HI'''! .\.\: ,lii|!li;!lilIiil;jiiiiJ!ij,'lj.; LIBRARY NEW YORK STATE VETERINARY COLLEGE ITHACA, N. Y. I Gift throu Olin I RL 81.F78r"' """"'"'"""""' ''^°'°9';aphic atlas of the diseases of th 3 1924 000 347 702 The original of this book is in the Cornell University Library. There are no known copyright restrictions in the United States on the use of the text. http://www.archive.org/details/cu31924000347702 PHYSICIANS' EDITION mOTOGRAPHIC ATLAS OF THE DISEASES OF THE SKIN A Series of Eighty Plates, Comprising more than One Hundred Illustrations, with Descriptive Text, and a Treatise on Cutaneous Therapeutics BY GEORGE HENRY FOX, A.M., M.D. CLINICAL PROFESSOR OF DISEASES OF THE SKIN, COLLEGE OF PHYSICIANS AND SURGEONS, N. Y. CONSULTING DERMATOLOGIST TO THE BOARD OF HEALTH, NEW YORK CITY PHYSICIAN TO THE NEW YORK SKIN AND CANCER HOSPITAL ETC. PHILADELPHIA & LONDON J. B. LIPPINCOTT COMPANY 1902 Copyright, igoo, by George Henry Fox Copyright, iQoi, by GEORGE Henry Fox Copyright, 1902, by GEORGE Henry Fox PBINTED BY J. B. LIPPtNOOTT COMPANY, PHIL*DEIPH1*, i). 8. /I. CONTENTS PAGE GENERAL CONSIDERATIONS i ACNE i; ACNE CACHECTICORUM 27 ACNE VARIOLIFORMIS 27 ALOPECIA 29 ALOPECIA AREATA 39 ANTHRAX 43 CANITIES 44 CARBUNCULUS 46 CHLOASMA . . 48 CHROMOPHYTOSIS . 53 CICATRIX 56 CLAVUS 57 COMEDO 59 CORNU CUTANEUM 63 DERMATITIS ... 64 DERMATITIS TRAUMATICA 64 DERMATITIS MEDICAMENTOSA 64 DERMATITIS VENENATA 65 DERMATITIS CALORICA 67 DERMATITIS HERPETIFORMIS 7i ECZEMA 73 ELEPHANTIASIS ^5 EPITHELIOMA ^^ ERYSIPELAS 9i ERYTHEMA 93 ERYTHEMA MULTIFORME 95 FAVUS 97 FIBROMA 99 FURUNCULUS '°' HERPES '°5 HYPERIDROSIS .107 HYPERTRICHOSIS "' ICHTHYOSIS "^ IMPETIGO CONTAGIOSA ''^ KELOID 120 iii IV CONTENTS PAGE KERATOSIS FOLLICULARIS ....... ... 124 LENTIGO 125 LEPRA 127 LICHEN PLANUS i33 LICHEN RUBER i37 LICHEN SCROFULOSUS 140 LUPUS ERYTHEMATOSUS . , i4i LUPUS VULGARIS i44 MILIARIA 150 MILIUM 152 MOLLUSCUM 153 MORPHCXA 155 MYCOSIS FUNGOIDES 156 N^VUS PIGMENTOSUS 158 N^VUS VASCULARIS 150 ONYCHIA 162 PAPILLOMA LINEARE 164 PEMPHIGUS 165 PHTHEIRIASIS 166 PITYRIASIS i6g PITYRIASIS RUBRA 172 PSORIASIS 173 PRURIGO 183 PRURITUS 185 PURPURA 188 ROSACEA 190 SCABIES 193 SCLERODERMA 194 SCROFULODERMA 196 SYCOSIS 197 SYPHILODERMA 200 TRICHOPHYTOSIS 206 URTICARIA 211 VERRUCA 217 VITILIGO 219 XANTHOMA 221 ZOSTER 223 LIST OF ILLUSTRATIONS ACNE VULGARIS FACIEI ACNE VULGARIS DORSl . ALOPECIA AREATA CHLOASMA CHROMOPHYTOSIS GUTTATA CHROMOPHYTOSIS DIFFUSA DERMATITIS MEDICAMENTOSA DERMATITIS VENENATA (2) DERMATITIS HERPETIFORMIS . DERMATROPHIA I ^l^^ljg^''"'^ } ECZEMA ERYTHEMATOSUM . ECZEMA PAPULOSUM ECZEMA IMPETIGINOSUM (2) . ECZEMA SQUAMOSUM ECZEMA CRURIS (2) . ECZEMA MANUS (4) • ELEPHANTIASIS .... EPITHELIOMA RODENS ERYSIPELAS FACIEI ERYTHEMA PAPULATUM . ERYTHEMA ANNULATUM ERYTHEMA BULLOSUM FAVUS {2) FIBROMA (2) HERPES FACIEI .... ICHTHYOSIS IMPETIGO CONTAGIOSA KELOID (2) KERATOSIS {^i7,^SA^^^_^ I _ . LEPRA TUBERCULOSA LICHEN PLANUS (2) . . . LICHEN PLANUS HYPERTROPHICUS . LICHEN RUBER PAPULOSUS . LICHEN RUBER SQUAMOSUS LUPUS ERYTHEMATOSUS LUPUS VULGARIS . . . . LUPUS SERPIGINOSUS . LUPUS EXEDENS . . . . TUBERCULOSIS VERRUCOSA (3) SEBORRHCEA—STEATOMA— MILIUM (3) PAGE . 14 22 . 38 48 . 52 54 . 64 66 . 70 70 . 72 74 • 76 78 . 80 82 . 84 . 86 . go . 92 . 94 94 . 96 . 98 . 104 116 . 118 120 . 124 126 . 132 134 . 136 138 ■ 140 144 ■ 146 148 • 150 ^ , 152 VI LIST OF ILLUSTRATIONS MORPHOEA (2) . . . MYCOSIS FUNGOIDES FACIEI . N^VUS PILOSUS . N^VUS VASCULARIS. PAPILLOMA LINEARE (2) PEMPHIGUS (2) . PHTHEIRIASIS CORPORIS PITYRIASIS MACULATA PITYRIASIS CIRCINATA (2) PITYRIASIS DIFFUSA . PITYRIASIS SEBORRHOICA PSORIASIS GUTTATA . PSORIASIS NUMMULATA PSORIASIS GYRATA . PSORIASIS CIRCINATA . DERMATITIS VENENATA . PSORIASIS DIFFUSA PSORIASIS EXFOLIATIVA . DERMATITIS EXFOLIATIVA PURPURA ROSACEA ERYTHEMATOSA ROSACEA PUSTULOSA ROSACEA HYPERTROPHICA . SCABIES SCROFULODERMA . SYCOSIS SYPHILODERMA ERYTHEMATOSUM SYPHILODERMA PAPULOSUM SYPHILODERMA PAPULO-SQUAMOSUM SYPHILODERMA PUSTULOSUM . SYPHILODERMA TUBERCULOSUM . SYPHILODERMA ULCERATIVUM . SYPHILODERMA MANUS (4) . SYPHILODERMA HEREDITARIUM (2) . TRICHOPHYTOSIS (3) • URTICARIA (3) VARini A /VESICULOSA], VITILIGO MANUUM .... XANTHOMA TUBEROSUM (2) . ZOSTER PECTORALIS PAGE 156 158 160 162 164 166 168 170 170 172 172 174 176 178 178 180 182 182 i88 190 I go 192 194 196 198 200 200 200 202 202 202 204 204 206 2IO 216 218 220 222 THE TREATMENT OF SKIN DISEASES GENERAL CONSIDERATIONS THE skin is an organ of the body constructed for the performance of definite functions. Like the internal organs, it is subject to both organic and functional disease. It may become the seat of indepen- dent pathological processes, but, owing to the intimate relationship of the skin to other organs, cutaneous disease is usually of internal origin. It is, however, not always due to impurity of the blood, as is commonly imagined. There are certain conditions which arise directly from thermic, traumatic, parasitic, and other external agencies, and some which develop in the cutaneous tissues without obvious cause, but the great majority of skin diseases are the result of systemic conditions which are apt to affect the skin in some indirect or reflex manner. To these conditions our therapeutic measures should be directed rather than to the skin itself, in fact, the human integument is not like a soiled or torn garment that can be renovated by some sartorial healer without any thought being bestowed upon the physical condition of the wearer. On the contrary, it is an important part of the entire economy, always sympathizing with the functional activity of the organs, often doing compensatory work, and entirely dependent upon the vascular and nervous systems for its normal nutrition and stimulation. For the student of dermatological therapeutics the first thing to learn is the great importance of treating the patient, and not merely the patient's skin. For some mysterious reason, this seems to be the hardest lesson for the 2 THE TREATMENT OF SKIN DISEASES average physician to learn. In a case of measles or scarlatina no physician thinks of relying upon local remedies for the cure of the disease, although he may wisely use cocoa-butter or some other application to lessen the burning sensation of the skin or to soften and disinfect the dry and desquamating epi- dermis. In many other dermatoses, although they may not run a definite course like the common exanthemata, the disease is quite as far removed from the surface of the skin, and there is no more need for local treatment except in so far as it may be productive of a comforting or palliative effect. But too often, in such cases, the physician will persist in treating merely the patient's skin (either by arsenic internally or ointments locally) until the disease gets well of itself through accidental cessation of the undiscovered cause, or until he has " tried everything " and given up in despair. The specialist is often accused of taking a narrow view of any given case, and failing to appreciate the relationship of various conditions which should enter into the question of its judicious treatment. It. is true that special study does tend to narrow one's field of vision. It is a valid objection which has often been raised against medical specialism, but it is a minor drawback which is offset a thousand times over by the great advantage accruing to the profes- sion as the result of special study. But the specialist need not limit the angle of his view, and, as a matter of fact, many specialists do not do so, in spite of the natural tendency, the existence of which is freely admitted. On the other hand, it is not an uncommon occurrence for the general practitioner — perhaps the very man who loves now and then to indulge in a philippic against special- ists and specialism — to take a very narrow and imperfect view of a case, and to base his therapeutics thereupon. Narrowness or broadness of view depends more upon the mental character, istics of the man than it does upon the nature and scope of his studies. The successful specialist in dermatology often pays the least attention to the con- dition of the skin, while the physician with a good supply of general medical knowledge often fails to look beneath it. Not infrequently the aid of the specialist is sought by some physician in general practice who has carefully studied the "medical progress" column of his favorite journal, and tried every GENERAL CONSIDERATIONS 3 new remedy and formula therein mentioned with results unsatisfactory to both his patient and himself. The former has perhaps a persistent eczema dependent wholly upon some internal cause. He eats everything that he cares for, takes little or no exercise, sleeps irregularly^ and, though having neither ache nor pain and considering himself well, is simply not in "good condition," to use the expressive phrase of the athletic trainer. The patient requires no sp^m/ treat- ment, and, instead of dosing him with arsenic, which is likely to do harm rather than good in the majority of cases, or depending upon a frequent change of ointments for an impossible curative effect, the specialist often obtains a brilliant result, not by recourse to the special skill or knowledge he may possess, but simply by treating the case on broad general principles, in other words, he does precisely what the general practitioner might do, is presumably so well qualified to do, and which, alas ! he so often fails to do through his anxiety to adopt some new and highly specialized method. In the treatment of diseases of the skin a correct diagnosis is of prime importance. To know exactly what is to be done is essential to its speedy and successful accomplishment. But diagnosis implies something more than merely giving a correct name to a pathological condition. It involves not only an accurate appreciation of the conditions which are present both in the skin and in the internal organs, but also a knowledge of the various causes which tend to produce these conditions. In this broad sense a perfect diagnosis of a skin disease is rarely if ever made, owing to the limitations of our medical knowledge. In the common and restricted sense of the word it is plain that two physicians may make a correct diagnosis in a given case,— /.^., they may apply the same name to the eruption. But to one the diagnosis is merely a name, while to the other it is a name suggestive of morbid conditions which must be dealt with and removed before a cure can be effected. If the treatment employed by the former prove successful, the result is commonly due to a happy chance in the selection of his remedies, or to the natural tendency of the disease to recovery. If success crowns the therapeutic efforts of the latter, a certain degree of credit can be claimed for the rational employment of means to accomplish a definite purpose. 4 THE TREATMENT OF SKIN DISEASES In all cases of skin disease the main factor in the production of a cure is the vis medicatrix naturce. There is a natural tendency manifested by nearly all eruptions to disappear under certain conditions which do not merely act upon the skin, but which influence the function of every organ of the body. In treat- ing a skin disease, it is the first duty of the physician to restore these conditions. In the progress of modern dermatology, many valuable remedies have been added to our therapeutic armamentarium, while many more of little or no value are constantly being foisted upon the profession as a result of commercial activity on the part of manufacturing chemists. Some of these valuable remedies are capable of producing most brilliant results when used with skill and discretion, but it remains a fact that the greatest mistake which a physician is liable to make in the treatment of skin disease is the complete reliance which he so often places upon remedies, both for internal and local use. If the physician could be induced to take a broader view of cutaneous medi- cine and pay less attention to the integument, his therapeutic success would be greatly enhanced. If, when he meets with an intractable case of eczema or psoriasis, he were willing to treat the case as if the patient had come to him without any skin disease whatever, seeking by various means to put him in his best possible physical condition, he would often find that the obstinate eruption which has withstood all methods of special treatment at his command would yield spontaneously or disappear under the very remedies which he had tried in vain and pronounced of no value. In the general treatment of a patient suffering from a disease of internal origin the main object should be to discover and remove the cause. But in many cases the precise nature and the exact location of the internal functional derangement which gives rise to an eruption are very difficult matters to deter- mine, and often it is much easier to remove the obscure cause by measures which tend to improve the patient's general condition than to discover what and where the cause may be. All therapeutic agencies which equalize the circula- tion, strengthen the digestive functions, induce refreshing sleep, and improve the nutrition of the body will be found to be powerful factors in the cure of cutaneous disease. When judiciously employed, these agencies will often effect GENERAL CONSIDERATIONS 5 a cure even when the cause of the eruption remains undetermined, and when, perhaps, no correct diagnosis has been made. Indeed, the improvement of a patient's general health by various hygienic and medicinal agencies will often loosen the hold which an obstinate eruption seems to have upon the skin and greatly enhance the therapeutic effect of local remedies which before had seemed to be of little value. In treating a patient with a view to improving his general condition, and thus striking at the root of many skin diseases, there are pharmacopceial reme- dies which render valuable service. Chief among these may be mentioned arsenic, iron, mercury, and the salts of potash and soda. But, while drugs may accomplish much in the way of toning up the sys- tem of a patient with skin disease, improving the digestion, and facilitating the elimination of waste products, it must not be forgotten that there are remedies outside of any pharmacopoeia which will accomplish the same purpose, and often with much greater celerity and directness. Indeed, there are few, if any, prescriptions which, in the treatment of a rebellious skin disease, will accom- plish as much as systematic bathing, exercise, and diet. Theoretically every physician professes to be a strong advocate of these measures, but in actual practice very few succeed in impressing upon the patient's mind an adequate sense of their importance. Good advice is not infrequently given as an accom- paniment of the Latin prescription, but no pains are commonly taken to see that the advice is acted upon. Not only in the treatment of skin diseases, but in many other ills for which medical advice is sought, both physician and patient are prone to rely in great part, if not wholly, upon an exclusive medicinal treatment, and both in the profession and among the laity the idea seems to be as prevalent as it is erroneous that for the cure of every ill a Latin prescription is absolutely essential. Dr. Piffard, the distinguished author of " Materia Medica and Therapeutics of the Skin," in speaking of the part played by drugs and other agencies in the relief or cure of cutaneous affections, says in his opening sentence that " drugs are by far the most important of the means at our command." Nearly all physicians begin practice imbued with this belief, but in time experience teaches some that it is not true. 6 THE TREATMENT OF SKIN DISEASES It is a severe reflection upon the medical practice of tiie present day, but it is nevertheless a fact, and one well worthy of thoughtful consideration, that many patients suffering from chronic eczema and psoriasis would recover sooner under the strict regimen of an athletic trainer than in the hands of an inveterate pharmacophile, whose idea of cutaneous therapeutics has never reached beyond the narrow confines of Fowler's solution and a frequent change of ointments. While pharmacopceial remedies and hygienic measures may be satisfactorily combined in the treatment of most cases of skin dis- ease, it is by far too common a mistake to rely upon the former and to regard the latter as an unimportant adjuvant. Bathing is a remedy which in cutaneous therapeutics should be esteemed on account of its prophylactic rather than its curative power. A daily bath invigorates both mind and body, quickens and equalizes the circulation of blood, stimulates the functional activity of the whole integument, and ren- ders it far less liable to become the seat of pathological processes. Incident- ally it has a cleansing effect upon the surface of the skin, but this is of comparatively little importance. The main object of a bath is to refresh and invigorate, not merely to cleanse. A normally active skin was designed by Nature to keep itself in a healthy condition, even without bathing, and the common talk about a bath being necessary to open the pores of the skin and allow excrementitious matter to escape has no more basis than many other absurd ideas gleaned from medical almanac pathology. It is normal perspiration that keeps the skin proper in a cleanly condition, and though soap and water may be advisable to improve the condition of the surface, it is certain that a man who works hard and perspires freely will have a far healthier and a really cleaner skin than he who eats heartily and leads a sedentary life, even though he may scrub continuously. In short, the great benefit which is unmistakably derived from a daily bath is attributable, not to its cleansing properties, but to its stimulant effect upon the nervous system. Baths may be thermometrically classified as hot (98° and over), warm (9o°-98°), tepid (85°-9o°), cool (65°-85°), and cold (65° and less). Each of GENERAL CONSIDERATIONS 7 these may prove advantageous in individual cases, and under certain condi- tions ; but for the great majority of persons in health, or suffering from no serious disease, the cool bath taken every morning is capable of producing the greatest benefit. Exercise exerts indirectly a beneficial effect upon skin diseases by im- proving the general condition of the patient. In some cases it may tempo- rarily increase his discomfort, but in the end will do far more good than harm. Private patients are often kept in bed and worried by frequent and painful change of dressings which fail to effect a cure, when perhaps this could be readily accomplished by simply using vaseline or some dusting powder on the affected skin, and insisting upon the patient dressing, and at least taking a drive if not a walk in the open air. In our dispensaries, the physician in charge finds it more convenient and more in accordance with the ideas of the patients to prescribe rhubarb and soda, and this or that ointment, than to spend time in regulating the diet and insisting upon out-of-door exercise. But in the great majority of dispensary patients, espe- cially women, improper diet and household confinement are the principal causes of the eruption, and here, as in many other cases, the best and speediest results may be obtained by simply removing these causes. In the case of clerks and shop-girls, with long hours of work and little time for play, it is difficult to get much out-of-door exercise ; but when "tonics" have lost their effect and local remedies have failed to remove an eruption, the necessity for a little breathing spell every day is obvious, and more exercise in the open air becomes imperative. Exercise is rarely thought of as a dermatological remedy, and few, if any, writers on cutaneous therapeutics ever condescend to mention it. And yet there is a large class of skin diseases in which systematic daily exercise of a more or less vigorous character will accomplish far more than a whole pharmacopoeia. With few exceptions, all skin diseases, and particularly those of an inflammatory character, tend to spontaneous recovery when the patient is in a normal condition, so far as the functions of other organs are concerned. Nearly every obstinate case of eczema or psoriasis can be cer- 8 THE TREATMENT OF SKIN DISEASES tainly and speedily cured by any judicious trainer, with no medical knowl- edge, if the patient is only willing to live and act as he would have to do in case he wished to distinguish himself in some athletic contest. A man ready to enter a prize-fight or a boat-race always has his skin in that per- fectly normal state in which Mature intended it to remain, and from which it so often becomes perverted by improper habits of life. Why, then, should we not learn a lesson from the tactics of the trainer? When the physician meets with an obstinate case of skin disease which refuses to yield to arsenic and ointments, why should he not give up his cherished secundum artem treatment and assume the more successful r61e of an intelligent medical trainer ? Of course it is not essential to pound a sand-bag or to row a boat in order to gain strength and health. Although many a sufferer from chronic skin disease would willingly adopt the most rigid course of training in order to secure a healthy skin, there are simpler and pleasanter forms of exercise which, combined with a strict diet, will accomplish the result. The patient need not be required to enter either a fight or a race, but if he is thoroughly prepared to do either, he will doubtless find that the chronic skin disease has disappeared in the process of preparation. In the treatment of skin diseases there is nothing more important than regulation of the diet. Since many eruptions depend wholly or in great part upon dietetic errors, it is very evident that judicious advice as to what should be eaten, and when and how it is to be eaten, is much more certain to strike at the root of the trouble than the common custom of prescribing antidyspeptic remedies, if a patient is accustomed to indulge freely in pie, cabbage, candy, or whatever may tend to induce a foul stomach, intestinal fermentation, and an irritable skin, it is conventional to prescribe pepsin, bis- muth, or some other antidote. It is common sense to say, "Stop it." While the importance of dietetic restrictions is generally admitted, there is a lament- able lack of unanimity among physicians as to what rules are best suited to patients in general, and as to what plan of diet should be adopted in any given case, in fact, the question of diet in skin diseases is one which has heretofore received but little attention, though offering an attractive field for GENERAL CONSIDERATIONS 9 careful observation and scientific research. Many time-honored notions as to the value or detrimental qualities of certain articles of food prevailing among the laity are accepted and acted upon by the profession, and rarely is any attempt made to ascertain by experience whether fact or fancy is the basis of these views. With this lack of definite knowledge in the domain of dietetics, and the frequent occurrence of idiosyncrasies which prevent patients from eating the very things that would, theoretically, be best for them, it is difficult to lay down positive rules applicable to all cases, but the following suggestions, based upon experience, may prove of more or less value : An occasional change of diet is essential. There is no more reason for living on the same food the whole year round than there is for wearing the same clothing, and much more discomfort, if not positive harm, is likely to result from so doing. An abundance of beef, like a fur overcoat, may be very desirable in this climate on "New Year's Day, but decidedly unseasonable on the Fourth of July. The "spring fever," or that feeling of lassitude which so often comes with the early warm days, and suggests to so many the necessity of medicine "to purify the blood," is simply an indication for a change not only of clothing, but of diet. During the brief season when fresh garden vegetables can be readily obtained, and later, when perfectly ripe fruit is abundant in the market, it seems almost a shame for any one to eat the food which can be had at any time and to neglect that which at other seasons is so difficult to secure. A change of diet is often beneficial, even if it be from a good to a bad diet, or what might be so considered. Nearly every inflammatory disease of the skin is greatly aggravated, if indeed it is not primarily caused, by the dietetic habits of the patient. The physician may be wholly unable to determine just what article of food is most responsible for the cutaneous trouble, or just where to look for the loose screw in the digestive apparatus which prevents the proper assimilation of food that others can eat with impunity. He is justified, however, in assuming that some article of food or dietetic habit may possibly cause the eruption, and hence a radical and even empirical change in the diet, although it may sometimes do harm, will in a 10 THE TREATMENT OF SKIN DISEASES large number of cases be followed by the best results. If the patient has been a large eater of meat, let him join the vegetarians for a limited time ; while, on the other hand, if he has taken little or no meat and a little of everything within reach, let him try the effect of an exclusive beefsteak and hot water diet. Although this latter plan of dieting, so popular with a few physicians, is about the last that should be recommended for long-continued use, it is often extremely valuable for a few days or weeks, and will frequently cleanse a coated tongue, sweeten a foul stomach, and lead to the disappear- ance of many derangements and disorders, including some which affect the skin. Although the ordinary stomach will tolerate an exclusive meat diet more readily than a purely vegetable one, the latter seems in general more conducive to a healthy state of the skin. For instance, a patient with chronic psoriasis will invariably note the fact that the scaly disks upon his body are more apt to look red and angry and to increase in size when he is partaking freely of meat. And in acne, eczema, and other diseases the dreaded oatmeal and buckwheat cakes may not do half the harm so often caused by a too highly nitrogenous diet. But while the vegetarian and the carnivorous advo- cate continue to wage their wordy warfare, the patient with a chronic skin disease will find that a change from one to the other will be more beneficial than a strict adherence to either doctrine. A rigid restriction of diet is often as important as a change. While it is true that "the board kills more than the sword," and that we all eat many things which we do not need, if not absolutely more than we need, it should be understood that a restricted diet does not necessarily imply a scanty or starvation diet. Many patients with skin disease eat heartily, exercise but little, and are too well nourished. The first step in the treatment of such is to reduce the weight five, ten, or perhaps twenty pounds. The ointments and lotions which at first have little or no effect often act like magic when this is accomplished. But many other patients with skin disease are thin and weak and nervous, and demand an opposite plan of treatment. Until the general condition of such patiei,its is greatly improved, as indicated by a decided increase in weight, no treatment can be expected to cure the cutaneous GENERAL CONSIDERATIONS II disorder. These patients cannot afford to eat everything which they happen to fancy. Their diet should be restricted to those articles alone which will tend to make flesh and blood. Medicinal tonics are often a delusion and a snare when nourishment is all that is required. How the diet may best be restricted is a problem often difficult to solve. The common advice to eat no shell-fish, no pastry, no fried articles of food, or no sweets may be judicious, but it rarely accomplishes any curative result. Because shell-fish, strawberries, or starchy food are productive of harm in certain cases, there is no valid reason why all patients should be subjected to their routine prohibition, and certainly no reason why the physician should be content with this limited restriction when there are many other edibles in a given case which are quite as likely to do harm. Patients often declare that they eat no sweets nor starchy foods with a Pharisaical air which plainly intimates their belief that such a meagre restriction is a clear title to health and happiness. While there are some who do suffer from amylaceous indigestion, many patients with skin disease can eat starch and sugar with impunity, and doubtless would be better off were they to avoid a great variety of made dishes and for a short time live simply on good bread and butter and plain cake. This proscription of sugar and starch is based largely on the theoretical assumption that most patients suffer from gout, and that many skin diseases result therefrom. This is one of the current medical fads. Twenty years ago nearly every man who failed to follow the simplest hygienic laws and felt at times more or less miserable was informed by his physician that he had malaria. "Now the same patient under similar circumstances is gravely told that he is gouty, and that his salvation depends upon the avoidance of sweets. If sugar and starch in any given case are found by experience to do harm, they should be forbidden ; but this is not going far enough. Other dietetic habits of the patient, of which the physician often remains in ignorance, are liable to do much more harm. It is advisable, therefore, not to say to a patient, " Don't eat this or that," but to tell him simply what he may eat, and then see that this regimen is strictly enforced. 12 THE TREATMENT OF SKIN DISEASES For a few days the more restricted the diet the better, and gradually more articles can be added to the list. By this method a definite idea can be formed as to what food is injurious and what can be taken with benefit. The internal use of water in the treatment of skin diseases is quite as important as its external use. Indeed, if water were a very scarce com- modity it would doubtless be more beneficial to renounce bathing than to limit the supply for internal use. Drinking freely of pure water every day tends not only to improve digestion, but facilitates the functions of nearly every organ and does far more to keep the skin in normal condition than is generally imagined. Taken frequently in copious draughts, it will wash out the stomach as thoroughly as by lavage, if not as speedily, it will tend to clear a coated tongue and regulate the bowels as no single remedy of the Pharmacopoeia can possibly do. It will remove the lithsmic condi- tion upon which many skin diseases depend, and by striking at the root of the trouble will effect a permanent improvement which could not be expected from any external application. In prescribing this valuable remedy it is often of little use to simply advise the patient to drink freely. A definite number of glasses should be ordered, amounting to two quarts, more or less, if good results are expected. This amount should be taken in small doses frequently repeated and upon an empty stomach, inasmuch as too much fluid with meals is very apt to impair their digestion. In catarrhal conditions of the stomach, the sipping of hot water (not warm water) a half-hour before each meal is often of great benefit, and in cold weather a frequent hot drink greatly promotes the activity of the circulation and thereby Improves the condition of the skin. For those who acquire a distaste for the plain hot water, a little salt or lemon or other flavoring can be employed to advantage ; but if the water is as hot as can be taken by a spoon it is seldom apt to nauseate as is the case with warm or tepid water. The free use of most bottled waters is recommended when patients object to the inexpensiveness or occasional impurity of Croton or other city waters ; but it is the water which does the good, whether it comes from a GENERAL CONSIDERATIONS 13 bottle or a pipe. Most of the lithia waters on the market have no special advantage over plain water, in spite of their numerous testimonials, and some contain very little lithia, notwithstanding their name. Many of the waters bottled at springs in various parts of the country are erroneously supposed to possess marvellous therapeutic properties. With the exception of the sulphur and saline waters, most of them are wholly devoid of special virtue not inherent in any good and reasonably pure water. When the product of these springs has been bottled for many months before reaching its final destination, it is very apt to have lost its freshness and original flavor. Unlike wine, water does not improve by age, and should therefore be expressed from the spring to the consumer with the utmost speed and directness. These suggestions as to the general treatment of a patient, irrespective of the local affection which leads him to consult the physician, are applic- able not only to patients with cutaneous disease, but to very many others whose cases call for the exhibition of sound common sense rather than any special medical skill. Indeed, it is a question whether dermatology should be regarded as a specialty. Unlike ophthalmology or laryngology, it does not call for any expertness in the use of instruments which the general physician is not expected to possess, except in a few cases which properly come within the domain of surgery. Dermatology is simply a branch of general medicine, and every practising physician should be competent to treat almost any case of skin disease, provided he possesses the skill and experience which are requisite to make a correct diagnosis. Diseases of the skin do not constitute a specialty any more than do diseases of the stomach or diseases of the lungs. Success in their treatment does not depend so much upon special knowledge as upon experience, sound judgment, common sense, and the application of those general prin- ciples of medical science which every physician is supposed to possess. The physician in general practice often makes a great mistake in thinking that he must employ some special remedy in every case of skin disease, and is very prone to select the latest therapeutic novelty mentioned in the medical journals. 14 THE TREATMENT OF SKIN DISEASES In SO doing he is very apt to forget the simple, and perhaps old-fashioned, measures which would certainly improve the patient's general condition, and to discard the remeaies of which he has had some experience, and which in his hands would doubtless prove far more effective than the new and untried methods, the name of which is legion. After these general considerations upon the subject of cutaneous thera- peutics, the particular affections of the skin will now be considered and more definite suggestions offered as to their treatment. ACNE VULGARIS Acne is without doubt the commonest affection of the skin. It is pre-eminently a disease of adolescence and tends in time to sponta- neous recovery, though often leaving scars upon the face which betoken neglect on the part of the patient or lack of skill on the part of the physician. Although Acne is an inflammatory affection of the sebaceous glands, it is usually associated with Comedo and a general inactivity of the skin. In the accompanying illustration it is plain to see that the functional activity of the sebaceous glands is impaired and that the natural oily secretion has become thickened and accumulated in the glandular ducts, producing an eruption of conical whitish papules. At the summit of many of these a large comedo is apparent. Many appear congested (Acne papulosa) and some have undergone suppuration (Acne pustulosa). In most cases of Acne we find in addition to the local glandular disturbance a poor circulation, indicated by cold hands and feet, and an impaired digestion, indicated by coated tongue and constipation. These general conditions increase facial congestion and aggravate the eruption. The best results in- the treatment may therefore be expected from dietetics, cold bathing and ather hygienic measures, and from the local use of mechanical agents which tend to empty the distended glands and stimulate them to contraction. Vigorous soap frictions and the frequent use of a curette will do infinitely more good than the customary prescription of ointments and lotions. Copyright, 1900, by G. H. Fox. ACNE VULGARIS. ACNE THE term acne signifies an inflammatory affection of the sebaceous glands. It occurs in youth, and is usually limited to the face, chest, and shoulders. With the disease are usually associated other affections of the sebaceous glands, such as seborrhcea and comedo. In most cases we find systemic conditions, such as indigestion and a poor circulation, which act as predisposing causes of the eruption and are usually responsible for its persistence. In the treatment of acne we have, then, not only a local but a general disorder to deal with, and success must depend upon the adoption not merely of measures which will remove the cutaneous lesions, but of such as will strike at the root of the trouble and effect a permanent cure. From a therapeutic standpoint, two distinct forms of acne should be recognized, and, adopting terms long used in the classification of leg ulcers, it is convenient to speak of indolent acne and of irritable acne. In cases of the former type the skin is naturally thick and coarse in texture. The sebaceous glands are large and usually inactive, and their ducts are more or less distended with dried secretion. Comedos are always numerous and, acting as local irritants, produce a constant crop of papules and pustules. In this type of the disease the most vigorous local treatment is indicated, and alone is capable of producing the most beneficial results. In cases of the irritable type the skin is usually thin and delicate. It may be oily or abnormally dry, and comedos, when present, are few and small. The lesions show little tendency to become pustular. In short, the disordered function of the sebaceous glands is by no means a prominent feature in these cases, but a marked tendency to recurrent congestion about the glands or of j6 the treatment of skin diseases the whole face is a notable characteristic. In this type of the disease attention to the predisposing causes of acne is of paramount importance, while local measures, excepting those of the most soothing character, are apt to do more harm than good. Erasmus Wilson recognized these types of acne, and remarked that in those cases in which a torpid action of the cutaneous system is evident, stimulating remedies must be employed ; whereas in those which are depen- dent on congestion, stimulants would be injurious and prolong the morbid action. Subsequent writers have failed to appreciate the practical importance of this .grouping of cases and have laid more stress upon the size and appearance of the lesions. The treatment of acne, as well as that of many other skin diseases, may be conveniently discussed under three heads, i. General Treatment. 2. Medi- cinal Treatment. 3. Local Treatment. The general treatment of a patient with acne, including hygienic and dietetic measures, is of supreme importance. Although local treatment alone, as Crocker states, will remove any eruption that may be present, in most cases only general treatment, judiciously planned and perseveringly carried out for a considerable period, will prevent its recurrence. In the great majority of cases, acne, when viewed etiologically, is no more a local disease of the skin than are the "blossoms" on an old toper's nose. "No one would think for a moment of treating the latter without taking into account the bibulous proclivities of their bearer. No one should expect to be successful in the treatment of acne who relies solely on local remedies and pays no attention to the indigestion, the poor circulation, or the menstrual derange- ment which is so often the very foundation-stone of the disease. By the medicinal treatment of acne is understood the use of drugs which are supposed to exert a direct action upon the disease. While various remedies may prove of benefit in treating the digestive, circulatory, and menstrual derangements which often act as predisposing causes of acne, it is doubtful whether any remedy is capable of producing a notable result through its direct action upon the skin. Certainly there is no specific for acne. ACNE ,^ The chief remedies which have been recommended for internal use, and employed by many, are the following : calcium sulphide, ergot, glycerin, and arsenic. Calcium sulphide (calx sulphurata, U. S. P.) is alleged to have a controlling effect upon the suppurative process, and to be of benefit not only in the pustular form of acne, but also in boils and abscesses. It may be given in doses of a tenth or a fifth of a grain every two hours, it sometimes causes pustules or abscesses, and an aggravation of the disease has been cited as the first effect in the cure of acne. Ergot has been used by many, and its beneficial effect ascribed to its action upon the cutaneous muscles (arrectores pilorum), which in contraction press upon the sebaceous glands and tend to promote their evacuation. Glycerin may be given in teaspoonful or tablespoonful doses three times a day, and it is claimed that it will soften the sebaceous secretion in the glands of the face while at the same time it checks intestinal fermen- tation. Arsenic, so dear to the heart of the routinist in every case of skin disease, may benefit some patients who are in need of a nerve tonic ; but, while of doubtful benefit in the indolent type of acne, it is usually prone to aggravate the irritable form of the disease. Piffard recommends arsenous acid in papular acne of an indolent character, calcium sulphide in acute painful pustular acne, and arsenic bromide in most cases not belonging to either of the above- mentioned types. As to these internal remedies for the cure of acne, it cannot be denied that in certain cases they are capable of producing some benefit. I have given most of them an extended trial, however, and feel confident that in compari- son with general treatment of the patient and vigorous local measures these vaunted remedies are scarcely worth the paper upon which their prescription is written. The local treatment of acne may be soothing or stimulating. In the irritable type of cases only bland applications in the form of powders, lotions, or ointments can be of service, and in indolent acqe such applications are i8 THE TREATMENT OF SKIN DISEASES often needed to allay the artificial inflammation excited by the irritating and epidermicidal applications which are frequently used. A stimulating treatment is called for in most cases of acne, and the appli- cations commonly employed vary in their action from a mild astringent to a severe caustic. These tend to quicken the circulation of blood and thereby hasten the absorption of inflammatory deposits, while at the same time they incite the glands to more vigorous action and thereby empty the distended ducts, in addition to these local remedies, a notable curative effect can be produced by the mechanical treatment of the disease through massage, soap frictions, and various instruments devised for the purpose of destroying pustular lesions and pressing out the sebaceous accumulation which gives rise to them. Among the soothing applications useful in acne may be mentioned cold cream, zinc ointment, lotions of hamamelis, magnesia, zinc, boric acid, etc., and various simple dusting-powders. A favorite lotion of calamine and zinc is the following : * IJ Pulveris calaminse preparatae ... 3 i 5 Zinci oxidi 3iii lo Glycerini . f3ii lo Liquoris calcis ■ f^i 5° Aquae rosse ad f^ivad loo m As the suppurative process is largely due to the infection of the glands by micro-organisms, a disinfectant lotion such as listerine or borolyptol, used pure or diluted, is often of marked benefit. Or the following weak mercurial lotion may be employed with good effect : * In most of tlie formute given in these pages, the quantities will be found expressed both in Apothecaries' measure and in decimal parts. The second column is not intended as an exact translation of the first into the metric system, but is so arranged that the percentage of each ingredient may be seen at a glance and more readily remembered. The quan- titative variation in the two columns is usually slight and never of great importance. Either the gram or the drachm may be taken as a unit without affecting tlie composition of the formula, and the liquid ingredients may be dispensed either by weight or fluid measure without making any practical difference. The greatest merit of the metric system is its decimal character ; but whatever weights and measures may tie used the advantage of making the sum of parts in any formula equal one hundred or some other decimal, seems too obvious to require argument. ACNE ,g 5 Hydrargyri chloridi corrosivi . . . gr^ o. lo Tincturae benzoini f§i lo. Aquae rosse ad Oi ad loo. m To be filtered and labelled "Poison ! For ex- ternal use ! " Among the stimulating applications which are of service may be mentioned sulphur, mercury, carbolic acid, chrysarobin, resorcin, and salicylic acid. Sulphur has always held a prominent place in the local treatment of acne, and while it cannot be denied that it is a most valuable remedy, it often fails to effect a cure when reliance is placed solely upon its use. In the form of powder (sulphur prascipitatum), it can be used either pure or diluted with an equal part of talcum or any toilet powder. In addition to its slightly astrin- gent effect, it is usually appreciated by the patient on account of its cosmetic value in concealing the redness of the face during the day. As a lotion sul- phur is of great value, tending both to check the formation of pustules and to lessen the persistent redness of old lesions. Among the many sulphur lotions recommended by writers, the most com- monly used and perhaps the most valuable is known as the "Lotio alba." It should be well shaken, dabbed upon the skin, and allowed to dry. ]J Potassse sulphuratae ... . . 3 i 3 Zinc! sulphatis 3 i 3 Glycerini . . f3i 3 Aquae rosffi ad f^ivad loo m Dissolve each of the first two ingredients in one-half of the water before mixing. Other stimulating sulphur lotions are the following : IJ Sulphuris praecipitati 3 iiss 20 Spiritus lavandulae 3 iii 25 Glycerini 3 ss 3 Alcoholis ad f5ii ad 100 ^ (Hebra.) 20 THE TREATMENT OF SKIN DISEASES Sulphuris sublimati y^theris . . . Alcoholis . . Glycerin! . . Liquoris calcis Aquae rosse . 3ii 5 5 5 aa f 3 ss 5 4u aa f3 iv ad 100 •fj]^ (Crocker.) 9 Sulphuris prsecipitati 3iv 15 Linimenti saponis mollis . . . f 3 x 35 Glycerini f 3 vi 20 Alcoholis fji 30 TTl 100 (Elliot.) One of the most stimulating applications of sulphur in common use is that known as Vlemingkx's Solution. This should be cautiously used upon the face, as it is liable to inflame the skin and cause considerable pain ; but in cases of chronic acne of the back it is capable of producing an excellent result. '^ Calcis fss Sulphuris sublimati ? i Aquae destillatae fjx m Boil, with constant stirring, until the mixture measures six fluid ounces ; then filter. This solution should be diluted at first with four parts of water, in a few days three parts of water may be used, and by gradually increasing the strength every few days in this manner the pure lotion may finally be used in some cases, either painted over or rubbed into the skin. When considerable dermatitis is occasioned, its use should be discontinued and a soothing oint- ment applied. ACNE 2, Lassar recommends the following strong soap and sulphur paste : ^ Naphthol lo parts Saponis mollis . 