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   A MANUAL OF'GENERAL  PATHOLOGY.  One
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                   PUBLISHED BY

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NLM001530150 
 
 
 

'NJ 
CUTANEOUS MEMORANDA
   HENRY G. PIFFARD, A.M., M.D.

Clinical Professor of Dermatology, University of the
  City of New York; Consulting Surgeon to the
     Charity Hospital, and to the Bureau of
         Out Door Relief Bellevue
              Hospital.
THIRD  EDITION.
"'*"■ '       NEW YORK
  WILLIAM WOOD & COMPANY
       56 & 58 Lafayette Place
              1885 
WR
Entered according to Act of Congress, in the year 1885.
                       by
           William Wood & Company,
    In the office of the Librarian of Congress, at
                  Washington.
 
PKEFACE.
  This is the third edition of the cutaneous
portion of the little book entitled Cutaneous
and Venereal Memoranda, first published in
1877.  It has been re-written and added to
both as regards text and illustration.
                       THE AUTHOR.
 New Yobk, October, 1885. 
 
TABLE OF CONTENTS.
CHAPTER                            PAGE
     I.—Anatomy of the Skin.........  1
    II.—Physiology of the Skin.......  7
   m.— Pathology of the Skin........  9
   IV.—Symptomatology.............  13
    V.—Diagnosis....................  19
   VI.—Nomenclature................  20
  VII.—Classification.................  22
  VTLL—The Rheumides..............  29
   IX.—Eczema......................  35
    X.—Psoriasis.....................  52
   XI.—Syphilis and the Syphilides ...  58
  XH— Treatment of Syphilis........  84
  XIH.—The  Scrofulides — Lupus
          Epithelioma................ 101
  XTV— Leprosy..................... 132
  XV.—Ichthyosis................... 136
  XVI—Erysipelas....................140
 XVH.—Acne— Comedo— Rosacea---143
XVTTT,—Urticaria — Zoster — Herpes—
          Chloasma................. 161 
vi
TABLE OF CONTENTS.
CHAPTER.                             PAGE
  XIX.—Scabies—Phthiriasis.......... 181
   XX.—Favus—Trichophytosis—Chro-
          mophytosis— Impetigo Con-
          tagiosa — Milium—Alopecia
          Areata — Lichen  iEstivus—
          Pernio—Verrucae.......... 194
  XXI.—Erythema...................227
 XXH.—Elephantiasis — Fibroma — Fu-
          runcle — Keloid — Lichen
          Planus — Lichen  Ruber —
          Molluscum...............234
 XXHI.—Pemphigus— Prurigo —Pur-
          pura....................... 248
XXIV.—Scleroderma — Scleriasis — Vi-
          tiligo...................... 258 
CUTANEOUS  MEMORANDA.
              CHAPTER I.

         ANATOMY OF THE SKIN.
  THE skin is composed of three principal
layers: an external horny layer called the
cuticle or stratuvi corneum, composed of
flat, dry, non-nucleated cells; a middle mu-
cous layer or  stratuvi malpighii, made up
of irregularly globular nucleated cells cov-
ered with fine projections or prickles.  The
deeper cells  of this  layer  are  somewhat
cylindrical, and contain pigment,  varying
in amount in  different races of men. These
two outer layers constitute the  epidermis.
Between these two layers there is indeed
another, called the stratum lucidum, which
layer, however, is  rarely seen  on ordinary
microscopical  examination.   The  internal
layer, or true skin, called derma, corium or
cutis vera, is  composed mainly of fibers of
connective  and yellow  elastic  tissue,  the
connective  tissue  greatly  predominating.
This latter gives strength to the skin, while 
2        CUTANEOUS MEMORANDA.

the yellow fibers endow it with elasticity.
The outermost portion  of the corium is not
smooth, but covered with projections called
papillce, of varying size and contour.   Their
structure is the same as that  of the corium,
but denser.  The lai'gest are  found  on the
nipple and the corona glandis, the next in
size  on the palmar surface of the fingers,
while the smallest occur over the general
surface of the body.

             BLOOD-VESSELS.
  The blood-vessels of the skin include ar-
teries, veins and capillaries.  The arteries
proceeding from  beneath ramify  loosely
in the deeper layers of the skin,  and give
ascending branches, which become capillary
and form a second and more superficial plex-
us, from which again loops extend into some
of the papillae; returning,  the capillaries
unite to form veins, and as such run along
the under surface of the skin, or enter the
deeper tissues.
              LYMPHATICS.
  The lymphatic vessels form a plexus in
the deeper portions of  the  derma, from
which branches run outwardly forming a 
ANATOMY.
3
second or  superficial  plexus, from which
again capillary loops  are given off to the
papilla?.
                 NERVES.
  The nerves, branching off from the larger
nerve trunks underneath, terminate in the
skin in several ways.   Some  deeply seated
end in oval extremities called Pacinian cor-
puscles, the precise function of which is un-
known.  Others  proceed  outwardly, and
terminate in the papillae of the fingers, in
bulbous expansions called Meissner's corpus-
cles.  In these resides the  special sense of
touch.   Other fine nerves pass through the
papillae, and terminate among the cells of
the stratum malpighii.  These latter are the
nerves of common sensation.  In  addition,
certain  fine fibers are distributed to  the
blood-vessels, and to certain special organs,
as the sweat glands, sebaceous glands, hair-
follicles,  and muscles.

THE SUDORIPAROUS AND SEBACEOUS GLANDS.
  The sudoriparous or sweat glands are or-
gans which consist of a tube convoluted into
a glomerulus or knot at its deeper extremity,
but whose free ends pursue a somewhat flex- 
4        CUTANEOUS MEMORANDA.

uous course outwardly, and passing through
the epidermis, open upon the surface.  The
untwisted tubes have an average length of
6mm. (1-4").  Their number has been esti-
mated at two million, giving, therefore, in
aggregate, a length of nearly eight miles of
perspiratory tubing.  The sweat glands are
formed by inversion of the epidermis during
foetal life.   The sebaceous glands, likewise
formed by ante-natal inversion  of the epi-
dermis, are of three sorts: First, glands of
simple structure and insignificant size, oc-
curring as offshoots or appendages of the
hair-follicles, into which they open. Second,
those of more complex structure and larger
size, and having  rudimentary  hairs  con-
nected with them, the  hair-follicle  and
gland having  a common opening on  the
surface.  Third, those which are still more
complicated and larger, without hairs, and
opening  directly  upon  the surface.   The
first are  found in  connection with coarse
hair of the head, beard, genitals, etc.  The
second upon the nose, forehead, cheeks, etc.,
and the third upon the internal  surface of
the prepuce, and behind the  corona glandis,
and upon  the  nipple,  labia  minora, and
vestibulum vulvae. 
ANATOMY.
5
             HAIR-FOLLICLES.
  The hair-follicles, also fcetal involutions
of the epidermis, consist of  sacs  running
down from the surface to various depths in
the derma and sometimes beneath it.  Out-
wardly they consist of two layers of con-
densed connective tissue.  In the outer layer
the fibers have a longitudinal, and in the
inner layer a circular direction.  Internal to
these are two cellular layers, the outer one
corresponding to the stratum malpighii, and
the  inner one to  the  stratum corneum.
These are known as the  inner and outer
root-sheaths.  At the bottom of the follicle
is a small projection called the papilla.

                 MUSCLES.
  The muscles of  the skin are of the smooth
or unstriped variety.  They arise from the
walls of the hair-follicle just below the  se-
baceous gland, and proceed  upward in an
oblique direction, sometimes bending round
the gland, and are inserted into the upper-
most  portions  of the derma, just  beneath
the papillae.  One, two,  or more  may be
attached to each follicle.  Smooth muscular
fibers unconnected with  hair-follicles  are 
6        CUTANEOUS MEMORANDA.

found in  the scrotum,  prepuce about the
female genitals, the nipples, face, and  to  a
limited extent in other parts.
  The appendages of the skin are the hair
and nails.
                THE HAIR.

  The hair consists of a tapering cylinder
partly  intra-cutaneous, pairtly aerial.  The
portion within the skin, imbedded  in  the
hair-follicle, is called the root.  Its deep end
is  somewhat  bulbous,  and embraces  the
papilla  of the follicle.   Mainly cellular  at
its deepest portions, the hair  soon becomes
differentiated into three concentric  layers,
which  are, externally,  a layer of flat epi-
thelial cells, next a thick layer of fibers, or
very long fusiform cells, and internally  a
pith or  medulla,  consisting of  nucleated
cells.   These central cells are often  absent
in the hair of the head, and are proportion-
ately most developed in the hair of the beard
and genitals.  The middle or fibrous layer
is the seat of  the  hair  pigment, which ex-
ists in varying amount on different persons.
The hair may be regarded as modified or
altered epidermis.   It is unnecessary to re-
fer to its peculiarities  as regards local dis-
tribution, these being familiar to all. 
        PHYSIOLOGY OF THE SKIN.       7

               THE NAILS.
  The nails may also be regarded as altered
epidermis.   They consist of three layers, a
thin external layer of non-nucleated cells, a
thick middle layer of nucleated and striated
cells, and an internal layer of nucleated and
pigmented cells.   The deep surface of the
nail is not smooth, but possesses ridges and
grooves.  The former project down into the
bed  of  the nail,  while  the  latter receive
linear projections from what corresponds to
the papillary portion of the derma.  The in-
terlocking  of these ridges and grooves ac-
count for the firm adherence  of the nail to
the nail-bed.
              CHAPTER H.

        PHYSIOLOGY OF THE SKIN.
  The skin serves as the limiting membrane
of the body, and as a protection to the or-
gans  and tissues beneath it.  Its stratum
corneum, being impervious to fluid, prevents
the softer tissues absorbing too much water
from a bath, and on the other hand curtails
the exhalation of moisture from the surface.
A body deprived of the  horny layer  of the 
8       CUTANEOUS MEMORANDA.

epidermis  would soon  desiccate and die.
The sudoriparous glands regulate the tem-
perature of the organism, and to a certain
extent act as excreting organs, removing
daily an appreciable amount of urea from
the system,  together  with other organic
and inorganic substances.   The sebaceous
glands excrete an unctuous substance called
the sebum, which serves to lubricate the hairs
and skin.  The blood-vessels and lymphatics
convey suitable nutriment to the  skin, and
remove the waste products connected with
disassimilation.  The nerves which  termi-
nate upon the  blood-vessels regulate the
blood supply of the skin;  those which are
distributed to the sudoriparous and seba-
ceous  glands  influence the  secretions  of
these  organs;  while those which  can be
traced  among the cells of the stratum mal-
pighii are nerves of common sensation, and
serve to convey to the more central organs
the sensations of heat, cold, pain, pressure,
etc.  On the other hand those which termi-
nate in the  papillai,  particularly of the
fingers, are organs connected with the special
sense of touch.   The skin as a whole must
not be regarded as an  independent  tissue,
but as one holding the closest relations with 
        PATHOLOGY OF THE SKIN.       9

the rest of the economy, being influenced in
great measure by general morbid conditions,
and in turn contributing its share, when in
a healthy state, to the general well-being of
its owner.
             CHAPTER m.

         PATHOLOGY OF THE SKIN.
  Under the term Pathology may be em-
braced a consideration of the pathological
processes which involve this organ, and also
the results of these processes, namely, the
lesions.  The two must not  be confounded.
The morbid actions, of which the skin is the
seat, are in the main the same as occur  in
other organs, and  are usually dependent
on  modifications of  the  blood supply  or
innervation.  The two are so intimately asso-
ciated that it is often difficult, indeed almost
impossible, to determine which is primarily
affected.   Depending  on these modifica-
tions  we  have hyperaemia, inflammation,
and anaemia; and, secondarily, hypertrophy,
exudation, atrophy, or heterology.  Beside
these  we may  have  functional derange-
ments of the  nerves of common sensation, 
10       CUTANEOUS MEMORANDA.
and  of  those of special sense.   The  lym-
phatics also act an important role, not yet
well understood, in connection  with  the
preservation of the integrity of the cutane-
ous functions, and, when the seat of primary
derangements,  are important elements in
dermal pathology.
  The  derangements  of one or  several of
those functions lead to the development of
what are  called  the special  lesions of the
skin.  The most important of these are :
Macules,      «—---— r-*~    *  wr

Papules,      _____a,   *Jb±.    Jki*.---.

Tubercles,        Mb^      J^fbh^
FIG 1.—SCHEME OP THE PRINCIPAL CUTANEOUS LESIONS
                IN PROFILE. 
        PATHOLOGY OF THE SKIN.       11

  Macules are small circumscribed discol-
orations of the surface, attended with very
slight, if any, elevation of the surface, and
are dependent upon either congestion, hem-
orrhage,   vascular  dilatation,  excess  or
absence  of pigment, or  the presence  of
fungi.
  Papules are small solid elevations of the
skin, of varying size, shape and color.
  Tubercles are likewise  solid elevations,
of larger size  than papules.
  Vesicles are elevations of horny epider-
mis by serous or plasmic fluid, and contain
a few leucocytes.  They may be acuminate,
flat, or umbilicated.
  Bullae are large vesicles.
  Pustules are elevations of the epidermis
by pus, and may also be acuminate, flat, or
umbilicated.
  Scales are collections   of  cells of  the
stratum  corneum, more  or less altered by
disease.
  Fissures are linear solutions of continuity,
of varying length and depth.
  Ulcers are solutions of  continuity,  of
varying depth and  outline, with perpendic-
ular, overhanging or sloping edges.
  These  lesions in various  combinations, 
12       CUTANEOUS MEMORANDA.

together with certain others, secondary and
dependent upon them, to be noticed later,
constitute the objective features of what is
termed a "skin disease."  The lesion is not
the disease.   The disease comprises  one  or
more lesions, with such concomitant phe-
nomena as may stand in a causative relation
to the lesion, or may be a result of it.  The
lesion itself may be an  insignificant portion
of the difficulty for which the patient seeks
relief.   This should always be  borne  in
mind.
  Macules are met with in Angioma, Chlo-
asma, Erythema, Ephelis, Rosacea,  Lepro-
sy,  Morphoea, Naevus,  Pellagra, Purpura,
Roseola,  Scarlatina,  Scorbutus,  Scrofula,
Syphilis, etc.
  Papules in Acne, Eczema, Lichen, Pru-
rigo, Rubeola, Scabies, Strophulus, Scrofula,
Syphilis, Variola, etc.
  Tubercles in Acne, Keloid,  Molluscum,
Leprosy, Scrofula, Syphilis,  Urticaria, etc.
  Vesicles  in  Eczema,  Herpes, Impetigo
Contagiosa,  Scabies,  Syphilis,  Sudamina,
Variola, Varicella, Zoster, etc.
  Bullae in Pemphigus, Leprosy,  Syphilis,
etc.
  Pustules  in  Acne,  Ecthyma,  Eczema, 
SYMPTOMATOLOGY.
13
Furuncles, Glanders, Scrofula, Syphilis, Var-
iola, etc.
  Scales in Eczema, Ichthyosis, Pityriasis,
Psoriasis, Syphilis,  Scrofula, Trichophyto-
sis, etc.
  Fissures in Eczema, Leprosy, etc.
  Ulcers in Intertrigo, Scrofula, Syphilis,
Traumatisms, etc.
  The  lesions may be termed the objective
symptoms or signs of disease; and the stu-
dent should as soon as possible familiarize
himself with their generic features, and then
study the modifications which appear in the
several affections to which they belong.
             CHAPTER TV.

            SYMPTOMATOLOGY.
  The lesions of the skin may be, and fre-
quently are, accompanied  and  connected
with general or local abnormal phenomena
of a subjective character. The general are
those which may be embraced under the or-
dinary name of febrile action, with all that
tliis term implies, namely, malaise, loss of
appetite, headache, impaired digestion, in- 
14       CUTANEOUS MEMORANDA.

creased heat of surface, increased frequency
of pulse, etc.
  The local symptoms are referable to dis-
tant organs, or to the skin itself.  Disease
of other organs may be provocative of skin
lesions, and per contra, skin lesions may act
as causative agents of derangement of other
parts.  The alimentary canal, the liver, the
generative organs, the kidneys,  etc.,  may
reflect their irritation to the surface; on the
other hand, extensive  lesions of the skin
may induce  important  changes  in other
parts of the economy.
  The  principle subjective symptoms con-
nected with the skin are Pain, Hyperaesthe-
sia, Anaesthesia, and Pruritus.
  Pain is not a frequent accompaniment of
cutaneous diseases, and is met with chiefly
as a hot or burning sensation in connection
with acute inflammations of the skin, or as a
neuralgic pain in certain cases of Zoster. If
the pain is severe and its cause cannot be
readily removed, it must of course be treated
symptomatically—that is, by the usual seda-
tives.  The pain accompanying Zoster de-
mands the same  treatment that a similar
neuralgia would if unaccompanied by  erup-
tion. 
SYMPTOMATOLOGY.
15
  Hypercesthesia is the prominent symptom
 of the affection called Dermatalgia—in fact
 constitutes its totality  so far as symptoms
 are  concerned.  It is also encountered  in
 certain cases of Leprosy, and in other affec-
 tions.
  Anaesthesia of the integument is encoun-
 tered in several affections, which more prop-
 erly belong to the domain of the neurolo-
 gist, but is of frequent interest to the der-
 matologist in connection with Syphilis and
 Leprosy.  The lesser degrees of deviation
 from normal sensibility, however, are not
 uncommon in a number of cutaneous affec-
 tions.
  Pruritus.—This is one of the most impor-
 tant of the subjective symptoms accompany-
 ing diseases of the skin.  It varies in inten-
 sity, in duration,  and  in location.   In its
 mildest degree it may be little more than a
 pleasurable sensation, while in the severest
 development it may render life a veritable
 burden.  Its duration may be ephemeral, as
 when it accompanies a temporary urticaria,
 or it may last for weeks or months as a
prominent symptom of Phthiriasis or Sca-
bies.  It  may even endure for years as an
accompaniment of true Prurigo.  It may be 
16       CUTANEOUS MEMORANDA.

general or localized.   The causes of pruritus
are various.  On the one hand, the trouble
may be due to disease of some of the inter-
nal viscera, the irritations of which are re-
flected upon  the skin.  On the other hand,
the cause of the pruritus may be located in
the skin itself.  In this latter case the cause
may be the presence of animal parasites, or
the existence of some idiopathic affection of
the skin, as  an eczema, or a prurigo.   As
a rule pruritus is worse at night than during
the day.  In the treatment of this distress-
ing symptom or complication, the ingenuity
of the physician will often Joe taxed to the
utmost.  The first points are to  discover
the cause,  and to remove it  if possible.
When the  itching accompanies temporary
derangement of the liver or uterus, a blue
pill or a nervine may accomplish all that is
desired; but if it depends upon  organic dis-
ease of these or other organs, palliatives are
frequently our only resource.  If the pruri-
tus be sufficiently severe to demand treat-
ment, and  the  nature of the case precludes
expectation of a radical cure, we can some-
times afford marked relief by certain topical
means,  among  which may  be mentioned
warm baths on retiring, the efficiency of 
SYMPTOMATOLOGY.
17
which may be increased by the addition of
an alkali or an emollient, such as carbonate
of soda or linseed meal, in the proportion of
one pound to 25 gallons of water.  A sponge
bath of vinegar or borax may also be tried,
or,  if the pruritus be local,  the  following
anti-pruritic combination may be of service:
  ?.  Chloral...........................
      Camphorse.................aa  3 j.
      Ungt. aq. ros..................  § j.
  This should never be applied to an exco-
riated surface, on account of the pain it will
produce.  In many cases it will have to be
used much weaker than the strength above
given.
  If these means fail, resort must be had to
direct sedatives, as opium, hyoscyamus, etc.
(Jab.) or the employment of an antipruritic
lotion as follows:
  IJ.  Acid. Hydrocyan. dil... tti.xv.—xxx.
      Glycerini..............§ j.
  M.   Should not be applied to abraded surfaces.
  1J.  Tinct. Digitalis........3 ij.—iv.
      Glycerini..............§ ss.
      Aq. Rosse.............I vj.
      M.
  IJ.  Aconitiae..............gr. j.
      Ungt..................3j.
      M. 
18       CUTANEOUS MEMORANDA.

    ]$.  Pulv. Gum. Acaciae---3 ij.
        Bals. Peruv............3 j.
        01. Amygdal...........3 jss.
        Aq. Rosas..............§ j.
        M.

    3.  Iodinii................gr. vj.
        Potassii Iodidi.........3 j.
        Alcohol...............3 vj.
        Aquae.................§ j.
        M.

    IJ.  Sodii Borat............3 iij.
        Morph. Mur...........gr. xv.
        Acid. Hydrocyan. Dil.. § ss.
        Glycerini..............| ij.
        Aquae.................1 vss.
        M.

    9.  Ammonii Carb.,
        Plumbi Acet.......aa 3 j.
        Aq. Rosae..............§ viij.
        M.

    5.  Acid. Hydrocyan. Dil.. 3j.
        Alcohol...............3 xiv.
        Mist. Amygdal. Amar.. § vj.
        M.

  If itching is caused by vermin it ceases
upon their destruction, and when dependent
upon eczema, with the disappearance of the
eruption.
  If the pruritus be at all severe it necessi-
tates scratching, and this is often practiced
with such vigor that more or less mechani- 
DIAGNOSIS.
19
cal wounding  of  the integument results.
Hence, secondary lesions, due to the scratch-
ing,  are frequently met with, varying in
character and  intensity.  These may  col-
lectively be  termed  " scratch-marks,"  and
consist, in milder cases, of little black points,
slightly or not at all elevated.  They are
produced by the desiccation of a small drop-
let of blood, the result of a nail wound.  If
a long scratch has been made, we may find
linear ridges of dried blood, and in severe
cases excoriations, pustules, and even ulcers.
In long-standing pruritus general darkening
of the surface  may occur.  These scratch-
marks may be the  only visible lesions of the
skin, and their cause should be properly ap-
preciated, and carefully distinguished from
the idiopathic lesions described in the  last
chapter.
              CHAPTER V.

                DIAGNOSIS.
  The importance of a  correct diagnosis
cannot be  overrated;  its difficulties, how-
ever, have been.  The lesion being directly
under the eye, a diagnosis should be easier 
20       CUTANEOUS MEMORANDA.

in this class of affections than in any other,
and as a rule it is.  All that is necessary is,
in the first place, to determine the character
of the lesion, i.e., to ascertain whether it is
a macule, papule,  or pustule,  etc.   This
offers little difficulty.   When accomplished,
turn to the table on page 12, and see in what
diseases the  given lesion occurs.  If more
than  one lesion exist, ascertain from  the
table what diseases present the lesions under
notice; and when this is done, carefully read
the special descriptions of the diseases them-
selves. If this plan is systematically followed
it will be surprising how soon one may be-
come a good cutaneous diagnostician.  It
must be remembered, however, that cases
sometimes occur which would  puzzle the
most skillful dermatologist.  No pains, how-
ever, should be spared in the effort to arrive
at a correct diagnosis,  as upon this will de-
pend in great measure the selection of judi-
cious treatment.
             CHAPTER  VI.
             NOMENCLATURE.
  Dermatological nomenclature is, unfortu-
nately, in an extremely inchoate condition, 
NOMENCLATURE.
21
and is the great bugbear of those who give
but  superficial attention to  the  subject.
Until, however, this matter shall have been
subjected to thorough revision by competent
authority, we  must make the best use  we
can of the materials at our command.  In
dermatology we deal with four sets of phe-
nomena, namely, diseases, affections, lesions
and symptoms.  Naturally a name which is
applied to one of these should not be used
in connection with either of the others; this
has not always been the case,  and as a con-
sequence we often find the same name given
at one time to a lesion, and  at another to a
disease.  Further,  a  single name has been
applied to different diseases, and a given dis-
ease has  received several names.  In the
following pages we shall endeavor to be con-
sistent in this respect, and shall select from
among the names proposed those which ap-
pear to us  most appropriate, and shall add
but little to the already overburdened glos-
sary of dermatology.  The  distinction be-
tween  a disease and an affection may be
thought too fine, but we will illustrate our
idea by a single example: Syphilis  is a dis-
ease;  but a macular, papular, or pustular
eruption depending upon it  is an affection. 
22       CUTANEOUS MEMORANDA.

Lesions and  symptoms have already been
considered.
             CHAPTER VH.
             CLASSIFICATION.
  The object of classification in dermatology
as in other branches of science, is to enable
one to obtain at a glance a comprehensive
view of the subject by grouping  together
the different diseases, according to their sev-
eral analogies.  As the affections of the skin
present  various kinds of phenomena,  such
as lesion, pathological process, infiltration,
exudation, anatomical  location,  pruritus,
pain, of  local or central origin, etc., an equal
number of classifications might be devised.
All of these various plans might be pursued
with  advantage,  provided  their  several
parts  are  consistent with each  other.  No
one of them, however, should be exclusively
employed.  The principal advantages to be
gained by classification are, facility in diag-
nosis  and suggestion  as  to  treatment.
These two points have not yet been har-
monized in a single classification, and  from
the nature of the subject do not at present
appear to be capable of union in a  single 
CLASSIFICATION.
23
scheme.   A  double classification is there-
fore advisable,  helps  us to diagnosis, that
is, a naming of  the disease under consider-
ation, and is of the first importance.
  The classification of Plenck and its modifi-
cations,  based upon  the character of the
lesion, attain this to  a certain extent; not
completely, however,  as a given disease,
eczema for example, is there confined to the
class vesiculoz.  As eczema sometimes pre-
sents  pustules  or papules  as   its  most
prominent lesion, the student relying en-
tirely upon Plenckian classifications would
often be  sadly  at fault.  As a  substitute,
therefore, we offer the table upon page 12
and  the  chapter on Diagnosis as the best
guides with which we are acquainted.
  A  classification, however,  based  upon
the  supposed nature of the affections, and
indicating their relations to each other, is,
it seems to us, the one that should demand
the greatest share of  attention from those
devoting their attention to this class of dis-
eases.  A rude attempt of this sort was
made a century  ago (Lorry, in 1777,)  Sub-
sequently,  Alibert  elaborated  a  similar
scheme.   This, at the time owing to certain
peculiarities of nomenclature, did not meet 
24       CUTANEOUS MEMORANDA.

the encouragement which it deserved. From
Alibert's time no similar effort was  made,
until  we, a few years  ago, attempted to
classify the diseases of the skin in the man-
ner indicated.   That this plan will have to
be modified in many of its  details, as our
knowledge of  cutaneous diseases advances,
admits of no doubt.  It is not perfect, but it
will, we think, prove of assistance to the prac-
titioner in arranging his plan of treatment
for any given affection, and it will stimulate
research, among those given to such pur-
suits,  for facts substantiating or negativing
the propositions we assume.  We arrange,
therefore, the commoner forms of cutaneous
eruptions in the following classes :
  Class  I. Diathetic affections.
    "   n. General non-diathetic affections.
    "  ni. Reflex affections.
    "  IV. Local affections.
    "   V. Affections of uncertain nature.
  By diathetic affections we understand such
as are the outward manifestations of a gen-
eral morbid constitutional condition,  or dia-
thesis, which  diathesis  may be  hereditary
or acquired, and lasts indefinitely or for life.
  The general non-diathetic affections  are
those which occur during, or in consequence 
CLASSIFICATION.
25
of, a  general  morbid condition, not heredi-
tary, and of temporary duration.
  The reflex affections are those which de-
pend  directly upon nerve  lesion, or else
occur through the medium of reflex action,
as secondary to pre-existing disease or de-
rangement of other organs.
  The local affections have no direct con-
nection  with  abnormal  conditions of  the
blood, nerves, or viscera.
  The affections  of uncertain nature are
those which we cannot place with any de-
gree of certainty in previous classes.
  In assigning the various diseases to these
different groups, we have been guided by
what  seemed to be their probable nature.
In many cases  the probabilities  were  so
strong as to amount to absolute conviction;
in other cases, the weight of probability
seemed to be  decidedly in favor of the as-
signed position;  while  others have been
frankly marked doubtful.

                CLASS I.
          DIATHETIC AFFECTIONS.
RHEUMIDES.
         Varieties.
            Eczema.
            Psoriasis. 
26       CUTANEOUS MEMORANDA.
Lupus.
Syphilides.
         Varieties.
           Macular.
           Papular.
           Tubercular.
           Vesicular.
           Bullous.
           Pustular.
           Squamous.
SCROFULIDES.
         Varieties.
           Erythematous.
           Corneous.
           Pustular.
           Tubercular.
           Phlegmonous.
           Lichen Scrofulosorum.
Leprosy.
         Varieties.
           Macular.
           Tubercular.
           Anaesthetic.
Ichthyosis.
               CLASS  n.
   GENERAL NON-DIATHETIC AFFECTIONS.
           Eruptive Fevers.
           Erysipelas. 
CLASSIFICATION.
27
      CLASS m.
  REFLEX AFFECTIONS.
 Acne.
 Comedo.
 Rosacea.
 Urticaria.
 Zoster.
 Herpes (labialis, preputialis, etc.).
 Xanthoma.
 Chloasmata (some).

      CLASS IV.
  LOCAL AFFECTIONS.
 Scabies.
 Phthiriasis.
 Favus.
 Trichophytosis.
 Chromophytosis.
 Impetigo contagiosa (?).
 Alopecia.
 Areata (?).
 Alopecia.
 Lichen iEstivus.
 Milium.
 Pernio.
Verrucae. 
28       CUTANEOUS MEMORANDA.

               CLASS V.
           Erythema multiforme.
           Erythema nodosum.
           Elephantiasis (Arabum).
           Fibroma.
           Furuncle.
           Keloid.
           Lichen planus.
           Lichen ruber.
           Molluscum.
           Pemphigus.
           Prurigo.
           Purpura.
           Scleroderma.
           Scleriasis.
           Vitiligo.
   Concerning the foregoing,  it may  be
 proper to make a few  remarks.   The term
 Rheumides  is applied to  the  affections
 which the French embrace under the names
 dartrous  or  herpetic.   The  existence  of
 such a diathesis is denied  by some, but the
 weight of evidence seems  to us to be de-
 cidedly in its favor. It includes the affec-
 tions known in this  country under the vul-
 gar name "Salt-rheum."   The Scrofulides
 include the affections frequently  known un- 
THE RHEUMH)ES.
29
der the  name of Lupus, together with one
or two others.
  The   second  group  inclvdes  affections
which  are  fully considered in all  works
upon general medicine.   They rarely come
under the care of the dermatologist, and
will not  receive further consideration in
this work.
  The fifth class  unfortunately  contains a
large number of affections which the present
state of  science will not permit us to defi-
nitely assign to other groups.  Their  proper
positions are problems of the future.
            CHAPTER Vm,

            THE RHEUMIDES.
  The affections embraced in this group are
among the  most  important  of  any with
which we have to  deal.  Their importance
depends upon their frequency and obstinacy.
As  they undoubtedly, in our judgment,
depend  upon   an  internal  constitutional
cause, it will be expedient to inquire a httle
into its nature.
  The constitutional condition, or diathesis, 
30       CUTANEOUS MEMORANDA.

to  which  we  have given  the name  of
rheumic,  corresponds to the  dartrous  or
herpetic diathesis of the French, and arises,
in all probability, from the retention in the
blood of certain excrementitious substances,
as uric and lactic acids;  in fact, the condi-
tion is one closely allied to those which are
at the root of rheumatism and gout.  The
trouble arises not so much in the processes
of assimilation and nutrition as  in those
connected with the retrogressive metamor-
phoses of  tissue.  Instead of  the thorough
conversion of waste albuminoid tissues into
urea by  the process of  oxidation, there is
partial failure, and as  a  result,  a super-
abundance of imperfectly oxidized products.
These are much less soluble than urea, and
although they exist in comparatively small
quantity, are not completely eliminated  by
the kidneys, and hence tend  to accumulate
unduly  in the  blood.   There  are strong
reasons, also, for believing that the liver is
the organ principally concerned in the con-
version of uric acid into urea, and failure on
its part to perform its full  duty in this  re-
spect tends to bring about the condition of
things in question.   The  excess of these ex-
crementa leads to irritation of the skin, and 
THE RHEUMDDES.           31
the  production  of the  special  affections
which pertain to this diathesis.
  Eczema and Psoriasis, which depend upon '
this diathesis, possess the following features
in common:
  They are not contagious.
  They  are frequently general;  not, how-
ever, by simultaneous invasion of the  sur-
face, but by spreading from different foci.
  They are frequently symmetrical.
  They are usually chronic.
  Their natural duration is indefinite.
  They are obstinate, and do not yield read-
ily to treatment.
  They are  frequently observed in several
members of the same family.
  They are frequently observed in different
forms in different generations of a family.
  Two or more forms may be present at the
same time, or may appear successively.
  They  do  not  always preserve their in-
dividuality, but sometimes merge one  into
the other.
  Relapses are frequent.
  They sometimes alternate with affections
of other organs, especially of the pulmonary
and gastric mucous membranes, and of the
joints. 
32       CUTANEOUS MEMORANDA.

