•-,-■■&:$>.'' '»JW try SURGEON GENERAL'S OFFICE LIBRARY Section Form 113c W.D.,S.G.O. No. .£9.2 36* GOVERNMENT PRtNTDS'Q OFFICE NLM001529714 A HAND BOOK * DEEMATOLOGY. FOR THE USE OF STUDENTS. By A. H. Ohmann-Dumesnil, A.M., M.D., Professor of Dermatology, St. Louis College of Physicians and Surgeons ; Consulting Dermatologist to the St. Louis City ' Hospital ; Physician for Cutaneous Diseases, Ai.exian Bros. Hospital, Etc ; Editor St. Louis Medical and Surgical Journal. %S ST. t€ St. Louis Medical and Surgical Journal Publishing Co. WR 8581, 1886 Copyrighted, 1889, by A. H. Ohmann-Dumesnil. INSCRIBED TO MY PARENTS, AS A TRIBUTE OF ESTEEM AND AFFECTION. The Author. PREFACE. This small handbook was not written to fill a long- felt want, but rather as a guide to students in their reading. At the request of a number of the stu- dents of the St. Louis College of Physicians and Surgeons, who desired to possess a short resume of forthcoming lectures, in order to better prepare themselves for an intelligent appreciation of the subjects spoken of, the author j'otted down the few notes which follow. For this reason, none but gen- eral, broad principles have received any attention. Details have been avoided, and the limitations im- posed by a handbook have precluded the possibility of dwelling upon pathological minutiae or elaborate consideration of differential diagnosis. All discus- sion of moot points has been avoided, and only those points mentioned which are regarded in the light of established facts. The acute exanthemata and the syphilodermata have not been considered, as they do not strictly pertain to the field of dermatology. If the perusal of these few notes will stimulate the student to continue further reading upon the subject and give rise to an interest in dermatology, the author will consider himself more than ade- quately rewarded for his pains. In conclusion, it may not be amiss to acknowledge aid derived from the works of Unna, Neumann, Hyde, Bulkley, Duhring, and others. Particular thanks are due to Dr. F. L. James for admirably executed drawings, and to Dr. F. M. Rumbold for seeing the work successfully through the press. O.-D. vi ILLUSTRATIONS. 1. Diagram of Cutaneous Furrows,..... 2 2. Diagramnatic Section of Human Skin, 4 3. Pacinian Corpuscle,..... 8 4. Section of Pacinian Corpuscle, ... 8 5. Sebaceous Gland of the Second Class, . . . . io 6. Sebaceous Gland of the Second Class, - - 10 7. Sebaceous Gland of the Second Class, ... io 8. Diagram of Nail,....... - 13 9. Nail and Nail-fold,..... 13 10. Author's Comedo Extractor,.......28 11. Author's Milium Needle, -..-... 29 12. Psoriasis, -..........70 13. Warts on Tattooed Lines,.......89 14. Elephantiasis,..........95 15. Trichorrexis Nodosa,........109 16. Molluscum Fibrosum,........113 17. Lupus,...........118 J8. Lepra,........ - 122 19. Rodent Ulcer..........125 20. Scutulum of Favus,.........138 21. Achorion Schoenleinii, - - 139 22. Achorion Schoenleinii,........139 23. Tricopbyton Tonsurans, ....... 143 24. Tricophyton Tonsurans,........143 25. Tricophyton Tonsurans. 144 26. Tricophyton Tonsurans,........144 27. Apparatus for Treating Tinea,......147 28. Microsporon Furfur, ........149 29. Sarcoptes Scabiei, - -.......151 30. Pediculus Capitis,........154 31. Claw of Same,.....- - - 154 32. Pediculus Corporis,........154 33. Pediculus Pubis, ... .....155 34. Demodex Folliculorum, - •**.......158 (JONT ENTS. The Skin, 1 Anatomy, 5 Symptomatology, 14 Primary Lesions, 15 Secondary Lesions, 16 Etiology, 18 Diagnosis, 19 Prognosis, 20 Classification, 21 CLASS I. disorders of secretion and excretion. Seborrhcea, 24 Asteatosis Cutis, 26 Comedo, 27 Milium, 28 Sebaceous Cyst, 29 Hyperidrosis. 30 Anidrosis, 32 Bromidrosis,33 Chromidrosis, 34 Haematidrosis, 34 Uridrosis, 34 Phosphor idrosis, 34 Sudamina, 34 CLASS II. HYPEREMIAS. Erythema Simplex, 36 Erythema Intertrigo, 37 CLASS III. INFLAMMATIONS. Erythema Multiforme, 39 Erythema Nodosum, 40 Urticaria, 40 Eczema, 42 Seborrhceic Eczema, 52 Herpes, 53 Herpes Iris, 54 Herpes Zoster, 54 Miliaria, 56 Pemphigus, 57 Lichen Ruber, 58 Lchen Ruber, 59 Prurigo, 60 Lichen Scrofulosus, 61 Acne, 61 Acne Rosacea, 64 Sycosis, 65 Dermatitis Papillaris Capi- litii, 67 Impetigo, 67 Impetigo Herpetiformis, 67 Impetigo Contagiosa, 68 Ecthyma, 68 Psoriasis, 69 Pityriasis Rubra, 72 Pityriasis Maculata et Cir- cinata. 73 Dermatitis Exfoliativa, 73 Fnrunculus, 73 Aleppo Bouton, 73 Anthrax, 73 Poisoned Wounds, 75 Dissection Wounds, 75 Pustula Maligna, 75 Equinia, 75 Dermatitis, 76 Dermatitis Herpetiformis, 78 CLASS IV. HEMORRHAGES. Purpura, 79 CLASS V. HYPERTBOPH1ES. Lentigo, 82 Chloasma, 83 Discoloration of the Skin, 84 Nsevus Pigmentosus, 84 Callositas, 85 Clavus, 86 Cornu Cutaneum, 87 Verruca, 88 Ichthyosis, 90 Xerosis. 91 Keratosis Pilaris, 92 vm CONTENTS. Scleroderma, 93 Morphcea. 93 Sclerema Neonatorum, 94 Elephantiasis. 94 Dermatolysis, 96 Hypertrichosis, 97 Onychogryphosis, 99 CLASS VI. ATROPHIES. Albinism. 101 Vitiligo. 102 Canities, 103 Atrophia Cutis, 104 Senile Atrophy, 104 Glossy Skin, 104 Striae et Maculae Atrophicae,105 Alopecia, 106 Alopecia Areata, 107 Alopecia Furfuracea, 109 Atrophy of the Hair, 109 Atrophy of the Nail, 110 CLASS VII. NEW GROWTHS. Keloid, 111 Fibroma, 112 Xanthoma, 114 Molluscum Epitbeliale, 115 Rhinoscleroma. 116 Lupus Erythematosus, 117 Lupus Vulgaris, 118 Scrofuloderma, 120 Lepra, 121 Carcinoma Cutis, 124 Epithelioma, 124 Sarcoma Cutis, 128 Naevus Vasculosus, 129 Telangiectasis, 130 Lymphangioma, 131 Neuroma Cutis, 131 Myoma Cutis, 132 CLASS VIII. NEUROSES. Hyperaesthesia, 133 Dermatalgia, 133 Pruritus, 134 Anaesthesia, 136 CLASS IX; PARASITES. Favus, 137 Tinea Tricophytina, 140 Tinea corporis, 140 Tinea capitis, 141 Tinea barbae, 142 Chromophytosis, 148 Scabies, 150 Pediculosis, 158 Pediculosis capitis, 153 Pediculosis corposis. 154 Pediculosis pubis, 155 Leptus, 157 Pulex, 157 Filaria, 157 Cisticercus, 158 CSstrus, 158 Demodex Folliculorum, 158 Cimex, 159 Culex, 159 Ixodes, 159 Handbook of Dermatology, THE SKIN. The skin, or common integument, is the covering which nature has provided as an envelope to the body. It is an organ which, whilst of considerable extent, is also, to a certain degree, complex in its structure. Intended primarily as a protection to the tissues underlying it, it serves also to perform a number of important functions. It has a soft, unc- tuous feel, rather smooth as a rule, certain local- ities, however, appearing uneven to the touch; it rolls more or less easily under the fingers and is quite elastic. It varies in thickness in different parts of the body, and also varies considerably in color in different individuals. The color may be a pale yellowish-pink, or it may have almost any one of a number of shades, varying from the one indi- cated to black. In the same individual, certain parts are found to be more deeply pigmented than the general surface, such as the nipple, the perineum, the scrotum, etc. The thickness of the skin varies in different parts of the body as well as in different individuals. It is, in general, thicker in men than in women, and in adults than in children. It is thinnest on the eyelids and prepuce, and here it varies from 1 mm. (1-25 in.) to 3 mm. (3-25 in.) On the back, buttocks, palms of the hands and soles of the 2 HANDBOOK OF DERMATOLOGY. feet it is thickest, and measures from 4.5 mm. (1-6 in.) to 7 mm. (1-4 in.) in thickness. This is merely an approximation as no two measurements are exactly alike, and different competent authorities differ in the results which they have found. The appendages of the skin are those portions which, while strictly not essential to it, are still found in connection with it. These are the hair and the nails, whose functions are purely protective. Besides these, we find that the skin is provided with small organs which play no inconsiderable part in its anatomy and physiology, and they may be briefly summarized as the coil (sweat) glands, the sebaceous glands and the muscles, to which may be added the nerves, the arteries, the veins and the lymphatics. Upon taking a careful view of the appearance presented by the skin, to the naked eye, it will be noticed that its surface is crossed by a large number of furrows, some of which are very fine and others equally coarse, and the coarser the furrows the Fig. 1.—Diagram of Cutaneous Furrows. deeper. It will also be found that the coarse furrows are more or less in parallel groups and situated at the flexures of joints, thus acting as compensating: media, by furnishing the increased amount of integ- ument required for the flexion and extension of the joint. The finer furrows are distributed over the HANDBOOK OF DERMATOLOGY. 3 entire surface of the skin and form a network of triangles ; and these, in turn, form a series of polyg- onal figures. Where these lines intersect, there will be found a small hole, the opening of a sweat gland, or of a sebaceous gland, or of a hair follicle with its hair protruding. Hairs cannot be found except at these intersections. There are comparatively very few intersections where this rule does not hold good. Where sebaceous glands and hair follicles are ab- sent, as on the palms of the hands and soles of the feet, there is a tendency for the furrows to arrange themselves in concentric curved elevations, which are crossed and intersected by large furrows. The concentric elevations are well-marked and contain the openings of the ducts of sweat glands. Lying directly underneath the skin, there is found the subcutaneous connective tissue and adipose tissue, which vary in quantity in different portions of the body, and serve to give the rounded appear- ance observed in the limbs and body. The functions of the skin may be stated, in gen- eral terms, to be the regulation of the body temper- ature, the protection of the finer tissues and the excretion of certain waste products. To this may be added the elaboration of certain secretions necessary for its own better maintenance. Besides this, ab- sorption and respiration are also exercised, to a certain degree. 4 HANDBOOK OF DERMATOLOGY. Fig. 1.—Diagrammatic Section of Human Skin. A Stratum corneum ; B, Stratum lucidum ; C, Stratum granulosum ; D, Stratum ' mueosum ; E.Corium ; F, Bloodvessels of corlum ; G, Subcutaneous connec- tive tissue ; H, Hair shaft -. I,Muscle ; L.Taetile corpuscle ; M,Subcutaneous bloodvessel; N. Hair bulb ; S, Sweat pore ; S L, Glomerulus of coil gland. The sebaceous glands are seen attached to the hairs. HANDBOOK OF DERMATOLOGY. ANATOMY. The skin is composed of two principal portions— the epidermis and corium; while, underlying it, is the subcutaneous connective tissue and fat. The Epidermis may be divided into four layers, as follows: stratum corneum, stratum lucidum, stratum granulosum, and stratum mueosum. The stratum corneum, or horny layer, is the outermost, composed of flat polygonal epithelial cells showing nuclei faintly, here and there. As we go deeper down, they appear less dry and show a certain relationship to the cells of the stratum mueo- sum. In the negro some pigment granules are irreg- ularly scattered through this layer. The stratum lucidum (Oehl's layer) lies imme- diately beneath the horny layer, and consists of two or three rows of transversely disposed epithelial cells which appear glistening. This layer is compar- atively thin. The stratum granulosum, or granular layer, is also thin ; being composed of one or two rows of granular bodies disposed in a horizontal manner. It is this layer which gives the color to the skin in white races. The stratum mucosum, mucous layer, or rete Malpighii, is the deepest and most important layer of the epidermis. It rests upon the corium and is con- nected with it by a series of prolongations (papilhe). It is built up of polyhedral, nucleated epithelial cells, filled with granular contents and united to each other by delicate fibres. The nuclei of these "prickle" cells are large, and delicate filaments 6 HANDBOOK OF DERMATOLOGY. radiate to the cell wall. Between these cells we have an intercellular substance known as the "cement substance." The lowest layer of cells dif- fers from the rest of the rete in that it is composed of columnar cells with large nuclei. They contain the largest portion of the pigment, and this layer is so distinct that it might almost be classed as an in- dependent one, or as a " pigment layer." The Corium, derma, or cutis vera, is divided into two layers, the stratum papillare, and the stra- tum reticulare. The stratum papillare, or papillary layer, is the uppermost, resting directly beneath the mucous layer of the epidermis. It is composed of fine con- nective tissue, the bundles of fibres of which decus- sate and become felted, as it were. It appears in the form of numerous digital prolongations—the papilla?—which are more or less developed in differ- ent portions of the body. They are bulbous, conical or blunt at the apex. They are either vascular or nervous, according as they contain the terminal loop of a blood-vessel, or the termination of a non-med- ulated nerve-fibre. The stratum reticulare,or reticular layer, is composed of coarser connective tissue fibres, the papillary layer gradually merging into it. It, in turn, also merges into the subcutaneous connective tissue. The Subcutaneous Connective Tissue serves the purpose of holding the fat, and supporting the vessels and nerves, also containing coil glands, hair follicles and Pacinian corpuscles. It is composed of loosely connected connective tissue bundles. The Bloodvessels of the skin are the arteries and veins, which take their origin from subcutane- HANDBOOK OF DERMATOLOGY. 7 ous branches, and are subdivided in the corium. They are more abundant on the flexor aspects of the limbs than on the extensor. There are three hori- zontal networks of these bloodvessels: one in the subcutaneous connective tissue, one in the deeper portion of the corium, and one just beneath the papillary layer. These are connected with each other by vertical branches. Besides this, we have the arterioles connected with the coil glands, the sebaceous glands, and the hair follicles. The blood- vessels, in general, are accompanied by filaments of the vasomotor system. The Lymphatic Vessels are relatively few, and are almost entirely limited to that portion of the skin beneath the epidermis. There are lymph spaces, however, separating the epithelial elements of the rete mueosum extending between the prickle cells and existing in the papillae of the corium, about the different glands, hair-follicles, and nail-beds. The Nerves of the skin are two-fold in charac- ter, viz.: non-medullated and medullated. They are derived from horizontal twigs in the subcutaneous tissue and distributed to the corium. The Non-Medullated fibres "penetrate to the epidermis between the epithelia in great abundance. * * * They either terminate between the prickle cells as ultimate bulbous terminations of finely beaded fibrillse, or they penetrate the epithelia them- selves in pairs." * We find similar filaments in the sheaths of hairs and ducts of the coil glands. The Medullated Nerves consist of the papil- lary loops, Pacinian corpuscles and tactile cor- puscles. • Hyde's Treatise. 8 HANDBOOK OF DERMATOLOGY. The papillary loops pass into papillae, the nerve forming one or more of these loops, and then returns to the subpapillary portion of the corium, or it turns back again to another papilla. The Pacinian corpuscle, or corpuscle of Vater, is a small ovoid body, 2.4 mm. long (1-25 in.) situated subcutaneously and occurring chiefly about the fin- gers, nippleB, and penis. The nerve proper is found in the centre, as a club-shaped termination, sur- Fig. 3.—Pacinian Corpuscle, Fig. 4.—Section of Pa- with its envelope. cinian Corpuscle. a, Terminal bulb of nerve ; b, Envelope about core -, c, Hyaline zone ; d, Lam- ellar envelope. rounded by a protoplasmic core. This, in turn, is covered by a series of concentric nucleated, vascular capsules, which grow denser towards the periphery. The tactile corpuscle (corpuscle of Meissner, or of Wagner) is also ovoid in form, composed of two or three capsules, and situated in the papillae of the corium. The capsule is formed of closely packed connective tissue fibres,with small nuclei and within a medullated nerve-fibre deprived of its myeline sheath. The filament divides, and surrounds and penetrates the capsule. It is claimed that these cor- puscles have efferent and afferent fibres. The Pigment exercises a varying degree of influ- ence in giving the color to the skin. It exists nor- HANDBOOK OF DERMATOLOGY. 9 mally only in the lowermost layer of cells of the mucous layer, some granules being irregularly scat- tered throughout the layer. It is not found, as a rule, in either the horny layer or in the corium. It is to the pigment that the color of the African race is chiefly due, it having no influence on the colora- tion of whites, unless it be under the influence of solar heat. The Muscles connected with the skin are stri- ated and unstriated. The striated muscular fibres extend from the subcutaneous tissues into the co- rium and are found chiefly about the face and neck. The unstriated muscular fibres are found surround- ing the nipple, in the orbicularis muscle, or in con- nection with glands. The arrectores pilorum are composed of fasciculi arising from the papillary layer of the corium and inserted into the outer layer of the hair follicle, the direction being oblique, and the fibres are so disposed as to include the sebaceous gland in the angle which is subtended. The Sweat Glands, or, as they are now called, the " coil " glands, consist of a globular coil situated in the subcutaneous tissue and deeper portions of the corium. The coil is a convoluted tube terminating in a cul-de-sac. It is lined with columnar epithelial cells, nucleated, with granular contents. The excre- tory duct passes upward to the epidermis, always taking its course between papillae, and pursues a straight or spiral direction. At the border of the epi- dermis, it loses its inner lining membrane as well as its investment of connective tissue, and becomes the sweat pore. This sweat pore is simply a channel, straight or spiral,connecting the duct of the coil gland with the surface of the stratum corneum. The coil 10 HANDBOOK OF DERMATOLOGY. gland secretes fat and granules of pigment, whereas the sweat pore excretes the sweat. The coil glands are also said to be concerned in the formation of the subcutaneous fat-cushion and " columnse adiposae." The Sebaceous Glands are situated in the corium, and fur- nish a fatty secretion whose pur- pose is to lubricate the skin and hairs. The STISk.\. glands themselves are H(n»\. U8ua^y racemose, and yros, are divisible into three ^ ^ varieties: 1° Those which open directly Ficgeous~GSieabnd into a hair follicle; 2° of the Sec- Those opening upon Fig. 6 — Sebaceous ond Class. ., . . , . Gland of the Seeond the skin and associ- class. ated with rudimentary hairs; 3° Those opening directly upon the surface, but not associated with hairs. The second are the most complex, the last the Fig. 7.—Sebaceous Gland of the Second Class, HANDBOOK OF DERMATOLOGY. 11 most simple. The structure of a gland consists of a basement membrane upon which polygonal cells rest, there being one or more layers. Towards the centre we have a mass of epithelial debris, oil glob- ules, etc. The layer of cells next to the basal mem- brane is composed of columnar cells. This gland, like the coil gland, is formed by a dipping-in of the epidermis in early foetal life. As already mentioned, the sebaceous glands are inclosed by the arrectores pilorum muscles whose contractions aid in the expul- sion of their contents; whereas, in the case of the coil glands, they impede this action. Hairs are fine, long, epithelial bodies, arising from depressions in the skin (hair-follicles). There are three kinds: 1° The short, fine hairs, or lanugo, covering the face, trunk and limbs; 2° The long, soft hairs, such as we find on the scalp ; 3° The short, thick hairs, such as the eyelashes. In a fully devel- oped hair we find it to consist of a point, a shaft, and a bulb embedded in a hair-follicle. The hair follicle is a depression in the corium whose axis is at an oblique angle relatively to the plane of the cutaneous surface. It is the peculiar distribution of the follicles that forms the whorls of hairs. Two-thirds of the embedded portion is situ- ated in the connective tissue of the corium. A folli- cle consists of an external longitudinal fibrous layer, a middle transverse layer, and an internal homoge- neous vitreous layer. At the base of the follicle there is a fibrous pedicle. The bulb, or root, is that portion of the hair which is embedded. It is bulb-shaped, extending below the follicle, and is implanted on a conical pro- jection—the hair-papilla. The bulb embraces the papilla, and externally is composed of pigmented 12 HANDBOOK OF DERMATOLOGY. cells forming the cortex. The cells become longer and more vertical higher up. Within the bulb we have the medulla, composed of non-pigmented hori- zontally broadened cells. The medulla rests upon the apex of the papilla, and forms a core to the bulb. The shaft extends from the surface of the skin to the distal extremity, which tapers to a point. It is straight, curled, or wavy, according to the amount of flattening which is present. The color of the hair depends upon the pigment cells and air in the shaft. The cortical portion is composed of flat, nucleated, fusiform epithelial cells, which are imbricated. It is upon this layer that the elasticity and extensibility of hair depends. The medullary portion consists of loose epidermal elements, pigment and fatty mat- ters. There is coloring matter in this as well as in the cortex. When a hair is about to be shed, it separates from the papilla, which is composed of fine connective tis- sue and contains bloodvessels and nervous filaments, and rises in the follicle until above the papillary apex. It is held by the prickle layer, and is then a " bed-hair." An epithelial bud springs below or into the corium on either side, forming a new hair. About the time the new hair is emerging, the old one is cast off. Nails are dense, horny, concavo-convex plates attached to the dorsum of the distal phalanges of the fingers and toes. There are four borders, the one at the distal point being free. The convex surface is exposed, the concave being implanted in the nail bed. The posterior portion of the nail, hidden by a fold of skin, is composed of from three to six rows of papillae. Immediately in front of this there is a len- HANDBOOK OF DERMATOLOGY. 13 ticular portion — the lunula—com- posed of converging ridges which become smaller, these two portions constituting the matrix, the tissue from which the nail ^. An- -^^^^vCTy^: , the >:'.-W- springs. terior to Fig. 8.—Diagram of, , , Nail? lunula, up to a, Nail bed ; b, Lunu- tne free D0r- la ; b and c, Matrix. The nail fold Is seen to dftr jo the Fig. 9. covertheattachedbor-uoi> 10 tuo dersof the nail. nail-bed a, Nail; c, Nail fold. which consists of higher ridges of papillae of uniform height on which are situated prickle cells. The nail consists of horny filaments passing from the matrix or floor of the nail-fold. The upper sur- face grows from the bottom of the nail-fold, and the under surface from the lunula. The nail-fold is that crescentic portion of integument which clasps the nail posteriorly and laterally. The lunula is the light colored space arising from the middle part of the nail-fold and extending some distance towards the distal portion of the nail. In other words, it is that portion of the matrix not concealed by the nail- fold. The light color which it presents is due to keratogenous cells. The white spots seen in nails are due to the presence of air. HANDBOOK OF DERMATOLOGY. SYMPTOMATOLOGY. A brief description of the symptoms observed in skin diseases is here given.it being essential to mas- ter these in order to come to a proper understanding of clinical descriptions. Symptoms may be either subjective or objective. For the former we must de- pend upon the patient; and, on this account, the varying degrees of intensity are difficult to deter- mine, much depending upon the physical build, mental peculiarities, and nervous organization of the subject. The principal Subjective Symptoms are as follows: 1. Anaesthesia. 