20 " Petrolati mollis 20 " Sulphuris prsecipitati 50 " m Too This is to be smeared upon the skin and allowed to remain for ten or fifteen minutes. It is then removed and the skin powdered. This should be repeated every day until the skin begins to peel. In the form of the officinal ointment, sulphur may be applied at night either alone or in combination with other drugs. As a rule, however, oint- ments are disagreeable and unnecessary in the treatment of acne, and as in most cases there is already an undue oiliness of the skin, sulphur ointments should be used only in the exceptional cases when the skin is harsh and dry. Mercurial applications are of service in acne, but they have a more super- ficial effect than the preparations containing sulphur. A lotion of corrosive sublimate is the best form to use, and its strength must vary according to the end which is desired. A weak solution may act as a soothing disinfectant. A one per cent, solution (about five grains to the ounce) will cause a burning sensation and soon produce a slight desquamation of the epidermis. The stronger solutions used by advertising "complexion specialists," with a view to giving the patient "a new skin," are extremely painful, and destroy the entire outer layer of epidermis. Although this heroic treatment sometimes produces a notable improvement in the appearance of an unhealthy skin, the effect is but temporary and does not warrant the pain and danger incident to this plan of treatment, particularly when carried out by one who possesses more assurance than skill. A milder application will produce the same result as surely and much more safely, if not as speedily. Carbolic acid has been recommended in the treatment of acne, and may be of some service. If applied pure to chronic papular lesions they will often disappear after the crust has fallen, but it is simpler and better to curette them. 22 THE TREATMENT OF SKIN DISEASES When the abscesses of Indurated acne, containing much pus, are evacuated, it is a good plan to swab the interior with carbolic acid by means of a little cotton wound around the end of a probe or wooden toothpick, in cases where a patient is anxious to have the outer layer of skin removed, the use of carbolic acid, salicylic acid, or resorcin is preferable to the application of corrosive sublimate, especially if the remedy is placed in the hands of the patient. Chrysarobin, in the form of a strong ointment, has been recommended in the treatment of acne, and it is certainly capable of producing a deep-seated inflammation of the skin and a peelingof the surface which will cause a notable improvement, if not a cure, of any case of severe acne. But the appearance presented by the stained face and the danger of severe conjunctivitis arising from the application of this drug so near the eyes are objections to its use which are almost prohibitory. A fifty per cent, resorcin ointment or a twenty per cent, salicylic ointment, although acting more superficially, will produce the requisite amount of inflammation and desquamation and effect very nearly the same result with less disfigurement and no danger. In the local treatment of acne, as in the care of the normal skin, soap and water play an important part. When the skin is very oily, soap is of service by virtue of its chemical effect, and vigorous friction of the face at night with a rough cloth dipped in a soap solution is often of great benefit through its mechanical action in pressing out the accumulation of fatty matter in the sebaceous ducts and stimulating the functional activity of the sluggish glands. The daily use of soap upon the face in health is largely a matter of custom, and very naturally is insisted upon by the soap-makers as the only means of securing a fine complexion. As a matter of fact, and in direct opposition to glaring advertisements and common belief, the frequent use of soap upon a healthy skin often tends to injure rather than to improve it. Fair cheeks that should look like peaches may be made to look like polished apples through excess of zeal in soaping and scrubbing, in acne, however, a condi- tion commonly exists which is almost invariably improved by a daily resort to vigorous soap frictions. Any of the many good soaps sold at a fair price ACNE VULGARIS DORSI Acne of the back and chest is commonly associated with acne of the face, although in some cases the eruption may be wholly confined to either the face or the trunk. In either location the eruption will be found to be follicular in its origin and to consist of indolent papules and pustules of varying size, with numerous comedos and a general plugging of the glandular ducts. In many patients small abscesses are liable to develop, and in some cases of long standing a number of sharply defined and sunken cicatrices may be found over the sternum as well as upon the back. The severe forms of acne of the trunk occur usually in male patients. The patient who was the subject of the accompanying illustra- tion manifested a strumous tendency, having a sluggish circulation and a thick, greasy, inaftive skin. There were many pustules present and more traces of former lesions in the shape of stains and pits, and at one point a dull red patch of skin was undermined by an accumulation of sanious pus. The eruption had persisted for several years and grown worse, in spite of the application of various ointments. A cold bath every morning and the vigorous use of a curette twice a week effeded a speedy improvement. This treatment is usually all that is required, but the progress toward a cure is apt to be slow in most cases. Copyright, 1900, by G, H Ff.x. ACNE VULGARIS. ACNE 23 will answer the purpose. Patients who will unhesitatingly put into their stomachs any kind of bread that looks and tastes good, without stopping to inquire the name of the baker, are often painfully worried over the question of whose soap they shall use. It is practically a matter of little consequence, since serious injury to the skin from poor soap is as rarely observed as it is frequently talked about. The main point is to select any good soap and to use it thoroughly. A perfectly pure and very elegant soft soap prepared by Bagoe (sapo olivas prasparatus) has been prescribed by the writer for many years, usually in the form of a fifty per cent, solution in perfumed alcohol. Hardaway recommends it in cases of acne of moderate severity, advising vigorous friction every night with a piece of flannel dipped in the following solution : B Saponis olivse prseparati . . 31 '5 Alcoholis -fSi IS Aquae rosae . f 5 vi 70 TU 100 The officinal linimentum saponis mollis (tincture of green soap), though a less elegant preparation, will perhaps answer the purpose quite as well. The superfatted soaps of German manufacture are less efficient than those which are slightly alkaline and yet not corrosive. The numerous medicinal soaps on the market are mostly very fine, but have no special value, since the various drugs incorporated with them usually have no appreciable effect upon the skin when applied in this manner. The application of hot water and of hot cloths to the face is very often recommended by physicians in the treatment of acne, and some advise "face steaming" to soften the skin and thereby facilitate the removal of comedos. The former may be beneficial when many highly inflamed and painful lesions are present, but as a routine prescription is liable to do more harm than good. The latter troublesome procedure is never necessary, and often injurious on account of its relaxing effect upon the skin. Elliot states that he has found both hot water and steaming to be harmful, increasing the amount of the 24 THE TREATMENT OF SKIN DISEASES eruption and inducing frequently a seborrhoea oleosa with dilated follicular orifices. Cold water is without doubt the best tonic for the skin, whether of the face or other parts of the body. In the treatment of acne, it tends to invigo- rate the circulation and to contract the follicles, and patients who have been accustomed to bathing the face in hot water will usually report a decided preference for cold bathing after they have made a change and carefully observed its effect. The importance of mechanical measures in the local treatment of acne, which I have upheld for many years as being far superior to the customary applications of sulphur, mercury, etc., is gradually becoming recognized, and treatment by vigorous massage and the use of the curette and comedo scoop is much more common now than formerly. Facial massage has recently come to be a favorite mode of improving the complexion, but is usually carried out with much more fuss than effi- ciency. It consists too often of gentle rubbing of the skin with the fingers or a corrugated rubber brush, and the inunction of various oils or fatty sub- stances. What is necessary is vigorous and frequent pinching of the skin between the thumb and finger. This can best be carried out by the patient, who should be instructed to devote five minutes to the procedure just before bedtime, or perhaps a minute several times during the day. if this practice were adopted by all young persons of either sex who suffer from a poor complexion there would doubtless be fewer patients with flabby and pimply skins. The objections raised, that such a practice tends to increase the inflammation of the skin, or to spread the disease by transferring micro- organisms from one follicle to another, are purely theoretical, and do not stand the crucial test of experience. In massage of the face the skin should be kept as dry as possible and the utmost force exerted by the thumb and fingers which the patient will consent to bear. Stroking the skin with the finger-tips in some particular direction may exert a profound impression upon the mind of the patient, but in the cure of acne it matters little in what direction the skin is rubbed or ACNE ,^ pinched, so far as the efficacy of the operation is concerned. It is usually convenient, however, to follow the natural lines of the skin. "No cold cream nor other greasy substance should be used in applying massage to the face. The main object is to empty the distended follicles, or in the case of an exceptionally dry skin to excite the secretion of sebaceous matter, which is Nature's emollient. Indeed, it is often a good plan, in place of using any oil or fatty matter, to dust the skin of the face with finely powdered pumice-stone in order to prevent the fingers from slipping as the skin is pinched between them. Galvanism will sometimes aid massage in stimu- lating the cutaneous circulation, but is rarely of sufficient benefit to pay for the trouble involved. The curette is of eminent service in the treatment of nearly all cases of acne. The strongest argument I can advance in its favor is that for several years past I have almost given up the use of ointments and lotions in my private practice and, so far as local treatment is concerned, have relied almost entirely upon the benefit derived from the use of this instrument. A sharp spoon or curette of almost any size or shape may be advantageously employed, but perhaps the most serviceable is an annular curette the size of a finger-ring. This can be most readily cleansed after using, and, if not too sharp, will do no injury to the healthy skin. It is capable of producing good results in various ways. It quickly destroys all the small pustules, scrapes off the heads of any projecting comedos, presses put a considerable quantity of fatty matter from the sebaceous ducts, and finally quickens the circulation and thus promotes absorption of inflammatory deposits. AUTHOR S RING CURETTE. Its vigorous use in severe cases of acne may be somewhat painful at first, and often causes considerable hemorrhage from the excoriated lesions. It does not produce an immediate improvement in the appearance of the face, as a paste or powder might do, but it cleanses and invigorates the skin, and in many cases 26 THE TREATMENT OF SKIN DISEASES has a far greater curative effect than any other method of local treatment. At the first sitting, the patient who has hoped for the prescription of some magic ointment or lotion of wonderful beautifying power may object to the harsh and unexpected method of treatment and to the temporary disfigurement some- times occasioned ; but as soon as the crusts dry and fall from the excoriated pustules, and the skin is found to be already much smoother, there is usually no objection to submitting to further treatment of the same sort once or twice a week. In the case of extremely sensitive patients, the curetting may be less vigorous or limited to a portion of the face, and the same beneficial result reached in longer time. After the curetting, the face should be sponged with absorbent cotton dipped in an antiseptic solution, and a soothing application may be prescribed to please the patient or to conform to custom, although it is by no means necessary. The curetting alone will do the work, aided by the frequent bathing of the face in cool water. in cases of acne indurata, where small collections of pus are deep- seated and form reddened and rounded papules, or when the skin is under- mined by dull red or purplish abscesses, puncture of these lesions is demanded. Any small pointed knife may be used, but the triangular acne lance, with a shoulder to prevent its going too deep, is the most serviceable instrument. The following cut shows a combination of the acne lance and a small curette which may do good service in pressing out comedos. When not in use both instruments may be unscrewed and concealed in the cylindrical handle. COMBINED ACNE LANCE AND CURETTE. An idea prevails among many patients with acne that a lancet or other instrument used upon the face is likely to produce scars. Since physicians are sometimes unjustly blamed for disfiguring cicatrices it may be well to explain to certain patients that it is the disease and not the lancet which produces the scar. ACNE 2-] ACNE CACHECTICORUM This name was applied by Hebra to a general pustular eruption affecting scrofulous individuals. The whole body, with the exception of the palms and soles, may be the seat of the disease, although it is most common upon the chest, back, and lower extremities. The eruption consists of indolent, dull-red papules or flattened pustules, which dry and form small crusts. A hemorrhagic condition of the lesions is not uncommon, and mingled with the eruption many purplish-red stains are frequently seen. Slight superficial ulceration may result and more or less pitting of the skin. The patient often presents patches of lichen scrofulosorum and various other evidences of the strumous taint. Some writers have described lichen scrofu- losorum as a papular and acne cachecticorum as a pustular form of scrofuloderma. As the disease is essentially one of impaired nutrition, the chief aim of treatment should be to improve the tone of the patient's general condition. An abundance of pure air and wholesome food combined with a systematic alternation of rest and moderate exercise is imperatively demanded. In no disease of the skin, perhaps, will such measures produce a more satisfactory result. Cod-liver oil and iron will also prove of great service after the digestive functions have been invigorated by the administration of nux vomica and the mineral acids. As the disease sometimes partakes of the nature of scurvy, the use of fruit and fresh vegetables, with strict attention to the hygienic surroundings of the patient, will naturally be found of great benefit. ACNE VARIOLIFORMIS This is a somewhat rare affection of the skin, which, in spite of the name, bears no relation to common acne, except that the two affections resemble each other in being follicular and pustular in character. Cases have been described as acne frontalis, acne atrophica, acne necrotica, and various other names which may serve to indicate the clinical characteristics of the disease. Its 28 THE TREATMENT OF SKIN DISEASES lesions are most frequently seen upon the temples, the upper portion of the face, and the scalp, but they may also occur upon the neck, trunk, and extremities. Upon the scalp they are most apt to occur, and are also most readily observed, in cases of partial or complete baldness. The lesions begin as small, flattened, inflammatory papules, which gradually undergo a process of central suppuration. A small, dark crust forms, which appears imbedded in the skin with a raised circular margin, and the lesion bears a slight resemblance to a drying small-pox pustule. And when this crust dries and falls a decided pit is left, which is at first red, but finally becomes white, as in variola. The eruption is usually a chronic one, tending to successive relapses, and, unlike ordinary acne, it may give rise to considerable itching. It occurs in early adult life, and is never seen in childhood. The etiology of the disease is obscure. Most patients appear to be in average health, although Hans Hebra states that very many suffer from gastric catarrh, and regards this as a frequent cause. He reports good results from the internal use of Marienbad water and from the local use of sulphur applications. In the treatment of varioliform acne 1 have found the ammoniated mercury ointment to be of decided value. In most cases it produces a marked improvement, if not a speedy cure. Potassium iodide, or the ordinary "mixed treatment" employed for syphilis, has also been found to be of service. These therapeutic facts, taken in connection with the slight resemblance of the eruption to the relapsing, corymbiform, pustular syphilo- derm, have led some to regard the disease as more or less remotely due to syphilis. It should be borne in mind, however, that mercury and the iodides are efficient remedies in many skin diseases which have no possible association with this disease. Crocker suggests that if the horny centre of the early papule were removed and iodoform or other antiseptic applied, abortion of the lesion would be induced and the scar avoided. But most of the lesions, as he also remarks, are in an advanced stage before the patient applies for relief. ALOPECIA ALOPECIA, or loss of hair, occurs under various conditions and results from a variety of causes. The term is applied not only to a gradual ^ falling of the hair, but also to the hairless condition which may eventually result. This baldness may in some cases be regarded as a symp- tom rather than as a disease. It is often physiological as well as pathological, and in very many cases a bald head has no more claim to be regarded as a disease than has old age. In accordance with the age at which it appears, alopecia has been described as congenital, senile, and premature. The first is rare and interest- ing, the second is frequent and insignificant, while the third is by no means uncommon, and of greater or less importance according to the point of view from which it is regarded. In cases of congenital alopecia there may be simply a tardy development of the hair, as is not unfrequently noted in regard to the teeth. In excep- tional cases there may be a complete absence of hair at birth, or a loss of hair may take place during infancy. This condition is rarely permanent, and is usually associated with imperfect development of the teeth and nails. As this condition is one dependent to a great extent upon a proper nutrition of the body, a modified diet will promise better therapeutic results than any local treatment, but where there is a congenital absence of hair- follicles no hope of a future capillary growth can be entertained. In certain cases of infantile alopecia where there exists a keratosis of the follicles and the hairs become gradually atrophied as a result of this condition, the daily use of soap may be beneficial and tend to improve the growth of the hair. 30 THE TREATMENT OF SKIN DISEASES The baldness of old age is in most cases as natural and as inevitable as old age itself. Just where the line should be drawn between senile and premature alopecia is as difficult to say as it is to state just when old age begins. Senile alopecia is largely a question of sex and heredity. The occu- pation, habits, and head-dress of the individual have very little influence in promoting baldness. An old man loses more or less of his hair through a decree of nature as immutable as that which causes the beard to grow upon his youthful chin. His aged wife usually presents neither beard nor baldness simply as a result of the inherited tendency characteristic of her sex. The statement that men grow bald while women do not on account of the former alone wearing tight-fitting hats is wholly devoid of proof, and is scarcely more reasonable than the fantastic explanation that while a woman drops her night-dress from her shoulders a man pulls his analogous garment over his occiput and in course of time loses his hair through friction. A man becomes bald and a woman retains a comparatively thick growth of hair in old age not on account of the reasons so frequently advanced as to the use of water, style of hats, etc., but because of an anatomical condition which is inherent in the sex. Every woman, however thin she may be, has a certain amount of subcutaneous fat which imparts to her form its character- istic roundness. Beneath the scalp this cushion of fat never entirely dis- appears. A man, on the other hand, however corpulent he may be, presents more bony prominences. The cushion of fat beneath his scalp, which is always present in youth, tends in many cases to disappear with increase of years. The subcutaneous tissue gradually hardens, and finally the scalp becomes so tightly drawn over the calvarium that atrophy of the hair-bulbs is an inevitable result. The characteristic location of a shiny pate is indica- tive of this mode of origin. Baldness never affects the whole scalp, but even in the most striking cases it is always noticeable that the hairless area cor- responds in outline with the fronto-occipital aponeurosis. Over the occipital and temporal muscles, which continue to furnish the soft cushion needed for the nutrition and proper function of the hair-bulbs, senile baldness is never seen, and the anterior tuft of hair, which often remains for years when ALOPECIA 3, the rest of the crown is denuded, doubtless owes its persistence to the fact that over tne upper border of the frontal muscle the scalp never is as tightly drawn as over the fibrous aponeurosis. While the wearing of close-fitting hats may be justly condemned as unsanitary, and by no means conducive to the most luxuriant growth of hair, the argument that baldness in men results from the wearing of stiff hats which cut off the supply of blood or interfere with the innervation of the upper portion of the head is far from being a valid one. If this were true the line of baldness would correspond very nearly with the line of pressure from the hat brim, but as a matter of fact a bald occiput can be frequently seen below the rim of the hat, while on the sides of the head the hair usually grows above the line of pressure. The cause of baldness is doubtless the same to-day as it was over two thousand years ago, and, judging their habits from their pictures, neither Socrates nor any of his bald-headed associates were in the habit of wearing a "cylinder" or "pot hat." From the foregoing it is apparent that there is no cure for true senile baldness, no matter at what age it may happen to occur. The condition is not a deplorable one, and so far as personal appearance is concerned it seems to be the prevailing opinion of the present generation that a bald head is far more becoming than the old-fashioned wig. When exposure to draughts causes unpleasant results, as sometimes happens when baldness coexists with a poor circulation, cold baths are to be recommended, and a light skull cap can be carried in the pocket for use in case of emergency. Premature baldness is an affection which is now, and probably always has been, a very common one. To many a young man who notes with a feeling akin to horror its slow and stealthy approach it becomes a subject of engrossing interest, and not infrequently a morbid sensitiveness is developed out of all proportion to the admitted seriousness of the condition. Unlike the fox in the fable who, losing his tail in a trap, persuaded his companions that it was an entirely unnecessary appendage, the victim of premature alopecia refuses to become reconciled to a condition which is sometimes irremediable, and falls into a mental condition so lamentable 32 THE TREATMENT OF SKIN DISEASES that one might suspect that the main trouble was within the caivarium. Much study and very much more discussion have been devoted to the nature and causes of premature alopecia, but there still exists among physicians as well as among barbers and the laity in general an infinite variety of unique and conflicting opinions. The growth of hair is a subject upon which nearly every man feels at liberty to entertain and to promulgate his personal and peculiar views, and, with the exception of the weather, it would be difficult to find any topic of ordinary conversation which has given rise to doctrines more positive and more absurd. In accordance with its origin and curability, alopecia has been described as idiopathic and symptomatic. In the former we have simply loss of hair without apparent cause ; in the latter we have falling of the hair as a result of either general or local disease, which may be apparent at first glance, or only become evident after a careful study of the case. Premature alopecia, like the baldness of old age, is in great measure a matter of heredity. With the majority of old men it is natural and unavoid- able for the hair to gradually turn gray and become sparse, it is quite as natural and equally unavoidable, in the case of certain young men, that the hair should begin to recede from either side of the forehead and grow thin upon the vertex. It is not to be considered as a disease or as a result of any disease. It is as much a physiological peculiarity inherent in the individual as the fact that his height is six feet or his weight two hundred pounds or that his breast and back are free from the slight growth of hair that is to be found upon the majority of men. in this idiopathic form of premature baldness the same change takes place in the scalp and subcutaneous tissue as is noted in advanced age. The cushion of fatty matter disappears, the connective tissue becomes more dense, and atrophy of the hair-bulbs results from unyielding bony pressure. When a young man is growing bald because his father or more likely his grandfather was bald before him, this tightening of the scalp is quite apparent. If the heads of a number of young men suffering from alopecia are carefully examined by the fingers alone, those who present this idio- ALOPECIA 33 pathic and practically incurable form of baldness can be readily distinguished from those whose loss of hair is symptomatic and resulting from either local or general malnutrition, if the scalp is soft and movable a favorable prog- nosis may be given, but if, on the other hand, the scalp is hard and draw^n over the upper portion of the skull almost like the cover of a ball, it may be safely concluded that the development of a bald and shiny area is simply a question of time. In the treatment of this idiopathic alopecia no benefit can be expected except when it is complicated by pityriasis or an inactive condition of the scalp. In other words, it is only the symptomatic alopecia that is amena- ble to treatment. The customary cantharidal lotion never yet restored the hair in any of these cases, and its routine prescription is hardly more rational than the beating of a gong by an Indian medicine-man. While heredity plays an important part in the production of premature baldness and constitutes an etiological factor which should never be ignored, the loss of hair, which is secondary to disease, both local and general, is extremely common, and its proper treatment is a subject of both interest and importance. Pityriasis capitis, or dandruff, is a common affection of the scalp, and very frequently the precursor of baldness. Eczema, seborrhoea, and psoriasis are also diseases which in a mild form often persist for years upon the scalp and occasion a temporary, if not a permanent, thinning of the hair, while favus, folliculitis decalvans; and ulcerative syphilis usually leave cicatricial patches of varying size and shape. Dandruff is now generally recognized as a frequent cause of falling hair and subsequent baldness. Alopecia furfuracea, seborrhoea sicca, erythema squamosum, eczema seborrhoicum, and pityriasis are some of the various names which have been applied to this common affection. As the essential feature in the great majority of cases consists throughout the entire course of the disease in a branny desquamation of the skin and a disordered function of the sebaceous glands may or may not be present as a complication, the term pityriasis (Greek nirvpov, bran) seems to be the most appropriate name which can be used. For ordinary dandruff the term eczema seborrhoicum, 34 THE TREATMENT OF SKIN DISEASES which is now frequently applied, is a misnomer, since the affection is neither eczematoLis nor dependent upon a flow of sebum. In the most common form of pityriasis capitis the desquamation is plainly seen upon the scalp, and no redness or other inflammatory symptoms are present. The small whitish scales are often scattered through the hairs, appear in profusion upon the patient's shoulders, and very soon fill the hair- brush. In other cases, where there is more of a seborrhoeal element present, there may be a greasy scurf upon the scalp, and in rare instances a thick asbestos-like crust forms at the roots of the hair. When this is raised a pale and glistening surface is found beneath, in most cases of dandruff, however, and especially in patients with an eczematous tendency, a subacute grade of inflammation is apt to be present, and often a true catarrhal eczema develops. More or less itching accompanies pityriasis, and is especially annoying after mental or physical exertion. The hair is usually dry and lustreless, and soon manifests a tendency to fall. The tendency to dandruff depends largely upon the habits and physical condition of the patient, and is always aggravated by an unhygienic mode of life. Overwork, worry, and dissipation frequently occasion acute attacks ; and I have known Wall Street patients from the condition of whose scalps one might almost judge whether stocks were up or down. Advice as to general treatment directed to the cause of the trouble will usually be neglected, since the affection is apt to be regarded as a trifling one, and patients will be found much more willing and anxious to try the effect of local remedies. When shampooing and brushing and the ordinary hygienic care of the scalp fail to remove the dandruff certain stimulating ointments and lotions will often be found of great service. These are usually of a parasiticide character, but it is by no means certain that their beneficial effect is due to this quality. Mercury, sulphur, resorcin, and salicylic acid are among the most efficient of external remedies. Walker mentions sulphur and salicylic acid as the two drugs which have most influence in curing dandruff, the latter being especially serviceable in the drier and more scaly forms of the ALOPECIA 35 disease. He advises a weak application at first (fifteen grains of each in an ounce of vaseline), the strength to be increased as may be necessary. The falling of the hair from syphilis usually occurs during the early months of the disease, and is usually coincident with an erythematous or papular eruption upon the scalp, it varies greatly in amount in different patients. In a typical case the scalp, especially upon the occipital region, becomes checkered with numerous small areas of partial baldness, and appears as though tufts of hair had been pulled out at regular intervals. Occasionally the eyebrows and lashes are more or less affected at the same time. The loss of hair is soon replaced by a new growth, and its return may be hastened in slight degree by the daily inunction of the oleate of mercury. Among the general causes of alopecia may be mentioned fevers and exhaustion resulting from overwork, anxiety, dissipation, or any other habit or condition which entails an excessive tax upon the nervous system. The falling of the hair which follows a prolonged febrile attack is usually but tem- porary, and the lost hair is restored as soon as the patient regains a normal condition of strength and vigor. Shaving the head under such circumstances is a practice which women sometimes undergo at the earnest solicitation of a barber, and often with the consent, if not upon the advice, of their physician. If the patient naturally enjoys an average amount of health and strength and makes a good recovery, the hair will grow long and strong in a few months whether it be shaved or not. If the patient be weak, on the other hand, and naturally possessed of little hair-producing energy, she may find to her intense disappointment that the hair will grow much more slowly than in the case of her vigorous sister and that the amount sacri- ficed is never entirely regained. In the case of most women who consult the physician on account of a defluvium capillorum, and of many men who are not afflicted with what might be termed an alopecial diathesis but who find their locks becoming thin, the loss of hair may be justly attributed to one or both of two causes. These are general debility and an inactive condition of the scalp. The proper nutrition of the hair depends not merely upon the condition of the 3(i THE TREATMENT OF SKIN DISEASES scalp, but also upon a healthful condition of both mind and body. A failure to appreciate this important clinical fact leads to the prescription of innumerable useless "hair tonics," and while this may be pardonable on the part of a barber or hairdresser, it is certainly a discredit to the intel- ligent physician. A natural growth of hair demands an abundant supply of nervous energy, and when this is withheld the falling of the hair becomes as inevitable as emaciation in the case of a child who is supplied with insufficient or innutritions food. When the normal vitality of a man or woman is exhausted through an excess of work, worry, or dissipation no amount of local treatment of the scalp can be expected to prevent a loss of hair. This should be regarded as the natural result of a definite cause, like the falling of hair after a prolonged attack of fever, and so long as a man will persist in working without any thought of his health, and in worrying when he should be resting, or a woman devote her whole time to onerous social functions which tax her strength beyond its utmost capacity, just so long will the starving hairs continue to loosen and fall in spite of cantharides, rum, and quinine, though prescribed and applied by all the doctors and barbers in the land. In the case of patients whose falling hair is largely due to an excessive wear and tear of the nervous system the physician will often act wisely to let the scalp take care of itself, as it is abundantly able to do under the simplest hygienic treatment. An inactive condition of the scalp with very little or no dandruff or other local disease is frequently an etiological factor in simple falling of the hair as well as in cases of premature alopecia. As a remedy for this con- dition shampooing and brushing are of great value, and in a majority of cases no further treatment is required. Shampooing or thorough washing of the head with soap is a practice which is advisable both in health and disease. When the scalp is in a healthy condition it is not strictly necessary, espe- cially if the hair is kept well brushed. But in order to keep the scalp in its best hygienic condition an occasional shampoo is desirable both for com- fort and cleanliness. A man with short hair may enjoy a weekly shampoo, while a woman, on account of the greater amount of time and trouble ALOPECIA 37 involved in the operation, may content herself with a thorough washing of the head but once a month. When there is dandruff, however, or even an inactive condition of the scalp, a shampoo once or even twice a week may be necessary for a short time. This often relieves an itching sensation, makes the scalp feel much more comfortable, and in some cases will alone suffice to check a slight falling of the hair. In shampooing the head the choice of soap is not a matter of so much importance as many have been led to imagine. Any good soap that will make a thick lather with warm or tepid water may be advantageously used, but it must be freely applied and thoroughly rubbed into the scalp either with the fingers or a small brush. Indeed, it is often necessary to advise patients to scrub the head rather than to rub it in order to gain the full benefit of a shampoo. After the roots of the hairs have been care- fully cleansed, the soap must be thoroughly removed from the hair by bending the head over a basin or bath-tub and pouring upon the occiput a plentiful supply of tepid or cool water. The hair must now be thoroughly dried by means of soft towels and gentle friction. In case of women with thick and long hair the drying process involves some time and trouble, and hot towels may be used to advantage. A little alcohol applied to the scalp after a shampoo will facilitate the drying of the hair and perhaps lessen any tendency to "catching cold," the fear of which deters so many from frequent indulgence in the luxury and benefit of a shampoo. There are many who cherish the erroneous belief that frequent shampooing may prove detrimental to the growth of hair, and it is astonishing to note how some ladies of culture and refinement will allow their scalp to remain for weeks or months in a condition which may be justly characterized as filthy. There is also another prevalent opinion, shared by many physicians and promulgated by some of my dermatological colleagues, that a daily washing of the head or wetting of the hair in connection with the morning bath has a tendency to induce premature alopecia. No facts have ever been offered to substantiate this belief, and having no statistics at hand that might tend to shake its foundation, I can only express my firm conviction that frequent 38 THE TREATMENT OF SKIN DISEASES washing of the scalp, so far as it has any effect upon the growth of hair, is beneficial rather than injurious. The argument that the practice is pernicious because the natural oil is removed by the water and the hair gets into a condition of dryness and brittleness is founded on theory rather than fact. Water alone will not remove the natural oil from the hair. Shampooing with soap and water does so, and usually leaves the scalp and hair abnormally dry for a short time. To remedy this a very little almond oil or vaseline may be rubbed into the scalp immediately after washing. But shampooing and brush- ing tend to stimulate the natural secretion of oil, and I have known some women with oily hair who objected to frequent shampooing on the ground that it tended to increase this condition. Norman Walker expresses his belief that there would be less baldness were it not for the prevalence of the absurd tradition that washing of the scalp is injurious. Brushing of the hair should be thoroughly performed twice a day at least, in order to promote its growth and to keep the scalp in a healthful state. Hair-brushes with thick and long bristles should be chosen, and stiff or wiry ones, which are liable to irritate the scalp, should be avoided. Women who find that their hair is falling are often loath, through fear of becoming bald, to have it brushed or combed as much as is advisable ; but the hair which comes out more or less abundantly with each brushing is already dead and certain to fall in time, and the sooner it is removed the better it will be for the health of the remaining growth. Electricity is one of the best stimulants that can be applied to the scalp, and in many cases where the scalp is found to be pale and inactive, with but a slight tendency to pityriasis, a galvanic current applied once or twice a week will redden the skin, tend to check the falling of the hair, and promote a more vigorous growth. Most of the so-called electric brushes commonly sold are fraudulent impositions upon their ignorant and confiding buyers. Some have a magnetized bar of soft iron in the back, but the electricity which theiy are supposed to impart to the scalp is wholly imaginary. A wire brush con- nected with a galvanic battery and used in place of the negative electrode I have often found of great benefit in the treatment of falling hair, especially in ALOPECIA AREATA This patient, a teacher by occupation, had suffered from alopecia areata for over twelve years, the hair falling out in spots and growing in again. During the past year the increasing baldness had necessitated the wearing of a wig, and the disease had begun to affeft the eye- brows. Pure carbolic acid was applied in this case, one-half of the scalp being dotted or striped with the acid every ten days. This treat- ment caused epidermic exfoliation followed by pinkish spots, but had no apparent effeft in restoring the hair. As the patient grew stronger under a general tonic treatment, and her frequent headaches disap- peared, the hair returned and grew quite as readily on the untouched portions of scalp as where the acid had been applied. Six months later, after the strain of nursing a sick relative, the hair began to fall again, thereby showing the dependence of the disease upon the state of the patient's general health. The illustration shows an advanced stage of the disease in which the individual areas of baldness have enlarged and coalesced until the greater portion of the scalp is denuded. The numerous patches of dark hair indicate that there were originally many bald areas of small size, the circular outlines of which are still suggested by the concave margin of the hairy patch upon the occiput. The growth of white hair at various points indicates a tendency to recovery, and constitutes a favorable element of prognosis. This non-pigmented hair, which often appears first upon the bald areas, gradually assumes a normal color. '■"■■''I i, Copyright, lyjo, by G. H. Fox ALOPECIA AREATA. ALOPECIA • ^g women. A mild current should be used and a slight pricking sensation imparted to the scalp. ALOPECIA AREATA Alopecia areata is an affection in which one or more rounded patches of baldness develop suddenly or gradually upon the scalp with no apparent cause. The eyelids, cilia, beard, and other hairy parts may also be affected. The skin upon the bald area is thin, white, smooth, slightly depressed, and usually has a peculiar velvety feeling, quite different from that of the normal scalp which has been recently shaved. As the successful treatment of a disease usually depends upon some knowledge of its cause, the etiological factors in alopecia areata must be con- sidered as highly important. But, unfortunately, there are conflicting theories and few established facts upon which the treatment of this disease can be based. While many dermatologists still adhere to the view that the disease is a trophoneurosis, the belief in its parasitic nature has certainly gained ground in recent years. Many at the present time seem inclined to the view that some cases are of neurotic origin, while others, and notably those which are unsymmetrical and increase by peripheral extension, are caused by micro- organisms. This view harmonizes the conflicting arguments based on epi- demics of the disease cited by champions of the parasitic theory and on loss of hair by traumatism presented by upholders of the neurotic origin of the disease. The course of alopecia areata is variable, and the prognosis is therefore uncertain as regards the time required for a complete cure. I have seen cases improve and recover in a month or two when absolutely nothing was done except to take a photograph of the scalp. On the other hand, 1 have tried the most approved methods of treatment for many months in some cases without noting the faintest indication of any benefit. The fact that a remedy has been followed by a cure in one or in several cases of alopecia areata is no positive evidence of its therapeutic value, and by the same process of reasoning one might claim that photography is a remedy of value simply because a cure has 40 THE TREATMENT OF SKIN DISEASES followed its use after many remedies had been unsuccessfully employed. In diseases of indefinite duration, when many remedies and many physicians are given a trial, it is a common observation that the last one usually gains the credit in case a cure results. Fortunately the disease tends naturally to get well in most cases, and any plan of treatment which brings an unusual supply of blood to the scalp, acting at the same time perhaps as a parasiticide, will improve the nutrition of the affected part and doubtless hasten the desired return of hair. Internal remedies may be used to advantage in cases of alopecia areata, as indeed they might be used in case of a broken bone. If the health of the patient can be notably improved by nerve tonics, anti-dyspeptic remedies, iron, cod-liver oil, or other therapeutic agents, they should certainly be given ; but no one has ever been able to demonstrate satisfactorily that arsenic or any other drug has a direct influence upon the course of this disease. The belief entertained by many that arsenic is of special value may be well founded, but proof of its efficacy is very difficult to obtain. While an improvement may follow the use of a certain drug in some cases, a notable lack of benefit is certain to be observed in other cases in which the same drug is admin- istered. Hence any great reliance upon internal treatment in this disease is not to be commended. Kaposi goes so far as to state that treatment of any kind can neither shorten the course of the disease nor prevent its outbreak in another locality. Among the local stimulants which have been found serviceable in the treatment of alopecia areata may be mentioned ammonia, chrysarobin, car- bolic acid, acetic acid, iodized collodion, and croton oil. In accordance with my own experience, it matters little which of these remedies be employed if the effect of keeping up a moderate but persistent congestion of the patch is obtained. Nor should too much stress be laid upon the germicide nature of the remedy, for ammonia has seemed to me, as well as to many others, to be quite as effective as any of the remedies recommended on account of their anti-parasitic qualities. The liquor ammonias fortior is a convenient and cleanly application, and ALOPECIA 4, can be dabbed on the bald patches once or twice a day with a brush, rag, or tuft of absorbent cotton. In case of slight vesication, its use may be temporarily suspended or a dilution employed. Chrysarobin may be used in variable strength according to the age of the patient and the chronicity of the disease. In young children a five per cent, ointment made with lanolin is strong enough, while in the chronic patches of adults an ointment of from fifteen to twenty per cent, may be used to advantage. The staining of the scalp, not to speak of the bed linen, and the ever-present danger of an unexpected conjunctivitis, are serious objections to the use of this valuable remedy. Carbolic acid is a convenient application, and may be used in the form of a