  They itch.
  The lesions are always superficial.
  They never leave cicatrices.
  They are more or less amenable to certain
definite methods of treatment, which  have
little  if any effect upon other cutaneous af-
fections.
  Treatment.—The treatment of the affec-
tions dependent  upon this diathesis includes
the  treatment  of  the constitutional con-
dition,  as well  as  that of  the particular
lesions.  The former will now be considered;
the latter in connection with the affections
themselves.  Accepting  the  view that the
trouble  depends  upon an accumulation of
certain excreta, our first object  is to depu-
rate the blood.  This may be  effected in
three ways, namely: by calling the kidneys,
the bowels, or  the skin itself into more
vigorous action.   If the kidneys happen to
be  diseased,  attempts  to  increase  their
functional  activity  should  be  made  with
very great caution.  If, however, they are
in a healthy state, diuretics may be freely
employed.  Of these, the most useful in our
experience are colchieum- caffein, digitalis,
and acetate of potassium. If we are unable
to depend  upon the kidneys, we can fre- 
THE RHEUMIDES.
33
 qucntly attain our  object  by free cathar-
 sis.  For  this purpose various purgatives
 are at our command, but the following com-
 bination has given us the most satisfaction :
   IJ. Herb, violae tricoloris ..  § j.
      Fol. sennae.............§ ss.
      Aq.  bullientis..........Oii.
      M                       J
 Let it  stand  until cool and  then  strain;
 of  this the  average dose  is  a tumblerful
 once  or twice a day.  It should be given,
 in quantity sufficient to produce four or five
 evacuations  daily, for two  or three  days,
 after which the dose may  be diminished.
 The effect  of active purgation  with this in-
 fusion is, in some cases of eczema, very sur-
 prising, and is due in part  to  the  viola, as
 senna alone will not produce the same good
 results.
  The excretory functions of the skin may
 be increased by diaphoretics, and especially
 by hot air or Turkish baths.
  It is not  alone necessary  to. remove the
excess of  excrementitious substances  from
the blood; they must, if possible, be pre-
vented from  forming in undue proportion.
This may be accomplished to a certain ex-
tent by promoting oxidation; both by  in-
       2 
34       CUTANEOUS MEMORANDA.

creasing the  supply  of  oxygen,  and  its
vehicles, the red blood corpuscles,  and by
stirring  up the liver  with hepatic stimu-
lants.  These latter agents include mercury
in various forms, podophyllin, iris versicolor,
leptandra and eupatorium.   They may be
employed for a consierable time,  if given
in sufficiently small doses.
  As uric and lactic acids, when existing in
undue quantity in the blood, tend to dimin-
ish the alkalinity of the serum; it will often
be expedient to employ alkalies.  Of these
lithia is  probably  the  most useful.  It  is
well, however, to give with it  a little iron
for the purpose of keeping up  the number
of red blood  corpuscles which lithia alone,
continued for some  time, tends  to diminish.
The following is my usual formula:
  J}.  Lithii benzoatis........4.    (3 i)
      Ferri benzoatis.........2.   (3 ss)
      Div. in the Chart No. xxx.
      M
  S. One powder three times a day, before
meals. 
ECZEMA
35
              CHAPTER IX.

                 ECZEMA.
  This, the  most  frequent  and most im-
portant  of the  rheumic affections,  com-
mences in several ways and presents differ-
ent aspects, according to the variety, stage,
etc., that come under view.
  The varieties depend, first, upon the char-
acter of the  primitive  lesion; second, on
the locality;  third, on the activity of the
process; and fourth, on its duration.
  Varieties as to Lesion.—These are five in
number: Vesicular, Pustular, Papular, Fis-
sured, and Exfoliative.
  The Vesicular variety pursues  the fol-
lowing course : After a preliminary  redness
or erythema, more or less localized, minute,
closely-aggregated vesicles appear; these last
for a day or two, rupture,  and cover the sur-
face with their contained fluid, which dries
into yellowish crusts.  If the crusts are re-
moved, a red eroded surface, exuding moist-
ure, is exposed to  view.  The  fresh secre-
tion dries  into  crusts as before,  and this
process  continues  for a variable  period.
After a time, however, the secretion dimin- 
36       CUTANEOUS MEMORANDA.

ishes in amount, and  the crusts  become
thinner  until gradually  the  secretion en-
tirely ceases, and we find a dry red surface
covered  with  fine  desquamating  scales.
These gradually lessen until finally the skin
returns to a normal  condition. The period
of redness and vesiculation is the first stage,
that of secretion and crusting the second,
while the dryness and desquamation consti-
tute the third.
  The  Pustular  variety  commences  with
the development of  small closely-packed
pustules  seated on a reddened base.  These
soon rupture, and their contents  dry into
greenish crusts.   Removal of  the crust ex-
hibits an excoriated surface similar to that
in  the  former  variety.   The subsequent
course of the eruption is the same as that of
the vesicular variety.
  The Papular  form is recognized by the
appearance of small red papules upon a red-
dened or sometimes scarcely altered surface.
The papules may be discrete or aggregated,
at first without  much,  if any, exudation.
By  scratching, however, the papules become
torn, and give issue to a slight  discharge
which dries into thin crusts.  This condition
is maintained for a variable period; at length 
ECZEMA.              37
the tendency to papulation lessens, and with
it the exudation, until finally the last stage
of the eruption is indistinguishable  from
that of the other varieties.
  The Fissured form is characterized  by
redness, followed by little fissures or clefts
in the epidermis, exuding a certain amount
of serous or sero-purulent fluid.  After a
time the secretion diminishes, then ceases,
the fissures  close and the surface becomes
dry, shiny and scaly,  and similar in aspect
to that presented by the late  stages of the
other varieties.
  In the Exfoliative  form we first find  ac-
tive  congestion,  then  exfoliation  of the
horny layer of the epidermis without forma-
tion of vesicles or  pustules, and a plentiful
exudation drying into yellowish or greenish
crusts.   The subsequent  stages  are  like
those of the vesicular and pustular varieties.
  Varieties depending on Location.—These
are chiefly eczema of the scalp, of the beard,
of the genitals, and of the hands and feet.
  Eczema of the Scalp.—This form is com-
mon in children, less  frequent in adults.  It
is usually of the vesicular, pustular, or  ex-
foliative variety.   The  exudation glues to-
gether the hair into masses, which sometimes 
38       CUTANEOUS MEMORANDA.

attain considerable  size, and present a dis-
gusting aspect, especially  when they be-
come the home of pediculi, a very frequent
accompaniment of  eczema in  the lower
classes, who often fail to observe a requisite
FIG. 2.—ECZEMA OF THE FACE AND SCALP.
degree of cleanliness in their habits.   Ec-
zema of the scalp is frequently accompanied
with adenitis of the lymphatic glands, situ- 
ECZEMA.
39
ated upon the neck, back  of  the  posterior
border  of the  sterno-cleido-mastoid.   In
these glands the inflammatory process may
become quite active, with considerable pain
and swelling.  They rarely suppurate; sub-
cutaneous abscesses of the scalp,  however,
are not  unfrequent in young children,  es-
pecially during the warmer months.
  Eczema of the  scalp is frequently asso-
ciated with eczema of the face, especially in
children,  and when  occupying the  latter
region exhibits its  most characteristic fea-
tures as shown in Fig. 2.
  Eczema of the Beard.—If  eczema occu-
pies the region of the beard, the inflamma-
tory process frequently extends to the hair
follicles, and the integument between them
may become  more  or  less profoundly infil-
trated, and accompanied with papules and
tubercles.  The hairs  are  sometimes sur-
rounded by small accumulations of pus, and
upon extraction the roots are found swollen,
and often covered with a thick white  mem-
brane, consisting  of the inner and  outer
root-sheaths.  This variety frequently be-
comes chronic, and constitutes one of the
varieties of the mentagra, sycosis, or barber's
itch of authors.  See cut, Fig. 3. 
40        CUTANEOUS MEMORANDA.
FIG. 3.—ECZEMA BARRffl. 
ECZEMA.
41
  Eczema of the genitals involves the penis,
scrotum, perinaeum, and Vulva.  One of the
main peculiarities  of  this  variety  is  the
tendency to remain moist even in the ab-
sence of much exudation, and when it be-
comes dry, it is apt,  upon  the  slightest
provocation, to resume  its former  condi-
tion.
  Eczema of the Hands and Feet.—When
the affection attacks the back of the hand or
dorsum of the foot, it presents  no special
peculiarities; but when it appears upon the
palmar or plantar surface it is different.  In
these regions it usually assumes the vesic-
ular, pustular, or fissured form, and the pe-
culiarities which characterize  it are due to
the great thickness  and strength of  the epi-
dermis covering these  parts.  The  vesicles
may attain  considerable size,  owing to the
inability of the  secretion to rupture  the
thick stratum corneum which confines it.
In some cases rupture does not take place at
all, but the pus undergoes  absorption, and
the elevated epidermis finally desquamates.
If fissures are a prominent feature, they are
both wider and deeper than when situated
elsewhere, and usually correspond to  the
natural lines and furrows of the skin.  Only 
42       CUTANEOUS MEMORANDA.

a slight amount of exudation  issues from
the clefts, and owing to the frequent ablu-
tion of the parts, rarely forms crusts.  The
third stage is characterized by a dry, polished
surface without much  scaling, but exhibit-
ing the lines of the skin in  an exaggerated
manner.
  Varieties depending upon the activity of
the process are acute and subacute.  These
names sufficiently indicate the character of
the eruption.  A given case  of  eczema,
however,  does  not  always  preserve the
character impressed upon it at the onset; an
acute eczema after a time usually  becomes
subacute, and one that is subacute may at
any later period take on an acute action.
  The varieties  depending upon  duration
are acute and chronic.  When the  eruption
passes through its second and third  stages
with commendable rapidity, say in three or
four weeks, it may with propriety be termed
acute; but if it halts in either of these stages
and  exhibits  a  te'ndency  to  persist  in-
definitely, it is called chronic.
  Chronic Eczema.—This form may com-
mence with acute or subacute symptoms.
In the former case, the eruption, having
passed through  the first stage, enters the 
ECZEMA.
43
 second, and remains therein  for weeks or
 months, often  preserving its acute symp-
 toms throughout;  finally it passes to the
 third stage, and recovery takes place.  More
 frequently, however, it passes through the
 first and  second stages with satisfactory
 speed;  but halts  in the third, in  which it
 may persist for years, varying its course by
 delusive appearances of  recovery, or now
 and again reverting to a former stage.
  Chronic  eczema  may,  however, appear
 without having been preceded  by the lesions
 which   characterize the  first and second
 stages  of  acute eczema;  but  instead, by a
 subacute  condition  from  the  beginning,
 marked by a slightly reddened  and elevated,
 sometimes papulated  patch, covered with
 fine, white, non-imbricated, and not very
 adherent scales.
  A feature common to all cases of eczema
is infiltration.  This varies greatly in degree
 in different cases, being generally most pro-
nounced in cases of long standing.
  Subjective Symptoms.—An acute eczema,
if at all extensive, may be ushered in by
febrile  symptoms, which usually abate in a
day or  two.  In  the majority of cases no
 pyrexia is  observed.  Locally, however, a 
 44        CUTANEOUS MEMORANDA.

 good deal of heat is experienced at first,
 which soon  gives way to pruritus.  This
 latter, varying in severity in different cases,
 may persist throughout the whole course of
 the eruption, and frequently proves the most
 annoying feature.   The scratching to which
 it gives rise tends to irritate and aggravate
 the eruption, and  to  modify its appearance
 by the production  of secondary lesions.
  Diagnosis.—Although eczema  is  an ex-
 tremely polymorphic eruption, its diagnosis
 is, in general, quite easy, provided the stu-
 dent  has properly availed himself  of  the
 clinical opportunities now provided at most
 of the American colleges. The examination
 of a dozen cases will impress upon his mind,
 far better than anything written, the char-
acteristic features of this affection. In some
cases,  however, the  eruption in  the third
stage may exhibit little else than a some-
what reddened, infiltrated  patch, covered
 with rather large scales, something like the
appearance presented by Psoriasis; or there
may be little infiltration and the scales quite
small, and it will be hard to distinguish  it
from Pityriasis.  In either case an absolute
diagnosis is not important, as the treatment
 would be substantially the same. 
ECZEMA.
45
  Complications.—Eczema  may occur  in
patients who are  scrofulous or syphilitic.
In the former case it is apt to present the
pustular form; but, in the latter, it presents
no special  features, except that it rarely
becomes chronic.  It may also arise in per-
sons predisposed to eczema, as an eruption
secondary to scabies, being excited by the
irritation accompanying the latter affection.
The health of persons  suffering from ec-
zema  is  generally good; but  rheumatic,
gouty, bronchitic, and gastro-intestinal trou-
bles may sometimes accompany or alternate
with the  eruption.
  Prognosis.—The prognosis is variable, and
is to be governed in the main by the length
of time  the eruption  has lasted, and the
number of  separate attacks the patient has
had, and also by the condition of the erup-
tion itself.   If this latter be in an acute con-
dition, and has lasted for a short time only,
the immediate prognosis is good,  and the
ultimate  prognosis (probability  of relapse),
will depend much  upon the patient's mode
of living.  If the eruption, however, be of
long standing, or if there have  been many
relapses,  both the immediate and ultimate
prognoses are more unfavorable. 
46       CUTANEOUS MEMORANDA.

  Treatment.—The treatment of eczema in-
volves a consideration of the diathesis and
general condition of the patient, and also of
the stage, condition, etc., of the lesion.  In
other words, it must be both  general and
local.
  General  Treatment.—This must be gov-
erned by the principles laid down in the last
chapter.  Hygiene,  diet,  cathartics,  diu-
retics,  hepatics,  alkalies,  chalybeates,  or
tonics, must be employed according to the
indications  furnished  by  each  individual
case.   Certain other drugs, however, have
been found useful.  Among  these are Ar-
senic, Viola Tricolor, Phosphorus and Calx
Sulphurata.
  Arsenic is useful in both acute and sub-
acute eczema, but in the former should be
given in exceedingly small doses, otherwise
the  irritation  will be increased and the
patient will  appear to be getting  worse
rather than better. In subacute eczema, on
the other hand, the drug may be pushed to
the limit  of tolerance  and  maintained at
that point for a considerable period, especial-
ly when the eruption is of long standing.
I greatly prefer arsenious acid  in tritura-
tion to Fowler's Solution. 
ECZEMA.
47
   Viola  tricolor was much  in vogue  in
former times, but later fell into disuse.  If
given too freely or in too large doses it often
aggravates  the patient's condition, as evi-
denced by increased heat, irritation and ex-
udation.   In chronic  cases this stimulant
action is desirable, and is often followed by
notable diminution of the eruption.   If  in
any case too much  irritation should  follow
its use, the  drug should be suspended for a
few  days, and  subsequently  resumed  in
smaller doses.   Viola tricolor is especially
useful in  eczema of  the face and  scalp  of
children.   The dose of the  fluid  extract
should not exceed one drop in acute cases,
but may be increased to five or ten drops  in
subacute  ones.   For adults  the doses are
proportionately larger.
  Phosphorus  has  been found of decided
service in long standing eczema.  It may be
given in  doses of 1-100 to 1-30 of a grain.
Larger  doses are dangerous, that is if the
preparation employed possesses its full ac-
tivity.
   Calx Sulphurata in small doses, from 1-50
to 1-25 of  a  grain will  be  found useful  in
acute cases in children, and in doses of 1-20
to 1-10 in  the subacute form.  In adults the 
 48        CUTANEOUS MEMORANDA.

 doses most useful are from 1-10 gr. to 1-2 gr.,
 according to the acuity of the eruption.  It
 is particularly of value in cases characterized
 by infiltration.
  Local  Treatment.—This will depend en-
 tirely upon the nature  of  the lesion.  In
 the  first  stage sedative lotions, such  as a
 lotion of laudanum and subacetate of lead
  J}. Tr. opii.......................
      Liq. plumbi. subacetatis ... .aa, 3 ij.
      Aq. rosae......................| iv.
      M
will  be of service  until  the vesicles have
fairly ruptured and the stages of exudation
and crusts set in.  In the second stage the
ungt. hydrarg. ammoniati, to which a little
compound tincture of benzoin has been
added, will frequently be found the most
useful application.
  If, however, the eruption is extensive, it is
safer to  employ the ungt. zinci. oxid., for
fear  that the mercurial application might
produce   salivation.   If  there  be much
crusting, the crusts should be previously re-
moved with starch (not  linseed) poultices.
The  parts should not  be  too frequently
washed,  but when  ablution is necessary
glycerine should be added to the water (a 
ECZEMA.
49
tablespoonful  to a basin of water), and  a
perfectly bland soap employed.
  A dilute solution of peroxide of hydrogen
will sometimes  act  more  promptly and
beneficially than any other application, es-
pecially if there be much purulent or serous
discharge.
  In the third stage, characterized by dry-
ness and scaling, benefit will  be derived
from the addition of tar to the  ointment
mentioned, either the ordinary  ol. picis or
the ol.  cadini, as in the following formula:
  fy. 01. picis seu. ol. cadini........3 j.
     Ungt. hydrarg. ammon......3 vij.
     M.
  The strong odor of the tar may be masked
in a measure by the addition of some essen-
tial oil, as rose, bergamot,  etc.   The  oint-
ment,  in whatever form it may be used,
should be thoroughly  applied night and
morning.
  An excellent convenient method of using
tar  is to dilute it with four or five parts of
turpentine  and filter the  mixture.   The
lotion  should  be  thoroughly rubbed  into
the affected parts night and morning.
  This treatment is adapted to  cases  in
which  there is not much thickening or infil- 
50       CUTANEOUS MEMORANDA.
tration of the derma.  If these conditions,
however, are present, it will be best to pre-
cede other treatment by alkaline applica-
tions varying in strength with the degree of
infiltration.  For  this purpose a 2% to 5%
solution  of  potash  answers very well;  or
the sapo viridis applied with  thorough
friction may be used.
  The spts. saponatus halinus,  or the fol-
lowing
  9.  Saponis viridis................§ vj.
      01. picis,
      Glycerini..................aa § j.
      01. rosmarini.................f ss.
      Alcohol......................Oj.
      M.
may  be  often advantageously  used   in-
stead of the simple potash or green soap.
  The foregoing embraces the main points
connected  with  the  local  treatment  of
eczema,  but there are some special matters
to which attention should be called.  If the
scalp be  extensively affected, the cure will
be  hastened by cutting  the  hair short, as
this abolishes the haunts of  pediculi, and
permits  the remedial  applications  to  be
made more thoroughly.   If the  region of
the. beard be affected, and we have the men- 
ECZEMA.
tagra-f orm eczema, with pus-
tules  surrounding  separate
hairs, it will be necessary to
extract the affected hairs one
by one, a task most readily
accomplished by means of a
pair of properly made forceps
specially designed for the pur-
pose,  as  shown  in the cut.
(Fig. 4.)
  In eczema of  the hands and
feet, when the  epidermis is
greatly thickened,  it had bet-
ter  be removed mechanically
by scraping or rubbing it down
with a file or sand-paper, after
which the alkalies may be ap-
plied.  While most eczemas
are  very amenable  to  treat-
ment, some cases, happily the
minority,  will tax to the ut-
most the patience and skill of
the  physician. 
52       CUTANEOUS MEMORANDA.
              CHAPTER X.

                psoriasis.

  This affection, though not so frequent as
eczema,  is still one  of great importance,
insomuch as it is frequently characterized
by a  degree  of obstinacy witnessed in but
few other diseases.
  It  may be described as a constitutional
and   diathetic  affection  characterized  by
patches  of infiltrated  skin,  covered with
thick, silvery-white imbricated scales.   The
patches vary in number, size, configuration,
and locality.  At the commencement they
may be quite small, merely papules covered
with  a  thick  white  scale,  the  so-called
psoriasis punctata;  if  larger, looking like
little drops of wax or plaster, they consti-
tute  the  P.  guttata.   If still larger, coin-
sized, the affection is termed P. nummulata.
If the patches be joined together, the term
P. diffusa is applied;  and if they cover
pretty much all the surface, the expression
P. universalis is appropriate.  The disease
may affect any portion of the surface, but
its special points of election are the elbows,
knees and hips.  Upon these and other parts 
PSORIASIS.
53
it frequently exhibits  a remarkable degree
of symmetry.
  Psoriasis rarely attacks the palms of the
hands, but as it occasionally does so, the fact
should be borne in mind in differentiating
it from eczema and syphilis  of the hands,
which it often greatly resembles.
  Course.—The affection, whether scant  or
extensive, is essentially a chronic affair, and
if  unrelieved  by  treatment  may last  for
months  or years.   Even when caused  to
disappear by treatment, it is  ever  ready  to
relapse upon the slightest or even without
any apparent provocation.  As a rule it is
worse in  winter that in summer.
  The eruption, having once appeared, is
characterized  by  the patches mentioned.
These are always dry, never  exhibiting the
moisture and  discharge, or alternations  of
dryness and exudation, that occur in eczema.
If the scales fall, or are rubbed off, they are
quickly renewed, and in two  or three days
exhibit the condition observed prior to their
removal.   After this  condition has  lasted
for an indefinite period, retrogressive changes
may occur either spontaneously or as a  re-
sult of treatment.   In either case, the des-
quamation gradually lessens, the size and 
 
PSORIASIS.
55
thickness of the scales diminish, the  infil-
tration subsides, and the surface pales, until
finally the normal condition  is resumed,
without  leaving mark or sign to indicate
the site of the late eruption.
  Diagnosis.—In typical cases there is very
little difficulty in arriving at a diagnosis.
All cases, however, are  not typical, and oc-
casionally we find the affection presenting
an aspect reminding us of  eczema or pityri-
asis;  in  these cases an absolute diagnosis
is not of great importance, since these three
affections are closely allied, and the treat-
ment which would be suitable for one would
answer for the other.  In certain instances,
however, it is a question between psoriasis
and syphilis.  In these  cases the previous
history of the patient must be elicited  in
the most thorough manner, as it will  often
enable a  correct diagnosis to be arrived  at
when the mere  appearance  of the lesion
would leave one in doubt.
  Prognosis.—Psoriasis  is never fatal, and
rarely interferes with the general  health.
The chief inconveniences are its persistence,
and its tendency to relapse, and thus afflict
the patient for many years, and perhaps for
life. 
56       CUTANEOUS MEMORANDA.

  Treatment.—Psoriasis  is  an   affection
which  will  certainly try the  patience  of
the sufferer and the  skill of the physician
more thoroughly than any other among the
commoner diseases of the skin.   The ob-
stacles to satisfactory results are, in the first
place, the difficulty of removing the erup-
tion, and in the second  place, the  almost
certainty of relapse.
  The disease requires both internal and ex-
ternal treatment, for while either alone may
be  sufficient to remove  the eruption, this
effect is more quickly obtained by their con-
junction.
  Experience has shown  that the two drugs
whose internal action is most efficient are
Arsenic and Phosphorus.
  Arsenic, given in small but gradually in-
creasing doses for a considerable period, or
in larger doses for a shorter time, will prob-
ably, in the majority of instances, if the
patient can take it long enough, remove the
eruption.  It sometimes, though rarely, ag-
gravates the trouble.  If it be used at all,
its employment should be thorough, and if
a quick cure is desired, the object should be
 to  introduce into the system the greatest
 possible amount of the drug in the shortest 
PSORIASIS.
57
 space of time consistent with due safeguards
 against the production of too much reactive
 irritation.  It is of course difficult to deter-
 mine in advance the appropriate  dose for
 any given case;  hence  it is best  to com-
 mence with small doses, increased from day
 to day  until conjunctival or gastric irrita-
 tion, etc., warn the physician that the limit
 of toleration has  been reached.  The dose
 must then be graduated  so as to keep just
 within this limit  until the removal of the
 lesions is effected.
  Phosphorus in doses of 1-64 to 1-32 of a
 grain sometimes removes the eruption with
 remarkable promptness.  Its effects should
 be carefully watched, and its administration
 suspended on the slightest indication of gas-
 tric intolerance.
  In the external treatment of Psoriasis,
 numerous  remedies  have been  tried,  with
 greater or less success.  Almost all of them
 have been abandoned, however,  in favor of
 Chrysarobin, the value of which in Psoriasis
 was first made known by Squire.  It may
 be employed in  ointment, but  better, we
think,  mixed with collodion.  The present
writer was the first, he believes, to use it in
this manner.  Its efficacy, however, is greatly 
 58       CUTANEOUS MEMORANDA.

 increased by the addition of salicylic  acid,
 as suggested by Dr. Fox.  I usually employ
 the following formula:
  1^.  Chrysarobin.............gr. xxx.
      Acid. Salicylici...........gr. xx.
      Collodion...............? i.
      M.                        3
  This is applied to  each of the spots, and
 the application is repeated every two or
 three days  until the scaling, infiltration and
 redness have disappeared.   Used  in  this
 manner it  gives rise to very little, if any,
 irritation around the spots, and the clothing
 is protected in great measure from stains.
  The older  treatment by  means of  tar,
green soap, and similar preparations is pretty
much abandoned by  the leading dermatolo-
gists  since the  advent of the chrysarobin
and salicylic collodion.
             CHAPTER  XL

      SYPHILIS AND THE SYPHILIDES.
  It was during the last decade of the fif-
teenth century that Syphilis first attracted
notice.   Whether it existed  before, and
whence it came, are questions which cannot 
SYPHILIS.
59
 be definitely answered.  Appearing first in
 southern Europe, it spread rapidly through
 other portions of the Continent and to the
 adjacent islands,  and soon became recog-
 nized as an important and formidable affec-
 tion,  in its  symptoms  and  consequences
 rivaling leprosy, with  which  it was  later
 confounded.  From that time until the pres-
 ent the disease  has continued to exist, and
 has spread to every country penetrated by
 the footsteps of civilized man.  Although
 the main features of the disease  are the
 same as those which it presented in the be-
 ginning, it has in certain respects been some-
 what modified.  It is more especially as re-
 gards its general severity that we are more
 fortunate than our predecessors.  Although
 we occasionally find isolated  cases which
 fully realize  the descriptions given in the
 past, they certainly are very rare.  As the
 severe cases of the present  day are chiefly
 those which have been neglected or improp-
 erly treated, it is not improbable that these
 causes were the  principal factors  concerned
 in the production of the state of affairs de-
 scribed by the older writers.  On the other
hand, the comparative mildness of  the dis-
ease as at present seen  is undoubtedly due 
60       CUTANEOUS MEMORANDA.
to the more general attention and more ju-
dicious treatment that it now receives.  The
wide diffusion of the disease, however, and
its ever readiness to assume,  under favoring
influences, the most malignant and destruc-
tive phases, render it worthy of the most
serious study.  It is in fact the most impor-
tant of the affections which receive attention
in this volume.   In consequence  of the
varied phenomena presented by the  disease,
we are compelled to consider it from several
points of view: more particularly its modes
of propagation, its lesions,  its course and
variations,  its  diagnosis,  prognosis,  and
treatment.

  MODES OF  CONTAGION AND  PROPAGATION.
  Syphilis is usually contracted during sex-
ual intercourse,  but this is not the  only
medium by  which it may be propagated; it
may be also communicated by  kissing, and
through  vaccination, and by  certain  un-
natural practices.   It may also be given by
syphilitic wet-nurses to their nurslings, and
vice versa, as well  as by drinking  vessels,
table utensils, pipes, etc.
  Manifestations.—The  manifestations of
syphilis  are so numerous  and multiform 
SYPHILIS.
61
 that the disease can only be comprehended
 in its entirety by a careful analysis  of  its
 phenomena from several different points of
 observation.  We shall, therefore, consider
 its lesions and  stages, and the tissues and
 organs liable to be affected.
  Lesions.—The principal lesions of syphilis
 are macules,  papules,  tubercles,  vesicles,
 bullae, pustules, gummata, and diffuse infil-
 trations, and, dependent upon some of  the
 foregoing, ulcerations, crusts and scars. The
 definitions  already  given (p. 10) of  the
 lesions met with in non-syphilitic affections
 of the skin apply equally to those of syphilis.
 It is necessary, however, to define the term
 gumma, a lesion which plays an exceedingly
 important part in connection with this dis-
 ease.  The  name is applied to certain cir-
 cumscribed nodules located  in the subcu-
 taneous  connective tissue,  or within the
 substance of various deeper organs.  These
 nodules  consist mainly of  collections  of
 closely-packed small round cells which pre-
 serve their  form and vitality for  a certain
 length of time; but which ultimately become
 the seat of  degenerative processes, and un-
dergo cheesy  metamorphoses, or disappear
by means of  suppuration and ulceration. 
62       CUTANEOUS MEMORANDA.

These gummata rarely appear in the early
stages of syphilis, but as a rule, play their
role in connection with  the later develop-
ments of the disease.
  Stages.—Three  stages of  syphilis  are
usually described, namely, the  primary,
secondary, and tertiary.   We must admit,
however, two others, to wit, a stage  of in-
cubation, which is present from the time the
disease is contracted, and lasts until the ap-
pearance of  the first  visible manifestation
of the disease.  When this  latter, to which
the name of chancre is given, develops, we
have the beginning of the so-called primary
stage.  This lasts until  the appearance of
certain  general symptoms announce  the
seconday stage.  This is in turn followed
by the tertiary; but between the  two there
is usually a stage or condition characterized
by the appearance of lesions which, under
the usual definitions, we hesitate  to term
either strictly secondary  or strictly tertiary.
To this period the term  intermediary may
with propriety be applied.
  The  stage of  incubation.—This period
varies from two to five weeks, but its usual
duration is from three to four weeks.  Its
commencement dates from the  entrance 
SYPHILIS.              63
of the syphilitic virus, but  during its con-
tinuance there is not the slightest symptom
or visible lesion that  can be recognized as
pertaining to the disease about to be de-
veloped.   If the  contagion gains entrance
through  an abrasion, this latter heals just
the same as it would have done if there had
been no inoculation; if  the  disease is con-
veyed with vaccination, the vaccine vesicle
pursues its early course unmodified.  At the
end of  the period of  incubation  we find
arising  at the point  where  the virus  has
entered a small,  somewhat tawny red, in-
dolent papule.  This papule  is  called  a
chancre, or the initial lesion of syphilis, and
marks the commencement of the " primary "
stage.
  Tlie primary stage.—The  papule may in
its further course undergo several modifica-
tions.  If situated upon the skin, as in arti-
ficial  inoculations, it  usually  remains as a
dry papule over which the stratum corneum
is  seen  tightly stretched,  later  this layer
separates, and is perceived at the summit of
the papule as a thin  scale.   If  the tissues
lying directly underneath  the  papule  be
delicately grasped between  the  thumb and
index finger a certain amount of resistance 
64       CUTANEOUS MEMORANDA.

is perceived.  This resistance is due to the
presence of a layer of hard infiltrated  tissue
constituting the so-called induration.  The
induration may be confined to a lamina not
much thicker or stiffer than a piece of parch-
ment, or it may approach the size of a split
pea or even the half of  a  small cherry.  It
is  this  induration  which constitutes  the
fundamental characteristic  of the true or
hard  chancre  as  distinguished  from the
chancroid. After an uncertain period, vary-
ing from two  weeks  to  two  months, the
chancre  undergoes retrogressive changes,
which consist in the subsidence Of the pap-
ule and disappearance of the induration.  In
many cases of cutaneous chancre the  above
described course is not  strictly followed.
The epidermis,  instead of remaining as a
tense membrane stretched over the papule,
gives way, and a superficial ulcer results.
The secretion from this ulcer  is scanty in
amount, and unless irritated contains but
httle pus.
  When the chancre appears upon the mu-
cous surfaces of the penis, it may present the
characters of the dry papule above described.
More frequently, however, erosion or ulcer-
ation  occurs, owing to the more delicate 
SYPHILIS.
65
character of the  epithelium.   When the
lesion is situated at the preputial reflexion
we not uncommonly find an excessive  de-
gree of induration.
  When  the chancre appears upon the fe-
male genitals, it rarely presents more than
the slight parchment induration, and some-
times even this is  absent or inappreciable.
In a very considerable number of cases in
females  the chancre  passes through  its
various stages and disappears without hav-
ing awakened the attention of the patient.
  Extra-genital chancres, as those situated
upon the lips and the mamma?, generally
exhibit marked induration.
  Chancre is usually painless, unless irri-
tated by  excessive venery or other causes.
Under these circumstances  it may become
inflamed and painful, and  covered with a
free  purulent exudation, and be with diffi-
culty distinguished from a chancroid.
  Chancre is not, as a rule, inoculable upon
a person  bearing it, or upon  another who is
already syphilitic.
  Adenitis.—Within a  week or ten  days
after the  appearance of the chancre  we
usually find other symptoms arising which
are highly characteristic of syphilis.  These 
66       CUTANEOUS MEMORANDA.

are indolent and indurated tumefactions of
certain lymphatic glands.  When the chan-
cre is located upon the genitals the inguinal
glands are first affected.  The increase in
size may occur upon  one side  alone, but
more frequently upon both.   As a rule, sev-
eral glands upon  each side are involved.
They may vary from the size of a hazel-nut
to that of a pigeon's egg, and as a rule are
painless; more rarely they become inflamed
and suppurate after the manner of the chan-
croidal bubo.  The enlargement and indu-
ration persist for  months, and  sometimes
for years.  In addition, certain  ganglia at
the back of the neck become affected in the
same way, though they  rarely attain the
size of  the glands in the  groin.   Beside
these, certain glands situated above the in-
ner humeric condyle, the so-called epitroch-
lear or cubital glands, frequently become in-
volved upon one or both sides.  When the
chancre  appears upon the finger in conse-
quence of an accidental  inoculation,  the
cubital glands are first involved, and subse-
quently the axillary.
  Diagnosis of chancre.—When a suspicious
sore  exhibits  the  characters  peculiar to
chancre,  and  especially marked induration, 
SYPHILIS.
67
together with involvement of the inguinal
and post-cervical glands, the diagnosis is ef-
fected without difficulty and absolutely.  If,
however, induration is absent, and gan-
glionic involvement has not yet occurred, or
the sore is inflamed and suppurating, the
diagnosis may be exceedingly difficult, in
fact, impossible.  The special points of dif-
ferential diagnosis between the chancre and
chancroid have already been given.
  Secondary stage.—After the primary stage
has lasted  from one to two months, addi-
tional  phenomena arise, and  usher in the
so-called secondary stage.  The earlier mani-
festations  of  secondary or  constitutional
syphilis include general febrile action, called
syphilitic fever, flat moist papules upon the
mucous  membranes  and the integument
surrounding the genital organs, called mu-
cous patches, and  a  general eruption or
efflorescence  upon the skin.  These symp-
toms do not always follow each other in the
same order, and one or more of them may
be absent.
  Syphilitic fever.—This is simply a febrile
attack more or less sharp, and accompanied
with general malaise, gastric disturbance,
headache, etc.  It usually lasts for a few 
68       CUTANEOUS MEMORANDA.

days only, and then passes off, and may be
quickly followed by the cutaneous eruption.
There is nothing distinctive in the character
of the fever that will enable it to be  recog-
nized as syphilitic  except  its previous his-
tory or subsequent developments. The mu-
cous patches and special eruptions will be
considered in subsequent pages.  The lesions
mentioned, especially the  early cutaneous
eruption, may disappear spontaneously, to
be followed by fresh outbreaks of eruption,
in which the lesions present a somewhat
graver aspect.  The cutaneous trouble may
be papular  or  squamous.   As a rule the
eruption is extremely superficial, and when
it disappears leaves a temporary stain, with-
out scar.  During this period, also, the hair
may fall out, producing a more or less com-
plete, but  also  temporary alopecia.  The
eyes, too, may become involved, and vari-
ously situated pains may torment the unfor-
tunate victim.
  Intermediate stage.—After the occurrence
of various secondary symptoms which have
disappeared spontaneously, or have been re-
moved by treatment, it is not uncommon to
have a lull lasting a few weeks or months, or
even years.  During this period we may have 
SYPHILIS.
69
absolutely no symptoms or  signs indicative
of syphilis;  or, perhaps, the occasional ap-
pearance of an isolated lesion, which may
partake of the superficial character of the
usual secondary  lesions, or,  on the other
hand, may be but a foretaste of graver trou-
ble yet to come.
  Tertiary stage.—If the disease has  not
been definitely and permanently arrested in
its development during the preceding stages,
it may pass on to the condition  known as
tertiary syphilis.  During  this period we
encounter profound modifications, not only
of the superficial, but also of the deeper tis-
sues and organs.   The mucous membranes
may become involved in extensive and de-
structive  ulceration.  The integument be-
comes the seat of tubercles, pustules,  and
ulcers, the periosteal membranes inflame,
and the bones  are affected with caries or
necrosis.  The vital organs also may become
involved in  the syphilitic processes.   Not
only the  lungs, liver, intestinal  tract, and
kidneys,  but the nerves, spinal cord,  and
brain may be  invaded, with ultimately a
fatal issue.
  In the tertiary stage the patient may suf-
fer greatly from debility, and the  establish-
ment of a general cachectic  condition. 
70       CUTANEOUS MEMORANDA.

