NATIONAL LIBRARY OF MEDICINE NLfl DD57b3E3 1 U.S. NATIONAL LIBRARY OF MEDICINE NLM005763239 US.Department ol U 5 Oeportment ot Health, Education, BY THE SAME AUTHOR. Eczema and its Management, a practical treatise based on the study of two thousand five hundred cases of the disease, pp. 344. $3.00. Neumann's Handbook of Skin Diseases, translated with notes, pp. 467. $4.00. Archives of Dermatology, a Quarterly Journal of Skin and Venereal Diseases. Vol. I. to VIII. (current.) Vol. I.-IV., $3 per year ; Vol. V. to VIII., $4 per year. The Skin in Health and Disease. Health Primer, pp. 148. Fifty cents. The Use and Value of Arsenic in the Treatment of Diseases of the Skin. Fifty cents. In Preparation. Principles and Practice of Dermatology : A theoretical and practical treatise on Diseases of the Skin, 8vo. MANUAL DISEASES OF THE SKIN WITH AN ANALYSIS OF EIGHT THOUSAND CONSECUTIVE CASES AND a fopm'..:lary BY L. DUNCAN BULKLEY, A.M., M.D. HI ATTENDING PHYSICIAN FOR SKIN AND VENEREAL DISEASES AT THE NEW YORK HOS- PITAL, OUT-PATIENT DEPARTMENT; DERMATOLOGIST TO THE HOSPITAL FOR RUPTURED AND CRIPPLED ; LATE PHYSICIAN TO THE SKIN DEPART- MENT, DEMILT DISPENSARY, NEW YORK; AUTHOR OF " ECZEMA AND ITS MANAGEMENT" ; EDITOR OF THE "ARCHIVES OF DERMATOLOGY " ; PERMANENT MEMBER OF THE AMERICAN MEDICAL ASSOCIATION ; FEL- LOW OF THE NEW YORK ACADEMY OF MEDICINE, ETC., ETC. 0 IC NEW YORK G. P. PUTNAM'S SONS 27 and 29 West 23D Street 1882 Copyright, 1882, By G. P. PUTNAM'S SONS. THE GOVERNORS NEW YORK HOSPITAL, WHOSE KIND APPRECIATION AND ASSISTANCE OF THE AUTHOR IN HIS CLINICAL WORK IN THEIR INSTITU- TION HAVE DONE MUCH TO ENCOURAGE HIM AND TO PROMOTE THE INTEREST OF THE PROFESSION IN THE BRANCH OF DERMATOLOGY, THIS LITTLE WORK IS INSCRIBED. PREFACE. The following pages represent an attempt to pre- sent the subject of Diseases of the Skin concisely, and yet with sufficient details to be of practical value to the student and practitioner. They are offered as an introduction to the study of a branch which is of great importance, and yet which is not readily grasped, owing to many reasons, such as the large number and variety of affections of the skin, their difficulty of recognition and the confused and unwieldy nomenclature often employed. The present little work has been largely prepared 4 for those following my clinics at the New York Hospital, and has indeed grown out of a Skin Phar- macopoeia arranged for their use. The aim has been to make it thoroughly practical, and it par- takes much of the style of class room conversations ^upon the various diseases as they appear clinically. Pathology is introduced but briefly, and no attempt has been made to enter the literature of the subject, or to present or discuss doubtful questions. Differ- ential diagnosis has not been fully entered on, for want of space, but in connection with each erup- tion mention is made of those with which it may v vj PREFACE. be confounded. In order to present the relative frequency and importance of different affections in the briefest space possible, a chapter is devoted to the analysis of eight thousand skin cases. The nomenclature and classification employed correspond in the main to those used by. many; the nomenclature being Latin, and the dis^afcs be- ing mostly grouped on a pathological basis. In this, as in other matters, the desire has been not to pre- sent new or startling features, but to harmonize, as far as possible, the views of dermatologists in various countries. It is hoped that the very com- plete index will be of much service. The matter of therapeutics has been dwelt on more largely than might be expected in a small " manual"; it is hoped, however, that this, with the " formulary," may be of a practical value to the prac- titioner, while they serve as a guide to the student in becoming acquainted with remedies. While this portion represents to a certain degree the treatment recommended by others, the actual application of remedies refers rather to their employment in my own practice. Acknowledgment is here made of aid derived from the writings of Hebra, Kaposi, Neumann, Duhring, Piffard, Wilson, Fox, Anderson, Hardy, and others, to the study of whose works it is hoped that the present may be a further incitement. i East 33RD Street, New York City. CONTENTS. CHAPTER I. PAGE On the Study of Dermatology.....................*........ i CHAPTER II. Anatomy and Physiology of the Skin........................ 5 CHAPTER III. Nomenclature and Classification of Diseases of the Skin...... 18 CHAPTER IV. Relative Frequency of Diseases of the Skin : Statistics of Eight Thousand Cases........................................ 25 t CHAPTER V. Diagnosis.............................................. 32 CHAPTER VI. Etiology................................................. 42 CHAPTER VII. Class I. Morbi Cutis Parasitici—Vegetable Parasitic Affections 46 CHAPTER VIII. Class I. Morbi Cutis Parasitici—Animal Parasitic Affections (continued)............................................ 63 CHAPTER IX. Class II. Morbi Glandularum Cutis—Glandular Affections.... 73 CHAPTER X. Class III. Neuroses—Neurotic Affections................... 90 vii vm CONTENTS. CHAPTER XI. Class IV. Exsudationes—Exudative or Inflammatory Affections 101 CHAPTER XII. Class IV. Exsudationes—Exudative or Inflammatory Affec- tions (continued)...................................... IJ[7 CHAPTER XIII. Class IV. Exsudationes—Exudative or Inflammatory Affec- tions (continued)—of Internal or Local Origin............. 138 CHAPTER XIV. Class IV. Exsudationes—Exudative or Inflammatory Affec- tions (continued)....................................... 164 CHAPTER XV. Class IV. Exsudationes—Exudative or Inflammatory Affec- tions (continued)....................................... 193 CHAPTER XVI. Class V. Hemorrhagise—Hemorrhagic Affections............ 209 CHAPTER XVII. Class VI. Hypertrophise—Hypertrophic Affections........... 212 CHAPTER XVIII. Class VII. Atrophise—Atrophic Affections.................. 235 CHAPTER XIX. Class VIII. Neoplasmata—New Formations................. 245 CHAPTER XX. Diet and Hygiene of Diseases of the Skin.................. 267 CHAPTER XXI. Therapeutics of Diseases of the Skin....................... 2715 Index................................................... 299 MANUAL OF DISEASES OF THE SKIN. CHAPTER I. ON THE STUDY OF DERMATOLOGY. While it is not possible for every one to become proficient to the highest attainable degree in every branch of medical practice, there is no reason why all who enter the profession should not acquire a fair knowledge concerning the diseases which affect the integument. There are indeed many reasons why accuracy should be cultivated in this rather than in many other departments of medicine; and it may be fairly said that he who understands the branch of diseases of the skin well, is better fitted for general practice than he who is master of any other one specialty. Dermatology is an especially inviting field, be- cause all the lesions of disease are exposed to view, and pathological changes can be studied on the skin as nowhere else in the body. Here inflammation 2 MANUAL OF DISEASES OF THE SKIN. and its processes and products can be watched while taking place; hypertrophy and atrophy occur here in their fullest extent; and these, with new forma- tions, constitute the richest field of pathological research, both in their gross features, and in their histological elements. And finally the study of vegetable parasites as they affect the integument has led to researches in other fields of pathology. But, again, dermatology is inviting because there is no branch of medicine, surgery not excepted, where accuracy of diagnosis can be obtained more surely and in a larger percentage of cases than in that of affections of the skin. In no class of dis- eases, moreover, are the results of treatment so plainly visible; the ill effects of wrong measures are at once seen, and the benefits from proper treat- ment are no less apparent, both to the patient and physician. The study of dermatology, therefore, is not to be underrated because so many of the diseases com- ing under its domain do not endanger life, and are found in those in apparently excellent health. For not only do disorders which may appear to be in- significant cause much distress to those affected, but not a few of the diseases of the integument are very important from their bearing upon the general health and usefulness both of the sufferer and of others. As illustrations of this last assertion may be mentioned the relations of certain diseases of the* ON THE STUDY OF DERMATOLOGY. 3 skin to the gouty state, of which they are often pre- cursory signs; also, the parasitic affections, which may sometimes spread through an entire school or community from carelessness; and, above all, the great importance of early recognizing every mani- festation of syphilis should be borne in mind, both for the welfare of the patient and as a preventive of the spread of the disease to others. It must further be remembered that many diseases not al- ways reckoned as belonging to the province of der- matology, such as small-pox, scarlet fever, measles, erysipelas, and others, exhibit skin phenomena which may at times be difficult of diagnosis, and may be closely simulated by quite different affec- tions of the skin. The relations of dermatology, 'therefore, to the practice of general medicine are most intimate and important, and a clear understanding of this branch is essential for general success. The close observa- tion and the appreciation of minute features which are called for in the study of diseases of the skin, are also elements in medical practice the cultivation of which cannot be too strongly insisted upon; while the effect of remedies, external and internal, which can be clearly observed in the treatment of these diseases, teaches much in regard to the thera- peutics of diseases of other organs. The error has often occurred of isolating derma- tology too much from the ordinary practice of 4 MANUAL OF DISEASES OF THE SKIN. medicine, and of regarding it as a department quite separate, and one difficult to understand and grasp; whereas, in point of fact, this branch cannot be rightly understood except by those thoroughly ac- quainted, theoretically and practically, with medi- cine as a whole. Skin diseases are not separate and distinct affairs, having relations and conditions quite different from those affecting other portions of the body, but must be studied on the same principles as diseases of other organs. They depend largely upon the same class of causes, and many of them resemble other maladies very closely; almost all of them have relations reaching further than the skin itself. With this view or thought in mind, we will briefly enter upon the study of the subject. CHAPTER II. ANATOMY AND PHYSIOLOGY OF THE SKIN. The skin is the largest, and in some respects the most important emunctory organ of the body, and upon a proper performance of its functions depends, to a great extent, the health and well-being of the individual. While its apparent purpose is merely as an outer investment, for the object of giving shape and symmetry to the human form, and of enabling it to resist external agencies which would injure or destroy more delicate structures, it has also functions of its own to perform which are most important. It furnishes the means of exhaling a large proportion of the fluid given off from the body, and is the chief means for maintaining ani- mal heat at an equable point. To fulfill its many duties, the skin is composed of a number of different elements, all united in a har- monious texture ; it contains excretory glands and organs of sensation, and has, as appendages, the hair and nails, all to serve definite purposes. In certain localities it undergoes changes in structure according to the necessities of the case; thus on the palms, soles, and buttocks it is thick and re- 5 6 MANUAL OF DISEASES OF THE SKIN. sisting; while it is thin and delicate on the eyelids, penis, and certain other regions. On the scalp, face, and elsewhere it produces hairs, which are but modifi- cations of its epithelial elements; and on the ends of the fingers and toes, another variation in epider- mal development gives rise to the nails. At the orifices of the body, as at the nos*e, mouth, urethra, vulva, and anus, its anatomy is altered to conform to the requirements of the parts, and the mucous membranes result, which are indeed but altered skin, whose diseases are often closely allied to or connected with those of the outward integument. The skin is composed in the main of two layers, quite different in their structure and composition. The lower or deeper one is called the corium, cutis vera, true skin, or derma, and the outer one is named the epidermis (Greek, epi, upon, and derma, skin). The derma or corium, the inner or deeper portion, which constitutes the leather of commerce, is com- posed of densely interwoven connective tissue fibres, firm and elastic, which interlace and form a texture resembling felt. At the deepest part of this corium or true skin, the fibres are separated, and between them are found masses of fat globules, constituting thepanniculus adiposus, or adipose tissue; in the outer portion the fibres are closely matted together, and the surface externally rises into minute prominences called the papillae of the skin, this portion having the name of the papillary layer, or pars papillaris. ANATOMY AND PHYSIOLOGY OF THE SKIN. 7 The epidermis, cuticle, or scarf skin, has no fibres, but is composed of roundish elements called cells. The deeper cells are more rounded or many-sided, and succulent, and compose what is known as the rete mucosum or rete Malpighii; this rests directly upon the papillae, and dips down into the interstices between them. In the cells of this deepest layer is found the pigment or coloring matter, normally in the colored races and in certain regions of the white body, as about the areolae of the breasts and else- where ; it also occurs in this layer pathologically in certain diseased states, hence the difficulty of re- moving pigmentary deposits in the skin. The outer layers of cells of the epidermis are more flat, and as they approach the exterior they become still more flattened, hardened, and lifeless, only waiting to be thrown off or removed by friction. The corium, or true skin, contains a number of elements which demand closer consideration. These are blood-vessels, nerves, lymphatics, muscular fi- bres, hair follicles, sebaceous glands, sweat glands, and nails. The blood and nerve supply of the skin is ex- ceedingly abundant, and is of the utmost impor- tance in its relations to its diseases. Its very great richness in these elements may be judged from the fact, that even a fine needle cannot be intro- duced into the skin without drawing blood and causing pain. The blood-vessels coming from be- 8 MANUAL OF DISEASES OF THE SKIN. low anastomose very freely in the skin and rise into the papillae. The nerves of the skin serve the purposes of pre- siding over its nutrition, of providing general sensa- tion which shall protect the parts from injury, and of furnishing the sense of touch. In the main the larger nerves are confined to the corium, but nerve elements have been also traced beyond the true skin even into the second or third layer of cells of the rete Malpighii; also in the sheaths of the hair follicles, and in the sebaceous glands. Within the papillae are found what is known as the tactile corpuscles ; these consist of a mass of nucleated cells, mingled with connective tissue, into which the medullated nerve fibre is seen to run and apparently to termi- nate. It is thought that in them lies the sense of touch. The nerves which preside over nutrition, the trophic nerves, have not yet been demonstrated, and very little is also known with regard to the vaso-motor nerves in the skin ; but that both these are exceedingly important in their relations to skin diseases cannot be doubted, from the structural changes, the functional glandular derangements, and also the congestion and inflammation which oc- cur so readily in the integument. The lymphatics of the skin are very numerous, and undoubtedly of importance in connection with its pathology. They have been recently demonstrated to be very abundant, both throughout the skin and ANATOMY AND PHYSIOLOGY OF THE SKIN. g in connection with the sebaceous and sweat glands and the hair follicles. As yet we know little of their real relations to the diseases of the skin, although in certain affections, as elephantiasis, morphcea, lymphangioma, erysipelas and others, they proba- bly play an important part. We see the lymphatic element exhibited in the multiple adenopathy of syphilis; also in the buboes connected with chan- croids, and the milder glandular swellings accom- panying prurigo and also inflammatory conditions on the lower extremities; likewise in the enlarged glands in the back of the neck, in pustular eczema and other diseases of the scalp. Muscular fibres exist in the skin in two forms or conditions. First, there is a small amount of smooth muscular tissue running horizontally, which is more developed in certain localities than in others. In some animals there is a considerable amount of striated or voluntary muscular fibre throughout the entire skin, whereby they are able to move it to a slight degree, and thus to assist in shaking off dust, insects, etc.; the dartos of the scrotum somewhat resembles this, but here the movements are almost, if not quite, entirely involuntary, and these frequently interfere materially with the treatment of eczema in this* region. The greatest development of the muscular fibre in the skin of man is found in the sec- ond form of distribution, in connection with the seba- ceous glands and hair follicles, next to be described. I* 10 MANUAL OF DISEASES OF THE SKIN. Hair and hair follicles.