thirty, or even a fifty, per cent, solution. I have streaked many patches with the pure acid and given patients considerable pain with no better result than may be obtained by the comparatively painless use of the weaker solution applied every day. Acetic acid may be used in the same manner, diluted to suit the needs of each case. Morrow recommends equal parts of acetic acid and chloro- form to be applied every second day, and less frequently as improvement occurs. Croton oil diluted with two or three parts of olive or almond oil may prove of value in certain chronic cases, but the intense dermatitis which is liable to result is undesirable, and may do harm instead of good by destroy- ing the growth of fine hair. Jackson reports good results from a lotion of bichloride of mercury used, not on account of its parasiticide qualities, but solely for its stimulating effect upon the scalp. Hyde states that solutions of formalin, from one-half to two per cent, in strength, are sometimes efficient, but adds that the remedy should be used with care, as it has occasioned severe dermatitis, and in several instances has given light hair a green color. Walker believes that local treatment merely hastens a recovery which time alone would often effect, and mentions sulphur, chrysarobin, and bichloride of mercury, in what he considers to be the order of their value. Shoemaker states that shaving the 42 THE TREATMENT OF SKIN DISEASES patches frequently, especially when they become covered with very fine hairs, will often stimulate the hair-forming apparatus, but this hardly coincides with a previously expressed belief that many bald heads in middle and advancing age are often due to constant cutting and shaving in early life. Various complicated methods of treating alopecia areata have been advised and have found enthusiastic followers. Explicit directions are usually given to wash the head with a certain soap for so many minutes and to apply one thing in the morning and another at night, etc., and cases are quoted in which the average time of cure was found to be so many days or weeks. A report of the new treatment and its surprising results always goes the round of the medical journals, but those who try these methods seldom publish either their success or their disappointment. Electricity has been highly recommended as a local stimulant in this disease, and I have seen a series of cases treated by means of the static current with apparently excellent result, but so much time and labor on the part of the physician is involved in this plan of treatment that a method which the patient can carry out at home is generally to be preferred. Blistering of the patches in alopecia areata has been strongly advised and frequently practised to the intense discomfort of the patient, but experience teaches that the results of this heroic method do not generally compensate for the amount of pain which it occasions. The subcutaneous injection of corrosive sublimate around the edges of a patch has been employed for its parasiticidal effect, and good results reported ; while injections of pilocarpine have been repeatedly used in vain on the strength of unverified statements as to its effect upon the growth of hair. Hypodermic treatment, like blistering, has no advantage over simple measures, and is far more objectionable. Epilation of the loosened hairs which are often to be found around or upon one side of a bald patch is a practice to be commended, since in many cases it seems to check the spread of the disease. ANTHRAX ANTHRAX, or "malignant pustule," is a phlegmonous affection of the skin, /\ resulting from infection by the anthrax bacillus. This is usually derived *- from some herbivorous animal suffering from a peculiar disease known as splenic fever. The affection is fortunately a rare one in this country, as it proves fatal in the majority of cases. The infected subject often succumbs to septicemia before the characteristic cutaneous lesion has had time to develop. This is usually seated on the hand or face, and appears at first as a highly inflamed vesicle upon a circumscribed and indurated base. This rapidly becomes dark and gangrenous, depressed in the centre, and is surrounded by a characteristic ring of vesicles. The infection may take place directly from a diseased animal in the case of those who have charge of horses, cows, and sheep, or it may result from the handling of hides, hair, horns, and hoofs in the case of butchers, tanners, upholsterers, and others. Flies and other insects may also be the means of conveying the infection, and doubtless many of the reported cases of death from the bite or sting of an insect may be explained upon the assumption that the poison of anthrax has been carried from a gangrenous sore on some animal affected with the disease. It is believed that the disease may also enter the system through the digestive or the respiratory tract. According to the reports of those who have had considerable experience in the treatment of anthrax in countries where it is not uncommon, an early and complete excision of the initial lesion, with thorough cauterization of the wound, appears to be the most successful method of treatment. A deep crucial incision and the free use of carbolic acid or corrosive sublimate has also been advised. The sooner an antiseptic treatment of the local lesion is commenced and the more vigorously it is carried out, the less will be the likelihood of general infec- 44 THE TREATMENT OF SKIN DISEASES tion. It is claimed by some writers that excision is likely to do more harm than good, and that since the micro-organisms causing the lesion are only in the superficial portion of the skin, a much better result is likely to be obtained by the application of carbolic poultices or of mercurial ointment. When lax tissue becomes intensely oedematous, multiple incision, with an antiseptic dressing, is advisable, and injections of carbolic acid may be made around the border of the patch to arrest its increase. Alcoholic stimulation is of great service in case of general infection. CANITIES Canities is a term appliea to gray or white hair, a condition which is usually acquired, and may be either local or general in its development. Its most common form is seen in the white hairs of old age. These are first noted over the temporal bone, which derives its name from this circumstance. Gray hair, however, like baldness, is not always indicative of senility, and often occurs in youth or middle age (Canities prematura). The partial form of canities may be congenital, but is usually acquired in youth or later years. It consists of a single patch or tuft of white hair upon the scalp, eyebrow, moustache, beard, or other hairy part (Canities circumscripta). The immediate cause of hair turning gray has been carefully studied, and seems to depend chiefly, if not entirely, upon a failure of the hair papilla to supply the requisite amount of pigment. A single hair does not change from black or brown to white throughout its entire length, but the color first dis- appears at the root, leaving a pigmented end, and as the hair grows in length a gray hair gradually takes the place of a dark one. Heredity plays an important part in the senile whitening of the hair, and in nearly every case of premature grayness a family tendency to this condition may be readily discovered. The condition is sometimes ascribed to neurasthenia, a lack of iron in the system, a sedentary life, or the habit of constantly wearing a closely fitting hat ; but positive proof of such causation is difficult to obtain. Severe nervous affections and sudden grief or fright may undoubtedly CANITIES 45 cause a speedy though gradual blanching of the hair whenever such a tendency already exists ; but the historic and other alleged cases of hair turning white in a single night are believed by many to be apocryphal. Kaposi claims that the cases reported, even by scientific men, of grayness developing suddenly in ship- wrecked individuals, those condemned to death, etc., must be based on errors of observation. He argues that it is physiologically inconceivable that the pigment granules in the fully developed hair should suddenly disappear. Nor can we believe that, under the influence of fright, etc., gases develop in the hair, and that these bubbles of gas or air conceal the pigment, inasmuch as many normally colored hairs contain air. In the treatment of gray hair the most sensible thing that can be done is to admire it. Indeed, there is, perhaps, no other sensible thing that can be done. As the condition has ordinarily no relation to the health of the patient, general treatment is not likely to produce any change in the color of the hair. On the assumption that the grayness is due to a lack of iron in the system, this drug is frequently prescribed ; but although it may benefit the patient in other respects, 1 have never known of a case in which it exerted any influence upon capillary pigmentation. So far as local remedies are concerned, not one has ever been sug- gested as having a possible curative effect. Hair dyes are used for the sole purpose of concealing the condition when it is thought to be an unfortunate or an undesirable one. in some cases their injudicious use only serves to call nearly everybody's attention to what might otherwise pass unnoticed. Nitrate of silver is one of the hair dyes most frequently used. In apply- ing it, the hair should first be shampooed thoroughly, then carefully washed and dried. A two per cent, solution of pyrogallic acid is then to be rubbed over the gray hairs from root to tip by means of a toothbrush. When dry again, a one per cent., or stronger, solution of nitrate of silver, according to shade desired, is to be applied in the same manner. When the lotion accidentally gets upon the scalp or face, the resulting black spots can be avoided by the immediate use of a saturated solution of potassium iodide. Every three or four weeks the dyeing of the hair must be repeated. 46 THE TREATMENT OF SKIN DISEASES Nitrate of silver and lead may be combined in one solution, as follows : 5. Argenti nitratis 5 Plumb! acetatis i Aquse rosae ad 100 m Much has been said about the great danger of lead poisoning from the use of hair dyes, and cases have been reported and repeatedly quoted. But when diachylon ointment, containing a large amount of lead oxide, can be smeared over a baby's skin with impunity, the fear of poisoning from a hair dye containing a small amount of lead seems to have little or no basis. Kaposi says that apart from the eczema which may arise from their unskil- ful application, the use of metallic hair dyes produces no evil effects. Anderson gives a method of dyeing the hair which he accidentally dis- covered during the treatment of a case of eczema marginatum. A lotion of corrosive sublimate (two grains to the ounce) was used for some weeks, and then a lotion of hyposulphite of soda (one drachm to the ounce) was prescribed. The morning after the first application of the latter, the hair of the part which before was bright red had become nearly black. One or two more applications rendered it jet black, while neither the skin nor the clothing was stained. CARBUNCULUS A carbuncle may be properly regarded as a furuncle with an extensive phlegmonous inflammation of the cutaneous tissue, resulting in a large gangre- nous slough and a disfiguring cicatrix. It is called anthrax benigna by some writers, but it is neither due to infection by the bacillus anthracis, nor is it justly characterized as benignant, in view of the fact that many cases have a fatal termination. It often begins like an ordinary boil, but quickly presents a greater area of painful induration, and is usually accompanied by a chill followed by a high fever. A number of pustular points develop upon the swollen and tense skin, and the lesion resembles a group of suppurating CARBUNCULUS 47 furuncles. At the end of a week or more there is a free discharge of pus and shreds of necrosed tissue from numerous openings. Finally the whole indurated mass is converted into a slough followed by a deep ulcer, which heals by slow granulation. A carbuncle owes its origin to an infection of the skin by the staphylococ- cus pyogenes aureus or some other pyogenic organism, it is allied both in nature and causation to a furuncle, and its more serious character has been explained by assuming that a deep-seated boi'l, covered by tense epidermis, will tend to spread laterally instead of upward through the skin. The affec- tion is usually met with in adult life, and appears especially prone to occur in connection with diabetes and other general pathological conditions. A favorable prognosis can be given in most cases, but in patients advanced in years and in those who have been subject to diabetes or alcoholism a fatal termination not infrequently occurs. The treatment of a carbuncle has come to be regarded in quite a new light since the advent of modern antiseptic methods, and the main object at the present time is not merely to afford relief from the intense throbbing pain, but to destroy the microorganisms which have found their way into the skin and are the cause of the disease. The application of a hot poultice, while it may prove temporarily grateful to the highly inflamed part, is now generally condemned as tending to favor the development and spread of the disease. If the carbuncle is treated by incision or by the injection of carbolic acid, an ointment or paste containing five per cent, of salicylic acid spread thickly on a piece of lint will have the soothing effect of a poultice and be entirely free from the objections justly urged against this time-honored application. If heat is thought desirable, cloths may be dipped in a satu- rated solution of boric acid in hot water and applied frequently. From an antiseptic point of view, this is far superior to the use of flaxseed. The method of treating carbuncle by a deep crucial incision as soon as necrosis of tissue has taken place, is the one most commonly employed by sur- geons. The raw surface exposed is now dressed with a carbolic or other anti- septic solution as soon as the free hemorrhage has ceased. In many cases it is 48 THE TREATMENT OF SKIN DISEASES advisable to thoroughly currette the sloughing mass and to pack the cavity with antiseptic gauze. This operation usually relieves the throbbing pain at once, and often reduces a high temperature to a normal degree. As the disease some- times extends in spite of free incision, a repetition of the operation may become necessary. A more radical treatment advocated by some surgeons is the complete excision of the carbuncle, and may be justified in those cases in which septicaemia develops at an early stage. The hypodermic injection of carbolic acid into the centre and around the border of a carbuncle has been highly recommended and proven of great service in checking the spread of the infiltration. The use of a small quantity of the pure acid is much preferable to the injection of a larger quantity of a five or ten per cent, solution, as the curative effect of the former is much more pronounced, and it is much less liable to be absorbed and thereby produce symptoms of carbolic poisoning. In mild cases a good result is usually obtained by the free application of any antiseptic ointment, without resort to surgical measures. Indeed, the routine treatment of carbuncle by crucial incision was condemned years ago by as eminent a surgeon as Sir James Paget. He advocated the application of a lead plaster with a central hole for the discharge of pus, hot fomentations, and washing out of the cavities with a weak solution of permanganate of potash. The internal use of calx sulphurata has been highly recommended as a remedy capable of lessening the pus formation, but it is certainly unreliable, if not quite useless. Antipyretics may be called for during the acute stage, and alcoholic stimu- lants are sometimes of advantage in case of extreme debility during convales- cence, but simple nourishing food and careful nursing are usually all that is required in the shape of general treatment. CHLOASMA Chloasma is a hyperpigmentation of the skin, which is not congenital like n^vus, but occurs usually in adult life and results from a variety of causes. CHLOASMA Chloasma is an abnormal pigmentation of the skin usually upon the forehead, cheeks and neck. It appears in the form of irregular brownish patches and is commonly bilateral, if not symmetrical. Its cause is obscure in most cases. The common name of "liver spots," which is often applied to this affeftion as well as to chromophytosis, is based upon surmise rather than upon any de- monstrable relation to hepatic derangement. It occurs often during pregnancy and in connexion with uterine derangement, but not with sufficient frequency to warrant the use of the name chloasma uterinum which was formerly in vogue. It is sometimes difficult to distinguish the affeftion from vitiligo which is due to an opposite condition, viz., a loss of normal pigmentation. The skin surrounding patches of vitiligo is always darker than normal, and on the face this affeftion may look very much like chloasma. On the other hand, the normal skin surround- ing a patch of chloasma is apt to look white by comparison and thus suggest vitiligo. It has been claimed that in the latter affeftion it is the pigmented skin, while in the former it is the white or normal skin, which shows a concave border, the abnormal patch having always a convex margin. This rule applies generally, but the accompanying illustration furnishes an exception to it, as the pigmented skin has a concave border and there was certainly no vitiligo in this case. ^^ \ Copyright, igrxj, by ii. H. Fox. CHLOASMA. CHLOASMA 49 It is often the direct result of a dermatitis, which may be traumatic, caloric, or toxic in character. It may also result from various internal diseases affecting the liver, kidneys, or pelvic organs. Finally it may, and often does, occur without any apparent disease or functional irregularity to which it may be justly ascribed. The traumatic causes which produce an extensive pigmentation of the skin are long-continued pressure and persistent scratching. A dark zone around the waist or a discolored band around the neck is not infrequently observed in women as a result of the pressure of fashionable clothing. In men dark streaks from trusses or straps are sometimes seen. In chronic pruriginous affections of the skin, more or less mottling or pigmentation of large tracts is apt to occur, and in certain individuals who suffer seriously and for a long time from pediculosis the naturally fair skin of the body may become so darkened that the patient seems to have become transformed into a mulatto. The discoloration of the skin produced by prolonged exposure to the sun's rays and commonly designated "tan " is often seen in summer upon the face, chest, arms, and other exposed parts. This is not the result of heat alone, as exposure to cold winds will produce the same effect, but it results from the chemical action of the blue, violet, and ultra-violet rays of the sun, and usually disappears spontaneously when the cause ceases to act. A remarkable case of caloric pigmentation has recently come under my observation. A patient took a long drive one very hot afternoon last summer, with nothing to shield her shoulders from the direct rays of the sun except a lace covering of uneven thickness and with large apertures. In a few hours she suffered severely from sunburn. When the dermatitis, which lasted for several days, subsided, a pigmentation was left upon the neck which reproduced most perfectly the pattern of the lace work, and has not yet entirely disappeared. Pigmentation of the skin results frequently from the application of mustard plasters and other irritating substances. This usually disappears in a short time, but in some cases may persist for years and, when it happens to occur upon the upper portion of a woman's chest, it may be the source of great annoyance. 4 JO THE TREATMENT OF SKIN DISEASES While the word chloasma has been used to designate these various forms of pigmentation, the term Is usually applied to the yellowish or brownish patches which occur upon the face, and are sometimes symptomatic of disease of Internal organs or of a general cachexia. The forehead and temples are its favorite seat, although it may also be found upon the cheeks, chin, neck, and elsewhere. The border of the patch usually fades off gradually into the sur- rounding healthy skin, but it is sometimes quite abrupt, especially on the fore- head, near the edge of the hair. The term chloasma uterinum is employed by some writers on account of the frequent appearance of the disease during pregnancy and its alleged connection with uterine and ovarian disease. But since a large proportion of women who suffer from dysmenorrhoea, displace- ments, and other forms of pelvic disease are entirely free from facial pigmen- tation, and as chloasma, on the other hand, often affects women with no ascertainable sexual disease, and is met with occasionally in the male sex, there seems to be no more foundation for the term chloasma uterinum than for the term chloasma hepatlcum, or "liver spot," which expresses a belief in some connection with the liver which is as unfounded as it is prevalent. The treatment of chloasma must naturally be first directed towards the cause. Whenever it is possible to ascertain and remove this, the hyperpigmen^ tation will gradually disappear. When the cause cannot be determined, or when found cannot be removed, our sole reliance must be upon local applica- tions. A general improvement of the patient's health may promote a decrease of the pigmentation. Gynascological treatment alone, from which much is often expected, is not likely to produce any brilliant results so far as the color of the skin is concerned. Water I regard as the best internal remedy. In the cases of many women the constant use of tea and coffee in excess seems to increase the tendency to chloasma, as well as to impair the complexion in other respects. If indulgence in these beverages is strictly forbidden, and the patient is encouraged to drink copiously of any pure water, a gradual disappearance of the pigmentation may be hoped for within a year, if not sooner. I have certainly seen excellent results from this method of treatment. The water should be fresh and pure, and taken CHLOASMA 51 freely to the extent often or twelve goblets daily, in order to prevent its inter- ference with the process of digestion, it is best taken before breakfast, at bed- time, and during the hours preceding meals when the stomach is comparatively empty. Water may also be employed in the form of baths, especially combined with systematic exercise. Patients with chloasma often perspire but little, and whatever tends to stimulate the cutaneous secretion and promote facial perspira- tion will prove of service in removing the pigmentary deposit. The hot-air or Turk- ish bath may be advantageously combined with the free use of water internally. The local treatment of chloasma, as well as of other cutaneous pigmentation, often produces a temporary benefit, but does not always prevent a return of the discoloration. Its object is to either bleach or blister the skin. In the former case, it modifies the deep color of the pigment granules ; in the latter case, it removes them with the deeper layer of the epidermis in which they are deposited. Hydrogen dioxide, or peroxide of hydrogen, as it is often called, is the best bleaching agent that can be applied to a patch of chloasma. It must be fresh and strong. The aqua hydrogenii dioxidi (U. S. P.) is a three per cent, solution, yielding ten per cent, of its own volume of nascent oxygen. While of service as a germicide in the treatment of ulcers, it is too weak to be of much use in the speedy removal of cutaneous pigmentation. It has the merit of being a perfectly harmless application, and if persistently used will sometimes produce the desired effect. The patient should be directed to keep the solution in a cool place, and to apply it- freely at least three times daily with a bit of absorbent cotton until a decided desquamation of the skin takes place. Failure often results from the use of a solution which has lost its strength and has little more effect than so much water. The stronger solutions on the market are to be preferred. Hydrozone is an aqueous solution of hydrogen dioxide which is three times as strong as the pharmacopoeial solution. Pyrozone of twenty-five per cent, strength is an ethereal solution of hydrogen dioxide supplied in a small glass tube. This is a powerful caustic, and whitens the skin to which it is applied like carbolic acid. Corrosive sublimate is the best blistering agent that can be used in this disease, since cantharides in solution or plaster has a tendency to cause pigmen- 52 THE TREATMENT OF SKIN DISEASES tation when applied to a healthy skin ; and some of the other agents recom- mended, such as hydrochloric acid, salicylic acid, soap, iodine, etc., are less effective and tend to inflame the skin without producing a blister and thereby removing the pigment. Corrosive sublimate should be of at least one per cent, strength (five grains to the ounce), and maybe applied to limited portions of the chloasmic patch when it is extensive. According to Hebra's method, the patient should be in bed or in a recumbent position, and a piece of thin muslin damp- ened and applied to the affected skin. This must be kept moist for three or four hours by means of the mercurial solution and a medicine dropper, care being taken that the solution does not accumulate at the edges of the muslin. This application causes considerable pain and swelling before a fully formed blister is produced, but half-way measures are nearly as painful and of no value. The bulla should be pricked, and lint dipped in a solution of bicarbonate of soda should be applied to the collapsed epidermis to allay the pain. The patch may then be treated as a simple burn, and when it is healed an almost pigmentless skin will be found. The less heroic remedies, which simply cause redness and desquamation of the epidermis, may in time produce a disappearance of the pigment, as is claimed by some ; but in my experience they are generally given up at the earnest solicitation of the patient before that time arrives. Here are some of them : 5 Vi Naphtholis 4 2 Glycerini Linimenti saponis mollis "fTl . ad IOC Hydrargyri ammoniati . . ID Sodii borati ... . . 10 Unguent! aquae rosse ■. . . . ad 100 m Bismuthi subnitratis . 3i 12 Hydrargyri ammoniati . . aa 12 Petrolati mollis .... ~, i ad lOO m o * "*-* Apply to the discoloration at night and remove in the morning with soap. CHROMOPHYTOSIS GUTTATA Chromophytosis is a parasitic disease which may be regarded as being upon rather than in the skin, inasmuch as only the external layer of epidermic cells is affefted by the growth of the fungus. The upper portion of the trunk is its ordinary seat. It is rarely, if ever, seen upon the face, and only in severe cases does the eruption extend down the abdomen to the pubic region. The eruption begins in the form of minute yellowish spots, which gradually increase in size and number. By their coalescence numerous guttate or irregular patches are formed. These macular lesions are of a light yellowish brown color and may be very slightly elevated above the surface of the skin. When scratched by the finger- nail a moderate degree of scaliness or roughness of the epidermis is produced. A mild pruritus is sometimes present, but usually there is no subjeftive sensation, and in patients. who bathe rarely the eruption may exist for a long time before it is accidentally discovered. The accompanying illustration represents a very common and typical form of the affeftion upon the anterior portion of the chest. The lesions, varying in size from a pin-head to a split pea, may be seen both . isolated and coalescing into irregular patches. A few will be noted upon the shoulder and upper arm and distinguished by their pale chocolate or fawn color from the brownish freckles upon the extensor aspeft of the forearms. The eruption was quite symmetrical, and in this case similar lesions existed upon the inter- scapular region. ■5 * * •" ■■ "SKtataT-** 'jrl Copyright, 1900, by G. H. Fox CHROMOPHYTOSIS GUTTATA. CHROMOPHYTOSIS 53 CHROMOPHYTOSIS Chromophytosis is one of the parasitic skin diseases due to the growth of the fungus called the microsporon furfur. It is characterized by the occurrence, chiefly upon the chest and back, of brownish-yellow dots or irregular patches which are slightly furfuraceous and readily removed with the outer layer of the epidermic cells in which the fungus flourishes. Tinea versicolor and pityriasis versicolor are names applied to the affection by some writers, and owe their origin to the unfortunate attempts made by older dermatologists to classify skin diseases according to genera and species. Un- like favus and ringworm, chromiophytosis is contagious only in a very slight degree, and a husband or wife may present a well-marked and extensive eruption for many months without the other becoming infected. Its frequent occurrence in clinics for pulmonary diseases formerly led to the belief in its relationship to tuberculosis, but this fact can be more readily explained. In these clinics patients are more frequently stripped for examination of the chest, and the chromophytosis thereby discovered whenever it happens to be present. Furthermore, the disease is one which develops most readily upon a slightly moist surface, and, since the bodies of tubercular patients are frequently bathed in a clammy perspiration, it is not at all strange that they should be especially liable to contract this common affection. Athletes who perspire freely are also the subjects of chromophytosis for a similar reason. The disease affects all sorts and conditions of men and women, but is met with almost exclusively in middle life. As it usually occasions little or no annoyance, and is concealed by the clothing, the majority of cases, perhaps, go untreated. As chromophytosis is essentially a local disease, external remedies are naturally indicated in its treatment, and, as it is the most superficial of all cutaneous affections, it can be readily understood that any topical application which will remove the outer layer of epidermic cells will also carry off the disease at the same time. it is unnecessary to mention the many efficient remedies which have been recommended and successfully used, but, stress should be laid upon the 54 THE TREATMENT OF SKIN DISEASES necessity of using any selected remedy with vigor, and of continuing its use until the last trace of the disease is undoubtedly removed. Cessation of treatment when the disease is apparently cured is frequently followed by a gradual return of the patches within a few months. It is of little use to cure nine-tenths of the eruptions, as is frequently done, and leave a few dots scarcely apparent to the naked eye to play the part of a nest egg and to hatch out a new crop of patches. Attention has been called by Allen to the fact that chromophytosis often extends down on the pubis, where the patches are concealed by the hairy growth. This region is, therefore, apt to escape the treatment which serves to remove the disease from the chest and back, and in many cases this accounts for its speedy return after vigorous treatment elsewhere has effected an apparent cure. Any chest protector, chamois vest, or flannel worn next to the skin must be thoroughly washed with the under- wear or thrown away in order to guard against reinfection. Among the best of the many good local remedies for chromophytosis are soap, salicylic acid, and sulphur. In chronic cases the patient should be directed to take a prolonged hot bath at night and to scrub the body and arms with soft soap. He may then apply, or, better still, have some one else apply, to each yellowish spot a little of the following paste : J} Acidi salicylici . 5 Sulphuris loti ... .... .40 Glycerini ........ 10 Saponis mollis . . . . ad 100 m This must be used more sparingly upon the breast and near the axillae than upon the back, where the skin is thicker and less likely to become inflamed. The object is to produce a slight dermatitis with desquamation, which will speedily remove the eruption. In the case of a woman with a delicate skin, a pleasanter though less speedy plan of treatment is to bathe the body night and morning with a saturated solution of hyposulphite of sodium in rose water. Either this solution or a five per cent, solution of carbolic acid may be advantageously sponged over the affected region for a CHROMOPHYTOSIS DIFFUSA The accompanying plate shows a case of chromophytosis in which the eruption was of long standing and of an unusual extent. The punftate and guttate spots which were undoubtedly present upon the upper portion of the chest at the outset are now seen only upon the lower portion- of the abdomen. Elsewhere they have coalesced and formed smooth, yellowish, diffused patches with a marginate border. A notable feature of this case is the entire absence of the eruption over the sternum^a region in which it is commonly found and to which it is frequently confined. This is the result of excessive perspiration which tends to destroy the parasitic growth, while a moderate amount of persistent cutaneous moisture conduces to its development. This will account for the usual absence of the eruption in the axillary region. It is quite uncommon to find such well marked patches upon the arms as are seen in the illustration, and only in exceptional cases does the eruption extend down upon the thigh. In severe cases a few small patches often exist unnoticed beneath the hair of the pubic region, and the frequent tendency of the disease to relapse after an apparent cure may be justly attributed to the faft that how- ever vigorously the treatment may be applied to the rest of the affefted skin, this region is very apt to be neglefted or overlooked. Copyrig-ht, irjoo, by G. H. Fo CHROMOPHYTOSIS DIFFUSA. CHROMOPHYTOSIS 55 week or two after the patches have disappeared, in order to insure a radical cure. Jamieson recommends that the affected parts be washed with soft soap and warm water to remove any greasiness of the surface. The skin is then dried and sponged over with vinegar and, while still wet, with the following lotion : 1^ Sodii hyposulphitis 3 vi 15 Glycerini f 3 iss 3 Aquae f 1 vi ad 100 m The application of the vinegar followed by the lotion is to be repeated daily for a week, when, as a rule, all traces of the disease will have vanished. The tincture of iodine causes a desquamation of the epidermis and thereby removes the eruption, and, since a dilution often tends to darken the patches and minute dots, it may be useful in determining whether any of the para- sitic patches still remain. A corrosive sublimate lotion or a chrysarobin ointment may be used with great benefit, but the former has the objection of being poisonous, while the latter always stains and often inflames the skin. Cutler notes the fact that the parasite will not grow under an adhesive plaster of any kind. If the surface of the disease is covered with a belladonna or capsicum plaster for a week or ten days, a cure is effected. The following formulae may prove of service : ^ Acidi salicylici . . 3 Sulphuris prsecipitati . . . • ' 5 Adipis lanse hydrosi . . 70 Petrolati mollis ad 100 m (Brocq_) 5 Hydrargyri chloridi corrosivi . . 3i i Saponis mollis . . . . . . § iii 60 Alcoholis . . . . . . - . f § ii ad 100 Olei lavandulae q. s. m Scrub the affected part night and morning. (Anderson) 56 THE TREATMENT OF SKIN DISEASES CICATRIX A cicatrix, or scar, is the new tissue formed in the process of healing after loss of substance. It varies greatly in size, shape, and appearance, and frequently constitutes such a deformity as to demand treatment. It is impossible to remove a scar and to leave a perfectly normal skin in its place ; but a large, ugly, and deforming cicatrix can often be excised and a comparatively insignificant linear scar left in its place. Small depressed or puckered scars can be readily removed by an elliptical incision. The deep pits resulting from varicella in childhood, and seen on the faces of young girls, are often regarded as undesirable and can be thus removed. The hypertrophic cicatrix producing a rounded or elongated fibrous tumor of the skin can either be excised or successfully flattened by means of the electrolytic needle introduced at short intervals. The current should be a mild one and not sufficient to greatly inflame the tumor or to produce ulceration. In cases where a true keloidal growth has developed, this method, like every other one, is doomed to fail. The prevention of cicatricial deformity is often much easier than its cure. In the healing of ulceration produced by burns, scalds, laceration, etc., much may be done to prevent the excessive contraction and deformity which often characterize a large scar. The operation of skin grafting as practised in recent years should be employed whenever an extensive sup- purating surface exists. This should be treated by the strictest antiseptic measures, and every effort made to hasten the healing of the wound. Splints will tend to prevent extreme deformity of joints during the healing process, while massage will soften the scar to a certain extent after cicatriza- tion is complete. For a small healing ulcer, whether syphilitic or not,, mercurial plaster is a simple and effective dressing, and by far preferable to the ointments so fre- quently applied. I agree with Johnston, who says that it not only stimulates, but at the same time tends to the production of a thin, flat cicatrix. From the use of thio-sinamine injections I have had no notable results. CLAVUS THOUGH the term clavus is rarely used outside of text books, there are very few who have not had an unpleasant personal acquaintance with the cutaneous affection which it designates. According to Hyde, its statistical frequency in America is only o. 173 ; while acne stands at 8. 184 ; and eczema scores 27. 140 ; but outside of our clinics far more persons are subject to acne than to eczema, while the unnumbered host of those who suffer from corns, if properly tabulated, would undoubtedly show that clavus is the most frequent of all skin diseases. The exciting cause of corns is intermittent pressure combined with friction, while among the predisposing causes it is only necessary to mention the slavish adhesion to fashion which leads all of us to wear stiff leather shoes whose con- tour bears little or no relation to the natural shape of the anterior portion of the foot. The pressure of the ill-fitting boot upon the toes, or, more strictly speak- ing, the pressure of the toes against the unyielding leather in walking, soon occasions hypertrophy of the horny layer at the point of irritation, and in time a dense, conical, pea-sized or larger mass is formed. The apex of the cone presses downward upon the sensitive papillae and causes the painful sensation which suggests a visit to the chiropodist. Corns are most frequently found upon the outer surface of the little toes, but may occur upon the sole of the foot and even upon the palm. Between the toes they often form from pressure of the opposing digits, caused by narrow shoes, and in this location they are softer and usually present a whitish, macerated surface. As barometers corns are failures, in spite of the claims made as to their utility in this regard. 1 am ready to agree with Hyde, however, who states that they are often unusually painful before, during, or after the occurrence of storms. 58 THE TREATMENT OF SKIN DISEASES The prophylactic treatment of corns consists in wearing a broad-toed, though not necessarily a square-toed, shoe. If shoes were made fan-shaped, like the imprint of a bare foot in the sand, instead of having the greatest width across the ball of the foot, they might look strange at first, but they would be comfortable for all time. Those, then, who cared more for comfort than for style, as most of us falsely profess to do, would have both comely and corn- less feet. The curative treatment of corns consists in softening the dense, hard, horny tissue, when it will exfoliate spontaneously, or be readily scraped away. The plan of treatment suggested by Hyde, as simplest and best, is as follows : "The part is thoroughly macerated for half an hour with water as hot as can be tolerated. Then the projecting callous portion of the corn is gently removed by cutting or scraping till, as nearly as may be, the surface is level with the plane of the adjacent skin. The part is then dried, and the entire surface, both of the seat of the corn and the adjacent integument, is completely covered with many narrow, short, and nicely adjusted strips of rubber plaster. When the trifling operation and dressing are complete, the patient should bear firm pressure over the corn without flinching, and walk with perfect comfort. The plaster remains until it separates spontaneously, which is usually in the course of a few days. The corn is then macerated at night with an oil poultice and the dressing afterwards reapplied, usually the second time by the patient. Persistence in this course is followed by complete relief, if the cover- ings of the feet be properly fitted." In my experience all attempts to soften the dense growth by hot bathing, poulticing, or oil dressings involve a great amount of trouble, and are rarely crowned with a commensurate success. A far simpler and more effective plan of treatment is to paint the corn with a saturated solution of salicylic acid in flexible collodion for several days in succession. Salicylic acid has the peculiar property of softening and destroying horny tissue, and is, therefore, of service in corns, callosities, and all other keratoses. It is an essential ingredient of nearly all the advertised ''corn cures," and the addition of cannabis indica, so often made, is entirely unnecessary. The solution may be applied to the corn COMEDO 59 by means of a small brush or the cork of the vial, and should it become too thick to flow readily, it can be made thinner by the addition of a little ether. The first application usually affords great relief, even to the most painful corn. After each succeeding application, a layer of the horny epidermis can be readily scraped off with a curette, or even the thumb nail, until soon a soft, smooth surface is left. In the case of soft corns the solution must be applied with extreme care to the macerated surface, and the toes kept apart by the inter- position of absorbent cotton. Vigier's formula is as follows : IJ Acidi salicylici gr. xv i Extracti cannabis indica; . . . gr. viii 0.50 Alcoholis m XV I Etheris tH, xl 3 Collodii flexilis ^ Ixxv ad 10 m For hard corns and callosities a simple, though somewhat slow, method of treatment is to rub the surface daily with sandpaper and then apply a drop or two of the tincture of iodine. Another corn cure is the following : To an ounce of strong vinegar add a sufficient quantity of bread crumbs. Let it stand for half an hour and apply as a poultice at night. In the morning the soreness will be gone and the corn can be picked out of the skin. In the case of obstinate corns two or more applications are required. Paring an inflamed corn with a knife or razor is at best only a palliative measure, and often an accidental incision of the skin will aggravate the inflamed condition. The application of strong acids is also objectionable, while the ' ringed corn plaster only aff"ords relief in place of a radical cure. COMEDO Comedo is a name applied both to a lesion and to a disease. In the former case it refers to a "black-head," or sebaceous follicle the duct of which is occluded by a yellowish plug, which varies in consistency 6o THE TREATMENT OF SKIN DISEASES according to its horny or fatty character. In the latter sense it implies a tendency of all the sebaceous glands in certain regions to become occluded in this manner. In short, comedo is a non-inflammatory affection of the sebaceous glands, and, though commonly associated with acne, may occur as an independent disease, it occurs most frequently upon the face, but in many cases is found also upon the upper portion of the chest and back. Comedos (called comedones by those who prefer to use the Latin plural) appear as black dots upon a normal skin, and, when numerous, are slightly elevated above its surface. Unusually large ones frequently develop in the concha of the ear. When firm pressure is made upon the skin at one side or around a comedo, the follicular plug is extruded, and appears as a soft, whitish thread, or as a dense, yellowish, spindle-shaped mass with a blackened tip. This black head of the comedo may be partly owing to an accumulation of dirt, but is chiefly due, as claimed by Unna, to a chemical change in the epidermic cells, which, together with fatty matter, compose the sebaceous plug. The blackness of the end of a comedo will partially disappear when the skin is rubbed with dilute muriatic or acetic acid. A double comedo is the result of two plugs situated very near each other, and between which the thin septum of cutaneous tissue has dis- appeared by pressure. This forms a single cavity with two external openings. A microscopic insect, called the Acarus folliculorum, is sometimes found in the substance of a comedo, but its presence is of little importance, as it neither causes nor affects the character of its chosen habitation, it has even been found in fatty matter scraped from the normal skin. Anemia, dyspepsia, and a lack of cleanliness have been assigned as causes of comedo, but the affection seems to result from some individual tendency which cannot be readily explained. In the treatment of comedo no internal remedy is likely to have any special effect ; but, as the disease occurs at an age when impairment of the health is by no means uncommon, general hygienic and tonic treat- COMEDO 6, ment is often demanded, and is capable of producing a decidedly beneficial effect upon the skin. As patients with comedo often suffer from constipa- tion and a sluggish circulation, vigorous exercise in the open air, a cool bath every morning, and the use of laxatives, either in the shape of food or medicine, will be found of great service. Among the local applications, soap and water vigorously applied will afford the best results, especially in cases where the skin is thick, greasy, and inactive. Steaming the face is not to be commended ; but a rough cloth dipped in hot water, smeared with a little soft-soap, and powdered with fine sea sand, can be used to advantage. Ointments and lotions are of little or no benefit unless they are strong enough to produce a dermatitis with resulting desquamation which may favor the evacuation of the follicular ducts. A mechanical method of treatment, however, is far superior to any application which has merely a stimulating or irritating effect upon the skin. If one wished to remove tacks from a piece of thick leather, greasing the surface would hardly be thought of as likely to accomplish the purpose, and yet ointments are often smeared upon the face in cases of comedo and acne with as little beneficial result. The sebaceous plugs, which are often tightly imbedded in the skin, must be pressed out by mechanical means. Vigorous massage or pinching of the skin at night, or perhaps several times during the day, may in time accomplish this end and leave the skin in a normal condition. To empty the distended ducts without delay, the use of a watch key was commonly advocated before the advent of stem-winding watches. This Instrument was objectionable on account of its square calibre and rough end being apt to cut the skin, and many years ago I suggested the use of a silver tube in its place. This instrument has met with favor, but it is only suited to the expression of comedos which correspond in size to its unvarying calibre. The comedo "scoop" or extractor which I have used in my practice of late years is in the shape of a very small spoon or dull curette with a U-shaped piece cut out of the free end. This exerts pressure upon the skin partly around the sebaceous plug, and is far more 62 THE TREATMENT OF SKIN DISEASES serviceable than a silver tube, especially as it is suitable to comedos of varying size, it may be made like the claw of a tack hammer and exert simultaneous pressure upon the opposite sides of a comedo, it presses out the horny mass with little discomfort to the patient, and with no injury to the skin beyond the production of a temporary red mark. p^ww A^-P"- smfim Before using this instrument, it is often advantageous to scrape the face or affected part with the ring curette mentioned in the treatment of acne. This removes the heads of such comedos as are raised above the surface of the skin, and by the temporary congestion which it induces, the subsequeht expression of the fatty plug is rendered more easy. When the follicular ducts are all emptied, a soothing or astringent lotion may be applied, although this is by no means necessary. Among the many applications recommended by writers are the. following : 5 Acidi tannic! gr xx 4 Zinci oxidi gr xv 3 Magnesise carbonatis . . . . gr xv 3 Aquse rosae f § i ad 100 m To be applied with a sponge, soft cloth, or an atomizer. (Elliott) 5 Sulphuris sublimati 20 Alcoholis 20 Tincturse lavandulse compositse ... 