  We see, then, from this general  review,
that syphilis is a disease capable of affecting
the entire organism, and often in a disas-
trous manner; we see that few if any of the
tissues or organs are exempt from its  rav-
ages, and  we are  forced  to the conclusion
that it is a disease which invites our earnest
attention and most careful  consideration.
To gain a proper comprehension of its varied
character we must study it from  several
points of view, and we  will commence with
its effects upon the different tissues.
  Syphilis of the mucous membranes.—The
first visible  manifestation of syphilis upon
the  mucous  membranes is  the chancre.
This  we  have  already  considered.  Next
comes the moist  flat  papule or "mucous
patch."  This lesion may appear upon the
mucous membranes of the genitals of  both
sexes, and  upon neighboring integument;
upon the lips, tongue, soft palate, tonsils,
and pharynx, and in fact any portion of the
buccal and nasal cavities.  It has also  been
met with in the external auditory canal, and
upon the palpebral con j uncti va.  T his lesion
consists of a flat elevation, varying from the
size of a split pea to that of a dime or even
larger.   Its  elevation  is  usually from ^y- 
SYPHILIS.
71
 £"  Its  surface is moist, finely  granular,
 and of a grayish aspect.  It is usually one of
 the first of the earlier manifestations of con-
 stitutional disease.  Subsequent to the ap-
 pearance of mucous patches, or sometimes
 preceding them, we may find diffuse conges-
 tions of the mucous membranes of the fauces
 and neighborhood, accompanied with a cer-
 tain amount of  irritation and  uncomfortable
 sensation.  This condition constitutes  the
 early  " sore throat" of syphilis.  This same
 diffuse congestion  may invade  the mucous
 membranes of the epiglottis, the glottis, and
 the larynx.  When it  does  so more or less
 hoarseness  and  even  complete  aphonia
 may be present.
  Beside these, and later on  in the disease,
 we are liable to encounter another peculiar
 lesion.  This may be described as a localized
 opaline or milk-white spot situated upon the
 tongue or  buccal membrane. These milk-
 spots  are  barely  if at all  elevated, and
 usually not eroded.  A single spot may ap-
 pear or several  may be  present at the same
 time.  When one is cured another crops out,
 and a succession of them not unfrequently
show  themselves throughout the secondary
and intermediate periods, and may consti- 
72       CUTANEOUS MEMORANDA.

tute the only visible manifestations of the
disease.  The use  of tobacco  and  negli-
gence in the care of the  teeth  encourage
these lesions.  In the later stages still  more
serious affections of the mucous membranes
are  liable  to appear, such  as ulcerations
about the  genitals, mouth, nose, pharynx,
larynx, etc.
  Syphilis  of the skin.—To the cutaneous
manifestations of syphilis the names syphilo-
dermata and  syphilides have been applied.
We prefer the latter term.
  Although  the different  syphilides  vary
greatly in  their aspect, lesions, and course,
they still possess certain common character-
istics.   These are color, configuration, and
the absence of local subjective symptoms.
  Color.—The color  of the  syphilides has
been likened to that of  copper, or of raw
ham, but neither resembles it exactly;  it is a
color sui generis, and peculiar to syphilis,
which must  be  seen to be exactly appreci-
ated, and is not  counterfeited by non-syphil-
itic affections of the skin, though sometimes
closely  approached in certain cases of  psori-
asis, lichen planus, and lupus.
  Configuration.—The earlier syphilides are
usually composed  of small lesions widely 
SYPHILIS.
73
diffused; the  latter, of  larger  ones, more
sparsely distributed.  The earlier ones in-
volving the skin but superficially, recover
without leaving cicatrices ;  the later ones in-
vading more deeply often exhibit a tendency
to ulceration  with consequent scarring, but
cicatrices may result even without ulcera-
tion.   The marks left  by the later syphil-
ides are usually brown, but  subsequently
become white, whiter even than the normal
skin.  The pigment is first removed from
the center of the spot, and later forms a ring
around  it just before its  final disappearance.
The white spot is thinner than the normal
skin, is  non-adherent  and quite smooth,
without the  irregularities and  puckerings
met with in scrofulous scars.
  The syphilides frequently exhibit a tend-
ency to assume a circular arrangement.  If
the eruption  consists of small lesions, they
will often be grouped   in round or  oval
patches, and  if of large  and isolated lesions,
the same  tendency will  be noticed.  A few
rounded groups of pustules may be the only
manifestation present.   The tendency of
these, unchecked by treatment, is to extend
centrifugally, healing in the center, and in
this way we  may have  a suppurating, per- 
74       CUTANEOUS MEMORANDA.

haps ulcerating ring inclosing an area of dis-
colored skin on its way to cicatricial degener-
ation.  If the lesion be an isolated ulcer, it is
usually round or oval, with perpendicular
sides and a grayish  base, the margins not ir-
regular and undermined as  in some other
forms of ulceration.  This circular configu-
ration  is observed  in but  few of the non-
specific eruptions.
  Absence  of  local subjective symptoms.—
The syphilides, both early and late, are char-
acterized by the absence of itching and pain.
The most extreme  generalized eruptions of
early syphilis  are as a rule free  from pru-
ritus and wide-spread ulceration, and if it in-
volves the skin only is unattended with pain.
The different syphilides present certain  spe-
cial peculiarities which we  will now con-
sider.
  The  further study of these affections  will
be  facilitated by  arranging or  classifying
them according to their predominant lesions,
as indicated upon p. 11.
  Macular Syphilide.—-This is the earliest
eruption of syphilis, and usually makes  its
appearance within  the first or second month
after the development of the chancre.  It
consists  of email red spots, from -j^" to \" 
SYPHILIS.
75
in diameter, scattered over the thorax, abdo-
men,  back,  and  upper  extremities.  The
macules may be  discrete or confluent, and
are usually upon a level with the surround-
ing  skin, but are sometimes slightly raised.
At first the color is rosy and disappears un-
der  pressure, but later becomes somewhat
darker  and  permanent.   The   eruption
usually lasts from four to eight weeks and
subsides spontaneously.
  Papular Syphilide.—This form sometimes
occurs by itself, at other times accompanies,
or appears just at the decline of the  last-
mentioned variety.  It consists of acuminate
or flattened elevations frequently decked
with a minute scale.   These papules persist
for  a few weeks, and  then disappear,  or
while still existing, may be complicated  with
much larger papules, in fact, tubercles.  The
papules proper exhibit no tendency to ulcer-
ate, but slowly subside, leaving after them a
small  brownish macule, which soon fades
away without leaving any perceptible alter-
ation of the skin.
  Tubercular Syphilide.—This  variety,  as
its name implies, is  an eruption  consisting
of tubercles, ranging in size from a pea to a
hazel-nut.  Their summits are usually cov- 
 76       CUTANEOUS MEMORANDA.

 ered with  a few fine scales.   They may ap-
 pear as an early or as a late manifestation.
 In  the former case, they  occur as  isolated
 lesions disseminated over the surface;  but
 when  occurring  later, they are frequently
 associated  in  circumscribed groups.  The
 tubercles disappear by absorption or by ul-
 ceration, in either case leaving a brownish
 mark behind, and a more or less evident cic-
 atrix as an ultimate condition.  When they
 ulcerate they become covered with a green-
 ish or greenish-black crust underneath which
 lies the ulcer.  This form of eruption is not
 infrequent, but is more commonly met with
 in cases of  neglected syphilis than in those
 which  have received careful and appropriate
 early treatment.  It is usually a late lesion.
  Vesicular Syphilide.—This is a rare lesion
 belonging  to  the   secondary period,  and
 usually consists  of moderate-sized vesicles,
•scattered  irregularly over the surface,  or
 collected in little groups.   Each vesicle is
 surrounded by a coppery areola; they break
 in a few days, and are replaced by thin crusts
 or  scales.  When  the crusts  are removed
 the surface beneath them is brownish red.
 This form  of eruption usually lasts several
 months, and is maintained during this period 
SYPHILIS.
77
by successive crops of new vesicles.  The
lesion is quite superficial,  on involving  the
skin very deeply, but generally leaves brown-
ish macules, which take some time to fade
away.  Occasionally, small vesicles develop
upon the  summits of papules in  connec-
tion with the early papular lesions.
   Bullous Syphilide.—This is an  exceed-
ingly rare lesion in  adults, but  is  quite
common as  a manifestation of  hereditary
syphilis  in infants.   It consists of  large
vesicles  or bullae appearing shortly after
birth, whose  favorite seat is the  hands and
feet, but they may also appear  upon  the
trunk and limbs.   It is the  so-called syphil-
itic pemphigus of infants.
  Pustular Syphilide.—Pustules  occurring
in connection with syphilis present several
varieties, as regards their aspect, course and
termination, and are among the most impor-
tant of the cutaneous lesions met with in this
disease.  They occur under three principal
forms.
  The first consists of small pustules dissem-
inated over the  surface, frequently in great
number.  Each pustule is found to rest upon
a hard and raised base, as if the upper half
of a papule had changed into a pustule.   A 
 78       CUTANEOUS MEMORANDA.

 hair  frequently runs  through  its  center.
 The course of these pustules is usually indo-
 lent; each one,  after lasting  two or three
 weeks, bursts, and its contents dry into thin
 greenish  crusts which adhere for a week or
 two longer.   Upon the falling or removal of
 the crusts we find a coppery papule with a
 depressed and perhaps  ulcerated summit.
 The papule  slowly disappears, leaving  be-
 hind a brown macule, which  in  turn gives
 place to a minute white cicatrix.  This form
 of eruption is so-called syphilitic acne.
  In the second variety we find the pustules
 larger than  the foregoing, and without the
 raised base, and as  a rule  less  numerous.
 They are  surrounded  with a tawny areola,
 without marked induration.   The pustules
 soon break, and  their contents dry in green-
 ish  or  sometimes  dark crusts;  upon  the
 removal  of the crusts superficial circular
 ulcerations will  be discovered.  These heal
 readily, but  always  leave cicatrices.  The
eruption  may persist for  several months,
being prolonged by the occurrence of fresh
pustules.  It  usually appears  during  the
latter portion of the secondary  period, and
may occur upon any portion of the cutaneous
surface, including the  scalp.  This  form is
the syphilitic ecthyma of authors. 
SYPHILIS.
79
  A third variety of pustule is met with oc-
curring in the tertiary stages of syphilis.
They are large, isolated, and scattered over
the surface, and vary in  number from  a
single  one to  thirty or forty.  These pus-
tules contain a mixture of  pus and sanious
fluid, and  soon dry into thick, dark-colored
crusts, covering a  deep  ulcer.  The ulcer
gradually enlarges and continues to  secrete
an ichorous and unhealthy pus, which like-
wise dries into a crust having a greater di-
ameter than the first one, which, still adher-
ing, it pushes before it.  This process con-
tinues, new crusts form, pushing forward the
earlier ones, until in time we have a strati-
fied  cone, half an inch or more  in  height,
projecting- from  the surface, upon  the re-
moval of  which  a  deep  ulcer with  abrupt
margins and an unhealthy base is perceived.
If the progress of the eruption is unchecked,
a fresh crust, possessing the characters of
the former, soon forms, the ulcer meanwhile
steadily enlarging.   This form of eruption
is sometimes called rupia.
  Squamous Syphilis.—We have  already
noticed the fact that papular and tubercular
lesions frequently exhibit scales  in connec-
tion with them.  In  some  cases this com- 
80       CUTANEOUS MEMORANDA.

mingling of characters is so decided that it
is hard to say which predominates, or even
to recognize the pre-existing lesions.   These
mixed forms may with propriety be termed
papulo- or tuberculo-squamous.  In addition
to these,  however, we may  have  lesions
which are  decidedly scaly from the  begin-
ing.   These true squamous syphilides con-
sist of brownish-red patches, covered with a
thin coating of scales.  The patches are usu-
ally rounded or  annular, forming circles, or
segments  of  circles and  are  very slightly
elevated above  the  surrounding surface.
The scales which cover them are of moder-
ate size,  but not -imbricated, but do not
form   very thick  laj^ers.  Usually  they
do not completely cover the coppery base,
but permit a little rim of  it to  appear
at the edge.  The scaly syphilide may  ap-
pear upon any portion of the surface, fre-
quently invading the  scalp.   It  may also
occur upon the  palm of the hand and sole
of the foot.
   Diagnosis of Syphilis.— Under ordinary
circumstances and in the majority of cases,
the diagnosis of syphilis is comparatively
easy.
  The chancre or first manifestation  of  the 
SYPHILIS.
81
disease, is to be distinguished from chan-
croid.  Mucous patches, whether occurring
about the genitals, the  anus, or the  mouth,
can  hardly be mistaken for anything else,
especially if the inguinal and post-cervical
glands are enlarged, and a chancre has pre-
existed.   It must be remembered, however,
that in females a large  proportion, if not a
majority, of chancres  pursue their course
without attracting  the attention of  the pa-
tient.  In many cases, too, their previous ex-
istence will be denied.  The various cutane-
ous manifestations  of  the disease are to be
distinguished from  non-specific eruptions by
their color, configuration, distribution, pre-
vious history, etc.  If proper attention has
been  paid to their peculiarities at the clinic,
little difficulty will in  general be  experi-
enced, as  there are but three or four non-
syphilitic  affections that  are likely to  be
closely counterfeited.   Syphilitic   roseola
may in many cases be indistinguishable from
simple roseola (rotheln) in  its objective as-
pects.  The history, however, and the course
of the eruption will usually assist the diag-
nosis.  Lichen planus sometimes very closely
resembles a papular syphilide, so closely in-
deed that even an  expert may be in doubt. 
82       CUTANEOUS MEMORANDA.

The diagnosis between a squamous syphilide
and certain not very typical forms of psoria-
sis  is also  sometimes difficult.  When the
eye cannot decide our recourse is to the his-
tory.  The squamous syphilide has probably
been preceded during a year or two by other
eruptions  differing from it  in  character;
psoriasis, by previous attacks of  the same
eruption which have appeared from  time  to
time for perhaps many years.  Some of the
pustular syphilides may resemble acne, more
particularly the  affection of the sebaceous
glands that often follows the excessive use
of  bromide  of  potassium,  the so-called
"bromic acne."   Ulcerative  lesions about
the face are sometimes difficult  to  distin-
guish from lupus.  In these cases a careful
study of the patient's history, and the ap-
pearances of former scars, if  any such exist,
are often of more value in a diagnostic point
of view than the aspect of the lesion itself.
Further, the syphilitic ulceration  has prob-
ably lasted but a few months, while the lu-
pous  disease may have been present  for
years.
  Syphilitic bone pains and  nodes present
little difficulty in diagnosis, but the affections
of the viscera and of^the nervous system will 
SYPHILIS.
83
frequently baffle the most careful and expert
diagnosticians.   In  fact a correct diagnosis
in many cases  can  only be determined by
carefully watching the effects of treatment.
   Prognosis.— The  general  prognosis  in
syphilis is good, both as regards the removal
of existing lesions, and the ultimate comfort
of the patient, in cases that are seen early in
the course of the disease, and are subjected
to judicious treatment.  On the other hand,
cases that  have been  neglected  or  badly
treated in the beginning are more difficult to
manage, and more  apt to present frequent
relapses. Besides these, there are a number
of other circumstances that  modify  the
course,  and  consequently  the prognosis.
Among them may be mentioned the general
health of the patient, his habits as regards
temperance in eating  and drinking, and his
ability to procure proper and sufficient nour-
ishment, medical attendance, etc.  His occu-
pation, if one necessitating much exposure,
may likewise influence the result.  In addi-
tion it must be remembered  that some cases
are naturally light, and that others, on the
contrary, are  particularly  severe.    These
various  elements therefore must be borne in
mind whenever we consider  the prognosis of 
84       CUTANEOUS MEMORANDA.

syphilis, either with respect to a particular
case, or as regards the  disease in  general.
The  various lesions,  too, have each  their
separate  and individual prognosis.   The
chancre is rarely more than a temporary in-
convenience.  Occasionally, however, it be-
comes complicated with phagedenic action;
and more or less  sloughing  may seriously
impair the beauty and symmetry of the af-
fected  organs.   Ulceration about  the soft
and hard palates  may permanently impair
the voice, and  be accompanied with even
more serious inconvenience.   Necrosis of the
bones may confine the patient to  bed, and
interfere for a greater or less time  with his
usual occupations.  Affections of the eye if
not promptly treated may seriously impair
vision, and  disease of the nervous centers
may produce permanent disability or speedy
death.
            ^CHAPTER XII.

         TREATMENT OF SYPHILIS.

  The treatment of syphilis must be consid-
ered under three heads :  First the hygienic,
second the specific, and third the local. 
SYPHILIS.
85
  Hygienic treatment.—The very first points
to which the physician should devote his con-
sideration are the condition of the patient's
general health, his habits, and his surround-
ings.  If his health is good, his habits cor-
rect, and  his circumstances comfortable,  it
is only necessary that these conditions  be
preserved.
  If, however, he is suffering from some pre-
vious disease,  this should be relieved, or its
effects obviated if possible.  If he  is intem-
perate, reformation is a sine qua non of suc-
cessful treatment.  Good health, good food,
good  air,  suitable clothing,  freedom  from
undue exposure to the elements, regular
exercise, and  methodical habits constitute
more than half of the treatment, and  com-
bined with proper specific medication rob the
disease  of most of its terrors.  Per contra,
the absence of these essential elements will
greatly impair the effects of otherwise judi-
cious treatment, and not unfrequently lead
to relapses annoying alike to the physician
and the patient.
  Specific treatment.—This  embraces the
use of mercury, the only known specific and
directly curative agent yet discovered, and
of the iodides of potassium and sodium, and 
86       CUTANEOUS MEMORANDA.

the chlorides of gold  and platinum, for the
relief of certain symptoms pertaining to the
later periods of the disease.
  The basis of anti-syphilitic treatment may
be expressed by a  single word,  and that
word  is  MERCURY.    That mercury when
properly administered cures syphilis is be-
yond a question ; that it is the best known
remedy for this purpose we firmly believe.
The question, however, is frequently raised
as to whether mercury, although curing the
syphilis,  may not produce effects nearly  if
not quite as bad as the original disease.
This will depend" entirely upon  the manner
in which it is administered.  Abundant ex-
perience has shown that if properly given it
may be continued almost indefinitely, with
the result of curing the disease, and without
in any  way injuring the health or constitu-
tion of the patient.  On the other hand  it
may be given in such a way as to produce
the most disastrous consequences.  Mercury,
then, is to enter  into the  treatment.  By
many it is given sparingly and with hesita-
tion, and is soon abandoned for the iodide  of
potassium.   The  majority  of practition-
ers, however,  rely pretty fully upon mer-
cury in the early  secondary stage, combine 
SYPHILIS.
87
 it with the iodide of potassium under the
 name  of " mixed treatment" in the inter-
 mediate period, and  trust  to  the  iodide
 alone in the management of tertiary lesions.
 Personally we use mercury in  all  stages,
 never  employing the iodide if it can  be
 avoided.
  An interesting and  at the  same time im-
 portant question arises at this point :   How
 does mercury cure syphilis ?   Is it by some
 alteration of the constitution of the blood,
 and the consequent induction of  nutritional
 changes, or is it by direct local action of the
 drug upon the lesion  itself ?  The former is
 the more prevalent belief, but the latter, we
 think,  is nearer the truth.   Mercury cures
 the lesions by its particles being brought
 directly in contact with them, and caderis
paribus, the larger the quantity  of mercury
 that can be made thus to act,  the sooner the
 cure, provided the remedy be used in  such
 a way as not to exhibit its own peculiar
 poisonous  effects.   Mercury, like  every
 other specific remedy, as soon as it poisons,
 ceases  to cure, and becomes in  addition a
 very ready and potent agent of mischief.
 By these two principles the treatment is to
 be guided. 
88       CUTANEOUS MEMORANDA.

  If the  lesion  under notice be  a chancre
(not a chancroid) it does not require cau-
terization,  but  instead  a local  mercurial
application, and for this purpose we know of
nothing better than the ammonio-nitrate of
mercury.   This  is a black  powder,  and
should be freely dusted upon the sore, and
renewed  as often as may be necessary.  If
this salt cannot be readily obtained,  the
following lotions  will  answer  almost  as
well:
             " Lotio  nigra."
    ]$. Hydrarg. chlor. mite.. gr. xxx
       Liq. calcis............ f § ij
       M.
  " Lotio flava 'seu'  aqua phagedenica."
  IJ.  Hydrarg. chlor. corros.... gr. xv
      Liq. calcis.................f?x
      M.
  The  bottles  should be shaken,"and the
mixture applied several times a day.
  If, in addition to  the chancre, there is in-
duration of the inguinal and post-cervical
glands and the diagnosis is absolute, give
mercury internally.  For this purpose we
prefer the protoiodide given in pill or in tri-
turation.  One grain  given  in divided doses
may be  considered the average  maximum 
                 SYPHILIS.              89

 daily allowance.  The following formulae
 will be found convenient:

    3.  Hydrarg.  protoiod.... gr. xv
  Make ninety pills.   Dose six pills or less
 per diem.

    ]J. Hydrarg, protoiod.....gr. xv
       Sacch. lactis...........gr cxl
       M.
  Divide  into  ninety powders.  Dose six
 powders or less per diem.

  In some cases it will be found that the
 protoiodide  given as  above  will produce
 symptoms  of  gastro-intestinal  irritation.
 Under these circumstances the dose must
 be diminished, or the drug combined with a
 sedative as follows :

    5 ■ Hydrarg. protoiod.... gr. xv
       Ext. lactucarii........  31
       M.
  Make ninety pills.
  Or,
    9. Hydrarg. protoiod,
       Pulv. opii...........aa gr. xv
       Sacch. lactis..........  3 ij
  Mix thoroughly,  and divide  into  ninety
powders.
  Or,
    5,  Hydrarg.  protoiod___gr. xv
        Pulv. ipecac, co.......gr. cxl
        M.
  Make ninety powders. 
90       CUTANEOUS MEMORANDA.

  Of these pills  or  powders  two may be
taken after each meal until there is evidence
of mercurial action upon the gums.  At the
very first suspicion of salivation, however,
the quantity must be diminished to four,
three, or even two pills or powders per diem.
The degree of tolerance of  mercury varies
with different patients, and  it is  frequently
necessary to  skirmish for a few  weeks,
increasing or diminishing the quantity until
the appropriate dose is ascertained.  When
this is determined it should  be  continued
without interruption, if possible, for at least
eighteen  months.  That this is  frequently
possible, we  know by experience ; that it
is desirable we  are fully convinced.  At the
end of  this time if the patient has had no
syphilitic symptoms other  than those for
which he first came under treatment, or if
he has been  for a considerable time with-
out specific manifestations,  all medication
may be  abandoned, in the hope that the
disease has been completely eradicated.  In a
considerable proportion of cases this hope is
not an unreasonable one.  This prolonged
mercurial treatment is of course not to be
thought of unless the diagnosis of syphilitic
chancre is absolute.  In cases of doubt as to 
SYPHILIS.              91
the nature of the sore, it is better to wait
for the development of secondary symptoms.
When these  appear the course just men-
tioned should be at once adopted and faith-
fully followed up for the period mentioned
with  as  few  interruptions  as  possible.
If there be mucous patches or other lesions
about the  mouth,  the trituration is to be
preferred to the pill, insomuch as the finely-
divided drug is thus brought into immediate
contact with  the lesions themselves, and by
its local action hastens their removal.   The
continued  use of mercury as here  recom-
mended is possible and practicable in a  cer-
tain number of cases.  In others, however, it
cannot be strictly carried out.  The causes of
failure are  usually due either to negligence
on the part of the  patient, or to too large
doses of the drug in the beginning.  A great
many patients, especially those of the lower
classes, abandon all treatment as soon as the
manifestations for which they sought relief
have  disappeared.   The almost  inevitable
result is, sooner or later, a relapse.   This is
again relieved by temporary treatment fol-
lowed by another relapse, until actual symp-
toms of the tertiary period appear in such a
form as to demand the use of iodide of potas- 
92       CUTANEOUS MEMORANDA.

sium or other agents for their relief.  On the
other hand, if mercury is pushed too freely
at the  start mercurial symptoms about the
mouth and even decided salivation may sud-
denly develop.  This state of affairs is to be
greatly deprecated, because in the first place
it  necessitates interruption of  the treat-
ment,  and  in the second  place  saliva-
tion is a positive evil, besides  being  a
source  of great annoyance to the patient.
If   salivation should  occur,  the mercury
must be absolutely withdrawn, and sulphur
in small doses frequently repeated is to be
substituted.   In addition the mouth should
be frequently washed  with tepid  water to
which  a little chlorate of potash and tinc-
ture of myrrh have been added.  Belladonna
and its alkaloid are also of service.   Under
the use of these means the salivation will
usually cease in a few days and buccal irri-
tation   gradually  subside.   The mercury
should not,  however, be  immediately  re-
sumed.  It is better to give some form of
iron for a  short time; Ferrum redactum
or some of the protosalts are to be preferred
to   other  preparations   of  this   metal.
When the general condition  has been re-
stored by the  tonic properties of the iron, 
SYPHILIS.
93
the mercury is to be  cautiously resumed,
and continued in such a way as not to bring
about a repetition of the former trouble. The
regulation of the dose of mercury appropri-
ate to each particular case cannot receive too
much attention at the hands of the physi-
cian.  The effort should be to give the larg-
est amount  that can be borne without the
production of gastric, buccal or other irrita-
tion ;  in other words, to overwhelm the dis-
ease without detriment to the general con-
dition of the patient.   Besides the grosser
signs of excess just mentioned, the patient's
spirits, strength, and weight will form use-
ful data for the  estimation of the  proper
amount to be given.   If, under a mercurial
course,  mental  depression  and  debility,
which are frequent accompaniments of syph-
ilis, are diminished or  relieved, the  drug is
doing good.   On the other hand, if they are
increased, something is wrong, and the  prob-
ability is that the dose is  too large.  In
cases of doubt it is safer to err on the side of
small doses than risk the larger.   In the
former case, recovery may be  a  little re-
tarded, but  no positive injury  inflicted ; in
the latter, recovery will be equally retarded
with  positive injury  in addition.   As the 
94       CUTANEOUS MEMORANDA.

same dose is not suitable in all cases, and as
there are no positive data by which it can
be determined in advance, its proper adjust-
ment necessitates close observation,  expe-
rience, and judgment.
  It will be noticed that thus far there has
been no employment of the iodide of potas-
sium.
  During the past ten  or twelve years we
have followed substantially the treatment
above described in all cases that have come
to us early in the disease, and in but few
instances (except in those  in  which the
iodide had been previously given) have we
found it necessary to employ it.   In  general
after the disappearance  of the lesions  for
which  the patient has  come under treat-
ment,  subsequent developments have been
trifling and  unimportant,  such as a few
scattered papules upon the  body or scalp,
and  milk-spots   and  superficial  erosions
about the mouth.  In no case, so far as our
notes  and  recollections serve,  have  iritis,
pustular or ulcerative lesions occurred.
  Although the protoiodide is the only prep-
aration of mercury of which we have yet
spoken, it must not be supposed that it is
the only one that is of service in early syph- 
SYPHILIS.
95
 ilis; on the contrary, it may be replaced,
 and frequently to advantage, by calomel, or
 protoxide of mercury, or by the metal itself
 in a state of minute subdivision, as found in
 blue pill, and in  triturations with chalk or
 milk sugar.
   The  foregoing  applies simply to cases of
 syphilis that come under treatment in its
 early stages.  In many instances, however,
 we will be  consulted at a later period, and
 for lesions  of  a more serious  character.
 This will often compel us  to  modify the
 treatment,  and to introduce an additional
 therapeutical agent, namely, the iodide of
 potassium.   This drug is extensively  em-
 ployed in  syphilis,  more  frequently, we
 think, than it should  be.  Its popularity is
 due principally to the  fact that it exerts a
 very prompt control over certain manifesta-
 tions of the disease,  and to the idea  pos-
sessed  by  many that  its effects upon the
system are  less  injurious than those of mer-
cury.   This opinion  we cannot altogether
share.  The iodide, however, has its special
functions to perform,  and under certain cir-
cumstances is  indispensable;  but  before
employing  it we must understand exactly
what it is  capable of  effecting.   Mercury 
96       CUTANEOUS MEMORANDA.

cures the disease, and by so doing removes
the cause that produces the various symp-
toms; the iodide, on the other hand, relieves
certain symptoms with wonderful rapidity,
but does not eradicate their cause.  In other
words relapses are far more frequent after its
use than after the judicious employment of
mercury.  The conditions to which it is ap-
propriate are affections of the periosteum
and bones, extensive ulcerations, gummata,
and affections of the nervous system.  In
cases accompanied  with severe periosteal
pains, the aid of the iodide may be invoked
for the relief  of this  symptom, a relief
which if given  in sufficient doses it usually
affords.   In  cases of extensive ulceration,
or other processes involving the integrity of
important organs and where there is not time
to wait for the more tardy action of mercury
or when this latter is contra-indicated by the
patient's general physical condition,  the
iodide should be used promptly and  freely.
The  cutaneous erruptions and ulcerations
pertaining  to  the  tertiary  period  disap-
pear  more  rapidly  under the use  of  the
iodide singly, or combined with the mercury
than  under  the  use  of  mercury  alone.
The  size of  the  dose  will depend   some- 
SYPHILIS.
97
 what upon the  patient's  previous famil-
 iarity with the  drug.  The less  he has
 taken on former occasions  the less he will
 probably need, and vice  versa.  In  the for-
 mer case, a dose of five to ten grains  three
 times a day will  usually be  sufficient.   It
 shoidd be given in an abundant menstruum,
 either water or some simple syrup agree-
 ably flavored,  or with the compound syrup
 of sarsaparilla, or  with the  compound tinc-
 ture of cinchona, if a tonic  is needed.  It is
 generally advisable to give mercury in ad-
 dition.   This may  be ordered separately, or
 in combination with iodide.  In the latter
 case the vehicle or menstruum should not
 contain  an alkaloid, as the probable result
 would be the precipitation of an iodo-hydrar-
 gyrate of the alkaloid.  In  this case, unless
 the mixture is well shaken,  the patient will
 get little or no mercury in the earlier doses;
 but as he  reaches  the bottom of the bottle
 will get more mercury than  he bargained
 for.  This  accident we have  several times
 known to occur.  In early syphilis the proto-
 salts of  mercury  are usually  preferred ;
but in  late disease,  especially  when used
 with the iodide, it is the almost  universal
custom to employ the persalts, the bichloride
       4 
 98       CUTANEOUS MEMORANDA.

 and biniodide  being  the favorites.   These
 may be given ordinarily in doses of gr. ^j—Ta2
 three times a  day.  Under this  treatment
 the lesions under consideration will usually
 improve  in  a  satisfactory  manner.  As
 soon as they have disappeared, the iodide
 should be  discontinued, and a persalt of
 mercury be given in small doses  for a con-
 siderable period.  If the patient  is already
 habituated to the use of the iodide  before
 coming under treatment, somewhat larger
 doses than those mentioned may be required.
  In cases of  extensive or advancing ulcera-
 tion about the tongue,  soft palate or fauces
 the iodide is  required,  and in considerable
 doses.  No definite dose can be named.  The
 drug must be pushed until it checks the prog-
 ress of the lesion, which it will usually do
 if enough of  it is  given.   As  soon,  how-
ever, as the trouble is checked and fully un-
der control, a persalt of mercury should be
prescribed,  and the iodide gradually dimin-
ished and finally abandoned, the mercury
being continued for a few months longer.
  In lesions of the nervous system also, our
chief dependence is upon the iodide.  If the
symptoms are not  urgent the drug may be
given in moderate doses of  about 15 grs. 
SYPHILIS.
99
 three times a daj'.  If the trouble, however,
 is grave, the dose must be rapidly increased.
 When the symptoms are finally mastered,
 the iodide is gradually diminished and sup-
 plemented by mercury.
  From the above it will be seen that mer-
 cury and iodide of  potassium hoth  have
 important roles to fill in the management of
 syphilis.    Their  properties  and  powers,
 however, are not identical, as many seem to
 think, and consequently they are not inter-
 changeable. They cannot be given one for
 the other, in the hope of attaining the same
 end;  but each must be used accordingly to
 the  special indications  of the  case, the
 iodide to relieve symptoms and lesions in
 the later periods of  the disease; mercury
 to cure  the disease itself in  all its stages.
 The  foregoing are  the   principal  agents
 to be  employed  in  the specific  treat-
 ment of syphilis, but a few words are neces-
sary in regard to their administration.  As
a rule, mercury  is  given by  the mouth ;
when, however, the stomach or bowels are
particularly irritable, the drug may be used
hypodermically,  or by fumigation.   In  the
former case, the bichloride orbicyanide may
be employed ; in the latter, calomel. 
100       CUTANEOUS MEMORANDA.

