■U^U-i LTH PRIMERS. KEEN, M.D., N L N 0057b 3 C J . }£^tans 0f Philadelphia ; Surgeon to St. Mary's Hospital, etc. of Medical and Hygienic SdQr—■ Th This series of American Health^ s is prepared to diffuse as widely and cheaply as possible, am^ all classes, a knowledge of the elementary facts of Preventive Medicine, and the bearings and applications of the latest and best researches in every branch ided (save eople how yes, etc. h especial 2s of Life; tions. srtance in consistent it, is fully nderstood and func- jeneral or in a compact torm and at a low price, reliable guides for the prevention of disease and the preservation of both body and mind in a healthy state. The authors have been selected with great care, and on account of special fitness, each for his subject, by reason of its previous careful study, either privately or as public teachers. Dr. W. W. Keen has undertaken the supervision of the Series as Editor; but it will be understood that he is not responsible for the statements or opinions of the individual authors. NLM005763270 Each Book is sold separately, neatly bound in Cloth. Price, 50 cents, or Subscriptions will be received for the Series of Twelve Volumes. —fJl. Hearing, and How to Keep It, By CHAS. H. BURNETT, M.D., of Philadelphia, Consulting Aurist to the Pennsylvania Institution for the Deaf and Dumb, Aurist to the Presbyterian Hospital, etc. -ji II. Long Life, and How to Reach It, By J. G. RICHARDSON, M.D., of Philadelphia, Professor of Hygi 4he University of Pennsylvania, etc. III. The Summc its Diseases, By JAMES C. N, M.D., of Philadelphia, Lecturer on Physical _ .a nosis in Jefferson Medical College, etc. IV. Eyesight, and How to Care for It, By GEORGE C. HARLAN, M.D., of Philadelphia, Surgeon to the Wills (Eye) Hospital. V. The Throat and the Voice, By J. SOLIS COHEN, M.D., of Philadelphia, Lecturer on Diseases of the Throat in Jefferson Medical College. VI. The Winter and its Dangers, By HAMILTON OSGOOD, M.D., of Boston, Editorial Staff Boston Medical and Surgical Journal. —J VII. The Mouth and the Teeth, By J. W. WHITE, M.D., D.D.S., of Philadelphia, Editor of the Dental Cosmos. VIM. Brain-Work and Overwork, By H, C. WOOD, Jr., M.D., of Philadelphia, Clinical Professor of Nervous Diseases in the University of Pennsylvania, etc. Jj IX. Our Homes, By HENRY HARTSHORNE, M.D., of Philadelphia, Formerly Professor of Hygiene in the University of Pennsylvania. -4i X. The Skin in Health and Disease, By L. D. BULKLEY, M.D., of New York, Physician to the Skin Department of the Demilt Dispensary and of the New York Hospital. ■4 •Jl XI. Sea-Air and Sea-Bathing, By JOHN H. PACKARD, M.D., of Philadelphi Surgeon to the Episcopal Hospital. XII. School and Industrial Hygiene, D., of Boston, Mass. »>«nerican Social Scienc _AKISTON, Publisher, Phila. By D. F. LINCOLN, M.D., of Boston, Mass., Che' "'" . • -■■ ■■« x-merican Social Science Association. / V z. \ ^ OToit J AMERICAN HEALTH PRIMERS. EDITED BY W. W. KEEN, M.D., Fellow of the College of Physicians of Philadelphia, and Surgeon to St. Mary's Hospital. 4* AMERICAN HEALTH PRIMERS. THE J (J a SKIN HEALTH and DISEASE. BY L. DUNCAN BULKLEY, M.D., 'it Attending Physician for Skin and Venereal Diseases at the New York Hospital, Out-Patient Department; Late Physician to the Skin Department, Demilt Dispensary, New York, etc. o*K PHILADELPHIA: PRESLEY BLAKISTON, IOI2 WALNUT STREET. I 880. cXyw>^ B 934-4 I880 Copyright. PRESLEY BLAKISTON. 1880. PREFATORY NOTE. The writer has endeavored to make this Health Primer serve both as a guide for the preservation of the health of the skin, and as a popular dictionary or encyclopedia in matters pertaining to Dermatology. He has therefore sought to introduce in its pages not only the medical terms used in reference to Dis- eases of the Skin, but also the popular names given, both those which are rightly and those which are wrongly applied. If, therefore, information be sought in reference to any particular matter, it will be well to consult first the index, which has been made par- ticularly full. It is hoped that this little book may be of much service in clearing up this vexed subject in the popu- lar mind, and that by its means disease may be avoided, or, when present, that it may be recognized and proper aid sought for and applied. I* Y CONTENTS. CHAPTER I. PAGE Anatomy and Physiology of the Skin . . 7 CHAPTER II. The Care of the Skin in Health . . .34 CHAPTER III. Diseases of the Skin......45 CHAPTER IV. Diet and Hygiene in Diseases of the Skin . 134 Index.........143 vi THE SKIN IN HEALTH AND DISEASE. CHAPTER I. ANATOMY AND PHYSIOLOGY OF THE SKIN. THE object of the present little book is fourfold; first, to correct certain popular prejudices in re- gard to the subject of diseases of the skin ; second, to give directions in regard to the care of the skin in health and for the prevention of disease; third, to afford a certain amount of popular information as to the principal diseases which affect the skin, their re- cognition and home management; and, lastly, to give directions whereby the patient may assist the practitioner in the cure of this class of diseases by his diet, hygiene, and mode of life, together with the manner he should himself treat the diseased portions. These points will best be considered more or less conjointly; and we will therefore divide our subject into two main parts, as indicated in the title. First, treating of the skin in health, its functions, and the care to be given it; and, second, the diseases to which it is liable, their recognition and management. In order to properly understand what is to follow, a 7 8 THE SKIN IN HEALTH AND DISEASE. brief exposition of the skin, in its physiology and anatomy, will be necessary. The skin is the largest single excretory organ of the body, and upon the proper performance of its functions depends, to a large degree, the health of the individual. The skin is generally spoken of as simply a covering for the rest of the body, an outer garment of tissue which serves to enclose and protect the parts within, to give symmetry, shape, and beauty to the human form. While it fulfils these ends in a marvellously perfect manner, it has functions which are peculiar to itself, and which it performs with as wonderfully satisfactory results as those executed by other organs of the body which receive more credit for their work. To fulfil its many duties, the skin is composed of very many different elements, all united in a harmo- nious structure, and thus constituting one vast organ, which, by its constant repair from within, resists the many agencies which constantly tend to destroy its integrity. To appreciate this latter remark, let any one note the injuries done to a kid glove when ex- posed as in a fall, and compare with it the power of the human skin in resisting and repairing injuries. The skin may be roughly divided into two general portions,— the deeper, called the corium, cutis vera, true skin, or derma, and the outer, cuticle, scarfskin, or epidermis (Greek, irti, upon, and Sipfia, skin). The inner, or deeper portion, which forms the largest mass of the skin, is composed of firm and elastic connective tissue-fibres, which interlace so as to form a structure resembling felt, which is extremely tough, and yet so elastic as to yield to every movement, and to regain its former position and state with a perfection which STRUCTURE OF THE SKIN. could not be excelled. The extent of this suppleness can be best appreciated when the skin becomes altered by disease, as is not at all uncommon when, in certain Fig. i. Section perpendicularly through the healthy Skin. a, Epidermis, or scarfskin; b, Rete mucosum, or rete malpighii ; c, Papil- lary layer ; d, Derma, corium, or true skin ; e, Panniculus adiposus, or fatty tissue ; f, g, h, Sweat gland and duct; i, k, Hair, with its follicle and papilla ; /, Sebaceous gland. 10 THE SKIN IN HEALTH AND DISEASE. cases, it is what is called hide-bound, as in sclero- derma, or when such an affection as eczema has so changed its state that every movement at an affected joint will cause deep and painful cracks or fissures. At its under surface the meshes of the corium be- come larger and larger, until we reach what is called the subcutaneous cellular tissue, which is very loose, and connects the skin" with the parts below; and it is this which permits so much motion. This subcu- taneous cellular tissue, in some parts of the body, is filled with fat, and forms the panniculus adiposus ; and it is here that most of the fat in corpulence is depos- ited. It is this tissue, also, which becomes filled with water in dropsy. The outer surface of the corium is not even and smooth, but is thrown into multitudes of elevations called papilla, and this portion takes the name of pars papillaris, or papillary layer of the skin. These minute elevations, or papillae, are exceedingly numerous, in some parts of the body there being as many as four hundred on every square line of the sur- face, that is, on each space a twelfth of an inch square. It is this corium, derma, or true skin, which makes the mass of the leather'used in commerce, where it is seen to vary from the most delicate kid to the coarse sole-leather, in which latter the separate fibres are readily seen with the naked eye. In this deeper skin are situated the organs of which we shall speak later, the sweat and sebaceous glands, the hairs, as also the nerves, blood-vessels, and absorbents or lymphatics of the skin. The outer layer of the skin, the epidermis, cuticle, or scarfskin, is not composed at all of fibres, but, on the contrary, of separate roundish elements called cells. These, of course, cannot interlace, as do the STRUCTURE OF THE SKIN: EPIDERMIS. II fibres of the corium, but are piled upon each other in layers to a varying extent in different parts of the body. Thus, upon the soles of the feet the epidermis may attain great thickness; also upon the palms, or wherever friction calls for more protection of the soft parts beneath; whereas on the face this layer is very thin. The epidermis, outer, or scarfskin, is also divided into two portions,— the outer, in which the scales are all flat, hard, horny, and lifeless, only waiting to be thrown off or removed by friction, and a deeper por- tion, in which the cells are round or many-sided, are soft and moist, are in fact growing and developing to replace those removed externally. This deeper, moist, or succulent part, which dips down between all the pa- pilla of the corium, has received the name of rete mu- cosum, or rete malpighii, from the name of the anato- mist Malpighi, who first described it. It is this epi- dermal layer which is removed by a blister, and which is frequently rubbed off in slight accidents, when the surface beneath feels raw and oozes a little clear liquid, or possibly a little blood. As long as accident or disease destroys only this outer epidermal layer, no scar is produced; but when in any way the corium, or true skin, is destroyed, a scar or cicatrix results, varying in severity according to the depth of the de- struction. Thus, many slight burns remove the epi- dermis only; whereas, those which are followed by any loss of skin, or ulceration, will leave scars which may prove very unsightly. It is this epidermis which forms the covering of many eruptions on the skin, as in the water-blisters of "cold-sores," "shingles," and chicken-pox. It is also raised in little vesicles, or water-blisters, in 12 THE SKIN IN HEAL TH AND DISEASE. eczema; and later in this disease the epidermis is largely removed, and we have a surface which is raw and weeping, but one which, however sore, always heals without a scar, because only the epidermal layer is destroyed. Many skin diseases affect this outer layer alone—as some of the parasitic diseases, those due to derangements of color, etc.; while many others are located in the true skin, or derma; of these lat- ter, some are destructive, and leave scars; others are entirely removable by absorption, and leave no traces of their existence. The color of the skin depends upon this outer or epidermal layer. If it were entirely removed, the surface would be of almost a blood-red color, owing to the abundant blood-vessels found everywhere in the corium. Where the epidermis is thickest, as upon the palms and soles, we lose almost entirely the red, and have a yellowish-gray tint; where it is thinner, we have the well-known pinkish flesh-color, and when a part becomes unusually flushed with blood, as in inflammation, and also in blushing, the red color pre- dominates, the filled blood-vessels showing through the epidermis. In the negro, the dark hue of the skin is due to the presence of a pigment, or coloring matter, in the lower layers of cells of the epidermis, that is, in the rete mu- cosum, the part directly above the papillge of the true skin. The corium, or true skin, which is made up of fibres, does not share at all in this pigmentation.' When there are discolored marks on the skin, as in freckles, moth-patches on the face, etc., the color de- posit takes place in this deeper layer of the epidermis; hence, they are very difficult of removal, because, in order to take away all the coloring matter at once, STRUCTURE OF THE SKIN: BLOOD-VESSELS. 13 this portion of the skin would have to be removed down to the papillae, as in the case of a blister. Now, this is painful and troublesome; and, moreover, expe- rience shows that it would be useless to blister off such deformities, because we not unfrequently see blisters on different portions of the body actually fol- lowed by staining of the skin, where no such staining existed previously. We can, however, not unfre- quently, by proper stimulants, induce an absorption of the pigment, or produce rapid change in the skin, when the new-formed cells will not have the color. Returning now to the corium, or true skin, we find in it a number of elements which should be under- stood. The blood supply to the skin is very abundant, as may be judged from the fact that even a fine needle cannot be introduced into it without drawing blood from some capillary or delicate blood-vessel. At the upper or outer portion of the corium the blood-vessels, or arteries, which have become exceedingly fine and delicate (and are called capillaries, from the Latin capillus, a hair, so very minute are they), rise into each one of the many papilla, or elevations of the papillary layer, and doubling upon themselves they descend again, and become veins, and finally enter into the larger veins, whereby the blood is carried again to the heart and the lungs to be purified. The outer or epidermal layer contains no blood-vessels, its cells are nourished indirectly from the portions be- neath. Hence, we do not draw blood by a blister, or when the skin is lightly scraped or rubbed off; it is only when we reach the deeper layer, or corium, and wound it, that we obtain blood. The nerves of the skin are a very important ele- 2 14 THE SKIN IN HEALTH AND DISEASE. ment, and the abundance of their distribution may be also judged from the pain caused by the entrance of a pin, or even the penetration of the minute sting of an insect. This very abundant nerve supply of the skin, which is undoubtedly for the purpose of protect- ing us against injury, is accomplished by the most delicate division and distribution of the nerves, until their extremities are lost among the deeper cells of the epidermis. It is exceedingly difficult to trace these nerve-fibres, and this has only been accomplished quite recently by means of staining the sections of the skin with chloride of gold. This kind of nerve gives ordinary sensation of pain, heat, and cold, etc.; but there is a somewhat different class or arrangement of nerves, whose function is to preside over the special sense of touch. These end differently; they enter the papilla of the corium, and appear to be wound up into a little knot. These little knot-like bodies are called tactile corpuscles, because the sense of touch is supposed to reside in them. They are always found on the palmar ends of the fingers, and are most nu- merous there, but are present to a lesser degree over most of the surface. They are found in about one out of every four papilla. There are two varieties of glands contained in the skin,— the one for the secretion of sweat, called the sudoriparous, or sweat glands, and the other for the secretion of an oily or greasy substance called sebum, these latter glands receiving the name of sebaceous or sebiparous glands. The sweat glands are in the form of minute tubes of about 4^ of an inch in diameter, which are twisted into coils at the very deepest portion of the corium, or true skin, or even in the subcutaneous tissue, and STRUCTURE OF THE SKIN: SWEAT GLANDS. 15 then extend through the entire thickness of the skin, and open on the surface; as the tube or duct passes through the epider- mis, it makes a num- ber of spiral turns, like a corkscrew. The openings of the sweat glands are arranged somewhat regularly, and may be seen with a magnifying-glass, es- pecially on the palms of the hands, in rows between the slightly elevated ridges of the skin. (See Fig. 3.) These glands are very numerous in some parts; on the sole of the foot and palm of the hand there being about 2700 in each square inch, while on the cheeks there are but about 550 in the same space, and on the forehead about 1250. According to careful computation, the total number of sweat glands in the body amounts to al- most 2,400,000; and as each little gland, Sweat Glands from the Palm of the Hand. Magnified twenty times. 1. Horny layer of epidermis. 2. Rete mu- cosum. 3. Papillary layer. 4. Derma, or true skin. 5. Subcutaneous cellular tissue. 6, 8, 9. Sudoriparous or sweat glands. 16 THE SKIN IN HEALTH AND DISEASE. when its coil is unravelled, would measure about -^ of an inch, their entire length amounts to not less than 153,000 inches, or about two and a half miles. We can readily understand, therefore, the very Fig- 3. Openings of the Sweat Glands on the Palm of the Hand. Magni- fied four times. 1. Openings of glands. 