20 Glycerini 20 Aquae camphorse - 20 m (Piffard) 5 Thymolis gr x .50 Acidi borici 3 ii 10. Aquae hamamelidis destillatae . . §iv 75. Aquae rosae S i ad 100. m Mop well over the surface once or twice daily. (Shoemaker) CORNU CUTANEUM CORNU CUTANEUM 63 A cutaneous horn is an epidermic outgrowth of a substance similar to the nail tissue. It may spring from a sebaceous gland or cyst, a warty senile patch, or a cicatrix. Its base is usually hollow for a short distance, and filled with a soft papillomatous mass. It occurs in both sexes and as a rule in advanced life. In most cases horns are seen upon the upper portion of the face and scalp, but they may also occur upon the lip, hand, genitals, or other parts. The growth may be single or multiple, and varies greatly in length, thickness, and general appearance. A filiform variety often appears upon the face, and is usually about a half inch in length. It has the appearance of an indurated and elongated fibroma or verruca. The typical horn is much thicker and longer. It may be cylindrical or flattened, and invariably curves or even twists like a ram's horn as it increases in length. The treatment of a cutaneous horn is usually a simple matter. The hard mass can be torn from the skin with little difficulty and without occa- sioning any great amount of pain. If the patient be unusually sensitive it may be advisable to inject cocain around the base of the horn before its forcible removal. The soft pulpy mass which is left should be curetted or bored with a cone of nitrate of silver, and when the black crust thus formed has fallen a smooth superficial cicatrix will be left. When an epithelioma has developed at the base of the horny growth, the curetting and boring with the silver stick must be done with extreme thoroughness. In case of large horns some have advised excision of the growth with a portion of skin surrounding the base, and in case of small horns abscis- sion by means of curved scissors has been recommended. The skin around the base is lifted by traction on the end of the horn and removed with one cut. When there is no development of epithelioma a cutting oper- ation is unnecessary, and usually undesirable, and even when the base of the horn has become the seat of epithelioma, its removal may be as thoroughly and much more readily effected by means of the curette and cautery. 64 THE TREATMENT OF SKIN DISEASES DERMATITIS Dermatitis is a name whicii might be justly applied to the long list of inflammatory skin diseases. It is restricted in common use, however, to certain inflammatory conditions, mostly of definite origin, to which no special name has been applied by the older dermatological writers. Dermatitis includes a variety of eruptions varying in severity from a mild erythematous rash to gangrene, and resulting from varying causes. These include all forms of external violence, the internal and local use of drugs, and the action of heat and cold. DERMATITIS TRAUMATICA This form of cutaneous inflammation may result from pressure, friction, scratches, blows, or any form of mechanical injury. Certain predisposing con- ditions often exist, and the external agency which would have little or no effect upon the skin of a person in health may produce ulceration upon aged legs or those affected by varicose veins, upon the back of paraplegic and other bed- ridden subjects, and upon the hands and feet of lepers. The treatment depends upon the cause of the inflammation and its result- ing character. This may be a slight patch of redness, a deep ulcer, or general excoriation. DERMATITIS MEDICAMENTOSA Eruptions, usually of an erythematous or urticarial character, but sometimes of a pustular, bullous, or ulcerative type, are not infrequently seen to follow the ingestion of certain substances whether classified as food or medicine. The eruption from which certain individuals are liable to suffer through indulgence in strawberries, shell-fish, etc., and the itching of the skin often attributed to buckwheat, cheese, etc., are sometimes classified as dermatitis ab ingestis, but from an etiological standpoint they belong naturally with the so-called "drug eruptions." DERMATITIS MEDICAMENTOSA The toxic eruptions resulting from the administration of various drugs as well as from the ingestion of certain articles ot food are usually of an erythematous form and appear as a roseola or as a diffused congestion of the skin. Papular, vesicular, nodular and urticarial forms are also met with. In some cases of drug eruption the offending substance circulating in the blood acts upon the vaso- motor centres and thus affects the skin, while in other cases the eruption is directly due to the irritation resulting from the cutaneous elimination of the drug. The eruption resulting from the administration of the balsam of copaiba has always been one of the most common forms of dermatitis medicamentosa, particularly in clinics for venereal disease. It usually assumes the form of an acute maculo-papular eruption of a bright, rosy hue, and but slightly elevated above the surface of the skin. It is commonly seen" upon the extensor aspect of the extremities but may affect the trunk and other parts. The subject of the illustration presented an unusually exten- sive eruption which, had all the clinical appearances of an erythema multiforme. In fact, had it not been for the rosy tint of the lesions and their speedy disappearance after the discontinuance of the drug, the eruption might have been regarded as a typical case of exudative erythema of the papular form. Cupyright, igoo, by (J, H. Pcj.x, DERMATITIS MEDICAMENTOSA. DERMATITIS VENENATA 65 Many drugs are capable of inducing in susceptible individuals a congestion or inflammation of the skin, but most of these rashes present no peculiarities which would enable one at a glance to name the drug responsible for the out- break. A few drug eruptions, however, are very characteristic, and readily recognized as such by any physician with moderate experience. Among these may be mentioned the scarlatiniform rash of belladonna, the bright red maculo- papular eruption of copaiba, and the pustules and pus-soaked condylomata of the bromides. The treatment of a drug eruption is a very simple matter when its nature is recognized. Except in perhaps a few cases of the bromide eruption, stopping the administration of the drug is followed by a speedy disappearance of the cutaneous inflammation. The medicinal origin of a dermatitis, however, is very apt to remain unrecognized unless the physician is both experienced and alert. As a consequence, the administration of a drug is often continued in the vain hope of curing the eruption which it has already caused. DERMATITIS VENENATA Dermatitis venenata is the term applied to various forms of inflamma- tion of the skin resulting from the chemical action of innumerable irritating substances. These may be drugs applied to the skin for a therapeutic effect, or other substances of mineral, animal, or vegetable origin which are brought in contact with the skin either by design or accident. Among the mineral substances are certain ones used in the industrial arts, such as arsenic, potassium bichromate, caustic soaps, etc. The eruptions frequently alleged to result from aniline dyes in stockings and underwear, and from various toilet articles, are sometimes possibly caused in this man- ner, but in most cases it is far easier to allege than to prove such a source of the dermatitis. Among the animal substances apt to cause a dermatitis may be men- tioned the secretion of the jellyfish and of caterpillars of the genus bombyx, the sting of certain insects, ammoniacal urine, and decomposing perspiration. 66 THE TREATMENT OF SKIN DISEASES Among the vegetable substances which may poison and inflame the skin are a number of plants, and chief among them in this country are the poison- ivy and other species of rhus. While some may handle this vine with impunity, others are not only poisoned by its slightest touch but even by its proximity. One patient has assured me that an attack of the character- istic eruption would result if he drove by a fire of burning brush which contained any branches of the poison-oak or poison-ivy. The eruption usually affects the back of the hands and the wrists as a direct result of handling the leaves. From this region it is doubtless conveyed to the face, which usually suffers coincidently, and in many cases is also conveyed to the genitals. It appears generally a few hours after the poisoning occurs, but may increase in severity for one or two days. It consists of closely aggregated vesicles upon a swollen erythematous base, and resembles an acute eczema of severe grade. The intense itching, or burning pain, is often agonizing. Lax tissue is apt to become highly oede- matous, and the eyes are often closed in severe cases affecting the face. One of the worst cases of poison-ivy eruption which I have ever seen occurred in an Italian laborer who had defecated in the woods and used the few leaves within his reach in place of toilet paper. The scrotum was almost the size of his head, while the oedematous penis was greatly elongated and twisted into a curl. In the treatment of poison-ivy eruption, a soothing application is indi- cated, and though no internal remedy appears to have any direct effect upon the inflamed part, a Dover's powder or other diaphoretic will often relieve the discomfort which has been severe enough to send the patient to. bed. For no other affection of the skin has such a host of remedies and "certain cures" been recommended. It is fair to conclude, whenever so many different remedies are used in one disease, that each one is about as good as the others and that none will prove to be a specific. A lotion is more agreeable than an ointment, and an alkaline lotion seems to be specially comforting. This may be due to the fact that the- poisonous principle found in the leaves of the plant is toxicodendric acid. DERMATITIS VENENATA Among the various forms of dermatitis resulting from the aftion upon the skin of toxic agents, whether animal, vegetable or chemical, the poison ivy eruption is one of the most common. It usually appears as a vesicular dermatitis upon the backs of the hands and rapidly extends upon the forearms. In most cases the face and other parts touched by the hands are simultaneously affefted. In the illustration the vesicles are seen to be both isolated and aggregated. They spring from a highly inflamed base and vary greatly in size. Their coalescence has produced bullae, which are both of linear and irregular form. Although in this particular case the der- matitis followed the handling of leaves of the Rhus toxicodendron, it must be borne in mind that an eruption identical in appearance may sometimes appear upon the hands, forearms and face of those who have handled nothing poisonous so far as can be ascertained, in some cases a vesicular or bullous dermatitis occurring annually and running an acute course may follow a severe attack of rhus poisoning. The poison ivy eruption usually runs its course in a few days or a week, unless the patient has an eczematous tendency which may aggravate and prolong the eruption. Its course is but slightly modified by any of the local applications commonly used and to which a marvelous efficacy is often ascribed. A lotion of lime water or a bicarbonate of sodium solution is quite as beneficial as any of the remedies which have been most highly recommended. r' r<^^ .1^' .^'■' ..^' ;.»^^H-S\ •'■ '■' >'■- ■^^^'«u— -:^4»r>.:.... Copyrig-ht, lyc-o, by i i. H, Fo DERMATITIS VENENATA. DERMATITIS CALORICA 67 But however it may be, it is quite probable that in a great majority of cases lime-water or a solution of bicarbonate of soda, applied by means of thin cloth, will be as grateful to the patient and as effective in curing the disease as any other of the many applications which might be used. Among other applications are the following : 5 Ichthyolis 50 Aquae ad 100 m B Bromini gr xv 3 Olei olivae f 5 i ad 100 m (Brown) ]J Extract! grindelise robustae fluidi . . f 3 i 3 Aquas ad f 3 i ad 100 (Van Harlingen) 5 Acidi carbolicl f 3 i i Glycerini f 3 ss 3 Zinci oxidi 5 ss 5 Liquoris calcis ad Oi ad 100 m (Grindon) 5 Zinci sulpliatis 3 i 6 Aquae f 5 ii ad 100 m (Hardaway) DERMATITIS CALORICA Under this title are included the varying forms of inflammation of the skin resulting from the action of heat (Dermatitis ambustionis) or cold (Dermatitis congelationis), and commonly known as burn, scald, frost-bite, and chilblain. Burns may be due (i) to the contact of the skin with a flame or heated solid substance ; (2) to electricity in the form of lightning, an artificial spark, or a strong current ; (3) to direct, reflected, or concentrated solar rays ; 68 THE TREATMENT OF SKIN DISEASES and (4) to the action of chemical caustics. Scalds are burns which result from the contact of steam or hot liquids. The effect upon the skin is practically the same, but the character of the burning agent can often be inferred at a glance from the fact that in the case of a scald the hair over the inflamed part has not been destroyed. Burns vary in character according to the intensity and the duration of the heat which is applied to the s'kin. They vary also in severity according to the extent of surface and the depth of the tissue affected. Three degrees of severity in burns have become classical, in the first degree an erythematous condition is the main feature, with more or less pain and swelling. This persists but a few days and is usually followed by slight desquamation, and in some cases by slight increase of pigment. In the second degree exuda- tion is manifested by the development of vesicles or bullas upon the surface of the skin, either immediately or in the course of a few hours. Often the epidermis is raised in large masses and a suppurating surface may follow infection of the skin, in the third degree an eschar results from devitaliza- tion of tissue. This may be superficial and follow the development of gelati- nous or sanguineous bullas. When deep no vesiculation appears upon the surface and the necrotic mass is surrounded by a zone of deep-red skin from which it gradually separates. The pain, though it may be intense at the outset, is usually less than in extensive burns of the second degree. In the treatment of burns a host of remedies has been employed, and many of them without any definite object in view. The dressings which have found most favor in years past have been such as tend to exclude the air and soothe the inflamed skin. But with the advent of modern antiseptic surgery a notable change in the treatment of burns has taken place. The main object of a dressing at the present day is to disinfect the denuded and sloughing surfaces, and thereby to check or lessen the tendency to suppuration. In a burn of the first degree, where redness and pain are the chief symptoms, a soothing lotion is most desirable, and nothing seems to act better than a saturated solution of sodium bicarbonate. When the affected DERMATITIS CALORICA 69 part (the fingers, e.g) can be immersed in this solution the smarting sensa- tion of the burn is quickly allayed, and a speedy recovery follows. When the burned surface is extensive, sheets of lint dipped in the solution may be spread smoothly over the surface. As soon as the pain is relieved and it is evident that the epidermis remains intact, a simple dusting powder of starch or stearate of zinc may be applied in place of the wet dressing. In a burn of the second degree the vesicles or bulte should be punc- tured to allow the serum to escape without loss of the epidermic covering. The cutaneous surface should now be cleansed as thoroughly as possible with hydrogen dioxide, borolyptol, or some other disinfecting lotion, and a dressing of lint soaked in carbolated oil and lime-water immediately applied. In a burn of the third degree, the sloughing tissue should be treated according to strict antiseptic principles. The clothing should at first be carefully removed by the aid of scissors, in order to prevent as far as possi- ble all injury to the epidermis. The parts should be thoroughly cleansed, carefully dressed, and slight compression exerted by means of a roller bandage. Opposing surfaces of skin should be kept separated by the dress- ing, and joints put in splints or subjected to extension in order to avoid de- formity from contraction during the process of repair. Mucous orifices included in the burn {e.g., the nostrils) should be firmly plugged to prevent an undesir- able diminution in size. As a severe burn is frequently accompanied by considerable shock and subsequent fever, the general treatment of the patient becomes a matter of importance. Opium is of great value in relieving the severe pain which is often present at the outset and in controlling the diarrhoea which frequently results from gastroduodenal irritation. Stimulants may be freely given where great depression exists, and hot bags applied to the extremities may be useful in promoting the general circulation. in treating the ulceration which so frequently follows an extensive burn, much time can be saved and some contractile deformity avoided by the resort to skin grafting. The effect of intense cold upon the skin is very similar to that of heat. 70 THE TREATMENT OF SKIN DISEASES Indeed, the cutaneous dermatitis resulting from cold may be divided, like the effects of heat, into three degrees. The mildest, or erythematous, degree may consist in a reddened and roughened or "chapped" skin, often seen upon the face and hands, or in a swollen, livid, and irritable condition of the skin, often noted upon the toes and fingers of children with a poor circulation, and com- monly known as chilblain (pernio). An exudative dermatitis with vesicu- lation or the rapid formation of large bullae often results from a frost-bite, and can hardly be distinguished from a burn of the second degree. When the feet, hands, ears, or nose are exposed for some time to a very low tempera- ture, the skin hardens and whitens and gangrene sometimes ensues, as in a burn of the third degree. The treatment of chilblain should be both constitutional and local. As the affection is peculiar to anaemic individuals and those whose circulation is inactive, the administration of iron, cod-liver oil, and tonics, combined with vigorous exercise and cold bathing, will often lessen the tendency in great degree. The local treatment consists in keeping the extremities warm and dry, and in the frequent application of some stimulating or astringent ointment or lotion, iodine tincture, turpentine, and a strong solution of nitrate of silver are among the many remedies recommended for this troublesome condition. In the treatment of frost-bitten parts there is a tradition that rubbing with snow in a cool room is the best procedure to adopt and that the sudden application of heat is injurious. It is true that a rapid restoration of the circulation in a frozen part is apt to be attended with considerable pain, but it is doubtful whether this will favor the necrosis of tissue which is likely to result from a severe frost-bite. A hot bath is probably the best plan of treatment for a frost-bite, although it may not prevent the development of vesiculation or gangrene if the vitality of the frozen part has been destroyed beyond hope of restoration. When blisters have formed they should be punctured, and raw or gangrenous surfaces treated antisepti- cally, as in the case of severe burns. DERMATITIS HERPETIFORMIS. Dermatitis herpetiformis is an inflammatory affection of the skin, characterized by polymorphic lesions, intense itching and a chronic course with marked exacerbations. The disease varies in appearance in different cases, sometimes presenting erythematous discs and rings as well as vesicles and resembling the vesicular form of erythema multiforme, and again presenting large bullae which bear a strong resemblance to the lesions of pemphigus. In most cases the lesions are vesicular and grouped, but the inevitable scratching tends to destroy this typical appearance, and hence the diagnosis in doubtful cases must be based upon the course of the disease rather than upon the appearance of the skin. The patient, though often of robust physique, usually presents a marked neurotic appearance and plainly shows the effect of loss of sleep from constant 'irritation of the skin. The eruption may be limited to the head, trunk or extremities, or, in a severe case, involve the greater portion of the body. The individual lesions run a short course, but fresh crops make the disease an essentially chronic one. The eruption often improves spontaneously and may entirely dis- appear, but repeated relapses are a notable feature of its course. The plate shows the grouping of the lesions and their vesicular character quite plainly upon the neck. The patient was in fair general health, but for eight years had suffered from frequent attacks, lasting a few days or a few weeks, with intervals ranging from one to six months. Copyriijhti I.J-J.J, by (i. H. Fo DERMATITIS HERPETIFORMIS. DERMATROPHIA. Atrophy of the skin may occur as a primary or secondary affection, result from various causes and present various clinical forms. Primary or idiopathic atrophy is most frequently seen in a macular or striate form. In the macular form round or oval spots of varying size are noted most frequently upon the neck and arms. They are whitish and wrinkled and may be either depressed or elevated, in the latter case they appear like cutaneous tumors, but pressure of the finger usually shows that there is a pit or hole covered by an abnormally thin skin. In the striate form, which is more common, numerous whitish and wrinkled streaks, wider in the center than at the ends, may be seen upon the abdomen, hips, thighs and the female breasts. Like the macules these striae may be of a purplish-red hue and hyper- trophic in an early stage of development. Soon, however, they become cicatricial in appearance, and the finger passed' over them detects a furrow or depression in the skin. Both maculae and stri^ develop usually without apparent cause, increase slowly, give rise to no inconvenience and last indefinitely. In women who have borne children and in men who have been extremely corpulent the stretching of the skin may give rise to striate atrophy. Diffuse idiopathic atrophy is comparatively rare, and in the few cases reported the extremities have usually suffered. The skin becomes thin and wrinkled and loses its elasticity so that a fold pinched between thumb and finger will remain elevated for some time. The veins are apt to be very prominent over the atrophied surface. X |P ' ^>' .,>."»-' 'I-.-- -.: r . ...t .1 f m 73 J3 O I ^*Mh^%fvJ^ . #';; DERMATITIS HERPETIFORMIS DERMATITIS herpetiformis is a chronic, relapsing, neurotic affection characterized by the eruption of erythematous patches, papules, pustules, vesicles, and bullae. The lesions usually show a marked tendency to appear in groups and are accompanied by a pruritus that is often extremely severe. The eruption may be limited to the face and arms, to the trunk, or to some other region, but in severe cases the whole body is usually affected. The disease presents various types, according to the character of the lesions. The most frequent is that in which a few vesicles occur in a group, though by no means so closely aggregated as in ordinary herpes. An ery- thema may precede the development of the lesions, but in any case the pruritus and consequent scratching soon cause the eruption to assume a highly inflammatory appearance. The lesions, when not excoriated, dry and present a puckered aspect. They run an acute course, but the eruption is continued by the constant appearance of new lesions. Often the disease subsides for a few weeks or months, and the skin becomes comparatively or quite normal in appearance, but a relapse may be anticipated, and the disease is liable to persist for many years if not successfully treated. The differential diagnosis between this disease and certain others is not always easy to make, and many cases of pemphigus and erythema multiforme are apt to be claimed as examples of the bullous or erythematous form. The etiology of the disease is obscure in most cases, but clinical observa- tion leads to the belief that the cutaneous lesions are but reflex manifestations of some disease of the nervous system. Fright, worry, and nervous shocks have preceded the eruption in several reported cases, while glycosuria and polyuria have been noted as coexistent in others. In pregnancy the eruption 72 THE TREATMENT OF SKIN DISEASES is liable to occur, and repeated attacks in successive pregnancies have been reported, the patients being freed from the eruption soon after delivery. The treatment of dermatitis herpetiformis is usually unsatisfactory. The cause is difficult to discover in the great majority of cases, and while improve- ment may take place under treatment, as it often does spontaneously, relapses may be confidently expected. There are few cutaneous diseases of an inflam- matory nature which are more rebellious to treatment, and a cure should be hoped for rather than predicated. A strict inquiry into the life and habits of the patient, with an examina- tion of the urine, should be the first step in treating every case. If anything is discovered that might be justly deemed an etiological factor, it should receive attention and be rectified if possible. Hygienic treatment of the patient is likely to do far more good than pharmacopceial remedies. Over- work and mental anxiety frequently intensify, if they do not cause, the eruption, and in such a case a short vacation, with its concomitant change of both mental and physical habits, is almost certain to be productive of great benefit. Arsenic may control or check the eruption in some cases of the vesicular or bullous type, acting as it often does in pemphigus ; but as a rule this drug should not be relied upon, and when it is not well tolerated by the stomach, an increase of the dose is certain to do more harm than good. Win- field praises cannabis indica as one of the most valuable sedatives. The fluid extract may be given in doses of two or three drops every three or four hours, according to the indications. Antipyrin and phenacetin have been used with good effect by some writers, and 1 have known the concentrated tincture of avena sativa in twenty-drop doses to relieve the highly nervous condition which frequently complicates each fresh outbreak of the eruption. The local treatment should vary according to the character of the lesions. Lotions are best adapted to the erythematous type, while a sulphur or salicylic ointment may be serviceable in the papular or excoriated type of the disease. When the itching is intense a strong carbolic acid lotion (fifteen to twenty per ECZEMA ERYTHEMATOSUM This patient, seventy-one years of age, had suffered more or less from eczema for twenty years. It had been chiefly confined to the face but occasionally affefted other parts of the body. The skin upon the forehead and cheeks was of a dull red hue and thickened to such a degree that the natural furrows were greatly exaggerated. The itch- ing of the affefted parts was intense and the eyebrows had been scratched or rubbed so persistently that only a short stubble-like growth of hair remained. A chronic conjunftivitis caused constant lachrymation with thickening of the lids and prevented the complete opening of one eye. The patient was a great eater of meat and suffered from consti- pation. A change of diet with an alkaline diuretic taken in copious draughts of water improved his general condition, while an ointment containing ten per cent, of oil of cade relieved the intolerable pruritus. While erythematous eczema may occur upon various portions of the body the illustration shows its favorite seat about the eyes. In this location it is often an extremely persistent and annoying affec- tion even while the redness and roughness of the skin is scarcely noticeable. C ipyright, igoo, by (_,. H, Fox. ECZEMA ERYTHEMATOSUM. ECZEMA 73 cent.) or a mixture of camphor and chloral in oil (one to five per cent.) may give considerable relief. General galvanism, recommended by Stelwagon, is one of the most effective anti-pruritics, and may be used to advantage in this as in other pruriginous affections of neurotic origin. ECZEMA The treatment of eczema furnishes an excellent test of a physician's skill and experience. Owing to the variety of conditions under which it appears, scarcely two cases can be treated alike and with equal success. While in many cases an injudicious treatment does more harm than good, and actually keeps up the disease, in other cases a most, surprising and gratifying result may be obtained by the employment of some simple but effective measures. It can readily be understood, therefore, that a knowl- edge of a few principles which govern the treatment of eczema is worth a whole volume of formula. Eczema is never an incurable disease. It is often extremely obstinate, and there are cases in which the physician must acknowledge his inability to effect a cure under the existing circumstances. But if the patient can be properly controlled, his diet carefully regulated, his mind put at ease, etc., it will then be found that simple treatment will usually accomplish a speedy cure. Eczema is far more amenable to treatment than most other skin diseases, but the causes of the eruption must be recognized and removed, before local applications can be expected to have much benefi- cial effect. The danger of rapidly curing an eczema or a leg ulcer is an ancient myth, it seems to have died repeatedly, but has never been effectually buried. Recent writers have partially resuscitated it by reports of cases of convulsions and broncho-pneumonia following a rapid cure of the disease. The rarity of such sequels would naturally suggest that they had no more to do with the eczema than falling downstairs or any other accident or disease. Duhring (" Cutaneous Medicine ") tells of an anaemic woman with 74 THE TREATMENT OF SKIN DISEASES a pustular eczema of the scalp which resisted several months of treatment. She suddenly contracted pneumonia and died, the eczema having rapidly disappeared with the advent of the pneumonia. That any metastasis oc- curred in this case is wholly without proof, and in the light of clinical experience seems quite improbable. In infancy, an eczema of scalp or face usually disappears with the occurrence of any acute inflammation of the lungs or brain, which seems to have a revulsive effect. An eczematous eruption may be drawn in by an internal congestive disease, but it can never be driven in by any external treatment. I agree with the majority of writers that no harm can result from curing an eczema, and that the general well being is promoted by removing a constant source of local and general irritation. The internal or medicinal treatment of eczema usually has little direct effect upon the eruption, but much can be accomplished indirectly through the use of laxatives, bitter tonics, and diuretics. In every case of eczema the bowels must be kept freely open. While continued purgation tends to weaken the patient, and is inadvisable, an occasional dose of calomel at night, followed by some mineral water in the morning, will prove of great benefit. Rhubarb and soda, cascara, or a pill of aloin, belladonna and strych- nia may be given daily as a prophylactic against constipation. When the tongue is heavily coated and the stomach foul, a dietary restricted to one or two articles of food should be rigidly enforced, and a tablet containing salol, sodium sulphite, or resorcin, given between meals, with a view to disinfecting the intestinal canal as far as possible. The fluid extracts of various vegetable substances other than those which have a laxative effect may be used to advantage in cases of chronic eczema. Among them may be mentioned cinchona, gentian, stillingia, taraxacum, rumex, etc. They often increase the appetite and improve the digestion through their action on the hepatic and other intestinal secretions, and produce, in short, what the older writers termed an alterative effect. Though capable of doing some good in many cases, they are by no means to be regarded as "a remedy for eczema," and too much dependence should not be placed upon their therapeutic value. ECZEMA PAPULOSUM While in most cases of eczema we find a diffused inflamma- tion of tile, skin, in tlie papular form of the disease the congestion begins in and is limited to the follicular plexus. A small red papule is thereby produced which is very apt to become excoriated by the finger nails, owing to the intense itching which is a prominent feat- ure of the disease in every form. When the lesions remain discrete the eruption is a dry one and to this condition the older dermatol- ogists applied the term "lichen." But in most cases of papular eczema the lesions tend to aggregate in groups and by increase in number to form diffused patches, which soon present the moist exuding surface, which is the most charafteristic symptom of ecze- matous inflammation. It is for this reason that the old term lichen simplex has become obsolete, and the eruption is now generally recognized as a form of eczema. In scabies urticaria and prurigo the papular form of eczema is often artificially produced by the irritation of the skin resulting from continued scratching, but fre- quently the eruption is of internal origin and develops spontaneously. It may occur upon various portions of the body, and is often noted in the vicinity of an exuding patch. In the accompanying ptate discrete papular lesions are seen scattered over the back, while in the interscapular region the tend- ency to grouping and the formation of inflamed patches is clearly shown. The eruption was of an acute charafter in this patient, and quickly yielded to zinc- ointment locally, with twenty grains of acetate of potash taken in a tumbler of water before each meal. ^' ..^- Copyright, iy,jo, by (i. H, Fi ECZEMA PAPULOSUM. ECZEMA 75 The alkaline diuretics, such as the acetate or citrate of potash and the salts of lithia, are of decided value in all cases where there is a notable degree of cutaneous congestion. They should be taken, well diluted, a short time before meals, and with the increased action of the kidneys, a marked decrease of the redness and burning sensation of the skin will frequently be noted. Arsenic is a remedy which has been greatly abused in the treatment of eczema and other skin diseases. It is one with a double edge, and apt, in many cases, to do harm rather than good, impairing the digestion and aggra- vating the eruption. Considering its routine prescription by so many phy- sicians, it would seem almost advisable to condemn its use entirely, but there are some chronic cases of localized eczema, characterized by thickening and scaling rather than by acute congestion, in which arsenic may be em- ployed to advantage. As regards antimony, calcium chloride, viola tricolor, and other internal remedies which have been considered by some to have an especially bene- ficial effect in eczema, it can only be said that in most cases a reliance upon them leads only to disappointment. In the local treatment of eczema a host of remedies has been recom- mended and frequently employed with no definite idea of what they are expected to accomplish. A change is usually made from one to another if the case does not progress favorably, and undeserved credit is often given to some local remedy when a cure is effected. While much can be accom- plished in most cases of eczema by appropriate local treatment, the idea is too prevalent that certain drugs or formula have a special and wonderful effect. Failure often results from undue reliance upon the therapeutic action of local applications, to the neglect of general measures which tend to improve the condition of the patient and thereby remove the cause of the eruption. A few remedies, with a knowledge of what they are capable of doing, are worth pages of formulas which promise far more than they ever fulfil. Local remedies in the treatment of eczema may be roughly divided into two classes, viz., those which soothe and those which stimulate. At 76 THE TREATMENT OF SKIN DISEASES the outset, in every case, the physician must determine whether the condi- tions present are such as demand a soothing or a stimulating plan of treat- ment, if the eruption be acute and irritable, the application selected cannot possibly be too bland ; while, on the other hand, if the eruption be chronic and characterized by much thickening of the skin, a soothing ointment or lotion is of no use, and something that will quicken the circulation of blood through, and improve the nutrition of, the tissues is what is plainly demanded. Among the soothing applications the oxide of zinc — in powder, lotion, ointment, or paste — has long been used and never excelled, in mild ery- thematous eczema or the intertrigo of children the powder, mixed with equal parts of starch or talcum, will be found both effective and agreeable. In all cases of superficial eczema attended by marked congestion and an intense burning sensation a zinc lotion is the most soothing application which can be made. The simplest plan of using this is to add one part of oxide of zinc powder to three or four parts of lime water, and apply frequently to the affected skin by means of a soft rag or tuft of cotton. As the zinc is insoluble, the mixture must of necessity be well shaken before each appli- cation. Calamine is often added to the zinc to render the deposit upon the skin less white and conspicuous, and a little carbolic acid is also added to the mixture for its supposable anti-pruritic effect, but the plain zinc and lime water is quite as serviceable. Here is a formula of the zinc and calamine lotion in common use : ]J Zinci oxidi 1 ss lo Calaminse 3 iv 2 Acidi carbolici f 3 ss 2 Glycerini f | i lo Liquoris calcis ad f | vi ad loo m Sig. — Shake well before using. In acute exuding eczema the oxide of zinc ointment of the pharmaco- poeia or any similar bland ointment may be spread thickly on pieces of stout muslin and bound smoothly over the eruption. Zinc ointment was ECZEMA IMPETIGINOSUM The term impetigo was formerly applied to various eruptions charafterized by crusting and most of which were undoubtedly forms of eczema. At the present time there exists a diversity of opinion as to the existence of a simple non-eczematous impetigo. The name is still used by some writers and applied to the small rounded pustules arising from local infeftion. The impetiginous or crusted form of eczema is an affeftion which is primarily of internal origin, but secondary pus infeftion of the skin often occurs and complicates the disease. Upon the face of nursing infants it is frequently seen and represents the " crusta lactea" of older writers. When there is a purulent, in place of a serous, discharge, the crusting often becomes very thick and of a ■dirty yellowish brown color. This falls spontaneously when the inflammatory process subsides, leaving a reddened skin, but as a rule no permanent trace of the eruption is left. The upper illustration in the accompanying plate shows the condition of the face so frequently seen in infantile eczema. A high grade of inflammation is usually present. The profuse serous dis- charge dries upon the surface of the skin and, mingled with the hemorrhage occasioned by the inevitable scratching, presents a dark reddish friable pellicle which soon becomes broken by the muscular movement when the little patient cries. The lower illustration shows a form ot eczema in which minute vesico-pustules develop and a profuse honey-like discharge dries upon the surface of the skin and forms a thick gummy crust of yellowish hue. \ > *'i r-H* i K'"i iglil, lyuD, by (j II. Kux. ECZEMA IMPETIGINOSUM. ECZEMA 77 most highly recommended by Erasmus Wilson, the celebrated English derma- tologist of a past generation, and it is equally valuable to-day in spite of the innumerable substitutes which are in common use. Many physicians seem to regard it as too old-fashioned, or perhaps too simple for them to pre- scribe, and so they add a little carbolic acid or a little resorcin, or something else which tends to convert it from a soothing into an irritating application, and thereby defeat the object of its use. If every physician were compelled by law to use plain zinc ointment in the local treatment of acute eczema many would find that their efforts to cure would be crowned with far greater success than at present. Now, after this encomium, 1 might add that 1 seldom use zinc ointment myself. All ointments are apt to be more or less disagree- able to patients, and should only be prescribed when it is absolutely neces- sary to do so — i. e., in about one-tenth of the cases in which they are commonly prescribed. In many cases of eczema a zinc paste or an ointment that will dry upon the skin is much preferable to a soft, greasy application. Upon the face and hands it needs no muslin. Upon the covered parts, the paste may be smeared over the eruption and covered with pieces of cheesecloth, which will stick like a plaster and prevent the rubbing off of the paste upon the clothing. The following is the formula of a paste now in general use : ? Acidi salicylici gr. x 2 Zinci oxidi 3 ii 25 Pulveris amyli 3 ii 25 Vaselini ad § i ad 100 ■m . (LaSSAR) A similar paste suggested by me many years ago is mentioned by Hardaway as still more acceptable : I^ Acidi salicylici 2 Bismuthi subnitratis 3° Amyli maidis -20 Unguenti aquae rosae ad 100 78 THE TREATMENT OF SKIN DISEASES A varnish, or linimentum exsiccans, may be made with acacia, traga- canth, or bassorin, with zinc or other drugs incorporated therein. The slight difficulty in preparing and applying such remedies seems to prevent their frequent use outside of our large clinics. The use of gelatin as an impervious coating has given satisfactory results in many cases. The following formula may be employed and the ingredients varied according to the consistency desired ; if more gelatin is used the application will be softer, but slower in drying : ]J Zinci oxidi 15 Gelatini . . 25 Glycerini }o Aquae ad 100 m Melt and apply every four days. in my service at the Vanderbilt Clinic, Dr. Dade has treated many cases of eczema during the past five years by means of such a varnish, and has found it of especial service in eczema of the flexures of the joints, where other dressings are difficult to apply. In chronic scaly patches it is advisable to first rub the skin with the oil of cade and then apply the hot glyco-gelatin varnish, covering it with a bandage when dry. The itching is generally allayed by the exclusion of air and the constant pressure exerted. Among the stimulating applications of service in treating chronic eczema may be mentioned tar, sulphur, resorcin, salicylic acid, and chrysarobin. On account of the deeper effect desired in treating an eczema with more or less thickening of the skin, these substances are best used in the form of an ointment, and wool-fat (adeps lan^e hydrosus), on account of its ready absorption by the skin, constitutes the most desirable ointment base. Tar, in spite of its objectionable odor and color, is one of the oldest and most effective cutaneous stimulants. It has a decided anti-pruritic effect, and in subacute cases, characterized by dryness and slight scaling, it is extremely beneficial in restoring the diseased skin to its normal condition. Among the various forms in which tar is used, the oil of cade seems to ECZEMA SQUAMOSUM. The squamous form of eczema is one very frequently met with, since nearly every case of diffuse eczema tends to become more or less scaly before it disappears. The amount of scaling varies greatly in different cases, ranging from a slight mealiness of the skin to thick whitish masses or irregular flakes of epidermis curling up at the margin. When the scales are thick and whitish' and the patches are isolated and numerous the appearance of erup- tion may suggest psoriasis, but the rounded and circumscribed character of psoriatic patches is always lacking in eczema. When the epidermis cracks and peels at the border a slight resemblance to ichthyosis results, but the absence of any polygonal arrangement of the horny plates and the redness and other symptoms of inflam- mation should prevent any error in diagnosis. The patient represented in the accompanying plate was shown at a meeting of the New York Dermatological Society by Dr. Robinson. The eruption had begun upon the legs, and gradually extended upward on the thighs with a marginate border which is quite unusual, since in eczematous patches generally the disease shades off gradually into the healthy skin. Although the eruption when photographed was dry and squamous, it had passed through an exudative stage when moisture and crusting were prominent symptoms. Upon the thighs are seen patches from which the scales had been removed by scratching, and which were red and moist (eczema rubrum). Copyriy^ht, lyr^j, by 'l. H. Fox ECZEMA SQUAMOSUM. ECZEMA 79 me to be the most desirable. The following ointment may be used to great advantage in many cases of eczema as soon as the acute stage has subsided : I^ Olei cadini lo Unguenti zinci ad loo in recent years ichthyol has become extremely popular as a substi- tute for tar, and thiol in less degree. The former is far more objectionable than tar so far as odor is concerned, and, in spite of the enthusiastic praise of its therapeutic efficacy by some of my colleagues, 1 find no occasion, after careful tests of its value, to use it in my practice. Sulphur and resorcin are often productive of good results in cases of superficial squamous eczema, although they have been known to fail. In cases where there are thick, horny scales, as in eczema of the palms and soles, salicylic acid is a most reliable remedy, accomplishing results which could be obtained through no other agency. Chrysarobin has a much deeper action and is indicated in case of obstinate circumscribed patches. Frictions with green soap were formerly much in vogue in the treat- ment of chronic eczema, and may be of service when crusts and scales are to be removed, in acute eczema soap and water are always objec- tionable on account of their irritating effect, but in chronic eczema soap frictions can certainly do no harm. The use of vulcanized rubber sheeting in the treatment of eczema has never attained the popularity in this country which its simplicity and effect- iveness would seem to warrant, and since the time of Hebra it -seems to have become almost obsolete. As regards this method of treatment, 1 venture to say that if some of my esteemed medical brethren would lay aside for a while their prescription pads and simply use rubber cloth in the local treatment of most cases of eczema, whether acute or chronic, they would be amazed at the unexpected and gratifying results. The pieces of rubber cloth should be of the heavy grade, applied smoothly, with the rubber side next to the affected skin, and changed at frequent intervals. 