—The relations of the hair follicles to the integument can be best under- stood by imagining the lower or fibrous portion of the skin to be soft and plastic, and the upper or epidermal layers to be pushed down into it without breaking, around a penetrating hair; the sheaths of the hair are thus seen to be cellular, and to a certain extent to correspond to the layers in the epi- dermis. Quite a number of separate layers of cells have been made out and described, but the practi- cal point to be remembered is, that they are cellu- lar, reaching down into a fibrous structure; this will be found to be of importance in reference to the vegetable parasitic diseases. At the bottom of the hair follicle thus formed, which in the case of larger hairs extends through the extreme thick- ness of the skin, the fibrous elements of the corium rise and form what is known as the hair papilla, from which the hair is supposed to take its growth. This contains blood-vessels and extends up into, and is embraced by the lower portion of the hair. The hair itself is composed, like the epidermis, of cells; at its deepest portion, within the follicle, these cells are seen to be quite round or polygonal, and are soft and succulent like those of the rete Malpighii. Those further outward are more flat and compressed, until finally all the cells are so flattened and condensed together that they appear like fibres, and these con- stitute the entire length of the hair, however great. ANATOMY AND PHYSIOLOGY OF THE SKIN, n Hairs exist over almost every portion of the sur- face of the body, with a few exceptions, as. in the palms and soles, the internal surface of the prepuce, and the glans penis, though in some situations they are so fine as to be hardly discernible with the na- ked eye. The number of the hairs is exceedingly great, varying vastly in different individuals. Be- tween seven and eight hundred have been counted on a square inch, and the total number on the scalp has been estimated at between ninety and one hun- dred and twenty thousand. Hair is very strong, and yet very elastic ; a single hair has supported a weight of over two ounces, although such strength is undoubtedly exceptional; repeated instances have occurred where the scalp has been torn from the head by means of the hair, so firmly is it attached, and yet in disease it may fall with the slightest touch or break with the gentlest traction. Hair is so very elastic that it may stretch almost one third of its length, and regain its former dimensions. Sebaceous or sebiparous glands.—These are irregu- larly shaped masses of glandular structure, belong- ing to the variety known as racemose glands, and with a single excretory duct ; they are almost in- variably connected with hairs of some size. Upon hairy parts, as the scalp, they form appendages to the hairs, and discharge their secretion into the hair follicles. Generally there are two to each hair, situ- ated on opposite sides ; but in some situations large 12 MANUAL OF DISEASES OF THE SKIN. hairs have a number, even from four to eight, situ- ated around them, forming a sort of collar about the hair. In other places, where the hairs are fine and rudimentary, the sebaceous glands are large, and the tiny hair appears there as an appendage to a comparatively large gland. All the sebaceous glands, however, are very minute affairs, and mostly situated in the outer portion of the corium. The secretion from these glands is of an oily nature, and when in a healthy condition, it is perfectly fluid at the temperature of the body. The quantity of the secretion is not very great in health, and its main function appears to be to keep the skin and hairs in a flexible state ; although the amount of solid matter thrown off thus must be of some importance in the economy. When these glands fail to act, we have a dry harsh condition of the skin, known as xeroderma; and when the secretion becomes blocked, it forms comedo, both of which states will be treated of in connection with acne. Sometimes the secre- tion is great, and appears as an oily coating on the skin ; or it may dry, forming coarse scales or greasy crusts, representing seborrhcea or acne sebacea. Neither of these conditions in which the secretion is observed represents the normal state of the seba- ceous material. The muscles of the skin, which are connected with the hair follicles and sebaceous glands, the arrcc- tores pilorum, play a part which it is important to ANATOMY AND PHYSIOLOGY OF .THE SKIN. ^ understand. These are attached to the lowest por- tion of the hair follicle, and, running diagonally, are inserted in the upper portion of the corium ; they thus embrace the sebaceous glands connected with the hairs, so that each time they contract, pressure is made upon the glands, and their con- tents more or less forced out. On the parts of the body, such as the face, back, and chest, where the sebaceous glands are very large and the hairs very insignificant, the glands lose this aid to the expul- sion of their secretion and very readily become clogged, thus furnishing one of the reasons for the prevalence of acne upon these parts. When these muscles contract under the influence of cold or men- tal emotions, the surface presents minute transitory elevations, cutis anserina, or " goose skin ;" this may be produced at will on entering a bath, by allow- ing the exposed surface to become a little chilled, while dry, when the hairs are seen to become erected, especially on the arms. Sweat or sudoriparous glands.—These are in the form of minute tubes, which are coiled up in the deepest portion of the corium, or even in the subcu- taneous adipose tissue, and then extending through the entire thickness of the skin, and after making several spiral turns within the epidermal portion, they open directly upon the outer surface. These glands are very numerous in some portions ; on the sole of the foot and palm of the hand there are about 2700 14 MANUAL OF DISEASES OF THE SKIN. in the square inch; on the legs there are about 55° in the same space, and on the forehead about 1250. According to careful computation their total num- ber amounts to almost 2,400,000; the total length of all of these minute tubes when uncoiled has been variously estimated at from two to eight miles. The action of these little glands is not intermit- tent but continuous, and sweat is incessantly exhaled in the form of vapor or insensible perspiration. It is only when the body becomes much heated, as by exercise or otherwise, or in disease, that the per- spiration manifests itself to the eye or touch. The total quantity of the fluid exhaled by the skin is subject to the greatest variations, according to tem- perature, moisture, exercise, quantity and quality of food and drink taken, etc. The average person in health gives off through the skin ordinarily be- tween one and two pounds or pints of fluid daily, a quantity almost equal to that excreted by the kid- neys. When animals are completely covered with an impermeable coating, as by varnishing the sur- face, death always takes place; and the story is current among physiologists, that a child who was covered with gold leaf in order to represent an angel in the ceremonies attending the coronation of Pope Leo X., died a few hours after the coating had been applied. Nails.—The nails resemble the hairs very closely in many respects, and are but altered portions of the ANATOMY AND PHYSIOLOGY OF THE SKIN. 15 epidermis. We speak of the root and the body of the nail, the root being that portion toward the trunk, and situated beneath the skin. The body of the nail, which represents the section of the hair within the follicle, is the remaining attached por- tion, while the free extremity of the nail, which custom and convenience remove frequently, corre- sponds to the free extremity of the hair. The matrix of the nail is that upon which the nail rests, and to which it is firmly attached. Nails grow from their roots just as do the hairs, and only slide over their matrix or bed, so that injuries to the matrix need not cause a disfigured nail, other than of the portion directly injured, whereas injury or disease at its root will generally cause a destroyed or de- formed nail. PHYSIOLOGY OF THE SKIN. The physiology of the skin is important to re- member, both in its relations to dermatology and to general medicine. As a great emunctory organ, it shares very largely with the lungs and kidneys the office of removing the superfluous water from the system. The skin and kidneys each excrete some, where between one and two pounds of liquid daily, while the lungs, perhaps, not over one half or two thirds as much. It can be readily understood, there- fore, how "a check of perspiration" can act harm- 16 MANUAL OF DISEASES OF THE SKIN. fully by throwing extra work upon other organs. These three great agents for removing or eliminat- ing water from the system act in harmony, and in- terchange their duties to a greater or less degree. Thus, in cold weather, when the skin perspires less, the kidneys are more active, as are also the lungs; in summer, again, when the perspiration may be pro- fuse, it is a common observation to find the urine more scanty. This vicarious action of these organs is frequently taken advantage of in medicine, as when, in kidney disease, we cause the skin to act profusely and remove water which threatens dropsy; also in pneumonia, where power for work of the lungs is seriously impaired, the action of the skin is excited in like manner. Again, in many diseases of the skin great advantage results from remedies which increase the action of the kidneys and bowels. The results of physiological research show that very considerable impression may be made upon the general system by simply acting upon the skin, as by baths, the cold pack, etc. ; advantage may often be taken thus of the absorbing power of the skin for the introduction of remedies through this channel, and nutrition also may be greatly affected by fatty inunctions. Failure in the action of the kid- neys, bowels, lungs, and liver, deranges the balance of the system, and may result in disease of any organ which has work thrown upon it which it cannot perform ; we must believe, therefore, that ANATOMY AND PHYSIOLOGY OF THE SKIN. 17 the skin undoubtedly may become diseased in the effort to produce its secretions from imperfectly elaborated blood, as well as from attempting to take its nourishment from that which has been insufficiently prepared in other portions of the economy. The beneficial effects often observed in skin dis- eases from the use of mineral waters in bathing and drinking, must not be attributed to their action upon the diseased tissues alone; the skin as an organ is often affected favorably, and performs its work better, and the kidneys and bowels are stimulated to action by the mineral ingredients. Even when used externally alone, other organs are more or less influenced by the mineral water, as it has been definitely shown that the urine can be affected, both in its liquid and solid elements, by means of baths and wet packs. CHAPTER III. NOMENCLATURE AND CLASSIFICATION OF DISEASES OF THE SKIN. Very much confusion, and much of the difficulty attending the study of dermatology, has resulted from the number and variety of terms which have been applied to these diseases, by different authors. Many affections have been called by quite different names, and often the same designation has been given to diseases which are quite distinct ; not only has every author or teacher felt at liberty to coin new terms, or to propose changes, but in some in- stances they have not even faithfully adhered to one name, but have made repeated changes, both in those employed by themselves and others. Happily at the present time this error of past study is appreciated by the majority of those who write and teach this branch, and the desire is becom- ing more and more fixed and manifest to use der- matological names that are not only plain, but such as can be adhered to by those of every nation and school. It would be useless to attempt to enter upon, much more to give severally, the various views which have been promulgated in times past CLA SSIFICA TION OF DISEA SES OF THE SKIN, i g and the different names and systems which have been put forward, only to last until the death of their producer, or not to find acceptance beyond his im- mediate circle. The dermatology of to-day looks back upon the heaps which have been piled up, only to endeavor to avoid the repetition of such follies ; and all who have this branch deeply at heart, are seeking for unity of thought on this subject. Inasmuch as different names may be given to dif- ferent diseases in various countries, the Latin lan- guage has become more and more adopted for the expression of exact science; and in order that many of the names which have been used and known from antiquity may not be changed, the older Greek terms are retained as far as possible, while the Latin is further used for secondary names and expletives. The following of this plan in various countries, to- gether with the publication of photographic and other representations of diseases, will soon har- monize dermatological thought, and render the study of cutaneous maladies much more easy. The classification of diseases of the skin, while not of the utmost importance, still often serves as an aid to the understanding of the branch. Vari- ous efforts have been made at forming a clinical classification ; but the plans have varied so much, according to the views of the writer, that no two have very greatly resembled each other, and few authors have quite agreed upon the subject. With 20 MANUAL OF DISEASES OF THE SKIN. the study of pathological anatomy, however, dis- eases of the skin, as well as those of other organs, have come to be placed in certain groups according to the pathological changes which have taken place. In- a very rough way, this was first proposed many years ago by Plenck, and followed by Willan and others, who divided skin diseases according to the gross features exhibited, and arranged them in eight orders, as follows: I. Papulae. V. Pustulae. II. Squamae. VI. Vesiculae. III. Exanthemata. VII. Tubercula. IV. Bullae. VIII. Maculae. But the insufficiency of this plan becomes manifest when it places in the same group diseases which not only have no relation to each other but which are widely dissimilar in appearance. Thus, scabies and variola appear together, because both exhibit pus- tules; varicella and eczema, because vesicles may be seen in both; acne and lupus, because tubercul- ous masses are developed in each, and so on. In 1845, Hebra published his attempt at a classi- fication of diseases of the skin on a basis of patho- logical anatomy, and his plan, simplified by himself and others, has since been followed more and more until now a considerable portion of the dermatologi- cal world acknowledges it as the best basis upon CLASSIFICA TION OF DISEA SES OF THE SKIN. 21 which to arrange dermatological thought. The fol- lowing classification is based entirely upon this plan, although considerably simplified from that first pro- posed by Hebra, and that given in his text-book. CLASSIFICATION OF DISEASES OF THE SKIN. Class I. Morbi cutis parasitici. Parasitic Affections. II. Morbi glandularum cutis. Glandular Affections. III. Neuroses. Neurotic Affections. IV. Exsudationes. Exudative or Inflammatory Affections. V. Haemorrhagise. Hemorrhagic Affections. VI. Hypertrophiee. Hypertrophic Affections. VII. Atrophiae. Atrophic Affections. VIII. Neoplasmata. New Formations. Class I. Morbi cutis parasitici. Parasitic Affections. i. Tinea trichophytina f corporis (or tinea circinata). (or ringworm) J capitis (or tinea tonsurans). {parasite— Tricho- 1 barbae (or sycosis parasitica). {phyton tonsurans), (.cruris (or eczema marginatum). A. Vegeta- ble. 2' lottevxS?**' (t*rasite—Achorion Schasnleinii). 3. Tinea versicolor (parasite—Microsporon furfur). (or pityriasis versicolor) ^ * B. Animal. Phthinasis ) capitis \ parasite—Pediculus). (or pediculosis) "j pl£is f ^ 2. Scabies (or itch) {parasite—Acarus scabiei). Class II. Morbi glandularum cutis. Glandular Affections. L. Diseases or THE Sebaceous Glands. I. Due to faulty secretion or excretion of sebaceous matter. 1. Acne sebacea (oleosa ) < cerea V (or seborrhcea). [cornea) « .. .. f nigra (or comedo). Acne punctata -j algida\or miiium^ 3. Acne molluscum (or molluscum sebaceum). II. Due to inflammation of the ( 4. Acne simplex (or vulgaris). sebaceous glands with sur--j 5. Acne indurata. rounding tissue. ( °. Acne rosacea. MANUAL OF DISEASES OF THE SKIN. B. Diseases OF THE Sweat- glands. I. As to quantity of j i. Hyperidrosis. secretion. ( 2. Anidrosis. II. As to quality of j 3. Bromidrosis. secretion. j 4. Chromidrosis. III. With retention of secretion. 5. Dysidrosis. 6. Sudamina. Class III. Neuroses. Neurotic Affections. 1. Zoster (herpes zoster or zona). 2. Pruritus. 3. Dermatalgia. 4. Hyperesthesia cutis. 5. Anaesthesia cutis. 6. Dystrophia cutis (or trophic disturbances). Class IV. Exsudationes. Exudative or Inflammatory Affections. 1. Rubeola (or measles). 2. Rotheln (or German measles). 3, Scarlatina. 4. Variola. 5. Varicella. 6. Vaccinia. 7. Syphilis. 8. Pustula maligna. 9. Equinia (or glanders). 10. Diphtheritis cutis. 11. Erysipelas. A. Induced by Infection or Contagion. B. Of Internal or Local Origin. I. Erythematous. II. Papular. III. Vesicular. IV. Bullous. V. Pustular. 1. Roseola. 2. Erythema 3. Urticaria. 4. Lichen 5. Prurigo. Is simplex. multiforme. nodosum. (simplex. planus. ruber. scrofulosus. (febrilis. iris- . ,. 1 progenitalis. gestationis. 7. Hydroa. 8. Pemphigus i ™?&ans. r b | foliaceus. 9, Pompholix (or cheiro-pompholix). 10. Sycosis (or folliculitis pilorum). 