2. Furrows be- tween the lines of openings. great importance of the skin as a secre- tory organ, when we consider the vast surface thus present- ed ; and direct ex- periments fully con- firm the judgment thus formed. The action of these minute glands is not intermittent, but continuous; and during the entire time sweat is ex- haled in the form of vapor, or insen- sible perspiration ; and only when the body becomes much heated, as by exercise or otherwise, does the perspira- tion manifest itself to the eye or touch. The total quantity of fluid thus given off by the skin is subject to the greatest variations, according to temperature, moisture, exercise, quantity and quality of food and drink taken, etc. In the average person in health, however, careful experimenters agree in placing the amount at about two pounds, or pints, daily, a quan- tity almost equal to that excreted by the kidneys. The office of this cutaneous perspiration is largely STRUCTURE OF THE SKIN: SWEAT GLANDS. IJ to regulate the temperature of the body by the evapo- ration from the surface; the cooling effect of fanning results from the evaporation of the moisture on the skin. The more violent efforts of the skin to reduce temperature are seen naturally in warm weather, or artificially in the Russian, or Turkish hot-air bath, when, as the body becomes more and more heated, the glands secrete more and more profusely. All know that if one sweating profusely gets in a draught of air, great cooling will result. It can be readily understood how, with this vast secreting surface exposed to the changes of the at- mosphere, we can readily " catch cold" from chilling the surface in a draught, or from exposure too thinly clad, and by a "check of perspiration" cause con- gestion of internal organs. When animals are com- pletely covered with an impermeable coating, as by varnishing the surface, 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. The importance, therefore, of the proper care of the skin can hardly be over-estimated, that these many pores through which this vast amount of fluid passes out of the system may not be clogged. Proper bathing and friction are all-essential elements of a healthy skin, and a perfectly active skin means a great deal towards a perfectly active general sys- tem. Besides the sudiparous or sweat glands, we have an- other glandular apparatus, situated in the skin, which is of especial importance, particularly as one of the most common and annoying of skin diseases, acne, 2* B 18 THE SKIN IN HEALTH AND DISEASE. has its seat in them; these are the sebaceous or sebi- parous glands. While the sweat glands are composed of a single tube coiled upon itself at its lower extremity, which is situated in the very deepest portions of the skin, the sebaceous glands are rarely, if ever, formed of a single tube, but have a duct, more or less straight, with a mass of glands grouped about its deeper end, form- ing what is known as a racemose gland, from the resemblance to a cluster of grapes (Latin, racemus). The sebaceous glands are almost invariably con- nected with the hairs; upon hairy parts, as the scalp, Large Sebaceous Gland. nified. Greatly mag- i. Hair in its follicle. 2.3,4,5. Lobules of the thpvfnrmnnnpnrl gland. 6. Excretory duct traversed by the hair. * lurillcippenu- ages at the sides of the hairs, and their ducts open into the hair fol- licles. Generally, there are two to each hair, situ- ated opposite each other; but in some situations large hairs have a number, even from four to eight, situated around them, forming a sort of collar about the hair. In some situations, on the other hand, as on the STRUCTURE OF SKIN: SEBACEOUS GLANDS. 19 Fig. 5- smooth face, nose, forehead, etc., the hairs are very small and rudimentary, while the sebaceous glands are large, and the hair there appears as an appendage at the side of the comparatively large gland. Very few of the glands open directly on the skin without a connection with a hair, although this latter may sometimes be so small as to escape ordinary observation. These sebaceous glands are very minute affairs, having a diameter from one one-hundred-and-twen- tieth up to one-twelfth of an inch, as in some on the nose and else- where. They are also short com- pared to the sweat glands. The secretion from these glands is of an oily nature, and, when in a healthy condition, is perfectly fluid at the temperature of the body. The quantity is not very great, and the main function of the secretion appears to be to keep the skin in a flexible state, though the amount of solid matter thrown off thus must be of some importance in the economy. When there is disorder of these glands, we have, as mentioned before, acne, and also one of the various forms of dandruff, or seborrhoea, and comedo, or what are popularly known as flesh-worms, etc. Under cer- tain circumstances they fail to act, more or less, and we have a hard, dry skin, xeroderma. In the proper care of the skin, the oily products of these glands, which adhere to it with the dead epidermal matter, are removed continually; whereas, neglect allows all Sebaceous Gland, with a small hair at- tached. Greatly mag- nified. 1. Hair. 2. Sebaceous gland. 20 THE SKIN IN HEALTH AND DISEASE. this to accumulate, the openings of the sebaceous, as well as those of the sweat, glands are clogged, work is thrown on other organs of the body, and slow disease is engendered. In this connection may be mentioned an element in the anatomy of the skin which was omitted, in the previous general consideration of the subject, for reasons which will presently appear, namely, the muscles of the skin. In certain animals a very abundant muscular layer is developed immediately beneath the skin, so that they possess the power of wrinkling it and shaking it, in order to rid them- selves of dust, insects, etc. In man this is-found only in a few situations and moderately developed; but the human skin possesses within its structure a cer- tain amount of muscular fibres, which are of especial importance in the present study of the sebaceous glands. These muscles in the skin belong to the class of what is called smooth, or unstriped, muscles, which differ from those composing the mass of mus- cles of the limbs, etc., in that they are not con- trolled by the will; they are, therefore, called in- voluntary muscular fibres. These are, of course, extremely small, but are quite readily seen by the microscope. They extend from near the end, or deeper portion, of each hair-follicle, in a slanting direction, and terminate, or are inserted, near the outer surface of the corium or true skin. The name given to these muscles is arrectorpili, or, in the plural, arrectores pilorum, so called because, when they con- tract, they cause the hair to stand more or less erect and to protrude a little from the skin; thus, in the cat, when excited or enraged, all the hairs become STRUCTURE OF THE SKIN: MUSCLES. 21 ///" K^ :•■■' Fig. 6. Hair in its fol- licle, Sebaceous Glands, and Mus- cle, from the Scalp. t> 2i 3. 4. 5. 6- Hair and its follicle. 7, 8. Muscles, arrectores pilorum. g, 10, n. Sebaceous glands. 12. Opening of hair follicle and duct for sebaceous glands. 22 THE SKIN IN HEALTH AND DISEASE. erect and bristling. The action of these muscles may be well observed in man in what is called "goose- skin," when, from exposure to cold, or sometimes from emotional causes, the skin may be observed to be thrown into numerous projections. This condi- tion may be readily observed on entering a warm bath : if the portion not immersed gets a little chilled, and if the surface be yet dry, the fine hair on the arm may be seen to rise and stand more or less erect, and, as the condition subsides, the mass of hairs sink to their former position all together. This may be re- peated several times, all rising and falling together, like a field of grain under the wind. It was to this action that Shakespeare referred in the utterance of the ghost to Hamlet, in the lines: I could a tale unfold, whose lightest word Would harrow up thy soul; freeze thy young blood ; Make thy two eyes, like stars, start from their spheres; Thy knotted and combined locks to part, And each particular hair to stand on end, Like quills upon the fretful porcupine. But these muscles have another action which is very important, and that is the emptying of the sebaceous glands. These latter structures have no muscular coat of their own, and their secretion, which is constant, oozes out upon the surface. Now, where there are large hairs, as upon the scalp and beard, these muscles more or less embrace the sebaceous glands, and by their contraction they empty them from time to time, and by this means prevent an accumulation or pre- vent the openings from becoming clogged. On the face, back, and chest, however, where we have acne developing, and where these glands are apt STRUCTURE OF THE SKIN: THE HAIRS. 2$ to become plugged up with the black specks so often seen, these muscles are almost entirely absent, and the secretion, having no particular expulsive force, readily becomes impacted, and, if at all hard, fails entirely of gaining exit. Another reason of the presence of acne on the face is the anatomical fact that, over most of the surface of the body, the sebaceous glands are connected with hairs of some size, and their ducts open into the fol- licles of these latter, and their hairs, by their con- tinual growth, keep the orifices of the glands free; whereas on the smooth part of the face (nose, forehead, cheeks), also on the neck and chest, the hairs are insignificant, and cannot thus assist in the outflow of the sebaceous secretion, and often even act as impedi- ments by themselves blocking up the openings. The hairs and nails are simply portions of the epi- dermis, or outer layer of the skin, altered in shape and structure to fulfil the ends assigned them. But the hairs are situated much more deeply than one might infer from this statement, and the longest and largest of them reach down through the entire thickness of the true skin or derma; though the finest, downy hairs, called lanugo, are very superficially inserted. Almost the entire surface of the body is provided with hairs of some sort, with a few exceptions, as the palms of the hands and the soles of the feet, etc., though over some portions of surface they are so fine as to be hardly discernible with the naked eye. Each hair is divisible into two portions, the root and the free extremity. The root is somewhat pear-shaped, that is, is a trifle larger below than at the surface of the skin, and its tissue is much softer than the exposed portion of the hair; it is indeed succulent, in the act 24 THE SKIN IN HEALTH AND DISEASE. of growing. At the deepest portion of the hair-folli- cle, or cavity in which the hair rests, there is a certain anatomical structure which is of the greatest impor- tance in reference to the growth and vitality of the hair, namely, the hair papilla. This is, of course, quite distinct from the papilla, which we have seen to cover the surface of the corium or true skin; it is situated deep in the tissues, at the bottom of each hair-follicle and projects into a small cavity at the lower end of the hair. This little hair papilla, which is only one-fifteenth of a line, or one one-hundred-and- eightieth of an inch long, is of vital importance to the life of the hair, as from it the materials come for the growth of the hair, there being a minute blood- vessel in its interior; and it is believed that the re- production of the hair, after it is lost from any reason, takes place from this papilla. Conversely is it also true that, as long as this papilla is intact and in a healthy state, the hair will be reproduced, even though extracted artificially. Thus, "plucking the hair out by the root" does not destroy the life of the follicle; only the hair is removed, the papilla from which it regrows remains. This explains the reason why so many of the methods for the removal of superfluous hair, especially from the faces of ladies, are generally useless, or worse than useless. If they are pulled out with the tweezers, there is a still greater stimulus given, and the hairs return yet more coarse and obtrusive. Shaving with the razor but removes the portions external to the skin, and at the same time stimulates greater growth. Numerous remedies have been brought forward from time to time for the removal of these obnoxious hairs, (this hairy state is known medically as hirsuties or STRUCTURE OF THE SKIN: THE HAIRS. 2$ hypertrichosis,) and the name by which they are known, depilatories, would indicate that they are capable of accomplishing the desired end of removal of the hair. A moment's consideration, however, will show the uselessness of the hope, which experience has also demonstrated to the writer time and time again. The directions given with these preparations are that they should be moistened with water, spread over the part and left on a few moments, or until they cause a little burning, when the surface is to be scraped with a blunt instrument, as a paper-cutter, and the hair will be found to come off with the paste. But what has been accomplished ? Simply this: the remedies which form the powder are found to be such as have the power of dissolving the hair to a greater or less degree, such as lime, baryta, etc., and after this has been done, the mass is scraped off with a dull instrument, instead of a razor, simply because the paste has softened the hairs more than soap softens the hairs in shaving. But the destruction has not reached deeper: the solvent may have penetrated a little further than would be removed in shaving, but it has not reached down and arrested the hair-pro- ducing power; and it cannot. Therefore the idea of permanently removing these deformities by this means is a delusion and a snare. The only method of really permanently removing superfluous hair is one which, in a measure, resembles that in which this is sometimes accomplished by dis- ease, namely, by means of something capable of de- stroying the life and vitality of the hair papilla itself. This is accomplished artificially only by the treatment of each individual hair-follicle in its interior; and this may be done by the physician in one or two ways. I 3 26 THE SKIN IN HEALTH AND DISEASE. have on several occasions seen ladies who had attempt- ed this destruction of the papilla by means of a heated needle introduced into the follicle, and the attempt had been followed by the production of small, black, indelible stains, like a tattoo, at the point experi- mented upon. This was caused by the introduction of a little carbon or lamp-black, which had been de- posited on the needle by the flame, deep under the skin, where it will remain during life. This same event has been recorded by others. Superfluous hairs can be removed either by the in- troduction of an irregularly shaped needle into the follicle (after the extraction of the hair), which is then twisted so as to break up the papilla and produce a little inflammation which closes the follicle, or a needle can be inserted, and a current from a battery be turned on, when the follicle is destroyed by what is known as electrolysis. These procedures could be done only by a physician. The hairs of the various portions of the body seem to have a definite or normal length, on reaching which they are shed, to be replaced over and over again. The number of hairs on a part, and capable of being produced upon it, exceed by far any estimate which could be prejudged in regard to it. In the case of a little girl with favus, a contagious disease of the scalp, caused by a vegetable parasite, my assistant ex- tracted by count, in the course of several months, not less than 70,000 hairs from some diseased patches on the front part of the scalp, covering certainly not one- third of the entire hairy surface. In another case, of a gentleman with ringworm of the beard of the cheeks, he himself extracted at various times within a few months between 40,000 and 50,000 hairs. In both STRUCTURE OF THE SKIN: THE HAIRS. 2J these instances the hairs were undoubtedly reproduced and extracted several times. In both cases there was ultimately a good growth of healthy hair on the parts treated. Mr. Wilson has made and collected some interesting observations on the subject of the hairs. On the scalp of a man twenty-five years of age, Mr. Wilson counted seven hundred and forty-four hair- pores in the square inch. If each gave exit to but one hair, the entire number on a scalp which measures about one hundred and twenty superficial square inches would amount, in round numbers, to 90,000; but as many openings give exit to two or more hairs, he es- timates the total number on an average head of hair at about 120,000. Flaxen hair is much more abun- dant than that of darker shades. Hairs vary very greatly on the different parts of the body both as to length and size, from the finest lan- ugo, or short, downy hair on the face, to the long hair of woman. Wilson mentions a lady whose longest hairs measured seventy-five inches, she standing five feet five inches in height, her hair being then nearly a foot longer than her height. The beard has also been known to attain great length; and the story is told, on good authority, of a carpenter whose beard measured nine feet in length, he carrying it in a bag when at work; also of another individual, a burgo- master in Holland, whose beard was so long that he was obliged to fold it up when moving about, and, having failed to do so on one occasion, he trod on it while ascending a staircase, and was thereby thrown down and killed. It has been estimated that a man, by shaving the beard, removes between six and seven inches in the course of the year; so that a man eighty years of age 28 THE SKIN IN HEALTH AND DISEASE. will have removed not less than twenty-seven feet of beard during his life. In regard to the size or diameter of the hair, it is by no means uniform. Few, if any, hairs are ever round. Wilson has measured a large number of hairs, and found the diameters to vary from y-^-jr to y^ of an inch. The common diameter of the average hair is about ^i-g- of an inch, that is, four hundred and fifty laid side by side would form a band an inch wide. Darker hair is more apt to be coarse than that which is lighter, though black hair is sometimes exceedingly fine and silky. Wilson states that his examinations show that the coarsest hair was found in females and the finest in males; and in children the diameter of the hairs is still finer. The strength of the hair is much greater than one would suppose. A single hair has supported a weight of 1150 grains, or nearly two ounces and a half, though the breaking weight is generally somewhat less than this. Hair is also very elastic; it can be stretched to almost one-third its own length, and regains its for- mer length almost perfectly. The nails are structures which are very nearly like. the epidermis and the hair, composed of a hard, horny matter arranged in the form of cells. They are, indeed, only altered portions of the external or epidermal layer of the skin, and rest upon their nail- beds in much the same manner as the epidermis or scarfskin lies on the true skin or derma. We speak of the root and the body of the nail,— the root being that portion towards the hand which is situated beneath the skin, the body all the rest of the nail. The ma- trix.vs> the bed upon which the nail rests and to which STRUCTURE OF THE SKIN: THE NAILS. 