2. Hyperaesthesia. 3. Analgesia. 4. Burning. 5. Tingling. 6. Smarting. 7. Itching. 8. Formication. 9. Pain (neuralgic). These hardly require any explanation, as they are terms in constant use and familiar to all. The Objective Symptoms are those which pre- sent themselves to the observer, and which in dermatology are termed lesions. Of these we have two kinds—primary or elementary, and secondary or consecutive. They are as follows: HANDBOOK OF DERMATOLOGY. 15 I. PRIMARY LESIONS. II. SECONDARY LESIONS. 1. Maculae; macules, spots. 1. Pigmentatio; stain. 2. Papulae; papules. 2. Squamae; scales. 3. Vesiculae; vesicles. 3. Crustae; crusts, scabs. 4. Bullae; blebs, blisters. 4. Rhagades; fissures. 5. Pustulae; pustules. 5. Excoriationes ; excori- 6. Pomphi; wheals. ations. 7. Turbecula; tubercles. 6. Ulcera; ulcers. 8. Phymata; tumors. 7. Cicatrices; scars. Primary Lesions. A macule, or spot, is a flat, discolored portion of the skin which may be irregular in size and shape and which is not the result of a previous lesion, such as in chloasma. A papule is a solid, circumscribed elevation of the skin, varying in size from a pin-head to a split pea, conical or semi-globular in shape, whose color may be red, pale or dark, yellow or white, as in mil- ium, acne, lichen ruber, etc. A vesicle is a conical or rounded, circumscribed elevation of the epidermis, containing a clear or opaque fluid, varying in size from a pin-point to a split pea, and conical, rounded, or umbilicated in form. It may be seen in herpes, zona, eczema, mili- aria, variola, etc. A blebs is an irregularly dome-shaped or flatten- ed elevation of the epidermis, varying in size from a split pea to a goose-egg and containing clear or opaque fluid, as in pemphigus and burns. A pustule is a circumscribed, flattened, conical, or umbilicated elevation of the epidermis, which varies in size from a pin-point to a silver half-dime, and which contains pus, as in acne, sycosis, eczema, etc. 16 HANDBOOK OF DERMATOLOGY. A wheal is an irregularly-shaped, more or less solid elevation of the skin, of an evanescent charac- ter, as in urticaria. A tubercle consists of a circumscribed, solid elevation of the skin, reddish or whitish in color, irregular in shape and varying in size from a split pea to a cherry, as in lepra. A tumor is a soft or firm prominence, of irregular shape, and varying in size, such as in fibroma, sar- coma, steatoma, etc. Secondary Lesions. A stain is similar to a macule in its character- istics, but differs from it in its origin, being the result or remains of a previous lesion or due to the presence of some foreign substance in the skin, as the pigmentation following ulcers, tattoo- ing, etc. A scale is a large or small, thick or thin, dry, laminated mass of epidermis which has separated from the underlying tissues, and which may vary in size and form, as in psoriasis, pityriasis rubra, etc. A crust is a collection of the dried products of a disease, which varies greatly in size, shape and color, as in eczema, favus, etc. A fissure is a linear solution of continuity, hav- ing its seat in the epidermis or down through the corium, as in eczema. An excoriation is a loss of tissue, confined to the upper layers of the skin, and varies in shape, size and depth, as in pediculosis and scabies. An ulcer is an excavation of the cutaneous tis- sue, the result of disease, and varying in extent, besides being irregular in shape. HANDBOOK OF DERMATOLOGY. 17 A scar is a connective tissue new formation occupying the place of normal tissue which has been destroyed. These constitute the elementary lesions of skin diseases. 18 HANDBOOK OF DERMATOLOGY. ETIOLOGY. In the consideration of the etiology of skin dis- eases, in general, we are led to a review of the general etiology of disease. For the purpose of con- venience, however, the causes of skin disease may be divided into external and internal. Thus we may have as external causes solar heat and light, temperature changes and general telluric and atmos- pheric agents. The seasons exert a marked influ- ence, and we may include under this head tem- perature, humidity, soil, water, etc. Among direct ■external causes are such as are frictional, traumatic, toxic and parasitic. Under these may be included the micro-organisms. Those causes of a general nature which exert an influence on the skin either in causing the appear- ance or prolonging the stay of diseases may be denominated systemic poisons, such as syphilis, etc., heredity, age, disordered functions, disease of the various viscera and diseases or lesions of the nerv- ous system. The so-called "diathesis"—the her- petic, the rheumic, the gouty, etc.—have also been invoked by some as causes of certain classes of der- matoses. Besides what has been enumerated, there are causes unknown up to the present, they having successfully eluded the most searching clinical in- vestigation and analysis. HANDBOOK OF DERMATOLOGY. 19 DIAGNOSIS. If there be any department in medicine in which nearly everything depends upon the accuracy of diagnosis, it is dermatology. It is essential to be exact, observing, critical and to possess a peculiar adaptability for the discrimination of color, form and size. Care and patience are also important requisites. The past history of the patient should be obtained, all previous diseases noted and an in- quiry made into his habits. The history of the present attack should also be carefully noted before an objective examination is made. To examine a patient properly, one of the pre- requisites is good light. Good diffused sunlight is the only one that can be relied upon, as many arti- ficial lights absorb all the yellow color. In the next place, the temperature of the room should be comfortable in order to avoid the circulatory changes due to too great heat or cold. Not only the portion implicated should be exam- ined, but the entire body as well, as such a pro- cedure not only aids greatly in forming a correct diagnosis, but often furnishes information not to be obtained in any other manner. The diagnosis of a patient should never be ac- cepted, and by refusing to consider this, and by making a thorough and careful examination the pernicious habit of jumping at conclusions, very often false, is avoided. Finally, we have a great aid to diagnosis in the microscope. This means is particularly valuable in parasitic diseases and those due to micro-organisms. 20 HANDBOOK OF DERMATOLOGY. PROGNOSIS. There is perhaps nothing more important to the patient than the prognosis of his affection, as this involves the question of a cure, or the reverse. It also includes consequent deformity, and it is this latter question which is of importance to the phy- sician, as he is enabled to protect himself from the accusation of maltreatment. Skin diseases are acute or chronic, amenable to treatment or very rebellious, with all the interme- diate degrees of stubbornness to therapeutic meas- ures. Some are destructive in their effects and some are essentially incurable. Again, there are affections which, while curable under some circum- stances, are not so under others, simply from the fact that they are dependent upon some general con- dition which cannot be relieved. It is on account of this that the examiner cannot be too careful in his inquiries into the general state of the patient. As a rule, diseases in infants and children have a tendency to be acute, and readily yield to proper treatment. In the old the tendency is to chronicity and consequent rebelliousness to therapeutic meas- ures. Tissues are more easily destroyed in the old, and proportionately regenerated in the young. The old are more prone to the influence of malignant processes. The skin is less active, is weaker and more of less atrophied in the aged, all of these factors influencing the prognosis to be made in a given case. HANDBOOK OF DERMATOLOGY. 21 CLASSIFICATION. The arrangement here presented is essentially that of the American Dermatological Association. Like all others, it contains defects, but it will be found to be simple and quite convenient, which are qualities to recommend it. Class I.—Disorders of Secretion and Excretion. A. Sebaceous Glands. B. Seborrhcea. Asteatosis Cutis. Comedo. Milium. Sebaceous Cyst. A. Erythematous. Erythema Simplex. A. Erythematous. C. Erythema Multi- forme. Erythema Nodo- sum. Urticaria. D. B. Erythematous, Ves- icular, Pustular, E. Papular, Squam- ous. Eczema. B. Sweat Glands. Hyperidrosis. Anidrosis. Bromidrosis. Chromidrosis. Sudamina. Erythema Intertrigo. C. Vesicular. Herpes. Herpes Zoster. Herpes Iris. Miliaria. D. Bullous. Pemphigus. E. Papular. Lichen Ruber. Prurigo. Lichen Scrofulosus. Class II.—Hypereemias. Class III.—Inflammations. 22 HANDBOOK OF DERMATOLOGY. (Class III—Continued.) Pustular. Acne. Acne Rosacea. Sycosis. Impetigo. Impetigo Contagi- osa. Ecthyma. B. G. Squamous. Psoriasis. Pityriasis Rubra. H. Phlegmonous. Furuncle. Anthrax. I. Erythematous, Ves- icular, Bullous etc. Dermatitis. Class IV.—Haemorrhages. A. Corium, etc. Purpura. Class V.—Hypertrophies. Pigment. C. Lentigo. Chloasma. Naevus Pigmento- sus. Epidermis, Papilloz. Callositas. Clavus. D. Cornu Cutaneum. Verruca. Ichthyosis. E. Keratosis Pilaris. Corium. Scleroderma. Morphcea. Sclerema Neonato- rum. Elephantiasis. Dermatolysis. Hair. Hypertrophy of the hair. Nail. Hypertrophy of the nail. Class VI.—Atrophies. Pigment. B. Corium. Albinism. Atrophia Cutis. Vitiligo. Atrophia Senilis. Canities. Striae et Maculae At- rophicae. HANDBOOK OF DERMATOLOGY. 23 C. Hair. Atrophy of the hair. Alopecia. D. Nail. Alopecia Areata. Atrophy of the nail. Class VII.—New Growths. A. Connective Tissue. Keloid. Molluscum Fibro- sum. Xanthoma. B. Cellular. Rhinoscleroma. Molluscum Epithe- liale. Lupus Erythemato- sus. Lupus Vulgaris. Scrofuloderma. Class VIII.- A. Hyperesthesia. Hyperaesthesia. Dermatalgia. Class IX- Vegetable. Tinea Favosa. Tinea Tricophyti- na. a. Tinea Corporis. b. Tinea Capitis. c. Tinea Barbae. Tinea Versicolor. Lepra. Syphiloderma. Carcinoma. Sarcoma. C. Bloodvessels. Naevus Vasculosus. Telangiectasis. D. Lymphatics. Lymphangioma. E. Nerves. Neuroma. F. Muscles. Myoma. —Neuroses. Pruritus. B. Anaesthesia. Anaesthesia. -Parasites. B. Animal. Scabies. Pediculosis. a. Pediculosis Cor- poris. b. Pediculosis Cap- itis. c. Pediculosis bis. Pu- The above does not contain a complete list of the diseases of the skin, nor is it more than a general guide. HANDBOOK OF DERMATOLOGY. CLASS I.—DISORDERS OF SECRE- TION AND EXCRETION. The diseases which are comprised in the above class, while purely functional in character, are of importance on account of their frequency and char- acter. They embrace the disorders of secretion and excretion of the sebaceous and sweat glands. They are not inflammatory in nature; and those patholog- ical processes, found accompanying these disorders which are not concerned in the purely functional disturbances of the glands, are accidental and not necessary accompaniments of the diseases. SEBORRHEA. Syn.— Seborrhagia, Fluxus Sebaceus, Dandruff, Acne Sebacea, Stearrhcea, Ichthyosis Sebacea. This disease is characterized by hypersecretion, and may exist upon any portion of the body, except the palms and soles. It is found most frequently upon the scalp (" dandruff"). It also occurs quite often upon the face and trunk. Two principal varieties are recognized—sebor- rhea sicca, and oleosa. Seborrhcea sicca is most frequent upon the scalp, although occurring in other localities. It presents the appearance of thin or thick crusts, composed of yellowish or greyish, sometimes dirty-looking scales, which separate quite easily and have an unctuous feel. The surface involved varies considerably in extent. The skin beneath these accumulations of sebum has a pale appearance, unless scratching or HANDBOOK OF DERMATOLOGY. 25 some irritating measure has caused a reddish ap- pearance. Itching is a symptom which is a con- stant accompaniment of this form of the disease. Seborrhea oleosa is the wet or oily form. It is seen most often during hot weather, and generally on the face about the alae of the nose. It presents a shiny, glistening appearance, the liquid sebaceous matter conveying the impression that oil has been poured upon the skin. A strong unpleasant odor accompanies the secretion, this being most marked about the umbilicus, genitalia and perineum. Seborrhoea may be either local or universal. As a rule, it is the former. In congenital, universal sebor- rhoea, the integument is stretched, the eyes and the lips are fixed ; and the fingers, toes, and auricles are undeveloped. Seborrhoea occurs at or after puberty; also in conjunction with or after severe fevers, systemic dis- orders, etc. While the disease is often dependent upon internal causes, cases are met with in which no known cause can be fixed upon. The differential diagnosis is comparatively easy, as the only disorders with which it might be possi- bly confounded, are eczema, psoriasis, ringworm, and erythematous lupus. The treatment of seborrhoea should be both con- stitutional and local, in the majority of cases. Good food, good air, good water, and, where debility or anaemia exists, cod-oil combined with ferruginous tonics and the hypophosphites. If the cause can be found,direct the treatment to that. A remedy of value, at times, is the sulphide of calcium (gr. 1-10 to 1-5 four times daily). Exercise should also be enjoined. Local treatment is very important and, frequent- ly, all that is necessary. The accumulated sebum 26 HANDBOOK OF DERMATOLOGY. should first be removed by soaking in oil and thor- oughly rubbing in— R Sapo. Viridis .......................................g viii. Alcoholis.............................................§ iv. Solve et Filtra. Take a half ounce of this mixture with water and shampoo the part well. Then dry the parts and apply some stimulating preparation, if there be not too much irritation following the wash. For stimu- lation, lotions may be employed such as contain car- bolic acid, cantharides, tincture of capsicum, bi- chloride of mercury, etc. Ointments are preferable, the following acting nicely: R Sulphuris precip............................... 3ss—3ij. Zinci oxidi............................................3ss. Ung. Aquae Rosse......................................5 i. M. The ammoniated mercury, red oxide of mercury, oleate of mercury, beta napthol, etc., may also be used with benefit. The prognosis of this affection is rather uncertain- The disease is essentially a chronic one, and much depends upon the general state of the patient. When occurring upon the scalp it may produce falling of the hair, unless treated energetically. It is more amenable to treatment upon non-hairy portions of the body. When universal, it is generally fatal. ASTEATOSIS CUTIS. In this there is a diminished or arrested secretion of sebum, generally local. The skin is dry, harsh and fissures easily at the flexures. It is found in all the atrophies of the skin, and accompanies some affec- tions (ichthyosis, lichen ruber, psoriasis). Local influences produce it, such as exposure to alkalies, alcohol, etc. There is no difficulty in recognizing this HANDBOOK OF DERMATOLOGY. 27 condition. The only method of treatment is to sup- ply the deficiency hy applying some bland fats or oils. COMEDO. Syn.—Acne Punctata, Black-heads. This disease, often found in connection with acne, presents the appearance of small black points, more or less marked, either on a level with the skin or as the central black dot of a slight, whitish elevation. The parts most frequently attacked are the face, neck and back. There are no subjective symptoms connected with comedo. It is a functional disease of the sebaceous glands in which, through some cause, the innervation is below par. An inspissation of sebum takes place in the gland itself and that portion in the duct con- tracts and hardens. Foreign material accumulates in the mouth of the duct and colors it black. Some- times the black dots occur in pairs, both ducts com- municating with one cavity—double comedo. The causes of comedo are various. Constipation, dyspepsia, gastric catarrh, etc.; hepatic troubles, chlorosis, anaemia may cause it. Some occupations, such as coal mining, working in tar, etc., also pro- duce it. There is no difficulty in making a diagnosis. Treatment should be directed to the general con- dition, in the first place. As constipation is the most frequent complication, it may be well to give an occasional dose of calomel, and the following acid aperient mixture: R Magnesise sulphatis............................... 3 iss. Ferri sulphatis................................. gr. xvi. Acidi sulphurici dil................................5 ij. Aquse ............................................S viij. M. Sig. Tablespoonful in water before breakfast. -28 HANDBOOK OF DERMATOLOGY. Locally, stimulants are indicated. Force out the -contents of each comedo with an extractor every day, Fig. 10.—Author's Comedo Extractor. then apply hot water (110° F.) followed by the fol- lowing ointment: R Sulphuris loti............................. .....3 as— 3i. Hydrargyri oleatis, (5 per cent).....................3 ss. Uug. Aquae Rosae....................................3i. M. Sig. Apply at night. When the comedones are small and in large num- bers, the following is a good application : R Acidi acetici dil......................................Si. Glycerini puriss...................................... 5 ii. Kaolini................................................5 iij. M. Sig. Apply at night. It is not necessary to mention here the stimulat- ing ointments which may be used with benefit. Sapo viridis, followed by a bland ointment, may be employed. Comedo is essentially chronic in its nature, but tends to heal spontaneously, generally disappearing at about the twenty-sixth year or a little later. MILIUM. Syn.—Grutum, Acne Albida, Strophulus Albidus, Pearly Tubercles. Milium is a common affection of the sebaceous glands, appearing as roundish, millet-seed sized, white papules, occurring for the most part about the eyelids and malar eminences. The milia are gener- ally opaque and are not accompanied by any sub- jective symptoms. The lesion is essentially a retention cyst, the sebaceous contents of the gland forming a hard HANDBOOK OF DERMATOLOGY. 29" round mass, the duct closing and the epidermis be- coming very thin. The contents, at times, although rarely, undergo calcareous degeneration and form dermatolithes (cutaneous calculi). Milium is entirely local in character, easily recog- nized and very amenable to treatment. The cyst i& emptied and its lining membrane destroyed. To accomplish this, the papule is cut open with a milium Fig. 11.—Author's Milium Needle. needle and the cyst wall scraped with a small, sharp spoon or with the convex edge of the needle. In- stead of this scraping, some irritating fluid, such as tincture of iodine, nitrate of silver, caustic potassa, carbolic acid, may be introduced. Finally we have the electrolytic method, which is rapid and effective. Any of the above measures, properly carried out, will cause the permanent disappearance of milia. SEBACEOUS CYST. Syn.—Atheroma, AVen, Steatoma, Sebaceous Tumor,. Follicular Tumor. The lesions in this trouble vary in size from a split-pea to a small egg, being rounded, hemispher- ical, or semi-globular. The skin covering this cyst is either normal or thinned and shining. The scalp, face, nucha, back and genitalia are most frequently affected. The duct of the sebaceous gland may still persist. When occurring upon the scalp the cyst is not covered by hair. Generally there is but one cyst and it occurs in preference in old persons ; adults being also subject 30 HANDBOOK OF DERMATOLOGY. to it. It is benign, unless ulceration, which may assume a malignant character, sets in. The treatment is purely surgical, electrolysis hav- ing also been successfully employed. Care must be taken to destroy the sac. In small sebaceous cysts the following, applied twice daily, sometimes causes their disappearance: R Ammonii sulphichthyolat.........................3 iss. Lanolini puriss.......................................Sl- M. The cysts have a tendency to enlarge unless re- moved. They are generally a source of annoyance to patients, on account of their location. HYPERIDROSIS. Syn.—Ephidrosis, Sudatoria, Idrosis. As its name implies, this disease is a functional disorder of the sweat glands, characterized by excess- ive sweating, either local or general, and depends upon some disturbance of the vaso-motor system of nerves. It is a common affection and, in summer or in exposure to other sources of heat, it is merely an intensification of a normal function. It may be transitory or permanent; or sympto- matic of fever or some other systemic disturbance. The form we are to consider more particularly is the local, permanent hyperidrosis. The parts most liable to be the subject of this disturbance are the pudenda, perineum, soles of the feet; the scalp and the palms of the hands being also frequently impli- cated. The skin assumes a pinkish hue, and appears sodden, the horny layer peeling off easily through maceration. Pressure upon the parts produces pain, in marked cases. HANDBOOK OF DERMATOLOGY. 31 General treatment, consisting of tonics of various kinds, combined with hygienic measures, is indi- cated. Locally, in mild cases, frequent washings, followed by astringent lotions or powders, are suffi- cient. As astringents may be used catechu, tannin, alum, zinc sulphate, etc. For instance: R Acidi tannici..........................................3ss Tinct. catechu.........................................Si. Alcoholis............................................5 vij. M. Use as a lotion. Weak solutions of permanganate of potassium, or of chloral hydrate are also beneficial. After using a lotion, a dusting powder should be freely applied. This may consist of talc, French chalk, magnesia, oxide of zinc, or bismuth subnitrate. By adding salicylic acid, a scruple to the ounce, the good effects will be enhanced. The form of hyperidrosis for which relief is most often sought is that affecting the feet. It is perhaps also the most difficult to relieve. If any of the methods given above fail to produce the required effect there are means still left, some one of which will prove successful. Thus, the daily application of a two per cent, sal- icylated mutton suet; painting the affected parts once every four or six weeks with a five per cent solution of chromic acid ; applying subnitrate of bis- muth liberally twice a day, without any further washing than that before beginning the treatment; bathing the feet in tar-water and then applying a solution of persulphate of iron morning and evening. The emplastrum diachyli renewed every second or third day will give good results in many cases; a belladonna or salicylic acid plaster will act in the same manner. Carb acid lotions, beta naphthoi 32 HANDBOOK OF DERMATOLOGY. in alcohol, boric acid in saturated solution, and cor- rosive sublimate solutions of varying strength are external applications employed in this affection. Hebra's method, which is the best, perhaps, is as follows: The feet are washed, and dried with a dusting powder. Then the soles and toes are covered snugly with pieces of cloth upon which has been spread, to the thickness of a knife-blade, the follow- ing ointment: R Olei olivarum opt...................................Sxv. Lithargyri.......................................Siij 3 vi. Aquae, q. s. Coque et fiat unguentum secundum atterc. Sig. Hebra's diachylon ointment. This application is to be made twice in twenty- four hours, the feet not being washed, but simply wiped dry with a cloth and dusting powder applied. In ten to fifteen days dusting powders only are used. If a relapse occurs the same course of treatment is repeated. The prognosis of hyperidrosis, especially of the local form, should be guarded. In old cases affect- ing the feet, the disease is very obstinate. ANIDROSIS. Syn.