11. Impetigo. 12. Impetigo contagiosa. 13. Ecthyma. CLA SSIFICA TION OF DISEASES OF THE SKIN. 23 B. Of Internal or Local Origin.— Continued. VI. Multiform, i. e., erythematous, papular, ves- icular, pustu- lar, etc. VII. Squamous. VIII. Phlegmonous. IX. Ulcerative. 14. Eczema. 15. Dermatitis calorica. venenata. traumatica. medicamentosa. ' 16. Dermatitis exfoliativa (or pityriasis rubra). 17. Psoriasis. 18. Pityriasis capitis. 19. Furunculus (furunculosis). 20. Anthrax (or carbuncle). 21. Abscessus. 22. Hordeolum. 23. Onychia. 24. Ulcus simplex. venereum. Class V. Hsemorrliagiae. Haemorrhagic Affections. I simplex. 1. Purpura •< rheumatica (or peliosis rheumatica). ( hemorrhagica. 2. Haematidrosis (or bloody sweat). 3. Scorbutus. Class VI. Hypertrophiae. Hypertrophic Affections. ( 1. Lentigo. A. Of Pigment, -j 2. Chloasma. ( 3. Melanoderma. 4. Morbus Addisonii. 5. Naevus pigmentosus. B. Of Epider- mis and Papillae. C Of Connect- ive Tissue. D. Of Hair. E. Of Nail. 1. Ichthyosis. 2. Keratosis pilaris (or lichen pilaris) 3. Cornu cutaneum. 4. Clavus. 5. Tylosis (or callositas). 1. Scleroderma. 2. Morphoea. 3. Sclerema neonatorum. 1. Hirsuties. 1. Onychogryphosis. f vulgaris. 6. Verruca \ senllis- j necrogenica. I, acuminata. 4. Elephantiasis (Arabum). 5. Dermatolysis. 6. Framboesia (or yaws). 2. Naevus pilosus. 2. Onychauxis. Class VII. AtrophisB. Atrophic Affections. A. Of Pigment, -J ( propria. 1. Albinismus. 2. Leucoderma (or vitiligo). 3. Canities. B. Of Corium. I propria. 1. Atrophia cutis •< linearis (or striae atrophicae). ( maculosa (or maculae atrophicae). 2. Atrophia senilis. 24 MANUAL OF DISEASES OF THE SKIN. I i. Alopecia. 2. Alopecia areata. C. Of Hair. 1 3. Trichorexis nodosa. 4. Fragilitas crinium (or atrophia ( pflorum propria). D. Of Nail. Onychatrophia. Class VTII. Neoplasmata. New Formations. I. Benign New Formations. A. Of Connective j 1. Keloid. 2. Fibroma (or molluscum fibrosum). Tissue. ( 3. Xanthoma (xanthelasma or vitihgoidea). B. Of Fatty Tissue. Lipoma. C. Of Granula- j T „_„_ J erythematosus. 2. Scrofuloderma. tion Tissue. | Im ^UPUS "j vulgaris. 3- Rhinoscleroma. D. Of Blood J 1. Naevus vasculosus. Vessels. | 2. Telangiectasis (or angioma). E. Of Lymphatics. Lymphangioma cutis. F. Of Nerves. Neuroma cutis. II. Malignant New Formations. (maculosa j 1. Lepra -< tuberculosa > (or elephantiasis Grascorum). (anaesthetica ) 2. Carcinoma. 3. Epithelioma. Q->r ^m-. i idiopathicum. 4. sarcoma -j pigmentosum (or melanosis). CHAPTER IV. RELATIVE FREQUENCY OF DISEASES OF THE SKIN : STATISTICS OF EIGHT THOUSAND CASES. The relative frequency and importance of the different diseases of the skin may be in a measure judged from statistics, although they often fail to rep- resent the true frequency of the affections recorded. Thus, very few of the febrile diseases of the skin ap- pear here, such as measles, scarlatina, and small-pox, because they comparatively seldom fall under the observation and care of the specialist; and many of the more trivial skin disorders occur also in much fewer numbers than in reality, as such cases rarely apply for treatment. Again, certain of the most common diseases, eczema and acne, are not as largely represented as they might be, inasmuch as many cases of eczema are left untreated, and acne is very generally disregarded. The statistics here presented are from eight thousand cases observed by the writer in private practice, and in the Demilt Dispensary and the Out-patient Departments of the New York and Bellevue Hospitals. It was thought best to exclude a large number seen in other institutions, as records 2 25 26 MANUAL OF DISEASES OF THE SKIN. of them had not been kept with sufficient uniform- ity and accuracy. Analysis of 8,000 Skin Cases. Disease. Abscessus............ Acne................ Adenoma............ Alopecia............. Anthrax............. Atrophia cutis........ Bromidrosis......... Cacatrophia cutis..... Canities............. Carcinoma cutis...... Cellulitis............ Chloasma............ Clavus .............. Congestio folliculorum. Cornu cutaneum...... Dermatalgia......... Dermatitis........... Dysidrosis........... Ecthyma............ Eczema............. Elephantiasis Arabum , Ephilide.............. Epithelioma........., Erysipelas............, Erythema............, Excoriationes......... Folliculitis capitis..... Furunculus........... Haemophilia.......... Herpes............., Hydroa............... Hypersesthesia cutis... Private Practice. 150 I 370 529 15 I 520 30 I T4 I I 349 1 1 19 3 24 13 32 1 2 36 3 1 87S 1 1 45 6 40 28 Public Practice. 69 I 10 873 284 I 7 73 3 7 928 2 16 453 5 20 5 2 2 142 4 17 r,8oi 2 4i 85 88 3 1 123 1 in 3 2 FREQUENCY OF DISEASES OF THE SKIN. 27 Analysis of 8,000 Skin Cases.—Continued. Disease. Hyperidrosis............ Hypertrichosis.......... Ichthyosis.............. Impetigo............... Impetigo contagiosa...... Impetigo herpetiformis... Keloid.................. Lentigo............... Lepra.................. Leucoderma............ Lichen................. Lupus.................. Lymphadenoma......... Lymphangioma......... Macula pigmentosa...... Miliaria................ Morbilli............... Morphcea............... Naevus.................. Neuroma................ Onychatrophia.......... Onychia................ Papilloma.............. Papulo-vesicular eruption. Paronychia.............. Pemphigus.............. Phlegmon.............. Phthiriasis.............. Pityriasis............... Pompholix.............. Prurigo................. Pruritus................ Psoriasis................ Purpura................ Rhinoscleroma......... Private Practice. 17 4 1 40 131 II I Public Practice. 155 4 4 5 231 14 57 no 16 19 2 3 104 37 2 2 1 1 3 10 2 2 n 2 1 5 7 386 18 112 202 28 28 MANUAL OF DISEASES OF THE SKIN. Analysis of 8,ooo Skin Cases.—Continued. Private Practice. Public Practice. Disease. ■a s a 3 0 H "(3 S 0 "c3 a 3 0 §3 Of-, 1 1 66 5 1 52 6 1 1 118 6 Rotheln................ 3 8 1 1 1 2 2 II I 2 10 I 3 3 12 2 9 3 128 I i 14 1 13 1 302 1 1 94 1 27 1 12 646 1 1 236 4 30 15 92 61 15 153 12 344 27 799 1 37 1 124 4 142 87 4 360 4 3 1 2 1 79 93 6 3 1 167 155 2 15 2 8 14 6 30 14 44 88 62 2 9 2 181 199 2 21 2 5 1 3 3 6 4 1 5 1 30 1 2 4 n 3 2 4 1 4i 4 4 8 5 2 4 2 1,320 9 4 2 I 14 6 6 3 55 n 1,263 2,583 2,577 2,840 5,417 8,000 Eczema is seen to come first in point of frequency, it occurring in 2,679 of the 8,000 cases, or 33.48 per FREQUENCY OF DISEASES OF THE SKIN. 29 cent, of the whole; the real frequency is probably even more than one-third of all skin affections as presented to the general practitioner, since the many cases of infantile eczema of family practice do not find their way into the statistics of the specialist; certainly far more than one half of the eruptions in small children (excluding eruptive fevers) are eczema. Acne is the next common disease here presented, with 973 cases, or 12.16 per cent. ; here again statis- tics fail to give the correct proportion, owing to the general neglect of this eruption. Acne formed more than one-fifth of the private cases. Syphilis comes next in frequency, forming about ten per cent, of all the cases, the proportion being somewhat larger in public than in private practice. The next name on the list, as to point of numbers, is phthiriasis, giving 397 cases, or nearly five per cent, in which the lesions were caused by lice; there were only eleven among the 2,500 private cases, showing how seldom the condition occurs among the upper classes. The eruptions due to vegetable parasites appear next in frequency, in almost the same proportion in private and public practice, namely, forming four and a half per cent, of all cases ; of these, two-thirds were caused by the parasite trichophyton tonsurans, giving rise to the various forms of ringworm, while there were only thirty-one cases of favus in the entire 8,000. 30 MANUAL OF DISEASES OF THE SKIN. Psoriasis appears next, and sixth on the list, with 333 cases, or a percentage of but 4.16, showing it to be much less common than is usually supposed ; the proportion of cases in private and public prac- tice was about the same. Urticaria is probably much more common than these statistics indicate, inasmuch as many patients with other diseases will give a history of being sub- ject to this eruption, for which they will seldom seek relief; it formed but 2.49 per.cent, of all cases. The remainder, even of the more commonly known eruptions, appeared in still smaller propor- tions, under two per cent., and a number of cutane- ous maladies occurred but once or twice among the entire number of cases analyzed. Zoster or shingles formed but a trifle over one per cent, of the 8,000 cases, although the eruption is so startling and often so painful that those affected generally apply for relief. Scabies was very rarely seen, but 118 times in public and ten times in private practice ; lupus formed but 0.86 per cent.; purpura but 0.49 per cent.; ichthyosis, 0.35 percent.; naevus, 0.33 per cent.; leucoderma, 0.25 per cent.; pemphi- gus, 0.21 per cent.; keloid, 0.14 per cent. ; morphcea, 0.10 per cent.; and scleroderma but 0.05 per cent. In regard to sex the patients were remarkably evenly divided, 3,897 males to 4,103 females in the total numbers; but in individual diseases great dif- ferences will be found. Thus in acne the females FREQUENCY OF DISEASES OF THE SKIN. 31 are double the number of the males, while with alopecia there were twice as many males as females. Chloasma is seen to be almost exclusively an affec- tion belonging to females, there being forty cases to two of males, while sycosis belongs to the male sex. In eczema the sexes are pretty evenly divided, 1,402 males to 1,277 females ; with lupus the females were almost three times as many as the males. Psoriasis presented almost an exactly equal number of both sexes, 169 males, 164 females. CHAPTER V. DIAGNOSIS. The diagnosis of individual diseases of the skin will be treated of in connection with each affection, but a few general rules or considerations may be here noted. Diseases and lesions of the skin should always receive very careful inspection and study, for, however simple the case may appear at first sight or in any of its elements, it is quite possible for other portions of the eruption to exhibit quite different features; and unless disease is taken as a whole, and also unless it is understood in each and all of its parts, no perfectly correct diagnosis will be arrived at, and consequently no intelligent thera- peusis. The first consideration, therefore, has to do with the examination of the patient. This should always be made in a very general and complete manner; the practitioner should never be satisfied with in- specting only a portion of the eruption present, but must insist upon viewing the whole of the diseased surface, and it is also important to examine the neighboring healthy skin as well. It is, likewise, 32 DIAGNOSIS. 33 very necessary to observe and note carefully the distribution of the eruption, for, as will be developed elsewhere, different affections have different seats of predilection, and modes of development and ar- rangement of their elements, which will often aid very considerably in the study of the case. As in- stances may be mentioned the proneness of eczema to affect the flexor surfaces ; while psoriasis, ichthyosis, and lichen are found by preference upon the ex- tensor surfaces of the body. In studying the dis- tribution of the eruption it is also well to bear in mind the tendency which certain eruptions have for a particular form of distribution; thus, the inclina- tion to circular arrangement of the lesions of syphilis, the disposition of the vesicles of zoster along the lines of nerve tracts, and the peculiar grouping of the vesicles of herpes febrilis and preputialis, are all very striking, while the rather symmetrical develop- ment of tinea versicolor, and the circular form and irregular location of patches of ringworm are like- wise characteristic. It is important always to discover the primary lesions of an eruption, the form in which it makes its first appearance; for, although when well devel- oped it may or may not have characters which are distinct, the earlier phases of its evolution will very generally point towards the proper diagnosis. The primary elements are generally discoverable near or outside the main line of eruption, if at all, although 2* 34 MANUAL OF DISEASES OF THE SKIN. occasionally they will reappear very characteristically in portions already traversed by the disease. Some- times the earliest stages are not present at the time, all of the lesions having passed into a more fully developed or retrograde state; but the previous condition may then be generally learned by very accurate questioning. In making the diagnosis of an.eruption, there are two methods by which the end can be arrived at; these should be employed together, in order to at- tain any true accuracy. The first is by recognizing the actual characters or features of disease present, and their likeness to a well known lesion or malady of the skin; the second is by exclusion, namely, by considering other eruptions which the one present might be mistaken for, and excluding each in turn, by the absence of some particular, distinctive fea- ture belonging to it. As remarked before, both methods must be employed where the case is at all doubtful; indeed, until one is familiar with the sub- ject, this process of mental logic should be asso- ciated with every case. There is nothing really so very special or peculiar in the lesions which are found upon the skin, or in the diagnosis of the diseases which affect the integu- ment. The pathological processes which occur here are precisely the same as those which take place in other portions of the body ; congestion, inflamma- tion, the results of altered nutrition, as hypertrophy DIAGNOSIS. 35 and atrophy, together with the development in the tissues of new formations, as cancer, etc., constitute, with the alterations caused by parasites, the lesions which are found upon the skin. The variety of the changes produced by these processes, results in con- siderable confusion to one unaccustomed to look upon them ; but a little careful observation will soon distinguish the elements of disease belonging to the various eruptions and processes, and by thus analyz- ing and separating the lesions found upon the skin a diagnosis can generally be made with certainty. True it is, that the gross features and grouping of elements seen in some skin diseases enable the prac- ticed eye to make a probable diagnosis in many instances at first sight; but as successful treatment depends absolutely upon accuracy of diagnosis, the greatest care should be exercised in determining this exactly. Various agencies effect certain pathological changes in the skin structure, which have received the name of lesions; each of these exhibits to the eye, and often to the touch, features which are dis- tinctive, and which, if recognized, establish with more or less of certainty the nature of the disease process present. It is essential, therefore, to fix firmly in the mind the elemental lesions, and to connect them with the various diseases with which they are associated. We will first give a few brief definitions of the 36' MANUAL OF DISEASES OF THE SKIN. terms used to express the parts or elements of which eruptions are composed ; these are spoken . of as primary lesions, and secondary lesions, the first the direct results of disease, the second, a more or less consequent condition. Of each of these there are eight, as follows : Primary Lesions. Secondary Lesions. i. Macula ; spot, macule. i. Tinctura ; stain. 2. Papula ; papule. 2. Squama ; scale. 3. Vesicula ; vesicle. 3. Crusta ; crust. 4. Bulla ; bleb. 4. Infiltratio ; infiltration. 5. Pustula ; pustule. 5- Fissura ; fissure. 6. Pomphus ; wheal. 6. Excoriatio ; excoriation. 7. Tuberculum ; tubercle. 7. Ulcus ; ulcer. 8. Phyma ; tumor. 8. Cicatrix; scar. First, of the primary lesions of the skin, eight in number. 1. Macula. Spots or macules are of various sizes, colors, or shapes; not elevated or depressed. These may be congestive, hemorrhagic, pigmentary, or from extraneous causes. Congestive maculae are seen in dermatitis, eczema erythematosum, erysipelas, erythema, leprosy, navus vasculosus, roseola, rotheln, rubeola, scarlatina and syphilis: hemorrhagic maculae occur in purpura, scorbutus^, and insect bites : pigmentary maculae are found in Addison s disease, chloasma, ephelis, leuco- derma, melanoderma, morphaa, navus pigmentosus, scleroderma, syphilis, and xanthoma: maculae from DIAGNOSIS. 37 extraneous cause are seen in nitrate of silver stain- ing, and from parasites in tinea trichophytina and tinea versicolor. 2. Papula. Papules or pimples are small solid ele- vations of the skin, inflammatory or neoplastic. Inflammatory papules occur in acne, dermatitis, eczema papulatum, lichen, phthiriasis, prurigo, pur- pura, scabies, syphilis, urticaria papulosa, and variola : neoplastic papules are seen in keratosis pilaris. 3. Vcsicula. Vesicles, or small water blisters, con- sist of small elevations of the epidermis, with clear fluid contents. Vesicles appear in dermatitis, dysidrosis, eczema, herpes, scabies, sudamina, varicella, variola, and zoster. 4. Bulla. Blebs, or larger water blisters, are so called from their resemblance to bubbles on the sur- face of agitated water. Blebs may be of any size from that of a split pea upward. Bullae are observed in hydroa, leprosy, pemphigus, pompholix, scabies, and syphilis infantile. 5. Pustula. Pustules represent small, round ele- vations of the epidermis, containing pus. Pustules are seen in acne, dermatitis, eczema, ecthyma, equinia, furunculus, impetigo, impetigo con- tagiosa, phtliiriasis, pustula maligna, scabies, sycosis, and variola. 