29 it is firmly adherent. Nails grow from the root, just as do the hairs, and only slide over their matrix or bed, so that an injury to the matrix, such as slivers beneath the nail, or run-arounds, or even a bad bruise, need not cause a disfigured nail other than of the portion directly injured; whereas, injury or disease of its root will generally cause a distorted and disfigured nail. I have seen a bruise of the root, and in one in- stance the sting of a bee over the root of the nail, followed by an irregularly formed nail, which lasted for a long time. Thus also eczema attacking the hand may affect the ends of the fingers, or even the sides at the ends, and the nails remain perfect; but when it is located on the back of the fingers, and in- volves the roots of the nails, the latter rarely if ever escape distortion and malgrowth. The nails seldom fail to give indication of sickness which has been at all severe, by an arrest of develop- ment which has taken place in the root at the period of sickness. Some studies have been made in this direction which may not prove uninteresting or with- out value in the present connection, which we will quote from Mr. Wilson. A French physician, Dr. Beau, has observed that the nails of the feet are four times slower in their growth than those of the hands. The latter increase in length one millimetre, that is, two-fifths of a line, or ^ of an inch, in one week, while the nails of the toes require four weeks for the same amount of increase. According to him, the length of the thumb-nail, including the root which is hidden from sight, is eight lines, that is, twenty milli- metres; consequently, the period occupied in the growth of that nail would be twenty weeks, or five months. In like manner, the nail of the great toe, 3* THE SKIN IN HEALTH AND DISEASE. measuring in length nine lines and a half, or twenty- four millimetres, and requiring four times the period of the thumb-nail, would consume ninety-six weeks, or nearly two years, in its growth. Dr. Beau has further remarked that during the continuance of every constitutional disorder the nails suffer to a greater or less degree. The portion of nail formed during the existence of an illness will be per- ceptibly thinner than that produced during health, and may be distinguished as a transverse groove. If the disease is serious, the groove will be proportionately deep. By this means the disease is traced with cer- tainty within the length of time required for the nail to completely renew itself. Thus, a transverse groove, situated eight millimetres (one-third of an inch) from the edge of the skin at the root of the thumb-nail, and two millimetres broad, would be calculated as follows: The nail projects three millimetres, or a little over a tenth of an inch, beneath the skin at its base; this, then, would take three weeks, representing three millimetres, for the change to show itself exter- nally, and this added to the eight millimetres would make eleven millimetres, or, at the growth of one millimetre a week, would place the sickness eleven weeks previously, while the breadth of the furrow across the nail, two millimetres, would represent two weeks' sickness. Mr. Wilson made an observation somewhat confirmative of this, although in such deli- cate measurements there was some little discrepancy between his results and those of Dr. Beau. In the main, however, the observations are correct, and have been verified by others. The nails also show peculiar characteristics in other states than acute sickness. Thus, in pulmonary con- PHYSIOLOGY OF THE SKIN. 31 sumption they are generally long, and curved both from side to side and from end to end; whereas, in certain other states, they are apt to be short, straight, and rather clubbed. They are subject to certain dis- eases, as will be mentioned later. In regard to what might be properly called the physiology of the skin, a few additional points may be considered with advantage. As stated before in connection with the sudoriparous or sweat glands, the skin is one of the great emunctory or excreting organs of the body, and shares very largely with the lungs and kidneys the office of removing the superfluous waste from the system. Thus the skin removes by exhalation somewhere about two pints of liquid daily, the kidneys about the same amount, and the lungs not much over one-half or two-thirds as much. It can therefore be readily understood how a "check of perspiration " acts disadvantageously, by throwing extra work upon other organs. These three great agents for eliminating or removing the water from the system act in harmony, and interchange in their duties more or less. Thus, in cold weather, when the skin perspires less, the kidneys are more active, and their secretion, as also that of the lungs, is more profuse; hence the great danger of their becoming inflamed during this season ; and in summer, when the perspi- ration may be profuse, it is a common observation to find the urine more scanty. This vicarious or interchanging action of these or- gans is frequently taken advantage of in medicine, as when, in such maladies as Bright's disease of the kidneys, the quantity of their secretion is diminished, we cause the skin to act profusely and remove the water which threatens dropsy and endangers life. In 32 THE SKIN IN HEALTH AND DISEASE. like manner, in certain .diseases of the skin, we find great advantage from giving remedies which increase the secretion from the kidneys. Also in pneumonia, where the power for work of the lungs is seriously im- paired, we keep the skin in good action by poultices, warmth, ipecac, spirits of Mindererus, etc. In some general diseases we act upon all these means of elim- ination ; and the courses of treatment at the various mineral springs derive a large share of their benefit from their action upon the skin and kidneys. The secretion from the sweat glands is almost en- tirely pure water, there being no less than 995.57 parts of water in each 1000 parts of the perspiration, and the largest other ingredient by far is common salt or chloride of sodium. But under certain circum- stances, as in high fever, severe disease of the kidneys, and in gout, the perspiration may contain urea, a poisonous substance which in health is largely removed by the kidneys. A very great part which the skin plays in the physi- ology of the system, as stated before, is that of regu- lating the temperature of the body. Thus, while cer- tain organs situated internally, mainly the liver and the lungs, together with the tissues generally, are day by day, hour by hour, and minute by minute produc- ing heat by means of the oxidation or combustion of the elements of food and tissue into substance and force (just as the same food elements if burned or oxidized outside of the body would give forth heat), the skin is continually radiating or giving off the heat; and by the proper balance of the two the temperature of the body is always kept at an even point — about 990 Fah. As the traveller approaches the colder Arctic regions, instinct leads him to consume more of PHYSIOLOGY OF THE SKIN. 33 the fatty, carbonaceous, or heat-producing foods, and his feelings prompt him to clothe the surface more warmly in furs, etc., to keep in the heat which he is continually making, and which is necessary to his life. Just as lives are lost from alcoholic liquor used as a stimulant in the Arctic regions in place of the heat- producing oils, so, by wilful neglect to preserve the heat which is produced, even in more temperate climes, we have many lives lost every year. But very good directions in regard to the protection of the skin have already been given in some of the pre- ceding books of this series, and need not be repeated here.* The intimate relations of all the organs of the body to each other must never be forgotten. Failure in action of the kidneys, bowels, lungs, liver, etc., de- ranges the balance in the system, and may result in disease of another organ, which has work thrown upon it which it cannot perform. Just as, when the stomach fails to do its work rightly, the bowels cannot do theirs, and diarrhoea results, so when the liver and organs of digestion fail to elaborate perfect blood, the skin becomes diseased, perhaps in trying to produce its secretions from imperfectly elaborated blood, or from attempting to take its nourishment from food which has been imperfectly cooked in the human laboratory. Again, a failure of the skin to do its work (and many skins are found to be dry and harsh) may result in damage to other organs. * See American Health Primers, Long Life, and How to Reach it, by Dr. J. C. Richardson; also, The Summer and its Diseases, by Dr. James C. Wilson; and Winter and its Dan- gers, by Dr. Hamilton Osgood. C CHAPTER II. THE CARE OF THE SKIN IN HEALTH. BEARING well in mind the many, many thousand pores or openings of the sweat and sebaceous glands, and remembering how the epidermal layer is constantly shed, it can be readily understood that to have a healthy skin we must have a clean one. Cer- tain of the diseases of the skin are caused by conta- gious elements, and others are caused by filth, and these may be escaped by attention to cleanliness. But as the skin is exposed to many external influences, of dust, etc., and, at the same time, is constantly pouring out its own secretions on its surface, there to become dry, while there is also the debris of the epidermis, which is constantly shed, baths are neces- sary, not only to the health of the skin, but also to that of the individual, and should be practised in health to such an extent as experience teaches to be beneficial. Much has already been said on this sub- ject in the previous books of this series already re- ferred to, and the reader cannot do better than to turn to the chapter on carelessness and ignorance in bathing, in Dr. Osgood's excellent Primer on " Win- ter and its Dangers." I must, however, take a little exception to the onslaught made upon the morning bath, for, if quickly and vigorously taken, and if a 34 THE CARE OF THE SKIN IN HEALTH. 35 good reaction be obtained after it, it is conducive to the restoration and maintenance of health; though many cannot bear it, and there is danger of its being overdone. When Turkish baths were introduced, it was thought that by this means we would be able to rid the system of many of its ills, and that their universal use would greatly promote health and prolong life. But it is questionable as to how much real benefit they are to the community (though they undoubtedly are of great value in certain cases), and it is not at all doubtful that they have been productive of harm in many in- stances. I do not know that it is the prolonged or repeated use of the Turkish bath which does the harm, for I have recently questioned an attendant who for five years spent three hours daily in it, and her health was perfect. The only difficulty she had was occasioned by her drinking inordinately of iced- water, until finally the stomach rejected it. She had dyspepsia, was obliged to leave this work, and I saw her with a nettle-rash six or eight months after ceas- ing her occupation. While she was employed at the baths, she was very well, and stated that the other girls were always well also, all the functions being performed with perfect regularity. The dangers from the bath result almost always from not carrying out all the directions indicated by experience in regard to its use; that is, there is dan- ger in becoming too rapidly heated, or in not allow- ing sufficient cooling-time, or in taking the bath too soon after or before eating, etc.; or a weakened heart, or a tendency to apoplexy, may be a source of danger. As a means of removing the external debris of the skin, the Turkish bath stands unequalled ; and as an 36 THE SKIN IN HEALTH AND DISEASE. occasional stimulant and quickener of the vital pro- cesses, it is certainly of great value; but in taking it, one must be guided by the sensations produced at each step, and by the advice of those experienced in the charge of the establishment, rather than by that of some friend who has stood this or that temperature, or has remained for such and such a time in it. In regard to the care of the skin of the face in health, a few words may not be unwelcome to some. Powders are very largely used by ladies to cover the defects of complexion, and the question is continu- ally asked, whether their use is injurious. I reply, that I have seen a number of instances where erup- tions on the face have been directly traceable to some of the toilet-powders and cosmetics sold in the shops. Therefore, as their composition is secret, and as some of them, by analysis, have been found to contain very poisonous ingredients, as large quantities of lead, and as others are known to be detrimental to the skin, they should be avoided as a class, however seductive the advertisements, or however positive the assurance on the part of druggists or friends that they are "perfectly harmless.'''' Such a recommendation recalls the Irishman's holy water, when in the dark he sprinkled a number of persons from an ink- bottle, mistaking it for the one containing holy water, remarking, as he did it, "if it does you no good, it will do you no harm." Patent and adver- tised remedies, while they seem to do no harm at the time, will often have a flood of light thrown on them by after-circumstances, which determine their real character and effect when too late. Those who value their health and beauty of complexion should never even try them. THE CARE OF THE SKIN IN HEALTH: SOAPS. 37 The application which I prefer for the purpose of removing the greasiness of the skin is pure rice-pow- der; and I direct patients not to get that already in packages, but to buy the freshly prepared and per- fectly pure article, by weight, from a reliable apothe- cary. Or, if a substance more absorbing to the greasy matter is much desired, I allow a little calcined magnesia to be used. A certain amount of friction applied to the face daily will do much to keep the pores of the sebaceous glands open ; and by stimulat- ing the face to prevent the formation of the black specks and red spots so common in young people. I generally direct that the face be rubbed to a degree short of discomfort, and that the towel be not too rough. There is no intrinsic reason why soap should not be applied to the face, although there is a very common impression among the profession as well as the laity that it should not be used there,— that is, while soap is acknowledged to be useful and necessary to the skin of every other part of the body, on that of the face alone, which resembles the rest of the surface in construction, the popular impression is that it should never be allowed. This is probably due to the possi- ble annoyance caused by the soap getting into the eyes, unless care be used. In direct opposition to this idea may be placed the fact that in the treat- ment advised by most dermatologists where the seba- ceous glands are disordered, as in seborrhcea, comedo, and acne, great reliance is placed upon solutions of what is known as sapo viridis, a potash soft-soap, im- ported from Germany, whence the treatment origi- nated ; or even in the rubbing in of this soap itself. The fact is, that many of the cases of eruptions upon 4 38 THE SKIN IN HEALTH AND DISEASE. the face are largely due to the fact that soap has not been used on that part; and it is also true that, if properly employed, and if the soap is good, it is not only harmless, but beneficial, to the skin of the face as to that of every other part of the body. This leads to a few words on the subject of soap and its use on the healthy and diseased skin. Much might be said on this subject, if space permitted. There are very great differences in soaps and in their effects upon the skin, and as familiar extremes may be mentioned the common yellow, bar, washing soap, and coarse soft soap, which are stimulating and very ir- ritating to many skins, and very old Castile, or some of the best toilet soaps, which have little, if any, effect on the healthy skin except that of cleansing. The requisites of good soaps are: first, that they shall not contain too much alkali, only enough to saponify the fat; second, that the fat from which they are made shall be good, pure, and sweet. For in the refuse sometimes employed for soap making we may find decomposed matter; and cases are on record where pus globules were actually found in a soap which had caused and kept up a skin disease, and in another instance minute spicula of bone were found, microscopically, in soap which had produced an erup- tion on the face each time it was used for shaving. Thirdly, good soap must be perfectly mixed, boiled, in order to produce the chemical process called sapon- ification. The latter may be produced, to a certain degree, by cold mixtures aided by pressure, but to make the best soap long continued boiling is neces- sary. Fourthly, a good soap should be free from ex- traneous substances as largely as possible. Many of the cheaper soaps have clays and earths mixed with THE CARE OF THE SKIN IN HEALTH: SOAPS. 39 them to increase the bulk and reduce the cost; many are colored, green, blue, red, etc., often with mate- rials of very questionable value, and are scented with some of the strong perfumes, often manufactured of petroleum, and of irritating character. For all these reasons a good soap cannot be cheap, and great caution should be used to avoid those which are thrust upon the market either as being very cheap or which are gotten up showily, as these are pretty certain disguises for poor material. A word may be added in reference to the so-called "medicated soaps," whose number and variety are legion, each claiming virtues far excelling all others previously produced. The recounting of the varie- ties and vaunted virtues of these soaps would many times fill this entire book. Now all or most of this attempt to "medicate " soap is a perfect farce, a de- lusion, and a snare to entrap the unwary and unedu- cated. The only quality required of a soap is that it shall be harmless, prepared of pure materials, and with no foreign admixture, as already described; to attempt more than this is to fail entirely. The healthy skin cannot be improved beyond health ; and the dis- eased skin cannot be restored to health by any possi- ble combination used in the form of soap that is employed by the laity; although, as remarked before, a certain potash soft-soap, sapo viridis, does enter into the medical treatment of certain diseases of the skin. Take, for instance, a soap which might possibly be thought to be an exception —a sulphur soap. Sulphur will cure the itch, and is used more or less in the treatment of several diseases of the skin, " therefore," says a money-making manufacturer, "sulphur soap will cure all diseases of the skin." It is advertised, 40 THE SKIN IN HEALTH AND DISEASE. thousands buy it, some recover of slight ailments, and the manufacturer reaps the profit. From my notes, I could give dozens and dozens of cases where all these soaps have been employed in vain or to the harm of the patient. Now the very idea of a soap .precludes the idea of its curing disease. Soap is to cleanse. It is applied but for a few moments and washed off, and is incapable of effecting the cure. The assertion can be made with truth, that scabies, or the itch, which sulphur, if rightly used, will certainly cure, never has been, and never can be, cured by this remedy used in the form of soap. The same is true of other diseases. Tar soap stands on a somewhat different footing, but its real virtues are a thousand-fold magnified in its advertisements. As an adjuvant, it is good, and not infrequently prescribed by dermatologists in the treat- ment of diseases of the skin, simply because if a good article is employed, the little stimulation of the tar, even for a short time, may do good in certain cases; and if used, it may prevent the patient from employ- ing other soaps which may prove injurious. But that it neither keeps the skin always well, nor cures it when diseased, my notes of cases afford very numerous in- stances. Carbolic soap is useless and may be danger- ous, because the carbolic acid may possibly become the blind beneath which a cheap, poor soap is used; for in all these advertised and patented nostrums the temptation is great to employ inferior articles that the pecuniary gain may be greater. The small amount of carbolic acid incorporated in the soap cannot act as an efficient disinfectant. But not only are many of these medicated soaps useless, but they are positively injurious in many ways. First, they often prevent the patient from applying THE CARE OF THE SKIN IN HEALTH: SOAPS. 