—Hypohidrosis. This disorder is characterized by a diminished amount, or total absence, of the sweat secretion. It is generally symptomatic and an accompaniment of some other trouble. When it exists independently the skin is dry, harsh, parchment-like, with a ten- dency to the formation of scales. In this form it de- pends upon a deficiency in the development, number, or function of the sweat glands. Anidrosis exists in chronic skin diseases such as ichthyosis, psoriasis, lepra, etc., and in certain of the neuroses, also in HANDBOOK OF DERMATOLOGY. 33 diabetes insipidus and mellitus. The treatment, in the variety which is not symptomatic, is tonics, hot or steam baths followed by massage of the skin. In general, there is very little to be done. BROMIDROSIS. Syn.—Stinking Sweat, Osmidrosis. In this disorder the condition is a qualitative dis- turbance of the sweat function. It is characterized by a heavy, penetrating, offensive odor, and may be either local or general, most frequently the former. It is seen more particularly in those whose complex- ion is dark, and in negroes. The greater the amount of perspiration the more intense the odor. While symptomatic of some diseases, it is, as a rule, idio- pathic and local. The portions most often implicated are the axillae, the genitalia, the perineum and the feet. The last especially emanate a most foul odor. Males are more often affected than females. It may appear at puberty or later in life. The diagnosis is easily made. The disease may be temporarily due to filth and negligence, but it occurs in those who are unexceptionally clean, and Mr. Thin claims that it is caused by the bacterium foetidum. The treatment is the same as that for hyperidro- sis with the exception of previously washing the parts in some disinfectant. For this may be em- ployed solutions of permanganate of potassium, cor- rosive sublimate, chloride or sulphate of zinc, all possessing the advantage of being odorless. Solu- tions of chloral hydrate are also said to act well. In obstinate cases much patience is required in 34 HANDBOOK OF DERMATOLOGY. order to obtain relief and energetic measures, in the form of strong antiseptics, may be necessary. CHROMIDROSIS. Syn.—Colored Sweat. Colored sweat is rarely observed. It may be yel- low, red, brown, black, green or blue (cyanidrosis). It may be generalized or localized. The majority of cases depend upon malingering in the subject. The genuine cases occur in women who are hysterical, anaemic, or who have menstrual disorders. Red sweat is due to the bacillus prodigiosum, most proba- bly. The treatment should be general and, where micro-organisms are found, locally antiseptic. H^matidrosis, or bloody sweat; Uridrosis, or urinous sweat; and Phosphoridrosis, or phosphor- escent sweat, are more in the nature of curiosities and will receive no consideration here. SUDAMINA. Syn.—Miliaria Crystallina. This affection is a functional disorder of the sweat glands manifesting itself as closely grouped vesicles having a whitish or pearl-colored appearance and of the size of a millet-seed. They may become conflu- ent. The back, chest, abdomen, extremities and limbs may be attacked, the face being exempt. The contents become absorbed in a few days and a mild desquamation follows. Successive crops may appear for weeks. There are no inflammatory symp- toms or subjective sensations observed. It occurs in the old and young, but more especially in those of weakened constitution. Sudamina de- HANDBOOK OF DERMATOLOGY. 35 pends upon an unusual activity in the secretion of sweat, which becomes so great that it cannot reach the surface rapidly enough, and getting between the layers of epidermis raises i t up in the form of vesicles. The diagnosis is easily made and treatment nil. The vesicles should not be opened, and all precau- tions taken to prevent excessive perspiration. HANDBOOK OF DERMATOLOGY. CLASS II—HYPEREMIAS. In this class of diseases we have the presence of an excess of blood in the vessels. There are two principal varieties of hyperaemia of the skin—active and passive. In the former there is increased red- ness, heightened temperature, due to an increased arterial flow; in the latter, a bluish color and low- ered or normal temperature due to a retarded flow of blood. The condition may be idiopathic or symp- tomatic. ERYTHEMA SIMPLEX. In this condition we have a heightened color of the skin involving more or less surface and disap- pearing under pressure. There is also an increase in temperature. The causes, in general, are heat, cold, injuries, or mechanical, poisonous or chemical agents, which are irritating. General disease or visceral complications produce symptomatic ery- thema. The idiopathic variety is divided into three principal classes, depending upon the cause—caloric, traumatic and chemical. Erythema caloricum is quite a common form, due to the action of heat or cold. Sometimes, the pro- cess is continued until inflammation arises. Erythema traumaticum is also common. It is due to pressure or rubbing such as is produced by bandages, trusses, garters, suspenders, etc. The friction of clothing or resting a part heavily against some solid body also produces it. Erythema veneratum is caused by a large num- ber of mineral and vegetable substances. Acids, HANDBOOK OF DERMATOLOGY. 37 alkalies, the anilines, mustard, arnica, turpentine, sulphur, mercurial preparations, etc., produce it, many being employed with that object in view. The symptomatic hyperaemias depend upon some internal cause, and are the result of derangements produced by diseases or drugs. When this form of hyperaemia occurs in nail-sized patches of a rosy color it is known as roseola. The only treatment is to remove the cause. If marked local irritation is present some- bland dust- ing powder or soothing ointment should be applied. ERYTHEMA INTERTRIGO. Syn.—Chafe. This disorder is simply a hyperaemia in which we find the skin hot, red, more or less excoriated, and the upper layers of the epidermis macerated. It occurs where the folds of the skin are largest or where the skin is subjected to a great deal of fric- tion, the neck, the internatal cleft, the perineum, the submammary fold, the axillae, the abdominal folds, the scroto-crural fold, etc., being the portions most frequently affected. The subjective symptoms consist of heat accompanied by more or less pain. When the disease is severe, a viscid, mucoid secre- tion is poured out. If this be permitted to go on, a dermatitis or eczema quickly supervenes. This disease is much more common in Summer than in Winter, being observed principally in in- fants and fleshy adults. Among the exciting causes are excessive or irritating underclothing, want of cleanliness, acrid secretions or foul deposits, and the friction of opposing surfaces of the skin. The diagnosis is easily made, except in aggra- vated cases, when it should be guarded, as the 38 HANDBOOK OF DERMATOLOGY. space of a day may show the trouble to be eczema or dermatitis. The treatment of erythema intertrigo is simple, but depends upon being faithfully carried out for its efficiency. In mild cases a simple dusting powder should be liberally applied, such as : R Pulv. Zinci oxid, Pulv. Cretae prep., aa,..................................Si- Talci Venet. Natri Bicarbonat. aa...................................5ij- M. Ft. Pulvis. This should be applied two or three times daily after washing the parts in cool water. Where we have a raw, excoriated condition, ac- companied by a thick, glutinous discharge, there should be a thorough cleansing followed by an astringent or slightly stimulating lotion, such as lotio nigra (diluted). Then apply over this a soft cloth on which has been spread a soothing ointment of which the following is an example: R Zinci Oxidi............................................3 ss. Pulv. Camphorae.......................................9j. Ung. Aquse rosae.......................................SJ- M. An ointment of this description soothes and acts also as a protective dressing. Erythema intertrigo is easily amenable to proper treatment, but prophylactic measures must be ob- served, as it is prone to relapses. HANDBOOK OF DERMATOLOGY. CLASS III.—INFLAMMATIONS. The inflammatory diseases of the skin form by far the largest as well as the most important class. The diseases are, apparently, of the most diverse character, both in appearance and in subjective manifestations. While this may be true, they still are properly classified under one head; for, in a pathological view, they are all involved in the same general process—inflammation. The degree of the process differs in different diseases, from an involve- ment of the superficial layers only of the skin, to those in which not only the entire skin, but the subcutaneous tissues are also implicated. Some of the diseases are acute and of short duration, heal- ing spontaneously; others, and these constitute the majority, soon become chronic and are not easily amenable to treatment. Again, some are benign in their course, occasioning little or no trouble, whereas others are a source of constant pain. The objective symptoms vary greatly in the different diseases, almost all the lesions being represented. The causes which lead to these inflammatory affec- tions are most diverse in nature, not only for the different diseases, but even in different examples of the same one. ERYTHEMA MULTIFORME. This is a polymorphous erythema in which pap- ules, tubercles or vesicles may appear. It is gener- ally of a severe type, malaise and fever accompany- ing it, the hands, forearms, backs of the feet and thighs, being most often affected. Other portions of 40 HANDBOOK OF DERMATOLOGY. the integument are also occasionally the seat of the trouble. It assumes the form of an annular lesion, sometimes. Relapses are frequent, the duration of the process lasting several weeks. General treat- ment, such as is indicated by the symptoms, is necessary. Locally, astringent lotions and pro- tective powders. Erythema papulatum, e. tuberosum, e. margin- atum, e. vesiculosum, and e. iris are varieties of the above. ERYTHEMA NODOSUM. Syn.—Dermatitis Contusiformis. This affection appears at first as erythematous patches on the lower limbs, most often over the tibiae, and soon assuming a node-like aspect. Burn- ing and pain upon pressure are the principal subr jective sensations, rheumatoid pains being also felt. In a short time, the reddish color changes to yellow- ish, greenish, etc. Successive crops may appear, each one lasting a week or ten days. It may be mistaken for a bruise, or for syphilitic nodes, when occurring over the tibiae. Astringent and cooling lotions are all that is necessary. URTICARIA. Syn.—Nettle Rash, Hives, Cnidosis, Febris Ur- ticata. This disease is one of frequent occurrence. It is characterized by a sudden eruption of wheals of various sizes and varying in number, which are either paler than the normal skin, or reddish. After a variable length of time these lesions disap- pear as suddenly as they came. Burning or pricking and itching accompany the eruption and scratching HANDBOOK OF DERMATOLOGY. 41 is apt to cause it to extend. In the acute form, at- tacks occur only when produced by some exciting cause and they are evanescent. When chronic, urticaria recurs again and again and the wheals have a tendency to persist. There are several varieties which are rather infrequent. Urticaria pigmentesa is followed by persistent pigmentation. In urticaria papulosa we have the formation of papules. When the wheals assume an enormous size we have urticaria tuberosa or giant urticaria. The diagnosis is comparatively easy. Where wheals exist, which are the the result of insect bites, the central haemorrhagic point will reveal the cause. The causes of urticaria are external and internal. The former are those agents which act as direct irritants to the skin. The latter are such as act from within. Among internal causes are febrile disturbances; certain articles of food, such as shell- fish, mussels, oysters, cheese, strawberries, etc.; certain drugs such as balsam copaiba, oil of turpen- tine, etc., and moral causes, such as fright, anger, grief. Disturbances of the genito-urinary, respira- tory, or digestive apparatus may also act as causes. This disease is probably a reflex vaso-motor dis- turbance, resulting in a sudden, circumscribed exudation, which is reabsorbed ; or, the result of an irritation of the peripheral nerves. The treatment of acute urticaria is expectant. Sometimes, an emetic will cut short an attack, and to prevent a recurrence a saline laxative should be administered. The internal exciting cause should always reoeive attention. Atropine in one-sixtieth grain doses will be found beneficial in aborting 42 HANDBOOK OF DERMATOLOGY. attacks. This can be given twice daily and its effects should be closely watched. Hydrobromate of quinia in three-grain doses twice daily, and sali- cylic acid, not to exceed seventy-five grains in a day, are also given with success. For local use, to allay the itching and irritation, cold water, hot water, vinegar, whisky, dilute or pure alcohol, solution of carbolic or of salicylic acid, solution of chloral, or ointments containing seda- tives may be used. Peppermint water, cherry laurel water or a mixture containing chloral hydrate and morphine act well. In fact, any application con- taining a sedative will be beneficial. ECZEMA. Syn.— Salt Rheum, Moist Tetter, Scall, Milk Crust. This multiform skin disease is the most frequently met with, constituting about one-third of all cases applying for treatment. The great number of vari- eties which have been made by different writers has only served to confuse the subject which, at best, is a difficult one in the consideration of the principles involved. We have here to deal with an inflamma- tion, and, as in other portions of the body, we have all the classical symptoms of that process present. In addition, multiform lesions appear and a sub- jective symptom, which is in the highest degree dis- tressing—itching. Clinically, there are several types of eczema, each one, however, having variations. This must not be forgotten, as these types are but different stages of the disease. There are six general symptoms observed in eczema which it is well to remember: 1° Itching, HANDBOOK OF DERMATOLOGY. 43 tingling, or burning pains; 2° Redness; 3° Ery- thema, papules, vesicles, pustules, or exudation; 4° Crusting and scaling; 5° Infiltration, thickening; 6° Fissures. Eczema erythematosum is a form of the disease in which the skin is red, hot, and exhibits some swell- ing. A moderate amount of itching is also present. This form may continue until it becomes chronic or it may lapse into some other type. It occurs in mid- dle life and old age, is symmetrical, and most often involves the face. It may involve a large or small extent of surface. Sometimes small papules are observed in connection with it. Eczema papulosum is characterized by a papular eruption with, occasionally, a few vesicles. It may exist alone or combined with the former type. The papules have a dark red color, and frequently a lit- tle crust of blood crowns the apex. Eczema vesiculosum is generally acute and a typ- ical case is rarely seen. When seen the vesicles have broken down and the surface presented is moist and thickened patches show themselves. Eczema pustulosum should present marked pus- tules ; but, as a rule, they soon break down, leading to the formation of crusts of a yellowish color. While the itching, as in the vesicular type, is not marked, it is frequently intensely painful. Eczema rubrum, or eczema madidans, presents a red and angry appearance, exudation being quite abundant. It is caused by a loss of epidermis, fol- lowing an acute or chronic process. The exudation generally forms crusts at different points. Eczema squamosum is characterized by a constant shedding of rather thin scales, from an erythema- tous surface. Itching is marked in this form. 44 HANDBOOK OF DERMATOLOGY. Eczema fissum is generally a result of the preced- ing, the fissures occurring about the flexures of joints penetrating to and deep into the rete Mal- pighii. These fissures are exceedingly painful, es- pecially when irritants find their way into them. Eczema sclerosum is observed chiefly about the palms and soles and finger tips, in which a degree of thickening of the skin takes place. Eczema intertrigo and eczema verrucosum relate to forms of the disease, the names readily suggest- ing the appearance. The stages of eczema may be divided into acute, subacute and chronic. . Acute Eczema may or may not have prodromata. The skin becomes red, hot and cedematous, the de- gree of this latter varying with the amount of sub- cutaneous tissue in the part attacked. In a very short time, papules, or vesicles may appear or the epidermis may become denuded. In some cases it remains erythematous. In this form of eczema it is frequently difficult to distinguish it from intertrigo or from dermatitis. Protection will frequently bring about a return to the normal. Subacute Eczema,while not presenting the intense inflammatory symptoms observed in the foregoing, is attended by moderate pain, itching and thicken- ing of the skin. In addition, more or less exuda- tion, with the formation of crusts, occurs. Chronic Eczema is marked by a tendency to recur and to persist. Itching is generally intense, although absent in some varieties. Crusts and scales are present and exacerbations of an acute character occasionally take place. Fissures show themselves and, at times, the skin merely appears tense, red and shining. HANDBOOK OF DERMATOLOGY. 45 Eczema is found at all ages and in both sexes. It is not contagious nor inherited, although a condi- tion predisposing to its development seems to be transmitted from one generation to another. Two classes of causes are recognized in this disease: local or external, and general or internal. Any agency which will irritate the skin, whether it be frictional, traumatic, chemical, or toxic, may call eczema into being. The constitutional causes are such as produce defective assimilation or debility and have been classified broadly as the gouty, the strumous, and the neurotic conditions. The first, including the "rheumic"of some authors, is perhaps the most common of the internal causes and by directing attention to this a marked effect is soon observed. Among causes not mentioned by authors is the influence of certain micro-organisms which primar- ily produce an irritation causing a subsequent ec- zema in those predisposed to it. Air and water are also active agents in the production of this disease as well as in its continuance. A consideration of the forms of eczema, attack- ing the different organs of the body, is perhaps the best and simplest mode of dealing with this compli- cated subject. Only such general notions in regard to treatment can be given as will serve for general guides. It is only in works especially devoted to the consideration of this disease that details can be given. They should be carefully studied, as eczema is the "keystone of dermatology" and a thorough knowledge of its symptoms and treatment ensures an equal acquaintance with the other diseases inci- dent to the integument. 46 HANDBOOK OF DERMATOLOGY. Eczema of the face and scalp.—In infants and children it is the pustular form which is most often encountered in these localities ; in adults, the erythematous and squamous, the pajmlar being seen in both. In eczema of the eyelids we have the thickened edges, red and exuding a viscid material which glues the lashes together. It is often necessary to employ constitutional measures in addition to the local application of soothing ointments. Eczema of the lips may exist alone, affecting the skin or involving the vermillion border, or the com- missures. It is generally rebellious to treatment, involvement of the upper lip depending upon nasal discharges. In adults, the lips sometimes fissure and become dry. In the latter cases, gastric de- rangements are generally the cause and should receive attention. Eczema of the ears is frequent in children, and involves the entire auricle, or external auditory canal. The ears become thickened, swollen and painful, and, later on, moist, crusty and itchy. Be- hind the ear, the most frequent site in adults, it persists and causes fissures to appear. Eczema of the scalp assumes three principal forms: the pustular, moist exuding, and dry scaly. In infants and children it is the first which is most often seen. The pustules soon burst and crusts are formed which mat the hair, and underneath a moist, reddened, irritable surface exists. In infants it fre- quently assumes the form of a yellowish crust, cov- ering the vertex and of considerable thickness, popularly known as "milk crust." It sometimes passes on to the moist exuding, which is the form HANDBOOK OF DERMATOLOGY. 47 seen in adults, although not so frequently in the lat- ter as the dry scaly. The itching is marked in all three varieties, and in the two former some pain is also present. Eczema of the face is pustular in children and erythematous or papular in adults. In the former crusts soon form, generally about the cheeks, invad- ing the ears, and in the latter the forehead, nose, eyelids, and cheeks are also involved. Eczema of the Hands and Arms.—Eczema of the hands is generally chronic. Sometimes it is acute and then it presents itself most frequently upon the dorsum and extends to the fingers. In the subacute or chronic state it is somewhat different in appear- ance from the condition presented in the acute form which is erythematous and papular, as a rule. In the chronic state we have a dry, hard, thickened skin, found most frequently upon the palms, having a tendency to scale and very liable to fissure at the natural folds. Owing to the exposure of these parts to external irritative influences the condition is very rebellious to treatment. Eczema of the arms exhib- its about the same characteristics as upon the integ- ument in general. At the bend of the elbow, how- ever, it frequently becomes squamous and fissures are very apt to occur. Eczema of the Feet and Legs.—In these localities the tendency of the disease is to become chronic in a very short time. Eczema of the feet in its general characteristics is similar to that of the hands. Some- times the eruption is vesicular about the toes. In eczema of the legs we have a condition generally assuming the form of eczema rubrum. Occasionally it is dry, shiny, and here the itching is always more 48 HANDBOOK OF DERMATOLOGY. or less intense. The disadvantageous conditions of circulation tend to render the affection stubborn in this locality and to lead to the formation of ulcers. A papular form is not infrequent on these extremi- ties. Eczema of the Anus and Genital Regions.—In these places we have a localization of eczema which is, in the highest degree, distressing. There may be but a very slight eruption, or a raw exuding surface, accompanied by marked thickening of the skin, may manifest itself. Eczema of the Trunk.—The trunk is sometimes invaded in its entirety, the form being erythema- tous or papular, sometimes squamous to a certain degree. The opposing surfaces of trunk and mamma in the female are affected by a moist, raw form, and the nipple by a thickened fissured variety. At the umbilicus we have an exuding form, and in the az- illoz a similar condition. Universal Eczema.