origin 
structural changes in the skin may be produced unless treatment is adopted. 
T reatment.-The first indication is to stop the use of the drug, if this is practicable. If the 
necessity for its continuance exists, it is well to administer with it full and increasing doses of arse- 
nic in any eligible form, since this agent has been known to control in some cases the tendency of 
the iodide to produce inflammation of the skin. The treatment of the papulo-pustular, urticarial, 
and bullous forms of iodic rash should, in the main, be that used for eczema, urticaria, and pem- 
phigus. The tuberous lesions need the stimulating and astringent action of perchloride of iron, 
tincture of iodine, and carbolic acid ; after this a zinc ointment may be applied. 
The petechial form of iodic intoxication is usually seen soon after the administration of 
the drug. It occurs mostly on the anterior aspects of the legs-not so often near the knees, but 
beginning just at or above the ankles-on the wrists, forearms, backs of hands, on the neck, and 
rather rarely upon the face. The eruption consists of pinkish or red spots, which scarcely fade on 
pressure, which are of miliary or lentil size, and even of quite large patches. These hemorrhagic 
spots are oval or round, until by fusion they become irregular and gyrate. As the eruption ages 
it becomes darker, remains in an indolent condition for weeks or months (particularly on the legs), 
turns brown, and then finally disappears. It is seen in the young, middle-aged, and in old subjects, 
in those who show no dyscrasia, and in those who are cachectic. It may be produced by a small or 
a large dose of the drug. BROMIDE ERUPTIONS. 
The eruptions due to the preparations of bromine resemble, in the main, those due to iodic 
intoxication, with the difference that the former are less likely to be as promptly and acutely 
inflammatory as the latter. 
Experience has shown that erythematous rashes may be produced by the bromides, but that 
papulo-pustular manifestations are by far the most constant. These lesions constitute the affection 
known as "bromine acne." 
The papulo-pustular lesions are found upon the face, neck, scalp, chest, back, and the thighs 
and legs, and less commonly on the arms. In fact, they are found on all regions rich in hair and 
sebaceous follicles, which are always the foci of the bromine inflammation. 
The papulo-pustules are of all sizes, even to that of nodules. They are of various shades of 
red or of purple, conical and obtuse, round or oval, and present at their apices a yellowish-white 
purulent fluid which has been described as smegma-like. These lesions are firm in consistence, 
and appear to be seated deeply in the skin. At their invasion there may be a sensation of burning 
and pruritus, but during their course they give rise to no symptoms beyond a mild sensation of 
soreness. They run an indolent course, show little tendency to break down into ulcers, subside 
and lose their crust-caps and their color slowly, and leave after them red spots or atrophic patches. 
In Fig. 2, Plate XLIX., is well shown a case of severe bromide-of-potassium eruption of not 
very common occurrence, which was treated by Jonathan Hutchinson, who gives the following 
account of the eruption : The sites of the eruption were the scalp, forearms, and legs, the majority 
of the lesions being near the hips and shoulders. The rash begins by the appearance of rounded 
prominent vesico-pustules, which are solitary, and also grouped like herpes. New lesions form at 
the margin of the affected territory. When the papulo-pustules have formed the pus secreted dries 
into crusts, and underneath the tissues become thickened and elevated, and of a dull pinkish-red 
color. A resemblance to condylomata may be noted. While some of these elevations were super- 
ficially ulcerated and gave issue to a moderate discharge, others became smooth and dry. As 
involution took place the color in the patches faded ; they lost their elevation and became simply 
brownish and scaly patches. 
The bromide preparations are prone to produce very troublesome acne in persons who are 
afflicted with that disease. It is often noted that patients may take small doses of the bromides 
with impunity, and only suffer from skin eruptions when the dose becomes large. Then, again, in 
some cases the bromide rashes appear soon after the commencement of the ingestion of the drug, 
and in others it may be taken for long periods before any skin lesion is produced. In somewhat 
exceptional cases the invasion of bromide rashes is sudden and rapid, though, as a rule, I think the 
reverse obtains. It is sometimes observed that the papulo-pustules of bromide intoxication become 
furuncular, and they may take on the features of carbuncles. Arsenic coadministered with the 
bromides often has the effect of preventing and of ameliorating bromide eruptions. 
343 SYCOSIS. 
Sycosis is an inflammatory affection of the hair follicles, most commonly of the face, beard, 
upper lip, and chin, attended with the presence of papulo-pustules and further advanced inflamma- 
tory conditions. It is also called non-parasitic sycosis in contradistinction to ringworm sycosis (see 
page 298), mentagra, and folliculitis barbae. A pathologically similar process may attack the hair- 
follicles of the neck, of the eyebrows, of the lids, of the nose, and of the pubes and axillae. 
Sycosis-or, as it is frequently called, simple sycosis-usually begins with the sensation of heat 
or itching upon a limited or extended surface of the beard, upon which a few or many papules or 
papulo-pustules soon form, in the centre of which a hair stands erect. This condition of the lesions 
being perforated or spitted by a hair is the essential one of this morbid process, since it always 
begins around or within the hair-follicles. A somewhat similar condition is seen in ringworm of 
the beard. The disease may begin in a scattered form or extend from one focus or from several. 
The papules and papulo-pustules of sycosis vary in size from a pinhead to a small French pea. 
They are conical or globose, sometimes flat, generally round, but sometimes oval in outline. They 
appear to be essentially inflammatory lesions, and in their early stages are of a pinkish-red, and 
later of varying shades of red hue. While in a given eruption there may be many true papules, 
it will be seen that the general tendency of the lesions is to become papulo-pustular. There is no 
rule whatever for the mode of development of this disease. In some cases a limited number of 
isolated lesions are present, more or less close together, in groups, or scattered irregularly over 
the beard. In others several large or small patches may be found scattered over the surface, 
which have been formed by the close packing together of individual lesions. In yet other cases, 
either as a result of acute or rapidly extensive invasion, or as the culmination of a slowly-increas- 
ing chronic process, the whole hairy part of the face may be the seat of this follicular inflammation. 
In short, we have every degree between a circumscribed and sparse and an extensive continuous 
eruption. With the increase of intensity of the morbid process, and particularly where the lesions 
are closely packed together, inflammatory changes take place in the connective tissue surrounding 
the hair-follicles and in the sebaceous glands. In this way large nodular masses or plaques are 
formed, which give the skin a dense feel and produce unsightly deformity. When, from lack of 
care, the pus of the lesions is allowed to dry, it forms crusts of small and large size of yellowish- 
green and brownish color, without any tendency to regularity of shape, which are scattered here 
and there without symmetry or order, the whole being accompanied by decided and even marked 
hyperaemia. These crusts may be thin or flat, or thick and rugose from the increased purulent 
collection being held in place by the hairs. To study the foregoing features in detail, it may be 
said that the few lesions on the neck in the figure of Plate L. show the isolated period of the 
lesion, which is further advanced on the right cheek. Down toward the chin we trace the acme 
of the disease in the encrusted spots, accompanied by hyperaemia, whereas on the chin itself a typ- 
ical picture of encrusted patches, covering considerable surface, is seen. In this way, though there 
is a multiformity of phases of inflammatory follicular lesions more or less indiscriminately blended 
together, the eruption presents to the eye a uniformity and symmetry of development and course 
which are both striking and characteristic. To digital examination the underlying oedematous and 
344 Part VII 
Plate L 
LEA BROTHERS & CO. PUBLISHERS , PHILADELPHIA. 
SYCOSIS. SYCOSIS. 
345 
more or less densely infiltrated condition of the skin is usually very well marked. In some cases 
a rugose, almost vegetating, surface may be produced by these superficial and deep inflammatory 
lesions. It was this feature, which is far from constant and only seen in severe cases, that led to the 
term "sycosis," it being thought that the appearances resembled the pulp of the fig. Abscesses 
and furuncles are occasional accidental concomitants. 
In simple sycosis the changes in the hairs are very well marked, and they show features of 
distinction from those of ringworm of the beard. The hair in the simple affection does not lose its 
lustre or shape. At first it adheres to the follicle quite firmly, and its evulsion causes acute pain. 
When examined it is found that the root-sheath has come away with it, and that the latter is of a 
dull-white color and considerably swollen. This being removed, the bulb of the hair will usually 
at this stage appear to be unaffected. As the inflammatory changes become more suppurative, the 
hair is less firmly held, and may be withdrawn with slight traction and with no discomfort to the 
patient. Later on, when the follicle becomes a minute abscess-cavity, the hair is spontaneously 
thrown out. 
Whatever may have been the mode of invasion, acute, subacute, or chronic, the course of 
sycosis is always slow, tedious, and of long duration. It is a disease fitful in its evolution, some- 
times progressing steadily, at others seemingly, but elusively, on the decline, and strikingly marked 
by exacerbations and remissions of greater or less severity and duration. Left untreated, it may 
disappear spontaneously, but more probably it will extend and become intensified. As it subsides 
the old lesions wither and pale, new ones cease to appear, the crusts fall, the skin becomes less red 
and thick and more supple, and the hairs become firmly fixed. In severe and persistent cases 
more or less hyperaemia, with a marked tendency to follicular congestion and inflammation, and 
with scaliness, remains. Indeed, even in mild cases the inflammatory sequelae are usually very 
annoying and recurrent. When the inflammation has been very suppurative, active, and chronic, 
the follicles are destroyed and alopecia is the result, which may be in spots or patches. In these 
severe cases cicatrices are not at all uncommon, and the unsightliness of the parts may be increased 
by the presence of keloidal nodules and tumors. 
Etiology.-The causes of sycosis are very obscure. It is seen in poorly nourished as well as 
in healthy subjects, in all grades of life, in those who shave and in those who do not. It is mostly 
seen in young adult subjects and in persons up to middle age. 
Jackson, in an interesting clinical study of sycosis, is led to think that patients whose occupa- 
tions compel them to live in close rooms filled with dust are especially liable to sycosis, and that 
the disease takes an especial hold on tailors. He is also disposed to regard a poor state of health 
and dyspepsia and constipation as possible etiological factors. Nasal catarrh is a cause in some 
cases of the affection on the upper lip. 
Pathology.-The inflammation begins in the perifollicular tissues, and from this focus invades 
the follicles and tissues around. 
Diagnosis.-In simple sycosis we do not find those large tubercular masses, scaly and fun- 
goid, which are seen in parasitic sycosis, nor are the hairs affected as in that disease. The clinical 
features of the two diseases may be clearly grasped by a study of the text descriptive of the two, 
and by an inspection of the plates, better even than can be given here in didactic form. The con- 
dition of the hair in a given doubtful case may be considered the crucial test, and if the parasite is 
absent and the integrity of the hair preserved, it is fair to assume that the affection is not of par- 
asitic origin. The large and small pustular syphilides may be mistaken for sycosis, but they are 
prone to occur all over the face, especially toward the middle line on the alae nasi, near the mouth, 
and at the margin of the scalp, which of itself is often attacked. Further, with the syphilides there 
is usually a history of infection and of present or past specific lesions. With a little care syphilis 
can always be excluded from the diagnosis. The appearances and course of eczema are so striking 346 
DISEASES OF THE SKIN. 
that it is only necessary to mention that occasional resemblances between it and sycosis exist which 
a little time and care will throw full light upon. 
Prognosis.-When seen early, proper treatment may promptly cure the disease. In chronic 
cases the outlook is rather unpleasant, particularly when there is a tendency for the disease to 
extend and become very suppurative. In some cases it seems much more persistent than others, 
and in all is prone to relapse. 
Treatment.-All conditions of impaired health should command our first attention. As 
internal remedies, when indicated, arsenic, Donovan's solution, alkaline preparations of iron and 
tonics may be of use. The sulphide of calcium may be mentioned in order to make the category 
as complete as possible. 
Local measures should be carefully and sedulously used. No rule can be laid down for the 
management of the hairs, for idiosyncrasy will have to determine whether they shall be shaved or 
clipped. One or two tentative efforts will soon indicate the procedure which will prove beneficial. 
The method of treatment is largely dependent upon the stage and condition of the eruption. 
In the acute inflammatory condition frequent soppings of the part with mild alkaline very hot water 
will be very beneficial, as recommended in Acne (at the same time cathartics and alkaline aperients 
may be given). Then zinc ointment, Lassar's paste, lead ointment or diachylon ointment may be 
applied, to any of which small and proper quantities of carbolic acid, thymol, or camphor may be 
added to relieve heat and pruritus. All pustules should be opened, and if possible these cavities 
should be touched with carbolic acid and glycerin (3ss-Loose hairs should be removed, and 
tentative efforts should be made at epilation generally, and, if relief is produced, the process should 
be repeated until all diseased hairs are removed. Very often a calomel ointment (oj-5j) will prove 
very beneficial, and I recall several cases in which a black-oxide-of-mercury ointment produced 
exceedingly rapid results. As the inflammation subsides, zinc ointment with corrosive sublimate 
(sj-to gr. i to 2) may be used. In the chronic stages a lotion of corrosive sublimate (one or two 
grains to the ounce of liquid) may be of decided benefit. 
In every case and in all stages thorough washing of the face with solutions of carbolic acid or 
corrosive sublimate, in strengths capable of being borne upon the skin without decided irritation, 
should be employed-not once, but several times a day in bad cases, and for considerable periods. 
This antiseptic treatment, though only adjuvant, is of great benefit. 
Scraping of the skin is indicated in those cases in which there are epidermal and papillary 
elevations. It should be done with care and gentleness, and may be made less painful with the aid 
of a strong solution of cocaine previously painted upon the parts. 
When there is much thickening and the inflammation is on the wane, the following ointments 
may be used : 
R. Ung. hyd. fort., gij; 
Ol. rusci, 3j ; 
Ung. diachyli, 5). M. 
R. Oleate mercury, 5j+5'jj 
Ung. zinci oxid., gj; 
Acid, carbol., gtt. xvj. M. 
R. Ung. zinci oxid., 
Ung. diachyli, ad. ; 
Bals. Peru., M. 
Boracic acid, resorcin in ointment form, are sometimes of great value and should be remembered. 
In all cases the ointments should be kept in perfect apposition for as long a time daily as possible. MOLLUSCUM SEBACEUM. 
This disease, also called molluscum contagiosum and m. epitheliale, is seen mostly in infants 
and young children of both sexes. It consists of tumors varying in size between a pinhead and a 
pea, and they may even be somewhat larger. These tumors rise abruptly from the skin in a ses- 
sile and a pedunculated form, and present a globular shape, the summit of which, when they are 
fully developed, is flattened, and in the centre of this a little dot-like depression filled with dirt is 
to be seen. In the very small tumors no depression or umbilication is present, but as they grow 
older this feature becomes more and more pronounced. There are cases reported in literature of 
what are called gigantic molluscum sebaceum, which are in all probability instances of molluscum 
fibrosum. The tumors of molluscum sebaceum present a variety of appearances of color. Some- 
times they do not differ in any way from the hue of the skin ; then again they may present a pearly 
appearance ; very often they look like little masses ol white wax ; and in some cases they may be 
of a pink or even reddish color. In structure they are comparatively firm and resistant, but when 
decided pressure is made a milky fluid or a sebaceous-looking, sinuous, worm-like mass may be 
seen to pass through the hole in the central depression. 
When there are many of these tumors on a portion of the body, they convey to the fingers 
passed over them a soft but moderately firm sensation which is very peculiar. 
Molluscum sebaceum is found on the face, forehead, eyelids, cheeks, nose, chin, neck, body 
anteriorly and posteriorly, breast, on the genitals, particularly of the male, and on the scalp. 
There may be few or many lesions, and they may be limited to one region, such as the face 
and breast, or to the penis. In Fig. i, Plate LI., the appearances of the disease upon the face are 
well shown. Here the lesions are of all sizes, from the minute elevations which are its first evi- 
dences, as seen about the nose and upper lip, to the large pea-sized tumors in the vicinity of the 
eyes and on the neck. In this picture the full clinical history of the affection is well shown, except 
that the tint of the tumors is quite uniformly pinkish. The flattened summits of the little globes, 
with their depressed dot-like centres, are noticeable. It will be seen that the tendency of the dis- 
ease is to an isolated distribution, but that the tumors grow near each other. In Fig. 2 a more 
copious development of tumors is shown upon the penis and scrotum, and it will be seen that these 
little bodies are quite closely packed, so that in some points they have coalesced. In this picture 
the various sizes of the tumors are well shown. In Fig. 3 we find a quite large tumor, which, as is 
very often the case, has flattened out more than usual. Near it are other smaller tumors. When 
the tumor thus becomes somewhat flat, if of a pearly color, it resembles, as Hutchinson suggested, 
little pearl buttons. In this scattered and grouped manner we find the disease usually, but in some 
cases it may involve large surfaces. I have seen a case in which the anterior and posterior parts 
of the trunk were covered with these little tumors, numbering, it was thought, fully eight hundred. 
Though the eruption may be thus extensive, it has not been seen to cover the whole body. 
The development of molluscum sebaceum is usually slow and rarely rapid. A few, or several, 
or many tumors appear, and when they are more or less grown new crops develop in their neigh- 
borhood or elsewhere. They are attended with no subjective symptoms whatever, and throughout 
their course they are painless unless artificially inflamed. When irritated they may become red, 
347 348 
DISEASES OF THE SKIN. 
painful, and the seat of suppuration, and their contents may as a result be extruded, leaving an 
epidermal shell. They may, however, undergo natural involution, and finally leave no trace of 
their existence. 
Etiology.-Nothing is known of the causes of molluscum sebaceum, nor does the health of 
the patients in general offer any basis for hypothesis. The dermatological world is to-day in a state 
of doubt as to its contagious nature, with a preponderance in favor of the non-contagionists. In 
literature many plausible cases are given which go to support the idea of contagion, but they are 
offset with so many negative facts that it is the part of prudence to as yet suspend judgment. 
Pathology.-This is in a far from settled state, and in a clinical atlas it would be but a waste 
of time to present the divergent views as to the points of origin and nature of the new growth in 
the tumors. 
Diagnosis.-If the reader will carry in his mind the appearances presented in Plate LI., it is 
hardly possible for him to fail to recognize molluscum sebaceum, since it stands alone in its clinical 
features. Should he, however, be given to delving into the mysteries of dermatological microscopy 
-the so-called scientific dermatology-he may perhaps hunt successfully for the " molluscous cor- 
puscles " which are described and figured in my friend Hyde's excellent treatise on Diseases of the 
Skin, page 371. 
Prognosis.-When limited in numbers molluscous tumors are readily removed. When they 
may be counted by the hundred they offer a formidable task, and the outcome depends upon the 
physician's zeal and the patient's endurance. Spontaneous absorption may take place. 
Treatment.-The most efficacious means of destroying small tumors is by the use of some 
well-adapted form of thermo-cautery, using such an instrument as will only touch the growth, and 
being careful not to burn too deeply. The objection to this method is the fright which the patient 
experiences. Large tumors may be freely incised and their contents extruded by pressure between 
the thumb-nails. After any destructive or expulsive process it is well to touch the parts with car- 
bolic acid and glycerin (3ss-3j), to dust them with iodoform, and to cover them with simple gauze, 
which should be well retained. Part VII 
Plate LI 
■ • 
LEA BROTHERS & CO. PUB LISHERS , PHILADELPHIA 
MOLLUSCUM SEBACEUM 
1. of' Face . 2. of Penis . 3. of Breast, ICHTHYOSIS. 
Ichthyosis, also called "fish-skin disease." is a chronic thickening of the skin, congenital or 
hereditary, attended by scaliness and dryness.1 The most simple and rational division of this dis- 
ease is that which makes three forms-namely, dry skin, or xeroderma (this term, however, if used, 
should not be confounded with the disease known as xeroderma pigmentosum), ichthyosis simplex, 
and ichthyosis hystrix. Though in some of their clinical features these affections seem to differ 
from one another, they are all due to the same morbid process, and they may be seen to merge 
insensibly into each other. In the simplest form of cases there is merely a little excess of epithelial 
development; in the second, medium class of cases, there is very marked epidermal increase, with 
more or less hypertrophy of the papillary layer; while in the third class, ichthyosis hystrix, there is ex- 
uberant increase of the epidermal elements, combined with marked hypertrophy of the papillary layer. 
Ichthyosis is rarely seen at birth, but appears within a few months, and even years, after it. 
In some cases the disease is distinctly hereditary ; in others it seems to be an acquired state. Rare 
cases, however, have been reported of the intra-uterine development of ichthyosis, of which the 
one described by Caspary2 is a notable instance. Stillborn or full-term children are somewhat 
uncommonly seen in which the epidermis is enormously hypertrophied, reaching in some cases fully 
half an inch in thickness in some parts. Such children, however, are hideous monsters, and are 
either dead at birth or they die soon after. Ichthyosis is due to abnormal conditions inherent 
in the skin itself, and is not the expression of any systemic morbid state. 
1 Many years ago a remarkable case of ichthyosis was exhibited throughout the country as the " man-fish of Tennessee." The 
late Dr. L. P. Yandell gave of it the following graphic description, which is so clear and admirable that it should be preserved : Dr. 
Yandell says : "Among others I visited the merman, but before seeing the case I had diagnosed it as one of ichthyosis, and a single 
glance was sufficient to verify the correctness of my conjecture. The man-fish presents a most magnificent example of the form of 
ichthyosis, or fish-skin disease, called ichthyosis serpentina, or serpent-skin; and his general effect is more that of a serpent than of 
a fish. But upon different parts of his body may be found nearly all the varieties of ichthyosis. The resemblance of this man's skin 
to the shed skin of a boa-constrictor lately brought me by a friend from the Zoological Garden in London is almost perfect. About 
his joints the skin is loose and wrinkled, hanging in folds, and the scales are large, suggesting the skin of a lizard or alligator about 
the limbs and belly. His arms and legs remind one of the skin of the buffalo-perch, the carp, or other large fish. The cuticle every- 
where is dry and harsh and never perspires. There seems to be an absolute absence of fat, and the man is shrunken and withered, 
of a dead ashen-gray appearance, except here and there, where he is brownish or blackish. Though only about fifty years of age, he 
impresses one as a very old man. The skin of the face is red and shining, and tightly drawn about the cheeks, pulling the lower lids 
down to such an extent as to perfectly evert them, making a horrid case of ectropion. In some places his scales are silvery, in others 
dark, and again in others are small and branny. His hair is very thin and dead-looking. The backs of his hands are fissured, and 
on his palms and soles the cuticle is greatly thickened. The fingers and toes seem shorter than natural, and the skin is drawn tightly 
back over both feet and hands. The septum between the fingers and toes seems to extend much farther down than usual, thus sug- 
gesting the webbed appearance before alluded to. He is considerably over six feet in height, and is a man of a low order of intelli- 
gence. He is married and is the father of several children, none of whom, fortunately, inherit his malady, and as ichthyosis is almost 
if not always a congenital disease, they are not likely ever to have it. The fish-man fails to present but a single variety of ichthyosis, 
and that is the porcupine disease, as it is called. In this, spines formed by hardened sebaceous material protrude from the skin, closely 
packed together. Wilson states that he has observed them a quarter of an inch long. Willan reports having encountered them of an 
inch in length. I have never seen them longer than an eighth of an inch. Many years ago two brothers in England having this 
form of ichthyosis were exhibited in the shows as porcupine-men." 
2 "Ueber Ichthyosis fcetalis," Vierteljahresschrift fur Denn, und Syphilis, vol. xviii., 1886, p. 3. 
349 350 
DISEASES OE THE SKIN. 
The development of ichthyosis is usually slow and insidious. I he child commonly shows no 
deviation from the health standard, but when it is a few months old or later on it is observed that 
the apices of its elbows and knees are rough and scaly. This condition may be so slight that it 
does not attract attention, but in general it slowly and steadily increases. In some cases the thick- 
ening of the epidermis begins elsewhere in more or less extensive patches. From these foci the 
dry, scaly condition extends, usually at first on the exterior surfaces, where in mild cases it may be 
confined, or it may go on increasing and involve nearly all portions of the body. It may remain in 
a mild and insignificant condition for months or even years, and then increase in intensity until its 
maximum is reached, which it usually retains with varying exacerba- 
tions and remissions during life. All cases of ichthyosis are better in 
warm than in cold weather, but improvement during the summer is 
always elusive, since in winter the disease becomes as bad as ever. 
During the course of grave systemic diseases ichthyosis has been 
noted to become much improved, but at convalescence it becomes 
bad again. As a rule, ichthyotic patients enjoy good health, and only 
complain of mild pruritus in uncomplicated cases. 
Dry Skin .-This condition exists in many phases. The skin is 
rather rough, dry, and moderately scaly. It has a dull color, and is 
traversed in all directions by the deepened natural furrows, large 
and small. In more severe cases the skin is rougher, very dry, even 
harsh to the touch, decidedly scaly (branny desquamation), and the fur- 
rows are deeper. In this state the skin may be nearly normal on some 
parts, such as the face and in the soft internal flexures of the joints, 
or it may be harsh and dry over the whole body; but in these cases the 
ichthyotic condition is accentuated on the prominences of the elbows 
and knees and on the extensor surfaces. In such patients the sweat 
is either wholly absent or very scanty in quantity, and the sebaceous 
secretion is similarly diminished. It is sometimes seen to form in plates 
and wavy elevations. The hair of the whole body is thinned, scaly, dull, 
lustreless, and brittle, and the nails are in bad cases dry, striated, lam- 
inated, thickened, and readily broken. As a rule, the hair and nails are 
affected in proportion to the severity of the general epidermal disease. 
Ichthyosis Simplex.-This form of ichthyosis may be considered 
as the acme of the disease, since its further stages are but excep- 
tional exaggerations of it. It begins in the same post-natal and 
insidious manner as "dry skin," and runs a similar course. It pre- 
sents very striking objective features. In wood-cut Fig. 58 universal 
ichthyosis simplex is shown in a woman who was many years ago a 
patient at Charity Hospital. The thickening of the epidermis is quite well shown to be in a mod- 
erate degree of development, and the expanses of tissue are seen to be broken up into patches of 
varying sizes and shapes. The hand passed over any portion of the body encountered a harsh, 
dry sensation, and brisk friction brought forth numerous scales. So rough was this woman's skin 
that she had great difficulty in keeping it clean, for it, as in all cases of ichthyosis, offered a 
favorable nidus for dust and dirt. Over the whole body very few hairs could be seen, and in the 
axillae and on the pubes they were absent. She scarcely knew what perspiration was, but very 
often picked off plates of sebaceous and epithelial matter. This case may very well be taken as 
Fig. 58. 
Ichthyosis Simplex, generalized. ICHTHYOSIS. 
35i 
a type of the mild form of simple ichthyosis, and a marked contrast will be seen between it and 
the advanced form portrayed in wood-cuts Figs. 59 and 60, which represent a personal case of a 
young girl of twelve years, who had the disease from the second year of life. In this condition 
the human skin presents re- 
semblances to the scaly coats 
of fish and to the hide of alli- 
gators. The Integument is 
uniformly thickened and scaly, 
rough, even rugose, to the 
touch, and of various colors 
of gray, greenish-brown, and 
brownish-black from dirt ad- 
mixture. Very often it is 
of a white, even of a pearly 
shining, hue. In some cases 
a greater or less degree of 
pigmentation takes place in the 
rete, which gives the patches 
a dark-brownish color. The 
scales thrown off are both 
branny and in the form of 
plates. An expanse of skin 
is seen to be divided up by 
quite deep furrows, longitudi- 
nal, oblique, transverse, spiral, and irregular, according to the natural lines of the parts and to 
their conformation-into mildly furrowed and corrugated patches which are of the most varied 
shapes, such as diamond, angular, polygonal, square, 
ovoid, polyhedral, like a parellelogram, and in a tes- 
sellated form ; all of which are shown in wood-cuts 
Figs. 59 and 60. Skin in such condition is harsh and 
inelastic. At the joints its rigidity of structure impairs 
motion more or less, and upon the fingers and hands 
and toes fissures or chaps are often formed which 
cause much pain and interfere with prehension and 
motion. On the face this condition causes much de- 
formity, gives rise to rigidity about the eyes, nose, 
and mouth, and in some cases causes ectropion. In 
very many cases the genitals of both sexes are spared 
the intensity of the disease. 
The palms and soles are dry, traversed by deeper 
furrows than normal, and show evidence of moderate 
thickening of the epidermal layers in most cases. In 
this form the hairs and nails are always more or less 
thickened and abnormal. While friction will loosen 
many large and small scales, removal (with some 
force) of the epidermic plates produces bleeding 
and pain and exposes a raw surface. 
There is no concomitant affection of the mucous membranes in ichthyosis. 
Fig. 59. 
Ichthyosis Simplex of Arms. 
Fig. 6o. 
Ichthyosis Simplex of Legs. 352 
DISEASES OF THE SKIN. 
In this second form of ichthyosis we find the same peculiarities that we do in the first. Thus 
in some cases the disease, which is always symmetrically developed, is limited to certain portions 
of the body, notably the elbows and knees and contiguous extensor surfaces. In very rare cases 
an ichthyotic condition is found on the upper, and not on the lower, extremities, and the reverse 
sometimes obtains. 
The older dermatologists have left us a liberal heritage of descriptive Latin terms applicable 
to phases of this affection, which there is no harm in remembering if too much effort is not required. 
Thus, the name ichthyosis scutellata is given to the affection when the edges of the patches are 
somewhat detached and the appearance of a depressed centre is shown. Ichthyosis nacree or 
nitida designates shining and transparent patches, /. serpentina when they have the green tint 
of the serpent's skin, I. sauroderma when they look like alligator or crocodile hide, and /. nigricans 
when they are of a dark-green or black color. 
Ichthyosis Hystrix.-This form of ichthyosis, which is very rare, is so called because the epi- 
dermal hypertrophy forms in the shape of little or large prominent warts, large warty knobs or 
patches, or in the shape of spines, something like the quills of a porcupine, hence the term " por- 
cupine disease." The horny growths vary according to the natural peculiarities of the parts on 
which they form. The distribution of these lesions is never general over the body, though a large 
extent of surface, such as the whole trunk, may be invaded. They also occur on the arms in front 
of the axillae, on the neck, at the umbilicus, and on the legs. It is not uncommon to find the fea- 
tures of the mild forms of ichthyosis coexist with this form. The lesions vary in size and shape. 
They may be of pinhead or millet-seed size, conical or globose, or even pedunculated from the 
presence of a bulbous enlargement at their summits. Again, they may be an inch or less in 
length. These horny growths cause inconvenience to their bearer in proportion as they occur 
on parts subject to active motion and pressure. 
Ichthyotic Patches over the Course of Nerves.-We quite often see patches of epidermal 
hypertrophy, more or less pigmented, with or without the evidence of papillary increase, in the course 
of one or more nerves. Their appearances are certainly those of localized ichthyosis, though, 
according to my reading, some authors describe them under the name ncevus uniits lateris, on 
account of their congenital nature and of their very common unilateral situation. I have seen 
them on the arm, forearm, and running into the palms, also along the sides of the chest-walls and 
abdomen in the course of the intercostal and abdominal nerves. According to my reading and 
observation, they are found in two forms : the first, in which they are unaccompanied by any mor- 
bid sensory disturbance, and are seemingly purely epithelial in origin ; and the second, in which 
the papillomatous condition is also well marked, and in the course of which various forms of mild 
and severe sensory disturbances, even to persistent pruritus and neuralgia, are complications. 
Further than this, we see still more advanced cases in which there is hyperplasia of the deep 
tissues, in which the morbid conditions belong to the intricate group of connective-tissue new 
growths. It is needless to say that these varied forms merge insensibly into each other. Under 
the title "congenital neuropathic papilloma" G. E. Wherry1 has described an interesting case in 
which these epidermo-papillary bands extended on the back of the right wrist and upper part of 
the metacarpus ; in the course of the external branch of the external radial nerve ; on the hypo- 
gastrium a little above the external abdominal ring, labium majus, and mons Veneris ; and on the 
inner surface of the right thigh. Caustic applications and section of the various nerves failed to 
produce relief of the itching. 
Pathology.-The morbid changes are those of structural increase, and they vary with the 
1 Practitioner, May, 1889, pp. 357 et seq. ICHTHYOSIS. 
353 
extent of the disease. In the first class of cases the epidermal layers are much thickened, and in 
the severer forms the papillae are also much increased in size. 
Etiology.-We know nothing of the causation of ichthyosis. It is sometimes seen in several 
children of healthy parents, and again one among a number may be affected. Maternal influences 
have been reputed to be causative, but nothing precise in fact or theory has been advanced on the 
subject. By some authors all forms of ichthyosis are looked upon as deformities, to be regarded in 
the same category with naevus and all kinds of congenital blemishes. 
Diagnosis.-So well marked are the features of ichthyosis, and so constant is the history of 
its early insidious development, that a mistake in diagnosis is scarcely conceivable. It must be 
remembered that varied appearances of scaling are offered in the declining stages of the acute 
and chronic inflammatory diseases, and that they may present points of resemblance to ichthyosis. 
Treatment.-This is at best of unsatisfactory effect. Local remedies alone are of value, and 
they only as palliatives. Baths of all kinds, particularly if an alkali is added, are beneficial. 
Inunction of all greasy substances, glycerin-and-soap inunctions, followed by baths and greasy 
applications, may be of benefit. In the treatment of these cases the physician has ample latitude 
to try all kinds of oils and ointment combinations, but his experience will force upon him the con- 
viction that man is but a humble agent for good in cases of congenital epidermal hypertrophy. LEPROSY: LEPRA GRAZCORUM. 
Leprosy is a chronic contagious disease originating in a definite parasite, affecting the whole 
organism and attended with new growths in the skin and mucous membranes, in the connective- 
tissue elements of the nervous system, and in the lymphatic system and viscera. It is a disease 
attended with marked, even hideous, deformities, with painful and unsightly mutilations, with all 
grades of sensory disturbances, and, after a more or less long period of uncertain course, inevita- 
bly leads to death, either by the marasmus which it causes or by the intercurrent diseases to which 
it gives a predisposition. In many of its features and in certain peculiarities of its course it pre- 
sents strong points of resemblance to syphilis, but it mainly differs from the latter disease in the 
fact that it does not seem to have the definite origin in an initial lesion which syphilis has, nor is it 
curable as that disease is. Both of these diseases, however, belong to the order of infective gran- 
ulomas, and their morbid processes are alike subacutely inflammatory, with a preponderance in 
favor of leprosy of acute intercurrent inflammatory conditions. Whereas in leprosy the nature 
and life-history of its causative bacillus are well established, the microbian origin of syphilis is yet 
far from being demonstrated. 
In olden times leprosy was introduced into various regions from India, China, and other 
Eastern countries through the channels of trade and colonization, and also through the agency of 
large armies. To-day it is to be found in Japan, China, India, Africa, along the Mediterranean 
coasts, in Spain, Portugal, Norway, Russia, Mauritius, Mexico, South and Central America, the 
Sandwich Islands, California, Minnesota, Iowa, Wisconsin, South Carolina, Louisiana, and Canada. 
It was at one time largely endemic in Great Britain, but was stamped out there by a systematic 
enforcement of segregation of the leper subjects. 
Those who have studied leprosy carefully and on the largest scale are united in dividing the 
disease into three principal forms, which, however, may merge into one another and are in the 
main interchangeable. These are-macular leprosy, tubercular or tuberculated leprosy, and anaes- 
thetic leprosy. 
Macular Leprosy.-In this, as in all the forms, there is to be quite constantly observed an 
order of systemic phenomena which goes to prove the general constitutional character of the disease. 
There is no uniformity in the severity or mildness of any of the symptoms, nor is there an absolute 
constancy of any symptom. In fact, there is no tendency to uniformity of course in the premon- 
itory stage of the disease. The first morbid symptoms, which would not cause suspicion in a region 
where leprosy was not endemic, are those of lassitude and depression, mental and physical, which 
cannot be referred to any particular lesion or systemic condition. Very soon a more or less pro- 
nounced fever of the intermittent and remittent type is observed. This fever may be mild or quite 
severe. Very often chilliness is complained of. These symptoms may last for a time, seemingly 
depart, and return at a longer or shorter interval. There are also nausea and want of appetite, and 
varied forms of circulatory disturbances. These premonitory symptoms may last several or many 
months, or two or three years, before the dermal effects of the disease show themselves. The first 
manifestations upon the skin are usually in the form of localized congestions. Thus, the face may 
354 Dart VI 
LEPROSY 
/. .\f lk' 111 li r Leprosy. 2. 7711) (' ic ■ i11 <■ i r I.('] ) / 'o .s'\\ 
LEA & CO: PUBLISHERS. PHILADELPHIA 
Fit.2. 
Plate LI LEPROSY: LEPRA GRALCORUM. 