41 for proper treatment, until the skin difficulty has be- come chronic ; second, in a very large share of cases, the variety employed is exactly the wrong one; and, third, because in many instances no soap at all should be used, or, if used, it should be in a particular man- ner suited to the individual case. Thus, all physicians see cases of eczema, and other skin diseases, which are constantly injured by the injudicious application of the soaps advertised to cure this and that affection. Now, the public certainly cannot be expected to dis- criminate between diseases which ofttimes years of study fail to make clear to the physician; nor can a druggist or friend do any better. The harm, then, resulting ultimately from these advertised soaps is very great. Another class of soaps, largely advertised and freely used, is what might be styled "soothing soaps." As examples of these, we have glycerine, honey, mallow, cuticura, oatmeal, lettuce, and almond soaps, together with a host of others. Now, these again are liable to adulteration, being too often made by unknown and irresponsible parties. At their best, they are only bland soaps (which, indeed, they often are not), and * are in no way superior to a perfectly pure, carefully prepared soap without these supposed healing addi- tions. In other words, soap is not and cannot be made healing, and where a healing application is re- quired, it certainly should not and cannot be in the way of soap. The safest soap to use of those ordinarily employed is undoubtedly very old white Castile soap, which is composed, or should be, of olive oil and soda; al- though the more expensive soaps of our best and well- known manufacturers may generally be relied upon 4* 42 THE SKIN IN HEALTH AND DISEASE. as effecting all that is possible in this way. As re- marked before, a good soap cannot be very cheap. There is an English soap which has met such warm commendation from writers that it should be men- tioned here, as I can endorse much that has been said by Mr. Startin, Mr. Erasmus Wilson, Dr. Tilbury Fox, and Mr. J. L. Milton, of London, concerning it. The latter gentleman made some studies in this matter, and on page 43 will be found a table from his little book on "The Hygiene of the Skin," showing the composition of certain soaps. It was through his instrumentality that Pears's Hospital (or unscented) transparent soap was made, which has obtained a wide reputation, and a deservedly good one; though, of course, there may be many other soaps possessing equally good qualities. In regard to the actual use of soap to the healthy skin, not a doubt can exist as to its value, for the greasy secretion and epidermal debris of the skin can only be removed by this means, together with good friction. But, on the other hand, soap can and fre- quently does, together with the water employed, cause ' actual disease of the skin. As an example of this we have what is known as the "washerwoman's itch," a distressing form of eczema of the hands, which is well- nigh incurable as long as the washing is persisted in. As to the use of soap on the diseased skin, there is* in general far more chance of doing harm with it than there is of doing good ; for, while cleanliness is val- uable or essential for health, too much washing can do much harm to many, if not most, skin diseases. The most common example of error in this regard is in the eczema of children, milk-crust, or tooth-rash, as ANALYSES OF THIRTEEN SAMPLES OF TOILET SOAP, r,y Dr. JOHN ATTFIELD, Professor of Practical Chemistry at the Pharmaceutical Society, London. {The figures in decimals show parts in ioo parts.) Name of Soap. Soda. Fatty Matter. Proportion of Soda to Fat. Moist-ure. Nitrated Ash. Coloring Ma-terial. Remarks. A fair Standard for | Toilet Soap. . . ( 6.6-7.7 60-70 *-?lA 15-20 12-13 Honey .... Elder-flower . . Brown Windsor . Lavender White Glycerine . English Transparent Foreign Transparent French Lettuce English Lettuce German White. . A Factory . 6.03 6.03 6.62 6.67 7-25 7-25 6.16 9.4 8.8 9.8 9.4 8.7 59-5 67.0 65-5 50.1 64.7 60.5 67.4 48.7 79-5 37-o 69.0 66.0 53-° 1 to 10 1 to II 1 to II 1 to 7^ 1 to g}{ 1 to 8X 1 to 9X 1 to 8 1 to 8y2 1 to 4X 1 to 7 1 to 7 1 to 6 2O.5 18.I IJ.O 22.0 2I.O 21-5 15.0 23-5 6.3 33-o 20.0 17.7 21.4 29.O 20.1 25.6 12.7 14.1 20.2 20.0 Vegetable. Vermilion. Ultramarine. Ochre, etc. C Vermilion -j and Ultra-(_ marine. Natural. Natural. . Natural. . | Chrome ^ { Green. J Ditto. . Moderately good. Rather greasy. Rather greasy. Impure and alkaline. >• Fairly good. f Somewhat impure \ and alkaline. Very good. Weak and alkaline. Somewhat alkaline. Excessively alkaline. Very alkaline. Very alkaline. f Unfit foruse on the 1 skin. 44 THE SKIN IN HEALTH AND DISEASE. it is sometimes called, where the mother will wash and wash the eruption in vain, using this and that soap in the hope of healing that which cannot heal while a denuded and raw surface is continually deprived of the covering which is formed for the protection of the soft tissues beneath. The same is constantly done with certain ulcerating affections, as varicose ulcers, where cicatrization is impossible if the newly grow- ing, delicate epidermal formations at the edges are removed by soap and water. These are but instances, which might be multiplied, so that it may safely be said that the introduction of so many soaps has pro- duced infinitely more harm than good. In eczema of the scalp, both of adults and infants, I have seen the disease prolonged and spread, time and time again, by the unwise eagerness to wash. In these cases I allow the parts to be washed only by rule, that is, each time by special direction; perhaps in some cases it may not be permitted once a week, and then the part is to be rapidly dried and the oint- ment or other dressing to be instantly applied. This is to form an artificial protection before the surface has had time to attempt to make its own protection in the way of an exudation from the surface. CHAPTER III. DISEASES OF THE SKIN. NO attempt will be made in this section to give a complete treatise on the diseases of the skin for lay readers, for the vastness of the subject renders that quite impossible in the present work : the treatise of Hebra, of Vienna, covers two large octavo volumes of over seven hundred pages each. Nor will it be possible, even, to define all the disorders to which this great organ, the skin, is subject,for on a card of classi- fication, used for teaching students, there are no less than one hundred names of different affections found. It would be useless, indeed, to go over such matters, for only about forty or fifty of these different diseases are met with each year in this country, even in special practice, and very many of the affections could not be recognized from a description as brief as would be necessary here. Moreover, the finer distinctions can be only learned from actual practice. The object of this section, therefore, will be rather to give a general idea of the way in which the skin becomes diseased, and a sketch of the more promi- nent affections and their means of recognition and prevention as far as possible, together with certain home remedies and measures; for their actual treat- ment must always be intrusted to a physician. 45 46 THE SKIN IN HEALTH AND DISEASE. First may be mentioned some of the popular ideas in regard to these affections, with criticisms upon them. Diseases of the skin are frequently, if not generally, looked upon as loathsome, and many fear to touch them lest they should contract the disease. In re- gard to this, it may be stated that there are only two or three out of the hundred which are contagious, and that not one case of skin disease in fifty could give the disease to another person. They are also regarded as indicative of something evil, of which the owner should certainly be greatly ashamed; and any eruption on the skin always subjects the bearer to a certain amount of suspicion that something was cer- tainly wrong either on the part of the sufferer or his ancestors. In answer to this, we may say that the skin is subject to many, many diseases of whose origin the patient and his progenitors are quite as innocent as is the sufferer from a common cold, a pneumonia, or a fracture. A very small proportion of the eruptions met with have any connection with syphilis. Again, many suppose and intimate that the cuta- neous disease is an outward expression of some poison which thus seeks exit from the system; and that if it is only allowed to work itself off through some erup- tion, all will be well. It is needless to do more than to deny all such crude dogmas, and to assert plainly that there is no scientific ground whatever for such assumptions; and also that there is no more mystery in diseases of the skin than in those of any other organ. There is no demon of disease, although dis- ease may at times almost make demons of men. As a variety of this form of popular thought, we have also the expression of "bad blood " as a cause of skin diseases, and many complain that their "blood DISEASES OF THE SKIN: POPULAR ERRORS. Off is in a dreadful state," adducing as a proof the erup- tion on the skin. Now nothing, or next to nothing, is definitely known in regard to the condition of the blood in disease, beyond a comparatively few well established facts; and chemical and microscopical study fails to show that there is " bad blood " in any of the diseases of the skin. It is, however, true that imperfect digestion has much to do with some skin diseases, and that internal remedies are necessary in very many of them arising from constitutional condi- tions; but it is equally true that certain other skin dis- eases are local in origin, and have nothing to do with the blood. In consequence of the prevailing idea that any dis- ease on the skin must be the result of some internal ferment, the external manifestation of " bad blood " seeking to gain exit, we have the dangerous and troublesome opinion, very prevalent, that it is not safe to cure eruptions on the skin lest "the disease" should fly to some other part of the system; and one hears continually the fear expressed lest the disease should be "driven in," or lest it should "strike in." Some old woman, male or female, medical or lay, has warned the patient or friends that such and such an eruption should by no means be cured, on account of the danger of " driving in the disease." Now, this fear rests upon absolutely no grounds whatever, either scientific or practical, as may be abundantly demonstrated. The authorities are en- tirely agreed in this matter, and the strongest con- firmation of it is found in Vienna, where the treat- ment of skin diseases is almost entirely by means of local remedies; and those who know most about it insist positively that no harm has ever come, within 48 THE SKIN IN HEALTH AND DISEASE. their experience, from the cure of cutaneous diseases. This the writer can abundantly confirm. This fear is especially expressed in regard to the eruptions of infancy, and in scores of cases have I heard that the family physician had said that it would not do to cure the particular case in question, lest convulsions or some internal disease should result therefrom; and yet in not a single instance, out of over five hundred cases of eczema which I have ob- served in children under five years of age, have I ever seen cause to regret successful treatment. But, on the other hand, exactly the contrary result has hap- pened, namely, that the former sufferers had gained in health and strength after the removal of their ex- hausting skin difficulty. It is high time that such errors of judgment were corrected. The very name given — eruptions, from the Latin, e rumpo, "I burst forth" — signifies how firm a hold this idea had upon medical opinion of a past, unenlightened age. The same idea is contained in the name eczema, which comes from the Greek tx£eiv, to boil over. But it may be claimed that it does happen that a cutaneous disease will sometimes disappear, and the patient have a severe fit of sickness, as pneumonia, and the like. To this it may be answered with posi- tiveness that this was not cause and effect; the inter- nal disease was not the skin disease striking in. On the other hand, it can be shown that if an internal disease, as a fever, attacks a person with a cutaneous affection, the outer one may disappear for a while, only to return when the internal or general sickness ceases, and this occurs whether the skin disease was being treated or not. It may therefore be stated, without fear of contradiction, that skin diseases can- DISEASES OF THE SKIN: POPULAR ERRORS. 49 not "strike in," cannot be "driven in," even if desired, and that there is no reason why, as a class, they should not be treated and cured as much as dis- eases affecting any other organ of the body. As an illustration of the errors of former times in re- gard to these matters, we may refer to the fact that there have been a number of pamphlets or theses written upon the danger of "driving in" the scabies or the itch, which is now demonstrated to be a purely local dis- ease, dependent upon the presence of an animal para- site burrowing in the skin, as will be more fully de- tailed later. This is an absurdity, which is, however, quite equalled by some popular ideas still prevalent. So far is it from being true that it is dangerous to properly treat diseases of the skin, that it may be stated that these latter are often the sign of a state or condition of the system which should be attended to for other reasons; and the surface eruption stands as the red signal-flag at the open drawbridge, to neglect whose warning is to rush into destruction. Thus, certain eruptions on the skin are a sure sign of a nervous breakdown, perhaps in a much-overworked man of business, and disregard of the warning may precipitate him into serious illness, as paralysis, etc. Many other skin affections, again, are the very ear- liest expression of the gouty state, and if they are neglected, and the same diet and mode of life are persisted in and medication neglected, the patient will, sooner or later, suffer from later manifestations of gout, and eventually acquire even incurable kidney or liver disease. Especially is this true of the erup- tions of syphilis, to neglect whose warning may entail an endless amount of danger, ending even in perma- nent destruction of the sight, most serious brain dis- 5 D 50 THE SKIN IN HEALTH AND DISEASE. ease, paralysis, etc., to say nothing of its transmission to offspring. The danger, then, becomes evident of either neg- lecting these matters entirely or of endeavoring to treat them by means of advertised soaps, salves, or washes, or any of the cure-all "blood-purifiers." While some of these may reach and be suitable for single cases here and there, they are useless or harmful for the many. It must always be remembered that it is the successful cases which are vaunted in advertise- ments, while the thousands who buy the quack rem- edies uselessly or to their harm are never heard from. In times past there has been very great divergence of thought in regard to the naming and classification of diseases of the skin, and much needless obscurity has thereby been thrown around the subject. But of late years those studying this branch are very much agreed in regard to the names to be employed, which are now, in all countries, based largely on the Latin and Greek. As examples of the varieties of diseases of the skin, we may state that certain are caused by the growth of vegetable parasites, like a mould, on and in the skin, and others are due to the presence of animal parasites, as the itch or scabies. Then there is a group of diseases whose seat is in the glands of the skin, acne, or the pimples which occur on the face of young people, being located in the sebaceous glands, while certain disorders of the sweat glands are also recognized. Next we have a class which are called "neurotic affections," because they are due to a nervous cause, such as shingles (or herpes zoster), pruritus, etc. The exanthemata embrace a number of contagious, DISEASES OF THE SKIN: CLASSIFICATION. 51 eruptive, febrile diseases, as measles, scarlet-fever, small-pox, etc. We have, then, a large "group of diseases which have so much inflammatory element that they are called exudative or inflammatory affections, the most prominent of these being eczema (or "salt rheum"), other members of the class being erythema, urticaria (or " nettle-rash "), boils, etc. In this fifth class are grouped thirty-one distinct diseases. Another group is formed by a few diseases which are characterized by hemorrhage into the skin, as purpura and scurvy. Then there are others known as hypertrophic affec- tions, because there is hypertrophy, or increase of some of the elements of the skin. Such are ichthyo- sis (or fish-skin disease), warts, elephant leg, and sev- enteen others. The next class is composed of atrophic affections, where there is atrophy or loss of some of the elements, such as alopecia (or baldness). Lastly, we have a variety of skin diseases caused by a new formation, or new growth, in the skin, under which head come lupus, cancer, syphilis, leprosy, etc. These groups, as well as the names of the separate diseases, are exhibited in the following CLASSIFICATION OF DISEASES OF THE SKIN. Morbi cutis parasitici. Parasitic Affections. Morbi glandularum cutis. Glandular Affections. Neuroses. Neurotic Affections. Hyperaemiae. Hypememic Affections. Exsudationes. Exudative or Inflammatory Affec- tions. Class I. II. " III. " IV. V. 52 THE SKIN IX HEALTH AND DISEASE. Class VI. Haemorrhagiae. Haemorrhagic Affections. " VII. Hypertrophiae. Hypertrophic Affections. " VIII. Atrophiae. Atrophic Affections. " IX. Neoplasmata. New Formations. Class I. Morbi cutis parasitici. Parasitic Affections. i. Tinea trichophytina f corporis (or tinea circinata). (or trichophytosis) J capitis (or tinea tonsurans). {parasite—Tricho- \ barbae (or sycosis parasitica). A. Vegeta- J phyton tonsurans) [cruris (or eczema marginatum). Tinea favosa (parasite—Achorion Schoenleinii). (or iavus) r Tinea versicolor (parasite-Microsporon furfur). (or chromophytosis) v^ * ' B. Animal. tiu.u- ■ • (corporis") i. Phthmasis J " . ( (or pediculosis) |pu^'is' j 2. Scabies (parasite — Acarus scabiei). {parasite — Pediculus). Class II. Morbi glandularum cutis. Glandular Affections I. Due to faulty A. Diseases of THE Sebaceous Glands. B. Diseases of THE Sweat Glands. 'oleosa "| i. Acne sebacea |cerea M°>" seborrhcea). cornea) exsiccata (or xeroderma). excretion "j . f nigra (or comedo). ot 2. Acne punctata | a,bida ( miiium). sebaceous | \ \ i matter. [ 3. Acne molluscum (or molluscum sebaceum). II. Due to inflammation of (4. Acne simplex (or vulgaris). sebaceous glands with< 5. Acne indurata. surrounding tissue. (6. Acne rosacea. I. As to quantity of fi. Hyperidrosis. secretion. (2. Anidrosis. II. As to quality of (3. Bromidrosis. secretion. (4. Chromidrosis. III. With retention of f 5. Dysidrosis secretion. | 6. Sudamina. Class III. Neuroses. Neurotic Affections. 1. Zoster (herpes zoster or zona). 2. Pruritus. 3. Dermatalgia. 4. Hyperaesthesia cutis. 5. Anaesthesia cutis. 6. Dystrophia cutis (or trophic disturbances). DISEASES OF THE SKIN: CLASSIFICATION. 53 A. Active Class IV. Hyperaemiae. Hypersemic Affections. c- .1. _ •_ 1 f idiopathicum. hrythema simplex < . „ „• y (traumaticum {; B. Passive, j * Roseola. Livedo mechanica. Livedo calorica. Class V. Exsudationes. Exudative or Inflammatory Affections. f A. Induced by Infection or Contagion. B. Of Internal or Local Origin. 1. Rubeola (or measles). 2. Rubella (or rotheln). 3. Scarlatina. 4. Variola. 5. Varicella. 6. Vaccinia. 7. Pustula maligna. 8. Equinia (or glanders). 9. Diphtheritis cutis. 