™»ww«»* 5555555555555555555555555555555R ^ lirt SURGEON GENERAL'S OFFICE LIBRARY Section Form 113c W. D.,S.G. O no. A.U.1G3. NWENT PRIXTINQ OFFICE 6 "\ ■> NLM001529652 HANDBOOK OF DEEMATOLOGT FOR THE USE OF STUDENTS. A. H. OHMANN-DUMESNIL, A. M., M. D., in Professor of Dermatology and Syphilology in the Marion-Sims College of Medicine, St. Louis; Ex-Consulting Dermatologist to the St. Louis City Hospital; to the St. Louis Female Hospital; Dermatologist to the Alexian Brothers Hospital; to the Pius Hospital; to the Rebekah Hospital; to the St. Louis Polyclinic and Emergency Hospital; Editor of the St. Louis Medical and Surgical Journal and of the Quarterly Atlas of Dermatology, etc. > \ ,„ \ Second Edition, Revised and Knlargeda Illustrated with Fifty Original Full-page Plates anV> Numerous Engravings in the Text. . o \ /? / A *&> 19*363 ST. LOUIS: Quarterly Atlas Company. ^I)IUi. ££^ V' ' ;5V'''GT0fV5^ Copyrighted, 1894, by A. H. Ohmann-Dumesnil. PRINTED BY OX & BARTON ST. LOUIS. ENGRAVINGS BY WESTERN PHOTO-ENGRAVING CO ST. LOUIS INSCRIBED TO MV MOTHER AS A TRIBUTE OF ESTEEM AND AFFECTION. THE AUTHOR. i PREFACE TO SECOND EDITION. In presenting this edition to the consideration of those who desire an insight into the vast field which dermatology offers, no attempt has been made to give a complete manual of the subject. A mere outline of dermatology has been roughly sketched, suffi- cient to enable the careful reader to grasp enough so as to induce him to pursue the subject further with a somewhat fuller under- standing of the various points involved. It is for this reason that pathology has been barely hinted at, as it is so vast a sub- ject that entire works are devoted to the histopathology of skin diseases alone. In order to render this little volume of practical utility, treatment has been made somewhat prominent without rendering it complex. The illustrations given, as well as the plates, are from the author's collection, with the possible excep- tion of a few anatomical diagrams, for which he acknowledges his indebtedness to the admirable drawings of various authors. The writer is under obligations for many valuable hints and much useful information to the leading authorities in dermatology. Foot-notes and references have been omitted, so as not to render the book too cumbersome, but it is hoped that this general acknowledgement will be taken by all in the same spirit in which it is made. I also desire to tender my thanks to Mr. John A. Hazenstab, of this city, for the practical assistance received from him in the photographic work which appears in this volume. A restricted formulary has been added, as well as a selected bibliography, both of which may prove useful. Being designed as a syllabus of the lectures delivered during a winter term it is the earnest hope of the author that it may prove not only useful to his students during their college days, but may also prove profitable to them at times when engaged in the more serious business of active practice. That it may meet with the approval of his colleagues as well is the sincere wish of The Author. Nov. 10, 1S«)4. ILLUSTRATIONS. PLATES. PLATE. I. Seborrhea Sicca, 32 II. Milium, 38 III. Urticaria, 60 IV. Acute Eczema, 62 V. Subacute Eczema, 64 VI. Chronic Eczema, 65 VII. Herpes Simplex, 73 VIII. Herpes Zoster, 76 IX. Lichen Ruber, 86 X. Acne, 90 XI. Acne Rosacea, 94 XII. Rhimophyma, 94 XIII. Sycosis, 96 XIV. Impetigo Contagiosa, 102 XV. Erythema, 103 XVI. Psoriasis, 104 XVII. Pityriasis Rubra, 108 XVIII. Carbunculus, 112 XIX. Purpura Simplex, 130 XX. Cornu Cutaneum, 146 XXI. Cornu Unguale, 148 XXII. Verruca Acuminata, 149 XXIII. Ichthyosis Hystrix, 151 XXIV. Elephantiasis, 158 XXV. Hypertrichosis, 162 XXVI. Onychogryphosis, 166 XXVII. Vitiligo, 170 PLATE. XXVIII. XXIX. XXX. XXXI. XXXII. XXXIII. XXXIV. XXXV. XXXVI. XXXVII. XXXVIII. . XXXIX. XL. XLI. XLIL XLIIL XLIV. XLV. XLVI. XL VII. XLVIII. XLIX. L. Strife Atropicse, 175. Alopecia after Erysipelas, 178 Alopecia Universalis, 179 Alopecia Areata, 180 Plica Polonica, 184 Keloid, 186 Fibroma, 189 Molluscum Epitheliale, 193 Lupus Erythematosus, 196 Lupus Vulgaris, 197 Lupus Scar, 108 Scrofuloderma, 200 Tuberculosis Cutis, 201 Lepra Tuberculosa, 204 Epithelioma, 208 Favus, 225 Tinea Capitis, 230 Scabies, 238. Porrigo e Pediculis, 242 f Sarcoptes Scabiei, 240 1 Pediculus Capitis. 240 / Pediculus Corporis, 248 ( Pediculus Pubis, 248 | Pediculus Pubis, hatching, 250 I Pulex Irritans, 250. / Cimex Lectularius, 252 ( Chicken Louse, 252 FIGURES. Cutaneous Furrows, 2 Vertical Section of Skin, 3 Section of Scalp, 4 Vertical Section of Epidermis, 5 Section of Skin, 6 Subcutaneous Adipose Tissue, 7 Papillary Vessels, 7 Cutaneous Lymphatics, 8 Pacinian Corpuscle, 9 Section Showing Pigment Layer, 10 Coil Gland, 11 Sweat Pore, 11 Sebaceous Gland, 12 Section of Hair, 13 Development of Hair, 14 Diagram of Nail, 15 Author's Comedo Extractor, 37 Fig lx. 19. 20. 21 22. 23! 24. Author's Milium Needle, 38 Author's Cutisector, 93 Hair in Sycosis, 97 Tattooing, 140 Hypertrichosis of Face, 163 Piffard's Epilating Forceps, 164 Author's Electric Needle-Holder, 164 Section of Vitiligo, 170 Trichorrexis Nodosa, 183 Author's Scarificator, 197 Piffard's Curette, 197 Scrofuloderma, 199 Lepra Tuberculosa, 204 Achorion Schoenleinii, 220 Tricophytou, 232 Microsporon Furfur, 236 Demodex Folliculorum, 262 TABLE OF CONTENTS. The Skin, 1 Anatomy, 4 Symptomatology, 16 Primary Lesions, 16 Secondary Lesions, 17 Etiology, 19 Diagnosis, 20 Therapeutics, 22 Pathology, 24 Prognosis, 25 Classification, 26 CLASS I. DISORDERS OF SECRETION AND EXCRE' Seborrhea, 32 Asteatosis Cutis, 35 Comedo, 36 Milium, 38 Sebaceous Cyst, 40 Hyperidrosis, 41 Anidrosis, 44 Bromidrosis, 45 Chromidrosis, 47 Hematidrosis, 47 Uridrosis, 47 Phosphoridrosis, 47 Sudamiua, 49 CLASS II. HYPEREMIAS. Erythema Simplex, 50 Erythema Caloricum, 50 Erythema Traumaticum, 51 Erytema Venenatum, 51 Erythema Intertrigo, 53 Roseola, 55 Erythema Scarlatiniforme, 56 CLASS III. INFLAMMATIONS. Erythema Multiforme, 58 Erythema Nodosum, 59 Urticaria, 60 Eczema, 62 Eczema Scborrhoicurn, 71 Herpes, 73 Herpes Iris, 75 Herpes Zoster, 76 Dermatitis Herpetiformis, 70 Miliaria, 81 Pompholyx, 83 Pemphigus, 84 Lichen Ruber, 86 Lichen Planus, 87 Prurigo, 88 Lichen Scrofulosus, 89 Acne, 90 Acne Rosacea, 94 Sycosis, 96 CLASS III.—Continued. Perifolliculitis, 98 Dermatitis Papillaris Capillitii, 99 Impetigo. 100 Impetigo Herpetiformis, 101 Impetigo Contagiosa, 102 Ecthyma, 103 Psoriasis, 104 Pityriasis Maculata et Circinata, 107 Pityriasis Rubra, 108 Furunculus, 109 Furunculus Orientalis, 111 Carbunculus, 112 Poisoned Wounds 113 Dissection Wounds, 113 Anthrax, 114 Equiuia, 115 Dermatitis, 116 Dermatitis Calorica, 118 Dermatitis Gangrenosa, 118 Dermatitis Medicamentosa, 119 CLASS IV. HEMORRHAGES. Purpura Simplex, 130 Purpura Rheumatica, 132 Purpura Hemorrhagica, 133 CLASS V. HYPERTROPHIES. Lentigo, 135 Chloasma, 137 Addison's Disease, 139 Discoloration of the Skin, 140 Nevus Pigmentosus, 142 Callositas, 143 Clavus, 145 Malum Perforaus, 146. Cornu Cutaneum, 147 Cornu Unguale, 148 Verruca, 149 Ichthyosis, 151 Xerosis, 153 Keratosis Pilaris, 154 Scleroderma, 155 Morphea, 156 Sclerema Neonatorum, 157 Elephantiasis, 158 Dermatolysis, 160 Donda Ndugu, 160 Frambesia, 161 Hypertrichosis, 162 Onychogryphosis, 166 CLASS VI. ATROPHIES. Albinism, 168 Vitiligo, 170 Canities, 172 Vlll TABLE OF CONTENTS—Continued. CLASS VI— Continued. Atrophia Cutis, 173 Senile Atrophy. 174 Glossy Skin, 174 Striae et Maculae Atrophica, 175 Ainhum, 177 Alopecia, 178 Alopecia Areata, 180 Alopecia Furfuracea, 182 Atrophyiof the Hair, 183 Plica Polonica, 184 Atrophy of the Nail, 186 CLASS VII. NEW GROWTHS. Keloid, 187 Fibroma, 189 Xanthoma, 190 Psorospermosis, 192 Molluscum Epitheliale, 193 Rhinoscleroma, 195 Lupus Erythematosus, 196 Lupus Vulgaris, 197 Scrofuloderma, 199 Tuberculosis Cutis, 201 Verruca Necrogenica, 201 Mycetoma. 203 Podelcoma, 203 Lepra, 204 Pellagra, 207 Carcinoma Cutis, 208 Epithelioma, 208 Sarcoma Cutis, 211 Nevus Vasculosus, 212 Telangiectasis, 214 Adenoma Sebaceum, 215 Lymphangioma, 216 Neuroma Cutis, 217 Myoma Cutis, 218 CLASS VIII. NEUROSES. Hyperesthesia, 219 Dermatalgia, 119 Pruritus, 221 Anesthesia, 224 CLASS IX. PARASITES. Favus, 225 Tinea Tricophytina, 228 Tinea corporis, 228 Tinea capitis, 230 Tinea'barbie, 231 Chromophytosis, 235 Erythrasma, 237 Scabies, 238 Pediculosis, 242 Pediculosis capitis, 242 Pediculosis corporis, 246 Pediculosis pubis, 249 Pulex, 252 Cimex, 255 Dermanyssus, 258 Ixodes, 259 Leptus, 260 Culex, 261 Pulex Penetrans, 261 Filaria, 261 CEstrus, 262 Demodex FoUiculorum, 262 Cysticircus, 263 Formulary, 264 Bibliography, 269. 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, unctuous feel, rather smooth as a rule, certain localities, 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 indicated to black. Thus we have the coppery hue of the North American Indian, the yellow cast of the Mongolian, the brown of the Poly- nesian, etc. In the same individual, certain parts are found to be more deeply pigmented than the general surface, viz., 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 thin- nest 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 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, and this variation is one which may be easily verified. 2 HANDBOOK OF DERMATOLOGY. The appendages of the skin are those portions which, while strictly not essential to it, are still found in connection with it. They are the hair and the nails, whose functions are purely pro- tective. 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 quite coarse, and the coarser the furrows the deeper. Fig. 1.—Cutaneous Furrows. A, Opening of Hair-Follicle. B, Sweat Pore. 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 integumentary surface required for the movements of flexion and extension. The finer furrows are distributed over the entire sur- face of the skin and form a network of triangles; and these, in turn, form a series of polygonal figures (Fig. 1). Where these lines intersect, there will be found a small hole, the opening of a coil gland, or of a sebaceous gland, or of a hair follicle with its hair protruding. Hairs cannot be found except at these inter- sections. There are comparatively very few intersections where this rule does not hold good. Where sebaceous glands and hair follicles are absent, 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 coil glands. HANDBOOK OF DERMATOLOGY. 3 Lying directly underneath the skin, there is found the sub- cutaneous connective tissue and adipose tissue, which vary in quantity in different portions of the body, and serve to give the rounded appearance observed in the limbs and body. They also aid as protectors of the underlying tissues and permit the integu- ment to be freely moved. The functions of the skin may be stated, in general terms, to be the regulation of the body temperature, 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, absorption and respiration are also exercised, to a certain degree. Fig. 2.—Diagrammatic Vertical Section of the Skin. A, Stratum corneum, B, Stratum lucidum; C, Stratum granulosum; D, Stratum mucr- sum; F, Stratum pigmentosum; E, Stratum papillare; G, S-ebaceous gland; H, Uav ■ I, Subcutaneous connective tissue; K, Pacinian corpuscle; L, Tactile corpuscle; M Vascular papillary leop; N. Coil gland; O, Airector pili muscle. 4 HANDBOOK OF DERMATOLOGY. ANATOMY. The skin is composed of two principal portions—the epider- mis and the corium; while, underlying it, is the subcutaneous connective tissue and fat. Fig. 3.—Section of Skin of Scalp. The Epidermis may be divided into five layers, as follows: Stratum corneum, stratum lucidum, stratum granulo- sum, stratum mucosum, and stratum pigmentosum. The; stratum corneum, or horny layer, is the uppermost, 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 muco- sum. In the negro some pigment granules are irregularly scat- tered through this layer. The thickness of this layer varies in different parts, being most pronounced in the palms and soles. The stratum lucidum (Oehl's layer) lies immediately beneath the horny layer, and consists of two or three rows of transversely disposed epithelial cells which appear glistening. HANDBOOK OF DERMATOLOGY. 5 Under the microscope it appears glistening, this being due to the presence of eleidin in the cells. This layer is comparatively thin. Fig. 4.—Diagrammatic Vertical Section of the Epidermis. A, Stratum corneum; B, Stratum lucidum; C, Stratum granulosum; D, Stratum rau- cosum; E, Stratum pigmentosum. The stratum granulosum , or granular layer is also thin; it is composed of one or two rows of granular cells disposed in a horizontal manner. It is this layer which gives the color to the skin in white races. It merges insensibly into the next layer. 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 connected with it by a series of digital prolongations (papillae). 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 radiate to the cell wall. Between these cells we have an intercellular substance known as the "cement substance." The lowest layer of cells differs 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 should be classed as an independent one, or as a " pigment layer." Its morphological structure is such as to insure resistance to all external pressure, constituting a true arch. As the cells are closely pressed against each other, and do not exhibit prickles, they differ sufficiently 6 HANDBOOK OF DERMATOLOGY. from the prickle cells in their structure and distribution to con- stitute them a distinct layer or stratum pigmentosum. The Corium, derma, cutis vera, or true skin, is divided into two layers, the stratum papillare, and the stratum reticulare. Fig. .1.—Section of Skin showing Papillae of Different Sizes. The stratum papillare, or papillary Wer, is the upper- most, resting directly beneath the mucous layer of the epidermis. It is composed of fine connective tissue, the bundles of fibres of which decussate and become felted, as it were. It appears in the form of numerous digital prolongations—the papillae—which are more or less developed in different portions of the body. They are bulbous, conical or blunt at the apex. They are either vas- cular or nervous, according as they contain the terminal loop of a blood-vessel, or the termination of a non-medullated nerve fibre. The stratum reticulare, or reticular layer, is composed of coarser connective tissue fibres, the papillary la}'er gradually merging into it. It, in turn, also merges into the subcutaneous connective tissue, which is still coarser and more open. HANDBOOK OF DERMATOLOGY. 7 The Subcutaneous Connective Tissue serves the purpose of holding the fat, and supporting the vessels and nerves. It also contains the convoluted portion of the coil glands, Fig. G.—Subcutaneous Adipose Tissue. the hair follicles and the Pacinian corpuscles. It is composed of loosely connected connective tissue bundles. The Blood-vessels of the skin are the arteries and veins, which take their origin from subcutaneous branches, which are subdivided in the corium. They are more abundant on the Fig. 7.—Papillary Yessels Injected. flexor aspects of the limbs than on the extensor. There are three horizontal networks of these blood-vessels: 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. This last net- work gives off loops which bend back upon themselves and which form the so-called "papillary loops" (Fig. S). They are numer- ous and are instrumental in making the skin very vascular, play- 8 HANDBOOK OF DERMATOLOGY. ing an important part in many cutaneous affections. 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 of nerves. The Lymphatic Vessels are relatively few, and are almost entirely limited to that portion of the skin beneath the epidermis. Fig. 8.—Cutaneous Lymphatics. A, Lymphatic vessel. B, Artery. There are lymph spaces, however, separating the epithelial ele- ments of the rete mucosum, extending between the prickle cells and existing in the papillae of the corium, about the different glands, hair-follicles, and nail-beds (Fig. 4). The Nerves of the skin are two-fold in character, viz. : non-medullated and medullated. They are derived from hori- zontal twigs in the subcutaneous tissue and distributed to the corium. The Nox- Medullated fibres "penetrate to the epidermis between the epithelia in great abundance. * * * They either terminate between the prickle cells as ultimate bulbous termina- tions of finely beaded fibrillae, or they penetrate the epithelia themselves in pairs." Whilst some observers claim to have dis- covered very fine filaments terminating in the nuclei of the prickle cells of the rete mucosum the observations have not received suf- ficient confirmation to make the statements positive. It is prob- able, however, that the statement is a correct one. The non- medullated nerves of the skin are so little understood and known that the subject invites further study in view of the fact of the important bearing they probably have in the etiology of many cutaneous diseases. We find filaments of these nerves in the sheaths of hairs and ducts of the coil glands. The Medullated Nerves consist of the papillary loops, Pacinian corpuscles and tactile corpuscles. HANDBOOK OF DERMATOLOGY. 9 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 fingers, nipples and penis. The nerve proper is found in the centre, as a club-shaped termina- tion, surrounded by a protoplasmic core. This, in turn, is cov- Fig. 9.—Pacinian Corpuscle. A, Medullated nerve fibre; B, Capsular enclosure; C, Central fibre; D, Core. vered by a series of concentric nucleated, vascular capsules,. which grow denser towards the peripherj^. Those vascular cap- sules are composed of flat cells containing long nuclei, the outer envelope consisting of polygonal flat cells very indistinctly nucleated. The tactile corpuscle (corpuscle of Meissner, or of Wagner) is also ovoid in form, composed of two or three cap- sules, 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 nryeline sheath. The filament divides, and surrounds and pen- etrates the capsule. It is claimed that these corpuscles have efferent and afferent fibres. The Pigment exercises a varying degree of influence in giving the color to the skin. It exists normally only in the lower- most layer of cells of the mucous layer (stratum pigmentosum), some granules being irregularty scattered throughout the layer. 10 HANDBOOK OF DERMATOLOGY. It is not found, as a rule, in either the horny layer or in the corium in the Caucasian. It is to the pigment that the color of the African race is chiefly due, it having no influence on the coloration of whites, unless it be under the influence of solar heat. Fig. 10.—Section showing Pigment Layer. The Muscles connected with the skin are striated and unstriated. The striated muscular fibres extend from the subcu- taneous tissues into the corium, and are found chiefly about the face and neck. The unstriated muscular fibres are found sur- rounding the nipple, in the orbicularis muscle, or in connection 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 folicle, the direction being oblique, and the fibres are so disposed as to include the sebaceous gland in the angle which is subtended. The action of these muscles is to cause the hairs which are normally at an angle to assume a perpendicular position. The Coil Glands, better known as the sweat glands, con- sist of globular coils situated in the subcutaneous tissue and deeper portions of the corium. The coil gland consists of three parts—the convoluted, situated in the subcutaneous connective tissue; the straight tube, passing through the corium; and the spiral portion included in the epidermis. The coil terminates in HANDBOOK OF DERMATOLOGY. 11 a cul-de-sac. It is lined with columnar epithelial cells, nucle- ated, with granular contents. The excretory duct passes upward to the epidermis, always taking its course between papillae, and Fig. 11.—Coil Gland. pursues a straight or spiral direction. At the border of the epi- dermis, it loses its inner lining membrane as well as its invest- ment of connective tissue, and becomes the siccat pore. This sweat pore is simply a channel, straight or spiral, connecting the Fig. 12.—Sweat Pore. duct of the coil gland with the surface of the stratum corneum. It also has a connection with the intercellular spaces of the strata above the stratum mucosum. This gland secretes fat and gran- ules of pigment, whereas the sweat pore excretes the sweat. The 12 HANDBOOK OF DERMATOLOGY. coil glands are also said to be concerned in the formation of the subcutaneous fat-cushion and "columnae adiposae." The Sebaceous Glands are situated in the- corium, and furnish a fatty secretion whose purpose it is to lubricate the skin and hairs, and act as a non-conductor of heat and cold to the surface by means of the fatty secretion furnished. The glands themselves are usually racemose, and are divisible into three varieties : 1° Those which open directly into a hair follicle; 2° Those opening upon the skin and associated with rudimentary- hairs; 3° Those opening directly upon the surface, but not as- sociated with hairs. The second are the most complex, the last Fig. 13.—Sebaceous Gland. the most simple. The structure of a gland consists of a base- ment membrane upon which a columnar layer rests, correspond- ing to the "pigment layer" of the stratum mucosum. Upon this polygonal cells rest, there being one or more layers, the topmost undergoing fatty degeneration. Towards the centre we have a mass of epithelial debris, oil globules, etc. This gland, like the coil gland, is formed by a dipping-in of the epidermis in early fetal life. As already mentioned, the sebaceous glands are in- closed by the arrectores pilorum muscles whose contractions aid in the expulsion of their contents; whereas, in the case of the coil glands, they impede this action. HANDBOOK OF DERMATOLOGY. 13 Hairs are fine, long, epithelial bodies, arising from depres- sions in the skin (hair follicles). They vary greatly in length, size and color. We find white, black, brown, blonde and red hair, with all the intermediate shades. Ringed hair is a peculiar condition, pathological in its nature. The darker the color the more coarse the hair. Irrespective of the color or the straight or curly condition, it may be stated in a general way that there Fig. 14.—Diagrammatic Section of Hair. A, Medulla. B, Shaft. C, Cortex. D. Internal layer of internal root-sheath. E, Outer layer of internal root-sheath. F, Internal layer of hair follicle. G, Middle layer of hair follicle. H, External layer of hair follicle. I, Adventitia. K, Root of the hair. L, Papilla. 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 eye- lashes. In a fully developed 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 cutane- 14 HANDBOOK OF DERMATOLOGY. ous surface. It is the peculiar distribution of the follicles that forms the whorls of hairs. Two-thirds of the embedded portion is situated in the connective tissue of the corium. A, follicle --------- Fig. 15.—Development of Hair in Embryo. consists of an external longitudinal fibrous layer, a middle trans- verse layer, and an internal homogeneous vitreous layer. At the base of the follicle there is a fibrous pedicle, surrounding the blood-vessels and nerves. The Bulb, or root, is that portion of the hair which is em- bedded. It is bulb-shaped, extending below the follicle proper, and is implanted on a conical projection—the hair papilla. The bulb embraces the papilla, and externally is composed of pig- mented cells forming the cortex. The cells become longer and more vertical higher up. Within the bulb we have the medulla composed of non-pigmented horizontally 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 HANDBOOK OF DERMATOLOGY. 15 the shaft. The cortical portion, or external layer, is composed of flat, nucleated, fusiform epithelial cells, which are imbricated in such a manner that the separations between the cell open upwards. It is upon this layer that the elasticity and extensi- bility of hair depends. The medullary portion, or marrow, con- sists of loose epidermal elements, pigment and fatty matters. There is coloring matter in this, as well as in the cortex. When a hair is about to be shed, it separates from the pap- illa, which is composed of fine connective tissue, and contains blood-vessels and nervous filaments, and rises in the folicle 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 one 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 lenticular portion—the lunula—com- posed of converging ridges which become smaller, these two portions constituting the matrix, the tissue from which the nail springs. Anterior to the lunula, up to the free border, is the nail-bed, which consists of higher ridges of papillae of uni- form height on which are situated prickle cells. Both the matrix and nail-bed are very vascular, and bleed quite freely when injured, this being due to the comparatively large size of the vascular papillae which supply the parts. Flfarn6 i^A~ The nail consists of horny filaments pass^g^^^g^^ B from the matrix or floor of the nail-fold. The Lunula; 'bc! upper surface grows from the bottom of the nail- Matrix- fold, and the under surface from the lunula. The nail-fold is that crescentic portion of integument which clasps the nail pos- teriorly 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, its upper boundary being a convex curve. 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, as a rule. 16 HANDBOOK OF DERMATOLOGY. SYMPTOMATOLOGY. A brief description of the symptoms observed in skin dis- eases is here given, it being essential to master these in order to come to a proper understanding of clinical descriptions. Symp- toms may be either subjective or objective. For the former we must depend upon the patient; and, on this account, the vary- ing degrees of intensity are difficult to determine, much depend- ing upon the physical build, mental peculiarities, and nervous organization of the subject. The principal Subjective Symptoms are as follows: 1. Anesthesia. 2. Hyperesthesia. 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 present 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: 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; excoriations. 6. Pomphi; wheals. 6. Ulcera; ulcers. 7. Turbecula; tubercles. 7. Cicatrices; scars. 8. Phymata; tumors. 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 we see in chloasma or purpura. A papule is a solid, circumscribed elevation of the skin, varying in size from a pin-head to a split-pea, conical or semi- HANDBOOK OF DERMATOLOGY. 17 globular in shape, whose color may be red, pale or dark, yellow or white, as in milium, acne, lichen ruber, etc. A vesicle is a conical or rounded, circumscribed elevation of the horny layer 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 maybe seen in herpes, zona, eczema, miliaria, variola, etc. A blebs is an irregularly dome-shaped or flattened eleva- tion of the horny layer of the epidermis, varying in size from a split-pea to a goose-egg and containing clear or opaque fluid, as in pemphigus and ambustio. A pustule is a circumscribed, flattened, conical, or umbil- icated elevation of the horny layer 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. A wheal is an irregularly-shaped, more or less solid eleva- tion of the skin, of an evanescent character, as in urticaria. A tubercle consists of a circumscribed, solid elevation of the skin, reddish, pinkish or whitish in color, irregular in shape and varying in size from a split-pea to a cherry or larger, as in tuberculosis and lepra. A tumor is a soft or firm prominence, of irregular shape, and varying in size, such as in fibroma, sarcoma, steatoma, etc. SECONDARY LESIONS. A stain is similar to a macule in its characteristics, but differs from it in its origin, being the result or remains of a pre- vious lesion or due to the presence of some foreign substance in the skin, as the coloration following ulcers, tattooing, 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. It may vary greatly in size, shape and color, as in eczema, favus, etc. A fissure is a linear solution of continuity, having its seat in the epidermis or down through the corium, as in eczema. Ax excoriation is a loss of tissue, confined to the upper layers of the skin, and varies in shape, size and depth, as in pe- diculosis and scabies. Ax ulcer is an excavation of the cutaneous tissue, the re- sult of disease, and varying in extent, besides being irregular in shape. 18 HANDBOOK OF DERMATOLOGY. 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. Several of these will be found combined as the result of the same process. When the lesions are taken together they constitute an eruption. A comparatively small portion of an eruption, which is separated, is known as a patch. When lesions are distributed over a large surface, the eruption is said to be disseminated. If the lesions are close to each other they are aggregated; if sep- arated the eruption is discrete. If the patches are round, like coins, they are nummular; if circular, with a clear centre, they are circinate, or annular. If they consist of portions of circles, which have coalesced, they are called gyrate. If con- sisting of very fine lesions it is miliary. This list might be increased many times, but the terms are for the most part, self- explanatory. HANDBOOK OF DERMATOLOGY. 19 ETIOLOGY. In the consideration of the etiology of skin diseases, in general, we are led to a review of the general etiology of disease. For the purpose of convenience, however, the causes of skin diseases may be divided into external and internal. Thus we may have as external causes solar heat and light, temperature changes and general telluric and atmospheric agents. The sea- sous exert a marked influence, and we may include under this head temperature, 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 appearance 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 nervous system. The so-called "diatheses"—the herpetic, the rheumic, the gouty, etc.—have also been invoked by some as causes of cer- tain classes of dermatoses. Besides what has been enumerated, there are causes unknown up to the present, they having suc- cessfully eluded the most searching clinical investigation and analysis. In general terms it maj' be stated that the causes of skin diseases, in so far as they are direct, may be determined with a fair degree of certainty. But the remote reasons are very diffi- cult of explanation, or only so in such an unsatisfactory manner as to lead to no definite conclusion. However, this is no pecu- liarity to be found in dermatology alone, as we find the same condition of affairs in medicine in general. The vast strides that have been made of late years bid fair to elucidate the general subject of etiology to a degree such as will prove of the highest value to therapeutics. 20 HANDBOOK OF DERMATOLOGY. DIAGNOSIS. If there be any department in medicine in which nearly everything depends upon the accuracy of the 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. A systematic method of examination should always be pursued. The past history of the patient should be obtained, all previous diseases noted and an inquiry made into his habits. Not only this, but the occupation, method of living, environments, and other circumstances surrounding him should be taken into con- sideration. The history of the present 'attack should also be cr.refully noted before an objective examination is made, and its duration carefully noted. To examine a patient properly, one of the prerequisites is good light. Good diffused sunlight is the only one that can be relied upon, as many artificial lights absorb all the yellow color. In the next place, the temperature of the room in which the ex- amination is made should be comfortable in order to avoid the circulatory changes due to too great heat or cold. Not only the portion implicated should be examined, but the entire body as well, as such a procedure not only aids greatly in forming a correct diagnosis, but often furnishes information not to be obtained in any other manner. The exact nature of an eruption may be clouded by the production of artificial lesions or the modification of the original ones by means of modes of treatment of various kinds, or other causes. By exposing the entire cutaneous surface, patches of the original trouble will often be found, and they will aid in clearing what might other- wise be a puzzling or false diagnosis. The diagnosis of a patient should never be accepted, and by refusing to consider this, and by making a thorough and care- HANDBOOK OF .DERMATOLOGY. 21 ful 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. In fact, even if the diagnosis be certain, the microscope should be used so as to obtain greater familiarity in its manipulation and, at the same time, confirm the conclusion formed by the inspection of a purely clinical picture. 22 HANDBOOK OF DERMATOLOGY. THERAPEUTICS. The treatment of skin diseases includes not alone the treat- ment of the lesions proper, but that of the remote causes as well. As these latter include general systemic disturbances as well as troubles of separate organs and systems, it will be readily seen that a good general knowledge of therapeutics is an essential to the successful treatment of cutaneous affections. By general therapeutics is meant the treatment of a uterine or ovarian dis- order causing an eruption, of a gout lying at the bottom of an eczema, of a catarrh causing an acne, etc. It is for this reason that the determination of the etiological factors is of so much importance. The treatment of skin diseases may be stated, in general terms, to be internal and local. The internal treatment is fre- quently all-sufficient, but should be judicious in its nature. One fact should never be lost sight of, and that is that arsenic is by no means the universal panacea which it is erroneously supposed to be. Its applications are extremely limited. In the form of Fowler's solution it generally does more harm than good. It should be given in the form of arsenious acid in the Asiatic pill. In any event, its administration should be limited to the indica- tions, which, as a general rule, are few in number. Iodide of potassium is another much abused remedy, which, when indi- cated is given in such small doses as to produce more of its deleterious than of its good effects. The different remedies administered are so numerous that the reader will not be bur- dened with their recital, but is referred to the treatment mentioned under each separate disease. The local applications which are made are of various forms. We have lotions which are solutions in water, alcohol, ether, or some similar vehicle, and clear, or containing some powder which is precipitated. These preparations are of a more or less evan- HANDBOOK OF DERMATOLOGY. 23 escent nature. Soaps are medicated and employed as detergents of small medicinal value, but still serving to aid the action of remedies in a slight degree. The ointment is a fixed dressing, permitting the perspiration to pass through it, and still remaining upon the integument. It constitutes a most valuable method of local medication. The cerate differs but little from the ointment, being more firm in its nature, and not yielding so readily to the bodily temperature. The bacilli, or tallow sticks, area modified form of the preceding for the purpose of applying a stiff ointment with greater facility. Pastes are generally composed of a base of glycerine and kaolin containing some medicament. They dry rather rapidly, but form good permanent dressings, adapted to particular cases. The gelatins, on the other hand, have a tend- ency to form an adherent pellicle which absorbs moisture, and thus prevents a softening and separation of the horny layer of the epidermis. Collodion and rubber solutions also form pelli- cles, but they are impervious to moisture, and thus lead to soft- ening of the surface of the skin, and consequent absorption of the remedies they contain. Plasters act in much the same man- ner, more especially the plaster mulls, which consist of a very thin layer of rubber spread over gauze and having an ointment spread over this, or partially incorporated so far as the active ingredient is concerned. To go into greater details as to remedies and the peculiar forms in which they are employed would necessitate more space than is available. 24 HANDBOOK OF DERMATOLOGY. PATHOLOGY. The pathology of skin diseases is merely general pathology localized upon one organ, and is a field rich in material and of the greatest promise to the investigator. We find the various changes, incident to tissues of other organs, showing themselves in those of the integument. Atrophy and hypertrophy manifest themselves in their various forms, as well as hyperplasias of dif- ferent degrees. Erythema, congestion, stasis and other circula- tory changes are numerous, both in form and number. Inflam- mation is one of the most important pathological processes observed, and the various, as well as variedv pictures it presents in relation to the skin are such as to lead us to make deductions most interesting and valuable, not only so far as the gross ap- pearance and causes are concerned, but on account of the differ- ent tissues implicated in the process. No less interesting are the neoplasmata or new growths, both malignant and benign. They form a large class of diseases in which it is of the utmost importance to determine the true nature of the process, so as to be enabled to arrive at a proper and satisfactory conclusion. Bacteriology plays a by no means unimportant part, whose value is best appreciated in the therapeutical applications to which it leads. It may be truthfully said that the pathology of skin dis- eases covers almost the entire domain of that subject; for, al- though it has not yet been found to embrace it in its entirety, up to the present time, the observations which are being daily made are becoming so numerous that the entire subject will soon be covered in the investigations which are so vigorously prosecuted. HANDBOOK OF DERMATOLOGY. 25 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 physi - cian, as he is enabled to protect himself from the accusation of maltreatment. From a cosmetic point of view it is also of more than ordinary importance. Skin diseases are acute or chronic, amenable to treatment or very rebellious, with all the intermediate degrees of stubborn- ness to therapeutic measures. Some are destructive in their ef- fects and some are essentially incurable. Again, there are affections which, while curable under some circumstances, are not so under others, simpl}- from the fact that they are depend- ent upon some general condition 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 3-ield to proper treatment. In the old the tendency is to chronicity and consequent rebelliousness to therapeutic measures. Tissues are more easily destroyed in the old, and proportionate^ easily regenerated in the young. The old are more prone to the influence of malignant processes. The skin is less active, is weaker and more or less atrophied in the aged, all of these factors influencing the prognosis to be made in a given case. Atrophy, hypertrophy and degeneration are also more prone to attack those in middle life or old age. Parasites are more common in the young. Of course, exceptions will be found oc- casionally, but the above are the most frequently observed. 26 HANDBOOK OF DERMATOLOGY. CLASSIFICATION. The arrangement here presented is essentially that of the American Dermatological Association. Like all others, it con- tains defects, but it will be found to be simple and quite conve- nient, which are qualities to recommend it. No attempt has been made to include all the known skin diseases in this list. A large number will be found mentioned in the text. As will be noted, the plan is partly etiological, partly pathological and, to a certain degree, symptomatic. However, it is a very good one to facilitate the formulation of a diagnosis. Class I.