6. Pomphus; a wheal. The flat, solid, slightly elevated lesions of urticaria or nettle rash are called wheals, or porhphi. 38 MANUAL OF DISEASES OF THE SKIN. In addition to urticaria, wheals may also appear about the bites of insects. 7. Tuberculum ; a tubercle. This term, which has no relation to tubercles of the lungs, refers to small solid elevations of the skin, larger than papules. Tubercles occur in acne, carcinoma, clavus, epithe- lioma, fibroma, lepra, lupus, lymphangioma, rhinoscle- roma, sarcoma, scrofuloderma, syphilis, and verruca. 8. Phyma; a tumor. This is a large swelling in or upon the skin, and may be of any size above that of a tubercle. Generally masses larger than a cherry are spoken of as tumors. The following diseases may present lesions classed as tumors: carcinoma, dermatolysis, elephantiasis, fibroma, keloid, lepra, lipoma, rhinoscleroma, sarcoma, and syphilis. The secondary lesions of the skin, eight in number, are as follows: 1. Tinctura ; a stain. A discoloration of the skin more or less permanent, left after a preceding le- sion. Stains may remain for a varying period after all inflammatory affections; they are most commonly seen after acne indurata, ecthyma, furunculus, lupus, phthiriasis, psoriasis, and purpura, and after certain lesions of syphilis, and ulcus they are apt to be per- manent. 2. Squama ; a scale. A portion of the epidermis more or less diseased and detached. DIAGNOSIS. 39 Scales occur in dermatitis exfoliativa, eczema, ichthyosis, lupus, pemphigus foliaceus, pityriasis, psoriasis, rubeola, scarlatina, syphilis, tinea favosa, tinea trichophytina, and tinea versicolor. 3. Crusta; a crust. A dried mass, generally of pus and epidermis, the product of some disease of the skin. Crusts follow inflammatory and destructive le- sions ; they are principally seen in dermatitis, eczema, ecthyma, favus, furunculus, herpes, hydroa, impetigo, lepra, lupus, pemphigus, phthiriasis, scrofuloderma, sycosis, syphilis, vaccinia, variola, and zoster. 4. Lnfiltratio; infiltration ; a thickening and hard- , ening of the skin from disease. In this the normal suppleness and elasticity are lost, and the skin readily breaks with each movement of the part. Infiltration and hardening of integument is seen in eczema, epithelioma, lepra, morphoea, rhinoscleroma, scleroderma, and ulcus. 5. Fissura; a fissure, or crack in the skin, con- sequent upon previous infiltration. Fissures appear principally in connection with the infiltration occurring in eczema, lepra, psoriasis, and syphilis. 6. Excoriatio; excoriation and ulceration of the surface, generally caused by scratching. Excoriations or scratch marks are observed in connection with eczema, phthiriasis, prurigo, scabies, and urticaria ; also in consequence of bites of insects. MANUAL OF DISEASES OF THE SKIN. 7. Ulcus; an ulcer. An excavation in the skin made by disease. Ulcers generally extend deep into the true skin, and leave a scar. Ulcers may occur in anthrax, carcinoma, chancroid, dermatitis, eczema, ecthyma, epithelioma, equinia, furuncle, herpes preputialis, lepra, lupus, onychia, pustula maligna, sarcoma, scleroderma, scrofuloderma, syphilis, and from traumatic causes and varicose veins. 8. Cicatrix; a scar. A new growth made up of hard, fibrous tissue, which replaces that lost by dis- ease or injury. Scars may follow ulcerative lesions in the diseases just mentioned, and are also seen in acne, atrophia cutis, favus, sycosis, vaccinia, varicella, variola, and zoster. All the lesions occurring on the skin, will be found to be made up of these elements, sometimes of a sin- gle one alone, far more often of several combined. Especially do we continually find those belonging to the two classes intermingled, namely, primary lesions combined with their results, or secondary lesions of the skin, and the one may be quite as characteristic of the disease as the other. Thus, the pearly, imbricated scales of psoriasis, and the yellowish greasy scales of seborrhcea are both suffi- ciently pathognomonic. The crusts of impetiginous eczema and of syphilis, the scars of certain diseases, DIAGNOSIS. 41 and the infiltration of eczema, all point clearly to the affections to which they belong. In certain af- fections we see little except the secondary lesions, as in phthiriasis, where the scratch marks or excori- ations are almost pathognomonic ; and in favus the entire external lesion is made up of crusts and scales. It will be observed that many diseases ap- pear under several of these lesions, according to the variety or stage of the eruption. To observe diseases of the skin satisfactorily, it is necessary that there should be good light; for this purpose daylight is almost essential, and plenty of it, preferably from a northern exposure. It is almost impossible to judge correctly of the color and char- acter of skin lesions by artificial light. CHAPTER VI. ETIOLOGY. THE etiology of various diseases of the skin has always been a matter of considerable difference of opinion among writers, but the subject is being cleared up more and more under the light of modern science and accurate study, and many points are now placed beyond the reach of controversy. In former periods it was supposed that all cutaneous disorders were manifestations of an internal poison or evil, a materies morbi, seeking exit by this channel: hence the general name given to this class of affections was eruptions (from the Latin e-rumpo, I burst forth), as is also signified in the Greek term, eczema (from sk8,£go, I boil over). This idea has by no means entirely disappeared, either from the public or professional mind ; in few, if any instances, how- ever, is it correct. Modern study has demonstrated a certain group or number of diseases of the skin to be entirely due to the local effect upon the integument, or its ap- pendages, of vegetable parasites which find a habitat there ; certain other lesions on the skin are wholly due to other local irritants, as the burrowing of the 42 ETIOLOGY. 43 scabies insect, or the scratching practiced for the relief of pediculi, or from other causes. Still other conditions recognized as disease are the direct re- sults of heat and cold, or mechanical and chemical irritants, as injury, dye stuffs, poison ivy, etc.; another group of affections are known to be purely local alterations in the skin tissue, such as fibroma, epithelioma, keloid, and the like. Yet other diseases have most intimate internal relations, such as acne, eczema, and urticaria; others, finally, as syphilis and the exanthemata, are the result of specific poi- sons. It will be impossible, therefore, to enter here fully into the subject of the causation of diseases of the skin, but the matter will be briefly referred to in connection with each malady. A few general con- siderations, however, may be of value. While some diseases are definitely due to a local cause, as a parasite, and others to a specific poison, in regard to a large number the etiology is by no means fixed, and both internal and external causes, as also individual and family tendencies, are of im- portance in their production. These may be briefly alluded to. i. Lnternal Causes.—:Food, which is wrong either in quantity or quality, is a frequent cause of skin disorder, as will be dwelt upon in the chapter on diet and hygiene. Derangements of the internal organs, as indicated by dyspepsia, constipation, and urin- MANUAL OF DISEASES OF THE SKIN. ary disturbance, likewise sexual disorders and ner- vous derangements, are frequently very closely con- nected with skin lesions; and the permanent cure of the latter often depends upon the successful relief of the former. Debility is also an important element to consider in this connection; and infancy, denti- tion, puberty, pregnancy, and the menopaus have all relations to cutaneous maladies. The internal administration of some medicines, as quinine, iodide and bromide of potassium, and copaiba, and other drugs, is sometimes followed by eruptions of peculiar nature. 2. External Causes.—Parasites, animal and vege- table, heat and cold, chemical and vegetable poisons, and mechanical irritation, as by friction, harsh un- derclothing, and above all by scratching, are fruitful causes of skin lesions, and must all be looked for. In some instances they are the sole efficient cause, and the eruption fades away when they are re- moved ; in other cases they are but a single factor, and the real cause is found in the internal or indi- vidual state. Thus, local agents may excite an eczema in one predisposed thereto; but the same irritation practiced upon a dozen other individuals will excite but a temporary inflammation of the skin. The lesions of late syphilis are frequently deter- mined as to their seat by a local injury. 3. Lndividual and Family Tendencies.—Some indi- viduals are far more prone to have skin affections ETIOLOGY. 45 than others, even as the lungs or kidneys are more often affected in one person than in another; those with light complexion and hair are more inclined to skin diseases than the dark. Again, families present the same peculiarity ; some affections are hereditary to a greater or less extent, such as syphilis, leprosy, cancer, and psoriasis ; eczema sometimes appeaTs to be inherited, but in reality this is rarely the case. The gouty, strumous, and nervous habits or states, whether hereditary or acquired, are of importance in connection with this subject. Other elements to be taken into consideration as bearing upon etiology, are the seasons, climate, oc- cupation, age, and sex, as will be developed in later pages. CHAPTER VII. CLASS I. MORBI CUTIS PARASITICI.—PARASITIC AFFECTIONS. THE first class of diseases in our classification em- braces eruptions having a well recognized and easily defined cause : namely, the existence in or upon the skin of parasites, whose presence and irritation cause the phenomena of disease. These parasites are rec- ognized to be of two kinds—vegetable and animal. The first group embraces three distinct kinds or va- rieties of disease; the second, two. The vegetable parasites producing the three dis- eases are supposed to be distinct one from another; they have not been found to be interchangeable in causing disease. The three vegetable parasites are the trichophyton tonsurans, causing the varieties of tinea trichophytina or ringworm, the achorion Schbn- leinii, causing tinea favosa or favus, and the micro- sporon furfur, inducing tinea or pityriasis versicolor. The action of these parasites is a purely local one ; that is, the lesions are produced by the local action of the vegetable growth upon and in the elements of the skin, and not by absorption or by any action of the parasite upon the blood or the system at large. PARASITIC AFFECTIONS. 47 When the eruption is communicated to another per- son, or develops elsewhere on the same individual, it is always by direct or indirect transference of the germs of the parasite to and upon the affected spot. i. Tinea trichophytina. Synonym: Ringworm. The growth of the parasite trichophyton produces quite different appearances as it affects the different portions of the body, and four distinct varieties of eruption from it are recognized : Namely, tinea tri- chophyton corporis, — capitis, — barba, and — cruris, affecting respectively the general surface and extrem- ities, the scalp, the bearded face, and the genital region. Although they are really the same disease, they will best be described and treated of separately, so different are the appearances at times presented. Tinea trichophytina corporis.—Synonyms: Ringworm of the body; Tinea circinata; Herpes circina- tus. This includes the eruption due to this parasite upon all parts other than the hairy scalp, the bearded face, and the genital region ; it is very commonly seen upon the face and hands of children. It is characterized by the development of a small red spot which enlarges peripherally with considerable rapidity, so that in two or three days or a week it may attain the size of a circle half an inch or more in diameter; as it increases at the border, it has a tendency to clear in the center. The margin is sharply defined, slightly raised, of a well marked 48 MANUAL OF DISEASES OF THE SKIN. red, and covered with a small amount of easily re- moved scales. Sometimes, in delicate skins, a few minute vesicles will form on a large spreading bor- der (herpes circinatus) ; this, however, is rare. When at all well developed, the center of the patch is of a dirty yellowish color with more or less scaling. There may be one or several patches; I have counted as many as one hundred and three on one child; they may attain some size, and by coalescing may form larger patches, or, the center clearing, gyrate forms may be produced by the red margins. They generally give rise to but little physical discomfort other than a slight itching. Diagnosis. Tinea circinata is most likely to be confounded with psoriasis, squamous eczema, syphi- lis, and erythematous lupus. The history of the case, and the rapid development of the circles of ringworm, with a tendency to clear in the center, will differ- entiate them. The diagnosis is established with cer- tainty in all the forms of ringworm by the discovery in the scales and hairs, of the parasite trichophyton tonsurans. The examination is best made by scrap- ing the surface with a dull knife and placing the debris in a little liquor potassae and glycerine, upon the slide of a microscope, and examining it with a power of from two to three hundred diameters. The mycelium appears as minute, slightly greenish tubes with parallel sides and rounded extremities, often branching, and the spores as minute rounded bodies, PARASITIC AFFECTIONS. 49 of even size, refracting the light strongly: some little care is necessary to distinguish the latter from fatty globules. Tinea trichophytina capitis. Synonyms: Ring- worm of the scalp; Tinea tonsurans; Herpes tonsurans ; Trichophytosis. Ringworm of the scalp is not always as easy of recognition as might be supposed, and in cases which have lasted any length of time the diag- nosis may be very difficult. The eruption begins, as upon the face and body, with a small red point, which increases peripherally in a more or less circular form, until it has attained almost any size. When first presented there are commonly seen one or more patches with a diameter of from half an incri.upwards, upon which the hairs are broken and stubbed, and the surface covered with a dirty grayish scaling; the history will be given that these were noticed quite recently, and mainly by the loss of hair. Sometimes instead of these dried patches there is an inflamed condition, and each point of attack of the parasite will be marked by a small pustule or mass of inflammation, surmounted by a crust; but generally other non-inflamed patches will also be visible. Sometimes the tendency to inflammation will be so great, that in place of single small points, the entire patch, half an inch or more in diameter, will become inflamed, boggy, slightly elevated above the skin, and tender upon pressure. When the dis- 3 MANUAL OF DISEASES OF THE SKIN. ease has lasted a' length of time, each hair is seen to stand in a little well of pus, from which it can be extracted without pain; and a gummy, purulent fluid exudes from the hair follicles on moderate pressure. This form or condition of the disease has received the name of tinea kerion. On attempting to extract the hairs from a non-in- flamed patch of ringworm, the stump readily crum- bles in the forceps without drawing the root with it; if the patch is scraped with a dull knife, many broken bits of hair will be found with the scales, which are seen to be filled with the spores of the parasite. This broken condition of the hair which is seen on these patches, may be readily discovered by passing the finger lightly over the surface at a slight dis- tance from the scalp. In certain old cases the distinctive features of ring- worm may be lost, and the scalp is moderately scaly, with thin hair, and among the long hairs may be found many which are broken and stubbed, as in the patches previously described. Diagnosis.—Ringworm of the scalp may be mis- taken for eczema, psoriasis, seborrhcea, and perhaps syphilis. The stubbed and broken condition of the hairs, and the presence of the parasite, are sufficient for the diagnosis. Tinea trichophytina barbae.— Synonyms: Ringworm of the beard; Parasitic sycosis ; Barber's itch; Tinea barba ; Sycosis parasitica. In the earli- PARA SI TIC AFFECTIONS. 51 est stages of ringworm of the beard, the eruption does not differ essentially from that observed else- where on the body ; there is first a small red point, which extends peripherally in circular form, while the center tends to clear, and becomes covered with a moderate amount of scaling. The eruption may remain in this condition without giving rise to much irritation, but in long standing cases, it occasions deep seated inflammation of the follicles of the part, with the production of boggy masses, corre- sponding to that condition just described as tinea kerion. Diagnosis.—The sharply defined ring, or portion of a ring, which can often be made out, red and more or less scaly, with the history of an increase from a small point, indicates the character of the eruption, together with a discovery of the parasite by a microscopic examination of the scales and hairs. But the eruption may be confounded with eczema, true sycosis, seborrhcea, and pityriasis, also possibly with psoriasis, acne, or syphilis. Eczema always manifests its character of an imperfectly de- fined margin, shading out into healthy tissue, and without the tendency to clear in the center, and generally exists elsewhere, or spreads out on to the neighboring parts. True sycosis presents single iso- lated pustules surrounding hairs, rather than the large boggy masses of the parasitic disease. Tinea trichophytina cruris.