—This condition is one which generally shows a repressed condition of the whole system. It is very distressing and rebellious to treatment. It begins as an erythematous eczema, but has tendencies to assume a more or less squam- ous form in those localities which are prone to assume a scaly process. It is seen in those who are adults or past that period of life. In this form the itching is marked. Infantile Eczema.—Nearly all cases of eczema occurring in children under five years of age, are classified under this general head. In these the dis- ease assumes an acute form, exudation and pustula- tion not being uncommon. Crusts and excoriations are generally present and the itchang is intense. HANDBOOK OF DERMATOLOGY. 49 The Diagnosis of the various forms of eczema is, at times, a very difficult matter. Eczema of the face resembles erythema, acne rosacea, and erysipelas; in the beard it is similar to sycosis or tinea barbae ; upon the lips it simulates mucous patches, or herpes labialis. The pustular form occurring on the scalp might be mistaken for pediculosis, the pustular syphilide, or favus, and the scaly form looks like seborrhoea, pityriasis, psoriasis, tinea tonsurans, and favus of long standing. On the dorsum of the hands it is sometimes similar to scabies, dysidrosis, lichen planus, or papular erythema; and on the palms (or soles) to psoriasis, or the squamous syphilide. On the legs, the ulcers resemble those due to varicose veins, or to syphilis. About the anus and genitals it might be confounded with tinea cruris, or pediculosis pubis, scabies or syphilides. The eczematous le- sions of the trunk are sometimes of a form suggest- ing psoriasis, tinea, herpes zoster, syphilis, or pityri- asis rubra. When about the breast, it might be taken for scabies, epithelioma, or"Paget's disease." In the axillae it frequently resembles tinea of that re- gion. The treatment of this disease is perhaps no less difficult or important than the diagnosis. And it is not only the treatment, but the management as well, that is productive of a good result. The diet and hygienic conditions of the patient should be care- fully looked after and, in a great measure, adapted to the general diseased condition. In all cases, it should be especially adapted to the individual, as each one is a law unto himself. Arsenic will not cure the disease. Generally, attention to the bowels and stomach, alkalies, bitter tonics and nutritives that are easily assimilated, are of benefit. While 50 HANDBOOK OF DERMATOLOGY. fats are often of benefit, starches and sugars should be avoided, as well as alcoholics. Overfeeding should also be restrained and, in some cases, " diet- ing" will be found of marked benefit. Local treatment, while extremely various, so far as a choice of remedies is concerned, is based on gen- eral principles applicable to all diseases. In irri- tated, acute conditions, soothing applications are indicated ; whereas, in chronic conditions, stimulat- ing remedies should be used, or even irritants, if necessary. It should never be forgotten that air and water have a deleterious effect upon eczema. The latter is of benefit only when modified by some addi- tion, and is of most use in the form of the continuous bath. In the treatment of eczema of the face and scalp, soothing and astringent measures should be em- ployed. Crusts should be removed by poultices or oils, and tannin ointment applied or one containing oxide of zinc and camphor. Where the process is pustular, remove the crusts with oil and apply cam- pho-phenique (pure) twice daily. Diachylon oint- ment to the face is very good, as also to the affected surface, after shaving the beard. Tar ointment occa- sionally acts well. In eczema of the hands and arms, apply cooling lotions and ointments, when the process is acute. In subacute cases, tar ointment, or one containing creasote, acts well. In chronic forms, sapo viridis, followed by diachylon ointment. In eczema of the palms (and soles), touching the surface to hot water (110° F.) and subsequently wrapping in diachylon ointment, is one of the best methods. Avoid all con- tact with water; and, if absolutely necessary to wash, put borax or bicarbonate of soda in the water. HANDBOOK OF DERMATOLOGY. 51 A stimulating mercurial application is also indi- cated, at times. Eczema of the legs is treated very much by means of the rubber bandage (Martin's) during the day, the surface being covered with a soothing ointment at night. The bandage must always be washed be- fore being reapplied, and care taken that it does not produce additional irritation. In chronic cases, stimulating applications should be made, such as : R Picis liquidae ...........................................Sij. Potassae causticae.......................................Sj. Aquae.....................................................3 v. M. This is diluted according to indications, and fol- lowed by some soothing application. Eczema of the feet should also be stimulated by tar ointment, fol- lowed by some soothing application. For the soles, the same treatment as for the palms. Eczema of the anus and genitals is dependent upon its success, in a great measure, upon internal and dietary management. Locally, a tar and zinc ointment is valuable, applying it after soaking the parts in hot water. Soothing powders are also good. The compound tincture of green soap, as fol- lows, is a good stimulant: R Olei cadini, Saponis viridis, Spts. vini rectiflcat. aa..................................Sj- M. Ultra et adde: Spts. lavendulee..........................................3ij. M. Of course, this should be followed by a soothing application. The condition of the bowels and kid- neys should receive particular attention, and the presence of haemorrhoids, and fistulae, and fissures, etc., should be determined and relieved. 52 HANDBOOK OF DERMATOLOGY. In eczema of the trunk, the treatment differs but little from that of other forms. In universal ecze- ma, we have a condition to deal with which is seri- ous, and requires tonics. Baths are serviceable here. Still the trouble is very rebellious, and frequently all the measures that can be devised do but little to ameliorate the condition. In infantile eczema, soothing applications are generally required, and the abstention from too much washing. Calomel is frequently necessary to evacuate the bowels, and is one of the best remedies for this purpose. Crusts should be removed, and a zinc or subnitrate of bismuth ointment applied to the local trouble. A little tannin added is sometimes of benefit. Often, when the trouble is about the body or extremities, the liberal use of a dusting powder containing some camphor is of value. The one great point to observe in connection with this form is to avoid overstimulation. Seborrhceic eczema is a variety whose place in nosology has not yet been definitely settled. It is characterized by fatty scales overlying a reddish base. The lesions are roundish or ovalish in shape, large or small, occurring for the most part on the scalp, trunk and limbs. There is pronounced itching present. It may be easily confounded with psoria- sis. It is essentially an inflammation of the secre- tory cells of the coil glands, and affects parts subject to hyperidrosis. The treatment is simple. Removal of the scales with sapo viridis and the application of an ointment containing from one-half to one drachm each of zinc oxide and sulphur to the ounce of excipient will procure relief. Relapses are very prone to occur. HANDBOOK OF DERMATOLOGY. 53 HERPES. Syn.—Fever Blister. Herpes is an inflammatory disease, in which we have the occurrence of small groups of vesicles, of about the size of a hemp-seed, and situated upon a slightly reddened base. The vesicles may occur almost anywhere, but seem to have a predilection for the face and genitalia. The subjective symptoms are slight and consist of a burning or tingling sensa- tion. The trouble is self-limited, running its course in from seven to ten days, and leaves more or less pigmented macules. The two varieties commonly described are herpes facialis and herpes progeni- talis. Herpes facialis attacks generally the lips (h. labi- alis) near the vermillion border, the cheeks, the nose, the eyelids, the ears, etc. The vesicles fre- quently coalesce. In three to six days they dry up and form crusts which are adherent, but soon drop off spon taneously. Herpes progenitalis is also frequently seen. It is most frequent on the prepuce (h. preputialis), and glans penis ; it is also seen upon the vulva and labia minora. It first appears as an erythematous spot, discrete vesicles show themselves and, breaking down, give rise to excoriations, or small superficial ulcers which are followed by crusts and some des- quamation. Relapses are frequent. This variety is important as it is apt to be confounded with venereal ulcers. The causes of this disease are febrile disturbances and external irritants. Bazin and Hardy have claimed the existence of a herpetic diathesis. Gas- tric and intestinal disorders also act as a causo 54 HANDBOOK OF DERMATOLOGY. The diagnosis is to be made from herpes zoster and eczema. The treatment is entirely symptomatic. Locally, protection to the vesicles is necessary. This can be accomplished by means of absorbent cotton upon which a weak zinc oxide ointment, or unguentum aquae rosae has been spread. When crusts make their appearance let them fall off spontaneously. In herpes progenitalis, if the vesicles have rup- tured, some astringent wash or ointment should be employed. By using a solution of one in eight of nitrate of silver on the excoriations and following this up with an astringent ointment, a rapid recovery will follow. Saline laxatives are useful to prevent relapses. HERPES IRIS. Syn.—Hydroa, Herpes Circinatus. This is comparatively rare. We have here small vesicles appearing in concentric circles, each one surrounded by an areola. The intervening integu- ment assumes a bluish, reddish, yellowish, or vio- laceous tint. The diagnosis is generally easily made and the treatment is, in the main, that of herpes. HERPES ZOSTER. Syn.—Zona, Clngulum, Shingles, Zoster, Ignis Sacer. Herpes zoster is acute in character and vesicular in form. It is preceded by malaise, fever, neuralgia, etc., which may last a few hours or days, or even weeks. The neuralgic pain is localized and marked. The eruption makes its appearance first as an ery- thema, soon followed by groups of papules which, in a short time, are changed into vesicles. The vesi- cles, which vary in size from a pin-head to a split- HANDBOOK OF DERMATOLOGY. 55 pea, are distributed in groups of ten or more, closely aggregated and surrounded by a marked, red areola. Frequently they coalesce. Successive crops keep on appearing. The vesicles become opaque, the con- tents become purulent, and, in from nine to ten days crusts have formed which drop off, leaving the skin slightly pigmented. The distribution of the vesicles is a notable feature. They are always situ- ated along the course of cutaneous nerves and this ia the reason that the disease is so rarely bilateral. The nervous origin of this trouble is well estab- lished. The disease is at its height during the first week. The vesicles have no tendency to rupture, but may be torn open. It is seen most often in winter. The causes are such as produce injury to nerve trunks or to the posterior spinal roots. The diagnosis is, as a rule, not difficult. It might be confounded with herpes but its distribution and subjective symptoms serve to differentiate it. The different varieties mentioned by some authors are merely named from the locality in which the lesions are found. The fact that the disease is gen- erally unilateral, that it most often attacks the trunk, and that, when in the temporal and ocular regions, it may attack the cornea, should not be forgotton. The treatment should be internal and external. For the former phosphide of zinc in doses of one- third of a grain four times daily is recommended. Arsenic is also useful in tonic doses given in the form of arsenious acid, Fowler's solution, or the bro- mide of arsenic. Morphine, bromide of potassium, and other sedatives are frequently necessary to re- lieve the intense neuralgic pains. Locally, protec- tion of the lesions is indicated. Cotton, upon which 56 HANDBOOK OF DERMATOLOGY. a soothing powder containing some anodyne has been spread, is probably the best. To soothe the local pains, galvanism may also be resorted to. The vesi- cles should never be opened and, if they accidentally burst, the ulcers should be treated antiseptically. MILIARIA. Syn.—Lichen Tropicus, Miliaria Alba, Miliaria Ru- bra, Prickly Heat. This common affection occurs in two forms, the papular and the vesicular. Miliaria papulosa is composed of an eruption of a very large number of minute, bright red papules, but a trifle elevated. The papules are crowded but never coalesce. The eruption appears rapidly and is preceded by excessive perspiration. Miliaria vesiculosa is similar in distribution and appearance with the exception that the lesions are minute vesicles. At first transparent, they become whitish and opaque {miliaria alba). The skin has a red color due to the areola surrounding each vesicle. The vesicles soon dry up and are followed by a slight desquamation. The portions most commonly attacked are the abdomen, the chest, the neck, and the arms, although any portion of the integument may be the seat of the disease. It is symmetrical in distribution. Burn- ing, tingling and itching are the accompanying sub- jective symptoms. The cause of miliaria is excessive heat, due to the atmospheric temperature, clothing, or both. Fleshy individuals, adults and children, are most subject to it. The affection is easily recognized, its sudden onset distinguishing it from eczema, and the subjec- tive symptoms from sudamina. HANDBOOK OF DERMATOLOGY. 5T The treatment is essentially refrigerant. Cool clothing, a cool room, plain food, acid drinks and saline aperients are beneficial. Absorbent dusting powders are indicated locally. Mild astringent lotions, such as very dilute sulphate of copper solu- tion, act well. Alkaline baths are excellent, or the " dabbing " on of a borax solution. No fear need be entertained from retrocession. Relapses are frequent and while not dangerous in our zone, miliaria may become transformed into a dermatitis or eczema on account of the scratching indulged in. For this reason it is well to watch it. It is essentially a disease of summer. Dysydrosis is a vesicular disease of a peculiar character in which the vesicles coalesce and form bullae in which the fluid is reabsorbed. Desquama- tion sets in and an excoriated surface is left. The affection is rare. Poiui'HOLYxand Cheiro-Pompholyx are similar affections which are rarely met with. They attack the hands and forearms most frequently. PEMPHIGUS. This is an uncommon disease which manifesto itself by the appearance of bullae of various sizes. It may be acute or chronic in character, two varieties being recognized : pemphigus vulgaris and pemphi- gus foliaceus. Pemphigus vulgaris is found most frequently upon the limbs. The blebs are roundish or ovalish and vary in size from a split-pea to a goose-egg. They contain serum or pus and have a reddened base. They vary in number from one or two to several dozen and occupy three to six days to develop. Suc- cessive crops appear. Itching and burning are pres- 58 HANDBOOK OF DERMATOLOGY. ent. In the acute form severe general symptoms frequently occur and death often terminates the case. Pemphigus foliaceus is a rare and a grave form. The blebs are flabby and rupture easily. It is chronic and after the blebs rupture there are left flakes on an unhealthy, excoriated surface. The serum in the blebs becomes puriform in a short time; sometimes the contents of the bulla are bloody. The reaction of the serum is neutral or weakly alkaline, becoming more markedly so as the lesions become older. The treatment should be both internal and ex- ternal. Any functional disorders which exist should be corrected. A good diet and hygienic condition should be 'insisted upon. Arsenic should also be exhibited in this disease as it acts almost as a spe- cific. Locally, very simple measures are necessary. Open the blebs freely and allow the contents to escape. Dress the lesions with dilute lotio ingra, or with dilute liquor picis alkalinus. A dusting pow- der or some bland ointment may be used as a dress- ing. If a large amount of surface be involved starch or gelatin baths should be employed. The contin- uous bath is excellent in grave cases. In pemphigus foliaceus tonics are particularly indicated. In ad- dition to this linseed oil, internally and externally, has given some of the best results. Relapses are common in pemphigus, and its course and final result are very uncertain. LICHEN RUBER. This disease is very rare. It begins as small coni- cal papules of waxy appearance, of brownish red color, symmetrical in distribution and having a ten- HANDBOOK OF DERMATOLOGY. 59 ■dency to invade extensive surfaces. The face is gen- erally affected. The papules flatten, acquire a cen- tral depression and desquamate slightly. The pap- ules acquire a uniform size and never grow large. They fuse into patches which are rough and of an even brownish-red color. It is not known to attack mucous membranes. The nails and hair become affected. A diffuse, yellowish, brown stain, in large expanses, follows the patches. Itching, when pres- ent, is mild in the beginning. In the chronic stage it is moderate, but never severe. Emaciation gen- erally accompanies this disease and, in long stand- ing cases, death by exhaustion occurs. Arsenic, internally, has been recommended but it does little good. Iron, strychnine and phosphor- us with quinine gives better results. Hot alkaline baths, frictions with tincture of sapo viridis and oily inunctions are valuable local measures. Where there is much thickening and fissures, such as in the palms and soles, balsam Peru and diachylon ointment (3 j to g j) is the best application. The disease is essentially chronic and difficultly amenable to treatment. LICHEN PLANUS. In this disease, which is regarded by some as a variety of lichen ruber, we have the formation of inflammatory spots and patches which remain local- ized. Flat, red papules form and these flatten into round, oval, angular, or polygonal outlines. Their surface is covered with a thick horny layer, silvery in appearance and having a central depression. The surface has a micaceous appearance, never waxy. The papules increase in size and may develop into patches. Each papule runs an independent course. 60 HANDBOOK OF DERMATOLOGY. They are of a deep red color at first, and later on be- come violaceous or lilac. When chronic, dense, hard, uneven surfaces are seen especially about the knees and ankles. It is then of a dark or crimson-brown hue. It is symmetrical, beginning at the inner part of the forearms near the wrists, upon the abdomen, and inner part of the legs and thighs. It rarely occurs on the palms or soles. The nails and hair are unaffected. It may attack mucous membranes. It leaves a dull-red, rusty-brown, or crimson-brown stain in irregularly shaped patches. Itching is marked in the beginning; afterwards it may be mild or intense. There is no serious systemic reaction. The treatment is similar to that of lichen ruber, which it greatly resembles in its tendency to chronicity. PRURIGO. Prurigo is very rare in this country, although common enough in Austria. It commences to make its appearance in early \ ears and generally contin- ues to remain through adult life. It consists of sub- epidermal papules which vary in size from a millet- seed to a split-pea. The lesions are discrete or situ- ated close to each other, but never grouped. They appear as pale-red elevations covered, at times,with a scanty dry epithelium (not scales), and having a hard, shotty feel. The itching is iutense, and as a result of the scratching, which is indulged in, the papules present torn tops, blood-crusts, and excoria- tions are present; and, eventually, thickening and hardening of the skin, and pigmentation. The portions most often attacked are the extensor surfaces of the arms, legs, and the trunk. The palms and soles are never affected and the head but rarely. HANDBOOK OF DERMATOLOGY. 61 The disease is exceedingly rebellious to treatment and all that can be done is to mitigate the symp- toms. Tar and sulphur applications act best, aided by antipruritics. The tendency is for the process to remain chronic. LICHEN SCROPULOSUS. This affection of the skin is not of common occur- rence. It consists of an eruption of flat, reddish or yellowish, grouped papules which are millet-seed sized. It occurs in scrofulous individuals chiefly on the trunk and about the openings of the hair folli- cles. Itching is present to some extent. Treatment by means of cod liver oil, internally and externally, is efficacious. ACNE. Syn.—Acne Vulgaris, Varus, Stone-pock, Whelk. This is one of the most common skin diseases. It consists of an inflammatory condition of the seba- ceous glands and manifests itself in the form of pa- pules, pustules and tubercles distributed, for the most part, about the face, neck, back and shoulders. There are no subjective symptoms except slight pain upon pressure when the disease is in its acute form. Acne papulosa is characterized by bright to dusky red papules varying in size from a pinhead to a split-pea. These papules undergo more or less reso- lution or may enlarge and become indurated. Or a minute quantity of pus may show itself at the apex. Acnepustulosa, as its name indicates, is distinctly pustular. The papules, in some cases, rapidly change into pustules, which develop until their acme is reached. Their contents are then discharged, a small crust forms and heals spontaneously, new crops appearing. 62 HANDBOOK OF DERMATOLOGY. Acne tuberculosa is characterized by a number of small or large, generally flattened, reddish tubercles which have a tendency to remain in statu quo, or to enlarge. Acne artiflcialis is that form due to the influence of external irritants, such as tar. Acne cachecticorum is found in those affected with some depressing disease. The lesions are indolent, papulo-pustular, more or less livid, and leave scars. Acne atrophica is a form in which variola-like scars follow the lesions. In acne, successive crops of lesions are continually making their appearance, and the tendency of the disease is to chronicity. The first appearance is generally at puberty, and it disappears spontan- eously at the twenty-seventh year or somewhat later. The causes of this disease are numerous. The most frequent are gastro-intestinal disturbances. Constipation is almost always an accompaniment and dyspepsia frequently so. Uterine disorders and genitourinary disturbances also act as factors. The diagnosis is not difficult. It must be distin- guished from eczema, small-pox, and syphilis. The history and subjective symptoms are sufficient to establish the difference. The treatment should be local and general. For the constipation which exists, particular attention must be paid to the diet. To cause the bowels to act more regularly, fluid extract of cascara sagrada, or the aperient mineral waters are useful. An occa- sional dose of calomel will be of benefit. Duhring's acid aperient mixture (p. 27) is productive of good results. Besides remedies for the regulation of the functions of the stomach and bowels sulphide of HANDBOOK OF DERMATOLOGY. 