—Disorders of Secretion and of Excretion. A. Sebaceous Glands. Seborrhea. Asteatosis Cutis, Comedo. Milium. Sebaceous Cyst. B. Sweat Glands. Hyperidrosis. Anidrosis. Bromidrosis. Chromidrosis. Sudamina. Class II.—Hyperemias. A. Erythematous. Erythema Simplex. Roseola. Erythema Intertrigo. Erythema Scarlatiniforme. HANDBOOK OF DERMATOLOGY. 2T Class III.—Inflammations. A. Erythematous. Erythema Multiforme. Erythema Iris. Erythema Nodosum. Urticaria. B. Erythematous, Vesicular, Papular, Pustular, Squamous- Eczema. Eczema Seborrhoicum. C. Vesicular. Herpes. Herpes Zoster. Herpes Iris. Dermatitis Herpetiformis. Miliaria. D. Bullous. Pemphigus. Dermatitis Bullosa. E. Papular. Lichen Ruber. Prurigo. Lichen Scrofulosus. F. Pustular. Acne. Acne Rosacea. Sycosis. Perifolliculitis. Dermatitis Papilaris Capillitii. Impetigo. Impetigo Herpetiformis. Impetigo Contagiosa. Ecthyma. G. Squamous. Psoriasis. Pityriasis Maculata et Circinata. Pityriasis Rubra H. Phlegmonous. Furunculus. Furunculus Orientalis. HANDBOOK OF DERMATOLOGY. H. Phlegmonous.—Continued. Anthrax. Equinia. Pustula Maligna. I. Erythematous, Vesicular, Bullous, etc. Dermatitis. Dermatitis Medicamentosa. Class IV.—Hemorrhages. A. Corium, etc. Purpura Simplex. Purpura Hemorrhagica. Peliosis Rheumatica. Class V.—Hypertrophies. A. Pigment. Lentigo. Chloasma. Addison's Disease. Nevus Pigmentosus. PL Epidermis, Papillce. Callositas. Clavus. Cornu Cutaneum. Cornu Unguale. Verruca. Icthyosis. Keratosis Pilaris. C Corium. Scleroderma. Morphea. Sclerema Neonatorum. Elephantiasis. Dermatolysis. D. Hair. Hypertrophy of the Hair. Hypertrichosis. E. Nail. Hypertrophy of the Nail. Ony chogryphosis. HANDBOOK OF DERMATOLOGY. 29 Class VI.—Atrophies. A. Pigment. Albinism. Vitiligo. Canities. B. Corium. Atrophia Cutis Atrophia Senilis Striae et Maculae Atrophicae. Ainhum. Hair. Alopecia. Alopecia Areata. Trichorrexis Nodosa. Plica Polonica. Piedra. Atrophy of the Hair. Nail. Atrophy of the Nail. Class VII.—New Growths. A. Connective Tissue. Keloid. Molluscum Fibrosum. Xanthoma. Psorospermosis B. Cellular. Rhinoscleroma. Molluscum Epitheliale. Lupus Erythematosus. Lupus Vulgaris. Scrofuloderma. Tuberculosis Cutis. Mycetoma. Lepra. S3rphiloderma. Mycosis Fungoides. Carcinoma. Epithelioma. Sarcoma. C. D. 30 HANDBOOK OF DERMATOLOGY. B. Celular.—Continued. Adenoma Sebaceum. Xeroderma Pigmentosum. C. Blood - Vessels. Nevus Vasculosus. Telangiectasis. D. Lymphatics. Lymphangiona. E- Nerves. Neuroma. F. Muscles. Myoma. Class VIII.—Neuroses. A. Hyperesthesia. Hyperesthesia Cutis. Dermatalgia. Pruritus. 13. Anesthesia. Anesthesia Cutis. C. Analgesia. Analgesia Cutis. Class IX.—Parasites. A. Vegetable. Tinea Favosa. Tinea Tricophytina. a. Tinea Corporis. b. Tinea Capitis. c. Tinea Barbae. Tinea Versicolor. Erythrasma. Actinomycosis. ~£>. Animal. Scabies. Pediculosis. a. Pediculosis Corporis. b. Pediculosis Capitis. c. Pediculosis Pubis. HANDBOOK OF DERMATOLOGY. 31 B. Animal.—Continued. Cimex Lectularius. Pulex Irritans. Dermanyssus Avium. Demodex FoUiculorum. Filaria Medinensis. Cysticercus Cellulosae. The above does not contain a complete list of the diseases of the skin, nor is it intended to be more than a general guide. 32 HANDBOOK OF DERMATOLOGY. CLASS I.—DISORDERS OF SECRETION 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 character. They embrace the disorders of secretion and excretion of the sebaceous and coil glands. They are not inflammatory in nature; and those pathological processes, found accompanying these disorders, which are not concerned in the purely functional disturbances of the glands, are acci- dental and not necessary accompaniments of the disease process. SEBORRHEA. Syn.—Seborrhagia, Fluxus Sebaceus, Dandruff, Acne Sebacea, Stearrhea, Ichthyosis Sebacea. This disease is characterized by hypersecretion of sebum, and may exist upon any portion of the body, except the palms and soles. It is found to occur most frequently upon the scalp ("dandruff"). It is also found quite often upon the face and trunk, although the latter is the most infrequent. Two principal varieties of this disease are recognized—sebor- rhea sicca, and oleosa. Seborrhea sicca is most frequent upon the scalp, although it occurs in other localities. It appears that it has a predilection for hairy parts so that we find it generally in the scalp, beard or eyebrows. It presents the appearance of thin or thick crusts, composed of yellowish or greyish, sometimes dirty-looking scales, which separate quite easily, are easily friable, and have an unctuous feel. The surface involved varies considerably in extent, from a patch not larger than a silver dime to compara- tively large areas. The skin beneath these accumulations of PLATE I. SEBORRHEA SICCA. HANDBOOK OF DERMATOLOGY. 33 sebum has a pale appearance, unless scratching or some irritat- ing measure has caused a reddish appearance. Itching is a symptom which is a constant accompaniment of this form of the disease, and is quite marked when hairy parts are involved; more so than in other portions. In the scalp or beard the sweating indulged in separates the scales, which appear branny (see Plate I) and they are distributed over the clothing of the patient. Seborrhea oleosa is the wet or oily form. It is seen most often during hot weather, and generally on the face about the alee of the nose. It presents a shining, glistening appearance, the liquid sebaceous matter conveying the impression that oil has been poured upon the skin. A strong, unpleasant odor accom- panies the secretion, this being most marked about the umbilli- cus, axillae, genitalia and perineum. This odor is more accen- tuated in those whose skins are dark, and is of a penetrating sort, being due to the decomposition of fatty acids. The conse- quent irritation of this decomposition produces some inflamma- tory reaction which manifests itself in more or less erythema. Seborrhea may be either local or universal. As a rule it is the former. In congenital, universal seborrhea, the integument is stretched, the eyes and the lips are fixed; and the fingers, toes, and auricles are undeveloped. A child so affected presents a more or less mummy-like appearance, which is accentuated by the accompanying emaciation. Seborrhea occurs at or after puberty ; also in conjunction with or after severe fevers, systemic disorders, etc. While the disease is often dependent upon internal causes,cases are met with in which no known cause can be fixed upon to account for its presence. The differential diagnosis is comparatively easy, as the only disorders with which it might be possibly confounded, are eczema, psoriasis, ringworm, and erythematous lupus. The treatment of seborrhea, in the majority of cases, should be both constitutional and local. Good food, good air, good water, and, where debility or anemia exists, cod-oil cdmbined 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 to six times dailjO. Exercise should also be enjoined. Local treatment is very important and, frequent^, is all that is necessary. In seborrhea sicca the accumulated sebum should first be removed by soaking in oil and thoroughly rubbing in— Ifc Sapo. viridis..................................................................................5vm\ Alcoholis........................................................................................,}iv. Solve et filtra. 34 HANDBOOK OF DERMATOLOGY. Take a half ounce of this mixture with water and shampoo the part well. A very good and efficient preparation is John- stone's ethereal antiseptic soap. It is a detergent which acts both rapidly and efficiently and prepares the integument for the subsequent applications. After using this or any other similar preparation it is proper to dry the parts and apply some stimu- lating preparation, if there be not too much irritation following the wash. For stimulation, lotions may be employed such as contain carbolic acid, cantharides, tincture of capsicum, bi-chlor- ide of mercury, etc. The following is an excellent mixture to use, and care should be taken, in connection with all lotions ap- plied to hairy parts, to see that the integument and not the hair receives the medication. R* Resorcini..........................................................................................%i. Beta-naphthol................................................................................3i. Tinct. cinchon. co........................................................................3^- Spts. myrciae..................................................................................gvi. M. Apply twice daily. In non-hairy parts ointments are preferable, the following acting nicely: R* Sulphuris precip................................................................3SS—3iJ- Zinci oxidi......................................................................................5ss. Ung. aquae rosae..........................................................................%i. M. The ammoniated mercury, red oxide of mercury, oleate of mercury, resorcin, beta-naphthol, 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 usually fatal. HANDBOOK OF DERMATOLOGY. 35 ASTEATOSIS CUTIS. In this there is a diminished or arrested secretion of sebum, generally local in small or large patches. The skin is dry, harsh and easily fissures at the flexures. It is found in all the atro- phies of the skin, and accompanies some affections (ichthyosis, lichen ruber, psoriasis). Local influences also produce it, such as exposure to alkalies, alcohol, etc. A congenital defect in the sebaceous glands, either in number or in size, may also act as a causative factor. There is no difficulty in recognizing this con- dition. The only method of treatment which is at all of any value is one which is calculated to supply the deficiency in secretion by applying some bland fats or oils. In addition to this, internal remedies of such a nature as to be of value in add- ing tone to the nervous system will be found valuable. Arsen- auro has an excellent influence in this respect, and greatly aids the efforts made to ameliorate the condition. It is, however, necessary that unremitting attention be paid to it, as it has a tendency to return to its former condition. 36 HANDBOOK OF DERMATOLOGY. 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, conical elevation. The parts most frequently attacked are the face, neck and back, although the chest may be impli- cated. It is often seen in the ears as well. There are no sub- jective symptoms connected with comedo. It is a functional disease of the sebaceous glands, in which, through some cause, the innervation is below par. An inspissa- tion of sebum takes place in the gland itself, and that portion which is in the duct contracts 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 communicating with one cavity—double comedo. It makes its appearance at or about the period of puberty, although it may occur at any age. It has been seen in infancy, and it is not uncommon in old age. The causes of comedo are various. Constipation, dyspepsia,, gastric catarrh, etc.; hepatic troubles, chlorosis or anemia may cause it. Some occupations, such as coal mining, working in tar, in machine shops, etc., also cause it. There is no difficulty in making a diagnosis, for the points are blackish, and pressure forces out a plug of sebum, thus serving to distinguish the trouble from powder or tattoo marks, which are blue. Treatment should be directed to the general condition in the first place. As constipation is the most frequent complication, it may be well to give an occasional dose of calomel, and Duhring's acid aperient mixture. A compound hepatic pill HANDBOOK OF DERMATOLOGY. 3*7 (O-D) at bed-time will also act as a good aperient to bring about a regular action of the bowels. Locally stimulants are indicated. Force out the contents of Fig. 17.—Author's Comedo Extractor. each comedo with an extractor every day, then apply hot water (110° F.) followed by the following ointment: R Sulphuris loti....................................................................5ss~5i- Hydrargyri oleatis (5 per cent.)..........................................5SS- Ung. aquae rosae..........................................................................§i. M. Sig. Apply at night. The following ointment, thoroughly rubbed in, will be found efficient in many cases if used after the hot water application: R Resorcini......................................................................................gr. xii. Ung. aquae rosae..........................................................................%i. M. Sig. Apply morning and night. When the comedones are small and in large numbers, the following is a good application: R Acidi acetici dil..........................................................................5i- Glycerini puriss.........................................................................gii. Kaolini.........................................................................................SnJ- M. Sig. Apply at night. The resorcin ointment mentioned above is also very efficient, and in these cases the previous application of hot water is not necessary. It is not necessary to mention here the stimulating 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. HANDBOOK OF DERMATOLOGY. 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. (See Plate II.) The milia are generally opaque, and are not accompanied by any 6 subjective symptoms. ^3 The lesion is essentially a retention cyst, the seba- £ ceous contents of the gland forming a hard, round mass, the duct closing and the epidermis becoming 1 very thin. The contents, at times, although rarely, £ undergo calcareous degeneration and form dermatoliths ^ (cutaneous calculi). Milium increases but slightly, * and then seems to be at a standstill. It is essentially j2 a non-irritating retention cyst, which simply produces "2 a bad cosmetic effect. It seems to occur most fre- ^ quently in females in early years, and may be distrib- ^ uted over the entire face. There seems to exist no 1-1 adequate cause explanatory of its origin. .!» Milium is entirely local in character, easily recog- ^ nized and very amenable to treatment. External applications are of no avail in its treatment. The cyst should be emptied and its lining membrane de- stroyed. To accomplish this, the papule is cut open with a milium needle and the cyst wall scraped with a small, sharp spoon, or with the convex edge of the needle. It is best, after performing this little opera- tion, to touch the denuded surface with a little cam- PLATE II. MILIUM. HANDBOOK OF DERMATOLOGY. 39 pho-phenique, so as to promote rapid healing. Instead of this scraping, some irritating fluid, such as tincture of iodine, nitrate of silver, caustic potassa or carbolic acid, may be introduced. Finally we have the electrolytic method, which is rapid and effective, although it is a tedious treatment. Any of the above measures, properly carried out, will cause the permanent disappearance of milia. 40 HANDBOOK OF DERMATOLOGY. SEBACEOUS CYST. Syn.—Atheroma, Wen, Steatoma, Sebaceous Tumor, Follicular Tumor. The lesions in this trouble vary in size from a split-pea to a small egg, being rounded, hemispherical, or semi-globular, hav- ing a soft, doughy feel. The skin covering this form of cyst is either normal or thinned and shining. The scalp, face, nucha, back and genitalia are the localities most frequently affected. This is a retention cyst, filled with sebaceous material or more or less liquid contents composed of broken down cells, debris and fat. As a rule, the duct of the sebaceous gland, from which the cyst originated, is closed; but this is not invariably the case, for it is merely partially occluded in some cases and persists. 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 to it. Occasionally, however, a number may be found. It is benign, unless ulcera- tion, which may assume a malignant character, sets in. The treatment is purely surgical, electrolysis having 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......................................................3iss. Lanolini puriss ................................................. *i M. The cysts have a tendency to enlarge unless removed. They are generally a source of annoyance to patients, on account of their location. They may become dangerous, especially when located upon the scalp. External irritation is apt to set in, ulceration follow and a fatal erysipelas supervene. For this rea- son extirpation of the cyst is always advisable. HANDBOOK OF DERMATOLOGY. 41 HYPERIDROSIS. Syn.—Ephidrosis, Sudatoria, Idrosis. As its name implies, this disease is a functional disorder of the coil glands, characterized by excessive sweating, either local or general. It 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 intensifica- tion of a normal function. It may be transitory or permanent; or symptomatic of fever or of some other systemic disturbance. The form we are to consider more particularly is the local, permanent hyperidrosis. The parts most liable to be the sub- ject of this disturbance are the pudenda, perineum, axillae and soles of the feet; the scalp and the palms of the hands being also frequently implicated. 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. The cause of hyperidrosis is without doubt located in the nervous system. It is a functional disturbance of the sympa- thetic ganglia in all probability, and for this reason attention should be directed to it in the way of general medication. Such remedies should be used as the condition demands, but it may be stated in general terms that nerve roborants are always in order. The compound syrup of hypophosphites with strychnia and malt before or during meals is of the highest value. Ar- senauro taken directly after meals will accentuate the action and aid very much in the amelioration of the paretic condition of the coil glands which is so prominently displayed in hyperidrosis. In addition to this, such general hygienic measures as ma)' be available will act as valuable adjuvants. 42 HANDBOOK OF DERMATOLOGY. Locally, in mild cases, frequent washings, followed by astrin- gent lotions or powders, are sufficient. Among the astringents which may be used are catechu, tannin, alum, zinc sulphate, etc. For instance: R Acidi tannici..................................................................... 5SS- Tinct. catechu..............................................................................o1- Alcoholis........................................................................................ovi3- M. Use as a lotion. Weak solutions of permanganate of potassium, or of chloral hydrate are also beneficial. A very good application is a one per cent, solution of chromic acid, or, if necessary, a stronger one. 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. A good astringent dusting powder may be made after the following formula: R Acidi salicylic..............................................................................9j- Talc. Veneti. Magnesiae carbonatae ........................................................aa, 3ij Cretae albae....................................................................................oss- M. Sig. To be freely dusted on. 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 of which will prove successful, if persisted in. Thus, the daily application of a two per cent, salicylated mut- ton suet; painting the affected parts once every four or six weeks with a five per cent, solution of chromic acid; applying subni - trate of bismuth liberally twice a day, without any further wash- ing than that before the beginning of the treatment; bathing the feet in tar-water and then applying a solutiou of persulphate of iron morning and evening, have all produced successful results in the hands of competent observers. 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. Carbolic acid lotions, beta naphthol in alcohol, boric acid in saturated solution, and corrosive sublimate solutions of varying strength are external applications employed in this af- fection with a fair degree of success. HANDBOOK OF DERMATOLOGY. 43" 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, He- bra's diachylon ointments. This application is to be made in twenty-four hours at least, the feet not being washed, but simply wiped dry with a soft cloth and dusting powder applied. In ten to fifteen days dusting powders only are used. If a relapse oc- curs the same course of treatment is repeated. It maybe neces- sary to resort to several courses of this treatment; but it will be noted that after each one a notable improvement has taken place. The method is applicable to any region which is not hairy. The prognosis of hyperidrosis, especially of the local form, should be guarded. In old cases, more especially affecting the feet, the disease is very obstinate. 44 HANDBOOK OF DERMATOLOGY. ANIDROSIS. Syn. —Hypohidrosis. This disorder is characterized by a diminished amount, or total absence of the sweat secretion. It is generally symptom- atic and an accompaniment of some other trouble. When it exists independently the skin is dry, harsh, parchment-like, with a tendency to the formation of scales. In this form it depends 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, as well as in diabetes insipidus and mellitus. When symptomatic the treatment of the causative disease is, of course, indicated. The treatment, in the variety which is not symptom- atic, is tonics, Turkish, hot or steam baths followed by massage of the skin. As in the case of hyperidrosis measures looking to the nervous system must be taken. It is necessary not only to stimulate the nerves by internal measures, but by external means as well. The functions of imperfectly developed glands must be artificially increased so as to bring about a development, if pos- sible. If there be areas which lack coil glands nothing can be done beyond adding to the pliability, softness and suppleness of the skin by aiding the sebaceous glands in their efforts in this direction. In general, there is very little to be done of a perma- nent nature. HANDBOOK OF DERMATOLOGY. 45 BROMIDROSIS. Syn.—Stinking Sweat, Osmidrosis. In this disorder the condition is a qualitative disturbance 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 com- plexion 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, idiopathic and local. The por- tions most often implicated are the axillae, the genitalia, the per- ineum and the feet. The last especially emanate a most foul odor. It is so fetid as to make the life of the patient a burden. and cases are known in which relief was sought in a suicide's grave. Males are more often affected than females. It may appear at puberty or later in life. Hyperidrosis is usually an accompaniment. The diagnosis is easily made. The disease may be tempo- rarily due to filth and negligence, but it occurs in those who are uuexceptionally clean, and Mr. Thin claims that it is caused by the bacterium fetidum, but numerous other micro-organisms are found. There is no doubt whatever that the decomposition of various fats greats aids in intensifying the smell, and the fact that the affected parts are more or less enclosed in confining; coverings also contributes to the intensification of this symptom. The treatment is the same as that for hyperidrosis, with the exception of previously washing the affected parts in some dis- infectant. For this there may be employed solutions of perman- ganate of potassium, corrosive sublimate, chloride or sulphate of zinc, all possessing the advantage of being odorless. Solu- tions of chloral hydrate are also said to act well. Trikresol is 46 HANDBOOK OF DERMATOLOGY. an agent which acts in a most excellent manner, being an efficient bectericide and a mild stimulant to the skin. In obstinate cases much patience is required in order to obtain relief and energetic measures, in the form of strong anti- septics, may be necessary. A case should not be regarded as beyond relief, after using one or two methods, but recourse should be had to such agents as the demands of the case may indicate, and persistent effort will meet with a certain degree of .success, if not complete cure. HANDBOOK OF DERMATOLOGY. 47 CHROMIDROSIS. Syn.—Colored Sweat. Colored sweat is rarely observed. It may be yellow, red, brown, black, green or blue (cyanidrosis). It may be general- ized or localized. The majority of cases which are looked upon as chromidrosis are really not such, but depend upon malinger- ing in the subject. The genuine cases which have been observed occur in women who are hysterical, anemic, or who have men- strual disorders. Men have also been observed to suffer from chromidrosis, but in them the disease is of a transitory nature, and usually disappears spontaneously. Red sweat is due to the bacillus prodigiosum, most probably, and is of a superficial nature. The treatment should be general, and, where micro- organisms are found, locally antiseptic. Hematidrosis, or bloody sweat, is almost always a purely neurotic phenomenon, and is to be carefully distinguished from hemorrhage of the skin. It is not an oozing of the blood, but rather the appearance of sweat containing the coloring elements of the blood. It is always indicative of a marked lowered vitality, and the prognosis is bad, so far as the general condition is concerned. However, it is rarely observed. Uridrosis, or urinous sweat, is more frequently seen as a symptom of grave maladies. It occurs most frequently in con- nection with uremic poisoning, although it is also observed in cases of acute rheumatism, in which strong sudorifics are admin- istered. The sweat, in such instances, is heavily charged with uric acid, and emits a marked and distinct Urinous odor. It is so powerful at times as to necessitate the free ventilation of the apartment in which the patient lies. Phosphoridrosis, or phosphorescent sweat, is looked upon much in the light of a curiosity. It can only be observed in the 48 HANDBOOK OF DERMATOLOGY. dark, and the body of one so affected emits a faint phosphor- escence or luminous appearance. The few who have observed this curious phenomenon unite in saying that it occurred in phthisical patients who are far advanced in the disease. HANDBOOK OF DERMATOLOGY. 49 SUDAMINA. Sy?i.-—Miliaria Crystallina. This affection Is a functional disorder of the sweat glands manifesting itself as closely grouped vesicles having a whitish, translucent or pearl-colored appearance, and of the size of a millet-seed. They may become confluent. The back, chest, abdomen, extremities and limbs may be attacked, the face being exempt, as a rule. The part most frequently attacked in our latitnde is the integument on the sides of the fingers, slightly encroaching on the dorsum. The toes are very apt to be attacked simultaneously, and be affected in a corresponding manner. The contents become absorbed in a few days, and a mild desquamatton follows. 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 depends 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 the stratum corneum, raises it up in the form of vesicles. The diagnosis is easily made. The treatment should be di- rected to the prevention of a recurrence. One of the best means is the application twice a day of a two per cent, solution of chromic acid. This effectually counteracts the pressure of the sweat and relapses are prevented. The vesicles should not be opened, and all precautions taken to prevent excessive perspira- tion. 50 HANDBOOK OF DERMATOLOGY. CLASS II.—HYPEREMIAS. In this class of diseases we have the presence of an excess of blood in the vessels and capillaries. There are two principal varieties of hyperemia of the skin—active and passive. In the former there is an increased redness which is bright in color, heightened temperature, these being due to an increased arterial flow; in the latter there is a bluish color manifest, and lowered or normal temperature due to a retarded flow of venous blood. This is the appearance denominated lividity. Either condition may be idiopathic or symptomatic. The idiopathic forms alone will be considered here, as the symptomatic properly appertain to the general practice and theory of medicine. ERYTHEMA SIMPLEX. In this condition we have a heightened color of the skin in- volving more or less surface and disappearing under slight pressure. There is also an increase of temperature. The causes, in general, are heat, cold, injuries, mechanical, poisonous or chemical agents, which are irritating in nature or by reason of the circumstances under which they exercise their influence. General disease or visceral complications produce symptomatic erythema. The idiopathic variety is divided into three principal classes, depending upon the cause—caloric, traumatic andchem- cal. Erythema caloricum is qrtite a common form, due to the action of heat or cold. It is accentuated by exercise when it is due to heat, and the want of exercise makes it more prominent when cold is its cause. The susceptibility of the skin is an im- portant factor in the rapidity of development, as well as the severity of the attack in this as well as the other varieties of ery - thema which are observed. If the causative process attain any HANDBOOK OF DERMATOLOGY. 51 degree of permanency, or if it continue for a certain length of time, inflammation is very apt to supervene. Erythema traumaticum is also common. It is due to pres- sure or rubbing, such as is produced by bandages, trusses, gar- ters, suspenders, etc. The friction of clothing or resting a part heavil}- against some solid body also produces it. Any mechan- ical pressure or friction acts directly upon controlling nerves of the bloodvessels and, as a direct result of this stimulation, an increased flow of blood takes place. Erythema venenatum is caused by a large number of mineral and vegetable substances. Acids, alkalies, the anilines, mus- tard, arnica, turpentine, sulphur, mercurial preparations, the various counter-irritants and epispastics, etc., produce it, many being employed with that object in view. As a rule but very little attention is paid to simple erythema when it first makes its appearance. Its persistence ma}' arouse some solicitude but, as it has a teudendy to spontaneous recovery, very few cases apply for treatment. The symptomatic hyperemias depend upon some internal cause, and are the result of derangements produced by diseases or drugs. The only efficient treatment is to remove the cause and if marked local irritation be present some bland dusting powder or soothing ointment should be applied. A powder is principally indicated in erythema traumaticum, and for such cases the fol- lowing will be found a good formula: R Zinci oleatis, Magnesiae carbouat............................................................aa, 3^3- M. Sig. Apply liberally to the affected part. In erythema venenatum, due to acids, au alkaline lotion is first applied and then an ointment composed as follows: R Bismuth subnitrat......................................................................oj. Morphiae sulphat......................................................................gr. v. Ung. aquae rosae........................................................................5J- M. Should an alkali be the cause, a mild acid followed by the same ointment will be found efficient. So far as other chemical and medicinal causative agents are concerned, the same plan of procedure should be followed. 52 HANDBOOK OF DERMATOLOGY. All the erythemata require a great deal of discrimination in their treatment. The management very often is of much more importance than simply medication'. It must never be forgotten that the most important part of the treatment depends upon a proper appreciation of the cause. HANDBOOK OF DERMATOLOGY. 53 ERYTHEMA INTERTRIGO. Syn.—Chafe. This disorder is simply a hyperemia in which we find the skin hot, red, more or less excoriated, and the upper layers of the stratum corneum macerated. It occurs where the folds of the skin are largest, or where the skin is subjected to a great deal of friction. For this reason, the neck, the internatal cleft, the perineum, the submammary fold, the axillae, the abdominal folds, the scroto-crural fold, etc., are 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 secretion is poured out. In addition to this the rete mucosum is apt to become exposed at certain points, and minute drops of blood will exude, a disagreeable and apparently very severe appearance, out of all proportion to the real state of affairs, being present. 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 infants and fleshy adults. Among the exciting causes are prolonged walking, or other exer- cise, or work, 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 aggravated cases, when it should be guarded, as the space of a day may show the trouble to have been transposed into an eczema or a dermatitis. The treatment of erythema intertrigo is simple, but depends for its efficiency upon being faithfully carried out. In mild cases a simple dusting powder should be liberally applied, such as: 54 HANDBOOK OF DERMATOLOGY. R Pulv. zinci oxidi, Pulv. cretae prec................................................................aa, 51. Talci veneti, Natri bicarbonat..................................................................aa, §ij. M. Ft. Pulvis. Or the dusting powder mentioned in connection with ery- thema simplex would act well. It should never be forgotten that the ingredients of this powder should be of mineral and not of vegetable origin. Starch and lycopodium, as well as the bland powders of the same kind, are easily affected by the fluids which occur in intertrigo. As a result, fermentation sets in, and the trouble is aggravated instead of being improved. This should be applied two or three times daily after wash- ing the parts in cool water. Where we have a raw, excoriated condition, accompanied by a thick, glutinous discharge, there should be a thorough cleansing of the part, followed by an astringent or slightly stitnu - lating 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....................................................................................3SS- Pulv. camphorae..........................................................................3j. Ung. aquae rosae........................................................................,5]. 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 observed, as it is prone to relapses, or to assume an inflammatory nature. HANDBOOK OF DERMATOLOGY. DO ROSEOLA. Syn.—Red Rash. The term roseola has been applied to erythematous macules which have a sharply defined border and which may vary in color from a light rosy hue to a dusky red. The size of these macules varies from that of the finger nail to areas as large as the palm of the hand, or even larger. As a rule the integument over the flexor surfaces is more prone to exhibit the eruption than that on the extensor aspects. The mode of onset is rapid, occupying but a very short period of time. Not only this, but new lesions will continue to appear at varying intervals until large portions of the integument, or even the whole of it is involved in the process. Occasionally the macules will coalesce. The trouble is entirely a symptomatic one, caused either by some general disease, or by the ingestion of medicaments or other substances of a nature irritative to the individual affected. Thus we find that in typhoid fever roseola manifests itself, as also in syphilis and in leprosy. In the algid stage of cholera it appears, and is seen in diphtheria. It is not infrequently observed in malaria, when it is known as roseola febrilis. Copaiba, turpen- tine and the balsams, in general, are a cause. It must not be forgotten that nervous excitement may also cause its appearance. Its duration, or the modifications which it may undergo, are entirely dependent upon the cause producing it, and this governs the treatment as well. Discontinuing a drug which produces it, will result in its disappearance. If a disease be the cause, recovery from its effects, or a change in the process will result , in a disappearance of the roseola. 56 HANDBOOK OF DERMATOLOGY ERYTHEMA SCARLATINI FORM E. This form of trouble derives its name from the circumstance that it first manifests itself as a marked scarlet erythema involv- ing large areas of integument. After the erythema has existed for some little time desquamation of a marked character takes place. It is of such a severe character that, in some cases, gloves and mocassins of epidermis are shed, leaving an angry red, glazed surface, which rapidly recovers its covering of horny cells. The trouble is an unusual one, and is much more formidable in appearance than in reality. It is prone to relapses, and should not be confounded with scarlatina, which it closely resembles in some respects. The fever which is observed, and the lack of involvement of the mucous membranes, as well as other promi- nent general symptoms of scarlatina should lead a careful observer to make a correct diagnosis. The cause of the affection is not yet well understood. It has been observed in connection with enteric fever, typhoid fever and similar conditions. It has also been seen to follow the administration of certain remedies, chiefly quinine. On the other hand, idiopathic cases occur and recur without an adequate cause to explain the matter, unless we assume that there exists a neu- rotic basis for the changes. The treatment should be of a sedative character so far as general medication is concerned, and soothing locally. Oint- ments are best used, as they promote the reparative process better than other forms of application. HANDBOOK OF DERMATOLOGY. CLASS III.—INFLAMMATIONS. The inflammatory, or exudative diseases of the skin form by far the largest, as well as the most important class. The dis- eases are, apparently, of the most diverse character, both in appearance and in subjective manifestations, and, while this is true, they still are classified under one head. For, from a path- ological point of view, they are all involved in the same general process—inflammation. The degree of the process differs in different diseases, from an involvment 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 dis- eases are acute and of short duration, healing 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 affections are most diverse in nature, not only for the different diseases, but even in different examples of the same one. The treatment is also of the most diverse in character, and demands much discrimination, being largely guided by the condition which is present. It is mainly a lack of judgment as to the proper application of certain remedies which has brought them into disrepute and causes them to be still upheld by a few. The prognosis of these diseases is, with a few exceptions, generally of a favorable nature. 58 HANDBOOK OF DERMATOLOGY. ERYTHEMA MULTIFORME. This is a polymorphous erythema in which papules, tuber- cles or vesicles may appear. The trouble manifests itself in large patches, the ground color of which may be somewhat variegated. The form of these patches is usually roundish or ovalish, the oval areas being, at times, rather prolonged, but their long diam- eters being parallel to the vertical axis of the body. It is gen- erally of a severe type, malaise and fever accompanoing it, the hands, forearms, backs of the feet and thighs, being most often affected. Other portions of the integument are also occasionally the seat of the trouble. It sometimes assumes the form of an annular lesion, the patch being formed of more or less well- formed concentric rings of different colors. Relapses are frequent, the duration of the process lasting several weeks. General treat- ment, such as is indicated by the symptoms, is necessary. Febrile conditions, rheumatoid and other complications, demand attention. Locally, astringent lotions and protective powders. A good lotion to apply is the loti& calaminae. Listerine is also a good application. The latter, however, should be followed by an application of a dusting powder containing precipitated chalk. Erythema papulatum, e. tuberosum, e. vesiculosum, are va- rieties of the above. These names have been applied to those forms in which a particular lesion predominates or is found alone. Erythema iris and e. marginatum are names applied to particular forms and do not indicate particular varieties. HANDBOOK OF DERMATOLOGY. 