  Local treatment.—If the views previously
expressed (p. 87), to the effect that mercury
cures syphilis in consequence of the particles
being brought  into direct  contact with the
lesion, are true,  it is to be expected that
local treatment,  when practicable, will be
exceedingly useful, and play an important
part  in  the management   of. the disease.
These expectations are fully verified by clin-
ical experience.
  The local treatment of the chancre has al-
ready been considered.  The mucous patch,
whether of the  genitals or of the mouth, re-
quires  local  applications.   The  most effi-
cient agent for this purpose is the acid nitrate
of mercury.  One or two  applications are
usually sufficient to dissipate patches  of or-
dinary size.  If this is not available, the
bichloride of mercury may be employed in a
plain one per cent solution, or dissolved in
collodion. Milder preparations, e.g., calomel,
black-wash, etc., are less  painful and less
efficient.   Nitrate  of zinc in  stick  form,
though not acting in a specific manner, will
cause  rapid disappearance  of  the  lesion.
Papular and tubercular lesions,  especially
about the face  and other exposed parts, de-
mand  speedy removal.   This may be best 
THE SCROFULIDES.
101
effected by daily friction with ungt. hydrarg,
ungt. hydrarg ammon., or hydrarg. oleat.
five  per cent.  In  ulcerative lesions, the
crusts  should be  removed, the ulcers  well
cleansed, and  gently  touched  with  liq.
hydrarg. nitrat.,  and  afterward  dressed
daily with  the protoiodide in ointment as
follows:
    1$. Hydrarg. protoiodidi  1.  (gr.xv)
       Cerati..............  30.  (§j)
       M.
  In many cases of extensive ulceration, or
of inveterate disease, the most prompt re-
sults are frequently obtained by means of
mercurial fumigation, by  inunction with
mercurial ointment, or by hypodermic in-
jection.  One or the other of these methods
is  of course imperatively demanded when
the  administration of  mercury by  the
mouth  produces irritation of the gastro-
intestinal tract.
            CHAPTER XDI.

            THE  SCROFULIDES.

  Under this designation we shall describe
certain  affections  that appear to depend in 
102      CUTANEOUS MEMORANDA.

great measure, if not wholly, on the scrofu-
lous diathesis.  They  include the  different
varieties of  lupus and  also the  affection
known as phlegmonous scrofulide or scrofulo-
derma,  phlegmonusum, together with the
affection described by Hebra under the
name of Lichen scrofulosorum.
  General Characters of the Scrofulides.—
These affections present a number of  gene-
ral characters which separate them as a class
from other cutaneous affections, and which,
if properly  appreciated, will  enable  us in
most instances to recognize them without
difficulty.  While some varieties are more
superficial than others, they all attack the
true skin beneath the  epidermis, and may
even penetrate to a considerable depth be-
low it.   Their color is usually a reddish vio-
let; less brown than eruptions of syphilis,
and not as  red  as  that of an acute dermic
inflammation.  Their course is exceedingly
chronic, and  usually painless.  They some-
times ulcerate,  but not always.  In either
case, however,  they leave indelible  scars.
The ulcers if present do not  display the
round  clean-cut appearance of  syphilitic
ulcers,  but are  more irregular in  outline,
and with uneven borders.  The bottom of 
THE  SCROFULIDES.
103
the ulcer may be fungous and bloody, or
with pale, unhealthy, and sometimes exu-
berant  granulations.   The  crusts  which
cover the ulcers are  thick, but  not very
hard, and of a greenish-black color.   Crusts
in some cases form  even in the absence of
ulceration.   In  others,  instead  of crusts,
there are fine adherent scales.
  The progress  of the scrofulides is slow ;
uncured cases of twenty or more years' dura-
tion are not infrequently seen.   Occasionally
they recover spontaneously, but their usual
course is to spread for an indefinite  period
unless arrested by proper treatment.  The
superficial varieties  cause deformity from
the  cicatrices which  follow  them.   The
deeper varieties  may terminate fatally.

                LUPUS.
  Definition and description.—Lupus  is a
chronic, non-contagious,  destructive disease
of the skin, characterized by  extreme ob-
stinacy and liability  to relapse.  Of this dis-
ease there are three principal forms, differ-
ing from each other in certain particulars,
but yet  presenting  several important feat-
ures in  common.   These are color, config-
uration,  location,  course, absence of pain 
104      CUTANEOUS MEMORANDA.

and  pruritus, difficulty of cure, and termi-
nation.
  The prevailing color of lupous lesions is
not the frank red of an acute congestion or
inflammation nor the coppery red of syphilis,
but rather a violaceous red, with a shade of
copper.   It disappears under the finger, re-
vealing, the instant the finger is removed, a
somewhat yellowish hue, to be replaced a
moment later by the color that was present
before pressure was applied.  The  color is
that which we would expect in a part con-
taining more than the normal  quantity of
blood, but  in which the circulation  was
sluggish, without, however, absolute stasis.
Sometimes  the  lesions present a somewhat
translucent  appearance, like  that  which
characterizes gelatinous bodies.
  In configuration, lupous  lesions  usually
exhibit a circular form, extending centrifu-
gally, not with the absolute circularity of
trichophytosis, but showing  a  strong tend-
ency to it whenever the  anatomical form
of the parts on which the lesion is  located
will  permit.  Irregularity of configuration,
dependent on location, is sometimes mark-
edly shown in connection with some forms
of lupus  of the  nose, in which the entire 
THE  SCROFULIDES.
105
lesion may assume the appearance of a but-
terfly with extended wings.   On the upper
eyelid the lesion takes a linear or oval form,
the long diameter corresponding with fur-
rows of the lid.  On  the ear the patch  is
very irregular in outline.
  The favorite location  of lupus is the face.
The nose, cheeks, the neighborhood  of the
eyes, temples,  forehead and  ears, may be
primarily affected or become the seats of
later  lesions.  I   have  also  met with  it
on the scalp and on the  penis.  It may also
appear on various parts  of the general
surface,  usually,  however,  in  connection
with, or  subsequent to  the development of
the disease on the face.
  With a rare exception to be mentioned
later, the course of the disease is essentially
chronic, and cases will be met with in which
it has continued for five, ten, twenty, and
even a greater number of years.
  As a rule, there is neither pain nor pruri-
tus.  Sometimes the patient, on being asked,
will state that there is slight itching, but
I have never seen scratch-marks or other
evidence  of severe pruritus.  If the lesion be
extensive, a sensation of local heat is some-
times complained of. 
106      CUTANEOUS MEMORANDA.

  The  difficulty of cure is proverbial, and
has been recognized from the earliest times.
There  is no  known internal remedy  that
can be depended on to stop the progress  of
the affection in its various forms.  Cures by
internal medication have been reported, but
the failures have far outnumbered them.
External treatment is more promising, and
of late years has been brought to a degree of
perfection that enables the surgeon to state
that the great majority of  cases seen within
a reasonable period after  their commence-
ment are permanently curable ; except those
in which the underlying diathesis is so pro-
nounced that fresh outbreaks  on parts other
than those  first affected, continually occur,
to the  great  annoyance of the surgeon and
the discouragement of the  patient.
  Except when the affection terminates in
death,  there is always a  scar left to indicate
the site of the previous lesion. This is  true
both of ulcerative and non-ulcerative forms.
  The  three  principal forms of  lupus are
Lupus erythematosus, L.  vulgaris  and L.
exedens, the first two of which present cer-
tain sub-varieties. 
            THE SCROFULTDES.         107

  Lupus  Erythematosus. — Erythematous
Lupus first appears as a small, reddish mac-
ule, in its earliest beginning  presenting  no
features  that are sufficiently characteristic
to enable its true nature to be distinguished.
It slowly increases, and when it attains a
diameter of  a quarter of an inch or so,
it can  be  readily  made out  as a very
slightly  elevated patch of  peculiar  color,
dry, and sometimes a little scaly.  The fine
scales  are not  imbricated  like  those  of
psoriasis, nor loosely attached like those of
pityriasis.  On the contrary, a small speck
of  the  stratum corneum partly  loosens,
presenting a free and unattached edge; but
if traction be made, it will  be  found that
the remainder of the scale is quite adherent.
These partly detached  scales may be found
all  over the  patch,  in some cases more
freely developed than  in others, but never
heaped  up in strata, as  in psoriasis.  The
patch continues to extend, and in four or
five years, sometimes sooner, may reach  an
inch in  diameter.  As a rule, before it quite
reaches  this size,  a  change  commences in
the centre ; the color become less marked ;
the elevation subsides, and  the skin looks
thinner even than normal. In other words, 
108       CUTANEOUS MEMORANDA.

atrophic changes in the skin are going on,
and  the ultimate  result is the replacement
of what was once normal  skin by a white,
depressed  cicatrix.   As these alterations
proceed, the lesion still extends at its pe-
riphery, and we have presented an annular
infiltration slightly raised above the normal
skin outside it, and above the cicatrizing
skin within.   These processes may go on
from year to year until the  patch has in-
volved a large extent of surface, half the
face for instance,  and during  the entire
period there may be no ulceration.  Mean-
time, other patches may form and increase
in size for an indefinite period.  Sometimes
the  extension  of  the patch ceases spon-
taneously,   and,  after  undergoing   the
atrophic changes   mentioned, its  seat  is
occupied  by a blanched,  depressed  scar.
This cessation of morbid action is rare, and
can never  be predicted  beforehand.  The
principal  diagnostic points  on  which  to
rely  are the color, the slight scaliness, the
chronic  course, and the tendency to  scar-
ring.    The  only  affections  liable to  be
mistaken   for  it  are chronic  erythema,
scaly eczema, and syphilis.   The absence of
infiltration in the  first of  these  should be 
THE SCROFULIDES.
109
sufficient to distinguish it from lupus.   In
eczema the history of  the eruption and its
special features,  together with  the  total
absence of all tendency to the formation of
cicatricial tissue, should make the diagnosis
clear.  A papulo-squamous syphilide might
somewhat resemble an erythematous lupus,
but the lesions in the former disease would
be far more numerous, they would not have
lasted  any great length of time, and  the
history of  the case and concomitant symp-
toms would probably be sufficiently distinct
to clear up  any doubts.
  Prognosis.—The prognosis of erythema-
tous lupus is good  so far  as any  given
lesion is concerned, provided it is not already
too extensive, as in the majority of cases it
can be controlled.  A  much  more  difficult
undertaking,   however, is to  prevent  the
appearance of fresh lesions at other points.
  Lupus Vulgaris.—The  typical lesion of
Lupus vulgaris in its early stage is a soft,
indolent, elastic tubercle of a yellowish or
brownish violet color, and with a  somewhat
translucent aspect.   The tubercle may exist
alone, or may form one of a group of  eight
or ten.  A  single group may be present, or
several others may  be present on different 
110
CUTANEOUS MEMORANDA.
parts.   The  lesion is exceedingly  chronic,
but gradually enlarges, and after attaining
           Fig. 6.—lupus vulgaris.
a certain size may  persist indefinitely  in 
THE SCROFULIDES.         HI
 that condition, and  finally  undergo resolu-
 tion  and  disappear, leaving  after  it a
 depressed cicatrix.  More commonly,  how-
 ever, superficial ulceration  occurs, and the
 lesion  becomes  covered with a darkish
 adherent crust or scab.   When this is re-
 moved  the ulceration is revealed.   In a
 short time it is covered  with a fresh crust,
 and each time that this is removed—and
 some patients have a habit of frequently
 picking them off—the ulceration is found to
 be  more extensive than  before.  The  ulce-
 ration extends superficially, involving, per-
 haps, the entire thickness of the skin, but,
 in this  form of lupus,  not going beneath
 it.  Occasionally a good  deal of infiltration
 occurs beneath  the  group of tubercles, and
 newly formed connective tissue makes its
 appearance,  the whole  giving rise to  an
 elevated or protuberant mass, to which the
 name of hypertrophic lupus has  been ap-
 plied.  Sometimes, on the other hand, well-
 defined  tubercles  do not  appear to have
 time  to  form, but degenerative  action
commences early,, and we have a group of
pustules soon crusting over and covering an
ulceration  of considerable  extent.    This
process goes on more rapidly in this than in 
112     CUTANEOUS MEMORANDA.
the other form, and the floor of the ulcers
is sometimes covered with irregular granu-
lations simulating a warty or papillomatous
       ^Fig. 7.—lupus and epithelioma.
growth.  To  this condition the name Ver-
rucous lupus is sometimes given. 
THE  SCROFULDDES.
113
  Diagnosis.—The only disease with which
Lupus vulgaris is liable to be confounded is
syphilis.  In  the latter disease the lesions
are more apt to be generalized, and their
progress  is much  more rapid.   In a few
weeks syphilis might entail a loss of tissue
that would require months or years of lupus
ulceration to  effect.  The ulcers of syphilis
have  much more sharply cut margins than
those of lupus, and the amount of discharge
is usually greater, and it possesses a peculiar
disagreeable odor not met with in the latter
disease.
  Prognosis.—The prognosis is  much the
same as that of  the erythematous.   If
taken in hand early, it may be eradicated
without very much difficulty. The tendency
to relapse, either at the site of the original
lesion, or at  other points, is not so great, I
think, as in the  other form.  On the otlier
hand epithelioma  sometimes develops on
the site of a long-standing lupous ulcer-
ation.   In  the transition period  it is not
always easy  to  determine the actual pres-
ence  of  epithelioma.   When,  however,
this   disease is frankly  developed,  its
characters are too distinct  to be mistaken.
  Lupus Exedens.—This disease commences 
114      CUTANEOUS MEMORANDA.

by the appearance of a soft tubercle, which
slowly but gradually increases in size until
it has attained the volume of a pea or small
hazel-nut.  By this time a crust will have
appeared on its summit.  On its removal an
ulcer  will be exposed.   This gradually in-
creases both as to area and depth, and after
a time, five or ten years perhaps, the tubercle
will have disappeared, and in  its place  we
find a more or less extensive  ulceration,
characterized  by  irregular,  overhanging
margins of  nearly normal or even less than
normal consistence, with perhaps a softish
tubercular development similar in character
and appearance to the original tubercle.  As
the ulceration advances  not  only the skin
but also the tissues beneath it are destroyed,
leading to great disfigurement of the affected
parts.  During the progress of the affection
additional and, not rarely, symmetrically
developed tubercles may  appear and slowly
degenerate into ulcers.  Before, however,
these secondary developments have attained
any great size the patient will probably have
succumbed.  In my own experience, phthisis
pulmbnalis has been the usual termination.
After a time, in some cases, the  morbid
action appears to change, and an epithelio- 
THE SCROFULIDES.
113
matous condition supervenes, evidenced by
everted and hardened margins, and more or
less  pain.  As a rule, Lupus exedens, pure
and simple, is not specially painful.  A por-
tion  only of the ulcer may  become epithe-
liomatous,  the  remainder  preserving its
primitive lupoid features.
  There are but three of the commoner af-
fections with which Lupus exedens could, by
any  chance, be confounded.   These are,
Syphilis, Lupus vulgaris, and Epithelioma.
In the  first instance the  duration  of  the
lesion is sufficiently characteristic.  In an
early stage of Lupus exedens I must confess
I do not know of any pathognomonic sign
by which it may be distinguished from an
early condition of Lupus vulgaris.  In a late
stage the depth of the ulceration is sufficient.
From epithelioma it is to  be distinguished
by the character of  the primitive nodule, of
the margin, the course  and the frequently
multiple lesion, the pain, finally by the mi-
croscopical appearances. In lupus the nod-
ule is softer than the surrounding normal
tissue, in epithelioma it is harder; in  lupus
the margin is  irregular and  often under-
mined and  not hardened ; in epithelioma it
is thickened, looking as if everted and hard. 
 116       CUTANEOUS MEMORANDA.

 In lupus the progress is very slow, in epithe-
 lioma more rapid; in lupus there may be
 several lesions in different stages of develop-
 ment, in epithelioma there is rarely  more
 than a single lesion ; lupus is comparatively
 painless, epithelioma is frequently painful.

          TREATMENT OF  LUPUS.
  The extreme difficulty of successfully com-
bating many, if not most, cases of Lupus,
necessitates a very thorough consideration
of every point  bearing on the subject.  In
this, as in all chronic affections, the hygienic
surroundings of the patient should first be
inquired into.  Is he living under the best
conditions possible ?  If not, is it practicable
to improve them ?  These points being satis-
factorily settled, we come to what may be
termed  the etiological treatment, that is to
say,  the management  of the underlying
scrofulous diathesis.  In many instances this
diathesis does not present very pronounced
features, and less attention may be  paid to
it, and the ultimate prognosis may be re-
garded more favorably.  On the other hand,
the most obstinate and continually relapsing
cases are those in which we find  the  most
marked evidences of constitutional impair- 
THE SCROFULIDES.
117
ment.  The drugs that are supposed to be
most useful in this connection are cod-liver
oil and preparations of iodine and iron.
  Besides what may be termed the etiologi-
cal  treatment, additional  internal medica-
tion will often be advisable,  and energetic
local treatment will,  in most, if not in all
cases, be requisite.  The importance of local
treatment will be appreciated when we con-
sider the fact that we are dealing with le-
sions which tend  to gradual extension and
involvement of new regions by an  appar-
ently infective process  similar to, but less
in degree than that manifested by cancer.
This infective quality is evidenced  by the
fact that, if a patch of lupus be incompletely
destroyed, the disease will most certainly re-
turn.  The plain  indication, then, is to re-
move the lupous  infiltration as soon and as
thoroughly as possible.  From these general
considerations we pass to  treatment of the
different forms of the disease.
  Treatment of Lupus Erythematosus.—In-
ternal  treatment  first requires notice.  So
far as I am aware, we possess no medicinal
agents capable of exerting a specific or elec-
tive influence over the lupous process. It
does not follow, however, that benefit will 
118      CUTANEOUS MEMORANDA.

not ensue from the judicious use not only of
the drugs already mentioned, but  also of
some others.  Phosphorus is certainly capa-
ble of influencing the disease, but it is a two-
edged sword that must be  handled with
great circumspection.  It is not wise, how-
ever, to  rely on internal treatment alone,
but in conjunction with it suitable  local
measures should be employed.   The meth-
ods of local treatment at present in vogue
endeavor to accomplish one of three  objects
—either to  produce absorption of the lupous
cells, to destroy them in situ, or  to  remove
them mechanically.
Fig. 8.—vidal's lupus scarifier.
  The most reliable modes of treating the
disease are the scarification plan of Vidal,
and the scraping and cauterizing treatment
of the author.   M. Vidal's method is a small
scarifier of  the shape and size shown in the
cut (Fig. 8).
  With  this instrument the diseased skin is
cut in parallel lines of about ^" apart.  At
the end  of a week the cuts are renewed, but
at an angle with  those  previously made. 
THE  SCROFULIDES.
119
This is continued week by week, until the
infiltration is destroyed and ceases to be re-
produced.
  The method devised and advised
by the author consists  in the use
of  the dermal curette (Fig.  9),
followed by the actual, or a power-
ful  potential cautery.  With the
curette the diseased surface is thor-
oughly scraped.   The  infiltration
will break down like old  cheese,
while the normal integument will
resist the  action  of  the scraper.
When  as much  of the  infiltration
as possible has been thus removed,
and the surface  of the traumatic
ulcer thoroughly cleaned and dried,
a potential caustic,  or  the  actual
cautery, should  be applied.  This
is necessary, as  it is impossible to
remove, by scraping alone, all of
the lupous cells ; some of them at
the margins  of  the  infiltration
extending  into  the   apparently
healthy  adjacent skin.   Of the
potential caustics, the chloride of
zinc, alone, or mixed with an equal   fig. 9 —
quantity of  the solution  of the™™^™- 
120      CUTANEOUS MEMORANDA.

chloride of chromium, is, on the whole, so
far as my experience goes, the most satis-
factory.  The caustic being applied, a little
absorbent cotton (as much as will  stick to
the part) is pressed on, and the wound  left
to take care of itself.   In from two  to three
weeks, sometimes longer, the crust will be-
come detached,  and the whole or  greater
part of the lesion will be found healed, or in
a healing condition.  The caustic is some-
what painful, and the swelling and  reaction
greater with the mixed chlorides than with
the zinc alone.   The mixture, however, ap-
pears to me to be more effective than either
of the chlorides  used by itself.  The actual
cautery (Paquelin's), however, is for several
reasons better than the potential.  First, the
pain, except at the moment of application,
is much less ; second, the slough separates
more quickly ; third, the part heals sooner ;
fourth, there is less local reaction ; and fifth,
a  better scar results.   The lesion  having
been properly scraped and dried, the Paque-
lin is brought to as near a white heat as pos-
sible, and slowly moved over the surface, be-
ing  kept in  contact with the tissue long
enough to produce an eschar about ^y or a
little more in thickness.  A bit of absorbent 
THE SCROFULIDES.
121
cotton is then applied, and without further
dressing the wound is left to take care of
itself, which it will usually do in the most
satisfactory manner.
  Treatment of Lupus Vulgaris.—This vari-
ety demands much the same treatment as
the one  previously described. *
  Treatment of Lupus Exedens.—The treat-
ment of this form of lupus is  to be con-
ducted on the same principles as hold in the
other varieties.   When the lesion is of com-
paratively small size, as in the first years of
its existence, it should be extirpated, if pos-
sible, with the knife.   If, for any reason,
this is impracticable,  scraping, followed by
the actual or potential cautery, will give the
best temporary  result, and  also the best
guarantee for the future.
  When, however, the lesion has already
attained a large  size, as two inches or more
in diameter, and extends deeply beneath the
corium, the condition may almost, though
not  absolutely,  be regarded as  hopeless.
The question of the amount of scar or de-
formity to be left after surgical interference,
no longer enters as an element to be consid-
ered in  deciding the character of the opera-
tion,  which should be thorough  and radicri 
122     CUTANEOUS MEMORANDA.

in the extreme.  Both the curette and the
knife must be brought into play, and every
ramification and trace of the disease be re-
moved, so  far as it can be mechanically.
After the  bleeding has ceased,  and the
wound cleansed, the parts should be thor-
oughly cauterized, preferably, I think, with
the pure chloride of zinc, and  the  cavity
packed with absorbent cotton.
  In two or three weeks the slough will have
separated, and if the patient  be possessed of
sufficient vitality—and he should not be op-
erated on  unless he does—a healthy ulcer,
with tendency to heal,  will  present itself.
In a few weeks more, however, there may
be at one or more points indications of re-
lapse. These must be immediately attacked,
and, by carefully watching for and destroy-
ing these  fresh  outcroppings, the surgeon
will be able, in a certain number of cases, to
control the disease. In this, as in all  the
varieties of lupus,  one  general statement
may be made, and this is  that half-way
measures do more harm  than good.  Attack
the lesion  in the most vigorous manner, or
leave it entirely alone.
     SCROFULODERMA PHLEGMONOSUM.
  This affection occurs almost always on the 
THE SCROFULIDES.
123
 face.  I do not recollect having seen it else-
 where. It commences with a little tumor
 taking its rise in the corium.  The tumor
 usually has an oval form, and gradually in-
 creases in size, reaching at length that of an
 almond, or a little larger.  The skin cover-
 ing the tumor presents a violet, reddish, or
 livid hue.   Little by little the tumor softens,
 and  the skin  becomes thinner and thinner,
 until at last it breaks, giving exit to an ill-
 conditioned scrofulous pus.  A crust forms
 over  the  opening,  damming  up the fluid,
 which, after a time, breaks out anew at the
 same or at some other point.   This process
 continues until several openings are made,
 which uniting, form an ulceration of greater
 or less extent,  and possessing  the usual
 scrofulous characters.  These abscesses may
 be single  or  multiple, and their number is
 variable.  This condition of affairs may pro-
 gress for months or years before final  cica-
 trization occurs.   The scar,  at first viola-
 ceous, ultimately becomes white, irregular,
and  reticulate.  In some cases the abscess
 does not open, but the pus is absorbed with-
out the occurrence of  ulceration ; but even
in these a violet spot remains for a  long
time, to  be  ultimately followed  by a de- 
124      CUTANEOUS MEMORANDA.

pressed and puckered scar.  Successive crops
may prolong the affection for years.
  This form of disease possesses such well-
marked characteristics, that it ought never
to be mistaken for abscesses occurring in the
subcutaneous  connective tissue  or in  the
glands.  As a rule, other plain indications
of the scrofulous diathesis are manifest.
  The prognosis will depend on the prompt-
ness with which judicious treatment is un-
dertaken.  If left entirely alone the ulcera-
tions will ultimately heal, but not until after
the lapse of many months, and considerable
scarring is the inevitable result.   If, how-
ever, the lesion be treated promptly and
properly, a much better result may be ob-
tained.
  Local  treatment, however, is  not to be
neglected. If the nodules have not yet  soft-
ened, they may sometimes be made to dis-
appear by the use of Ungt. Iodinii, or Ungt.
Potassii Iodidi.  If they have already  soft-
ened, and contain pus, remove this by aspi-
ration with a hypodermic syringe ; inject  a
few drops of tincture of iodine,  and apply
pressure.  If this fails, lay open the abscess
freely,  scrape its  cheesy walls  with   the
dermal curette, and apply tincture of Iodine,
Carbolic  acid, Liq. Hydrarg. Nitratis,  or 
           THE SCROFULIDES.         125

Ungt. Hydrarg. Biniod.  An application of
one of these may be sufficient to induce the
formation of laudable pus, after which sim-
ple applications should be employed so long
as matters  proceed favorably.  If stimula-
tion is again needed it should be employed.
Instead of the drugs mentioned, the actual
cautery, after scraping, may be employed.
This has, on the whole, given me the best
results.   The  affection  requires energetic
local treatment, and the sooner it is under-
taken the less will be the amount  of subse-
quent scarring.

         LICHEN SCROFULOSORUM.
  This affection, first clearly described  by
Hebra, consists in an eruption of miliary
papules of a pale  yellow or reddish-brown
color, though  sometimes the normal hue is
preserved.   The  papules are  disposed  in
groups, sometimes forming circles or seg-
ments of circles, beyond which pigmentary
macules, marking the site of earlier papules,
may occasionally be seen.   The little eleva-
tions are always  covered with fine scales.
Pruritus  is  insignificant.    The  papules
promptly attain  their maximum develop-
ment, but then persist unaltered  for a long 
126      CUTANEOUS MEMORANDA.

time.   At last they gradually undergo reso-
lution  after having  existed for months or
even years.   Sometimes tubercles, resem-
bling  those of acne, and which may go  on
to suppuration, develop in the neighborhood
of the papules. The horny layer of the epi-
dermis between  the groups of papules ex-
foliates in fine scales.  Each papule is situ-
ated at the orifice of a hair-follicle and forms
an elevation consisting of  a mass of horny
cells.  These cells contain a larger amount of
entangled fatty matters than usual.   After
removal  of  the  semi-globular  epidermic
mass,  which constitutes the papule, the open
mouth of  the piliferous follicle may be per-
ceived with the  naked  eye.  The eruption
may occur upon any part of the body, and
be more or less generalized.  In about ninety
per cent, of the  cases met with by Hebra,
other  scrofulous lesions, as enlarged lym-
phatic glands, peri ostites, caries, etc., were
encountered.
  This disease is  exceedingly rare in this
country,  as I have met with but three well-
marked cases. In these, however, the  af-
fection was readily diagnosticated in conse-
quence of  the  typical character of  the
lesions, recalling, in the most exact manner, 
THE SCROFULIDES.
127
 the description given above!  I know of no
 other affections with which it might be con-
 founded.
  The prognosis is good.  All of the cases
 treated by Hebra recovered, as did the ones
 under my own observation.
  Treatment.—Hebra recommends the use
 of cod-liver oil, both internally and extern-
 ally.  He commences with an ounce, morn-
 ing and night, on an empty stomach.  Lo-
 cally, he applies the oil with a liberal hand,
 so as to  keep  the affected parts constantly
 saturated with it.   At the commencement
 of treatment four frictions a day should be
 employed, and the parts covered with flan-
 nel ; later, two  in  the  twenty-four hours
 will  be sufficient.   He  found warm baths
and vapor baths prej udicial. The diet should
be nutritious and highly  nitrogenous, and
proper hygienic conditions should be en-
forced.  I have  nothing to add  to this ex-
cept the addition of other antistrumics, as
iodide of iron, etc.

              EPITHELIOMA
  As  cancer is considered by many to be
a constitutional  disease, and as the epithe- 
128      CUTANEOUS MEMORANDA.

lial form in many respects resembles lupus,
we shall consider the affection in this place.
  Epithelioma of the skin is a tumor origi-
nating in the stratum Malpighii, and charac-
terized by  a tendency to increase in size, to
invade adjacent  tissues,  both  superficially
and  deeply, and  to destroy them, and ulti-
mately to destroy the life of the individual
that bears  them.   The growth commences,
generally speaking, as a proliferation down-
ward of the cells of the interpapillary por-
tions of  the  stratum   Malpighii.  These
downward  roots  or shoots assume various
forms.  After a time the rapid  increase in
the number of new cells and the circumfer-
ential  pressure  of  the  surrounding  con-
nective tissue compels them to occupy the
least possible  amount of space.  This they
seek to accomplish by arranging themselves
in concentric and  stratified layers, constitut-
ing the stratified cell-nests, or " epidermic
globes " of histological writers.  Thus firmly
compressed they form  little  microscopic
masses, which, when a number of them are
aggregated, give rise to a tubercle or nod-
ule,  the peculiar  characteristic of which is
hardness.   After  a time, probably as the re-
sult  of pressure and deprivation of nutrient 
EPITHELIOMA.
129
material, these nodules "break down," that
is, undergo a necrobiotic process,  which
leads to ulceration.  This process continues,
and the amount of tissue-destruction is lim-
ited only by the degree of vital endurance
possessed by the patient.
  Epitheliomata, however, are not all alike,
either in their behavior or mode of  origin.
Sometimes they appear to arise spontane-
ously and  without apparent cause;  some-
times, on the other hand, they are second-
ary  developments  arising  as  sequels  to
chronic and long-continued local irritation.
Some  epitheliomata   invade  the  tissues
deeply and infect the neighboring lym-
phatic glands, others  confine their ravages
to the cutaneous tissues proper.  Some run
a rapid course, others exist for years before
acquiring a very large size.  They vary also
as regards the grade of malignity exhibited
in different cases, slowly corroding superfi-
cial one spossessing this feature to a much
slighter degree than the others.
  Treatment.—Extirpation is the first thing
to be thought of, provided the case is not so
far advanced that ultimate recovery is hope-
less, or even temporary alleviation improb-
able.  If an operation is admissible it should
          5 
130     CUTANEOUS MEMORANDA.

be performed as early and as thoroughly as
possible.   When the lesion is conveniently
situated and fairly circumscribed, excision,
including  a broad margin of  surrounding
tissue, appears  to  me to be the most judi-
cious procedure.  When more diffuse or ir-
regular, caustics may be employed, or exci-
sion of a part or the whole followed by the
caustic application.  The caustic employed
may be either Vienna paste, sulphuric acid
paste, one or more of the caustic chlorides,
or arsenic.  The former are active destroyers
of tissue, but exert no poisonous influence
on the system.  The last is energetic to  a
degree, exceedingly painful, and in a num-
ber of instances its application has been fol-
lowed by fatal  poisoning.  Of the various
modes of using arsenic that of  Marsden  is
perhaps the best.  His method is as follows :
"A thick paste of arsenic is made according
to the following formula :
     5. Arsenious acid..........   3 ij.
        Mucilage of gum acacia..  3 j.
  To be well mixed together, and made into
a thick paste.
  "The patient's  health having  been at-
tended to, the whole of the cancerous  sur-
face is to  be spread over with this paste, 
EPITHELIOMA.
131
provided it is not more than a square inch,
and the paste must be sufficiently thick not
to run ;  a piece of dry lint is then pressed on
to the part, overlapping the paste half an
inch all round ;  this must be left for a short
period, say ten minutes, by which time any
superabundant paste will  have been taken
up by the extra lint, which is then to be
carefully cut away with  a sharp pair of
scissors; in  an hour, or at  most two, the
lint covering the paste will  have become
dry and hard, and it will adhere closely and
firmly  to the  cancer.  In  the course of
twenty-four hours  the surrounding parts
will commence to swell, become red, and to
a certain extent inflamed, and the patient
will experience a drawing pain.  In general,
this is by no means severe, and does not last
more than one or two days.  At the expira-
tion of from forty-eight hours to three days,
according to circumstances, bread and water
poultices are to be  constantly applied  and
changed every two or three hours ; the pain,
redness, and swelling will by this time have
subsided, and a distinct line of demarcation
be seen extending entirely around the can-
cerous  mass ; the skin ulcerates, and a  fis-
sure is formed, separating the slough from 
132      CUTANEOUS MEMORANDA.

the healthy tissues ; the fissure continues to
deepen, until the entire cancer comes away,
leaving a healthy cup-like depression vary-
ing in size and depth according to the mass
removed.   Healthy granulations will now
commence, and it will be well  to continue
the poultices for some time ; indeed it often
happens that no other application need be
used."
  As regards the use of internal remedies
little can be said.  Besides tonics and robor-
ants to improve the general condition, ar-
senic, as  a specific  remedy, is  almost the
only one that  need be  considered.  This
drug certainly appears to have been useful,
and in fact curative in a few cases of pre-
sumably  malignant  disease, but whether
these cases were genuine epitheliomata can-
not be determined.
            CHAPTER  XIV.
                LEPROSY.
  Leprosy, though a rare disease  in the
United States, is occasionally met with and
therefore merits notice.  By English writers
it is usually called Elephantiasis Grarorum,
and by continental authors, Lepra. 
LEPROSY.
133
  The disease presents three principal vari-
eties, namely, the Tubercular, Macular, and
Anaesthetic.  The  symptoms of these vari-
eties usually commingle in varying propor-
tions in different cases.  Before the symp-
toms of leprosy become sufficiently distinct
and characteristic to be recognized as such,
we  commonly  find  a prodromal  stage of
greater or less,  often of years' duration.   In
this  stage there is nothing to particularly
attract attention to leprosy, and  the only
evidence of ill-health may be  a feeling of
languor or  loss of force,  with sometimes
mental depression.  Occasionally  a brown-
ish  discoloration (macule),  or an isolated
bulla, may  appear from time  to time, the
first  one usually healing before the second
makes its appearance.  Later  the macules
become more abundant and larger, from the
size of a coin to that of a hand ;  but it is
difficult to appreciate with the fingers any
thickening or  infiltration.   The patches at
first  are of a reddish-brown, and as they in-
crease peripherally their  advancing border
retains this color, while  the  centre  aud
other  portions gradually lose it  and fade
into  a dirty gray, and sometimes to  dead
white. 
134     CUTANEOUS MEMORANDA.