355 
be the seat of flushes and of congestion, together with more or less oedema, or red patches may 
appear on the body which may be pink or all stages of red up to a tint of port-wine hue, and 
sometimes resembling purpura. These erythematous patches may be both large and small in 
size. The small erythematous patches are usually round, oval, or irregular, varying from a five- 
cent nickel piece to the palm in size. In some cases they are slightly raised, but at their margins 
there is usually a little elevation which tends to extend, and coincidently the centre of the patches 
may become slightly depressed. Being usually of a frank inflammatory hue at first, they soon 
become of a sombre tint, and in their course assume grayish-brown, yellowish-brown, reddish- 
brown, bronze, and purple colors. 
In some cases, particularly in large patches, a tendency to blanch in the centre is observed, 
which may thus convert them into a uniform whitish surface or produce a promiscuous mottling of 
reddish brown and white. In many patches a smooth, shiny, even glistening, surface is to be seen. 
As the erythematous process thus gives way to pigmentation of the skin, the epidermis becomes 
much affected, and presents a scaly, shrivelled, withered look. The hairs on the affected area lose 
their lustre, become thin and white, and fall out. The sebaceous secretion may be increased or 
wholly absent. This group of erythema and pigmentation, usually complicated by oedematous 
swelling, followed by blanching of the skin, may be reproduced several times at irregular intervals 
in the early period of leprosy, which Danielssen calls the " periodically eruptive stage." In this 
early period pressure upon the patches causes their momentary disappearance, but as the disease 
increases and we reach the "permanently eruptive stage," the pigmentations are not thus affected. 
In the full development of macular leprosy we may find a uniform dark reddish-brown or 
brown pigmentation, in large or small patches, all over the body, and very constantly on the face ; 
or we may observe a conglomeration of whitish, shrivelled, atrophic patches indiscriminately min- 
gled with pigmented ones, the whole being in striking contrast with the healthy skin. In Fig. I, 
Plate LIL, macular leprosy is well shown in the form of a large facial patch and of many small ones 
scattered over the body. In this period of development there is usually more or less, and some- 
times even severe, hyperaesthesia in the affected areas, which may also be the seat of heat and 
itching. As the acuteness of the process subsides and pigmentation and atrophy begin, anaes- 
thesia gradually develops until perhaps all tactile sensibility is lost. 
The foregoing is in the main a correct clinical picture of macular leprosy, but it should be 
emphasized that, though there is a large group of cases which come under this designation in their 
conformity to the type-form, very many other cases are of a mixed type and present the features 
of the tuberculated and anaesthetic varieties in greater or less combination with those of the mac- 
ular variety. All forms of leprosy, therefore, may be said to run into each other, so that in most 
cases we assign a given case to a particular variety owing to the preponderance of its typical 
lesions or to peculiarities in its course. 
Tuberculated Leprosy {Lepra tuberosa}.-The same order of prodromal phenomena, and 
the same inconstant and irregular evolution, as are found in the macular form are peculiar to the 
tubercular variety of leprosy. In this type of the disease the most striking and always constant 
manifestation is the development of cutaneous tubercles, which may be of the size of a bean or 
of a walnut, or it may exist in the shape of diffuse nodules or even large patches. These leprosy- 
tubercles may not elevate the skin markedly ; they may be moderately salient or they may stand 
out in a boss-like manner. They are firm and dense in structure, often complicated with marked 
oedema, and are of various shades of red, reddish brown, and greenish black. They are always 
symmetrically developed, and while in their early stages they may present round, oval, linear, 
angular, serpentine shapes, and seem to be quite well circumscribed, as they grow older they lose 
all form, merge into one another, adapt themselves to the tissue arrangements of the parts on 356 
DISEASES OF THE SKIN. 
which they are found, and become seamed by deep clefts which are the exaggerated natural furrows 
of the skin. It is this diffuse thickening of large areas of skin in the disease that warrants the term 
" tuberculated " rather than "tubercular" leprosy. In the disease all the layers of the skin are 
involved as well as the subcutaneous tissues. 
The most marked appearances of tuberculated leprosy are seen upon the face. The tubercles 
and tubercular plaques are here large and diffuse, and small, more or less prominent, of varying 
colors, the basis of which is a brownish red, and which may be even pink in some cases and pur- 
plish brown in others. The forehead is usually much infiltrated, and the greatly thickened skin is 
traversed by deep and shallow exaggerated surface-furrows, transverse and vertical. The appear- 
ances are accentuated and rendered leonine (the so-called leontiasis) by the diffuse increase in the 
thickness of the cushions of fatty tissue which exist ridge-like under the eyebrows. In all cases 
the alae nasi and the cheeks are more or less studded with tubercles and distorted, and the upper 
and lower lips are usually swollen, in many instances to the extent of jutting out in a horizontal 
manner. The chin likewise is very much deformed, often appears by hypertrophy to be double, 
and is frequently the seat of tabulated swellings. The skin over the malar bones is usually 
involved. A fairly average but characteristic picture of tubercular leprosy of the face is given in 
Fig. 2, Plate LIL, which will convey to the mind the appearances better than a representation of 
the most advanced condition would. The result of this tubercular leprosic thickening of the skin 
of the face is to cause more or less hideous deformity and to give various expressions to the suf- 
ferer, such as sullenness, imbecility, and dulness, stupidity, moroseness, and fierceness. Very 
often the unsightliness of the picture is enhanced by the loss of the nasal bones, which causes the 
much-thickened nose to sink down. The hideousness of the patient often does not end here : the 
eyes become blear and the cornea opaque ; the ears become enlarged and tabulated, so that they 
hang down to, or nearly to, the shoulders ; and the neck becomes distorted by swelling of the lym- 
phatic ganglia. Ulceration of limited or great extent may occur in any of the new growths. If to 
this horrible picture there is added leprous infiltration into the mouth, tongue, and upper air-pas- 
sages, as so commonly occurs, and if there is coexisting paralysis of some of the facial muscles, 
the acme of the distortion will be complete, and it will be seen that leprosy takes first rank among 
all diseases in the production of hideous deformities of the human face. In these bad cases noth- 
ing can be more deplorable than the patient's condition. The affection of the mouth and lips im- 
pairs phonation and renders eating and drinking most difficult and distressing. The swelling of 
the mucous membrane of the nose renders breathing labored and whistling ; the infiltrations into the 
larynx cause the voice to be harsh and raucous, even to be wholly lost. 
The changes in the eyes are seen mostly in the conjunctiva and cornea, but they go still 
deeper and destroy the whole organ. 
The next most mutilating lesions of leprosy of the tubercular variety are those of the hands. 
The fingers become swollen and distorted and the whole hand a mass of tabulated tubercles. As 
a result, the usefulness of these members is destroyed. In similar manner may the feet be attacked. 
Elsewhere on the body and on the extremities the leprous nodules and plaques form in greater or 
less extent, sometimes scattered, sometimes localized and crowded together. Like the lesions of 
the face and hands, they are of different sizes, shapes, elevations, and vary from each other very 
often in color and in the fact that some ulcerate and others do not. 
The course of this form of leprosy, of the macular variety, and of the forms resulting from a 
mingling of the two kinds, is essentially slow and without any chronological order. The infiltra- 
tions usually develop slowly and with or without hyperaesthesia and burning sensations. Sometimes 
their onset is sudden and their formation rapid. Whatever may be their mode of evolution, their 
subsequent course is always chronic and indolent. Having reached their development, the tuber- 
cles and nodules may remain for months and years without any perceptible change. Then, again, LEPROSY: LEPRA 
357 
we may see more or less absorption and involution occur in a few or many of them. As in the 
macular, so in the tuberculated form, exacerbations of the disease are usually ushered in by a fever 
which may be severe or mild, cyclical or continuous. A severe erythema, localized or diffuse, 
presenting many points of resemblance to erysipelas, usually precedes the formation of new nod- 
ules, and following this hyperaemic state some or many of the nodular lesions may undergo absorp- 
tion and more or less disappear. When they are wholly absorbed, they leave pigmented or pig- 
mentless patches, usually anaesthetic and covered with a scaly, wrinkled, and crumpled epidermis. 
Ulcerations of all degrees and extent are very common and often horrible. They lay bare and 
destroy the bones and penetrate and destroy the joints. In the tuberculated as in the macular 
variety we commonly see periods of activity or of intermission and remission, which are usually of 
quite long duration (months or years). 
During the early periods of leprosy there is very little, and perhaps no, disturbance of the 
health. The bodily functions are well performed and mental activity is unimpaired. As years roll 
on, however, slowly and surely, but sometimes rapidly, the patients show signs of breaking down, 
either from the interference of the disease with the respiratory or digestive functions, from the 
progressive marasmus, or from some intercurrent cerebral, pulmonary, renal, or hepatic complica- 
tion, or from some adynamic febrile condition. 
Anaesthetic Leprosy {Lepra nervorum}.-This form of the disease may show itself with little 
or no appreciable or visible change in the skin, and it may be a concomitant condition of the mac- 
ular and of the tubercular types. In it we find the most varied symptoms of sensory disturbance 
in the skin, the most severe trophic lesions, as well as various paralyses of motion. Besides these, 
during its course there are recurrences of bullous lesions, which, though not peculiar to it alone, 
occur much more commonly than in the other forms. 
There may be a distinct premonitory stage in the anaesthetic as well as in the other forms of 
leprosy. The most noticeable and common symptoms of the early and perhaps prodromal stage are 
those of hyperaesthesia, which may be simply an excessive sensitiveness, feeling of heat and cold, 
of formication, neuralgias, and pains of all descriptions, burning, lancinating, pricking, shooting, 
throbbing, etc. In addition there may be more or less jerking of the muscles. The integument of 
the hands and face, of the trunk and extremities, and, in fact, of the whole body, of the bands, in the 
form of stripes, broad, and narrow and small patches, and even spots, may thus be affected. Thus 
normal and diseased areas are intermingled without the slightest order or symmetry. These condi- 
tions may be accompanied by no visible change, or the morbid areas may become red and oedema- 
tous, and even of darker hue. This state of hyperaesthesia, peculiar to early stages of the dis- 
ease, may last for varying periods of several months or more than a year, and it then gradually 
declines until a condition of anaesthesia is left which is permanent. In the hyperaesthetic stage 
bullae appear on the face, arms, trunk, or elsewhere on the body. They come singly or in numbers, 
scattered or grouped together. They show no orderly evolution, and may disappear and reappear 
on the same spot. By this bullous process more or less of the whole body may be invaded, d hese 
lesions may leave excoriations and ulcerations of much severity, or they may heal and leave pig- 
mented or whitish spots, which are usually devoid of sensation. The morbid areas which have 
been the seat of bullae and those which have not show a tendency to enlarge and coalesce, and thus 
large surfaces of the body are invaded. Besides the pigmentations and permanent blanchings of 
the skin, we find more or less atrophy with concomitant change in the epithelium. The combination 
of lesions then presents a variegated, sometimes piebald, picture. 
The trophic lesions of anaesthetic leprosy are, for obvious reasons, most striking upon the face, 
hands, and feet. Upon the face the whitened and atrophic patches are often accompanied with motor 
paralyses of greater or less number, and deformities of the most varied character are produced. 35& 
DISEASES OF THE SKIN. 
The hands are always deformed to a greater or less degree. In some mild cases there is sim- 
ply atrophy of the skin, which may be stretched and glossy, but there is always degeneration of the 
interossei muscles, which, with the contraction of the tendons, gives the hands a claw-like look, called 
by the French main en griffe. In severe cases those mutilations occur which have given rise to the 
name " lepra mutilans." The ends of the anaesthetic fingers become sore and ulcerated ; the bones 
become diseased and are extruded in whole or in part. Very often the nail is left intact, and when 
a whole phalanx has been lost the soft parts so shrink and adapt themselves that the nail becomes 
seated on the second or even the third phalanx. The stumps become pointed or club-shaped. By 
this gradual and usually irregular destruction all of the fingers of a hand may be destroyed, leaving 
it a wedge-shaped, swollen mass of deformity, perhaps complicated by troublesome ulcers. In like 
manner, the toes are destroyed and unsightly distortions are left. Ulcers which may perforate the 
feet are not uncommon, and they partake of the same unhealthy character peculiar to all leprous 
lesions. These perforating ulcers may occur in the other forms of leprosy. 
The hairs, nails, and all the appendages of the skin are involved. 
In well-marked cases the trunks of the large nerves become swollen and the seat of pain. 
They feel like cords under the skin. Paralysis of motion and atrophy of the muscles, particularly 
of the face, hands, and feet, develop sooner or later and produce in the limbs a fixed flexion, and 
are followed by similar conditions elsewhere. 
In general, the course of anaesthetic leprosy is more chronic than that of the other forms, and 
death ensues in from ten to twenty years after the onset of the disease, while, on an average, a 
fatal termination occurs in the macular and tuberculated types in from eight to twelve years. 
Exceptionally, death may occur at earlier and later dates in all forms. The causes of death are 
the same in all forms of leprosy. 
Leprosy is never observed in infantile life, is usually met with at the tenth or twelfth year, but 
is mostly seen in subjects between thirty-one and forty years of age. Between forty-one and fifty 
years it is less commonly seen, and about as frequently between the ages of twenty-one and thirty. 
Liveing says that not i per cent, of all lepers are found at childhood, and not 2 per cent, after sixty 
years of age ; at eleven to twenty years and fifty-one to sixty years the percentage is about 9, so 
that the great majority of lepers are between twenty-one and fifty years of age. Statistics show 
that the disease is rather more frequent in males than in females. 
The pathological new formations are small round-cell infiltrations, the so called granuloma, in 
the cells and interstices of which the specific bacillus may be found. 
Etiology.-The disease depends for its development upon the Bacillus leprce, which in some 
occult way gains entrance into the system. Various more or less plausible hypotheses as to the 
methods and ways of infection of leprosy have been offered, all of which are far from satisfactory. 
Sexual intercourse has been urged as a cause, but we have no knowledge in any case of the infect- 
ing lesion appearing upon the genitals, and being followed by the constitutional disease. In the 
same way, the bites of insects, cuts, burns, and various wounds have been thought to be the starting- 
points of the disease. Much as leprosy resembles syphilis in its later course, the well-defined, early, 
methodical evolution of the latter is never observed in the former. It is very probable that leprosy, 
like syphilis, is caused by the deposit of infectious material upon some spot which serves as its port 
of entry into the system. But in leprosy we know nothing of the circumstances of contagion, 
nothing of the initial nodule, patch, spot, or lesion, nothing of any primary or second period of 
incubation, and, in fact, the disease is a blank to us until recognizable manifestations show them- 
selves. All this is different in syphilis. 
There is now one case on record which affords us a glimpse of the mode of development of 
leprosy. In 1884, Arning inoculated the arm of a convicted criminal with leprous matter, and as a 
result a moderate tumefaction of the skin occurred in situ. Within a few months (a period of five LEPROSY: LEPRA GREECORUM. 
359 
years from the date of Arning's experiment) my friend Dr. Morrow found tuberculations on parts 
remote from the point of original puncture, and a pronounced state of leprosy of the patient. 
This case seems eminently satisfactory, particularly as Morrow has demonstrated the Bacillus lepra 
in sections of skin excised by him from the criminal. If, as is very probable, this case shows the 
natural evolution of leprosy, it proves that it is very much prolonged and irregular. 
With these facts before us, it would be but a waste of time to go over the etiological factors 
which were claimed to be the causes of leprosy before the days of the discovery of the specific 
bacillus. They may, however, be mentioned, as follows : climate, soil, race, defective hygiene, diet, 
and hereditary tendency. 
Though the micro-organism is the essential cause of the disease, there undoubtedly are con- 
ditions of the individual and his surroundings which tend to its development. Certain it is that 
some people and races are more susceptible to leprosy, and that it luxuriates more in some coun- 
tries and climates. 
There is a growing opinion that leprosy is not transmitted from parents to offspring ; ergo, 
that it is not an hereditary disease. According to this view, children of lepers who become leprous 
in later years are victims of post-natal contagion. 
While there can be no doubt whatever of the contagiousness of leprosy, the experience of all 
ages proves that the contagion is not active, and that the danger to communities and countries may 
be averted by timely means. In southern latitudes leprosy seems to take root and spread to a 
fearful extent, and it might do the same in the United States ; but beyond a few imported and some 
very exceptional sporadic cases we are free from the disease. According to my knowledge, there 
has not been a day for the past fifteen years that we have not had from one to five cases of leprosy 
in Charity Hospital, and yet we have never heard of an instance of contagion. This seems remark- 
able, for these lepers in years gone by slept with other patients when the wards were very crowded, 
worked with them, ate with them, and generally mingled with them. Like testimony can be 
obtained from a score of observers. Still, with all this negative evidence, we know most positively 
that leprosy may be introduced into a country, and that it may then produce frightful ravages. 
The conclusion is obvious that where we cannot get rid of these objectionable people, they 
should be put away by themselves, segregated, under the most favorable conditions to them- 
selves possible. 
Diagnosis.-When well developed, leprosy presents such a striking picture that it is readily 
recognized. In its macular stage it may resemble erythema multiforme and syphilis, but all doubts 
can usually be cleared up promptly by a consideration of the history. The tubercles of leprosy 
may resemble those of syphilis, but in the former disease the coexistence of pigmentations, of 
atrophic and pigmentless patches, and of ulcerations, would indubitably point to leprosy. But 
clinical features still being bewildering, we may find out in one case the fact of the patient 
having lived in a country where leprosy is endemic, and in the other a typical history of syph- 
ilitic infection. 
Prognosis.-This is in all cases unfavorable. Mildness of the symptoms, long periods of 
quiescence of the disease, and prolonged good health are assuring circumstances, and the reverse 
is equally true. The supervention of intercurrent diseases renders the prognosis more grave. 
Treatment.-Internally, chaulmoogra oil, gurjun balsam, and strychnine may be tried in 
increasing doses, and the first two remedies in the form of ointment or emulsion may also be 
rubbed on the lesions. Little effect, however, may be expected of any internal remedy. 
Chrysarobin, pyrogallol, and salicylic acid, either separately or in combination, with collodion 
as the vehicle, are of much benefit in producing absorption of the nodules. All of these drugs 
may be used in the form of ointment. Ichthyol and resorcin are much praised by Unna in the 
treatment of leprosy. DISEASES OF THE SKIN. 
360 
In the management of a disease which extends over so many years, and which is attended 
with such varied complications, a large number of conditions arise which call for medical care. 
Thus, the febrile state may require alkaline diuretics, cathartics, quinine, and other antipyretics. 
Tonics, nervous stimulants, and sedatives will also be required. The erythema and erysipelas 
call for appropriate applications and management, and ulcers should be carefully cleansed and 
dressed. PART VIII. 
LICHEN PLANUS. 
Lichen planus is a chronic inflammatory affection of the skin, having a marked individuality, 
and characterized by the formation of papules of peculiar color, shape, and course. It is well to 
remind the reader thus, in advance, that much confusion has been caused by recent publications in 
which lichen planus and lichen ruber are described conjointly. These two diseases are entirely 
distinct from one another ; no relation whatever between them has ever been shown to exist, nor 
are there any cases on record in which they have been present on the same patient at one time, 
nor have they ever been known to alternate with each other in occurrence. 
Lichen planus, as a rule, begins symmetrically on one region of the body, and after having 
remained on that for a time it may appear on other regions, always in a bilateral manner. Thus 
the most common mode of invasion of the disease is upon the wrists and lower forearms, and less 
frequently on the backs of the hands and the extensor surfaces of the forearms. In some cases 
both the flexor and extensor surfaces of these parts are attacked. While it is not uncommon to 
see the disease thus limited, and to so remain for longer or shorter intervals, it may also appear 
synchronously upon the neck and elsewhere. The next situation upon which the disease is prone 
to appear is the lower hypogastric region, and then in turn follow the inside surface of the thigh, 
particularly over the vastus internus muscle and near the knee, and then on the calf and antero- 
interior portion of the leg. It is rather rare to see all of these regions invaded at once, and 
inquiry in such generalized cases will reveal the fact that the disease began on one part and suc- 
cessively invaded the others. The conclusion is therefore permissible that if we find on any or all 
of these regions a peculiar chronic papular eruption, a suspicion of lichen planus is warranted. 
The papules of lichen planus begin as small pinhead or millet-seed-sized elevations which may 
be obtuse or somewhat conical. They may or may not be seated around hairs and follicular open- 
ings. They are at first of a pink or red color, slightly scaly, sufficiently salient to be appreciated 
by the finger-tip, and round in outline. They grow more or less rapidly, and as they do they flatten 
out in a distinct manner. In this period of their development they are round or oval, show a tend- 
ency to a central depression or umbilication, which is then minute. When the papules have reached 
an area of half a line they attain the color which is peculiar to them. They are then of a light 
violaceous, even of a purplish-red, hue, which may or may not be more or less masked by the thin 
layer of very adherent epidermis which covers them, and which at times gives them a glistening 
micaceous appearance. The further growth of these lesions is always observed to result in pap- 
ules of oval, round, or angular outline, which have an area of one to three lines, a distinct central 
depression, and an elevation of about half a line-in some regions more, in others less. If the 
reader will examine Fig. i of Plate LIIL, he will observe an accurate picture of the various sizes 
of lichen-planus papules, from the initial speck-like body to the well-developed round, oval, angular, 
and polyhedral papule. The large papules in this figure may be said to represent the average 
361 362 
DISEASES OF THE SKIN. 
acme of the papule of this disease. In Fig. 2 the early development of the papules is well shown, 
and besides standing out in marked contrast to the papules of Fig. 1, we see a number of very 
large flat papules of irregular, angular, and polyhedral shape. These, like the lesions shown in 
Fig. 1, were pictured from life under my direction. These papules may be said to belong to the 
mammoth variety, since they are as large as we ever see these lesions. They may later on lose 
their distinctive individuality ; by further development and by fusion of several they become dif- 
fuse patches. It will be noted that the color of these larger lesions is deeper than that of the 
smaller ones (see Fig. 1), and that it is of a crimson-brown hue. This deepening of the color is 
often observed in old lesions, particularly when seated on the legs. The lower large papules (Fig. 
2) are covered with a thin, shining epidermis which gives them a silvery appearance ; and this tissue 
is everywhere traversed by minute slight and superficial fissures, which correspond to the surface 
lines of the skin, rendered deeper and more noticeable by the increased density of the patches. Above 
the scaly papules is a group of four lesions, and above that two other papules, all of which present 
the peculiar and not constant features of lichen planus. These papules are large, flat, centrally 
depressed, surrounded by a larger and deeper than ordinary inflammatory areola, and of a uni- 
formly angular shape. Careful examination shows on their surface some little bodies placed 
irregularly, very adherent, rough to the touch, of a dirty-white color or of red appearance from 
translucency. These are little concretions of epidermis which have formed as a result of the 
chronic inflammatory process. They are not in any way connected with the hair-follicles or gland- 
structures of the skin, as Robinson has well shown,1 but are caused by "growth downward of the 
rete and a transformation of the rete-cells to granular and corneous cells, as in the normal process 
on the free surface." These collections of epithelial matter may be seen on a few or many papules. 
As these lesions grow old, provided they are not subjected to much washing or friction, there is a 
tendency to a thickening of their epithelial covering, as shown in the lower lesions of Fig. 2. This 
epidermal thickening may be in the form of thin layers or in irregular, very adherent masses of 
less and more than a line in area. By their increase they may form rugose, irregular surfaces, 
and about the knees, elbows, ankles, and on the legs they form dense, hard, rough, sometimes 
even warty-looking patches, which are of a bluish-red, a crimson-brown, or dark brownish-black 
color. When lichen-planus lesions thus become transformed, their individuality is more or less 
masked, and even lost. To these chronic thickened patches French authors give the names lichen 
hypertrophique, lichen cornee. They may be in the shape of large and small patches, in bands, and 
in irregular areas of large size. 
There is no well-marked desquamation in uncomplicated cases of lichen planus. In the early 
stages of the papules they may have the perceptible epidermic film, and perhaps some detached 
scales, but these particles do not fall plentifully and are more commonly removed by scratching, 
rubbing, washing, or friction. Even in the chronic hypertrophic and rugose conditions of lichen 
planus there never is seen a frank, free desquamation. I have several times seen a curious feature 
in this disease. Patients sometimes present themselves when these lesions are silvery and mica- 
ceous, and a short time after nothing of a scaling nature is to be seen ; but if they scratch the parts 
they immediately produce the silvery appearance and the scales are present. In very warm weather, 
when perspiration is active, the scaliness of lichen planus is often not perceptible, but when the parts 
are dry and harsh it is. 
It was formerly taught that the papules of lichen planus, having reached a diameter of three 
and at the most four lines, ceased thereafter to grow ; consequently that they never individually 
formed patches. In the main this view is correct, but papules may in consequence of irritation 
and friction on coapted surfaces, on parts subject to continued and tight pressure and movement, 
become developed into well-formed patches having an area of an inch or even more. 
1 " Lichen planus and Lichen ruber," Journal of Cutaneous and Genito-Urinary Diseases, Feb., 1889, PP- 49~51 • PART VIII 
PLATE LIII 
Flg.l 
Fig.2. 
FiLo 
Fig'. 3 
"SHarrisiSoils,uth.Hiiia 
LEA BROTHERS & CO. PUBLISHERS , PHILADELPHIA 
LICHEN PLANUS. LICHEN PLANUS. 
363 
This brings us to a consideration of the course of the papules. It is a striking feature of 
lichen planus that its papules show a marked tendency to retain their own individuality. It is true 
that a number of contemporaneous papules may seem to run a similar course, but if they are 
studied for a considerable period it will be seen that there is more or less lack of uniformity in 
their evolution. Thus some grow to greater size than others, some begin to subside at an early 
date while others are continuing to grow, so that it is not far from the truth to say that each pap- 
ule seems to run a course, entirely irrespective of its fellows, either of short or long duration. In 
their uncomplicated state lichen-planus papules are round or oval in outline, and they become 
angular, polyhedral, star-shaped, and of irregular outline by being packed so closely together, or 
by the arrangement of the surface lines of the skin, or by the motion of the parts on which they 
are seated. Any one can convince himself of the truth of this assertion by studying the course 
of a number of sparsely-placed papules and a group which are in close juxtaposition. When very 
densely packed together, these papules come to abut against one another, but they even then for 
a long time preserve their outline so plainly that it can be readily distinguished. Under the influ- 
ence of irritation of friction and of treatment these papular outlines, however, may be, and are 
often, lost. 
The papules of lichen planus never become transformed into vesicles, pustules, or bullae. 
We now come to a consideration of the decline and involution of the papules. One of the 
prominent features of lichen planus is its chronicity, since it always lasts months, and it may persist 
for a few, and even for many, years. It is a disease the evolution of which is remarkably uncer- 
tain. In some cases the papules, few or many, appear, and are within a few weeks or months fol- 
lowed by others. Again, a very copious eruption is followed at longer or shorter intervals by 
others, large or small. In this way old lesions are replaced by new ones, and, though at times 
there may be but few of them on the body, the patient is at no time free from the disease. The 
limited development and erratic course are in my experience more commonly seen in America 
than copious eruptions with corresponding subsequent outbursts. 
In general, the structure of lichen-planus papules is so firm and compact that they retain their 
integrity in the main for comparatively long periods. Consequently, we do not observe changes 
in them from day to day. 
They reach an elevation varying between the thickness of letter-paper and that of blotting- 
paper, and are seen to jut up abruptly from the skin level. When the papules are numerous and 
aggregated, they retain their individuality for quite long periods, yet even among these some 
undergo involution sooner than others. Upon the forearms, neck, palms, soles, and thighs the 
salience of the papules is more marked than upon the scrotum, penis, abdomen, and legs. Hav- 
ing reached their full development, these lesions may retain their silvery corneous covering, or the 
latter may be increased. In many cases upon the arms the superficial scaly condition is sooner or 
later lost, either by the rubbing of the clothes or by constant washings. The lesions then have a 
smooth, slightly shiny surface devoid of scales, and they still retain their characteristic violaceous 
tint. Whether they have thus lost their epidermal layer or not, as the lesions decline they subside 
until the skin-level is reached. In many papules the umbilication becomes even more pronounced 
during the period of decline than in that of maturity. In some cases scaliness (more or less) per- 
sists ; in others the violaceous patches show limited inflammatory action still remaining in the skin, 
but no prominence. In this declining state moderate thickening of the skin may be felt. The 
further process of involution is very slow and uncertain. The violaceous and purple color fades 
by degrees, and a brownish-pink color remains, which is later on replaced by quite persistent pig- 
mentations, either of dull red, brownish red, or even crimson. On the lower extremities these 
stains may last for years. 
The ultimate structure of the skin which has been the site of lichen planus presents a number 364 
DISEASES OF THE SKIN. 
of features. In many cases when the pigmentations disappear the skin seems normal again. In 
other cases, particularly old and inveterate ones, decided atrophy may occur, which is either dot- 
like and around the hair-follicles or in the shape of little round or oval spots. In rather excep- 
tional cases a diffuse patchy atrophy is observed. The foregoing description pertains to uncom- 
plicated cases of lichen planus. During their course there is never an active exfoliation of 
scales. 
In some cases of this disease hypertrophy of the epidermal coverings of the papules occurs 
to a well-marked extent. This is particularly the case where the epidermis is thick-on the knees, 
ankles, elbows, palms, soles, and legs-but it may be present on any part which is subjected to 
chronic irritation. In some cases individual lesions become thus horny and scaly. In general, 
however, this excessive corneous development is seen in old ones, where large or small patches 
have been formed. In all instances the epidermal increase is firm and not easily detached. Hyper- 
trophic papules look like little violaceous or purplish-brown corns. In certain cases of linear 
arrangement of papules they, becoming hard and horny, are converted into dull-colored ridges 
or lines of great density. 
The rugose patches of chronic lichen planus are of uneven, warty surface, of great firmness, 
usually sharply limited, and of dull purple, even brownish, color. Over them we may find the pin- 
head-sized pearls already spoken of, freely scattered or densely grouped. They can be picked out 
by the aid of a sharp instrument, and it is seen that they leave little pits. Further epidermal 
hypertrophy may be seen in more or less prominent conical, globose, and irregular-shaped masses, 
which give the affection a coarsely warty look. These hypertrophic conditions of lichen planus 
are very chronic and persistent. They rarely or never undergo normal involution, and are only 
removed by the most active and continued treatment. In these remarkably exuberant instances 
of corneous hypertrophy there is comparatively little epidermal exfoliation. The scales are very 
adherent. 
We are now in a position to study the appearance presented by Figs. 3, 4, and 5, Plate Fill. 
The rule is that the disease is symmetrically developed. In very many cases of lichen planus we 
find a few papules scattered particularly over the inner surface of the wrist, and perhaps on the 
corresponding surface of the forearm. About as frequently, however, we find a few groups of 
papules with outlying isolated ones on these regions. In Figs. 3 and 4 a very typical picture of 
lichen planus of long duration is shown in the person of one of my patients. In this case we find 
evidence all over the outer forearms of previous papules which had come and gone and left their 
characteristic stains. Besides these evidences of decline we see scattered over the outer forearms, 
the backs of the hands, and the fingers (a much less common situation than the inner aspects of 
these parts) a number of well-developed violaceous and purplish-red, large, round, and oval pap- 
ules, some of which are covered with well-marked corneous layers which appear white and silvery, 
and others lack this feature. It will be seen that the smaller lesions show a well-marked oval or 
round outline, but that this becomes indistinct in the larger papules. The picture is very striking, 
and if a few of the small and of the angular patches shown in Fig. 1 were interspersed among the 
old papules and stains, it would be perfect. 
Lichen planus of the palms is not common. I showed a case recently at the New York Der- 
matological Society in which the papules were more or less coalesced and horny. The nails are 
rarely if ever affected in this disease. 
Upon the neck lichen-planus papules soon lose their salience, and perhaps their scaliness, and 
become converted into patches. Here, as upon the forearms and wrists, friction often plays a 
prominent part in doing what we may designate polishing off the papules. This occurs also on 
the lower abdomen as a result of contact with the clothes. Upon this region the lesions, which are 
always symmetrically placed, may be isolated or grouped in greater or less numbers. LICHEN PLANUS. 
365 
Fig. 5 shows in a marked degree die appearance of lichen planus on the leg. The size, the 
great number, and the extent of distribution of the lesions, combined with many pigmentations, 
show that the disease was very chronic in its course. When lichen planus is found on the legs it 
will generally be found also upon the upper extremities, and perhaps on the abdomen. 
The disease is more commonly seen on the inner aspect of the thighs, near the knees, and 
principally over the vastus internus muscle. Here it is usually seen in much the same form as 
shown in Figs. 3, 4, and 5. 
In Fig. 5 the patchy condition of lichen planus is admirably shown. The coalesced patches 
of the middle and upper thirds of the picture are very characteristic. They are of irregular out- 
line, more or less scaly, and surrounded by isolated patches, well-defined papules, and pigmenta- 
tions, all existing without symmetry or order. In very many cases a much less advanced condi- 
tion may be seen. The soles may be the seat of 
papules, which then have a tendency to become 
quite salient and horny. About the ankles ru- 
gose deep-colored patches are sometimes seen. 
Upon the penis and scrotum the disease 
shows itself as papules and patches, and an an- 
nular arrangement of the lesions is not uncom- 
mon on these parts, where they are rarely very 
much elevated or scaly. A ringed arrangement 
of the papules is sometimes seen elsewhere. 
In wood-cut Fig. 61 the appearances, taken 
from life under my observation, of the well-marked 
linear arrangement of lichen planus are well 
shown. The papules in some cases are seated 
in distinct lines, which correspond to the direc- 
tion of the cutaneous nerves. This is sometimes 
marked on the forearm anteriorly and posteriorly, 
and is characteristically well shown on the leg in 
the wood-cut. Two months after this picture was 
made this linear arrangement of the papules was 
rendered more perfect by their more or less end- 
to-end coalescence. A linear arrangement of 
lichen-planus papules is not uncommonly seen 
upon scratch-marks upon regions not previously 
the seat of the disease, in persons thus affected 
elsewhere. In my judgment, the lichen ruber moniliformis of Kaposi and Neumann is simply an 
abnormal development of lichen planus, as will be shown in the next section. 
As a rule, large areas of skin are not invaded by lichen planus, and the drawings I have 
presented will give an idea of rather more extensive development than is seen in the majority 
of cases. Usually there are a few or many isolated papules and patches on some or all of the 
localities I have named. The disease is often limited to the forearms, not uncommonly to these 
parts and to the lower abdomen, and in rare cases it is found on all the mentioned classical sites. 
I have seen eruptions nearly covering the forearm, the whole neck, large portions of the lower 
abdomen, and legs, but I have never seen the whole body covered, as Colcott Fox tells me 
he has done. 
The subjective symptom of lichen planus may be summed up in one word-itching-which may 
be mild or very intense. It is usually paroxysmal, and worse at night. Cases are seen in which 
Fig. 6i. 
Lichen planus: Linear Arrangement of Papules. 366 
DISEASES OF THE SKIN. 
this symptom is wholly absent, and others in which it causes the patient great distress and leads to 
sleepless nights. 
Etiology.-In many patients suffering from lichen planus no deviation from the normal stand- 
ard of health is apparent. In some cases the disease is accompanied by gastro-intestinal disturb- 
ances, by a condition of suboxidation, and by a rheumatic tendency. By some it is thought to be 
of neurotic origin. I have seen it frequently in persons to whom poverty denied fresh air and 
proper and sufficient food, and whose nutrition was decidedly below par. In my experience it is 
rather more frequently seen in women than in men. 
Lichen planus is rarely seen in young subjects. It is a disease of adult and middle life up to 
old age. It may last years without causing any impairment of the health, and it is often astonish- 
ing to see with what complacency extensive and very chronic eruptions are borne. 
The pathology of this disease shows it to be an inflammatory process on the rete and upper 
part of the dorsum, with cell infiltration. 
Diagnosis.-Such are the well-marked characters of lichen planus that its recognition is 
usually very easy. It is well to remember that some forms of sparse and aggregated papular 
eczema may present points of resemblance, the distinction of which will soon be determined by 
the history of the case (and usually the sites of the eruption) and its course. Some cases of the 
papular syphilides, particularly of the large and small flat varieties, present resemblances, in the 
color, the shape, and the distribution, and perhaps in the scaliness, of the lesions, to lichen planus. 
But as these syphilitic lesions are usually quite early manifestations, and are often accompanied 
by other specific evidences and by a history of infection, the diagnosis need not long remain in 
doubt. In a case of great doubt (should such occur) a mercurial treatment will cause the syph- 
ilide to disappear, and will have no influence upon lichen planus. 
Prognosis.-The disease is chronic and persistent to a remarkable degree. It is also prone 
to relapse at intervals of months and of many years. It may be said not to react unfavorably in 
general upon the health. 
Treatment.-The internal treatment of lichen planus is dependent upon the findings in each 
case. Wherever impairment of health exists, it should be remedied according to its nature and 
indications. The disease, though treated of in dermatological works, yet belongs to general med- 
icine. Arsenic will be found of decided value in those cases in which the health seems unaffected. 