59 ERYTHEMA NODOSUM. Syn.—Dermatitis Contusiformis. This affection appears at first as erythematous patches of a rosy tinge about the size of the finger nail and of quite a delicate hue. This eruption may appear about the shoulders, back, chest, arms and neck. It also occurs on the lower limbs, most often over the tibiae. In this last locality it soon changes in form and the lesions assume a node-like aspect. Burning and pain upon pressure are the principal subjective sensations, rheu- matoid pains being also felt. In a short time the reddish color changes to yellowish, greenish, etc., as observed in contusions. Successive crops may appear, each one lasting a wreek or ten days. It may be mistaken for a bruise, or for syphilitic nodes, when occurring over the tibiae. To prevent relapses internal treatment should be given and the last consists of salines, alka- lies and anti-rheumatics. One of the best combinations of these is such a one as will combine the two latter. Lithia potash water is a pleasant form of this combination, and valuable as well. Locally, but little treatment is needed. Astringent and cooling lotions are all that is necessary. An efficient formula will be found as follows: R Menthol.........................................................................................3J- Aluminis........................................................................................gr-vj- Aquae..............................................................................................5VJ- M. Sig. Apply frequently to affected part. €0 HANDBOOK OF DERMATOLOGY. URTICARIA. Syn.—Nettle Rash, Hives, Cnidosis, Febris Urticata. This disease is one of frequent occurrence. It is character- ized by a sudden eruption of wheals of various sizes and varying in number, which are either paler than the normal skin, or red- dish. (See Plate III) After a variable length of time these le- sions disappear as suddenly as they came. Burning or pricking and itching accompany the eruption and scratching is apt to cause it to extend. In the acute form, attacks 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 infrequent. Urticaria pigmentosa is that form which is followed by persistent pigmen- tation. In urticaria papulosa we have the formation of papules taking place. When the wheals assume an enormous size we liave tirticaria tuberosa or giant urticaria. The diagnosis is compartively easy. Where wheals exist, which are the result of insect bites, the central hemorrhagic 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 external causes may be mentioned chemical and mechanical agents. In the latter, drawing a blunt object, or forcibly applying the hand or some similar pressure, will cause the appearance of wheals correspond- ing to the exciting cause. Dermographism is a phase of this. Among internal causes are febrile disturbances; certain articles of food, such as shell-fish, mussels, oysters, clams, cheese, strawberries, etc.; certain drugs, such as balsam copaiba, oil of PLATK III. URTICARIA. HANDBOOK OF DERMATOLOGY. 61 turpentine, etc., and moral causes, such as fright, anger, grief. Disturbances of the genito-urinary, respiratory or digestive apparatus may also act as causes. This disease is probably a reflex vaso-motor disturbance, resulting in a sudden, circumscribed exudation, which is reab- sorbed; 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 receive attention. Atropine in one-sixtieth grain doses will be found beneficial in aborting attacks. This can be given twice daily, and its effects should be closely watched. Hydrobromate of quinia, in three-grain doses, twice daily, and salicylic acid, not to exceed seventy-five grains in a day, are also given with success. In the chronic form gastric disturbance should receive particular attention. Seng, in teaspoonful doses, will act well. 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 sedatives, may be used. Peppermint water, cherry- laurel water, or a mixture containing chloral hydrate and mor- phine act well. In fact, any application containing a sedative will be beneficial. 62 HANDBOOK OF DERMATOLOGY. 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 varieties which have been made by different writers has only served to confuse the subject, which, at best, is a difficnlt one in the consideration of the principles involved. We have here to deal with an inflammation, 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 subjective symptom, which is in the highest degree distressing— itching. It is of the utmost importance that a proper conception of this disease be acquired, as it is, in the language of an eminent dermatologist, the " keystone " of dermatology. It is imppossi- ble in a work of such limited scope as the present one, to give more than a bare outline of the principal points connected with the subject. Clinically, there are several types of eczema, each one, how- ever, 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, tingling, or burning pains; 2° Redness; 3° Erythema, papules, vesicles, pustules, or exuda- tion; 4° Crusting and scaling; 5° Infiltration, thickening; 6° Fissures. Eczema erythematosiim is a form of the disease in which the skin is red, hot, and exhibits some swelling. 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 middle life and old age, although sometimes observed PLATE IV. ACUTE ECZEMA, HANDBOOK OF DERMATOLOGY. 63 in youth, 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. Eczemapa pulcsum (Plate IV) is characterized by a papular eruption with, occasionally, a few vesicles. It may exist alone or combined wTith the former type. The papules have a dark red color, and frequently a little crust of blood crowns the apex, the result of scratching. Eczema vesiculosum is generally acute and a typical case is rarely seen. When it is seen the vesicles have broken down and the surface presented is moist, and thickened patches show them- selves. Eczema pustulosum should present marked pustules: but, as a rule, they soon break down, leading to the formation of crusts of a yellowish color. While the itching, as in the vesicu- lar type, is not marked, it is frequently intensely painful, and the consequent scratching leads to the destruction of the lesions. Eczema rubrum, or eczema madidans, presents a red and angry appearance, exudation being quite abundant. It is caused by a loss of epidermis, following 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 erythematous surface. In some cases the scales are rather thick and adherent. Itching is marked in this form. Eczema fissum is generally a result of the preceding, the fissures occurring about the flexures of joints penetrating to and deep into the rete Malpighii. These fissures are exceedingly painful, especially when irritants find their way into them. The fold of the elbow is particularly prone to this form, not to men- tion the palms and soles. 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 suggesting 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 edematous, the degree of this latter varj-- ing with the amount of subcutaneous tissue in the part attacked. In a very short time, papules or vesicles may appear or the epi- dermis ma)' become denuded. In some cases it remains ery- thematous. In this form of eczema it is frequently difficult to 64 HANDBOOK OF DERMATOLOGY. distinguish it from intertrigo or from dermatitis. Protection will frequently bring about a return to the normal. Subacute eczema, while not presenting the intense inflamma- tory symptoms observed in the foregoing, is attended by moder- ate pain, itching and thickening of the skin. (See Plate V.) In addition, more or less exudation, with the formation of crusts, occurs. Chronic eczema (Plate VI) 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, or rough, thickened and with more or less crusts. Eczema is found at all ages and in both sexes. It is not contagious nor inherited, although a condition 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, chemi- cal 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 beneficial effect is soon observed. Among causes not generally mentioned by authors, is the influence of certain micro- organisms which primarily produce an irritation causing a sub- sequent eczema 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, attacking the dif- ferent organs of the body, is perhaps the best and simplest mode of dealing with this complicated subject. Only such general notions in regard to treatment can be given af will serve for gen- eral guides. It is only in works especially devoted to the con- sideration of this disease that details can be given. They should be carefully studied, as eczema, as has been stated, is the "key- stone of dermatology," and a thorough knowledge of its symp- toms and treatment ensures an equal acquaintance with the other diseases incident to the integument. Eczema of the face and scalp.—In infants and children it is the pustular form which is most often encountered in these local - PLATE V SURACUTE ECZEMA. PLATE VI. mrmmrmm <■' CHRONIC ECZEMA. HANDBOOK OF DERMATOLOGY. 65 ities; in adults, the erythematous and squamous, the papular 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 addi- tion to the local application of soothing ointments. Eczema of the lips may exist alone, affecting the skin or involving the vermillion border, or the commissures. It is gen- erally rebellious to treatment, involvment of the upper lip depending upon nasal discharges. In adults, the lips sometimes fissure and become dry. In the latter cases, gastric derange- ments 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. Behind the ear, the most frequent site in adults, it per- sists and causes fissures to appear. Eczema of the scalp assumes three principal forms : the pus- tular, 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 frequently assumes the form of a yellowish crust, covering the vertex and of considerable thickness, popularly known as "milk crust." It sometimes passes on to the moist exuding, which is the form seen in adults, although not so frequeutl}- in the latter 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, invading the ears, and in the latter the fore- head, nose, eyelids, and cheeks are also involved. In the erythe- matous form thick ridges occur over the forehead, at the root of the nose, on the cheeks, etc., giving a leonine appearance and saturnine expression. 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 appearance 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 exter- 6 . 66 HANDBOOK OF DERMATOLOGY. nal irritative influences the condition is very rebellious to treat- ment. Eczema of the arms exhibits about the same character- istics as upon the integument in general. At the bend of the elbow, however, it frequently becomes squamous, and fissures are very apt to occur. Eczema of the feet a?id 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. Sometimes 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 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 extremities. 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. The scrotum is particulary prone to an erythematous form with pronounced thickening of the integu- ment Eczema of the trunk.—The trunk is sometimes invaded in its entirety, the form being erythematous or papular, sometimes squamous to a certain degree. The opposing surfaces of the trunk and mammce in the females are affected by a moist, raw form, and the nipple \>y a thickened fissured variety. At the umbilicus we have an exuding form, and in the axillcz a similar condition. In those who are stout the folds about the neck or abdomen and other parts are affected by an exuding raw condi- tion, which itches intensely. Universal eczema.—This condition is one which generally shows a depressed condition of the whole system. It is very distressing and rebellious to treatment. It begins as an erythe- matous eczema, but has tendencies to assume a more or less squamous 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 and sometimes so intense as to be unbearable. Infantile eczema.—Nearly all cases of eczema occurring in children under five years of age, are classified under this general head. In these the disease assumes an acute form, exudation and pustulation not being uncommon. Crusts and excoriations are generally present and the itching is intense. HANDBOOK OF DERMATOLOGY. 67 The diagnosis of the various forms of eczema is, at times, a very difficult matter. Eczema of the face resembles etythema, 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 seborrhea, 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 lesions of the trunk are sometimes of a form suggesting psoriasis, tinea, herpes zoster, syphilis, pityriasis 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 region. 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 as- similated, are of benefit. While fats are often of benefit, starches and sugars should be avoided, as well as alcoholics. Overfeed- ing should also be restrained, and, in some cases, "dieting" will be found of marked benefit. Local treatment, while extremely various, so far as a choice of remedies is concerned, is based 011 general principles appli- cable to all diseases. In irritated, acute conditions, soothing applications are indicated ; whereas, in chronic conditions, stimu- lating 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 addition of a bland substance, 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 employed. Crusts should be removed by poultices or oils, preferably the latter, and tannin ointment applied, or one containing oxide of zinc and camphor. 68 HANDBOOK OF DERMATOLOGY. Where the process is pustular, remove the crusts with oil and apply campho-phenique (pure) twice daily. Diachylon oint- ment (Hebra) to the face is very good, as also to the affected surface, after shaving the beard. Tar ointment occasionally acts well in the proportion of fifteen grains to a half-drachm to one ounce. In eczema of the hands and arms, apply cooling lotions, followed by bland 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. A stimulating mercurial application is also indicated, 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 before being reapplied, and care taken that it does not produce additional irritation. A better method is to use twice daily the sol. antipruritic co. (O-D) immediately followed by this ointment: R Menthol........................................................................................5ij. Bismuthi subnitrat..................................................................5nr- Ung. aquae rosae.........................................................................^iv. M. In chronic cases, stimulating applications should be made, such as: R Picis liquidas................................................................................gij. Potassae causticae.....................................................................^j. Aquae..............................................................................................5V- M. This is diluted according to indications, and followed by some soothing application. Eczema of the feet should also be stimulated by tar ointment, followed by some soothing applica- tion. For the soles, the same treatment as for the palms. The treatment of eczema of the anus and genitals is depend- ent for its success, in a great measure, upon internal and diet- ary management. Locally, a tar and zinc ointment is valuable, appljdng it after soaking the parts in hot water. Soothing pow- HANDBOOK OF DERMATOLOGY. 69 ders are also good. The compound tincture of green soap, as follows, is a good stimulant: R Olei cadini, Saponis viridis, Spts. vini rectificat..............................................................aa, 5J. M. Filtra et adde: Spts. lavendulae..........................................................................5^1 ■ M. Of course, this should be followed by a soothing application. The condition of the bowels and kidneys should receive particu- lar attention, and the presence of hemorrhoids, and fistula, and fissures, etc., should be determined and relieved, if neces- sary. In eczema of the trunk, the treatment differs but little from that of other forms. In universal eczema, we have a condition to deal with which is serious, and requires tonics. Baths are serviceable here. Still the trouble is very rebellious, and fre- quently all the measures that can be devised do but little to ame- liorate the condition. All efforts must be directed to reduce the thickening of the skin, and a most important point is to see to the perfect action of the emunctories. Locally, the best treat- ment is the continuous application of diachylon ointment, and internal remedies to allay the pruritus. In infantile eczema, soothing applications are generally required, and the entire abstention from 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. A variety of the disease which is not infrequently seen is the so-called parasitic eczema. It is generally characterized by a miliary papular eruption, which spreads very rapidly by ex- tension. This is greatly aided by the scratching of the patient in his efforts to allay the itching, which is quite marked. If the process be permitted to go on untreated, extensive excoriations manifest themselves and superficial destruction of tissue occurs. To relieve the condition simple measures are amply sufficient. 70 HANDBOOK OF DERMATOLOGY. The application two or three times daily of a six per cent, car- bolic acid solution or of a one to 800 bichloride solution will, in the majority of cases, prove amply sufficient. Where a purulent process has occurred a preliminary wash with peroxide of hydro - gen will prove a valuable adjuvant. HANDBOOK OF DERMATOLOGY. 71 ECZEMA SEBORRHOICUM. Syn.—Dermatitis Seborrhoica, Hydrosis Oleosa. Seborrheic eczema is a disease whose place in nosology has not yet been definitely settled. It resembles seborrhea in some of its stages, and in others it closely simulates psoriasis. At its inception it appears in the form of a reddish macule, which is finger-nail in size. This becomes larger, several lesions co- alescing and the patch assuming a roundish form. At other times a scaly lesion appears. 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, over the sternum and between the scapulae, and limbs. There is pronounced itching present, which is sometimes intol- erable. It may be easily confounded with psoriasis. There is, however, a marked difference in the appearance of the scales. In psoriasis they are more silvery and glistening and there is not such a marked border. Moreover, there is no inflammatory areola such as is found in seborrheic eczema. In the latter the removal of the scales will not show the peculiar punctate bleed- ing seen iu psoriasis. According to Unna it is essentially an in- flammation of the secretorv cells of the coil glands, and affects parts subject to hyperidrosis and seborrhea. The treatment is comparativel}' simple. If scales exist or if seborrhea be marked over the affected areas, sapo viridis is to be employed for the removal of these secondary products. If hy- peremia or inflammation be acute a mildly stimulating ointment is indicated, and for this purpose the following may be employed: R Sulfuris loti ..................................................................................gr.xv. Lanolini, Ung. aquae rosae..................................................................aa, 5SS. M. 72 HANDBOOK OF DERMATOLOGY If the trouble is chronic a more stimulating application is indicated, such as: R Sulfuris loti...............................................................................7)1 Zinci oxidi................................................................................5SS- Ung. aquae rosae.........................................................................ol- M. The disease occurs at all ages and has a tendency to become chronic. Whilst treatment causes its rapid disappearance it is exceedingly prone to relapse. PLATE VII. HERPES SIMPLEX. HANDBOOK OF DERMATOLOGY. 73 HERPES. Syn.—Fever Blister, Cold Sore. 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 grouping of vesicles is one of the peculiarities of all herpetic diseases. The patches vary in size, from that of the little finger nail to that of a silver half-dollar, and they are more or less roundish in shape. The portion of skin intervening may pre- sent here and there a few scattered vesicles, but there maj' be none. Where but a few vesicles exist in all, of course no defi- nite grouping is to be expected. The vesicles may occur almost anywhere, but seem to have a predeliction for the face and geni- talia. The subjective symptoms are slight, and consist of a burning or tingling sensation. The trouble is self-limited, run- ning 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 progenitalis. Herpes facialis generally attacks the lips (//. labia lis) near the vermillion border (see Plate VII), the cheeks, the nose, the eyelids, the ears, etc. The vesicles frequently coalesce. In three to six days they dry up and form crusts which are adher- ent, but soon drop off spontaneously, leaving a reddened base behind them. When the lips are attacked they swell consider- ably and are very tender to the touch. If the eruption be irri- tated superficial ulceration is apt to set in, a condition which will considerably retard recovery. Hefpes progenitalis is also frequently seen. It is most fre- quent on the prepuce (//. preputialis), and glans penis; it is also seen upon the vulva and labia minora. It first appears as an 74 HANDBOOK OF DERMATOLOGY. erythematous macule, discrete vesicles show themselves, and, breaking down, give rise to excoriations, or small superficial ulcers, which are followed by crusts and some desquamation. Relapses are frequent, and the eruption may alarm the patient, on account of the locality in which it occurs. It is a possible source of danger from the fact that it offers a susceptible surface for any possible venereal contagion. This variety is also important as it is apt to be confounded with venereal ulcers. The causes of herpes are febrile disturbances and external irritants. Bazin and Hardy have claimed the existence of a her- petic diathesis. Gastric and intestinal disorders act as a cause, as well as those mentioned above. The diagnosis is to be made from herpes zoster and eczema. In the former the distribution and subjective symptoms are so well marked that no mistake could occur. In the latter the va- rieties are always distinct and there is exudation. Moreover, each vesicle is not provided with an areola, as in herpes. 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 aquas rosae has been spread. The following will be found a good ointment to use, as it is mildly astringent and markedly dessicative. R Bismuth, subnitratis....................................................................5iy- Cerati simplicis..............................................................................5J. M. Sig. Apply frequently. When crusts make their appearance let them fall off spon- taneously. In herpes progenitalis, if the vesicles have ruptured, 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 recov- ery will follow. When the vesicles have not burst it is a good plan to open them and to use the following dusting powrder. R Cocaini muriat Zinci oleatis..... M. Saline laxatives are useful to prevent relapses in all forms. No promise can be made, however, that the trouble will not re- lapse, and opinions in this respect should be conservative. gr.xv. 5ij- HANDBOOK OF DERMATOLOGY. HERPES IRIS. Syn.—Hydroa, Herpes Circinatus. This is a comparatively rare affection. It is characterized by small vesicles appearing in concentric circles, each lesion surrounded by an areola. The intervening integument assumes a bluish, reddish, yellowish, or violaceous tint, but generally there are several of these rings occurring simultaneously, giving the eruption a rainbow appearance. The vesicles in a ring are apt to coalesce, forming an annular vesicle, the center being ap- parently normal. This bursts, a thin crust is the result, and when it falls off a macule remains which persists for some little time. The trunk and extremities are the parts most often af- fected. The diagnosis is generally easilv made and the treat- ment is, in the main, that of herpes. 76 HANDBOOK OF DERMATOLOGY. HERPES ZOSTER. Syn.—Zona, Cingulum, 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 lo- calized and marked, being the most important symptom to the patient. The eruption makes its appearance first as an erythema, soon followed by groups of papules which, in a short time, are changed into vesicles. The vesicles, which vary in size from a pin-head to a split-pea, are distributed in groups of ten or more, closely aggregated and surrounded by a marked, red areola (See Plate VIII). Frequently they coalesce. Successive crops keep on appearing for two or three weeks. The vesicles assume an opaque hue, the contents 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 alwa3^s situated along the course of cutaneous nerves, and this is the reason that the disease is so rarely bi- lateral. The nervous origin of this trouble is well established. This is not only proved by the fact of its distribution over areas supplied by cutaneous nerves, but the nerves themselves have been demonstrated to suffer organic alterations. In children there is not such a marked involvement of the nerves and, in consequence, we do not find them complaining so much of the neuralgia. On the other hand, a high fever—the zosterian fever —is apt to manifest itself. This symptom is one never seen in adults. It has been generally supposed that one attack insures im- munity from subsequent ones. This, however, is evidently in- correct, for the evidence of numerous observers goes to show PLATE VIII. HERPES ZOSTER. HANDBOOK OF DERMATOLOGY. 77 that a patient may not only have more than one attack of the disease, but may have them several times within a year. 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. Expo- sure to cold is not an uncommon cause. Sudden psychic dis- turbances, such as anger, fright, etc., has been invoked as exciting causes. Micro-organisms have also been accused of producing zoster. The diagnosis is, as a rule, not difficult. It might be con- founded with herpes, but its distribution and subjective symp- toms serve to differentiate it. The different varieties mentioned by some authors are merely derived from the locality in which the lesions are found. Thus we have zoster pectoralis, lumbalis, dorsalis, brachialis, cruralis, ophthalmicus, etc. The fact that the disease is generally uni- lateral, that it most often attacks the trunk, and that, when in the temporal and ocular regions, it may attack the cornea, should not be forgotten. Zoster ophthalmicus is not only accompanied by excruciating pain, but is dangerous on account of the possi- bility of being attended by perforation of the cornea, and conse- quent impaired vision. 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 arsenauro, arsenious acid, Fowler's solution, or the bromide of arsenic. Morphine, bromide of potassium, and other sedatives; are frequently necessary to relieve the intense neuralgic pains. Locally, protection of the lesions is indicated. Cotton, upon which a soothing powder containing some anodyne has been spread, is probably the best. The fol- lowing should be liberally applied not less than twice daily: R Pul. camphorae............................................................................5J' Cretae preparat............................................................................5iij- Talc. Yeneti................................................................................3JJ' Magnesiae carbonat...................................................................5ij- M. The cotton application is an absolute necessity to ensure the vesicles from being burst, for deep ulcers, which are stubborn to 78 HANDBOOK OF DERMATOLOGY. treatment, are apt to result. In some localities an ointment i better application, and the following will be found of value : R Cocaini muriat. Zinci stearat co. Ung. aquae rosae M. To soothe the local pains, galvanism may also be resorted to. The vesicles should never be opened, and, if they acci- dentally burst, the ulcers should be treated antiseptically. gr. xx. .3jss. HANDBOOK OF DERMATOLOGY. 79 DERMATITIS HERPETIFORMIS. Dermatitis herpetiformis is a form of inflammation of the skin which is but occasionally seen. It is polymorphous in form attacking almost any portion of the integument, or the whole cutaneous covering. It is characterized by successive crops of lesions, and these may be of various characters, such as vesicles, papules, pustules, and excoriations secondarily. A most intense itching is a prominent symptom. Burning is also an accompa- niment of the affection. The itching frequently shows itself before any appreciable lesion can be seen. Then it most fre- quently begins as a vesicular eruption arranged in herpetic groups, or in circinate forms. In addition, various other inflam- matory lesions appear, and scratching causes marked and deep excoriations, some of which suppurate and crust. Relapses are numerous, and follow each other in quick succession. The dis- ease is sometimes grave in character and occasionally fatal. In general, it may be said of dermatitis herpetiformis that it is more or less herpetic in its type. It may last for months or years, and is, at present, the subject of much discussion. Its proper place in nosology has not yet been determined. The treatment which has been so far essayed does not seem to have been successful. Although conceded to be a disease of neurotic origin, beyond any doubt, the ordinary remedies appli- cable to such conditions seem to be powerless. Arsenious acid is the best internal agent combined as follows: R Acidi arseniosi..............................................................................gr. 1-20. Piper, nigris................................................................................gr. jss. Ext. gentian................................................................................gr. ijss. M. Ft. pil. No. I. One such after each meal, with occasionally a sulphur and cream of tartar powder, acts quite well. 80 HANDBOOK OF DERMATOLOGY. Externally the tar preparations, oil of cade and other agents has been more or less successful, but none has proven satisfac- tory so far. Herpes gestationis is now regarded as a form of this disease, as are also the hydroas of some, herpes circinatus bul- losus, etc. In herpes gestationis we have a cause present which is self- limited, and although the same sudden acute attacks occur as in the ordinary forms of dermatitis hypertiformis, when parturition is accomplished the skin affection leaves. The treatment in such cases is entirely palliative and consists of anodynes, both inter- nally and externally. HANDBOOK OF DERMATOLOGY. 81 MILIARIA. Syn.—Lichen Tropicus, Miliaria Alba, Miliaria Rubra, Prickly Heat. This common affection occurs in two forms, the papular and the vesicular. There is a mixed form, however. 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 ap- pears rapidly and is preceded by excessive perspiration. The papules are so closely aggregated that the general appearance of the eruption is that of a bright red, elevated irregular rash, and it requires close investigation to see the separate lesions. Miliaria vesiculosa is similar in distribution and appearance with the exception that the lesions are minute vesicles having thin walls. 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. It sometimes occurs that a purulent process sets in in the lesions, whether they be papular or vesicular, and this always complicates the disease, although the process is superficial and is followed by small, thin crusts. The portions most commonly attacked are the abdomen, the chest, the neck, and the arms, although any portion of the in- tegument may be the seat of the disease. It is symmetrical in distribution. Burning, tingling and itching are the accompany- ing subjective symptoms. The cause of miliaria is excessive heat, due to the atmos- pheric temperature, clothing, or both. Fleshy individuals, whether adults or children, are most subject to it. The affection 82 HANDBOOK OF DERMATOLOGY. is easily reconized, its sudden onset distinguishing it from ec- zema, and the subjective symptoms from sudamina. The treatment is essentially refrigerant. Cool clothing, a cool room, plain food, acid drinks and saline aperients are bene- ficial. Absorbent dusting powders are indicated locally. These powders should also be cooling in their nature. A useful form is the following: R Cretae preparat. ............................»............................... jrj- Sodii bicarbonat......................................................................... 5ijss. Pulv. camphorae..........................................................................3l- M. Mild astringent lotions, such as very dilute sulphate of cop- per solution (gr.x-gvj.) act well. Alkaline baths are excellent, or the "dabbing" on of a borax solution. No fear need be en- tertained from retrocession. Relapses are frequent and while not dangerous in our zone, miliaria may become transformed into a dermatitis or eczema by reason of the scratching indulged in. For this reason it is well to watch it. It is essentially a disease of summer. HANDBOOK OF DERMATOLOGY. POMPHOLYX. Syn.—Hydroa,Dermatitis Bullosa, Erythema Bullosum. Dysidrosis, pompholyx and cheiro-pompholyx are vesicular affections in which the tendency is observed of the lesions to coalesce and form bullae. A certain amount of pain, heat, ting- ling, smarting and itching is manifested. A peculiarity of these bullae is that they flatten, their fluid contents are reabsorbed, and despuamation sets in. Relapses are frequent, and the process seems to owe its origin to a neurotic base. Cheiro-pompholyx seems to be limited in its distribution to the hands and arms or feet, and more particularly to the extensor surfaces. In this variety heat, external irritants and similar causes are active fac- tors in its production. Hot weather is also a cause. In the treatment of all these forms it is essential that tonics should be administered, combined with such nervines as may seem indicated in the case in hand. Locally mild stimulating applications will serve the best purpose. Cases of these troubles, however, are comparatively rare, or at least very unusual. Besides, they disappear spontaneously in later years, although much relief may be afforded by treatment. 84 HANDBOOK OF DERMATOLOGY. PEMPHIGUS. This is an uncommon disease which manifests itself by the appearance of bullae of various sizes. When the bullae are large, there may be but one, or at most, a small number. When small, on the other hand, a large number will be found present. The disease may be acute or chronic in character, two varieties being recognized: pemphigus vulgaris and pemphigus foliaceus. Pemphigus vulgaris is found most frequently upon the limbs. The blebs are rouudish or ovalish, and vary in size from a split-pea to a goose-egg. Their walls are distended and more or less glistening. They contain serum, or pus, and have a reddened base. They vary in number from one or two to sev- eral dozen, and it requires them three to six days to develope. Successive crops appear. Itching and burning are present. In the ordinary form there is a tendency to chronicity, the patient is run down to some extent, anemia is present, together with languor and physical weakness. The nervous system' seems to be impaired, and the functions in general are sluggish in their performance. In the acute form severe general symptoms almost always occur, and death often terminates the case. It is always serious in character and requires close attention. 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. Healing is very slow, and the granulations which form are unhealthy in character and appearance. The serum in the blebs of pemphigus becomes puriform in a short time; sometimes the contents of the bullae 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 external. Any functional disorders which exist should be corrected. A good HANDBOOK OF DERMATOLOGY. So diet and superior hygienic conditions should be insisted upon. Arsenic should also be exhibited in this disease, as it acts almost as a specific. The best form in which to exhibit it is as arseni- ous acid in the Asiatic pill. Locally, very simple measures are necessary. Open the blebs freely and allow the contents to escape. Dress the lesions wTith dilute lotio nigra, or with dilute liquor picis alkalinus. A dusting powder or some bland oint- ment may be used as a dressing. If a large amount of surface be involved, starch or gelatin baths should be employed. The continuous bath is excellent in grave cases. In pemphigus folia- ceus, tonics are particularly indicated. In addition to this, lin- seed oil, internally and externally, has given some of the best results. Relapses are common in pemphigus, and its course and final result are ver}' uncertain, even under the best of treatment. 86 HANDBOOK OF DERMATOLOGY. LICHEN RUBER. This disease is very rare. It begins as small conical papules, of waxy appearance, of brownish-red color, symmetrical in dis- tribution, and having a tendency to invade extensive surfaces. The face is generally affected. The papules flatten, acquire a central depression, and desquamate slightly. The papules ac- quire 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 present, is mild in the beginning. In the chronic state it is moderate, but never severe. Emaciation generally accompanies this disease, and, in long standing cases, death by exhaustion occurs. Arsenic, internally, has been recommended, but it does little good. Iron, strychnine and phosphorus with quinine gives bet- ter 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 occur in the palms and soles, balsam Peru and diachylon ointment (5j to 53) is the best application. The disease is essentially chronic and amenable to treatment only with difficulty. Lichen ruber moniliformis is simply a modification of lichen acuminatus. It manifests itself in the form of lines of papules running in a vertical direction upon the arms and abdomen, the thighs being also implicated. A curious circumstance in con- nection with this is that it is the anterior surface of the body which is implicated. But a few cases have been observed up to the present time. PLATE IX. ****-»., vr*£*-Zfc. ;'■ •■J Hfe^htfe *fcZ2 <■ r~jH Sci^HfeSl HfiiwSi' '•faBr^jl v * - '-*sa ££«■ K&^BlRa LICHEN RUBER PLANUS. \ HANDBOOK OF DERMATOLOGY. S7 LICHEN PLANUS. Ill this disease, which is regarded by some as a variety of lichen ruber, we have the formation of inflammatory spots and patches, which remain localized. 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 of greater or less size. Each papule geuerall}' runs an independent course. The lesions are of a deep red color at first, and later on become 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 (See Plate IX) , upon the abdomen, the back 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 greath- resembles in its tendency to chronicity. One of the best local applications is pure campho-phenique applied two or three times a day, this being supplemented by arsenic given internally. A rapid result follows this mode of treatment. 