8o THE TREATMENT OF SKIN DISEASES Since eczema occurring upon different parts of the body presents cer- tain peculiarities which call for a special method of treatment, it is advis- able to consider a few of these regional varieties separately, and to briefly indicate their therapeutic requirements. Eczema of the head requires a varied treatment, according to the age of the patient, the chronicity of the disease, the length of the hair, etc. While in infants and men with short hair an ointment can often be used to advantage, in most cases of eczema capitis an oily lotion is prefer- able. In dry, squamous eczema of the scalp, a mixture of one part oil of cade with two or more parts of almond oil may be rubbed in thoroughly every night and the head shampooed once or twice a week. In the pus- tular or exuding variety of the disease, thick crusts are apt to form which can be most speedily and comfortably removed by having the patient wear a vulcanized rubber skull cap for one or two nights. A soothing lotion or soft ointment may then be carefully applied, and, as the exudation ceases, a slight addition of tar, resorcin, or salicylic acid will often be found to hasten the cure. In children, an occipital eczema should always lead one to suspect the presence of pediculi. The sulphur or ammoniated mercury ointment nec- essary to destroy them may sometimes produce a temporary aggravation of the eczema, but the latter will be found difficult to cure so long as the pediculi remain and occasion a continual pruritus. The hair of chil- dren, especially in summer, may be closely cut to facilitate the treatment of eczema, but in the case of girls and women the cutting of long hair should never be advised, although its presence may involve extra labor in the application of local remedies. Eczema of the ears is usually associated with eczema capitis, but may occur alone and affect either the auricle and surrounding parts or the exter- nal auditory canal. If the disease is acute, a zinc lotion is beneficial ; but if there is much thickening of the auricle a stimulating ointment or paste is called for. For the scaly condition of the auditory canal, which is frequently accompanied by an annoying pruritus, a weak solution of nitrate ECZEMA CRURIS To the student of physiognomy not alone the face but nearly every portion of the body presents characteristic features which indicate the temperament and general physical condition of a patient. The color of the skin, the contour of the joints, the firmness or flabbiness of the subcutaneous tissue — all may furnish unmistakable indications of systemic conditions which determine the clinical form, the chronicity, and often the therapeutic indications in a case of crural eczema. The accompanying plate shows two legs belonging, respect- ively, to two female patients and presenting a contrast which makes them well worthy of study apart from their dermatological interest. Compare the knees for an instant and see how easy it is to recognize what the older physicians were wont to describe as the nervous and the phlegmatic temperaments. As a natural result of this tem- perament, diathesis, general physical condition or whatever it may be termed, we have in the one case a typical neurotic eczema — a dry, scaly, pruriginous, chronic and rebellious patch ; while in the other case we have a typical exuding eczema — a moist, swollen, acute, and crusted patch far more amenable to local treatment. In the former case a five per cent, ointment of chrysarobin was used locally while every effort was made to improve the health of the patient. In the latter case the application of vulcanized rubber cloth quickly removed the crusts and checked the discharge. Copyright, ifioo, by G. H. Fox. ECZEMA CRURIS. ECZEMA SI of silver— or, better still, the oil of cade, either pure or diluted— may be applied frequently by means of a swab. The daily syringing of the ear is very apt to interfere with a cure. Eczema of the nostrils may be treated like eczema of the auditory canal, in some cases, however, the inflammation is very acute, and the crusts, which form rapidly and block the passages, must be first removed by the application of a bland oil or some very soft and soothing oint- ment, like the following : ]^ Adipis lanx hydros! 3 Adipis porci 6 Liquoris calcis . ad 20 m Eczema of the beard sometimes occurs in an acute form, and resembles sycosis, since pustulation may take place around the hair follicles. There is usually considerable swelling and surface exudation, and while a soothing lotion or paste is applied externally, the bowels must be freely opened and the general health of the patient improved in every possible way before the eruption will yield. Upon the upper lip the disease is often secondary to a chronic nasal discharge which requires treatment more than the resulting eczema beneath the nostril, in the dry, squamous form of eczema of the beard, with more or less thickening, soap frictions and a stimulating oint- ment are indicated. The following paste may be found of service : 5 Acidi tannici 3 i 10 Sulphuris praecipitati 3 ii '5 Zinci oxldi 20 Amyli aa gr. cl 20 Petrolati mollis gr. clx ad 100 m (Rosenthal) Eczema of the genital regions is not very common, but when it does occur is apt to be extremely annoying. The penis and scrotum, and espe- 82 THE TREATMENT OF SKIN DISEASES cially the latter, may present an acute, moist eruption, for which a zinc lotion is applicable. But soon this condition disappears, and a thickened skin is left, with a dry, harsh, or excoriated surface and a marked deepening of the natural furrows. For this condition, the soothing applications may afford temporary relief from the pain and itching. But more severe treat- ment is necessary to restore the skin to its normal state. I have found chrysarobin, when cautiously used, to be of the greatest service in these cases of chronic scrotal eczema. A mild ointment should be tried at first. A strong ointment is apt to give considerable pain for a half-hour, but 1 have known this to be followed by the first good night's rest that the patient had enjoyed for many months. For an acute eczema of the female genitals, attended by great pain and swelling, the application of very hot cloths will often give immediate relief when many kinds of ointments and lotions have been used with abso- lutely no effect. For chronic eczema of the labia, with infiltration and annoying pruritus, a strong galvanic current has, in numerous instances in my experience, afforded the greatest relief and done much toward effecting a cure. Eczema of the anus and perineum constitutes one of the most annoying forms of the disease, the patient not only being robbed of much of his night's rest, but rendered most uncomfortable at times during the day. The pruritus is often so intense that the sufferer must hastily retire from company, or perhaps indulge in a little clandestine scratching regardless of appearances. This form of eczema occurs in nervous individuals, and is essentially symp- tomatic. Frequently there is but little thickening of the skin and few excoria- tions, and a hasty examination of the part would hardly show any cutaneous disease. In other cases of long standing there will be found much infiltration with fissures and considerable scaling or crusting. In treating this variety of eczema local measures are chiefly palliative and the general health of the patient must be improved in every possible way. A sea voyage or vacation of some length will often do much good. When this is not feasible, the daily work hours should be shortened, and all sources of worry and mental anxiety removed if possible. ECZEMA MANUS Eczema of the hand, though usually of internal origin, is often greatly aggravated by external irritation. Its persistence may be due in great measure to the occupation of the patient, and the eruption is frequently seen in washerwomen, bartenders, bricklayers and those who handle corrosive chemicals. Occurring upon the palm the eruption is usually dry and scaly and presents certain clinical peculiarities due to the thickness of the epidermis in this locality. The illustration in the upper left corner of the plate shows a typical papular and exuding eczema similar to that which is seen upon other portions of the body. Upon the back of the hands eczema is very apt to appear in the form of moist, orbicular patches of an extremely obstinate charafter. The upper right illustration shows a common form of squa- mous eczema which bears a strong resemblance to psoriasis of the palm. It is indeed a difficult matter to distinguish palmar psoriasis from some cases of palmar eczema by an examination of the palm alone. The charafteristic psoriatic eruption upon other parts is generally the basis of the diagnosis. The lower left palm shows a marginate exfoliation of the thickened epidermis which is unusual since eczema, as a rule, has no circumscribed border, but gradually fades away into healthy skin. The lower right illustration presents a rather common form of chronic palmar eczema in which desquamation has ceased and redness, thickening and fissuring are the chief clinical features of the disease. Q 5 p o 2 O 0) CB o c 13 ■ -\ C 2 m o N m D O T| 03 '^ S c > • o en - c S ECZEMA 83 The bowels should be kept freely open by small doses of calomel and phosphate of soda or mineral water, taken every morning. When hemor- rhoids are present, an operation for their removal should be performed without delay. The diet must he restricted to simple nutritious articles of food, and any peculiar dietetic habits carefully considered. I have known several cases to be greatly benefited by abstention from tobacco, and others in which an excessive use of coffee seemed to increase the pruritus. Locally, a strong carbolic lotion may be employed if the skin is not excoriated, or a soothing ointment applied if there are inflammatory symptoms. To lessen the chronic thickening of the skin nothing is better than a chrysaro- bin ointment or varnish. Eczema of the hands and feet usually requires a special method of treat- ment, owing to the thickness of the epidermis upon the palms and soles, and the peculiar conditions which result. The palms are more frequently affected than the soles. They may present a swollen appearance, with a few vesico-pustules or moist, crusted patches, a diffused, scaly aspect, with painful cuts or fissures, or, at a later stage, the whole surface may be comparatively smooth, reddened, and cross-lined by the natural furrows of the skin. A scaly patch upon the palm often presents an appearance so closely resembling syphilis that even an expert is unable to determine its char- acter solely from its clinical aspect. As in such a case a correct diagnosis is the basis of successful treatment, it is well to bear in mind the fact, which is rarely mentioned in any text-book, that eczema of the palms is almost invariably symmetrical, while the squamous syphiloderm is very apt to be found only on one palm. For eczema of the hands the brown rubber gloves used by surgeons will often do more good than any local application. They should be sufficiently large to be drawn on and off without risk of tearing, and worn for a short time both day and night. It is advisable to have two pairs, so that a frequent change can be made in order to keep them clean and comparatively odorless. 84 THE TREATMENT OF SKIN DISEASES The maceration of the skin softens the dry, horny epidermis, removes all crusts, heals the painful fissures, and quickly imparts to stiffened fingers a notable increase of flexibility. Eczema of the feet may be treated in a somewhat similar manner by means of vulcanized rubber sheeting. One piece cut to fit the sole and other small pieces made to cover eczematous patches upon the dorsum of the foot can be kept in position (the rubber side next to the skin) by means of a tight stocking. Eczema of the legs, with or without ulceration, is of frequent occurrence, and may persist for many years if not properly managed. The lower third is usually its seat, and, whether the surface be dry or moist, there develops in time a decided thickening of the skin, which calls for vigorous local measures. The application of a soothing ointment may please the patient by affording slight temporary relief from pain or itching, but it will never effect a cure. Rest in bed is advisable if there is much swelling ; but when the patient is obliged to continue work and be for many hours daily on the feet, a carefully applied bandage is the next best thing in the way of prophylaxis. When there is a dry, scaling surface, an ointment containing oil of cade or salicylic acid — or, better still, chrysarobin — may be rubbed into the patches night and morning or applied on strips of cloth beneath a bandage. When an exuding surface is present the application must not be too stim- ulating at first, and in very many cases of eczema of the leg the application of strips of thick vulcanized rubber cloth will be found simpler and more effective than any ointment. When there is much infiltration of the leg, with more or less crusting, the rubber bandage is an ideal method of treatment, as it macerates the surface, favors exudation, and quickly reduces the swelling through the equable pressure which it exerts. Often the cir- cumference of an eczematous leg will be lessened several inches in a few days. When the skin is irritable, and especially in hot weather, the band- age will sometimes cause the eczema to spread, and must be discontinued in such a case. ELEPHANTIASIS Elephantiasis is a rare disease in this country, though quite common in certain tropical regions. It is generally regarded as the result of venous or lymphatic obstruftion which may be caused by the presence in the vessels of a parasite called the filaria sanguinis hominis. The disease usually affefts but one of the lower extremities. The penis and scrotum in males and the vulva in females are also frequently affefted and tumors reaching below the knees and of great weight are gradually developed. The surface of the skin may remain smooth, but around the ankle there is often a dark papillomatous growth, suggestive of the bark of a tree. In some cases the arms, face, or a limited portion of the trunk may become the seat of what is commonly termed elephan- tiasis, although it is improbable that all cases classed under this head are of the same nature. The subjeft of the illustration was an elderly woman who presented herself at the Vanderbilt Clinic and disappeared before a full history of the case was obtained. The legs were symmetrically affefted and the chronic oedema had caused marked thickening and induration of the tissues without, however, any notable change in the condition of the skin. Where the swollen legs were in constant apposition below the knees a slight squamous eczema had developed. The patient had suffered from recurrent erysipelatous attacks, each of which had increased the size of the legs. There was no pain nor tenderness and the patient complained only of the difficulty in locomotion. Copyri^^ht., i^^^, by G. H. Fox. ELEPHANTIASIS. ELEPHANTIASIS ELEPHANTIASIS, as the name implies, is a considerable and often enormous thickening of the skin, which affects chiefly the legs and genitals. The disease is endemic in certain tropical countries, and sporadic cases sometimes develop elsewhere. At the outset there is usually fever and a local inflammation involving the lymphatic vessels. Recurrent attacks are the rule, and with each one the cutaneous hypertrophy is increased. The occlusion of the lymphatics has been found in many cases of endemic disease to be due to the filaria sanguinis hominis, the embryos of which are carried from one patient to another, it is claimed, through the agency of mosquitoes. The cause of elephantiasis is uncertain. It is neither contagious nor hereditary, and usually occurs in middle life. The dark-skinned races, and particularly those living in malarial regions near the seacoast, seem most liable to be attacked by the disease. Like leprosy, it has been ascribed to a fish diet, but without convincing proof of this origin. In the treatment of elephantiasis much can be done in the early stage to relieve the inflammatory symptoms. Rest in bed, elevation of the limb, and the application of antiphlogistic lotions are plainly indicated during the acute exacerbations. But cases are rarely seen in this country until the characteristic hyper- trophy has developed through repeated erysipelatous attacks. For this con- dition the rubber bandage may be advantageously used when leg or arm is affected. A speedy, though perhaps not permanent, diminution in the size of the limb can often be effected. From nerve stretching, and from the persistent use of a strong galvanic current, good results have been 86 THE TREATMENT OF SKIN DISEASES reported. The ligature of the large artery supplying an elephantiasic part has often been performed, but no brilliant result has seemed to follow this procedure. When the scrotum or leg has enlarged to such a degree as to impede locomotion, amputation is advisable. The early removal of a patient from the country where the disease is endemic is generally followed by an improvement and sometimes a cure. When the hypertrophy is great, the inflammatory exacerbations sometimes continue to recur in spite of a change of residence. As in leprosy, the change of climate is the first and perhaps the most important point to consider in the way of treatment. EPITHELIOMA Epithelioma is a malignant disease involving the skin or m.ucous mem- brane, and characterized by a downward growth of epithelial cells into tissues where they do not normally exist. These occasion an inflammatory process, which, sooner or later, leads to ulceration and considerable destruction of tissue. Three clinical forms of the disease are commonly described. The first, or superficial form, begins usually as a pale, waxy nodule of the size of a split pea, and most frequently seated upon the upper portion of the face. Sometimes an aggregation of several of these small nodules occurs, and a firm undulating tumor is formed, which has been aptly compared, in appear- ance, to the crown of a molar tooth. The central portion of this tumor becomes crusted in time, and finally a shallow, glazed ulcer with an indurated border is formed. Not infrequently the disease begins as a small and per- sistent abrasion, or as a roughened patch, which after a few years' duration tends to crust formation, and finally develops the same characteristic ulcer. This often cicatrizes in the centre as it extends at the periphery, and, in the course of five, ten, or fifteen years, involves a considerable extent of skin by means of this slow, serpiginous growth. The term rodent ulcer has long been applied to this superficial variety of the disease. Some claim that the EPITHELIOMA RODENS Rodent ulcer is regarded by most writers as a superficial form of epithelioma. The fad that it usually occurs upon the upper portion of the face, is charafterized by extensive loss of tissue with very little new growth, and never involves the neigh- boring glands has led some English surgeons to describe it as a distinft affeftion. The disease is rarely painful, it spreads very . slowly and may persist for jjiany years without any notable change except in size. In some cases, however, it may develo{5 with greater rapidity and destroy a large portion of the face and neck. Occa- sionally the rodent ulcer gradually assumes the form of ordinary epithelioma. In the case of the patient represented in the plate the disease had existed for several years, it had begun in the usual manner with a crusted papule which showed little or no tendency to heal. In faft, it had resisted simple treatment and gradually extended at the margin, which was slightly elevated, indurated, and sharply defined. As a result of caustic applications made by several physicians at various times, a portion of the superficial growth had healed, forming a number of cicatricial islands in a sea of dull red glazed granulations. '"^ %"""*^tV ^^'. m Copyrifjht, iqno, by G. H. Fox, EPITHELIOMA RODENS. EPITHELIOMA 87 two affections are pathologically distinct though nearly identical in clinical appearance. The second, or deep-seated, form of the disease may develop from the superficial variety, or begin as a firm, flattened tumor of the skin with a central depression. This gradually becomes the seat of an ulcer with an uneven, readily bleeding surface, and with an indurated and everted border. This form is attended from the outset by considerable pain, and as the disease progresses the suffering increases. The infiltration of the healthy skin goes on steadily if the disease is not properly treated. Sooner or later the lymphatic glands of the region become involved and gradual exhaustion precedes the fatal termination. The third, or papillomatous, form presents the appearance of a warty excrescence at the outset, rapidly ulcerates, and pursues the course already described. The cause of epithelioma is beyond our present knowledge. Continued irritation of the skin will not alone suffice to produce it, although it may frequently determine its location in certain cases. Lewis mentions an epitheli- oma developing on the side of the nose at the point where the eyeglasses rested for many years. This may or may not have been an etiological factor. 1 have seen so many cases of superficial epithelioma develop upon the side of the nose a short distance from the point so often reddened and depressed by the constant pressure of eyeglasses, that the local irritation seems to have little or nothing to do with the origin of the growth. An epithelioma of the lip is frequently attributed, and perhaps justly, to the frequent use of a pipe ; but it is also a fact that the disease often occurs upon the lip in the case of men who do not use tobacco in any form. It frequently develops upon the site of a mole, cutaneous horn, or some papillomatous degeneration of the skin such as is quite common in advanced life. No proof of its hereditary nature can be adduced from the fact that it occasionally develops in successive generations. The disease is one which never gets well spontaneously, and its prognosis depends entirely upon the location, stage, and extent of the growth. Its 88 THE TREATMENT OF SKIN DISEASES malignancy varies greatly, and while in many cases the growth may remain for many years with very slight or no perceptible increase, in other cases, and particularly those of the deep-seated variety, it tends to spread rapidly at times, and if not vigorously treated soon gets beyond the reach of surgical measures. The prognosis is more unfavorable when the disease attacks the mucous membrane, and when its situation renders its complete removal a difficult task. In the treatment of epithelioma mild measures are likely to do more harm than good. Many lives have been sacrificed to that fear of the knife which is quite natural to most patients, and which has led many to avoid radical treat- ment, in the vain hope that some more agreeable treatment would suffice to effect a cure. No one can blame a patient for this instinctive dread of an opera- tion which does not seem to him to be absolutely necessary, but no words of condemnation can be too strong for the physician who encourages the erroneous belief that some mild application may take the place of vigorous surgical treat- ment. Even the charlatans who trade upon the willingness of their victims to submit to the torture produced by some violent escharotic, rather than undergo a painless operation by a skilful surgeon, are often successful in effecting a cure, and cannot be justly accused of a do-nothing plan of treatment. Too often a physician with little or no experience will putter or experiment with a small epithelioma until it gradually grows larger and deeper, and becomes much more difficult to cure. Too often both physician and patient are deceived by an apparent improvement in the superficial aspect of the growth, while all the time the disease is infiltrating the deeper tissues and steadily tending toward that point of progress where it becomes evident to all concerned that further delay must be extremely dangerous. Every physician who undertakes the treatment of an epithelioma assumes a grave responsibility, and if he allows the disease to progress from month to month or from year to year, he is guilty in many cases of a flagrant malpractice. There are unfortunately some cases of neglected epithelioma which are incur- able, and for every case of this description there are often from one to a half- dozen physicians upon whom the patient has relied for proper advice, if not for EPITHELIOMA 89 treatment, and to whose ignorance or neglect the final death of the patient Is directly due. Epithelioma is a local disease, and the main object of treatment should be to completely remove the growth before it has produced irreparable injury. It may be cut out, scraped out, bored out, or burned out, but it must in some way be thoroughly destroyed. When the lip or tongue is involved or when the infiltration of the skin is extensive and deep, and neighboring lymphatic glands are involved, nothing can take the place of the knife in the hands of an expert surgeon. In most cases, however, the disease is quite superficial at the outset, and it is largely a question of choice whether it shall be destroyed by means of curette or a caustic, or by a combination of both. Of the many chemical caustics which have been used in the treatment of epithelioma, arsenic stands first, and can best be used in the form of a paste, first recommended by Marsden. This is composed of two parts of arsenous acid and one of powdered acacia, mixed with a sufficient quantity of water. While caustic potassa, chloride of zinc, and the acid nitrate of mercury are not only painful, but tend to destroy healthy as well as morbid tissue, arsenic exerts a selective action, and will remove a superficial epithelioma without injury to the surrounding healthy skin. The strength of the paste can be varied, and cocaine combined with it to lessen intense pain. Applied on a piece of stout muslin no larger than a quarter of a dollar, it may be allowed to remain for several hours or several days, according to the effect desired and the ability of the patient to endure pain. Bougard's paste, which is a mixture of various caustics, has the advantage, it is claimed by some, of being less painful than the plain arsenical paste, and less apt to do harm when applied to a large surface. Kaposi speaks highly of a pyrogallic ointment of from ten to twenty per cent, strength, remarking that it destroys only the diseased tissue, and is pain- less in its action. For several years I used this ointment, applying it freely to the raw surface after curetting. It occasions considerable pain when first applied, but this ceases entirely after an hour or two. It promotes free suppu- ration, and undoubtedly tends to destroy any superficial remnants of the morbid 90 THE TREATMENT OF SKIN DISEASES growth, but it has by no means the efficacy of arsenic, and after thorough curet- ting, using first a large and then a slender curette or burr, I much prefer to bore into the raw surface with a cone of nitrate of silver. The use of the curette is condemned by many writers on account of its failure to destroy all of the diseased cells, and the consequent probability of the return of the disease. A superficial erasion, it is true, does little good, and may. indeed, be productive of harm. Like repeated cauterization with nitrate of sil- ver and other mild measures, it may tend to stimulate the growth by increas- ing the cell proliferation and invasion of tissue. But if a curette is vigorously used, a small epithelioma can often be very quickly and, after an injection of cocaine, painlessly destroyed by means of this instrument alone, it is advis- able, however, after removing the mass of morbid tissue, which is always much softer than the normal skin, to treat the raw surface with a view to destroying minute foci of disease which escape the action of the curette. Little crypts or prolongations of the disease often remain after curetting, and may be discovered and destroyed by means of a dental burr dipped in carbolic acid, or a sharp cone of nitrate of silver firmly pressed into them. Even in cases where the arsenical paste is to be used, it is advisable to first remove the mass of soft tissue with the curette, and thereby lessen the time required for the paste to do its destruc- tive work. The raw surface produced by the use of a curette or left after the removal of a slough may be covered with a small piece of mercurial plaster. This makes the simplest dressing, and beneath it granulation will proceed rapidly and the smoothest cicatrix result. The use of the actual or galvanic cautery in the treatment of epithelioma is to be condemned, since it must necessarily destroy much healthy tissue or fail to destroy all of the morbid growth. In the use of the curette or burr the sense of touch is far more important than that of sight, and usually reveals the direc- tion in which the disease is tending to spread. By the vigorous use of the latter instrument the morbid tissue can be mostly destroyed in an ordinary case of epithelioma as readily as a dentist digs out the soft carious substance from a dental cavity, and the inflammation resulting often suffices to destroy the cells which are not reached by the steel. ERYSIPELAS Erysipelas is an acute inflammation of the skin and subcu- taneous tissue accompanied by fever and charafterized by redness, pain, tumefaction, and an advancing marginate border. It runs an acute course in about a week and sometimes terminates fatally. It is due to the streptococcus erysipelatis or some other specific micro- organism which may find an entrance through some cut or abrasion. In facial erysipelas, the most common form of the disease, the specific germ undoubtedly enters the system through the mucous membrane of the 'throat or nose. The disease often begins with a chill and the constitutional symptoms, even in a mild case, are quite marked. A high tem- perature is very common, and in severe cases;, particularly those affefting the scalp, inflammation of the cerebral meninges and various internal organs is apt to ensue. Acute eczema of the face and the poison ivy eruption are often mistaken for erysipelas, and at the outset the diagnosis is not always evident at first glance, especially as in the latter disease vesicles or bulte frequently develop upon the red and swollen skin. The high fever, however, and the circumscribed border of the inflamed part will usually lead to a correft diagnosis upon careful 'observation. The patient represented in the plate came to the Vanderbilt Clinic after suffering for three or four days. He was very weak and complained of fever and headache. The eruption, as may be seen, presented the abrupt border, and small bullae were present upon the cheek. Copyright, i^^^j, by G. H. Fux. ERYSIPELAS. ERYSIPELAS 91 ERYSIPELAS Erysipelas is a disease which varies greatly in its severity, it may run its course in a few days in one case and last a few weeks in the next. This uncertainty of duration makes it difficult to estimate the value of remedial treatment in most cases, and has doubtless led many to overestimate the value of certain methods of treatment, and to depreciate the influence exercised by the vis medicatrix. Among the internal remedies given in erysipelas the tincture of the chloride of iron has long been the chief. Whatever its therapeutic value may be, it is certainly used by most physicians in a routine manner, as their fathers or pre- ceptors did before them. The widespread belief that iron does some good in erysipelas seems to be the strongest, if not the only, proof of its efficacy, it is usually given in doses of a half drachm or more, every two or three hours, dur- ing the height of the attack, but the modern antipyretics will be found of much more service during this period, and stimulants will be found useful when the fever has abated. Hypodermic injections of pilocarpin (gr. \) have been suc- cessfully used by Da Costa. The profuse sweating induced by the drug lessens the patient's temperature, and seems to check the further development of the inflammation. in the local treatment of erysipelas the source of infection should be sought for, and in case of any wound or abscess this should be treated surgically in accordance with approved antiseptic methods. When the face is the seat of disease the nasal cavity should be carefully examined, all crusts removed, and an antiseptic spray used frequently. Various applications have been highly commended for their therapeutic virtues, but the reputation of many of them has doubtless been based upon the fact that the disease generally terminates favorably whatever may be applied to the surface. The attempts made to check the peripheral extension of the inflammation by painting the healthy skin with tincture of iodine, nitrate of silver, or carbolic acid have often failed, and in many cases have done positive harm by increasing 92 THE TREATMENT OF SKIN DISEASES the inflammatory process. Collodion or strips of adhesive plaster applied just beyond the margin of the erysipelatous patch are more likely to confine the dis- ease by diminishing the vascularity of the skin and exerting pressure upon the lymphatic vessels. The scarification of the border of the patch, with subse- quent application of a bichloride dressing, and the injection of carbolic acid at the periphery, have been strongly urged, but these are somewhat heroic methods of treatment, and apparently not superior to the simpler measures already mentioned. To the swollen, reddened, and painful surface ichthyol, creolin, tannin, iodine, iodoform, and many other applications in the form of powder, lotion, and ointment have been highly praised. Ichthyol in particular has been strongly advocated in recent years in cases of erysipelas, as in many other skin diseases. It may be used with water, oil, or collodion, and of a strength varying from ten to fifty per cent. Creolin has been used by Koch, white lead by Harwell, zinc paint by Blackader, picric acid by Tassi, and various similar remedies by various eminent therapeutists. Duckworth has called attention to chalk ointment, a favorite remedy in the erysipelas wards of Saint Bartholomew's Hospital. It is made of prepared chalk and lard in equal proportions. The precipitated carbonate of lime is equally serviceable and makes a whiter ointment. Patients are said to experience a feeling of relief from this application, and to prefer it to others which may have previously been used. It does not get in the eyes, as does flour when freely dusted over the erysipelatous surface, and is superior to white paint, which at times causes considerable pain. The ointment may be renewed twice or oftener in twenty- four hours. Most of these applications are apt to make the patient look worse, some- times make him feel worse, and never exert any notable curative result in spite of the fact that the patient gets well. Although the looks of a patient, whose face is doubly disfigured by the disease and its treatment, is not a matter of the first importance, the comfort or discomfort produced by any local application should certainly be taken into consideration. Until it is definitely proven that a certain application tends to abort, modify, or cure the disease, it is ERYTHEMA PAPULATUM Erythema papulatum is one of the most common forms of erythema multiforme. It presents rounded, elevated and flattened lesions which are at first of a deep red color but gradually become dull and purplish and fade in one or two weeks. The eruption is sometimes accompanied by slight fever at the outset, and the patient usually suffers from an intense burning sensation of the affected skin, especially when it is rubbed or otherwise irritated. The lesions may be found upon various portions of the body but the hands and feet are the favorite site of the eruption. Upon the backs of the hands it is very rarely absent. In some cases the lesions are hemispherical in form (E. tuber- culatum) and frequently the flattened papules present a central vesicle (E. vesiculosum). More rarely they become the seat of a rapidly developing blister (E. bullosum). The disease sometimes designated Herpes iris is simply a vesicular form of exudative erythema occurring generally upon the hands. The lesions are elevated discs with a central vesicle or bulla and a series of concentric whitish rings which may be either smooth or herpetic. The papular lesions shown in the plate present for the most part a central depression indicating the site of an aborted vesicle. One lesion near the sole suggests the Herpes iris type. Cnpyri^lit. i(|oo, In' (t. H. T''ox ERYTHEMA PAPULATUM. ERYTHEMA 93 advisable to avoid all such as cause discomfort or unnecessary disfigurement. A five per cent, solution of sodium salicylate, as recommended by Besnier and Hallopeau, or a weak bichloride solution is certainly a less objectionable dress- ing, and, doubtless, quite as effective as those already mentioned. According to my experience, a ten per cent, solution of sodium hypo- phosphite or a saturated solution of boric acid in rose v^ater, applied frequently by means of cloths or light compresses, will prove most agreeable to the patient, and accomplish all that can be expected from local treatment. As the disease is an infectious one, the complete isolation of the patient is imperative, and especially when the disease occurs in a hospital ward. A large and well-ventilated room is desirable, and the physician in charge should take every precaution in the shape of cleanliness and disinfection to prevent the conveyance of the disease to some other and perhaps remote patient. Recurrent attacks of erysipelas can sometimes be avoided by treatment of the nose and throat, since a catarrhal condition with slight ulceration of the mucous membrane of this region tends to invite an attack. Many cases, however, of so-called recurrent erysipelas are simply a local dermatitis with considerable cedema, and may arise from various causes. ERYTHEMA Erythema, or simple congestion of the skin, occurs as the result of a variety of causes, both internal and external. It appears usually in the form of red macules, or patches of varying size and shape. Sometimes a large extent of surface is involved, and an epidermic desquamation may follow the eruption, as it does in scarlatina. The patches of simple erythema are not raised above the surface of the normal skin as a rule, and usually assume a dull hue before they disappear. Erythema, like dermatitis, may result from injury, heat, cold, or contact with poisonous substances, in many cases it is difficult to determine whether there is a simple hyperasmia or an inflammation of the skin present, and the precise diagnosis is a matter of no very great importance. 94 THE TREATMENT OF SKIN DISEASES In one common form of erythema, known as intertrigo (erythema intertrigo), a redness of the skin results from pressure and friction of oppos- ing surfaces. This is often noted about the genitals and neck of fat infants, and sometimes beneath the pendulous breasts of women. From heat and irritation of the sweat in hot weather the hyperemia often passes into an inflammatory condition with maceration of the epidermis, and in some cases pronounced eczematous symptoms develop. The treatment of erythema consists mainly in removing the exciting cause, whether this be some external irritant or an error of diet. If it seems necessary, a cooling or soothing application may be made to the skin, in mild cases a greasy ointment is more uncomfortable than the eruption itself, and a dusting powder or lotion is far preferable, although even this may be quite superfluous. Many complicated powders have been recommended in the text-books, but powdered starch or talcum is practically as efficient as any. Before using any powder, the skin should be gently bathed with cool water and carefully dried, and any tight or ill-fitting undergarment cast aside. Should there be a burning sensation present, a lotion of zinc oxide in lime water or a saturated solution of boric acid may be used to advantage. in the intertrigo about the genitals of infants it is important to have the napkins changed as soon as they are wet, since the persistence of the disease is often due to the irritation of the urine. Much stress is laid upon this point by every writer, but another of even greater importance is rarely mentioned in the text-books. A partial phimosis often exists in male infants, which causes a retention within the prepuce of a portion of the urine voided. This dribbles slowly after the napkin has been changed, and tends to keep the scrotum and surrounding parts moist and irritated, in every such case the physician should make a forcible retraction of the prepuce, if it is necessary, and carefully instruct the mother or nurse to do the same after each passage of urine, and before the dry napkin is applied. Attention to this point will often effect a speedy cure of an intertrigo which has long persisted in spite of dry napkins and a useless variety of powders. ERYTHEMA ANNULATUM. Erythema multiforme is an inflammatory affection characterized by marked exudation into the cutaneous tissue which produces a notable elevation of the various lesions. In this respect it differs from the erythema simplex, arising from either internal or external cause, in which there is merely hyperaemia with very little or no elevation of the lesions. One of the rarer forms of the exudative erythema occurs in rings and is known as erythema annulatum vel circinatum. The lesion begins as a small flattened, bright red disc which gradually increases in size and becomes depressed in the center from absorp- tion of the exudation. A variation in color is then usually noted. The peripheral portion of the disc, being of most recent develop- ment, presents the bright red tint of active conjestion, while the central portion, even before it becomes depressed, gradually assumes a dull livid hue. The disease usually runs its course in from one to three weeks, unless it be protracted by the successive outbreak of new lesions. The face and neck is a favorite site, although the lesions may appear upon the trunk and extremities. The plate represents two rings which have coalesced and formed a patch resembling a figure eight, with a disappearance of the exudation where the raised borders have met. When many rings exist and run together, as they sometimes do upon the trunk, an eruption of fantastic design is usually produced. (E. marginatum, E. gyratum.) Copyright, 1900, by G. H. Fox. ERYTHEMA ANNULATUM. ERYTHEMA BULLOSUM The bullous type of exudative erythema occurs when the attack is sudden and the inflammatory process unusually intense. Its cause is usually difficult to discover, but it has been frequently noted in this country that immigrants, whether crossing the ocean in the cabin or the steerage, are especially prone to suffer from erythema multiforme, and particularly in the spring and fall. The sudden changes of temperature in this climate appear to be more of an etiological faftor than any possible change of diet. The patient represented in the plate was an Irish girl who had been but three weeks in this country. The eruption had begun a week before the photograph was taken, and was chiefly on the face, although the hands were swollen and dotted with rounded papules gradually becoming vesicular and the ankles were slightly affefted. Some bullous lesions on the extensor aspeft of the fore- arm presented a red, elevated areola, while others were surrounded by normal skin, like those seen upon the face. The patient had a heavily coated tongue, but claimed to be feeling well in spite of the eruption. Calomel and soda tablets were ordered and in two days the eruption was rapidly disappearing. At this time there were papular lesions upon the backs of the hands with many yellowish crusts and a few excoriated lesions upon the forearms and face. f \ Copyright, jgoo, by G, H. Fox. ERYTHEMA BULLOSU M. N ERYTHEMA MULTIFORME 95 ERYTHEMA MULTIFORME Multiform erythema is a name applied to a distinct affection of the skin in which there is a marked exudation into the cutaneous tissue which tends to raise the red disks or patches considerably above the level of the surrounding skin. It includes not only the papular, annular, and marginate forms of exuda- tive erythema, but those bullous and nodular eruptions which are described by some writers as separate diseases under the names of herpes iris and erythema nodosum. The cause of multiform erythema is obscure, and owing to its sudden and often unexpected onset, and to its tendency to run a definite course, which is scarcely modified by treatment, it has been regarded by some as closely allied to the acute exanthemata. The eruption occurs in both sexes and at all ages, although in youth it is especially common. Its relation to rheumatism and malaria is claimed by some writers, but Crocker, who is strongly of the opinion that the rheumatic and gouty are particularly liable to the disease, is compelled to state that, in a large number of cases, no irritating or exciting cause can be discovered. The disease is of most frequent occurrence in the spring and autumn, and seems prone to attack those who have just landed from ocean steamers. In our large clinics in New York the occurrence of the disease among immigrants has frequently been noted, and sometimes ascribed to a complete change of diet. But as the first-cabin as well as steerage passengers are sometimes affected, it seems improbable that any dietetic origin can exist, and 1 am more inclined to attribute its occurrence to the sudden changes of temperature which are not uncommon in this region. Crocker cites cases in which exposure to cold, heat; or wind would evoke an attack of the papular type. The treatment of erythema multiforme is unlikely to influence the course of the disease in any notable degree — although it may frequently tend to make the patient more comfortable. Kaposi claims that we are unable to prevent the first eruption or subsequent relapses, or to accelerate the invo- lution of the lesions, and that treatment is therefore superfluous. 