63 calcium, in quarter grain doses, is to be given four times daily in the suppurative form of the disease. Arsenic is sometimes useful in the indurated forms, in doses of one or three drops of Fowler's solution in wine or iron, or in one drop doses, in water, of a one per cent, solution of bromide of arsenic, thrice daily, after meals. Ergot is said to be a valuable internal remedy in acne. The local treatment should be either soothing or stimulating according to the indications presented. The latter is generally the plan that is to be adopted. The methods of stimulating are numerous. Sapo viridis, pure or diluted, may be applied. This is washed off, after a short time, and a bland ointment applied. Hot water cloths applied at night and fol- lowed in the morning by cold douches, and frictions are valuable. Sulphur is probably the best remedy. It may be applied in the form of ointments or lotions, varying in strength from twenty grains to two drachms to the ounce. The following lotion, recommended by Bulkley, is good: R Sulphuris loti.........................................3 j. ..Etheris..............................................3 vj. Alcoholis............................................3 iijss. M. Sulphuret of potassium may be used, also Vle- mingkx's lotion. Ichthyol, which is very rich in sulphur, is also excellent, put up in ointment form in the strength of one-half to one and one-half drachms to the ounce. Sulphur and oleate of mer- cury in combination is also excellent. In those cases in which pustulation begins at the apices of the papules, it is due to cocci from with- out, and may be prevented by opening the small pustules and applying a 1-1000 bichloride solution, 64 HANDBOOK OF DERMATOLOGY. this to be repeated before each regular application, in order to prevent the local suppurative process. In the indurated and tubercular forms of acne, free scarifications and warm cloths to induce haemor- rhage is a very good plan of reducing the hyper- plasia. Local mercurials, in conjunction with this, act very well. Care, however, should be taken not to overstimulate the skin with these external appli- cations, as more damage may result from this than benefit from the remedy. While acne is difficultly amenable to treatment, proper management generally secures good results. ACNE ROSACEA. Syn.—Gutta Rosea. This trouble is a rather common one, occurring in both sexes. It is usually confined to the nose and adjacent parts, such as the cheeks and central por- tion of the forehead, or it occasionally involves but a limited part and remains localized. There are no subjective symptoms. It is usually divided into three stages: the hyperaemic, the inflammatory and the hypertrophic. In the first stage there is more or less diffuse red- ness of the part, the process being a passive hyper- aemia somewhat inclined to stasis. When the nose is attacked, it looks shining and greasy from the seborrhoea which is present. This stage may be permanent or it may pass on to the second in which the redness is more marked, the capillaries are en- larged, and visible as small, bright red, delicate lines running over the surface. In addition, acne of a papular and pustular type is found. In the third stage, hypertrophy of the cutaneous tissues takes place, the vessels become greatly enlarged, the nose HANDBOOK OF DERMATOLOGY. 65 becomes nodulated, of a violaceous tinge, pendulous and, sometimes, of enormous proportions [rhino- phyma), the openings of the ducts of the sebaceous^ glands being patulous. This disease is essentially chronic. In women it frequently does not go beyond the first stage, and not often beyond the second in any. The causes are varied, such as uterine disorders,. exposure to heat and cold, excesses in eating or drinking, the free use of alcoholics, and any of those conditions which produce acne. The diagnosis is not difficult, as a rule, since it only needs to be differentiated from acne, syphilis, lupus vulgaris, or lupus erythematosus. The treatment is, in the main, that of acne. Stim- ulants locally, and careful general medication. The withdrawal of alcohol and proper dietetic measure* must be enforced. In the second stage, the dis- tended bloodvessels should be destroyed by cutting them open; by electrolysis, which is the best method ; by cutting across at short intervals ; or by other measures, which may suggest themselves. Strong local stimulating measures are indicated. In the third stage nothing but surgical measures. will prove of much avail. SYCOSIS. Syn.—Sycosis Non-parasitica, Mentagra, Acne Mentagra, Folliculitis Barbae. Sycosis is a chronic pustular disease limited to the hairy portions of the face and, on that account, found only in men. It begins as a small, red macule surrounding a hair. In a short time, it is trans- formed into a small pustule, non-elevated, through whose center a hair emerges. There is deep-seated 66 HANDBOOK OF DERMATOLOGY. pain, burning and tingling. If permitted to con- tinue, the skin becomes red, the pustules increase in number, the integument thickens and nodules form. The upper lip is a favorite site for sycosis; the beard is also frequently involved, while the eyelashes, eye- brows, pubes, and axillae are only occasionally the seat of the disease. While not contagious, sycosis is easily infectious. As the suppurative process is due, in a great meas- ure, to bacilli and micrococci, auto-inoculation is a common occurrence, and hetero-inoculation is pos- sible. Epidemics have occurred through the me- dium of barber shops. The diagnosis is easy. Lupus, eczema, the pus- tular syphilide and tinea barbae somewhat resemble sycosis but the character of the pustules, each one pierced by a hair, easily distinguishes it. Pathologically, sycosis is a perifolliculitis, which may be deep or superficial, according as micro- organisms have penetrated deeply or not into the hair follicle. The hairs can be easily extracted, and when this is done a small, white cylinder of epi- thelium is found adhering—the root-sheath. The treatment should be local. There are very few cases in which general treatment is indicated and, in these, the condition requiring it has but little influence on the cutaneous trouble. One of the most important things to do is to epilate daily and shave. Then apply a germicide. For this pur- pose bichloride lotions in the strength of 1-500 or 1-1000, or campho-phenique pure, should be thor- oughly applied. Not only this, but the pustules should be emptied. While the epilation and shav- ing is practiced once daily, the application of germi- cides should be made twice. In acute cases, this is HANDBOOK OF DERMATOLOGY. 67 followed by the application of soothing ointments. In chronic cases, stimulating applications are indi- cated. The ammoniated mercury ointment ten grains to the ounce, oleate of mercury 5%, or some similar preparation, is useful. If small abscesses exist they should be opened. If tubercles are pres- ent, free scarification, or curetting, will prove of benefit. In sycosis of the eyelashes, epilation followed by the application of yellow precipitate ointment, one to fifty, is followed by good results. While sycosis is curable, it is chronic and rebel- lious to treatment and relapses are not rare. Dermatitis Papillaris Capillitii is a rare trouble, in which pustules occur, forming scar-like plaques, the hairs being clustered in tufts, or ab- sent. When present they atrophy, but remain firm in their follicles. Papillomatous vegetations cov- ered with crusts sometimes form. This trouble oc- curs about the nucha, occiput and vertex. IMPETIGO. This rare affection generally occurs in children, who are poorly nourished. It is composed of pus- tules, which begin as such, and whose size varies from a split pea to the finger-nail. They are semi- globular in form, and markedly raised, have thick walls and an areola. They are yellowish or whitish, firm to the touch, and neither rupture nor coalesce. They may occur anywhere, but preferably on the face, hands and feet. They are generally few in number, probably a dozen in all. The disease is benign; there is no burning or itching. In a few weeks the lesions disappear. All that is necessary is to open the pustules and apply protective dressings. 68 HANDBOOK OF DERMATOLOGY. Impetigo Herpetiformis is a very rare disease, occurring in women, the termination being always fatal. IMPETIGO CONTAGIOSA. This disease is uncommon, occurring in infants and children, and consisting of small, discrete ves- icles which become pustules in a day or two. These latter increase in size, assuming a round or ovalish form. There are but a few, as a rule, and these occur upon the face and hands. They have a tend- ency to coalesce. There is an areola surrounding each lesion. The pustules do not burst, but thin crusts form, which have the appearance of being "stuck on " the skin. The process occupies about eight to ten days. It is contagious and auto-inocul- able. Patients recover spontaneously. Cleanliness and zinc oxide ointment, or the ammoniated mer- cury ointment, six to ten grains to the ounce, are all that is necessary. ECTHYMA. This is also a pustular disease in which there is the formation of a few flat pustules which are of the size of the finger nail. The distribution is discrete. Each one is surrounded by an areola, and is painful to the touch. A few days after their appearance there are formed dark crusts, not adherent, beneath which there is an excoriated, angry-looking base. The course is acute, lasting from five to ten days. There is heat, pain and some itching present. Chil- dren and adults are subject to it. The process is superficial and attacks those whose general health is bad, or the debilitated. The treatment consists in the administration of tonics and such remedies and means as will put the general condition in better HANDBOOK OF DERMATOLOGY. 69 form. Locally, alkaline baths and cooling lotions during the first week of the process. Later on, the crusts should be removed and stimulating oint- ments employed as dressings for the excoriated sur- faces. If these appear sluggish, they may be touched with the stick nitrate of silver. In a few weeks, the process will have terminated favorably. PSORIASIS. Syn.—Psora, Alphos, Lepra Alphos. Psoriasis is observed quite often, coming next to eczema in point of frequency. It commences as a red macule which increases rapidly in size becoming covered with scales. These scales are superficial, rather thick, white, shining, resembling mother-of pearl. The patches which may vary from a silver dime to a large superficies are scattered. They are very slighly elevated and are accompanied by a sense of burning and by itching. When the scales are scratched or scraped off, a reddened base is revealed and, here and there, small points of oozing blood. The disease is at first rapid in its evolution; but in a very short time, it lapses into a state of chronicity. The extent of integument which is attacked varies from one or two small lesions up to an involvement of nearly the entire skin. The portions which are subject to this trouble are, in general, the extensor surfaces. The knees and elbows, the back, the chest, and the scalp most frequently exhibit it. It is not often seen on the face, nor on the palms or soles. Psoriasis is very prone to relapses after a greater or less interval of time. It is not contagious. Psoriasis punctata is that form wherein there are pin-head lesions present. In psoriasis guttata the 70 HANDBOOK OF DERMATOLOGY. lesions are larger, and out of each one, there ex- udes a drop resembling mortar. Psoriaris nummularis exhibits round, coin-like Fig. 12.—Psoriasis. lesions, while psoriasis circinata shows patches in which the centre has cleared up to some extent. HA NDB OOK OF DERMA TOL OGY. 71 When several of these latter coalesce and the portions overlapping disappear we have serpentine lines con- stituting psoriasis gyrata. When large areas are in- volved the name of psoriasis diffusa has been ap- plied to the condition. The causes of psoriasis are unknown. It generally occurs after puberty in persons enjoying good health, and consists of a hyperplasia of the elements of the mucous layer. The diagnosis is apt to be difficult. It may be con- founded with eczema, syphilis, seborrhoea, tinea cor- poris and lupus erythematosus. The treatment of this trouble should be both gen- eral and local. If any abnormal general state be present, it should be corrected. Arsenic has been recommended as an adjuvant but it does not seem to exert much influence. If employed it should be used only in the ehronic stage. 'Shen it is to be continued a long time. It may be given in three or four drop doses of Fowler's Solution in wine of iron after each meal, or in the form of the Asiatic Pill made as fol- lows : R Acidi Arseniosi...................................... gr. ij. Piperis uigris ....................................9ij. Pulv. Glycerrhiz. rad ............................. . 9ij. M. ft. pil. No. 40. Sig.: One pill thrice daily after meals. Iron and phosphorus have been recommended, as well as alkalies. Large doses of iodide of potassium unaccompanied by any external treatment have suc- ceeded in causing the disease to disappear. About 250 to 300 grains are to be administered daily, com- mencing with a small dose and increasing. Locally, if the condition be acute, alkaline lotions and bland ointments should be applied. If chronic and scaly, remove the scales by means of sapo viridis 72 HANDBOOK OF DERMATOLOGY. and water. Then apply some tarry preparation such as may be used by combining pix liquida, or oil of cade in some extemporaneous preparation. Creasote ointment or sapo viridis alone are praised by some. Salicylic acid is a good agent in the strength of twenty to sixty grains to the ounce. Chrysarobin and pyrogallic acid, while good are irritating and stain the skin unless combined with other remedies. Wilkinson's ointment, as modified by Hebra is an excellent application. It is made as follows: R Sulfuris lotiL Olei cadini, aa........................................3iv. Saponisviridis, Adipis.aa.............................................Sj. Cretae preparatse.....................................3iiss. M. The following combination is also useful: R Chrysaroblnl, Acidi Salicylic!, aa.....9...........................gr. xv. Ichthyol.............................................3 j. Unguenti Aquae Rosae................................3 j. M. A neat application is one made by dissolving thir- ty grains of salicylic acid in one ounce of traumaticine and painting on the lesions once a day. The cold pack will often relieve the patient of the eruption it and is very grateful to the affected skin. While the eruption generally yields readily to treatment, relapses are very frequent and the disease may reappear at any time. PITYRIASIS RUBRA. This rare affection begins as red, scaly patches and, after a time, it involves large areas or even the whole integument. There is a free desquamation of thin, papery scales, as much as a gallon in a night. The color of the skin is red, but it is not thickened HANDBOOK OF DERMATOLOGY. 73 itself. Fissures seldom occur. The nails may be- come affected. There is very little burning or itch- ing, the trouble being generally chronic. It occurs in adults and while general remedies are indicated, arsenic does not afford those results which have been claimed for it. Externally bland oils should be ap- plied. Pityriasis maculata et circinata consists of rosy patches, which are scaly. There is some itch- ing. It lasts from one to three months. It is an un- common disease. Dermatitis Exfoliativa is rare. It is an erythe- matous or bullous inflammation, accompanied by marked general disturbance. Desquamation takes place and it is prone to relapses. It resembles pityriasis rubra very much. PURUNCULUS. Syn. Furuncle, Boil. The furuncle is a lesion which shows itself at first as a reddish macule. It soon becomes tender to the touch. It assumes a conical form, the base being in- filtrated ; and, in a short time, a central suppurating point is observed. It takes a week or ten days to develop. It varies in size from a split pea to two or three inches in diameter. The color is a deep red, pain is present and " throbbing " marks the incep- tion of suppuration. When the pus is evacuated a central mass of connective tissue, the "core," es- capes. Any portion of the body may be attacked, but single boils or a number of them are most fre- quently observed about the face, ears, neck, back, axillae, buttocks, perineum and legs. The causes of furuncles are various, such as a gen- eral bad state of the system, inflammatory disorders, 74 HANDBOOK OF DERMATOLOGY. etc. In some cases there seems to exist a predispo- sition to their formation (furunculosis). The treatment, in general terms is to attend to the condition of the patient. If several boils are present, or have appeared in successive crops, sulphide of calcium (gr. \-\) every two hours, should be given. Locally, the lesions may be aborted by applying caustics to the forming core, or injecting carbolic acid in oil, or campho-phenique, into the boil. Otherwise, suppuration is to be encouraged by warm poultices and the boils cut open, their contents allowed to es- cape and antiseptic dressings applied. Aleppo Bouton, Delhi Boil, Biskra Bouton, are phlegmonous processes, analogous to furuncle, en- demic in Oriental countries. ANTHRAX. Syn. Carbunculus, Carbuncle. Anthrax consists of a dense, infiltrated, red phleg- mon,varying in size from a small hen's egg to an or- ange and involving the subcutaneous tissues. Its appearance is preceded by malaise and chill, and fever is a frequent accompaniment. The process is at times so grave as to result fatally. Suppura- tion takes place in a number of points which dis- charge by seperate apertures, so that the disease may be, in a way, considered a multiple boil. The parts most affected are the neck, the back and the outer aspects of the hips. The lesion is usually sin- gle. The termination of this disease is by slough- ing, a number of small sloughs being thrown off or the entire mass coming whole. The causes are similar to those producing furun- cles, although it is contended by some to be due to the bacillus of anthrax. HANDBOOK OF DERMATOLOGY. 75 The treatment demands general supporting meas- ures and a very nutritious diet. Locally, various means have been resorted to. Crucial and circular incisions are adopted by some, whereas others do not seem to regard them favorably. Cold applica- tions, warm fomentations, poultices, etc., are em- ployed. The principal points to observe are: to keep the parts aseptic and to promote a rapid separation of the slough. When there is indication of this lat- ter, the slough should be picked out and antiseptic dressings applied. The ulcer which results will ter- minate in a firm scar. Carbuncle is a grave disorder which frequently ends in the death of the patient. Poisoned Wounds may be local or constitutional. They are due generally, to the bites of insects, snakes, scorpions, centipedes and spiders. The lesions are higly inflammatory and here campho- phenique applied pure, is especially serviceable. Dissection Wounds may be local or constitution- al in character. The lesions may be acute or indo- lent. Lymphangitis follows the former and the lat- ter develop into the Verruca necrogenica or anatomi- cal tubercle which is very chronic in character, al- though not particularly inconvenient, there being no subjective symptoms. Pustula Maligna, or Malignant pustule, the charbon of the French is due to inoculation from cat- tle suffering from murrain. It occurs most often about the hands and arms and induces severe con- stitutional symptoms which may become rapidly fatal. Equinia, glanders, or farcy is also a malignant contagious disease derived from horses suffering 76 HANDBOOK OF DERMATOLOGY. from it. Tubercular, vegetating or ulcerative lesions accompanied by grave general symptoms, are noted. Besides this, marked lymphangitis, hard nodules which break down and suppurate, and involvement of the mucous membranes are observed. This trou- ble is rare and general measures only are indicated. DERMATITIS. This is a general term employed to designate sim- ple inflammation of the skin. We find the cardinal symptoms of inflammation present, pain, heat, red- ness, and swelling—and, in addition, itching and multiform eruptions. The intensity of the process varies in different cases. There are four principal classes: Dermatitis traumatica, d. venenata, d. calorica and d. medicamentosa. Dermatitis Traumatica is due to external influ- ences of a mechanical nature which occasion a loss of the epidermis, and of the corium, accompanied by inflammation. Pigmentation is apt to follow. The remedial measures are protective and antiphlogistic. Dermatitis Venenata includes those inflammations of the skin due to contact with poisons, either vege- table or mineral. That due to rhus venenata, rhus toxicondendron, nettle, mezereon, arnica, or other plants of the same families is apt to become highly inflammatory, accompanied by marked oedema, pain, heat and itching. The dermatitis due to the rhus family is most often encountered, the effects of poison oak and poison ivy being well known. The eruption begins as an erythema, becomes vesicular and may continue in a pustular form or develop into blebs. The treatment is soothing. Alkalies externally (to neutralize the toxicodendric acid) followed by sooth- ing ointments is the best. Solution of sulphate of HANDBOOK OF DERMATOLOGY. 77 zinc is also beneficial. It is said that fluid extract of grindelia robusta, one drachm to four ounces of water, is very good. In the case of poisoning due to aniline dyes in stockings and underwear, removal of the clothing together with soothing measures is sufficient. Arnica, croton oil, mustard, mercurial ointment, acids, strong alkalies, cantharides, etc., all exert an influence in producing dermatitis. The treatment suggests itself. Dermatitis Calorlca is caused by both heat and cold resulting in burns and frost-bites (pernio). The lesions may be erythematous, vesicular, bullous, or gangrenous according to the severity of the process. Dermatitis Gangrenosa may occur in small patches or in diffused areas. The causes of this form are ob- scure. It generally occurs in violaceous or purplish patches which afterwards ulcerate, a slough being thrown off. In Raynaud's disease (symmetrical gan- grene) there is a symmetrical involvement of the ex- tremities—generally in the feet. This form is un- common. Dermatitis Medicamentosa, due to the ingestion of various medicinal agents, is seen rather frequently, the most common are the pustular dermatoses due to the injection of bromine and iodine compounds. We have in this class all the lesions represented. Mor- phia will produce urticaria,or erythematous macules and nearly every drug has an influence of a similar character. By careful observation, the physician can trace the origin of these eruptions and a simple withdrawal of the exciting cause—the drug—will be followed by a spontaneous recovery. 78 HANDBOOK OF DERMATOLOGY. Dermatitis Hepetiformis is a form of inflamma- tion of the skin which is rare but occasionally seen. It is attended by multiform lesions, is accompanied by burning and itching and is sometimes grave in char- acter and occasionally fatal. It is prone to relapses, Prodromata usher in its presence. It is more or less herpetic in its type. It may last for months or years and is, at present, the subject of much discus- sion. Herpes gestationis is now regarded as a form of this disease, as also the hydroa of some, herpes circinatus bullosus, etc. The treatment is to meet the general and local indications as they present themselves. HANDBOOK OF DERMATOLOGY. CLASS IV.