88 HANDBOOK OF DERMATOLOGY, PRURIGO. Prurigo is very rare in this country, although common enough in Austria. It commences to make its appearance in early years and generally continues 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 situated 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 in- tense, and as a result of the scratching which is indulged in, the papules present torn tops, blood-crusts, and excoriations 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. The flexor surfaces are rarely the seat of the eruption, but the buttocks are the most frequent. Remissions occur in the severity of the itching, which is occa- sionally of a mild character for a certain length of time. Severe forms are known as prurigo ferox and those not as severe are denominated prurigo mills. The disease is exceed- ingly rebellious to treatment and all that can be done is to miti- gate the symptoms. Tar and sulphur applications act best, aided by antipruritics. The tendency is for the process to be chronic and remain so. HANDBOOK OF DERMATOLOGY. Sf) LICHEN SCROFULOSUS. Syn.—Lichen Scrofulosorum, Lichen Circumscriptus, Tubercu- losis Cutis Lichenoides. This affection is one which, whilst not exactly rare, is suf- ficiently uncommon to attract more than ordinary attention. It occurs most often in children, but is seen in adults also. The subjects of this cutaneous affection are of strumous habit, or what used to be denominated scrofulous. The eruptions consist of flat, reddish or yellowish miliary papules, which are grouped. Each one surrounds the opening of a hair follicle, and it is no unusual thing to find the papule tipped at its apex with a minute crust. This is caused by the itching, which is quite marked at times. The breast, abdomen and back are the parts most fre- quently affected by the disease. The treatment should be directed more to the cause than to the eruption itself. Pure air, nutritious food and the best of sanitary surroundings are of the highest importance. Cod liver oil and hypophosphites internally are of value. The iodo-bro- mide of calcium compound is perhaps the best internal remedy, and it may be combined with the syrup of the iodide of iron in anemic cases with benefit. Externally cod liver oil is of benefit. The following ointment is also of value: R Tinct. iodini...........................................................................osp- Ung. aquae rosae.....................................................................5J- M. This should be applied daily, morning and evening, and rubbed over the enlarged lymphatic glands, which are almost always an invariable accompaniment of the disease. If the treatment be energetic a good result may be expected. 90 HANDBOOK OF DERMATOLOGY. ACNE. Syn.—Acne Vulgaris, Varus, Stone-pock, Whelk. This is one of the most common of the skin diseases. It consists of an inflammatory condition of the sebaceous glands and manifests itself in the form of papules, pustules and tuber- cles distributed, for the most part, about the face, neck, back and shoulders (See Plate X). There are no subjective symp- toms except slight pain upon pressure when the disease is in its acute form. Acne papulosa is characterized by bright to dusky red pa- pules varying in size from a pin-head to a split-pea. This distribution may be discrete or they may be closely aggregated, presenting a disagreeable appearance. These papules undergo more or less resolution or may enlarge and become indurated. Or, a minute quantity of pus may show itself at the apex. The cause of this pustulation in pustular acne is entirely from with- out. The micrococcus pyogenes aureus or albus falling in the opening of the sebaceous follicle finds a good soil in which to develop. The inflammatory condition furnishes an excellent cultivating medium and, as a result, the pus increases, going down in a vertical direction along the canal of the gland. Acnepustulosa, as its name indicates, is distinctly pustular. The purulent process begins below and works it way up, and slight pressure elicits quite a marked degree of pain. The pa- pules, in these cases, rapidly change into pustules, which develop until their acme is reached. Their contents are then discharged, a small crust forms, and the lesion heals spontaneously, new crops appearing. Ac?ie tuberculosa is characterized by a number of small or large, generally flattened, reddish tubercles, which have a tend- PLATE X. ACNE. HANDBOOK OF DERMATOLOGY. 91 ency to remain in statu quo, or to enlarge. When a certain stage in the enlargement has been reached suppuration occurs, and this process is always a deep one, beginning in the subcutaneous connective tissue. The formation of pus, however, is not a con- stant accompaniment, and infiltration and induration may occur, giving rise to the so-called acne indurata. Acne artifcialis is that form due to the inflence of external irritants, such as tar. Acne cachecticorum is found in those affected with some de- pressing disease. The lesions are indolent, papulo-pustular, more or less livid, and leaves scars. There is always a stasis, and a generally unhealthy appearance is observable in the lesions. The acne, as a rule, improves as the general condition becomes better, without any treatment of the eruption. .Icnc atrophica is a form in which variola-like scars follow the lesions. This form is known as acne varioliformis or acne necrogenica, and is one of the varieties requiring prompt and energetic treatment in order to avoid the disagreeable resultant disfigurement. In acne, successive crops of lesions are continually making their appearance, and the tendency of the disease is to chronicity. When pustules exist the disease is spread by auto-infection. Patients will " pick" a lesion, and, in searching for others, in- fection takes place, and thus the eruption is spread over large areas, where it would not occur if it were not for this uncalled-for irritation. The first appearance is generally at puberty, and it disappears spontaneously at the twenty-seventh year, or some- what later. Acne, however, has been observed in old age and in middle age, but never in early childhood. . The causes of this disease are numerous. The primary pre- disposing cause is the excessive functional activity which occurs in the sebaceous glands at puberty, aided by the presence of comedones. The most frequent exciting causes are gastro-intes- tinal disturbances. Constipation is almost always an accompani- ment, and dyspepsia frequently so. Uterine disorders, especially of the functional variety, and genito-urinary disturbances also act as factors. The diagnosis is not difficult. It must be distinguished from eczema, small-pox and syphilis. The history and subjective symptoms are sufficient to estabish the difference. The treatment should be both local and general. For the constipation which exists, particular attention must be paid to the diet. To cause the bowels toactmoreregularlv, fluid extract of cascara sagrada, or the aperient mineral waters are useful. An 9'2 HANDBOOK OF DERMATOLOGY. excellent aperient is the compound hepatic pill (pil. hepat. co.), which is both thorough and satisfactory. An occasional dose of calomel will be of benefit. Duhriiig's acid aperient mixture is productive of good results. Besides remedies for the regulation of the functions of the bowels the stomach should be attended to, if there be an indication presented. Disturbed gastric and intes- tinal digestion demand close attention. It is recommended that sulphide of calcium, in quarter grain doses, should be given four times daily in the suppurative form of the disease, in order to stop the suppuration. Its value is doubtful. Arsenic is some- times useful in the indurated forms, in doses of one or three drops of Fowler's solution in wine of iron, or in one drop doses, in water, of a one percent solution of bromide of arsenic, thrice daily, after meals. The best form in which to administer it is, without doubt, as arsenauro in five to ten drop doses, in water, after meals. Ergot is said to be a valuable internal remedy in acne, but should be used carefully. In young females particular care should be paid to any func- tional disorders of the uterus which may present. By far the most common form is dysmenorrhea, and at every catamenial period it will be observed that the eruption is aggravated. This is so important a factor that if this trouble be completely relieved, the acne will frequently disappear entirely in some cases. The local treatment should be either soothing or stimulating, according to the indications presented. The latter is generally the plan to be adopted, as the cases are already somewhat ad- vanced when seen. 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 followed in the morning by cold douches and frictions, are valuable. Sulphur is probably the best general 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 Sulfuris loti Etheris ........ Alcoholis .... M. Sulphuret of potassium may be used, also Vlemingkx's lo- tion. Ichthyol, which is very rich in sulphur, is also excellent, put up in ointment form in the strength of one-half to one and 5J- 7>A- 5iijss. HANDBOOK OF DERMATOLOGY. 915 one-half drachms to the ounce. in combination is also excellent. Sulphur and oleate of mercury It should be used as follows: R M. Hydrarg. oleat., 5 per cent., Sulfuris loti..........................................aa, .")SS-5J. Ung. aquae rosae..................................................= j. By far the best treatment in general is that in which the external applications are supplemented by surgical procedures. B3- these latter is meant the sys- tematic puncturing and emptying of pustules and scar- ification of papules and tubercles. Many lesions are apparently papules, but by puncturing them deeply with a milium needle a small drop of pus will exude and thus shorten the process. Then Vlemingkx's solu - tion should be lightly applied at night and the follow- ing in the morning: R M. Resorcin puriss...................................................3j. Ung. aquae rosae..................................................5J- jj In those cases in which pustulation begins at the apices of the papules, it is due to cocci from with- 3 out, and may be prevented by opening the small pus- ^ tules and applying a 1-1000 bichloride solution, this £ to be repeated before each regular application, in order to prevent the local suppurative process. Of course, sulphur preparations are contraindicated on account of the black precipitate which forms. Carbolic acid lotions, chloro-phenique or other parasiticides which do not conflict with sulphur may be used. In the indurated and tubercular forms of acne, free scarifications and warm cloths to induce hem- orrhage is a very good plan of reducing the hyperplasia. Local mercurials, in conjunction with this, act very well. Care, however, should be taken not to oversti- mulate the skin with these external applications, as more damage may result from this than benefit from the remed3r. While acne is difficultly amenable to treatment, proper man- agement generally secures good results. 94 HANDBOOK OF DERMATOLOGY. 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 the central portion of the forehead and chin, or it occasionally involves but a limited part and remains localized. There are no subjective symptoms. It is usually divided into three stages: the hyperemic, the inflammatory and the hypertrophic. In the first stage there is more or less diffuse redness of the part, the process being a passive hyperemia somewhat inclined to stasis. When the nose is attacked, it looks shiny and greasy from the seborrhea which is present (See Plate XI). This stage may be permanent or it may pass on to the second in which the redness is more marked, the capillaries are enlarged, 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 rtose becomes nodu- lated, of a violaceous tinge, pendulous and, sometimes, of enor- mous proportions {rhinophyma) , the openings of the ducts of the sebaceous glands being patulous (See Plate XII). 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. PLATE XI ACNE ROSACEA. PLATE XII. RHINOPHYMA. HANDBOOK OF DERMATOLOGY. 95 The treatment is, in the main, that of acne. Stimulants lo- cally, and careful general medication. The withdrawal of alco- hol and proper dietetic measures must be enforced. In the second stage, the distended bloodvessels should be destroyed by cutting them open; by electrolysis, which is the best method, but the needle should be used rather superficially, as better re- sults follow than if it be plunged deep into the tissues; by cut- ting across at short intervals; or by other measures, which may suggest themselves. Strong local stimulating measures are indi- cated. In the third stage nothing but surgical measures will prove of much avail, and these must be made to conform to the individual case. 96 HANDBOOK OF DERMATOLOGY. SYCOSIS. Syn.—Sycosis Non-parasitica, Mentagra, Acne Mentagra, Folli- culitis 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 transformed into a small pustule, non-elevated, through whose center a hair emerges. There is deep-seated pain, burn- ing and tingling. If permitted to continue, the skin becomes red, the pustules increase in number, the integument thickens and nodules form (See Plate XIII). The upper lip is a favorite site for sycosis; the beard is also frequently involved, while the eyelashes, e}Tebrows, 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 measure, to bacilli and micrococci, auto-inoculation is a common occurrence, and hetero- inoculation is possible. Epidemics have occurred through the medium of barber shops. The diagnosis is easy. Lupus, eczema, the pustular syphi- lide and tinea barbae somewhat resemble sycosis, but the char- acter of the pustules, each one pierced by a hair, easily dis- tinguishes it. Pathologically, sycosis is a perifolliculitis, which may be deep or superficial, according as micro-organisms have pentrated deeply or not into the hair follicle. The hairs can be easily ex- tracted, and when this is done, a small white cylinder of epithe- lium is found adhering to the root-sheath. But little pain is experienced in epilation when the process is deep; on the other hand, pushing the hair down in the follicle is very painful. PLATE XIII. SYCOSIS. HANDBOOK OF DERMATOLOGY. 97 The treatment should be local. There are very few cases in which general treatment is indicated, and in these, the condi- tion requiring it has but little influence on the cutaneous trouble. One of the most important things to do is to epilate daily or shave. Then apply a germicide. For this purpose bichloride lotions in the strength of l-.">00 or 1-1000, or campho-phenique pure, should be thoroughly applied. Not only this, but the Fig. 20.—Hair in Sycosis. pustules should be emptied. While the epilation and shaving is practiced once daily, the application of germicides should be made at least twice. In acute cases, this is followed by the application of soothing ointments. In chronic cases, stimulating applica- tions are indicated. The ammoniated mercury ointment, ten grains to the ounce, oleate of mercury five per cent., or some similar preparation, is useful. If small abscesses exist they should be opened. If tubercles are present, free scarification, or curet- ting, will prove of benefit. In sycosis of the eyelashes, epilation followed by the appli- cation of yellow precipitate ointment, one to fifty, is followed by good results. While sycosis is curable, it is chronic and rebellious to treatment, and relapses are not rare. 98 HANDBOOK OF DERMATOLOGY. PERIFOLLICULITIS. This trouble is one which is occasionally met with in adults and children, males and females. It is essentially of inflamma- tory nature, and the lesion is invariably pierced by a hair. It appears at first as a macule, which rapidly changes to a flat papule of a rather bright color. This, in turn, becomes a pus- tule which may be either superficial or deep. The distribution is not limited to any particular portion of the body. The scalp may be the only portion affected, or the chest, back, limbs or hands may be severally or conjointly the seat of the disease. The most prominent subjective symptoms are pain and itching, and the scratching indulged in to allay the latter, is an active factor in spreading the process. It is partly for this reason that successive crops are observed. There is no doubt whatever that perifolliculitis is due to micro-organisms which may be entirely confined to the surface or go down deep into the hair-follicle. In no case, however, is there complete destruction of the hair bulb or papilla. The treatment should be such as will ensure the destruction of the causative organisms. The best method consists in freely applying campho-phenique to the affected parts several times daily. This not only prevents a spread of the process, but insures rapid recovery from the existing eruption. Where patches are of limited extent bichloride solution or solution of trikresol will be found effective. HANDBOOK OF DERMATOLOGY. 99 DERMATITIS PAPILLARIS CAPILLITII. Syn.—Acne Kelod, Sycosis Capillitii, Sycosis Frambesia. This rare trouble manifests itself at the edge of the scalp at the occiput, and travels upwards to the vertex, speading laterally in its course. It first manifests itself in the form of small papules which coalesce and finally form thick tuberculous masses of a warty nature. At this stage pustules are found here and there. A foul discharge oozes out from between the papillae, and bleed- ing follows the slightest touch. Abscesses form underneath, and in the course of time shrinking occurs, with an indurated atrophic condition of the scalp. The hairs then become clustered in tufts and bald spots occur here and there. The best treatment is without doubt the application of solu- tion of pyrozone twenty-five per cent, at the very inception of the process, and later on the destruction of the more actively destructive parts by means of the same or of cauterizing agents, followed by antiseptic dressings. 100 HANDBOOK OF DERMATOLOGY. IMPETIGO. This unusual affection generally occurs in children who are poorly nourished. It is composed of pustules, 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. They have thick walls and are surrounded by an areola. They are yellowish or whitish in color, firm to the touch, and neither rupture nor coalesce. They may occur anywhere, but prefer- ably 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 disap- pear. General roborant measures are the most important in the treatment. The local treatment is a very simple one. HANDBOOK OF DERMATOLOGY. 101 IMPETIGO HERPETIFORMIS. This is an exceedingly rare disease, which, so far, has only been observed in pregnant women, and has invariably had a fatal termination. It is characterized by the appearance of pin- head sized opaque pustules, which become green in color. The lesions are grouped in a circle and several patches are in close proximity to each other. The groin, umbilicus, breast and armpits are the favorite sites; but almost the entire body may be covered. When the eruption occurs it lasts but a couple of days. The pustules dry up and crusts of a dirty brown follow. Relapses occur at short intervals, and are manifested by another ring of pustules outside of the former one and so on until they attain such a size as-to touch. Each new crop is ushered in by rigors and a rise in the fever, which is always present. The whole disease lasts but a few weeks or months until death ap- pears. The trouble seems to be of a septicemic character. 102 HANDBOOK OF DERMATOLOGY. IMPETIGO CONTAGIOSA. This disease is uncommon, occurring in infants and chil- dren, and consisting of patches of small, discrete vesicles 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 tendency to coalesce. There is an areola surrounding each le- sion. 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-in- oculable. When a case occurs in a family of children they all acquire it unless prophylactic means are adopted. Whilst the hands and face are generally the parts attacked, other accessible localities'may become implicated (See Plate XIV). Patients re- cover spontaneously. Cleanliness and zinc oxide ointment, or the ammoniated mercury ointment, six to ten grains to the ounce, are all that is necessary to hasten a recovery, although a prelim- inary antiseptic wash is advantageous. PLATE XIV. .«#&- -*;* P ■¥'iss- Traumaticini................................................................................Ty']- M. Sig. Apply twice daily. HANDBOOK OF DERMATOLOGY. 145 CLAVUS. Syn.—Corn. This is an exceedingly common trouble which affects the feet. A corn is a circumscribed callosit}-, generally seated on the toe, having the form of an inverted cone whose apex presses upon the corium, producing a sharp pain. Corns may occur on the sole of the foot, on the ball of the big toe, or over bunions. In these localities the pain is accentuated. The cause of this hy- pertrophy is friction caused by shoes which are too tight or too loose 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 or greatly atrophied, leaving the papillary nerve loops bare. Cut- ting or paring and the measures recommended for callosity are applicable here. An efficient method is the application of the following, daily, for a week : R Acid. Salicylic............................................................................5J- Ext. Cannabis Indicae..............................................................gr.x. Collodion.....................................................................................5J. 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, provided that suitable shoes are worn. 146 HANDBOOK OF DERMATOLOGY. MALUM PERFORANS. Syn.-—Malum Perforans Pedis, Perforating Ulcer of Foot. Malum perforans first appears as a thickening of the epider- mis on the dorsum of the hand or foot. A sinus soon forms which penetrates as deep down as the bone. The nails become altered, hairs grow on the dorsum of the affected extremity, and more or less destruction of tissue takes place. It is generally the local manifestation of certain spinal and nerve lesions. It is not unusual to find it in anesthetic leprosy. The treatment is purely surgical, agents tending to strengthen the system at large being also administered. In some cases it is necessary to resort to amputation of the affected part. CORNU CUTANEUM, HANDBOOK OF DERMATOLOGY. 147 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 ap- pears rough or wrinkled. It is more or less elongated or round- ish, or it may occur as a rough or irregular projection. The length of these horns varies from a few lines to several inches (See Plate XX). The area of the base is always the largest of any cross section of the growth. In some cases the growth seems to have a tendency to extend laterally and very little in a vertical direction. A small ridge of skin generally surrounds the base. Cutaneous horns may be single or multiple. The face, scalp and penis are the favorite sites of its occurrence. In time 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 cauterization of the base. In some cases, occurring upon the penis, amputation is the only certain method of relief. Early removal of these growths should always be counseled. 148 HANDBOOK OF DERMATOLOGY. CORNU UNGUALE. Syn.—Nail Horn. This peculiar condition up to the present is an unique one. It is characterized by horny growths upon the fingers and toes somewhat curved, and several inches in length, situated at right angles to the digits. The bases of these growths occupy the nail beds of the nails, and a true nail growth surrounds one-half of the horn, the remainder consisting of hypertrophied horny cells (See Plate XXI). In the case figured it will be observed that there is a verrucous growth in the palms of the hands, the several lesions being distributed in linear fashion. No subjec- tive symptoms are noticed, and the growths interfere but little with the ordinary manipulations the hands are called upon to perform. PLATE XXI. CORNN UNGUALE. PLATE XXII. VERRUCA ACUMINATA. HANDBOOK OF DERMATOLOGY. 149 VERRUCA. Syn.—Wart. This is a circumscribed hypertrophy of the epidermis and papillae. Warts may be hard or soft, pointed or flat, sessile or pedunculated, smooth or rugous, congenital 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 integument, 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 zvarts, are filiform, papilli- form, or have a cockscomb appearance (See Plate XXII). They are of a rosy, or bright red color, and are found upon the geni- talia and upon the skin. In the former locality they grow rap- idly and exuberantly ; are moist, and give forth a fetid and sick- ening odor. Upon the skin they do not grow so rapidly, and are dry and odorless. Verruca fiIiformis is the wart that is slender and threadlike. It is of the color of the normal skin, and occurs chiefly about the eyelids, and most frequently in the old. J "erruca glabra is the smooth and shining wart which is frequently seen in adults and those past middle life. It has a tendency to spread laterally to the size of the finger-nail. Vcmica plana is the flat wart, frequently pigmented, seen in adults. Verruca senilis, as its name indicates, is met with in the old. The face, trunk and extremities are its sites of predilec- 150 HANDBOOK OF DERMATOLOGY. tion, although frequently seen on the trunk. It is often pig- mented, and 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 geni- talia. After a time the surface becomes rugous, and it frequently disappears spontaneously. One of the causes of verruca is irritation, either mechanical or other. Friction, acrid discharges, etc., may cause these growths to appear. Gonorrhea and gleet cause their appearance about the genitalia. Investigations have shown that some are due to micro-organisms and that they are auto-inoculable and contagious. The treatment is destruction of the growth. Although con- tended 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 results, except in children in whom slight friction of the growths will cause their disappearance. Still they are quite successful in some cases. The use of caustic alkalies or acids or excision is.prac- ticed by many, but electrolysis is as certain, less painful and un- attended 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 fre- quently 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. An agent which is quite efficient for the purpose is hydrozone, whose action is almost always followed by a dissappearance of the warts without a return. PLATE XXIII. ICHTHYOSIS HYSTRIX. HANDBOOK OF DERMATOLOGY. 151 ICHTHYOSIS. Syn.—Fish-skin Disease, Xeroderma Ichthyoides, Ichthyosis Vera, Ichthyosis Congenita. This disease, or deformity, consists in a tendenc}' to the ex- cessive 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 usually reaches it highest state of development, but may become more marked with advancing years. 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 sharply separated by the normal furrows ex- ist, a slight desquamation being present. The skin feels a little drawn and is less sensitive than unattacked portions. 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 (See Plate XXIII). The color here is a grey or greenish-black. This constitutes so-called "alligator skin." Ichthyosis sebacea is characterized' by rather thick scales to which there is added an admixture of sebum. In general, the scales in this affection are adherent. 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. There is an absence of perspiration noted, on account of the absence or want of development of the coil glands. The disease is hereditary, and in Paraguay endemic among the males. The diagnosis is easily made. 152 HANDBOOK OF DERMATOLOGY. 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 regu- larly; and after each bath, one of the following ointments ma) be rubbed in: R Ung. aquae ros3e, Lanolin (puriss)................................................................aa, 5iy' M. R Adipis benzoati, Ung. aquas rosae................................. ...............................aa, .^iv. M. R Adipis benzoati........................................................ 51J. Glycerinas.................................................................... .")i- Ung. petrolei.........................................................................gij. M. This disease is incurable. A few cases are reported as hav- ing recovered spontaneously. The administration of nerve tonics is frequently of benefit. HANDBOOK OF DERMATOLOGY. 153 XEROSIS. Syn.—Xeroderma. This disease is similar to asteatosis and to ichthyosis. It appears to hold a middle place between the two. It is congenital. The epidermis is dry, rough and harsh, shedding furfuraceous scales. The extremities and limbs are the portions most fre- quently affected, especially upon their outer aspects. The treat- ment to be pursued is the same as that in ichthyosis, and better results may be expected. 154 HANDBOOK OF DERMATOLOGY, KERATOSIS PILARIS. Syn.—Lichen Pilaris. This affection is of comparatively frequent occurrence. It is characterized by a number of discrete conical elevations of the size of a pin-head, of a grey or whitish color, sometimes sur- rounded by an areola, and each lesion is centrally pierced by a hair. 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 scratch- ing 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 flexor surfaces of the thighs. Males are most frequently the subjects of it. It is only where lanugo hairs exist that we find it. It is a chronic affection, attended with mild itching, in some cases. The causes are unknown, want of cleanliness playing but a secondary part. Adults are generall}- 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 imprisons the hair, and the pressure exerted leads to the erythema observed. There is very little difficulty in recognizing the trouble even when scratching has produced inflammatory symptoms. The treatment is, in the main, that of ichthyosis. There seems to be a tendency to the ichthyotic process in individuals affected with keratosis pilaris, as shown by the general state of the skin. Such internal remedies as will produce stimulation of the cutaneous glands are always of benefit, and will greatly aid in procuring a disappearance of the trouble. HANDBOOK OF DERMATOLOGY. 155 SCLERODERMA. Syn.—Sclerema, Scleriasis. In this rare affection the skin is yellowish or waxy, pig- mented, 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 maybe ribbon-like in its distribution. There frequently exist ridges at the sides of the affected area. No subjective symptoms are present, except the hide-bonnd feel- ing caused by the induration of the integument and consequent want of elasticity. It is essentially chronic in its course, affect- ing the head, trunk or limbs. When the face is the seat of this disease, it has a fixed, wooden appearance, and the skin has a hard feel. The treatment consists of baths, massage and frictions. The galvanic current also tends to produce resolution. Mild salicylic acid ointments are of benefit, but treatment must be persistent to avail. The disease may disappear spontaneously, leaving an atro- phied condition of the affected portion, or it ma3' recur after apparently having left. 156 HANDBOOK OF DERMATOLOGY. MORPHEA. Syn.—Addison's Keloid. Morphea is of infrequent occurrence, and is regarded by many as a stage of scleroderma. It consists of one or more dis- crete patches, bands or lines of a pale, whitish color, having a delicate lilac-colored areola. The patches bear a great resem- blance to a piece of fat bacon let into the skin. The causes lead- ing 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. The affected area may become the seat of scleroderma, a not unusual occurrence, and this has led to the idea that it is merely an earlier stage of the latter. All treat- ment which has been attempted up to the present has proven unsatisfactory. It sometimes disappears spontaneously however. HANDBOOK OF DERMATOLOGY. 157 SCLEREMA NEONATORUM. This affection, although congenital, is not observed until a few days after birth. There is at first an edema of the skin, which feels cooler than normal. I^ater on, it has a dense, hard feel and is more or less shining. The color of the skin is yel- lowish, reddish or violaceous. The face has a peculiar expres- sion, due to the want of flexibility of the skin, which latter also seriously interferes with suckling, the lips being hard and wooden. The disease involves the whole surface and, as a rule, the chil- dren affected by it die early. Some have been saved by the ap- plication of warmth, massage and stimulation, accompanied by oily inunctions. It is a rare condition and those infants who do recover never arrive to maturity, but rapidly succumb to some intercurrent disease. 158 HANDBOOK OF DERMATOLOGY. ELEPHANTIASIS. Syn.—Elephantiasis Arabum, Pachydermia, Bucnemia, Elephant Leg, Barbadoes Leg. This disease occurs chiefly in the Tropics. It begins, at first, in an attack of erysipelas or dermatitis in which the lymph- atics are more or less involved. When recovery has taken place it is found that the integument of the portion involved is slightly thickened. Successive attacks take place, the thickening grow- ing more and more until the volume and density are such as may be seen in typical cases. It is then tense, glossy and edematous. When the disease has existed some time the skin is rough, pa- pillomatous, hanging in thick folds and more or less pigmented. Seborrhea is present, the mouths of the sebaceous follicles are patulous and the whole presents a marked deformity. In the form seen in the Temperate Zones there is not such a marked accentuation of the symptoms. The partis enlarged and remains so (See Plate XXIV) and occasions only slight inconvenience to the sufferer, not attaining the immense proportions observed in the Tropics. The leg, arm, scrotum and penis, and the labia and clitoris are the portions generally affected. These parts attain enormous proportions and give rise to pain accompanied by a sense of weight, due to the thickening of the tissues. The cause is at- tributed by some to the filaria sanguinis hominis. The process consists in a hypertrophy of the deeper layers of the skin, in which the connective tissue participates. The lymph channels become blocked up and enormous growths result. The skin proper may attain a thickness of two inches or more. The treatment is mainly surgical. Excision of some of the affected portions such as the scrotum, labia, etc., ligation of the SISVUNIVHd3T3 AIXX H.I.V'I.I HANDBOOK OF DERMATOLOGY. 159" femoral artery or of the brachial, have been followed by good results. In some cases, however, amputation becomes absolutely necessary. Electrolysis has yielded some excellent results, but this means must be employed for years to obtain any marked change for the better. In the milder cases systematic massage is useful but it must be continued for a long period of time. 160 HANDBOOK OF DERMATOLOGY. DERMATOLYSIS. Syn.—Cutis Pendula, Rhinoceros Skin. In this rare affection we have a thickening of the skin, which feels unctuous and soft, accompanied 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 which is successful is the excision of some of the redundancy. This peculiar condition is seen to af- fect the extremities generally and is not often observed about the trunk. The so-called "elastic skin" is a form of dermatolysis which differs from the above in the fact that there is a certain amount of resiliency remaining in the integument and is not usually per- ceptible to the eye without further examination. In this form there is a hypertrophy (longitudinal) of the yellow elastic fibres. 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. 161 FRAMBESIA. Syn.—Yaws, Polypapilloma Tropica, Parangi (Ceylon), Coco (Fiji), Amboyne Button. This is a peculiar tropical disease which has been claimed to be a modified form of syphilis, to which it bears many analogies. but with which it cannot be identified. It has an incubation period, the primary lesion being a papule which appears on the lip, breast, groin, genitals and perineum. In about a week the apex becomes yellow and a week later it discharges, and a crust is formed overlying an ulcer which may persist for a month or two. A month after, the secondary stage occurs, ushered by fever and sometimes hermaturia, epistaxis or albuminuria. Marked fever always exists. An eruption of fine papules appears on the face and neck and covers the entire body in three days. In a week these lesions are yellow at the top and increase in size and soon look like raspberries. The lesions may coalesce and form large ulcers. A tertiary stage may occur. In this tubercles and nodules form, breaking down and being covered with crusts. The dis- ease may end in spontaneous recovery. As a rule, one attack procures immunity from subsequent ones. It is not auto-inoculable. Treatment internally is limited to tonics, except in the ter- tiary stage, in which mercury and iodide of potassium are of value. Locally, sulphur in the first two stages, and antiseptics wherever ulcers or similar lesions appear, should be employed. 162 HANDBOOK OF DERMATOLOGY. 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 prin- cipal visible seats of this trouble in women. When the affected portion is covered by clothing there is but little attention paid to it (See Plate XXV). 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 hypertri- chosis. Hypertrichosis may be congenital or acquired. In the for- mer 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 climateric 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 causa- tion. 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 become stronger and to increase in growth. Shaving has the same effect. Depilatories are probably the best PLATE XXV. HYPERTRICHOSIS. HANDBOOK OF DERMATOLOGY. 163 palliative measures. The following are among the most effi- cient: R Barii sulphid..................................................................................5ij. Pulv. zinci oxidi, Pulv. talc Yenet..................................................................aa, 5hj- M. R Sodii sulphid..............................................................................Jij- Pulv. zinci oxidi, Cretae preparatae..................................................................aa, 5nj. M. Fig. 22.—Jo-Jo, The Russian. Hypertrichosis of Face. Either one is made into a paste, with water, and applied tor ten or fifteen minutes. As soon as the skin feels hot it is scraped off with a dull knife'aud a soothing ointment is applied. These 164 HANDBOOK OF DERMATOLOGY. 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, on account of the in- tense pain it produces. 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 twirl- ing in it a needle whose point has been dipped in fused caustic potassa or in chromic acid. The inflammation which it provokes subsides in a few days. The other method is by electrolysis, as introduced by Hardaway and popularized by him. A fine steel broach or irido-platinum needle, connected with the negative pole of a galvanic battery (a strength of about 3 milliamperes being used), is carefully passed alongside of the hair into the follicle until the point reaches the papilla. The positive elec- trode is then applied to some indifferent part of the body, such as the hand. In a short time a frothing takes place at the open- ing of the follicle. Slight traction is made upon the hair, with a Fig. 24. Author's Electric Needle-Holder. pair of forceps, and, if it conies out easily, the operation is com- plete. The current is then interrupted 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, but by using care no untoward after-effects are produced. In those cases due to nervous disturbance it is best to treat the cause first before any local measures are attempted. Many recover from the hirsuties by these means alone. HANDBOOK OF DERMATOLOGY. 165 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 completely destroyed to insure a non-return of the hair. 166 HANDBOOK OF DERMATOLOGY, ONYCHOGRYPHOSIS. Syn.—Onychauxis. The above is a generic term employed to designate hyper- trophy of the nail (See Plate XXVI). 