—Synonyms : MANUAL OF DISEASES OF THE SKIN. Ringworm of the thigh and genital region; Chinese, Burmese, and Tokeleau ringworm; Eczema margina- tum. The fourth and last variety of the eruption due to the presence and growth of the trichophyton tonsurans, is that about parts which are kept warm and moist, as in the genital region and axillae, and presents features which at times render it very diffi- cult of recognition. But the development of the eruption here is the same as elsewhere; namely, from a small point which enlarges peripherally, with a tendency to clear in the center. When presented for treatment, however, one seldom sees small points or even rings; but generally there is a more or less reddened surface with a sharply defined margin, which is red, slightly elevated above the skin, and from which a few scales can be scraped. This mar- gin, which is generally not more than a line in width, is of a reddish color, while the surface behind is of a brownish, dirty yellow hue, sometimes quite red and inflamed from previous treatment; occasionally small, newly developing points will be found within the larger area or outside of the main line of dis- ease. On the male the eruption on the scrotum exactly corresponds to that upon the thigh ; gen- erally the two thighs and the sides of the scrotum are affected unequally. In the region around the anus, and upon the buttocks where the parts come in contact, the eruptions on the opposing surfaces are seen to correspond to each other, and to present the PARA SI TIC AFFECTIONS. 5 3 sharply defined margin, and soggy, perhaps whitened tissue within. The itching from ringworm in the genital region is generally most intense, and the suffering may be very great. These cases often last a great length of time, being relieved by treatment but not cured until the accurate diagnosis is made. Diagnosis.—The eruption in this location is mainly liable to be mistaken for eczema, and intertrigo; often the two eruptions are combined, either being first developed ; the sharply defined margin, and the more or less tendency to clear in the center, should always attract attention. Eczema in this region is worse towards the crotch, and tends to become lighter towards the periphery; simple chafing or erythema intertrigo has the character of eczema in a lighter degree. Prognosis.—The prognosis of all the forms of ring- worm is good ; there is a definite local cause, and if it can be removed the disease will surely get well. But the prognosis varies a good deal, with the form and location of the disease, and the individual pa- tient. Ringworm of the body always yields more or less readily. On the scalp and beard it frequently remains uncured for months and years, because of the great difficulty of reaching the parasite, deep in the follicles; in the genital region, if properly treat- ed, it is perfectly manageable. Treatment. — This is comparatively simple, al- 54 MANUAL OF DISEASES OF THE SKIN. though the details are difficult of execution in some cases. A number of home remedies are of value in ringworm of the body, such as laying a penny wet in vinegar on the spot, ink, iodine, castor oil, etc. Any of the mercurial ointments, preferably the red precipitate or citrine ointment (Formulae 90, 92, 93, 98), well rubbed in, will suffice for the removal of the disease on the body. Oleate of mercury in five or ten per cent, solution is also valuable, but there is a possibility of salivating with the too free use of it. Sulphurous acid, if thoroughly applied, is one of the best and most cleanly parasiticides ; to be of value, however, it must be absolutely fresh, for by contact with the air a portion of the sulphurous acid evaporates, while the remainder is converted into sulphuric acid, which is irritating to the skin and useless to destroy the parasite. For this purpose an unopened package should be obtained, and a small bottle repeatedly filled therefrom. It is to be applied thoroughly to the skin, two or three times a day, undiluted, unless it appears too irritating, and the effect may be heightened by covering the part with oiled silk. Sometimes additional local stimu- lation is necessary, as with the compound tincture of green soap (Formula 39) ; if too much irritation has been set up, soothing treatment will be required. (Formulae 25, 26, 83, 84, 85). Ringworm in the gen- ital region is similarly treated. Ringworm of the scalp and beard, when recent, PARASITIC AFFECTIONS. 55 may be removed by the means previously described, but when deep seated, it is very difficult for the remedy to reach the fungus in the follicles, and the extraction of the hairs becomes necessary. If, how- ever, we attempt to pull out the hairs from a tolera- bly well developed patch of ringworm, they break off, and considerable care will be necessary to insure their removal; they must be drawn perpendicularly to their axis, and repeated attempts will often be made before success is obtained. When depilation is practiced, it is always well to rub into the sur- face afterwards a solution of bi-chloride of mercury (Formula 45) ; but this should not be intrusted to the patient, for serious accidents have been reported from the careless use of this remedy. In older patches, where the hairs have less tendency to break, and where large surfaces are to be treated, the method of wholesale depilation described under favus may sometimes be resorted to with advantage. The plan of destroying the parasite by inflaming the skin, which has recently found many advocates, consists in powerfully stimulating the scalp with such irritants as croton oil, repeatedly applied until an ar- tificial tinea kerion is produced, and a muco-purulent fluid exudes; the loose hairs are then easily ex- tracted and the inflammation is allowed to subside under soothing treatment, when the disease is fre- quently found to be cured. This plan must be adopted with caution, as it is not safe to treat too 56 MANUAL OF DISEASES OF THE SKIN. large a portion in this manner, and sloughing has occurred from its careless employment. The internal treatment of ringworm maybe briefly disposed of. As moss does not grow upon the bark of perfectly healthy trees, with plenty of air and sunlight, so parasitic diseases seldom flourish upon individuals in perfect health, as has been repeatedly shown by failures in attempts at inoculation. It is always desirable, therefore, especially in cases which have lasted any length of time, to investigate most carefully the general health, and to prescribe intel- ligently therefor. Arsenic will not cure the disease, but may be required as a nerve tonic, or as an im- prover of nutrition, in connection with other reme- dies ; the same may be said of many other agents. An eczematous habit or diathesis will often be found in ringworm cases; in eczema marginatum constipation aids the congestion and slight irritation of those parts which give the proper nidus for the de- velopment of the parasite; see treatment of eczema. Tinea favosa. Synonyms: Favus; Porrigofa- vosa ; Crusted ringivorm; Honeycombed ringworm. The second vegetable parasitic disease is due to the growth in and upon the skin of the achorion Schonleinii. This is a comparatively rare affection in this country ; it occurring only 31 times in our 8,000 cases. The parasite may affect any and every part of the surface of the body, but is more commonly PARASITIC AFFECTIONS. 57 seen or recognized upon the scalp. Here it is really often severe and obstinate, because of the great size and depth of the hair follicles into which the fungus penetrates. Upon the rest of the surface, where there are no large hairs, the eruption is very super- ficial, and much more easily cured. The charac- teristic lesion of favus consists of a slightly raised, circular, cup-like mass, of a bright yellow sulphur color, commonly seated around a hair, with a de- pression in its center. When first appearing, the little cups are exceedingly minute, perhaps not much larger than the head of a small pin ; but if left undisturbed, they may grow to the size of a quarter of an inch or more in diameter; they are easily dislodged, and the surface beneath presents a red, glazed appearance. The mass thus removed is found to consist entirely of the spores and mycelium tubes of the parasite, which may be readily recognized under the microscope, when ground up with a little water or glycerine, and magnified 300 diameters. But this characteristic cupped appearance of favus is not seen in every case as presented for treat- ment ; more commonly there are yellowish masses, having somewhat the appearance of dried pus, around and among the hairs, which may become darkened by dust or blood. In cases which have existed for some time a large portion of the scalp may become affected, and exhibit the disease in various degrees of severity, in cups or simply dried 3* 58 MANUAL OF DISEASES OF THE SKIN. scaling. This superficial development, however, is by no means the only portion of the disease ; the parasite penetrates the hair and along its root- sheaths, so that when greatly affected, the hairs may be very easily extracted, and do not readily break off. The disease is far more destructive in its tend- ency than tinea capitis, and may not only destroy the growth of the hair, but also the follicle itself, and the eruption may be followed by great cicatrization ; in old cases patches of scar tissue of greater or less ex- tent are always found, slightly reddened, and perhaps with some scattered hairs upon them. The disease always interferes very greatly with the nutrition of the hair, and renders it dry and harsh. Favus sometimes appears on other parts than the scalp, and if left undisturbed yellow cups will form, and around them there is generally a ringed, erythe- matous, scaly surface, very closely resembling ordi- nary ringworm. In rare cases a large portion of the body may be affected with favus. Favus is always seen in those exhibiting ill health, and generally oc- curs in strumous subjects. It is questionable, how- ever, whether the disease itself, although purely a local one, has not something to do with lowering of the health and vitality of the individual. Diagnosis.—This is not ordinarily difficult. No other disease exhibits the characteristic cups ; and if doubt exists the microscope will always decide. Pustular eczema of the scalp, some cases of syphilis, PARASITIC AFFECTIONS. 59 and psoriasis are the only diseases with which it can be confounded. Treatment.—The treatment of favus differs with its situation ; upon the scalp, owing to the great size of the hairs and depth of the follicles, it is gener- ally most rebellious, unless the treatment be very thoroughly and faithfully persisted in until perfectly cured. External applications if lightly applied are of very little service, because they will not penetrate the depth of the follicle; and although the external mani- festations are removed, it will crop out again when left to itself. Two methods of treatment are therefore applicable: the one of removing the hair and allowing the parasiticide to penetrate into the open follicles; the other of causing an inflammation, which, by its intensity, shall destroy the life of the parasite. De- pilation is most to be relied upon, and if thoroughly and efficiently performed is followed by success. The hairs may be extracted by the forceps, but this is a slow procedure when a large surface is involved ; and the methed recently employed by the writer for extracting the hairs en masse is a much more ready and more certain.method. This consists in having sticks prepared of a very adhesive material (Formula 20), which are made to adhere to the hairs, and then pulled off. The hair should be cropped to about one- eighth of an inch long, over the part to be treated ; the sticks are then melted on the end in a spirit-lamp, 60 MANUAL OF DISEASES OF THE SKIN. and applied with a slight rotary or twisting motion, to work the short hairs into their substance. After they have cooled, they are removed by bending them over and pulling the hairs in succession, with a slight twisting motion. The sticks are prepared for fur- ther use by burning the hairs in the flame and wip- ing the end firmly upon a sheet of paper. After depilating by this or other means, a solu- tion of bi-chloride of mercury (Formula 45) is to be well rubbed into the skin by the operator. To be very effective depilation should be practiced every day or so until all the affected hairs are removed; it is well to give the patient an ointment (Formulae 92, 93, 102), to be well rubbed into all the affected parts night and morning. In epidermic favus the cups are simply picked out and the surface well rubbed with pure sulphurous acid, the oleate of mercury 5 per cent., or one of the mercurial ointments (Formulae 92, 93, 102). Most cases of favus should also have some internal treatment of a tonic character (Formulae 52, 53, 58, 59), in order that the general health may be raised to the standard which will resist the development of the parasite. Tinea versicolor. Synonyms: Pityriasis versi- color; Chloasma?; Liver-spots; Chromophytosis. The third and last vegetable parasitic disease of the skin is that due to the presence of the microsporon PARASITIC AFFECTIONS. 6\ furfur. This is seen first and mainly on the chest, in the form of yellowish-brown, slightly scaly patches of various sizes and extent. Sometimes the erup- tion consists of very many small points, at other times of patches which may cover a very considera- ble area. The back is almost always affected at the same time, though to a less degree, and the eruption may occasionally spread under and upon the arms, and even upon the neck and face; and in rare cases upon the lower limbs. Usually it is quite symmet- rical ; when there is much sweating the surface will be almost free from scales, and may be quite red. There is often slight itching accompanying it. Upon scraping the patches and placing the scales beneath a microscope, groups or masses of round spores are seen and more or less mycelium among the epidermal scales. This eruption has considerable tendency to recur, and in many cases it lasts for years, being partially removed by treatment, and then relapsing, owing to the failure to entirely reach and destroy the para- site. Diagnosis.—This is comparatively easy ; the erup- tion may be mistaken for chloasma, leucoderma, ringworm, erythematous eczema, and seborrhea, This eruption was formerly called chloasma, but this term is now given to a pigmentary affection, having no connection with the one now described, nor has the present eruption any connection with liver dis- 62 MANUAL OF DISEASES OF THE SKIN. order. True chloasma occurs on the face, and sel- dom, if ever, in a manner to resemble tinea versi- color. In leucoderma there are white patches upon a yellowish or brown base, whereas in the parasitic disease now described we have yellow patches upon a normal skin. Seborrhoea of the chest presents cir- cular patches, which are more red in color; the scales are very greasy, and the parasite is not found under the microscope. Treatment.—The treatment is often ineffectual in permanently removing the eruption, because not persisted in long enough. It consists of the appli- cation of a parasiticide, of which there are many of value. Sulphurous acid in solution will remove the eruption very quickly, also Vlemingkx' solution (Formula 37), and a few sulphur vapor baths will aid greatly; preparations of mercury, as the oleate, citrine ointment diluted, and others, are also effec- tual; also solutions of corrosive sublimate, four grains to the ounce, with a little ammonia; like- wise tarry preparations, well rubbed into the skin, such as the compound tincture of green soap, or the liquor picis alkalinus (Formulae 39, 40, 42). It is also well to have the patient wash the surface very freely, and for this purpose even yellow bar soap may be used to advantage. CHAPTER VIII. CLASS I. MORBI CUTIS PARASITICI.—PARASITIC AFFECTIONS—(Continued^) A nimal Parasitic Affections. Two distinct diseases of the skin are recognized as due to animal parasites, although there are a number of parasites which may at times attack the human integument. These two principal ones are phthiriasis and scabies. i. Phthiriasis. Synonyms: Pediculosis; Morbus pedicularis; Lousiness. Three distinct forms of pediculi are found upon the human skin, occupying severally and chiefly the body, the head, and the pubis. Hence we speak of three forms of this affec- tion or condition, namely,phthiriasis corporis, phthi- riasis capitis, and phthiriasis pubis. Phthiriasis corporis.—The body louse has as favorite seats of occupation the regions about the shoulders and hips, and here the greatest number of skin lesions will be usually found. These consist of inflamed and torn papules of various sizes, together with abundant scratch marks or excoriations. There 63 64 MANUAL OF DISEASES OF THE SKIN. is also a curious lesion seen, which is caused by the manner in which the insect obtains its nourishment; this consists of a very minute red point, not elevated above the surface of the skin, and is in reality the end of a small plug of blood occupying a dilated follicle, into the bottom of which the insect has penetrated with its proboscis in order to suck blood. On strip- ping the patient with phthiriasis corporis, one gen- erally finds none of the parasites upon the body, but they may commonly be found in the folds of the clothing about the parts affected, and here like- wise are laid the eggs or nits, which may be seen by careful inspection, as minute, oval, whitish bodies, adherent to the fibres of the clothing. In debilitated subjects and in long standing cases the itching may give rise to so much scratching that very considera- ble lesions result; even ulcerated points, covered with thick crusts. Phthiriasis capitis exhibits many of the re- sults of scratching and inflammation upon the scalp, in the form of excoriations covered with more or less crusts. The itching is generally quite considerable, and the patient unconsciously tears off the crusts, continually making the eruption worse. In severe cases a large portion of the scalp may be the seat of inflammatory action, and the hairs, accordingly, may be matted together by the exudation; the glands of the back of the neck become enlarged, and the scalp emits a fetid odor. The pediculi may generally be PARASITIC AFFECTIONS. 