—HAEMORRHAGES. Cutaneous haemorrhages occur either by extravasa- tion or diapedesis. When the result of external in- jury they are idiopathic; or symptomatic as the ex- pression of some internal disturbance. The appear- ances presented are known as petechiae, vibices, ecchymosee and ecchymomata. Petechias are roundish, ovalish or irregular in form, varying in size from a pin-point to the thumb- nail. Vibices are long, narrow, streak-like and vary in length from a few lines to several inches. Ecchymoses are large, irregular, non-elevated lesions. Ecchymomata are extensive extravasations, deep- seated, flat or elevated, and various in size and shape. PURPURA. Syn.—Hiemorrhoea Petechialis. There are three forms of this disease which are met with, differing from each other in appearance, etiology and in the general symptoms which accom- pany them. These forms are: purpura simplex, pur- pura rheumatica and purpura haemorrhagica. Purpura Simplex is rarely accompanied by any general disturbance. It shows itself as reddish, claret-colored, roundish or irregular haemorrhagic spots appearing quite suddenly. The size of these lesions varies from a pin-point to a split-pea, and the spots generally occur upon the lower extremities, symmetrically ; sometimes, larger areas are involved. 80 HANDBOOK OF DERMATOLOGY. There are no subjective symptoms connected with the eruption. Occasionally, the patient suffers some malaise and loss of appetite previous to the appear- ance of the lesions. This form is seen more often in the old. Its dura- tion varies from fifteen days to several months, and crops may successively appear. The spots are dis- tinguished from insect bites, which they resemble, by the presence in the latter of a central haemorrha- gic point, surrounded by congestion. Purpura, Rheumatica, or peliosis rheumatica, is a variety in which the prodromal symptoms are marked. The most prominent of these are the rheu- matic pains about the joints. The arms, thighs and legs are generally the seat of the eruption, although the abdomen is frequently involved. The haemorr- hagic spots are reddish or purplish in color, the size varying from a split pea to the finger-nail. As it fades away, the eruption assumes various shades such as yellow and green. This variety may last for months, relapses taking place. It is sometimes difficult to make a diagnosis but close inspection will show its haemorrhagic character. Purpura Hemorrhagica, or land scurvy, or morbus maculosus Werlhoffii is the most severe form of the disease, being ushered in by marked premonitory symptoms. The spots first appear upon the limbs, spreading rapidly to the trunk. All varieties of shapes are seen and in size they vary from the thumb-nail to the palm. Sometimes several patches coalesce. At times, more or less severe haemorrhages occur from the mouth, nostrils, gums, bowels, blad- der, etc. The severity of the attack may be such as to cause death in a short time, from exhaustion, or it may continue for months with relapses. HANDBOOK OF DERMATOLOGY. 81 The blood is extravasated in the corium, subcu- taneous tissues or about the glands and follicles. There is a gradual absorption which takes place after the blood has been thrown out. Pressure does not cause a disappearance or paling of the lesions. Th© treatment adopted must be according to the requirements of the case. Internally, in the simple form, ergot, iron, quinine and the mineral acids are Indicated. In the rheumatic, diet and hygiene, stimulants, malt liquors, etc. In the haemorrhagic form, prompt action is necessary. Ergot, quinine, iron, the mineral acids, rest, and whatever is neces- sary as the symptoms arise. Externally, astringent lotions and ice are the applications which are most satisfactory. HANDBOOK OF DERMATOLOGY. CLASS V.—HYPERTROPHIES. The hypertrophic affections of the skin are, as a rule, to be looked upon as deformities, as they have no tendency to become inflammatory. Any of the layers of the skin may participate* in this process, singly or conjointly. The hair and nails may also become the seat of hypertrophic changes. There is generally an increase in the normal constituents of that portion of the skin which is affected by this process. LENTIGO. Syn.—Freckle. Lentigo is a hypertrophy of the pigment which is characterized by a number of pin-head to finger-nail sized, brownish spots occurring for the most part upon the face and hands. The shade of color of the macules depends a great deal upon the complexion of the individual. In negroes they are black; in read-headed persons, in whom freckles are most common, they generally have a light brown or rusty appearance. The site in which they most frequent- ly occur is on the bridge of the nose and below the eyes. Occasionally they are black even in the white race. They occasion no discomfort whatever except from a cosmetic point of view. They consist of an increase in the deposit of pig- ment, which is intensified by direct solar rays. When they are made to disappear this exposure will occasion a return. The treatment is such as will be indicated in the consideration of chloasma. HANDBOOK OF DERMATOLOGY. 83 CHLOASMA. Syn.—Melasma, Liver Mark, Mother's Mark. This is somewhat similar to lentigo so far as the symptoms are concerned, with the exception that in chloasma larger areas are involved and they are less in number. It occurs most frequently on the face, chest, abdomen and hands. It may occur at any age after puberty, or even before. It is caused by direct solar heat ("tan"), sinapisms, scratching, and certain irritants applied to the skin, these con- stituting idiopathic forms. Among symptomatic forms are the pigmentation due to syphilis, Addi- son's disease, tuberculosis, cancer, lepra, scleroder- ma, and other diseases. The physiological and path- ological changes which take place in the uterus play such an important part in the production of chloasma as to have given rise to the classification of a separ- ate variety. Chloasma Uterinum is that form due to uterine dis- orders. The face is principally affected. The abdo- men and the breasts, around the nipples, are also the seat of this trouble. The latter is frequently seen in virgins. Chloasma uterinum may occur at any time from puberty to middle age, its most common cause being pregnancy. It depends also upon dys- menorrhoea, chlorosis, anaemia, hysteria, etc. The treatment of chloasma demands internal treat- ment in its symptomatic form only, and it should be directed to the condition present. Locally, the best application is bichloride of mercury which may be given in varying degrees of strength. A lotion such as the following may be used : R Hydrargyri bichloridi...............................gr iv. Zinci sulphatis.......................................3 *s. Alcoholis............................................3 iJ« M. Sig. Apply morning and evening. 84 HANDBOOK OF DERMATOLOGY. Other remedies may be employed such as sulphur, sapo viridis, ammoniated mercury, subnitrate of bis- mutti, acetic acid, etc., in various combinations. Veratria, ten to twenty grains to the ounce, has been recommended. A rapid method consists in apply- ing continuously to the affected part, cloths satur- ated with a solution of corrosive sublimate of the strength of five grains to the ounce of alcohol or water. In a few hours, a blister forms, the roof of which is carefully cut out and a bland dusting pow- der, such as starch, is applied. The new epidermis is without pigment, but the effect is only transitory. Chloasma is very obstinate to treatment and even when apparently cured, will return. This is more especially true of chloasma uterinum. Discoloration of the skin may be due to the deposit of various pigments. A bluish-gray or slate color, known as argyria, is produced by the internal administration of nitrate of silver. Vermillion ,indi- go, India ink, gunpowder, etc., are employed for this purpose in tattooing. In the latter case, the marks may be removed, in some cases, by tattooing in papaine. . N^VUS PIGMENTOSUS. Syn.—Pigmentary Mole. These growths are congenital, occurring either singly or in numbers. In form they are oval or cir- cular, or irregular. They vary in size from a pin- head to large tumor-like masses. Sometimes the distribution is along the course of nerves. Several varieties have been named, such as nevus spilus where the growth is smooth; nevus verrucosus in which a warty, rough surface is present; nevus mullusciformis or lipomatodes a combination of HANDBOOK OF DERMATOLOGY. 85 fatty tumor and mole. All are pigmented and, in many (nevus pilosus) the growth is covered with hair. These moles grow in size for a time after the birth of the individual and then cease. They may occur singly or in numbers. Treatment is surgical except in the case of small growths. Large ones are best excised. In smaller ones, electrolysis is most advantageous. In the latter case, it is not necessary to introduce theneedle very deeply. CALLOSITAS. Syn.— Tylosis, Tyloma, Callus, Callosity. This affection consists of indurated, circumscrib- ed patches of thickened epidermis, varying in size, extent and thickness. The color varies from yellow- ish to yellowish-gray or yellowish-black and is de- pendent upon the admixture of foreign matters. When thin, callus is translucent; but opaque when thick. It is smooth and horny. The hands and feet are most often the seat of this trouble which is, for the most part, due to friction and pressure. There are no subjective symptoms except, at times, when pain is experienced through too much thickening of the callus. Cracks and fissures some- times appear and become a source of irritation. An- other complication is the formation of abscess be- neath a callus. When the pus is evacuated the entire mass is thrown off. Occasionally, when such an occurrence takes place at the end of the finger, the distal phalanx may be lost. Callus is simply a heaping up and packing to- gether of the horny cells of the epidermis. The con- dition is easily recognized and one for which treat- ment is not often demanded. 86 HANDBOOK OF DERMATOLOGY. When it is desirable to remove this overgrowth, the exciting cause must be removed. Then, bathing in hot water, poultices, or applying pure rubber to the part will soften the mass. Sapo viridis or caustic potassa (1—2 %) are good keratolytic agents. Vin- egar, acetic acid, and mercurial plaster are also good. Salicylic acid, one drachm to the ounce, is excellent. When the mass has been softened, scrap- ing with a dull knife will hasten its removal. Cal- lus, however, disappears spontaneously if the causes which produce it are removed. CLAVUS. Syn.—Corn. This is an exceedingly common trouble which affects the feet. A corn is a circumscribed callosity, seated on the toe, having the form of an inverted cone whose apex presses upon the corium producing a sharp pain. The cause of this hypertrophy is fric- tion caused by shoes which are too tight or too loosely fitting. The treatment is to remove pressure and friction, and to cause a disappearance of the callosity. At the site of the corn the mucous layer of the epidermis is generally absent. Cutting or paring and the measures recommended for callosity are applicable here. An efficient method is the ap- plication of the following, daily, for a week : R Acid, salicylic.......................................3j Ext, Cannabis Indicse...............................grx Collodion..............................................3 j M. At the end of that time soak the corn in warm water for some time and it will come off. If it has not entirely disappeared a second course of this treatment will produce the desired effect, provid- ing that suitable shoes are worn. HANDBOOK OF DERMATOLOGY. 87 Malum Perforans Pedi or perforating ulcer of the foot first appears as a thickening of the epider- mis on the dorsum. A sinus soon forms which pene- trates as deep down as the bone. The nails become altered, hairs grow on the dorsum of the foot and more or less destruction of tissue takes place. It is generally the local manifestation of certain spinal and nerve lesions. The treatment is purely surgical, agents tending to strengthen the system at large being also administered. CORNU CUTANEUM. Syn.—Cutaneous Horn. This disease or rather deformity, while rare, is full of interest. The growth is solid, hard and dry and its surface appears rough or wrinkled. It is more or less elongated or roundish, or it may occur as a rough or irregular projection. The length of these horns varies from a few lines to several inches. The area of the base is always the largest of any cross section of the growth. Cutaneous horns may be single or multiple. The face, scalp, and penis are the favorite sites of its occurrence. They drop off spontaneously and when this occurs the base is the seat of epithelioma. They grow slowly, occurring in middle life, and seem to originate from a wart. The treatment is excision and thorough cauteri- zation of the base. In some cases, occurring upon the penis, amputation is the only certain method of relief. Early removal of these growths should al- ways be counseled. 88 HANDBOOK OF DERMATOLOGY. VERRUCA. Syn.—Wart. This is a hypertrophy of the epidermis and papil- lae. Warts may be hard or soft, pointed or flat, sessile or pedunculated, smooth or rugous, congen- ital or acquired, single or multiple. They vary in size from a pin-head to a bean. They are painless, as a rule, and occur upon the hands, feet, face, scalp, neck, and genitals. Other portions of the integu- ment, such as that covering the legs and arms and that upon the trunk may also be the seat of these growths. The following clinical forms are the ones most frequently observed: Verruca acuminata, or venereal warts, are fili- form, papilliform, or have a cockscomb appearance. They are of a rosy or bright red color and are found upon the genitalia and upon the skin. In the for- mer locality they grow rapidly and exuberently; are moist and give forth a fetid and sickeniug odor. Upon the skin they do not grow so rapidly and are dry and odorless. Verruca filiformis is the wart that is slender and threadlike. It is of the color of the normal skin and occurs chiefly about the eyelids. Verruca glabra is the smooth and shining wart which is frequently seen in adults and those past middle life. Verruca plana is the flat wart, frequently pig- mented, seen in adults. Verruca senilis, as its name indicates, is met with in the old. The face, trunk and extremities are its sites of predilection. It is often pigmented and HANDBOOK OF DERMATOLOGY. 89 when irritated there is a tendency for epithelioma to form. Verruca vulgaris is the most commonly seen. It is of the size of a split-pea, occurring chiefly upon the hands and genitalia. After a time the surface be- comes rugous, and it frequently disappears spon- taneously. One of the causes of verruca is irritation, either mechanical or other. Friction, acrid discharges, etc., may cause these growths to appear. Dr. Fox Fig. 13.—Warts on Tattooed Lines. {Jour. Cut. and Ven. Dis.) reports a case due to tattooing. Gonorrhoea and gleet cause their appearance about the genitalia. Recent investigations have shown that some are due to micro-organisms and that they are auto-inocula- ble and contagious. The treatment is destruction of the growth. Although contended by some that, in the vulgar form, Fowler's solution, or carbonate of magnesia will cause them to disappear, these methods do not seem to be always attended with uniformly good 90 HANDBOOK OF DERMATOLOGY. results. Still they are quite successful in some cases. The use of caustic alkalies or acids or excision is practiced by many, but electrolysis is as certain, less painful and unattended by any scars. About the genitals, excision followed by cauterization of the base, is one of the best methods. Keeping these growths dry and freely applying boric acid succeeds frequently in causing their disappearance. In some varieties of warts the application of salicylic acid in •collodion, as mentioned under clavus, is attended with excellent results. ICHTHYOSIS. Syn.—Fish-skin Disease, Xeroderma Ichthyoides, Ichthyosis Vera, Ichthyosis Congenita. This disease, or deformity, consists in a tendency to the excessive formation of the horny layer of the epidermis. Although congenital, it does not appear, as a rule, until the second or third month after birth. It becomes more marked then until puberty, when it reaches its highest state of development. Two varieties are recognized: ichthyosis simplex and ichthyosis hystrix. Ichthyosis Simplex may be limited to certain localities or it may be universal. There is marked dryness of the skin; bright, thin, pearly scales sharp- ly separated by the normal furrows exist, a slight desquamation being present. Ichthyosis Hystrix is a more pronounced type of the disease. The scales are piled up so that they form spinous elevations which are firmly adherent to the skin underneath. The color here is a grey or greenish-black. This constitutes so-called " alliga- tor skin." Ichthyosis Sebacea is characterized by rather thick HANDBOOK OF DERMATOLOGY. 91 scales to which there is added an admixture of sebum. In general, the scales in this affection are adher- ent. The principal portions involved more severely are the knees and elbows and upper portion of the dorsum of the foot. The face is always exempt. The disease is hereditary and in Paraguay endemic among the males. The diagnosis is easily made. Treatment is entirely palliative. Remove the scales with sapo viridis and hot baths ; or, in mild cases, the Turkish bath will loosen them. Warm or vapor baths should be taken regularly; and after each bath, one of the following ointments may be rubbed in: R Ung aquae rosae Lanolin (puriss; aa...................................3 iv M. R Adipis benzoat Ung. aquae rosae aa...................................Sir M. R Adipis benzoati......................................Sij Glycerines...........................................3i Ung. petrolel.........................................Sij M. The disease is incurable. A few cases are report- ed as having recovered spontaneously. XEROSIS Syn.—Xeroderma. This disease is similar to asteatosis and also to ichthyosis. It appears to hold a middle place be- tween both. It is congenital. The epidermis is dry, rough and harsh, shedding furfuraceous scales. The extremities are the portions most frequently affected, especially upon their outer aspects. The 92 HANDBOOK OF DERMATOLOGY. treatment to be pursued is the same as that in ichthyosis. KERATOSIS PILARIS. Syn.—Lichen Pilaris. This affection is of comparatively frequent occur- rence. It is characterized by a number of discrete conical elevations of the size of a pin-head, of a grey or whitish color, sometimes surrounded by an areola. Between these lesions the skin is dry and harsh. The feeling imparted to the hand, passed lightly over the eruption, is the same as that experienced from a nutmeg-grater. By scratching one of these elevations freedom is given to an imprisoned, curled hair, which then emerges. The limbs are the localities most often invaded, especially on the extensor surfaces. It Is only where lanugo hairs exist that we find it. It is a chronic affection, attended with mild itch- ing, in some cases. The causes are unknown, want of cleanliness playing but a secondary part. Adults are generally attacked and males most frequently. The lesions consist of an accumulation of horny cells about the openings of the hair-follicles. Sebum mixes with this and forms a hard mass which im- prisons the hair. There is very little difficulty in recognizing the trouble even when scratching has produced inflam- matory symptoms. The treatment is, in the main, that of ichthyosis. There seems to be a tendency to the ichthyotic pro- cess in individuals affected with keratosis pilaris, as shown by the general state of the skin. HANDBOOK OF DERMATOLOGY 93 SCLERODERMA. Syn.—Sclerema, Scleriasis. In this rare affection the skin is yellowish or waxy, pigmented, having a hard feel as if made of wood. It is indurated in plaques which are round or oval, varying in size from a small coin to the palm; or it may be ribbon-like in its distribution. There frequently exist ridges at the sides of the affected area. No subjective symptoms are present, except the hide-bound feeling. It is essentially chronic in its course, affecting the head, trunk or limbs. When the face is the seat of this disease, it has a fixed, wooden appearance. The treatment consists of baths, massage and frictions. The galvanic currrent also tends to pro- duce resolution. Mild salicylic acid ointments are of benefit. The disease may disappear spontaneously leaving an atrophied condition of the affected portion, or it may recur. MORPH03A. Syn.—Addison's Keloid. Morphoea is of infrequent occurrence and is re- garded by many as a stage of scleroderma. It con- sists of one or more discrete patches, bands or lines of a pale, whitish color, having a delicate lilac-color- ed areola. The patches bear a great resemblance to a piece of fat bacon let into the skin. The causes leading to this trouble are unknown. It is observed more frequently in women than in men. Atrophy takes place after the process has existed some time. All treatment which has been attempted has proven unsatisfactory. It sometimes disappears spontan- eously. 94 HANDBOOK OF DERMATOLOGY. SCLEREMA NEONATORUM. This affection, although congenital, is not ob- served until a few days after birth. There is at first an oedema of the skin,which feels cooler. Later on, it has a dense, hard feel and is more or less shining. The color of the skin is yellowish, reddish or viola- ceous. The face has a peculiar expression due to the want of flexibility of the skin which latter also seriously interferes with suckling, the lips being har.d and wooden. The disease involves the whole surface and, as a rule, the children affected by it die early. Some have been saved by the application of warmth, massage and stimulation, accompanied by oily inunctions. ELEPHANTIASIS. Syn.—Elephantiasis Arabum, Pachydermia, Bucn- emia, Elephant Leg, Barbadoes Leg. This disease occurs chiefly in the Tropics. It be- gins, at first, in an attack of erysipelas or dermatitis in which the lymphatics are more or less involved. When recovery has taken place it is found that the integument of the portion involved is slightly thick- ened. Successive attacks take place, the thickening growing more and more until the volume and den- sity are such as may be seen in typical oases. It is then tense, glossy and cedematous. When the dis- ease has existed some time the skin is rough, papil- lomatous, hanging in thick folds and more or less pigmented. Seborrhoea is present, the mouths of the sebaceous follicles are patulous and the whole presents a marked deformity. The leg, arm, scrotum and penis, and the labia and clitoris are the portions generally affected. These parts attain enormous proportions and give HANDBOOK OF DERMATOLOGY. 95 rise to pain accompanied by a sense of weight. The cause is attributed by some to the filaria sanguinis hominis. The process consists in a hypertrophy of the deeper layers of the skin. 96 HANDBOOK OF DERMATOLOGY. The treatment is mainly surgical. Excision of some affected portions such as the scrotum, labia, etc., ligation of the femoral artery or of the brachial, have been followed by good results. In some cases, however, amputation becomes necessary. Electro- lysis has yielded some excellent results, but this means must be employed for years to obtain any marked change for the better. DERMATOLYSIS. Syn.—Cutis Pendula. In this rare affection we have a thickening of the skin, which feels unctuous and soft, accompan- ied by a hypertrophy of the subcutaneous connective tissue. In consequence of this, the skin hangs in folds which are thick and may be quite large. The only method of treatment is the excision of some of the redundancy, which is not often observed about the trunk. The so-called " elastic skin " is a form of derma- tolysis which differs from it in the fact that there is a certain amount of resiliency remaining in the in- tegument. Frambcesia, yaws, or polypapilloma tropica, is endemic among the negroes of the West Indies. It it regarded as a phase of syphilis by some authors. The lesions commonly observed are tubercles of various sizes occurring upon the face. A discharge exudes and crusts form. Alterative treatment seems to have a more or lets beneficial effect upon it. Donda Ndugu is an affection seen in Central and East Africa characterized by the appearance of white papules upon the lower extremities. A boggy swelling appears which sloughs beneath the healthy tissues. HANDBOOK OF DERMATOLOGY. 