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. It is not unusual for pain to manifest itself in connection with this form of hypertrophy. In onyxis or onychia there is more or less ulceration taking place at the nail fold, or beneath the nail, which becomes dull in color, thickened, sometimes friable. This process is seen in some cases of syphilis, and is always attended by marked pain. Onychomycosis is a thickening of the nail due to the inva- sion of the parasite of ringworm or of favus. The nail assumes a dull yellowish color, is brittle and friable, and examination shows the infiltration of the fungous growth. Paronychia, better known as " ingrowing" nail, is character- ized by an increase in size, accompanied by a piercing of the tissues by the nail substance. This a particularly painful trouble, frequently accompanied by marked inflammatory symp- toms. In nearly all of these troubles the treatment is surgical. In onychomycosis it is best to scrape the nail well and apply para- siticides. Where ulceration exists, caustics are of benefit. When a perverted growth persists it is best to entirety remove PLATE XXVI. ■^.Yl ONYCHOGRYPHOSIS. HANDBOOK OF DERMATOLOGY. 167 and prevent the return of the nail. In order to accomplish this, the matrix must be completely 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 place any dependence. 168 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 congenital or acquired, idiopathic or symp- tomatic. 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 condition, so far as a radical cure is concerned, although the appearance may be ameliorated. 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 albinoes. They are observed but infre- quently. In them the hair is white, the pupils red, and a gen- eral absence 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 blacks as are affected in this manner are known as "piebald" negroes. In the colored races the achromic spots have a white appearance, as also in Caucasians. A close inspection of the affected areas, however, will show that it is, in reality, a pinkish color, due to the pre- dominance of the blood-vessels of the mucous layer of the epi- dermis. The finer blood-vessels are plainly visible as red lines, HANDBOOK OF DERMATOLOGY. 169 delicately traced upon the light background of the skin. There are no subjective symptoms connected with this deformity. It has a tendency to increase, sometimes. The deformity is heredi- tary in the partial form. The condition depends upon a congenital deficiency of pig- ment, but the cause of this deficiency is unknown. There is no treatment to improve the condition, which is a permanent one. Some help may be rendered by the use of harm- less dyes, but these are merely of a temporary nature. 170 HANDBOOK OF DERMATOLOGY. VITILIGO. Syn.—Acquired Achroma, Acquired Leucoderma, Acquired Leucopathia, Acquired Leucasmus. This disease is frequently met with, more particularly in negroes. It appears in the form of roundish or irregular white macules and, if the affected portion be hairy, the hairs are also Fig. 25. Section of Yitiligo. white. The spots are milky-white and vary in size from a silver five cent piece to large areas (See Plate XXVII). Vitiligo is an acquired achromia occurring in adults. The dorsum of the hand PLATE XXVII. fe "' ' ****•; 1 :.;'; % - '■• 1 Utl*. VITILIGO HANDBOOK OF DERMATOLOGY. 171 is generally first involved, although in some, it is never the seat or this affection. The areas are often symmetrically disposed or seem to be abruptly arrested at the median line. In some, the areas seem to be ranged equally from the middle line on each side. 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 peripheral displacement than a de- ficiency of pigment. This displacement from the center to the circumference would tend to confirm a nervous influence in the production of the condition and possibly suggest some method of dealing with it successfully. There are no subjective symptoms in this trouble. The ma- cules 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, but nothing yet has been definitely deter- mined. The diagnosis is to be made from chloasma and tinea versi- color. 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 manner. Ascending galvanic currents have a good effect in some cases. A dye made of a weak infusion of walnut husks is an agent which conceals the deficiency in color, but it is not lasting in its effects. The disease has a tendency to increase until the lapse of a certain length of time, when it remains stationary. 172 HANDBOOK OF DERMATOLOGY. CANITIES. Syn.—Poliosis, Trichonosis Cana, Trichonosis Discolor, Blanch- ing of the Hair. This disease, better known as grayness of the hair, may be congenital or acquired, and its appearance may be slow or sudden. As a rule, it is progressive and permanent, constituting one of the physiological changes incident to old age. The portions first attacked are the temples and beard; then the vertex, and finally, the remainder of the pilous system. If the hair be thick, the portions lying nearest to the scalp are very apt to retain their color. 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, heredity, de- ficient nutrition and innervation of the hair follicle, functional and organic nervous affections, keeping the head covered, etc. The white color is due to a want of pigment, to the uneven surface of the hair shaft, or to air bubbles in the shaft. In ringed hair, we have alternate layers of pigment, and the want of it producing the strange condition which is observed in child- ren and adults. The treatment of canities is sometimes successful by means of hypodermic injections of muriate of pilocarpine, gr. 1-12, once or twice a week. The same remedy may be administered by the mouth, in doses of gr. 1-G, in water, twice daily, but no certain results can be promised. The only other method is palliative, by the use of dyes, but this is hardly to be recommended. HANDBOOK OF DERMATOLOGY. 173 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 ulcerative pro- cesses; or to certain affections of the skin, such as lupus, favus, etc. It is observed to occur in irregular forms, and its cause is undoubtedly neurotic. Thus, a traumatism to a certain part will be located across or over a nerve trunk, and the skin supplied by branches of that trunk will undergo atrophic changes in smaller or larger areas,, this change being accompanied by a cer- tain amount of sensory disturbances of the integument in the affected locality. This change is observed in childhood, and in females most commonly, although it is also seen in adult life in both sexes. No treatment will restore the atrophied portions to the nor- mal, although galvanism will aid in preventing a spread of the atrophic process. 174 HANDBOOK OF DERMATOLOGY. SENILE ATROPHY. This form of atrophy of the skin is generally universal, and depends upon the degenerative processes incident to old age. It is always present in the aged to a certain degree, becoming more pronounced as years increase in number. 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 in quantity, and wrinkles form, the elasticity and resiliency of the integument being markedly diminished. The corium is thinner, the papillae are smaller, and the epidermis more or less dry and horny. The calibre of the arteries diminishes, whereas that of the veins increases, and a decrease in the normal temperature results. The whole process is a retrograde metamorphosis. Various degenerative changes take place, such as the fatty, the colloid, the amyloid, the larda- ceous, the waxy, and the vitreous. Simple atrophy is the more common form observed, and these latter manifest themselves only in the presence of the same process occurring in other organs. 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 upon the extremities and is due to organic nervous troubles. The face is affected at times; in such cases, the muscles participate in the change, giving rise to hemiatrophia facialis. PLATE XXVII 1. STRI/E ATROPHIC/E. HANDBOOK OF DERMATOLOGY. 175 STRI/E ET MACUL/E ATROPHIC/E. Syn.—Atrophic Lines and Spots. The lesions, in this condition, consist of lines or spots which are smooth and glistening in appearance. The skin at their site is thin and apparently distressed, presenting very much the ap- pearance of a thin 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 generally irregu- lar or broken. The direction is more or less oblique and, when several exist, they are parallel. 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 line and are isolated. There are two classes of these atrophies—idiopathic and symptomatic. In the former we find the thighs, pelvis, tro- chanters and buttocks the seat of the lines and spots. The chest, back, and other portions are sometimes affected. Syphilis and pneumonia cause the spots about the trunk. The symtomatic 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 preg- nancy are known as the linece albicantes. In another form the lines are comparatively broad and smooth, with no breaks in their continuity (See Plate XXVIII) . This form is seen to follow severe general diseases, such as ty- phoid fever, and would seem to be the result of nerve alterations and not due to purely mechanical causes, like the other forms are. 176 HANDBOOK OF DERMATOLOGY 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 disappeared. The stretching of the rhomboid meshes of the connective tissue is the cause of these changes in some cases. There is no treatment for this condition, which is generally of little importance, as it occasions no inconvenience, and, be- sides, is not situated upon visible parts, and so causes but little annoyance from a cosmetic point of view. HANDBOOK OF DERMATOLOGY. 177 AINHUM. When first observed, this trouble was supposed to be endemic in and limited to Brazil, but a number of isolated cases has been observed in Europe and this country since the disease was first described. It attacks the toes, but more particularly the little one. A depressed ring forms in the integument of the proximal phalanx giving much the same appearance as if a string had been tightly drawn around it. In the course of time spon- taneous amputation occurs. No pain attends the process beyond that due to pressure upon the distal phalanx, which becomes markedly enlarged. The process is generally idiopathic, and its cause is nervous in nature, disintegration in nerves bringing it about. It has been observed to occur in anesthetic leprosy, but whether caused by the disease, or merely an accompanying accidental process has not been satisfactorily determined. The changes in the tissues are atrophic, and the process is so intense that even the bones participate in it and become ab- sorbed in part. The natural termination of a case is spontaneous amputation at the site of the lesion. The only treatment is amputation, which is followed by a rapid repair of the tissues and a good stump. 13 17S HANDBOOK. OF DERMATOLOGY. 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 of the hair papillae and follicles. It is temporary, the retarded growth appearing later on. It may be localized or general. The locality most often affected is the scalp. But there is no particular distribution or symmetry. 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 seborrhea 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 to any appreciable degree. 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 grad- ual in its development, symmetrical, invading the vertex and up the corners 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 general causes. Seborrhea sicca, psoriasis, the vege- table parasites, etc., are among the local causes, while erysipelas often causes a marked defluvium (See Plate XXIX). Typhoid PLATE XXIX. Kf: tf><£xrA; &* k £■•■>■.• ERYSIPELAS. PLATE XXX. 4r f I 0 ALOPECIA UNIVERSALIS. HANDBOOK OF DERMATOLOGY. 179 fever, syphilis and leprosy are among the systemic disorders which cause alopecia (See Plate XXX). 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 essentially stimulation. A good bristle brush should be used and, in addition, sapo viridis as a sham- poo, followed by the application of a strong sulphur ointment, beta-naphthol ointment, bichloride of mercury lotion (five grains to eight ounces) , hypodermic injections of muriate of pilocarpine (gr. i) twice a week, or some other stimulating measure. In the symptomatic form, the disease causing the condition should re- ceive attention, but the local treatment is not to be neglected. An excellent stimulating lotion is the following: }$_ Resorcini ........................................... Beta-naphthol.................................. Tinct. cinchon. co......................... Spts. myrciae................................... M. Sig. Apply to scalp twice daih When a more active stimulant is needed the following should be well rubbed into the scalp twice daily: $. Ol. gaultheriae, Etheris sulphuric................................................................aa, %). M. There is but little hope of a return of the hair except in the symptomatic forms, although as long as the papillae of the hairs are not destroyed it is possible for a new growth to take place. ■3i- 3j. 3»j- 5vi- 180 HANDBOOK OF DERMATOLOGY, ALOPECIA AREATA Syn.—Area Celsi, Porrigo Decalvans, Alopecia Circumscripta, Tinea Decalvans. This disease consists in the formation of one or more bald spots, on the head or in the beard, and these macules vary in size from a small coin to the palm of the hand. Upon examining the patches they present a round, smooth appearance. Some lanugo hairs and a few broken off ones are occasionally found in the patches, which are sharply defined, having usually a round- ish or ovalish contour. The favorite sites of the patches are the parietal portions of the scalp, vertex and occiput. The patches may apparently coalesce (See Plate XXXI). The disease comes on suddenly, several patches following each other in close suc- cession. There are no subjective symptoms observed, as a usual thing. The majority of cases are of neurotic origin. In some, how- ever, it appears to be due to a micro-organism, and small epi- demics, produced by contagion, occur. The cause of this latter form—microsporon Audouinii, of the British, has never been satisfactorily demonstrated. The French are still of the undoubted opinion that the majority of cases are parasitic in nature, which may be true enough in France, but certainly does not hold good in this country. The treatment depends upon the origin of the trouble. If nervous, general nerve tonics should be given, this not being required in those cases in which the trouble depends upon micro- organisms. Locally, we have many remedies to choose from, the general plan being to produce a strong stimulation of the affected areas. Thus, the patches maybe blistered with tincture of cantharides, collodion or some similar preparation, every ten PLATK XXXI ALOPECIA AREATA. HANDBOOK OF DERMATOLOGY. 181 or fifteen days, a soothing dressing being employed in the inter- vals. Tincture of sapo viridis, aqua ammonia, oleate of mercury (•")—10 per cent.), corrosive sublimate, gr. iij—iv, to the ounce of alcohol, beta-naphthol, supplemented by frictions with a coarse towel, etc., are among the stimulating applications employed. Ointments containing cantharides, chrysarobin, pyrogallic acid, and similar stimulating agents are in use. Among lotions, the following is a good one. 1$ Tinct. cantharidis, Tinct. capsici ..................................................................aa, .^ss. Olei ricini..............................................................................~^\j. Aqua? coloniensis.......................................................................^i. M. The applications given under the head of alopecia will be found quite useful as well. A method which gives good results is galvanism. An ascend- ing 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 treatment. In a length of time, varying from two months to as many years, the hairs return. They may be white at first, but are soon replaced by a crop of the normal color. No alarm shold be experienced if the first crop which appears should fall out, for it is always replaced by a new one of the natural color, which will be a per- manent one. Alopecia areata generally occurs but once in a life- time. 182 HANDBOOK OF DERMATOLOGY. • ALOPECIA FURFURACEA. Syn.—Pityriasis Capitis, Alopecia Pityrodes Capillitii. This consists of a slow thinning of the hair beginning in early life and progressing steadily. The individual hairs are very thin, short and pointed. A constant furfuraceous desquama- tion is present. The scales are small and thin, being rather like fine bran. They consist of small horny epithelial cells derived from the stratum corneum of the epidermis. There is also .a moderate degree of seborrhea. This, however, is not necessa- rily a constant companion of the disease. Itching is more or less marked. The trouble is seen more often in men than in women. It maybe inherited, and it has been suggested that it is contagious. Although no parasite or micro-organism has been identified as the cause, there have been epidemics observed in which a common origin in the shape of combs or brushes could be determined. For this reason the contagious nature of the trouble has been stoutly maintained by some observers. The corium is thinned in this trouble. The treatment is stimulation, together with such means as will relieve the seborrhea. These means have already been adverted to, and it is unnecessarj' to repeat them here. HANDBOOK OF DERMATOLOGY. ATROPHY OF THE HAIR. Syn.—Atrophia Pilorum Propria. In true atrophy of the hair, it is only this structure which is affected. The process may be observed in all wasting diseases. It also occurs as a purely idiopathic foim, affecting most often the hairs of tfie 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. It is the hairs which are longest which are so affected. Whilst not common, it is not unusual to find the hair of the head affected in this manner in both men and women. Fig. -~y.—Trichorrexis Nodosa. Triehorrexis nodosa, or nodositas crinium, is characterized by the presence of small whitish nodes on the shaft of the hair, at irregular distances, and resembling very much the nits or ova' of pediculi. It is not so rare as has been generally supposed. It affects the hair of the pubes and of the beard most often, and consists of a broom-like Assuring at the points where the nodes 184 HANDBOOK OF DERMATOLOGY. exist, appearing as if two brushes were stuck into each other. Before this typical condition is attained a number of stages are passed through. The first change observed consists in a swell- ing of the shaft of the hair. This is followed by an increase in the swelling and a splitting up of the cortex into longitudinal fibres. The swelling finally bursts, but some fibres remain, which, holding the two parts of the shaft, give it- the peculiar appearance of two brushes stuck into each other at their bristle ends. It is claimed to be of neurotic origin. Plica polonica is a matted condition of the hair, seen most frequently in Poland, and affecting women. In those cases the hair is closely matted and a mixture of filth, parasites, and the exudates of inflammation and foreign matters give it a most re- pulsive appearance and disagreeable smell. The entire mass of hair of the scalp, or merely limited portions, such as a tress or a plait, may be the portion subject to the change. The hairs form such a tangled mass that they cannot be separated from one another. On the other hand, cases exist in which the patients are scrupulously clean, and in whom the condition supervenes in twenty-four hours (See Plate XXXII). A microscopic exam- ination of the hairs reveals a condition of trichorrexis, and in addition, an atrophy of the hair shaft and its medulla. The facts that it occurs after severe shocks to the nervous system, and a deficienc}' of nutrition of the hair exists, point to a neurotic origin. Among the Poles a superstition exists to the effect that if a plica be removed, the patient will die. The treatment of this condition consists in removal of the matted mass of hair and the administration of nerve tonics. 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. It is more than probable that the nodes are composed of masses of fringe which, by increasing in number, cause a split- ting up of the cortex of the hair into fibres, and the growth continuing between these, we have the production of the nodes. The condition is a comparatively rare one, and looked upon more in the light of a curiosity. Fragilitas crinium, or fragility of the hair, is a condition in which there exists an uneven formation of the hair-shaft, accom- panied by great brittleness. In addition, the hairs split at the free extremity. It may affect a few hairs only, or numbers. This fragility is found in those whose general condition is below par. One of the causes of the brittleness is insufficient PLATK XXXII. PLICA POLONICA. HANDBOOK OF DERMATOLOGY. 18.1 lubrication caused by inactivity of the sebaceous glands. An- other cause is the pernicious habit of frequently washing the hair with alkaline solutions or the continued application of per- oxide of hydrogen for bleaching purposes. In all these essential atrophies of the hair much care and discrimination are to be employed in their treatment. Whilst a number are amenable to treatment, there are cases in which no therapeutic means seem to be of any avail. They are by no means common and, on that account, a prognosis should always be formulated with great care. 186 HANDBOOK OF DERMATOLOGY. ATROPHY OF THE NAIL. This may be congenital or acquired. In the former case it is due to an arrest of development. In the latter, general wast- ing 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, absolutely necessary. Locally, the nail should be kept in some bland ointment and protected. For this purposes the ung. diachyli (Hebra) is among the best which may be used. This will accomplish about all that is possible to be done by topical measures. Ptyerything should be done to avoid contact of the nails with all such agents, especially of a chemical nature, as have a dele- terious influence upon horny growths-. Softening of the nails by any means should also be carefully avoided. PLATE XXXIII. KELOID. HANDBOOK OF DERMATOLOGY. 187 CLASS VII. —NEW GROWTHS. The class of new growths is an important one. As a general rule, they are painless and of slow growth. This is particularly true of the connective tissue new growths. Those depending upon cellular deposits are more or less destructive, frequently malignant. The majority are not painful. Besides these, we have new growths made up of bloodvessels, of lymphatics, of muscles, 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. An- other class resist all treatment and pursue a chronic course, last- ing ofttimes as long as the affected individual himself. KELOID. Syn.—Kelis, Kelos. Keloid is a connective tissue new growth which manifests itself in the form of an oblong plane, and elevated ridge, or a cylindrical mass, processes being given off at the periphery in nearly all cases. The color is whitish or slightly reddened, it being somewhat lighter than the surrounding integument, in ne- groes. The surface is smooth and more or less shining. Over the surface bloodvessels are to be seen branching in various di- rections. The portions usually affected are the trunk, especially that portion over the sternum, the back, the nucha, and the face. Itching is present in the majority of cases and the growths are sensitive on pressure. Pain is also present 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 (See Plate XXXIII) . lss: HANDBOOK OF DERMATOLOGY. The true cause of keloid is unknown. False keloid is ob- served 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. It is a com- paratively rare condition, and very few undoubted cases have been reported. The structure of keloid is a new formation of the dermatic framework." In true keloid we find bundles of connective tis- sue fibres, parallel to each other, and the papillae of the cutis intact. In hypertrophic scar, no papillae exist, and the connect- ive tissue, while abundant, is loose and irregularly distributed. In cicatricial, or false keloid, the bundles of connective tissue are present, but the papillae are absent. The treatment of keloid is unsatisfactory, as the disease tends to return after excision or cauterization. Multiple punc- ture, scarifications, curetting, are all ineffectual. The growth generally lasts throughout the life of the individual. Spontane- ous resorption is said to have-occurred in a few isolated exam- ples. It has been latterly claimed that electrolysis 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, meas- ures should be taken to relieve it. A good application for this purpose is this: $. Cocaini muriat..........................................................................j)j. Lanolin............................................................................. 5yi- Ung. aquae rosae...................................... ..........................^ij. M. When the deformity is great, it is best to excise the mass in the hope that, if a return takes place, it may not be so large or disfiguring as the original mass. PLATE XXXIV. FIBROMA. HANDBOOK OF DERMATOLOGY. 189- FIBROMA. Sy?i.—Molluscum Fibrosum, Molluscum Simplex, Molluscum Pendulum. This connective tissue new growth is of rather infrequent occurrence. It appears as elevated, sessile, or pedunculated tumors, varying in size from a pin-head to enormous masses. All sizes may be found in the same case. Generally, a number exist, although it is found singly. In some cases the tumors seem to cover the entire body (See Plate XXXIV). 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. Fibromata occur chiefly upon the trunk, the face, the ears, the genitalia, and the limbs. The growth of these tumors is very slow, but continuous. Its benign nature precludes subjective symptoms except when the large size produces irritation and pain. Fibroma can be read- ily recognized and differentiated from molluscum epitheliale, cj'sticircus 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 inher- ited. The growth is composed of a dense, white, fibrous mass, enclosed in a capsule, the center softening when the mass is large and producing pain on account of the degenerative process which sets in. Ulceration is apt to take place and may lead to complications not inherent to the disease itself. The treatment is surgical. The tumors should be removed when this is possible. In cases where they exist in hundreds this is scarcely permissible, and only the largest should be ex- cised. There is no tendency whatever to recur, if the removal has been thoroughly done. 190 HANDBOOK OF DERMATOLOGY XANTHOMA. Syn.—Xanthelasma, Vitiligoidea, Fibroma Lipomatodes. This disease derives its name from the yellow color its ap- pearance presents. It occurs in two forms—xanthoma planum and xanthoma tuberosum. Xanthoma plantern, 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 vel- vety 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 lesions may be single or they may be multiple. When a number exist they are usually of small size and incline to exist in groups. The macules may be discrete or become confluent. They occur most often upon the eyelids. Other portions of the integument and the mucous membranes and internal organs may be affected. There are no subjective symptoms connected with this form of the trouble. 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. The lesions occur in numbers and at times invade a considerable proportion of the cutaneous envelope. When both varieties occur in the same individual, we have the condition known as xanthoma multiplex, which is composed of the two former described in varying proportions. The pathology of this affection is not yet definitely settled. It is, probably, a connective tissue new growth, with fatty de- HANDBOOK OF DERMATOLOGY. 191 generation. 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. Excision of patches of xanthoma planum of the eyelids is not to be recommended on account of the cicatricial contractions which ensue. 192 HANDBOOK OF DERMATOLOGY. PSOROSPERMOSIS. Syn.—Darier's Disease, Icthyosis Sebacea Cornea, Follicular Vegetating Psorospermosis. This is a comparatively rare affection which is claimed to be caused by psorosperms. The process seems to implicate the hair-follicle, the outer portion of which is dilated. It, however, occurs in non-hairy parts, such as the palms and soles. The first indication of the disease is in the form of small brown or yellow crusts, which are elevated and quite adherent. When removed by maceration the lips of the depression are red and everted. On the under surface of the crust a softish prolonga- tion is seen. New lesions are apt to occur as crops of papules. In old cases which have existed for some time, the lesions may become confluent. In certain portions of the skin, such as in the groins, armpits, etc., a purulent, most fetid exudation flows out of the depressions. The only treatment so far offered, which seems at all satis- factory, is the use of the thermo- or electro-cautery to destroy the lesions. PLATE XXXV. MOLLUSCUM EPITHELIALE. HANDBOOK OF DERMATOLOGY. 193 MOLLUSCUM EPITHELIALE. Sy/i.—Molluscum Contagiosum, Molluscum Sebaceum, Epithe- lioma Molluscum, Acne Varioliformis. This affection is unusual, and consists of roundish, eleva- tions, 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 (See Plate XXXV). A blackish point is occasionally observed 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 beyond a very slight itching at times. 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, although clinical experience points that way. As to its pathology, we are reasonably certain that the pro- cess occurs in the sebaceous glands, and, when the contents of one of the papules is examined, it is found to abound in the so- called molluscous bodies. The theor}' is that the disease is pri- marily an affection of the rete mucosum, and the prickle cells are transformed into these molluscous bodies. Molluscum epitheliale is not difficult to recognize. It is to be differentiated from sebaceous cyst, molluscum fibrosum and verruca. The treatment is entirely local. Small lesions may be treated by stimulating applications, such as those containing white pre- cipitate, etc. Enucleation of the sac and its contents is the best H 194 HANDBOOK OF DERMATOLOGY. method. Electrolysis is also excellent. A method sometimes practiced is to split open the lesion and introduce a small amount of some caustic, but it is painful and not more efficient than other means. The disease is easily amenable to proper surgical interference. If left alone, it tends to spontaneous recover}-, after having ex- isted for a variable length of time. HANDBOOK OF DERMATOLOGY. 195 RHINOSCLEROMA. This rare disease is characterized by the presence of an ir- regular elevated patch, composed of tubercles, of the color of the skin or reddish-brown. The mass is well defined and occurs about the nose, its alae and the upper lip. It is hard to the feel, although somewhat elastic. It is slow in progress, gradually encroaching on the nasal mucous membrane and extending to the phaiynx. There are no subjective symptoms connected with it except pain on pressure. As the growth advances in the nose and encroaches on the pharynx it produces obstruction to the res- piration and it may be positively dangerous to life when it at- tacks the larynx. It is seen in children and adults. It consists of a cellular growth, and late observations tend to show that it is due to encapsulated micro-organisms. The former treatment by cauterization, which acted but temporarily, has been in great part supplanted by injections of corrosive sublimate or salicylic acid solutions, which are followed by apparent successes. 196 HANDBOOK OF DERMATOLOGY. LUPUS ERYTHEMATOSUS. Syn.—Lupus Erythematodes, Vespertilio, Batswing Disease, Seborrhea Congestiva, Lupus Superficialis, Lupus Sebaceus. This cellular new growth is not as frequently seen in this country as in Europe. It begins as one or more reddish-brown patches, which increase in size indefinitely. The patches are about the size of the small finger-nail and attract but little atten- tion at their inception. As they enlarge they apparently ap- proach each other. When they have approached to a sufficient extent they coalesce. At the margin 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 adherent 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 (See Plate XXXVI). The vermillion of the lips, the scalp, the ears, the back and the hands and feet may also be involved. Some burning and itching are sometimes present. The disease is essentially a chronic one and is very re- bellious to treatment. An apparent recovery is simply a short respite and new crops of lesions soon make their appearance. 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 re- lapses are very apt to occur. PLATK XXXVI, •-4"--. \," •J 'At ''Imrni LUPUS ERYTHEMATOSUS. PLATK XXXVII. LUPUS. HANDBOOK OF DERMATOLOGY. LUPUS VULGARIS. Syn.—Nolime Tangere, Lupus Exe- dens, Lupus Vorax. This affection, while common in Europe, is exceedingly uncommon in this country. It is extremely chronic, slow in its evolution and destructive in its process. It begins as softish nod- ules, of the size of millet-seed, located in the corium, and appearing to view as dark red macules upon the skin. Patches form in which papules or softish tuber- cles show themselves. These patches have well-defined, more or less elevated edges (See Plate XXXVII). Involu- tion may take place; but, as a rule, ulcers form which have a dirty floor, an abundant secretion of pus, and rather soft edges. This ulceration is markedly destructive in some cases, and may pro- duce extensive ravages, attacking the underlying tissues, causing necrosis of the bone as well as caries, complete destruction of skin and muscles; ajid organs, such as the eyes, succumb to the destructive action of the process. Cicatrization takes place as the process advances, so that it is not unusual to observe a lesion with a scar in the cen - tre and nodules and ulceration at the 198 HANDBOOK OF DERMATOLOGY. periphery. The scars are rather thick, with centrifugal bands, giving a stellate appearance. A scar may be quite large and thin, with sharply defined blood-vessels running over its surface (See Plate XXXVIII). Variations in the process are in the appear- ance only which is presented. As it may consist only of tubercles or papules (lupus tuberculosus); atrophy and desquamation fol- lowing involution (lupus exfoliativus); ulceration {lupus exe- dens); a vegetating process (lupus vegetans or hypertrophicus); or the occurrence of horny or warty growths (lupus verrucosus). 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 disease by extension of the process, and the larynx is also attacked. Pain, more or less marked, is an invariable accompaniment. In the earlier part of the process are found nest-like masses of large nucleated cells which, disappear to give way to the gen - eral cell infiltration. Tubercle bacilli are also found, abund- antly 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, onty 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 reported from the use of ointments or solutions of corrosive sublimate, one or two grains to the ounce, applied continuously to the patches, or the same agent in tincture of benzoin, freely painted on the patches, is said to act well. Sulphurous acid, pyrogallol (ten per cent, ointment) and iodoform have been recommended. A very good method is the free application of chromic acid, fol- lowed hy an ointment of this composition: I£ Aristol..................................................................................5j. Ung. aquse rosae.........................................................................gj. M. Coque et fiat unguentum. Multiple scarifications or curetting with a sharp spoon, fol- lowed by some of the above applications, is well spoken of by some. Cauterization with the Paquelin knife, galvano-cautery, or chemical caustics has its adherents. Electrolysis has also been advised. The remedies proposed and lauded for this dis- ease are very numerous, and more or less efficient, and care should be observed in formulating a prognosis. PLATK XXXVIII. LUPUS SCAR. HANDBOOK OF DERMATOLOGY. 199 SCROFULODERMA. The scrofulodermata are, as a rule, chronic, indolent, hyper- emic processes which induce changes in the skin and subcuta - Fig. 128.—Scrofuloderma. Scars following Ulceration. neous tissues. There is a tendency to break down, and to the formation of ulcers. The contiguous ganglia become infiltrated, 200 HANDBOOK OF DERMATOLOGY. hard, and are also inclined to undergo degenerative changes. The nodules which are formed rapidly break down, and the resulting lesions have a purplish appearance, uneven floors, pale granula- tions and thin pus. The cicatrices are irregular, corded and disfiguring (See Plate XXXIX). The chief varieties of scrofu- lodermata are the papular and the pustular (small and large). The disease occurs, as a rule, in early childhood, and before puberty, although it is also seen in early adult life. A constant accompaniment is the peculiar lymphatic engorgement and mat- ting together of the ganglia which has so long been characterized under the name of "strumous" glands. The peculiar appear- ance of patients so affected will readily enable a diagnosis to be made. The destructive character of the process, and the pecu- liarly offensive nature of the discharges, as well as the slowness with which the healing process sets in, are characteristic of the disease. Very frequently large areas are involved, and, in the course of time, spontaneous healing will take place. The treat- ment should be general, directed to the struma; and, locally, antiseptic and stimulating applications. Among the former the syrup of the iodide of iron in comparatively large doses combined with cod-liver oil is useful. The best remedy for the purpose, however, is the elixir of the iodo-bromide of calcium compound in marked doses. This not only exerts a general influence on the constitution, but it also causes a reparative change in the glands and improves the quality of the integumentary tissues. Locally, a good ointment to apply is one composed as follows: $. Aristol...........................................................................................5J- Tinct. iodini co........................................... ........................ 5J- Ung. aquae rosae...................................................................gij. M. Sig. Apply twice daily. Iodoform is also of utility, but its disagreeable odor is some- what of a drawback to its use. PLATK XXXIX. SCROFULODERMA. PLATE XL TUBERCULOSIS CUTIS. HANDBOOK OF DERMATOLOGY. 201 TUBERCULOSIS CUTIS. Primary tuberculosis of the skin is a rare affection. No matter where it occurs it is always the result of infection. As a rule it is observed in those suffering from tuberculosis of the lungs and intestines and, on this account, it is most often seen at the orifices of mucous outlets. A nodule appears which breaks down, resulting in an unhealthy sore or ulcer, whose floor is studded with small tubercles (See Plate XL). The adjacent skin or mucous membrane is always infiltrated and the whole presents an unhealthy appearance. Pain is always present. In those cases due to direct inoculation the process occurs upon that portion of the integument which came in contact with the infecting tuberculosis material. Microscopic examination will always reveal the tubercle bacilli. The treatment must generally be directed to the general tu- berculosis which is present, as a rule, in those affected with tuberculosis of the skin. Locally, one of the best agents to use is iodoform, but to obtain results from it, it is best to modify the soil by strong caustics which do not coagulate albumen such as pyrozone solution, lM per cent. This prepares the lesions for the action of the remedies which are to follow. The prognosis is never good in this class of cases, as the generalized tuberculosis generally ends fatally. Verruca xecrogexica, or dissection wart, is a form of local tuberculosis which is quite common in those who are in the habit of handling cadavers. For this reason demonstrators of anatomy, medical students, those who perform post-mortems, butchers, etc., are most often affected. The necrogenic wart ap- pears at first as a persistent reddish, flat elevation on the dorsum of the hand or in the interdigital fold and it persists in remain- ing, undergoing a nervous change. Several may coalesce or they ^02 HANDBOOK OF DERMATOLOGY, may remain isolated, and vary from the size of a pin's-head to that of the thumb-nail. They sometimes disappear spontaneously, or remain stationary, becoming pigmented. At times they break down and ulcerate. Radical extirpation is the only proper method of treatment to adopt. HANDBOOK OF DERMATOLOGY. 