It also may be of benefit in neurotic and malarious persons, and in cases of debility it should be 
given with tonics. Alkaline diuretics (see section on Eczema) are also of benefit in some cases. 
I have seen benefit from the use of chlorate of potassa (gr. x to xx) given in water before meals, 
and dilute nitric acid (gtt. xfl-xx + xxx), well diluted, in water after meals. 
Topical treatment, however, is the more important. Water-packs (perhaps with a little alkali) 
are of benefit when practicable. In extensive cases alkaline baths are necessary, for they allay 
pruritus and tend to lessen hyperaemia. Frictions with the compound tincture of green soap, tarry 
ointments, and collodion preparations, as directed in the treatment of chronic eczema and psoriasis, 
are of great benefit. As these matters have been fully considered in the sections on the treatment 
of these diseases, I need not repeat them here. Careful and continuous treatment is required in 
all cases to produce a cure. LICHEN RUBER. 
Lichen ruber is a chronic subacute inflammatory disease of the skin, manifesting itself by the 
development of myriads of minute, uniform-in-size papules, which, by coalescence, lose their ana- 
tomical characters entirely and form diffuse, not very scaly, patches of thickened skin, which are 
traversed by well-marked furrows formed by the deepening and exaggeration of the natural sur- 
face-lines. 
Lichen ruber is a rather rare disease which has attracted much attention within the past fifteen 
years by reason of the fact that by some it has been claimed to be identical in nature with lichen 
planus, while others have insisted that it is a disease sui generis. There is no doubt whatever that 
it is a distinct disease, having a sharply marked individuality, presenting not the faintest relation to 
lichen planus, and being totally distinct from certain forms of lichen which belong to eczema and 
from lichen pilaris. To Hebra certainly belongs the credit of having first described this disease in a 
clear manner, and of having separated it from all other forms of disease. There is a disposition on 
the part of certain eminent French dermatologists to claim the honor which I think should, with all 
frankness, be given to Hebra, for their countryman Devergie who seemingly described lichen ruber 
under the title " pityriasis pilaris " as long ago as 1857. But in an attentive reading of Devergie's 
article we find the following sentence. Speaking of four observed cases, he says : " The disease 
has been constantly preceded by the three following affections: psoriasis palmaria, pityriasis capitis, 
and pityriasis rubra." The gist of the matter is this : That Devergie certainly saw cases of lichen 
ruber in 1857 or earlier, and gave a far from satisfactory description of the disease, by which, how- 
ever, in the light of the studies of Hebra and of various observers of to-day, we can recognize it 
as lichen ruber. But it certainly cannot be claimed, that Devergie's description of it brought it 
to light, as Hebra's certainly did. Further than this, Devergie's title, which is now put forward 
again by several eminent French authors, is both confusing and inappropriate. The word "pity- 
riasis " is to-day, as of old, used to express the idea of a scaly disease, one in which desquamation 
is the essential feature of its course. Now, lichen ruber is, in every particular, a papular disease, 
and its scales, not large, thick, or by any means constant in development, may be absent for days 
or weeks. Is it an indication of precision in nomenclature to call a disease after a secondary con- 
dition which is more or less inconstant and never very strikingly prominent except in its very late 
stage, and to ignore its salient features, particularly when they are papules of striking appearance 
and uniformity, which are the essential basis of the whole disease? Lichen ruber is nothing if not 
a papular disease, and, though scaly during its course, this feature should not be made too prom- 
inent, since it is but a small part of the picture. The term " pityriasis pilaris," if used at all, is 
appropriate only to a small portion of the surface invaded by lichen ruber-namely, the hands- 
and perhaps to other portions of the extremities. As will be shown in the section on Pathology, 
lichen ruber is a disease of the papillae and papillary derma, generally with no marked predilection 
to hair-follicles, which, however, may be consecutively involved in the general course of the dis- 
ease. Therefore, I say that it is most misleading to tack the word " pilaris " to any appellation 
which may be substituted by any observer for the term "lichen ruber," for the simple reason that 
367 DISEASES OF THE SKIN. 
368 
it is not essentially a disease of the hair-follicles, though in its extension these structures may be 
invaded if the regions upon which they are seated are attacked. 
In a recent paper1 I traced the history of lichen ruber on the lines of personal observation of 
a number of cases very favorable for study, and showed its clear distinction from lichen planus. It 
is from this paper that I now take the description of the disease. 
Before entering into a minute clinical study of lichen ruber, I would say that the disease is 
portrayed in the most striking and accurately natural manner in its period of papular evolution in 
Fig. 1, Plate LIV., and that it is shown in its period of maturity in the upper half of the picture of 
Fig. 2 and at the bend of the elbow in Fig. 3. A study of these three figures will give any one, I 
think, a very clear idea of lichen ruber. Certain features of the disease, due to local tissue pecu- 
liarities, will be described farther on, and will then be readily comprehended. The reader, having 
thus seen in the figures mentioned how the disease looks in its increasing and mature stages, 
can supplement his knowledge by a study of wood-cuts Figs. 64 and 65, which show the radical 
changes produced in the skin in the chronic stage. 
I shall base my description chiefly upon the appearances presented by a remarkably typical 
case, which furnished all the illustrations to this section, and which was under my observation for 
a long time. 
Lichen ruber may be divided into three well-marked stages : First, the stage of isolation of 
the papules ; second, the stage of coalescence of the papules ; and, third, the resulting chronic, 
moderately infiltrated, slightly pigmented, corrugated, and scaly stage. 
The invasion of the disease begins with the appearance of distinctly isolated papules, which 
more or less promptly form patches by multiplication and coalescence. While infiltration and vary- 
ing degrees of desquamation take place in the coalesced patch or patches, the area of the disease 
is further increased by new crops of isolated papules which appear at their margins or at some 
distance from them. It thus occurs that we usually find all three stages existing in the same 
patient. For clearness of description, therefore, we shall follow this division. 
The Stage of Isolation of the Papules.-This is well shown upon the posterior aspect of 
the shoulder and of the back in Fig. 1, Plate LIV., and upon the arm and forearm in Fig. 3, extend- 
ing from the coalesced patch at the inner aspect of the elbow, and was also observed on the exter- 
nal aspects of these parts, where the papules were quite widely scattered. On the hypogastrium 
and flanks the papules are, for the most part, isolated, but are more numerous than those on the 
arms. In these regions, therefore, we can study the eruption in its first stage. There are none 
of the classical features of inflammation to be observed, for the affection, though subacutely inflam- 
matory in nature, evidently develops a froid. When first visible the papules are of the size of the 
point of a pin or needle, and, in fact, are so small that they can hardly be called miliary. If there 
were but few, they might be mistaken for little collections of dirt seated very superficially at the 
various follicular openings. They present to the touch a sense of firmness of structure even thus 
early, and give to the skin a roughened feel. They soon become miliary in size, and for the most 
part look like little brownish-red elevations. On parts where the skin is thin and delicate, such as 
the inner aspect of the arms and on the abdomen, when examined individually with the magnifying- 
glass they look like little conical masses of yellow wax, and to the eye are of a neutral orange color. 
The minute conical papules are well shown on the hypogastrium in the chromo-lithograph Fig. 2 ; 
on the wrist in wood-cut Fig. 62 ; and on the arm and forearm in colored Fig. 3. There is an entire 
absence of circumferential hyperaemia, though this feature may be observed in a mild degree upon 
the face, neck, and palms, usually, however, resulting from friction. In their early stage, then, the 
papules are miliary and conical, and I can readily understand why observers who strive for elab- 
1 " Lichen Ruber, as observed in America, and its distinction from Lichen Planus," New York Medical Jotirnal Jan. 5, 1889. part vm 
PLATE LIV. 
Fi£ .1 
■ Fife .4 
FFr.8 
LEA BROTHERS & CO. PUB USHERS PHILADELPHIA 
LICHEN RUBER. LICHEN RUBER. 
369 
oration in nomenclature call the disease lichen ruber acuminatus. This conical condition of the 
papules is not of long duration. The lesions grow slowly but surely in area, and as they do so 
they increase in salience ; their surface becomes rounded and obtuse, as is very clearly shown upon 
the hypogastrium, the shoulders, and the arm in the chromo-lithographic plate. They may retain 
this rounded, bee-hive shape for a period equally as long as they remained conical, and conse- 
Fig. 62 
Diffuse Infiltration and Scaling of the Palm and Thickened Condition of the Nails. 
quently it would be equally as reasonable and appropriate to call the disease in this stage lichen 
ruber obtusus as it would lichen ruber acuminatus ; but, as we have seen in many other diseases, 
nothing but confusion in the end results from redundancy in nomenclature. At this time the 
papules are still very minute bodies, but they have not yet attained their growth. They continue 
to increase in area until they reach a diameter of a line or even less, when they may be said to be 
fully formed, since henceforth they, as papules, undergo no peripheral growth. Remaining in the 
obtuse condition for a short time, as they grow they become flattened, and then a depression in 
their centres corresponding to the orifice of the follicles may sometimes be readily noted and at 
other times not seen. This central depression, however, is very minute-so much so that the term 
" umbilication " can hardly be applied to it. Here, again, the elaborator of nomenclature has his 
opportunity, and he might favor us, as he has done to the bewilderment of many, with the term 
lichen ruber planus, thus merging the two diseases together. The fully-formed papule then pre- 
sents a rounded outline, with perhaps, in some cases, a tendency to ovoid, but nothing akin to the 
angularity, star-shape, or polygonal shape of lichen planus is seen. The papules jut up sharply 
and vertically from the surface of the skin. There is a wonderful uniformity in the size of these 
lesions: each papule seems destined to cover an allotted space, and it does it and no more. From 
the commencement of their development very minute, thin, more or less adherent scales are seen 
on the papules, and from them during their whole course a similar mild desquamation may occur. 
In their fully-developed condition, therefore, the papules are rounded, slightly umbilicated, and 
scaly. Owing to the increase of corneous cells on their surfaces, they present a slightly shining 
and glistening appearance, which is best seen in the sunlight in an oblique direction. 1 hey never 
have the decidedly micaceous silvery appearance of the lesions of lichen planus. In this stage of 
isolated papules their color often varies in a striking manner from a dark yellow to a brownish red, 
according to the condition of the circulation. They never have the deep violaceous-red, and even 
crimson-red, color of the papules of lichen planus, which further differ markedly from those of lichen DISEASES OF THE SKIN. 
370 
ruber in the fact that they convey to the eye the impression that they result from much more pro- 
found morbid changes. If, now, the reader will contrast the appearances of lichen planus presented 
in Plate LIII. with those of lichen ruber in Plate LIV., he will see the very striking differences 
between the two diseases. 
When the papules of lichen ruber are thus fully developed, when they are not very numerous 
and are distinctly isolated and clustered in groups, they may perhaps be mistaken for a short time 
for lichen planus, particularly if they should occur on the inner surfaces of the arms and near the 
wrists, on the abdomen, or on the antero-inner surface of the thighs or legs. Under no other cir- 
cumstances whatever, I think, can a trained observer confound the two diseases. In this connec- 
tion the reader is advised to study the appearances of the papules of lichen planus of Fig. i, Plate 
LIV. But even under these conditions time and the natural course of the papules will soon settle 
the question as to their nature, if it has not already been cleared up by the history of the eruption 
and of its concomitant features. A study of the myriads of maturing and mature papules on the 
hypogastric region and shoulder, as shown in the chromo-lithograph Figs, i and 2, fortified by the 
facts already brought out, will, I think, be sufficient to convince the observer that the papules of 
lichen ruber differ in the most marked manner from those of lichen planus. (See section on Lichen 
planus and Figs. Nos. 1 and 2 of Plate LIII.) 
When a portion of the body thus becomes the seat of these scattered papules, new crops con- 
tinue to appear more or less rapidly, and become intermingled among the older ones, until, in the 
end, they are so closely aggregated that they fuse together, and may cover the whole surface, but 
sometimes little oases of unaffected skin are left. While this is going on new papules, distinctly 
isolated, form at the periphery or on parts of territory beyond, and run a subacute course until, in 
the end, nearly if not the whole body becomes covered. The extension of the disease is therefore 
progressive from one or more parts ; it rarely or never jumps from the upper to the lower extrem- 
ities, nor does it run the erratic course of eczema. 
The promiscuous intermingling of new crops of papules, which, in the end, form a diffuse 
patch or patches, is shown in Fig. 1 of the colored plate, while upon the hypogastrium, in colored 
Fig. 2, the progressive invasion of the disease from above downward by the development of new 
papules is illustrated. Then, again, in Fig. 3 of the colored plate the extension of the disease by 
the evolution of papules at the margin of the large patch at the elbow, and by many outlying 
lesions in regions beyond, shows further how the disease progresses. 
The Stage of Coalescence of the Papules.-The transition of the isolated papules into 
diffuse patches of eruption is shown in the chromo-lithograph Fig. 2 on the abdomen in a more 
graphic manner than pen can depict. When, by reason of maturity of growth and multiplication 
of numbers, the papules have coalesced, it will be seen that they are arranged in distinct and sym- 
metrical rows, corresponding to the direction of the surface furrows and the connective-tissue 
framework of the parts. Thus in the coalesced papular patch of Fig. 1 of the colored plate, just 
in the middle line and covering an imaginary oblique line drawn from the tip of the shoulder 
to the axillary fold, the papules, which elsewhere are more or less scattered, but all of which 
show the tendency to grouping and fusion into patches, have formed a patch of about two square 
inches. Now in that patch, by close scrutiny, the reader will see that the papules have begun 
to arrange themselves into distinct lines which encircle the limb and the joint in a transverse 
direction. 
On the hypogastrium (see Fig. 2, Plate LIV.) the scattered papules are present low down ; 
higher up they are seen to be coalescing, and about the middle of the picture they are seen to be 
further fusing and showing a tendency to become arranged in lines corresponding to the natural 
furrows of these parts. Higher up, the picture shows an entire absence of papular lesions and an LICHEN RUBER. 
3/i 
expanse of morbid skin of a dull neutral orange color, traversed by lines and giving forth scantily 
minute scales. 
A very accurate idea of the development and 
course of lichen-ruber papules is conveyed by a 
study of black-and-white Fig. 63. This figure was 
taken directly from life. A solar print was made 
from a photograph of the anterior abdominal wail, 
just as is shown in Fig. 2 of the chromo-lithograph. 
A portion of this photograph, two inches wide by 
three inches in length, at a point just below and 
external to the umbilicus, where the papules were 
in a discrete, coalescing, and coalesced state, was 
magnified by solar print into a figure sixteen 
inches by thirty-two inches long, and from this 
large figure the smaller one (Fig. 63) was cut out. 
In this black-and-white Fig. 63, at the region 
marked a, the papules are shown in an isolated 
state, of uniform size, round in outline, no longer 
conical, but semiglobular on their surface. In the 
region b, just beyond, the papules are seen after 
they have reached their maturity and have become 
flattened, and still preserve their roundish outline, 
though clustered close together. In the territory 
just above, marked r, it will be seen that the pap- 
ules have lost their primordial form entirely, and 
have become fused together. The lesion there 
seen is a general moderate thickening of the skin 
in its upper layers. What were papules have be- 
come fused together into a patch which is trav- 
ersed with parallel lines with shorter and less dis- 
tinct transverse markings. These lines are the 
natural furrows of the skin broadened and deep- 
ened by the disease. They are admirably well 
shown in Fig. 2 of Plate LIV., particularly on the 
right-hand side, over the ribs and abdomen, and 
also at the bend of the elbow in Fig. 3. They 
vary in direction according to the conformation 
of the part, and are, as is well known, arranged 
in conformity with the deep connective-tissue 
framework of the skin. For a time the individ- 
uality of the papules seems preserved in this 
linear arrangement, but it is gradually lost by 
fusion. It results from this process of fusion 
that the skin of a person suffering from lichen 
ruber comes to present in its chronic stage a min- 
iature resemblance to alligator or elephant hide. 
For some time, therefore, the contour of the individual papules in the stage of coalescence 
may be quite clearly made out, as is well shown in the middle portion of the eruption in the 
Fig. 63. 
Reproduction of a Greatly Magnified Solar Print of a Patch of Lichen 
Ruber. Lower third (a) shows the rounded, discretely placed pap- 
ules. In middle third (<5) papules are shown flattened out and coa- 
lesced. In upper third (r) the coalesced papules have become ar- 
ranged in the lines of the natural furrows of the skin. DISEASES OF THE SKIN. 
372 
Fig. 64. 
Showing Chronic Stage of Lichen Ruber: left anterior abdominal wall. This picture may be contrasted with Fig. 2, Plate LIV., 
which depicts the disease in the process of development. LICHEN RUBER. 
373 
Fig. 65. 
Showing Chronic Stage of Lichen Ruber: posterior and median surface of trunk. 374 
DISEASES OF THE SKIN. 
chromo-lithograph Fig. 2, just below the umbilicus. In this stage of the eruption lichen ruber may 
be said to be fully developed, since beyond it retrograde changes are observed. It is then a vast 
conglomeration of fused papules of a characteristic warm brownish-red color, giving forth their 
branny scales in moderate quantity. When the fingers are passed over an extensive surface a dry, 
smooth, leathery feel is communicated. There is not as yet observed that harsh sensation which 
has been compared to that of a nutmeg-grater or of a file-a condition which, however, may occur 
later. 
There is in this stage decided infiltration of the skin, but it is evidently superficial and not 
seated in the derma and connective tissue. It is comparable to that of dermatitis exfoliativa, and 
not to that of eczema. Later on it may be more pronounced, particularly on the palnis and soles 
and on the fingers. 
The Chronic Infiltrated, Corrugated, and Scaly Stage.-More or less rapidly the tend- 
ency of the disease shows itself in the effacement of its papular elements. These little bodies 
become more and more indistinct individually, until at last the eruption consists of a uniform 
brownish-red, slightly scaly, superficial thickening of the skin, which is traversed by the minute 
natural furrows arranged in longitudinal, circular, oblique, and transverse directions. Owing to 
the increase in the corneous elements of the skin these furrows become deeper than normal, and 
they divide up the morbid areas into various shapes, some very noticeable, others less so, and cor- 
responding to their direction after the manner of the hide of an alligator. This constitutes the 
third stage, in which the disease, as shown in Fig. 64, resembles in miniature the hide of the alli- 
gator, whereas in Fig. 65 the resemblance is nearer to the hide of an elephant than to that of any 
other animal. The condition is one which is chronic, indolent, infiltrated, rough, scaly, irregularly 
corrugated, and slightly pigmented. In this stage all signs of previous papulation have disap- 
peared, and no new lesions then show themselves. At this period, judging from my experience 
with cases seen on this side of the Atlantic, the disease may undergo involution after considerable 
periods. The disease, however, frequently persists until a dry, file-like, harsh, infiltrated skin 
results, the superficial disease having then caused a true inflammation of the whole thickness of the 
skin. A person unfamiliar with this disease would never think that the small, non-inflammatory, 
and seemingly insignificant papules could be the forerunners of such a radical and unsightly 
deformity of the integument. 
It is perhaps well to particularize a little further as to this chronic stage. Over the outer 
aspect of the forearms and on the similar surfaces of the legs, upon the hands and on the fingers, 
the papules show a tendency to develop around the hair-follicles, forming little corneous pyramids ; 
and in many instances they (when the circulation is not active and the capillaries are not turgid) 
give the parts the appearance of a plucked fowl. Further, in the chronic stage of lichen ruber 
upon parts rich in hair-follicles (the scalp and face, however, always excepted) the appearances 
may be somewhat like those of a coarse file or nutmeg-grater. On plain level surfaces there is 
much roughness and corrugation, but not this file-like condition. Thus in black-and-white Fig. 64, 
showing the left abdominal wall in the chronic stage, the appearances are, as we have seen, those 
of alligator-hide, whereas those of black-and-white Fig. 65 resemble more closely the hide of an 
elephant. 
In the chronic stage the brownish-red color of the eruption becomes deeper, the itching may 
be rather more pronounced, the infiltration is greater, the skin surface decidedly rougher and more 
scaly, and the minute hairs are either destroyed or their nutrition is much impaired. But in this 
stage the dull-brown color may cease and the roughened skin may return to its normal hue, or 
even may be only a little more pinkish than normal. 
It should be remembered, therefore, that the roughened feel of the skin can only be noticed LICHEN RUBER. 
375 
in the very early papular stage and in the late infiltrated stage, and that it is smooth and leathery 
in the middle stage.1 As involution occurs the suppleness and natural glossiness of the skin return, 
but a diffuse, brownish-yellow pigmentation of mild character may be left, accompanied for a time 
with moderate desquamation. This pigmentation is, in a measure, 
characteristic of the disease in that it has not the red tinge of a 
departed eczema nor the brownish-red hue of a vanished psoriasis. 
More particularly, it differs wholly and radically from that of lichen 
planus in being uniform in sheets, rather than blotchy, patchy in spots, 
and in not being of a rusty-brown, a brownish-red, or a crimson-red 
color, which is so constant in the latter affection. In lichen-planus 
pigmentation there is evidence of much quite deep effusion of the red 
corpuscles ; in lichen ruber it is very trifling and superficial. 
The thickened scaly condition of the palm in lichen ruber is well 
shown in wood-cut Fig. 62, in which the appearances are those of 
chronic, scaly, and infiltrated eczema of these parts. The extent to 
which epidermal hypertrophy may occur in this disease is well shown 
in wood-cut Fig. 66, in which it is evident that the increase in the 
corneous cells of the sole of the foot was very great. In Fig. 4 of 
the colored plate the thickening and deep corrugation of the skin of 
the fingers is well shown in a characteristic manner, and on the dor- 
sum of the hand and on the knuckles old papules may be seen. The 
disease affecting these parts causes much annoyance and suffering. 
Movements of the fingers and hands are much impaired, if not ren- 
dered wholly impossible, and the patient suffers from a feeling of 
tension and rigidity. The same occurs in the feet, which become so 
much swollen that shoes of a very large size are rendered necessary, 
and locomotion may be very painful and difficult. 
The condition of the nails is very striking in lichen ruber, and 
resembles in many particulars that of eczema and psoriasis. It is well shown in Fig. 4 of the 
colored plate and in wood-cut Fig. 62. The nails become much thickened, opaque, of a dull-white 
Fig. 66. 
Excessive Hypertrophy of the Epidermis 
of the Soles. 
1 My studies have convinced me that the main reason why lichen ruber is not clearly understood by dermatologists lies in the fact 
that too much stress is laid on the conical condition of the papules, which is thought by many to exist throughout the whole course of 
the disease. According to my reading and experience, the file-like condition of the skin in the third stage of lichen ruber is supposed 
by most observers to be the direct outcome of the early conical papular stage. In other words, it is thought that the multiplication 
and growth of the conical papules result in the harsh, file-like condition of the chronic stage. The facts presented in this section 
show very clearly that this is not the case, except perhaps on the hands, as will be explained a little farther on. The disease does 
begin by the appearance of conical papules, which soon become rounded and then flat, and are finally lost in a general thickening 
of the integument, mainly of the epidermis. The resulting file-like and harsh condition of the skin is simply due to its quite deep 
corrugation, which condition is produced by the deepening of the natural-surface furrows or lines ; in other words, by a greater or less 
superficial fissuration in a uniformly thickened skin. The loss of elasticity consequent upon the thickness and harshness of the skin 
tends to accentuate the condition of corrugation, even to the production of deep fissures, when the part is submitted to much move- 
ment and stretching. 
On the backs of the hands, and perhaps on the outer aspects of the arms and legs, when the hair-follicles are large and the epi- 
dermis is tolerably thick, the papules may be more pronounced and prominent than elsewhere on the body. Thus we find them form- 
ing little pyramids around the hairs. Now, when these circumfollicular papules become very numerous and coalesce, they form 
patches which are rougher by far than those found on the soft skin of the trunk, owing to their greater prominence and to the increased 
thickness of the epidermis of the parts. In these localities, therefore, the rough file-like harshness of the skin may be largely due to 
the prominence of the papillary follicles; which feature has been here more persistent than elsewhere in consequence of the greater 
corneous development of the papules. But even in this case the great harshness would not be complete without the severe subjacent 
infiltration of the skin. 376 
DISEASES OF THE SKIN. 
or dirty-yellow color, rough and serrated, traversed with longitudinal ridges, and often fully four 
times as thick as normal. They often are so brittle that they attain very slight length. Lichen 
ruber is attended with a mild pruritus, which is worse in hot weather or when the circulation is 
increased. It also causes much suffering and distress by reason of the thickening of the skin and 
the formation of fissures, particularly in the lines of motion (hands, fingers, legs, etc.). The hairs 
also become thin and withered, and finally fall. In lichen ruber the mucous membranes are not 
affected. 
This disease runs a chronic, erratic course. The evolution of the papules may be tolerably 
rapid, and it may be slow. It has periods of remission of more or less length, and of well-marked 
exacerbations. It is symmetrical in its distribution, spreading from the upper parts of the body 
downward, usually in anatomical succession. It shows a tendency to attack a large extent of sur- 
face rather than a number of limited ones, and to invade the body in a uniform way. 
In some cases lichen ruber may exist upon a patient for long periods without any perceptible 
impairment of the health : in other cases, particularly the inveterate ones, a progressive emaciation 
occurs which leads to death, either from marasmus or exhaustion or by reason of some grave inter- 
current disease. All ages and both sexes and persons in all conditions of life and health seem to 
be affected by lichen ruber. 
Etiology.-We are ignorant of the causes of lichen ruber. All authors speak of them in any 
but a definite manner. We read of neurotic tendency, debility, gastro-intestinal irritation, and 
many other vague generalities, but in the details of the various cases reported nothing clear 
and precise is stated. I am, from my own studies, unable even to advance a theory as to the 
origin of the disease. 
Diagnosis.-Lichen ruber may at some period of its course resemble more or less strikingly 
eczema, psoriasis, pityriasis rubra, and lichen planus, but familiarity with the facts which have 
already been presented ought certainly to lead the reader to a correct conclusion. 
Eczema, in its papular state, may perhaps resemble lichen ruber for a short time, but its tend- 
ency to multiformity, to oozing, and its intense pruritus will usually establish its nature. Psoriasis 
does not run the peculiar course of lichen ruber, and rarely tends to a generalized development ; 
its lesions are of various sizes, very scaly, with little tendency to coalesce into patches, and prone 
to appear on parts where the epidermis is thick. Pityriasis rubra has no early papular stage, and 
in its later stages there is greater redness, more profuse scaling, in large and small flakes, and 
there are never the hardness, thickening, and deep corrugation which are to be seen in lichen ruber. 
If by any chance a few isolated or even grouped papules in the flattened stage of lichen ruber are 
seen on the localities so constantly invaded by lichen planus-wrists, hypogastrium, and anterior 
surfaces of the legs-the case might be regarded as one of lichen planus, but the error, if it should 
be committed, would soon be rectified by the characteristic course which is inevitable to papules 
of lichen ruber. 
As I have already pointed out, the distinctive features of the two diseases are so sharply 
marked and so prominent that no one but a tyro can possibly confound them. This statement 
will be borne out by an attentive study of Plates LIII. and LIV. 
Pathology.-Briefly stated, the pathological appearances in lichen ruber show an hypertrophy 
of all the layers of the epidermis, associated with an exudative inflammation in the papillae and 
papillary derma. 
Full details of the microscopic study of the sections taken from a typical case, together with 
lithographic drawings, are given in my essay on lichen ruber.1 
Seeing that pathological studies show that the morbid process begins in the papillae and papil- 
lary derma, it follows that the disease is not one peculiar to the hair-follicles, hence that the name 
1 See New York Medical Journal, Jan. 5, 1889. LICHEN RUBER. 
377 
pityriasis pilaris (with and without the word rubra), as given by French authors to this disease, is 
manifestly incorrect, inappropriate, and will be productive of confusion. 
In the study of very many sections of skin taken from one of my most typical cases it was 
only by means of the greatest diligence and most painstaking search that we found a specimen of 
a morbid hair with which to complete our pathological picture. The reason of this was that the 
portions of skin excised were taken from the abdomen and the outer thigh, where hairs were few. 
The truth of the matter is this : that the morbid process in lichen ruber in its active stage centres 
itself in the papillae and papillary derma, and that when it attacks regions rich in hair-follicles the 
latter become involved in the same sort of morbid change. But about the hair-follicles the papules 
become so prominently striking that a person who is not familiar with the disease in all of its stages 
and phases might very readily be led to conclude that it is essentially a disease of the hair-follicles, 
whereas their involvement is, in the majority of the cases, only a small part of the whole patholog- 
ical process. 
In this connection it is well to emphasize the clinical fact that when lichen ruber attacks the 
scalp it does not produce a typical papular eruption, but rather gives rise to appearances of red- 
ness and scaling which resemble pityriasis capitis. 
Prognosis.-The earlier writings of Hebra produced the impression upon the mind that lichen 
ruber was a deadly disease, that it was chronic in its nature, and that it gradually became compli- 
cated with asthenia and emaciation, over which all treatment was powerless. Later observations 
convinced this observer that at least some cases were curable by means of the long-continued ad- 
ministration of arsenic. Kaposi1 in his lectures says that we can with certainty promise a cure in 
all cases of this disease except those generalized ones in which severe marasmus has supervened. 
My experience with the disease in this country, where it is very rare indeed, is of course rather 
limited, including the observation of, in all, eight cases, but it has not convinced me of its inevit- 
ably deadly nature nor of its relentless progression from bad to worse. In my first case the 
patient at the age of thirty-eight became attacked with lichen ruber, which extended over nearly 
the whole body. Yet he did not fall sick, nor did his nutrition in any manner apparent to the 
senses suffer. In one month the disease nearly covered the body, and under treatment he pre- 
sented no evidence of the disease at the end of three months. Six years later, without known 
cause, he had a second generalized attack, similar as to the extent of the lesions and the absence 
of sickness and emaciation, and this was cured by energetic treatment in about two months. Since 
that time (1879) the man has remained free from the disease. 
The history of my second case shows very clearly that the first attack of lichen ruber was 
very extensive, lasted a full year, and then disappeared under the use of simple domestic remedies. 
A second attack, two years later, less extensive, however, lasted only a few months, and then dis- 
appeared spontaneously. The third attack, which began in March of this year (1888), is now, 
December 23d, practically cured, and during its existence the woman, though she became some- 
what thin during the summer, did not suffer from a condition of ill-health greater than she had 
experienced in past years when her skin was free from disease. I do not wish to be understood as 
drawing conclusions as to the modified severity, and I may almost say ephemeral course, of the 
disease in this country from these two cases, for I simply put on record the facts as they presented 
themselves. 
It may be further added that cases observed by others in this country were not, as a rule, 
attended with a deadly outcome, and that French authorities do not look upon the disease as 
inevitably tending to a fatal result. 
Treatment.-German authorities since Hebra's time have used arsenic in full and long-con- 
tinued doses in the treatment of lichen ruber, and the remedy is looked upon by them as unique 
1 Pathologie und Therapie der Hautkrankheiten, Wien, 1883. 378 
DISEASES OF THE SKIN. 
and specific in its action. While I have faith in the therapeutical action of this drug in many skin 
diseases, and have no doubt of its efficacy in some cases of lichen ruber, I am far from the opinion 
that the treatment can be summed up in one word, arsenic, as German writers seem to imply. In 
my first case, during two attacks of the disease the patient was treated by alkaline diuretics with 
the view of reducing cutaneous hyperaemia, and by a well-regulated system of external medication. 
In my second case neither arsenic nor alkaline diuretics were beneficial, and I may say that they 
were even harmful. A combination of citrate of iron, quinine, phosphoric acid, and strychnine 
improved the patient's appetite, allayed nervousness, and increased nutrition. Such was the ben- 
efit that she thought she derived from this combination that she showed a zeal to use it even to 
excess. My experience with the treatment of lichen ruber has thoroughly convinced me that suf- 
ficient stress has not heretofore been laid upon external treatment. The disease being a moder- 
ately exudative one with much epidermal increase, the indications for baths and cutaneous stimula- 
tion are, I think, clearly marked. Stated briefly, my experience teaches me that frequent hot 
alkaline baths (sal soda and borax ioo°-ii5° F.) are of the greatest value. They relieve cuta- 
neous hyperaemia, soothe the pruritus, carry off the effete epidermis, and undoubtedly cause absorp- 
tion of the products of inflammation. After numerous trials I have come to place high esteem 
upon brisk and thorough frictions of the affected surfaces with the compound tincture of green 
soap. These may be made every day. If possible, this tarry liquid should be rubbed into the skin 
two or three hours before the bath is taken, and where the surroundings of the patient will admit 
of it a mild friction after the bath should be made and the skin then left unwashed. If during- the 
day the patient cannot allow the film resulting from such frictions to remain on the body, the parts 
should be very sparingly anointed with vaseline. I am convinced that much of the chronicity of 
the disease may be mitigated and shortened by oily inunctions, and that the inelastic, roughened 
condition of the skin incident to the disease tends of itself decidedly to perpetuate its existence. 
Alkaline baths, as hot as can be borne with comfort, at night, followed by the tarry frictions, and in 
the morning repetition, if possible, of the same, but under any circumstances by the inunction of 
some bland oily preparation, such as vaseline, constitute, in my experience, the most decidedly 
valuable therapeutic measures. About the hands and fingers, and indeed on all parts where the 
epidermis is much thickened, especially where there are fissures (sometimes deep and painful), the 
greatest care should be exercised that the parts are fully and continuously covered. For this pur- 
pose I know of no remedy so beneficial as freshly-made diachylon ointment with balsam of Peru 
(5j and 3j). The action of this ointment may be enhanced when used upon the fingers or limbs, 
or indeed on any parts where a roller bandage can be applied, by moderate and graduated pres- 
sure. When the disease is severe about the nails great care is necessary in removing epidermal 
increase and in keeping the parts well invested in the ointment. 
THE SO-CALLED LICHEN RUBER MONILIFORMIS (CORAL-STRING "LICHEN 
RUBER") OF KAPOSI. 
This disease is of great rarity: Kaposi and Neumann have each seen one case of it. My 
friend Dr. George H. Fox exhibited a case before the New York Dermatological Society which I 
had the opportunity of seeing. My impression of the disease is that it is an anomalous form of 
lichen planus, which sometimes is developed in bead-like and linear shapes. It certainly differs 
radically from lichen ruber. I give Neumann's remarks concerning it as follows : This affection, 
shown in wood-cut Fig. 67, occurs on many portions of the body, is generally symmetrical on both 
sides, preferably near the joints, where it is especially marked, and consists of long rows or strings 
of reddish scar-like spots or spots resembling keloid, running in the long axis of the body, and LICHEN RUBER. 
379 
Fig. 67. 
The so-called Lichen Ruber Moniliformis, 380 
DISEASES OF THE SKIN. 
attacking principally the neck, which it completely surrounds. The spots are red and shining. 
From the anterior axillary region it extends to the arms, elbows, and so on to the upper third of 
the forearm, and it is here most marked. It is also seen on the hypogastric region and groins and 
on inner surface of thighs, where the coral strings have a diagonal course. These extend to the 
nates, posterior axillary region, over the buttocks, and from the lower third of the upper extremity 
to the upper third of the lower extremity. These strings generally run parallel with the long axis 
of the limb or body, converging, however, at the joints and diverging somewhat at the upper and 
lower half of the joint. These strings are arranged so thickly in oblique directions that the spaces 
between are rhombic in shape : on the neck this is particularly noticeable from under part of jaw 
to upper shoulder and clavicular region. 
Upon the hypogastrium these strings are from 6 to 12 cm. long, thread-like, and said threads 
the thickness of a quill, mostly single and crossing so as to form rhombic interspaces. These 
meshes are sometimes very dense. On the inner surface of the upper extremity they run mostly 
in a diagonal direction. The raphe scroti sometimes shows a single thick cord of the spots, and 
small ones are found on the right half of the scrotum. These strings begin at the peripheral ends 
thin as threads, gradually thicken and become more elevated as they converge, as, for example, 
near the elbow, where they are 1 cm. thick, cylindrical rolls. Their color is bright to a rosy red, 
with yellowish cast at first on the upper edges, then glistening and resembling coral. Their upper 
surface is entirely smooth, shining, and not desquamating ; their consistence is very firm. They 
are sensitive to pressure. At the beginning of the strings the grooves between them are plainly 
seen, but as they converge and thicken some of the grooves become filled up, and at this point 
of coalescence of the strings we have the lumps resembling little cherries. The strings them- 
selves resemble a string of coral, with here and there a young pearl of pale-red and yellowish 
glistening color. 