97 Parangi is a skin trouble having mixed features and which is found in Ceylon only. HYPERTRICHOSIS. Syn.—Polytrichia, Hirsuties, Hairiness. Hypertrichosis is really not an increase in the number of hairs, but in their size and length. Hairs which are normally short and fine—the lanugo hairs —suddenly grow in length as well as in diameter. Hairs which are of ordinary length, also grow to be many feet long and their different forms produce examples of homines pilosi, bearded women, hairy children, etc. The chin, upper lip, sides of the face, and forehead are the principal visible seats of this trouble in women. When the affected portion is covered by clothing there is but little attention paid to it. There is, however, no particular region in which this deformity appears. Any portion of the integument, where hair follicles are present, may be the seat of hypertrichosis. Hypertrichosis may be congenital or acquired. In the former it is more apt to be general. In the acquired form it is, as a rule, local, and appears after puberty. It is found more often in persons of a dark complexion and in women with masculine peculiarities, and in those who have passed the cli- macteric or who are sterile. The causes are obscure. Stimulation or irritation of the skin, such as that caused by epispastics, may cause it. Spinal troubles and insanity also seem to exert an influence in its causation. Two methods of treatment may be resorted to— the palliative, and the radical. Among the former is epilation, a method which causes the hair to be- come stronger and to increase in growth. Shaving 98 HANDBOOK OF DERMATOLOGY. has the same effect. Depilatories are probably the best palliative measures. The following are among the best: R Barii sulphid.........................................3 ij Pulv. zinci oxidi_ _ Pulv. tale venet aa ....................................3 iij M. R Sodii sulphid...........................................3 ij Pulv. zinci oxidi, Cretae preparatse aa,....................................3 iij M. Either one is made into a paste, with water, and applied for ten or fifteen minutes. As soon as the skin feels hot it is scraped off with a dull knife and a soothing ointment is applied. These preparations should be used with caution. Sulphide of arsenic, quicklime, and sulphide of calcium are also used as depilatories. Ethylate of sodium freely applied is claimed to destroy the hair completely. It should be freely and thoroughly rubbed over the surface, followed by a dressing of cold cream. It must be done under the influence of chloroform. Thin scars are apt to follow its use. For the radical cure, there are two principal methods. In the first the hair is extracted and the follicle destroyed by twirling in it a needle whose point has been dipped in fused caustic potassa or in chromic acid. The inflammation which it pro- vokes subsides in a few days. The other method is by electrolysis, as introduced by Hardaway and popularized by him. A fine steel or irido-platinum needle, connected with the negative pole of a gal- vanic battery (a strength of about 3 milliamperes being used), is carefully passed alongside of the hair into the follicle until the point reaches the HANDBOOK OF DERMATOLOGY. 99 papilla. The positive electrode is then applied to some indifferent part of the body. In a short time a frothing takes place at the opening of the follicle. Slight traction is made upon the hair, with a pair of forceps, and, if it comes out easily, the operation is complete. The current is then inter- rupted and the needle withdrawn. In this manner a number of hairs are treated at one sitting. A small inflammatory areola appears at the opening of the follicle, but subsides in a few days. Scars may result if the walls of the follicle have been punctured. In those cases due to nervous disturbance it is best to treat the cause first before any local meas- ures are attempted. Many recover from the hirsu- ties by these means alone. In all the radical measures which are attempted, there is always a return of a certain percentage of the hair on account of their incomplete destruction. The papilla must be destroyed to ensure a non-re- turn of the hair. ONYCHOGRYPHOSIS. Syn.—Onychauxis. The above is a generic term employed to desig- nate hypertrophy of the nail. This process may be due to general or to local causes, and it may consist in an increase in length, in breadth, or in thickness. The nails of the hand and feet may be affected, either singly or in numbers. The nails themselves often become rugous or furrowed. The color may vary from a pale yellow to black or brown. The form is at times distorted, so much so that a nail may assume the shape of a ram's horn. In onyxis or onychia there is more or less ulcera- tion taking place at the nail fold, or beneath the 100 HANDBOOK OF DERMATOLOGY. nail, which becomes dull in color, thickened, some- times friable. This process is seen in some cases of syphilis. Onychomycosis is a thickening of the nail due to the invasion of the parasite of ringworm or of favus. The nail assumes a dull color, is brittle and friable, and examination shows the infiltration of the growth. Paronychia, better known as "ingrowing" nail, is characterized by an increase in size accompanied by a piercing of the tissues by the nail substance. In nearly all of these troubles the treatment is surgical. In onychomycosis it is best to scrape the nail well and apply parasiticides. Where ulceration exists, caustics are of benefit. When a perverted growth persists it is best to destroy the nail. In order to accomplish this the matrix must be com- pletely destroyed. That portion posterior to the lunula and that beneath it must be thoroughly cauterized, or the growth of the nail substance will continue. The thermo-cautery, or galvano-cautery are probably the best methods upon which to depend. HANDBOOK OF DERMATOLOGY. CLASS VI.—ATROPHIES. In this class are included those processes which bring about a degeneration or a diminution of the component parts of the skin. They may be congen- ital or acquired, idiopathic or symptomatic. As a rule, they are benign, so far as any danger to life is concerned. Many are to be viewed simply in the light of deformities. Others are incidental to old age, and nearly all of them are of such a nature that little, if anything, can be done to remedy the con- dition. ALBINISM. Syn.—Congenital Achroma, Congenital Leucoderma, Congenital Leucopathia, Congenital Leucasmus. This is a congenital deficiency of pigment which may be universal or partial. Those in whom there is a universal want of pigment are known as albi- noes. They are observed but infrequently. In them the hair is white, the pupils red, and a general ab- sence of normal pigment can be noticed. In the partial form we see a variety which is rather more frequent. It is best observed in negroes, in whom the want of color appears in marked contrast with the rest of the skin. Such as are affected in this manner are known as " piebald " negroes. There are no subjective symptoms connected with this de- formity. It has a tendency to increase, sometimes. The deformity is hereditary in the partial form. The condition depends upon a congenital defi- ciency of pigment, but the cause of this deficiency is unknown. 102 HANDBOOK OF DERMATOLOGY. There is no treatment to improve the condition, which is permanent. VITILIGO. Syn.—Acquired Achroma, Acquired Leucoderma, Acquired Leucopathia, Acquired Leucasmus. This disease is frequently met with, more partic- ularly in negroes. It appears in the form of round- ish or irregular white macules and, if the affected portion be hairy, the hairs are also white. The spots are milky-white and vary in size from a silver five cent piece to large areas. Vitiligo is an acquired achromia occurring in adults. The dorsum of the hand is generally first involved, although in some, it is never the seat of this affection. The areas are often symmetrically disposed or seem to be abruptly arrested at the median line. A close examination of vitiligo will show that there exists an increased amount of pigment at the periphery of the lesion, suggesting that it is rather a displacememt than a deficiency of pigment. There are no subjective symptoms in this trouble. The macules are more marked in Winter than in Summer. As to the causes very little is known. Some cases are, no doubt, traceable to a nervous origin. The diagnosis is to be made from chloasma and tinea versicolor. The treatment is, in general, unsatisfactory. The local measures to be attempted are entirely cosmetic. Occasionally, the application of some stimulant like acetum cantharidis will induce a partial return of pigment. The burning glass also acts in this man- ner. Ascending galvanic currents have a good effect in some cases. A dye made of a weak infusion HANDBOOK OF DERMATOLOGY. 103 of walnut husks is an agent which conceals the de- ficiency in color. The disease has a tendency to increase until the lapse of a certain length of time, when it remains stationary. CANITIES. Syn.—Poliosis, Trichonosis Cana, Trichonosis Dis- color, Blanching of the Hair. This disease, better known as grayness of the hair, may be congenital or acquired, and its ap- pearance may be slow or sudden. As a rule, it is progressive, and permanent, constituting one of the physiological changes incident to old age. The por- tions first attacked are the temples and beard ; then the vertex and finally the remainder of the pilous system. Alkalies and various chemical agents have a bleaching effect upon the hair. Sweating has the contrary. Nervous disturbances, such as neuralgia, fear, grief, etc., produce canities, and cases are on record in which the hair turned white in a single night. In alopecia areata the first hairs which reappear are white and are then followed by others of a normal color. The causes of canities are senile alterations, her- edity, deficient nutrition and innervation of the hair follicle, functional and organic nervous affections, keeping the head covered, etc. The white color is due to a failure of pigment, to the uneven surface of the hair shaft, or to air bub- bles in the shaft. In ringed hair, we have alternate layers of pigment and the want of it producing the condition. The treatment of canities is sometimes successful by means of hypodermic injections of muriate of 104 HANDBOOK OF DERMATOLOGY. pilocarpin, gr. -fe, once or twice a week. The only other method is palliative, by the use of dyes, but this can hardly be recommended. ATROPHIA CUTIS. Syn.—Atrophy of the Skin, Atrophia Cutis Propria. Atrophy of the skin may be partial or general, idiopathic or symptomatic. The skin becomes thin, shining and more or less translucent. There are no subjective symptoms. It may occur in exhaustive diseases; or following pressure, such as is caused by tumors, callosities, etc.; or it may be due to ulcera- tive processes; or to certain affections of the skin such as lupus, favus, etc. SENILE ATROPHY. This form of atrophy of the skin is generally uni- versal, and depends upon the degenerative processes incident to old age. The skin becomes thin, of a brownish tint, with pigmentary deposits here and there. All the appendages of the skin participate in the changes. The secretions are diminished and wrinkles form, the elasticity and resiliency of the integument being markedly diminished. The corium is thinner, the papillae are smaller, and the epider- mis more or less dry and horny. The whole process is a retrograde metamorphosis. Various degenera- tive changes take place, such as the fatty, the col- loid, the amyloid, the lardaceous, the waxy, and the vitreous. Nothing can be done to retard this process which is slow and progressive. Glossy Skin, as its name implies, is an atrophy of the skin in which the integument is thin, smooth, and very glossy and shining. It is generally found HANDBOOK OF DERMATOLOGY. 105 upon the extremities and is due to organic nervous troubles. STRLSI ET MACULE ATROPHICA. Syn.—Atrophic Lines and Spots. The lesions, in this condition, consist of lines or spots which are smooth and glistening in appear- ance. The skin at their site is thin and apparently depressed, presenting very much the appearance of a scar. In color it may be whitish, pearly or bluish. The lines vary from one to three lines in width, and one-half to several inches in length. They are gen- erally irregular or broken. The direction is more or less oblique and, when several exist, they are par- allel. Atrophic spots are roundish or ovalish in shape, varying from a millet-seed to the thumb-nail in size. They present the same peculiarities as the lines and are isolated. There are two classes of these atrophies—idio- pathic and symptomatic. In the former we find the thighs, pelvis, trochanters and buttocks the seat of the lines and spots. The chest, back, and other portions are sometimes affected. Syphilis and pneu- monia cause the spots about the trunk. The symp- tomatic form is observed upon the thighs, abdomen and mammae. It is due to an extreme distension of the cutaneous structures. It occurs in pregnant women, in those having large abdominal and other tumors, and in fat persons. The lines caused by pregnancy are known as the linee albicantes. An atrophy of. the mucous layer of the skin is present in these lesions, and the papillae of the corium have disappeared. The connective tissue occurs in thin bundles, and the fat cells have disap- 106 HANDBOOK OF DERMATOLOGY. peared. The stretching of the rhomboid meshes of the connective tissue is the cause of these changes. There is no treatment for this condition, which is generally of little importance as it occasions no in- convenience and, besides, is not situated upon visible parts. ALOPECIA. Syn.—Calvities, Defluvium Capillorum, Baldness. Baldness is a deficiency in the number of hairs ; seen most often upon the scalp. Three principal varieties are recognized, viz.: congenital, senile and premature. Congenital Alopecia is a rare condition, due to an arrest of development. It is temporary, the retarded growth appearing later on. It may be localized or general. Senile Alopecia is symmetrical. It is seen at the vertex, the frontal region, or involving the entire calvarium. It is more commonly seen in men. When the case is one of long standing the skin is smooth, shining, and sometimes there is seborrhoea oleosa present. In those who are old, atrophy of the skin is present. It is generally the scalp only which is so affected, the axillae, pubes, chest, beard, etc., not participating in the process. Premature (or presenile) Alopecia occurs in the young and may be idiopathic or symptomatic. The idiopathic form is seen in men most often, and in those of sedentary habits. It is gradual in its development, symmetrical, invading the vertex and up the cor- ners of the forehead. The hair is thin and not very long. It seems to be hereditary in some families. The symptomatic form of this variety of alopecia may be local or general and is due to local or gen- HANDBOOK OF DERMATOLOGY. 107 eral causes. Seborrhoea sicca, psoriasis, the vege- table parasites, etc., are among the local causes, while typhoid fever, syphilis and leprosy are among the systemic disorders which cause alopecia. In this latter form all the hair may fall out. The changes observed in senile and premature alopecia are due to the fact that the follicles are starved, the epidermis is thinner and the corium is contracted to a greater or less degree. The treatment is stimulation. A good bristle brush should be used and, in addition, sapo viridis as a shampoo, followed by the application of a strong sulphur ointment, beta-naphthol ointment, bichlo- ride of mercury lotion (five grains to eight ounces), hypodermic injections of muriate of pilocapine (gr. £) twice a week, or some other stimulating measure. In the symptomatic form, the disease causing the condition should receive attention, but the local treatment is not to be neglected. There is but little hope of a return of the hair except in the symptomatic forms. ALOPECIA AREATA. Syn.—Area Celsi, Porrigo Decalvans, Alopecia Cir- cumscripta, Tinea Decalvans. This disease consists in the formation of one or more bald spots, on the head or in the beard, which vary in size from a small coin to the palm. Upon examining the patches they present a white, smooth appearance. Some lanugo hairs and a few broken- off ones are occasionally found in the patches, which are sharply defined, having, usually a roundish or ovalish contour. The favorite sites of the patches are the parietal portions, vertex and occiput. The 108 HANDBOOK OF DERMATOLOGY. disease comes on suddenly, several patches follow- ing each other in close succession. There are no subjective symptoms. The majority of cases are of neurotic origin. In some, however, it appears to be due to a micro-or- ganism, and small epidemics, produced by contagion, occur. The cause of this latter form—microsporon Audouinii, of the British—has never been satisfac- torily demonstrated. The treatment depends upon the origin of the* trouble. If nervous, general nerve tonics should be given, this not being required where the trouble depends upon micro-organisms. Local- ly, we have many remedies to choose from, the gen- eral plan being to produce strong stimulation. Thus, the patches may be blistered every ten or fifteen days, a soothing dressing being employed in the intervals. Tincture of sapo viridis, aqua ammonia, oleate of mercury (5—10%), corrosive sublimate, gr. iij—iv, to the ounce of alcohol, beta-naphthol, sup- plemented by frictions with a coarse towel, etc. Ointments containing cantharides, chrysarobin, py- rogallic acid, and similar stimulating agents are employed. Among lotions the following is a good one: R Tirct. cantharidis, Tinct. capsici, aa.....................................3 ss. Olei ricini .............................................3ij. Aquae coloniensis......................................Si. M. A method which gives good results is galvanism. An ascending current, properly applied, is a very satisfactory method of treating this disease. Alopecia areata is a self-limited disease. It is not very common, and is somewhat stubborn to treat- ment. In a length of time,varying from two months HANDBOOK OF DERMATOLOGY. 109 to as many years, the hairs return. They may be white at first, but are soon replaced by a crop of the normal color. ALOPECIA PURFURACEA. Syn.—Pityriasis Capitis, Alopecia Pityrodes Capillitii. This consists of a slow thinning of the hair be- ginning in early life and progressing steadily. The hairs are very thin, short and pointed. A constant furfuraceous desquamation is present, as also a mod- erate degree of seborrhoea. Itching is more or less marked. It is seen more often in men than in women. It may be inherited, and it has been sug- gested that it is contagious. The corium is thinned in this trouble. The treatment is stimulation to- gether with such means as will relieve the seb- orrhoea. ATROPHY OF THE HAIR. Syn.—Atrophia Pilorum Propria. In true atrophy of the hair, it is only this struc- ture which is affected. It may be observed in all wasting diseases. It also occurs as a purely idio- pathic form, affecting most often the hairs of the beard. It consists of a splitting up of the hair into longitudinal fibres, atrophy of the bulb being also present to a greater or less extent. Trichorrexis Nodosa, or Nodositas Crinium, is characterized by the presence of small whitish nodes ^Maasa^giaiiHDs^c *$7*z?% Fig. 15.—Trichorrexis Nodosa. on the shaft of the hair, at irregular distances, and resembling very much the nits or ova of pediculi. 110 HANDBOOK OF DERMATOLOGY. It is rare. It affects the beard and consists of a broom-like Assuring at the points where the nodes exist, appearing as if two brushes were stuck into each other. It is claimed to be of neurotic origin. Piedra is also a nodose condition of the hair, in which dense, black, horny nodes, containing masses of spores, are found along the hair-shaft. Fragilitas Crinium, or fragility of the hair, is a condition in which there exists an uneven formation of the hair-shaft, accompanied by great brittleness. In addition, the hairs split at the free extremity. It may affect a few hairs only, or numbers. ATROPHY OF THE NAIL. This may be congenital or acquired. In the for- mer case it is due to an arrest of development. In the latter, general wasting diseases, heat, cold, chemicals, etc., act as causes. The nails become thin, narrow, friable, furrowed, grooved, eaten in, etc. The condition which is presented is so suggestive that there is no difficulty in recognizing the trouble. To treat the cause is, of course, necessary. Locally, the nail should be kept in some bland ointment and protected. This will accomplish about all that is possible to be done by topical measures. HANDBOOK OF DERMATOLOGY. CLASS VII.—NEW GROWTHS. The class of new growths is an important one. As a rule, they are painless and of slow growth. This is particularly true of the connective tissue new growths. Those depending upon cellular deposit are more or less destructive, frequently malignant. The majority are not painful. Besides these, we have new growths made up of bloodvessels, of lym- phatics, and of nerves. Many of these diseases are amenable to surgical interference, others run so rapid a course, or are of such a malignant character as to defy all operative interference. Another class resist all treatment and pursue a chronic course, lasting ofttimes as long as the individual himself. KELOID. Syn.—Kelis, Kelos. Keloid is a connective tissue new growth which manifests itself in the form of an oblong plane, an elevated ridge, or a cylindrical mass, processes being given off at the periphery. The color is whitish or slightly reddened, it being somewhat lighter than the surrounding integument, in negroes. The surface is smooth and more or less shining. The portions usually affected are the trunk, that portion over the sternum, the back, the nucha, and the face. Itch- ing is present in the majority of cases and the growths are sensitive on pressure. Pain is also pres- ent to a very marked degree, in some cases. The disease develops from a few nodules which coalesce. Generally, keloid is single, although it may be multiple. 112 HANDBOOK OF DERMATOLOGY. The true cause of keloid is unknown. False keloid is observed after incisions, the application of leeches, vesicants, etc., and after having the ears pierced. The true, or " idiopathic " keloid appears without any assignable cause. It is seen most often in females and negroes and during adult life. The structure of keloid is a "new formation of dermatic framework." In true keloid we find bun- dles of connective tissue fibres, parallel to each other and the papillae of the cutis intact. In hypertrophic scar, no papilla3 exist and the connective tissue, while abundant, is loose and irregularly distributed. In cicatricial, or false keloid, the bundles of connec- tive tissue are present but the papillae are absent. The treatment of keloid is unsatisfactory, as the disease tends to return after excision or cauteriza- tion. Multiple puncture, scarifications, curetting, are all ineffectual. The growth generally lasts throughout the life of the individual. Spontaneous resorption is said to have occurred in a few isolated examples. It has been latterly claimed that electroly- sis has a good effect, but it is as yet too early to base any positive statements upon the results obtained. When the pain is excessive, measures should be taken to relieve it. When the deformity is great, it is best to excise the mass in the hope that, if a re- turn takes place, it may not be so large or disfiguring as the original mass. FIBROMA. Syn.