96 THE TREATMENT OF SKIN DISEASES When rheumatism, gout, or anaemia are present, sodium salicylate, potas- sium iodide, or some preparation of iron may do the patient good, and indi- rectly benefit the eruption. The iodide of potassium has been highly recom- mended by Villemin in ten-grain doses, three times daily, but it is well to remember that this remedy, like arsenic, is double-edged, and if it fails to bene- fit the eruption, is very likely to aggravate it, especially when continued for some time. As in most of the inflammatory diseases of the skin, the alkaline diuretics, such as the citrate or acetate of potassium, will prove of service in stimulating the kidneys, and thereby lessening the intense hyperasmia of the skin. Locally, a simple dusting powder or, if there is much burning or itching of the skin, a zinc lotion may be used. When an urticarial condition of the erup- tion is present, and the burning sensation is intense and annoying, the following lotions are of value, but should not be applied except to an unbroken skin. ^ Acidi hydrocyanici diluti .... . 3 ii ^ Chloralis .... .31 2 Spiritus myrcise ... . . .3 xiv 20 Emulsi amygdalae amarse . . ad § viii ad 100 m (Atkinson) IJ Acidi hydrocyanici diluti . . -31 3 Bismuthi subnitratis ... 3 ii 3 Aquae aurantii florum . . . ad 3 iv ad 100 m (Van Harlingen) To smear a greasy ointment on the skin, as is too- frequently done, is of no avail, and is apt to be disagreeable to most refined patients. In severe cases of erythema nodosum rest in bed is desirable, and a lead lotion may be applied frequently to the painful nodules, either hot or cold as may seem more grateful to the patient. Meanv/hile the general condition of the patient may be improved by iron, bitter tonics, and nutritious food, and a return of the disease prevented. FAVUS Favus is caused by the growth in the epidermis of a vegetable organism called the achorion. It usually appears upon the scalp but may affeft the trunk and extremities. It is charafterized by the formation of small, yellowish, cup-shaped crusts, each seated at the mouth of a hair follicle and often perforated by the hair shaft. In chronic cases the accumulation of these crusts, which are at first of a bright yellow hue, forms a thick, friable, pale yellow mass raised considerably above the level of the skin. Upon the scalp the develop- ment of the crusts interferes with the growth of hair and in time produces more or less baldness. In many cases a wiry condition of a few sparse hairs growing from a scalp which presents cicatricial depressions is positive evidence of former favus, although the aftive disease may have been cured for many years. The disease is far less common in this country than in certain parts of Europe, and is more frequently observed in our seaport cities than in the interior. The disease is usually an imported one (from Poland or elsewhere) and has increased notably within the past twenty years. The upper illustration shows a boy with favus capitis. The charafteristic bright yellow cup-shaped crusts are present. The lower illustration presents the form called favus corporis (or favus epidermidis). This patient was presented several times at meetings of the New York Dermatological Society. At one clinic he would get nearly well, then stop treatment and in three or six months appear at another clinic with the disease in full bloom. Copyright, h/j>j, by _ ^^ l'- •• FIBROMA FIBROMA is a connective-tissue neoplasm which may form one or many nodular, pouch-like, or pendulous tumors of the skin. It has been called molluscum pendulum, molluscum fibrosum, and fibroma molluscum. A very simple form, to which the names acrochordon and fibroma filiforme have been applied, consists of a small thread-like excrescence, a few lines in length, which is most commonly seen upon the neck of middle-aged or elderly women. These are usually multiple and sometimes quite numerous. They give rise to no annoyance, although they may be considered undesirable by those who prefer to have a normally smooth skin. Another common form of fibroma is the firm, rounded tumor which fre- quently develops upon the face in adult life, and is commonly spoken of as a mole (nsevus fibrosus). When small these are of the color of the surrounding skin, but when they attain the size of a small pea they are apt to be of a dull red hue, and may be slightly constricted at the base. In most cases of multiple fibroma the tumors are soft and pouch-like, vary in size and density, and frequently cover the greater portion of the body. They may be congenital, but usually develop or increase in number and size in later life. Some of the tumors may be slightly indurated and feel like split peas imbedded in the skin, but the great majority are soft, and pressure with the finger shows that the corium at their base is thinner than elsewhere. Frequently one or more large pendulous tumors may co-exist with hundreds of small tumors, either sessile or pedunculated. When a broad pendulous tumor forms and appears like a ridge or flap of redundant skin, the disease has been described under the name of dermatolysis or pachydermatocele. This growth differs in no essential respect from the large pedunculated tumors. The skin in some cases appears coarse in texture loo THE TREATMENT OF SKIN DISEASES and is slightly pigmented, while in others it is atrophied from tension and appears smooth and fine. The periphery of the growth is generally more dense than the included, projecting portion. The cause of this fibrous growth is unknown. Many patients with multi- ple fibroma are small, poorly developed, and weak, and the disease may occur in successive generations. The treatment of fibroma consists solely in the removal of the tumors. The small filiform excrescences so common upon the neck, or longer ones which may develop on the back or in the axilla, can be best treated by means of sharp, curved scissors. It is advisable to first seize the growth with a pair of delicate forceps and make gentle traction in order to remove it entirely and yet without injury to the adjacent skin. The slight hemorrhage, which is sometimes rather persistent, ca-n be readily checked by touching the cut surface with a stick of nitrate of silver. The firm, rounded fibroma so often occurring upon the face can be best treated by means of an electrolytic needle. This should transfix the growth in the direction of the cleavage lines of the skin, being introduced at one or more points according to the size of the tumor. This method of treatment will cause the growth to shrivel, and perhaps become necrotic. In the latter case the blackish crust which forms will usually fall in a week or ten days. In using electrolysis for a fibrous mole upon the face of a girl or a woman, it is well to bear in mind that it is far better to destroy too little than too much tissue. In the former case the operation can be repeated, while in the latter case a depressed scar or pit is apt to be left, to the dissatisfaction of the oatient and the discredit of the operator. In cases of multiple soft fibroma the tumors may be excised when they are few in number or situated so as to become inflamed by the friction of the cloth- ing. When numerous, their successive ablation is rarely desired by the patient. The large flaccid tumors or rolls of skin seen in cases of fibroma pendulum (dermatolysis) may be removed by the knife or galvano-cautery, but these growths are extremely vascular, and when they involve the head, an opera- tion is usually a serious matter. FURUNCULUS loi FURUNCULUS A furuncle, or boil, is an acute phlegmonous nodule involving the skin around one or more follicles, and terminating in necrosis of its central por- tion. It begins as a painful induration, rapidly forms a rounded or conical, reddened tumor, and usually presents a yellowish point or follicular depres- sion at the summit. After several days of throbbing pain, suppuration takes place, and the core of the boil, a whitish necrotic mass, is evacuated. A furuncle may occur singly, or a number appear at the same time, and in many cases successive crops of boils keep the patient in misery for months or years, if proper treatment is not instituted. They occur upon vari- ous parts of the body, but most frequently upon the neck, shoulders, but- tocks, and hands. The etiology of furunculus is a most interesting subject, and though it has been carefully studied, there still remain some unsettled problems. That a boil is of a parasitic nature, and directly due to the presence in the skin of a microorganism (usually the staphylococcus aureus), is generally ad- mitted, but there is much said and written concerning a furuncular diathesis or predisposition on the part of the patient, which is much easier to claim than to substantiate. Diabetic patients seem to be especially prone to suffer from boils and carbuncles, and the reason for this has never been satisfac- torily explained. A relationship of boils to gout, chronic disorders of the digestive system, and disturbances of menstruation has been claimed, but it is very doubtful whether the assertion of such a relationship can be sup- ported by facts. As to sewer gas and arsenical wall papers being causative factors in furunculosis, the idea seems scarcely more absurd than would the assertion that they cause pediculosis. When boils occur in Bright's disease, tuberculosis, and convalesence from various fevers, it is not because the skin has undergone any pathological change which renders it a more favorable soil, but because ordinary ablution has perhaps been neglected, and through the favoring influence of local heat and moisture the furuncular germs have found their way into the follicles. 102 THE TREATMENT OF SKIN DISEASES The disease is one of external origin, and is contagious. This accounts for its frequent occurrence in damp and crowded buildings, and for its occasional epidemic form. The fact that it occurs frequently in perfectly healthy subjects, and with especial frequency among boat crews (as con- tagious impetigo does among football players), points to its entire independ- ence of any general disorder of nutrition or any local condition other than that which exists in the normal skin. 1 cannot agree with Jamieson, who states in his admirable work on Skin Diseases that a well-recognized cause of boils is found in the regimen pursued by those training for boat-racing or pugilists. He says that the more out of condition they are before going into training, and the harder they train, the greater the liability to boils, or, ex- pressed otherwise, the more sudden the change. This is attributed to a rapid alteration in the condition of the blood and tissues, due both to the variation in dietary and the increased metamorphosis of tissue from exercise. The fact that the oarsmen's hands are most frequently the seat of the boils is more readily explained by the hypothesis of microbes on the oar handles. In short, the favorable soil which is mentioned by so many writers has little or nothing to do with the diet or the general health, but results simply from a lack of absolute cleanliness. The treatment of a furuncle is much simplified by this view of its eti- ology. Internal treatment can have no direct effect upon the disease. Yeast, the remedy to which so many have pinned their faith in past years, and in which 1 used to be a firm believer, must be discarded as a therapeutic delusion. Arsenic, that much-abused remedy, which sometimes does good in other skin diseases, cannot possibly do anything but harm in this disease. Sulphur, which in some one of its forms has been so highly recommended and so faithfully prescribed, must be condemned as having no more value than its internal use in scabies. Even calx sulphurata (sulphide of calcium), which has been almost universally conceded to be of value in all suppurating skin diseases, must be recognized as inadequate to cure a boil. 1 have long been of the opinion expressed by Hyde, that it is extremely doubtful whether this drug exerts any influence whatever upon furuncles. Hardaway refers FURUNCULUS 103 to the laudation of the drug by various therapeutists, and adds that, after using it in a routine way for sixteen years, he is unable to affirm that he has ceen any constant or certain effect from it. Allen recommends the internal use of the hyposulphite of sodium in doses of from ten grains to a drachm, given well diluted, in the morning, or in smaller doses repeated during the day. He attributes its beneficial action to its elimination through the glands, but others who have tried the remedy are inclined to believe that this beneficial action is purely hypothetical. Although internal treatment can neither cure nor directly influence the course of a boil any more than it can affect ringworm or other local skin diseases, it may improve the health of the patient and indirectly lessen the amount of inflammation produced by it. A man in perfect health is as liable to have a boil as one who is weak and debilitated, provided the furuncular germs find access to a follicle, but in the case of the latter the inflammation and suffering resulting from the local infection will naturally be much greater. The application of iodine, nitrate of silver, or carbolic acid to the surface of the inflamed skin is not likely to do good, and may serve to increase the inflammation, as does that most popular of domestic remedies, "soap and sugar." When a patient with a boil applies for treatment, the microorganisms which cause it are already deep in the skin, and the best method of reaching and destroying them is to introduce a little carbolic acid into the follicular open- ing around which the boil begins to suppurate within forty-eight hours. If a sharp-pointed wooden toothpick is dipped in pure liquefied carbolic acid, and carefully and repeatedly pressed into the minute pustule or crust which forms at the summit of an incipient boil, it will often succeed in checking its further development. This procedure ought not to cause much pain, as the acid tends to act as a local anaesthetic. When the boil has developed into a conical pustule on a reddened and indurated base, a small bit of absorbent cotton wrapped tightly around the point of the toothpick will enable one to introduce more acid into the furuncu- lar mass, with the effect of quickly lessening the throbbing pain and causing a decided diminution in its size. Even when a core has formed, the use of the 104 THE TREATMENT OF SKIN DISEASES acid will hasten its expulsion and prove far more beneficial and much less disagreeable to the patient than the ordinary treatment by free incision and poulticing. At this stage it is unnecessary to incise a boil, although there is no great objection to doing so, if it will please either physician or patient. Before the boil is fully "ripe" incision does more harm than good. Piffard says: "A furuncle should never be opened prematurely. The core or slough remains attached by its deeper extremity for some time, and until this is loosened and discharged the boil will not heal. If prematurely opened the pus is discharged, but the core remains attached much longer than if the furuncle were permitted to fully mature." The ordinary hot flaxseed poultice, however grateful it may feel ■ when applied, has been the means of multiplying boils in very many cases. By macerating the surrounding skin and smearing it with the inoculable pus from one boil, the poultice naturally tends to the production of a successive crop. If used at all, it should be made with a saturated solution of boric acid, or water containing one or two per cent, of carbolic acid or one-tenth of one per cent, of bichloride of mercury. After the furuncle has been treated with carbolic acid in the manner above described, a salicylic ointment or paste may be applied in place of a poultice. The following formula will prove both soothing and prophylactic : IJ Acidi salicylic! 5 Tincturse calendulse 5 Amyli 5 Unguenti zinci oxidi ad 100 m In cases where successive crops of boils have appeared, as they frequently do, the disease is termed furunculosis, and there is a prevalent belief that a furuiicular diathesis exists ; i. e., a systemic condition of which the boils are simply an external manifestation. When this idea is abandoned, together with all internal remedies, and strict attention is paid to external cleanliness and thorough cutaneous disinfection, 1 believe that few, if any, cases of furunculosis will occur. HERPES Herpes is an affection consisting of vesicles in one or more groups upon an erytliematous base. It- runs an acute course and while often disappearing in a few days may persist for a week or more, especially when the eruption appears in successive crops. The affection should be differentiated from zoster, which some writers describe as one of the forms of herpes. Zoster is almost invariably unilateral, occurs in multiple patches which usually follow the course of the cutaneous branches of a sensory nerve, and rarely affects a patient more than once. Herpes, on the other hand, is usually bilateral, frequently occurs as a single small patch, and .when multiple, appears independent of any nerve distribution. Moreover, it is especially prone to occur in the form of recurrent attacks. Herpes is most commonly seen upon the lips but in severe cases it may affect the whole lower portion of the face including the ears and nose. Its outbreak is often attended by a slight degree of fever. It may be noted at the outset of a severe cold or any affection which is liable to be ushered in with a chill. Local irrita- tion in predisposed persons may also evoke the eruption, particularly upon the genitals where it is also common, f^ Copyright, 1900, by G. H. Fox HERPES FACIEI. HERPES ,05 HERPES Herpes is a name applied to a group of vesicles which is most frequently seen upon the lips, and commonly known as a "cold sore." It is often ob- served in connection with acute affections which are ushered in by chilliness and fever, but may occur independently as a direct result of wet feet and exposure to a draught of air. in some cases the eruption is not limited to the lips, but occurs upon the nose, cheeks, and neck. The prepuce and vulva are also favorite seats of the eruption, and certain individuals are prone to suffer from recurring attacks. The disease runs an acute course, rarely lasting more than three or four days if the affected skin is not irritated in any way. Herpes, whether occurring upon the face or genitals, is manifestly neu- rotic in character, and results from reflex irritation, due to some systemic or local condition which is not always discoverable. An acute general catarrhal condition may be the cause of herpes progenitalis as well as of herpes labialis. Local irritation, which is a frequent etiological factor in the case of genital herpes, rarely, if ever, provokes an eruption upon the face. Although the former is frequently the result of venereal excesses and a disregard of strict personal cleanliness, it may occur in men who have never had any venereal disease, and apparently from no local irritation. The treatment of herpes labialis is of no great importance, as the erup- tion tends naturally to a speedy cure. Whether any therapeutic measures can hasten this cure, or do more than satisfy the patient's desire for some kind of treatment, is a question not easy to decide. To abort an attack of labial herpes by painting the patch with spirit of camphor, rubbing it with a piece of borax, or applying alcohol, may indeed be possible, as some have claimed, but in my experience the desired result is rarely attained. When the vesicles have formed, the burning sensation may be relieved by a zinc lotion, and, later, the thin crust may be softened by applying a little cold cream. The following lotion of Leloir may be employed early with a hope of shortening the attack : io6 THE TREATMENT OF SKIN DISEASES § Cocainse hydrochloratis 2 Resorcini 3 Aicoholis ad 100 m In the treatment of genital herpes, cleanliness is of the utmost impor- tance. If the parts are bathed several times daily in warm water (without soap), especially after each urination, the raw surface left by the rupture of the vesicles will usually heal readily, while the powders, washes, pieces of linen, and tufts of cotton so frequently prescribed are quite as liable to irritate as to soothe. When suppuration has taken place, a lotion of boric acid may be used, and a little of the same in form of powder carefully applied. The superficial cauterization of the raw surface with a lotion or pure stick of nitrate of silver is recommended by miany, but even the slight pain caused by this application is usually unnecessary. Brocq advises the following powder : I^ Zinci oxidi . 2 Hydrargyri chloridi mitis 2 Bismuth! subnitratis ad 10 To prevent attacks of recurrent herpes, it may be advisable to carefully investigate the sexual habits of the patient, and possibly to circumcise a re- dundant prepuce, but in most cases a strict hygienic regimen that will put the patient in his best physical condition will prove of the greatest service. Schiffand Leistikow have derived benefit from an ointment containing five or ten per cent, of coal tar rubbed upon the genitals two or three times a week. Piffard suggests the systematic application of astringents, tannin, catechu, etc., with a view to toughening the membrane. Monin recommends the cold douche for thirty seconds over the lumbar vertebra to be given twice a week. Wolff and Duhring strongly advise arsenic, the former continuing its use for six or eight months. Qiiinine has been found in some cases to control the dis- position to relapse. HYPERIDROSIS ,07 HYPERIDROSIS Hyperidrosis, or excessive sweating, may be pliysiological, and result from active exertion, from an unusually high temperature, or from a combi- nation of both. An excess of perspiration may also be pathological, and occur in connection with tuberculosis, articular rheumatism, malarial and other fevers, and any exhausting disease. Under these circumstances the hyperi- drosis is usually universal. Localized hyperidrosis is a common affection, and one which is of particu- lar interest to the dermatologist. The hands, feet, head, and axilla are the regions most frequently affected, and when the perspiration is greatly increased in amount, the patient suffers not only from the unpleasant mois- ture, but from the tenderness of the macerated skin which usually results. In some cases the hands or feet alone may be affected. Moisture of the hands, at all times disagreeable, frequently interferes with the daily occupation of the patient, especially when this involves the handling of delicate fabrics. Under slight emotional excitement the perspiration is sometimes increased to such an extent that it will drip from the fingers. In severe and chronic cases the palms present a shrivelled appearance, such as may be seen in washer- women, or in a normal hand after a prolonged hot bath. In hyperidrosis of the feet the stockings are quickly moistened, and in time even the shoe-leather absorbs more or less perspiration, which, under- going a chemical decomposition, gives rise to a pungent and offensive odor. The skin upon the soles becomes macerated, and often so tender that locomo- tion is seriously impeded. The epidermis sometimes peels in large flakes, and much walking is liable to produce blisters. Excessive perspiration of the axilla is frequently noted when patients are stripped in the clinic, and is consid- erably increased by the excitement or embarrassment incident to the occasion. Hyperidrosis is a purely functional disease of the sweat glands, and results from paralysis of the sympathetic or other disturbance of the nervous centres. Cardiac disease and various neurasthenic conditions seem to predis- pose to its occurrence, and may be regarded as an indirect cause of the io8 THE TREATMENT OF SKIN DISEASES affection. Many cases of cerebral and spinal disease and tumors pressing upon the sympathetic have apparently given rise to profuse local sweating, but still we find hyperidrosis^ existing in many cases where no cause what- ever can be discovered. The disease is sometimes unilateral, and due to faulty innervation of the affected region or to a possible neuritis. It has been known to follow severe migraine and zoster gangr^nosis. Kaposi mentions a woman with syphilis, the left side of whose face and right side of body were covered with drops of sweat on the slightest emotional excitement, while the rest of the body remained dry- The treatment of hyperidrosis is more apt to be palliative than curative, since, as has been remarked, the cause of the disease is difficult to remove even when it may be discoverable. An improvement of the patient's physical condition, whenever this is possible (and it is possible in about ninety-nine per cent, of cases), should be the first therapeutic consideration. Systematic cold bathing, which is such an admirable tonic to the general nervous system, and capable of doing so much good in various cutaneous reflex disorders, will often tend to remove the hidden cause of hyperidrosis, in addition to its having a directly beneficial effect upon the skin. Many patients have as great a horror of cold water in the morning as they have of fresh air at night. 1 have had to argue long with many women and young girls before inducing them to jump into a tub of even cool water upon getting out of bed in the morning. I have rarely found any who could not do it with benefit to themselves, and 1 have been cordially thanked by scores for the prescription, or rather for my vigorous insistence upon their taking it. Many of my patients, who have given up a strict diet as soon as they were no longer under my care, have continued to take and enjoy the cool bath prescribed, and months or years later have confidentially told me that it had done infinitely more for their health and complexion than all the various medicines which they had taken previous to the adoption of this simple and delightful remedy. 1 do not claim that cold bathing will cure hyperidrosis, but if this is insisted upon in the case of those to whom it is a novelty, in spite of their assertions as to a weak heart, a tendency to rheumatism, or a failure to react, HYPERIDROSIS 109 I am certain that it will tend to lessen the excessive perspiration, and cer- tainly constitute an excellent foundation for other therapeutic measures. The use of sea salt or dairy salt will make a bath more stimulating to the skin, and often relieve pruritus, but as a tonic it is the action of the low tem- perature upon the terminal nerve filaments that is most desirable. Salt to be of any service in a bath must be used in large quantity as recommended by Piffard. The use of tar, carbolic acid, or sulphur soap in connection with the bath will add nothing to its beneficial effect. The internal treatment of hyperidrosis includes quinine, which would naturally be indicated when any malarial origin of the affection can be justly assumed; iron, the mineral acids, and any remedy which might seem of ser- vice regardless of the perspiratory disturbance. Ergot and belladonna have been prescribed for their direct effect upon the functional disorder of the sweat glands, but the most that can be claimed from their use is a temporary effect. The fluid extract of ergot may be given in doses of a half drachm, three times daily, and atropine in doses of xfo- to W of a grain. Agaracin, 1- of a grain, is highly recommended by Piering. Crocker has found sulphur the best of all internal remedies in his experience, and cites an obstinate case in which, after almost every variety of treatment had been tried in vain, sul- phur kept the disease under for twelve months, and then even the sulphur failed to do good. He gives a level teaspoonful of the precipitated sulphur twice a day in milk. When it purges too much, it may be combined with astringents, as in the following formula : JJ Pulveris cretae compositse 3 vi 35 Pulveris cinnamomi compositae 3 ii lo Sulphuris praecipitati 3 i ad 100 m A teaspoonful to be taken twice a day. The condition of the digestive apparatus is commonly thought to have little or nothing to do with the disease, yet, according to Hyde, meat should always be 'largely eliminated from the dietary. Occasional purgatives or laxa- tives in the form of mineral water, taken early in the morning, have been advised no THE TREATMENT OF SKIN DISEASES with a view to increasing the elimination of fluid by the intestines and thereby lessening the cutaneous discharge. The free use of water and other cooling beverages during the hot summer months, so agreeable and beneficial under normal conditions, may be found objectionable and should be restricted when a notable aggravation of the disease is thereby occasioned. The effect of clothing in producing or increasing a tendency to hyperi- drosis is worthy of consideration, and garments which are too warm, too tight, or of too rough texture should be avoided. But the disease occurs upon uncovered parts, and often in the coldest winter months. The necessity for a very frequent change of underclothing scarcely needs to be mentioned. The local treatment of hyperidrosis has called forth so many remedies that it may be fairly assumed that no single one is of preeminent value. All of the absorbent powders and astringent lotions which have been recom- mended do a little good, but rarely if ever cure the disease. For hyperidrosis of the head and hands a lotion is most convenient to use, especially during the day. 1 have used one to three per cent, of quinine in cologne water with good effect, but would not say that it is better than a one per cent, solution of formalin or naphthol, or lotions of permanganate of potash, sulphate of iron, bichloride of mercury, and other astringents and disinfectants which have been praised. For hyperidrosis of the axilla a powder is most convenient to use, and the subcarbonate of bismuth or the stearate of zinc will usually act as well as the complicated mixture of several powders to which some have ascribed especial virtue. The skin should be carefully wiped dry with a soft cloth before applying the powder, and the patient made to understand that frequent and vigorous scrubbing with soap and warm water will do more harm than good. The application of extremely hot water will, however, tem- porarily check the perspiration, and ladies who suffer from axillary hyperi- drosis can sometimes attend a dinner party in comfort after holding for a few minutes in each axilla a large ball of absorbent cotton dipped in water as hot as can be borne. Hyperidrosis of the hands may be treated by the lotions and pow- HYPERIDROSIS m ders already mentioned. When the pahns are chiefly affected, they may be bathed in a solution of alum or tannin, carefully dried, and a powder composed of salicylic acid and talcum (one to five), or plain boric acid, rubbed frequently between them. In very obstinate cases, painting the palms (or soles) with a five per cent, solution of chromic acid may be tried. Pollitzer says that it always stops the sweating at least for several days and sometimes cures permanently. The application may be made every ten or twelve days, but great care must be exercised lest there be any rhagades, or cracks, in the epidermis, as lymphangitis, with serious conse- quences, may result. Faradization, which has been advocated by some writers, can be most conveniently employed in cases of manual hyperidrosis. To be effective it should be repeated every day or two. Meanwhile the following lotion may be used : ]J Tincturae beliadonnse lo Aquae cologniensis ad loo m Hyperidrosis of the feet is the most common and unpleasant form of the disease, since in this region the decomposition of the sweat is most likely to be accompanied by a fetid and disgusting odor (bromidrosis). In many individuals, perspiration of the feet is not agreeable to the olfactories even before putrefaction takes place ; but when the fluid is swarming with bacteria the affected person is almost banished from human society. In mild cases a frequent change of shoes as well as of stockings, and the persistent use of any astringent or disinfectant lotion, or finely pow- dered alum as an absorbent powder, will prove a simple and efficient method of treatment. On account of the power which boric acid exerts in arresting decomposition, and its freedom from irritating qualities. Thin, of London, advises a change of stockings twice a day, and, when there is any fetid odor, the immersion of the stocking feet for several hours in a jar containing a saturated solution of boric acid. When dried and freed from the bacterium foetidum, which he claims to be the cause of the disagreeable 112 THE TREATMENT OF SKIN DISEASES odor, the stockings may be worn again. He also recommends each patient to provide himself with a half dozen pairs of cork soles, which may be changed daily and soaked in the boric acid solution with the stockings. In severe forms of the disease the diachylon treatment of Hebra may be employed. Lead plaster and olive oil are melted together and stirred until a smooth mass results. This is spread on pieces of stout linen and plastered smoothly over the feet, which should previously be thor- oughly cleansed with soap and water. Lint smeared with the ointment should be introduced between the toes. A light stocking or bandage is now applied. This dressing is to be renewed twice each day, the foot being wiped with a dry cloth, but not washed. The patient may walk about with a loose shoe which does not cover the dorsum of the foot. This treatment is continued .one or two weeks, according to the severity of the disease. The diachylon dressing is then superseded by some absorbent powder, and the patient allowed to resume his shoes and stockings. In a few days a brownish-yellow layer of cuticle begins to peel from the affected skin, and a clean, white, healthy surface is exposed. When this layer of cuticle has been completely detached, the foot may be washed and the daily powdering continued. A simpler method is to strap the feet carefully with lead or soap plaster. , This may be repeated every three or four days, and often a prompt cure will result. In the German army the military regulations prescribe a salicylic suet (salicylic acid, two parts ; mutton suet, one hundred parts). A French army surgeon advises washing the feet thoroughly, applying subnitrate of bismuth and renewing frequently without further washing. It is claimed that a cure will often be accomplished in a fortnight. The question as to possible harm in checking an excess of perspiration has repeatedly been raised, but no case of injury has ever been reported. Even the common fear that a bath taken while perspiring may invite dis- ease or death is entirely groundless, and ranks with the myth respecting the retrocession of cutaneous eruptions. HYPERTRICHOSIS HYPERTRICHOSIS is an abnormal growth of hair, whether it be in amount or in locality. It may be congenital, and consist of an unusual hairiness of the whole body, with the exception of the palms, soles, and certain other regions where hair follicles are never present, and tends to increase in later years. It may be localized, as in the case of a hairy mole. Hypertrichosis also occurs as an acquired affection, and may result from local irritation of the skin— e.g., by the continued use of a stimulating plaster— or from some indefinite disorder of nutrition, the origin of which may be looked for in some arrest of development or disturbance of the nervous system. The bearded women on public exhibition, and countless similar cases of less degree in private life, are examples of this latter form and of special interest from a therapeutic point of view. The causes of hypertrichosis are not usually apparent, and the disease or deformity must be accounted for in most cases by ascribing it to some freak of nature. Occasionally the growth is evidently hereditary, and occurs in several members of a family. In my experience it is vain to seek for any con- dition or peculiarity common to all patients. Some are in fine physical condi- tion, while others are debilitated. Some are extremely nervous ; some are not so in the slightest degree. Some are stout and some thin. Some are dark and others of light complexion. Some are maidens from sixteen to sixty years of age ; while among those who are married, some have children and some have none. The common idea that the growth of a beard in the female is necessarily associated with masculine traits of character is certainly not founded upon fact, for most of my patients have presented the highest type of feminine refinement. A relationship between facial hypertrichosis and a malformation or 114 THE TREATMENT OF SKIN DISEASES imperfect development of the reproductive organs has been claimed, and doubt- less exists in some cases. 1 have repeatedly noted its connection with deficient menstruation, and seen a growth of hair upon the body diminish after a resto- ration of a suppressed menstrual flow. Persistent local irritation, which increases the hypersemia of any hairy part, may cause hypertrichosis, but the idea which seems to prevail among fashion- able ladies, that sea-bathing or the use of vaseline upon the face will occasion an abnormal growth of hair is too fantastic for serious discussion. No proof of the assertion is ever shown, and how such an erroneous idea originated is difficult to imagine. The treatment of hypertrichosis may be either palliative or radical. Hairs may be pulled out, but, the papilla from which the hair grows not being destroyed, the hair soon grows again. There is a common tradition which is particularly disquieting to ladies with a few hairs upon the chin. It is to the effect that for every hair that is pulled out two will be certain to grow, or that the growth will become thicker and stronger as a result of this procedure, it is a question whether there is any basis for this prevalent belief, it does not explain why the first hairs should grow, and it is certain that when there is any tendency to an increase in the growth, as is frequently the case, new hairs will develop whether any be pulled or not. It is said that the American Indians have tried for many generations to destroy their beards by constant epilation, and have only succeeded in producing a thin, weak growth of hair upon the chin. This lack of success might encourage rather than deter ladies from their attempt to destroy hair by epilation ; but, as a matter or fact, the pulling of a few hairs has no effect upon the growth of others in the immediate vicinity unless the skin is kept in an inflamed condition, and the rudimentary hair- bulbs thereby stimulated to an abnormal functional activity. The shaving of the hair has probably no more effect in increasing its growth. Certain ladies are compelled to shave because they have a beard. They do not have the beard as a result of shaving. A young man may use his razor persistently for the purpose of developing a fine mustache, and with time and shaving his heart's desire is usually attained. Time, without the aid of a HYPERTRICHOSIS ,,5 razor, will accomplish the same result, in spite of the prevalent belief to the contrary. When hairs upon a lady's face are few and far between, there is no objec- tion to pulling or cutting them with small curved scissors ; but when they are numerous, this operation involves too much time and trouble, and some depila- tory is far preferable. This will remove the hair temporarily and leave the skin smooth and presentable for weeks or months, according to the strength of the growth and its tendency to increase. I have known a light downy growth to be permanently removed by repeated use of a depilatory powder at long intervals. But it is hopeless to attempt the permanent removal of well- developed hairs by the use of any lotion or paste, and the numerous remedies advertised in the daily papers, with brazen assurance, or a guarantee that they will accomplish this purpose, are certain to fail in the production of any result save sore disappointment. Depilatories, carefully used, are of great value as a palliative measure, especially in the removal of hair from the extremities where its permanent eradication would involve a great amount of time, trouble, and expense. But the unskilful use of a depilatory upon the face will sometimes burn the skin, and leave it red and tender for several days, and its too frequent use may keep up an irritable condition, which will greatly favor an increased growth of hair. A depilatory is composed of the sulphide of calcium or barium mixed with starch. This powder, moistened with sufficient water to form a paste, is spread over the hairy part, and, when dry, carefully removed with a wet sponge or cloth. The only method of permanently removing hair which experience has found to be practicable is by the use of electrolysis. This operation originated in America, and during the past twenty years has been adopted by derma- tologists in all countries, it was first proposed by Michel, of St. Louis, for the radical cure of trichiasis, and was afterward applied to the facial hirsuties of women by Hardaway. In the performance of this operation it is necessary to have a galvanic battery capable of giving a steady current of from two to ii6 THE TREATMENT OF SKIN DISEASES five milliamperes, a fine needle, and a suitable needle holder, which is to be attached to the negative cord of the battery. A sponge electrode attached to the positive cord may be applied to the palm of the hand by the patient after the needle has been inserted in the follicle. The current generated by the battery does not destroy the hair papilla by means of heat, but through a chemical decomposition of the fluid contained in the cutaneous tissues. This gives rise to a slight amount of subsequent inflammation and causes a com- plete destruction of the papilla, or, at least, of its hair-forming function. The needle which 1 have used for over twenty years is a delicate, flexible, steel jeweller's brooch. Hardaway prefers a fine irido-platinum needle. For the removal of coarse hairs, as in a case of nasvus pilosus, an ordinary small cambric needle will answer the purpose. This may be bound to the metal end of the negative cord by a few turns of fine copper wire, the fingers being pro- tected by sliding an inch or more of rubber tubing over the joint. If a special needle-holder is employed, the shorter and lighter it is the better will it serve its purpose. The spring-button electrodes I have found objectionable on ac- count of the suddenness with which they close the circuit and the consequent shock which the patient receives. A strong light is desirable for the operation. The patient should sit comfortably in a high reclining chair, with the head of the operator on a level with her chin. The needle is now introduced into the follicle, and the success of the operation depends largely upon the skill with which this is done. Good eyesight and a steady hand are as strictly essential as they are in rifle shooting. But many a man, even thus endowed, can never acquire the art of repeatedly hitting a bull's-eye. And many physi- cians 1 have found who, after long practice, have failed to acquire the peculiar knack of introducing a needle into the follicle without pricking the skin. Some simply jab it into the skin as near the hair as possible, and thereby give rise to the erroneous impression, held by many, that the operation is a very painful one and likely to leave scars. When the needle is carefully introduced, the patient, holding the insu- lated handle of a moistened sponge electrode, may apply this to the palm of ICHTHYOSIS Ichthyosis is a congenital deformity rather than a disease of the skin. it is frequently hereditary and is characterized by a notable dryness of the epidermis resulting from a lack of the usual sebaceous and sudoral secretions. In the mildest form, the surface of the skin, especially upon the extremities and in the winter season, may appear mealy or present an appearance suggestive of parchment. In the more common form the epidermis cracks into irregular plates which adhere in the center and curl up at the margins. Frequently these epidermic plates are polygonal in shape and of a dirty hue, giving the surface of the skin a peculiar serpentine appearance. In the severest form of the disease infants are born with a thickened horny skin, which breaks into large plates. These may become detached, leaving a thin bright red corium beneath. Such infants rarely live. The illustration shows upon the legs the horny plates of epidermis with peeling edges. Also the roughened and wrinkled condition usually seen about the elbows and knees. The patient, a girl of sixteen, had a brother similarly affected. Copyright, iij'xj, by G. H. F»" Copyright, iqoo, by G. H. Fox. KELOID. KELOID ,2, remain for years without apparent change, while others tend to increase by an even peripheral extension or by the growth of the clawlike prolonga- tions. Occasionally a tumor may decrease in size, and even disappear in time, but this termination is likely to involve a question of diagnosis between true keloid and a hypertrophic cicatrix. The scars of certain ulcers are often raised by the puckering of the skin in the process of healing, and frequently these increase in size and density, and become firm, rounded tumors, bearing a very strong clinical resemblance to keloid. Tumors either rounded or ridged, so often left by acne, sycosis, variola, scrofuloderma, and syphilis, are often called keloid, although they lack the essential features of this disease. Such tumors invariably tend to flatten and to disappear in time, and are quite amenable to treatment. They may be excised and a smooth linear cicatrix left in their place. True keloid has a marked tendency to develop upon a cicatricial base, and this clinical fact tends greatly to complicate the question of diag- nosis. Just where the line should be drawn between a simple elevated cicatrix and a scar keloid which has not as yet become painful or sent out any clawlike prolongations into the healthy skin is an extremely difficult matter to decide. Keloid occurs in both sexes and at any age. In the negro it is notably common as compared with its occurrence in the white race. Its hidden cause appears to be associated with some individual predisposition, of the nature of which we are ignorant. In certain cases a keloidal tumor is certain to develop wherever the skin is cut, pricked, or injured in any way. Many writers have made a distinction between true and false keloid, claiming that the former arises spontaneously and that the latter develops upon an injury to the skin. So far as we know, every keloid may arise from some injury to the skin, although in very many cases it is impossible to get any history of even the prick of a pin or a scratch. Apparently idiopathic keloid and keloid developing upon a cicatricial base (scar keloid) are one and the same in nature. But every elevated and dense cicatrix is by no means a keloid simply because it may and often does sub- sequently become the seat of this disease. 