Another peculiarity observed upon the skin consists in very numerous punctiform brownish- 
red and dark-brown flat spots the size of poppy-seed, found between the coral strings as well as 
upon the other parts of the skin. These spots are round, polygonal, facetted, very firm, flat, at 
their periphery brownish red, on their surface are of a dirty-yellowish brown, glistening hue, and 
show for the most part at the centre punctiform depressions, as though they had been pricked with 
a needle. The spots or nodes are disseminated, numerous, arranged in circular fashion, but for 
the most part in long rows which follow the coral strings. 
Upon still other portions the spots are smaller, like linseed, and flat, found in the interspaces 
and in the region of axilla, shoulders, back of neck, bend of forearm, and next upon breast and 
hypogastrium. 
The third appearance is punctiform, small, diffuse, sepia-brown pigmentation of the skin. At 
first this is found intermingled in the region of the last above-mentioned spots ; lastly, upon nates, 
skin of buttocks, posterior portion of the upper extremity, as well as in the entire region of knee- 
joint and the neighboring posterior surface of the upper and lower extremity. 
The mucous membrane of the cheeks is covered with diffuse gray epithelial growth. LUPUS VULGARIS. 
Lupus vulgaris-the Latin adjective being used to distinguish this disease from lupus erythe- 
matosus-is a chronic hypertrophic disease of the skin caused by a small round-cell new growth, 
and characterized by the development of papules and nodules which undergo various phases of 
degeneration. It is a disease peculiar to childhood and early adult life, and it is rare to see it 
appear after the twenty-fifth year. It is found in weakly subjects and in those whose health is 
seemingly perfect. It may attack all grades of society, but is more commonly observed among 
the poorer classes. In America it is far less common than in England and on the continent of 
Europe. It is seen much more frequently in the female than in the male sex. Its course is mark- 
edly chronic, the new growths increasing slowly during months and years. It may disappear, and 
return again at variable periods. Beginning symmetrically, it may remain localized to the region 
first attacked, may extend to parts beyond, and may show itself upon regions remote from the 
primary focus. As a rule, lupus causes no subjective symptoms other than the discomfort incident 
to a chronic aphlegmasic nodule or ulcer, but when developed by contiguity or spontaneously on 
mucous membranes it often causes considerable suffering. It is not infrequently accompanied, 
particularly in young subjects, with enlargement, and even suppuration, of the cervical ganglia, 
and by inflammation of the Meibomian follicles, and certain affections of the eye which are com- 
monly looked upon as evidences of struma. 
Lupus vulgaris usually begins upon the face, rather more frequently about the alae nasi, but 
also on the cheeks, near and on the ears, on the eyelids, and on the upper and lower lips. In the 
vast majority of cases it is thus limited to parts above the patient's collar. It also may be found 
sometimes alone, but usually in association with some facial lesion ; upon the hands and fingers ; 
upon the forearm ; on the trunk, particularly near the nates ; on the legs ; and also on the feet and 
toes. The rarity of occurrence of the disease increases as we get down to the end of the fore- 
going list. 
Whereas in early years and in the earlier years of the evolution of lupus the disease is quite 
symmetrical in its development, as it grows old it very often shows a tendency to asymmetry. In 
some cases the disease is localized upon the lower extremities coexistent with patches upon the 
face and trunk. In others the upper extremity of one side may be involved at the same time as 
the lower limb of the other side. 
In middle and old age the disease is sometimes observed to spontaneously decline and 
disappear. 
Lupus vulgaris is essentially a chronic inflammation, which results in infiltration into any or 
all of the layers of the corium. In some cases the morbid process seems to expend itself super- 
ficially in the papillary derma, and to show no tendency to deeper evolution'. In others the deeper 
layers of the corium are invaded, and in still others the subjacent connective tissues are also 
involved. These facts alone are sufficient to convey the idea that the appearances produced by 
this morbid process are multiform and very varied, and this polymorphism is further increased 
and modified by the surface-changes which take place in the new growths. 
Lupus vulgaris begins in a mild and insidious manner by the appearance of one, several, or 
381 382 
DISEASES OF THE SKIN. 
many little pinkish-red or reddish-brown points, which may appear like mere dots of pinhead size, 
which are at first inappreciable to palpation, and seem to be inlaid in the skin like mosaics. These 
primary lesions with such a harmless look, and without any local or general systemic symptoms, 
are the forerunners of the most unsightly blemishes and deformities. They increase very slowly 
in size, and when they have attained an area of a line or two, which may take months, they may 
or may not be slightly salient and present a roundish Hat surface. At this time puncture of any 
of these lesions with a sharp-pointed instrument shows that their structure is not firm, and that 
they can be readily broken up or scooped out. As the papule increases in size its color becomes 
more pronounced, until a pinkish-red or brownish-red hue is produced. The contents of a lupus 
nodule present several appearances. In some cases the mass consists of soft, subacutely inflam- 
matory tissue, having no especially well-marked features. In many instances the scraped-out tissue 
will appear soft and gelatinous in structure, and comparable to wine jelly, to liquefied glue, and to 
apple jelly. In some cases, therefore, the appearances which strike the eye are those of a soft 
lowly inflamed dull reddish mass ; in others the skin seems to be the seat of a colloid degeneration, 
as if it were infiltrated by drops or masses of liquefied glue. Very often we find an indiscriminate 
intermingling of these soft red and brownish-red, gelatinous-looking lesions. By the growth of the 
lupus nodules their area is increased, and those near each other coalesce. Thus a patch is formed 
which may or may not present symmetry of outline. 
Usually, however, lupus patches are without definite shape, and are skirted by outlying pap- 
ules and nodules. The foregoing changes, which are essentially hypertrophic, are sooner or later 
complicated by degenerative processes which may be local or extensive. It is usually the case 
that when the papular, nodular, or tubercular phase of lupus is reached these lesions individually 
or collectively in patches undergo degeneration. They soften and ulcerate, and slowly become 
encrusted. This ulceration and incrustation usually go on quite slowly, without a free production 
of pus. The evidences of molecular decay in the lesions do not show themselves by an open dis- 
charging sore. On the contrary, the morbid tissue becomes dark, and almost imperceptibly a yel- 
lowish-green or bluish-red crust is formed. If this is uplifted, the surface beneath will be red, raw, 
uneven, more or less granulating, and even fungating. In most cases the ulceration remains 
superficial, and only very exceptionally does it extend to parts beneath and beyond the morbid 
focus of infiltration. 
Interstitial absorption or spontaneous resolution is sometimes observed in lupus nodules and 
patches, either alone or synchronously with molecular degeneration. Instead of the nodule becom- 
ing dark and scabbed, it gradually loses its slight elevation, sinks down, and becomes whiter by 
degrees, until a thin whitish or pearly depressed cicatrix is left. These degenerative and resolutive 
changes are usually seen in the older and more central parts of the disease. 
The extension of lupus is by two ways, either of which may exist alone or in combination with 
the other. Sometimes the lupus patch or patches may grow by peripheral extension. The increase 
may occur at any segment of or around the whole margin of the patch ; the advancing area may 
be of decidedly irregular outline, or it may be marginated in a roundish or festooned manner. The 
next mode of extension, besides peripheral increase, is by the evolution of outlying new lesions 
near the mother-patch or more or less remote from it. By the coalescence of these new growths 
and the increase in the mother-patch a large morbid surface may be formed. In this we reach the 
acme of the lupus picture, which is a composite one formed by the blending of multiform morbid 
changes. In the centre of a large patch there are to be seen crusts of varying size mingled with 
lesions undergoing degeneration and spontaneous resolution, perhaps excoriated surfaces, and 
atrophic scaly plaques, all scattered without order or symmetry of evolution. On the irregular 
round or festooned margin are also to be seen new lesions, which will sooner or later present the 
same features as are shown in the old central patches. Such is lupus vulgaris. Geo.S. Harris <8c Sone Lith-Phila. 
3art VII 
Fife,!. 
/. L u p u s E xeden s. 
2. Lupus Seupi^inosus . 
3. Ij 11})us Sei'Jncisiis . 
4. Chronic hyperplasia oC the \ nl\-ra: 7he so called Lupus \rilvae. 
Fife .4. 
Fife. 8. 
Fi§.2. 
LEA BFfOTHEFjS & CO. PUBLISHEFfS . PHILADELPHIA 
Dlate LV LUPUS VULGARIS. 
383 
Let us now study the disease as it is portrayed in Plate LV. The central figure (i) shows in 
a typical manner what is called lupus serpiginosus, or creeping lupus. Upon the nose and upper 
lip we see crusts seated upon a surface in which there is decided loss of tissue. These crusts are 
strikingly suggestive of lupus in their irregular size, their greenish-brown color, and in their site 
on the face of a young.girl. Over the cheek, as far as the ear, we find a confused mass of papules 
and nodules, which have undergone in some places absorption and in others ulceration. Then on 
the neck, as far down as the shoulders and sternal region, the striking picture is presented of an 
expanse of their whitish scar-tissue studded irregularly over with lupus papules and nodules, which 
are also present at the periphery of the cicatricial area. The development of new lupoid lesions 
upon territories previously traversed by the same disease is not at all uncommon. Besides these 
strikingly diagnostic appearances, this figure is interesting in the fact that it is evident that the 
lupus-infiltration took place in the upper and papillary derma, and remained there throughout the 
course of the disease. Had the morbid process extended deeper, we should see a more advanced 
state of the lesions and a thicker and more rugose scar-tissue upon the neck. Upon the nose and 
lip, however, the infiltration was, as is so commonly the case, involved in the skin quite deeply. 
In Fig. 2 the destructive form of lupus is shown, known as lupus exedens, and when of espe- 
cial severity and depth lupus terebrans. In this figure the color and site of the crusts are pathog- 
nomonic, and the evidences of quite deep destruction are well marked. 
Lupus of the face often leads to hideous deformities. The eyelids may be everted or 
destroyed, the ears much deformed, and the symmetry of the nose lost. The mouth even is 
often much distorted. 
Fig. 3 of Plate LV. also presents a characteristic picture of lupus which was at one time of 
the serpiginous variety. It will be seen that the whole cheek has been traversed by the eruption, 
and that the background of the picture presents a thin reddish cicatricial tissue. In time this red- 
dish tissue will become blanched like the scar-tissue on the neck in Fig. i. At the margin of the 
red area of Fig. 3 a number of heaps of epidermis, resembling a severe psoriasis, are shown. 
Some are large, others are small, but all of them are formed of piled-up layers of effete epidermis. 
This feature of the disease constitutes what has been dignified by the title lupus exfoliativus. This 
condition is simply a coincidence. As a result of the chronic inflammation in the skin itself, hyper- 
plasia of the corneous cells occurs in a greater or less degree. Sometimes the scaling is thin, 
papery, limited, and moderate in quantity. At others the epidermal increase is considerable, owing 
to the chronicity of the subjacent morbid process. In the centre of the morbid area the large 
greenish-brown, uneven, irregular, elevated crust, mingled with epidermal masses, stands forth 
in a strikingly distinctive manner. Besides these various clinical features of lupus, there are yet 
others to be considered. 
A superficial ulceration is sometimes seen to accompany the disease, to which the term lupus 
exulccrans has been applied. The condition is commonly seen in the serpiginous form, and there 
is really no need of a second name. In wood-cut Fig. 68 lupus exulcerans of the hands is well 
shown. 
It sometimes happens that the lupoid infiltration is very great in the papillary derma, and that 
ulceration or necrobiosis is absent. In these cases we find thick, elevated, and irregularly warty 
patches are formed, which have been termed lupus hypertropliicus and lupus verrucosus. This 
form of the disease is seen upon the hands and forearms, as shown in wood-cut Fig. 69, also about 
the nates and on the legs. It is peculiarly rebellious to treatment. 
Lupus has been known to lead to cancerous degeneration. It may attack the mucous mem- 
branes of the mouth and nose, producing thickening of these tissues of a reddish color, which 
soon forms into grayish-red patches. These are prone to ulcerate and to leave irregular and 
foul ulcers. 384 
DISEASES OF THE SKIN. 
Lupus is stated by some authors to attack the external female genitals, but there has never 
been reported a satisfactory case. In Fig. 4 of Plate LV. a picture is given of a singular lesion in 
a patient who was under my observation at Charity Hospital for many years. From its general 
appearances and course it might well have been regarded as a very satisfactory case of lupus of 
the vulva, but the microscope showed that the morbid tissue-changes were those of inflammatory 
tissue. 
Fig. 68. 
Lupus Exulcerans. 
It is claimed by some authorities that lupus vulgaris is simply a dermal tuberculosis, while 
others are less pronounced in their opinion and claim a partial relationship. As there is still a 
conflict of opinion, some authors denying that there is any relation between the two diseases, it 
is well to leave the question as yet sub judice. 
It may be well in this connection to state that Riehl and Paltauf have described, under the 
title tuberculosis verrucosa cutis, a chronic warty and hypertrophic affection which is sometimes 
found on the hands of persons who handle decomposing animal matters. In England and America 
this condition, which Riehl and 
Paltauf think so rare and start- 
ling, has long been known as 
verruca necrogenica, or post- 
mortem warts. To the Ger- 
man observers we are indebted 
for the fact that in these mor- 
bid growths tubercle bacilli are 
found. Unna thinks that lupus 
verrucosus and verruca necro- 
genica are identical diseases. 
Under the title tuberczilosis 
papillomatosa cutis my friend 
Dr. Morrow has described a 
case presenting enormous papillomatous lesions about the face, which were said to have their 
origin in the tubercle bacillus. 
o 
Etiology.-Until the question of the claimed relation between lupus and the Bacillus tuber- 
culosis is settled in an absolutely satisfactory manner we cannot speak definitely of the cause of 
lupus vulgaris. The old-time claim that lupus is an evidence of struma is based upon clinical facts 
which are occasionally presented in a very striking manner. Then, again, we find lupus in persons 
who are not scrofulous, and in whom no lowered standard of health can be ascertained. Lupus is 
Fig. 69. 
Lupus Vulgaris (hypertrophic and verrucous). LUPUS VULGARIS. 
385 
sometimes seen to develop upon portions of skin which have been the seat of injury and around 
the sinuses leading to degenerated lymphatic ganglia. 
Further than the foregoing we cannot go without entering the boundless area of hypothesis. 
Pathology.-The lupoid lesions belong to the class of small round-cell granuloma. 
Diagnosis.-Usually the history of lupus vulgaris and its appearances are so striking that little 
difficulty is experienced in diagnosticating it. This disease may be mistaken for the non-ulcerating 
and ulcerating tubercular syphilides. Lupus usually begins in early life ; syphilis usually has a his- 
tory and is contracted commonly at adult age. Lupus has a history of the rather methodical pro- 
gression of a similar and definite order of lesions ; syphilis unfolds itself with lesions which com- 
monly differ more or less strikingly with each outburst. Lupus shows a tendency to invade the 
face alone ; syphilis in one form or several is found upon the body generally. In any very doubt- 
ful case specific treatment may be adopted, and the result will usually be that syphilitic lesions 
wither, while lupoid manifestations will remain unchanged. 
Rodent ulcer may sometimes be mistaken for lupus, but the doubt should soon be cleared up. 
Rodent ulcer begins as a little pimple or scaly nodule, or upon a birthmark of some kind, or as a 
minute and rebellious encrusted fissure ; all of which may ulcerate. It is a disease of middle and 
advanced life, usually unique in development, unsymmetrical, and its lesions present a firmness of 
structure not seen in lupus. The favorite locality of rodent ulcer is the middle third of the face, 
or that zone which takes in the nose, eyes, and ears. 
Prognosis.-Though the disease is chronic in duration, its long-continued existence is in many 
cases compatible with perfect health. When such delicate parts as the eyes, nose, larynx, and 
pharynx are involved, the prognosis is grave in accordance with the extent of the lesion and of 
its propinquity to vital parts. 
Treatment.-The traditions of dermatology compel us to enumerate cod-liver oil, preparations 
of iron-notably the syrup of the iodide-the hypophosphites, quinine, hygiene, and fresh air. 
They are all good, and in appropriate cases should be used according to indications (for any devia- 
tion from the health standard in a lupus patient should be treated), but they will rarely if ever 
cause the disappearance of a single lupoid nodule. The rule, therefore, should be to put all cases 
upon as perfect a plane of health as is possible. 
The local treatment is the one upon which we must pin our faith. Our object, briefly stated, 
is to remove the new growth with as little damage to the surrounding tissues as possible, and to 
produce as smooth and sightly a cicatrix as we can. To this end our remedies and measures should 
be used with the greatest care and precision. Superficial lesions will usually yield to our now 
numerous mechanical measures and leave satisfactory scars. Deeper ones, however, while they 
require active treatment, must always be handled with the fear before us that carelessly radical 
treatment may leave unsightly fibroid and retractile cicatrices. 
In the early stages of lupus the little nodules may be destroyed by careful puncture with 
nitrate-of-silver cones or with fine-pointed pieces of wood dipped in carbolic or chloro-acetic acid. The 
patches may be painted with collodion and salicylic acid, or the same combined with carbolic acid, 
creasote, or pyrogallic acid. Lactic acid has been praised for its effective energy, and my friend 
H. G. Piffard speaks in glowing terms of his success with a 10-20 per cent, hydronaphthol plaster. 
According to Unna, a 25-50 per cent, salicylic-acid plaster is sometimes followed by marvellously 
good results. 
In many cases the thermo-cautery is productive of excellent results, but great care is necessary 
in selecting an appropriate instrument and in its management. Various ingenious instruments 
have been devised for this purpose, notably those of Besnier of Paris. 
The dermal curette or sharp spoon is by far the simplest and most effective means at hand 
for the treatment of lupus. By it the diseased tissue should be scraped away, the operator always DISEASES OF THE SKIN 
386 
bearing in mind that the sightliness of the final result is equally as important as the thoroughness 
of erasion. 
Balmanno Squire1 of London, among his many excellent contributions to the knowledge and 
treatment of diseases of the skin, has devised a knife which he calls the multiple linear scarificator. 
"The incisions are methodically separated by interspaces sufficiently broad to avoid the risk of 
mortification, and each scarification is delayed until (within a few days) the previous incisions have 
healed." With care and attention to the peculiarities of the case this method may be of benefit in 
many severe and long-standing cases. Between the intervals of operation a salicylic plaster may 
be applied or the surface may be painted with salicylic acid and collodion. 
2 On Lupus Vulgar's, or the Wolf, London, 1888. MOLLUSCUM FIBROSUM. 
Molluscum fibrosum occurs in the form of sessile and pedunculated tumors of varying sizes, 
which appear upon the body generally in limited or in very great numbers. They are composed 
of new growths of connective tissue, and, while the majority of them are permanent, spontaneous 
involution may occur in some tumors. They occur in great profusion upon the trunk, also on the 
head and upper extremities, and more sparsely upon the lower ones. They are found in all sizes, 
from the still inappreciable pea-sized subcutaneous nodule to tumors as large as a clenched fist or 
a cocoanut or a child's head. Besides the tumors proper, we find flaps or apron-shaped masses of 
skin which are of similar histological nature, and which are termed dermatolysis. 
The only way to convey a clear idea of these tumors is to study them in the light of their 
mode of development and course, since by that method all of their clinical features may be clearly 
brought out. 
The first stage in the development of fibroma molluscum is seen to be a slight uplifting of the 
skin in the form of a somewhat round spot having an area of a quarter of an inch and even less, 
being slightly convex, and at its highest part being frequently at this stage about one-half a line 
higher than the normal plane of the skin. These young spots or elevations are at first of a very 
light pink; later many are of a rosy hue, even of a reddish and slightly bluish color. This increase 
of color is not absolutely limited to the surface of the morbid growths. Examined thus early in 
their development with the tip of the finger, the molluscous tumor feels soft and much more readily 
depressed than the rest of the skin, and conveys the idea that the whole derma is slightly thinned. 
As the tumors grow larger, and when they have attained a diameter of about half an inch, they 
can be studied with much more accuracy. Thus, if the tip of the index finger is placed directly 
upon one of these spots at this time or at any time until it undergoes retrogression, if that occurs, 
it can be pressed gradually and slowly downward into the skin, and a sensation is conveyed as if 
the integument is pierced by a hole. Undoubtedly there is a round or oval spot of thinned derma 
in which the uplifted tissues can be invaginated : this thinning of the derma proper can be readily 
appreciated from the time of the earliest appearance of the tumors as slight soft swellings up to 
their reaching the size of a nutmeg and perhaps later, not only by pinching it between thumb and 
forefinger or by grasping a fold between the blades of a forceps horizontally held, but also by 
pressing very gently but firmly with the end of a probe or other small instrument, and then sud- 
denly withdrawing the pressure. Thus treated, the skin over the morbid growth is easily indented 
and slowly rights itself, whereas on the healthy skin the rebound is prompt and sharp. Up to the 
time of the maturity of the molluscous tumor it is evident that there is structural continuity between 
the underlying morbid growth and the skin above. This fusion of the newly-formed elements with 
the skin takes place quite early in the development of the molluscous tumor. In some instances 
I found very small subcutaneous tumors by careful palpation and examination, which later on con- 
tracted adhesions with the skin, and later became salient. 
The development of fibroma molluscum is seen, therefore, to begin subcutaneously-whether, 
as Rokitansky thinks, in the deep connective-tissue meshes, or, according to Fagge and Howse, in 
the connective-tissue wall of the hair-follicle, or further, according to Virchow, Kaposi, and many 
387 388 
DISEASES OF THE SKIN. 
others, from the connective-tissue framework of the fatty tissue, I am unable to say. Beginning 
as a minute circumscribed neoplasm, it pushes upward and contracts adhesions with the overlying 
skin ; then, increasing in volume and area, it shows itself as distinct tumors at first, and in some 
cases in all stages covered with skin of normal hue, or at first of slightly pinkish color, which may 
increase to a red, and even to a red-and-blue or mottled color, according to the condition of pres- 
sure upon the vessels and capillaries in the overlying skin. With this explanation I think nothing 
further is required in describing the color of the tumors of fibroma molluscum. 
When the tumors have reached a diameter of nearly one inch their course can be studied 
quite accurately. At this time the tumor will be either round or oval, according to the direction 
of the bundles of the strong subcutaneous connective-tissue framework of the part invaded. On 
the back they are mostly round, while on the sides -of the body they are oval, and their axes show 
a tendency to follow the oblique line of the ribs. Whether round or oval, in general it may be 
said that a tumor reaches its full development when it occupies an area of an inch, though they 
may grow much larger. Thus formed, it may remain for a long time indolent and unchanged, or 
it may slowly increase and become hard and firm ; and whereas it was at first to the feel rather soft 
and slightly compressible, it becomes hard and unyielding as it slowly increases in height and area. 
Or from the period of full development it may gradually retrogress, and later be replaced by the 
warty growths, pouches, or nipples to be considered later on. My studies of my own cases and 
my reading of those of other observers teach me that, in general, retrogression of the tumors of 
fibroma molluscum occurs mostly, and perhaps I may say only, in young subjects, particularly in 
those under twenty years, and that beyond thirty it is very exceptional to see involution. I have 
never seen it at this age. 
When the tumor reaches a goodly size certain changes may be observed in its shape. Thus 
it may become broader at its base and result in a sessile tumor, in which event it is usually perma- 
nent ; or, again, the protruded portion of the tumor may in- 
crease in volume in a greater degree than at its base. The 
result is that we find, later on, a pedunculated tumor which, 
continuing to grow, may become pendulous, and constitutes 
then what the older writers called molluscum pendulum. 
A clear idea of molluscum fibrosum may be gained by a 
study of Fig. i, Plate LVI. Over the face and anterior sur- 
face of the trunk and outer aspect of the arms is a vast num- 
ber of sessile tumors, from those of a very minute size up to 
well-developed lesions. With one exception these tumors are 
sessile ; that is, broad at their base. On the side of the right 
nipple a warty-looking, pedunculated tumor may be seen. In 
the figure the scattered and grouped conditions of the tumors 
are well shown. Their color is also well brought out, some 
being of flesh tint, others pinkish, and still others having a 
decidedly bluish hue. It is sometimes possible to see an inter- 
lacement of venous capillaries on some of these tumors. It is 
not at all uncommon to find one or more truly pedunculated 
tumors among such a number of the sessile variety as are here shown. Then, again, we not 
uncommonly see cases in which one or perhaps several pendulous tumors are present upon the 
body. An excellent delineation of molluscum fibrosum pendulum is given in wood-cut Fig. 70, in 
which the large tumor hangs by a narrow pedicle from the outer aspect of the thigh. In this case 
the overlying skin was rather thin, but seemingly normal. In Fig. 71 a molluscous tumor hanging 
from the sole of the foot is shown, and in wood-cut Fig. 72 two tumors are seen to hang down 
Fig. 70. 
Molluscum Fibrosum Pendulum. Qeo.S Harris & Sone Lith-Phila 
Part VIII 
Fig.l 
1 .MOLLUSCUM F1BROSUM. 
2. SCLERODERMA. 
Fig 2. 
LEA BROTHERS & CO. PUBLISHEPS , PHILADELPHIA 
Plate LVI MOLLUSCUM FIBROSUM. 
389 
from the sternal region of a woman. These tumors are outwardly to the touch soft, and some- 
times present the sensation of a 
scrotum between the fingers. Their 
contents give the impression of a 
mixed interlacement of small and 
large bundles of fibres somewhat re- 
sembling a varicocele. Sometimes 
they feel like a flaccid hydrocele 
with a bunch of fibres within it. 
In very old cases they are hard, 
firm, and very fibrous. 
Further, a tumor may grow 
large of itself, and even may fuse 
with other tumors ; then the activity 
of growth in the elevated portion of the neoplasm continues with rapidity and great increase, and 
a true flap of skin is formed, called sometimes 
dermatolysis. The cases of dermatolysis in which 
there are no coexistent fibroma molluscum tu- 
mors have undoubtedly begun and developed 
in the manner just described. One of the most 
notable examples in literature is the case of Mar- 
cacci, in which the tumors sprang from the occi- 
put and base of the neck, and developed into 
mammoth proportions, covering large parts of 
the anterior and posterior surfaces of the trunk. 
They are shown in wood-cut Figs. 73 and 74. 
These dermatolytic tumors may reach enor- 
mous size. They are usually found on the occip 
ital region and neck, the trunk, particularly on its anterior and lateral surfaces, the outer part of 
the thighs, the buttocks, and the 
face. They sometimes become 
ulcerated between their folds and 
give forth a disgusting odor. 
They are both very disfiguring 
and the cause of much discom- 
fort by reason of their unwieldi- 
ness and their interference with 
muscular action. 
Let us now go back again to 
the study of the course of the 
fibroma molluscum. When the 
tumors had reached an area of 
not quite half an inch their ele- 
vation was hardly sufficient to 
allow of their manipulation, ex- 
cept that they could be invagi- 
nated by a small finger. When 
larger they were readily examined, and between the thumb and forefinger uniformly a sensation 
Fig. 71. 
Molluscum Fibrosum Pendulum of Foot. 
Fig. 72. 
Molluscum Fibrosum Pendulum. 
Fig. 73. 
Fig. 74. 
Molluscum Fibrosum; Dermatolysis. 
Molluscum Fibrosum; Dermatolysis. 390 
DISEASES OF THE SKIN. 
was conveyed as if there was contained within a number of thread-worms or of boiled vermicelli. 
In such tumors the neoplasm is soft and gelatinous, and may be attended with exuberant growth, 
since they may either increase rapidly or begin to wither and undergo involution. This condition 
is in marked contrast with the feeling and consistence of the tumors of slow growth seen in older 
persons, in which we find a perhaps tabulated and perhaps solid tumor, but usually hard, firm, and 
resistant to pressure. In the case under consideration almost all of the tumors were of this soft 
consistency, while in other cases of older subjects I have observed scarcely any tumors but those 
of fibroid structure. I am led to believe, therefore, that the softer and more exuberant tumors are 
seen in earlier life, whereas the harder and more dense ones are developed later in life. Certain 
it is that the older the patient grows the more slowly do the tumors grow, and that with the slow- 
ness there is greater density of structure. As a corollary of this, it may be stated that in propor- 
tion as the tumor is of rapid development and of succulent structure, so is its tendency to involu- 
tion greater, and that in proportion as the growth is slow and condensed, so is the future of the 
tumor that of permanence. When removed, the soft tumors are found to be of a gelatinous struc- 
ture and to adhere to the fingers, while the older ones are firm and resistant. Under the micro- 
scope the former are found to be composed of a succulent, oedematous, wavy connective tissue 
with many cells, while in the latter the fibres are firm and not oedematous, and the cells less 
numerous. 
Let us now study the features observed in the process of retrogression or involution of the 
molluscous tumors. The soft contents of the tumors are distinctly adherent to the cutis above 
them in the period of full development, and the atrophy of the skin which may occur is found to 
be in exact proportion to the rapidity of development and to the firmness of the structure of the 
tumor. In the soft form the skin may be-or at least often seems-perfectly normal in thickness, 
while over old and firm tumors it is generally more or less thinned and adherent to the neoplasm. 
In young persons, therefore, there is very little destruction of the skin up to the period of full 
development of the tumor ; later on it may occur in the manner yet to be described. 
Being fully matured, the tumor, which undergoes retrogression, gradually grows more pedun- 
culated. It seems that then the skin around it begins to grow narrow, and that the mouth of the 
pouch of skin, if we may thus term it, grows smaller, just as by the strings of a purse we may 
close it more or less. Indeed, this gradual encroachment of the surrounding skin upon the base 
of the pouch-like tumor plays an important-perhaps the most important-part in its retrogression. 
Coincidently with this circumferential closing up of the skin the invagination of the tumors grows 
less and less easy of accomplishment. Evidences of involution are now seen in the tumors them- 
selves. The adherence of the neoplasm to the derma at the period of development being well 
marked, it may be found to become detached gradually, so that the overlying skin can be readily 
pinched over the tumor. To be more minute, at first the skin proper can only be pressed together 
by forceps held horizontally to the plane of the skin, and very soon a fold can be grasped between 
the thumb and forefinger. 'Then as the neoplasm slowly retrogresses it can be felt to gradually 
melt away or withdraw in salience and breadth, and then continue until in some tumors only a 
fibrous cord can be felt contained in a flabby pouch of skin. Traction on this showed that the 
cord was deeply attached to the connective tissue underneath. In proportion as the neoplasm 
melts away, so does its cutaneous envelope and the encircling ring of skin at the base of the tumor 
undergo change. The skin itself becomes flaccid, and then gradually wrinkled. The color pales 
visibly, since the tension of the capillaries of the skin is much lessened. The circumferential clos- 
ing of the skin around the base of the tumor goes on gradually and slowly, while coincidently the 
skin becomes thinned and more wrinkled, and the tumor less salient, more circumscribed in area, 
and difficult to grasp. This we may term an intermediary stage in the life of the molluscum ; it is 
no longer a tumor proper, nor has it yet become a warty growth. In the case which forms the MOLLUSCUM FIBROSUM. 
391 
main basis of this description the area of the tumors was about one inch before the retrograde 
changes took place, yet I saw the process overtake larger and even smaller tumors. The further 
features of involution are similar and continuous to those already described. The circumferential 
constriction at the base of the tumors steadily goes on, and there is often an appreciable thickening 
of the skin at this point. The hole in the derma gradually closes up. and in time no evidence of 
the neoplasm can be seen or felt. What has become of it we cannot say. It is probable that the 
young connective tissue forming the growth has undergone fatty degeneration, and has been 
absorbed. It is an interesting question yet to be solved, whether the ring-like constriction of the 
skin at the base of the tumor has any influence on its degeneration. Whether, in proportion to 
the growth of the ring-shaped constriction, there is a concomitant pressure on the vessels which 
tends slowly to strangulate the growth of the contained neoplasm, we are unable to state. 
While the above-described changes have been going on in the neoplasm and in the circum- 
ambient zone of skin, the cutaneous envelope of the tumor, which has become a mere empty pouch 
of skin, grows slowly and gradually less in height and area. In the case upon which these features 
were observed these warty growths or purse-like outgrowths of skin were of various sizes, from 
that of half an inch in length and from two lines downward in area, in every degree, until they 
were found to be the size of a canary-seed and even as small as bird-shot. The larger ones could 
be extended from the skin fully half an inch as a thin, wrinkled pouch, translucent and firmly 
continuous with the plane of the skin. This long outgrowth, when traction ceased, gradually 
subsided, coiled itself up, and presented the appearance of a pedunculated mole or warty 
growth. 
Very many remained thus large, forming tumors of the size of a pea, while the greater num- 
ber underwent slow retrogression until they finally became a little warty growth which could scarcely 
be pinched between the nails. Thus we see that what had been a well-marked tumor of fibroma 
molluscum had successively become an undoubted cutaneous pouch, which had gradually withered 
until it had formed either a pea-sized pedunculated tumor or even a very minute warty growth. 
On the space of four square inches I counted in one case eighty of the minute warty growths 
of various sizes. Seen in a group, they look like so many minute nipples, being in color very 
much like the virgin nipple or the scrotum of the young boy. In some a faint brown color could 
be seen, but none of them possessed the hue of normal skin. To the touch they presented a 
peculiar soft, velvety sensation. The most minute ones thus remain, and never undergo further 
retrogression. 
In the early part ol the stage of what I may call warty formation the distended skin may be 
invaginated by means of a probe, and this procedure may be practised generally in the larger and 
permanent growths. But as the outgrowth grows smaller invagination by any instrument becomes 
more difficult, and is finally found to be impossible. 
The time occupied in the development of the tumors varied. I traced the course of several 
tumors until they attained a diameter of half an inch, which occupied a period of four months, and 
again I saw several of the same size fully eight months in reaching their growth, while in other 
and larger ones fully a year elapsed before maturity. As the patient grows older the time of 
development and decline becomes more prolonged. The period of involution and retrogression 
also varied in length. I saw several tumors which grew to a diameter of half an inch which occu- 
pied eight months in the period of involution. But the patient assured me that his relatives and 
he himself had seen fully two large crops of tumors come and go and leave the warty outgrowths 
in the period of one year. He thus had had successive crops from his earliest days. 
The small velvety tumors thus produced are called acrochordon, the large pedunculated ones 
naevus mollusciforme. 
Etiology.-Molluscum fibrosum may be of hereditary origin, and may originate in persons 392 
DISEASES OF THE SKIN. 
mentally and physically below par, as claimed by Hebra. It is found also in those who are seem- 
ingly perfectly healthy. Localized tumors may occur as a result of traumatism. 
Diagnosis.-Multiple fibromatous tumors may be distinguished from those of molluscum seba- 
ceum by the absence of the central depression so common in the latter. Large tumors may be 
diagnosticated by their interior fibrous condition and by the absence of lobulation: 
Treatment.-When single and pedunculated the tumors may be removed by appropriate 
surgical procedure. ' SCLERODERMA. 
Scleroderma is a chronic affection manifesting itself in diffuse, patchy, and band-like infiltra- 
tions of the skin. It is found more frequently upon the upper portions of the body, particularly the 
scalp, face, neck, arms, and forearms, and also on the trunk. The legs are less commonly attacked, 
and almost always coincidently with some other and upper portion of the body. As a rule, the 
disease is symmetrical in its development, in the sense that it occurs on both sides of the body, but 
the bilateral patches or bands may not be seated on symmetrical regions. The disease may excep- 
tionally occupy the whole body or it may be found on several parts. It may be limited to the face 
or neck, to the upper extremities, or it may exist only on the trunk. 
For purposes of clinical description scleroderma may be divided into two forms-the first con- 
sisting of large areas of morbid integument, and perhaps occupying a whole region and even 
more ; and second, a form in which the skin in spots or patches or ribbon-like bands is involved. 
The first symptoms of scleroderma are a swollen and infiltrated condition of the skin. If the 
disease is seen quite early, the oedema will be found to be of a doughy consistence, and perhaps 
more or less sharply marginated. In most cases, however, a distinctly indurated infiltration of the 
skin is the symptom which is first observed. In the early stage a moderate amount of salience is 
seen in a sclerodermatous patch, but it seems to be an elevation caused by the bulging out of the 
skin by reason of its condensation, rather than in consequence of its great hypertrophy, for it is 
doubtful whether it is really thickened. In its incipient stages the color of the skin in scleroderma 
may be natural, perhaps a little more than usually pallid, or of a pinkish or slightly violaceous pink 
hue. If, however, any symptoms of subacute or very subdued erythema are present, they disap- 
pear before long, and then the skin takes on appearances which are strikingly characteristic. In 
the early stages little if any disturbance in the corneous layers is seen. But as the induration 
slowly and surely becomes condensed, the skin becomes white, firm, cold, and has a corpse-like 
rigidity. Sometimes it has the color of white wax, of a billiard ball, or of alabaster. It may be 
slightly scaly or decidedly so, and may be freckle-like in spots or large patches, or pigmented, of a 
brownish hue. In some cases this pigmentation comes on quite early, in others less promptly, and 
in many instances no discoloration is to be seen. To the touch sclerodermatous skin is often as 
hard as a board ; again, it may be brawny and leathery, and in some cases it is of stony density, 
as if it were petrified. Its hardness varies in different cases and often in different parts of the 
same individual. When pressed by the finger-tip in its early stage slight pitting may be produced 
in scleroderma, but in the fully-developed rigid condition no impression whatever is produced. In 
the early stages likewise a fold of sclerodermatous skin may with difficulty be pinched up, but 
gradually the process becomes more difficult, until at last it is utterly impossible. As the con- 
densation occurs in the skin it seems to become welded or soldered to the underlying connective 
tissues, and gradually it fuses with them and becomes immovably attached to the fasciae, bones, or 
joints. It of course will be understood that this extreme condition is reached more or less grad- 
ually in all cases. In the early stage of the disease the line of demarcation between the sound 
and morbid tissues may be but indistinctly made out. In the stage of condensation, however, it 
can always be sharply defined. 