10. Erysipelas. I. Erythematous. II. Papular. III. Vesicular. IV. Bullous. V. Pustular. VI. Erythematous, papular, ves- icular, pustu- lar, etc. VII. Squamous. 1. Erythema 2. Urticaria. 3. Lichen 4. Prurigo. 5. Herpes {multiforme. nodosum. f simplex. J planus. j ruber. [scrofulosus. ( febrilis. J iris. j progenitalis. [gestationis. VIII. IX. Phlegmonous. Ulcerative 6. Hydroa. t, ,. (vulgaris. 7. Pemphigus (foliflceus. 8. Pompholix (or cheiro-pompholix). 9. Sycosis. 10. Impetigo. 11. Impetigo contagiosa. 12. Ecthyma. 13. Eczema. (calorica. 14. Dermatitis -< venenata. (traumatica. Dermatitis exfoliativa (or pityriasis rubra). Psoriasis. Pityriasis capitis. Furunculus (furunculosis). Anthrax. (simplex. (venereum. (.zi. Onychia. b r.8. \ 19. J 20. Ulcus 54 THE SKIN IN HEALTH AND DISEASE. Class VI. Haemorrhagiae. Haemorrhagic Affections. f simplex. i. Purpura \ P*P>»l°sf.- rheumatica (or pehosis rheumatica). [ haemorrhagica. 2. Haematidrosis (or bloody sweat). 3. Scorbutus. Class VII. Hypertrophiae. Hypertrophic Affections. , „ _ (*• lentigo. 4. Naevus pigmentosus. A. Of Pigment -I 2. Chloasma. 5. Morbus Addisonii. (3. Melanoderma. fi. Keratosis pilaris (or lichen pilaris). B. Of Epidermis I 2. Ichthyosis. f vulgaris. and ^ 3. Cornu cutaneum. , ,,. senilis Papilla. | 4. Clavus. 6. Verruca j acuminata [5- lylosis (or callositas). (necrogenica. C. Of Connect- f1. Scleroderma. 4. Elephantiasis (Arabum). ive Tissue *> 2- °clerenia neonatorum. 5. Dermatolysis. ( 3. Morphcea. 6. Frambcesia (or yaws). D. Of Hair. i. Hirsuties. 2. Naevus pilosus. E. Of Nail. i. Onychogryphosis. 2. Onychauxis. Class VIII. Atrophias Atrophic Affections. A. Of Pigment. J1- Albinismus. 2. Leucoderma (or vitiligo). I 3. Canities. f propria. B. Of Corium. i *' AtroPhia c"t's ■} linearis (or striae atrophicae). ~ (maculosa (or maculae atrophicae). z. Atrophia senilis. n „ „ [ 1. Alopecia 2. Alopecia areata. L. UF hair. ■< 3. I nchorexis nodosa (atrophia pilorum propria I or fragilitas crinium). D. Of Nail. Onychatrophia. Class IX. Neoplasmata. New Formations. I. Benign New Formations. A. Of Connective fi. Keloid 2. Fibroma (or molluscum fibrosum). 1 'Ssue. I 3. Xanthoma (xanthelasma or vitiligoidea). B. Of Granula- fi. Lupus Jvulga«s. 3. Scrofuloderma. tion Tissue l _ (erythematosus. ~ ... . tion 1 issue. 1^ Rhinoscleroma 4. Syphiloderma. C. Of Blood- fi. Naevus vasculosus. Vessels. - (2. Angioma (or telangiectasis), D. Of Lymphatics. I1- Lymphadenoma cutis. „ „ .T I2- Lymphangioma cutis. E. Of Nerves. Neuroma cutis. DISEASES OF THE SKIN.•' LESIONS. 55 II. Malignant New Formations. 1. Lepra \ u e . j- (or elephantiasis Graecorum). r fepitheliomatosum (epithelioma and rodent ulcer). 2. carcinoma | papillomatosum (or papilloma). 3. Sarcoma {idiopathicum J ( pigmentosum (or melanosis). A few words may be added in reference to the names used to express the parts or elements of which eruptions are composed, which are spoken of medi- cally as lesions, and brief definitions will therefore be given. Thus, we speak of Macula, spots, macules, or stains of the skin of various sizes, colors, or shapes, not elevated or de- pressed. Papula, papules or pimples, small elevations of the skin, solid and generally red. Vesicula, vesicles, or small water-blisters, with clear fluid contents. Bulla, blebs, or large blisters, so called from the resemblance to a bubble on the surface of agitated water. Bullse may be of any size, from that of a split pea upward. Pustula, pustules; small, rounded elevations of the epidermis containing pus or matter. Pomphus, a wheal; the name given to the flat, solid elevations of urticaria or nettle-rash. Tuberculum, a tubercle. This term has no relation to "tubercle of the lungs," but is quite a different matter, and is used to designate solid elevations of the skin larger than papules. Phytna, 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. $6 THE SKIN IN HEALTH AND DISEASE. Then there are a number of other terms which serve to designate the results or changes taking place in the skin from disease, as the following: Squama, a scale ; a portion of the epidermis which is more or less detached. Crusta, a crust; a dried mass, generally of pus and epidermis, the product of some disease of the skin. Fissura, a fissure or crack in the skin, such as oc- curs on the knuckles in chapped hands. Excoratio, or excoriation; a laceration of the sur- face, generally made by scratching. Ulcus, an ulcer; an excavation in the skin made by disease. Ulcers generally extend deep into the true skin and leave a scar. Cicatrix, a scar; a new growth made up of hard, fibrous tissue, which replaces that lost by disease. As remarked before, it will be impossible, as well as useless, to treat of all the diseases of the skin in the present compass, and we will therefore consider some of the more prominent, and, for convenience of reference, will take them in the order in which they present themselves most frequently for treatment. Eczema. (Salt Rheum, Moist Tetter, Scall.)—Fore- most among all diseases of the skin in importance, both from the numbers affected and the distress occa- sioned, must ever come this protean, multiform, or ever-varying eruption—eczema. Attacking all classes and conditions, from the cradle to the grave, appear- ing about equally in both sexes, it forms about one- third of all cases of skin disease, as shown by statis- tics. But this by no means indicates the frequency of the disease, for multitudes have it who never seek its cure, so that it may safely be regarded as forming DISEASES OF THE SKIN: ECZEMA. 57 nearer one-half of all existing cases of skin disease. The name eczema is not, however, an indefinite one for skin disease in general, as many suppose, nor for a class of diseases, but represents a well-defined affec- tion of the skin, quite distinct from all other diseases. The forms under which eczema appears are so varied that it is difficult to give a brief definition of the dis- ease or a short description of its phases and conditions. We may state, however, that eczema is an inflam- matory, acute or (^ironic, non-contagious affection of the skin, exhibiting varied appearances, according to the stage of the eruption, its seat, and the condition of the patient. It is never a purely local disease, but always has some constitutional conditions back of it, foremost among which is debility. This debil- ity may be general, or may affect single organs or systems, as the digestive, the nervous, etc., or even the skin itself, as when this organ has been enfeebled by one of the eruptive fevers, as scarlatina. Eczema often appears to be contagious, as when a whole family is attacked or when a nurse has it after attending a child affected. But in these cases it is generally found that either the same influences are at work producing the disease in all, or that some other eruption has been mistaken for eczema. True eczema cannot be produced in one not pre- disposed to it by any artificial means. When the skin is irritated by croton oil, or by a burn or a scald, or by poison-ivy, etc., the eruption is a dermatitis, that is, an inflammation of the derma, or skin, and not ec- zema; though, in a proper subject, true eczema may be thus started, indeed, does often take its origin, from some recognized local cause. In infancy eczema may begin at any time, from a 58 THE SKIN IN HEALTH AND DISEASE. few weeks upward, and, when well developed, exhib- its a raw, moist, red surface, which tends to cover itself with crusts, which are replaced as often as they are washed off. Its most common seat is on the face and scalp, also about the buttocks. It commences generally as a number of scattered red points, which quickly run together, and soon begin to exude moist- ure. It is always exceedingly itchy, and even the youngest child will try to rub or tear the affected part. When occurring on the faTce and scalp, and becoming crusted, it is popularly known as crusta lactea or milk-crust, because popular opinion associ- ates it with nursing. The little sufferer is very fre- quently left untreated, with the assurance that the eruption will cease when the teeth appear; but these come, one after another, and yet the eruption re- mains, and it is then called "tooth-rash." Still, no relief is attempted, with the expectation that when all the first teeth are cut the eruption will disappear. This it very often does, but the child has now ac- quired the eczematous habit, and will be liable to renewed attacks for years or perhaps for a lifetime. But the eruption does not always vanish when the teeth appear, and I have seen instances where the real milk-crust had lasted until the cases were seen, one at twelve years of age and one at thirty-one. This form of eruption, when discharging much fluid, is sometimes called by the people moist or run- ning tetter (tetter being a popular name for disease of the skin), or running scall, or scald-head, a term of doubtful meaning. Very frequently during hot weather infants at the breast will be subject to a very slight form of papular eczema, or lichen, in which there are scattered red DISEASES OF THE SKIN: ECZEMA. 59 points, slightly elevated, on the cheeks, or on the arms and body, which do not give much annoyance. This is called popularly a "heat eruption," red gown, or red gum, or strophulus. It is an innocent affair, which may be relieved with a little zinc ointment, half a drachm to the ounce of cold cream. Another form of somewhat the same condition, which is common in small children, is the intertrigo, or chafing, as popularly styled. In this we have an even red surface, from which the outer epidermal covering is absent, and which is decidedly raw, so that cleansing is painful. This condition occurs where two surfaces of skin touch, as in the neck of fat infants, in the groins, etc. In many cases it is simply the result of want of care, filth, etc. ; some- times the continual bringing up of the milk, which runs down into the neck, will keep up the trouble. But sometimes the disease is a real eczema, and re- quires careful treatment. For ordinary cases, clean- liness and washing with a good, non-irritating soap, and the subsequent free use of lycopodium powder, will be all that is required. Fuller's earth, well dried and very finely powdered, is also an excellent appli- cation. There is a great tendency for any powder which is applied to form a paste with the secretion from the part. This must be prevented. In children somewhat older, say from five to ten years of age, eczema is frequently seen as raw, moist, red patches behind the ears or in the bends of the elbows or knees, or sometimes as separate, smaller, and more inflamed spots, covered with crusts, espe- cially about the face and hands. This latter is the impetiginous or pustular eczema of writers, the crusted tetter or scall of popular parlance. 60 THE SKIN IN HEALTH AND DISEASE. In older life, eczema is far more apt to present va- ried appearances, which often render the diagnosis very difficult. No part of the body is exempt from liability to attack, and at times the entire surface may be affected at once. The characters of redness and itching are always present, together with a cer- tain amount of thickening of the skin. Writers speak of a variety of forms, according to the lesions (forms taken, as papules, pustules, etc.), and also make a number of varieties, according to the location of the eruption; but the disease, in its real essence, is always one and the same. There are certain varieties which are of special interest and may receive further brief mention. Eczema of the face in adults is sometimes exceed- ingly obstinate, owing to the difficulty of properly applying treatment, the constant motion of the face, and its exposure to external irritants. Especially about the mouth and nose we may have the itching, slight thickening and redness of the skin remain long after there are any great outward signs of the disease; and these may recur again and again, forming very obstinate erythematous eczema. On the scalp a very slight chronic eczema may per- sist a long time without giving rise to very much an- noyance other than some desire to scratch the scalp, which is followed by a shower of white scales. This is one of the forms of disease popularly called dan- druff ox dandriff. When the part is examined, we see only a moderate redness, with a few scratched points and a considerable amount of scales, with a greater or less thinning of the hair. This will be more fully spoken of under, seborrhoea, or acne sebacea, the more common cause of dandruff. DISEASES OF THE SKIN: ECZEMA. 61 When occurring upon the hands, eczema manuum, eczema has received a number of designations. Thus, washerwoman's itch is a raw, itching, cracked, erup- tion of the hands, which may quite disable them; this has for its local cause the constant irritation from soap, soda, and water. Bricklayer's,grocer's, or baker's itch is much the same affection, caused by the irritat- ing effects of occupation ; in these latter, the hands are more apt to have a dry, hard, papular eruption, which some might describe as a lichen, which indeed differs little from eczema. Eczema on the lower legs is often a most distressing and obstinate affection. It is seen mainly as a red surface, eczema rubrum, hot to the feel, covering a greater or less portion of the limb, and giving rise to great burning, aching, and itching. It is very fre- quently due to varicose veins, but also very often oc- curs independently of them. It is more commonly found in those who have led sedentary lives or who stand much upon the feet. It is very often associated with constipation or dyspepsia, and in old persons is sometimes the first sign of a general breakdown. But, so far from being neglected in such cases, it should be taken as the signal-flag of danger, and should receive careful medical attention. The itching and burning of eczema in this and other locations can hardly be appreciated by those who have not experienced it, and the scratching, which it is impossible to avoid, without assistance, renders the disease worse and worse. Eczema upon the legs not infrequently gives rise to ulceration of" greater or less extent, which ulcers are extremely difficult to heal while the condition which causes them exists. Happily, in the rubber bandage, 6 62 THE SKIN IN HEALTH AND DISEASE. of recent introduction, we have a most excellent as- sistant to the cure of these cases, and if judiciously applied, it is capable of affording the greatest relief in a very large proportion of instances, both in those in which large varicose or swollen veins are visible, and in those not so characterized. But, as remarked, this condition of the skin is often the result of long- continued constipation or obstructed circulation in the abdomen, and should be so recognized and treated. Space fails to describe more particularly the various forms and conditions under which eczema may ap- pear; suffice it to say that in the more acute forms we more commonly have a larger or smaller surface of red skin, congested, more or less hot, and often ex- uding moisture. In the more chronic varieties, the thickening of the skin is the marked feature, which is attended with much, often fearful, itching, while the surface may be more or less covered with dry and hard scales. Eczema may at times resemble almost every other disease of the skin, and the diagnosis in some cases becomes very difficult. In regard to the causes of eczema, they are of two kinds; first, the local, and, second, the general or pre- disposing causes. Anything which irritates or inflames the skin can excite eczema in one subject to it; thus we see the eruption appearing again and again in many cases, as often as the local irritation is repeated. The list of exciting causes is of course as great as the number of articles or conditions which might irritate or inflame the skin. Thus, poison-ivy may start a real eczema, also arnica, croton oil, poisonous dye- stuffs, as in some colored socks, sulphur ointment, etc. Or the changes of temperature, heat and cold, DISEASES OF THE SKIN: ECZEMA. 63 also friction, etc. In infants, irritating diapers, or neglect to change them promptly, is a frequent cause of eczema of the lower parts; and I have reason to believe, on the other hand, that too frequent and careless washings, or irritating soap or towels, may frequently give rise to it. But there is some state of system back of all this, in order to have these irritants give rise to true ecze- ma. While we must acknowledge that the skin, as an independent organ, can have its own diseases which are independent of other organs, we cannot deny that, just as in gout and rheumatism, there is a certain acid condition of the blood which gives rise to the inflammation of the fibrous structures around the joints, so in some skin diseases there is a somewhat similar state which occasions the local disease in the skin. We have, then, many cases connected with an acid, gouty, or rheumatic state of the system, and in others what is known as a strumous or scrofulous con- dition. Still other cases are wholly nervous in origin. We have also some cases where there is only a gen- eral debility, which acts as a cause. It can, there- fore, be taken as a fact, that eczema does not attack persons in perfect health, but signifies the necessity of medical, dietetic, and hygienic treatment. The treatment of eczema is so varied, according to the patient, the location of the eruption, its stage, and condition, that no rules can possibly be given for its home management. Indeed, it should always be treated medically, and certainly never by quack medicines. There are, however, certain elements which may with advantage be attended to by the patient, who 64 THE SKIN IN HEALTH AND DISEASE. can thus aid greatly in the treatment of the case. Diet and hygiene are all-important, and will be spoken of in a separate chapter, in connection with that of other diseases. When speaking of bathing, I men- tioned that too frequent or too severe use of soap and water frequently delayed the cure in many diseases of the skin. In none is this more true than in ecze- ma ; and the surfaces affected should only be washed by rule, as directed by the physician. The frequent use of water will keep up the eruption in very many instances, especially in those with tender skins. It should always be remembered, that after washing, the surface must be protected from the atmosphere as quickly as possible by the dressing suitable to the case. Sea-bathing, as a rule, aggravates eczema. Much difference in the progress of the case maybe made by the manner in which the applications di- rected are used. As a rule, ointments act much bet- ter when spread on muslin or lint and laid on the part than when spread on the diseased surface, how- ever carefully this may be done. Most ointments should be used freely, spread on linen or lint as thick as the back of a table-knife, and then laid upon the part and made to fit closely upon it. Where the sur- face is at all curved or irregular in outline, it is far better to spread a number of strips, and lay them on, partly overlapping each other. In treating the hand, it is very common for patients to rub on the ointment and then draw on a glove. This is a poor way, in- deed, as the glove generally takes off much of the ointment, and the results are by no means as good as when the above plan is followed. Much may be accomplished, frequently, in the way of preventive measures, in eczema. A large share of DISEASES OF THE SKIN: ECZEMA. 