  Sometimes these spots may disappear en-
tirely without leaving any mark.  When the
spots first appear they are commonly hyper-
cesthetic, but as  the disease progresses this
condition  gradually disappears, and ulti-
mately the white patch becomes completely
anaesthetic.  This  is readily explained by
the early congestion and subsequent destruc-
tion of the finer nerves.  In company with
the macules, or without  them,  tubercles
may arise.   These are thickened elevations
of the skin,  sometimes quite circumscribed,
at other times more diffuse, but commonly
without much discoloration.  At first they
may be hyperaesthetic, subsequently becom-
ing anaesthetic.   They appear, upon  any
part of  the body, but very frequently make
the face their favorite  seat, showing them-
selves above the eyebrows, about the lips,
and upon  the ears.  When they are devel-
oped to any great extent, they render the
features repulsive and disgusting to  the last
degree.   The  tubercles frequently persist
throughout  the whole course of the  disease
but sometimes undergo ulceration, or disap-
pear by interstitial atrophy and absorption.
Accompanying the tubercles there may be
patches of skin  which are anaesthetic, but 
LEPROSY.
135
which exhibit no other change.  This anaes-
thesia may be temporary or permanent.
  The anaesthetic form of leprosy may arise
as a late stage in the course of a case which
at the  beginning had exhibited tubercular
features  mainly,  or  it may occur without
such previous tubercular development. The
principal cutaneous lesions met with at the
commencement of  this form  are  bulla.
These vary in size, and  persist  for a short
time only.   Commonly  they  rupture,  dry
up, and leave a stain which after a time be-
comes  anaesthetic.  Hyperaesthetic patches
of varying extent may appear from time to
time, and persist  for months or longer, and
be ultimately succeeded by anaesthesia. The
anaesthetic portions of skin may also undergo
a certain degree of atrophy, which proc-
cess may involve  the subcutaneous tissues,
and result  in  ulceration,  and,  if situated
upon hands or feet, to caries of the bones.
  Treatment.—We  are hardly justified in
calling leprosy incurable, in view of the  fact
that in some cases the progress of the dis-
ease has undoubtedly been stayed.  In the
majority of cases temporary alleviation and
retardation  of its progress is quite possible.
The drugs which appear to have the great- 
136      CUTANEOUS MEMORANDA.

est influence in this direction are  Oleum
Gynocardii and Nux Vomica.  The former
is used internally in doses of ten  to thirty
drops, and externally in the form of an oint-
ment.  The nux vomica is given internally
in full doses.  The treatment must be main-
tained for many months.  The drugs above
mentioned  may be used in alternation, giv-
ing each for a month at a time, and then re-
placing it by the other.
            CHAPTER XV.

              ICHTHYOSIS.

  This is one of the rarer affections of  the
skin, and of much less importance than the
disease last described.  To  the naked  eye
its prominent characteristic appears to be
an excessive development of epidermis ;  and
in the anatomical classifications it is placed
by the side of  psoriasis and pityriasis in the
class of squamous diseases.   As a rule,  ich-
thyosis is developed in early life, even a few
months after birth, though  exceptionally it
may appear for the first time after adoles-
cence.  Once  fairly established, it is rarely 
ICHTHYOSIS.
137
cured, but persists indefinitely, and usually
during the whole  life of  the patient.  It is
markedly hereditary, and frequently affects
several members of a family.
  Ichthyosis manifests itself in the begin-
ning by great dryness of  the skin, with ex-
cessive production of horny cells ;  but, as a
rule, there  is at first little change  in  the
color of the skin ; that is to say, the skin is
not reddened.  The natural lines of the skin
are deepened and become more manifest,
mapping  out the surface into little areas,
plainly visible to the naked eye,  which,  un-
der ordinary circumstances, could only be
perceived with the aid of a lens.  The  dry
and scaly condition of the skin would at first
suggest the idea of  pityriasis; but a more
careful examination shows that the constant
fine, bran-like desquamation, so prominent
a feature  in pityriasis, is absent in ichthy-
osis.
  Later, as ichthyosis advances, the masses
of epidermis become much thicker, and sep-
arated into little  hillocks, as it were,  by
numerous  lines and  fissures.  The fissures
extend through the epithelial accumulation,
but do not generally invade the rete or  the
derma, and hence are not accompanied with 
138      CUTANEOUS MEMORANDA.

the oozing  found in some other affections.
The color of the surface changes  also, be-
coming  tawny, dark, and at last almost
black.   This  is due not so much to pig-
mentary discoloration  of the skin  proper.
as to  accumulation of  dust and dirt among
the epidermic  scales.   Finally, in a fully-
developed case, we have a more or less gen-
eralized  epidermic hypertrophy of  dark as-
pect, and everywhere seamed by cracks and
fissures, interfering sorely with the comfort
of the patient.  A remarkable peculiarity of
this disease  is the diminution or absence of
perspiration.  In many cases this function
is merely diminished, in others it appears to
be totally absent.  This is undoubtedly due
either  to congenital absence or defective
formation of the sudoriparous glands, or to
their early atrophy.
  Prognosis.—As a rule, the local difficulty
is never wholly remedied.  A cure may gen-
erally be considered out of the question, and
the affection expected  to annoy the patient
to a greater or less degree during his entire
life.  A certain amount of relief, however,
may be afforded by treatment.
  Treatment.— The first therapeutical  in-
dication is to remove the scales.   This may 
ICHTHYOSIS.
139
 be done by daily, or twice daily frictions with
 green soap, aided by alkaline, hot  air, or
 vapor baths.  After the frictions with soap
 and the baths, the skin should be thoroughly
 rubbed with some emollient.   A very excel-
 lent formula for this purpose may be pre-
 pared as follows:
 1$  Potassii iodidi.................  |j.
    Ol. pedis bubuli,
    Adipis......................aa  § ijss.
    Glycerini......................  f 3 j.
    M.
  Instead of this we may use cod-liver  oil,
 egg oil, or sperm oil.  After we  have suc-
 ceeded in removing the scales and getting
 the skin in a tolerably fair condition, if  we
 stop treatment,  the  morbid condition will
 soon return as bad as ever.  It will there-
 fore be necessary to continue treatment in-
 definitely, by the more or  less frequent use
 of alkaline and Turkish baths with daily in-
 unctions.   Jaborandi, by  stimulating the
 sudatory function, produces decided  ameli-
oration.   By these means, and  by these
alone,  the condition of the patient may be
rendered quite comfortable, so long as they
are persisted in. 
140     CUTANEOUS MEMORANDA.
NON - DIATHETIC  AFFECTIOXS.
            CHAPTER  XVI.

              ERYSIPELAS.
  Definition and  Description.—Erysipelas
is  an inflammatory affection of the skin,
more frequent on the  face than elsewhere,
characterized by heat, intense redness and
swelling, and a tendency to the formation
of vesicles  and bullae, and usually accom-
panied with more or less febrile disturbance.
The affection having once appeared, spreads
rapidly and  may involve a large extent of
surface, the entire face for instance, in two
or three days.  It usually reaches its height
in about a week, after  which, if everything
goes favorably, it begins to decline, and by
the end of the  second week or sooner, the
swelling and redness will have disappeared,
and the horny layer of  the epidermis be in a
desquamating condition.   The disease  al-
most invariably runs  an  acute course, and
terminates in, at the most, three weeks. 
ERYSIPELAS.
141
  Diagnosis.—The  features  presented by
erysipelas are so characteristic that there is
little difficulty in diagnosticating the affec-
tion.
  Prognosis.—The disease, in the great ma-
jority of cases, terminates favorably, in a few
cases fatally.
  Etiology.— Although  erysipelas is a very
common disease, its etiology is by no means
clear.  In the majority of cases careful ob-
servation  has shown that it follows some
lesion of continuity, and it is supposed by
many that this is always the case.   In some
instances, however, this previous lesion can-
not be demonstrated.
  The treatment that we have found  most
useful embraces the use of three important
remedies.   These are  aconite, belladonna,
and quinine.   The first of these is given in-
ternally at the outset  of  the disease, while
the fever is high or increasing.  It should
be given in rather full doses, and continued
until  defervescence commences.  At the
same time belladonna  should  be used ex-
ternally, the affected parts being thoroughly
anointed once or twice daily with a mixture
of equal parts of belladonna ointment and
lard,  The belladonna may be pushed  until 
142      CUTANEOUS MEMORANDA.

its specific effects on the throat are appar-
ent.  It should then be diminished.  After
defervescence commences quinine in moder-
ate tonic doses is of great service in promot-
ing a prompt convalescence, 
REFLEX  AFFECTIONS.
            CHAPTER XVII.

                  ACNE.

  Acne is an  inflammatory disease of the
sebaceous glands, affecting by preference, if
not exclusively, those which  are connected
with rudimentary hairs, and  is usually lo-
cated on the face, neck, chest, or back, or on
two or more of these localities at the same
time.  It is characterized by papules, pus-
tules,  tubercles,  and  indurated  nodules,
which,  on  disappearing,  may  leave cica-
trices.   It affects  both sexes, and is most
common between the  fifteenth  and forty-
fifth years, corresponding to the period of
most active sexual life. Its course is usually
chronic, and when untreated may persist for
years.   The principal varieties  are Acne
Vulgaris and Acne Indurata. The former
of these is most frequently met with in early
life, and may be said to consist in an erup-
tion of small or medium-sized discrete pap- 
144      CUTANEOUS MEMORANDA.

ules or pustules, not surrounded by much
infiltration,  but  frequently  accompanied
with comedones.  This affection may pass,
by  insensible  gradations,  into Acne Indu-
rata, which consists of larger papules, tuber-
cles, and pustules, with reddened, infiltrated,
and hardened bases, and more or less sur-
rounding congestion and infiltration.
  The  diagnosis is  usually  easy,  the only
affections with which it is liable to be con-
founded  being a papulo-pustular or  tuber-
cular syphilide, a papular  eczema, rosacea,
lupus, and certain medicinal rashes.
  From syphilis it  can be distinguished  by
the previous history, duration, and in early
syphilis the more or less general diffusion of
the lesions over the whole body.  In late
syphilis the lesions most nearly resembling
an indurated acne usually exhibit an ulcera-
tive tendency.   A papular eczema  of the
face may sometimes closely simulate a mild
Acne vulgaris.  In  the former affection the
papules do  not necessarily correspond to
the sebaceous follicles, and, besides,  if the
eczema has lasted  for  any length of time,
there is usually more interpapular infiltra-
tion, and a disposition  to the formation of
scales.  Advanced rosacea is frequently com- 
ACNE.
145
plicated  by acne, but when existing alone
and  in an early stage  is characterized  by
localized congestions, not specially  involv-
ing the sebaceous glands.  In some cases of
superficial lupus a plentiful development of
papules might suggest an acne, but  in acne
the  individual  lesions usually run  their
course in from one to three or four weeks,
while in  lupus they persist for months.
  We have placed  acne in the group of  re-
flex  affections, in consequence of a firm be-
lief that  in the great majority of instances
it  is not a primary condition,  but one de-
pendent  on irritation, derangement, or dis-
ease of other organs reflected on the  skin.
The  organs specially involved are those con-
nected with  the sexual and digestive sys-
tems.  Acne vulgaris is pre-eminently a dis-
ease of youth, frequently first showing  itself
at the inception  of puberty, or shortly after,
and  lasting, with varying severity, for sev-
eral  years.  In young adolescents there is
little doubt that it is often connected  with
too frequent  sexual excitement, more  espe-
cially of  an unnatural kind.  In  young
women menstrual irregularities play a not
unimportant  role.   In  one case it may be a
scanty or deferred menstruation ; in another, 
146      CUTANEOUS MEMORANDA.

a too frequent or profuse one, and in still
another  more or  less dysmenorrhcea.  In
other cases again these functions  may be
performed in a comparatively normal  man-
ner, but  constipation or dyspepsia  is  pres-
ent, and  seems to constitute  the principal
etiological factor.
  Acne Indurata  is more common  in  older
persons.   In women it is most frequently
due to menstrual  or gastric trouble, while
in men its origin  must be sought in gastro-
enteric or hepatic derangement, the latter
not rarely due to excessive use of spirituous
beverages.
  Treatment of Acne Vulgaris.—The first
point to be considered is the probable cause
of the eruption, and the means best  adapted
to its removal.  A detailed consideration of
these will take us too much  out of our  way.
The next point to be looked  into is the gen-
eral  hygienic condition of the patient.  If
there is  room for improvement in  this re-
spect it should certainly not  be neglected.
Fresh air, exercise, diet, etc., should be duly
regulated, and any habits that are  prejudi-
cial to health should be corrected.   Atten-
tion  to the foregoing may  involve the em-
ployment  of  tonics,  neurotics, emmena- 
ACNE.
147
gogues, etc.   Among  the first, cinchona
and its derivatives are, I believe, rarely in-
dicated, except when the condition calling
for the tonic treatment is the result of ex-
cessive menstrual or seminal losses, or is de-
pendent on malarial poisoning.  Iron, if pre-
scribed, should be given sparingly and for
short periods only, for if given in excess and
for too long a time it is capable of producing
anaemia,  and  is  even credited with  the
power  of exciting an acneform eruption.
Nux vomica  and  strychnia  are tonics,
peptics, and  neurotics,  and may often be
usefully employed ; so also the bromide of
potassium may prove useful as an anaphro-
disiac and sexual sedative, but its special in-
fluence on the sebaceous glands  should not
be overlooked, and care should be taken that
it  does not  do more harm than good.  If
menstruation be deficient, any of the well-
known emmenagogues may be employed,
the  blue  cohosh  (Caulophyllum  thalic-
troides) having given me great satisfaction
in this connection.   Functional  dysmen-
orrhaea is sometimes promptly relieved by
Pulsatilla or viburnum opulus, and menor-
rhagia by  ergot.   The regulation of the
bowels by laxatives, etc., when necessary, 
148      CUTANEOUS MEMORANDA.

should be borne in mind.  All this should be
regarded  as preliminary, and brings us to
the direct treatment of the eruption, which
treatment will be either internal or external
—or, better, a combination of both.
  The remedies specially interesting in con-
nection with the direct internal treatment
of Acne vulgaris are arsenious acid, bromide
of arsenic, sulphide of calcium, and sulphur.
The action of these drugs is by no means the
same, and the indications for their employ-
ment are  far from being  identical.  While
making this statement, it must be under-
stood that the writer is not prepared to pre-
sent their several indications with the pre-
cision that might be desired.   Literature is
almost  silent  on the subject, and personal
experience (too  often deceptive)  is  the
writer's main guide to the differential selec-
tion of the drugs mentioned.    Arsenious
acid has  appeared best adapted to those
cases in which the papular element was the
most prominent, the papules being- indolent,
not very painful, and slowly pursuing their
course to resolution  without  changing to
pustules.  Sulphide of calcium, on the other
hand, is best adapted  to cases characterized
by a plentiful development of sensitive and 
ACNE.               140
painful papules, rapidly becoming pustules,
which pursue a somewhat acute  course.
The greater the tendency to pustulation, the
more strongly  the sulphide is indicated.
The  bromide of  arsenic occupies a middle
ground between arsenious acid and sulphide
of calcium,  and is probably adapted to a
greater number of  cases than the drugs just
mentioned.  Sulphur has always enjoyed a
certain measure of repute in the treatment
of acne,  but I have rarely found it of ser-
vice  except in a  few  extremely  indolent
cases, in which doses of from five to fifteen
grains, alone, or mixed with bitartrate  of
potassium, have appeared to excite a bene-
ficial influence.   Ergot in doses of 20 minims
of the fluid extract, continued  for several
weeks, is sometimes extremely useful.  The
external treatment of Acne vulgaris should
go hand in hand with the internal.  Recol-
lecting that the lesion of acne runs a defi-
nite  course, the progress of lesion should
be hastened as much  as. possible.  An in-
flamed papule having appeared, it, on the
one  hand, remains a papule for a week  or
two, and then gradually undergoes resolu-
tion  without  suppuration, and gradually
disappears—or it  may change into a pus- 
150      CUTANEOUS MEMORANDA.

tule, the pus appearing at  its summit—
sometimes  more deeply.  After  the pus
       is discharged, the lesion gradually
       disappears, leaving a slight macule,
       which in turn fades away.   In either
       case the duration of the lesion may
       be materially shortened.  This may
       be accomplished by freely  incising,
       or rather puncturing, each advanc-
       ing lesion with a lancet point.  The
       slight bleeding that follows  should
       be encouraged by  fomentations  of
       icarm  water.   This to be  followed
       by applications of water as hot as it
       can be borne, and which should  be
       repeated two or three times  a day,
       each application lasting five  or ten
       minutes.   The patient is  then  di-
       rected to procure a proper  lancet,
       one with a guarded point is  prefer-
       able (Fig. 10),  and to puncture every
       new  lesion  as  it   appears.    As
       comedones frequently co-exist with
       Acne vulgaris, they should be next
       disposed of.   This  accomplished,
lance,  various ointments  and lotions  are
of service, the most useful of which, in my
experience,  are  Ungt. Hydrarg.  Ammon.,
 
ACNE.
151
Ungt. Sulphuris,  Ungt. Sulphuris Iodidi
diluted, and lotions containsng a little Hy-
drarg.  Chlor.  Corros. (gr.  j.—ij. to  the
ounce), or sulphur.  An admirable applica-
tion  is  precipitated  sulphur,  intimately
mixed with three or four times its weight of
any simple toilet powder.  All that is really
needed is a mildly stimulating application,
and one not strong enough to produce much
irritation.
  Treatment  of Acne Indurata.—The pre-
liminary treatment will be the same as in
the other form.  That  is to say, the causes
of the affection must be inquired into as
minutely as possible.  Hygiene and the gen-
eral health of  the patient  should receive
careful  consideration, and all obstacles to a
cure should be removed so far as practicable.
The direct internal treatment is in the main
the same as  in the preceding variety.   Ar-
senic and sulphide of calcium are to be used
on  the  same  indications  as already laid
down, but in addition valuable  service is
sometimes rendered by mercury,  phospho-
rus, and the  iodides of potassium and sul-
phur.  This is  especially the case when the
eruption is subacute with large  tubercles
and much surrounding infiltration.  The ex- 
152      CUTANEOUS MEMORANDA.

ternal treatment involves the employment
of scarification and hot water, if the lesions
exhibit an acute character. If subacute, act-
ively irritant applications are more useful.
Of these the Sapo Viridis is one of the most
important.  This  should  be applied every
night to the affected parts until a consider-
able  degree  of  irritation is  produced—as
much, in fact, as  the patient can conven-
iently bear without too  much  suffering.
When this limit is reached, the applications
of the soap are discontinued, and emollients
used until  the artificial inflammation shall
have subsided.  When this has taken place
it will be generally found that the original
infiltration and induration are lessened.  An-
other series of green-soap applications are
then  to  be  made  in the same manner,
and after subsidence of the irritation to be
followed by another course,  if necessary.
When the whole or greater part of the infil-
tration disappears and the tubercles levelled
down, as it were, lotions  of sulphur, etc.,
will  prove serviceable in combating  the
remaining  hyperemia.   Instead  of Sapo
Viridis,  ointments  containing  Hydrarg.
Bichlor.,   Hydrarg.   Biniod.,   Potassii
Iodid., Sulphuris Iodid., etc., may be em- 
COMEDO.
153
 ployed.   The object sought in these appli-
 cations  is the  substitution of an artificial
 inflammation which tends to a spontaneous
 subsidence, and usually results in a benefi-
 cial modification of the pre-existing lesions.

                  COMEDO.
             Syn. : Acne punctata.
   Definition and  Description.—The term
 Comedo is applied  to a condition in which
 the  skin, especially of the face, is studded
 with little black  points looking like grains
 of gunpowder.   These points indicate  the
 opening of  the  sebaceous follicles, and  the
 black speck itself is caused by the dirt which
 has been entangled in the external extremity
 of the plug of sebum which fills the follicle.
 If the skin in the  neighborhood  of  these
 points be firmly compressed, the sebum will
 be forced out of the follicle in the form of a
 little worm-like  body.   Comedo, then, is
 simply a condition in which the sebum is re-
 tained in the follicle for  an unusual length
 of time.   This distends the follicle, and the
 longer  the   retention is  maintained  the
larger the follicle becomes.  The process, as
a rule, goes  on without giving rise to any
special local  irritation, and nothing marks 
154      CUTANEOUS MEMORANDA.

the progress of the affection other than an
increase  in the size and number of the af-
fected glands.   Occasionally inflammation
ensues, and a papule, or, perhaps, a pustule
forms, giving rise to a common form of sim-
ple acne.  Comedo  occurs most  frequently
in young persons, of both sexes, from the
age of puberty to the twenty-fifth or  thir-
tieth year. It is  rarely seen in those more
advanced in life.
  Course.—The progress of  the affection is
slow and indolent, and if uninterrupted by
treatment is frequently prolonged for years,
gradually becoming less evident, and finally
disappearing entirely.
  Diagnosis and Prognosis.—As Comedo is
totally unlike any other affection of the skin,
its diagnosis offers no difficulties.  The prog-
nosis, however, is not so easily decided.
  While in-some cases proper treatment will
produce prompt amelioration and total dis-
appearance of the  eruption, in others  the
most careful  and persistent efforts are fol-
lowed by continual and annoying relapses.
  Etiology.—The affection consists, as above
stated, in retention of  the sebum with en-
largement of the sebaceous follicles, and de-
pends, we believe, in the majority of cases, 
COMEDO.
155
on gastro-intestinal or genital irritation ;  in
fact, on the same causes as acne simplex,
which has already been considered.  Mas-
turbation, in particular, we are satisfied, has
much to do with the continuance and ag-
gravation, if not the origin of the affection.
  Treatment.—Attention should be given to
the general health if this seems to be in any
way disordered.   Dyspeptic conditions, an-
aemia, and constipation, are sometimes pres-
ent, and both the general condition and the
local difficulty sometimes  improve rapidly
under the use of  small  doses of iron, nux
vomica, and sulphur, continued for two  or
three weeks or longer.  If  masturbation be
a complicating feature, the habit must, of
course, be abandoned.  It is not, however,
an  easy matter to determine whether this
practice is indulged in or  not,  as direct in-
quiries on the subject are usually fruitless.
If the question, however, can be positively
determined, phosphoric acid  and ergot are
likely to prove of service.  The principal in-
dications for local treatment are to remove
the sebaceous plugs and to stimulate, if pos-
sible, the functions of the skin.  The im-
pacted sebum may be removed by squeezing
the skin around  the follicle between the 
156      CUTANEOUS MEMORANDA.

nails, or more readily  with the aid of a
watch-key.   This very common device is
objectionable, as  the sharp corners of  the
watch-key tube may cut into the skin, and
incite inflammation, leading to  the forma-
tion of an acne papule.   A much better way
is to use a little instrument that I have do-
vised  for  the purpose,  and which is here
shown (Fig. 11).
FlG. 11.—COMEDONB EXTRACTOR.
  The little circular ring at the end  of the
instrument is placed over the comedo and
gentle pressure is made.  This will  gener-
ally cause the plug to emerge from the fol-
licle.  Sometimes, however, it requires con-
siderable pressure to  effect this;  more,  in
fact, than it is prudent to exert or the pa-
tient cares to endure.  This difficulty can  be
remedied by first distending  the mouth  of
the follicle with the point of a needle, and
afterward applying- the instrument.
  If the  affection be at all extensive and the
comedones  numerous, the  physician can
teach the patient how to use the instru-
ment, and then abandon this part of the 
ROSACEA.
157
treatment to  the  latter's  own  care.  The
patient, with the aid of a looking-glass, can
thus, in a few seances, free himself, at least
temporarily,  of the  greater  part  of  his
trouble ; and by resorting to the operation,
from time to time, when necessary, keep his
face in  a very presentable condition, until
the tendency to the return of the affection is
broken up, or of its own accord deserts him,
which it will usually do in four or five years
from its first appearance.

                ROSACEA.
  Definition and Description.—Rosacea, at
its commencement, is characterized  by the
appearance of small reddened  macules, or a
diffused, reddened  patch  on  the nose or
cheeks, or both. The redness gradually ex-
tends until after some months,  or perhaps
years, a considerable part of the face may
be  involved.   The  principal characteristic
at this stage is a diffused superficial redness,
without much, if any, infiltration.  In this
condition the  affection may persist indefi-
nitely, and perhaps never go beyond it. More
frequently, however, it passes on to the sec-
ond stage, characterized by the  appearance
of  minute blood-vessels.   As the disease 
158      CUTANEOUS MEMORANDA.

progresses, these vessels  increase in size,
both as  to  length and breadth,  and fre-
quently become tortuous and varicose.   At
the same time the integument itself thick-
ens, and occasional  pustules  arise.  These
are generally seated in the sebaceous glands,
and are in reality an acne secondary to the
rosacea.   They are rarely, however, a prom-
inent feature of the affection, and should be
regarded as accidental  complications due to
the extension of  the morbid action from the
surrounding tissues  to the glands.  This
second, or varicose, stage of rosacea is like
the first, of gradual development, often re-
quiring years, but still  progressing with
slow but  steady step.  In some  cases the
affection halts in this  stage ;  in others the
morbid action continues, and is accompanied
with infiltration of the cutaneous tissues.
This may result  in very great thickening of
the integument,  and in severe cases lead to
decided hypertrophy and deformation of the
nose, which is the  part most liable to be the
subject of this form of rosacea.  This thick-
ening and hypertrophy may be uniform, or,
more frequently, somewhat irregular,  bud-
ding out in different  places  into rounded
elevations or tubercles.   These are  not 
ROSACEA.
159
 proper  acne tubercles,  but projections  of
 the general  integumentary tissues, includ-
 ing, of course, many sebaceous glands.  The
 large and tortuous veins which character-
 ized the  second stage are also present  in
 this, but the red color, so prominent in the
 earlier periods of the disease, in many cases
 disappears in great measure as the hyper-
 trophic changes advance.  Rosacea may oc-
 cur at any period of adult life, but, as a rule,
 does not become developed to any great ex-
 tent until middle age or later.
  Treatment.—The first step in the manage-
 ment of rosacea is to ascertain the exciting
 cause.  This done, the next is to remove it,
 if possible.   If the patient is dyspeptic, or
 suffers  from habitual constipation,  these
 conditions must be relieved  by measures
 that need not be here considered.
  If the liver seems at fault, mild  chola-
gogues, in small doses and long continued,
are often  of  decided service.  If spirituous
indulgence appear to be the principal cause,
it is of course necessary that this should be
corrected.  If uterine disorder appears to be
at the root of the trouble, this sometimes re-
quires the special arts of the gynecologist
for its removal, at other times may be vastly 
160     CUTANEOUS MEMORANDA.

benefited by a little simple medication.  For
instance, an amenorrhoea, due to anaemia,
may sometimes be removed by the judicious
use of iron, sometimes by arsenic ; if  ma-
larial complications  are present, the same
drugs, or  quinine or eupatorium, may be
more advisable.   If neither  anaemia nor
malaria be present,  the  amenorrhoea  may
often be relieved by direct uterine excitants.
  I may further state that I have, in a num-
ber of instances, vastly improved and some-
times cured rosacea by internal treatment
alone, and without recourse to any external
applications whatever.  In many cases, how-
ever, this  can hardly be done, or at least not
so quickly as by the judicious use of topical
measures  in  addition.  The  selection  of
these, however, will depend in great meas-
ure on the stage and condition of the erup-
tion at the time it comes under notice.  If
acne be present as  a  complicating lesion,
this should be first disposed of in the way
already indicated.  This accomplished, we
find ourselves face to face with, in the first
stage, a  chronic congestion  of the   skin.
Local depletion, by scarification, and hot
fomentations  are of special benefit, as also
the method of Hebra,  which consists in the 
URTICARIA.
161
use  of  green-soap or alkaline  soap-spirit,
followed by lotions containing sulphur.  In
the second stage, the first thought should
be directed to getting rid of the tortuous
and varicose veins.  This may be most con-
veniently done by using a fine-pointed gal-
vano-cautery, the fine point of  a Paquelin
cautery, or an ordinary needle, heated to
redness, or by  electrolysis.  Scarification
and the soap treatment should follow.
  In the third or hypertrophic stage, when
the skin has acquired an enormous increase
in thickness and  extent, it may be reduced
by excising portions of it, or by electrolysis,
or by puncturing it freely with the cauteriz-
ing point of either the galvano- or Paquelin
cautery.  The writer has employed all of
these methods, and in addition has obtained
very decided  shrinkage of  hypertrophic
noses by the use of the galvanic  current.
            CHAPTER XVTH.

               URTICARIA.

  Urticaria is an affection usually character-
ed by the sudden development of  white 
162      CUTANEOUS MEMORANDA.

or red elevations called wheals, accompanied
with heat and  pruritus.   Sometimes these
symptoms precede  the eruption,  and the
irritation to which  they give rise leads  to
rubbing and scratching, which  speedily in-
duce the lesions mentioned.  Once out they
may last a few  minutes only, or persist for
a few hours  and even for a day or two.   In
some cases they may appear and disappear
several times in a day.  The wheals may  be
few or numerous, and the affection may ter-
minate after the first crop have disappeared ;
more frequently, however, there  are  re-
newals of eruption for a few successive days,
and  in  some cases  this may be kept up for
weeks or months, constituting chronic urti-
caria.
  The  pruritus attending  an outbreak  of
urticaria may be intense, and  lead to the
formation of unmistakable scratch-marks,
and  these indeed may be the only visible
lesions  at the  time the  patient visits the
physician.  In many persons suffering from
urticaria,  even in  the absence of  actual
eruption, if the finger-nail or a pencil point
be sharply drawn across the skin, a  white
line, soon  becoming red and elevated, will
appear. This lasts for a short time and then 
URTICARIA.
163
disappears.   Almost every portion  of  the
surface may be the seat of wheals, though I
have never seen it on the palms or soles, or
upon the scalp.  In  some cases the appear-
ance of the wheals  is preceded by oedema,
especially of the face, hands and feet. This
may last a few days  before giving place to
the  characteristic lesion.   Occasionally the
wheals may present a purplish appearance,
due  to extravasation of blood, constituting
an Urticaria hemorrhagica. The stains last
for some days after the wheals disappear.
Severe urticarial attacks, and especially the
cedematous  form, are sometimes accom-
panied with febrile.
  If  the patient offers for inspection verita-
ble wheals no difficulty can arise  in deter-
mining the nature of the affection.  If, how-
ever, the wheals are absent, and nothing but
scratch-marks are present, the  history of the
case will  give the  necessary information.
In the cedematous form the presence of a
burning heat and pruritus will probably give
a clue to what may be expected.
  The eruption we are speaking of must of
course not be mistaken for the somewhat
similar one caused by contact with the com-
mon nettle (Urtica dioica, or urens). 
164      CUTANEOUS MEMORANDA.