—Molluscum Fibrosum, Molluscum Simplex, Molluscum Pendulum. This connective tissue new growth is of rather •infrequent occurrence. It appears as elevated, ses- sile, or pedunculated tumors, varying in size from HANDBOOK OF DERMATOLOGY. 113 a pin-head to enormous masses. All sizes may be found in the same case. Generally, a number exist, Fig. 16— Molluscum Fibrosum although it is found singly. Fibroma appears soft and elastic to the feel—occasionally dense. The skin covering it is normal in color—sometimes reddish. In the large growths, it is thinner than normal. 114 HANDBOOK OF DERMATOLOGY. Fibromata occur chiefly upon the trunk, the face, the ears, the genitalia, and the limbs. The growth is very slow, but continuous. Its benign nature precludes subjective symptoms ex- cept when the large size produces irritation and pain. Fibroma can be readily recognized and differentiated from molluscum epitheliale, cysticircus cellulosae, neuroma, or lymphangioma. Fibroma begins in early life and continues to grow. It is seen most often in stunted individuals, and is said to be inherited. The growth is composed of a dense, white, fibrous mass, enclosed in a cap- sule, the center softening when the mass is large. The treatment is surgical. The tumors should be removed when this is possible. In cases where they exist in hundreds this is scarcely possible, and only the largest should be excised. There is no tendency whatever to recur. XANTHOMA. Syn.—Xanthelasma, Vitiligoidea, Fibroma Lipomatodes. This disease derives its name from its yellow color. It occurs in two forms—xanthoma planum and xanthoma tuberosum. Xanthoma planum, or macular xanthoma, occurs in ovalish or crescentic macules, of a straw or sulphur yellow, varying in size from a pin's-head to the thumb-nail. The macules are velvety to the touch, and incline to be symmetrical. In appearance they resemble a piece of chamois skin which has been inserted into the integument until level with its surface. The macules may be discrete or become confluent. They occur most often upon the eyelids. Other portions of the integument and the mucous HANDBOOK OF DERMATOLOGY. 115 membranes and internal organs may be affected. There are no subjective symptoms. Xanthoma tuberosum consists of small masses, varying in size from a millet-seed to a cherry, and having a deep yellow color. They are softish, and occur about the trunk and joints. This form is not frequently seen. When both varieties occur in the same individ- ual, we have xanthoma multiplex. The pathology of this affection is not yet defin- itely settled. lb is, probably, a connective tissue new growth, with fatty degeneration. Cholesterin crystals are found in abundance. There is also a marked number of new cells. The treatment is surgical. Removal of the affected portion is indicated, but only in those localities in which an operation will improve the appearance. Electrolysis has been employed, latterly, with good results notably in the plane variety, and promises to be the method of the future. It should always be tried. A one in ten solution of corrosive sublimate in xanthoma of the eyelids has been lauded lately. MOLLUSCUM EPITHELIALE. Syn.—Molluscum Contagiosum, Molluscum Seba- ceum, Epithelioma Molluscum, Acne Varioliformis. This affection is unusual, and consists of roundish elevations, wart-like in appearance, and having a waxy, whitish, or pinkish color. The papules are flattened, and show a greater or less depression in the center. A blackish point is occasionally ob- served in this central depression. The lesions vary in size from a pin-head to a split pea. They occur singly or in numbers. They are firm and easily movable. There are no subjective symptoms. 116 HANDBOOK OF DERMATOLOGY. The face and genitalia are most often the seat of these growths. The limbs are also involved, at times. Children are most often the subjects of this disease. It is said that the cause is to be looked for in some local irritation, and there are those who contend that this affection is contagious. This latter point is still sub judice. As to its pathology, we are reasonably certain that the process occurs in the sebaceous glands, and, when the contents of one of the papules is examined, it is found to abound in molluscous bodies. The theory is that the disease is primarily an affection of the rete mueosum, and the prickle cells are trans- formed into molluscous bodies. Molluscum epitheliale is not difficult to recognize. It is to be differentiated from sebaceous cyst, mollus- cum fibrosum and verruca. The treatment is entirely local. Small lesions may be treated by stimulating applications, such as those containing white precipitate, etc. Enucleation of the sac and its contents is the best method. Elec- trolysis is also excellent. A method sometimes prac- ticed is to split open the lesion and introduce a small amount of some caustic. The disease is easily amenable to proper surgical interference. If left alone, it tends to spontaneous recovery, after a variable length of time. RHINOSLEROMA. This rare disease is characterized by the presence of an irregular elevated patch, composed of tuber- cles, of the color of the skin or reddish-brown. The mass is well defined and occurs about the nose, its ahe and the upper lip. It is hard to the feel, although somewhat elastic. It is slow in progress, gradually HANDBOOK OF DERMATOLOGY. 117 encroaching on the nasal mucous membrane and ex- tending to the pharynx. It is seen in children and in adults. It consists of a cellular growth, and late observations tend to show that it is due to micro- organisms. The former treatment by cauterization, which acted but temporarily, has been in great part supplanted by injections of corrosive sublimate solu- tions, followed by apparent successes. LUPUS ERYTHEMATOSUS. Syn.—Lupus Erythematodes, Vespertilio, Bats- wing Disease, Seborrheica Cogestiva, Lupus Superficial, Lupug Sebaceus. This cellular new growth is not frequently seen in this country. It begins as one or more reddish- brown patches, which increase in size indefinitely. As they approach each other they coalesce. At the margi u grayish or yellowish scales show themselves. When the disease is developed, it presents itself as one or more sharply defined patches of various sizes, of a violaceous or reddish color, covered with adher- ent scales which may be scanty or appear like a mass of sebaceous matter. The follicles of the sebaceous glands are large and open. The patches are always dry. The localities usually affected are the cheeks and bridge of the nose. These coalesce and form a butterfly-like patch. The vermillion of the lips, the scalp, the ears, the back and the hands and feet may be involved. Some burning and itching are some- times present. The disease is essentially chronic and very rebellious to treatment. Stimulating and caustic applications are the best, the curette and galvano-cautery rendering good service. Multiple scarifications also act favorably. Some cases recover spontaneously, but relapses are very apt to occur. 118 HANDBOOK OF DERMATOLOGY. LUPUS VULGARIS. Syn.—Noli me Tangere, Lupus Exedens, Lupus Vorax. This affection, while common in Europe, is ex- ceedingly rare in this country. Jt is extremely chronic, slow in its evolution and destructive in its process. It begins as softish nodules of the size of a millet-seed located in the corium and appearing to SI RONG 8 BRINSLEY.SC'.tM Fig. 17.—Cicatrices due to Lupus. {Archives of Ophthalmology.) view as dark red macules upon the skin. Patches form in which papules or softish tubercles show themselves. These patches have well-defined more or less elevated edges. Involution may take place; but, as a rule, ulcers form which have a dirty floor, HANDBOOK OF DERMATOLOGY. 119 an abundant secretion of pus and rather soft edges. This ulceration is destructive and may produce ex- tensive ravages, cicatrization taking place as the process advances. The scars are rather thick, with centrifugal bands, giving a stellate appearance. Variations in the process are the appearance only of tubercles or papules (lupus tuberculosus); atrophy and desquamation following involution (lupus exfol- iativa) ; ulceration (lupus exedens); a vegetating process (lupus vegetans or hypertrophicus); or the occurrence of horny or warty growths (lupus verru- cosus). The regions most frequently attacked are the face, especially about the nose and upper lip, the ears, the trunk, the genitalia, and the extremities. The mucous membranes also become the seat of the dis- ease by extension of the process, and the larynx is also attacked. Pain, more or less marked, is an ac- companiment. In the earlier part of the process are found nest- like masses of large nucleated cells which disappear to give way to the general cell infiltration. Tu- bercle bacilli are also found, abundantly in recent active lesions, usually within the cells. The diagnosis is to be made from epithelioma, syphilis, psoriasis, lupus erythematosus, and acne rosacea. The treatment is a difficult matter. Internally, only such remedies should be administered as are demanded by the general condition of the patient. Locally, the most modern treatment is based upon the action of parasiticides. Good results are re- ported from the use of ointments or solutions of cor- rosive sublimate, one or two grains to the ounce, applied continuously to the patches, or the same 120 HANDBOOK OF DERMATOLOGY. agent in tincture of benzoin freely painted on the patches is said to act well. Sulphurous acid, pyro- gallol (10% ointment) and iodoform have been recom- mended. Multiple scarifications or curetting with a sharp spoon, followed by some of the above appli- cations, is well spoken of by some. Cauterization with the Paquelin knife, galvano-cautery, or chem- ical caustics has its adherents. Electrolysis has also been advised. The remedies proposed and lauded for this disease are very numerous, and more or less efficient. SCROFULODERMA. The scrofulodermata are, as a rule, chronic, indo- lent, hyperaemic processes which induce changes in the skin and subcutaneous tissues. There is a tend- ency to break down and to the formation of ulcers. The contiguous ganglia become infiltrated, hard and are also inclined to undergo degenerative changes. The nodules which are formed rapidly break down and the resulting lesions have a purplish appear- ance, uneven floors, pale granulations and thin pus. The cicatrices are irregular, corded and disfiguring. The chief varieties of the scrofulodermata are the papular and the pustular (small and large). The treatment should be general, directed to the struma; and, locally, antiseptic and stimulating applications. Tuberculosis Cutis.—Tuberculosis of the skin is exceedingly rare. It is characterized by indo- lent, roundish, ulcers of the skin having a slightly infiltrated base and pale floor. They generally occur at mucous outlets. Sometimes they are the effect of direct inoculation with tubercle bacilli. Good results have been reported from the external use of iodoform. HANDBOOK OF DERMATOLOGY. 121 Ainiium is a disease of the little toe, found in negroes in Brazil and Africa. An indurated ring forms around the toe and keeps contracting until, in the course of years, spontaneous amputation occurs. The toe increases in size by development of fatty tissue. Podelcoma, Madura Foot, Mycetoma or Fungous Foot, attacks the feet, which then become cedema- tous, and are covered with vesicles, or tubercles over which are found small black granules. Sin- uses form which penetrate to the bone and through which granular or cheesy masses discharge. It is supposed to be due to a mycelium—cheonyphe Carteri. This trouble is confined to India. LEPRA. Syn.—Elephantiasis Graeeorum, Lepra Arabum, Leontiasis, Satyriasis, Leprosy. This affection is one which is constitutional and rather infrequent in temperate zones, at the present time. It is slow and insidious in growth and rather progressive in character. Premonitory symptoms are observed in the majority of cases, these consist- ing of malaise, chills, fever, languor, loss of appe- tite, etc. Nearly every organ of the body may become affected. In general, three varieties of the disease are recognized, viz.: tubercular, macular and anaesthetic. Lepra tuberculosa or tubercular leprosy, begins as macules which are of a reddish or brownish color, round, oval or irregular in outline and occurring chiefly about the face, trunk and extremities. There may be some scales, or the skin may appear shining. In a variable length of time tubercles arise. These oonsist of irregular nodules, softish to the feel and 122 HANDBOOK OF DERMATOLOGY. rather firm, of a reddish, yellow or brown color. The face and hands are most frequently affected. The brows, nose, lips, chin and ears become thick- ened and nodulated, giving a peculiar leonine ap- pearance to the features (leontiasis). The larynx Fig. 18.—Lepra. (N. Y. Medical Record.) and soft palate become involved. The tubercles may be reabsorbed, but they generally ulcerate and, towards the last, mutilation, chiefly of the extremi- ties, is a result of this process (lepra mutilans). The course of the disease is extremely slow. HANDBOOK OF DERMATOLOGY. 123 Lepra maculosa, or macular leprosy, has the ap- pearance of the tubercular at its inception. Some- times, the macules are white, with enlarged capil- laries at the border. At first, there is hyperaesthesia and, later on, anaesthesia of the affected portions. Occasionally, the macules bear a close resemblance to vitiligo. Lepra anesthetica, or anaesthetic leprosy, first manifests itself by the appearance of bullae. Scars generally follow, and these are white and shining, somewhat resembling plates of mica. The affected areas are anaesthetic, other portions of the integu- ment sharing in this want of sensibility. There is a symmetry in the distribution of the lesions. The nerves, which are subcutaneous, are felt to be indu- rated, and, like cords, fusiform nodes being found in some. The skin is dry and haish, the muscles atrophy aud the hair falls out. The extremities ulcerate and lepra mutilans generally supervenes. Any two or all of the above varieties may be present in the same individual. The causes of leprosy have never been definitely ascertained. Jt has no connection whatever with syphilis. As to its being contagious, there is also Borne doubt. Its iufectious character has been defi- nitely ascertained, experimental inoculations hav- ing produced the disease. The process which takes place in leprosy is a small, round cell infiltration which depends for its origin upon the bacillus leprae, whose principal habitat is along the walls of blood-vessels, it being also found in all the lesions. It may occur at any age, children being the sub- ject of the disease as well as adults and the old. 124 HANDBOOK OF DERMATOLOGY. The treatment of leprosy is ineffectual unless it be in its earliest stages. Hygienic measures, baths plain or with sulphur, or iodine and the use of oil of cashew nut, Gurjun balsam and chaulmoogra oil constitute the principal therapeusis. Lately ich- thyol, internally and externally, has been claimed to effect a cure in the earlier stages, but there is not enough evidence yet upon which to base a decision. Pellagra, Lombardian leprosy or mal rosso is seen chiefly in Italy and consists of a chronic ery- thematous process invading those portions of the skin which are exposed. Desquamation takes place leaving a red, shining surface. Where there is no scaling the skin becomes thick, dry and yellowish or brown in color. General symptoms of marasmus are also present. The disease is found in the poor, and the treatment is one based upon general prin- ciples, being roborant and tonic. CARCINOMA CUTIS. Under the general term of carcinoma of the skin is included three principal varieties of malignant tumors, the epithelial, the fibrous, and the melanotic sarcomata. The skin may be primarily involved by the process or it may become affected after other organs or tissues have been attacked. In all the forms given above there is more or less of an epithe- lial involvement. EPITHELIOMA. Syn.—Epithelial Cancer, Cancroid. This is by far the most common malignant neo- plasm of the skin. Three varieties are described— the superficial, fhe deep and the papillary. HANDBOOK OF DERMATOLOGY 125 Superficial Epithelioma.—This form begins as small papules or flat infiltrations reddish, yellowish or grey in color. The growth has a tendency to arise in lesions of the skin, such as excoriations, fis- sures, etc., or it may take its origin from a wart, Fig. 19.—Rodent Ulcer. (Cin. Lancet and Clinic.) mole, naevi or from the orifices of sebaceous glands. The shape is circular, oval, linear or irregular. It is only observed in those at or past middle life. There is a tendency to spread and the formation of an ulcer—rodent ulcer—which invades large areas, 126 HANDBOOK OF DERMATOLOGY. having irregular, granulating floor, perpendicular infiltrated edges and secreting a viscid serum. The head and face are most frequently attacked by this variety. The course is slow or rapid ; the termina- tion may be a spontaneous healing, after a number of years, or a rapidly destructive process. Deep Epithelioma.—This variety known also as tubercular epithelioma originates in the same manner as the superficial or from nodules situated deeply in the skin or subcutaneously. A tumor forms, some- times surrounded by "satellites," or a thick " but- ton," which in the course of time degenerates into an ulcer such as has already been described. The process differs in this, however, that it has a ten- dency to extend down into the tissues involving muscles, fasciae, bones, etc. It is eminently destruc- tive in character and may, in a comparatively short time, cause death from exhaustion, haemorrhage, etc. Papillary Epithelioma.—This variety may be de- scribed, in a few words, as a malignant papilloma. A warty growth is first observed, which may grow to a considerable size. The surface is dry or secretes an offensive sanguineous fluid. Fissures form, de- generation occurs and ulcers arise such as those described above. About three-fourths of all the cancers of the skin are observed upon the face and head. Any of tlie varieties first described may occur in this locality. The genitalia, back of the hand and foot, are also occasionally involved. Any portion of the integu- ment may be the seat of this affection. In PageVs Disease of the Nipple we have a form which is peculiar from the fact that at its inception it simulates eczema very closely. In a short time, however, its malignant character declares itself. HANDBOOK OF DERMATOLOGY. 127 Epithelioma is to be distinguished from lupus- vulgaris, syphilis and sarcoma. The treatment is entirely local, no internal reme- dies being of any avail except in so far as general measures may be indicated by the state of the pa- tient. Excision, scraping, or cauterization comprise the methods of treatment of epithelioma. Of the first two methods it is unnecessary to speak here, they being purely surgical. Among the caustics employed are Vienna paste, caustic potassa and chloride of zinc. Pyrogallol and concentrated lactic acid are said to destroy the cancerous tissue without attacking the normal structures. The former is used in the strength of ten per cent, and is painless. The latter is mixed with some inert powder so as to form a paste and is exquisitely painful. The method of applying these agents is spread upon cloths. Cosmes' Paste and Marsden's Paste are also em- ployed. The thermo-cautery and galvano-cautery are excellent means when they can be employed. Whatever method is adopted should be thorough. It is absolutely necessary to remove the entire malignant mass, so as to obviate any possibility of a recurrence. When relief is nought the process has generally advanced so far that a return is almost always certain. In very few cases, in which a few nodules exist and are small and isolated, thorough removal ensures a " cure." Lenticular Cancer, scirrhous, hard or fibrous cancer rarely occurs primarily in the skin. It is al- most always secondary to some cancerous involve- ment of other parts. It occurs as small, firm nodules in the substance of the skin or in the subcutaneous connective tissue. The skin is generally reddened. They sometimes break down, forming ulcers and 128 HANDBOOK OF DERMATOLOGY. subsequently cicatrices. Cancer en cuirasse is that form in which the integument of a large part or of all of the chest is infiltrated by the cancerous mass. Returns generally occur after extirpation. Tuberous Carcinoma occurs on the chest, hands, arms and face in the form of multiple nodules, which are rather large and have a tendency to break down and form deep ulcers. Melanotic Carcinoma, or pigmented carcinoma, is that form in which a marked deposit of pigment occurs. It generally takes its origin from pigment- ary naevi or moles. It is very markedly malignant. SARCOMA CUTIS. Sarcoma of the skin is malignant to quite a marked degree. It shows itself as a primary or sec- ondary growth, occurring as a single or as multiple tumors, varying in size, from a pea to a goose's egg. It may show itself upon any portion of the integu- ment and may occur at almost any age. It has been seen at birth. At first the tumors are isolated, the intervening integument being apparently normal, later on, it becomes red, swollen and infiltrated. - A peculiarity of sarcoma is that it does not ulcerate. The treatment is unsatisfactory and death is the in- evitable result, in all cases. The diagnosis is deter- mined definitely by microscopic examination. Melanotic Sarcoma, or melano-sarcoma has the general features of sarcomata. It is pigmented, the color presented varying from a grey to black. It is extremely malignant in character and quick in its evolution. All treatment is unavailing and a rapid termination in death is to be expected. Mycosis Fungoides, or granuloma fungoides, is a neoplastic disease caused by streptococci or diplo- HANDBOOK OF DERMATOLOGY. 129 cocci and characterized by button-like tumors occur- ring in various portions of the integument, notably the face. After a time, they become firm, sausage- shaped, lobulated, of a peculiar red color, producing a sort of leonine countenance. General symptoms set in and all the treatment consists in securing the comfort of the patients, who do not survive longer than two to four years, on an average. NJEVUS VASCULOSUS. Syn.—Naevus Sanguineous, Naevus Vascularis. This affection is frequently seen and easily recog- nized. It is congenital, occurring either in the skin or subcutaneously, and the formation is com- posed of bloodvessels. Naevi of this kind are roundish or irregular in shape, vary in size and are bright red, violaceous, or bluish in color. The head and face are most frequently affected. Some grow, others become smaller ; but the majority remain sta- tionary. Naevus vasculosus is very vascular, easily compressible, the skin underlying it being normal. Generally, it is single, but it may be multiple. There are no subjective symptoms. There are two divisions of naevus vasculosus—nae- vus tuberosus and naevus simplex. Nevus tuberosus, or angioma cavernosum is tumor- like, prominent and erectile. It is very vascular and, at times, pulsating. Nwvus simplex, or angioma simplex, consists of non-elevated macule-like patches, which are more or less smooth. It is occasionally described as ne- vus flammeus or " port wine mark." N»vtfV> .;£^«.>S '■-'*. stSfe NAnONAl IIBMR NLM D01S2T71 M NLM001529714