203 MYCETOMA. Syn.—Madura Foot, Fungus Foot, Podelcoma. This disease, which is endemic in India, occurs in two forms, black and pink. The latter is more common. In either form there are fungoid growths looking like red mould. The beginning is characterized by redness, swelling and some indu- ration. Later on the reddish fungus growths occur, and in the black variety there are then observed black granular particles resembling gunpowder, which give way later on, to black or dark brown masses. It is the foot which is generally attacked, although the hands. scrotum, or rarely the shoulders, may be the seat of the trouble. When the nodules have existed some time each one has a sinus which penetrates down to the bone, and gives exit to a serous exudation containing pus and round granules. The process is a disintegration caused by a fungus, the che- onyplie Carteri, which is closely allied to that of actinomycosis. The only efficient treatment consists in the adoption of sur- gical measures of a radical nature. 204 HANDBOOK OF DERMATOLOGY. LEPRA. Syn.—Elephantiasis Grecorum, Lepra Arabum, Leontiasis, Satyriasis, Leprosy. This affection is one which is constitutional and rather in- frequent in temperate zones, at the present time. It is slow and Fig. 29.—Lepra Tuberculosa. insidious in growth, and rather progressive in character. Pre- monitory symptoms are observed in the majority of cases, these plate xli. LEPRA TUBERCULOSA. HANDBOOK OF DERMATOLOGY. 20» consisting of malaise, chills, fever, languor, loss of appetite, etc. Nearly every organ of the body may become affected. In general, three varieties of the disease are recognized, viz. : tubercular, macular and anesthetic. Lepra tuberculosa, or tubercular leprosy, begins as macules which are of a reddish or brownish color, round, oval or irregu- lar 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 consist of irregular nodules, softish to the feel and 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 thickened and nodulated, giving a peculiar leonine ap- pearance to the features (leontiasis) (See Plate XLI). The larynx and soft palate sometimes become involved. The tuber- cles may be reabsorbed, but they generally ulcerate and, towards the last, mutilation, chiefly of the extremeties, is a result of this process (lepra mutilans). The course of the disease is extremely slow. Lepra maculosa, or macular leprosy, has the appearance of the tubercular at its inception. Sometimes, the macules are white, with enlarged capillaries at the border. At first there is li3Tperesthesia and, later on, anesthesia'of the affected portions supervenes. Occasionally, the macules bear a close resemblance to vitiligo. The hair growing on a patch of macular leprosy are apt to become thinned and almost invariably turn white. Lepra anesthctica, or anesthetic leprosy, first manifests itself . by the appearance of bullae. Scars generally follow, and these are white and shiny, somewhat resembling plates of mica. The affected areas are anesthetic, other portions of the integument 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 indurated, and, like cords, fusiform nodes being found in some. The skin is dry and harsh, the muscles atrophy and the hair falls out. The extremities ulcerate and lepra mu- tilans generally supervenes. Ain' two or all of the above varieties may be present in the same individual. In fact, it is seldom that a pure, unmixed case of any variety is met with. A mixture of two forms is generally seen. The causes of leprosy have never been definitely ascertained. It has no connection whatever with syphilis. As to its being 20G HANDBOOK OF DERMATOLOGY. contagious, there is very strong doubt. Its infectious character has not been definitely ascertained either, experimental inocula- tions having produced the disease apparently, but subsequent investigation showing that the cases were probably leprous be- fore the inoculations were practiced. 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, lymphatic vessels, it being also found in all the lesions. It may occur at any age, children being the subject of the disease as well as adults and the old. The treatment of leprosy is ineffectual unless it be in its earliest stages. Hygienic measures, baths plain or with sul- phur, or iodine and the use of oil of cashew nut, Gurjun balsam and chaulmoogra oil constitute the principal therapeusis. Chaul- moogra oil has benefitted some cases to a remarkable degree and has proven a complete failure in others. Lately iehthyol, in- ternally 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. There is no doubt, however, that if the patient can bear large doses of this remedy improvement takes place with rapidity. The cure of leprosy has not yet been discovered and still remains a desideratum. HANDBOOK OF DERMATOLOGY. 207 PELLAGRA. \ Syn.—Lombardian Leprosy, Mai Rosse. This is essentially a trophoneurotic disease, observed chiefly in Italy. It begins as a chronic erythematous process, invading principally those portions of the skin which are exposed. After a time desquamation takes place, and this leaves a red, shining surface. In those localities in which the desquamation takes place the skin becomes thick, dry and yellowish or brownish in color, Relapses occur every year, and the duration of the dis- ease is about five j^ears. After this length of time a lethal con- clusion terminates the case. Marked nervous symptoms occur during its course and paresis is no uncommon complication. Insanity sometimes occurs, and mental hebetude and dullness always accompanies the process. The disease occurs in the poor and debilitated who live in unsanitary surroundings. Treatment, to be of any value, must be begun early in the disease and is chiefly symptomatic. It is claimed that Fowler's solution, in one or two drop doses, thrice daily is useful. 2( is HANDBOOK OF DERMATOLOGY. CARCINOMA CUTIS. Under the general term of carcinoma of the skin is included three principal varieties of malignaut tumors, the epithelial, the fibrous, and the melanotic sarcomata. The skin may be prim- arily 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 epithelial involvement. EPITHELIOMA. Syn.—Epithelial Cancer, Cancroid. This is by far the most common malignant neoplasm of the skin. Three varieties are described—the superficial, the deep and the papillary. 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 existing lesions of the skin, such as excoriations, fissures, etc., or it may take its origin from a wart, mole, nevus or from the orifices of sebaceous glands. The shape may be circular, oval, linear or irregular. It is only ob- served in those at or past middle life (See Plate XLII) . There is a tendency to spread and the formation of an ulcer—rodent ulcer-—which invades large areas, having an irregular, granulat- ing 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 termination may be a spontaneous healing, after a number of years, or a rapidly de- structive process. As a rule, however, rodent ulcer is slow in its spread, whereas, superficial epithelioma is rather rapid and has a greater tendency to the destruction of tissues. PLATE XLII. #1 EPITHELIOMA. HANDBOOK OF DERMATOLOGY. 209 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, sometimes surrounded by "satellites," or a thick "button" arises, 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 tendency to extend down info the tissues involving muscles, fasciae, bones, etc. It is eminently destructive in character and may, in a comparatively short time, cause death from exhaustion, hemorrhage, etc. Papillary Epithelioma.—This variety may be described, 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, degeneration occurs and ulcers arise such as those described above. About three-fourths of all the cancers of the skin are ob- served upon the face and head. Any of the varieties first described may occur in this locality. The genitals, back of the hand and foot, are also occasionally involved. Any portion of the integument may be the seat of this affection. In Paget's 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. It is a question at issue as to whether this trouble is a form of epithelioma or of psorospermosis. At all events, it is essentially destructive in action and malignant in character. Epithelioma is to be distinguished from lupus vulgaris, syphilis and sarcoma. In all forms of epithelioma there is marked infiltration of the skin and a decided induration of the edges, the borders may be everted and are frequenly undermined. A constant symptom is a sharp, shooting, lancinating pain, which seems to start from the centre of the lesion and radiate therefom. The treatment is entirely local, no internal remedies being of any avail, except in so far as general measnres may be indi- dated by an enfeebled state of the patient. Excision, scraping, or cauterization comprise the usual methods of treatment of epi- thelioma. 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. P}rro- gallol and concentrated lactic acid are said to destroy the cancer- ous tissue without attacking the normal structures. The former 210 HANDBOOK OF DERMATOLOGY. is used ill 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, Bougard's Paste and Mars- den's Paste are also employed. The thermo-cautery and galvano- cautery are excellent means when they can be employed. Whatever method is adopted should be thorough. It is abso- lutely necessary to remove the entire malignant mass, so as to obviate any possibility of a recurrence. When relief is sought, 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." A very good method, and one which is nearly always efficient, consists in thoroughly cleaning the ulcerated surface, and then thoroughly applying chromic acid. This is to be followed by pyrogallol ointment in the strength of two parts in one hundred of cold cream. If this ointment is too strong europhen ointment, one drachm to the ounce will be proper. The acid should be applied once or twice a week as indicated. Lenticular Cancer, scirrhous, hard or fibrous cancer rarely occurs primarily in the skin. It is almost always secondary to some cancerous involvement 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. The tumors sometimes break down, forming ulcers and subsequently cica- trices. Cancer en cuirasse is that form in which the integument of a large part or of all of the chest is infiltrated by the cancer- ous 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, accom- panied by more or less pain. Melanotic Carcinoma, or pigmented carcinoma, is that form in which a marked deposit of pigment occurs. It generally takes its origin from pigmentary nevi or moles. It is very markedly malignant. It is a tendency to manifest itself in differ- ent black or dark tumors, and does not exhibit a general involve- ment of the integument. HANDBOOK OF DERMATOLOGY. 211 SARCOMA CUTIS. Sarcoma of the skin is malignant to quite a marked degree. It shows itself as a primary or secondary 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 observed at birth. At first the tumors are isolated, the intervening integu- ment being apparently normal. Later on, it becomes red, swollen and infiltrated. A peculiarity of sarcoma is that it does not ulcer- ate. The treatment is unsatisfactory and death is the inevitable result, in all cases. The diagnosis is determined definitely by microscopic examination. Melanotic Sarcoma, or melano-sarcoma has the general features of sarcomata. It is pigmented, the color presented vary- ing from a grey to black. It is extremely malignant in character and quick in its evolution. It is not unusual for the entire integ- ument to share in the pigmentation, and a case is on record in which all the secretions were black. All treatment is unavailing and a rapid termination in death is to be expected. Mycosis Fungoides, or granuloma fungoidcs, is a neoplas- tic disease, probably caused by streptococci or diplococci, and characterized by button-like tumors occurring in various portions of the integument, notably the face. After a time, thej* become firm, sausage-shaped, lobulated, of a peculiar red color, produc- ing a sort of leonine countenance when on the face. On the extremities they are verj- aptly said to resemble tomatoes. Gen- eral 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. The disease occurs in patients twenty to forty years of age, and has been known to persist for thirtv Years. 212 HANDBOOK OF DERMATOLOGY. NEVUS VASCULOSUS. Syn.—Nevus Sanguineus, Nevus Vascularis. This affection is frequently seen and easily recognized. It is congenital, occurring either in the skin or subcutaneously, and the formation is a new growth composed of blood-vessels. Nevi 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 frequentty affected. Some grow larger, others become smaller; but the majority remain stationary. Nevus vasculosus is very vascular, easily compressible, the skin under- lying it being normal. Generally, it is single, but it may be multiple. There are no subjective symptoms connected with it. There are two divisions of nevus vasculosus—nevus tuber- osus and nevus simplex. Nevus tuberosus or angioma cavernosum is tumor-like, prominent and erectile. It is very vascular, and, at times, pul- sating. It is occasionally seen on the scalp. Nevus simplex, or angioma simplex, consists of non-elevated macule-like patches, which are more or less smooth. It is occa- sionally described as nevusflammeus, or "port wine mark." Nevus pigmentosus may be verrucous or pigmented, but these are accidental modifications, which merely modify the ap- pearance. The growth consists of dilated or hypertrophied blood- vessels and capillaries, the former predominating in the cavern- ous and the latter in the simple variety. The arrangement of these vessels is quite complex. The diagnosis is very easily made. HANDBOOK OF DERMATOLOGY. 213 The treatment of this deformity depends, in a great meas- ure, upon the condition present, the parts implicated, and the means at command. The simplest method is compression. It is long and tedious and unsatisfactory. Vaccination has been tried. The ligature is good in small erectile nevi. When the lesion is small caustics may be used or active cauterizing agents. Bichloride of mercury in collodion or traumaticin (gr. viii to 5i), or tartar emetic in the same strength are good applications. Nitric acid, solution of carbolic acid (fifty per cent.) and chromic acid of thirty per cent, strength have been employed success- fully. Ethylate of sodium is efficient, but very painful. The injection of a solution of the sesqui-chloride of iron is advocated, this substance coagulating the blood. In the smooth variety, linear scarifications, made close to each other and crossed, or punctate scarifications, dipping the needles in some caustic or coagulating fluid, have been successful. The actual cautery, the thermo- cautery, and the galvano -cautery are still employed by some. The simplest method, however, which is easy of application and effective in its action, is electrolysis. The positive pole should be large, the needle being attached to the negative. The needle is plunged into the nevus perpendicularly and the circuit closed. If done carefully, there will be no slough formed. The needle should be introduced at points close to each other. The strength of the current employed should vary from four to six inilliamperes. The prognosis should always be guarded. Whilst some of these nevi readily yield, others seem to recur again and again with a persistency which is discouraging. 214 HANDBOOK OF DERMATOLOGY. TELANGIECTASIS. In this we have one or more small bright red points or lines which may occur upon any portion of the integument. Telangi- ectases are acquired, and are composed of enlarged capillaries. They occur most frequently on the face and hands. When occurring as lines they are generally seen upon the malar emi- nences, the nose, and about the alse nasi, constituting the condi- tion known as rosacea. Telangiectasis may occur at any age, without any known cause. There are no subjective symptoms connected with it. It is easity recognized. The electrolytic needle is very efficient in causing a rapid and permanent disap- pearance of this deformity. Angioma pigmentosum ET atrophicum, xeroderma pigmen- tosum, or melanosis lenticularis progressiva is a rare affection characterized at first by a hyperemic condition and numerous split-pea sized telangiectases, together with disseminated, brown- ish macules. Among the complications attending it are ectropion, ulcerative keratitis, and more or less malignant neoplasms. It generally appears before the third year and may last twenty-five years. It has never been observed in natives of this country. HANDBOOK OF DERMATOLOGY. 21o ADENOMA SEBACEUM. This is a rather unusual affection which occupies a middle ground. It is congenital but it increases with age or acquires a sudden development at puberty. It consists essentially of red rounded papules, varying in size from a millet-seed to a split- pea, and distributed about the naso-labial fold, on the nose, cheeks and at the root of the nose. In fact, its distribution is that of acne rosacea, for which it might be mistaken. There is one peculiarity which is sufficient to distinguish it from all other similar troubles. Each lesion has a small telangiectasis in con- nection with it. It occurs, so far as has been observed, in individuals of im- perfect mental development, in epileptics and in insane individ- uals. The best treatment is extirpation by means of electrolysis, employed in the same manner as for moles or telangiectases. 21(j HANDBOOK OF DERMATOLOGY, LYMPHANGIOMA CUTIS. Syn.—Lymphangioma Tuberosum Multiplex. This exceedingly rare affection is characterized by trans- parent, numerous, discrete tubercles which elicit pain upon pres- sure, and sink below the level of the skin. The disease occurs about the trunk and extremities. The color is a dark red. It is of slow growth and benign. The tubercles, which are illy-de- fined, consist of a mass of enlarged lymphatic vessels and en- larged lymph spaces. Surgical measures are probably the only efficient means to employ in this trouble, which is rather in the nature of a de- formity. HANDBOOK OF DERMATOLOGY. 21~ NEUROMA CUTIS. This trouble is also exceedingly rare. It simulates fibroma, to a great extent, in appearance. Paroxysmal pains manifest themselves. The growths consist of connective tissue and non- medullated nerve fibres. Pressure produces intense pain. The extremities of amputated stumps are most liable to this trouble, as also scars in other parts of the body. Excision of the neuroma produces relief of a permanent. character. 218 HANDBOOK OF DERMATOLOGY. MYOMA CUTIS. Syn.—Dermatomyoma, Liomyoma Cutis. This is a tumor of the skin composed of non-striated mus- cular fibres. Rose-colored macules and pea-sized firm tumors are found. No subjective symptoms are present. Another form is composed of single tumors which are sessile or pedunculated and attain the size of a hen's egg. They are painless and usu- ally vascular. The disease is rare and not malignant. When there is a preponderance of connective tissue it con- stitutes afibro-tnyoma and when blood-vessels are present to a large extent we have the myoma telangiectodes. HANDBOOK OF DERMATOLOGY. 219 CLASS VIM. —NEUROSES. These diseases are purely functional in character and are merely changes in the normal sensibility. The symptoms are purely subjective, no structural lesions of the skin being present, although changes occur in the nerve-trunks and branches in some cases. Secondary lesions due to scratching are found in some cases. HYPERESTHESIA. This is, in general, a symptomatic condition of the skin wherein its sensibility is exalted. It is dependent upon some functional nervous disease or upon some lesion of a nerve trunk. It ma)- be either unilateral or symmetrical and involve small or large areas. Hysteria is a common cause. Its severity, dura- tion, etc., depend upon the exciting cause. The causative dis- turbance must be treated in order to relieve the condition, and locallv, annodvne spra}Ts may occasionallv afford temporarv re- lief. DERMATALGIA. Syn.—Neuralgia of the Skin, Rheumatism of the Skin. This is also a purety functional affection, idiopathic and symptomatic in character, the symptoms being subjective. It is characterized by intense pain, located in the skin, and which may be local or general. The pain is spontaneous and may be either constant or intermittent. The idiopathic form is rare. Rheumatism or gout is a verj7, common cause of the symptomatic variety. The general treatment should be directed to the cause. 220 HANDBOOK OF DERMATOLOGY, Locally, the galvanic current, blisters, applications containing the tincture of aconite root, or of belladonna are beneficial; and, if the whole surface be involved, vapor baths. At times, very hot or very cold applications bring relief. In some cases all ap- plications, no matter what their nature, aggravate the trouble. In these a hot air bath is often 'of benefit. HANDBOOK OF DERMATOLOGY. 221 PRURITUS. Syn.—Itching. This functional affection is characterized b}r one symptom— itching—which may vary in intensity and character. It may be general or local. Among the varieties of the former we have pruritus senilis, incident to middle or old age ; pruritus hiemalis, or winter itch, due to sudden falling of the temperature; and the itching depending upon gastro-intestinal and allied conditions. The local forms nxepruritus vulvcz, pruritus scroti, pruritus ani, etc. All forms are at times attended b3^ an intolerable itching, and serve to make the subjects of this disorder thoroughly miser- able. If the temperature of the affected part be suddenly raised or lowered an attack of itching supervenes. If the patient be in company the nervous excitement will cause an intolerable desire to scratch which becomes a torture if it cannot be indulged in. Uterine disorders, organic disease of the uterus and ovaries, renal and hepatic diseases, genito-urinary diseases, and certain drugs are causes of this distressing affection. Diabetes is a common cause of pruritus vulvae and scroti. It is easy to recognize the trouble if a careful examination be made to exclude parasites and other diseases attended by pruritus. The only objective lesions ever seen in this affection are the secondary ones caused by scratching—excoriations, torn follicles, blood-crusts, papules, pustules, hyperemia, thickened skin, pigmentation, etc. The treatment of this trouble depends for its success, in a great measure, upon the degree of relief which is afforded to the condition producing it, the local measures which are adopted being merely palliative. Externalty, water, hot or cold, or HANDBOOK OF DERMATOLOGY. alternately hot and cold, aids occasionally. Alkaline baths, sul- phur baths, and vapor baths prove of service at times. In the local forms of the disease lotions or ointments do some good. The best anti-pruritic is probably carbolic acid in the strength of a two to five per cent, aqueous solution. Thymol, menthol and alcohol have proven useful. The essence of pep- permint water gives good results occasionally, as also diluted nitric acid. Acetate of lead, morphine, chloral hydrate, cam- phor, sulphite of soda, dilute hydrocyanic acid, chloroform, di- lute water of ammonia alone or in combination, have all been lauded. Infusion of tobacco, decoctions of belladonna and aconite, diluted, are also said to possess efficacy. Tar combined with caustic potassa is frequently of benefit, as in the liquor picis alkalinus. The sol. antipruritic compound is of value in some cases. It sometimes happens that ointments act better, especially in localized forms^ of the disease. The majority of the remedies already mentioned may be combined in ointment form. Among the combinations which are effective are the following, applied twice daily: I£ Camphorae, Chloralis hydrat Ung. aquae rosae M. I£ Cocaini muriat _____...........................................[-)i. Lanolini puriss...........................................................................~}i. M. In many of the cases the previous application of pure crea- sote in full strength, twice a week, will be followed by excellent results. Iu pruritus vulvae it is well to order vaginal injections of chloro-phenique together with the external applications. Hot water alone followed by a bland ointment will secure relief in some cases, as also in some of pruritus ani. Ointments are the best in this latter. If hemorrhoids or fissures exist they should be looked after. Mercurial ointments occasionalty afford relief. As a rule, but temporary relief can be obtained from exter- nal applications and this is not constant. The number of reme- dies which has been suggested for the relief of pruritus is legion, showing how uncertain their action is. It is absolutely necessary that internal treatment should be conjoined to the local. The condition presented by the patient. aa, tyi. ...... .~»i. HANDBOOK OF DERMATOLOGY. 223 of course, is the best indication of the treatment which is neces- sary. Arsenauro, however, is always of use on account of its marked tonic effects upon the nervous system. It should be persisted in for a long period of time. 224 HANDBOOK OF DERMATOLOGY. ANESTHESIA. In this we have diminished or lost sensibility. It may be local or general, diffused or circumscribed. It may exist alone or be accompanied by other disturbances of the cutaneous nerves. It may be either idiopathic or symptomatic, the former being very rare. The latter is due to causes either central or peripheral. Diseases of the nervous system, functional or or- ganic are the most frequent causes. These are generally of such a serious nature as to engage the entire attention and their relief is followed by a disappearance of the cutaneous symptoms. Analgesia is due to the same causes, the symptom being a loss of sensibility to pain. PLATE XUII. FAVUS HANDBOOK OF DERMATOLOGY. 225 CLASS IX.—PARASITES. This class of diseases is one of the most important from the fact that nearly all the affections included in it are contagious. The lesions produced by the parasites are various in character and more or less intense in their effects upon the skin. Irrita- tion accompanies all, and itching is also a more or less prominent symptom. There are two classes of cutaneous parasites, vege- table and animal. Among the former we have two groups, the epiphytic, or those limited in their action to the surface of the integument; and the hypophytic, or those which penetrate into follicles. The animal parasites, likewise, either roam upon the surface or burrow into the epidermis. Although purely local in character, the parasitic diseases of the skin sometimes produce such extensive local disturbances as to affect the general system. This, however, is evanescent in character, giving way rapidly upon the removal of the cause of the local irritation. The prin- cipal vegetable parasites are the achorion Schoenleinii, the trich- ophyton and the microsporon furfur; the principal animal para- sites which infect the skin being the various pediculi and the sarcoptes scabiei. FAVUS. Syn.—Tinea Favosa, Honeycomb Ringworm, Porrigo Favosa, Crusted Ringworm. Favus attacks both the hairy and non-hairy portions of the integument. It is found most often upon the scalp of children. In those portions devoid of hair it presents the appearance of sulphur-yellow or dirty-looking scutulae or "cups" of a peculiar appearance (See Plate NLHI). The "cups" are concavo-con- 16 226 HANDBOOK OF DERMATOLOGY. vex a half line or more above the general surface and more or less discretely distributed. The convexity of the "cup" is that portion where it is attached to the skin. When occurring in a hairy part, such as the scalp, the "cup" has the same general ap- pearance except that one or more hairs pierce it in the center. These crusts are very friable, break down easily and, when this has occurred, the affected portion is apparently covered by an irregular crust, varying in size and extent. An odor resembling that of decayed straw or of a mouse's nest can be almost invaria- bly detected. The hairs become affected, by the invasion of the parasite, losing their lustre, becoming friable and splitting lon- gitudinally. The nails also become affected by contact and be- come opaque, yellowish, thickened and friable. Fig. 30. Achorion Schoenleinii. More or less itching is present and an amount of pain de- pending upon the intensity of the inflammation which is present. For, upon removing a "cup" it is found to rest upon a reddened inflamed base, and this is of such a severe nature at times as to lead to suppuration, the formation of abscesses and enlargement of neighboring lymphatic glands. When suppuration takes place on the scalp permanent alopecia is apt to result. Children, and especially those in poor circumstances, are most liable to this trouble, which is easily acquired from mice, cats and rabbits. HANDBOOK OF DERMATOLOGY. 227 The parasite causing this disease is the achorion Schoenlei- nii which consists of a large proportion of mycelium and some spores (conidia). There is no doubt, however, that several var- ieties of this parasite exist, as shown by the clinical features presented in different cases. Some act superficially and others invade the follicles, showing that the parasite is both epiphytic and hypophytic. Cultures of different varieties result differently and yet the microscope fails to give definite information in re- gard to this. The diagnosis is comparatively easy, especially if micro- scopic examination be made. If lice or an eczematous process be present, the diagnosis may be obscured, but careful examina- tion of a case will lead to the suspicion that favus is present. The treatment consists in the application of parasiticides. In the superficial form of favus but little difficulty will be experi- enced, whereas that form which invades the hair follicles often proves troublesome. To accomplish a cure requires much care and attention, and even then months may elapse before a patient can be safely discharged. As the details of treatment are very similar to those employed in ringworm, the reader is referred to that subject. Very old cases of favus may have produced such a drain upon the constitution of the patient as to necessitate a course of tonic treatment. In addition, it should never be forgotten that cleanliness is an essential to a successful issue, as well as the removal of the crusts by means of bland oils or poultices carefully applied before any curative measures are attempted. 22S HANDBOOK OF DERMATOLOGY. TINEA TRICOPHYTINA. Syn. —Ringworm. This disease, commonly known as ringworm, attacks the hairy and non-hairy portions of the body. Three principal varieties are observed, viz: tinea corporis, tinea capitis and tinea barbae. TINEA CORPORIS. Syn.—Tinea Circinata, Herpes Circinatus, Ringworm of the Body. This form of tinea is more or less multiform, being macular, vesicular, papular, or squamous, but rarely pustular in form. The outlines of the lesions are more or less distinctly circular. The color is reddish with a tendency to pale at the center and to desquamate at the periphery. Moderate itching accompanies the process, and, in time, distinct annular lesions develope, which gradually enlarge peripherally. The lesions are usually slightly elevated above the general surface. The erythematous form is the one most frequently observed. The vesicular form is occa- sionally seen, the vesicles soon drying up and forming scales. The papular and pustular, epecially, are seldom observed. Tinea corporis is contagious to quite a marked degree, as are all the forms of ringworm. Tinea cruris, or eczema marginatum, is a variety observed on the inner portions of the thighs and encroaching upon the scrotum. It also occurs in the axilla, where it is known as tinea axillaris. Its borders are sharply defined against the normal skin, and more or less exudation accompanies the condition. The HANDBOOK OF DERMATOLOGY. 229 central portions clear up and the periphery is frequently studded with papules. The itching in this form is marked, and the dis- ease obstinate, probably because an eczematous process is an accompaniment. The scrotum sometimes participates in the process, and becomes moist and angry-looking. Care should always be taken to establish a diagnosis. Tinea unguium or onychomycosis, is the term employed to designate this affection when it attacks the nails, which then become opaque, brittle and friable, as well as yellowish in color. Some of the rarer forms of skin disease produced by a sim- ilar, if not identical parasite, are Tokelau ringworm, Burmese ring-worm, Malabar itch, etc., the clinical symptoms being ex- aggerated . Tokelau ringworm, or tinea imbricata, is clinically recog- nized by the fact that it rather affects the non-hairy parts and consists of a number of concentric rings about one-eighth of an inch apart, which consist of scales, the free edges of which point to the center of the lesion. The whole body may be implicated. When the scales leave there remains a fawn-colored macule. 230 HANDBOOK OF DERMATOLOGY. TINEA CAPITIS. Syn.—Tinea Tonsurans, Herpes Tonsurans, Porrigo Furfurans, Tinea Tondens, Ringworm of the Scalp. This constitutes that form in which the scalp is affected. In this there is noted the occurrence of one or more circumscribed patches upon which the hair is dry, brittle, broken off short, and suggestive of partial alopecia (See Plate XLIV). The scalp itself at the seat of the disease presents scaling, or crusting, or a vesicular eruption. There is marked itching present, the ten- dency being for the process to spread. When an attempt to ex- tract the hairs is made, they are apt to break off. Sometimes, exudation takes place, a more or less marked phlegmonous or suppurative process occurs and the formation of scars follows. The disease in this locality occurs most frequently in children and is highly contagious. It is also most rebellious to treatment, owing to the fact that the process is deep down in the hair folli - cles. Tinea kerion, or kerion Celsi, is sometimes observed to fol- low an active inflammation of a circumscribed portion of the scalp affected by ringworm. A tumor, reddish in color, forms, and from numerous distended follicles there exudes a thick, viscid fluid. It has a boggy appearance. It is rather uncom- mon, and is most often observed in neglected or improperly treated cases. Occasionally, however, artificial kerion is pro- duced for the relief of very obstinate forms of tinea capitis. PLATE XLIV- 'V\ C^ n * $ '*£h "•^ v \ ** «•* TINEA CAPITIS. HANDBOOK OF DERMATOLOGY. 231 TINEA BARBAE. Syn.—Tinea Sycosis, Sycosis Parasitica, Mentagra Parasitica, Sycosis Contagiosa, Barber's Itch. Tinea barbae is that form of ringworm which affects the beard. At first, small hyperemic, slightly desquamating patches are observed; but, in a short time, larger areas become involved, the skin is congested, papules and tubercles form and event- ually the tubercles break down and give exit to a mucoid, puri- form fluid, the parts being then extremely painful. The hairs ,become dry, brittle and break off easily. Theyr fall spontane- ously and are easily extracted. Crusting of a portion of the sur- face is not an unusual occurrence. In cases which have existed for some time subcutaneous abscesses form as also large pustules which are exceedingly painful. The lymphatics enlarge and the face and neck present an ugly, inflamed and lumpy appearance. The diagnosis of the various forms of ringworm is a com- paratively easy matter, providing that the presence of the para- site be suspected. Ringworm of the body may be confounded with some forms of eczema, psoriasis, seborrhea, syphilis, lupus erythematosus, and herpes iris. It is an epiphytic trouble and the fungus may be found on and between the scales of the horny layer of the epidermis. It consists of mycelium and spores, the latter being arranged in chaplets. In the early stage of the dis- ease spores alone may be present. The mycelium is long ten- uous and has numerous branches. Tinea capitis is easily recognized when typical. It might be confounded with alopecia areata, but this is hardly probable; for, in ringworm the apparently bald spot is studded with the stumps of broken off hairs which can be extracted if a little care. be taken. Both diseases, however, sometimes coexist, and 232 HANDBOOK OF DERMATOLOGY. ringworn of the scalp is also complicated by eczema in some cases. The fungus here is hypophytic. It penetrates into the mucous layer of the skin, and even the corium. It invades the hair follicles and the hair bulb. In these cases, the bulbs are full of spores, the shaft is split longitudinally, and conidia exist for quite a distance above the level of the scalp. The mycelia are sparsely distributed. Tinea barbae can only be confounded with sycosis or eczema of the same region. The fungus produces perifolliculitis invad- ing the follicle and the hair. It is also hypophytic here and the Fig. 31.—Tricophyton. process is similar to that occurring upon the scalp. The bulb of the hair, however, is usually much enlarged by the mass of in- filtrated spores, and, for this reason, the hair is extracted with more difficulty. The treatment of these various forms has a three-fold object in view. 1° The prevention of the dissemination of the disease; 2° the limitation of auto - infection; and 3° the destruction of the parasite. The third is always paramount in importance, as it includes the other two. In tinea corporis we have a comparatively simple matter to deal with. The condition is one easily amenable to treatment. The number of remedies which have been used for this purpose HANDBOOK OF DERMATOLOGY. 232 is very large. Thus, after washing with sapo viridis, apply am- moniated mercury ointment, one-half to one drachm to the ounce. Nitrate of mercury ointment one to two drachms to the ounce, or yellow sulphate of mercury fifteen to thirty grains to the ounce are also efficacious. A method which is excellent is the application of corrosive sublimate two grains to the ounce of compound tincture of benzoin once daily. Two or three appli- cations will suffice. Among the remedies employed are: sul- phurous acid, hyposulphite of soda, tincture of iodine, acetic acid, boracic acid, campho-phenique, Wilkinson's ointment, etc. The choice of a remedy depends very much upon the amount of surface involved, and the ease with which it may be obtained. The treatment of tinea capitis is a more complicated affair. As the parasite penetrates more deeply it is a much more diffi- cult matter to reach it with parasiticides. In the first place, all crusts and scales should be removed. Then epilation may be practiced. This may be done by extracting the hairs by means of epilating forceps, care being taken to go a small distance be- yond the diseased area, or a quicker method (and one also much more painful) is to employ Bulkley's adhesive sticks, which are melted and made to adhere to several hairs at a time. These are then torn out. The hairs having been extracted it becomes necessary to make some application, and such as have already been mentioned under the treatment of tinea corporis may be emplo3^ed. Another method, practiced by some, is to produce an arti- ficial kerion, by means of croton oil, which brings about supur- ation in the hair follicles, and thus destroys the parasites. Sticks made of two parts of the oil and one each of cocoa butter and white wax are used for this purpose. A solution of salicylic acid is applied after each treatment and poultices may be needed. A method lately introduced is that by means of a galvanic current, and known as cataphoresis. The negative pole, sat- urated in a 1-1000 solution of corrosive sublimate, is applied to the affected part, the positive pole being at some indifferent site. The liquid penetrates the skin and attacks the parasite in situ. One of the recent methods devised for the treatment of various tineas of the head is as follows: All crusts are removed, the hair cut as short as possible, and then a pasteboard cylinder which fits the head closely is put on the patient. This cylinder has wires passing through, some inches above the vertex, so as to form a support upon which a small dish containing sulphur is 2:i4 HANDBOOK OF DERMATOLOGY. placed. The sulphur is ignited, a cover which fits tightly is placed on the cylinder. The sulphur soon ceases burning on account of the lack of air, but enough sulphurous anhydride has been formed to destroy a portion of the fungus. This operation is repeated twice daily, and cures are said to be effected in three or four weeks. A remedy which has been highly extolled in the treatment of tinea capitis is chrysarobin, which should be rubbed in once daily. The best formula for this purpose is this: R* Chrysarobini Lanolini........ M. The large number of methods devised for the treatment of this affection shows its obstinacy and the most expert often fail to procure any relief. In such cases the disease finally cures spontaneously, after a number of years, and often without any consequent alopecia. The treatment of tinea barbae is similar to that of tinea capi - tis. Epilation should be practiced on alternate days. On the other days the beard should be shaved. Parasiticides are to be employed. If pustules or small subcutaneous abscesses form, they should be promptly opened and treated with antiseptics to prevent the re-formation of pus. Like the disease affecting the hairy scalp, this form is frequently intractable and it requires much patience to arrive at a satisfactory result. Favus and ringworm are diseases, which require much at- tention not only in treatment, but in prophylaxis. As the dis- eases are highly contagious, much care should be taken to avoid dissemination of the parasite. WThen children, the subjects of this disease, attend school or are inmates of asylums or other in- stitutions in which a large number of individuals come in contact with each other, they should be segregated. This is a necessity which has been demonstrated by the rapidity with which an epidemic springs up and the great difficulty of stamping it out. All the clothing, toilet articles, towels, etc., used by one affected with a vegetable parasitic disease should be reserved for him alone and no one else permitted to employ them. Another precaution to observe is the avoidance of all mois- ture to the parts affected. It is a noted fact that all these fungi thrive upon moisture, and if this be furnished, results of a satis- factory nature will be considerably retarded, besides giving the fungus a better opportunity for further dissemination. HANDBOOK OF DERMATOLOGY. CHROMOPHYTOSIS. Syn.—Tinea Versicolor, Chloasma, Pityriasis Versicolor. This vegetable parasitic disease is eminently epiplrytic. It appears as brownish macules, irregular in shape and size and distributed, for the most part, over the chest and back. There is present a furfuraceous desquamation, the itching being slight. Upon rubbing one of these macules it will be observed that the upper layers of the epidermis roll up and fall off. It is generally seen in adults and it occasions but slight discomfort. It spreads with greater or less rapidity and seldom invades the limbs, al- though the groins and axillae are often affected. It seems to be most abundant in those localities in which the perspiration is free. It is due to the microsporon furfur, alow vegetable organism with weak contagious properties. It presents the appearance of slender, short myeelia, which are abundant and cross each other in all directions. In addition there are masses of spores occur- ring in groups with, here and there, single ones scattered and occuring at the tips of the myeelia. The diagnosis is sometimes difficult to make from vitiligo, from the objective symptoms solely. It also resembles chloasma, closely, at times. Microscopic examination, however, will clear up any doubts which may exist. The treatment is simple in principle, although not always successful in practice, as the disease is often most intractable. Moreover, unless the applications be made thoroughly, the fungus will grow anew. On this account the disease must be closely watched during treatment. Among some of the agents which are successful in the treatment of this affection we have mercu- rials, such as corrosive sublimate lotions two or three grains to 23(5 HANDBOOK OF DERMATOLOGY. to the ounce, saturated solution of boric acid, sulphurous acid, hyposulphite of soda, the red oxide of mercury in ointment, oleate of mercury diluted, campho-phenique once daily to the dry skin, or the following: I£ Acid salicylic................................................................... ,~)SS. Sulfuris loti............................................................................5JSS- Lanolini, Yaselini..................................................................................aa, ,")]■ M. Sig. Apply at night and wash off the next morning. Fig. 32. Microsporon Furfur. Benzine is occasionally of use, although much reliance can- not be placed upon it. Chrysarobin ointment varying inversely in strength to the amount of surface to be covered is excellent. If the scales be abundant, they are best removed by means of sapo viridis or its tincture, before the applications are made. The greatest care must be taken in making the applications thorough, for this disease is most prone to relapses. For this reason, it is also necessary to prolong a course of treatment even after an apparent cure has declared itself. HANDBOOK OF DERMATOLOGY. 237 ERYTHRASMA. This is a rather rare disease, which manifests itself in those portions of the integument which are opposed to each other, such as the axilla, the internatal cleft, etc. It shows itself in the form of dark-red or brownish macules. It is slow in spreading, and has a tendency to become chronic. It is caused by the micro- sporon minutissimuni. The treatment to be pursued is essentially the same as that employed for chromophytosis. Mycosis Vaginalis is due to either leptothrix vaginalis or oidium albicans, and is characterized by pruritus. A weak solu- tion of sulphate of copper cures the disease. 238 HANDBOOK OF DERMATOLOGY. SCABIES. Syn—The Itch. The eruption caused by this parasite is beyond doubt the most serious of all the animal parasitic dermatoses. Whilst lim- ited in its area at its inception, it spreads very rapidly, chiefly through the efforts at scratching by the patient. The typical lesion which is characteristic of the presence of the parasite is a vesicle which is the abiding place of the female, which burrows under the horny layer of the epidermis, whereas the male limits his movements to the surface in search of the female. After fecundation, the female immediately tunnels underneath the upper layer of the skin for the purpose of depositing her ova, which mature as she pursues her way, so that by the time the eggs are laid the first one has already released its tenant. These furrows have the appearance of a small piece of black thread drawn under the skin, the dark appearance being caused by the deposits of excrement made by the female. Such a cuniculus is easily opened, and byr the use of a proper magnifying glass the ova may be distinctly made out. The burrowing will easily explain the intense itching of the trouble, as well as account for the fact that the flexures of joints, and those portions of the in- tegument which are thinnest, are chosen for the purpose of lay- ing eggs. Add to this the fact that contagion is the method of acquiring the trouble, no difficulty will be experienced in remem- bering the fact that the skin between the fingers and the flexures of the wrists is that which is generally affected (See Plate XLV). The extension of the trouble is easy, and secondary lesions soon appear after the establishment of the trouble. The vesicles are torn open, the parasite released, the floor of the vesicle is torn as well as the cuniculus, pustules form, papules develope as a HANDBOOK OF DERMATOLOGY. 23& result of the lesion, crusts form here and there, and we have finally presented the picture of an inflammatory, polymorphous eruption of an exudative nature, in which the attacks of itching are irregular and intense. So far as the distibution of the lesions is concerned, one general rule may be formulated. The older the affection, the greater the dissemination. After it is once well established, the eruption is most marked in those portions which are most accessible to the scratching fingers. One of the most common accessory causes in the perpetuation of the trouble is filth. An unclean body necessitates scratching to loosen the accumulated epidermal scales, and thus indirectly aids in the further dissemination of the parasites. Filthy underwear forms a permanent depot for the sarcoptes to lodge in, besides acting as a preventive to the thorough action of any remedial measures which may be undertaken. Fortunately, the better conditions which prevail in this country have done much to lessen the num- ber of cases, which, to the uninitiated, is truly appalling in the large continental cities. Yet during the late civil war in the United States, scabies was one of the curses with which both armies was afflicted. A peculiarity of scabies is that it does not affect the face or head. The parasite which causes the disease is known as the sar- coptes scabiei. It was formerly called the acarus scabiei, from the fact that it belongs to the order acarina, family acaridae, class arachnoidal It is a minute roundish animalcule barely visible to the naked eye, being equal in surface to the cross sec- tion of a small pin and pale yellowish in color. The female is much larger than the male, varying in length from 7" to t1" and in breadth from t1" to «"' . The form is somewhat ovalish, the head being closely set to the body and also oval in form (See Plate XLVII). There are no eyes. The thorax is provided with four short, jointed legs, terminating in suckers and bris- tles. The abdomen is likewise provided with similar legs of equal number. In the female the abdominal legs terminate in bristles, whereas in the male the last pair is also provided with suckers, the other two terminating in bristles. In the male we observe the external genital organ very plainly, whereas in the female there is a cleft visible at the abdominal extremity. When viewed upon its ventral surface there may be distinguished a number of cross striations which are undulating, and here and there small spinous processes from which bristles emerge. The head is provided with strong mandibles, and six hairs project from it The habitat of the female is in the skin. As soon as it finds itself upon the integument, it begins burrowing to form 240 HANDBOOK OF DERMATOLOGY. a cuniculus wherein to lay its eggs. The male roams about on the surface looking for females to fecundate. The young are very hardy and develope very rapidly, the period of incubation varying from eight to ten days. With a little care the female sarcoptes can be extracted, as well as the young in various stages. The male is more difficult to obtain, yet a little patient research will generally be rewarded by obtaining a specimen. The treatment of scabies consists essentially in the destruc- tion of the parasite which is the exciting cause of the trouble. A large number of methods have been successfully used to accom- plish this purpose, and in each instance the thoroughness of ap- plication is the most essential part. From time immemorial the specific for scabies has been sulphur, and it has served a good purpose when properly applied. I do not propose to give all the methods employed, but will merely enumerate a few which are efficient. In Paris, where an enormous number of patients are treated daily at the Hopital St. Louis, the patients are given a hot bath with frictions of black soap (savon noir) and well scrubbed. Then Wilkinson's ointment is well rubbed in, and the clothing which has previously been subjected to an intense heat in an oven, is resumed. One such treatment is sufficient. In Vienna the treatment is analogous. It is essential, however, that the ointment be well rubbed in. Another method consists in scrubbing the skin well with soap (sapo viridis) and water, and then rubbing in a sulphur ointment containing a drachm of the precipitated sulphur to the ounce of fresh lard. A method which is cleaner, and which I have successfully employed, is this: The patient takes a hot bath with some alkaline soap, in the morning, putting on a complete change of clothes. He then applies in the interval, i. e., before assuming the change of clothing, and after thoroughly drying the skin, the following: 1$. Sodii hyphosulphit Aquae destillat........ M. After being applied it is permitted to dry on the skin, then the clothing is put on. In the evening before retiring the following is applied: Y%. Acid, hydrochlorici dil Aquas destillat............... M. If it be too severe the acid may be further diluted so as not to prove too painful. Sviij. Sviij. r>vj. ?iv. PLATE XLVII. ' '*\ ^:y, •., V'-' i ■ i t .» A « .-1 .<• ,': ill.» , •• Sarcoptes Scabiei. Pediculus Capitis. HANDBOOK OF DERMATOLOGY. 241 The effect of this treatment is marked, and it possesses sev- eral advantages over other methods. It is cleanly, in the first place. It is easy of application, and it ensures a precipitation of sulphur in an exceedingly divided state in every small fissure which may exist, thus making it as thorough as it is possible to do so. The process should be repeated daily for three or four days, not omitting the change of underwear and clothing. The clothes temporarily cast off should be subjected to a dry heat sufficiently intense to kill any lurking parasites, and yet not so high as to scorch the material. A little carefulness exercised in this matter will result in a satisfactory result, and no unneces- sary expense will be incurred by the destruction of clothing. The point to be observed, however, is that whatever method be adopted, make the applications thorough, and further eliminate all possible cause of infection. 17 242 HANDBOOK OF DERMATOLOGY. PEDICULOSIS. Syn.—Phthiriasis, Lousiness, Pedicularis, Malis Pediculi. Pediculosis is an affection found chiefly in individuals who are living in circumstances which engender filth, carelessness, and overcrowding. The parasites are prone to roam about, and easily change their host. Unlike the acarus scabiei, they are epizoic. They live upon the surface of the integument and de- posit their ova upon the hairs or in the clothing. Three princi- pal varietes are recognized, viz: pediculosis capitis, pediculosis corporis, and pediculosis pubis. PEDICULOSIS CAPITIS. Pediculosis or phthiriasis capitis is an affection which, whilst not common in this country, is seen sufficiently often to attract more than passing attention. In Europe it is much more fre- quent in occurrence, and there, as here, it is among the poorer classes, and those who are strangers to cleanliness, that it is more frequently observed. A little care in making an examina- tion will enable a diagnosis to be easily reached by the fact that the parasite is easily seen, as well as its ova. In a mild case of the trouble the patient complains of itching in the scalp, and this sensation is not confined to any one point, but seems to be changing its location continually, occasionally occurring in sev- eral points at one and the same time. Scratching of a mild char- acter momentarily relieves the pruritus. The hairy scalp alone is affected, the parasites confining themselves to this area. To find the little pests it is necessary to part the hair, as they limit their roamings to the integumentary surface, as a general thing. Upon the hairs will be found "nits," or ova, tightly glued to the PLATE XLVI. ■IPS ......... |K$^** V. * \ ^ \ - .: -mr.rf" • PORRIGO E PEDICULIS, HANDBOOK OF DERMATOLOGY. 243 shaft, and presenting the appearance of minute white bodies, or apparent nodes. Should the condition have existed some time, the multiplication of the pediculi has been so great, and the con- sequent irritation so marked, that scratching is more severe, and as a natural consequence, a dermatitis more or less seveie in character is set up. Papules, pustules, crusts and excoriations exist in various proportions, accompanied by a glairy exudation, which tends to mat the hair. Fermentative changes set in, and are attended by a disagreeable fetid odor of a more or less sour smell. Add to this the accumulation of extraneous matter, and the condition of extreme filth which is presented can be better imagined than described. As a result of scratching low down on the occiput, we have the pruritus extended some distance down the neck, and the efforts made to relieve this produce ex- coriations and crusts of a dirty color, the condition being known as porrigo e pediculis (See Plate XLVI). The site of predilec- tion of pediculi capitis is the occiput, the vertex, the temples also being favored spots. Whilst more frequently observed in those having long hair, it is also often observed in those who keep their hair trimmed short. It is seen at all ages, and may be easily acquired by those of cleanly habits who may come in contact with the persons, clothing or bedding of patients having pediculosis. Street cars, railway carriages, cabs, and other conveyances are a frequent source of contamination. The pediculus capitis or head louse is grayish in color, of an elongated ovalish form. The female is somewhat larger than the male, the sizes varying from f" to li1" in length and about one-half of this in breadth. The head is somewhat acorn -shaped, provided with distinct eyes and five-jointed antennae (See Plate XLVII). The legs, which are attached to the thorax, are pro- vided with four joints exclusive of the claw, with which each one terminates. The legs and body are provided with hairs, which are quite distinct. Strong mandibles exist, and enable the parasite to traverse through the stratum corneum of the skin down to the rete malpighii from which it can derive its suste- nance in the form of blood. The habitat of the pediculus capitis is on the scalp; the female, however, being frequently found upon the hairs where it goes to deposit its ova for incubation. The ovum or "nit" is a whitish, oval or pyriform body about i1" in length, and is distinctly visible. It is attached to the hair by a peculiar glutinous substance. One or more ova may be attached to the same hair. The incubation period varies from six days to a week, and the females are very prolific, being al- most continually occupied in laying eggs. It may be readily 244 HANDBOOK OF DERMATOLOGY. seen how an enorniQiis multiplication of the parasite is possible in a comparatively short space of time. The treatment of pediculosis capitis must not only be cura- tive, but proplrylactic. In order to obtain a permanent release from the pests it is absolutely necessary to remove all causes of possible contagion. In order to insure this, individuals simi- larly affected should be avoided, and all head coverings sub- jected to a process which will effectually destroy the parasites and their ova. Combs and hair brushes' should likewise be thoroughly cleansed after each time they are employed, and no other individual should be permitted to use them any more than hats, caps, or similar articles of dress. In the case of males af- fected with pediculi of the head, the treatment is comparatively a simple matter, as the hair may be clipped very close, thus af- fording an opportunity of making applications more thoroughly. All ointments should be avoided, as they are disagreeable to use, whereas liquid preparations are more agreeable and cleanly. I have found one of the best remedies to employ for this pur- pose is campho-phenique, which not only kills the parasite and destroys the ova rapidly, but has the further effect of acting as a vulnerary on the secondary lesions which have been caused by scratching.' It may be used two or three times daily on the dry scalp. In the case of females with long hair we have a more complicated condition of affairs to deal with. The hairs are fre- quently full of ova, and these must be eliminated pari passu with the destruction of'the pediculi. For this purpose a thorough shampoo with sapo viridis is unexcelled, as it dissolves the nits and cleanses the hair. When the hair and the Scalp have been thoroughly' dried the same remedy as mentioned above may be used. A preparation which has met with success in Russia, not only in pediculosis, but scabies as well, is the thorough use of benzine. Its disagreeable odor, however, will always limit its use. The remedies which have been successfully used in pe- diculosis are numerous, and all have been highly lauded.' A solution of bichloride of mercury varying in strength from 1 to 1000 to 1 to 5000 is well spoken of, also an infusion of staphi- sagria thoroughly applied. The use of coal-oil is popular with the lower classes, but is often followed by a marked dermatitis frequently of an eczematous character. Solution of creolin, of the strength of eight per cent, is claimed to be efficient. A six per cent, solution of carbolic acid is an effective lotion in pedicu- losis, but it generally permits the ova^to hatch, and a new crop of parasites to appear. The principal point to observe, no mat- ter what measures be adopted, is that the treatment be thorough, HANDBOOK OF DERMATOLOGY. 245 and this implies not only the application of the remedy to the affected parts so as to reach every point, but also a frequency sufficient to accomplish the purpose completely, and not such as will permit of relapses through the hatching of the undestroyed ova. 24G HANDBOOK OF DERMATOLOGY, PEDICULOSIS CORPORIS. Pediculosis corporis is an affection which is produced by the pediculus corporis sen vestimenti. It is common enough to be seen under circumstances in which masses of individuals con- gregate, and have no opportunities or inclinations to keep them- selves clean. Soldiers who are any length of time in camp, laborers who live in camps, several occupying one tent, the dwellers of tenement houses of the lower class, and similar indi- viduals seem to be infested with the body louse. As a rule, it is adults who are most subject to the trouble, and men more fre- quently than women. The itching which is present is intolera- ble, and is most severe about the shoulders and sides of the body, although the limbs and trunk are often the seat of pruritus. The head is never attacked, and this will be immediately explained when we consider that the habitat of the pediculis corporis is the clothing and not the integument. The lesions presented upon the body are almost pathognomic of the trouble, and, when found, should always lead to a careful examination of the clothing worn next to the skin. The objective phenomena which are seen con- sist of secondary lesions, and these are, for the most part, exco- riations of a marked character, four to six inches in length, and several in number parallel to each other. They are the result of scratching, and to be found in those portions most accessible to the hands, viz : the scapular regions, the flanks, the buttocks, the outer surfaces of the thighs, etc. The scratching, at times, is so severe as to produce bleeding and consequent crusts. If the trouble be superficial, ulcers will form. The underwear will stick to the denuded patches, and its removal will lead to fresh bleed- ings accompanied hy pain. When a case has progressed thus far the arms will share in the general involvement, and the spectacle presented by a patient thus affected is that of a most miserable being. HANDBOOK OF DERMATOLOGY. 247 Among the modifications observed in the subjective symp- toms occurring in pediculosis corporis is the presence of short and jagged scratch marks, due to digging of the nails into the integu- ment. Another condition is seen which should not be hastily misjudged. This consists of pigmentation of a light or dark brown color, at first disseminated in macules of varying size. In cases of long standing it may become diffuse and involve the entire integument which has been subjected to the depredation of the parasite. The pediculus corporis is the largest of the pediculi. It some - times attains comparatively enormous proportions and is quite voracious, abstracting the blood of its host quite freely, and in amounts that are comparatively large. It is stoutly built, the female being considerably larger than the male. It varies in size from*1" to-'" in length, being about one-third as broad. In color it is a dirty-gray which has a reddish tinge after it has abstracted blood. The female is much broader at the abdomen on account of the ova which it must contain. It may be distinguished from the male by the notch which exists at the distal end of the abdomen (See Plate XLVII I). This parasite is provided with three strong four-jointed legs, having claws at their extremities and provided with hairs. The abdomen has seven well-defined notches on each side. The head is large and somewhat acorn-shaped, the eyes being quite prominent. The antennae, which are strong, are five- jointed, and very mobile. The mandibles are unusually powerful, and easily cut the integument of the host. As mentioned above, the parasites live in the seams of the clothing and it is here that the female deposits her ova, which hatch in five or six days. It is said that in eighteen days they will reproduce. When the parasite desires food it will roam on the skin, and it is on this account that very few are ever found outside the clothing. The treatment of this condition is very simple in principle, but it is not such an easy matter to carry out in actual practice. It is to be divided into two parts—the treatment of the patient and that of his clothing. A good bath and destruction of the clothing is certainly not difficult to order, but it cannot be carried out in many instances. What can be done, however, and if it be done thoroughly it will result in success, is to adapt the means to be used to the conditions presented. The treatment of the patient should consist in the application of campho-phenique to the entire affected surface. This remedy kills whatever parasites may be lurking on the skin, and it acts as an antiseptic and vul- nerary, promoting a rapid healing of the dermatitis which has been excited bv the scratching. Washing thoroughly with a slightly 248 HANDBOOK OF DERMATOLOGY. alkaline soap and then apptying a 1 to 1000 solution of bichloride of mercury is also a good plan. No method, however, will be effective unless uninfected clothing be assumed after its use. If, as it often happens, the patient has no change of clothing, the parasites must be picked out of the garments and killed, a matter which is easy, as they are found with but little trouble. To insure the destruction of the ova it is absolutely necessary to subject the clothing to a high degree of heat. It is better after this to soak it in a fairly strong alkaline solution and boil it, and then thoroughly wash it. Such a course will rid the patient of these parasites; but, unless he avoids those persons and locali- ties where body lice flourish, he will acquire them again. They may be picked up occasionally, as in the case of head lice, in public conveyances, sleeping cars, unclean hotels; or, in fact, wherever perfect cleanliness does not reign, and where all sorts and conditions of individuals may congregate, or occupy furni- ture which will be occupied by others. PLATE XLVIII. - -.V'"'"'■- ''tl •'■-*■ «%*, ' Pediculis Corporis. Pediculus Pubis. HANDBOOK OF DERMATOLOGY. 249 PEDICULOSIS PUBIS. Pediculosis pubis is an affection much more commonly en- countered in males than in females. It manifests itself by an intense itching about the mons veneris, which scratching does not seem to allay by any means. Beginning with fugitive sensa- tions of pruritus, the symptoms after some time become incessant and well nigh intolerable. Should the symptoms be permitted to go on untreated for a protracted length of time the itching ceases entirely or almost so, although the parasite will continue increas- ing its numbers. It is not entirely limited to the pubic region. It may occur wherever there are coarse or stout hairs and it may affect individuals at all ages, from infancy to old age. It is not infrequently found about the hairs of the legs, if these be at all coarser than the ordinary lanugo hairs. The hair of the chest and of the axillae also afford a convenient nidus for the parasite. The beard is occasionally seen to harbor it as well as the eye- brows and eyelashes. But here it stops. The scalp in never affected*, as the hair of the head is doubtless too fine to afford the grasp which doubtless the parasite needs. So far as second- ary symptoms are concerned we find little if any occurring except in the axillae or eyelids. In the former excoriations and poly- morphous eruptions occur; whereas, in the latter, a condition resembling tinea tarsi is developed as a result of the rubbing oc- casioned by irritation. Bluish macules are sometimes seen upon the anterior and upper portions of the thighs, due to the bites of the pediculi. These laches bleuatres, as they have been denomi- nated, are pathognomic of pediculi pubis and are supposed to be due to a fluid ejected by the parasites when they prepare to ex- * In Nov., 18'JL', Rona presented a known exception in the case of a boy of 14 who presented pediculi and their ova on the head. neck, eyebrows and eyelashes. The mi- grations of all the forms of pediculi have been mentioned by several authors, but they- are the exception rather than the rule. 250 HANDBOOK OF DERMATOLOGY. ercise their depleting power. The macules disappear spontane- ously and seem to occasion no subjective symptoms whatever in the patient beyond more or less fright at their apparently sudden appearance. The pediculus or phthirius pubis*, or as it is commonly known, the "crab-louse," is of a light grayish color, almost translucent at times. Size of the pediculi vary from i1" to l111. The thorax is almost imperceptible, the form depending more upon that of the abdomen, which has been very aptly denomi- nated shield-shaped. It is provided with small eyes which show up quite distinctly (See Plates XLVIII and XL.IX). The an- tennae are rather long and five-jointed. There exist six four- jointed legs, the two last of which are provided with large, strong claws bearing a close resemblance to those of the lobster. These claws are so muscular, that in efforts to dislodge the parasite from a hair the hair itself is frequently pulled out. In addition to the legs which have been described, there exist eight teat-like pro- jections in the sides of the abdomen, these being prehensile feet provided each with four to ten hairs. The female, as is usual in this family of parasites, has a notch at the extremity of the ab- domen. Reproduction is very rapid, the ova being hatched out in six to eight days. The ova are goblet-shaped and so strongly attached to the hairs, that after hatching the shells will remain in situ. These are more or less translucent and exist along the shaft of the hair in varying numbers. The difficulty of dislodg- ing them is frequently a cause of relapses so frequently seen in the affection. The grown specimens are unusually voracious in their habits and endowed with more than ordinary vitality. They lie flat against the skin with great tenacity, by means of the four pairs of short feet with which they are provided, and being very pale in color they frequently escape detection and must be liter- ally scraped off in order to be distinctly seen. When in search of food they range about, most generally through the medium of hairs, although the clothing also acts as a carrier and transports them quite some distance from their original habitat. Occasion- ally ova are directly transplanted to new quarters by means of the finger-nails. The treatment of pediculosis pubis is not always as easy as some would have us fondly imagine. When the trouble is con- fined to the pubic region it is not difficult to obtain a successful result; but when it has been disseminated overbroad areas it re- * Among the names applied to this parasite may be mentioned phthirius inguinalis, phthirius pubis, and morpio. PLATE XLIX. Pediculus Pubis, emerging from Ovur HANDBOOK OF DERMATOLOGY. 2ol quires care and attention to completely eradicate the little pests. The best method of treating the condition when it affects the eye- brows and eyelashes is to remove the pediculi and their ova with fine forceps. It is not a difficult thing to do and is always radi- cal in its results. As they are never present in great numbers, very little time is required, and all that is necessary may be done in one short sit- ting. So far as other parts of the body are concerned, an}- one of a number of methods may be successfully employed. A method which is very popular, but which is not only filthy, but very fre- quently liable to bring on untoward effects, is the use of mercurial ointment. Other ointments are equally disagreeable to use, and should be discarded in view of the fact that more cleanly and agreeable methods are always at hand. Lotions are certainty more desirable, but thoroughness should be observed in their use, not only for each application, but for the length of time they are applied. They should be used twice a day for not less than eight days, as this will insure the destruction of whatever parasites which may have been hatched out during the interval, and will furthermore prevent the breeding of a new generation. An easily procurable lotion is a six per cent, aqueous solution of carbolic acid. One which is of value when no excoriations exist, is com- posed as follows: $. Hydrarg. bichlorid................................................... ...............gr. iv. Aceti aromatic.................................................................. ftyj- M. When excoriations or other secondar}^ lesions exist, however, it has been my custom to employ campho-phenique, as it is not only an efficient parasiticide, but it also acts beneficially as an antiseptic, procuring a rapid resolution of the artificial inflam- matory process, and is unaccompanied by any danger of produc- ing toxic symptoms. Moreover, it acts as an antipruritic, and thus fulfills the requirements of an ideal remedy in this condi- tion. 252 HANDBOOK OF DERMATOLOGY. PULEX IRRITANS. The cutaneous trouble occasioned by the pulex irritans, 01 common flea, is one which frequently gives rise to groundless fears and alarms. The lesions which appear as results of the bites of this parasite are erythematous in character, a number of them appearing like roseola and liable to be mistaken for measles. The lesions may be discrete and few in number, or there may be many of them distributed over comparatively a large area of the integument. At the time the flea bites there is a sharp stinging sensation, which gives way in a comparatively short space of time to burning and itching of a rather severe character. If the lesions be numerous, these subjective sensations are intensified in charac- ter, and the efforts made to subdue them will result in secondary lesions. The diagnosis is not a difficult one to make if the lesions be closely examined. No matter what secondary lesions are present, the primary macules will always exist here and there. Each one of these has a central punctum which is minute in size and darker in color, besides being generally elevated above the general surface of the macule. It is due to a hemorrhage and the small clot of blood can be distinctly made out with the help of a magnifying glass, and can be even removed with the point of a needle. This will serve to distinguish the eruption from the different forms of roseola. Whilst fleas are not essentially human parasites, they seem to have a fondness to adopt the human body for a host, and although not frequently seen in this country they are common enough in the rural districts of Europe, where dogs, cats, and human beings herd together in small, close, filthy quarters. The pulex irritans is quite familiar to all who have ever owned cats or dogs. It possesses a large abdomen, small thorax and roundish head provided with small eyes (See Plate XLIX). It is a light brown in color when mounted, but as found when PLATE L- Cimex Lectularius. Chicken Louse. HANDBOOK OF DERMATOLOGY. 