  The prognosis is always good, as the acute
form can be  brought to a speedy termina-
tion, and the chronic,  as  a rule,  no  less
surely  but more  slowly; at least this has
been my own experience of late years.
  Urticaria is undoubtedly a reflex affection,
and in acute cases can usually be traced to
disorder of the gastro-intestinal  tract from
errors of diet—certain foods, as shell-fish, be-
ing especially liable in some persons  to in-
duce an attack.  In chronic cases the gastro-
intestinal and hepatic organs, and in woman,
uterus and  ovaries, are not  unfrequently
the starting-point of the trouble.  In some
instances, however, we will not be able to
find sufficient evidence to convict any of the
organs mentioned.
  I have tried  most of  the methods men-
tioned by authors, and have settled down to
the following, which rarely disappoint me :
In an acute attack give ten grains of Ipecac.,
or its equivalent in fluid extract, every ten
minutes, until  free emesis is secured.  As
soon as  the patient recovers a little from
this, place him in a  Turkish bath and let
him  remain  there till free diaphoresis oc-
curs, after which shampoo and dry him.
This usually breaks up an attack.  If it does 
ZOSTER.
165
not a second application of Ipecac, and the
bath  will  almost surely succeed.  In the
chronic form, careful search should be made
for the exciting cause.   If uterine, appropri-
ate treatment must be adopted, together
with Turkish baths.  If the cause be gastro-
intestinal or hepatic, a dose of calomel or
blue-pill, followed by  a suitable cathartic,
should  be  first ordered.  This should then
be followed  by small  doses of almost any
one of the efficient cholagogues, either alone
or combined  with small  doses of arsenic or
nux vomica.   Turkish baths two or three
times a week should also be taken.  Outside
of large cities the Turkish bath  cannot be
readily  obtained.  In  default  of  this, free
diaphoresis, by some other means, should
be obtained.

                 ZOSTER.
  Zoster is an affection characterized bjr the
development of a cluster or clusters of mod-
erate  or large-sized vesicles on  a circum-
scribed  patch or  patches of inflamed skin.
When there  are two or more patches, they
are arranged in a line, and the line follows
the course of the principal nerve-trunk sup-
plying the part.  The portions of integu- 
 166      CUTANEOUS MEMORANDA.

 ment most frequently affected are  those
 which are supplied by one of the intercostal
 nerves. The regions supplied by the branches
 of the fifth pair of cranial nerves, the sciatic,
 the anterior crural nerve, and the nerves of
 the shoulder, arm, and forearm, are also not
 unfrequently affected.  The affection some-
 times commences with a sharp, neuralgic
 pain in one of the regions  mentioned.  A
 few days or weeks later the patient finds a
 little erythematous patch, which is slightly
 sore, the pain being  usually of a burning
 character.  A  few hours  or  a  day later an-
 other patch of the same sort is met with
 over the course of the affected  nerve, and
 then others, to the number  of five or six,
 may appear.   Shortly after  its appearance
 the first patch becomes studded with vesicles
 from  five to twenty  in  number, and the
other patches in turn become affected in the
same manner.   When the eruption is fully
out, the  neuralgic pain  sometimes  disap-
pears.  In other cases it continues, and may
even become more severe.   The vesicles at
first contain a clear and transparent serum,
which, however, may soon become opaque.
If  the vesicles are ruptured the corium is
exposed, and the fluid, if  not removed,  con- 
ZOSTER.
167
cretes into a brownish crust.  If the vesicles
are not ruptured they persist for a week or
ten da3^s, when their contents begin to un-
dergo absorption, leaving an adherent scale
or scab which finally drops off, leaving a
reddened, and perhaps  slightly depressed
macule, that in time  fades away.  If the
implication of the skin has been very super-
ficial, no scar results.  In many cases, how-
ever, the morbid action extends more  deeply,
and small, white, depressed scars remain to
mark the site of the disease.  If the  neural-
gia have persisted  up to this  time  it may
now cease, or, as in some cases,  persist in-
definitely, even for years.
  If  zoster  attack  a scrofulous subject, or
one of  advanced age, or  in a depraved state
of health from any cause, the affection may,
in its  local manifestations, become much
more severe.   The vesicles, on  rupturing,
may be followed by ulcers of a  more per-
sistent character. Sloughing may occur and
death has sometimes resulted from  the dis-
ease.
  One marked peculiarity of zoster is the oc-
currence of the disease on one side only, the
region supplied by  the corresponding nerve
of the other side being unaffected. Cases of 
168      CUTANEOUS MEMORANDA.

double zoster have been, though rarely, ob-
served.  Another peculiarity connected with
the disease is  the  fact  that it, like the
eruptive fevers, attacks the patient but once
in his life.   A few cases of recurrent zoster,
however, have been  recorded.
  The diagnosis of zoster is, as a rule, ex-
ceedingly simple.  It can only be  mistaken
for one of  the forms of herpes or hydroa.
The characteristic features of zoster have
just been pointed out, and the differential
diagnosis between it and herpes is discussed
in con  ection with that disease.
  The prognosis of  zoster is usually good ;
that is,  in the majority of cases the patient
will entirely recover from the effects of the
disease in from two to four weeks.
  If the patient be  in other than apparent
good health, the first care should be con-
cerning his hygienic surroundings.  Good
air, food, etc., should be secured if possible,
and if the patient suffers sufficiently to make
repose in bed a desideratum, this should be
not only permitted, but encouraged.   In
severe cases it should be insisted on, even if
the patient thinks that his business or other
duties  require  him to be up and about.   If
fever be present  aconite should be  given, 
HERPES.
169
The best  local  treatment  with which I
am acquainted  is the application of fluid
extract of  belladonna  all       :=sij
over the  eruption.   Three
or four applications  should
be  made in succession, per-
mitting each application to
dry before another is made.
Over these a  thick  coat of
collodion  should be applied.
Under these applications I
have seen apparent abortion
of the eruption.
          HERPES.
  Under the general name of
Herpes may be included
affections characterized by
the development of a cluster
of small vesicles, on a slight-
ly, if at all,  inflamed base,
and usually located on, or in
the neighborhood of, mucous
membranes.
  There  are two principal
varieties of herpes, which,  as they differ so
markedly  in their nature and behavior, will
be  considered separately.    These are H.
labialis and H. progenitalis.
Fig. 12.—vesicles
   op zoster. 
170      CUTANEOUS MEMORANDA.

            HERPES LABIALIS.
  The vesicles of Herpes  labialis are small
in size, not  usually  exceeding one line in
diameter.  They are situated on a reddened
and  slightly inflamed base, appear  upon
either the upper or lower lip or upon both,
or clustered about the angle of the mouth.
The vesicles usually  rupture on the second
or third day, leaving a denuded surface.  If
the serum which filled them is not wiped
away it dries into a thin, transparent scale
or crust.  This remains attached for a day
or two longer and then drops off, leaving a
slightly  reddened mark,  which gradually
fades away, without leaving any trace be-
hind.  The eruption may be  unilateral or
bilateral, more frequently the former.   The
affection is rarely painful, a little  heat or
pruritus  being usually the extreme limit of
inconvenience.
  The only affections with which Herpes
labialis is likely to be confounded are, first,
a well-defined disease known as Zoster, and,
second, certain anomalous  vesicular affec-
tions which are included under the  provis-
ional name of  Hydroa.   The differential
diagnosis between Herpes labialis and zoster
is best appreciated by an analytical compar-
ison of the two : 
HERPES LABIALIS.
171
      Herpes.
  Is  frequently bi-
lateral.

  May attack   fre-
quently.

  Little  pain,  but
slight  sensation of
heat or itching.
                            Zoster.
                        Is unilateral (with
                      very  rare   excep-
                      tions).
                        Occurs but once in
                      a patient's life (with
                      rare exceptions).
                        Neuralgic  pain,
                      often  severe in the
                      course of one of the
                      nerves  underlying
                      the eruption.
                        Vesicles large,
                        Fluid     often
                      opaque.
                        Vesicles often per-
                      sist until the fluid is
                      absorbed.
                        Duration  two  to
                      four weeks.
                        Lesion  deeper,
                      often  extends to the
                      corium.
                        Often leaves cica-
                      trices.
  The affection is a trivial one and the prog-
nosis is always good.
  Herpes labialis often occurs at the close of
  Vesicles small.
  Fluid  usually
transparent.
  Vesicles   usually
rupture in a day or
two.
  Duration  four  to
ten days.
  Lesion superficial.
  Never leaves cica-
trices. 
172      CUTANEOUS MEMORANDA.

some mild febrile affection or during the
course of an acute catarrhal one, and has re-
ceived the common names of " fever-sore "
and  " cold-sore."   Beyond  this we know
nothing as to its etiology.
  Herpes  labialis usually requires  little, if
any treatment.  At most  a drop  or two of
tincture of camphor, or a little simple dust-
ing powder may be applied, if the surface is
moist or weeping.   Some  persons are more
subject  to the affection than others, that is,
they have an attack on the slightest provo-
cation.  If this tendency to frequent attacks
could be controlled,  it would be a great con-
venience to them.  Unfortunately I do not
know of any means  of doing it.

          HERPES PROGENITALIS.
  Definition and Description.—This  affec-
tion is characterized by the development of
crops of  vesicles on the genital organs.   It
is  most frequently met with on  the penis,
and occurs either on the integumentary sur-
face  or on the adjoining mucous membrane.
  The vesicles resemble  those of  Herpes
labialis,  and when  seated  upon  mucous
membrane rupture in a few hours, or a day
perhaps, after their appearance.  On rupture 
          HERPES PROGENITALIS.       173

they leave little excoriations or ulcers,which,
if the patient's health be good, heal in a few
days.   In other cases the ulcerations may
extend, neighboring ones unite and give rise
to a condition that may readily be mistaken
for  venereal sores.   One of the  favorite
tricks of  charlatans is to inform the patient
that they are of venereal origin,  in fact,
a manifestation of  syphilis, and milk his
pocket accordingly.
  A peculiarity of Herpes progenitalis is the
tendency to frequent relapses or returns of
the affection.  The first attack having dis-
appeared, another may occur in  six weeks,
two months, or later, and this be followed
by others at  somewhat irregular intervals,
the disease in this way continuing to annoy
the patient for several years.  The vesicles
are not,  as a rule, accompanied with much
pain.   Sometimes there is a little itching,
and, after rupture  of the vesicles, a little
soreness  if the organ be roughly used.
  In the female the vulva may be the seat
of a similar affection, usually termed Herpes
vulvaris. It  pursues  the same course as in
the male, and a relapsing form is sometimes
met with.
  Diagnosis.—The diagnosis of Herpes pro- 
174      CUTANEOUS MEMORANDA.

genitalis is not always easy.  A simple, un-
irritated herpes should not be mistaken for
anything else,  as the absence of all indura-
tion is usually sufficient to exclude chancre,
at least in the male.  The absence of  puru-
lent secretion in like manner excludes the
chancroid.   Where, however, the  herpes
has been irritated, little] ulcerations  with
free secretion may closely simulate  chan-
croids, and also a form of chancre described
by  the French  as  '' multiple  herpetiform
chancre."  In  these  cases it  may  be ex-
tremely difficult to positively determine the
true nature of  the lesion in  question, time
alone declaring this with certainty.
  The diagnosis between Herpes progenitalis
and Zoster should  not  be difficult.   This
latter affection  rarely invades  the genital
regions, but when it does so it  possesses its
ordinary characteristics, namely, clusters of
vesicles on inflamed patches of integument,
accompanied  with neuralgic pain.
  Prognosis.  — The prognosis  of  simple
Herpes preputialis or vulvaris  is always
good, so far  as the present attack is con-
cerned, as a week usually suffices to end the
matter.  The prognosis as regards relapse,
however, is not so good, and cannot be de- 
          HERPES PROGENITALIS.       175

clared with any certainty.  That is, at the
first attack it will be  impossible  to say
whether others will occur, and if they do
whether the tendency to relapse will be over-
come by treatment.
  Etiology.—The etiology of Herpes progen-
italis is obscure.  It is not a febrile affection
like Herpes labialis, nor is there any reason
to  believe that it depends  on any grave
nerve-lesion as in  zoster.  The individual
attacks usually appear to be excited by
peripheral irritation (phymosis sometimes)
but the relapses are often unexplainable.
  Treatment.—The treatment of this form
of jherpes involves the use of means calcu-
lated to relieve the existing eruption, and to
prevent relapses. As regards the temporary
treatment nothing, as a rule, is required be-
yond cleanliness and the  application of  a
little simple dusting powder.  If ulcerations
are present, a little  stimulating ointment,
as one containing a small quantity of balsam
of Peru, or the Ungt. Resinoz, may be em-
ployed.
  The prevention of relapse is a much more
difficult matter.  The affection not unfre-
quently occurs  in persons with a phymosis
or a redundant prepuce.  I have known of 
176      CUTANEOUS MEMORANDA.

two  cases in which curtailment of the re-
dundancy put a stop to the recurrence of the
affection.  In others the mucous membrane
of the balano-preputial region is very deli-
cate  and sensitive.   In  these  cases  much
benefit will accrue from a systematic appli-
cation of astringents, tannin, catechu, etc.,
with a view to  toughening the membrane.
Thus far, in my own hands, internal medi-
cation has failed  to prove of any certain
service, except  that in a  few cases quinine,
in full doses, has  appeared to control the
disposition to relapse.

               CHLOASMA
  Chloasma is a designation which has been
quite loosely applied, and by many writers
has been made to embrace several  distinct
affections—to include, in fact, all brownish
or yellowish brown  discolorations, larger
than freckles, by whatever cause produced,
Some, on the other hand, confine the term
to parasitic discoloration (Chromophytosis),
while others, including Hebra, exclude the
parasitic affection, but embrace both cases
that arise  from external  and mechanical
causes, and  those  that are symptomatic of
certain internal  conditions  and  diseases, 
CHLOASMA.
177
speaking of the former class of cases under
the name of Idiopathic chloasma, and the
latter   as  Symptomatic chloasma.   The
writer,  however,  prefers  to restrict  the
name chloasma to certain  discolorations of
the skin of internal origin, and assigns the
name melasma to cases of  non-parasitic
cutaneous  discoloration due to  external
agencies.
  Under these restrictions chloasma may be
defined  as a  diffuse brownish discoloration
of the skin, usually located on the forehead
and cheeks.
  Chloasma may arise during the  period of
pregnancy, and gradually  increase as  this
condition advances.   After delivery it  usu-
ally diminishes and may entirely disappear,
or it may remain as a marked disfigurement
for a considerable period, if not for life.  To
this  form  the  title  macula gravidarum
is  sometimes given.  Chloasma may  also
develop independently  of  pregnancy as a
symptom  or sign of uterine disease,  and
then receives the name of  chloasma uteri-
num.  When arising under  these circum-
stances  it is  hkely to be present as long as
the uterine  irritation  remains, and some-
times persists after the  exciting cause has
apparently ceased to be active. 
178     CUTANEOUS MEMORANDA.

  The diagnosis of chloasma presents little
difficulty.   The  band-like discoloration on
the forehead and the similar patches over
the malar  bones and neighboring integu-
ment are characteristic,  the only other pig-
mentary lesion of these  parts at all resem-
bling it, being  the  tanning  which comes
from frequent exposure to the sun.  We can
hardly conceive that any one can mistake
the latter condition  for the former. Para-
sitic discoloration (chromophytosis) does not
invade the  face, though  occasionally seen
upon the neck.
  The  prognosis of chloasma is uncertain.
Some cases are  permanently relieved by
treatment,  while others  relapse continually,
even after the best directed efforts for their
relief.   The affection sometimes disappears
spontaneously after the menopause.
  In true chloasma of  uterine origin it is
probable that the seat of the discoloration is
extremely superficial and located external to
the cells of the stratum Malpighii.  We may
therefore  hope,  by  removing the horny
layer, to remove with it the abnormal pig-
mentary deposit, or, at least, a portion, and
by the termination of pregnancy,  or relief
of the uterine disorder, to prevent its reform-
ation. 
CHLOASMA.
179
  Before attempting the local treatment of
chloasma an effort should be made to ascer-
tain its cause.   If pregnancy be present it is
hardly worth  while to attempt any treat-
ment until gestation is over.  If uterine dis-
ease be the fons et origo of the trouble this
must, of course, receive attention if any per-
manent benefit is hoped for.  Having con-
sidered the etiological factors, the question
of topical applications is then to be consid-
ered.  The principal indication is to procure
an  exfoliation of the stratum corneum, un-
der the  expectation that the newly-formed
horny layer will  be free from  pigmentary
deposit.  There are quite a number of agents
capable of destroying the superficial layers
of the epidermis, and causing their exfolia-
tion, as cantharides,  mustard, iodine, and
corrosive sublimate, and any of them might
be used  for the purpose, were it not that
some of them are very  apt to  produce a
melasmic condition that may last longer
and prove more disfiguring than the original
affection.  Mustard is especially objection-
able on this account.   Of the epidermicides
mentioned, corrosive sublimate is to be pre-
ferred, as the least likely to produce these
disagreeable sequelae.  It should be used as 
180      CUTANEOUS MEMORANDA.

a lotion  of  the strength of three to  five
grains to the ounce, applied two or three
times a  day until  the  stratum corneum
loosens.  This may then be rubbed off with
a damp towel, and is replaced by epidermis
less pigmented than before, or perhaps alto-
gether normal.  If necessary, the  applica-
tions  may be repeated, and  the new horny
layer  removed by the same means.  Instead
of the foregoing, tincture of iodine, iodized
glycerine, sulphur ointment, or sapo viridis
may be employed. 
SCABIES.
181
LOCAL  AFFECTION'S.
            CHAPTER  XIX.
                 SCABIES.
  Definition and Description.—Scabies is a
zooparasite disease, produced  by the lodg-
ment and increase of certain minute insects
on and under the skin. It is usually charac-
terized by the appearance of little transpar-
ent, isolated, non-umbilicated vesicles upon
the skin, especially between the fingers and
on other parts of the hands.  The develop-
ment of these vesicles is accompanied with
itching, usually worse at  night.  The pruri-
tus leads to scratching, and this scratching
of the diseased parts and scratching or hand-
ling of other portions of the integument,
leads to the extension of the disease to them,
and we  find  that, as a  rule, the affection
next  invades the  penis  in  the male, the
breasts in women,  and the feet in children,
from  which  parts it  may extend  to  all
other portions of the surface—the anterior, 
182      CUTANEOUS MEMORANDA.

however,  in preference to  the posterior.
The head  and face are rarely, if ever af-
fected.
  After a few days, in some cases, later in
others, additional phenomena are presented.
These, as a rule, are papular, and pustular
forms of eczema, in those predisposed to this
affection, together with  scratch-marks and
rather large, isolated, and  commonly um-
bilicated pustules.   In those possessing a
decidedly  pyogenic constitution, furuncles
and abscesses may appear.   In other words,
the eruption in advanced cases is frequently
polymorphous.
  These are the lesions visible on a cursory
examination, but none of  them are abso-
lutely diagnostic, although the vesicles first
alluded to are not, so far as I am aware, met
with in any other affection.  There is, how-
ever, another lesion that is pathognomonic,
and which, if detected, leaves no doubt as to
the nature of the affection.  I allude to what
is called the cuniculus, or burrow, made by
the insect that causes the disease.   This le-
sion is a fine line, more frequently curved
than straight, and of a whitish or grayish
color,  sometimes  interrupted  with black
points.  The line is usually from one-fourth 
SCABIES.
183
 to one-half inch in length, and can be  de-
 tected  only by close  inspection, but  more
 easily with the aid of  a lens.  It is usually
 found near the vesicles,  sometimes  upon
 their surface, but  occasionally is at a dis-
 tance from them.
   Pruritus  is almost an invariable accom-
 paniment, and may be mild, but is usually
 worse at night, when the patient is warm in
 bed.
   Etiology.—Scabies  is caused by the pres-
 ence of an insect called the Acarus scabiei,
 or Sarcoptis hominis.
   Prognosis.—This is always  good, as the
 disease can be readily cured.
   Treatment.—The French method of treat-
 ment is, of  all that have been proposed, the
 most  thorough  and effective.  It may  be
 carried out as follows: The patient is first
 placed in a warm bath for half an hour, in
 order to thoroughly macerate and soften the
 epidermis.   He is then  vigorously  rubbed
 with soft  soap, not  only on the parts  that
seem  to be specially affected, but all  over
ttie surface, except the head. A soft scrub-
bing-brush adds to the efficiency of this part
of the treatment, twenty minutes or a half
hour  being occupied  in accomplishing  it. 
184      CUTANEOUS MEMORANDA.
The soap having been washed off, the skin
is thoroughly dried, and a sufficiency of or-
dinary sulphur ointment, or, better, the fol-
lowing—
5. Potassii iodidi....................3 j.
   Ungt. Sulphuris.................§ j.
   M.
FIG. 13.—FEMALE ACARUS.     FlG. 14.—MALE ACARUS.
is rubbed all over the body in the most care-
ful manner, special attention being devoted
to the regions most affected.  The patient is"
then put to bed, where he remains until the
following morning. A warm bath, to cleanse
the skin of the sulphur, completes the oper- 
PHTHIRIASIS.
185
ation, and in ninety-nine cases out of a hun-
dred the parasite is destroyed, the scabies is
cured, and the patient has only to recover
from the secondary eruptions and the effects
of the somewhat severe and painful course
through which he has been put.  Emollient
applications are now usually indicated.
  If the patient resume the clothing that he
wore previous  to  treatment, he will, in all
probability, recontract the disease.  It must
therefore be destroyed, or thoroughly disin-
fected.  This may be accomplished by thor-
ough baking in an oven, or fumigation with
sulphur.  The bedclothes that have been in
use prior  to treatment should also be disin-
fected.  There  is but  one objection to the
treatment, and that is its severity.  This, of
course, may be diminished to any desired
extent, but if this is done a single operation
will not usually suffice to effect a cure.

               PHTHIRIASIS.
  Phthiriasis is the name given to a zoopar-
astic disease caused by an invasion of the
skin by  lice, of  which there are three kinds:
the Phthirius,  or  Pediculus capitis;  the
Phthir., or Ped. corporis; and  the Phthir.,
or Ped.  pubis.  As the affections  produced 
186      CUTANEOUS MEMORANDA.

by these insects differ somewhat they will
be described separately.

          PHTHIRIASIS CAPITIS.
  This affection is due to the lodgment and
increase of  the Phthirius  capitis or head-
louse, on the scalp, which  part it alone in-
vades, the other portions of the body being
exempt from its attacks.  The presence of
the insect gives rise to irritation and itching,
and this to scratching.  In  some persons the
insect is tolerated without much inconven-
ience, but in others—especially in children
with an eczematous tendency—considerable
reaction may result and manifest itself  by
vascular and pustular eruptions, accompan-
ied with more or less exudation and the for-
mation of crusts. In addition, glandular en-
largements in the post-cervical regions, and
small abscesses may appear on this region
and  on the scalp.  The hair is frequently
matted together by the exudation, and in
severe cases we meet with a mass of mingled
hair-crusts and lice, constituting a fetid and
disgusting collection of vitalized filth.
  The principal etiological  factor in this dis-
ease is shown in Fig. 15.
  The appearance of  this insect is familiar, 
          PHTHIRIASIS CORPORIS.       187

I presume, to all, and need not be specially
described.
  A very effectual method of curing the af-
fection is to shave off all the hair.  This it
is often undesirable to do.  Under these cir-
cumstances an antiparasitic ointment or lo-
tion may be employed.  Mercurial or sulphur
    Fig. 15.—phthirius capitis, or head-louse.
ointments  are effective,  but perhaps the
most popular application is the tincture of
Delphinium  staphisagria.    Tobacco  has
been employed, but is dangerous.   Crude
petroleum, or its refined product,  kerosene,
is a very eligible preparation, and the one
most frequently employed by the author. 
188      CUTANEOUS MEMORANDA.

It should be applied daily until the affection
is at an  end.  Kerosene destroys the pedi-
culus, but  does  not appear to  retard the
hatching of the ova.   The young, however,
are destroyed as soon as hatched, and the
affection is thus, in a short time, controlled.
The empty egg-shells may remain attached
to the hairs for a considerable time, thus de-
ceiving one into the belief that the parasitic
affection still exists.   A co-existing  eczema
should be  treated in accordance with the
principles that underlie the treatment  of
that disease.

          PHTHIRIASIS CORPORIS.
  Definition  and Description.—  This is a
zooparastic affection, due to the invasion of
the skin  by the Phthirius or Pediculus cor-
poris.  It is characterized by pruritus, which
leads to  scratching and the development of
certain secondary lesions which may be con-
veniently termed scratch-marks.   These, in
milder cases, may consist simply  of little
black points, slightly, if at all, elevated above
surface of the skin.  They are produced  by
the desiccation of a small droplet of blood,
resulting from the wounding of a few pap-
ill :c with the finger-nail; next we may find 
          PITHIRIASIS CORPORIS.       180

red lines or streaks, surmounted with black-
ish-red ridges of dried blood.  These minute
incrustations are rarely absent, and, to a cer-
tain extent, are pathognomonic of the affec-
tion.  As  the  insects increase  in numbers,
the irritation  likewise increases, and  the
pruritus becomes  intense, keeping the pa-
tient busy with his nails the greater part of
the time.   A  superficial  scratching, how-
ever, will not afford sufficient relief, and the
unhappy sufferer  tears the  skin with his
nails until  he is a mass of bleeding excoria-
tions.  Under the infkience of the continual
irritation the skin darkens, and the body is
covered with lines and blotches more or less
deeply  pigmented.   When the disease is
severe upon the lower extremities it is not
unusual to find enlargement and tenderness
of the  inguinal glands.   The affection is
most frequently met with in advanced life.
  The majority of  cases of severe pruritus
met with, at least in this city, are examples
of Phtliiriasis and no case of general pruritus
should be passed without special  examina-
tion as to its connection with vermin.  The
presence or absence of pediculi  should  be
positively determined, and they usually can
be without difficulty.  Search for the insect 
190      CUTANEOUS MEMORANDA.

should not be made on the skin, as, unless
very abundant, they will not be found there,
but on the  undergarments.   Once found,
the diagnosis is made.  If after thorough
and  repeated examinations  they are not
  Fig. 16.—phthirius or pediculus corporis, also
       called pediculus vestimentorum.
found, the pruritus must be referred to some
other cause.  In Phthiriasis the regions that
usually exhibit the most  distinct evidences
of  scratching  are the upper part  of  the
chest, the thighs, legs, and back ; the head,
belly,  and genital region being compara- 
PHTHIRIASIS PUBIS.        191
tively free.  In advanced cases the patient's
expression, gait, and behavior are so char-
acteristic that the experienced observer will
frequently make a correct diagnosis before
a single lesion is brought to his eye.
  The form and appearance of the insect are
shown in Fig. 16.
  Treatment. — A warm  bath,   thorough
soaping, and a good scrubbing will free the
body of the patient from the parasite.   The
clothes and bed-clothes, however, must be
disinfected by baking, prolonged  boiling, or
sulphur  fumigation.   If practicable,  they
had better be destroyed. A certain amount
of pruritus will remain  for some time after
the destruction of the insect.  This may be
alleviated  by  applications of tincture of
Delphinium, of Stramonium and other anti-
pruritics.
           PHTHIRIASIS PUBIS.
  This affection is  due to the Phthirius or
Pediculus pubis, the general  form and ap-
pearance of which is shown in Fig. 17.
  This insect  exhibits a preference for the
pubic region.   It  is not, however, confined
to this locality, as we have found it in the
eyebrows, beard, and axilla, as well as the
hairy parts of the chest, thighs, and  legs. 
192      CUTANEOUS MEMORANDA.

It is, I believe, never met with on the scalp.
The insect  derives its nourishment  from
the skin, to  which  it is usually  found
strongly attached.  It  lays its  eggs,  how-
ever,  among the  hair,  to which  it firmly
glues them.
     Fig. 17.—phthirius pubis, or crab-louse.

  The affection is most frequently contract-
ed during sexual intercourse,  but  some-
times by wearing infected clothing, sleeping
with an infected person, or  in a bed  where
one has slept,  and probably also at the
water-closet.
  The presence of the insect gives rise to
more or less pruritus of the affected regions, 
PHTHIRIASIS PUBIS.
193
and commonly  leads  to  inspection of the
parts and detection of the cause.
  Pruritus of the hairy parts of the body,
other than the scalp, should always raise
suspicion as to the presence of  the insect,
and a careful examination will settle this
question without difficulty.
  Treatment.—If  the   eyebrows  are  in-
volved,  carefully  pull  out  or  snip off
every  hair to  which the  eggs  of  the
insect are attached.   Then  thickly smear
the  part  with  mercurial ointment.  The
whiskers, beard, and  moustache,  if those
parts  are  involved,  may  be  treated  in
the  same  manner.  The  pubic  region and
other hairy parts should  then be carefully
examined,  and  the affected regions should
be shaved with a razor.   If  a warm bath,
with soap and a scrubbing-brush,  be  then
employed,  the probability is that no further
treatment will be necessary.  The less effi-
cient means of cure are the employment of
Ungt. Sulphuris, Ungt.  Hydrargyri, etc.,
or lotions of bichloride, tincture of delphine,
petroleum, kerosene, and the like.
7 
194     CUTANEOUS MEMORANDA.
            CHAPTER XX.
                 FAVUS.
  Favus is a parasitic affection of the skin,
characterised by the development of pale
yellowish  crusts,  in connection with  the
hairs and their follicles.  It is more frequent
on the scalp than  elsewhere, but may be
met with on any part of the body that is
supplied with hair.   It usually commences
by the appearance of small white specks or
points.  These gradually increase in size,
become  yellow in color and  umbilicated,
forming small crusts, the umbilication being
traversed by a hair, or if the hair be absent,
will be found to correspond to the mouth of
a hair-follicle.   The crusts slowly augment
and project somewhat above the level of the
skin.  If one of them be removed, it will be
found to have somewhat the form of a con-
cavo-convex lens, its upper surface having
a marked depression or concavity surround-
ed by an elevated border. Its under surface
is convex  and the  convexity will be found
to correspond to a small depression in the
skin from  which it was removed.  Other 
FAVUS.
195
crusts appear in the neighborhood or scat-
tered over different parts of the scalp, and
gradually increase in size; contiguous ones
join by mutual extension, so as to form a
mass of considerable  proportions mottled
over with little depressions perforated by
hairs.  As the disease further  advances.
portions of the crusts drop  off, carrying
with them some of the hairs.   Ultimately
the  crusts disappear, leaving a  surface at
first somewhat reddened  but  afterward
white, dry, atrophied and cicatricial in as-
pect and deprived of hair.  The progress of
the disease is slow, and when uninterfered
with by  treatment, may last  for ten  or
twenty years before it completes its course,
which it  will do  when it has permanently
destroyed all the hairs of the affected region.
Favus of the scalp attacks children by pref-
erence, being but rarely found in adults as
a recent affection.  It is highly contagious
and may be transferred directly from one to
another, or by means of caps, brushes,  etc.
This affection is not confined exclusively to
the human race, but in some instances ap-
pears  to originate in  the mouse.   Cats
which  catch  mice  diseased in this manner
become infected  from them, and children 
196      CUTANEOUS MEMORANDA.

playing with the cats contract the disease in
turn from the latter.
  Favus is not limited to the scalp, but may
appear upon any part of the body.  When
it occurs upon parts furnished with but fine
and  rudimentary hairs, as the general sur-
face,  it commences as  a small, red, very
slightly raised spot.  This enlarges and be-
comes a little scaly until it has  reached  a
diameter from half an inch to an inch.  Upon
this  reddened  patch one or more  small
white points, not larger than pin-heads, ap-
pear.  These increase  in size and develop
into the characteristic sulphur-yellow um-
bilicated crusts.  This epidemic  favus ap-
pears to attack adults as freely as children.
  Favus is usually accompanied with  a cer-
tain amount of pruritus, rarely severe, which
leads  to  scratching  and the mechanical
transfer of the disease  from one  part to
another.
  Etiology.—Favus is  caused by the lodg-
ment and development of a minute fungus
upon  the  surface and  in the hair follicles.
This fungus has received the name of Achor-
ion Schonleinii,  after its  discoverer.  It
consists of round or ovoid  spores, about
one-three thousandth of an inch in diameter, 
FAVUS.
197
together with  tube-like  structures  called
mycelium, some of which are simple, others
branched; some contain spores and others
are empty.   In addition there is a consider-
able amount of fine granular matter.  The
appearances presented under the microscope
are shown in Fig. 18.
        Fig. 18.—achorion schonleinii.
  The spores penetrate deeply into the hair-
follicle, even to the bottom,  where their
further  multiplication causes  destruction
of hair-root and finally of the papilla.  They
sometimes invade the bulbous portion of the
root itself, but rarely  to any extent,  and
probably never involve the free portion  of
the  shaft.   When  the  growth has filled 
198      CUTANEOUS MEMORANDA.

the follicle it appears  at its  orifice as the
white speck already alluded to, and by fur-
ther increase  constitutes the substance of
the typical crusts.
  Treatment.—This maybe accomplished as
follows:  Let the scalp be oiled twice a day
for two  or three days  Then with a small
spatula  remove  all  the superficial  crusts.
Some of them will be found quite adherent,
but a dull-pointed knife-blade and a  little
patience, will  be all that is  required.  If,
now, a mercurial or sulphur ointment be ap-
plied, the  disease will be prevented  from
showing itself on the surface, and will be,
to all appearance,  cured.  If these appli-
cations,  however, be discontinued under the
supposition  that the  disease is  in reality
cured, a  few weeks will suffice to dissipate
this error, as the disease will reappear, and
in a short time be in as bad a state as before
treatment, due  to  the fact that the  hair-
follicles still contain the spores in abundance.
It is necessary,  therefore, to destroy them
in situ, by the aid of such medicinal agents
as will, by local  contact, put a stop to  their
further  development and growth.  These
medicinal agents are  called parasiticides.
In order to destroy the spores, it is neces- 
FAVUS.
199
sary that the drug made use of  shall gain
entrance to the follicles, which it cannot do
if they are blocked up with the hairs.  Re-
moval of the hairs then becomes
necessary.   This is effected by
epilation, or removing the hairs
one by one with a pair of suit-
ably constructed forceps (Fig.
19).'
  If the disease is at all exten-
sive, epilation of the entire sur-
face at one sitting is impractic-
able.  The best way is to pro-
ceed systematically and remove
every hair  from a limited  area
^say one or two square inches.
When the patience of the sur-
geon  or of the patient is  ex-
hausted, desist for the time and
apply to the denuded spot  a
suitable  ointment  or  lotion.
For  this purpose  nothing  is
more convenient than a  one-
half  to  one per cent, solution
of bichloride  of mercury  in LA**
water.  The follicles,  deprived ceps.
of their hairs, permit a ready entrance of the
solution, which, coming directly in contact

-epi-
FOR- 
200      CUTANEOUS MEMORANDA.

with the spores, destroys them, or perhaps
simply kills  the epithelium  of  the  inner
root-sheath, which, when exfoliated, carries
with it the infiltrating fungus.  On the fol-
lowing day another portion of the scalp is
epilated and the lotion applied as before,  to
the portion just denuded and also to that
previously operated on.  This procedure is
repeated day by day until the whole of the
affected region has been deprived of hair.
If, now,  all the hairs have been  extracted
and the lotion has effectually  destroyed the
intrafollicular  fungus,   the disease   is,  of
course, at an end.
  Such a result, however, is rarely attained
so easily, as many hairs will  be  broken  in
the attempt at extraction, and many spores
will  escape the action  of the parasiticide.
These, of course, would constitute new foci
of disease.  It is, therefore,  necessary  to
continue the use of the parasiticide until the
broken hairs  have grown  to a  sufficient
length to again permit of an attempt at their
extraction. After a week or so, the epilation
should be resumed, and repeated a third  or
fourth time if necessary.  Finally,  if the
growing  hairs appear to present a healthy
aspect, treatment may be temporarily sus- 
TRICHOPHYTOSIS.
201
pended.   The  patient, however,  must be
kept under close observation, and the  first
indications of relapse immediately taken in
hand.
  In Favus of the general surface, epilation
and the elaborate treatment just mentioned
are unnecessary, as the disease can be read-
ily cured by much simpler means.  If at the
commencement,  when the  erythematous
disks only are apparent, a few applications
of the tincture of iodine will be sufficient to
dissipate the disease.  If later, when  the
crusts are  present, these  should be picked
out with the  point of a knife and the  iodine
freely applied.   After sufficient has been
used to secure thorough  desquamation of
the epidermis, it will usually be found that
the disease has  been cured.
  In many, if not most cases of Favus, it
will be found that the general health is be-
low par.  Under these circumstances, con-
stitutional treatment will  be advisable.
The drugs most frequently indicated are cod-
liver oil and iron.