393 394 
DISEASES OF THE SKIN. 
The surface appearances in fully-formed scleroderma are varied. In some cases the areas are 
smooth, whitish, and shining ; in others they may be covered over indiscriminately with telangiec- 
tasic spots and pigmentations in bands, striae, and in diffuse form. Sometimes the pigmentation is 
almost of black hue. In all cases with the condensing infiltration of the skin the surface lines 
and furrows become gradually less distinct, until they finally are wholly effaced. The sebaceous 
secretion is more or less diminished, and the perspiration may be absent. But in some cases the 
activity of the sebaceous glands is seen in hypersecretion, and that of the coil-glands in a cold 
sweat. 
In this stage of marble-like hardness the skin may remain for long periods without undergoing 
any visible change. Coincident accidental ulcerating lesions which are usually very difficult-to heal 
may appear upon it. 
If we may term this indefinite period one of condensation, we may call the next period that 
of atrophy. Gradually and imperceptibly the skin becomes thinner, while it still retains its con- 
densed structure. This atrophy of sclerodermatous skin is of very uncertain and erratic course. 
It may be slow or rapid in its development; it may involve a whole patch of the disease or a few 
or all of them ; it may be limited in extent, or involve a whole morbid surface ; it may take the 
form of round or irregular areas, or it may be band-like in shape. In some cases a large surface 
of sclerodermatous skin in the stage of condensation may be replaced by a band-like state in the 
stage of atrophy, showing that some portions of the infiltration have undergone absorption. 
The atrophic bands and areas of scleroderma vary within marked degrees. They have a 
smooth, exceptionally wrinkled, white, sometimes glistening and tendon-like hue, sometimes irreg- 
ularly pigmented, and often slightly scaly, and seem to consist of a fibrous tissue covered with epi- 
dermis. They may be as thin as parchment or quite thick ; sometimes they can be pinched into 
folds without difficulty ; at others they are immovably fixed over the deep and hard tissues of 
fasciae, bones, and joints. They undergo no further change. 
A happier outcome than the above may occur in scleroderma. The indurated surfaces may 
gradually become softer, more nearly of normal hue, more elastic, and more movable over the 
deep parts, until a normal or very nearly normal condition is reached. Unfortunately, this perfect 
involution is not common, nor does it generally occur in the full extent of tissue involved. 
We are now prepared to study the varying appearances of scleroderma in the various por- 
tions of the body. Upon the face the results of scleroderma are very striking. The countenance 
becomes changed and the features rigid, stony, and void of expression. Under all or any emotions 
there is absolutely no alteration. The eyes are staring and the lids immobile, the mouth slightly 
open, but scarcely if at all capable of motion, and the alse nasi pinched and drawn. This expres- 
sion is often like that of a marble bust or ghastly like that of a corpse. The arms are always more 
or less deformed and distorted. If there be only a band on the flexor aspect, the forearm becomes 
bent on the arm. If the hardening process envelops the whole limb, the latter becomes much 
reduced in size. As the disease increases the hide-bound condition becomes more pronounced, 
the skin firmly encircles the muscles and is immovably fixed over the joints. In Fig. 2, Plate LVL, 
scleroderma affecting the arm and forearm is shown as well, perhaps, as such a difficult subject for 
colored illustration can be done. The first point which strikes the eye is the flexed condition of 
the limb, which always increases gradually until perfect immobility may be produced. The band- 
like form of the disease is shown over the antero-exterior surface of the arm. Elsewhere the 
disease gives a peculiar puckered and gnarled appearance to the tissues. In this case a slight 
pinkish tint may be seen, but the color may be, as already stated, white, pearly, and like parchment 
or like an old billiard ball. The function of these members is impaired or destroyed. 
The deformities produced by scleroderma upon the hands and fingers, and upon the feet 
and toes less frequently, may be moderate flexion or a claw- or talon-like distortion. In bad SCLERODERMA. 
395 
cases each phalanx becomes contracted, withered, and curled up on the next one, until the fingers 
become rigidly and immovably crumpled up upon the palm. This condition has been called 
" sclerodactylic." 
Upon the body the deformity will be a band-like or diffuse binding down of the tissues, and will 
of course vary with the seat and extent of development of the morbid process. In this way the 
chest-walls are disfigured and the symmetry of the breast more or less destroyed. When the 
chest-walls are largely involved in this hide-bound condition, serious interference with respiration 
is produced. 
Upon the legs also the deformity will be in keeping with the site and extent of the disease. 
The mucous membranes of the mouth, tongue, gums, palate, and pharynx may be involved in 
the same morbid infiltration. 
Scleroderma at its invasion may be accompanied by no systemic symptoms. Later on, rheu- 
matic symptoms of varying severity and allied changes within and outside of the heart may super- 
vene. But these complications are by no means constant. Sclerodermatous patients may for long 
periods enjoy seeming good, and even robust, health. In later stages grave intercurrent diseases 
usually supervene and kill the sufferers. 
As regards local symptoms, no general and definite statements can be made. In some cases 
there is neither spontaneous pain nor does the pressure of the morbid parts cause any uneasiness. 
In others pain and tenderness exist, or may be produced by pressure of any kind. It is never 
described as very severe. 
In the course of Raynaud's disease there is frequently a pale, waxy, corpse-like condition of 
the skin of the fingers, which seems thickened and firmly bound around the bones. This condi- 
tion, which is due to local asphyxia, and not to fibrinous infiltration with lymphatic complication, has 
been wrongly called scleroderma. It has no pathological relation whatever to the latter disease. 
In most cases the normal sensibility of the skin is uninfluenced during the whole course 
of the disease. In some, however, it is gradually impaired until an anaesthetic condition may 
be induced. 
In its course scleroderma may be quite rapid or very chronic. The disease lasts months and 
years, during which, in the most erratic and uncertain manner, it may go from place to place, hav- 
ing periods of well-defined exacerbation and longer or shorter periods of remission or quiescence. 
Then, again, in some cases it may attack a limited region, usually symmetrically, and expend itself 
in all its stages upon that, leaving the rest of the body free. As has already been stated, perfect 
involution may occur in small or large areas, or deforming atrophy may result. 
At the present day it is impossible to state definitely whether scleroderma and morphoea are 
due to one and the same morbid process. Clinically, they are in many particulars distinct; hence 
they should not as yet be merged the one in the other in clinical description. 
Pathology.-The most diverse opinions are held by microscopists of high repute as to the 
pathological processes involved in this disease. It may be stated, however, that in all probability 
it depends upon both increase of the connective-tissue elements and upon a diffuse thickening and 
stasis of the lymph-vessels. 
A case is reported by Mery 1 showing the conditions in involvement of the muscles in sclero- 
derma. The disease began in a young woman of twenty-two, and ended in death from pericarditis 
in a year. At the autopsy the muscles of the limbs were found to be hard, atrophied, discolored, 
and to resemble fish-muscle. Under the microscope the lesion was found to be interstitial hyper- 
trophy of the connective tissues, and that the muscular fibres were unchanged. Very pronounced 
peri-arteritis and endo-arteritis of the vessels of the muscles were found. The nerves were healthy. 
The myocardium was involved. The affection is really a muscular sclerosis. 
1 Bulletin de la Societe d'Anatomie, February, 1888. 396 
DISEASES OF THE SKIN. 
Etiology.-Although long pages have been written upon the causes of scleroderma, we can 
state all that we know in a very few lines. 
It is a disease sometimes seen in children, but mostly in adult life, rarely appearing late in life. 
It affects females rather more frequently than males. By several authors-notably my friend Dr. 
J. E. Graham-scleroderma is thought to be intimately related to rheumatism, one reason being 
that it is found principally in temperate climates and that it occurs in seasons when there are 
sudden chano-es of the weather. 
Other observers consider it to be due to some change in the central and peripheral nervous 
system and in the sympathetic system-that it is, in fact, a trophoneurosis. Erysipelas, exhausting 
emotional disturbances, exposure to the sun and to cold, and nervous debility have been regarded 
as predisposing causes of greater or less influence. This being the sum of our knowledge of the 
one hundred and twenty odd recorded cases, it is to be hoped that the future will throw more 
light upon it. 
Diagnosis.-It is usually easy to make the diagnosis of scleroderma. It may be mistaken 
(as I have seen it) for diffuse cancer of the skin {cancer en cuirasse of Velpeau). The pain, the 
ganglionic involvement, and the increasing cachexia of the latter disease will soon lead to its 
recognition. 
Prognosis.-This can only be determined by a study of the case when it is well advanced. 
Should such an one show a tendency to localization and involution, the outlook is good. In exten- 
sive cases, where the disease is severe and persistent, particularly when affecting the face and 
chest-walls, the prognosis is grave. 
Treatment.-It is important to put the integument under the most favorable conditions and 
to improve the health. No therapeutic agents or measures have produced any apparent result. 
Baths, galvanism, and inunctions may be tried in hopes of benefit. ACNE ROSACEA. 
Acne rosacea, also called gutta rosea and rosacea, is a chronic inflammatory affection of the 
nose and the cheeks more commonly, and of the forehead and chin less frequently, and exception- 
ally of the whole face. This affection in times past was considered to be a form of acne, but the 
consensus of opinion to-day is contrary to that view. Rosacea is a subacute passive inflammation 
or congestion of the skin, accompanied with increase of the subcutaneous connective tissue and by 
hypertrophy of the skin itself, and all changes in the sebaceous follicles are secondary to these more 
extended and profound morbid processes. While rosacea may be, and oftentimes is, complicated 
by acne, the latter disease when chronic may also be accompanied by a secondary rosacea. Though 
thus in many instances existing together, and depending the one upon the other, the two affections 
are nevertheless distinct morbid processes. 
Acne rosacea usually begins in a mild and subacute manner, as a localized and perhaps quite 
insignificant redness or flushing of the skin. In the early stage it consists of a simple pinkish 
blush, which may or may not undergo exacerbation. Coincidently with this increase of color the 
natural oiliness of the parts is seen to be increased, and there may or may not be seen scattered 
over the surface acne papules or pustules. The appearances presented vary greatly in different 
cases. The redness varies between a bright hue and bluish red, and becomes deeper as the affec- 
tion becomes established. In some cases it is limited to the tip or alae of the nose ; in others the 
whole organ is involved in a symmetrical patch of congestion, which extends upon the cheeks 
and resembles in shape a butterfly. There is commonly very little if any swelling. In some cases 
the disease extends from the nose up on the forehead, and may involve the whole of that region. 
In like manner, more or less of the cheeks and chin may be invaded. There is always a greater or 
less degree of oiliness of the surfaces due to excessive sebaceous secretion. Pressure of the fingers 
causes the patches to become blanched temporarily, and it is noticed that the redness is greater at 
times than others, owing to conditions of the circulation, to the temperature of the air, and to the 
ingestion of stimulants or food. Extremes of heat and cold always aggravate the affection. As 
time goes on we observe that the thickness of the skin becomes increased, and the orifices of the 
sebaceous follicles more patulous and prominent; in fact, evidence of hypertrophy of this structure 
is very apparent. Early or later in this the first stage of rosacea enlargement of the capillaries is 
also to be seen. These minute vessels first look like little faint red lines well in the epidermis, but 
as the affection becomes intense they become more and more prominent until they reach a decidedly 
superficial position in the horny layer, and sometimes look as if they were seated directly on it. 
Their course is horizontally oblique and directed toward the median line. This combination of 
morbid phenomena-namely, redness of a bright or dull passive character, perhaps a scattered 
development of acne lesions of various kinds, patulous and prominent sebaceous follicles, thick- 
ened condition of the skin, and visible enlarged and tortuous capillaries-constitutes the clinical 
picture of rosacea in what is termed its first stage. The disease may be slight, amounting simply 
to a blemish, or so well marked as to cause disfigurement. It may be limited or extensive, may 
involve a part or the whole of one region, or may spread over several. 
397 398 
DISEASES OF THE SKIN. 
By the continuance of the capillary congestion, the serous exudation, and the connective-tissue 
increase rosacea becomes more or less hypertrophic and deforming. This further development 
has been termed the second stage of the affection. It is of various degrees of severity. The 
nose usually comes to have a warty or slightly nodular or hob-nailed appearance, due to the 
increase in the structure of the skin, and to have a firm, elastic consistence. The sebaceous 
gland-openings are usually very large and patulous, and are sometimes plugged up with sebum 
and epidermal cells. In this stage the cheeks, chin, and forehead may look decidedly thickened, 
uneven, and perhaps nodular ; but we do not often see the fleshy excrescences or tubercles which 
sometimes look like the clapper of a bell, as we do on the nose. It is the latter organ upon which 
rosacea expends itself most disfiguringly. The morbid enlargement may be limited to the tip, 
Fig. 75 
Fig. 76. 
Acne Rosacea, hypertrophic stage (front view). 
Acne Rosacea, hypertrophic stage (side view). 
which is converted into a rough round, pedunculated mass of grotesque appearance. The nose 
may be enlarged in all directions or perhaps only in one. Thus it may be lengthened or rendered 
much broader. In wood-cut Figs. 75, 76, is well shown the enormous hypertrophy which acne 
rosacea may cause, in which the nose becomes as large as one or two fists. In the hypertrophied 
condition the temperature of the nose is always lowered. This condition has been called pfund- 
nase. By it the mouth may be wholly concealed and eating and drinking made very difficult. 
Rosacea is said to be in the second stage when there is moderate hypertrophy, and in the 
third stage when excessive deformity is present. 
Rosacea lasts months and years. Its invasion is usually slow and painless, and very often so 
insidious that it is not an object of concern to the patient. In exceptional cases, however, its onset 
is comparatively sudden, and its course rather more rapid than usual. It runs an erratic course, 
with exacerbations and remissions of less or greater severity and length, but commonly the 
disease tends to establish itself firmly. Only occasionally do we see a tendency to spontaneous 
involution. ACNE R OSA CEA. 
399 
Rosacea is said to be more frequent in women than in men, but it rarely attains the extent of 
development in the female which it does in the male. Thus it is that we more commonly see the 
disease in the first stage in women, whereas in men it very frequently goes on to the stages of 
deformity. 
Rosacea is a disease of adult life and middle age, and not infrequently is seen in those who 
have long suffered from acne. Its symptoms are varied. Usually patients complain of heat and 
burning of various degrees in the parts early in the course of the affection, and they experience 
exacerbations when the circulation is for any reason increased or when they are exposed to 
extreme changes of temperature. At the menstrual epoch rosacea very often becomes more 
intense. 
Etiology.-Our knowledge of the causes of rosacea is not sharply precise. The affection 
often occurs in women at the appearance of the menstrual function, and its development and 
course seem in many instances to be more or less affected with aberrations of that function. In 
some women a slight rosacea precedes each menstruation ; in others amenorrhoea seems to aggra- 
vate it. Uterine disorders are said to be factors in causation, though the pathological link has 
never to my mind been clearly traced by any one. In many instances dyspepsia seems to cause 
more or less ephemeral or chronic rosacea. At the menopause rosacea is often developed, and it 
then runs a persistent course. In men this disease is largely caused by strong drink, alcoholic or 
malt. In America spirituous beverages are so numerous and promiscuously taken that we cannot, 
as they can in continental Europe, describe a rosacea due to wine-drinking and another form 
caused by brandy-drinking. Certain it is that these liquids cause at first a tolerably acute conges- 
tion of the face, which is followed by stasis and true rosacea. 
We certainly see this disease, however, in persons who have never been given to alcoholic 
indulgence or to fancy-dish menus. Sufficient facts have been reported to bear out the view that 
in some cases rosacea is of hereditary origin. 
Diagnosis.-Rosacea may be mistaken for the tubercular syphilides, lupus vulgaris, and lupus 
erythematosus, but such an error should be of short duration. In syphilis there is, besides the 
history of the disease and usually of other lesions, a tendency to ulceration in spots or patches 
which we do not see in rosacea. Lupus vulgaris is a disease of early life; rosacea, of adult, middle, 
and later periods. In rosacea there is more hypertrophy than in lupus erythematosus, and there is 
not observed in it the peripheral mode of extension peculiar to the latter disease. 
Prognosis.-The outlook of this disease depends largely upon the habits and the constitution 
of the patient, and the care with which treatment is followed. Left alone, it progresses from bad 
to worse. 
Treatment.-In many cases much can be done by close attention to diet and hygiene. The 
aim should be to put the patient in as perfect a state of health as possible. All stimulants should 
be interdicted, and the most simple and digestible food should be ordered. Any stomach or ute- 
rine affection should receive proper treatment. In general, saline aperients are very beneficial, 
among which the mixture of acetate of potassa and Rochelle salts (see formula in section on 
Treatment of Eczema) is most excellent. Saline cathartics and natural cathartic waters are also 
very beneficial. Locally, in the first stage, much can be done. The first essential is to thoroughly 
sop the affected parts with very hot water, and then apply some astringent and stimulating oint- 
ment. When there is much hyperaemia the following formulae are very good : 
R. Zinci oxid., 
Pulv. amy]i, da. gij; 
Liq. Goulard., 5j; 
Pulv. camph., gr. xx ; 
Vaseline, M. DISEASES OF THE SKIN. 
400 
R. Bismuth subnit., giij; 
Aq. camphorse. M. 
Apply freely and often. 
R. Calamine, 5>ij; 
Liq. Goulard., 5j; 
Spts. camphorse, 5iij; 
Aquae, §vj. M. 
Use freely. To be well shaken. 
R. Hydrarg. bichloridi, gr. j-f-ij; 
Ammon, mur., gr. vj; 
Aquae camphorse, §iv. M. 
R. Lac sulphur., 5ij; 
Aq. camphorse, 5iv. M. 
Ointments are also very beneficial when the hyperaemia has decidedly subsided. They are as 
follows : 
R. Lac sulphur., 5'j 
Pulv. camph., gr. xij; 
Vaseline, SJ- M. 
R. Resorcin, 3ss+i5j '■> 
Lac sulphur., 3j+5>j ; 
Ung. aq. rosse, 5J. M. 
In this connection it is well to consult the section on the Treatment of Acne. 
In many cases mercurial plaster or equal parts of mercurial and zinc ointments are of decided 
benefit in causing absorption. 
For the second and third stages of rosacea mechanical treatment is necessary. It is well to 
divide transversely all superficial vessels, using a small thin bistoury, or electrolysis as recommended 
by Hardaway. After such an operation very hot or very cold water may be applied on compresses. 
Collodion containing in suspension chrysarobin and salicylic acid (see Treatment of Psoriasis) is 
sometimes of decided benefit, even when much hypertrophy exists. Strong solutions of caustic 
potassa and soda, applied with great care to the morbid parts, often induces decided withering. 
Any of these operative measures may be followed by the application of an ointment of sulphur, 
by pure carbolic acid, or other stimulating drug. 
In the third stage of rosacea the disease presents various surgical problems which the experi- 
ence and art of the operator will be called upon to meet in the manner which promises the best 
results. RHINOSCLEROMA. 
Rhinoscleroma is a very rare chronic disease, due to a new growth of granulation-tissue, 
unaccompanied by painful symptoms of any kind, and producing marked deformity of the nose 
and contiguous parts. It has been seen in Germany, Italy, India, Brazil, Egypt, and England, and 
less than forty cases of it are 
recorded in literature. It has 
not, to my knowledge, been ob- 
served in America, and the fol- 
lowing description is derived from 
Hebra and Kaposi. 
Rhinoscleroma appears in the 
form of flat or rather elevated, 
sharply-defined, isolated, or con- 
glomerate tubercles, rounded 
prominences, or plate-like struc- 
tures of extraordinary density, 
which attack the skin or the mu- 
cous membrane of the alae or 
septum nasi and the adjacent 
portions of the lip ; that is, it is 
localized to the immediate cir- 
cumference of the anterior nares. 
The tubercles and rounded prom- 
inences (see wood-cut Fig. 77) 
are either of the color of the 
normal skin, and smooth and 
supple on the surface, or they 
are of a uniformly bright or dark 
brownish-red color, crossed by 
some dilated vessels, have a 
glossy, shining appearance, and 
are without hair or follicles. The 
epidermis covering them is then 
dry and cracked. Here and there 
are deeper rhagades correspond- 
ing to the furrows radiating from 
the attachments of the alae nasi. A small quantity of viscid, sticky fluid is secreted from them, or 
they are covered with yellowish dry adherent scabs where the rhagades are situated. The skin is 
not movable over the tubercles ; it can only be pinched up together with them. The tubercles 
appear infiltrated into the substance of the skin itself. They feel exceedingly hard to the touch. 
Fig. 77. 
Rhinoscleroma. 
401 402 
DISEASES OF THE SKIN. 
They may be as hard as cartilage or as ivory. On compressing some of them a certain amount 
of elasticity is perceptible. The skin immediately adjoining the hard infiltrated parts is quite 
normal. The new growths are developed on one or both alae nasi or the septum cutaneum, 
and spread from thence outward. The nose becomes much deformed and its orifices much 
narrowed and even completely stenosed. 
The tubercles do not undergo any sort of metamorphosis even in many years. They do not 
soften in the centre, nor do they ulcerate on the surface. Superficial excoriations are the utmost 
changes manifested. 
Whereas these growths are not of themselves painful, when large they give rise to uneasiness, 
and even pain, on pressure. They cause distress by preventing the entrance of air into the nos- 
tril, and necessitating the patient to breathe with the mouth open. 
Rhinoscleroma has no deleterious effect upon the constitution. It attacks both sexes, and has 
been seen between the fourteenth and fortieth years. 
There is a disposition upon the part of several recent observers to regard rhinoscleroma as 
of microbian origin and to class it among the chronic infectious diseases. Much is now being 
done in the study of its morbid anatomy, but only confusion of the mind would result just now 
from a presentation of results obtained and conclusions drawn by the various investigators. 
In the diagnosis of rhinoscleroma late syphilitic lesions, keloid, and epithelioma must be borne 
in mind ; but in general a correct conclusion will be drawn by one who has read the foregoing 
description and has studied the wood-cut figure. 
The treatment of this disease is very futile in results. If practicable, the growths may be 
removed by erasion, but the indications for this operation seem to be very rare. As a rule, the 
surgeon's duty will be tentative, with the view of making the patient as comfortable as possible. ELEPHANTIASIS. 
Elephantiasis is a chronic and more or less frequently-recurring inflammation in the lymphatics 
and blood-vessels, accompanied by great hypertrophy of the connective and lymphoid tissues and 
of the skin itself, and attended with marked deformity. It occurs in rare and sporadic cases in 
America, England, and on the continent of Europe, but is quite common and endemic in character 
in tropical and subtropical countries, particularly on low and marshy coasts. It is frequently seen 
in Japan, India, the West Indies, Central and South America, Southern and Western Africa, and 
the Samoan and Hawaian islands. 
Elephantiasis commonly begins in a brusque manner, with more or less fever (sometimes even 
of great severity), chills, pain in the back, great thirst, and nausea and vomiting. This morbid 
combination is sometimes called elephantoid fever. Exceptionally, in tropical climates these sys- 
temic symptoms are mild and insignificant in character, and in northern latitudes they are usually 
not of severe type and may be wholly absent. Coincidently or very shortly after the onset of the 
constitutional disturbance, inflammatory symptoms appear in the leg or legs, arms, or face, or in 
the scrotum or penis. The redness, which is usually quite intense, may be limited at first to the 
course of the veins or lymphatics, which become very prominent, or it may be patchy or diffuse. 
It is generally described as of erysipelatous character, The skin, besides being red, becomes hot, 
swollen, tense, and painful, especially in the course of the lymphatics and large vessels. The lym- 
phatic ganglia become swollen and painful when parts near them are affected. The systemic 
symptoms and the local inflammatory process may persist for two or more weeks, and then grad- 
ually subside. It will then be noted that the affected member is more or less swollen and oedema- 
tous. After a long or short period of quiescence (one or several months, and rather exceptionally 
one or more years) a new febrile disturbance and local erysipelatous inflammation occur again 
and run a similar course to the first. As a result, the limb or limbs are left still more swollen and 
oedematous. In some cases each successive attack is less severe than its predecessor ; in others 
all the recurrences are of uniform severity. The elephantiasic affected parts are usually not the 
seat of pain in the intervals of quiescence. Thus months and years go on and the elephantiasis 
finally becomes thoroughly established as a permanent deformity. Then the parts aflected present 
a firm, hard, tense, and resistant feel to the touch. In the early periods indentation or pitting may 
be produced by firm finger-tip pressure, but later on this effect cannot be produced, and a sensation 
is communicated to the examiner as if he were pressing the rind of ham or bacon. The skin, 
which is much thickened, sometimes becomes very tense and smooth, again brawny and rough in 
structure. In some cases the color of the limb is whiter than normal, of a waxen tint; in others 
it is pigmented, being either mottled in large or small patches or uniformly of a dark hue. Some- 
times enlarged lymphatics may be seen on the elephantiasic member. 
fhe leg is the part most commonly attacked. In wood-cut Fig. 78 elephantiasis is well shown 
below the knees, as it appeared in a recent case at Charity Hospital. The enlargement began 
near the ankles, and their girth was enormously increased. In this case a rather unusual feature 
is observed-namely, the absence of morbid change in the feet themselves. Toward the knees the 
morbid process gradually subsided. In this case the disease existed bilaterally. Usually one leg 
403 404 
DISEASES OF THE SKIN. 
is attacked after the other, and exceptionally the onset of the disease occurs in the two lower 
members. In wood-cut Fig. 79 the left leg and thigh are shown to be uniformly enlarged and 
pigmented in a mottled manner. There is 
also evidence of incipient disease in the scro- 
tum. It will be noted that the distension of 
the limb is uniform from the foot to the groin. 
Wood-cut Fig. 80 shows a marked contrast to 
the foregoing one. About the joints sulci 
which correspond to the natural cutaneous 
folds of these parts are well shown. These 
sulci are very common. Some of them are 
superficial, others very deep, and in general 
they grow gradually deeper with the increase 
of the elephantiasic process. They are often 
the cause of much discomfort, owing to a foul 
viscid secretion (the result of sweat, seba- 
ceous matter, and liquefied epithelium) which 
escapes from them. They are sometimes the 
seat of excoriations and of ulcerations. In 
addition to this disgusting concomitant, ec- 
zema, varicose ulcers, and ruptured lymphatic 
vessels sometimes add to the patient's suffer- 
ing and discomfort. Epidermal masses and scales, crusts, sebaceous concretions, and blood-crusts 
are also present in some cases. 
Elephantiasis may-but quite 
rarely, however-attack the upper 
extremities and cause enormous 
hypertrophy. It usually begins in 
the forearm in a unilateral or bi- 
lateral manner. From this region 
the arm itself may be invaded. 
The whole face or portions of it 
-namely, the lips, ears, cheeks, 
or chin-may also be attacked. 
Elephantiasis of the scrotum, 
also called lymph-scrotum, is not 
at all uncommon, particularly in 
tropical climates. The organ be- 
comes greatly enlarged, so that 
it may hang down to the knees, 
and even lower down. The scro- 
tal walls are enormously thick- 
ened, cedematous, and pigmented, 
and often give issue to minute 
streams of a pinkish milky fluid, 
readily coagulable, which escapes from the lymph-vessels. This form 
of elephantiasis, as well as the other forms, is frequently accompanied 
with chyluria. 
Fig. 78. 
Elephantiasis of both Legs. 
Fig. 80. 
Fig. 79. 
Elephantiasis of Leg and Thigh. 
Elephantiasis of Leg and Thigh. ELEPHANTIASIS. 
405 
The penis and labia majora may also be attacked by elephantiasis, which produces enormous 
hypertrophy. 
Elephantiasis is rather more common in men than in women, and is more frequent in the dark 
than in the light races. It has been generally believed that the date of invasion of this disease is 
in adult life and toward middle age. Moncorvo,1 however, has studied this question in more than 
two hundred cases, and he claims that it does occur in very young persons. Out of forty-five of 
his cases Moncorro found that twenty-eight were children, and seventeen were adults who gave a 
clear history of the onset of the disease in infancy. In the twenty-eight cases the disease began as 
early as the fifteenth day and as late as the fourteenth year of life. In the remaining seventeen 
cases the disease began between the second and twelfth years. Moncorvo, concludes that ele- 
phantiasis may begin in intra-uterine life and during the whole of childhood. As a rule, however, 
we may term the disease one of adult life. 
Etiology.-The endemic form of elephantiasis is thought to be caused by the introduction 
into the system of the Filaria sanguinis hominis. It is supposed that it gains entrance into the 
body of the victim through the puncture of the proboscis of the mosquito, which, having come in 
contact with the parasite in the low marshes, acts as the medium of infection to the human race. 
It is difficult to account for the various sporadic cases seen in this country and in England. I have 
seen elephantiases of the penis which have been thought to originate in gunshot wounds of the 
pubes and of the organ itself, in the inflammation produced by strong injections, and also in 
stricture of the urethra. 
Pathology.-The disease results in occlusion of the lymphatic vessels and in great connective- 
tissue increase. 
Treatment.-In the early stages the treatment must be symptomatic, both generally and 
locally. Removal of the patient from regions where the disease is endemic is a wise measure if 
practicable. Dr. Thomasz,2 has recently recommended, in the early stages of the disease, sulphide 
of calcium, which he thinks acts by reason of its parasiticide influence on the filariae. He gives 
one-grain doses to adults twice a day, and increases the dose to one and a half and two grains as 
soon as tolerance is established. Thomasz states that he has thus treated seventeen cases, of 
which seven of less than six months' standing were cured in one and a half and two months. Cases 
of longer standing were simply improved. 
Massage and strapping with cotton or india-rubber bandage are very beneficial. Ligation of 
the main artery of a limb, and perhaps of some of its branches, may be of benefit in some cases, as 
it has been in the hands of a number of surgeons. Surgical procedures are usually necessary in 
elephantiasis of the penis and scrotum, and these deformities are often thereby much relieved. 
Dr. Raimundo Menocal3 of Havana, in the case of a young man suffering from great enlarge- 
ment of the left leg formed by two extensive fleshy masses, made under chloroform a long 
anterior incision through the whole length and thickness of the morbid tissue. The skin was 
then carefully dissected back, exposing the hypertrophied mass of cellular tissue, which was sepa- 
rated with considerable difficulty from the subjacent muscular layer and removed in one piece. 
The skin was brought together with sutures, the wound treated antiseptically, and the whole 
retained with a compress bandage. A second operation on the posterior portion of the leg was 
then done. The result in each instance was very satisfactory. It would seem that this procedure 
is susceptible of extended application. 
1 " De Elephantiasis des Arabes chez les Enfants," Rev. mens, de Mai. de I' Enf, Paris, 1888, vi. 10-22. 
2 Ceylon Med. Journal, Aug., 1888, and The Satellite, Nov., 1888. 
3 Lancet, April 20, 1889. LEUCODERMA. 
Leucoderma or vitiligo is a chronic affection of the skin characterized by the development of 
a few or many whitish pigmentless spots. It is seen more frequently in warm climates than in 
cold and temperate ones, and more often in persons with dark than with fair skins. Consequently, 
it is seen very commonly in the negro and in Oriental races, and sometimes in the Indian. In 
general, it is found most frequently in adult 
and middle ages, but it is not uncommon to 
see it in young children, and even in old age. 
Its most constant sites are the face and 
neck, the trunk, the backs of the hands, and 
it is also seen on the upper and lower extrem- 
ities. It begins without any symptoms as a 
small spot or spots which appear whiter than 
the normal skin, and come to be of a pinkish 
or milky-white hue. These spots are at first 
round or oval, but as they become enlarged or 
as they fuse together they form rather irreg- 
ular or gyrate patches. Their surface is of a 
perfectly smooth, whitish, perhaps pearly color, 
and on a level with the surrounding skin. In 
the affected patches the hair may be normal or 
more or less white, but there is no evidence of 
implication of the sweat or sebaceous follicles. 
In fact, the skin looks perfectly normal except 
that its pigment is absent. To the touch no 
abnormality is apparent, nor is sensation, as 
a rule, in any way altered or impaired. The 
margins of these whiter patches are very 
abrupt and sharply defined. In some cases 
and in some lesions there is just at the border 
of the pigmentless patch a ring of deeper col- 
or than normal, which gradually shades off into 
the surrounding skin. In some cases this pig- 
mented zone is very well marked ; in others it 
is exceedingly slight. In this event it is fair to 
assume that the lesion consists in an irregular distribution of the pigment. In other cases the 
margins of the patches end in skin which seems wholly unaffected. In this instance, therefore, 
there is decided atrophy of pigment. ■ 
Leucoderma is well portrayed in Fig. i, Plate LVIL, in which the small and large patches over 
the anterior surface of the trunk are of striking appearance. In wood-cuts Figs. 81 and 82 
Fig. Si. 
Fig. 82. 
Leucoderma in the Negro. 
(Front View.) 
Leucoderma in the Negro. 
(Back View.) 
406 3eo.S Harris&Sone Li th Phil a 
Part VIII 
Fig.l 
l.Leucod erm a. 2. Ch loa sm a . 
3. A1 o p e ci a A re ata . 
Fig. 3 
LEA BFjOTHEFjS & CO. PUBLISHERS. PHILADELPHIA . 
Fi|2. 
Dlate LVI LEUCODERMA. 
407 
extensive leucoderma is depicted in the negro. Patients thus attacked are called piebald negroes, 
and it is not at all uncommon to see whole regions, and perhaps the whole body, in this pigment- 
less condition. 
The course of leucoderma is peculiarly chronic. The mode of invasion of the disease is by 
the successive appearance of one or a few spots at rather short or more or less prolonged periods. 
Phe lesions as a rule remain permanent, increasing slowly or rapidly, continuously or at intervals, 
until a large surface, and even the whole body, is invaded. This inveterate course, however, has 
many exceptions. It is not at all uncommon to see leucodermatous patches appear upon the backs 
of the hands and on the face regularly in summer, and to disappear as cold weather comes on. Then, 
again, leucoderma of one region passes away, while it appears in others, and thus goes on until the 
greater portion of the body has been covered. In young subjects this affection may thus come and 
go, and rather exceptionally in persons toward old age its evolution is followed more or less 
quickly by its involution. Likewise, it is true that leucoderma appearing during any period of 
illness or of lowered condition of the system may disappear as health becomes re-established. 
The affection is disquieting to patients by reason of its disfigurement (particularly on the face, 
neck, and hands), rather than from any other cause. 
Allied to leucoderma, which is an acquired affection, is albinism, which is a congenital absence 
of pigment in the skin and hairs. Albinos, as a rule, are persons who mentally and physically are 
below the normal standard. 
Etiology.-Leucoderma occurs rather more frequently in males than in females, and in adult 
and middle life rather than at the extremes thereof. It is often seen in those who are well and even 
robust. Then, again, debilitated persons from malaria, cardiac disease, rheumatism, phthisis, or 
from any adynamic cause, sometimes are attacked by it. In no case can the cause be definitely 
stated, so we are forced to use that vague term disturbance or impairment of innervation. Leu- 
codermatous spots follow many acute and chronic inflammatory diseases of the skin. 
Prognosis.-The outlook as to the health in this disease is usually good. Hope may be 
expressed of the final restoration of the normal color of the skin, but positive assurances can 
rarely be given. 
Diagnosis.-Bearing in mind the fact that the skin is only deficient in pigment, in leucoderma 
there can be no good ground for mistaking it for morphoea or lepra. 
Treatment.-If there is a condition of lowered vitality, appropriate medication should be 
instituted for its relief. Various authors recommend arsenic in full and increasing doses, with 
the idea of reproducing the pigment by means of the hypersemia which it induces. As our 
armamentarium is so limited, it is well if no contraindication exists to give the remedy a trial. 
Locally, the patches may be rubbed with brisk friction, with tinctura cantharidis, tincture of 
capsicum, croton oil (with great circumspection), turpentine, and spirits of ammonia. Mustard 
plasters may be applied for a short time at proper intervals. The following applications may 
be used : 
R. Hydrarg. bichlor., gr. ij 4 iv ; 
Aq. coloniensis, jij; 
Aq., £iv. M. 
To be rubbed on with a sponge once or twice a day. 