6$ the eruption in this disease is due to the scratching which results from the intense itching peculiar to the disease. This itching will frequently be very trouble- some before much or anything is seen on the surface. If, therefore, by the mental control of older persons, or by physical restraint of children, we can assist in pre- venting the development or increase of the disease, we can assist much in the medical treatment of the case. Also in infants who are beginning to chafe, much can be done to prevent the full development, by as- siduous care of the parts. Too much washing aggra- vates the trouble, and should be avoided as much as possible, the parts being wiped off with bran-water, or oatmeal-water (made by boiling a handful of bran or a few teaspoonfuls of oatmeal in a quart of water), and immediately dusted with lycopodium, or starch- powder. When the parts are really raw, a little weak oxide of zinc ointment, half a drachm to the ounce, may be applied, spread on strips of muslin. It is well to scorch the cloth first against a hot stove. The irritating action of certain articles of clothing must ever be borne in mind. Thus, woolen clothing must never be allowed in contact with eczematous skin; and when flannels are first put on in the au- tumn, they not unfrequently give rise to so much irri- tation that eczema may result. The poisonous effects of certain dyes must not be forgotten, as cases are continually presenting them- selves where colored socks have been the starting- point of eczema. Instances are also on record where gloves, colored shirts, etc., have caused artificial eruptions which may pass into eczema; and I have seen eruptions produced by black crSpe when it touched the skin ; also from a hat-lining. 6* E 66 THE SKIN IN HEALTH AJSTD DISEASE. In regard to the prognosis, or the probabilities as to the cure of any particular case of eczema, it may be stated that the disease varies so greatly in different persons, that no general statement can be made in regard to the time which will be required. It may, however, be distinctly stated, that eczema is a cura- ble disease, though in certain forms it may prove very obstinate. The fault very often lies in the pa- tient, who becomes wearied of the restrictions im- posed and of the routine measures employed, when a little more patience would result in a cure. Malaria has been claimed by some as a cause of eczema, and although its influence in producing the disease has been greatly overdrawn, it may unques- tionably have its effect in prolonging it. In cases wnere malaria is influencing the case for bad, there will very frequently be found an increase of the itch- ing or burning of the eruption at some particular part of the day (other than on undressing at night, when the itching is almost always much aggravated). Sewer gas may also act as a depressing agent to the system, and thus keep up the disease. Acne. (Pimples. Flesh-worms.)—Next to eczema in frequency, if indeed it is not more frequent, is acne, which is often the bane of much happiness to young people. Few persons pass through the period between fifteen and twenty years without having some development of the pimples of acne, although in com- paratively few are they sufficiently numerous or last- ing to warrant medical interference. The seat of acne is in the sebaceous or oil-glands of the skin, and the eruption shows itself as papules or pustules (commonly called pimples), of various sizes, scattered more or less abundantly over the face, DISEASES OF THE SKIN: ACNE. 6y neck, back, and chest. Each individual spot gener- ally takes from a few days, say four, to a week or ten days to run its course (although in the indurated form they may last weeks), and the disease is kept up by fresh crops appearing from time to time. Generally, however, these inflamed papules or pustules are not the only signs of disorder of the sebaceous glands, but we have associated with them numerous little black specks in the skin ; these are popularly called flesh-worms or grubs, because of the resemblance which the little masses pressed from them have to a worm, and because of the popular idea that they are in- deed "flesh-worms." These little specks are called each a com'edo, in the plural, corned'ones or com- edos, and consist of the hardened sebaceous matter which should be poured out on the surface as a fluid, but which, from wrong ac- tion, becomes hardened, and thus distends the cavity of the glands. The blackened end is due to dust from the atmosphere. The dis- tended gland is well shown in Fig. 7. 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 mi- nute animal which inhabits these glands, although by no means of such a size, as one might imagine. It is exhibited in Fig. 8; it is called the demodex or stea- Sebaceous gland, distended with se- cretion, in com/edo. Greatly magnified. 1. Minute hair in its fol- licle. 2,3. Lobes of the gland distended. 68 THE SKIN IN HEALTH AND DISEASE. Fig. 8. tozoon folliculorum; its length is from T-^n to -ife of an inch, and its breadth about g^ of an inch. But this little animalcule is per- fectly harmless and entirely innocent of the disease, as it is not supposed that it has the slightest effect in producing any disorder of the sebaceous glands. There may be several found in a single plug, or, again, many plugs may be examined without finding any of them ; their ex- istence is mentioned only to clear up the popular ideas on the subject. Acne is one of the few diseases of the skin peculiar to a particular time of life; it may be said never to occur in young children; is rarely, if ever, seen before twelve to fifteen years of age, and is rare after thirty; although the rosaceous form may occur much later, even up to fifty years of age. While acne is a disease of the seba- ceous glands, it is not to be regarded solely as such, for it has relations with the rest of the system which it is im- portant to bear in mind. Indiscretions in diet can bring on fresh spots at almost any time; the articles which do this most frequently and certainly, are richly fried foods, fried oysters or fried egg- plant being types of the worst class of them. Buckwheat griddle-cakes will al- most certainly provoke an eruption of acne in those predisposed to it, as will also sausages and mince pie. Pastry of all kinds should be largely Demodex folliculorum. Very greatly magnified. DISEASES OF THE SKIN: ACNE. 69 avoided by those subject to acne, as also nuts, raisins, and cheese, hot bread, cake, preserves, etc. It is not the fat in these things which is bad, for oils are fre- quently given internally in acne. Butter, also, which is popularly supposed to be so harmful, is not so unless it is burned or melted into other substances. One of the most frequent causes of acne in those of older years is the use of fermented liquors, ales, beer, and wine, and it is often quite impossible to re- move the eruption while these are persisted in; and their use again may cause a relapse. But acne has also relations with internal states which often require very careful medical investiga- tion ; for, in by far the larger number of cases in those who have the eruption after the age of twenty, we will find derangements of the urine, as shown by chemical and microscopic examination, which indicate dis- orders of digestion, imperfect liver action, etc. Again, constipation is a very frequent accompaniment of acne and a cause of its obstinacy, and frequently requires medical care, although home measures may benefit this, and with it the eruption to a certain extent. It is not sufficient to use occasional purgatives, nor to keep the bowels acting with the mineral waters or injections, although these are of more or less service, and may serve to keep the eruption in check. In regard to the actual treatment of acne, the meas- ures suited to different cases vary so greatly that no brief directions can be given. It is hardly necessary to say that there is no one remedy which will cure the disease; for, as previously remarked, there is no such thing as an actual disease to be "driven out of the blood," as so many non-medical people imagine. Disease is wrong action, and, to remove it, we must THE SKIN IN HEALTH AND DISEASE. set the action right. Arsenic will not cure acne, although it may come in as an aid when other causes are removed. In some cases of acne the eruption has been ex- cited by a particular indiscretion, either in eating, or from a check of perspiration, or some cause which has deranged the system. In these cases, therefore, what remains is really a local disease, and the erup- tion may be removed by local treatment alone,—■ washes, ointments, etc. A simple wash, of quite considerable service in acne and quite harmless, may be made with a drachm of precipitated sulphur, a drachm of tincture of camphor, a drachm of glyce- rine, and four ounces of rose-water. Most of the lotions advertised for these eruptions contain sul- phur, corrosive sublimate, lead, or bismuth. Some are harmless and comparatively inert, but many are positively injurious; and I have seen a number of instances where acne was caused by the so-called cos- metics. It is a common habit with many to squeeze out the little plugs which blacken the face. There is no objection to so doing, provided the skin is not bruised in the process, and provided it is successfully done. If one is squeezed, and th'e little plug does not come out, it will inflame and harm will be done. But squeezing out these plugs is about the same as empty- ing the bowels by an injection : it does not cure the state. It is better, however, to have them removed, because then the glands can have a chance to con- tract to their normal size under proper treatment; for they cannot themselves force out the hardened plug. The common, natural process for the expulsion of it is by means of inflammation, causing a papule or DISEASES OF THE SKIN: SEBORRHEA. y\ pustule. The plugs may be pressed out between the two thumbs or by means of a watch-key, or, what is better, by a small silver tube, made for the purpose, about an eighth of an inch in diameter, with the ends rounded and drawn down to about one-sixteenth of an inch opening. This is placed over the black speck, and, by a firm, quick pressure downwards, the little worm-like mass is made to rise within the tube, and may afterwards be brushed off. Some little irri- tation may be caused, so that it is well always to do this at night. Wens on the scalp and face are greatly-distended sebaceous glands, forming little sacs containing more or less cheesy matter. Sometimes they have an open- ing from which this may be squeezed. The treatment is by excision. We may here best speak of seborrhaa, steatorrhaa, or acne sebacea, a disorder of the sebaceous glands very frequently found to accompany ordinary acne, but which may occur alone. This consists in an ab- normal or unhealthy secretion of these glands, and shows itself on the surface .either in the form of a greasy coating or condition of the skin or scalp, or in the collection of yellowish scales which are very greasy. Many faces are always greasy and oily, and it is only with the greatest difficulty that the deform- ity can be hidden; and, again, we occasionally have a scalp whose hair is in such a constant state of oili- ness as to be very distressing to its owner. The dry form of seborrhcea appears sometimes on the face, especially on the nose and cheeks, but more frequently upon the scalp, in the form of whitish or yellowish greasy scales. Upon the scalp it forms much of so-called dandruff or dandriff, and is a very 72 THE SKIN IN HEALTH AND DISEASE. annoying complaint. Not only is it annoying from the constant shedding of the scales, like snow, upon the clothing, but is particularly uncomfortable, be- cause it is surely attended, sooner or later, with loss of hair. In many of the cases of alopecia, or loss of hair, this condition has preceded. The popular idea is that the dandruff destroys the hair,—"eats it off," as the patients say. This is not wholly true, but, like so many popular ideas, there is a grain of truth in it. Seborrhcea causes loss of hair in two ways; first, because the hair loses its proper lubrication, which should come from the oily secre- tion poured upon it continually by the sebaceous glands, their secretion drying into scales; and, sec- ond, because the same causes which produce the se- borrhcea operate also to undermine the nutrition of the hair, and it falls as a consequence. The dandruff does not "eat off the hair," but it should never be neglected, because its natural end is in baldness. The causes of seborrhcea are the same as those of acne, and the dietetic and hygienic rules of the one apply to the other. It is a disease of debility, like acne, and requires tonics. It is useless to try to remove seborrhcea perma- nently by washing or combing the head, or by stiff brushing. These measures often aggravate it. There should be a certain amount of brushing daily, but that with a comparatively soft brush; while the fine- toothed comb, by removing a considerable quantity of greasy matter adhering to the scalp (which would subsequently dry and fall), gives relief for a longer time, still, by the irritation following its use, it may rather aggravate the disease. The scalp should be occasionally washed out, and an ointment or some DISEASES OF THE SKIN: BALDNESS. oily matter applied immediately thereafter. The most harmless application, and yet one often of very great service, is a pomade made of one drachm of" tannin in an ounce of rose-ointment. It should be applied to the roots of the hair, and well rubbed into the scalp. Another remedy of value is that com- monly used by the laity, namely, castor-oil and alco- hol, with a little spirits of rosemary. The careful use of these will generally keep the trouble in check; but as this, like so many skin affec- tions, is a sign of debility, or often of imperfect digestion, permanent relief can be expected only from a thorough investigation of the cause and condi- tion of the patient. The subject of alopecia, or baldness, may be treated of here, inasmuch as it is so very frequently, though not always, the result of the disorder we have been describing. Hair falls very frequently after acute sicknesses, al- most always after scarlatina, erysipelas of the head, etc., and also during the course of syphilis. It is regained afterwards, as a rule, though in the case of syphilis careful and complete treatment for the disease is necessary. When baldness is hereditary, medical skill can do comparatively little to prevent it or to restore the loss. But where there is a low form of chronic eczema, or a seborrhcea, giving rise to the difficulty, or where the loss of hair is from general debility, the fault may be remedied, the fall arrested, and generally a very fair amount of hair restored. But to accomplish this restoration of the scalp to health, many elements need to be taken into con- sideration ; therefore a dozen cases of baldness might be treated in a dozen different ways and with success, 7 THE SKIN IN HEALTH AND DISEASE. provided each plan were adapted rightly to the state then present. The hair, deriving its nutrition and stimulus of growth from the general system, must and does suffer with lowered vitality; and, while it may be stimulated into a temporary growth by various local irritants, this can neither be healthy nor perma- nent, because the fountain whence the supply of nourishment is drawn fails to a greater or less extent. We can appreciate, therefore, the evil of advertising this or that remedy as a sure cure for baldness; the fallacy of which is proven by a dozen or a hundred failures to each success. Nor are remedies or appli- cations more efficacious which propose to afford " nu- triment" for the hair, or to "nourish it" by means of substances applied to the scalp. The growth and nourishment of the hair comes from and through its very deepest portion, the bulb, which is tightly buried in the deepest part of the tissue, and no outer appli- cation can possibly reach it, even if it could or did contain any substances capable of affording "nutri- ment" for the hair-growth. Besides the general falling of the hair, we have a very peculiar affection in which the hair is lost com- pletely from more or less circumscribed patches, which then appear perfectly smooth and white and shining. This has the name of alopecia areata, and always commences in the above manner. Generally a small spot becomes bald very suddenly, as in a night, the patient or friends first noticing the com- pletely smooth spot in the morning. This was for- merly thought to be a parasitic disease, like ring-worm; but it is now known not to be such, but is of nervous origin. Sometimes the disease progresses very rap- idly, so as to sweep off every hair from every portion DISEASES OF THE SKIN: PSORIASIS. 75 of the body, leaving the entire surface as smooth as an infant's, and without even downy hair. Psoriasis. (Dry Tetter.)—The next most common disease is probably psoriasis, which comes far behind eczema and acne in frequency, forming only about one-fifteenth of the whole number of cases of skin diseases. Psoriasis may affect persons of all ages, but is very uncommon in young children, and seldom develops for the first time in persons over forty years of age. It is characterized by the presence of sepa- rate spots or patches of diseased skin, which are of a dull red color, and have on their surface (unless it has been removed) an abundance of white scales, which fall readily. These scales are spoken of medically as micaceous, because they are in layers like mica. It is also spoken of as a furfuraceous eruption, be- cause of the bran-like character of the desquamation, or scaling, which will sometimes fill the bed or clothing with scales. The separate patches of psoriasis are generally cir- cular, and may be of any size. Thus, when they are very small, like a pin-head, the eruption is called punctate; a little larger, like drops of mortar spat- tered on it, it takes the name of guttate psoriasis; when still larger, like a coin, it is spoken of as num- mular, and so on. Sometimes large surfaces may become covered by the union of a number of smaller patches, each one of which has a strong tendency to grow larger in diameter. Psoriasis has a very decided preference for the outer or extensor surfaces of the joints, as on the elbows and the front of the leg and knee; while eczema affects more commonly the inner or flexor surfaces, as the bends of the elbows and knees. It not unfrequently j6 THE SKIN IN HEALTH AND DISEASE. attacks the scalp, and then gives rise to much scaling, and is one of the causes of dandruff or dandriff. The surfaces of psoriasis are never moist, except when greatly scratched or irritated ; while eczema tends to show moist surfaces. Psoriasis rarely itches, whereas eczema seldom fails in this. The cause of psoriasis varies, and no short state- ment could be made popularly which would aid any in avoiding it. It is not contagious; it has no con- nection with venereal disease; is not caused by any parasite; it is only to a very slight degree hereditary. Psoriasis was formerly called also lepra by some writers; but the latter term is now given to true leprosy {elephantiasis Gracorum), with which psoria- sis has no connection whatever. In regard to the disease translated "leprosy" in the Bible, there is considerable difference of opinion. Many believe that a number of distinct diseases of the skin are in- cluded in the descriptions given, and that the " un- cleanness" was simply ceremonial. Neither the true leprosy, nor psoriasis, which latter some of the cases appear to be, (as that of Moses's hand and of Miriam, also that of Naaman and of Gehazi, who are spoken of as being '' as white as snow," ) are at all contagious. We still have a considerable amount of the true lep- rosy, and cases present themselves occasionally in New York, both brought from foreign countries and ac- quired here. The writer has seen nearly a dozen cases in this country. It is indeed a loathsome and distress- ing disease, for which but little can be done; in this it differs greatly from psoriasis, which is amenable to treatment, although often very rebellious, and having a great tendency to relapse when removed. Syphilis. (Venereal Disease.)