65 seen moving upon the hairs, and their nits are found attached to the same. Phthiriasis pubis.—The true cause of itching about the pubis will sometimes pass long unrecog- nized. In some cases there will simply be a moderate amount of itching about the genital region, with the occasional development of scratched papules, but in other instances all these parts may be very much torn, and a considerable eruption exist. The pediculus pubis or crab louse differs from the preced- ing varieties in being much smaller and more round; it holds very firmly by means of its crab-like claws to the hairs, and is generally found firmly attached to the hair, near its exit from the follicle, and with its body in close contact with the surface. Thus it may readily escape recognition, and appears more like a little scab or crust than a living insect. When it is dislodged, it still holds firmly to the hair, and is with some difficulty removed. It de- posits its eggs or nits upon the hairs of the part, and generally they can be found, as minute white specks, attached to them. This crab louse may also infest the hairs of the axillae, eyebrows, eye- lashes, and even the hairs of other parts, as the beard. Diagnosis.—Upon the scalp the eruption resem- bles eczema, pustular syphilis, and possibly psori- asis; but the inflammation caused by lice, and the resulting crusts and the itching, are generally far 66 MANUAL OF DISEASES OF THE SKIN. greater than those in these eruptions. In some cases, however, very few lesions will be seen, and the scalp may be kept so clean that no pediculi can be discovered. But, however great care is exer- cised, some nits may almost always be found on the hairs when the eruption is due to lice. Phthiriasis of the body may be mistaken for many eruptions, ec- zema, scabies, pustular syphilis, also for pruritus and prurigo; but the peculiar locations of the principal lesions over the region of the shoulders and about the loins should excite suspicion; and a careful ex- amination will generally reveal the marks of the finger nails in the torn papules and streaks, and great care will reveal the hemorrhagic specks al- luded to. Phthiriasis pubis may also resemble sim- ple eczema and scabies; but the finding of the parasite renders the diagnosis clear. Many of the cases of phthiriasis of the body and genital regions were formerly called pruritus and prurigo; these terms, however, belong to entirely distinct diseases; pruritus, or itching, is a symptom of phthiriasis, as also of many other skin affections. Treatment.—For phthiriasis of the scalp simple cleansing alone does not suffice, but some agent must be employed which is directly a parasiticide. The most effective and sure application is that of ordinary petroleum or kerosene oil, the commoner the better, as it contains a larger proportion of the volatile elements, which are destructive to the life PARASITIC AFFECTIONS. 67 both of the parasite and its nits. The head should be thoroughly soaked with it two or three times during a day, and left wrapped up in a cloth for twenty-four hours. At the end of this time it is thoroughly washed, and if there are any excoria- tions, they may be treated with a little zinc or white precipitate ointment (Formulae 83, 84, 85, 91.) One such thorough application is generally sufficient for the complete cure of the disease ; the nits will then be found to be loosened upon the hairs, and to come out with tolerable readiness; it is never necessary to cut the hair in these cases. Other treatment may be used, as an infusion of stavesacre, as also white precipitate ointment in full strength. Lotions of bi- chloride of mercury should not be entrusted to pa- tients for this purpose, as they are more or le.ss dangerous. Phthiriasis corporis is very easily remedied. The patient is simply to take a warm bath with soap and water, after which fresh clothes, which have been thoroughly boiled and ironed with extra care, are put on; the parasites adhering to the clothing are thus removed, and the clothes which are taken off should be thoroughly baked or boiled. Some care should also be exercised that other articles of cloth- ing which the patient has worn be similarly treated, lest lice develop anew from the nits attached to them, however carefully removed from other gar- ments. 68 MANUAL OF DISEASES OF THE SKIN. Phthiriasis pubis is sometimes a little difficult of removal because patients do not make sufficiently thorough applications. Any of the mercurial oint- ments (Formulae 90, 92, 93) are quite sufficient for the destruction of the parasites, as also ammoniated mercury well dusted on; the danger of salivation should always be borne in mind when the simple unguentum hydrargyri is employed. In very rare cases it is necessary even to shave the parts affected with pediculi pubis; but this need seldom be the case if care is exercised. It need hardly be stated that none of the varieties of pediculi can by any possibility appear beneath the skin, or affect the system at large, as is so often popularly supposed. They are air-breathing insects, and remain wholly upon the surface of the body, and the lesions caused are due to the irritation from them and the consequent scratching. 2. Scabies. Synonym: The itch. This affection, quite different from the conditions just described, is due to the boring into the skin or rather beneath the epidermal layer, of a minute insect, the acarus or sarcoptes scabiei. The female does the mischief, she burrowing for the purpose of laying her eggs, which may be found in a little track which she leaves behind her, called the cuniculus or furrow. The male is said never to penetrate the skin. This little track which the female leaves forms the path- PARASITIC AFFECTIONS. 69 ognomonic sign of the disease ; it consists of a minute brownish black line, generally curved, which appears as though a bit of dark colored sewing silk had been run beneath the surface. If the skin is washed or wiped, this,«instead of being removed, will stand out still clearer, and will be seen to terminate at a point of inflammation, a papule, vesicle, or pustule, or to pass over the surface of one of these. The point of inflammation is caused by the presence of the insect, and she will be found at that extremity of the cuni- culus or furrow ; behind her a number of oval eggs in various degrees of development may be observed microscopically, and between them minute black particles, which latter are supposed to be the faeces of the insect. Very recent cases may not present cuniculi, if time has not elapsed for a sufficient bur- rowing of the insect, but papules or vesicles may form immediately on her penetrating the epi- dermis. The lesions of scabies are peculiarly multiform, exhibiting papules, vesicles, and pustules often of some size, also scratch marks and crusts, each case varying greatly according to its duration and the condition of the individual in regard to health, cleanliness, etc. In light cases, or in very healthy subjects, papules predominate, with a few vesicles when the skin is delicate; whereas in broken down constitutions and in children, very severe inflam- matory lesions may result, with large pustules ; or, 70 MANUAL OF DISEASES OF THE SKIN. these may be scratched, and large, superficial, raw patches form, covered with more or less crusts. There are certain places of predilection which aid very greatly in recognizing the disease. The first in importance is the region about the fingers., especially where they join on the back of the hand; next, on the inner surface of the wrists, also the soles of the feet, and about the malleoli in children. In males there will almost invariably be found one or more lesions about the penis and scrotum, partaking of the same inflammatory character; and often cuni- culi or furrows of the insect may be found here very perfectly developed. In the female the region of the nipple is very often affected, also the flexor sur- face of the forearm and the fold in front of the axilla in both sexes; the face and head generally escape. The itching of scabies may be quite severe, but is generally of a mild form, and bearable; it is even pleasant compared to that in severe eczema. There will almost always be found the history of contagion in scabies, and rarely will one member of a family be attacked alone, especially if there are children. Scabies is becoming a comparatively rare disease in this country; among the 8,000 cases analyzed it only formed 0.39 per cent, in private, and 2.18 per cent, in public practice. Occasionally it appears in public institutions, and many cases are seen together, and the^ disease may be difficult to eradicate. In some countries, as in Scotland, it is much more fre- PARASITIC AFFECTIONS. 71 quently met with, and in statistics from Glasgow it forms about twenty-five per cent, of all cases of skin disease. During our late war it was quite common, and was often spoken of as the " army itch." Diagnosis.—As may be judged, the eruption of scabies may be confounded with very many affec- tions of the skin; eczema, liclien, phthiriasis, pru- rigo, pruritus, and urticaria papulosa ; between pap- ular and vesicular eczema of the hands, and mild recent scabies, the diagnosis is often very difficult. Prognosis.—This is good ; of however long stand- ing, the disease may be rapidly and thoroughly cured if proper and complete treatment is carried out. The system is never affected, and there is no harm in removing the disease as quickly as possible. Treatment.—This is accomplished purely by ex- ternal means. As an indication of the plan to be followed we may mention the rapid cure of the dis- ease practiced in the Hopital St. Louis, in Paris. The patient is fipst very thoroughly rubbed all over from head to foot with soft soap, especial attention being paid to the regions most apt to be affected: this process occupies about half an hour. The pa- tient then takes a warm bath, remaining in it for half an hour or so, in the meantime scouring the skin thoroughly. On coming out of the bath, he is thoroughly rubbed from head to foot with an oint- ment containing sulphur (Formulae 100, 101), and this process also takes half an hour at least, particular 72 MANUAL OF DISEASES OF THE SKIN. attention being given to the portions mentioned as most commonly affected. The clothes, which have been thoroughly baked while the patient was in the bath, are now put on, and it is expected that the disease is thus entirely cured. The idea of the first friction is to open the furrows, as far as possible re- moving the eggs which would hatch out; these, with the male insect which could be thus reached, the bath then removes from the skin. The sulphur ointment being then thoroughly rubbed into all the parts, enters the open cisniculi and completes the destruction of the insects. The clothes having been baked at a high temperature, all the insects which may have lodged upon them are destroyed. Sometimes cases of scabies are over-treated, or are so severely irritated by the measures used for the destruction of the parasite, that an artificial papular eruption results, which more or less imitates the disease. In such cases a soothing treatment may be employed for a few days, such as is suitable for an eczema, and the case is then left a little with- out treatment. If there are still the elements of scabies remaining they will then become apparent. CHAPTER IX. CLASS II. MORBI GLANDULARUM CUTIS.—GLANDU- LAR AFFECTIONS. The diseases belonging to this group are divided into two classes, namely: those relating to the sebaceous glands, and those affecting the sweat glands. The diseases of the sebaceous glands comprise six distinct varieties, several of which may often be found more or less associated in the same individ- ual. Of the sebaceous diseases we find two orders : First, those due to faulty secretion or excretion of the glands: acne sebacea, acne punctata, acne mol- luscum ; and second, those exhibiting inflammation of the sebaceous glands with the surrounding tissue: acne simplex, acne indurata, acne rosacea. i. Acne sebacea. Synonyms: Seborrhcea; Se- borrhagia; Steatorrhoea ; Fluxus sebaceus. Three distinct forms of this variety of functional sebaceous disorder are recognized : acne sebacea, or seborrhcea, oleosa, cerea, and cornea. Acne sebacea oleosa.—In this the skin is more oily than natural, and has a greasy, shiny appear- 4 73 74 MANUAL OF DISEASES OF THE SKIN. ance. When the scalp is affected the hair has an unctuous appearance, and emits a nauseous odor. Upon the face and the forehead it may exist to such an extent that the oily secretion will stand in drops upon the skin. Acne sebacea cerea.—This dry form of sebor- rhcea is characterized by the presence of greasy masses of scales or crusts, of a yellowish or greyish- brown color, which tend to adhere to the skin. Upon the nose and cheeks it may present a very disagreeable and annoying coating : upon the scalp the secretion may either remain quite greasy and accumulate, so that it can be removed as a yellow- ish, crusty mass, with the finger nail; or, it dries into scales, which fall continually upon the clothing, and thus constitutes a large share of the cases ordinarily called dandruff'or dandriff. Commonly a large por- tion of the scalp is affected, and loss of hair ensues to a greater or less extent. Seborrhcea of the scalp often resembles closely a dry scaly eczema, a pityri- asis, or psoriasis. Acne sebacea cornea is characterized by the development, principally upon the face, of horny sebaceous masses and concretions which, when forci- bly removed, are found to have projections into the orifices of the sebaceous glands ; sometimes their re- moval causes slight bleeding. This condition may remain, especially on elderly persons, for a length of time, and may result in epithelioma. GLANDULAR AFFECTIONS. 75 Treatment.—The constitutional treatment of these functional subaceous disorders is essentially that of inflammatory acne to be described later. Locally stimulating and astringent applications are called - for; on the scalp tannin and white precipitate oint- ment (Formulae 87, 90,91) are most serviceable, with an occasional shampoo with tar. soap, or green soap in solution (Formula 38); later, mildly stimulating lotions are called for, and still later those with cantharides (Formulae 49, 50, 51). The local treat- ment of seborrhcea of the face is practically that of the other forms of acne; with the addition of a bis- muth and white precipitate ointment (Formula 91). 2. Acne punctata. Two forms of disease are rec- ognized which are due to retention of the sebaceous matter, namely: acne punctata nigra, or comedo, and acne punctata albida, or milium. Acne punctata nigra, or comedo, represents the little black specks seen upon the face, commonly called black-heads, zvorms, or grubs. These consist of hardened plugs of sebaceous matter contained within the cavity and ducts of the glands; the black- ened end is probably due to dust from the atmos- phere, although this has been disputed of late. The foundation for the popular idea that these plugs, which can be squeezed out, are themselves worms or insects, lies in the fact that there is in reality a very minute animal which infests the se- y6 MANUAL OF DISEASES OF THE SKIN. baceous glands; it is, however, by no means of such a size as one might imagine. It is called the demo- dex or steatozoon folliculorum, and is exceedingly small, being in length from Tj M. et ft. unguentum. Use : Soothing and protective ; a drachm of .tincture of camphor or chlo- roform may be added, or from five to fifteen drops of carbolic acid, as an antipruritic. 84. Unguentum calamines. R Acidi carbolici, gtt. v—xvj............ 32— 1 03 Pulveris calaminae prep., 3 ss— 3 j• • •• 1 Zinci oxidi, 3 ss—3 j,.............. I Unguenti aquae rosae, § j............. 31 M. et ft. unguentum. Use : Soothing and protective. 85- Unguentum bismuthi sub-nitratis. R Bismuthi sub-nitratis, 3 ss— 3 ij...... 1I94— 7I77 Unguenti aquae laurocerasi, § j....... 31110 M. et. ft. unguentum. Use : Soothing and mildly astringent. 86. Unguentum bismuthi (vel zinci) oleatis (Anderson). R Bismuthi oxidi,............................. (vel zinci oxidi), 3 ij......................... 7177 Acidi oleici, § ij............................ 62 20 Unguenti petrolei, § ij-f- 3 ij................. 70 Cerae albae, 3 vj............................ 23 32 Olei rosae, gtt vj............................ I32 M. Rub up the bismuth (or zinc) oxide with the oleic acid, and let it stand for two hours; place in a water bath, add the vaseline and wax, and when dissolved stir until cold and add the oil of roses. Use : Soothing and astringent in acute inflammatory conditions. 87. Unguentum acidi tannici. R Acidi tannici, 3 j........................... ' 3I88 Unguenti aquae rosae, § j.................... 31 10 M. et ft. unguentum. Use : Astringent; of especial service in eczema of the scalp and ears. THERAPEUTICS OF DISEASES OF THE SKIN. 295 — n|66 94— 388 R M. R M. 77— 10 15 88. Unguentum picis et zinci. R Unguenti picis liquidae, 3 j— 3 iij..... 3 Zinci oxidi, 3 ss— 3j................ 1 Unguenti aquae rosae, ad § j.......... 31 M. et ft. unguentum. Use : Antipruritic and protective ; of especial value in infantile eczema. 