R. Hyd. bichlor., gr. j 4 ij; 
Collodion flex., 5j. M. 
To be painted upon the spots. 
Importunate patients may be treated with galvanism, but the doubt of its efficacy should be 
plainly stated. CHLOASMA. 
Chloasma is an affection characterized by the development of pigmented spots or patches 
upon the face or elsewhere on the body. These patches are of yellowish-brown, brown, and even 
black color, and are usually sharply marginated. Their surfaces are smooth, and there is, as a 
rule, no concomitant implication of the hairs or involvement of the sweat or sebaceous follicles. 
The affection, therefore, is simply an hypertrophy of pigment, with no further alteration of the skin. 
In size the patches vary between that of a pea and of the palm, or they may involve a region or 
regions. Usually they consist of uniform sheets of discoloration, but a patch may be broken up 
in an indefinite manner into a large number of various-sized islets. Their shape is' subject to 
much variation, and it is largely dependent upon the conformation of the parts upon which they 
are seated. 
Chloasma is divided into two varieties-idiopathic and symptomatic. 
Idiopathic chloasma is generally known as lentigo or freckles, and is also called ephelis- 
a name which can be dispensed with. 
Lentigo or freckles are small pigment-spots which appear and disappear upon the face and 
hands, particularly in persons of fair skin. They usually appear in summer and fade away as 
winter comes on, but they are sometimes permanent. Many people are prone to them ; others 
are the reverse. They have no pathological importance or significance. 
Symptomatic cloasma is due to external and internal causes. Of the former we may mention 
prolonged hypertemia from pressure and scratching, heat and cold, and any stimulant application 
to the skin. 
The most interesting form of the symptomatic affection is called chloasma uterinum or liver- 
spot. This is well shown in Fig. 2 of Plate LVIL, upon the classic sites, the forehead, cheeks, and 
upper lip. In some cases the affection is thus limited ; in others it is more or less extensive. 
This affection is peculiar to adult life, and is seen during pregnancy and the existence of men- 
strual and uterine disorders. It is not common to see it at the menopause, and, though found 
mostly in the married, it also affects single women. The pigmentation of Addison's disease 
belongs to the category of symptomatic chloasma. 
Etiology.-Pregnancy and menstrual and uterine disorders seem to be the most common 
causes. The disease is seen sometimes among men, and usually without apparent cause. Neuro- 
pathic conditions are said to be pathological factors in some cases. Syphilis, as we have seen (see 
section on Pigmentary Syphilide), may cause marked pigmentation of the skin. 
Diagnosis.- I his is usually very readily arrived at. Tinea versicolor maybe mistaken for 
chloasma, but in the former the patches are more numerous, they usually begin on the trunk, and 
very rarely attack the face ; they are scaly, very slightly pruritic at times, and usually very slightly 
but appreciably elevated. In tinea versicolor the parasite can always be readily detected, and then 
the diagnosis is beyond doubt. 
Treatment.-Of course all internal morbid conditions should be carefully sought for and cor- 
rected. Locally, our means may be summed up in one word-stimulation. For this purpose the 
bichloride of mercury is the most efficient agent. It may be used in the same manner as directed 
408 CHLOASMA. 
409 
for the treatment of Leucoderma ; or the strong solution of Hebra may be used. This consists 
of five grains of corrosive sublimate to the ounce of alcohol or water, and should be applied by 
continuous compresses until slight vesication and a raw surface result. Then a dusting powder or 
zinc ointment may be applied until all inflammatory symptoms have subsided, and then the strong 
applications may be made again. I have seen decided benefit in a few cases by the cautious appli- 
cation of acetic acid, carbolic acid, and of cantharidal collodion and vinegar of cantharides. It 
should always be remembered and explained to patients that any of these applications may occa- 
sionally produce even deeper pigmentation than existed before their use. ALOPECIA AREATA. 
Alopecia areata is a chronic affection characterized by the sudden shedding of the hair and 
the development of whitish bald patches, which quite rapidly undergo atrophy. It is found most 
commonly upon the scalp, particularly on the occipital and parietal regions and behind the ears, and 
on the eyebrows and beard, but is also seen upon the axillae and pubes, and it may invade the 
small hairs of the body generally. In its course the disease may cause the fall of the hair from 
circumscribed spots of greater or less size and numbers, and it may clear off every vestige of hair 
from the whole body. 
Alopecia areata attacks both sexes with about equal frequency, is perhaps more common in 
children than in adults, and is less frequently observed as we reach old age. 
This disease usually begins upon the scalp with sudden invasion. To the surprise of the 
patient, he or she finds a bald white spot, there having been no prodromal symptoms, such as heat, 
pruritus, or pain. Very exceptionally, however, these symptoms may be present. These spots of 
alopecia areata are at first round or oval in shape. As they grow larger with greater or less 
rapidity, they may become irregular or gyrate or in the shape of bands or ribbon-like. In the 
early stage of the affection we find a smooth whitish surface, and occasionally a very faint pinkish- 
white hue may be seen. Thus early the follicular openings may be a little elevated, and the sur- 
face may be not quite smooth. Slowly or rapidly, but surely, atrophic changes set in. Then we 
find that even lanugo hairs are absent, and that there may be perceptible thinning of the skin 
itself, so that the finger-tip passed over a patch notices distinctly that at the margin the thickness 
of the scalp is rather greater. Then the surface of the patches is of polished smoothness, and 
examination with the glass may show that even greater atrophy has taken place at the follicular 
openings, which appear shrunken. The color of the morbid patches is usually of a dead white, 
but as they grow older they may come to assume the hue of a billiard-ball which has been used for 
some time. At the margin of these lesions the hairs may be normal in appearance, but we occa- 
sionally see a few scattered and broken ones. Whereas in early stages the alopecia patches were 
on a level with the surrounding skin, and sometimes a little higher from puffy but faint oedema, as 
time goes on they sink down, until they may present a flat or concave, depressed surface. These 
lesions may be very slightly scaly, but usually preserve their smooth shininess throughout. As a 
rule, there is no disturbance of sensation in the patches, but rather exceptionally there is more or 
less impairment of it, and even in some rare cases anaesthesia. Alopecia areata is portrayed in 
Fig. 3, Plate LVII. 
The course of alopecia areata is not at all uniform. In some cases the fall of hair takes place 
at night, and in the morning the patient finds that he is bald in a spot or spots. In others, the 
shedding of the hair is more or less gradual until a bald spot is produced. Sometimes the course 
of extension is quite slow, and again it is so rapid that it is perceptible from day to day. Then, 
again, periods of quiescence of varying length occur, followed by more or less active exacerbation. 
In some cases new spots follow old ones at irregular intervals ; in others the increase of the disease 
is by the enlargement of the original spots. The disease usually lasts months and even years, and 
when recovery takes place it is, as a rule, by slow and tedious degrees. In general, this happy 
410 ALOPECIA AREATA. 
411 
result is more prompt and rapid in young than in middle-aged and old subjects. The first appre- 
ciable sign of improvement is a pinkish tint in the patches. Then we see small soft, downy hairs 
scattered in more or less abundance or sparseness. These hairs at first are wanting in color. 
They frequently show a lack of vitality, and fall out in a most exasperating manner. In auspicious 
cases, however, they slowly gain in structure and firmness, until in the end, months or years having 
elapsed, the patches are healthy and covered with normal hairs. In exceptional cases the restora- 
tion of the hair is complete, except that its color is permanently absent. Relapses are not uncom- 
mon even months or years after recovery. 
Etiology.-As long ago as 1843, Oruby claimed that this disease was caused by a special 
fungus, and to-day the view that it is caused by a micro-organism is firmly held by many. Robin- 
son in an extended study reaches the conclusion that it is caused by certain micrococci which are 
to be found in the lymph-spaces. Other observers regard the disease as a trophoneurosis and 
dependent upon disturbed or impaired innervation. Then, again, others think that there are two 
forms of alopecia areata, the one caused by a specific microbe (though there is an obvious want 
of a clear definition and life-history of it) ; the other due to trophic nervous disturbance. The 
proper plan is to watch and wait while we mark, learn, and inwardly digest the evidence as it is 
brought forward. 
Alopecia areata has been observed to coexist with atrophy of the skin in contiguous parts, 
and also to be a concomitant of morphoea. It has been known to follow neuralgias and epilepsy, 
to be present in neuropathic subjects, and to result from injuries, nervous shock, and fright. It 
may be seen in debilitated and overworked subjects, and also in those of robust build. 
Pathology.-The skin is generally atrophied, the hair-bulbs atrophied, and the shaft shrunken. 
Diagnosis.-Such are the striking features of alopecia areata in its course and history that 
its recognition is always very easy. Ringworm of the scalp may perhaps in late stages appear 
like alopecia areata, but a close study of the case with the aid of what has been said of ringworm 
(see page 262 et seq.} will soon settle the question. 
Prognosis.-In young subjects with localized and not old patches there may be recovery. 
Extensive eruptions in old or young are of very uncertain outcome. The more recent the erup- 
tion the better the prognosis, and conversely the longer it exists in a stubborn manner, the less 
probable is the restoration of the hair, d'hen, again, when we find well-developed atrophy with no 
lanugo-like appearances, particularly in cases of long standing, we cannot give very encouraging 
assurances. On the contrary, a returning blush and fulness of the patch, with lanugo hairs, are 
harbingers of hope. 
Treatment.-Many eminent authorities think that much benefit is to be derived from internal 
medication in alopecia areata. Tonics of all kinds may be used, and arsenic may be given in full 
and progressive doses. Where the outlook is so uncertain, and very commonly so gloomy, it is 
incumbent upon us to exhaust every means which offers a possibly favorable result. 
Locally, the parts should be well shampooed every day or two, and each day should be washed 
with a watery solution of the bichloride of mercury (1 part to 1000 or 2000). Then the following- 
should be well rubbed into the patches for several minutes at least twice a day : 
R. Tr. cantharidis, Iss+^j; 
Tr. capsici, -Sij+gss; 
Aq. coloniensis, giij; 
Aquae, ad £iv. M. 
Or, 
R. Liq. ammoniae, 3'j+3'v> 
Tr. capsici, 5ss; 
Aq. coloniensis, gij ; 
Aquae, ad §iv. M 412 
DISEASES OF THE SKIN. 
Or, 
R. Acidi carbolici, 3j+5ij; 
Chloroformi, sjss; 
Aquae, ad gviij. M. 
Or a still stronger application, as follows: 
R. Spts. terebinthinse, 3ss+5j 
Chloroform!, §ss; 
Liq. ammoniae, o>j+.5>v", 
01. olivae, ad giv. M. 
In inveterate cases blistering may be employed by means of cantharidal collodion or acetum 
cantharidis. By some chrysarobin ointment (3ss + 3j = 5j) is well thought of, while others claim 
excellent results from the use of sulphur ointment. Faradization of the scalp may be tried, and 
in a therapeutic emergency the suggestion of Radcliffe Crocker of injecting hypodermically into 
the scalp one-thirtieth of a grain of pilocarpine may be tried. 
Tilbury Fox thought well of vesication, followed by the application of the following: 
B. Tr. nucis vomica?, gss ; 
Tr. cantharidis, £vj; 
Glycerinae, ; 
Aq. destillatae, §iss; 
Aq. rosae, . §iij. M. 
Whatever treatment may be adopted, it should be followed with a steady hand and with 
untiring perseverance. KELOID. 
Keloid is a new growth of fibrous tissue developed in the skin in the form of pinkish elevated 
tumors or nodules. It begins as a small, well-defined papule or tubercle which is smooth on its 
surface and elastic on pressure. As a rule, slowly-but exceptionally more rapidly-this mass, 
which reaches an elevation of one to three lines above the skin level, increases in size by the 
development of spurs or processes like cords which extend into the surrounding parts like the 
claws of a crab. In its full development keloid consists of a body and prolongations which some- 
times present crab-like appearances ; hence its name. Throughout its course spontaneous pain of 
varying severity may be felt; pressure usually causes the patient to flinch. The size of keloid 
tumors varies from that of a pea to that of a band or patch one or more inches in area. In wood- 
cut Fig 83 between and above the breasts is seen a transverse band of keloid, and from its 
Fig. 83. 
Keloid. 
end numerous spurs projecting into the healthy skin. Above and over the breasts are round, rod- 
like, and irregular-shaped tumors. The whole offers a good picture of a case of multiple keloid. 
In shape keloid presents much variation according to the site on which it is developed, being round 
or oval at first, but later on markedly irregular. It is firmly seated in the skin, and more elevated, 
as a rule, in the centre than elsewhere. The pinkish color is quite constant, but a brownish-red 
hue is sometimes seen in the patches. The color is not uniform, but in streaks and patches ; in 
other words, there is a pinkish or brownish-red background more or less broken-up by whiter lines 
or spots. The epithelium covering keloid is stretched and shiny, sometimes scaly, and over it 
usually no hairs are to be seen. Keloid is seen in all ages of life and in dark races more frequently 
than in light ones. The sternal region is perhaps the most common situation, but it is found else- 
where on the trunk, particularly over the scapulae, and also on the face and extremities. 
413 414 
DISEASES OF THE SKIN. 
Keloid has been divided into two forms-the true or spontaneous and the false or cicatricial, 
or, better still, named hypertrophic cicatrix. Clinically, this division should be maintained, though 
histologically the new growths are similar. In wood-cut Fig. 84 is well shown a whitish scar at the 
elbow, and over it are several large and small growths which are termed false keloid. In this form 
of hypertrophic cicatrix there is little or no tendency to 
clawlike outshoots, nor indeed to the peripheral extension 
of true keloid. 
There is a growing opinion that all keloid has its 
origin in some lesion of continuity, such as a burn, leech- 
bite, cupping incision, scar of smallpox, acne, herpes 
zoster, or other small lesion. 
Prognosis.-Spontaneous involution may occur in 
keloid, and such an event is not at all uncommon in 
hypertrophic cicatrices. 
Treatment.-Operative procedures are always of 
doubtful value, since keloid shows a marked tendency to 
return after extirpation, even when the incision is made much beyond the new growth. Multiple 
transverse scarifications are advised by Vidal. My friend W. A. Hardaway, who as a pioneer in 
the use of electrolysis in diseases of the skin has done so much for science, thinks well of this 
method of treatment in' some cases of keloid. Caustic potash and soda solutions of considerable 
strength have been used with varying success. Mercurial plasters may be of benefit if kept on 
the new growth for a long time. 
For pain, soothing and stimulating liniments and ointments may be used. Internal medication 
is wholly inefficacious. 
Fig. 84. 
Keloid of Scar. XERODERMA PIGMENTOSUM. 
Xeroderma pigmentosum is a disease peculiar to early life, presenting polymorphous lesions 
ot the most varied orders, attended by a great complexity of symptoms, chronic and unending in 
its course, and leading to the most disfiguring deformities and in many cases to death. Various 
names have been given to this disease since the original one of Hebra-xeroderma. Thus, Neisser 
calls it lioderma essentialis cum melanosi; Pick, melanosis lenticularis progressiva ; Vidal, la dcrmatose 
de Kaposi ; Radcliffe Crocker, atropho-derma pigmentosum ; Piffard, lentigo maligna ; while I myself 
years ago ventured to propose the provisional term angioma pigmentosum et atrophicum. After 
nearly twenty years' consideration of the subject the term " xeroderma pigmentosum " has been 
quite generally settled upon, and it will probably live. 
It should be clearly understood that the dry skin of ichthyosis-or,. as it is called by some, 
xeroderma-is an entirely different affection from the one under consideration. 
This disease is of exceeding rarity, since there are but forty-one cases of it on record, of which 
I have had the fortune of having had seven1 under observation for very many years. Of the cases 
reported, many are described in a very unsatisfactory manner. 
In a general way, xeroderma pigmentosum consists in an indiscriminate intermingling of small 
red vascular spots or telangiectases and pigmentations, combined with more or less extensive 
atrophic patches ; all of which, we shall find, have intimate pathological relations. Superadded to 
these polymorphous lesions there are sequelae or new growths which are at first of a benign nature, 
and may thus remain, or they may degenerate into malignant growths. 
Xeroderma pigmentosum may be said to be a disease whose evolution begins, as a rule, in 
very early life. Of my seven cases, it began in six at about the sixth or seventh month, and in 
one about the fourteenth month, of life. Of the remaining cases by other observers, it began 
between the third month and the end of the first year in ten, and between the first and second years 
in fourteen cases ; and there is inherent evidence in the histories of several other cases of very 
early evolution. In the face of this strong array of facts we find cases reported by Kaposi, Heitz- 
mann, and Vidal in which the appearance of the disease is stated to be respectively at sixteen and 
nine and more years. While I do not take the ground that these cases are not true instances of 
this disease, I must confess that I am very sceptical about them, seeing that they are so exceptional 
in their course. It should be distinctly borne in mind that the coincidence of epitheliomatous and 
other malignant growths does not of necessity constitute xeroderma pigmentosum ; and that 
because a child had severe freckles in early life and some malignant tumor in after years, the 
two may simply be coincidences. The weight of evidence therefore places the disease as one of 
very early childhood. 
The invasion of xeroderma pigmentosum is very constant, beginning about the face or under 
the eyes as a well-marked smooth, superficial erythema, which is often regarded by the parents or 
guardians as the result of sunburn. With the exception of this blemish there is no impairment of 
health ; indeed, the fact of the good health of most children is well attested. The erythematous 
1 In the Medical Record for March io, 1888, will be found my essay on the subject, in which the clinical history and a tabular 
abstract of all the cases are given. 
415 416 
DISEASES OF THE SKIN. 
patches extend, coalesce, and gradually creep over the face and neck, usually stopping at about the 
third rib by an abrupt margin. This condition of the face, neck, and trunk is of variable duration- 
from one to several months, during which the erythema may become less red. As this prodromal 
hyperaemia disappears, pigmented spots and red ones, or telangiectases, make their appearance, 
scattered irregularly over the affected regions. The pigmentations are at first of a light-brown 
and may become of a blackish-brown, and even black, color. They vary in size from a pinhead to 
a lentil, and usually are not much if at all elevated, and of very irregular shapes. Scattered 
among them with great irregularity, but less numerous, are the red or telangiectasic spots, which 
are smaller, rather more salient, and of irregular outline. By a strong glass a congeries of capil- 
laries can be made out. In most cases thorough pigmentation of the face and neck takes place in 
about six months. Upon the hands there is not such a marked prodromal erythema as upon the 
face, and in some cases there was no evidence of its presence. With the evolution of these lesions 
there are no marked local subjective symptoms. If a case be carefully studied and frequently 
observed in its early years, it will be very often plain to the eye that the pigmented spots follow 
exactly upon the site of a pre-existing red spot, and the conclusion will be obvious that the red 
lesion was the forerunner and that its pigmented fellow was the sequel. 
This I have seen to take place time and again. Very often pigmented spots appeared where 
the red one was only visible by means of a glass. The pathological relationship, therefore, 
between the red and the pigmented spots is, to my mind, very clear. My friends Dr. Duhring 
and Dr. J. C. White deny this relationship, but I think that, had their observations been made 
upon very young children in whom the disease was active, and not on older ones, and had they 
extended over longer periods of time, they would be of my belief. Later on I will show that the 
microscope demonstrates the intimate relationship claimed. The further course of these two orders 
of lesions is well shown in the histories of the cases. They are erratic, they come and they go, 
they have periods of exacerbation and of remission, but their hold is never lost. If one disappears, 
it is soon replaced by another or by several. Thus, as the child grows older its disfigurement 
becomes more or less rapidly worse, the disease relentlessly persisting. There is no record of a 
case in which anything like amelioration in its course was observed. A very few children escape 
with the disfiguring pigmentations and perhaps slight atrophy, but even these are either attacked 
later on by severer lesions or the milder ones remain indelible for life. The period of activity of 
the pigmented spots and telangiectases is greatest in the very early years and during childhood. 
After the fifteenth or sixteenth year they may appear and disappear, but rarely in such profusion 
as in the early years. 
These two orders of lesions-the telangiectases and pigmentations-are peculiar to what we 
may call the stage of hypertrophy of xeroderma pigmentosum. Disfiguring as they are, we find 
that in every case-in some in a mild, in others in a severe form-atrophic changes are soon super- 
added. In the majority of cases atrophy begins about the end of the first year of the existence of 
the morbid changes, but it may occur at any subsequent period. Its course is subject to marked 
exacerbations and remissions, and, though it occurs on both sides of the body, it is not usually 
symmetrical. In some cases it progresses and produces hideous deformities by reason of the size 
and situation of the patches ; in others, again, it is limited in extent and not strikingly observable. 
Upon the face this form of atrophy reduces the skin to the thinness of parchment, and destroys 
nearly all of the follicles. 
Such atrophic patches are usually traversed by minute lines, and frequently so transparent 
are they that the vessels can be seen beneath. Upon the hands and arms and feet and legs 
atrophy is not usually as well marked as upon the face, and it occurs mostly on parts subjected 
to tension, such as over the knuckles. If an atrophic patch of the skin of the face be attentively 
watched for a long period, it will be seen that there is a constant evolution and involution of the □■eo.S.Harrt.s JcSone Lith-.Phila 
Fig.l 
Dart VIII 
Fig .4 
XERODERMA PIGMENTOSUM. 
Fig 5. 
Fig.2. 
Fig. 6. 
i 
Fig. 3 
LEA BROTHERS & CO. PUBLISHERS PHILADELPHIA 
Plate LVIII XERODERMA PIGMENTOSUM. 
417 
telangiectasic spots, which are here sometimes followed by pigmentations. The atrophy of the 
skin takes place in proportion to the growth and atrophy of these minute vessels, and always where 
the atrophy of the skin is active close observation will show this rapid development of the red spots. 
This process seems to go on until all of the vessels of the part have undergone increase and 
decay ; in fact, until no more are left or until the skin is reduced to such a dense fibrous condition 
that they can luxuriate in it no longer. Due undoubtedly to the excessive vascularity and exposed 
position of the parts, atrophic changes are prone to occur upon the forehead, also on the scalp, 
about the eyes, nose, mouth, and ears. As a result, besides the disfigurement, ectropion occurs 
with its train of bad symptoms, and incomplete stenosis of the nasal and oral apertures and 
deformities of the ears are produced. It is an interesting fact that when the atrophic process is 
at an end no further pigmentation takes place, and a smooth, white, mother-of-pearl surface is left. 
An inspection of colored Plate LVIII. will give the reader a very clear idea of this disease. The 
five cases there figured were under my care for many years. In Figs, i, 2, and 3 the combination 
of pigment-spots and telangiectases is well shown. These cases may be taken as examples of the 
mild form of the disease. In Fig. 4, in addition, tumors are seen about the eyes and on the fore- 
head, and the eyes are closed in consequence of incipient pannus. In Figs. 5 and 6 new growths 
are seen at different ages of the same girl, and it will be noted that in Fig. 6 the new growth has 
invaded the eye-tissues and that sight is almost impossible. Later on the eye itself was destroyed. 
On the right cheek are several large new growths. The atrophic changes were well marked in 
this case, but they are very difficult to depict. 
In almost all cases, particularly in those in which the pigmentations are deep and extensive, 
hypertrophic changes take place, very often coincidently with the atrophic processes. We find in 
the course of xeroderma pigmentosum epithelial new growths. In their simplest and most rudi- 
mentary form these consist of plaques or spots or thickened pigmented epidermal cells, resembling 
keratosis senilis. This may be the full development of the hyperplastic process in a given case, or 
it may be the starting-point of larger growths. While the atrophic process is to be dreaded for its 
terrible disfigurements, these at first seemingly simple and harmless growths are often more terri- 
ble in their effects, since their development produces the leaven upon which malignancy may later 
on be engrafted. These are border-line lesions between benign and malignant new formations. 
These keratosic patches may long remain as such, or they may be cast off and re-formed, and they 
may disappear. But about the face, particularly at the junctions of the skin with the mucous mem- 
branes on the cheeks, chin, and ears, their tendency is to become larger. They soon form sessile 
or pedunculated, more or less elevated tumors, whose surface, after the shedding of their pig- 
mented epidermal covering, may in general be termed fungating. At first they are of a deep-red 
or purple-blue color, soft and compressible, and remind one of erectile tumors. They frequently 
become pale, less vascular, and so brittle and friable that they fall off, leaving sometimes a surface 
which heals spontaneously, or an ulcer which may be very intractable, which may extend in depth 
and breadth, and frequently are surrounded by thickened and everted edges, which may become 
the seat of malignant degeneration. 
Thus far in the hyperplastic processes of xeroderma pigmentosum we have found two prin- 
cipal forms of new growth : First, the keratosic plaque or tumor ; second, the large and at first 
vascular tumor. While the tendency to malignancy is often found in the first, it is very constant 
in the second form ; yet, on the other hand, the latter tumors frequently wither and fall. A study 
of the forty reported cases of this disease shows that malignant new growths were present in 
seventeen, and non-malignant growths (at the time of report) in six cases. Further, that of nine 
cases in which no new growths were noted, in five the children were respectively two and a half, 
three and a half, five and a half, six, and twelve years old-ages far too young to warrant the 
prognosis of the future exemption from new growths. Of the remaining four cases, two were 418 
DISEASES OF THE SKIN. 
seventeen, one eighteen, and one twenty-two years of age. Their chances of immunity were 
better, yet the ugly fact obtrudes itself that in one case new growths, which underwent malignant 
degeneration, appeared at about the thirty-fifth year. This, however, was in the rather exceptional 
case of Heitzmann. 
Of the seventeen cases in which malignant new growths appeared, epithelioma was noted 
fourteen times, melano-sarcoma once, sarco-carcinoma once, and cancer in one case. Out of my 
own seven cases epithelioma occurred in three children. In wood-cut Fig. 85 an enormous tumor 
is seen seated over and below the ear, while others are present upon the cheeks and forehead. 
These tumors were of the sessile and pedunculated shapes already spoken of. 
The six instances of benign new growths are as follows : Papillary warts, two cases ; papilloma, 
two cases ; granuloma and pannus, of each one case. This foots up new growths of both kinds in 
twenty-three out of forty cases ; and experience shows that in any of the six cases of benign'new 
growth malignancy may occur. The dates, as far as can be ascertained, at which the malignant 
new growths began are as follows : 
From four to ten years 8 cases. 
" ten to twenty years 7 " 
" twenty to thirty-five years " 
Total 17 cases. 
These statistics would seem to indicate that the period of greatest malignancy is under ten years, 
nearly as great until twenty years, and not great 
beyond the twentieth year. 
Of the forty cases of xeroderma pigmento- 
sum, twenty-one were males and nineteen were 
females. Several members of a family were 
usually attacked-in some cases males alone, 
in others the females, and in still others both 
males and females. 
The occurrence of malignant growths, par- 
ticularly epithelioma, in such young subjects is 
remarkable and exceptional, and is to be ex- 
plained on pathological grounds to be considered 
shortly. What has struck me as being equally 
singular is that there is no evidence, presented 
by any case, either during life or after death, of 
metastasis to the viscera. This seems to be an- 
other peculiarity of this wonderful disease. 
It is impossible to give an exact description 
of all of these tumors. In general they are red 
or purple, sessile or pedunculated, fungating or 
raw ; smooth, sometimes encrusted, again oozing, 
and often the seat of hemorrhage. 
The pathology of this disease has been well studied by Kaposi, Geber, Neisser, and Pick, 
and it is to their writings that I am indebted for the facts I present. 
Neisser gives the histological appearances of the skin of xeroderma pigmentosum as follows: 
The pigment is distributed in isolated spots, similar to melanotic tumors, and is seated in the deep 
layers of the epidermis and rarely in the corium. The pigment is precisely similar to that of 
melanotic new growths, and differs from that of ecchymosis. In spots where there is an accumu- 
lation of pigment the interpapillary prolongations of the rete Malpighii are more abundant and 
Fig. 85. 
Xeroderma Pigmentosum, with new growths. XERODERMA PIGMENTOSUM. 
4i9 
compressed than in the normal state. This augmentation in number and size of these prolonga- 
tions seems to be the first stage of the ulterior epithelioma. It was from this fact that Kaposi was 
able to predict the development of epithelioma in one of his cases. 
The little, dirty-yellow, warty elevations undergo corneous transformation, and there is in them 
a rapid increase of the papillary vessels. The atrophic condition is similar to that of senile atrophy 
of the skin, and involves the connective tissue of the papillae and upper portion of the derma. 
The subcutaneous tissues are usually not altered, at least not until late. It thus happens that the 
morbid skin usually freely glides over it. 
In the white spots there is an entire absence of pigment, and the lines of demarcation between 
the thinned epidermal and capillary layers is perfectly regular. With atrophy of the epidermis 
there is absence of pigment, while in spots where it is thickened the pigmentation is great. The 
production of the pigment seems to depend on the alteration in the vessels. 
Leloir's results are similar to the foregoing. He found in the atrophic spots very few vessels 
and an absence of the papillary loops of capillaries. In the superficial layers of the derma embry- 
onic cells were abundant, and also there was a large quantity of elastic fibres in the deep layers of 
the papillae, which seem to have replaced the atrophied connective tissue. This condition probably 
gives rise to the hidebound tension observed in some cases. 
Pick says that at first the epidermis is entirely unchanged, but thickened, and from it conical 
processes pass into the rete, which reduce and thin it. In the corium there is an abundance of 
vessels ; the endothelium of the same and of the capillaries is swollen and folded, so that it obstructs 
the lumen. Around the adventitia of the vessels are masses of small-cell infiltration, particularly 
in those of the papillae. Pigment deposit keeps pace with the invasion of the vessels and with the 
small-cell infiltration of the corium. The cell-infiltration is undoubtedly the carrier of the pigment. 
From this it would seem that in the majority of the pigmentations the cell-increase is not great, but, 
beginning with the keratosic patches, it becomes more and more abundant. In the fawn-colored 
pigmentations, in which it almost conclusively appears that the rete is the seat of pigment, the 
vessels are dilated and distended with blood, and it is evident that they have their origin in the 
red spots. While the keratosic or warty patches are also related to the pigmentations, there is 
found much variation in the amount of cell-infiltration and vascular change. This fact explains 
why some tumors are very vascular and others firm and dry. 
With these facts before us Kaposi's explanation of the occurrence of epithelioma at such early 
ages as being due to the rapid changes going on in the epithelial layer in the production and rapid 
disappearance of new papillae and epithelium, and of the pigment-carrying elements, is very sat- 
isfactory. 
Treatment.-Though every suitable external remedy has been tried, no case of xeroderma 
pigmentosum has ever been cured. Our measures, therefore, should be directed toward placing 
the skin at rest, and removing any possible source of irritation to the morbid parts. Especial 
care should be taken of the eyes, nose, mouth, and ears, since in these situations the disease 
expends its activity and malignancy. The details of this preventive treatment will suggest them- 
selves as the cases present. Knowing so well as we do that these pigmented warts carry in 
their train such terrible consequences, they should be removed as soon as possible with the sharp 
spoon. In fact, all both small and large tumors should be removed as soon as possible. There 
need be no fear of excessive hemorrhage, and if the operation is performed tolerably early we 
are warranted in expecting prompt cicatrization. Especially should this procedure be adopted in 
small and commencing lesions about the eyes, nose, mouth, and ears. The sooner they are 
destroyed the greater is the immunity of the patient to further growth and perhaps malignant degen- 
eration. All large tumors should be removed and the subjacent tissues scraped thoroughly, if 
necessary, to the periosteum and bone. INDEX. 
A. 
Abscess of corpus spongiosum, 53 
of testes, 43 
of vulvo-vaginal glands, 60 
Acarian burrow, most common seat of, 323 
structure of, 321 
Acarus, embryonic, 321 
scabiei, 319 
transitory stages of, 321 
Acne, 226 
anthracoide iodopotassique, 341 
diagnosis of, 229 
prognosis of, 229 
relations to acne rosacea, 397 
treatment of, 229 
Acne-form, pustular syphilide, 132 
Acne rosacea, 397 
clinical history of, 397 
diagnosis of, 399 
etiology of, 399 
first stage of, 397 
hypertrophic, 398 
prognosis of, 399 
relations to acne, 397 
second and third stages of, 398 
symptoms of, 397 
treatment of, 399 
Acne simplex, 226 
etiology of, 227 
symptoms of, 227 
Acrochordon, 391 
Acute circumscribed angio-neurotic cuta- 
neous oedema, 279 
cutaneous oedema, 279 
Adenitis, 53 
treatment of, 54 
Adler Smith on the treatment of ringworm 
of the scalp, 268 
Affections of bones in hereditary syphilis, 
161 
of nails in hereditary syphilis, 160 
Albinism, 407 
Alexander on the treatment of ringworm 
of the scalp, 267 
Allen on pemphigus, 290 
Alopecia areata, 410 
course of, 410 
diagnosis of, 411 
duration of, 410 
etiology of, 411 
micrococci of, 411 
mode of attack, 410 
pathology of, 411 
prognosis of, 411 
treatment of, 411 
Anaesthetic leprosy, 356 
course of, 358 
symptoms of, 357 
treatment of, 359 
trophic lesions of, 357 
Anatomy of the acarus, 320 
Andrews on the treatment of gonorrhoeal 
ophthalmia, 51 
Angioma pigmentosum et atrophicum of 
Taylor, 415 
Angio-neurotic cutaneous oedema, 279 
Anthrarobin in psoriasis, 242 
Antipyrine erythema, 254 
Arning's inoculation in leprosy, 358 
Arsenious acid in treatment of eczema, 216 
Artificial bullous eruptions, 295 
Atropho-derma pigmentosum of Radcliffe 
Crocker, 415 
Auspitz on the mechanism of urticaria, 284 
B. 
Bacillus leprae, 358 
Baerensprung on herpes zoster, 314, 317 
Balanitis, 81 
causes of, 82 
complications of, 83 
diagnosis of, 83 
prognosis of, 84 
symptoms of, 82 
treatment of, 84 
Balsam of Peru in scabies, 330 
Bandaging the testes, 48 
Barber's itch, 298 
Barlow and Warner on subcutaneous tu- 
mors in infants, 282 
Baths in psoriasis, 240 
Batswing disease, 309 
Belladonna eruption, 254 
Benign new growths in xeroderma pig- 
mentosum, 415 
Bidenkap's experiments with the chan- 
croid, 90 
Blanc on the treatment of ringworm of the 
scalp, 267 
Blebs, 184 
Blue pill in syphilis, 166 
Bockhart on staphylococci in ecthyma, 308 
Body louse, 252 
Brocq on ephemeral cutaneous nodes, 282 
Bromide acne, 343 
eruptions, 343 
clinical history of, 343 
Bronson on anthrarobin in psoriasis, 242 
Bru injection, 33 
Bubo, chancroidal, 97 
Buchanan Baxter on pityriasis rubra, 270 
on the forms of exfoliative dermatitis, 
270 
Bullae or blebs, 184 
Bullous eruption in leprosy, 357 
of iodic origin, 339 
Bullous eruptions, anomalous and mixed 
forms of, 291, 292 
Bullous syphilide, 139 
hereditary, 159 
c. 
Calomel in syphilis, 166, 168 
Cancer en cuirasse, 396 
Caspary on ichthyosis fcetalis, 349 
Cauterization of chancroids, too 
Cavafy on the treatment of ringworm of 
the scalp, 266 
Cazenave on pemphigus, 291 
Cephalic chancroid, 89 
Chancre, duration of, 111 
hard, treatment of, 114 
secretion of, 111 
serpiginous, 96 
stage of repair, 94 
treatment of, 100 
treatment subsequent to cautery, 101 
Chancroid, 86 
appearances of, 92 
cephalic, 89 
clinical history, 90 
complications of, 98 
diagnosis of, 99 
frequency, 89 
Gjor's three cases of, 90 
modes of contagion, 88 
nature of, 87 
non-specific nature of, 91 
peculiarity of, 87 
period of activity of, 94 
phagedenic, 96 
prognosis of, 100 
scars following, 95 
seat of, 95 
serpiginous, 96 
treatment of, 100 
Chancroidal bubo, 97 
lymphangitis and bubo, 97 
phimosis, 67 
ulcers, 94 
Cheiro pompholyx, 332 
Chloasma and Addison's disease, 408 
diagnosis of, 408 
etiology of, 408 
treatment of, 408 
varieties of, 408 
Chordee, 21, 30 
treatment of, 30 
Chromophytosis, 259 
Chronic urticaria, 279 
Chrysarobin internally in psoriasis, 239 
Chyluria in elephantiasis, 404 
Cicatricial phimosis, 67 
Cingulum or girdle and zona, 313 
Circinate form of papular syphilide, 129 
Circumcision in phimosis, 68 
Classification of skin diseases, 192 
Clerc on exulcerous chancroid, 95 
Cleveland's modification of Sims' specu- 
lum, 64 
Clover's acne evacuator, 231 
Coca in syphilis, 167 
Colloid degeneration of tubercular syphi- 
lide, 146 
Complications of balanitis, 83 
of chancroid, 98 
of gonorrhoea, 28-40 
of gonorrhoeal vaginitis, 62 
Condition of nails in lichen ruber, 376 
421 422 
INDEX. 