—Next in frequency DISEASES OF THE SKIN: SYPHILIS. JJ in statistics come the eruptions on the skin which are caused by syphilis, although, probably, the real frequency of this dreadful disease is by no means indicated thereby, as many affected with it shun obser- vation even of regular physicians. Syphilis is an infectious disease, always acquired by means of the poison which has come from some other person affected with the same. It never can by any possi- bility develop anew of itself. As is known, the most common mode of acquiring the disease is by impure contact; but it is not so generally known that many have become infected by means and in ways of which they were quite as innocent as is one who receives scarlet-fever, measles, or small-pox. Cases are on record which show this abundantly, and the writer has met with not a few. There is no necessity of alarm on the subject; but it is only right that the public should know of the possibilities in regard to this disease, for many have been unjustly accused in times past, because of igno- rance on this subject, both on the part of the profes- sion and the people ; and cases are continually occur- ring to everyone who sees much in this line, where it is impossible to discover when or where the original poison was acquired. The secretion from the sores of syphilis is contagious, including that from certain whitish, slightly raw surfaces, called mucous patches, occurring in the mouth and elsewhere later in the disease. The physician, therefore, stands in constant danger of contamination, and not a few members of the pro- fession have thus suffered in caring for others. Glass- blowers are wont to pass the blow-pipe from mouth to mouth, and instances are on record where a number 7* 78 THE SKIN IN HEALTH AND DISEASE. have been infected by the contagion which was car- ried on the tube from the mouth of one person affected with syphilis. The same has been recorded with ref- erence to smoking-pipes. Syphilis has also been communicated directly from the sores in the mouth, called mucous patches, to the lips of another in the act of kissing; and the writer has seen the disease given by means of a bite. Not long ago a number of cases of syphilis were traced to a man who had communicated the disease by using his saliva to moisten the ink in the process of tat- tooing. Again, infants who have the disease by inheritance may in turn give it from their mouths to the breast of a healthy nurse.; and the writer had one case where this had happened, and the disease was thence given again to the nurse's own child, who long suffered from the effects of the disease. Or, a wet-nurse, with the disease, can introduce it into another family, as has occasionally happened, through the nursing infant. Wet-nurses, therefore, should always be carefully ex- amined by a physician before employment. In regard to the dangers of the introduction of syphilis by vaccination, they have been very greatly overrated; for, while undoubted instances of this have occurred, they are infinitesimally few in num- ber compared to the number of vaccinations per- formed; and it may be said that this never occurs now that the danger is known, for medical skill can very readily avoid such an accident. No new cases have been reported for some time. This danger can be absolutely provided against by the use of the vac- cine virus obtained from the calf. As remarked before, when introducing the subject DISEASES OF THE SKIN: SYPHILIS. jg of the acquirement of syphilis, these items in regard to its mode of transmission, which might be multi- plied considerably, are given not to cause any unne- cessary alarm, but for the double reason that the true facts might be known, and that some care may be exercised in cases where there is any possibility of contagion. Where the mouth is affected, I always caution patients of the danger of giving the disease to others. In this connection may be mentioned the danger attending the habit of indiscriminate kissing inflicted upon children. Aside from its uselessness and repul- siveness, there is real danger that disease may be thus communicated. Syphilis has also been reported as given by means of certain toys, for the poison may be left on any article, dry on, and then when applied to the mouth may be removed and give the disease. Thus, the balloon-whistles often sold in the streets, frequently by the lowest class of persons, also any other toys which are applied to the mouth, may be a source of great danger. It is well to know that these accidents can take place only through broken skin, for where the epi- dermis or scarfskin is perfect and sound absorption does not take place. Thus, a chancre of the lips or nipple will be found to be formed upon a previous fissure or crack; the inoculation of the finger of a physician will be found to be in the site of some pre- ceding cut or scratch, etc. The same is true in re- gard to other poisons. Thus, the wounds sometimes incurred in dissecting do not occur when the cuticle is unbroken, but follow either a previous scratch or one made in dissecting. The first sore of syphilis, occurring on the place 80 THE SKIN IN HEALTH AND DISEASE. where the poison entered, is called a chancre. It is often quite an innocent-looking affair, having a pecu- liar hardness or induration. The other form of vene- real sore chancroid, is a local disease, not followed by constitutional syphilis; but this local sore is often more serious looking than the true chancre. Bubo is the name given to the swelling of a lymphatic gland near the seat of the sore, as in the groin. The subject of the hereditary transmission of syph- ilis is one which can be hardly entered upon here, and information must be sought from a medical ad- viser, where it is desired. Suffice it to say that the disease is so transmitted in a certain proportion of cases, and is the source of much premature death and disease. He, therefore, who exposes himself to venereal dis- ease does not endanger alone his own health, peace, and happiness, but assumes a risk for posterity which is criminal on his part. The physician alone can un- derstand the terrible nature of this disease; and could the people but see a tithe of what is witnessed by a physician who practises in this line, there would be such a wave of popular feeling and action that, if it could not sweep prostitution far from the habitation of enlightened man, would at least restrain its ravages by sanitary laws even more stringent than those ap- plied to small-pox and other contagious diseases. The opinion is strong among many medical men that the person who communicates venereal disease should be punished as severely by the law as he who would voluntarily spread small-pox, commit arson, or murder. The manifestations of constitutional syphilis are so varied and different in individual cases that no at- tempt can be made to open the subject clearly at the DISEASES OF THE SKIN: SYPHILIS. 81 present writing; for only a perfect knowledge of the disease and long training can render its recognition possible in every case. The lesions or appearances which it produces on the skin may simulate almost every disease which affects that organ, and frequently the diagnosis will prove very difficult. It would, therefore, be useless and misleading to attempt in the space at command to give any intimations of any characteristic appearances. The prognosis of syphilis is always one of great in- terest to the patient: Is the disease curable ? The manifestations present at any one time are generally quite readily removable by proper medical treatment, but when this is done, the disease should never be re- garded as cured ; for the chances are very great that if treatment be suspended immediately on their dis- appearance, and if all care for the health be neglected, that there will pretty surely be later difficulty from it. To be at all sure that one will not suffer from later manifestations, the treatment proper to the disease should be carried out very completely and for a great length of time. The necessary duration of treatment cannot be foretold in any one case, but it is to be measured by months, and even years, rather than by days or weeks. The best authorities now believe that some treatment should be carried out faithfully and persistently for at least two years. This does not mean that medicine is to be taken regularly the entire time for this period, for the greatest weight of au- thority is in favor of what is known as the intermit- tent treatment, where there are certain definite breaks or interruptions in the taking of medicine. These are not, however, to be taken by the patient at will; nor are they to be determined by the absence of act- F 82 THE SKIN IN HEALTH AND DISEASE. ual signs of disease, but according to rules well rec- ognized and known. The occurrence of relapses or reappearance of eruption, etc., is to be regretted, and should be guarded against and prevented rather than waited for and taken as indications for treatment. If this last be done, the case may continue for many, many years, generally going on from bad to worse, until brain lesions, or disease in other important or- gans, may endanger or destroy life. In regard to the treatment of syphilis, absolutely nothing can be said, for under no circumstances should the patient, even though he be a medical man, attempt to guide his own case—like the lawyer plead- ing his own case in court, he has a fool for a lawyer or physician and a fool for a client or patient. If well treated, and if the patient be able and will- ing to follow every necessary direction, there is com- paratively little need for anxiety or distress in syph- ilitic patients; the more dreadful manifestations need not appear; these are seen mainly in hospitals among the poor and neglected, who have had too little food and too much alcohol and tobacco. In regard to the fear of taking mercury, lest it should " remain in the system," as is often said pop- ularly, there is absolutely no ground whatever for such fears. Mercury taken in proper doses and when re- quired, has been proved to be a tonic, the number of the red globules actually increasing greatly under its use; that is, the blood improves in quality. Many years ago the practice was to salivate for syphilis; this is as doubtless harmful and unnecessary. The modern treatment of syphilis cannot but benefit the patient in every way. Tinea. (Ringworm.)—7The word tinea has been DISEASES OF THE SKIN: RINGWORM. 83 adopted of late years to indicate the group of diseases which are caused by the presence and growth upon and in the skin of a vegetable parasite. These diseases are perhaps more common than would appear from statis- tics, because many of the cases are left untreated or cared for by home remedies. The affections coming under this head are really three in number, and are distinct from each other ; they are all known as vegetable parasitic eruptions. They are, first, the various forms of ringworm of the body, scalp, beard, etc., which have the general name tinea trichophytina, because caused by the parasite known as trichophyton tonsurans. Second, we have favus, or tinea favosa, Pi&- g< popularly known as crust- ed or honey-comb ring- worm. Third, the tinea versicolor or pityriases versicolor, or liver spots. We will briefly speak of each. Ringworm, as properly understood, has nothing to do with any worm or animal life, but is caused by the growth in the skin of a low form of vegeta- ble life allied to ordi- nary mould. When some of the scales or a hair affected are placed in liq- uid, and magnified about 300 times, we can very readily see the spores, or seeds, and the myceliu?n, or threads, of the fungus, as shown in Figs. 9 and 10. Scale from ringworm of the body. Greatly magnified. The faint outlines are the edges of the epidermal cells; the heavier-jointed masses are the mycelium of the tri- chophyton tonsurans. 84 THE SKIN IN HEALTH AND DISEASE. Ringworm of the scalp (tinea trichophytina capitis, called, also, tinea or herpes tonsurans) shows itself as a dry, scurfy, or scaly condition of some portion of the scalp, gen- erally in separate patches, more or less circular, on which the hairs are broken off, and the sur- face presents a dirty appearance, with some redness beneath. In cases which have lasted long, a large portion of the scalp may be invaded, and there may be very little of the broken off or nibbled off appearance. The disease was called herpes tonsurans, from the 3 suggestion of a monk's tonsure 0 which is produced by the dis- ease. When masses of this dis- ease become much inflamed, the condition is known as tinea ke- rion. On the face, body, or limbs, the disease appears in the form of rings of various sizes, gener- ally pretty round, and of a red- dish color; they commence as minute points and increase in size pretty rapidly, healing in the centre as the disease progresses centrifugally. When this eruption comes in the crotch of the thigh, it takes the name of eczema mar- ginatum. Chinese and Burmese itch are the 'same affection, modified by climate, etc. Certain cases of psoriasis and eczema, also some eruptions of syphilis, look much like ringworm. "M A hair from ring- worm of the scalp. Greatly magnified. The shaft of the hair is pen- etrated with the myce- lium, and adjoining are groups of spores of the trichophyton tonsurans. DISEASES OF THE SKIN: FAVUS. 85 In the beard this disease forms what is known as barber's itch, and may prove at times a very obsti- nate and annoying difficulty. All these eruptions, as also favus, to be next de- scribed, are contagious, and children with them should not go to school or play with others so as to expose them, nor should one with ringworm of the scalp or beard go to the barber's to have the hair cut or to be shaved. Some of the cases of ringworm of the face or hands in children or adults are trivial matters, and may be safely treated at home by such remedies as ink, a penny wet in vinegar, etc. ; but ringworm of the scalp or beard always requires very careful attention, and is often very rebellious at the best. Very fre- quently it can be cured only by epilation, that is, the extracting of the hairs separately by means of forceps, and the subsequent application of very severe reme- dies. When thus pulled out, the hairs grow again freely, and sometimes it becomes necessary to take out the same hairs again and again, before the disease is eradicated. In a case of this disease in the beard, under the writer's care, not less than 40,000 hairs were extracted during a period of some months, be- fore the disease was removed. When subsequently seen, he had a luxuriant growth of long, soft black beard. In another instance, a girl, with ringworm of the scalp, had between 30,000 and 40,000 hairs ex- tracted ; and a girl with the next variety, favus, had also between 70,000 and 80,000 hairs taken from the front portion of the scalp before the disease yielded. The condition known as plica Polonica was thought lo be a separate disease of the seal}), due to a para- 8 86 THE SKIN IN HEALTH AND DISEASE. site. It is now known to be only a matting together of the hair, from neglect and filth, and is not a dis- ease proper, but may be combined with any other affection. The next variety of tinea, namely, tinea favosa, or favus, is due to the growth of another fungus, called the achorion Schonleinii, and is not nearly as common Fig. n. Spores and Mycelium of the Achorion Schoenleinii, form- ing the Crust in Favus. Greatly magnified. as the ringworm just described. This is the porrigo of some older writers, though this term has also been applied to other eruptions, as impetiginous eczema. When fully developed, it is seen in the form of small cup-shaped crusts of a pale-yellow color, which may be picked off quite readily, and are found to be easily broken up, and leave behind them a small red depression devoid of cuticle. These crusts are formed entirely of the mass of growth of the vegetable para- site, or mould, as shown in Fig. n. In old cases the cups are not always easily recog- DISEASES OF THE SKIN: LIVER SPOTS. 87 nized, and we may have merely a mass of dirty yel- lowish crusts matting the hair together, with some scaling. Favus may also appear on the skin elsewhere than on the scalp, when it is called epidermic favus. The cup-like crusts may generally be seen here, though sometimes the erup- tion is only scaly, and looks much like the ordinary ringworm. The third and last variety of disease caused by a vegetable parasite, is the tinea, or pityriasis versi- color, formerly called liver spots, and also chloasma by some writers, though this latter name is now applied to quite a different eruption, as will be described later. Tinea versicolor ap- pears principally upon the chest and back, from which places it may sometimes spread on to the arms and neck, and even cover most of the body. It is made up of a number of patches of a Spores and Mycelium of the Microsporon furfur, causing tinea versicolor. Greatly magnified. 88 THE SKIN IN HEALTH AND DISEASE. light-brown color, which are generally roundish and of a size varying from that of a pin-head to an inch or more in diameter. They are not elevated, but almost on a level with the skin, and are either a little scaly on the surface or may be made to scale with a slight scraping. If the scales be moistened with equal parts of liquor-potassae and glycerine, and magnified three hundred times, the spores and threads of the vegetable growth can be plainly recognized, as shown in Fig. 12. These vegetable parasitic eruptions being wholly local diseases, acquired by contagion, require only local applications, as a rule, for their removal. The remedies are called anti-parasitic, and are such as de- stroy the life of the plant,— largely preparations of mercury, sulphur, and tar. As used by medical guid- ance, they are perfectly harmless; and among hun- dreds of these eruptions thus treated, no harm has come to the patient. Of course there is absolutely no possibility of such a disease "striking in," or be- ing " driven in," to some other part of the body. In some cases, in addition to the local applications, there is need of internal treatment and hygienic and dietary measures; because, just as moss will not grow upon a perfectly sound and vigorous tree exposed to plenty of sunlight, so the vegetable parasite, mould, or moss, will not flourish on the human frame which is in perfect sanitary condition and full of the vigor of health. Herpes. (St. Anthony's Fire; Shingles; Water-blis- ters.)