122 THE TREATMENT OF SKIN DISEASES The treatment of keloid has always been considered as very unsatis- factory, although some have reported complete success in the treatment of certain cases. If the diagnostic points above mentioned are borne in mind, it is an open question whether true keloid can be cured. In many severe and unmistakable cases, every attempt to remove the tumors by deep and wide excision or by the free use of caustics has failed to accomplish any permanent result. Many of the tumors have shown their disposition to recur even before the wound had healed, in the treatment of several cases which looked very much like keloid and which had been called keloid, 1 have had most gratifying success both by linear scarification and by electrolysis, but 1 am not positive that 1, or any one else, has ever cured a case of true keloid. The methods of treatment to be mentioned are such as will certainly prove of service in cases of hypertrophic cicatrix or tumors which appear keloidal and which might be properly termed keloidoloid. Linear scarification, recommended by Vidal in the treatment of lupus and other- skin diseases, is of considerable value in reducing the size of the fibrous growth. The parallel cuts seen upon the surface of the skin after use of the scarifying knife or scalpel should be covered with a mercurial plaster, or some caustic application may be applied by means of a soft brush. In a case of reticulated scar tissue upOli the face of a young lady whose cheeks looked like waffles, 1 used the glacial acetic acid subsequent to scarification with a most desirable result after many repeated operations. Electrolysis is a simpler method of treatment and quite as effective. On account of the density of the tissue a cambric needle should be used in place of the finer ones mentioned in connection with the electrolytic treatment of hypertrichosis, it is to be attached to the negative cord of the battery and should transfix the base of the tumor, making a series of .parallel lines through it. A current of five milliamperes or more should be used, and its action will be noted in the speedy whitening of the tissue in the vicinity of the needle. After a number of punctures the tumor may appear larger than ever for a few minutes, but contraction soon takes place, and in a week or ten days it will often be notably smaller. The opera- KELOID 123 tion may now be repeated and the treatment continued for months, or as long as is necessary to bring the growth to a level with the surrounding skin. Caustics, such as potassa fusa, were formerly in vogue for the destruc- tion of cutaneous tissue, but have been largely supplanted by the electro- lytic needle, in keloidal tumors Marie injects a twenty per cent, creosote oil. Leistikow uses a galvano-cautery with fine platinum wire in place of an electrolytic needle, and then covers the tumor with a pyrogallic acid plaster, or the following : 5 Ichthyol 10 Pyrogallol 10 Collodii flexilis ad 100 m Thiosinamine, first used by Dr. Hans Hebra in the treatment of lupus and other tuberculous affections, has been highly praised by Tousey, Newton, and others in the treatment of keloid and hypertrophic cicatrices. A ten per cent, solution of the drug in absolute alcohol or sterilized glycerin and water is used, and from ten to fifteen minims may be injected subcutaneously near the fibrous growth, the injections being repeated every two or three days. According to Tousey, a marked effect upon the blood is produced. He found that the number of white blood-cells was reduced within five minutes to a third of the normal amount. They increased again rapidly, and for forty-eight hours there was pronounced leucocytosis. The injections are attended by considerable pain, and are sometimes followed by a feeling of tension in the keloidal growth or scar tissue. Nau- sea and vomiting are apt to be occasioned by the injection of larger doses than ten minims, and headache or a drowsy sensation is often produced. Experiments with thiosinamine injections at the Vanderbilt Clinic have not produced any brilliant results, and the mere softening of the tissue reported in several cases might be as readily obtained by some other and less disa- greeable method of treatment. 124 THE TREATMENT OF SKIN DISEASES KERATOSIS FOLLICULARIS This disease has been called keratosis pilaris and lichen pilaris, but it is a disease of the follicle and not of the hair. It consists of an abnormal desquamation and accumulation of horny cells in the hair follicles which produces an eruption of numerous small, conical, follicular papules of a whitish hue, or of a reddish color when they have become scratched and inflamed. Usually there is little, if any, itching present. The disease is most frequently seen upon the extensor aspect of the arms and thighs, but in some cases the greater part of the trunk may be covered with the lesions. The skin then presents an appearance resembling that temporary physiological condition known as "goose flesh." It is always worse in the winter, when perspiration is lessened. The skin of those affected is apt to be unusually dry, while the eruption itself is harsh and rough and feels almost like a nutmeg grater. When the disease has existed for years, the hairs upon the affected parts are usually broken off close to the skin or entirely absent, and occasionally some may- be found coiled up in inflamed follicles beneath the accumulation of horny epidermis. Under the name of lichen pilaris, Crocker describes an affection which seems to me to be a corymbiform variety of keratosis follicularis. (See plate.) The epidermic plugs become horny spines projecting above the surface of the skin, and the follicles are usually inflamed. I have observed this eruption upon the upper part of the chest as well as in groups upon the shoulders, but have never noted any symmetrical arrangement of the patches, or seen a patch develop in a night, as it may do according to Crocker's description. Keratosis follicularis is allied to ichthyosis, and is often associated with the latter disease. The same method of treatment is required in either disease to keep the skin soft and in as nearly a normal condition as possible. Hot baths, soap frictions, and the free use of a little glycerin in water or of some very soft emollient ointment will best accomplish this pur- pose. In severe cases the use of a soap containing both sulphur and sand KERATOSIS The term keratosis implies a hypertrophic development of the horny layer of the skin and has been applied to a number of der- matoses varying in nature and in clinical appearance. The condition may be congenital or acquired. In the former case it is allied to ichthyosis and is most apt to affect the hair follicles upon the extensor aspect of the extremities. This condition is not primarily an inflammatory one, but congestion often results from the pressure of the epidermic masses retained in the follicles, and the affected surface is not only harsh and dry, but is dotted wjth numerous follicular elevations. These conical papules are often of a decidedly horny character and usually of a reddish hue (lichen pilaris). Severe itching is at times present, and the use of the finger nails in addition to the choking of the follicles may lead to a partial destruction of the hair. Localized keratosis is most apt to occur upon the palms and soles. In the congenital form (tylosis palmse et plantse) the skin of the palmar and plantar surfaces is greatly thickened and presents a smooth horny surface. In the acquired form of keratosis callous patches may occur as the result of pressure, or circumscribed patches may develop spontaneously and usually as the sequel of an inflam- matory process. The subject of the upper illustration presented a somewhat similar condition of the other palm, with a marked hypertrophy and elevation of the free end of the nails. The lower illustration shows an unusual eruption, viz.. a follicular keratosis on a woman's fore- arm, the lesions occurring in a distinct group. y Copyright, iijoo, byi;. 11. I'^nx, I. KERATOSIS DIFFUSA. II. KERATOSIS FOLLIGULARIS. LENTIGO 125 is advisable, as mild measures do not suffice to soften and remove the fol- licular plugs. This may be followed by the inunction of a ten per cent, salicylic acid ointment, or either of the following : IJ Pulveris pumicis 10 Sulphuris prsecipitati . . ... 20 Saponis mollis ... ^5 Adipis ad 100 m 5 Naphtholis 10 Cretse preparatas 5 Adipis lanse hydrosi 30 Adipis 30 Saponis mollis ad 100 The eruption always has an unwashed appearance, and in some cases may, indeed, be aggravated by neglect of ablutions. In most cases, how- ever, the disease is due to an innate cutaneous disposition, and no amount of scrubbing will remove the unwashed appearance, although it may tend to lessen it. LENTIGO Lentigo, a disease commonly known as freckles, consists of small yel- lowish, brownish, or blackish spots of hyperpigmented skin, which are to be seen upon many faces, especially during the spring and summer. They may also be seen upon the backs of the hands, and even on portions of the body not directly exposed to the sun's rays. The disease is most frequent in youth, and affects those individuals, whether blond or brunette, who do not tan readily and evenly on exposure to the sun. The most marked cases are to be found among mulattoes. Freckles usually disappear in great part, or wholly, during the winter, and are thus to be distinguished from the pigmentary nasvi which frequently appear in the form of small round dots upon the backs of the hands, fore- 126 THE TREATMENT OF SKIN DISEASES arms, or scattered in small number over the body. These latter discolora- tions are permanent and more frequently observed in later life. In the treatment of freckles, prophylaxis is of importance, but few ladies are willing to remain indoors or constantly carry a sunshade to prevent the contraction of so harmless a disease. When the dark spots have appeared upon the face in large numbers, the solution of hydrogen dioxide may be used as recommended in the treatment of chloasma, it will tend to lessen, even if it does not wholly remove, the discoloration. The following ointment has been most highly praised and will have some, though often but very little, effect upon the freckles : 5 Hydrargyri ammoniati 3 i lo Bismuthi subnitratis 3i lo Unguenti aquae rosse f i ad loo Apply at night. The most efficient method of removing freckles is to apply a minute drop of pure carbolic acid to each dark spot by means of a wooden tooth- pick or a little cotton wound around the end of a probe. The immediate effect is to whiten the spots, but on the following day, and for several days after, the patient's face will look more spotted than ever. When the freckles are very numerous, a temporary retirement from social functions becomes necessary, and a little unpleasant itching or burning of the face may be endured. But at the end of five or ten days the epidermis destroyed by the acid will have fallen in the shape of thin crusts, the freckles will be gone, and the pinkish hue left in their stead will speedily fade and leave the complexion quite clear. The main objection to this method of treat- ment is that the freckles may return in a short time upon repeated exposure to the sun. The plan recommended by Hardaway, of touching each spot with the point of an electrolytic needle, I have tried repeatedly, and though it is well adapted to the treatment of a pigmentary nasvus in an adult, I much prefer the carbolic acid in the treatment of freckles. LEPRA The patient whose face is shown in the accompanying plate was at the Skin and Cancer Hospital for about two years. He was born in Denmark, but spent twenty years in the West Indies, where he undoubtedly contrafted the disease, although apparently well when he left there in 1891. A few years later a brownish spot appeared on outer side of left knee, and in 1895- he began to notice small nodules on his forehead. Following this, brownish discs or circles appeared upon the trunk, while both hands and feet became swollen and dis- colored, with a diminution of cutaneous sensibility. He had lost fifteen pounds during two years previous to entering hospita-1, was weak and drowsy most of the time, and unable to close his hands firmly. During his first year in hospital he took chaulmoogra oil at frequent intervals, increasing the dose up to one hundred drops daily, when nausea usually compelled the cessation of its use. Nux vomica was then substituted until the stomach could again tolerate the oil. Under this treatment his general health improved, his strength and weight increased and the lumps upon the forehead and the macules upon the trunk almost disappeared. The nasal obstruftion and diffi- culty in breathing, of which he had complained, was relieved and his eyesight improved to a notable degree. Though not cured he was finally able to leave the hospital and to obtain work as a gardener. The portrait does not show a marked case of tubercular leprosy with a hideous aspeft which would be readily recognizable. It does show, however, the charafteristic /^a'^j- which may be noted even in mild cases of the tubercular type of this disease. I ^ " ..J*'^^ h Copyri,L;ht, irjoo, by G. H, Fox. LEPRA. LEPRA LEPROSY is a chronic infectious disease which involves not only the skin but the nerves and many other organs of the body. It is probably caused by the bacillus lepr^, runs a very slow course, and usually terminates fatally. In its clinical aspect leprosy presents a wide variation, and there are two classes of cases which look quite unlike each other, though equally typical of the disease. In some cases the skin is principally affected, and characteristic nodules and macules are observed. In other cases the nervous system appears to bear the brunt of the attack, and loss of sensation and muscular atrophy are the prominent symptoms. For convenience of description, writers have usually divided leprosy into three varieties : the tubercular, the macular, and the anaesthetic. Many cases can be readily classed in one of these divisions ; others are of a mixed form and present characteristics of each variety. Tubercular leprosy may begin with a slight eruption of macules of a brownish-red hue, but sooner or later a group of characteristic lumps or nodules appears upon the face, forearms, and elsewhere. These occurring, as they frequently do, above the eyebrows, change the patient's expression, and produce a typical facies even in the early stage of the disease. When the tubercles increase in size upon the forehead, the face often presents a peculiar leonine expression ; and when the cheeks, chin, and lobes of the ears are affected, a hideous aspect is sometimes produced. The tubercles may remain unchanged in size and appearance for years, or they may dis- appear, and a crop of new ones take their place. In severe cases they show a marked tendency to ulcerate, particularly upon the extremities. Loco- motion is impeded, and the swollen hands become almost useless. The 128 THE TREATMENT OF SKIN DISEASES lymphatic glands are generally swollen, and recurring attacks of fever, with a temporary outbreak of red nodules suggestive of erythema nodosum, are not uncommon. A typical plantar ulcer is frequently seen in the course of the disease, and often resists all attempts at healing. The mucous membrane is liable to become affected, as well as the skin. Small tubercles appear upon the velum of the palate and in the larynx, and the voice becomes husky and weak. The nasal membrane is thickened, and the patient breathes through the mouth. Nodules appear upon the conjunctiva, involve the iris, and tend to produce a partial loss of sight. The tubercular is generally considered to be the most serious form of leprosy, and after a slow and painful course of eight or ten years the patient usually succumbs to exhaustion, or death ensues from a pneumonia or enteritis undoubtedly of leprous origin and due to morbid growths in the lungs or intestines. While this is the typical course of tubercular leprosy, it must be borne in mind that all cases are not equally severe and do not present the abhorrent symptoms commonly associated with the disease. I have known lepers whose faces were far less unsightly than the faces of patients with ordinary acne, whose suffering could not be compared with that so often occasioned by eczema, and who are now practically well, in spite of the common statement and general belief that leprosy is an incur- able disease. The anesthetic form of leprosy is one in which the nervous system is principally affected, and the symptoms are in the main such as might result from multiple neuritis of other than leprous origin. It is the more common type of leprosy in tropical regions, while the tubercular form appears to pre- vail in colder climates. It is characterized by the development of macular and ansesthetic patches, muscular paralysis and atrophy, bullous eruptions and mutilating ulcers. The anjesthetic patches may be of variable size and correspond with the macular areas, or affect skin of normal appearance. The paralysis and atrophy give to the face a characteristic expression. The eyebrows and eyelashes fall, although the scalp may remain free from all manifestation of disease. The hands are frequently converted into rigid LEPRA 129 claws, the fingers being flexed and bent backward by the contraction of the tendons. The outbreak of bullae is common, especially upon the extremities, and most annoying, as they are very apt to form ulcers which not only per- sist, but frequently perforate the phalangeal joints, and -lead to extensive muti- lation of the hands and feet, in many cases of the anesthetic type these members become transformed into mere stumps or clubs. The nerves be- come enlarged by a leprous deposit, and the ulnar can usually be readily felt at the elbow, like a fine whipcord. At first this is hyperassthetic, and pres- sure upon it will cause a patient to wince or jump, but later in the course of the disease the sensibility is almost entirely gone. The macular form of leprosy may be associated with either of those already described, or appear with no tubercles and but a slight amount of anesthesia. The macules may be preceded by a loss of sensation, but are sometimes hyperesthetic at the beginning and gradually lose their sensibil- ity. They are rounded or oval, of a dull reddish-brown or bronzed hue, and tend to whiten in the centre, leaving a narrow band at the border of the patch, which is somewhat elevated. The whole patch may be slightly furfura- ceous. The face, trunk, or extremities may be the seat of these patches. Upon the back they may coalesce and spread in a serpiginous manner. The etiology of leprosy appears to have become more definite since the discovery of the bacillus lepras by Hansen, in 1874. While the presence of bacilli in nodules, lymphatics, and internal organs is not an absolute proof that they are the cause, and not a product, of the disease, and although inocu- lations of leprous tissue in the human subject have proved negative or un- certain, it is nevertheless a fair assumption that leprosy is one of the germ diseases, and that, as in the case of tuberculosis, the disease develops through the entrance of bacilli into the system. How these enter is an unsettled question. The contagiousness of leprosy has been both accepted and denied by the highest authorities. In the light of our present knowledge it seems possible, and, indeed, probable, that the disease may be transmitted through direct con- tact ; but when we consider that men and women live for years with leprous 130 THE TREATMENT OF SKIN DISEASES wives and husbands without contracting the disease, and that a few months' sojourn in a leprous country is far more dangerous than nursing lepers in a climate where leprosy is not endemic, it would seem that the disease were contagious only in a very slight degree, if at all. As a matter of fact, leprosy does not spread except in certain localities where climatic influences, peculiarities of diet, uncleanly habits, or some other unknown factor tends to favor its development in a healthy person, in the city of New York a dozen or more lepers may have been found at any time during the past twenty years, either in or out of hospital, and yet there has never been a single case reported in which leprosy has been contracted by any one associating with those afflicted by this dreaded disease. As leprosy is endemic in Iceland as well as in countries near the equator, neither heat nor cold seems to play a part in its causation ; but in damp re- gions, whether inland or by the sea, the disease appears to be especially prevalent. The hereditary nature of leprosy has been claimed, and the occurrence of cases in successive generations, and its limitation to a few families in any locality, would seem at first thought to substantiate the view that it is trans- missible in this way, but no positive proof of heredity in this disease has as yet been presented. The disease is never congenital, like syphilis. It is rare in childhood, unlike tuberculosis. When children of leprous par- entage present undoubted manifestations of the disease, it is fair to assume that it has been acquired, and not transmitted by heredity. The descend- ants of Norwegian lepers who have settled in Minnesota and other North- western States have never, so far as known, developed the disease. In the treatment of leprosy a change of residence is of the greatest im- portance. Cases which are bound to terminate fatally in lazarettos in countries where the disease prevails— notwithstanding the fact that they may have the best medical care— will often improve spontaneously when removed to a region where leprosy shows no tendency to increase. A prominent professional gentleman who has been under my observation for the past twenty years contracted the disease during a sojourn ot two LEPRA Ui years in South America. A few small but unmistakable macules developed about ten years later, and he complained of numbness in his hands. Treat- ment in his case consisted of chaulmoogra oil, which he took intermit- tently for a short time, and then discontinued it on the ground that it was worse than the disease. For many years he has had practically no treat- ment, and the disease has never interfered with his work nor given him any annoyance. Had he remained in South America I have little doubt but that the disease would have run its usual course. Among the internal remedies which have been used with more or less success in the treatment of leprosy may be mentioned chaulmoogra and gurjun oils, strychnia, and salicylate of sodium. Difference of opinion has been expressed as to the value of these remedies, and the fact should be borne in mind that good results may be obtained from a remedy in a country where leprosy tends to improvement, while its beneficial action may be counteracted by the conditions surrounding a patient in a laz- aretto or the place where the disease was contracted. 1 have seen a number of patients improve steadily under the use of chaulmoogra oil, and a few become practically and permanently cured of the disease. Without doubt, much of this improvement has been due to a change of climate and to the natural tendency of the disease to improve under the best hygienic conditions. The oil, however, has produced a notable result in some cases, and appears to be the most efficient internal remedy which 1 have tried. The oil should be given in rapidly increasing doses, if the patient's stomach will tolerate it, until one hundred drops are taken daily. Some patients can take more, but, sooner or later, nausea is apt to compel a diminution of the dose or a temporary cessation of the remedy. It should be taken in the form of an emulsion, and may be added to any emulsion of cod-liver oil and taken after each meal. When patients are unable to take this remedy, even in small doses, or in cases where the stomach shows signs of rebelling after its pro- longed administration, the tincture of nux vomica, sulphate of strychnia, or hoang-nan may be given in its place. Strychnia is said to be of 152 THE TREATMENT OF SKIN DISEASES especial value in the aniesthetic type of the disease. It will certainly do good as a nerve tonic in most cases, whether or not it has any direct effect upon the leprosy. Arning has obtained good results in Hawaii from the administration of salicylate of sodium, fifteen grains three times a day. In the local treatment of leprosy, gurjun oil has been highly praised as an inunction as well as an internal remedy. While baths and inunc- tions may improve the general condition of the patient by contributing greatly to his comfort, they cannot be expected to influence the course of the disease. For the large and unsightly nodules, the use of a reducing agent such as resorcin has been recommended by Unna. This may be applied in the form of an ointment or varnish of twenty to fifty per cent, strength, and repeated after the skin has peeled from the surface of the nodules. This will produce a notable reduction of their size in a short time. For the indolent and obstinate ulceration that often occurs, the alter- nating use of aristol powder and mercurial plaster will be found of service in most cases. Sometimes, thorough cauterization or curetting of the ulcer is advisable. The segregation of lepers in countries where the disease prevails is highly important and tends to check its spread, in a climate where the disease is not endemic and where patients tend to improve spontaneously the compul- sory segregation of all cases is quite unnecessary, and any attempt to carry this out through legal enactments, as has been proposed, would lead to rank injustice. The few lepers constantly to be found in the city of New York and other Atlantic seaports are no menace to the health of the community. The prevalent dread of leprosy among those who know nothing of the dis- ease is as absurd as it is unfounded. Newspapers rniay find it to their advantage to make a great hue and cry over every case of leprosy discovered in a Chinese laundry or elsewhere, but members of the medical profession, aware of the fact that the disease has never shown any tendency to spread in this region, should do all in their power to allay the painful apprehension of harm on the part of the public, instead of increasing it by talking and writing of a danger that does not exist. LICHEN PLANUS Although lichen planus may appear upon various portions of the body, and sometimes present a general eruption, the anterior asped of the forearm is its most frequent and charafteristic site, in some cases the eruption is limited to the forearms, and only in rare cases is this part found to be free. Upon the woman's arm, shown \n the upper illustration, many isolated lesions may be noted, some of which show the charafteristic angular, outline, flattened glistening summit, and central depression. Near the bend of the elbow the tendency of the lesions to aggregate in small clusters is well shown. The coalescence of such clusters has produced the large patch with the scaly surface which extends along the forearm. The desquamating rings seen upon the wrist are an exceptional feature of lichen planus which is rarely met with and only in cases in which the eruption is abundant and acute. Upon the man's arm, shown in the lower illustration, the indi- vidual lesions are somewhat larger, but show the same tendency to coalescence, and upon the radial asped; where the eruption was of longer duration the charafteristic glistening surface of the patch is clearly seen. The peculiar purplish hue of the eruption in cases of lichen planus is always a striking feature, and as it is rarely met with in other affeftions, it serves as a very important point in differential diagnosis. C(»p>TiKlit, n/'O, by *'-. H Vo\ LICHEN PLANUS, LICHEN PLANUS 133 The prognosis of leprosy is serious, though not necessarily fatal. The common belief, founded on the statements of many authoritative writers, that leprosy is an incurable disease, is not in accordance with facts. Leprosy can be cured, has been cured, and would be cured in many cases if the patient were not given to understand that his condition is hopeless and speedy death inevitable, if you, my kind reader, or 1, both in perfect health, were told that we had been stricken by some incurable plague and could not possibly recover ; if we were shunned by our dearest friends and finally driven from home ; if we were condemned by municipal authority to solitary con- finement in some cell or barricaded hovel, and food poked at us through a window, how long do you imagine we would live? And yet this is the way some cases of leprosy are treated at the close of the nineteenth century, and without even a protest from the medical profession. LICHEN PLANUS The older dermatologists, following the lead of Willan, applied the term lichen to all papular eruptions, whether eczematous, urticarial, or syphilitic in character. Hebra was the first to claim that the name should be restricted to those diseases in which papules are the sole and characteristic lesions. In the diseases to which he applied the term lichen, the papular lesions persist as such throughout their entire course and never undergo a transformation into vesicles or pustules, as so frequently happens in eczema and syphilis. There are three such diseases now recognized, and known as lichen planus, lichen ruber, and lichen scrofulosus. Lichen planus is a disease characterized by the eruption of flattened, shining, angular papules of a purplish red hue. They usually have a central depression and become slightly scaly before disappearing. The lesions vary in size in different cases, but in any given case little or no variation is noted. They are usually about the size of a large pin's head. They do not increase at the periphery and form a patch as do the small scaly papules of psoriasis, 134 THE TREATMENT OF SKIN DISEASES but by an increase in number and by aggregation they usually form patches of irregular shape which tend to become more or less scaly. The eruption is usually symmetrical and appears most frequently upon the inner aspect of the forearms, around the waist, and on the thighs. In exceptional cases the greater portion of the trunk and extremities may be cov- ered. The lesions may remain isolated throughout the course of the disease, but they commonly form in groups which coalesce into patches. A marked tendency of the lesions to develop in a line, especially upon a scratch, is often noted, and in severe cases patches of long standing sometimes flatten in the centre and leave scaly rings. Upon the thighs and legs a hypertrophic form of the disease is apt to occur in which the patches are considerably elevated and usually intensely pruritic. The surface of these hypertrophic patches may be quite smooth if not excoriated, or it may be roughened like a piece of coarse sand-paper. When lichen planus dis- appears it is apt to leave a pigmentation of the skin which may be very marked in some cases. The etiology of lichen planus is very obscure. It occurs in both sexes and usually in adult life. Although in many instances a patient may be apparently in excellent health, it is fair to assume that the eruption is not a dispensation of Providence, but due to some internal derangement for which the patient is unconsciously responsible and for which the best remedy is a radical change in his or her ordinary habits of life. 1 have known a very strict limitation of the diet to bread and milk to accomplish a far more brilliant and speedy result in a case of generalized lichen planus than could possibly be hoped for through local applications. How it did it cannot be definitely stated. Whether it would accomplish the same result in many other cases is doubtful. But such a fact is convincing to me that the cause of the disease must be looked for beneath the skin, and explains the fact that local remedies are so frequently of little or no value. Some have attributed the disease to nervous exhaustion and others to digestive or uterine disturbance, but in many cases the internal derangement cannot be definitely located. The internal causes are similar to if not LICHEN PLANUS HYPERTROPHICUS Since lichen planus even in its most typical form is apt to pass unrecognized by the physician with limited dermatological ex- perience, it is not surprising that the unusual forms of the disease must furnish of necessity a severer test of diagnostic skill. Acute general lichen planus is liable to be mistaken for a papular eczema, as many of the lesions may be congested and elevated instead of being flattened and shiny. When covering the entire trunk the eruption may bear a strong resemblance at first glance to a papular syphilide, or on account of its unusual development, it may be regarded as a lichen ruber. The hypertrophic form of the disease is commonly observed upon the lower extremities and occurs in raised patches. Upon the tibial region these often present a greyish, roughened surface and have a peculiar harsh feeling when rubbed with the finger. About the knee and inner aspeft of the thighs the irregular patches are apt to be smoother and of a dull crimson or lilac hue, as seen in the accompanying plate. When of long standing these lesions are usually more or less pigmented, and often the seat of a pruritus which is almost intolerable. As a result of this, the lesions may be- come excoriated, and therefore bear still less resemblance to ordinary lichen planus. Copyright, jgoo, by G. H. Fox. LICHEN PLANUS HYPERTROPHICUS. LICHEN PLANUS 135 identical with those which cause eczema. But why one patient with ner- vous exhaustion or indigestion should have lichen planus and another one suffer from eczema is a question not readily answered. The treatment of the patient who suffers from lichen planus is far more important than the treatment of the eruption. Most writers agree in the glittering generality that iron, quinine, arsenic, cod-liver oil, pepsin, bis- muth, alkalies, etc., may be prescribed according to circumstances, but in many cases there is no anaemia, no malaria, no sign of struma, no indiges- tion, nor even a trace of the popular uric acid diathesis, and the above routine remedies are no more likely to do good than venesection, the great routine panacea of former days. 1 do not object to these remedies when- ever there exists a definite indication for any one of them, but 1 do protest against the too common idea that there is nothing for a physician to do in a case of lichen planus but to give medicine and to prescribe local appli- cations. The patient's general condition can usually be improved, and this can be done by hygienic rather than by medicinal measures. No one, I imagine, ever saw an athlete in training, with an eruption of lichen planus. In my opinion the best method of curing the disease is to put the patient under a course of training which will tend to bring him or her to an approximation of the highest possible physical and mental condition. This can usually be done in lichen planus, as in many other skin diseases, by good air, good food, good company, and a systematic alternation of hard work and perfect rest, while an undue or a sole reliance upon pharmacopoeial remedies can rarely if ever accomplish it. Arsenic has been highly recommended and is commonly prescribed in this disease. It sometimes does good, but as frequently, perhaps, does harm through being prescribed when the eruption is acutely inflamed and spread- ing, instead of being withheld until the inflammatory stage has passed and the eruption shows a tendency to spontaneous disappearance. Tilbury Fox claimed that arsenic always made his cases worse. At the suggestion of the older Professor Boeck, of Christiania, Dr. R. W. Taylor advises the administration of fifteen grains of potassium chlorate 1^6 THE TREATMENT OF SKIN DISEASES in four ounces of water, fifteen minutes after eating, followed in another fifteen minutes by twenty drops of dilute nitric acid in a wineglass of water. Blaschko advises the internal use of antipyrin to relieve the severe itching. Local applications' may be of service by soothing the skin and allaying the itching in the early and spreading stage of the eruption, or by stimulating it and hastening its disappearance when the eruption shows a disposition to yield. It is a noteworthy fact, however, that there are few if any inflam- matory affections of the skin which respond so reluctantly to the action of local remedies as does the eruption of lichen planus. The calamine and zinc lotion is always soothing and hence advisable at the outset, or, if the itching is severe, ten per cent, of oleum cadini in zinc ointment may be frequently applied. The following lotion is recommended by Wehl : li Naphtholis 2 Glycerini ... 10 Alcoholis ad 100 m In more chronic cases a corrosive sublimate lotion of one-half of one per cent, strength may be used, or the following ointment recommended by Unna : 5 Hydrargyri chloridi corrosivi gr v i Acidi carbolici gr xx 4 Unguenti zinci oxidi ad §i ad 100 m, This ointment is mentioned by most writers and generally highly praised. My own experience leads me to coincide with Kaposi, who states that he has never noticed the slightest effect from it. Crocker advises the following : ]J Olei rusci Til xx 4 Unguenti hydrargyri ammoniati §1 ad 100 m LICHEN RUBER PAPULOSUS. Lichen ruber and pityriasis rubra pilaris are names applied to the same disease. In its first stage the eruption is characterized by numerous small, firm acuminate papules, tending to become tipped with minute whitish scales and to aggregate into large patches. The face and hands at this time are apt to be reddened and stiff and present the appearance of a dry eczema or ichthyosis. The aggre- gation of the papular lesions produces the squamous form of the disease. The patches may be rounded (like psoriasis) or band-like, especially on the extremities. When the scales have fallen or been rubbed off the infiltrated patches, the skin usually presents a dull red and characteristic rugous appearance. The patient illustrated in the plate had suffered from repeated exacerbations of the disease, the skin being almost normal at times. The small conical shotty papules are plainly seen about the knee, while upon the inner surface of the thigh it is evident that they have increased in number and coalesced, giving the skin a peculiar dry, leathery appearance. The hand is similarly affected and the dry, scaling surface might be mistaken for a chronic eczema. Upon the thigh, between the thumb and finger, some of the acuminate lesions have become flattened and show a central follicular depres- sion. This resemblance to the lesions of lichen planus has led some writers into the erroneous belief that the two affections are closely related. o m c CD m J3 > C r O CO c an LICHEN RUBER 137 The use of Vlemingkx's solution as recommended in cases of acne (page 20) may be advantageously employed in lichen planus, the strength of the application varying according to the chronicity of the patches. Herx- heimer paints the patches twice a week with ten per cent, of chrysarobin in traumaticin. For very obstinate papules or patches the use of the galvano- cautery has been recommended, and is said to relieve the intense itching which is often present. in the case of elevated horny patches, which are very apt to be found upon the shins, the application of pure carbolic acid has been advised. The following varnish may prove of service, if care is taken that it is not con- tinued long enough to produce salivation : U Hydrargyri chloridi corrosivi 2 Creosoti . . 4 Acidi carbolici 10 CoUodii ad 100 m A salicylic acid ointment or plaster of twenty per cent, strength will remove the roughness of the patches and tend to hasten their disappearance. Lichen planus runs an extremely variable course, some cases tending to a spontaneous recovery in a month or two, others persisting for many months, or even years, in spite of vigorous local measures, it is this uncertain course which has led many to overestimate the value of internal and local remedies which may have been followed by a speedy cure in a few successive cases of a mild type. There is no plan of treatment which will cure every case in a definite period, as has been claimed by some enthusiastic writers. LICHEN RUBER Lichen ruber is a chronic relapsing disease characterized by an eruption of small reddish acuminate papules seated usually at the orifice of hair fol- licles. By aggregation these form rounded or elongated patches covered by fine whitish scales or marked by an exaggeration of the natural furrows of 138 THE TREATMENT OF SKIN DISEASES the skin. The disease was fully described by Hebra, in 1862. Since then it has been confounded with lichen planus, an entirely distinct disease, and the French school have given to it the name of pityriasis rubra pilaris. There are three clinical forms of the disease, which, like the clinical forms of eczema, are successive in their development and liable to coexist upon different portions of the body. In the papular form there are numerous small, acuminate or flattened lesions which do not increase in size but aggre- gate and form patches. They are often tipped with minute scales, and hence the patches formed by their coalescence present a white, scaly appearance resembling psoriasis. This is the squamous form of the disease. When the scales disappear from the patches the thickened skin presents a brownish-red, leathery appearance, and the parallel cutaneous furrows are so pronounced that we have the rugous form of the disease. The cause of lichen ruber is unknown. It is neither hereditary nor con- tagious, and probably has its origin in some undiscoverable nervous derange- ment. The disease is quite common in childhood and early adult life, and though occurring in both sexes, the majority of my patients have been males. The treatment of lichen ruber is usually unsatisfactory so far as internal remedies are concerned. Arsenic is the one upon which most reliance is placed. According to Brocq, no internal medication is known that is truly efficacious, but he advises, nevertheless, the cautious use of sodium arsenate. Crocker says arsenic is contraindicated on account of its tendency to increase keratinization of the tissues which is already excessive, and adds that marked aggravations have followed its injudicious use. He prefers in- jections of one-sixth of a grain of nitrate of pilocarpin to restore the sweat secretion. Arsenic is the main remedy of the Vienna school, and is pushed to its extreme limit in all except the manifestly hopeless cases. Kobner and others have given arsenic by hypodermic injection in lichen ruber, but this form of treatment is not usually popular with patients and is rarely necessary except in cases where the most speedy effect possible is desired. Kaposi says that after the treatment by injections he has more often observed an cedema of the eyelids, sensations of heat and burnin g m LICHEN RUBER SQUAMOSUS The squamous form of lichen ruber may simulate psoriasis when scaly discs are present. When the greater part of the body has been affected and the eruption is on the decline ichthyosis is sometimes suggested. The disease is always a chronic one. There is usually noted an alternation of exacerbation and improvement, but the prognosis is .always unfavorable. The accompanying plate shows two clinical forms of lichen ruber, the papular and the squamous, and also the manner in which the former is transformed into the latter by aggregation of the small conical lesions. These papules do not increase in size but by multiplying, especially at the border of a scaly patch, they steadily encroach upon the healthy skin until nothing can be seen but a solid mass of scale- tipped lesions. The plate also shows the tendency of the scaly patches to assume the form of a long band of varying width and shape, which is extremely characteristic of the disease as Hutchinson has indicated in his descrip- tion of "Lichen-psoriasis." Another photograph of this patient, taken several months later, shows the same vertical band, but instead of running over the left hip only, the eruption has now formed a whitish girdle and runs over both hips. The tendency to this localization of the eruption may already be noted in the increased number of papules upon the lower portion of the back where the girdle developed later. .Mff"^ ^"""t^ -^1 Copyright, 1900, by G. H. Fox. LICHEN RUBER SQUAMOSUS. LICHEN RUBER 139 the skin, intense lentiginous and chloasma-like pigment spots, as well as rapid relapses, than is noted after ingestion of the drug. The alkaline diuretics are indicated when there is much congestion of the skin and the eruption is increasing. They are particularly serviceable when the patient complains of great heat in the skin, a symptom which is often the forerunner of a fresh eruption of papules. Cod-liver oil is generally useful, especially in the later stages of the disease, when the skin is very dry and emaciation is a prominent symptom. Sherwell has found considerable benefit accrue from the use of linseed oil, both internally and locally. The local treatment of lichen ruber is mainly palliative, and is similar to that which would be called for in a case of general dry eczema or uni- versal psoriasis. Baths are of great service, and those containing bran or starch have been recommended. Taylor speaks highly of warm alkaline baths, while others suggest the use of vinegar. Brocq advises the use of ten per cent, of tartaric acid in glycerole of starch. Intense pruritus is often the most annoying symptom of the disease ; and in one case I found that two per cent, of oil of peppermint in almond oil was the most agreeable application among a large number which were prescribed. The prognosis in lichen ruber is extremely grave. The fourteen cases upon which Hebra based his original description of the disease all terminated fatally, and the majority of cases, if watched for a sufficient length of time, will be found to grow worse after numerous relapses, and finally to lapse into a condition of profound marasmus. Many cases have been reported as cured by arsenic ; but, without doubt, many of these have been cases of universal lichen planus, which is very rarely fatal, and frequently tends to a spontaneous cure. Other cases have been only apparently cured, as the disease often disappears for many months with, or even without, treatment. A relapse, however, is almost certain to take place, according to my experience, and the disease goes on from bad to worse until the patient's strength is finally exhausted, and a fatal termi- nation ensues. I40 THE TREATMENT OF SKIN DISEASES LICHEN SCROFULOSUS Lichen scrofulosus, as the name would imply, is a papular eruption occurring among those who present other characteristic manifestations of the scrofulous taint. The lesions are follicular, pinhead-sized, of a dull red or yellowish hue, and occur in groups or circles upon the trunk. The disease is uncommon in this country, and on account of the eruption not presenting a very striking appearance, and giving rise to little or no annoyance, it may be readily overlooked. It is most frequently met with in childhood, and is more common in the male sex. It is often associated with acne cachecticorum, and with eczema of the genital region. The treatment of lichen scrofulosus is simple, and the eruption, al- though often persisting or recurring for years, is never difficult to cure. Hebra's chief reliance was upon cod-liver oil, which he gave internally to the extent of the patient's tolerance, while keeping it constantly applied to the affected skin. Kaposi recommends the oil either with or without iodine, and gives the following in tablespoonful doses morning and evening : B lodinii puri i Olei morrhuse looo m Crocker recommends the following ointment as quite as effectual and much more pleasant than the external use of cod-liver oil : 9 Liquoris plumbi subacetatis ttl xv 3 Thymolis gr. v i Olei cadini th, v i Vaselini ad § i ad 100 m The hygienic surroundings of the patient must be carefully looked after and a goodly supply of fresh air and