E. 
Ecthyma, 307 
cachecticorum, 307 
diagnosis, 308 
etiology, 308 
prognosis, 308 
treatment, 308 
Ecthymatous chancroid, 96 
syphilide, 135 
Eczema, 202 
acute, 207 
diagnosis of, 214 
etiology, 211 
in infants, treatment of, 217 
local treatment of, 217 
of anus, 209 - 
treatment of, 224 
of breast, treatment of, 224 
of ears, treatment of, 223 
of eyelids, treatment of, 223 
of face, 208 
treatment of, 222 
of genitals, 209 
treatment of, 224 
of hands and feet, 208 
treatment of, 224 
of infants, treatment of, 225 
and young children, 210 
of joints, 210 
treatment of, 225 
of legs, 210 
treatment of, 225 
of lips, treatment of, 224 
of nipples and breast, 209 
of nostrils, treatment of, 222 
of scalp, treatment of, 223 
of trunk, 209 
of umbilicus, 210 
retinosum, 207 
rubrum, 206 
squamosum, 206 
treatment of, 215 
verrucosum vel papillomatosum, 207 
Eichoff on hydroxylamin in ringworm, 302 
Elephantiasis, 403 
age at which it is developed, 405 
clinical history of, 403 
common seat of, 403 
etiology of, 405 
of face, 404 
of penis, 405 
of scrotum, 404 
of upper extremity, 404 
pathology of, 405 
treatment of, 405 
Elytritis, 60 
Ephemeral erythemata, 253 
diagnosis of, 255 
etiology of, 255 
prognosis of, 255 
treatment of, 255 
Epidemics of pemphigus in infants, 293 
Epidermal concretions in lichen planus, 
362 
Epididymite a bascule, 42 
Epididymitis, 40 
causes of, 45 
diagnosis of, 45 
prognosis of, 45 
treatment of, 46 
Epilation in ringworm, 286 
Epithelial pearls in lichen planus, 364 
Epithelioma following xeroderma pigmen- 
tosum, 418 
Eruptions due to belladonna, 254 
chloral, two forms of, 254 
quinine and its preparations, 254 
of iodic origin, 338 
Condition of nerves in leprosy, 358 
Condyloma-like lesions from bromide of 
potassium, 343 
Condylomata lata, 123 
in hereditary syphilis, 157 
Congenital neuropathic papilloma, 352 
phimosis, 66 
Conrad of Berne on specificity and non- 
specificity of gonorrhoeal vaginitis, 
61 
Contagiousness of chancroid, 88 
of gonorrhoea, 27 
Coral-string lichen ruber, 378 
Corbett on bandaging the testes, 47 
Corona veneris, 145 
Corpus spongiosum, abscess of, 53 
Cosmi's paste in herpes erythematosus, 312 
Coster's paint, 268 
Crab louse, 250 
Crocker on dysidrosis, 333 
Crocker's lotion for urticaria, 287 
Croton oil in the treatment of ringworm of 
the scalp, 268 
Crusts, 189 
Cseri on vaginal secretions, 63 
Cullerier on chancroid, 89 
D. 
Dactylitis syphilitica, 161 
Debove on urticaria and hydatid cysts, 283 
Deformities in leprosy, 356 
Denslow on ergot in acne, 230 
Dermal curette in lupus, 385 
Dermatitis exfoliativa, 273 
clinical history of, 274 
following eczema, 270 
pemphigus, 270 
psoriasis, 270 
herpetiformis, 256 
tuberosa of iodic origin, 340 
Dermatolysis, 389 
Descriptive vocabulary of skin diseases, 177 
Devergie on pityriasis pilaris, 367 
on pityriasis rubra, 270 
Diachylon ointment in treatment of eczema, 
219 
Dilating forceps, 67 
Diseases of the skin, the description of, 177 
general considerations of, 175 
primary lesions in, 176 
secondary lesions in, 176 
subjective symptoms in, 176 
Division of ulcers, 189 
Doctrine of the chancroidal virus, 86 
Dohrn on pemphigus in infants, 294 
Dolan on treatment of scabies, 331 
Dressings of penis in gonorrhoea, 29 
Dreyfous on the etiology of herpes zoster, 
3'8 
Dry skin, 350 
Dubuc, multiple herpetiform chancres of, 
109 
Duhring on dermatitis herpetiformis, 275 
on treatment of herpes zoster, 318 
Dumesnil on lupus erythematosus of the 
hands and feet, 311 
Duvaine and Fereol on ephemeral cuta- 
neous nodes, 282 
Dysidrosis, 332 
course of, 333 
diagnosis of, 333 
essential lesions of, 332 
etiology of, 333 
mode of occurrence, 332 
pathology of, 333 
prognosis of, 333 
symptoms of, 333 
treatment of, 334 
Erysipeloid, 257 
Erythema, 195 
circinatum, 256 
diagnosis of, 198 
prognosis of, 198 
treatment of, 198 
due to syphilis, 254 
faciei, 253 
from antipyrene, 254 
belladonna, 254 
chloral, 254 
cold, 253 
heat, 253 
iodine, 338 
iodoform, 254 
opium, 254 
quinine, 254 
wind, 253 
fugax, 254 
clinical history of, 255 
diagnosis of, 255 
etiology of, 255 
treatment of, 255 
marginatum, 197 
migrans, 257 
multiforme, 196 
diagnosis of, 198 
etiology of, 197 
prognosis of, 198 
treatment of, 198 
nodosum, 199 
diagnosis of, 200 
etiology of, 200 
prognosis of, 201 
treatment of, 201 
of mucous membranes, 123 
preceding xeroderma pigmentosum, 416 
serpens, 257 
etiology of, 257 
prognosis of, 258 
symptoms of, 258 
treatment of, 258 
simplex, 253 
traumatica, 253 
Erythemata, symptomatic, 253 
Erythematous eczema, 203 
eruptions from bromine, 343 
spot, 178 
syphilide, 120 
hereditary, 1 57 
Erythroxylon coca in syphilis, 167 
Etiology of gummata, 141 
Eustachian catheter as a vehicle of syphilis, 
108 
Evidence of contagion in pemphigus in 
infants, 294 
Evolution of secondary period of syphilis, 
117 
Excoriations, 187 
Exfoliative dermatitis following eczema, 270 
following pemphigus, 270 
following psoriasis, 270 
External use of chrysarobin in psoriasis, 241 
Exulcerous chancroid, 95 
F. 
Falcone on acute circumscribed oedema, 
280 
False keloid, 414 
Favus, 243 
of the nail, 245 
Fereol on ephemeral cutaneous nodes, 282 
Fibroma molluscum, 387 
Filaria sanguinis hominis as a cause of ele- 
phantiasis, 405 
First period of incubation of syphilis, J06 
Fissures or rhagades, 188 
Fournier on the frequency of chancres, 89 INDEX. 
423 
Fox's, G. H., acne evacuator, 231 
Fox, Tilbury, on dysidrosis, 332 
on anomalous and mixed forms of bul- 
lous eruption, 292 
F owler's solution in treatment of eczema, 216 
Freckles, 408 
G. 
Gangrene in paraphimosis, 70 
in phimosis, 67 
of scrotum, 44 
Gelatin jelly of Peck, 221 
General consideration of hereditary syphi- 
lis, 156 
Genito-crural ringworm, 305 
Gjor's experiments with the chancroid, 90 
three cases of chancroid, 90 
Glossary of skin diseases, 177 
Glycerol plumbi subacetat, 223 
Gonorrhoea, complications of, 40 
in the female, 55 
causes of, 55 
course of, 56 
treatment of, 63 
in the male, 20 
complications of, 28-40 
diagnosis of, 27 
diet in, 29 
dressing in, 29 
of penis in, 29 
etiology of, 22 
micrococcus gonorrhoeas, 26 
injections in late stage of, 31-34 
internal medication in, 35 
in acute stage of, 29 
lesions of, 27 
local treatment in acute, 30 
modes of contagion in, 27 
peculiar forms of, 21, 22 
prophylaxis of, 28 
purgatives in, 29 
stages of, 21 
symptoms of, 20 
treatment of acute stage in, 28 
general, 28 
of Douglas' cul-de-sac, 60 
of female urethra, 58 
symptoms of, 58 
tendency of, 58 
treatment of, 64 
of vagina, 59 
abscess of vulvo-vaginal glands, com- 
plicating, 60 
complications of, 62 
Conrad of Berne on the specificity and 
non-specificity of, 61 
diagnosis of, 62 
different foci in, 59, 60 
treatment of, 64 
of vulva, symptoms of, 56 
treatment of, 63 
passage of sounds in, 39 
treatment of hemorrhage in, 40 
Gonorrhoeal inflammation of spermatic 
cord, 43 
of vas deferens, 43 
Gonorrhoeal ophthalmia, causes of, 48 
diagnosis of, 50 
prognosis of, 50 
symptoms of, 49 
treatment of, 50 
Gowers on boracic acid as a cause of 
psoriasis, 238 
Graham on the etiology of scleroderma, 396 
Granuloma following xeroderma pigmento- 
sum, 418 
Grave symptoms in urticaria, 278 
Greene's mixture for gonorrhoea, 38 
Green iodide of mercury in syphilis, 166 
Greenough on scabies, 323 
Greenough's application for psoriasis, 240 
oil of cade mixture for psoriasis, 240 
Grindelia robusta in zoster, 318 
Gummata, diagnosis of, 143 
etiology of, 141 
prognosis of, 143 
resembling erythema nodosum, 141 
tertiary or late, 142 
Gummatous syphilide, 139 
H. 
Hallopeau on the treatment of ringworm 
of the scalp, 269 
Hardaway on electrolysis in keloid, 414 
on the treatment of acne rosacea, 400 
of follicular inflammation of the 
nares, 223 
of ringworm of the scalp, 269 
Hard chancre, treatment of, 114 
Hardy's modification of Hehnerich's oint- 
ment in scabies, 329 
Head louse, 248 
Hebra and Kaposi on rhinoscleroma, 401 
on pemphigus, 291 
on pityriasis rubra, 270 
on psoriasis, 237 
on the etiology of ringworm of the groin, 
305 
propagation of the acarus scabiei, 320, 
321 
treatment of chloasma, 408 
Hebra's ointment in scabies, 330 
in xeroderma, 415 
Hehnerich's ointment in scabies, 329 
Hemorrhage in gonorrhoea, 40 
Hereditary syphilis, treatment of, 168 
Herpes circinatus, 303 
bullosus, 292 
gestationis, 292 
iris, 256 
modes of development of, 256, 257 
phlyctenoides, 292 
progenitalis, 72 
diagnosis of, 74 
etiology of, 73 
et vulvse, 315 
treatment of, 75 
zoster, 313 
abdominalis, 315 
cervico-brachialis, 314 
subclavicularis, 314 
clinical history of, 313 
diagnosis of, 318 
dorso pectoralis, 315 
etiology of, 317 
facialis, 314 
frontalis, 315 
genitalis, 315 
lumbo femoralis, 315 
inguinalis, 315 
occipito collaris, 314 
ophthalmicus, 315 
pathology of, 317 
sacro-ischiadicus, 315 
treatment of, 318 
Hervieux on pemphigus in infants, 294 
Hilton on chordee, 21 
History of venereal diseases, 86 
Hives, 277 . 
Hutchinson, J., on bromide of potassium 
eruption, 343 
on cheiro pompholix, 332 
on the treatment of ringworm of the 
scalp, 269 
Hyde on lupus erythematosus of the hands 
and feet, 311 
Hyde on the etiology of ringworm of the 
beard, 301 
Hydroa vesiculeux of Bazin, 292 
Hydroxylamin in ringworm, 302 
Hypertrophic cicatrix, 414 
Hypodermic medication in syphilis, 167 
I. 
Ichthyosis, 349 
development of, 350 
diagnosis of, 353 
etiology of, 353 
pathology of, 352 
treatment of, 353 
Ichthyosis hystrix, 352 
nacree, 352 
nigricans, 352 
nitida, 352 
sauroderma, 352 
scutellata, 352 
serpentina, 352 
simplex, 350 
Ichthyotic patches over course of nerves, 352 
Idiosyncrasy in urticaria, 283 
Impetiginous syphilide, 134 
Impetigo contagiosa, 336 
and vaccination, 337 
contagion of, 337 
diagnosis of, 337 
etiology of, 337 
extent of eruption in, 336 
mode of invasion, 336 
origin of, in pus, 337 
parasitic origin of, 337 
primary lesion of, 336 
symptoms of, 337 
treatment of, 337 
herpetiformis, 275 
clinical history of, 275 
diagnosis of, 276 
etiology of, 275 
prognosis of, 276 
treatment of, 276 
India-rubber plaster, 221 
Induration of the ganglia and lymphatics 
in syphilis, 113 
Initial lesion of syphilis, 108 
appearances and characteristics of, 109 
Internal urticaria, 279 
use of chrysarobin in psoriasis, 239 
Inunctions in syphilis, 167 
Iodic eruptions, 338 
prognosis of, 342 
treatment of, 342 
tumors, 341 
Iodide of potassium as a cause of urticaria, 
339 
in psoriasis, 239 
in treatment of eczema, 217 
Iodoform erythema, 254 
Itch, 319 
J- 
Jackson on sycosis, 345 
Jamieson's lotion for urticaria, 287 
Jarisch on central nerve lesions in pemphi- 
gus, 296 
K. 
Kaposi on an anomalous form of lupus 
erythematosus, 311 
on pityriasis rubra, 272 
on the nervous origin of herpes zoster, 317 
pathology of xeroderma pigmentosum, 
419 
Kaposi's acne lancet, 231 424 
INDEX. 
Kaposi's ointment in scabies, 330 
Keloid, clinical history of, 413 
etiology of, 413 
most common site of, 413 
prognosis of, 413 
symptoms of, 413 
treatment of, 413 
true, 414 
Vidal's, scarifications in, 414 
Klotz on lupus erythematosus of the hands 
and feet, 311 
Klotz's compound salicylated plaster, 220 
L. 
La dermatose de Kaposi of Vidal, 415 
Laillier on the treatment of ringworm of 
the scalp, 269 
Lanceraux, papule seche, no 
Lang on the parasitic origin of psoriasis, 238 
Larkspur in pediculosis capitis, 249 
Lassar's paste, 219 
Lead ointment in treatment of eczema, 219 
Leber on the pathology of xeroderma pig- 
mentosum, 419 
Leloir on central nerve lesions in pemphi- 
gus, 296 
on syphilis and herpes progenitalis, no 
on xeroderma pigmentosum, 419 
Lenticular or flat papular syphilide, large 
and small, 126 
diagnosis of, 130 
sites of appearance, 127 
Lentigo, 408 
maligna of Piffard, 415 
Leontiasis, syphilitic, 145 
Lepra graecorum, 354 
mutilans, 358 
nervorum, 357 
tuberosa, 355 
Leprosy, 354 
contagiousness of, 359 
course of, 356 
diagnosis of, 359 
etiology of, 359 
mode of development, 358 
pathology of, 358 
periodically eruptive stage of, 355 
prognosis of, 359 
resemblances between, and syphilis, 354 
time of life observed, 358 
treatment of, 359 
Leprous fever, 354 
Leucoderma, 406 
course of, 407 
diagnosis of, 407 
etiology of, 407 
in the negro, 407 
prognosis of, 407 
treatment of, 407 
Lewis on white lead in herpes zoster, 318 
Lichen cornee, 362 
hypertrophique, 362 
planus, 361 
clinical history of, 362 
course of papules in, 363 
diagnosis of, 366 
etiology of, 366 
mode of invasion of, 361 
of scrotum, 364 
of the palms and soles, 364 
pathology of, 366 
prognosis of, 366 
stage of decline of papules in, 363 
symptoms of, 365 
treatment of, 366 
ruber, 367 
chronic infiltrated, corrugated, and 
scaly stage of, 374 
Lichen ruber, condition of nails in, 375 
course of, 376 
diagnosis of, 376 
etiology of, 376 
moniliformis, 378 
clinical history of, 380 
pathology of, 376 
prognosis of, 377 
stage of coalescence of the papules, 370 
of isolation of the papules, 368 
treatment of, 377 
urticatus, 278 
Linear arrangement of papules in lichen 
planus, 365 
Lioderma essentialis cum melanosi of 
Neisser, 415 
Localized form of gummata, 141 
Local treatment of lupus, 385 
Lupus and cancer, 383 
and struma, 384 
and tuberculosis, 384 
diagnosis of, 385 
pathology of, 385 
prognosis of, 385 
treatment of, 385 
erythematosus, 309 
diagnosis of, 311 
etiology of, 311 
of hands and feet, 311 
pathology of, 311 
prognosis of, 312 
symptoms of, 311 
treatment of, 312 
local, 312 
exedens, 383 
exfoliativus, 383 
exulcerans, 383 
hypertrophicus, 383 
of mucous membranes, 383 
of the female genitals, 384 
sebaceus, 309 
serpiginosus, 383 
terebrans, 383 
verrucosus, 383 
vulgaris, 381 
clinical history of, 382 
general consideration of, 381 
Lustgarten and Mannaberg on gonococci 
in healthy urethrae, 61 
Lymphangite a froid, 52 
Lymphangitis, causes of, 52 
chancroidal, 97 
diagnosis of, 52 
treatment of, 53 
M. 
McBride on the mode of occurrence of 
epididymitis, 40 
McCall, Anderson, on psoriasis rupioides, 
234 
Macular leprosy, 354 
clinical history of, 354 
premonitory symptoms of, 354 
Macules or pigmentations, 190 
Main en griffe in leprosy, 358 
Malignant new growths in xeroderma pig- 
mentosum, 415 
Matas on acute circumscribed oedema, 280 
Mauriac on neuralgic herpes progenitalis, 
73 
on the infrequency of chancroid, 89 
Maury's injection, 33 
Mechanism of the acarian burrow, 321,322 
of urticaria, 284 
Mediate contagion in syphilis, 108 
Medicated powders for skin diseases, 218 
Melano-sarcoma following xeroderma pig- 
mentosum, 418 
Melanosis lenticularis progressiva of Pick, 
415 
Menocal on the surgical treatment of ele- 
phantiasis, 405 
Mercurial fumigation in syphilis, 168 
ointments in psoriasis, 241 
Mery on scleroderma, 395 
Methods of observation in skin diseases, 176 
of reduction of paraphimosis, 70, 71 
of scarification in lupus, 386 
Microbe of alopecia areata, 411 
Micrococcus gonorrhoeae, 25, 26 
Microsporon furfur, 259, 260 
Miliaria crystallina, 335 
diagnosis of, 335 
etiology of, 335 
prognosis of, 335 
treatment of, 335 
Miliary papular syphilides, large, i?6 
diagnosis of, 126 
small, 125 
diagnosis of, 126 
Mistura viridis, 38 
Mixed infections in gonorrcea, 60 
Mixtures, Lafayette, 37 
for injection, 32-34 
Modern treatment of urethritis, 35 
Modes of development of herpes iris, 256, 
257 
of formation of the favus cup, 243 
Molluscous corpuscles, 348 
Molluscum contagiosum, 347 
epitheliale, 347 
fibrosum, 387 
clinical history of, 387 
diagnosis of, 392 
etiology of, 391 
evolution of, 390 
origin of, 387 
pendulum, 388 
of foot, 389 
treatment of, 392 
sebaceum, 347 
clinical history of, 347 
diagnosis of, 348 
etiology of, 348 
mode of development, 347 
pathology of, 348 
prognosis of, 348 
site of, 347 
treatment of, 348 
Moncorvo on elephantiasis in children, 405 
Morphine in zoster, 318 
Morrant Baker on erythema serpens, 258 
Morrow on the infection and systemic dis- 
semination of leprosy, 359 
on the bacillus leprae, 359 
Mucous patches, 123 
Multiple attacks of zoster, 314 
hard chancres, 109 
herpetiform chancres of Dubuc, 109 
linear scarificator, 386 
Munchmeyer on urticaria from cold, 283 
Muscular sclerosis in scleroderma, 395 
Mutilations in leprosy, 356 
N. 
Naevus mollusciformis, 391 
unius lateris, 352 
Naphthol in psoriasis, 242 
Nature of chancroid, non-specific, 91 
Neisser on the pathology of xeroderma pig- 
mentosum, 419 
Nelaton's forceps, 67 
Nettle rash, 277 
Neumann on lichen ruber moniliformis, 378 
on lymph stasis in urticaria, 284 
on pemphigus, 291 INDEX. 
425 
Neuralgia, a sequel of swollen testicle, 44 
of testes, 44 
Neuralgic complications of herpes pro- 
genitalis, 73 
Neuropathic conditions in herpes zoster, 317 
Neurotic form of gummata, 141 
New York Hospital clinic ointment in sca- 
bies, 330 
Nodes of the skin, 281 
ephemeral and persistent, 281 
rheumatic, 282 
Non ulcerative tubercular syphilide, 144 
o. 
Onychia, syphilitic, 131 
treatment of, 132 
Opium in zoster, 318 
Orchi-epididymitis, 40 
most frequent seat of, 43 
symptoms of, 40 
Osler on acute circumscribed oedema, 280 
P. 
Paget on the mode of occurrence of epi- 
didymitis, 40 
Papillary warts following xeroderma pig- 
mentosum, 418 
Papilloma following xeroderma pigmento- 
sum, 418 
Papular and papulo-pustular dermatitis of 
iodic origin, 338 
eczema, 205 
syphilide, 125 
hereditary, 155 
in the negro, 129 
Papule seche of Lanceraux, no 
Papules, 178 
of lichen planus, 363 
Papulo-pustular eruption from bromine, 343 
Paraphimosis, 69 
complicated by chancroid, 98 
from scabies, 326 
methods of reduction of, 70 
prognosis of, 70 
reduction of, 70, 71 
treatment of, 70 
Passage of sounds in gonorrhoea, 39 
Pathology of urticaria, 284 
Peculiarities of iodine eruptions, 338 
Pediculosis capitis, 247 
clinical history of, 247 
description of, 248 
etiology of, 248 
prognosis of, 249 
treatment of, 249 
corporis, 251 
clinical appearances of, 251 
diagnosis of, 252 
etiology of, 251 
treatment of, 252 
general consideration of, 247 
pubis, 250 
lesions of, 250 
symptoms of, 250 
treatment of, 251 
Pediculus capitis, 248 
ova of, 249 
corporis, 251, 252 
pubis, 250 
Pemphigus, 289 
diagnosis of, 296 
etiology of, 295 
prognosis of, 296 
treatment of, 296 
acute, 290 
acutus adultorum, 292 
circinatus, 292 
Pemphigus foliaceus, 291 
gangrenosus, 290 
in children, clinical history of, 293 
etiology of, 294 
prognosis of, 296 
in infants and young children, 293 
etiology of, 294 
localis, 291 
malignans, 290 
pruriginosus, 291, 292 
solitarius, 291 
vegetans of Neumann, 291 
vulgaris, or chronic, 289 
Period of general manifestations in syphi- 
lis, 106 
of greatest malignancy in xeroderma 
pigmentosum, 418 
Periodically eruptive stage of lepra, 355 
Perionychia, syphilitic, 131 
treatment of, 132 
Periurethral phlegmon, treatment of, 53 
Petechial form of iodic intoxication, 342 
Pfund nase, 398 
Phagedenic chancroid, 96 
Phimosis, 66 
chancroidal, 67 
congenital, 66 
different forms of, 67 
from scabies, 326 
general considerations of, 66 
treatment of, 67 
Pick on pilocarpine in urticaria, 286 
on xeroderma pigmentosum, 419 
Piebald negroes, 407 
Piffard on hydronaphthol plaster in lupus, 
385 
Piffard's acne evacuator, 231 
Pigmentary syphilide, 153 
Pil hydrarg. et hyoscyami comp, in syphilis, 
165 
Pilocarpine hypodermically in alopecia are- 
ata, 412 
Pityriasis pilaris, 367 
pilaris, 367 
rubra, 270 
course of, 271 
diagnosis of, 272 
etiology of, 272 
pathology of, 272 
symptoms of, 270 
treatment of, 272 
versicolor, 259 
Plumbum causticum in vegetations, 80 
Pompholyx, 332 
Pontoppidan on pemphigus acutus adulto- 
rum, 292 
Porcupine disease, 352 
Premonitory symptoms of leprosy, 354 
Psoriasis, 233 
commencing lesion in, 234 
course of, 234, 237 
diagnosis of, 238 
etiology of, 237 
local treatment, 239 
of palms and soles, 235 
of the face, 236 
of the scalp, 236 
treatment of, 239 
Purpura urticans, 278 
Pustular eczema, 205 
syphilide, 132 
Pustules, 183 
Pyrogallol in psoriasis, 241 
Q. 
Quincke on acute circumscribed cutaneous 
oedema, 279 
Quinine eruption, 254 
R. 
Radcliffe Crocker's treatment of scabies, 331 
Reduction in paraphimosis, modes of, 70 
Requirements for the study of skin diseases, 
175 
Resolutive tubercular syphilide, 144 
Retrojections in gonorrhoea, 34 
Reynaud on the mode of occurrence of 
epididymitis, 40 
Reynaud's disease and scleroderma, 395 
Reynolds on the treatment of ringworm, 269 
of the scalp, 268 
of favus, 246 
Rheumatic cutaneous nodes, 282 
Rhinoscleroma, 401 
diagnosis of, 402 
treatment of, 402 
Ricord's injections. 33 
Riehl and Paltauf on acute circumscribed 
oedema, 280 
on tuberculosis verrucosa cutis, 384 
Ringed form of erythematous syphilide, 122 
of tinea circinata, Arning on, 303 
Unna on, 303 
Ringworm of beard, 298 
diagnosis of, 301 
etiology of, 300 
prognosis of, 301 
treatment of, 301 
of body, concentric circles in, 303 
of groin, 304 
of scalp, 262 
course of, 263 
diagnosis of, 264 
etiology of, 264 
prognosis of, 264 
treatment of, 265 
Robinson on the micrococcus of alopecia 
areata, 411 
pathology of dysidrosis, 333 
Rochard's ointment, 241 
Rodent ulcer and lupus, 385 
Roesen on pemphigus in infants, 294 
Rosenbach on erysipeloid, 258 
Roswell Park on oxide of zinc as an anti- 
septic application, 297 
Roux on the gonococcus, 26 
Rupia, or rupial syphilide, 137 
Rupial eruption, early and small, 137 
diagnosis of, 138 
large form of, 138 
prognosis of, 138 
s. 
Salicylic acid in psoriasis, 241 
Salsotto on a form of the papular syphilide, 
125 
Sangster and Mott on nerve degeneration 
in pemphigus, 295 
Sarco-carcinoma following xeroderma pig- 
mentosum, 418 
Sarcoptes hominis, 319 
Scabies, 319 
clinical history of, 324 
course of, 327 
diagnosis of, 328 
etiology of, 327 
most frequent sites of, 325 
ointments used in, 330 
prognosis of, 328 
quick cure of Hardy in, 329 
subjective symptom of, 327 
time of life most frequent, 327 
treatment of, 328 
Scabietic. inflammation, results of, 326 
nodules resembling hard syphilitic prim- 
ary lesions, 326 426 
INDEX. 
Scabietic ulcers of penis resembling chan- 
croids, 326 
Scars or cicatrices, 189 
Scavenzio's calomel injections in syphilis, 
168 
Schmiegelow and Bacon on the treatment 
of eczema of the nares, 223 
Schwartz on the treatment of gonorrhoea in 
women, 65 
Scleroderma, 393 
and morphoea, 395 
clinical features of, 393 
diagnosis of, 396 
etiology of, 396 
involution of, 394 
prognosis of, 396 
treatment of, 396 
Seat of chancre and lymphatic ganglia 
compared, 113 
Second attacks of zoster, 314 
period of incubation of syphilis, 106 
Secretan on the treatment of pemphigus, 
297 
Secretion of chancre, 111 
Serpiginous chancre, 96 
chancroid, 96 
syphilide, 150 
Shingles, 313 
Shoemaker on the treatment of ringworm 
of the scalp, 267 
Siegesbeckia orientalis in tinea tonsurans, 
269 
Skene's reflex catheter, 64 
Sounds, passage of, in gonorrhoea, 39 
Spermatic cord, gonorrhoeal inflammation 
of, 43 
Spiritus saponatus alkalinus, 220 
Squamae or scales, 187 
Squamous syphilide of palm, 129 
Squire on the treatment of lupus by scarifi- 
cation, 386 
Squire's glycerol plumbi subacetat, 223 
Staphylococcus pyogenes albus in ecthyma, 
308 
aureus in ecthyma, 308 
Strapping testicle in epididymitis, 48 
Strubing on acute circumscribed oedema, 
280 
Subcutaneous nodular tumors of iodic 
origin, 342 
Sulphide of calcium in elephantiasis, 405 
in scabies, 331 
Sulphur in eczema, 220 
in psoriasis, 241 
Sycosis, 344 
clinical history of, 344 
course of, 345 
diagnosis of, 345 
etiology of, 345 
parasitica, 298 
pathology of, 345 
prognosis of, 346 
treatment of, 346 
Symptomatic erythemata, 253 
Syphilide, bullous, 139 
hereditary, 159 
ecthyma-form, 135 
diagnosis of, 136 
prognosis of, 136 
erythematous, 120 
diagnosis of, 123 
hereditary, 157 
gummatous, 139 
generalized form of, 139 
localized form of, 140 
neurotic form of, 141 
impetiginous, 134 
large flat papular, 130 
diagnosis of, 131 
Syphilide, large flat papular, prognosis of, 
131 
of palm, squamous, 129 
hereditary, 155 
papular, 125 
hereditary, 157 
pigmentary, three forms, 153 
pustular, 132 
large or impetigo-form, 134 
course of, 135 
diagnosis of, 135 
prognosis of, 135 
small or acneform, 133 
serpiginous, 150 
deep, 151 
diagnosis of, 152 
prognosis of, 152 
superficial, 150 
course of, 133 
diagnosis of, 134 
tubercular, resolutive, 144 
diagnosis of, 147 
ulcerative early and late, 148 
Syphilides, miliary papular, 125, 126 
Syphilis, evolution of secondary period in, 
117 
general discussion of, 105 
hereditary, 155 
affections of bones in, 161 
of nails in, 161 
prognosis of, 156 
treatment of, 161 
early indications for systemic, 163 
tonic treatment of, 165 
umbilicated papule of, no 
unilateral development of, 148 
Syphilitic dactylitis, 161 
infection, modes of, 107 
onychia, 131 
perionychia, 131 
treatment of, 132 
virus, vehicles of, 107 
Syringes, some of the best, 32 
T. 
Tannate of mercury in syphilis, 166 
Tarnowsky on chancroid, 89 
Tarry preparations in treatment of eczema, 
220 
psoriasis, 240 
Tattooing as a cause of syphilis, 108 
Teeth in hereditary syphilis, 160 
Tertiary gummata, 142 
Testicle, strapping of, in epididymitis, 48 
Theories of the modes of infection in lep- 
rosy, 358 
Thymol in psoriasis, 242 
Tinctura saponis viridis comp., 221 
Tinea circinata, 303 
clinical history of, 303 
diagnosis of, 305 
etiology of, 305 
prognosis of, 306 
treatment of, 306 
favosa, 243 
course of, 244 
diagnosis of, 245 
etiology of, 245 
of body, 244 
of scalp, 243 
prognosis of, 246 
treatment of, 246 
ultimate effect of, 244 
sycosis, 298 
tonsurans, 262 
course of, 263 
diagnosis of, 264 
etiology of, 264 
Tinea tonsurans, prognosis of, 264 
tricophytina barbae, 298 
clinical history of, 298 
diagnosis of, 301 
etiology of, 300 
prognosis of, 301 
treatment of, 301 
cruris, 304 
versicolor, 259 
clinical history of, 259 
course of, 26c 
diagnosis of, 260 
etiology of, 260 
prognosis of, 260 
symptoms of, 260 
treatment of, 261 
Tonic treatment of syphilis, 165 
Treatment of acne, 229 
rosacea, 399 
of adenitis, 54 
of alopecia areata, 411 
of balanitis, 84 
of chancre, too, 101 
of chancroid, ico 
of chloasma, 408 
of chordee, 30 
of dysidrosis, 334 
of ecthyma, 308 
of eczema in infants, 217, 225 
local, 217 
of anus, 224 
of breast, 224 
of ears, 223 
of eyelids, 223 
of face, 222 
of genitals, 224 
of hands and feet, 224 
of joints, 225 
of legs, 225 
of lips, 224 
of nares, 223 
of nostrils, 222 
of scalp, 223 
squamosum, 206 
of elephantiasis, 405 
of epididymitis, 46 
of erythemata. ephemeral, 255 
of erythema circinatum, 198 
fugax, 255 
multiforme, 198 
nodosum, 201 
serpens, 258 
of gonorrhoea in female, 63, 64 
in male, 28 
of gonorrhoeal ophthalmia, 50, 51 
of hard chancre, 114 
of hereditary syphilis, 168 
of herpes progenitalis, 75 
zoster, 318 
of ichthyosis, 353 
of impetigo contagiosa, 337 
herpetiformis, 276 
of iodic eruptions, 342 
of keloid, 413 
of leprosy, 359 
of leucoderma, 407 
of lichen planus, 366 
ruber, 377 
of lupus, 385 
by scarification, 386 
erythematosus, 312 
of lymphangitis, 53 
of miliaria crystallina, 335 
of molluscum fibrosum, 392 
sebaceum, 348 
of paraphimosis, 70 
of pediculosis capitis, 249 
corporis, 252 
pubis, 250 INDEX. 
427 
Treatment of pemphigus, 296, 297 
of phimosis, 67 
of pityriasis rubra, 272 
of psoriasis, 239 
of rhinoscleroma, 402 
of ringworm of beard, 301 
of scalp, 265-268 
of scabies, 328, 329 
of scleroderma, 396 
of sycosis, 346 
of syphilis, hereditary, 161 
tonic, 165 
of syphilitic perionychia, 132 
of tinea circinata, 306 
favosa, 246 
tricophytina barbae, 301 
versicolor, 261 
of urethritis, modern, 35 
of urticaria, 285 
of vegetations, 79, 
of xeroderma, 419 
Troisier and Brocq on ephemeral cutaneous 
nodes, 282 
True keloid, 414 
Tubercles, 181 
Tubercular syphilide, 144 
resembling psoriasis, 147 
ulcerating, 149 
Tuberculated leprosy, 355 
course of, 356 
symptoms of, 355 
Tuberculosis papillomatosa cutis, 384 
verrucosa cutis, 384 
Tumors, 185 
u. 
Ulcerating tubercular syphilide, 149 
Ulcers, 188 
Ulcus elevatum, chancroid, 96 
Umbilicated papule of syphilis, no 
Unilateral development of syphilis, 148 
Unna on lupus verrucosus and verruca ne- 
crogenica, 384 
on mechanism of urticaria, 284 
Unna on salicylic acid plaster in lupus, 
385 
Unna's glycerine and gelatin jelly, 220 
gutta-percha plaster mulls, 221 
powder-bags, 218 
prescriptions for acne, 231 
salve mulls, 221 
Urethrorrhoea, 23 
Urticaria ab ingestis, 283 
acute, 277, 278 
clinical history of, 278 
diagnosis of, 284 
prognosis of, 284 
treatment of, 285 
bullosa, 278 
chronic, 279 
clinical history of, 279 
diagnosis of, 284 
treatment of, 285 
ephemera, 278 
etiology of, 282 
evanida, 278 
haamorrhagica, 278 
in children, 280 
internal, 279 
lesions of, 277 
cedematosa, 278 
of iodic origin, 339 
papulosa, 278 
pathology of, 284 
perstans, 278 
pigmentosa, 281 
prognosis, 284 
recidiva, 278 
subcutanea, 278 
treatment of, 285 
versiculosa, 278 
V. 
Van Harlingen's ointment for eczema, 223 
Varying features of chancroidal ulcers, 95 
Vas deferens, gonorrhoeal inflammation of, 
43 
Vegetations, 76 
Vegetations, diagnosis of, 78 
prognosis of, 78 
treatment of, 79 
Venereal diseases, general considerations 
of, 19 
Verruca necrogenica, 384 
Vesicles, 183 
Vesicular eczema, 205 
Vespertilio, 309 
Vetault on hydrocele, 44 
Vidal on the treatment of ringworm of the 
scalp, 269 
Vitiligo, 406 
clinical features of, 406 
Vleminckz' solution, 241 
Vocabulary of skin diseases, 177 
W. 
Wheals, 185 
White, J. C., on scabies, 319 
White's ointment in scabies, 330 
White verrucous growths and epithelioma 
following psoriasis, 237 
Wilkinson's ointment, 241, 242 
Wolff and Weyl on the parasitic origin of 
psoriasis, 238 
X. 