253 living it is of a marked dark brown and venr glossy in appear- ance. It varies in length from &"' to li,l;,:. It has well marked five-jointed antennae, and is provided with six legs. These latter organs are peculiar in that the}' are three-jointed, the last joint, however, being terminated by a toe which has five joints and which itself terminates in two claws. This last toe and joint are well provided with bristles, located on the posterior surface. The last pair of legs are much longer and stronger than the two ante- rior pairs and they are very powerful and muscular, thus enabling the animal to leap and project itself through comparatively long distances. Again, we find that the three pairs of legs are much crowded anteriorly, but folding in such a manner that when the flea is at rest the abdomen is apparently held midway. The animal is quick of movement, not only when it is hopping, but also when it is running, which it does upon the slightest indica- tion of danger or disturbance. Its favorite roaming ground is close to the skin, in animals, where it is buried in the thick growth of fine hair. Here it is that it performs its depredations, prefer- ring those regions where the skin is thin, such as the flexures of the joints. When it attacks the human it generally seeks those regions which are covered by clothing and warm, and never attacks the scalp. The neck is frequently sought by them, in men, perhaps on account of the attraction furnished by the white color of the collar. The pulex irritans breeds very rapidly, and, so far as I have been able to determine, it deposits its eggs on the skin and they hatch out in about a week. The treatment of flea-bites is perhaps not so important as the adoption of prophylactic measures. For the former a num- ber of adequate applications may be used, and one of the best perhaps is an aqueous solution of some antipruritic, such as the sol. antiprurit. co. This should be applied several times in the day and a quick recovery will result. But it will scarcely prove efficient unless the skin is freed from the little pest which causes the trouble. To accomplish this the clothing should be care- fully removed and exposed to the air, and a carefulness exer- cised that the fleas will not leap into other articles of clothing. If there be pets about the house see to it that the cats and dogs are freed from parasites, and if they have been acquired from strange animals, avoid them in the future. To keep animals free from fleas is a most difficult matter, but the parasites may be killed by rubbing in well some pyrethrum powder, which de- stroys them and is not noxious to the host. Bathing dogs with carbolic soap will rid them of fleas if care be taken to submerge them completely so that the parasites will be carried off in the 254 HANDBOOK OF DERMATOLOGY. water. But I do not desire to enter into the subject beyond call- ing attention to the fact that many cases of flea-bites occur in patients in which the diagnosis must be made from the lesions, as the parasite has long since betaken itself to new fields and cannot be found. It is for this reason that great care should be taken not to mistake flea-bites for exanthematous troubles, and vice versa. HANDBOOK OF DERMATOLOGY. CIMEX LECTULARIUS. The cimex lectularius or "bed bug" is almost universally disseminated, and occasions lesions which give rise to consider- able alarm, and which are frequently wrongly interpreted, this being one of their peculiarities. The parasite occasions much discomfort by its bite, and it requires a certain amount of atten- tion to make a proper discrimination. The most severe lesions are found in those who have the most tender skins, and the sub- jective symptoms also vary in proportion to this factor. In in- fants and children, more especially, the lesions are apt to take on an inflammatory appearance, whereas in adults who have particularly resisting integuments scarcely any perceptible ob- jective symptom is to be seen. On the other hand, those whose skins are most susceptible are conscious of a sharp pain with a slight dull aching sensation following, the pruritus not being so severe as those whose epidermis is thick, and in whom the itch- ing occasioned by the bite of the parasite is intolerable. The particular lesion caused is a small circumscribed edema with a minute central punctum, which is hemorrhagic. The lesions are of the size of the small finger-nail or even smaller, and re- semble the wheals of urticaria with the exception of the outer erythematous zone. In the bite of the bedbug they are white, and furthermore are more persistent. In any case, the pruritus excited leads to the formation of secondary lesions brought on by the scratching. Any portion of the body may be the seat of the eruption, although as a general rule, the hands, wrists, feet, ankles and face are those most frequently involved, as they are the most accessible localities. It is no uncommon thing to be awakened out of a sound sleep by a pruritus of such an intense nature as to deprive the subject of rest, and a close inspection will reveal a cimex as the cause of the trouble. The constant subjection to the irritation nightly is very apt to bring on a train 256 HANDBOOK OF DERMATOLOGY. of nervous symptoms, and reflex excitability which may be in- correctly interpreted unless the true cause be discovered. The cimex lectularius, acanthia lectularia, or common bed- bug, is probably one of the best known animal parasites which attacks the human being. Its geographical distribution is almost universal, the varieties found in the tropics being much larger than those encountered in temperate zones. When fasting the cimex is flat, of a yellowish-red color, and varying in length from 1"' to 2"1 . When glutted with blood it has a distinct red color, and is appreciably enlarged by the blood which it contains. It is unusually tenacious of life, being able to exist for protracted periods of time without food.. When, it has an opportunity, however, it is gluttonous. It has a penetrating odor, disagreea- ble in the extreme, although compared to cinnamon by some. The parasite has a large abdomen, a small thorax and a diamond- shaped head, the eyes being fairly large and prominent; two antennae, which are four-jointed and very mobile, project ante- teriorly (See Plate L). There exist three pairs of legs, three- jointed in character, and terminating in a single claw. The body is provided with a number of bristles, none, however, being per- ceptible on the legs. The female proliferates not only frequently, but large broods are the result. The young, as soon as hatched, begin their depredations, and as they are often not larger than a very small pin's head, they frequently escape detection, although the odor reveals their presence. The habitat of the bedbug is in the cracks of the wood of bedsteads, in the bed-clothes, under wall paper, in old books, in fact, wherever a small chink or crack can afford them a hiding place. They are not infrequently found in the clothing, having wandered there from the cracks of clothes- presses or wardrobes. As a rule, the bedbug attacks his host when the latter is asleep, and the attacks of the parasite are always fierce. The irritation produced is not only caused by the direct wound inflicted, but by the injection of an acid fluid which is intended to prevent the coagulation of the blood as it is drawn. It is for this reason that micro-organisms are apt to be injected by the parasite into lymphatic spaces, and thus infection be produced without any very clear cause for it. The treatment for the cutaneous trouble caused by the cimex is usually a simple one so far as allaying the symptoms.is con- cerned. Dilute alkalies, vinegar, alcohol, whisky, etc., are the more commonly recognized domestic remedies. It is best, how- ever, to use a dilute solution of bichloride of mercury, as it will not only cause the disappearance of the symptoms, but will act as an antiseptic, and prevent any possible phlegmonous compli- HANDBOOK OF DERMATOLOGY. 257 cations. Campho-phenique will do the same thing, and possesses an added advantage in being an anesthetic. Treatment ma3r be deemed superfluous when one or two small lesions exist, but when an infant is affected from head to foot it becomes a matter of some moment, as the result of such an extensive cutaneous irritation may take on a serious character. It is also for this rea- son that care should be exercised not to mistake the trouble for irritation or some exanthem. The principal thing to do, how- ever, is to get rid of the "bugs." This is not such an easy matter as it might seem, as every housekeeper will testify to. To rid furniture of bedbugs is possibly yet a problem, for the females deposit their ova in minute cracks which are difficult to reach with parasiticides. Mercurial preparations are probably the best for this purpose, and yet they are fraught with some danger to those sleeping in the bed so treated. . Moreover, whilst the bed- stead may be clean, the seams of the mattresses will be found teeming with these pests, and a thorough and careful search for, and destruction of them, seems to be an almost hopeless and interminable piece of work. The only thorough method, per- haps, is to have everything new, and to live in quarters free of the cimex. i8 HANDBOOK OF DERMATOLOGY. DERMANYSSUS AVIUM. The eruption caused by this parasite is rarely, if ever, seen in cities, although it is not of unusual occurrence in the country. It produces an eruption most often upon the dorsum of the hands, about the wrists and forearms, although other portions of the body are liable to be attacked. The attack generally begins with itching, which is soon followed by an eruption more or less dif- fused, and which may be erythematous and papular, or mixed, vesicles and wheals making their appearance. It is seen in those who come in contact with domestic fowls, and the parasite is ordinarily derived from the chicken-house. The trouble is often very annoying, and aggravation is by no means uncommon from repeated exposure to the cause. Women and children suffer more severely from this cause than men on account of the greater delicacy of their skin. The peculiar localization of the eruption, together with its strict limitation, should immediately arouse suspicion, more especially when observed in those whose duties cause them to visit chicken-houses or aviaries. The dermanyssus avium, or chicken louse, as it is more com- monly known, is a familiar parasite to those who raise chickens, and it is an enemy whose destruction is constantly sought on account of its fatal effects on poultry. It is about l1" long and perhaps one-third as broad. It is rather pale in color. Its ab- domen is quite long in proportion to the entire body and its head is somewhat mushroom-shaped and provided with two rather small but distinct eyes (See Plate L). It has no antennae, but is provided with powerful mandibles. It has three pairs of three- jointed legs which, like the body, are not provided with bristles. This parasite is very prolific and voracious, attacking not only common fowl but pigeons and other domesticated birds, and ex- tending its depredations even to quadrupeds. It is chiefly found in the woodwork of houses, whence it issues at night to feast upon HANDBOOK OF DERMATOLOGY. 259 the sleeping fowl. A number, however, will remain on their host, and it is chiefly in the flexures of the joints and upon the neck that they are to be found. Young birds will not infrequently die of the exhaustion induced from the drain of blood, and the older ones become emaciated. The treatment of the eruption caused by the chicken louse is a very simple one, consisting of the application of a three per cent, solution of carbolic acid, which rapidly allays all the symp- toms. To prevent recurrences the infested chickens and their quarters should be avoided. If this avoidance cannot be effected, attention should then be turned to the fowl and their habitation. For the former the use of carbolized oil, pyrethrum powder or dilute oil of orris will effectually rid them of the parasites. The building in which they are kept can be rid of the parasites by washing with a solution of some strong alkali, such as common lye, and it is better, after this has been done, to thoroughly whitewash the structure within and without, having previously isolated the fowl and destroyed their parasites. Occasionally in the human the parasite will be found upon the skin, but it does not seem to thrive upon the integument of man and it quickly disappears. IXODES AMERICANUS. The lesions occasioned by this parasite are of the most acute character and may result quite seriously. The subjective sensa- tions are of a painful, burning nature, whilst the lesions are of an inflammatory character. When observed it will seem as if the parasite is imbedded in the skin, and surrounding the part in which it is buried there is a bright red areola with occasionally a small wheal. If the parasite is torn away a portion remains be- hind and a slight phlegmonous process results, generally leading to suppuration and final resolution. The genital regions seem to be particularly affected, although the lower limbs are also attacked to quite a considerable degree. The trunk and upper extremities are also subject to the depredations of this troublesome parasite. Males are more subject than females on account of their outdoor life and occupations. The ixodes Americanus (amblyoma Americanum) or wood- tick, as it is ordinarily known, is about the size of the cimex lec- tularius and has the same general form. It is red in color and has a rather small head and distinct, small eyes. The variety most commonly encountered has a white spot situated about the center of the back. It is provided-with three pairs of three-jointed legs 260 HANDBOOK OF DERMATOLOGY. provided with a single claw. The most prominent feature is the powerful suction apparatus which it possesses. This consists of three divergent, sharp, trunks, which are brought close together, driven into the skin, and then separated, thus giving a hold which will not relax. The efforts made to remove the tick result in tearing off the bod}^, and thus leaving the embedded portion to act as a foreign body on the skin. The tick does not limit its depredations to the human being, but attacks all quadrupeds upon whom it can secure a hold. It seems to be most plentiful in dead leaves, rotten wood, and vegetable matter undergoing dry decay. It is quite prolific, and individuals travel together in great numbers, so that it is not rare for several hundred to fasten themselves upon one host. So far as the treatment of the condition caused by this parasite is concerned, it is a very simple matter. To get rid of the parasites it is merely necessary to apply olive oil liberally wherever they are to be found. The action of the oil is two-fold—it causes the ticks to fall out and acts as a soothing remedy to the wounds they have produced. If they have already been torn off, a mixture of equal parts of olive oil and campho-phenique will act very satisfactorily, so will carbolized oil of a strength of about two per cent. As regards prophylaxis, it is well nigh impossible to attain. Oil of pennyroyal and other essential oils will not prevent ticks from attacking the skin. It may keep off a certain number, but individuals are so voracious that after a tramp through the woods they will be found and their locality will not be difficult to establish. The only prophylactic that is certain is to avoid the localities where they hold forth. LEPTUS. There are two species of the animal parasite. We have the leptus Americanus, or American harvest mite, which is quite common in this country. It attacks the integument of those only in whom it is tender, and for this reason women and children suffer most from its depredations. It attacks principally the scalp and axillae, although other parts of the body may suffer. The other species, the leptus irritans, ordinarily known as the mower's mite, is much more difficult to get rid of, for it attacks the ankles and legs, and buries itself deep in the integu- ment, causing a polymorphous dermatitis. The leptus Ameri- canus, on the other hand, merely insinuates the anterior portion of its body in the integument, after the fashion of the ixodes, and does not cause such serious symptoms. The same treatment as that for ixodes is indicated. HANDBOOK OF DERMATOLOGY. 261 CULEX PIPIENS. The culex pipiens, or mosquito, is a common parasite in tropical and sub-tropical countries, as well as in the temperate zones. It produces lesions which have a certain degree of im- portance on account of the errors to which they may lead. The insect, in its attempt to suck the blood of its host, produces minute erythematous macules of a bright red hue. Pain is at first felt and then a marked itching sets in. The exposed portions of the integument are affected, although there are some mosquitos which are able to penetrate ordinary under-garments. When infants are covered with mosquito bites the trouble may lead to a suspicion of measles. A careful search for the central hemor- rhagic punctum of each lesion will readily disclose the true cause. Alkalies, especially dilute ammonia, relieves the trouble promptly. It may not be uninteresting to note that the mosquito has been accused of disseminating yellow fever. PULEX PENETRANS. This animal is also known as the nigua, chigoe, chigger, jigger, rhynchoprion penetrans and other local names. It occurs in the tropics, where it is called the sand-flea, on account of its resemblance to the ordinary pulex. It produces marked inflam- matory changes culminating in abscesses, in many cases, whereas in others ulcers take place. The female, when about to lay her eggs, digs her proboscis in the skin, preferring that part under or near the toe-nails. The arms, scrotum, toes and feet are also parts which may suffer. The female is usualty not content with the insertion of the long proboscis, but also buries its head. The only method of treating the condition properly is to dig out the head with a blunt needle before any marked inflammatory symptoms declare themselves, and dress the part with some anti- septic oil. If ulcers, abscesses or gangrene have developed surgical measures should be adopted. FILARIA MEDINENSIS. Syn.—Dracunculus Medinensis, Guinea Worm, Dracontiasis. This is a nematode worm which is only found in tropical countries. It obtains entrance into the body in drinking water, and it soon begins its migrations. It gives rise to no particular symptoms until it is near the surface of the body. Then some pain and itching are experienced. The first manifestation of its presence is simultaneous with the subjective symptoms. A slight 262 HANDBOOK OF DERMATOLOGY. elevation may be felt and it gives the sensation of a roll or bun- dle of string. After this a vesicle appears of the size of a pin's head, which may become as large as a bean. This bursts and the head of the worm can be seen. This parasite is about a half line in diameter and of variable length, up to three feet or more. A favorite locality for it to show itself is the ankle. Usually there is but one. Much care must be taken to extract it. It should be seized by the head and gently drawn out. The por- tion so drawn is rolled around a stick or roll of adhesive plaster, and a little more is rolled on this day by day until the entire worm has been taken out. Assafetida is highly lauded in this trouble. CESTRUS. Syn.—Gadbreeze, Bot-Fly. In this species the larvae is the part which produces all the trouble. It is principally in Central and South America that cases are observed. The larvae are deposited in the integument, and work their way in a more or less direct line, which suggests lymphangitis, but differs from it in being purplish in color, More or less pain is produced during the process. After a cer- tain length of time suppuration of the skin takes place at a point— the distal one of the track—and the larvae emerge. The treat- ment is to inject carbolic acid in the sinus produced. DEMODEX FOLLICULORUM. Syn.—Steatozoon, Entozoon, or Eimouea FoUi- culorum, Acarus FoUiculorum. g g This acarus is a very common one found in ,2 sebaceous glands, and in man it is entirely inuocu- .y ous, although in the dog it produces very serious ^ general disturbance. There is no doubt that it is ^ derived from the external world, as the head is JsS' Ferri sulphatis..........................................................................gr. xvj. Acidi sulphurici dil.................................................................51J. Aquae..............................................................................................ovnJ- M. Sig. Tablespoonful in water before breakfast. Arsenical Mixture. Ifc Liquor potassae arsenitis.........................................................5ij- Vini ferri........................................... ...........................................^j. Aquae destillat.........................................................q. s. ad., ,^iv. M. Sig. Teaspoonful in water after each meal. Liquor Acidi Arseniosi Hydrochlorici (De Yalangin's). ty_ Acidi Arseniosi........................ ..........................................5SS- Acidi hydrochlorici........................................................ 5JSS- Aquae destillat.................................................. ^xx, M. PILLS. Asiatic Pill. [£ Acidi arseniosi....................................................................gr. ij. Piperis nigris..................................... .......T)ij. Pulv. glycerrhiz. rad......................................................3J- M. ft. pil. no. 40, Pil. Hepatic Co. (O-D). fy Hydrarg. chlorid, mit., Pulv. podophyllin.........................................................aa, gr. ij. Pulv. ipecac.............................................................................gr. j. Ext. colocynth. co...................................................................gr. xij. Ext. nucis vomic..................... ..............................................gr. iv. Ext. belladonnae................................................................gr. ij. Ol. anisi........................................................................................gtt. j. M. ft. pil. no. S. Sig. One pill at bedtime. HANDBOOK OF DERMATOLOGY. LOTIONS. Tincture of Green Soap. $ Sapo. viridis................ ov"J- Alcoholis...........,...................... oiv. Solve et filtra. Sig. Use diluted. Liquor Picis Kalinus. fy Picis liquidae................ o1!- Potassae caustica_- ?y')- Aqiue........................... .lv- M. Sig. Use diluted. Compound Tincture of Green Soap. ty Olei cadini, Saponis viridis, Spts. vini rectificat............... aa> ol- M. filtra et adde. Spts. lavandulae................. .)n- M. Bulkley's Sulphur Lotion. r£ Sulphuris loti........................................ 5J- Etheris............................ .5vi- Alcoholis............. oiijss. M. Calamine Lotion. $ Pulv. calaminae................. 31)- Zinci oxidi.............. 5SS- Glycerini............. m- xv- Aquae rosae.................. .">]■ M. Vlemingkx's Solution. $ Calcis vivaj .............. ,)1V Sulphur, sublimat........... ol- Aquae destillat ............. ~>x- M. Coque ad. ,-,vj et filtra. Sol. Antiprur. Co. (O-D). $ Hvdrarg. bichloridi gr- ij- Anniion. muriat §r- lv- Acidi carbolici o*y Glycerini ~A); Aqua.- rosae........... cl- s- a(^-- ovJ- M. 266 HANDBOOK OF DERMATOLOGY. Lotio Sulphuris Co. IJ Sulphuris precipit.............................................. ~}j. Etheris fort....................................... ,">iv. Alcohol dil..............................................................Siijss. M. fiat lotio. ")xxx. Spiritus Capillaris (Unna). IJ Resorcini.......................................................... Alcoholis 95°............................................. Spts. coloniensis........................................___ 5xx. Olei ricini..................... ...............................................^ss. M. OINTMENTS. Hebra's Diachylon Ointment. IJ Olei olivar. opt.......................... • *xv. Lithargyri................................................ ■ -.)"]--,5vi. Aquae..................................................................................q. s. Coque et fiat ungentum secundem artem. Wilkinson's Ointment (Hebra). IJ Sulphuris loti, Olei cadini .......... .......aa, ~yiv. Saponis viridis, Adipis ......aa, ?>]. Cretse preparatae.................................................. iyjss. M. Helmerich's Ointment. IJ Sulphuris.......................................... =ij. Potass, carb ......^j. Adipis..................................................................Sviij. M. Unguentum Lanolini Co. (O-D). IJ Lanolini puriss, Ung. aquae rosae ......................^j. M. Unguentum Chrysarobini Co. (Unna). IJ Chrysarobini, Acidi salicylic..... ......aa, gr. viij. Ichthyol.................... .....................Qij. Vaselini flavi ............. 3yj. M. HANDBOOK OF DERMATOLOGY. 267 Brooke's Lupus Ointment. FJ Hydrargyri oleat., 5 per cent............................. .........=j. Acid, salicj'lic ............................. ..........................gr. x-xv. Ichthyol................................. Olei lavandulae................... M. et fiat ung. m. xv. q. s. PLASTERS, PASTES, ETC. Unna's Comedo Paste. IJ Acidi acetici dil.................... 5J. Glycerini puriss...... ...............%i]. Kaolini.............................. ... 5iij. M. Sig. Apply at night. Bulkley's Adhesive Sticks. IJ Cerae flavae .......................5"j- Laccae in tubulis 5ss. Resinae......................... 5VJ- Picis Burgundicae........... 5X1- Gummi dammar........... ......ojss. M. Cosme's Paste. IJ Acidi arseniosi ............................ ...................gr. x- Hydrarg. sulphuret. rubr.......................... 3SS- Ung. aquae rosae............... oSS. M. Vienna Paste. IJ Calcis vivae, Potassae............................................. ......................aa, p. ae. M. Sig. Make into a paste just before using. Lassar's Paste. IJ Zinci oxidi, Amvli Adipis * .......aa, ,-,i] ..............")iv M. Zeissl's Sulphur Paste. IJ Sulphuris precipit., Glycerini, Potassii carbonat., Alcoholis dilut ........aa, 3]. M. ft. pasta. HANDBOOK OF DERMATOLOGY. Compound Salicylic Plaster. (Klotz). IJ Emplast. diachyli simp., Emplast. saponat..............................................aa, %). Petrolati.................................................................... .~)iij- Acidi salicylic..................................... ,"))■ M. ft. emplastrum. Hebra's Paste. IJ Glycerini, Acid, carbolic, Lac. sulphuris, Spts. vini rectific...........................................aa, ,"")']• M. ft. pasta. Bougard's Paste. IJ Wheat flour, Starch................................. .....................................na, 5ij. Arsenic......................................................... Kr- ij- Cinnabar, Sal ammoniac...........................................................aa, gr. x. Corrosive sublimate..............................................gr. j. Sol. chloride of zinc at f>L>u ............. ~>j. Mix. HANDBOOK OF DERMATOLOGY. 2<><) BIBLIOGRAPHY. Auspitz, H. System de Hautkrankheiten. Anderson, T. McCall. Treatise on Diseases of the Skin. Behrend, Gustav. Die Hautkrankheiten. Brocq, L. Traitement des Maladies de la Peau. ., . , . t-v { Eczema and Its management. ( Acne. Crocker, Radcliffe H. Diseases of the Skin. Duhring, L. A. Diseases of the Skin. Fox, Tilbury. Diseases of the Skin. Hvde, J. Nevins. Diseases of the Skin. Jackson, Geo. T. Diseases of the Hair and Scalp. Jamieson, Allan. Diseases of the Skin. Kaposi, M. Yeber Hautkrankheiten. Lesser, E. Lehrbuch der Hautkrankheiten. Leloir, H. Affections Cutanees d'Orgine Nerveuse. Liveing, Robt. Diagnosis and Treatment of Skin Diseases. Morris, Malcolm. Diseases of the Skin. Neumann, I. Handbook of Skin Diseases. T1 . f System of Dermatology. Morrow, P. A. < J . aj ( Drug Eruptions. ^■rr t TT /^ ! Diseases of the Skin. Piffard, H. G. - . ,. , „, ( Materia Medica and Therapeutics of the Skin. Raymond, P. L'Urticaire Pigmentee. Robinson, A. R. Manual of Dermatology. Shoemaker, J. V. Diseases of the Skin. Squire, Balmanno. Manual of Diseases of the Skin. Unna, P. G. Histopathologie der Hautkrankheiten. Yidal and Leloir. Pathologie des Maladies de la Peau. Ziemssen, II. von. Handbook of Diseases of the Skin. ATLASES. P. A. Morrow's. L. A. Duhring's. Henri G. Piffard's. R. YYT. Taylor's. Geo. II. Fox's. C. Kopp's Atlas. Yan Haren Noman's. 270 HANDBOOK OF DERMATOLOGY, JOURNALS. Journal of Cutaneous and Genito-Urinary Diseases. British Journal of Dermatology. Quarterly Atlas of Dermatology. Annales de Dermatologie et de Syphiligraphie. Archiv fuer Dermatologie und Syphilis. Journal des Maladies Cutanees et Syphilitiques. Monatshefte fuer Praktische Dermatologie. Giornale delle Malattie delle Pelle. The above list could be greatly extended, but it is sufficiently large, especially for those whose reading is limited to but a por- tion of the literature of dermatology. HANDBOOK OF DERMATOLOGY. I X Acanthia lectularia, 250. Acarus folliculorum, 202. scabiei, 239. Achorion Schcenleinii, 226. Achroraa, acquired, 170. congenital, 168. Acne, 90. albida, 38. artificialis, 91. atrophica, 91. cachecticorum, 91. keloid, 99. mentagra, 96. uecrotica, 91. papulosa, 90. punctata, 36. pustulosa, 90. rosacea, 91. sebacea, 32. tuberculosa, 90. varioliformis, 91, 193. vulgaris, 90. Addison's disease, 139. keloid, 156. Adenoma sebaceum, 215. Acquired achroma, 170. leucasmus, 170. leucoderma, 170. leucopathia, 170. Ainhuni, 177. Albicans, oidiuni, 237. Albinism, 168. Aleppo boil, 111. bouton, HI. Alligator skin, 151. Alopecia, 178. areata,180. circumscripta, 180. congenital, 178. furfuracea, 182. idiopathic premature, 178. pityrodes capillitii, 182. senile, 178. svmptomatic, 178. Alphos, 104. Amboyne bouton, 161. Anesthesia, 16, 224. Anesthetic leprosy, 204. Analgesia, 16, 224. Anatomical tubercles, 201. Anatomy, 4. blood-vessels, 7. corium, 6. epidermis, 4. hair follicle, 13. hairs, 13. muscles, 10. nails, 15. D K.X. Anatomy—Continued. nerves, 8. Pacinian corpuscle, 9. pigment, 9. sebaceous glands, 12. subcutaneous connective tissue sweat (coil) glands, 10. tactile corpuscles, 9. Angioma cavernosum, 212. pigmentosum et atrophicuni simplex, 212. Anidrosis, 44. Anthrax, 114. Appendages of the skin, 2. Area Celsi, 180. Argyria, 140. Arrectores pilorum, 10. Asteatosis cutis, 35. Atheroma, 40. Atrophia cutis, 173. cutis propia. 173. pilorum propia, 183. Atrophic lines and spots, 175 Atrophies, 168. Atrophy of the hair, 183. nail, 186. skin, 173. senile, 174. Baldness, 178. Barbadoes leg. 158. Barber's itch, 231. Batswing disease, 196. Bedbug, 256. Biskra bouton, 111. Blackheads, 36. Blanching of the hair, 17 Blebs, 17. Bloodvessels, 7. Bloody sweat, 47. Body louse, 247. Boil, 109. Bouton Aleppo, 111. Amboyne, 161. Biskra, 111. Bromidrosis, 45. Bucnemia, 158. Bulb of hair, 14. Bulla, 15. Burning, 16. Cachectic acne, 91. Calculi, cutaneous, 38 Callositas, 143. Callosity, 143. Callus, 143. HANDBOOK OF DERMATOLOGY. Calvities, 178. Cancer, connective tissue, 208. en cuirasse, 210. epithelial, 208. fibrous, 210. lenticular, 210. scirrhous hard, 210. Cancroid, 208. Canities, 172. Carbuncle, 112. Carbunculus, 112. Carcinoma cutis, 208. melanotic, 210. pigmented, 210. tuberous, 210. Chafe, 53. Charbon, 114. Cheiro-pompholyx, 83. Chigger, 261. Chloasma, 137. uterinum, 137. Chromidrosis, 47. Chromophj'tosis, 235. Cimex lectularius, 255, Cingulum, 76. Classification, 26. Clavus, 145. Coco, 164. Cnidosis, 60. Coil glands, 10. Colored Sweat, 47. Cold sore, 73. Comedo, 36. double, 36. Common bedbug, 256. flea, 252. wart, 149. Congenital achroma, 168. alopecia, 178. leucasmus, 168. leucoderma, 168. leucopathia, 168. Connective tissue, subcutaneous. Contagious molluscum, 193. Corium. 6. stratum papillare, 0. stratum reticulare 6. Corn, 145. Cornu cutaneum, 147. unguale, 148. Corpuscle of Meissner, 9. of Vater, 9. of Wagner, 9. Pacinian, 9. tactile, 9. Crab louse, 250. Crust, 17. Crusted ringworm, 225. Culex, 261. pipiens, 261. Cuniculus, 238. Cutaneous calculi, 38. horn, 147. Cutis, 6. pendula, 160. Cysticircus cellulosae, 263. Dandruff, 39. Darier's disease, 192. Defluvium capillorum, 178. Delhi boil. 111. Demodex folliculorum, 262. Derma, 6. Dermatalgia, 219. Dermatitis, 116. bullosa, 83. calorica, 117. contusiformis, 59. exfoliativa, 108. gangrenosa, 117. herpetiformis, 79. medicamentosa, 118. papillaris capillitii, 99. seborrhoica, 71. traumatica, 116. venenata, 116. Dermatoliths, 38. Dermatolysis, 160. Dermatomyoma, 218. Dermographism, 60. Diagnosis, 20. Discoloration of the skin, 140. Disorders of secretion, 32. Dissection wounds, 113. wart, 201. Donda Ndugu, 160. Double comedo. 36. Dracunculus, 201. Drug eruptions, 118. Dysidrosis, 83. Ecchymomata, 130. Ecchvmoses, 130. Ecthyma, 103. Eczema, 62. acute, 63. of anus, 66. of arms, 66. of axillae, 66. chronic, 64. diagnosis, 67. of ears, 65. erythematosum, 02. of eyelids, 65. of face, 64, 65. of feet, 66. fissum, 63. or genitals, 66. of hands, 65. infantile, 66. intertrigo, 63. of legs, 66. of lips, 65. of mammse, 66. marginatum, 228. of nipple, 66. papulosum, 03 parasitic, 69. pustulosum, 03. rnbrum, 63. of scalp, 64, 65. sclerosum, 63. seborrhoicum, 71.. squamosum, 63. subacute, 64. treatment, 67. trunk, 66. of umbilicus, 66.. universal, 66. verrucosum, 63. vesiculosum, 63. Elastic skin, 160. Elephant leg, 158_ HANDBOOK OF DERMATOLOGY. Elephantiasis, 158. Arabum, 158. Grecorum, 204. Ephidrosis, 41. Epidermis, 4. stratum corneum, 4. stratum granulosum, 5. statum lucidum, 4. stratum mucosum, 5. Epithelial cancer, 208. Epithelioma, 208. deep seated, 209. molluscum, 193. papillary, 209. superficial, 208. Equinia, 115. Eruption, 18. Erythema, 50. bullosum, 83. caloricum, 51. intertrigo, 53. iris, 58. multiforme, 58. nodosum, 59. papillosum, 58. scarlatiniforme, 5G. simplex, 50. traumaticum, 51. tuberosum, 58. venenatum, 51. vesiculosum, 58. Erythematous eczema, 62. Erythrasma, 237. Etiology, 19. Excoriation, 17. Exfoliative dermatitis, 108. Farcy, 115. Favus, 225. Febris urticata, 60 Fever blister, 73. Fibroma, 189. lipomatodes, 190. Filaria sanguinis hominis, 189. Medinensis, 261. Fish-skin disease, 151. Fissure, 17. Flea, common, 252. Fluxus sebaceus, 32. Fly, bot, 262. gad, 262. Follicular tumor, 40. vegetating psorospermosis, 192. Folliculitis barbae. 96. Foot, perforating ulcer of, 146. Formication, 16. Fragilitas crinium, 184. Frambesia, 61. Freckle, 135. Functions of the skin, 3. Fungous foot, 203. Furrows, 2. Furuncle, 109. Furunculosis, 109. Furunculus, 109. Orientalis, 111. Gad-fly, 262. General considerations, 1. Giant urticaria, 60. Glanders, 115. Glands, coil, 10. sebaceous, 12. sweat, 10. Glossy skin, 174. Granular layer of epidermis, 4. Granuloma fungoides, 211. Grayness of the hair, 172. Grutum, 38. Guinea-worm, 261. Gutta rosea, 94. Hematidrosis, 47. Hemorrhages, 130. Hemorrhea petechials, 130. Hair, atrophy of, 183. fragility of, 184. follicle, 13. hypertrophy of, 162. sudden graying of, 172. Hairiness, 162. Hairs, 13. Harvest mite, 260. Head-louse, 243. Heat, prickly, 81. Herpes, 73. bullosus, 80. circinatus, 80. facialis, 73. gestationis, 80. iris, 75. labialis, 73. preputialis, 73. progenitalis, 73, tonsurans, 230. zoster, 76. Hirsuties, 162. Hives, 60. Honey-comb ringworm, 225. Horn, cutaneous, 147. Hydroa, 80, 83. Hyrosis oleosa, 71. Hyperemias, 50. Hyperesthesia, 16, 219. Hyperidrosis, 41. Hypertrichosis, 162. Hypertrophies, 135. Hypertophy of the hair, 162. of the nail, 166. Hypohydrosis, 41. Ichthyosis, 151. congenita, 151. hystrix, 151. sebacea, 32, 151. sebacea conea, 192. simplex, 151. vera, 151, Idrosis, 41. Ignis sacer, 70. Impetigo, 100. contagiosa, 102. herpetiformis, 101. Inflammation, 57. Intertrigo, 53. Itch. 238. mite, 239. Itching, 16. Ixodes, 259. Kelis, 187. Keloid, 187. 274 HANDBOOK OF DERMATOLOGY. Keloid, Addison's, 156. Kelos, 187. Keratosis pilaris, 154. Land scurvy, 133. Lanugo, 13. Lentigo, 135. Leontiasis, 204. Lepra, 204. Alphos, 104. anesthetic, 205. Arabum, 204. macular, 205. mutilans, 205. tuberculosa, 205. Leprosy. 204. Leptus, 260. Lesions of the skin, 16. primary, 16. secondary, 16. Leucasmus, acquired, 170. congenital, 168. Leucoderma, acquired, 170. congenital, 168. Leucopathia, acquired, 170. congenital, 168. Lice, 242. Lichen circumscriptus, 89. moniliformis, 80. pilaris ,«154. planus, 87. ruber, 86. scrofulosus, 89. scrofulosorum, 89. tropicus, 81. Lineae albicantes, 175. Linear atrophy, 175. Liomyoma cutis, 218. Liver mark, 137. Lombardian leprosy, 207. Louse, body, 246. crab, 249. head, 242. Lousiness, 242. Lupus erythematodes, 196. erythematosus, 196. exedens. 197. exfoliatavus, 198. hypertrophicus, 198. sebaceus, 196. superficialis, 196. tuberculosus, 198. vegetans, 198. verrucosus, 198. vorax, 197. vulgaris, 197. Lymphangioma cutis, 216. tuberosum multiplex, 216. Lymphatics of the skin, 8. Lunula, 15. Maculae et striae atrophicae, 175. Macule, 16. Madura foot, 203. Mai perforans, 146. Mai rosse, 207. Malignant pustule, 114. Malis pediculi, 242. Malum perforans, 146. Malum perforans pedis, 140. Matrix of nail, 15. Medullated nerves, 8. Melanosarcoma, 210. Melasma, 137. Mentagra, 96. Medicinal rashes, 118. Microsporon furfur, 230. Miliaria, 81. alba, 81. crystallina. 49. papulosa, 81 rubra, 81. vesiculosa, 81. Milium, 38. Milk crust, 64. Mite, harvest, 260. Moist tetter, 62. Mole, pigmentary, 212. Molluscum contagiosum, 193. epitheliale, 192. fibrosum, 189. pendulum, 189. sebaceum, 193. simplex, 189. Morbus maculosus Werlhoffii, 133. Morbus pedicularis, 212. Morphea, 150. Morpio, 250. Mosquito, 261. Mother's mark, 137. Mucous layer of epidermis, 5. Multiple boil, 112. Murrain, 114. Muscles of the skin, 10. Mycetoma, 203. Mycosis fuugoides, 211. vaginalis, 237. Myoma cutis, 218. telangiectodes, 218. Nevus flammeus, 212. lipomatodes, 142. mullusciformis, 142. pigmentosus, 142, 212. pilos.us, 142. sanguineus, 212. simplex, 212. spilus, 142. tubtrosus, 212. vascularis, 212. vasculosus, 212. verrucosus, 142. Nail, atrophy of. 180. fold, 15. horn, 118. hypertrophs' of, 166. ingrowing, 166. Nails, 15. Nerves of the skin, 8. medullated, 8. non-medullated, 8. Nettle rash, 60. Neuralgia of the skin, 219. Neuroma cutis, 217. Neuroses, 219. New growths, 18i. Nodositas crinium, 183. Noli me tangere, 197. Non-medullated nerves, 8. Non-parasitic sycosis, 90. Objective symptoms, 16. CEstrus, 262. Oily seborrhea, 33. HANDBOOK OF DERMATOLOGY. 275 Onychauxis, 166. Onychia, 166. Onychogryphosis, 166. Onychomycosis, 166. Onyxis, 166. Osmidrosis, 45. Pachydermia, 158. Pacinian corpuscle, 9. Paget's disease, 209. Pain, 10. Papillae, 6. Papillary layer of corium, 6. Papular acne, 190. eczema, 63. urticaria, 60. Papule, 16. Parangi, 161. Parasites, 225. Paronychia, 166. Pars papillaris, 0. reticularis, 6. Patch, 18. Pathology, 24. Pearly tubercles, 38 Pediculosis, 242. capitis, 242, corporis, 246. pubis, 249. Pediculus capitis, 243. corporis, 247. pubis, 250. Peliosis rheumatica, 132. Pellagra, 207. Pemphigus, 84. acute, 84. chronic, 84. foliaceus, 84. vulgaris, 84. Perforating ulcer of foot, 146. Perifolliculitis, 98. Petechiae, 130. Phosphoridrosis, 47. Phtheiriasis, 242. Phthiriasis, 242. Phthirius inguinalis, 250. Phymata, 16. Piebald skin, 170. Piedra, 184. Pigment of the skin, 89, Pigmentary mole, 142. nevi, 142. Pityriasis capitis, 182. maculata et circinata, 107. rosea, 107. rubra, 108. versicolor, 235. Plica Polonica, 184. Podelcoma, 203. Pointed wart, 149. Poisoned wounds, 113. Poliosis, 172. Politrichia, 162. Polypapilloma tropica, 161. Pomphi, 16. Pompholyx, 83. Pore, 11. Porrigo decalvans, 180. favosa, 225. furfurans, 230. Prickle cells, 5. Prickly heat, 81. Primary lesions, 16. Prognosis, 25. Prurigo, 88. mitis, 88. ferox, 88. Pruritus, 221. hiemalis, 221. senilis, 221. Psora, 104. Psoriasis, 104. circinata, 105. diffusa, 105. guttata, 104. gyrata, 105 nummularis, 105. punctata, 104. Psorospermosis, 192. Pulex irritans 252. penetrans, 261. Purpura 130, hemorrhagica, 133. rheumatica, 132. simplex, 130. Pustula maligna, 114. Pustular acne, 90. eczema, 63. Pustule, 17, Red rash, 55. Rete Malphgihii, 5.. Reticular layer of corium, 6. Rhagades, 16. Rheumatism of the skin, 219. Rhinoceros skin, 160. Rhinophyma, 94. Rhinoscleroma, 195. Ringed hair, 13. Ringworm, 228. crusted. 225. honey-comb, 225. of the beard, 231. of the scalp, 230. of the body, 228. Rodent ulcer, 208. Rosacea, 94. Roseola, 55. Salt rheum, 02. Sarcoma cutis, 211. melanotic, 211. Sarcoptes scabiei, 239. Satyriasis, 204. Scabies, 238. Scale, 17. Scar, 18. Sclerema, 155. Sclerema neonatorum, 157. Scleriasis, 155. Scleroderma, 155. Scrofuloderma, 199. Sebaceous glands, 12. cyst, 40. tumor, 40. Seborrhagia, 32. Seborrhea, 32. congestiva, 196. oleosa, 33. sicca, 32. Seborrheic eczema, 71. Secondary lesions, 17. Secretion, disorders of 32. 276 HANDBOOK OF DERMATOLOGY. Senile atrophy, 174. calvities, 178. Shaft of hair, 14. Shingles, 76. Siderosis, 141. Skin, 1. Smarting, 16. Spots, 16. Squamae, 16. Stain, 17. Stearrhea, 32. Steatoma, 40. Steatozoon folliculorum, 262. Stinking sweat, 45. Stone-pock, 90. Stratum corneum, 4. granulosum, 5. lucidum, 4. mucosum, 5. papillare, 6. pigmentosum, 5. reticulare, 6. Striae et maculae atrophicae, 175. Strophulus albidus, 38. Subcutaneous connecti;e tissue, 6. Subjective symptoms, 16. Sudamina, 49. Sudatoria, 41. Sweat, bloody, 47. colored, 47. phosphorescent, 47. urinous, 47. Sweat glands, 10. pore, 11. Sycosis, 96. capillitii, 99. frambesia, 99. non-parasitica, 96. parasitica, 231. Symptomatology, 16. Symptoms, objective, 16. subjective, 16. Tactile corpuscles, 9. Tattooing, 141. Telangiectasis, 214. Tetter, 62. Therapeutics, 22. Thickness of skin, 1. Tick, 259. Tinea barbae, 231. capitis, 230. circinata, 228. cruris, 228. decalvans, 230. favosa, 225. sycosis, 231. tondens, 230. tonsurans, 230. tricophytina, 228. unguium, 229. versicolor, 235. Tingling, 16. Trichonosis cana, 172. discolor, 172. Trichorrexis nodosa, 183. Tubercle, 17. Tuberculosis cutis, 201. cutis lichenoides, 89. Tumor, 17. Tyloma, 143. Tylosis, 143. Ulcer, perforating of foot,?146. rodent, 208. Ulcer, 16. Uridrosis, 47. Urticaria, 60. acute, 60. chronic, 61. giant, 60. papulosa, 60. pigmentosa, 60. tuberosa, 60. Varus, 90. Venereal warts, 149. Verruca, 149. acuminata, 149. filiformis, 149. glabra, 149. necrogenica, 201. plana, 149. senilis, 149. vulgaris, 150. Vesicle, 17. Vesicular eczema, 63. miliaria, 81. Vespertilio, 196. Vibices, 230. Vitiligo, 170. Vitiligoidea, 190. Wart, 149. dissection, 201. Wen, 40. Wheal, 17. Whelk, 90. Wood-tick, 259. Wounds, dissection, 113. poisoned, 113. Xanthelasma, 190. Xanthoma, 190. multiplex, 190. planum, 190. tuberosum, 190. Xeroderma, 153. ichthyoides, 151. pigmentosum, 214. Xerosis, 153. Yaws, 131. Zona, 76. Zoster, 76. I ■> ■ '.' « "7* Vv Ar*- • **-•. - -+*-/£*■ .-•- > **••:, >■ %& ^sw -■- %^^^ ' : -■■■; *x%te■'&%& A' *&?&■&* * -**h-... %^i" -y; ^ Ay<% ^{1/.%$^ ^S^V^g xWV"-^^ /-.l&w* ^5 I :'y:A'^ •?+*AA' Aj ^i ■r> "^ "^v ,v rA *'y k °^ ^i^: j^^k&<5 e^ .^j^:^p- ^s^^; j^ "M - 5^ - rA .> "^F %A4%A& W* #, .■*?«& i^ *** ^ is. #s 1%V^ #v^ VU'W\& J&8L V/5 3? Si NLM001529652