             TRICHOPHYTOSIS.
  Trichophytosis is a contagious phyto-para-
sitic affection, characterized by the develop- 
202      CUTANEOUS MEMORANDA.

ment of circular patches, commonly known
as ringworm, on various parts of the surface
of the body.  These patches increase centrif-
ugally, and are accompanied with profound
al terations of the hair on the affected parts.
  Trichophytosis depends on the lodgment
and growth of a parasitic fungus called the
Trichophyton Tonsurans, the  discovery of
which is due to M. Gruby, in 1842.
  The fungus itself  consists of spores and
mycelial  tubes.   The  spores  are  mostly
round and much  smaller than  those of the
Achorion Schonleineii described in connec-
tion  with favus, and the mycelium is usu-
ally not so abundant.  The favorite, if not
exclusive, seat of the parasitic  growth is in
the hairs and  hair-follicles.  After it  has
gained a lodgment in the follicle, it almost
immediately  invades  the hair-root, infil-
trating it abundantly among and between
the longitudinal  fibres of the hair.   This
infiltration proceeds in an outward direc-
tion, until it has extended a short distance
(one-sixteenth  to  one-eighth  of an inch)
beyond the surface of the skin.   The spores
separate the fine fibres of the hair, and by
pressure force them apart.  The portion of
hair just without the follicle, and no longer 
TRICHOPHYTOSIS.
203
possessing the support of the follicular walls,
yields to the rupturing force of the parasite,
and breaks off, leaving a ragged and brush-
like extremity protruding from the  follicle.
If a hair be  extracted and examined under
the microscope, it will  exhibit  the  appear-
ances shown in the annexed cut, Fig. 20.
  Fig. 20.—portion of a hair infiltrated with the
spores of the trichophyton tonsurans.

  By the aid of these  spores the disease is
conveyed from one to another under circum-
stances that will be noted later.  The dis-
ease is met with in  some of the lower ani- 
204      CUTANEOUS MEMORANDA.

mals, and may be conveyed from them to
man.
  Varieties.—There are four principal varie-
ties of Trichophytosis founded on the differ-
ent appearances  and course  presented  by
the disease according to the locality which
is invaded by it.  These varieties are known
as Trichophytosis  capitis, Trichophytosis
barbae,  Trichophytosis corporis,  and Tri-
chophytosis genito-cruralis.   As the varie-
ties differ in many essential respects, both as
to appearances, course, and appropriate treat-
ment, they will be separately described.

         TRICHOPHYTOSIS CAPITIS.
  Trichophytosis capitis is a disease of earl y
life,  occurring among infants and children,
and never, so far as the author's experience
goes, among adults.   It is characterized by
the  appearance upon the scalp of one or
more small,  round, white,  scaly patches,
apparently deprived  in part  or wholly of
hair.  The patches  extend in a centrifugal
manner with greater or less rapidity.  They
increase in size,  and others appear in the
neighborhood,  and  if  the disease  is  un-
checked, soon fuse together until more or
less  of the scalp is involved, when the ap- 
TRICHOPHYTOSIS.          205
pearances noticed in the smaller patches are
observed over the whole surface.   The ulti-
mate result, if unchecked by treatment, is
involvement of the entire scalp, with de-
struction of the hair-follicles and permanent
loss of hair.
  On close inspection, the apparently bald
portions of scalp in the early stages of the
disease are  found in  reality to be covered
with innumerable short hair-stumps project-
ing a little above the  surface.  The appear-
ance of this short stubble is very peculiar.
The broken hairs  do not resemble closely
clipped healthy ones  of  the same  length,
but are lustreless, and of  lighter color than
the  neighboring normal  hair.   Their ex-
tremities are rough  and often  brush-like,
due to splitting up of the  shaft, and separa-
tion of the fibres by the spores of the tricho-
phyton.  Sometimes  a few hairs of  normal
length will be scattered  over the affected
surface.
  The affection  is exceedingly contagious,
the  most so of  any of the  phyto-parasitic
diseases of the skin, and  is frequently con-
veyed by  the use of hats, brushes, etc.,
which have been previously used  by per-
sons  affected with the disease.   It is also 
206      CUTANEOUS MEMORANDA.

probable that  the  spores may be conveyed
some little distance through the air, as the
affection  sometimes  spreads  rapidly  in
schools,  even where ordinary precautions
are employed.
  If a patch commences near the border of
the scalp, by farther extension it may spread
down upon the forehead, temples, or neck,
in which case the portion beyond the scalp
presents the features peculiar to  Tricho-
phytosis corporis.
  Diagnosis.—In  its early and advancing
stages little or no difficulty should be ex-
perienced in the  diagnosis.   The  circular
shape and the broken hairs are sufficiently
characteristic, and are not met with in any
other affection of the scalp.  In the stage of
decline, however, especially after a case has
been subjected to  treatment, recognition of
the affection may be more difficult.  Under
these circumstances  the microscopical ap-
pearances of the hairs will be sufficient to
determine the matter.
  Prognosis.—This variety of trichophytosis
is very difficult to cure,  especially if the
disease have gained  any headway.  It can,
however, be cured by appropriate and per-
sistent treatment. 
TRICHOPHYTOSIS.
207
  Treatment.—The principle that underlies
the treatment of  Trichophytosis capitis is
the same that prevails in the management
of favus.  This is to destroy the fungus in
situ.  This may be accomplished in various
ways.  One method consists in the applica-
tion of croton-oil to the affected surface in
such a manner that a pustular inflammation
of  the follicles  shall be induced.   This
loosens the hair and destroys the fungus.
A careful trial of this method has satisfied
me that it is of decided service, but it is
rendered still more efficient by combining it
with  epilation.  It may  be carried out as
follows : Melt together equal  parts  of  cro-
ton-oil and white wax.   When the mass is
fluid pour it into a hollow cylinder made of
paper, and about one-half inch in diameter.
When cold it acquires  a convenient  and
suitable consistency.  Epilation is then re-
sorted to, and in as thorough  a manner as
possible, after which the mixture  of  wax
and oil is rubbed into the patch.  This will
usually excite the requisite degree of inflam-
mation.   After  this  has subsided  careful
microscopical examination of the hair should
be  made,  and  the epilation and  oil again
employed, if  necessary.  In  very young 
208       CUTANEOUS MEMORANDA.

children the foregoing application will prove
too  irritating, and its strength should be
reduced.  In which case equal parts of cro-
ton-oil, cocoa-nut-oil, and white wax, melted
together,  will give a stick of  suitable  con-
sistence and milder  in its action.  By the
persistent and intelligent use of these means
the trichophytosis will be ultimately cured.

          TRICHOPHYTOSIS  BARBAE.
  Syn : Mentagra parasitica ; Sycosis parasitica.
  Definition  and description.—This is an
affection due to the lodgment and develop-
ment of the Trichophyton  tonsurans on the
hairy parts of the  face in  adult  males.   It
appears upon the  cheeks,  chin, and upper
lip, and at first as  a  very slightly elevated,
circular,  reddish  patch, upon which a few
scales  may be perceived.   This patch ex-
tends centrifugally,  and if  the hairs  are
sparse exhibits a  tendency to assume a nor-
mal  aspect  at its centre, thus forming a
ring, whose advancing periphery is a little
raised above  the  surface.  If, however, the
hairs are  plentiful, it mows  them  down as
in Trichophytosis capitis, and leaves nothing
but a bushy stubble.  Later,  other and simi-
lar patches appear which, by mutual exten- 
TRICHOPHYTOSIS.
209
sion, may unite with each other, modifying
the typical circular form of the lesions.
  If the disease last for any length of time,
additional  phenomena may be  presented.
These  are due to secondary  inflammation
excited by the presence of the parasite, and
may consist in  papules, tubercles, pustules,
small  abscesses,  and even ulceration, and
may be present to such an extent as to ren-
der the  affection exceedingly disfiguring.
The extent and severity of these lesions will
vary with the individual peculiarities of the
patient;  some  cases presenting little more
than the special  trichophytic appearances,
while others exhibit the secondary lesions to
a marked degree.
  Trichophytosis  barbae, like  the  other
varieties, is exceedingly contagious, and is
frequently transferred from one to another
by the  indiscriminate use of unclean shaving
appliances.  It may also be contracted from
persons  suffering  from other  forms of
trichophytosis.
  Treatment consists in epilation and the
application  of  an  anti-parasitic lotion or
ointment.   The tincture of iodine,  the bi-
chloride  lotion, or  a mercurial  ointment,
will usually prove  sufficient.  Treatment 
210      CUTANEOUS MEMORANDA.

should not be abandoned until all chance
of relapse is past.

        TRICHOPHYTOSIS CORPORIS.
  This affection  is due to the development
of the  trichophyton on portions of the sur-
face that are  but poorly supplied with hair,
or rather on portions on which the hairs are
exceedingly minute  and rudimentary,  as
upon the greater part of the body.
  It commences  as a slightly scaly erythe-
matous spot.   This erythema sometimes
appears to be on  a level with the surround-
ing surface,  but in other  cases  quite  an
appreciable degree of elevation may be per-
ceived.  As the spot enlarges it  shows a
tendency to heal in the centre,  so that in a
short time we find a reddened ring circum-
scribing  apparently healthy  integument.
The ring enlarges indefinitely until it  may
have attained a diameter of several inches.
At last it begins  to die out at various points
along  its periphery, making  the ring  in-
complete, until finally it disappears entirely.
In the  meantime, however, other rings may
arise elsewhere,  and exist  in any number,
and, if contiguous, may coalesce  at some
point of their circumference and form a fig- 
TRICHOPHYTOSIS.
211
ure of eight, or if several rings unite various
irregular fig-ures may result.
   Treatment.— Under   ordinary  circum-
stances the treatment of trichophytosis cor-
poris  is exceedingly simple, a  few applica-
tions of the tincture of iodine being usually
sufficient to remove it.  If the  color of the
iodine is  objected  to,  applications of bi-
chloride, or of mercurial or sulphur ointment
may be employed instead.

    TRICHOPHYTOSIS  GENITO-CRURALIS.
  This affection  is located  in the genito-
crural region,  as  its name  implies, and
usually  commences as  a slightly elevated
patch at the upper part of  the thigh near
the scrotum.  As the  patch  increases it
pales  in  the  centre, forming a ring whose
advancing border is  sharply defined, and
more  elevated than the  other portions.  As
the ring increases in size it  may extend to
the scrotum, descend for some distance upon
the thigh or mount upon the abdomen.  A
similar ring sometimes forms on the scrotum
where it  lies in contact with the thigh.
Not unfrequently the  other thigh and other
side of the scrotum become affected in the
same  manner, thus giving  the affection a 
212      CUTANEOUS MEMORANDA.

somewhat  symmetrical  appearance.   The
natural moisture of the parts is increased by
the irritation of the fungus,  and together
with the  macerated scales,  and  perhaps
crusts, may give the eruption somewhat the
appearance of an eczema.  As the affection
advances, the hairs become  disorganized as
in the other varieties of trichophytosis, and
papules, vesicles, and pustules may occur.
  The most successful treatment with which
I am acquainted consists in the  application
of equal parts of tincture of iodine and col-
lodion to the advancing borders of the erup-
tion, with a mild chrysarobin ointment to
the central portions.  After the parasite is
destroyed  soothing   applications   of  zinc
ointment.

            CHROMOPHYTOSIS.
  Chromophytosis is an affection of the skin
characterized by the appearance  of super-
ficial yellowish-brown macules  or patches
on the upper part of the body—most fre-
quently met with on the chest.   It  com-
mences by the appearance of macules, very
slightly, if at all elevated above  the surface
of the skin,  and covered with barely per-
ceptible scales.  It usually begins  upon the 
CHROMOPHYTOSIS.
21'A
chest,  extends gradually over the greater
part of this region, mounts upon the neck,
and descends to the abdomen.  It may also
stretch around to the back and cover this
region.  It never invades the face, and sel-
dom, if ever, the limbs.  The eruption may
consist of a  few  large patches, with  very
frequently a  large number of smaller ones
upon the outskirts, or it may be composed
almost entirely of macules from the size  of
a pea to that of a dollar.  The patches are
sometimes slightly scaly.  The progress  of
the affection  is slow, so that months and
even years may elapse  before it becomes
generalized over  the trunk.  The affection
occurs  more particularly in persons who are
out of health, and not unfrequently appears
during the course of phthisis and syphilis.
It is most likely to be met with in those
who  are warmly clad and wear flannel next
the chest, and who,  at  the  same time, are
negligent in  matters  of  cleanliness.   It
rarely, if ever, occurs in those who make a
practice of bathing daily.  The affection is
believed to be contagious, but I have never
been able to trace a case to this cause.
  Chromophytosis depends on the germina-
tion and growth, among the epidermic cells, 
214      CUTANEOUS MEMORANDA.

of a microscopic fungus, discovered by Eich-
stedt, in 1846, and known as the microsporon
furfur (Fig. 21). The spores are, as the name
implies, exceedingly small, but of varying
size and uniformly round ; the mycelium is
sometimes simple and  sometimes branched.
        Fig. 21.—microsporon furfur.

  Chromophytosis,  as  well  as the  other
vegeto-parasitic diseases of  the skin, are
favored and  promoted by cachetic  condi-
tions, and any indications of ill-health on
the part of the  patient should be carefully
considered  and  remedied,  if  possible.  To
this end,  good  air,  good food,  suitable
clothing should be  secured.  In  addition,
proper internal  medication, either ferrugi-
nous, cinchonic,  or oleaginous, should  not be 
CHROMOPHYTOSIS.
215
forgotten.  If the patient also suffers from
phthisis or syphilis, the usual constitutional
treatment for these diseases should be main-
tained.  These points being  attended to,
the local  treatment is then to be decided
on.  As the cause of the disease is a fungus
flourishing among the epidermic cells,  the
first and main indication is to  get  rid of it.
This can  only be accomplished by means
that will succeed  in  causing the death  and
exfoliation of the stratum  corneum.   The
epidermicide which I at present prefer,  and
find amply sufficient, is chrysophanic acid.
A five per cent,  ointment is  to be rubbed
into the patches  once or twice daily, until
sufficient  irritation  has  been produced to
loosen the outer  epidermic cells.  When
these begin to loosen, the patient is thor-
oughly  rubbed with green soap, put into a
warm bath, scrubbed with a soft flesh-brush,
and the affected epidermis removed.  After
the bath he is thoroughly dried, rubbed with
an emollient, and put to bed until the next
day.  If the treatment has been sufficiently
thorough  the  patient is rid of his disease.
In  the majority  of  cases, however, this  is
not the case. 
216      CUTANEOUS MEMORANDA.
          IMPETIGO CONTAGIOSA.
  Impetigo contagiosa is a contagious affec-
tion of the skin characterized by the appear-
ance of vesicles  subsequently drying into
peculiar crusts.  It commences not unfre-
quently with constitutional symptoms of a
pyrexial character, varying in severity in
different cases.   In two or three days, one
or more small vesicles may appear upon any
portion of the cutaneous surface.   These
gradually enlarge for a few  days, then dry
into thin light yellowish  or straw-colored
scabs or crusts.    The vesicles  and crusts
may be indefinite in number, and successive
eruptions may prolong the disease for sev-
eral months.  During the progress of the
affection, associates—adults as well  as chil-
dren—may contract  it.   Inoculation  with
the fluid contained  in the vesicles will give
rise to similar lesions.
  Removal of the  crust reveals a slightly
reddened  surface,  with  very  little  or no
moisture, and no ulceration or even erosion
of the surface, the lesion  being extremely
superficial.  After  the  spontaneous  fall of
the crust, a  bluish-red macule or stain is
left, which gradually fades away. 
MILIUM.
217
  The  affection  sometimes  follows shortly
after vaccination, generally within the sec-
ond or third week after falling of the crust.
  The disease is eminently contagious, and
I believe the contagious element to be a
fungous  growth which  is  plentifully dis-
tributed  through  the crusts.   The  same
fungus is found in vaccine crusts, which ex-
plains  our ability to trace the affection in
so many  cases to a recent vaccination.
  The treatment of this affection is exceed-
ingly simple ; all that  is necessary is to re-
move the crusts and to  apply a mercurial
or a sulphur ointment, two or three times a
day,  and in a short time all  traces of  the
affection  will disappear, except the macules
which mark the previous site of the erup-
tion.  These gradually fade, and ultimately
the skin  assumes a normal  aspect, without
mark or scar.

                 MILDUM.
  The  affection  known  as Milium is char-
acterized  by the development, in the super-
ficial layers of  the skin, of a  number  of
minute white papules looking  something
like small grains of sand.  They are in real-
ity sebaceous follicles, with occluded open- 
218      CUTANEOUS MEMORANDA.

ings,  distended by sebum.  Their favorite
seat is the neighborhood of the eyelids, al-
though they are sometimes met elsewhere.
They are usually quite numerous  if the
affection has existed for any length of time,
but their course is indolent; they are pain-
less and unaccompanied with inflammatory
symptoms.  The}' are most frequently met
with  in females, and rarely appear  except
in adults.
  Milium rarely, if  ever, produces any in-
convenience except so far as it detracts from
the comeliness of the visage.  The tendency
of the affection is toward increase  in the
number of the little granules, but they rarely
attain a size larger than that of the head of
a large pin.
  The causes which produce this occlusion
of the sebaceous follicles are absolutely un-
known.
   Treatment.—The principal indication is to
remove the little granules  as  soon as they
become large enough to permit of operative
procedure.   The  instrument   usually em-
ployed for this purpose is an ordinary lancet
with which  the   stratum  corneum that
covers them is divided.  The  little grain  is
then dug out with the point of the instru- 
ALOPECIA AREATA.         219
ment.   To facilitate  their  extraction  we
have employed  a  needle-like  instrument
with a curved lanceolate point, as shown in
Fig. 22.
  This  little needle is quite similar
to the one used by oculists in connec-
tion with the treatment  of  cataract.
The needle is  introduced in such a
way that  nearly the whole of the
epidermis is removed  from above the
granule.  Then, by a dexterous  turn,
the little tumor is pried out.   After a
little practice a large  number can be
removed  in a  very short  space of
time.

         ALOPECIA AREATA.
  Alopecia areata is an affection char-
acterized by the loss of hair  from the
scalp or other parts.  The  affection
commences by  small  circumscribed,
usually round  patches, which grad-
ually enlarge, until contiguous  ones
unite.   The parts most frequently af-
fected are the scalp and region of the milium
head, though  all parts of the  bodyNEEDLE
may be  affected, and all of the hair be shed.
The bald pitches are surrounded by appar-
ently healthy hair.
Fig. 22. 
220      CUTANEOUS MEMORANDA.
  The  causes of alopecia areata are  not
definitely known.   A few, chiefly French
authors, believe that it is due to a fungus,
which they call  the Microsporon Audouini
and hence classify the affection  with the
                  Fig. 23.
Phytoses,  or diseases  depending on vege-
table parasites.  The majority of observers
do not  accept this view, but believe that
the affection is due to a circumscribed as-
thenia, depending on defective innervation. 
ALOPECIA.
221
   The treatment of this affection is simple.
 If the patches have not yet acquired a very
 large size, the marginal hairs for T^ inch to
 J-  inch are carefully epilated.   This done,
 the   further  treatment  will  depend on
 whether the patch  is apparently congested
 and slightly elevated, or whether depressed
 and pale.   If in  the former case, I  have
 found a local application of nux vomica of
 great service.   From 3 ss. to 3 j. of the fluid
 extract to an ounce of simple or rose-water
 ointment, may  be thoroughly  rubbed into
 the affected parts  once or twice  a  day.
 Another convenient application consists of
 equal parts  of tincture of nux  vomica and
 castor-oil,  or  a two per  cent, solution of
 strychnia in oleic acid.
  On  the other hand, if the scalp is pale and
 depressed, an active stimulant  is required,
 and for this purpose I am in  the habit of
 using  the  ordinary  Collodium  cum  Can-
 tharide of the  pharmacopoeia.  This beins:
applied sometimes blisters, but  quite as fre-
quently fails  to.   If  it blisters,  the  next
dressing will be a little  simple  cerate until
the blister has healed.  This is  followed by
a mild stimulating application, as castor-oil
with a little tin  lu. e of cantharides or spirits 
222      CUTANEOUS MEMORANDA.

of rosemary, or a lotion or ointment of cor-
rosive sublimate, one to two grains to the
ounce, or the turpeth ointment above men-
tioned.  If, at the end of two weeks or so,
there is no sign of new hair, the cantharidal
collodion is again applied.  When new hair
begins to appear, it is usually quite fine and
delicate, and of a much lighter  color than
normal.  As soon as it shows itself the razor
may be brought into requisition, and used
two or three times a week, mild stimulants
to the  scalp being  continued.  In addition
to the drugs mentioned, I have sometimes
used croton-oil, cardol, ammonia, and other
substances having an analogous action.
            LICHEN iESTIVUS.
  This affection, commonly known as "prick-
ly heat,"  is met with in hot climates gener-
ally, and also in the United  States, chiefly
during the months of July and August.  It
appears as small  red  pointed papules scat-
tered over the surface, and sometimes inter-
spersed with small vesicles.  The neck, face,
arms, and legs appear to be the portions
most frequently  and  severely affected,
though no parts are exempt,  except the
scalp, the palms of the hand, and  soles  of
the feet.  The eruption itself is insignificant, 
PERNIO.
223
but as it  is often accompanied with severe
itching and pricking sensations, it demands
relief.   The affection  is  manifestly con-
nected with a high temperature, and it may
be expected when the  average heat runs
above 80°.
  The  anatomical seat of the affection has
not been positively determined.  The affec-
tion is to be distinguished from scabies and
eczema, the  only diseases with which it is
liable to be confounded by the inexperienced.
  Treatment.—Generally relief can be  af-
forded by sedative applications, as the lot.
plumbi et opii, or the lot. flava. If trouble-
some at night, comfortable rest can usually
be secured by a small dose (gr.  ss.) of opium
and sometimes decided amelioration.  Free
action of the bowels and  kidneys is likewise
of great  service.  We have also seen the
most  marked benefit from  two  or three
Turkish baths.

                 PERNIO.
      Syn : Erythema pernio ; "chilblain."
  Definition and description.—This affec-
tion, so common  in cold climates, affects, by
preference, the feet, hands, nose, and ears,
and consists in a condition of  chronic con- 
224      CUTANEOUS MEMORANDA.

gestion,  accompanied with  lowered  local
vitality, resulting from partial congelation
of the parts.  It is characterized by redness,
usually with a purplish tinge, together with
more or  less pain of a burning  character.
In  severe  cases  fissures  and  ulcerations
sometimes  form.  The affection,  or rather
the disposition to it, often lasts for years,
giving little or no" trouble  during the  sum-
mer, but causing inconvenience and suffer-
ing as cold  weather sets in.
  Etiology.—The  affection is due, in  most
cases, to a partial freezing of the tissues,
followed by a rapid thawing out;  as, for in-
stance, a person, after prolonged exposure
to cold, imprudently enters a heated room,
and seeks a place nearest the fire.  Tramp-
ing about  in melting snow may reduce the
temperature not quite to the freezing point,
but sufficiently near it to materially retard
the circulation.  If now the feet be gradually
and slowly warmed by friction, etc.,  little
harm may result, but if  rapidly  warmed
and overheated before a hot fire,  the  reac-
tion will be too sudden, and chilblains are
apt to result.
  Treatment.—Remembering that the con-
dition is  one of lowered local vitality, the 
PERNIO.
225
 chief indication will be to employ stimula-
 ting applications.   Those most in vogue are
 frictions with camphorated oil, turpentine,
 capsicum, and the like.  For a  number of
 years the author has employed the galvanic
 current with the utmost benefit.  When the
 feet are affected,  the  patient is seated so
 that one buttock rests on a sponge-covered
 plate connected with  the positive pole  of
 the  battery.   The  corresponding foot  is
 then  placed in a basin partially  filled with
 salt  water,  and into  the basin  the other
 electrode is placed.  The current is now
 permitted to  flow,  and its  strength is so
 regulated that  the patient shall just per-
 ceive a  slight sensation of warmth. The
 seance usually lasts for about ten  minutes
 for each foot,  and  is repeated two or three
 times a week.   The current seems to more
 or less completely restore the vitality of the
 part; and under its influence I  have seen
 obstinate pernial ulcerations  heal without
 the employment of other treatment.   In
 milder cases the relief of the itching and
 bnrning is sometimes very striking.   Possi-
 bly the faradic current would act as well as
the galvanic,  but on  this point I cannot
speak from experience. 
226      CUTANEOUS MEMORANDA.
               VERRUCA.
  Verrucae, or " warts," are papillary excres-
cences of the derma, due to hypertrophy
and prolongation of the papillae, with hyper-
plasia of epidermis.  Their favorite seat is
the fingers  and hands.  They may,  how-
ever, occur elsewhere, as upon the forearms
and other parts of the body.
  The cause  of their growth  is unknown.
They  sometimes  undergo spontaneous  in-
volution, and disappear as mysteriously as
they came.
  The treatment usually recommended is to
pare down  the wart with a sharp knife, to
the level of the surrounding skin, and then
to apply some caustic, as the  nitrate of  sil-
ver, or glacial acetic, or one of the mineral
acids, repeating the  application  until the
wart is destroyed.  The chloride of ammo-
nium frequently applied will sometimes  re-
move them.
  The  writer usually removes  them  by
means of the dermal curette. 
ERYTHEMA.            227
DISEASES  OF  UNCERTAIN  NA-
                TURE.
            CHAPTER XXI.

               ERYTHEMA
  Definition and description. — Erythema
consists in a circumscribed or diffused patch,
or several  such patches, characterized by
redness, a little heat and sometimes itching.
The patches may be of temporary duration
only, or may persist for a considerable time.
The name is not strictly applicable to any
definite and particular disease,  but should
rather  be taken in a  generic sense as the
designation  of  a symptom,  implying the
idea of superficial congestion.  Thus the
redness which follows exposure to the sun
or to artificial  heat has been termed ery-
thema  caloricum; that which follows the
application  of  irritating  substances  like
mustard  or capsicum,  has  been termed
erythema ab acribus ; that which is induced 
 228      CUTANEOUS MEMORANDA.

 by the pressure of badly fitting garments-
 garters, stays, pads, straps, trusses, etc.,—
 has  been termed  erythema  traumaticum.
 These are all trivial affairs, which soon dis-
 appear when the cause which produced them
 no longer continues in action.  There are,
 however, other forms of congestion or sim-
 ple  hyperemia of the skin that appear to
 be due to internal  causes.  Such, for in-
 stance, as the temporary flushings  of the
 face that occur in women about  the time of
 the  menopause, and which  last sometimes
 for a few minutes  only, sometimes for an
 hour or more.  When these are frequently
 repeated, the hyperemia becomes more per-
 sistent, giving rise to a chronic condition
 which, in time, may lead  to a pronounced
 rosacea.
  In certain cases, dyspeptic conditions and
 hepatic derangements  may give  rise to
 hyperemic conditions of the face, which may,
 with equal propriety, be called erythema.
  In addition to the foregoing there are two
definite affections of  the skin that have re-
ceived the generic name of erythema with a
qualifying addendum : I allude  to the so-
called Erythema multiforme, and E. nodo-
sum.  These will be considered separately. 
ERYTHEMA.
229
         ERYTHEMA MULTIFORME.
  Definition and description.—Will an, the
father of English  dermatology, described
certain cutaneous affections under the titles
Erythema marginatum, E. papulatum, and
E.  tuberculatum;  later writers added  to
these  the  expressions  E.  circinatum,  E.
vesiculosum, etc.  Herba has properly, we
think, included them all under the  general
name of Erythema multiforme, implying an
erythematous affection of multiple lesion.
  The eruption may consist of patches of
redness, over which circumscribed elevations
also red are scattered.  These elevations may
be few or plentiful, and may vary from one-
eighth to three-fourths of an inch  or more
in diameter.  The small ones may, according
to size, be called papules or tubercles, while
the larger ones, which are always flattened,
may assume the appearance of an elevated
ring,  around which a second or third ring
may develop.
  These various lesions  rarely persist more
than  a week or  ten days, at the end  of
which time  they gradually subside  and dis-
appear, leaving after them bluish  stains
which last  a few  days longer.  After  the 
230      CUTANEOUS MEMORANDA.

disappearance of the first eruption, or even
while it is still in full efflorescence, a second
crop of lesions may come out, and after this
a third,  prolonging the trouble in this way
for several weeks  or months.  The eruption
may consist simply of papules or of tubercles,
or more frequently  several or all  of the
lesions  mentioned above  may coexist  in
varying proportions.   The  favorite seats of
Erythema multiforme  are the backs of the
hands,  wrists,  the feet and  ankles.  The
eruption, however, may occur upon any part
of the surface, and sometimes becomes quite
general.
  The outbreak of E.  multiforme is some-
times characterized by prodromata of a mild
febrile character,  which exist for a day or
two before the appearance of the cutaneous
lesions,  and subside  as the latter develop.
The  subjective local symptoms are  slight,
and  may consist in a little burning or itch-
ing at the seat of the eruption, but rarely
sufficiently intense to cause  much incon-
venience.   The eruption is more frequent
in spring and autumn than at other seasons,
and in some individuals exhibits a tendency
to recur at these times.
  For the last few years we have adopted 
ERYTHEMA.
231
the following plan of treatment (the same
that we recommend in acute urticaria) with
very satisfactory results.  In  adults, from
five to  ten  drops of the fluid  extract  of
ipecac, are given every ten minutes until
the patient vomits.   As soon as his stomach
is calmed down a little and the patient feels
capable of the requisite exertion, he is placed
in  a Turkish bath  until he sweats  freely.
He is then shampooed in the usual manner,
dried off, and  put to bed.  The  next day
another Turkish bath  is taken, and,  if
necessary, a third.   In  one  instance  we
have known the  efflorescence  to disappear
while the patient was taking his first bath,
and no further eruption occurred.  In  de-
fault of the Turkish  bath, a wet pack or a
full dose of  Jaborandi might  be  tried.   In
cases of longer  standing  apparent  benefit
has followed the use of belladonna, pushed
until  physiological  effects are  developed,
and quinine in  full doses.  Several years
ago, in a case then under my care, coffee ap-
peared to  be the exciting cause, and relin-
quishment of this beverage was followed by
permanent disappearance of the eruption.
In a few cases of this sort  the  cause  of the
trouble can be discovered, and rational treat- 
232     CUTANEOUS MEMORANDA.

ment be adopted ; in many, however, this
cannot be done, and we  must either try
purely empirical treatment or give a placebo,
and wait for a spontaneous recovery.