Xeroderma of Hebra, 415 
or dry skin, 349 
pigmentosum, 415 
clinical history of, 415 
invasion of, 415 
pathology of, 418 
treatment of, 419 
Y. 
Yandell's description of ichthyosis, 349 
Z. 
Zona, 313  
or ■ 
Yhersai t 
INCLUDING 
©iaqnosis.Woqnosis & treatment 
BY 
ROBERT W. TAYLOR, A.M, M.D., 
PROFESSOR, of DERMATOLOGY IN THE NEW YORK POST-GRADUATE MEDICAL SCHOOL; SURGEON TO THE CHARITY HOSPITAL, NEW YORK, AND TO THE DEPARTMENT 
OF VENEREAL AND SKIN DISEASES OF THE NEW YORK HOSPITAL; LATE PRESIDENT OF THE AMERICAN DERMATOLOGICAL ASSOCIATION; 
JOINT AUTHOR OF BUMSTEAD AND TAYLOR'S "PATHOLOGY AND TREATMENT OF VENEREAL DISEASES," ETC. 
ILLUSTRATED WITH TWO HUNDRED AND THIRTEEN FIGURES, MANY OF THEM LIFE SIZE, ON 
.fifty-eight Beautifully (Holoreii plates. 
ALSO, MANY LARGE AND CAREFULLY EXECUTED ENGRAVINGS IN THE TEXT. 
PHILADELPHIA: 
LEA BROTHERS & CO. 
1889. Entered according to the Act of Congress in the year 1889, by 
LEA BROTHERS & CO., 
In the Office of the Librarian of Congress, at Washington. All rights reserved. 
Westcott & Thomson, 
Stereotypers and Electrotypers, Philada. 
Dornan,Printer, 
Philadelphia. TO THE MEMORY 
OF 
FREEMAN J. BUMSTEAD, M. D„ LL.D., 
Professor of Venereal Diseases at the College of Physicians and Surgeons, New York; Surgeon to the New York Eye 
and Ear Infirmary; Consulting Surgeon to Charity Hospital, New York, 
THIS VOLUME 
is 
AFFECTIONATELY DEDICATED 
BY THE AUTHOR. PREFACE. 
In preparing this work I have aimed to present to the eye as well as the mind our most recent 
knowledge of the diagnosis and treatment of Venereal and Skin Diseases. For the accomplish- 
ment of this purpose I have adopted the plan of an Atlas, in which the plates, imitating nature as 
closely as possible in form, size, and color, should be accompanied by an illustrated text simple 
and clear in explanation and abounding in therapeutical suggestions. 
In this I have had at command the world's entire pictorial literature in the domain of Derma- 
tology and Venereal Diseases. While my own cases have been largely drawn upon, I have not 
hesitated to make selections from other works whenever desirable, and I take this opportunity to 
acknowledge the kindness of Hutchinson, Kaposi, Neumann, Ricord, Squire, and Clerc in con- 
senting to my use of their plates. In addition to these, illustrations will be found drawn from 
the works of Baerensprung, Cazenave, Cullerier, Tilbury Fox, Hebra, Mayr, and Parrot. In the 
selection of these plates the leading design has been to provide a series illustrating the successive 
stages of typical cases. As far as possible the figures have been drawn life-size for the purpose 
of securing accuracy of detail with naturalness of color. Besides these, the numerous wood-cuts 
throughout the text will, it is hoped, prove of much aid to the reader. 
In the preparation of the text I have aimed at clearness and terseness of statement, and to 
avoid as far as possible the cumbrous and redundant vocabulary of terms which prove such a 
serious drawback to the study of these interesting diseases. It has also been my aim to bring out 
fully, clearly, and prominently all the varying, and often multiform, clinical features of the differ- 
ent diseases, in order that the combined study of the text and the plates may go far to fill a vqid 
in the practice of those to whom extended clinical observation is denied. The treatment, which I 
have endeavored to make very full, simple, and practical, is such as I have found to give the best 
results in private practice, and also in the vast number of cases which are treated annually at 
the Charity Hospital and at my clinic at the New York Hospital. Besides this, the therapeutics 
of all authorities have been studied, and those which are of real value have been incorporated 
in the text. 
In fact, it has been my constant endeavor to make this work thoroughly practical-in effect, a 
series of clinical lectures such as no hospital can furnish to the student-and, at the same time, to 
make it a work that the busy practitioner can use to advantage in his every-day practice. With 
this end in view, I have not entered largely into a consideration of the pathology of skin diseases, 
since that study, in many instances, is still in a very unsettled state. 
As the successive parts have appeared I have been much gratified by the kind expressions of 
welcome with which each has been received ; and I now submit the work as a whole, confidently 
trusting that the vast amount of labor it has cost me may not have been vainly expended in the 
effort to do my share toward the general advancement of syphilography and dermatology. 
ROBERT W. TAYLOR. 
40 West Twenty-first Street, New York, 
August 7, 1889. 
5 CONTENTS. 
VENEREAL, DISEASES. 
Part 3. 
Page 
GENERAL CONSIDERATIONS. 19 
GONORRHOEA IN THE MALE 20 
EPIDIDYMITIS, 40. 
ORCHI-EPIDIDYMITIS, 40. 
LYMPHANGITIS, 52. 
ABSCESS OF THE CORPUS SPONGIOSUM, 53. 
PERIURETHRAL PHLEGMON, 53. 
ADENITIS, 53. 
GONORRHOEA IN THE EEMALE. 55 
GONORRHCEA OF THE URETHRA, 58. 
GONORRHCEA OF THE VAGINA, 59. 
PHIMOSIS. ......................................... 66 
PARAPHIMOSIS 
HERPES PROGENITALIS 72 
VEGETATIONS............................................................................................. 76 
BALANITIS -. 81 
THE CHANCROID OR SOFT CHANCRE.. 86 
CHANCROIDAL LYMPHANGITIS AND BUBO, 97. 
CHANCROIDAL BUBO, 97. 
SYPHILIS 105 
Part 33. 
•S' YPHIL IS (Con tinned} 117 
SYPHILIDES, 119. 
THE ERYTHEMATOUS SYPHILIDE, 120. 
ERYTHEMA OF MUCOUS MEMBRANES; MUCOUS PATCHES AND CONDYLOMATA LATA, 123. 
7 8 
CONTENTS. 
Page 
S YPH I LIS (Continued} 117 
THE PAPULAR SYPHILIDES, 125. 
THE LENTICULAR OR FLAT PAPULAR SYPHILIDE, 126. 
THE LARGE FLAT PAPULAR SYPHILIDE, 130. 
SYPHILITIC ONYCHIA AND PERIONYCHIA, 131. 
THE PUSTULAR SYPHILIDES, 132. 
THE SMALL PUSTULAR OR ACNE-FORM SYPHILIDE, 133. . 
THE LARGE PUSTULAR OR IMPETIGO-FORM SYPHILIDE, 134. 
THE ECTHYMA-FORM SYPHILIDE, 135. 
Part 333. 
RUPIA OR RUPIAL SYPHILIDE : 137 
THE BULLOUS SYPHILIDE, 139. 
THE GUMMATOUS SYPHILIDES, 139. 
THE TUBERCULAR SYPHILIDES, 144. 
THE ULCERATIVE SYPHILIDES, EARLY AND LATE, 148. 
THE LATE ULCERATING TUBERCULAR SYPHILIDES, 149. 
ULCERATING TUBERCULAR SYPHILIDE, 149. 
THE SERPIGINOUS SYPHILIDES, 150. 
THE DEEP SERPIGINOUS SYPHILIDE, 151. 
THE PIGMENTARY SYPHILIDE, 153. 
HEREDITARY SYPHILIS 155 
THE ERYTHEMATOUS SYPHILIDE, 157. 
THE PAPULAR SYPHILIDE AND CONDYLOMATA LATA, 157. 
THE BULLOUS SYPHILIDE, 159. 
THE VESICULAR SYPHILIDE, 159. 
THE PUSTULAR SYPHILIDE, 159. 
THE TUBERCULAR SYPHILIDE, 159. 
AFFECTIONS OF THE NAILS, 160. 
THE TEETH IN HEREDITARY SYPHILIS, 160. 
AFFECTIONS OF THE BONES, 161. 
OSTEOCHONDRITIS, 161. 
PERIOSTITIS, 161. 
TREATMENT OF SYPHILIS 161 
TREATMENT OF HEREDITARY SYPHILIS. 168 CONTENTS. 
9 
DISKASKS ON THIS SKIN. 
Part 3b. 
Page 
GENERAL CONSIDER A ITO NS. 175 
PRIMARY LESIONS I?8 
THE ERYTHEMATOUS SPOT, 178. 
PAPULES, 178. 
TUBERCLES, 181. 
VESICLES,-183. 
PUSTULES, 183. 
BULL/E OR BLEBS, 184. 
WHEALS, 185. • 
TUMORS, 185. 
SECONDARY LESIONS.................................... xg7 
SQUAMZE OR SCALES, 187. 
EXCORIATIONS, 187. 
FISSURES OR RHAGADES, 188. 
ULCERS, 188. 
CRUSTS, 189. 
SCARS OR CICATRICES, 189. 
MACULES OR PIGMENTATIONS, 190. 
CLASSIFICATION OF DISEASES OF THE SKIN .. ............ 192 
ERYTHEMA I95 
ERYTHEMA MULTIFORME Ig6 
ERYTHEMA NODOSUMI99 
ECZEMA2O2 
ERYTHEMATOUS ECZEMA, 203. 
PAPULAR ECZEMA, 205. 
VESICULAR ECZEMA, 205. 
PUSTULAR ECZEMA, 205. 
ECZEMA RUBRUM, 206. 
ECZEMA SQUAMOSUM, 206. 
ECZEMA RIMOSUM, 207. 
ECZEMA VERRUCOSUM VEL PAPILLOMATOSUM, 207. 
ACUTE ECZEMA, 207. 
ECZEMA OF THE FACE, 208. 
ECZEMA OF THE HANDS AND FEET, 208. 
ECZEMA OF THE GENITALS, 209. 10 
CONTENTS. 
Page 
ECZEMA (Continued) 202 
ECZEMA OF THE ANUS, 209. 
ECZEMA OF THE TRUNK, 209. 
ECZEMA OF THE NIPPLES AND BREAST, 209. 
ECZEMA OF THE UMBILICUS, 210. 
ECZEMA OF THE JOINTS, 210. 
ECZEMA OF THE LEGS, 210. 
ECZEMA OF INFANTS AND YOUNG CHILDREN, 210. 
A CNE 226 
ACNE SIMPLEX, 226. 
PSORIASIS 233 
FAVUS {TINEA FAVOSA) 243 
Part b. 
PEDICULOSIS. 247 
PEDICULOSIS PUBIS, 250. 
PEDICULOSIS CORPORIS, 251. 
ERYTHEMA FACIEI AND EPHEMERAL ERYTHEMATA 253 
SYMPTOMATIC ERYTHEMATA, 253. 
ERYTHEMA CIRCINATUM 256 
HERPES IRIS. 256 
ERYTHEMA SERPENS. 256 
TINEA VERSICOLOR 259 
TINEA TONSURANS 262 
RINGWORM OF THE SCALP, 262. 
PITYRIASIS RUBRA.................................................................................... 270 
DERMATITIS EXFOLIATIVA 273 
IMPETIG0 HERPETIFORMIS. 275 
Part b3. 
URTICARIA 277 
CHRONIC URTICARIA, 279. 
INTERNAL URTICARIA, 279. 
ACUTE CIRCUMSCRIBED ANGIO-NEUROTIC CUTANEOUS (EDEMA, 279. 
URTICARIA IN CHILDREN, 280. 
URTICARIA PIGMENTOSA, 281. 
EPHEMERAL AND PERSISTENT NODES OF THE SKIN, 281. CONTENTS. 
11 
Page 
PEMPHIGUS 289 
CHRONIC PEMPHIGUS OR PEMPHIGUS VULGARIS, 289. 
ACUTE PEMPHIGUS, 290. 
PEMPHIGUS FOLIACEUS, 291. 
ANOMALOUS AND MIXED FORMS OF BULLOUS ERUPTIONS, 292. 
PEMPHIGUS IN INFANTS AND YOUNG CHILDREN, 293. 
TINEA TRICOPHYTINA BARBAE................. 298 
TINEA CIRCINATA 303 
TINEA TRICOPHYTINA CRURIS, 304. 
ECTHYMA 
LUPUS ERYTHEMATOSUS........................................................................... 309 
LUPUS ERYTHEMATOSUS OF HANDS AND FINGERS, 311. 
HERPES ZOSTER 313 
Part to. 
SCABIES 319 
DYSIDROSIS OR POMPHOLYX 332 
MILIARIA CRYSTALLIN A 335 
IMPETIGO CONTAGIOSA 336 
ERUPTIONS OF IODIC ORIGIN................................................................. 338 
ERYTHEMA, 338. 
PAPULAR AND PAPULO-PUSTULAR DERMATITIS OF IODIC ORIGIN, 338. 
URTICARIA, 339. 
THE BULLOUS ERUPTION, 339. 
DERMATITIS TUBEROSA, 340. 
SUBCUTANEOUS NODULAR TUMORS, 342. 
THE PETECHIAL FORM OF IODIC INTOXICATION, 342. 
BROMIDE ERUPTIONS 343 
SYCOSIS........................................................................................................ 344 
MOLLUSCUM SEBACEUM. 347 
ICHTHYOSIS...................... .......... ............................................................... 349 
DRY SKIN, 350. 
ICHTHYOSIS SIMPLEX, 350. 
ICHTHYOSIS HYSTRIX, 352. 
ICHTHYOTIC PATCHES OVER COURSE OF NERVES, 352. 
LEPROSY: LEPRA GRZECORUM........................... ............................... ...... 354 
MACULAR LEPROSY, 354. 
TUBERCULATED LEPROSY, 355. 
ANAESTHETIC LEPROSY, 357. 12 
CONTENTS. 
Part 11333. 
Page 
LICHEN PLANUS........................................................................................ 361 
LICHEN RUBER........................................................................................ 367 
THE STAGE OF ISOLATION OF THE PAPULES, 368. 
THE STAGE OF COALESCENCE OF THE PAPULES, 370. 
THE CHRONIC INFILTRATED, CORRUGATED, AND SCALY STAGE, 374. 
THE SO-CALLED LICHEN RUBER MONILIFORMIS OF KAPOSI........... 378 
L UPUS VUL GARIS 381 
MOLLUSCUM FIBROSUM.......................................................................'.... 387 
SCLERODERMA 393 
ACNE ROSACEA.......................................................................................... 397 
RHINOSCLEROMA................................................................................., 401 
ELEPHANTIASIS 403 
LEUCODERM A 406 
CHLOASMA................................................................................................... 408 
ALOPECIA AREATA 410 
KELOID......................................................................................................... 413 
XERODERMA PIGMENTOSUM. 415 LIST OF COLORED PLATES 
AND THEIR SOURCES. 
VENEREAL DISEASES. 
PART I. 
Plate I ,-Facing Page 20. 
Fig. Author. 
1. Acute Gonorrhoea in the Male Cullerier. 
2. Acute Gonorrhoea in the Female 
3. Abscess of Vulvo-vaginal Gland 
4. Gonorrhoeal Epididymitis 
5. Gonorrhoeal Orchi-epididymitis 
6. Acute Vaginitis 
7. Suppurative Orchitis, with Hernia Testis " 
8. Appearance of Hernia Testis 
9. Lymphangitis from Acute Gonorrhoea 
10. Phlegmonous Abscess of Corpus Spongiosum 
11. Phimosis complicating Acute Gonorrhoea . 
Plate 11. -Facing Page 66. 
1. Paraphimosis from Acute Gonorrhoea Kaposi, 
2. Congenital Phimosis Cullerier. 
3. Gonorrhoeal Ophthalmia 
4. Intense Chemosis in Gonorrhoeal Ophthalmia 
5. Simple Paraphimosis 
6. Suppurating Buboes (Strumous) 
7. Indolent Adenitis from Syphilis 
8. Vegetations of the Glans Penis Ricord. 
t 
Plate III .-Facing Page 84. 
1. Chancroid of Free Border of Prepuce Clerc. 
2. Chancroid of Prepuce . " 
3. Chancroids of Glans and Prepuce ; Ulcus elevatum Kaposi. 
4. Superficial Serpiginous Chancroid of Glans Cullerier. 
5. Multiple Chancroids, some coalesced Kaposi. 
13 T4 
LIST OF COLORED PLATES AND THEIR SOURCES. 
Fig- Author. 
6. Chancroids of Fraenum, with Slight Paraphimosis . . '. . . . Ricord. 
7. Intra-preputial Chancroids, complicated with Phimosis and Gangrene . . " 
8. Chancroids on Free Margin of Phimotic Prepuce Kaposi. 
9. Gangrenous Perforation of Prepuce from Chancroids Cullerier. 
10. Paraphimosis, complicated with Chancroids 
Plate IV ,-Facing Page 94. 
1. Chancroids of Vulva and Anus Cullerier. 
2. Chancroids of Anus of a Woman 
3. Chancroids of the Margin of the Anus and Perinaeum of a Man . . . " 
4. Successful Inoculation from Pus of Fig. 3 
5. Chancroids of the Vulva, Anus, and Internal Surface of Thighs . . . " 
6. Chancroids from Auto-inoculation through Coaptation of the Labia Majora . Kaposi. 
7. Chancroids of Vulva in Active Stage Cullerier. 
8. Chancroids of Os Uteri 
Plate V. -Facing Page 96. 
1. Chancroidal Bubo, Serpiginous Kaposi. 
2. Chancroidal or Virulent Bubo Cullerier. 
3. Chancroid with Ulceration of Lymphatics of Dorsum of Penis and with Sup- 
purative BuboKaposi. 
4. Large Hard Chancre of Prepuce, complicated with Ulceration and Suppurating 
Bubo of Left Side Ricord. 
Plate VI. -Facing Page 72. 
1. Herpes Progenitalis PenisBaerensprung. 
2. Herpes Progenitalis Vulvae Kaposi. 
3. Vegetations or Venereal Warts of the Skin. Ricord. 
4. Condylomata Lata, much hypertrophied . 
Plate VII .-Facing Page 98. 
1. Indurated Chancres of Prepuce and Skin of Penis Clerc. 
2. Multiple Indurated Chancres Cullerier. 
3. Indurated Chancre with Tendency to PhagedenaClerc. 
4. Indurated Chancre with Typical Induration Cullerier. 
5. Indurated Chancre of Prepuce Clerc. 
6. Indurated Chancre of Meatus and Urethra Cullerier. 
7. Indurated Chancre with Molecular Gangrene and Surrounding CEdema . . Kaposi. 
8. Indurated Chancre of Meatus and I;ossa Navicularis ....." 
9. Indurated Chancre of Prepuce Cullerier. 
10. Indurated Chancre of Meatus Kaposi. 
11. Persistent Induration Cullerier. 
12. Indurated Chancre with Roseolous Spots on Neighboring Parts . . . Kaposi. 
13. Indurated Chancre with Molecular Gangrene and Hard CEdema . . . Cullerier. 
14. A Series of Chancroids in the Course of the Lymphatics Kaposi. LIST OF COLORED PLATES AND THEIR SOURCES. 
15 
Plate VIII .-Facing Page 102. 
Fig. Author. 
1. Indurated Chancre of Left Labium Minus Cullerier. 
2. Multiple Indurated Chancres of the Vulva, with Superficial Gangrene and Hard 
CEdema of the Subjacent Tissues 
3. Indurated Chancre of the Hypogastric Region ......." 
4. Indurated Chancre of Labium Minus 
5. Indurated Chancres of Labium Majus and Chancroids Kaposi. 
6. Mucous Patches, or Condylomata Lata, of Penis and Scrotum .... Cullerier. 
7. Confluent Mucous Patches, Condylomata Lata, of the Labia Majora and Anus . 
8. Mucous Patches of the Fauces " 
9. Mucous Patches of the Tongue 
10. Mucous Patch of Toe 
11. Confluent Mucous Patches of the Cervix Uteri 
12. Indurated Chancre at the Base of Nipple Ricord. 
Plate IX. -Facing Page 108. 
1. Indurated Chancre of Upper Eyelid Cullerier. 
2. Superficial Indurated Chancre of I?orehead " 
3. Indurated Chancre of Lower Eyelid " 
4. Indurated Chancre of Tongue Hutchinson. 
5. Indurated Chancre of Upper Eyelid " 
6. Indurated Chancre of Upper Lip Kaposi. 
7. Condition of Finger in Stage of Repair of Fig. 10 . . . . . . Hutchinson. 
8. Indurated Chancre of Finger Kaposi. 
9. Indurated Chancre of Nipple " 
10. Indurated Chancre of FingerHutchinson. 
11. Indurated Chancre of Pulp of Finger " 
12. Indurated Chancre of I7inger, Stage of Repair Ricord. 
13. Indurated Chancre of Upper LipKaposi. 
14. Indurated Chancre of Finger Hutchinson. 
15. Indurated Chancre of Tongue Kaposi. 
16. Indurated Chancre of Pubes . " 
17. Indurated Chancre of Chin " 
18. Indurated Chancre of Scrotum, Parchment-like Cullerier. 
19. Simple Balanoposthitis Clerc. 
20. Balanoposthitis, with Superficial Ulceration 
PART II. 
Plate X .-Facing Page 120. 
Figs. 1 and 2. Erythematous Syphilide. Taylor. 
Plate XI .-Facing Page 124. 
Figs. 1 and 2. Small Miliary Papular Syphilide Ricord. 
Plate XII. -Facing Page 126. 
Large, Flat, Papular Syphilide and Indurated Chancre of Pubes, 
Hutchinson : New Sydenham Society Collection. 16 
LIST OR COLORED PLATES AND THEIR SOURCES. 
Plate XIII ,-Facing Page 128. 
Fig. . Author. 
1. Erythematous and Scaling Syphilide of Palm Ricord. 
2. Ulcerating Syphilide of Palm 
3. Bullous Syphilide of Palm Neumann. 
4. Syphilitic Perionychia of Hand Cullerier. 
5. Syphilitic Perionychia of Feet 
Plate XIV .-Facing Page 132. 
1. Small Pustular Syphilide of Back ... . . . . . . . . Squire. 
2. Small Pustular Syphilide of Face and Chest, with Indurated Chancre of Upper 
Lip Neumann. 
3. Small Pustular Syphilide of Arm Ricord. 
Plate XV .-Facing Page 134. 
1. Large Pustular Syphilide of Face Kaposi. 
2. Large Pustular Syphilide of Back Ricord. 
Plate XVI. -Facing Page 136. 
1. Ecthyma-form Syphilide of Arm Ricord. 
2. Ecthyma-form Syphilide of Arm Taylor. 
3. Ecthyma-form Syphilide of Back Neumann. 
PART III. 
Plate XVII. -Facing Page 138. 
1. Rupial Syphilide of Arm .... Hutchinson : New Sydenham Society Collection. 
2. Rupial Syphilide of Face Squire. 
3. Ulcerating Tubercular Syphilide in Form of Zona Ricord. 
Plate XVIII ,-Facing Page 142. 
1. Gummatous Syphilide of Knee Ricord. 
2. Gummatous Syphilide of Shoulder 
3. Gummatous Syphilide of Ankle 
4 Gummatous Syphilide of Buttocks Kaposi. 
Plate XIX .-Facing Page 144. 
1. Tubercular Syphilide of Face Cazenave. 
2. Tubercular Syphilide of Arm Taylor. 
Plate XX .-Facing Page 148. 
1. Serpiginous Tubercular Syphilide of Back . . . . . . ... Kaposi. 
2. Serpiginous Tubercular Syphilide of Arm Ricord. 
Plate XXL-Facing Page 152. 
1. Pigmentary Syphilide Taylor. 
2. Precocious Ulcerating Tubercular Syphilide Ricord. LIST OF COLORED PLATES AND THEIR SOURCES. 
17 
Plate XXII .-Facing Page 158. 
Fig. Author. 
1. Erythematous Syphilide in Patches in Hereditary Syphilis .... Parrot. 
2. Erythematous Syphilide, Diffuse in Hereditary Syphilis Meyer. 
3. Papular Syphilide in Hereditary Syphilis Parrot. 
Plate XXIII. -Facing Page 160. 
1. Moist Papular Syphilide in Hereditary Syphilis Meyer. 
2. Papular Syphilide in Circles in Hereditary Syphilis Hutchinson: New Syd. Society Collection. 
3. Papular Syphilide in Groups in Hereditary Syphilis Parrot. 
4. Eacies of Syphilitic Infant, with lussures of Lip, etc. in Hereditary Syphilis . " 
Figs. 5, 6, 7, 8, and 9. Syphilitic Teeth in Hereditary Syphilis .... Hutchinson. 
Figs. 10, 11, 12, and 13. Nails of Hereditary Syphilis " 
Figs. 14 and 15. Bullous Syphilide of Palm in Hereditary Syphilis . . . Neumann. 
Figs. 16 and 17. Bullous Syphilide of Sole in Hereditary Syphilis . . . " 
SKIN DISEASES. 
PART IV. 
Plate XXIV. -Facing Page 196. 
Erythema Multiforme Baerenspr'ing. 
Plate XXV. -Facing Page 198. 
Erythema Nodosum .... Hutchinson: New Sydenham Society Collection. 
Plate XXVI. -Facing Page 202. 
1. Erythematous Eczema Taylor. 
2. Eczema Papulosum, etc. Baerensprung. 
Plate XXVII. -Facing Page 206. 
Eczema Rubrum (2 Figs.) . . . Hutchinson: New Sydenham Society Collection. 
Plate XXVIII. -Facing Page 226. 
Acne Hutchinson: New Sydenham Society Collection. 
Plate XXIX. -Facing Page 234. 
Psoriasis of Body and Arm . . . Hutchinson : New Sydenham Society Collection. 
Plate XXX. -Facing Page 236. 
1. Psoriasis of Arm Cazenave. 
2. Psoriasis of Palm Hutchinson: New Sydenham Society Collection. 
Plate XXXI. -Facing Page 244. 
Tinea Favosa Hebra. LIST OF COLORED PLATES AND THEIR SOURCES. 
i8 
PART V. 
Plate XXXII. -Facing Page 252. 
Fig. Author. 
Pediculosis Corporis .... Hutchinson: New Sydenham Society Collection. 
Plate XXXII I.-F acing Page 254. 
Erythema Faciei .... Cazenave. 
Plate XXXIV.- Facing Page 256. 
Erythema Circinatum .... Hutchinson: New Sydenham Society Collection. 
Plate XXXV.-Facing Page 258. 
Tinea VersicolorHutchinson: New Sydenham Society Collection. 
Plate XXXVI ,-Facing Page 262. 
Kerion and Ringwc/m of Head . . Hutchinson: New Sydenham Society Collection. 
Plate XXXVII ,-Facing Page 270. 
Pityriasis R-.bra//a/r/««.««.■ New Sydenham Society Collection. 
Plate XXXVIII .-Facing Page 274. 
Herpetiformis Neumann. 
PART VI. 
Plate XXXIX ,-Facing Page 278. 
Urticaria Baerensprung. 
Plate XL .-Facing Page 290. 
Pemphigus Hutchinson: New Sydenham Society Collection. 
Plate XL! .-Facing Page 298. 
Tinea Tricophytina Barbae Neumann. 
Plate XLII .-Facing Page 304. 
1. Tinea Circinata of Body and Inguinal Regions Baerensprung. 
2. Tinea Circinata of Body and Inguinal Regions, Hutchinson: New Sydenham Society Collection. 
Plate XLI1I .-Facing Page 306. 
Ecthyma Cazenave. 
Plate XLIV .-Facing Page 308. 
Lupus Erythematosus .... Hutchinson: New Sydenham Society Collection. 
Plate XLV .-Facing Page 316. 
Herpes Zoster Hutchinson : New Sydenham Society Collection. LIST OF COLORED PLATES AND THEIR SOURCES. 
19 
PART VII. 
Plate XLVI. -Facing Page 326. 
Fig. Author. 
Figs. 1 and 2. Scabies .... Hutchinson: New Sydenham Society Collection. 
3. ScabiesSquire. 
Plate XLVIL -Facing Page 332. 
1. Miliaria Crystallina Neumann. 
Figs. 2, 3, and 4. Dysidrosis Tilbury Fox. 
Plate XLV1I1. -Facing Page 336. 
1. Impetigo Contagiosa Tilbury Fox. 
2. Eczema Impetiginodes from Lice . . Hutchinson: New Sydenham Society Collection. 
Plate XL1X ,-Facing Page 338. 
1. Bullous Eruption of Iodide of Potassium. Hutchinson: New Sydenham Society Collection. 
2. Bromide of Potassium Eruption 
Plate L ,-Facing Page 344. 
Sycosis Neumann. 
Plate LI .-Facing Page 348. 
Figs. 1 and 3. Molluscum Sebaceum of Face and Breast, 
Hutchinson: New Sydenham Society Collection. 
2. Of Penis and Scrotum Kaposi. 
Plate LI I ,-Facing Page 354. 
1. Macular Leprosy . . ✓ . . . . . . . . . Neumann. 
2. Tubercular Hutchinson: New Sydenham Society Collection. 
PART VIII. 
Plate LIU .-Facing Page 362. 
Lichen Planus (5 Figs.) Taylor. 
Plate LIV. -Facing Page 368. 
Lichen Ruber (4 Figs.) Taylor. 
Plate LV. -Facing Page 382. 
1. Lupus Hutchinson: New Sydenham Society Collection, 
2. Lupus Squire. 
3. Lupus Taylor. 
4. The So-called Lupus of the Vulva 
Plate LVL -Facing Page 388. 
1. Molluscum Fibrosum . Hutchinson: New Sydenham Society Collection 
2. Scleroderma Neumann. 20 
LIST OF COLORED PLATES AND THEIR SOURCES. 
Plate LVI1 .-Facing Page 406. 
Fig. Author. 
Figs. 1 and 3. Leucoderma and Alopecia Areata, 
Hutchinson: New Sydenham Society Collection. 
2. Chloasma Squire. 
Plate LVIIi ,-Facing Page 416. 
Xeroderma Pigmentosum (6 Figs.) Taylor. LIST OF WOOD-CUTS 
AND THEIR SOURCES. 
Fig. Source. Page 
1. Vegetations Causing Perforation of Prepuce ..... Taylor. 77 
2. Vegetations of the Vulva 77 
3. Multiple Indurated Chancres of the Breast ..... Fozirnier. 109 
4. Chancre of the Breast ......... 112 
5. Indurated Chancre of Base of Nipple ...... 113 
6. Ringed Erythematous Syphilide ....... Squire. 122 
7. Papular Syphilide in the Negro ....... Taylor. 127 
8. Papular Syphilide of Scalp ........ Kaposi. 128 
9. Papular Syphilide of Chin 128 
10. Papular Syphilide in Circles ........ Ricord. 128 
11. Circinate and Scaly Papular Syphilide ...... Kaposi. 129 
12. Squamous Syphilide of Palm ........ Cullerier. 129 
13. Tubercular Syphilide of Pace ........ Taylor. 145 
14. Tubercular Syphilide of Face ........ Ricord. 146 
15. Generalized Tubercular Syphilide ....... Taylor. 147 
16. Serpiginous Syphilide of Neck and Back ...... 152 
17. Face of Syphilitic Child ......... Parrot. 158 
18. Extensive Destruction of Face. ....... Duhring. 159 
19. Extensive Bone Disease ......... Parry. 161 
20. Erythema Iris ........... Baerensprung. 197 
21. Eczema Rimosum .......... Squire. 203 
22. Eczema Impetiginosum 203 
23. Indurated Eczema ...... Revue Photographique des Hdpitaux. 204 
24. Eczema Verrucosum. ..... " " " " 204 
25. Psoriasis Rupioides .......... Anderson. 235 
26. Psoriasis of Palm .......... Taylor. 235 
27. Psoriasis of Nails .......... Hutchinson. 236 
28. Psoriasis of Nails and Hands ........ Taylor. 236 
29. Hair Infiltrated with Achorion Schonleinii...... Gudden. 243 
30. Favus of the Skin ......... Anderson. 245 
31. Favus of Hand. ........ Jackson. 245 
32. Pediculus Capitis ......... Kuchenmeister. 248 
33. Hair with Ova of Pediculus Capitis ....... Kaposi. 248 
34. Pediculus Pubis . Schmarda. 250 
35. Pediculus Corporis .......... Kuchenmeister. 252 
36. Microsporon Furfur Cornil and Ranvier. 260 
37. Tricophyton Tonsurans " 264 
38. Epilating Forceps .......... Taylor. 266 
21 LIST OF WOOD-CUTS AND THEIR SOURCES. 
22 
Fig. Source. Page 
39. Dermatitis Exfoliativa .......... Taylor. 273 
40. Tinea Tricophytina Barbae ......... 11 299 
41. Hair from Ringworm of Beard ........ Kaposi. 300 
42. Epidermis Invaded by Tricophyton ........ 304 
43. Ecthyma Cachecticorum Neumann. 307 
44. Herpes Zoster of Head Hutchinson. 315 
45- Herpes Facialis ........... Baereiisprung. 316 
46. Herpes Zoster of Brachial Plexus ........ Taylor. 317 
47. Acarus Scabiei, Female: Dorsal Aspect ....... Kaposi. 320 
48. Acarus Scabiei, Pregnant Female : Ventral Aspect ....." 320 
49. Acarus Scabiei, Male : Ventral Aspect ......." 320 
50. Burrow of Acarus Scabiei 321 
51. Larva of Acarus Scabiei 321 
52. Second Moulting of Acarus Scabiei ........ 322 
53. Acarian Burrow in Epidermis 322 
54. Section of a Burrow through a Pustule ....... 11 322 
55. Section of a Burrow .......... 322 
56. Crust of Scabies, etc. 324 
57. Dermatitis Tuberosa: Iodic . • . . . . . . . . Taylor. 340 
58. Ichthyosis Simplex of Body 350 
59. Ichthyosis Simplex of Arms 35 1 
60. Ichthyosis of Legs 351 
61. Lichen Planus: Linear Arrangement of Papules ....." 365 
62. Lichen Ruber: Diffuse Infiltration and Scaling of the Palm . . . " 369 
63. Solar Print of Lichen Ruber 371 
64. Chronic Stage of Lichen Ruber: Left Abdominal Wall . . . . " 372 
65. Chronic Stage of Lichen Ruber: Back 373 
66. Excessive Hypertrophy of Soles ........ 375 
67. The so-called Lichen Ruber Moniliformis ....... Neumann. 
68. Lupus Exulcerans ........... Hebra. 384 
69. Lupus Vulgaris : Hypertrophic Neumann. 384 
70. Molluscum Fibrosum Pendulum . . . Revue Photographique des Hopitaux. 388 
71. Molluscum Fibrosum of Foot .... " " " •< 389 
72. Molluscum Fibrosum Pendulum ........ Taylor. 389 
73. Dermatolysis Marcacci. 389 
74. Dermatolysis ............ " 389 
75. Acne Rosacea : Hypertrophic .... Revue Photographique des Hopitaux. 398 
76. Acne Rosacea: Hypertrophic .... " " " " 
77. Rhinoscleroma Neumann. 401 
78. Elephantiasis of Both Legs Taylor. 404 
79. Elephantiasis of Leg and Thigh . . . Revue Photographique des Hopitaux. 404 
80. Elephantiasis of Leg and Thigh ... " " " " 404 
81. Leucoderma: Front View Taylor s Collection. 406 
82. Leucoderma: Back View. ........ " " 406 
83. Keloid ............. Neumann. 413 
84. Keloid of Scar Squire. 414 
85. Xeroderma Pigmentosum ......... Crocker. 418 OPYRIGHTED, 1888, BY LEA BROTHERS &* CO. 
or 
YeneREAk 
INCLUDING 
©iaqnosis, Prognosis & Wealmont 
BY 
ROBERT W. TAYLOR, A. M., M. D., 
•<*** 
SURGEON TO CHARITY HOSPITAL, NEW YORK, AND TO THE DEPARTMENT OF VENEREAL AND SKIN DISEASES OF THE NEW YORK HOSPITAL; 
LATE PRESIDENT OF THE AMERICAN DERMATOLOGICAL ASSOCIATION. 
Illustrate!) witl) ©nc anb Ninety-Swo /igures, 
MANY OF THEM LIFE-SIZE, ON 
FIFTY-EIGHT BEAUTIFULLY COLORED PLATES. 
ALSO MANY LARGE AND CAREFULLY EXECUTED ENGRAVINGS THROUGH THE TEXT. 
PART IL-VENEREAL DISEASES. 
PHILADELPHIA: 
LEA BROTHERS & CO. 
1888.