89. Unguentum cadini et zinci. R Olei cadini (vel rusci), 3 ss—3j...... T|94— 3'^ Zinci oxidi, 3 ss—3 j.............. T 94— 3,* Unguenti aquae rosae, §j.......... 31!10 I M. et ft. unguentum. Use : Antipruritic and mildly astringent. 90. Unguentum picis et hydrargyi i. Liquoris picis alkalini, 3 j— 3 iij..... 3 (See Formula 42.) Unguenti hydrarg. ammon., 3 ij— 3 iv 7 Unguenti aquae rosae, ad § j........ 31 et ft. unguentum. Use : Antipruritic and mildly stimulating; of especial value in psoriasis of the scalp. 91. Unguentum hydrargyri et bismuthi. Bismuthi sub-nitratis, 3 j........... ~ 3I88 Unguenti hydrarg. ammon., 3 j— 3 iv 3 88— Unguenti aquae rosae, ad § j....... 3i|i° et ft. unguentum. Use : Astringent and slightly stimulating. 92. Unguentum hydrargyri nitratis. R Unguenti hydrargyri nitratis, 3 j— 3 iij 3 Unguenti aquae rosae, ad 3 j....... 31 10 Olei geranii, gtt. v.........r-. . ■ .. .. 28 M. et ft. unguentum. Use : Mildly stimulating in chronic eczema. 93. Unguentum hydrargyri oxidi rubri. R Unguenti hydrarg. oxidi rub., 3 j— 3 iij 3188— Unguenti aquae rosae, ad § j........ 31110 M. et ft. unguentum. Use : Mildly stimulating in chronic eczema. 1555 5— 11 [66 11166 296 MANUAL OF DISEASES OF THE SKIN. 94. Unguentum diachyli. (Hebra's Diachylon ointment). R Olei olivarum optimi, 1 xv.................. 466J54 Plumbi oxidi, § iij + 3 vj..................... n6(62 Olei lavandulae, 3 ij........................ ^|75 M. Add the oil to two pounds of water and heat it with constant stir- ring • the litharge is to be slowly sifted in while it is well stirred, freshwater being added as required. The ointment is to be stirred until cold and the lavender then added. In winter a slightly larger quantity of oil is required to make a soft ointment. Use: Astringent and soothing, but irritating to some skins in acute conditions. 95- Unguentum diachyli modifcatum. R Emplastri diachyli,......................... 1 Vaseline, aa, §j............................ 3T|I0 M. Dissolve with heat, and stir until cold. Use : Astringent and soothing in subacute eczema. 96. Unguentum hydrargyri cum plumb o (Startin). R Plumbi acetatis............................. Hydrargyri chloridi mitis, aa. gr. x............ 64 Zinci oxidi............................... Unguenti hydrargyri nitratis, aa 3j.......... 1 29 Adipis recentis,............................ Olei palmae rectificati, aa. § ss............... 1555 M. et ft. unguentum. Use : Moderately stimulating ; much used in England in eczema capitis. 97. Unguentum plumbi et stramonii. R Liquoris plumbi subacetatis diluti, 3 j........ 3J75 Acidi tannici, 3j.......................... J 29 Unguenti stramonii, § j..................... 31!10 M. et ft. unguentum. Use : Astringent and soothing ; of especial value in external hemorrhoids. 98. Unguentum acidi chrysophanici. R Acidi chrysophanici, 3 ss— 3 ij........ i]94— 7J77 Unguenti aquae rosae, § j............. 31 10 M. Dissolve with heat and stir until cold. Use : Powerfully stimulating and irritant to many skins; of especial value in psoriasis and ringworm. 297 THERAPEUTICS OF DISEASES OF THE SKIN. 99. Unguentum acidi pyrogallici. R Acidi pyrogallici, 3j— 3 ij........... 129— 7175 Unguenti aquae rosae, §j............ 3i'io I M. Dissolve with heat and stir until cold. Use : Moderately stimulating in weakest, caustic in greatest strength; of especial value in psoriasis and ringworm. 100. Unguentum styracis et sulphuris. R Styracis liquidis, 3 ij................. 10 Unguenti sulphuris, 3 ij— 3 iv........ 7 77— 15 55 Unguenti petrolei, ad § j............. 31 10 | M. et ft. unguentum. Use : Anti-parasitic and moderately stimulating, for scabies. 101. Unguentum sulphuris compositum. (Modified Wilkinson's ointment.) R Sulphuris sublimati,......................... Olei cadini, aa 3 ij.......................... 7 77 Cretae preparatae, 3 ijss...................... 971 Saponis viridis.............................. Adipis, aa. § j.............................. 31 M. et ft. unguent. Use : A rather stimulating remedy for scabies. 102. Unguentum hydrargyri et olei rusci. R Olei rusci, 3 ss— 3 j................. 2(50— Unguenti hydrarg. oxidi rub., 3 j— 3 iij 3 88—11 Unguenti aquae rosae, ad •§ j.......... 31!10 M. et ft. unguentum. Use : Mildly stimulating and anti-parasitic, in chronic eczema and ring- worm. 103. Unguentum hydrargyri et iodinii. R Unguenti hydrargyri........................ Unguenti iodinii comp....................... Unguenti diachyli (Formula 94) aa § ss........ 15 55 Misce intime. Use : Powerfully stimulant ; to be rubbed well into the skin over syphilitic indurations and bone lesions. 298 R M. MANUAL OF DISEASES OF THE SKIN. 104. Unguentum acidi carbolici. Acidi carbolici, 3 j— 3 ij............. * 29 Glyceriti amyli (Formula 24) (vel unguenti petrolei), § iv......... 124 41 77 et ft, unguentum. Use ; Antipruritic, to be used freely to the body, especially after alkaline baths. 105. Unguentum anti-prut iticum. R 88— 7 77 Gummi camphorae,..;.............. Chloralis hydratis, aa. 3 j— 3 ij....... 'Rub together until a liquid results, then add slowly with friction,.............. Unguenti aquae rosae, § j............. M. et ft. unguentum. Use : Powerfully antipruritic ; if applied where the surface is abraded it causes burning and irritation. 31 R M. 106. Unguentum picis et belladonnes. Unguenti picis liquidae, 3 vj............. Unguenti belladonnae, 3 iv............... Tincturae aconiti, 3 j.................... Zinci oxidi, 3 ij......................... Unguenti aquae rosae, 3 vj................ et ft. unguentum. Use : Powerfully antipruritic ; of especial service in pruritus and eczema of the vulva. 107. Unguentum sulphuris hypochloridi. R Sulphuris hypochloridi, 3 j— 3 ij....... 3 88— 7 Extracti rumicis rad. 3 ij— 3 iv....... 7 77— 15 Unguenti aquae rosae, § j............ 31 10 M. et ft. unguentum. Use : Stimulating and absorbent, in acne indurata. 108. Solutio hydrargyri. R Hydrargyri chloridi corrosivi, gr. iv........... Glycerinae, 3 j. Aquae destillatae, 3 vij. M. Use : For hypodermic injection in syphilis; twelve drops contain one tenth of a grain of mercury. INDEX. Abortion, syphilis a cause of, 127. Abscesses of the skin, 204 (141). Absorption by the skin, 16. Acarus or steatozoon folliculo- rum, 76. Acarus scabiei, 68. Accuracy of diagnosis in skin disease, 2, 34, 35. Achorion Schonleinii, 46, 56. Achroma, or leucoderma, 236. Acne albida, 76. disseminata, 78. indurata, 73, 78, 79. juvenilis, 78. mentagra, 157. molluscum, 73, 76 (247). nigra, 75. papulosa, or simplex, 73, 78. punctata, 73, 75, 76. rosacea, 73, 78, 79 (137, 174. 175)- sebacea cerea, 74. sebacea cornea, 74. sebacea oleosa, 73, 74. simplex, 73, 78. vulgaris, 78. causes of, 13, 80, 81. •diagnosis of, 80 (51, 109, 137, 159. 247)- frequency of, 29, 31. treatment of, 75, 81, 82, 83. Acquired achroma or leucoderma, 236. Adenopathy, 9, 120. Addison's disease, 212, 214. Age, influence of, on the produc- tion of skin diseases, 45. Air, effect of, in eczema, 186. Albinismus, 235. Alopecia, 239-242. areata, 239, 241. furfuracea, 200. •idiopathic, 240. symptomatic, 239. syphilitica, 239. vulgaris, 239. Alphos, 195. Anaesthesia cutis, 90, 99. Anaesthetic leprosy, 260. Analgesia, 99. Analysis of 8000 cases of skin disease, 25. Anatomy of the skin, 4, Angioma, or telangiectasis, 256. Anidrosis, 85. Aniline, dermatitis frdm, 189. Animal parasitic affections, 63. Anthrax, 201, 203. Anus, eczema of the, 180. Aphthous stomatitis, diagnosis from mucous patches, 126. Applications, method of making, in eczema, 186. Area Celsi, 241. Argyria, 214: Arms, eczema of the, 176, 177. Arnica, dermatitis from, 189. Arrectores pilorum, 12, 13. 299 300 TNI Arrectores pilorum, connection with acne, 13. Arsenic, dermatitis from, 189. Artificial eruptions, 72, 189, 191. Atrophia cutis, 237, 238. pilorum propria, 243. senilis, 238. Atrophy of corium, 237. of hair, 238. of nail, 244. of pigment, 235. of skin, 237, 238. Atropine in mercurial salivation, 132. Auditory canal, eczema of the, 174. Avoidance of certain kinds of food in skin disease, 271, 272, 273. Baker's itch, or eczema of the hands, 176. Balanitis, diagnosis from chan- croid, 207 ; from herpes, 152, Baldness, idiopathic, 240. symptomatic, 239. syphilitic, 239. Balnea, 275. Bandage, rubber, in eczema of the legs, 179. Barbadoes leg, 227. Barber's itch, 50. Baths in skin diseases, 276. Baths, mercurial, in syphilis, 130. Baths, Turkish, harm from, 97, 274, 276. Beard, ringworm of the, 50. \ Belladonna eruption, diagnosis from roseola, 139. Belladonna in mercurial saliva- tion, 132. Birth-mark, 256. Black-heads, 75. Black measles, 102 (108, 210): Black small pox, 108, 210. Blanching of the hair, 237. Bleb, 36, 37. Blood-vessels of the skin, 7. Bloody sweat, 210. Body louse, 61. Boils, 201. Breasts, eczema of the, 181. Bricklayer's itch, or eczema of the hands, 176. Broad condyloma, or mucous patches, 125, 222. Bromides, eruption from, 195,267. Bromidrosis, 86. Bronzed-skin disease, 214. Bruises, diagnosis from erythema nodosum, 141. Brushes, tooth, syphilis transmit- ted by, 119. Buboes, 9. Bucnenia tropica, 227. Bullae, 20, 37, 153. Bullous eruptions, 122, 153, 154. Burmese ringworm, 52. Callositas, callus or callosity, 220. Cancer of the skin, 262 (124, 248). Canities, 235, 237. Carbuncle, 203. Carcinoma cutis, 262 (124, 248). Causes of skin diseases, 42. Caustics, 278. Cauterization of chancres, 129. Chafing or intertrigo, 189. Chancre, 118, 120, 129 (207). extra-genital, 119. Chancroid, 118, 207. Chaps or fissures in eczema, 169. Charbon, 133. Cheiro-pompholix, 88, 156, 157. Cheloid, 246. Chicken-pox, in, 112, 113. Chinese ringworm, 52. Chloasma, 212, 213 (31, 61, 125, 213, 216, 236). Choleric roseola, 139. Chromidrosis, 86, 87. INDEX. 301 Chromophytosis, 60. Chylopoietic viscera, importance of attention to in skin diseases, 81. Cicatrical keloid, 246. Cicatrix, 36, 40. Cingulum, 90. Circumcision, syphilis transmitted during, 119. Claret stain, 255. Classification of skin diseases, 18. Clavus, 216, 219. Clothes louse or body louse, 63. Cnidosis, 142. Coffee, effect in skin diseases, 271. Cold sores, 151. Color of skin, 7. Comedo, 75, 76. Condylomata, 125, 222. Confluent small-pox, 108. Congestive seborrhoea, 249. Congestion in eczema, 167. Connective tissue, hypertrophies of, 223. Constipation, 56, 80, 81, 185, 207, 269. Constitutional causes, 43, 44. Contagious impetigo, 161. Copaiba eruption, 121, 139, 191. Corium, 6. atrophy of, 237. Corns, 219. Cornu cutaneum, 216, 218. humanum, 218. Corpuscles, tactile, 8. Cosine's paste, 278. Cb'uperose, 79. Crab louse, 65. Crabs, 65. Cracks, or fissures, 36, 39, 169. Croton oil, dermatitis from, 189. Crusta lactea, or milk crust, 164, 168, 182. Crusts, occurrence of, 35, 38, 168. Crusted ringworm, 56. Cuniculus, the, in scabies, 68, 69. Cutaneous horns, 216, 218. Cuticle, structure of, 7. Cutis anserina, 13. pendula, 229. variegata, 236. vera, 6. Cysts, sebaceous, 77. Dandruff, or dandriff, 74, 200. Dartos of the scrotum, 9. Death from varnishing skin, 14. Debility a cause of baldness, 240. in eczema, 184. Definition of terms, 36. Degeneratio unguium, 244. Demodex folliculorum, 76. Depilation, 50, 55, 59, 60. Depilatories, 232. Derma, 6. Dermatalgia, 90, 98. Dermatitis, 188. calorica, 188. contusiforrrtis, 140. exfoliativa, 193. gangraenosa, 189. medicamentosa, 190. traumatica, 188. venenata, 188, 189. Dermatology, on the study of, 1. relations to medi- cine, 3. Dermatolysis, 223, 229 . Dermatosclerosis, 223. Dermatosyphilis, 120. Desquamative dermatitis, 193. Diagnosis, 32. Diet, definition of the term, 268. errors of, causing skin dis- ease, 81, 97, 267. in eczema, 186, 269. Diphtheritis cutis, 135. Discoloration of the skin, 38, 212. Distribution of eruptions, 33. 302 INDEX. Drinking utensils, syphilis trans- mitted by means of,Ji 19. Dry tetter, 195. Dyes causing eruptions, 189. Dysidrosis, 87, 157, 177. Dyspepsia in skin disease, -82, 184, 240, 269. Dystrophia cutis, 90, 99. Ears, eczema of the, 174. Eating tetter, or lupus, 249. Eating utensils, syphilis trans- mitted by means of, 119. Ecthyma, 157, 162. Ecthyma, syphilitic, 122. Eczema, 164-188, acute, 17c. chronic, 171. dry, 175. erythematosum, 172. fendille, 173. fissum, 171, 173. impetiginosum, 171, 172. infantile, 182, 183. madidans, 168, 171, 173, 178. marginatum, 52, 180. moist, 175. papulosum, 171, 172. pustulosum, 171, 172. rimosum, 171, 173. rubrum, 171, 173. sclerosum, 171, 173. squamosum, 171, 173(74, 168). vesiculosum, 171, 172. causes of, 184, 185. congestion in, 167. cracks of, 169. crusting in, 168. definition of 42, 165. diagnosis of, 174, 175, 176,177, 178, 179, 180 (48, 50, 51, 53, 58, 61, 65, 66,8o, 88,122,123, Eczema, diagnosis of, 126, 136, 141,144, 147, 149,152, 155, 159, !94, 197,207, 210, 217, 228, 250,264). diet in, 269. exudation in, 168, 175. frequency of, 28, 165. infiltration in, 168. itching of, 166, 167. location of, 174, et seq. of the anus and genital region, 180. of the auditory canal, 174. of the breasts, 181. of the eyelids, 174. of the ears, 174. of the face, 174. of the feet and legs, 178. of the hands and arms, 176, 177. of the lips, 174. of the scalp, 174. of the trunk, 181. papules in, 167. pruritus in, 96. stages of, 170. statistics of, 28, 165. thickening in, 168. varieties of, 169, 170. vesicles in, 167. Eggs or nits of pediculi, 64. Elasticity of the hair, 11. Electrolysis, 233, 257. Elephantiasis Arabum, 223, 227. Graecorum,258 (196, 227, 236). Elephant leg, 227. Emplastra, 279. Emplastrum mercuriale, 129, 279. Emunctory function of the skin, 5. Endemic verrugas, 229. Ephelis, 213. Ephidrosis, 84. cruenta, 210. Epidemic roseola, 103. Epidermal hypertrophies, 216. Epidermis, 6. Epilation, 50, 55, 59, 60. Epithelial cancer, 258, 263. Epithelial nests, 264. Epithelioma, 258, 263 (182, 250, 252, 254, 255). Equinia, 134. Errors of diet in eczema, 269. Eruption, definition of, 42. Eruptions, artificial, 72, 189, 191. caused by dyes, 189. feigned, 87, 191. Eruptive fevers, 101. Erysipelas, 135. migrans, 135. vaccinal, 115. bullae in, 155. diagnosis of, 136 (141, 174, 175, 203). Erythema, 138, 139. annulare, 140. iris, 140. marginatum, 140. multiforme, 140, 154. nodosum, 139-141. papulatum, 140. simplex, 139, 140. tuberculatum, 140. vesiculosum, 140. diagnosis of, 141 (105, 121,137, 147, 152,174, 175, 177, 210, 250). varieties of, 139, 140. Erythematous eczema, 171, 172. eruptions, 138. lupus, 249. scrofulide, 249. syphilis, 120. Etiology of skin diseases, 42. Exanthemata, 20, 101. Exanthematous nature of syph- ilis, 117. Excessive sweating, 84, Excoriatio, 36, 39. mx. 303 Excoriations 36, 39, 63. Excretory function of the skin, 5, 15- Exfoliative dermatitis, 193. dermatitis, diagnosis of, 194. External causes of skin diseases, 44- Extra-genital chancres, 119. Exudation in eczema, 167. Exudative affections, 101. Eyelids, eczema of the, 174. Face, eczema of the, 174. Facial herpes, 151. False measles, or rotheln, 103. Family tendencies a cause of skin disease, 44, 45. Farcy, 135. Fatty tissue, new formation of, 248. Favus, 56. diagnosis of, 58, 59 (176, J97). Febrile herpes, 150, 151. Febris urticata, 142. Feet, eczema of the, 178. Feigned eruptions, 87, 191. Females, skin diseases in, 30. Fermented liquors, 271. Fever sores, 151. Fibroma, 245, 246. lipomatodes, 247. Filaria sanguinis, 228. Fish-skin disease, 216. Fissura, 36, 39, 169. Fluxus sebaceus, 73. Folliculitis pilorum, 157. Food in eczema, 269. Fragilitas crinium, 239, 243. Frambcesia, 223, 229. Freckles, 212. Frequency of skin diseases, 25-31. Furfuraceous alopecia, 200. Furrow or cuniculus, 68. 304 INDEX. Furuncular inflammation due to vaccination, 115. Furuncles, 201. Gangrene of the skin, 188, 189. Genital region, eczema of the, 180. German measles, 103. Giant urticaria, 143. Glanders, 134. Glands of the skin, 12, 13, 14. sebaceous, diseases of, 73. sweat, diseases of, 83. Glandular affections, 73. enlargement in syphi- lis, 120. Glassblower's pipe, syphilis trans- mitted on, 119. Glossy skin, 99. Glycerita, 280. Goose skin, 13. Gouty state in skin diseases, 184. Grayness of hair, 237. Grocer's itch, or eczema of the hands, 176. Growth of nails, 15. Grubs, 75. Grutum, 76. Gummy syphilis, 124. Gutta rosea, 79. H^MATIDROSIS, 87, 209, 2IO. 209. purpura, 209, 210. small pox, 108. Hair, atrophy of, 238. elasticity of, 11. follicles, structure of, 10, II. gray, 237. loss of, 239. muscles of, 12. papilla, structure of, 10. structure of, 10, 11. Hairs, number of, 11. Hairy mole, 214, 231, 233. Hands, eczema of, 176, 177. Head louse, 63. Heat eruption, or prickly heat, 146. Hebra's classification of skin dis- eases, 20. Hemiatrophia facialis, 226. Hemorrhagic purpura, 210. small pox, 108. Hereditary syphilis, 117, 127. Herpes, 150. circinatus, 47, 151. facialis, 151. febrilis, 150, 151. generalise febrile, 151. gestationis, 150, 152. iris, 150, 151, 154. labialis, 151. preputialis or progenita- lis, 150, 151, 152. tonsurans, 49. zoster, 90, 150. diagnosis of, 152 (137, 175. 207). Hirsuties, 231. Hives, 142. Honey-combed ringworm, 56. Hordeolum, 201, 204. Horny excrescence, 218. Hydroa, 153 (151, 162). Hydro-adenitis, 204. Hygiene, 273. Hyperaemia, 167. Hyperaesthesia cutis, 90, 98. Hyperidrosis, 84. Hypertrichosis, 231. Hypertrophiae, 212. Hypertrophies of connective tis- sue, 223. of epidermis and papillae, 216. of hair, 231. of nails, 233. of pigment, 212. Hypodermic injections of mercury in syphilis, 131. INDEX. 