          ERYTHEMA NODOSUM.
  Quite different from the affection last de-
scribed is the  one  to which the name of
Erythema nodosum has been applied.  This
disease is  characterized by an eruption of
reddish and  somewhat acuminate  tumors
from the size of a small cherry to that of an
egg, and  usually situated  upon the lower
extremity between the  knee and  ankle.
The number of  tumors varies.  There may
be but half a dozen of them when the affec-
tion is confined to the lower extremities,
or two dozen or more when diffused over
other regions,  as the  abdomen and upper
extremities.  Not  unfrequently the  affec-
tion is ushered in  by slight fever, which
subsides as the  eruption develops.   At first
the swellings are a little painful and tender
on pressure, with a feeling of tension in the
affected parts.  The color is at first a light
red, as from an active hyperemia ;  it soon
becomes darker, however, and assumes a
purplish tinge which gives place to a yellow- 
ERYTHEMA.
233
ish green, that in time fades away with the
diminution of the swelling in the course of
ten clays or  two weeks.   The  appearance
presented is very like that of a bump on the
forehead,  so common in childhood  as the
result of  a slight  blow.  It is  this aspect
that  has given it the name of  Dermatitis
contusiformis.  The tumors may not all
appear on the first day of the eruption, but
may take two or three days before the crop
is all  out.   As the first crop subsides, a sec-
ond may appear, as in the case of Erythema
multiforme, and even a third or fourth, pro-
longing the affection in this way for six
weeks or two months.
  The treatment-of  this affection is simple.
Seen at the commencement,  if there be the
slightest febrile action, or elevation of tem-
perature, aconite in apyretic doses should
be given and continued for at least a couple
of days ; later, iron in moderate quantities
is of service, and, perhaps, also the mineral
acids.  Locally, I apply compresses of hama-
melis for the first few days, to be succeeded
by  arnica (root) as the  lesions begin to
assume the appearance  of  a bruise.   An
elastic bandage materially hastens  the reso-
lution of the  tumors. 
234      CUTANEOUS MEMORANDA
            CHAPTER XXH.

             ELEPHANTIASIS.
  This name is given to a disease character-
ized by great hypertrophy of the skin and
subcutaneous tissues of the lower limbs and
genitals, an affection which is specially fre-
quent in certain tropical countries, but met
with occasionally in the temperate zones.
  Course.—The course and symptomatology
vary somewhat in different cases.  In the
majority, however, the disease is ushered
in by a chill followed by a febrile attack.
These symptoms are accompanied by inflam-
matory swelling of one of the legs, some-
what resembling a mild  erysipelas.  After
a few  days the febrile symptoms subside,
followed by more or  less  complete disap-
pearance of the local inflammatory trouble.
As  a rule, however, the  swelling does not
entirely disappear, but leaves the leg a little
larger than before the attack.  After a vary-
ing and uncertain period,  which may be a
few weeks or even months, a recurrence of
the febrile attack  takes place with  renewed 
ELEPHANTIASIS.
235
swelling of the limb.  Again the abatement
of the symptoms leaves the limb a little lar-
ger than before.
  These phenomena are renewed  from time
to time, each occurrence being followed by
a permanent addition to  the size of the af-
fected  member.   Later the febrile attacks
cease, but the limb nevertheless continues
to slowly enlarge until it may ultimately at-
tain an immense size.  Sometimes the affec-
tion is confined  to the foot and ankle, or to
the foot  and leg, or again the thigh may be
involved. Occasionally both limbs are af-
fected, but as a rule the disease commences
in one, Jong before  it appears in the other.
In addition  the  scrotum  or  penis, or both,
may likewise enlarge, pari passu with the
diseased limbs, or the genitals may alone be
affected.   In the female the labia  majora,
*o a less extent the  labia  minora,  may
andergo the same changes.
  Treatment.—Palliative and antiphlogistic
measures during the febrile attacks are  of
course  indicated, and quinine in large doses
alone, or in combination with opium, would
seem to be the remedy most likely to control
or moderate the symptoms.   In the intervals
between  the paroxysms,  and in the later 
236        CUTANEOUS  MEMORANDA.
Fig. 24.—elephantiasis. 
FURUNCLE.
237
stages of the disease, internal medication
appears  to  be  without  influence.   Local
treatment alone gives promise of relief.  If
the  lower extremity  be  the  part affected,
methodical  compression  by a bandage or
elastic stocking will palliate the trouble to
a certain extent, but is not likely to prove
curative. Ligature of the femoral artery
has been repeatedly tried but with varying
results.  If the genitalia are affected, ampu-
tation of the redundant  parts affords  effi-
cient and permanent relief.

                FIBROMA.
  This name is applied to  certain tumors of
varied size and form, which sometimes ap-
pear upon the skin.  They may be simply
semi-globular protrusions, or  form sessile
tumors with a comparatively small pedicle.
In some cases but a single tumor is present,
in others two thousand have been counted.
  Neither internal nor external medication
exercises  the  slightest influence on these
growths—excision is the only  remedy.

                FURUNCLE.
  Definition and description.—A furuncle
or "boil," is a small or moderately sized, 
238      CUTANEOUS MEMORANDA.

red and painful inflammatory elevation, of
the skin.  Its  first appearance is  usually
heralded by a sharp stinging sensation fol-
lowed by pruritus.  A papule then appears
and gradually increases in size and becomes
hard and painful. In a day or two a whitish
point appears at the apex.   This small col-
lection of  pus  enlarges until  nearly the
whole tumor becomes purulent, constituting
a small abscess.  Later, this little abscess
bursts and  discharges its pus, and, in addi-
tion, a firm cylindrical, whitish substance,
commonly termed the  "core."  Reparative
action then commences, and recovery takes
place, with a depressed scar varying with
the size of  the  boil.   Furuncles may occur
singly, or successively, or in crops of three
or four at a time, and a succession of crops
keep up the trouble for several months  or
longer.
  The diagnosis and prognosis  of Furuncle
are familiar to all.
  Etiology.—Boils were formerly regarded
as evidences of  excessive good health, or as
the results  of high living  and overfeeding,
and a crop of them was looked on as a good
sign, and they were  even spoken  of  as
" healthy"  to have.  This view is now quite 
FURUNCLE.
239
abandoned, and furuncles are more generally
regarded as evidence of depraved nutrition ;
their exciting cause, however, is unknown.
  Treatment.—The indications for treatment
are to relieve the existing furuncle and to
prevent the occurrence of others.   If a fu-
runcle be seen at the very commencement—
that is, while it  exists simply as a papule,
before the formation of pus—it may be of-
ten aborted.   This may be accomplished by
touching it with a white-hot needle, or sharp
point of a Paquelin cautery.  Instead of the
actual cautery, nitrate of silver may be ap-
plied. The part should be first washed clean,
to remove grease,  etc., from  the surface,
after which the  solid stick should be thor-
oughly  applied.  This treatment,  when
adopted sufficiently early, usually prevents
the further development of the  furuncle.
If pus lias already formed, the boil should
be allowed to go on to maturity without sur-
gical  interference.  A little  belladonna  or
stramonium  ointment may  be applied  to
ease the  pain, and a warm poultice to has-
ten maturation.  When fully " ripe," if it
has not already opened, it may be incised
and the contents evacuated.  It should then,
if possible, be dipped in water as hot as can 
240      CUTANEOUS MEMORANDA.

be borne for  ten  or fifteen  minutes, then
dried, and the cavity filled with a little pel-
let of absorbent cotton or marine lint, over
which should be placed a piece of sheet lint
smeared with  a little simple cerate or, bet-
ter, perhaps, equal parts of stramonium and
resin ointments.   The boil should not be
poulticed after opening.   It has often been
noticed, when a boil is  freely poulticed af-
ter opening, that  a number of fresh ones
appear in the vicinity.  I presume that this
is due to a little of the pus gaining entrance
to the sudoriparous or  sebaceous  follicles
and, by its  irritant properties,  exciting fu-
runcular inflammation.   A furuncle should
never be opened prematurely.  The core of
slough remains attached by its deeper ex-
tremity  for some time,  and until this is
loosened and   discharged the boil  will  not
heal.  If prematurely opened the pus is dis-
charged,but the core remains attached much
longer than if the furuncle were permitted
to fully mature.
  The constitutional treatment will involve
the use of remedies called for by any mani-
fest impairment of health, and  particularly
iron, quinine,  and the mineral acids.  The
prophylactic or, as it might be called,  the 
KELOID.             241
specific treatment, intended to break up and
remove the tendency to furuncular inflam-
mation, calls for the employment  of a dif-
ferent class of drugs.
  Among these the sulphite  of sodium, in
twenty-grain doses two or three times a day,
has been highly recommended.  Personally,
I have used to advantage the " syrup of the
hypophosphites"  in dessertspoonful  doses
three times daily.  Just at present the drug
most in vogue is the Sulphide of Calcium.
There is no doubt, however, as to its efficacy.
It should be given in 1-10 grain doses four
or five times a day.

                 KELOID.

  This affection is characterized by the de-
velopment upon  the skin of one  or  more
flatfish, smooth-surfaced tumors of varying
shape and size.  In some cases the natural
color of the skin is preserved, in some it is
heightened,  but more frequently it is a trifle
paler than the normal, or it  may  be  quite
white, often possessing a marked cicatricial
aspect.  In fact if  it were  not for its eleva-
tion, keloid might  often pass for an ordinary
cicatrix.   Sometimes arms or processes pro- 
242      CUTANEOUS MEMORANDA.
ject from the main body of the tumor, as
thin bands into the surrounding skin.
  The keloid tumors  gradually increase in
size up to a certain point, at which further
progress ceases.   They then remain station-
ary for the  rest of the  patient's life.  In
very rare instances they undergo involution
and finally disappear.
  Keloid may arise spontaneously, or sub-
sequent to some wound or local irritation of
the skin, and writers have consequently dis-
tinguished two  varieties  of  the affection:
the one which originates spontaneously be-
ing called true "keloid,  and the other spu-
rious.
  Treatment—At  first  thought  excision
would seem to be an appropriate measure
of relief ; but experience has shown that in
the great majority of cases the disease will
certainly return, and often more extensively
than at first.   Excision, therefore, should
not be regarded as likely to result in a radi-
cal cure, and should only be employed when
the situation, or great size of the tumor,
renders its removal imperative, or when the
temporary relief thus  gained more  than
counterbalances the  inconveniences  of  an
operation.  Removal by caustic promises no 
LICHEN PLANUS.
243
better results than the knife.  It  must be
admitted then  that we are without any
means, that can be relied upon, which will
enable us to successfully control this curious
disease

             LICHEN PLANUS.

  This is a somewhat rare disease,  and is
characterized by the development of flat pap-
ules upon various parts of the body.   They
are usually of a dull red or  somewhat purp-
lish color, with  a characteristic central de-
pression.  The  affection greatly resembles
certain  papular syphilides, and in  fact a
diagnosis between the two may be exceed-
ingly difficult, if we judge by aspect alone.
The concomitant symptoms and the history
may alone enable us to judge between the
two affections.  The affection is essentially
chronic in its course, and the papules upon
subsiding leave dark stains, which  persist
for some time before finally fading away.
  Treatment.—Concerning    this,  Wilson,
who has had an extensive  experience with
this disease, says : " Our first object should
be to regulate the functions of the  economy
wherever any disorder may be apparent; in
the next place  we should  endeavor to re- 
244      CUTANEOUS MEMORANDA.

store the vigor of the system by tonic reme-
dies, such as bitters, quinine, nitro-muriatic
acid,  and chalybeates;  and these  objects
being effected, we may finally have recourse
to the tonic-nutritive operation of arsenic."
Locally he  recommends a lotion of the bi-
chloride of mercury (two grains to the ounce
of bitter almond emulsion). The eruption
is frequently  rebellious, but usually yields
in the end to treatment.
   Taylor has recently contributed  the re-
sult of  his  observations concerning lichen
planus, and has derived benefit from the use
of oxidizing agents and alkaline diuretics.

              LICHEN RUBER.
   This name is given to an eruption to which
attention was first  called by Hebra.  The
following description  is an abridgment of
the one which he gives in the first edition
of his work :
   The affection consists in an eruption  of
papules, which always remain such, never
changing into vesicles or pustules, and never
undergoing any  modification except when
the eruption of new papules changes a dis-
crete into a confluent lesion.  The  papules
always present an intense red  color except 
MOLLUSCUM.
245
when covered  with scales.  In the begin-
ning the papules are miliary, and each cov-
ered with a fine scale.  They never increase
in size, but preserve their original volume
throughout the whole  course of the disease.
Fresh oapules may arise between the orig-
inal ones, or  at  a distance  from  them.
When the papules are  in contact, they form
continuous patches of variable  size and con-
tour,  red, infiltrated,  and covered  with
scales.  The entire surface may be invaded
in this  manner.   In  advanced  cases the
pruritus may be intense.
  The condition of the  general health varies
with  the extent of the eruption.  At the
beginning it may not be  appreciably  af-
fected,  but as the  disease  advances, the
organic functions  deteriorate and nutrition
suffers.   The appetite  or sleep may not be
much disturbed, but the subcutaneous  fat
gradually  diminishes,  until  finally  the
patient falls into a condition of marasmus,
and at last dies.  At least  this was Hebra's
experience with thirteen of the first fourteen
cases seen by him.
               MOLLUSCUM.
 Syn : Molluscum contagiosum ;  Acne varioliformis.
  Definition and description.—We  confine 
246      CUTANEOUS MEMORANDA.
the term molluscum to an affection charac-
terized by the development of small tumors
of peculiar  aspect, scattered  more or  less
freely over the surface.  These little tumors,
or more properly tubercles, vary from the
size of a hemp seed to that of  a pea.  They
are sessile or pedunculated, and each is fur-
nished with a small depression or umbilicus,
from which, by pressure, a thickish white
substance, like sebum, may be made to pro-
trude.  Their color is usually that  of the
normal skin, but may be a little redder, with
sometimes a translucent aspect.   The little
tubercles are most frequently met with on
the face, but are sometimes encountered on
the neck, chest, back,  limbs,  and genitals.
Their number varies from three or four to
twenty or thirty,  or possibly more.  They
do not  appear simultaneously, but  succes-
sively, coming  out one after  another for
weeks  and  months, so that in advanced
cases they may be encountered in various
stages.  Having attained a certain size they
may so remain for an indefinite period, but
after a time usually  discharge their con-
tents, dry up, and shrivel away.  Sometimes
 inflammation and suppuration occur.  The
 affection is met with at all ages and  in both 
MOLLUSCUM.
sexes, but the majority of cases have been
observed in  young  females.  It has been
frequently encountered  simultaneously  in
several  members of  a family, and has thus
given rise to the idea that it  may  be con-
tagious.   This point,  however, cannot  be
considered as definitely settled, although
the weight of evidence appears to me to  be
in favor of the contagion theory.   The erup-
tion is unaccompanied with pain or other
subjective symptoms, and does  not appear
in any way to influence the general health.
  The treatment of molluscum is exceed-
ingly simple. All that is necessary is to
destroy the  tubercles  that are present at
the time of the patient's visit,  and subse-
quently a few more that were hardly large
enough to be seen the first time.   The de-
struction  may be accomplished by  shaving
off the tubercles at the level of the skin,
squeezing out the remainder of their con-
tents, and then applying a nitrate of silver
point, or a red-hot needle to the little cavity
that remains.
  Bateman states that the internal use of
arsenic is of service.   I have never tried it,
as the external measures just spoken of are
usually sufficient.  Sometimes the tubercles 
248      CUTANEOUS MEMORANDA.

are so closely grouped as to become almost
confluent and to form a patch of  some size.
In these cases, instead of using  the knife,
their destruction may be effected by the use
of alkaline caustics.
            CHAPTER XXHI.
               PEMPHIGUS.
  Pemphigus is a chronic  affection of the
skin,  characterized by the development of
bulhe, from the size of  a pea to that of an
egg, upon any portion of the body.  They
may be few or numerous,  but if many be
present at the  same  time  they are  some-
times found aggregated in little  groups of
three or four together.  Their contents are
usually serous and transparent ; but  some-
times the admixture of  a little pus renders
the fluid  slightly opaque.  Of Pemphigus,
one of the older writers described ninety-
seven  varieties.  For present needs, how-
ever, two will suffice.  These are Pemphigus
vulgaris  and Pemphigus foliaceus.   It will
be best to describe them separately.
          PEMPHIGUS VULGARIS.
  In this form the bullae, well distended by 
PEMPHIGUS.
249
fluid, persist unchanged for several days,
at the end of which time they rupture, and
discharge a thin, not very plastic fluid,
differing greatly in  this  respect from the
plastic exudation  of  eczema.   Sometimes
the stratum corneum reapplies itself to the
skin, and remains in contact until the sur-
face beneath is entirely healed and covered
with a new epidermis.   It is then shed, and
reveals a circumscribed reddened,  surface,
which  soon, however,  regains  its normal
color.  At other times the covering of the
bulla? is detached soon after rupture, and
displays  a red  and oozing  surface.  This
becomes drier  as  the  new-formed, horny
layer replaces the old,  when the heightened
color gradually fades away.  After the dis-
appearance of the bulla?, which marked the
invasion of the disease, or even before they
are completely gone, fresh ones may arise,
or, on  the other hand, several weeks  may
elapse  before  a recurrence takes  place.
These relapses may prolong the disease for
an  indefinite period.   Finally,  either spon-
taneously or as the result of treatment, no
new bulla?  appear, and the patient is  well.
This favorable  termination, however,  does
not always occur ; but the affection persist- 
250      CUTANEOUS MEMORANDA.

ing for several years,  the  patient is carried
off by some intercurrent disease.

          PEMPHIGUS  FOLIACEUS.
  This form differs from the other mainly
in the fact that the bullae are not filled with
fluid, that is, the epidermic  covering is not
tense or  stretched but somewhat flaccid.
The bullae are often of large size,  forming
flatfish fluid  tumors as large as the hand.
Bulla?, arising  in  close proximity to  each
other, by mutual extension become conflu-
ent, and the epidermis at  the same  time
appears  to thicken.  The eruption may be
limited in distribution, or may invade  sev-
eral regions.  If the thickened epidermis is
stripped off,  the reddened surface will be
found  covered with  a whitish exudation
resembling a diphtheritic membrane.
  Treatment. — Until within  a  very  few
years  most authorities believed that  very
little could be done for this  affection by in-
ternal treatment, and some  German writers
appear to be of this opinion still.
  Hutchinson,  however, states that he has
been uniformly successful in controlling
and  curing the  affection by means of
arsenic.    The author, and others in  this 
PRURIGO.
251
country, have had a like favorable experi-
ence  with this  drug in the disease under
notice.  The drug should  be given in full
doses, and continued for some time after the
eruption has ceased to appear.
  The local treatment is  not without im-
portance.   That which  I have found  most
serviceable is to rupture the bulla as soon
as it  appears, sop up the  fluid with a soft
rag, and then apply the nitrate  of zinc to
the raw surface.  The  pain, at first sharp,
soon  passes off; the patient suffers  little
subsequent  inconvenience  from the lesion.
It will, moreover, usually heal in about one-
third  the time it would take if left alone.

                PRURIGO.
  Prurigo is a name that has been used in
a variety of significations, chiefly to denote
a condition of itching  or pruritus, arising
from a number of causes—in other words, as
the name of a symptom  rather  than of a
disease.  We  here confine it, however, in
accordance  with  present  dermatological
usage, to  a special disease first clearly de-
fined by Hebra.  The disease is quite rare
in this country,  and the following  descrip-
tion is taken from the author just named : 
252      CUTANEOUS MEMORANDA.

  The affection in all cases commences by
the  appearance  of  small   subepidermic
papules,  more  easily appreciable by touch
than by  sight, since they rise but  little
above the level of the skin, and do  not dif-
fer from  it in color.  They are always iso-
lated.  They give rise  to a good  deal  of
irritation, and in  consequence of scratching
become a little  more elevated and of a red-
der  color.  Repeated scratching  destroys
their  epidermic covering  and permits the
discharge of  a  transparent  or  yellowish
serum, or if the papilla?  be wounded the
escape of a droplet  of blood,  which forms a
minute blackish crust upon the summit of
the papule.   As  the papules exist in con-
siderable number, this process, repeated  in
them all, produces the aspect to which the
name of ordinary prurigo may be given.
  When, however, the affection has lasted
some time,  new  phenomena  are added  to
those  already  mentioned.   Pigmentation
of skin,  gradually increasing, and corre-
sponding to the location of the  scratch-
marks, becomes a prominent feature.  The
natural lines and furrows of the skin become
more widely separated, and  more  distinct
than  in   the  normal  condition, specially 
PRURIGO.
253
 noticeable about the backs of the hands and
 wrists.   The downy hairs are torn out by
 scratching, or broken off and disorganized,
 and the skin itself is harder and thicker than
 in health.
  In severer cases all of these symptoms be-
 come exaggerated.   The papules are larger,
 the  itching more intense, the excoriations
 more severe,  and the number  of  blackish
 blood-crusts  increased.    In  addition we
 notice a more general brownish pigmenta-
 tion, and a detachment of the outer layers
 of the epidermis under the form of a whitish
 branny desquamation.   In some  cases  a
 vesicular or pustular eczema may be devel-
 oped, masking, to  a certain extent,  the
 peculiar features of the primary affection.
  The disease is exceedingly chronic, and in
 Hebra's experience  persists throughout the
 whole lifetime of the patient.   It does not,
 however, appear to exert any  noxious in-
 fluence on the general  health, or to shorten
 the life of the unhappy sufferer.
  Many of the features of prurigo are com-
mon to it, and the various forms of pruritus,
as,  for instance, the  itching,  the  scratch-
marks, and the pigmentation of the  surface.
On the other hand, the peculiar papules are 
254      CUTANEOUS MEMORANDA.

pathognomonic, and are sufficient, in con-
nection with the other symptoms, to enable
the nature of the affection  to be promptly
recognized.
  Hebra  found the disease  incurable ; he
nevertheless was able to obtain great ameli-
oration of the condition of the skin by judici-
ous and persistent treatment.  Internal medi-
cation was useless, but local measures, calcu-
lated to  soften  and hasten the desquama-
tion of the external layers of the skin, were
of decided service.   Baths of all sorts, warm,
cold, or vapor, were of the first importance.
In addition, thorough applications of green
soap  were   frequently  employed.   Sul-
phur, whether used in baths, ointments, or
soap was found  very useful, as was also
Vlemingkx's  Solution. The various prepara-
tions of tar were found to possess a marked
influence in diminishing the irritation.
  Quite recently the internal  administration
of Jaborandi has been found very beneficial.

                PURPURA.

  Definition  and description.—Purpura is
an  affection  due to localized  effusions of
blood into the skin,  and is characterized by
the  sudden  appearance  of  small  macules 
PURPURA.
255
from  one-twelfth to  one-half inch in  di-
ameter on various parts of the surface.   A
comparatively small number only may be
present, or, on the  other hand, so many
that it would prove tedious to count them.
The spots, at the  moment of their first  ap-
pearance, are red, but soon assume a pur-
plish hue.  The color is not removable by
pressure. After a few days they undergo the
changes  of color that we are  all familiar
with in connection with ecchymoses  from
contusion.
  The eruption may be thickly sprinkled
over the whole surface, except the face and
scalp, which are usually spared. The macu-
les may all appear in a single day, or addi-
tions may  occur for several successive days.
The spots  go through their changes and
disappear in from one to two weeks.  After
a variable  period a fresh crop may appear,
and this may be repeated a number of times.
  In some cases  hemorrhage  from  the
mucous surfaces takes place, and may be so
profuse as to seriously endanger  the life of
the patient.
  In simple Purpura  there is, as a rule, a
total absence of constitutional symptoms—
that is, there is no  febrile action either be- 
256      CUTANEOUS MEMORANDA.

fore or after the eruption.   There    ^iso
absence of pain and itching.  The eruption
may attack those in a debilitated condition,
or  those  who  appear to  be in  perfect
health.
  Purpura hemorrhagica, on the other hand,
may be preceded by a vague feeling of ill-
ness,  but without well-defined symptoms.
As  the disease  advances, however, hemor-
rhages from the nose,  mouth, bowels,  or
bladder may produce serious debility and
even prove fatal.
  Diagnosis.—The diagnosis of purpura is
easy,  the only affection with which the in-
experienced would be likely to confound it
being  Scurvy.   In Scurvy the gums  are
swollen and may be ulcerated, and the pur-
ple spots are not mere macules but patches
of considerable size.  In Scurvy there is also
swelling of the lower  limbs,  not  a soft
oedema, such as  occurs in Bright's disease,
but a  hard, boardy feeling that  is  rarely
met with in any other affection.  In Scurvy
it is usual also to have more or less debility.
The history of the case will also throw light
on the diagnosis.  Purpura usually  comes
on without assignable cause, while Scurvy
is always the result of improper diet, such 
PURPURA.             257
as  exclusive  confinement  to  salt  food,
absence of vegetables, etc.
  Prognosis.—In simple purpura the prog-
nosis is  usually  good,  but in the hemor-
rhagic form there is danger of exhaustion and
collapse  from loss of blood.  The effusions
may also invade the tissues of the internal
organs, and in this way interfere with the
performance of vital functions.
  Etiology.—We may frankly say that we
do not  know  the causes that bring  about
this  affection.  The disease consists  essen-
tially in an effusion of blood from ruptured
cutaneous capillaries, or possibly  to diape-
desis of the red corpuscles, without rupture
of the vessel.  As immediate causes of this
condition some have asserted that the blood
was  thinner than  usual, others  that  the
blood was normal, but  that the capillaries
were weakened.   Both of these  assigned
causes are  theoretical  and not  based on
known facts.  Various remote causes have
also  been suggested, as hepatic  congestion
(Cauty), internal obstruction (Bateman), en-
larged spleen (Fuchs), debility of the nervous
powers  (Wuson)>  deficient  or  suppressed
menstruation  (Cazenave), etc.   The  last-
mentioned cause we have seen  exemplified
            9 
258      CUTANEOUS MEMORANDA.

in a case in which the purpura partook ol
the nature  of vicarious menstruation, com-
ing on for  several months, at the time of,
and instead of the natural flow.
  Treatment.—The most varied treatment
has been recommended for this affection —
for instance, iron in large doses, in order to
repair the supposed deficiencies in the blood:
tannin,  gallic acid, the mineral acids, etc.,
under the idea that they would act as astrin-
gents, and  many other  methods  equally
irrational and useless.
  At present the treatment most in vogue
consists in  the administration of full  doses
of ergot, either  hypodermically or by  the
mouth.
           CHAPTER XXIV.

        SCLERODERMA—SCLERIASIS.
  Under  these  and  similar  names  two
different affections have, we think, been
described.  The affection to which we will
confine the first of these appellations com-
mences as a circumscribed infiltration of the
skin and  subcutaneous tissue.   The part
affected is slightly elevated, and  the skin of 
SCLERODERMA.
259
a brownish red  color,  with a very slight
tendency to a  furfuraceous desquamation.
Upon touching the part it conveys to  the
finger a sensation of hardness, and the skin
is found to be cemented to the subcutaneous
tissue, and the whole tightly bound down
to the muscles, or to the bones if they are
near the surface.  If we attempt to pinch
up the skin in folds, the effort will be as
futile as if  we tried to  pinch up the paint
from a board, or the bark from a tree.
  As the lesion gradually advances, the por-
tions first affected undergo a change.  The
elevation subsides, and gives place to a de-
pression, the heightened color disappears,
and is replaced, first by a normal, afterward
by a  much paler hue,  and finally by a
glistening  white.  In  other  words,   the
hyperplasia  which  first  appeared is  suc-
ceeded by  atrophy.   The tightness  of the
skin, its close approximation to the bone,
and its absolute non-mobility become even
more striking than in the early stage.  If
the lesion be situated  upon the hands  and
feet, the shrunken integument may induce
permanent contractions of the fingers  and
toes, with more or less deformity.  Sclerosed
bands and patches may appear upon several 
260      CUTANEOUS MEMORANDA.

parts, and by gradual extension involve a
very large portion of the surface.
  When limited in extent, scleroderma does
not appear to be specially prejudicial to life
or health; but when extensive, it may be
associated with visceral and other internal
changes, capable of inducing a fatal result.
  The cause of this affection is unknown.
  Internal treatment appears to be without
influence in modifying the affection; exter-
nally the application  of the constant gal-
vanic current has in several instances proved
of service.

               SCLERIASIS.
  This affection is  distinguished from the
one last described by the rapidity of its de-
velopment,  and  the   extent  of  surface
that may become involved within  even a
few days.  Commencing usually, if not al-
ways, upon the upper portion  of  the  body,
the integument of the thorax and abdomen
and the posterior portions of the trunk may
become involved  in a  week or  ten  days,
without extension to the lower  extremities.
The  skin preserves its natural color and sen-
sation, but is tightly bound down to the
subjacent tissues as in the former affection. 
VITILIGO.              261
  After a time, in the majority  of cases,
spontaneous resolution occurs, and the skin
returns to the normal state.

                 VITILIGO.
             Syn.—Leucoderma.
  Definition and  description.—Vitiligo  is
an affection characterized by a localized dis-
appearance of the cutaneous  pigment.   It
becomes noticeable by the  development  of
one  or  more  small pigmentless spots, the
color of which varies from a dead white to a
faint rosy hue, the particular tint depending
on the activity of the circulation in the af-
fected part.  The  hair, if there be any on
the spot, loses its color and  becomes white.
Surrounding these pale patches there is fre-
quently a border characterized by increased
pigmentary deposit which gradually shades
off into the  hue of the normal surrounding
skin.  The appearance of one spot is usually
followed by the development of others. The
spots usually for  a time increase  in size
and unite with neighboring  ones after form-
ing an irregular patch of considerable extent.
A considerable and even the major part of
the surface may be thus invaded. With the
exception of the loss of color, the affected 
262      CUTANEOUS MEMORANDA.

1
 
VITILIGO.
263
portions do not present any other anomaly,
but appear  to preserve their various func-
tions unaltered.  The parts most frequently
affected are, in my  experience, the hands,
face, neck, and genitals.
  The affection, once developed,  may con-
tinue for an indefinite period, or after a
time come to a standstill and remain in that
condition  for  many years.   Occasionally,
spontaneous recovery may take place, that
is, the skin may recover its normal colora-
tion.  This I have  seen, and in one patient
alternations of vitiligo and normal color has
occurred a number of times.
  The affection affects the negro as well  as
the Caucasian, and probably also the races
of intermediate  tint.   I  have never met
with the affection in childhood  in the white
race, but have seen it from early adult life
to old age.
  The affection can be confounded with but
one or two others.  These are  partial albin-
ism and certain phases of macular leprosy.
Albinism, when   complete, consists  in a
congenital diffuse absence of pigment; when
partial, of congenital white spots surrounded
by skin  of  normal  hue.  Vitiligo, on the
other hand, is an  acquired affection.  The 
264      CUTANEOUS MEMORANDA.

history of the case  will be sufficient to de-
termine the diagnosis.   I have  seen a case
of macular leprosy in which there was a not
very distant resemblance to Vitiligo, and I
can readily imagine that there may be cases
in which the likeness would be still more
striking.  The history of the case, however,
and  a close examination of the lesion, to-
gether with the fact that the white patches
of leprosy are anaesthetic, will obviate  any
difficulties in the way of diagnosis. 
INDEX.
                                            PAGE
 Acne.............................................. 143
   "  punctata..................................... 153
 Alopecia areata...................................  219
 Anatomy of the skin..............................   1
 Anesthesia........................................  15

 Blood-vessels......................................   2
 Bullae................................. ..........   11

 Chromophytosis.................................  212
 Chloasma.............................. ..........  176
 Classification......................................  22
 Comedo........................................... 153

 Diagnosis........................  ...............   19

 Eczema........................................   35
 Elephantiasis......................................234
 Epithelioma........................... ...........12T
 Erysipelas......................................... 140
 Erythema........................................ 227
    "    multiforme............................229
    "    nodosum...............................232

 Favus.............................................  193
Fibroma.........................................  237
Furuncle..........................................237 
266                 INDEX.

                                             PAGE
Hair............ ................................   6
Hair-follicles  ....................................   5
Herpes .......................................... 169
   "   labialis.................................... 170
   "   progenitalis................................ 172
Hyperesthesia....................................  15

Ichthyosis......................................... 13G
Impetigo contagiosa................_...........216

Keloid............................................ 241

Leprosy.........................................132
Leucoderma..........................,........... 261
Lichen aestivus....................................222
   "   planus...................................243
   "   ruber...................................244
   "   scrofulosorum............................ 125
Lupus............................................ 103
  "  erythematosus.............................. 107
  "  exedens....................................113
  "  treatment of.....  ........................ H6
  "  vulgaris..................................... 109
Lymphatics.......................................   2

Macules .......,............. ...................  U
Mentagra parasitica..............................208
Milium..............................___  ......217
Muscles...........................................   5

Nails...............................................   rj
Nerves ...............  ..........................    3
Nomenclature..................  ...............  20

Pain.............................................  14 
                     INDEX.                  267

                                             PAGE
Papules............................................  11
Pathology of the skin.............................    9
Pemphigus.......................................  248
     "    foliaceus...............................250
     "    vulgaris..............................  248
Pernio............................................  223
Phthiriasis......................................  185
     "    capitis.................................  185
     "    corporis...............................  187
     "    pubis..................................  191
Physiology of the skin............................    7
Prurigo___.......................................  251
Pruritus...........................................   15
Psoriasis... ......................................   52
Purpura...........................................  254
Pustules...........................................   11

Rheumides  ......................................   29
Rosacea........................................  157

Scabies............................................  180
Scales.............................................   11
Scleriasis.........................................  260
Scleroderma ..  ..................................  258
Scrofulides.....................................  101
Scrofuloderma phlegmonosum....................  122
Sebaceous glands.................................    3
Sudoriparous glands..............................    3
Sycosis parasitica.................................  208
Symptomatology.................................   13
Syphilis...................... ....................   58
   "    treatment of..............................   84

Trichophytosis...................................201 
268                  INDEX.

                                                PAGE
Trichophytosis barbae.............................208
              capitis............................. 204
              corporis............................ 210
              genito-cruralis..................... 211
Tubercles.........................................  11

Ulcers............................................  H
Urticaria......................................... 161

Verrucae...... .................................... 226
Vesicles...........................................  H
Vitiligo............................................ 261

Zoster.....................................t...... 165 
 
 
 
 
 
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