— We come now to the eruptions which are much less common than those already mentioned. Indeed, those thus far described, together make, up about three-quarters of all the cases of skin disease DISEASES OF THE SKIN: SHINGLES. presenting themselves for treatment. The older def- inition of herpes related to an eruption which crept or increased peripherically, and the term has in former times been applied to a number of eruptions. It is now restricted to a single form of skin disease, name- ly, one characterized by the presence of flat vesicles, generally grouped together in a peculiar way. The most common variety is what is known as herpes zoster, zona, or shingles; also as ignis sacer, or St. Anthony's Fire. In this the disease is limited to one side of the body, extending horizontally from the middle line behind to the middle line in front, and consists of groups of flattened vesicles, with a certain amount of redness and tenderness of the skin be- tween. Sometimes, when this attacks the region of the arms or legs, it runs down the limb; on the head it may occur over the eye, or about one ear, or on one side of the neck. This eruption is attended with very considerable pain in many cases, especially in older subjects. The pain sometimes precedes the eruption, and is thought to be simply a neuralgia, for which a mustard plaster, or the like, is applied ; when, in a day or so, the eruption appears, and the diagnosis should be plain. In some cases the pain afterwards is very severe in- deed ; which is accounted for by the fact that the essence and cause of the disease is an inflammation of the sensory nerve, or nerve of feeling, distributed over the part occupied by the eruption. Some cases, formerly or wrongly called "erysipelas" of the head or face, are now known to be this affection. The causes of this acute inflammation of the nerve- trunk, and the resulting inflammation of the skin, are not always determined. Generally, the exciting cause 8* 90 THE SKIN IN HEALTH AND DISEASE. is cold; but, strange to say, it is exceedingly uncom- mon for a person to have this eruption a second time. There is a popular impression that if the shingles should encircle the whole body, the patient would die. This is based on the fact that the eruption never does, and never can, encircle the body, if, as is almost always the case, there is a single nerve-tract affected. The nerve runs around from the spinal column to the middle line in front, to meet the nerve from the other side; and the eruption cannot go further than the inflamed nerve extends. It is not impossible to have two nerve-tracts affected at the same time, and such cases are on record, though they are very rare; and, moreover, cases have been ob- served where the two nerves were opposite each other on the body, and, consequently, where the eruption did encircle it, and yet the patient recovered. The treatment of these cases is always medical. The only suggestion to be made is to avoid irritation, and also to avoid poulticing the sores. The common "cold sores," or "fever blisters," seen about the mouth and lips, either after a fever or with "a cold," are designated medically as herpes febrilis, or herpes facialis or labialis. Very little is known of their significance; their course is short; they cannot be prevented, though tincture of cam- phor, freely and repeatedly applied, will very often arrest them. Very much the same eruption will appear about the genital regions, and sometimes give occasion of great annoyance. This is very apt to recur, and to become very rebellious to treatment. It is of especial interest in the matter of the diagnosis between it and the chancre and chancroid acquired by venereal contact. DISEASES OF THE SKIN: ERYSIPELAS. 91 This herpes progenitalis, as it is called, is a compara- tively harmless affair, and, of course, is never gotten by contagion. There are some other rare forms of herpes which cannot be treated of here. The herpes circinaius of older writers is now known as tinea circinata, and is one of the forms of ringworm already described. Hydroa is a recent term used to designate irregular eruptions of vesicles or water-blisters. Erysipelas. (St. Anthony's Fire.)—Very much that passes under this name among the people has no connection whatever with the true disease as known medically. Eczema, acne rosacea, herpes zoster, erythema, etc., often pass for erysipelas. True erysipelas is an acute inflammatory disease of the skin, more commonly of the head and face, at- tended with considerable fever, generally beginning with a chill, and accompanied by considerable pros- tration. The skin appears swollen, red, and shiny, and burns and is tender to the touch. The disease spreads tolerably rapidly until, perhaps, the whole head or scalp is involved. In some cases, called ery- sipelas migrans, wandering or migratory erysipelas, the eruption travels over much of the surface of the body, disappearing in one part as it moves on, and may be thus repeated one or more times. Erysipelas very frequently starts from a wound, the so-called surgical erysipelas, and is justly dreaded by surgeons. Sometimes it spreads from one patient to another, as in a hospital; and in some instances the very v/ards will become so infected with the disease that every operation will be followed by erysipelas. It is then necessary to fumigate the building, and sometimes even to abandon certain wards for a time. 92 THE SKIN IN HEALTH AND DISEASE. No rules of treatment can be given, as the disease should always be managed by a physician; for it is a serious one, and may prove fatal. Urticaria. (Nettle-rash; Hives.)—Although not the next most frequent disease on our list as presented for treatment, urticaria, or nettle-rash, is one of the more common forms of skin affections. In this country this eruption is generally called " the hives," although among English writers this term is applied to varicella or chicken-pox. Urticaria appears in the form of flat, solid elevations of the skin, of various sizes, and but little height, which appear suddenly on various portions of the body, and, after lasting a varying length of time, often disappear quite as suddenly, leaving no trace of their former location. Occasionally, however, a small papule is left in the centre of the former wheal, as these eleva- tions are called. This form has received the name of urticaria papulosa, or lichen urticatus. The eruption is attended with stinging, burning, or pricking sensa- tions, and a strong desire to scratch, and the suffering is often very severe. Sometimes the eruption comes out but once, and that after taking some indigestible substance, or some- thing especially irritating to the particular individual. The more common internal causes are certain fish, oysters, lobsters, crabs, etc., especially if a little stale ; also mushrooms, raspberries, strawberries, bananas, etc. An attack of acute urticaria may result from these or other causes, and pass off either when the substance has been expelled from the stomach, or when the process of digestion has finished. In many more cases we have chronic urticaria, where some wrong action of the internal organs keeps DISEASES OF THE SKIN: ERYTHEMA. 93 up the disease. This will often require all the skill and sagacity of both the physician and patient com- pletely to overcome it. Often very radical change of the mode of life is necessary. Commonly, the itching in urticaria is worse a short period after a meal; sometimes only when the patient gets warm in bed. Occasionally we find urticaria en- tirely periodic, coming on at a regular time every day, or every other day, or with some such regularity, and it will be found to be a manifestation of malaria, and entirely curable by quinine given before the expected paroxysm. In persons of delicate skin, fleas, lice, bed-bugs, and mosquitoes will cause the wheals of urticaria to arise, and a case which has long proved rebellious to medicine may yield at once to proper and sufficient personal care. Erythema.—Closely allied to urticaria we have ery- thema, whose manifestations often resemble it very greatly. Two or three kinds of erythema are recog- nized by dermatologists; erythema simplex is a simple redness of the skin in blotches or patches, much re- sembling an ordinary blushing, but more permanent. The skin feels hot to the touch, and also to the patient, and the sensations are decidedly unpleasant. These congestive patches often come and go quite rapidly like urticaria, but they are not elevated; they are often called "erysipelas." The word "erythematous " is often applied to other affections of the skin, as to eczema, etc., without meaning any connection with true erythema, but only that this congested condition of the.skin exists. Another kind of erythema is called erythema multi- forme t because, although properly an erythema, we 94 THE SKIN IN HEALTH AND DISEASE. may in some cases have small papules as well as blotches, and the inflammatory action may even go on and form vesicles or blisters. Thus, one of the varieties is called erythema papulatum and tubercu- latum; another, erythema annulare or marginatum, or there may be blisters formed in a little circle, in ery- thema iris, or herpes iris. Still another form of ery- thema is erythema nodosum, where we have nodes or lumps formed, mainly on the outer or back surface of the forearms or on the front of the shins. These are somewhat elevated, very tender, and look much like abscesses forming, but they never break unless very badly managed. All these forms of erythema are more or less as- sociated with a rheumatic habit or condition of body, and very frequently there will be considerable joint pain with them. They are generally due to indis- cretions of diet and to the effects of cold in checking the secretion of the skin. The treatment is generally laxative and cooling. But little need be done locally; a little wash of bi- carbonate of soda, or lead and opium, will often prove very grateful. Lichen.—Three varieties of lichen are now recog- nized—lichen simplex, lichen planus and ruber, and lichen scrofulosus. Lichen simplex is very like pap- ular eczema, and some writers make no distinction between them. It is an eruption of small, inflam- matory, pointed papules, red and very itchy, located mainly on the extensor surfaces of the limbs, also on the body, mainly on the back. In lichen planus the papules are much larger and are flat on the summit, which may even be slightly depressed in the centre. They are more of a pinkish DISEASES OF THE SKIN: PRICKLY HEAT. 95 purple, with whitish top, and have great tendency to become grouped together, forming even quite large patches. These appear often first about the wrists, especially on the inner or flexor surface. The erup- tion is a very chronic one, although quite curable. Lichen ruber is a disease which has been described as existing mainly in Germany, but recent study shows it to be the same eruption as lichen planus, only much more aggravated. Another condition is spoken of as a lichen, namely, lichen pilaris, more properly called Keratosis pilaris, because it is not at all an inflammatory disease, like the true lichen, but is simply an accumulation of epi- dermics around the orifices of the hair-follicles in certain situations. When examined closely, these are seen each to surround a hair. As a condition re- sulting from neglect, it may be frequently seen on the thighs and arms, and shows the necessity of proper and sufficient bathing to cause this epidermis, which thus accumulates, to be daily removed. Nothing is known as regards the actual causation of lichen as far as regards diet, etc. ; consequendy little can be said for the lay reader as regards treat- ment. Lichen is not contagious. The little rashes which sometimes appear very transiently upon nursing or teething children, belong, many of them, to the class lichen simplex; thus, lichen strophulus or strophulus, red gum or red gown, white gum, and tooth-rash are properly forms of lichen or of papular eczema. Lichen tropicus, miliaria, or prickly heat, is a very acute form of lichen simplex, coming out under the influence of much heat. There is very much burning and pricking with it; some writers claim that it is caused by blocking up 96 THE SKIN IN HEALTH AND DISEASE. and inflammation of the sweat glands. The treat- ment should be very mild and soothing; ointments and irritating washes should be avoided. Thorough dusting of the skin with lycopodium or rice powder gives the most relief. The system should be cooled down. There need be no fear of " driving in " this eruption. Epithelioma. (Skin Cancer.) — Epithelioma is a local disease of the skin causing ulceration and, in some instances, great destruction. It is often spoken of as "skin cancer," but it is doubtful as to any re- lationship between the two. True cancer causes death by general prostration, and the glands and other organs may be attacked later. Epithelioma re- mains a local disease, and if it destroys life it does so by its own extension, as for example when it causes the destruction of the eye and penetrates the brain. Epithelioma generally appears upon the face, al- though no part is necessarily exempted. It will often come first as an insignificant nodule, or little lump, upon which a crust will form and be thoughtlessly picked off, again and again, until at last a deeply ulcerating surface may result. The surface beneath the scab generally bleeds very easily. A common situ- ation is on the lower lip, especially in males, and smoking has much to do with its formation here. An old name given to this, and also to lupus, next to be described, was noli me tangere, the Latin for " touch me not," thus giving a striking hint as to the danger of meddling with these growths. They should never be tampered with ; they should not be touched, unless they are cured. A little patch or spot may remain, quite like a small wart on the nose, cheek, or lip, for many years, giving little, if any, annoyance. DISEASES OF THE SKIN: LUPUS. 97 It is finally picked more and more; then some salve is applied to heal it; then it is burned lightly, and, not healing, it is touched again more deeply. An open ulcer may finally result, which then progresses rapidly, even to the destruction of much surface. Now, no salves, or washes, or slight cauterizations will cure these affairs, and only radical, thorough treatment should be undertaken. They should be excised, scraped out, or burned out, to the whole depth of the disease. When properly managed, these can often be perfectly cured, always, however, with the production of a scar proportioned to the size of the ulcer. It is proper to add here a caution against those who advertise to cure cancers. It may be taken as a rule, that those who advertise to cure are ignorant or un- principled, or both; and the cases narrated are either purely fictitious (as has been often proven), or the disease removed was not a cancer, but some of the many diseases liable to attack the skin, for every- thing presented to " cancer doctors " is called a can- cer. These cases result too seriously for intelligent persons to trust them to any but educated advice and treatment. Rodent Ulcer is a term applied to certain forms of epithelioma, especially about the face. Lupus. (Eating Tetter.) — Fortunately, this disease is uncommon in this country, compared to Paris and Vienna, and also does not present nearly the ravages there observed. First, it must be premised that many cases of tubercular syphilis much resemble lupus, and the two are frequently confounded. We must also state that lupus is entirely distinct from syphilis, and that the term syphilitic lupus is improper, 9 G 98 THE SKIN IN HEALTH AND DISEASE. Two varieties of lupus are recognized—Lupus ery- thematosus and lupus vulgaris. Erythematous lupus is so called because it is very superficial, and sometimes appears as little more than a dark-red, well-defined spot of variable size, which persists for months or years, and gradually increases, often in spite of the best treatment. When showing its typical develop- ment, it appears as one or more reddish patches of various sizes, either shiny or covered with thin gray- ish or yellowish scales, which adhere tolerably firmly. The base is often seen to present numerous minute openings, which are the mouths of sebaceous glands. Lupus vulgaris differs from the preceding variety in having tubercles or roundish masses of a pulpy, soft deposit, which may run together and cover large surfaces, and then the disease appears as an even, red surface, covered with white scales, quite firmly at- tached at one side. These masses of disease also have a very strong tendency to ulcerate, especially when interfered with ; and then they become covered with scabs and crusts, with a raw surface beneath. This disease always leaves scars, even when the masses are absorbed with little, if any, ulceration. Older writers speak of lupus exedens, where the dis- ease caused great destruction, and to this the term noli me tangere, "touch me not," was applied. These cases are happily very rare here, and it is doubtful if some of them were not cases of epithelioma, as already described, or cases of tubercular or gummy syphilis, a late, tertiary form, sometimes causing much destruction. Little is known as to the causes of lupus, except that it is reckoned as one of the strumous or scrofulous diseases. It is somewhat benefited and sometimes DISEASES OF THE SKIN: ITCHING. 99 cured by internal treatment; but main reliance must be placed on proper local applications. Scrofuloderma is a term which has been applied to lupus, but is now recognized to be distinct from it. The masses of diseased skin are dark-red, apt to be hard, a little raised above the surface, and covered with more or less adherent scaly crusts. It is much more amenable to treatment — as tonics, cod-liver oil, good diet, etc.—than is lupus, which often resists all treatment. King's-evil is an old name given to scrofulous af- fections. Pruritus. (Itching of the Skin.)—Pruritus simply means itching, and is used, of course, in connection with many diseases in which this is a feature. Thus, eczema is attended with great pruritus or itching, as are also certain other eruptions. But in the present sense it is spoken of as a disease, for in many instances we have pruritus without any outward lesions or eruptions on the skin, except those caused by scratching. There is a peculiar itching of the skin, which seems to be so dependent upon the advent of cold weather, that it has received the name of pruritus hiemalis; in England it has been called winter prurigo. It does not seem to depend upon the wearing of flannel, for it occurs in those whose skins are not thus irritated. The itching occurs mainly at night, and affects the back, the backs of the arms, thighs, and legs. The suffering may be very great from it. Itching may also be confined to certain parts of the body, and become distressing beyond measure, and sometimes resist the most patient and thorough at- tempts at its removal. IOO THE SKIN IN HEALTH AND DISEASE. In the main, however, itching is only a symptom, and the cause should be investigated with great care, for otherwise all treatment is very unsatisfactory. Thus, occasionally, a case of scabies or the itch will remain long unrecognized, and many futile attempts will be made to relieve the itching, which will be ab- solutely impossible until the parasite is reached and destroyed. Many patients with eczema will beg only for something to stop the itching, which cannot be accomplished until the disease is checked. In cases where there is itching, the cause must al- ways be searched for, and the case treated accordingly, instead of simply giving this or tha