305 Ichthyosis, 216. hystrix, 217. Idiopathic baldness, 240. Idrosis or hyperidrosis, 84. Ignis sacer or zoster, 90. Impetiginous eczema, 171, 172. Impetigo, 157, 160. contagiosa, 157, 161. syphilitic, 122. diagnosis of, 160 (162, 163). Incubative period of chancre, 118. Individual tendencies, 44, 45. Induration of chancre, 119. Infantile eczema, 182, 183. syphilis, 127. Infiltratio, 39, 168. Inflammatory affections of the skin, 101. Inherited syphilis, 117, 127, 128. Initial lesion of syphilis, 118. Injections, hypodermic, of mer- cury in syphilis, 131. Insensible perspiration, 14. Internal causes of skin diseases, 43- Intertrigo, 189 (53). Inunction, mercurial, in syphilis, 130. Iodide eruption, 191, 267. Iritis, syphilitic, 120. Itch, the, 68. baker's, or eczema of the hands, 176. barber's, 50. bricklayer's, or eczema of the hands, 176. grocer's, or eczema of the hands, 176. washerwoman's, or eczema of the hands, 176. Itching, or pruritus, 94 (70, 96, 166). Ivy, poison, 189. Kelis, 246. Keloid, 245, 246. Keratosis pilaris, 216, 218 (147). Kerion, 50, 51, 55. Kidneys, relation to skin, 15. King's evil, or scrofuloderma, 253. Kiss, syphilis given by, 119. Labial herpes, 151. Land scurvy, or purpura, 209. Lead pencils, syphilis transmittep by, 119. "Leeting" surface, 168. Legs, eczema of, 178. Lentigo, 212. Leontiasis, 258. Lepra, 196, 258. anaesthetica, 260. maculosa, 259. mutilans, 260. tuberculosa, 260. vulgaris, 194. Willani, 194. Leprosy, 258 (226, 236, 261). Leucasmus, acquired, 236. universalis, 235. Leucoderma, 235, 236. diagnosis of, 236(62, 125, 214, 261). Leukoplakia, 126. acquisita, 236. congenital, 235. Lice, body, 63. Lichen, 145.146. agrius, 146. circumscriptus, 146. pilaris, 147, 218. ruber planus, 146. scrofulosus, 147. simplex, 146. syphilitic, 121. tropicus, 146. urticatus, 143, 146, 148. diagnosis of, 147, 148 (7Ti 122,141,177> 194.197.207). 306 INDEX. Liniae albicantes, 238. atrophicae, 238. Lipoma, 248. diagnosis of, 248 (247). Lips, eczema of, 174. Liquor picis alkalinus, 284. Liver spots, 60, 213. Local causes of skin disease, 43. Loss of hair, 239. Lotions, 281. Lousiness, 63. Lues, 117. Lupus, 249. erythematosus, 249. exedens, 251. hypertrophicus, 251. sebaceus, 249. syphiliticus, 123, 124, 251. tuberculosus, 251. vulgaris, 251. diagnosis of, 250 (48, 80, 197, 254, 255, 261, 264). frequency of, 30. Lymphadenie cutanee, 257. Lymphangioma, 257. ' diagnosis of, 248, 257- tuberosum mul- tiplex, 257. Lymphatic new formations, 257. Lymphatics of the skin, 8. Lymph scrotum, 228. Maculae, 20, 36. atrophicae, 238. Macular leprosy, 259. syphilis, 120. Malaria, 97, 143, 184. Males, skin diseases in, 30. Malignant pustule, 133, 134. Matrix of the nail, 15. Measles, 3, 101, 102, 103. black, 108, 210. diagnosis of, 102, 103 (105, 109, 113). Measles, German, 103. Medicinal eruptions, 188, 190. Melanoderma, 212, 213, 216. Melanotic cancer, 262. Mentagra, 157. Mercurial salivation, treatment of, 132. Mercurial vapor baths in syphilis, 130. Mercury, hypodermically, in syph- ilis, 131. in syphilis, 128,130, 131. Method of -applying ointments, 186, 187, 293. Microsporon Audouini, 241. furfur, 60. Miliaria, 89. Milium, 75, 76. Milk crust, 164, 171, 172. in skin disease, 271. Mixtures, 286. ' Mixed treatment in syphilis, 131. Moist eczema, 175. papules or mucous patches, 125, 264. tetter, 164. Mole, hairy, 214, 231, 233. pigmentary, 214, 215. Mollities unguium, 244. Molluscum contagiosum, 76, 77. fibrosum, 246. pendulum, 246. sebaceum, 76, 77. simplex, 246. Morbilli, 101. Morbus Addisonii, 212, 214. pedicularis, 63. Morphcea, diagnosis of, 225, 226 (236, 261). 223, 225. frequency of, 30. Moth patches, or chloasma, 213. Mother's mark, 255, 256. marks, or naevi, 214, 255. Mucous patches, 125. INDEX. 307 Mucous patches, diagnosis of, 126 (152, 175, 181, 222, 264). Multiform eruptions, 164. Muscles of the hair follicles, 12. Muscular fibres of the skin, struc- ture of, 9. Mycosis, 230. fungoi'de, 231. NjEVUS araneus, 256, 257. flammeus or naevus vascu- losus, 255, 256. pigmentosus, 212, 214. pilosus, 214, 231, 233. sanguineus, 255. spilus or naevus pigmen- tosus, 214. vasculosus, 255, 256. verrucosus, 215. Nails, atrophy of, 244. P hypertrophy of, 233. structure of, 14, 15 ■ Neoplasmata, 245. Nerves, new formations of, 258. of the skin, 8. Nesselsucht, 142. Nettle rash, 142. Neuroma cutis, 258. Neuroses, 90. New formations, 245. Nitrate of silver discoloration, 214. Nits of pediculi, 64, 65. Nodes, syphilitic, diagnosis from erythema, 141. Noli me tangere, 251, 264. Nomenclature of skin diseases, 18. Non-parasitic sycosis, 157 (l75)- Number of hairs, 11. Nursing, syphilis communicated by, 119. OAK, poison, 189. Occupation, influence of, in the production of skin diseases, 45, 274. Oily seborrhcea, 73. Ointments, 293. mode of applying in eczema, 186, 187. Onychatrophia, 244. Onychauxis, 234. Onychia, 205, 206. Onycho-gryphosis, 234. Onycho-mycosis, 205. Osmidrosis, 86. Pachydermia, 227. Pacinian corpuscles, or tactile cor- puscles, 8. " Paget's disease," 182. Painful subcutaneous tubercle, 258 Palmar syphilis, 126. Panniculus adiposus, 6. Papilla, hair, structure of, 10. Papillary layer of the skin, 6. hypertrophies, 216. Papular eruptions, 145. Papule, 20, 37. moist, or mucous patch, 125- Parasitic diseases, 46-72. sycosis, 50 (51, 157)- sycosis, diagnosis of, 175. Parchment skin, xeroderma, or ichthyosis, 216. Pars papillaris, 6. Patches, mucous, 125 (264). Pediculosis, 63. Pelade, 241. Peliosis rheumatica, 210. Pencils, syphilis transmitted by, 119. Pemphigus, 153, T54- cacheticus, 155- foliaceus, 154. gangraenosus, 155- malignus, 155- pruriginosus, 155 • syphiliticus, 122, 128. 308 INDEX. Pemphigus vulgaris, 154. diagnosis of, 155 (194, 261). frequency of, 30. Perspiration, insensible, 14. Phlegmonous eruptions, 201. Phthiriasis, 63. capitis, 64. corporis, 63. pubis, 65. diagnosis of, 65, 66, 67, 68(70, 160, 175, 180). frequency of, 29. Phyma, 36, 38. Physiology of the skin, 15. Pian, 229. Piebald skin, 236. Pigmentary atrophies, 235. hypertrophies, 212. mole, 214, 215. naevus, 212, 214. syphiloderm, 124,125. Pigment of the skin, 7. Pills, 289.. Pimples of acne, 78. "Pitting" of small-pox, treat- ment of, no. Pityriasis, 74. capitis, 193, 200. maculata et circinata, 104. pilaris, 218. rubra, 182, 193, 217. versicolor, 60. diagnosis of, 197 (51, 74, 176, 182, 217). Plantar syphilis, 126. Plaques muqueuses, 125. Plasters, 279. Pointed condyloma, 222. Poison ivy, 189. oak, 189. sumac, 189. Polytrichia, 231. Pompholix, 156 (88, 153). Pomphus, 36, 37. Porcupine men, 217. Porrigo, 162. decalvans, 241. favosa, 56. Port wine marks, 255. Powders, 290. Pox, 117. Predisposition to skin affections, 45- Pregnancy, influence on the skin, 44. 239. Preputial, or progenital herpes, I5L Prickly heat, 146. Primary lesion of syphilis. 120. lesions of the skin, 35. Prurigo, 145, 148. podicis, 148, 180. scroti, 148, 180. diagnosis of, 66, 149. pruritus in, 96. Pruritus, 90, 94 (66, 148). ani, 95. hiemalis, 95. scroti, 95. senilis, 95. vulvae, 95. diagnosis of, 96 (66, 71). Psoriasis, 74, 193, 194. aggregata, 196. buccalis, 126. circinata, 196. diffusa, 196. gyrata, 196. inveterata, 196. nummularis, 196. orbicularis, 196. punctata, 196. syphilitica, 126. diagnosis of, 197 (48, 5o, 51, 59, 65, 66, 74, 122, 126, 147, 176,177, 182,194, 197, 207,250). Psoriasis, frequency of, 30. pruritus in, 96. Purples, 209. Purpura, 209. hemorraghica, 209, 210. rheumatica, 209, 210. simplex, 209. variolosa, 210. frequency of, 30, Pustulae, 20, 36, 37. Pustula maligna, 133. Pustular eczema, 175. Quantity of fluid daily excreted by the skin, 14. Quinine eruption, 190, 267. Recurrent exfoliative dermatitis, 194. Red gum, or lichen simplex, 146. Removal of superfluous hairs, 232. Rete malpighii, 7. mucosum, 7. Rhagades or fissures, 36, 39. Rheumatic purpura, 209, 210. Rhinoscleroma, 249, 255. Rhus toxicodendron, 189. venenata, 189. Ringworm, 47. Burmese, 52. crusted, 56. honeycombed, 56. Tokelau, 52. diagnosis of, 48, 5i. 53- frequency of, 29. Rodent ulcer, 263. Rosacea, 257. Roseola, 138. aestiva, 139. annulata, 139. autumnalis, 139. cholerica, 139. epidemic, 103. infantilis, 139. LX. 309 Roseola, syphilitic, 120, 139. vaccinia, 139. variolosa, 139. diagnosis of, 139. Rose rash, or roseola, 139. Rotheln, 103 (121). Rougeole, 101. Rubber bandage in eczema of the legs, 179. Rubeola, 101. diagnosis of, 102, 103, (121). Running tetter, or eczema, 164. Rupia, syphilitic, 123. Salicylic acid, eruption from, 190. Salivation, treatment of mercurial, 132. Salt rheum, 164. Sapo viridis, 284. Sarcoma cutis, 258, 265. Sarcoptes scabiei, 68. Scabies, 68. diagnosis of, 70 (66, 88, 144,147, 149, 160, 163, I77> I79, 181, 182, 207). frequency of, 30. over-treated, 72. Scale, 36, 38. Scall, 164. Scalled head, or milk crust, 164. Scalp, eczema of, 174- 1, Scaly tetter, 195. Scarf skin, structure of, 7. Scar, 36, 39. Scarlatina, 3, 104. Scleroma, 223. neonatorum, 223, 227. Scleriasis, 223. Scleroderma, 223. diagnosis of, 224 (177, 225, 226, 261, 263). frequency of, 30. 310 INDEX. Scorbutus, 209, 211. diagnosis from pur- pura, 210. Scratching, causing skin lesions, 63, 69, 167. Scrofulide erythemateuse, 249. tuberculeuse, 251. Scrofuloderma, 249, 253. Scurvy, 211. land, 209. Sebaceous cysts, 77. glands, anatomy of, n. glands, diseases of, 73. glands, secretion from, 12. Sebiparous glands, n, 12. Seborrhagia, 73. Seborrhcea, 73, 200. congestiv'a, 249. diagnosis of, 73, 74 "(50, 51, 62, 176, 197, 250, 264). Sebum, 12. Secondary lesions, 35. Segars, syphilis transmitted by, 119. Senile atrophy of the skin, 238. Sex in skin diseases, 30, 45. Shingles, 90. frequency of, 30. Skin, anatomy of, 5. atrophy of, 237, 238. grafting and syphilis, 119. diseases, analysis of 8,000 ■ cases of, 125. Small-pox, 107. Spargosis or.elephantiasis Arabum, 227, 260. Spiritus saponis kalinus, 284. Spitze condylom, 222. Spots or macules, 36. Squamae, 20, 35, 38. Squamous eruptions, 193. Stains, 36, 38. St. Anthony's fire : term applied I to erysipelas, 135, and herpes, 150. Starch, iodide of, in syphilis, 132. Statistics of 8000 cases of skin dis- ease, 25. Steatorrhoea, 73. Steatozoon folliculorum, 76. Stimulants in skin disease, 271. Sterility caused by syphilis, 127. Striae atrophicae, 238. Strophulus albidus, 76. prurigineux, 149. Struma, 253. Structure of the skin, 5, 6. Styes, 204. Subcutaneous connective tissue, 6. painful tubercle,258. Sudamina, 89. Sudoriparous glands, 13. Sumac, poison, 189. Sunburn, 213. Superfluous hairs, 231. Supra-renal melasma, 214. Sweat, bloody, 87, 211. glands, action of, 14. glands, anatomy of, 13. glands, diseases of, 83. glands, number of, 13, 14. Sweating excessive, 84. colored, 86, 87 offensive, 86. Sycosis, 157. parasitica, 50. diagnosis of, 159 (51, 175)- Symptoms in diagnosis, 32. Syphilis, 117. vaccinal, 114. diagnosis of, 121, 126 (48, 50, 51, 58, 65, 66, 80, 139, 147, 159, 160, 163, 174,176,177, 179, 181, 182, 202,210, 214, 230,236,250, 254, 255, 261, 264). INDEX. 3H Syphilis, exanthematous nature oi "?• Syphilis, frequency of, 29. initial lesion of, 118. length of treatment of, 132. modes of transmission of, 117, 119. Syphilitic alopecia, 239. gumma, diagnosis from lipomata, 248. lupus, 123, 124, 251. mucous patches, diag- nosis from eczema, I75-. onychia, 206. roseola, 120, 139. Syphiloma, 124. Tactile corpuscles, 8. Tar wash, alkaline, 284. Tattooing, syphilis conveyed by, 119. Tea in skin disease, 271. Telangiectasis, 256. Tetter, dry or scaly, 195. Tetter, moist, 164. Therapeutics of skin diseases, 275- Thickening, or infiltration, 36, 39, 168. Tinctura, or stain, 36, 38. Tinea barbae, 50. capitis, 49. circinata, 47. corporis, 47. cruris, 51. decalvans, 241. favosa, 56. furfuracea, 60. kerion, 50, 51. sycosis, 50. tondens, 49. tonsurans, 49. trichophytina, 47. 5°' Tinea unguium, or onychomyco- sis, 2051 versicolor, 60. diagnosis of, 48, 50, 51, 53, 58, 59, 61 (175, 176, 180, 182, 194, 197, 242). Tissue, adipose, 6. Tokelau ringworm, 52. Tooth brushes, syphilis transmit- ted by, 119. Toys, syphilis transmitted by, "9- Transmission of syphilis, modes of. 117, 119. Trichauxis, 231. Trichophyton tonsurans, 29, 46. Trichophytosis, 49. Trichorexis nodosa, 239, 243. Trichorrhcea, 239. Trophic nerves of the skin, 8. Tubercle, subcutaneous painful, 258. Tubercula, 36, 38. Tubercular leprosy, 260. Tumor, 36, 38. Tyloma, 220. Tylosis, 216, 219, 220. Ulcer, 36, 40, 205, 206. rodent, 263. Ulcus, simplex, 206. venereum, 207. Unilateral atrophy of the face, 226. Urticaria, 138, 142. acute, 143. chronic, 143. bullosa, 154. papulosa, 143. pigmentosa, 144. tuberosa, 143. diagnosis of, 144 (71, 121, 141, 147, 149)- frequency of, 30. 312 INDEX. Vaccinal erysipelas, 115. roseola, 139. syphilis, 114. Vaccination, 113. safety of, 113-116. syphilis communi- cated by, 119. furuncular inflamma- tion due to, 115. Vaccinia, 113. Vapor baths, mercurial, in syphi- lis, 130. baths, when harmful, 276. Varicella, in. Variola, 107. maligna, 108. modificata, 108. Variolous purpura, 210. roseola, 139. Vaso-motor nerves of the skin, 8. Vegetable parasites, 2. Vegetations, 222 (126). Venereal ulcer, 207. warts, 222 (126). Verruca, 216, 221. acuminata, 221, 222. necrogenica, 221, 222. senilis, 221. vulgaris, 221. Verrugas, endemic, 229. Versicolor, pityriasis or tinea, 60. Vesicula, 20, 36, 37. Vitiligo, 236. Vitiligoidea, 247. Vlemingkx' solution, 283. Warts, 221, 222. Washerwoman's itch, or eczema of the hands, 176. Water, effect of, in eczema, 186. in skin disease, 275. Watering or " leeting " surface in eczema, 168. Wens, 77. Wheal, 36, 37. Wilkinson's ointment, 297. Xanthelasmoidea, 144. Xanthoma, 245, 247. multiplex, 248. planum, 247. tuberosum, 247. Xeroderma, 85, 86, 217. Yaws, 229. Zona, 90, 150. Zoster, 90. frequency of, 30. BULKLEY. Archives of Dermatology. A Quarterly Journal of Skin and Venereal Dis- eases. Edited by L." Duncan Bulkley, A.M., M.D., Attending Physician for Skin and Venereal Diseases at the New York Hospital, Out-Patient Department; late Physi- cian to the Skin Department, Demilt Dispensary, New York, etc. Price, per year, $4.00 ; specimen copies, $1.00 The aim of the Archives of Dermatology has been and shall still be to meet the wants of the general prac- titioner, and to serve as a communication between the specialist, whose entire attention is devoted to skin and venereal diseases, and those in general practice, that the daily-gained experience of the latter may reach the former. The Archives of Dermatology is now the only Sci- entific Journal published in the English language devoted exclusively to skin and venereal diseases, and is of service to every practitioner. With a view of furnishing simple matter in each issue of immediate practical advantage to the general prac- titioner, the editor will endeavor, as space permits, to give, as in the past, plain comments on common diseases of the skin in the form of serial articles. The digest department will continue, as before, to epitomize the current literature of the day by means of the able staff of collaborators, who have already so faith- fully and earnestly aided the Journal. opinions of the "ARCHIVES." " This journal, under Dr. Bulkley's management, continues .to be conducted with much spirit. It contains not only original papers which represent most of the dermatological work done in the States, but excellent abstracts of all Eu- ropean work in this department."—London Practitioner. " In every sense a credit to American literature."—Medical Record. " ' The Archives of Dermatology' is not only the only journal in the English language devoted to the specialty of skin diseases, but, it may be safely said, is unequalled by any similar journal, French, Italian, or German. The num- bers before us present an excellent example of a journal which, while contain- ing scientific matter for the specialist, also furnishes practical information for the general practitioner. Here the practitioner may find what it is impossible to get in any text-book,—from the circumstances of the case,—a varied armory, from which he can draw weapons for every emergency. We can cordially recommend this journal to the general reader as a special journal which is not for specialists only."—Philadelphia Medical Times. G. P. PUTNAM'S SONS, Publishers, New York. BULKLEY. Eczema and its Management. A Practical Treatise Based on the Analysis of Two Thousand Five Hundred Cases of the Disease. By L. Duncan Bulkley, A.M., M.D., Physician for Skin and Venereal Diseases at the New York Hospital, Out- Patient Department, etc. Price, . . . $3 00 " The whole work is fascinatingly interesting, and we recommend it to the general practitioner, for whom it is chiefly written, as a most valuable guide to the intelligent treatment of one of the most fre- quent as well as troublesome of skin affections. * * * In regard to treatment, he enters most minutely into details. * * * The chapter on diet and hygiene is equally comprehensive. A formulary is also appended."—Philadelphia Medical and Surgical Reporter. " Every general practitioner should read this book, that he may know how to cure eczema."—American Specialist. " The book is a clear guide. It is practical, simple, direct in style, logical in arrangements, and exhaustive in the treatment of the subjects. It cannot fail to extend the reputation of its distinguished author."—Philadelphia Medical Times. " In every sense it is a good book, worthy of the most careful study by every member of the profession, general practitioner or specialist." —Detroit Lancet. '' This book is one of the most valuable contributions to medical science which has been made within a decade."—Medical Herald, Louisville. " A work which, in good faith, teaches the physician of average intelligence how to bring such cases to a successful issue. * * * Any physician who sees one case of eczema per annum can afford to buy and study this valuable book. It is a model of what a medical monograph should be, uniting the thoroughness of the German in- vestigator with the practical acumen of the American practitioner." —St. Louis Clinical Record. G. P. PUTNAM'S SONS, Publishers, New York. ^JAl LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY C )NAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY C ✓^1 M^ \ LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF Mi NLM005763239