proper food insured. As the general health of the patient improves under this treatment, the eruption will grad- ually disappear, and often with it the glandular swellings and other signs of struma which may have been present. LUPUS ERYTHEMATOSUS Erythematous lupus has often been called the "butterfly" form of lupus on account of its occasional outline when involving the ridge of the nose and malar regions. In most cases, however, there is no suggestion of this resemblance, and very often this charafteristic site of the eruption remains entirely free. The portrait shows a typical, rounded spot upon the cheek, slightly elevated, and with a dry, harsh, scaly surface. These scales are quite adherent, and when one is forcibly raised the under surface often shows a number of prolongations corresponding to the follicular orifices. The disease is also shown in two very common localities, viz., near the ear and upon the scalp. The crusting seen in the patch upon the auricle is un'usual, but the bald spot upon the crown, with its dull red hue and slight roughness of surface, is very typical. Such a patch often serves as a basis of diagnosis in cases where the facial lesions might appear to be of doubtful charafter. The cause of erythematous lupus is unknown. The bacillus tuberculosis is not found in sections of the affefted skin, and there is no kinship between this disease and lupus vulgaris save in the name and an occasional clinical resemblance. The treatment is, in most cases, notably unsatisfaftory. Some recent and superficial patches, unaccompanied by much congestion, will yield to applications of pure carbolic acid, but in cases of long standing, and especially in those of an irritable type, stimulating treat- ment often does more harm than good. I have seen excellent results follow the internal use of salicylate of sodium. Copyright, ujoo. by G H. Fox. LUPUS ERYTHEMATOSUS. LUPUS ERYTHEMATOSUS IN this country the erythematous form of lupus is met with more fre- quently than lupus vulgaris, the common lupus of European countries. It occurs usually upon the face, in a circumscribed or discoid form, and, owing to the fact that it is so often located upon the bridge of the nose and adjoining malar region, it has been termed the "butterfly" or "bat's-wing" form of lupus. The patches are circular or oval at the outset, slightly reddened or purplish in hue, and covered with fine, adherent scales, which, when carefully removed, often show prolongations upon the under surface corresponding to the orifices of the sebaceous glands. The disks may be somewhat depressed in the centre, and when of long standing present a peculiar pitted or worm-eaten appearance. The disease runs a very slow course, as a rule, and the rounded lesions may coalesce and form irregular, roughened patches upon the face, scalp, and, occasionally, upon other portions of the body. In rare instances the hands, arms, and, indeed, the greater portion of the body may be the seat of the disease. While lupus erythematosus is regarded as a tuberculous affection by such eminent authorities as Hutchinson, Jamieson, Boeck, Besnier, and Hal- lopeau, and clinical observation shows its frequent coexistence with various undoubted symptoms of tuberculosis, it must be admitted that the tubercle bacilli have never been found in the affected skin. Bacteriological researches have failed to give any positive results, and all attempts to inoculate animals have been unsuccessful. In view of these facts, many others regard the disease as entirely distinct from lupus vulgaris, and quite independent of tuberculosis. The treatment of erythematous lupus is so often unsuccessful that 142 THE TREATMENT OF SKIN DISEASES the disease has been regarded by some as the opprobrium of dermatol- ogy. Not all cases are rebellious to therapeutic measures, and occasionally the disease is seen to disappear spontaneously. But most cases of long standing are obstinate, and even the most vigorous measures fail to accom- plish any brilliant result. A general tonic treatment may be useful in some cases, although not curative, and when impaired nutrition is evident, cod-liver oil and the compound syrup of the hypophosphites will be found of great value. But a large proportion of patients seem to be as strong and well as the average physician who is called upon to prescribe for them, and some of the ordinary alcoholic tonics are apt to flush the face and do more harm than good. In cases where the patches are highly congested, better results can be obtained by the use of laxatives, diuretics, and remedies which control the heart's action and tend to lessen cutaneous congestion. Brocq recommends ergotine, belladonna, quinine, digitalis, hamamelis, and aconite. Arsenic has been used by many on the recommendation of Hutchinson, but it is very doubtful if others have been successful in curing their patients through its use. Phosphorus has been highly praised by Anderson and Bulkley, and good results reported, but, as PifTard remarks, "the remedy is a two-edged sword that must be handled with great circumspection." iodide of starch, recommended by Anderson, may benefit the patient, but is not likely to influence the eruption in any notable degree. Cases have been reported by Besnier as cured by the internal use of iodoform, but this plan of treatment does not seem to have found favor with many others. Qiiinine is a remedy which has apparently cured some cases, and which certainly seems to have a direct and decided effect upon the eruption. I have seen some cases aggravated as well as improved by its use. Unna and Morris give ichthyol internally and claim that it tends to lessen the hyper^emia of the patches. The local treatment of erythematous lupus must vary according to the LUPUS ERYTHEMATOSUS '43 character of the eruption. Much harm frequently results from the use of applications which simply irritate and cause the eruption to spread. In the early stage of the disease, and also in chronic cases when there is much congestion of the patches, a soothing or mildly astringent lotion is apt to prove of the greatest service. The " lotio alba," used so frequently in the treatment of acne (page 19), has often a marked effect in lessening the congestion and improving the appearance of the patches. The frequently repeated and long-continued application of spirit of camphor is a simple method of treatment, superior to the ointments commonly used, and in acute cases is worthy at least of a trial. Strong alcohol alone has been found to be of decided value in many cases, including those of long standing. When the patches are dry and scaly, vigorous friction with soap in alcohol (linimentum saponis mollis u. s. p.), followed by the application of mercurial plaster, has been highly recommended by foreign writers. I have seen improvement follow this plan of treatment, but have never known it to cure a case. An ointment or plaster of salicylic acid, gradually increased in strength until the inflammatory reaction is as great as the patient will tolerate, is one of the best applications to chronic patches. Brocq speaks highly of the following formula : 5 Acidi salicylici 5 Acidi pyrogallici 10 Vaselini ad 100 m This may be used at the outset and superseded later by a twenty per cent, or even stronger ointment of salicylic acid in lanolin. Although this will do much good in carefully selected cases, it will as certainly do harm in most cases taken at random. Other drugs, such as chrysaro- bin, naphthol, iodine, and resorcin, may also be used to advantage, but 1 cannot indorse the suggestion of Bowen that all the stimulating agents should be tried in rotation. When a decided improvement follows a change from one stimulant to another, it is usually a coincidence due to some 144 THE TREATMENT OF SKIN DISEASES cause entirely apart from the local treatment and cannot be expected to occur in the treatment of another case. Superficial cauterization and scarification of the patches have proved of little value in my experience. The same may be said of electrolysis. if the patient is anxious to have the patches removed in the shortest possible time, and will not hold his physician responsible for a resulting cicatrix, the curette or the thermo-cautery, or a combination of both, is capable of effecting the desired result. The application of liquid air v^ill destroy the vitality of the morbid tissue very quickly and cause a curative ulceration. In my service at the Vanderbilt Clinic this remedy has been tested during the past year, and one patch of erythematous lupus was quickly destroyed by its use. But the pain occasioned during and shortly after its application, and the de- pressed scar resulting after healing of the ulceration, would not lead me to recommend this novel therapeutic method. LUPUS VULGARIS Lupus vulgaris is one of the forms of cutaneous tuberculosis. The eruption consists of disseminate or aggregated nodules which tend to soften and ulcerate. A chronic patch therefore usually shows more or less cica- tricial tissue in the centre, while new lesions are slowly developing at the border. The disease runs a very slow course, in strong contrast with the nodular syphilide, to which the eruption may bear a strong resemblance. It is common in youth, and through neglect or ineffective treatment often persists during middle life and even in old age. The face is the most common seat of the disease, and in time a fright- ful appearance may be occasioned by its ravages. The nose is often de- stroyed, the eyelids and lips drawn apart from loss of tissue or puckered into narrow slits from ulceration and contractile cicatrization. The external ear is often destroyed and a mere orifice left, and even this may be oc- cluded by the disease. Lupus of other parts is comparatively rare, but LUPUS VULGARIS In the case of the young man who is the subject of this illustra- tion, the disease began at six years of age and has slowly but steadily spread over the neck and a portion of the cheek. The lesions are rather superficial and have shown little tendency to soften and ulcerate. They are most prominent at the advancing border of the patch and some isolated ones enclose areas of normal skin. Where the disease appears to have first developed, patches of wrinkled cicatricial tissue are to be seen dotted with many dull red, flattened tubercles, which are evidently tending towards a spontaneous disappearance. The patient has always been in fair health, although the indica- tions of a scrofulous taint are manifested in the thickened lips and peculiar doughy skin, and may be discerned in the partial view of the physiognomy revealed in the portrait. In the treatment of this case a steel burr dipped in carbolic acid was used for a time with good effect, but as the patient did not care to suffer the slight pain involved in this rapid and efficient method, a twenty per cent, salicylic plaster was applied at the Vanderbilt Clinic and during the past few months a notable improvement has taken place. The lesions have ulcerated beneath the plaster, applied suc- cessively to small portions of the diseased skin, and a complete cure is expected. Copyright, iy,jo, by G. H. Fox. LUPUS VULGARIS. LUPUS VULGARIS '45 large patches, often of a serpiginous character, may be found upon the trunk or extremities. The mucous membranes of the nose and throat are often simultaneously affected. Lupus is a local disease, resulting without doubt from accidental inocu- lation of the skin with the bacillus tuberculosis. It is never hereditary, but the children of tuberculous parents and others who are weak, delicate, and poorly cared for are most likely to become infected. The treatment of lupus vulgaris is mainly of a surgical character, and three ends which should be sought are (i) the removal of the morbid tis- sue, (2) with as little ' pain as possible, and (3) with the least resulting disfigurement. One of the oldest remedies in the treatment of lupus, and one still recommended by some surgeons, is the knife. This will certainly remove the disease when limited in extent, and with the modern improvements in skin-grafting, a patch of lupus of al- most any size might be excised and the wound healed. But this cannot be accomplished without much dread and discomfort on the part of the patient, and where a plastic operation on the face is involved, the result is seldom satisfactory from a cosmetic point of view. The prevalent fear of the surgeon's knife may be irrational, but it exists, nevertheless, and, in spite of the favorable results reported by Hahn, Senger, and others, in no case of lupus, large or small, is excision, in my opinion, preferable to other methods of treatment at our command. The cautery, as commonly employed, is another agent, which 1 would unhesitatingly condemn. Acting equally upon healthy and diseased tissue, it must either produce an unnecessarily deep ulcer, or else the smooth, superficial, and delusive cicatrix will soon appear studded with isolated nodules. Whether a Paquelin or galvano-cautery be used, the operation is generally painful and the result either uncertain or disfiguring. Doubtless the best method of employing heat in the treatment of lupus is that advocated by Besnier. This method consists in making punctate and linear scarifications by means of variously shaped needles, knives, and 146 THE TREATMENT OF SKIN DISEASES buttons of platinum, connected with a galvano-caustic battery. The use of the flat electrode may be successful in the destruction of lupus tissue, but the time required to effect the result is so great as to render the method of comparatively little value. The curette is an instrument well deserving the high reputation it has acquired in the treatment of lupus. When used alone it is apt to prove insufficient to effect a cure. It usually removes the greater portion of the diseased tissue with ease, and when cocaine is injected or even applied on pledgets of cotton to the raw surface, a large patch may be scraped with but little pain or discomfort to the patient. The healthy tissue re- mains uninjured, and a wound is left, which, properly dressed, will heal speedily and leave a smooth cicatrix. The size and shape of the curette is largely a matter of taste, but the form of the Volkmann spoon can hardly be improved. For recurrent isolated nodules appearing in the cica- trix after a previous unsuccessful operation, and for the minute points of diseased tissue noted after multiple scarification, even the smallest curette is apt to prove too large. A dental burr or a dental excavator can be used in such a case to great advantage. Indeed, whenever lupus appears in the form of dissem- inated nodules, burrs of varying size will be found greatly superior to a small curette. With such an instrument many small and deeply seated nodules of lupus can be bored out which would escape the action of any scraping process. Since recommending the use of the dental burr many years ago in the "journal of Cutaneous and Venereal Diseases," I have used it many times and with the greatest satisfaction. Mr. Morris, of London, has devised a similar instrument for this purpose, claiming ad- vantages over the burr (obtainable from any dental instrument dealer) which seem to me theoretical rather than practical. As regards scarification in the treatment of lupus, too much, I think, has been said in its favor, while the objection raised against it, that it promotes the absorption of bacilli and leads to pulmonary tuberculosis, is largely hypothetical. Linear scarification, as advocated by Squire and LUPUS SERPIGINOSUS Lupus vulgaris commonly attacks the face, the isolated nodules slowly coalescing and forming a raised patch. In exceptional cases, however, it may appear also upon the neck, trunk, and extremities. Though usually a disease of very slow development, it may occa- sionally run a comparatively acute course, though never spreading with the rapidity v/hich charafterizes the development of a tubercular syphilide, to which it often bears a strong clinical resemblance, Although lupus vulgaris usually presents a definite type, there are variations in its clinical appearance which have given rise to various names, such as lupus disseminatus, lupus verrucosus, lupus exedens, lupus serpiginosus, and others. In the serpiginous form of the disease the nodules cdalesce and gradually disappear from the central portion of the patch, either with or without ulceration, and leave a cicatricial area which may be dotted here and there with islands of lupus tissue. The margin of the slowly spreading patch is raised and often covered with crusts, resulting from the softening and ulceration of the peripheral nodules. This form of the disease is very apt to occur upon the neck, espe- cially in strumous or tuberculous subjefts, and is more likely to occasion pain, or discomfort, than is lupus of other regions. in the case of the patient portrayed in the accompanying illustration, aged thirty, the disease began at fifteen, as a group of small reddish nodules. This gradually increased in size, and in ten years involved the greater portion of the neck anteriorly. A patch on the left hand was of eight years' duration, and one on the tip of the nose of subsequent development. Copyright, jgoo, by G. H. Fox LUPUS SERPIGINOSUS. LUPUS VULGARIS M? Vidal, is certainly an improvement upon the punctiform scarification em- ployed by Dubini, Volkmann, and Veiel. There is no doubt but that it will cure lupus in most cases, and leave the most satisfactory cicatrix, but this method of treatment involves usually an amount of time and patience which greatly lessens its value as a therapeutic measure. The only cases in which it is superior to other plans of treatment are those of ulcerating lupus of the nose. Here the curette and various applications which will remove the diseased tissue are liable to produce considerable deformity, and cause the patient to go through life with a misshapen or stumpy nose. Scarification, however, in such cases, while it gradually destroys the lupus, permits a new growth of connective tissue to take its place, which tends to preserve the size and form of this important feature. As Vidal has shown by microscopical observation, the lupus cells gradually alter their configuration and assume the shape of fibres of con- nective tissue, and, as Squire has claimed, the nose may often be actually rebuilt. Of caustics and various applications which tend to destroy lupus tissue by virtue of their chemical effect, a long list might be given. All have proved of service in certain cases, few have manifested any remarkable and distinctive therapeutic value, while none have as yet found their way into general favor. I will merely mention nitrate of silver, caustic potash, chloride of zinc, lactic acid, ethylate of sodium, iodoform, and aristol, and remark that, in spite of time-honored usage or eminent recommendation, they possess no special value in the treatment of lupus. The use of bichloride of mercury, on account of its bacillicide prop- erties, has been advocated by Doutrelepont, Tausini, White, and others. My own experience with this method of treatment has proved unsatis- factory, and the slight improvement which took place in a few cases appears to have been due to a stimulating effect such as would follow its application to the nodules of acne or rosacea, rather than to any parasiti- cide action. The reported experience of others has been similar to mine. For many years I have used a strong ointment of pyrogallol, varying 148 THE TREATMENT OF SKIN DISEASES from twenty-five to fifty per cent. The application is sometimes quite pain- ful for the first twenty-four or forty-eight hours, and may give rise to con- siderable inflammation of the part. But the continued use of the ointment soon produces a benumbing sensation in the locality to which it is applied, and no further complaint of pain is made until the ointment is discontinued and a simple dressing is substituted. This application, coinciding with the separation of the sloughing tissue, will often be regarded by the patient as more painful than the pyrogallol. When the dirty, brownish, pultaceous slough has separated and left a clean, raw surface, mercurial plaster may be applied, beneath which the ulcer will become converted into a smooth, pliable cicatrix. Or, if the raw surface be considerable in extent, Thiersch's method of skin transplantation may be employed with benefit. I have no hesitation in recommending this use of (i) the curette, (2) the strong pyrogallol ointment, and (3) the mercurial plaster as a most admirable method in the treatment not only of lupus but of rodent ulcer. It is a method which has many advantages and few objectionable features. Salicylic acid is a remedy which experience has proved to be of service in the treatment of lupus and other forms of cutaneous tuberculosis as well as in many other affections of the skin. Unna advocates its use in most enthusiastic terms. He recommends the application of varying strength, but all containing two parts of beech tar creosote to one part of salicylic acid. The pain caused by the acid alone is very severe, and constitutes a serious objection to its use, but it is greatly mitigated by the anaesthetic action of the creosote, which Unna speaks of as the "morphine of the skin." The creosote has an antiseptic and bacillicide effect, and is therefore both cor- rigent and adjuvant to the salicylic acid. A strong plaster is at first applied to destroy the epidermic covering of the lupus tissue. Before the second plaster is applied to the raw surface, a solution of cocaine may be employed, which will temporarily deaden the pain, which in a short time yields to the more lasting anaesthetic effect of the creosote. Recently a number of new methods have been advocated for the cure of lupus. The phototherapy of Finsen consists in focussing the chemical rays LUPUS EXEDENS Lupus exedens is an uncommon form of ordinary lupus characterized by more or less destruction of tissue with extensive ulceration or deforming cicatrices. It often bears a strong resem- blance to epithelioma, and in many cases of a severe type the diagnosis is not readily made without the aid of the microscope. Even with this aid, the exclusion of either diagnosis does not neces- sarily follow, as it must be borne in mind that an epithelioma some- times develops upon a patch of long standing lupus, and in such a case is apt to develop with unusual rapidity. That lupus is closely related to, if not identical with, tuber- culosis of the skin is now generally admitted. At the same time the disease often develops spontaneously in children who present no other evidence of tuberculosis, and the inoculation of the skin with, tuberculous tissue rarely if ever produces a patch of typical lupus vulgaris. In the case illustrated the disease had existed for many years. Occasional attempts to cure it had only met with partial success. The deformity of the features is a characteristic result of the ulcera- tion and subsequent cicatrization. ''^- Copyright, 1900, by G. H. Fo LUPUS EXEDENS. LUPUS VULGARIS I49 from the sun or an arc lamp upon the affected patch. It has been success- fully employed in a number of reported cases, but a treatment which involves a daily sitting of an hour, continued for many months, is too tedious to warrant the praise which has been bestowed upon it. The Roentgen ray treatment has also been employed and good results claimed ; but, like cauter- ization with a fine stream of hot air, as advocated by Hollander, or freezing with a spray of liquid air, the treatment is one which must be considered of doubtful merit until others have confirmed the statements of enthusiastic pioneers. The constitutional treatment of cutaneous tuberculosis may be conven- iently divided into the specific and non-specific, the former aiming at a direct action upon the morbid growth, the latter merely improving the general con- dition of the patient, and thereby modifying the soil upon which the tuber- culosis is implanted. Despite the vagueness of the term, there is certainly sucn a thing as scrofula. It is an inherited or acquired condition of certain tissues, which leads to the development of definite and characteristic symptoms. It doubt- less renders the subject of this diathesis especially liable to the engrafting of tuberculosis in the strict sense of this term. Although no one can assert that cod-liver oil, or iodine, or the hypophosphites have ever produced the slightest direct effect upon lupus or other tuberculous lesions, there is no question as to the value of these remedies in combating the scrofulous diath- esis. In the therapy of cutaneous tuberculosis, these remedies may there- fore be justly considered as prophylactic, and clinical observation has repeatedly shown that in certain cases they are a valuable and often indis- pensable adjuvant to local measures. Experience teaches the value of iodide of starch as a reconstructive agent in all cases of struma, whether tuber- culosis be present or not. In 1880, McCall Anderson advocated the use of this remedy in eiVthematous lupus, and, strangely enough, implied that it was of no value in lupus vulgaris. His formula consisted of twenty-four grains of iodine to an ounce of starch, the iodine to be triturated with a little water, and the starch to be added slowly, the mass to be dried by a gentle I50 THE TREATMENT OF SKIN DISEASES heat, and kept in a close-stoppered bottle. By use of this remedy, he claimed that the largest amount of iodine could be most easily introduced into the system. I have used this remedy, freshly prepared, with great satisfaction, and 1 think with great benefit, not only in cases of lupus vulgaris, but in many cases of acne occurring in lymphatic subjects, and also in cases where chronic syphilis is combined with struma. For the specific treatment of cutaneous tuberculosis, various plans have been advocated, but the method promulgated in 1890 by Robert Koch is the only one which seems worthy of discussion. In both Europe and America a remarkable diversity of opinion has been expressed as to the value of lymph injections in the treatment of cutaneous tuberculosis. The unbounded enthusiasm which greeted the introduction of this new method ten years ago has completely subsided, and many who were then ready to pay fabulous prices for a few drops of the lymph are now busied with newer remedies and find no use for tuberculin. My own experience has led me to the belief that tuberculin exerts a specific action on lupus tissue, and is of great value, not only as a diagnostic test, but as a remedial agent. The new tuberculin now prepared for profes- sional use, though inferior to the old preparation for diagnostic purposes, may be employed with less danger of unpleasant symptoms, and with equal efficacy. MILIARIA Miliaria is a disease resulting from obstruction of the perspiratory ducts. It may occur under two clinical forms : Miliaria crystallina (sudamina) and miliaria rubra (prickly heat.) The minute drops of sweat which collect in the spiral ducts of the per- spiratory glands as they pass through the epidermis, cause an eruption of numerous discrete transparent vesicles, which appear like drops of dew upon the chest or abdomen of patients suffering from acute rheumatism, pneumonia, typhoid, or one of the eruptive fevers. In the modern and cooling treatment of the febrile state these minute pearly vesicles are less TUBERCULOSIS VERRUCOSA Like lupus vulgaris, the somewhat rare affeftion known as tuberculosis verrucosa is the result of the infeftion of the skin by the tubercle bacillus, it has been termed by some writers lupus verru- cosus, although the charafteristic tubercles of lupus are never present In one patient, i have noted this eruption upon the dorsum of the foot, while a patch of typical lupus vulgaris was present upon the arm. The hands are most frequently affefted, and the disease usually begins as a small warty growth over one or more of the knuckles. Its course is a slow one and there is no tendency to spontaneous recovery, although the central portion of the patch may be converted into a cicatricial area. Fissures and raw spots may be noted but there is never any extensive ulceration. The accompanying plate presents three illustrations of the disease. The upper hand, that of a young man, shows the simplest and most frequent form. The patch has become flattened and mani- fests a slight serpiginous tendency. The lower hand, that of a man aged forty-five, shows an extensive and typical form of the disease. The eruption in this case improved under treatment at the outdoor department of the Skin and Cancer Hospital, but after the patient had allowed eight years to elapse between visits it was found to have increased considerably in extent. Curetting beneath a spray of ethyl chloride is a plan of treatment which in such cases promises the best results. The boy, nine years old, whose leg is portrayed, had no eruption save the patch in the popliteal space which was of eighteen months' duration. Copyright, n/jo, by (r. H. Fox, TUBERCULOSIS VERRUCOSA. MILIARIA 151 frequently seen than formerly. They usually disappear in a few days, and may be followed by a slight desquamation. A dusting powder of starch, or some other absorbent, is the only treat- ment required. The fme red rash, either vesicular or papular in character, which appears upon the trunk as a result of heat, friction of clothing, or excessive perspira- tion, constitutes the inflammatory form of the disease known as miliaria rubra. The obstruction of the sweat duct may be either a cause or a result of the inflammatory condition. In infancy this heat rash often occurs from excess of clothing, and was formerly termed strophulus or "red gum." When the infant is nursed only at one breast, the side of the face and the arm coming in contact with the mother often presents the minute punctate eruption. In adult life the eruption (formerly called lichen tropicus) is liable to appear during the hot summer months, and affects those who perspire excessively from over-exertion or too warm clothing. It is especially apt to be noted in those who are in poor health, who bathe infrequently, who drink much beer or spirits, and who have a weak circulation. This "prickly heat," as the eruption is commonly called, often develops sud- denly and is attended by an intense burning sensation, which is at times intolerable. It bears a slight resemblance to acute papular eczema, but its sudden occurrence in connection with profuse sweating, its rapid course, its sensation of burning rather than of itching, the minuteness and dis- creteness of the lesions, and the absence of tumefaction and of moist patches will form a basis for differential diagnosis. Not infrequently, minute pustules are scattered among the fme vesicles and papules, and sometimes a few large indurated pustules or furuncles may develop, especially in cases where cleanliness has been overlooked, and several relapses have taken place during a hot spell. In the treatment of prickly heat, cold bathing, light clothing, and a few hours of perfect rest will usually give great relief, and often effect a cure. To lessen the congestion of the skin, an alkaline diuretic— such as ,52 THE TREATMENT OF SKIN DISEASES the granular effervescent citrate of potash— will often prove of decided benefit. in the local treatment, lotions or dusting powers may be used. Lime water, or a two per cent, solution of sulphate of copper, is doubtless as beneficial as any other lotion, while plain starch or talcum powder will probably do as well as the following combination : 5 Pulveris camphorse 3 ss 5 Zinci oxidi 3 iss 20 Amyli 3 vi ad 100 m (Anderson.) MILIUM The rounded whitish tumors of the size of a millet seed often seen upon the cheeks, temples, and eyelids are called milia. They are caused by an accumulation of sebum in glands seated just beneath the epidermis, the ducts of which have become obliterated. They may be few or num- erous, and often remain for years unchanged in appearance, and giving rise to no discomfort. Sometimes they aggregate, become dry and hard, and appear like cutaneous calculi. The treatment of a milium consists in removing the minute seed-like mass with as little injury to the skin as possible. This may be done by puncturing the epidermis obliquely, or almost horizontally, above the little tumor, with a triangular acne lance or any knife with a fine, sharp point. The white, rounded, cystic mass may now be picked out upon the point of the knife. If this little operation is done with extreme care and the requisite amount of skill, not the slightest bleeding is occasioned, and no trace of the puncture is left. Some writers speak of opening each one of the little pearly masses, squeezing out the cheesy sebaceous matter, and cauterizing the sac with a point of nitrate of silver or a drop of tincture of iodine. Such harsh treat- ment would produce a most undesirable, though not a permanent, disfig- SEBORRHOBA—STEATOMA— MILIUM The term seborrhoea sicca has been applied to a variety of affeftions in which there is neither increase nor modification of the sebaceous secretion and to which the name pityriasis would be far more applicable. Seborrhoea oleosa implies an abnormally oily or greasy skin. It commonly affedts the face or scalp. Upon the nose and adjoining region is sometimes seen a circumscribed patch of congested skin dotted with numerous follicular openings. Occasionally, as in the case of the patient in the plate a greasy pellicle forms upon the surface of the patch. Steatoma (wen or sebaceous cyst) is a rounded tumor containing sebaceous matter. It commonly develops upon the scalp or forehead in adult life. The growth is of variable size and is supposed to originate in a distended sebaceous gland, the duft of which has become obliterated. in time the resulting tumor is composed of a dense capsule containing whitish matter. Occasionally, as in the case of the patient in the middle illustration, the sebaceous duft remains and pressure may cause the contents of the cyst to be extruded in the form of a cheesy thread. A milium is a distended sebaceous gland— a steatoma on a small scale. It is usually seen upon the upper portion of the face, especially on the eyelids and malar region, and appears as a dense yellowish-white miliary mass imbedded in the skin just below the epidermis. As a rule, a milium has no dud. Occasionally, as in the case of the patient in the plate, the cheek may be dotted with minute white milia or distended sebaceous glands, from which the contents can be pressed out (acne albida of older writers). MOLLUSCUM 153 uration, and for facial milia is quite unnecessary. In case of large milia upon the scrotum, which resemble small wens, this method of treatment may be satisfactorily employed. The use of the electrolytic needle has been suggested in the treatment of milium, but removal by puncture is much more speedy and desirable. MOLLUSCUM Molluscum is a name applied to a small, superficial, globular or flat- tened tumor of epithelial character. The names molluscum contagiosum and molluscum epitheliale are used by some writers, but the adjectives are quite unnecessary. Since the disease formerly called molluscum fibrosum is now generally known as fibroma, there can be no danger of confounding simple molluscum with any other disease through ambiguity of nomencla- ture. The molluscous tumors, which may occur singly or in numbers, con- tain semi-solid cheesy contents, which can be readily pressed out from the summit, or from a central umbilication which is usually present. They are most frequently seen upon the face (particularly on the eyelids), the neck, and the genitals. They are usually of the color of the surrounding skin, but may become inflamed and reddened, especially when two or three are closely aggregated. The larger tumors are apt to become pedunculated. A considerable difference of opinion exists as to the cause of mollus- cum; some regarding the tumor as the result of a parasitic infection of the skin. It is certainly contagious in a mild degree, and sometimes spreads among children in a school or asylum. In a large proportion of cases, the hands of the patient will be found to be the seat of ordinary warts. Although the disease occurs with much greater frequency among the poorer classes, it cannot be considered as the offspring of poverty and un- cleanliness. Damp and crowded dwellings may favor its development, and I have known a number of cases to occur in such a locality. Ill health is not always a factor in its production, for while most of the moUus- 154 THE TREATMENT OF SKIN DISEASES cous children I have examined were strumous or weakly, there have been some upon whose faces not even the dirt could conceal the glow of health. The treatment of molluscum consists in removing the tumor with as little inconvenience to the patient, and as little injury to the skin, as is possible. In the case of adults and many children, it is a simple matter to shave off the tumor, with a scalpel or any thin-bladed knife, upon a level with the surrounding skin. For tumors on the eyelids a pair of fine curved scissors can be used to advantage. The slight hemorrhage may be quickly checked by touching the cut surface with a stick of nitrate of silver. A large pedunculated tumor ligated with a silk thread will speedily shrivel and fall. The use of the dermal curette is doubtless the simplest and speediest method of removing the tumors. It is unnecessary to apply nitrate of silver with a view to preventing a return of the growth, for this is quite unlikely to occur after curetting. But the application of the silver stick is advisable, since it will serve to check the hemorrhage at once and cover the wound with an excellent plaster. The use of nitric acid, or the acid nitrate of mercury, which has been suggested, is uncalled for, and might tend to the production of a scar. Pinching the tumor between the blades of epilating or other forceps will usually set up enough inflammation to destroy the growth and prevent its return. In the absence of a curette or forceps, the plan, suggested by Kaposi, of squeezing out the contents of the tumor between the thumb nails will also attain the 'desired end. The application of sulphuric, mercurial, and other irritating ointments has been recommended, especially in cases where the mollusca are numer- ous. This method of treatment is efficient, but unnecessarily slow in effect^ ing a cure. Owing to the superficial location of the growth, no scar should be left after treatment. But when one or more tumors have suppurated, as occa- sionally happens, the crust which forms may be scratched by the child and a slight pit result. MORPHCEA Morphoea begins by the development of small spots which at first are smooth and of a dull whitish hue. These become wrinkled and of a horny charafter as they increase in size. The patches are usually surrounded by a faint zone of a peculiar vio- laceous tint. They develop slowly, persist indefinitely, and some- times disappear spontaneously. In the upper illustration is seen a rare form of morphoea occurring in circles upon a woman's shoulder. The disease was of several years' duration, having begun on the right forearm. Minute whitish spots soon were found on both arms. Many of these coalesced, forming irregular or oval patches. The rings upon the shoulder appeared as though sunken or inserted into the skin and were surrounded by a faint lilac hued halo. In the lower illustration a more common and typical form of. the disease is shown upon the right hip of a man aged thirty- six. The patch was of eighteen months' duration, having begun in the form of several small whitish spots, which multiplied and coalesced as they increased in size. This composite patch was irregular in form and presented the dense fibrous condition of the skin with the shrivelled surface which is usually charafteristic of a well developed case. Upon the patient's right calf the disease had existed for two years. The skin in this region was slightly hidebound, as in cases of scleroderma, and presented an atrophied or cicatricial appearance. The galvanic current was used with beneficial effeft in this case. ■ 1 i p ^ ip^^ d^l P^P rer* p^ _ -■■ ,*> 1 ^jI^^BBBkv' KfJI'^^jH HR^^^^fl H^'' W 'M B^; ' « < , w^^^^ut 9^^. (** - *.^ ■■ . i n lllm^ n Pi C'lpyri^^ht, igoo, by G. H. Fox. MORPHCEA. M MORPHGEA ORPHCEA is regarded Dy many writers as a circumscribed form of scleroderma. Pathologically the two affections are closely related, but clinically they are quite distinct. In a few reported cases the peculiar features of each have been present. In its typical form the disease is characterized by one or more whitish, indurated, circumscribed patches of various size and shape. They are usually surrounded by a narrow zone of a faint lilac hue, and upon the extremities often appear in a line following the course of a nerve. The surface of the patch may be smooth and of the color of old ivory, but generally it is dry and wrinkled and usually of a dirty-white hue. Patches of morphcea may remain for months or years without percep- tible change, and then gradually disappear, leaving a normal or an atrophic condition of the skin. The band form of the disease, described by some writers, has not, according to my experience, presented the characteristic features of morphcea, but has seemed like a case of simple linear atrophy, following the course of a nerve. The cause of the disease is unknown. While mental anxiety and nervous depression, on the one hand, and various forms of local irritation and injury have seemed in some cases to be possible etiological factors, the disease develops in the majority of cases without any apparent cause. in the treatment of morphcea, a good result is to be hoped for rather than promised. Time and patience are always necessary in carrying out any therapeutic method, and in my experience the patient usually becomes discouraged and inclined to stop all treatment long before any definite result is attained. No benefit has ever resulted from the administration of arsenic or 156 THE TREATMENT OF SKIN DISEASES Other internal remedies, so far as reports of cases show. Local treatment may prove of some slight service, though incapable of producing any brilliant results. Hyde remarks that, considering the favorable issue in the majority of untreated cases, and the ill consequences of over treatment in others— namely, the production of irritation— one should look with caution upon all local management of the disease. Since the patch is largely due to local obstruction of the blood vessels and lymphatics, any form of treat- ment which will tend to improve the general circulation is likely to do good. Cold bathing and daily massage are, therefore, to be recommended. The galvanic current has been used in many cases, and improvement, if not a cure, has resulted. Crocker suggests that it should be applied in the neighborhood and not over the patch, as anything that irritates the diseased area induces further thickening. Allen reports favorable results from the use of electrolysis. Brocq believes that the disappearance of patches may be hastened by a combination of the following measures : I. The internal use of iodide of potassium in doses of fifteen to thirty grains ; 2. Electric baths ; 3. Electrolytic puncture twice a week with a current of from eight to fifteen milliamperes, lasting twenty seconds ; 4. Application of mercurial plaster, and 5. Th£rmocautery to spine once a week, at point of emergence of nerves supplying the affected part. MYCOSIS FUNGOIDES Mycosis fungoides is a chronic and, so far as present experience goes, an incurable disease, it presents a variety of clinical appearances, and in its early stage may be mistaken for erythema, eczema, psoriasis, or some other inflammatory disease, in time, however, and in some cases at the very outset, characteristic fungoid tumors appear which are unmis- takable. In the pre-fungoid stage, erythematous discs, circles and semicircles, or infiltrated scaly patches, with a sharply defined margin, are usually present. Itching is a prominent and distressing symptom which is rarely absent. MYCOSIS FUNGOIDES The patient whose face is portrayed in the accompanying plate was at the New York Skin and Cancer Hospital, where he suffered for over a year from a general, and for the most part, a typical eczema. The early stage of mycosis fiingoides is often charafterized by an eruption which looks very much like a dry eczema, but this patient presented large areas of a moist eruption which was attended by intolerable itching. The only peculiarity of this eczema was its unusual obstinacy. It seemed impossible to obtain relief, not to speak of a cure, through methods of treatment from which much benefit would be ordinarily expefted. Finally a number of tumors appeared upon the face and trunk and the serious nature of the disease became apparent. Before and after leaving the hospital the disease grew steadily worse, and after his death in a neighboring city, I learned that a diagnosis of leprosy had been made and based upon the finding of leprous bacilli. It is possible that this patient might have become infefted with leprosy, but all the symptoms were plainly those of mycosis fungoides. It is also possible that the microscopical exami- nation of the tissues may have been at fault. The size and softness of the tumors in this case and the rapidity of their growth and dis- appearance are by no means charafteristic of leprosy, and a com- parison of this plate with the one preceding will doubtless enable any one familiar with the two diseases to make a corred; diagnosis in each case from the portrait. Copyright, ly^xj, by G. H. Fox. MYCOSIS FUNGOIDES. MYCOSIS FUNGOIDES 157 The lesions may subside and entirely disappear for a time in some cases, but treatment seems to have very little effect in causing their removal. The tumors which may develop at any time in the course of the disease vary in size and shape, and are rarely persistent. Some will disappear rapidly while others are developing. Some are rounded and elevated, while others are flattened, and by healing in the centre form rings or gyrate patches. Pig- mentation of the skin is common, and both superficial and deep ulceration frequently occurs. As the disease increases in severity, the strength of the patient lessens, and death results in a few months or years. The disease is probably of an infectious nature, but the immediate cause is uncertain. It is considered by many to be closely allied to general sarcoma. The treatment of mycosis fungoides can only be palliative, since a fatal termination is almost certain. The internal use of arsenic has been thought by some to have a beneficial effect. Doutrelepont reports improvement in advanced cases under arsenical treatment, but Kaposi has seen no effect from this method. In cases in which 1 have used this drug, both by the mouth and by hypodermic injection, no good result has been attained. A nutritious diet, with strychnia, will often tend to improve the patient's condition, and morphia in the later stages is advisable. The local treatment should be directed to the relief of the pruritus and to general antiseptic measures. Frequent baths and the application of a strong carbolic lotion will fulfil each of these indications. Excision of tumors is unnecessary, unless they have attained a very large and uncomfortable size. When ulcerated surfaces are present, they may be dusted with aristol powder, or the following, as suggested by Brocq : 5 Pulveris camphorae 65 Naphtholis ad 100 m Morris mentions a case in which considerable local improvement followed the use of resorcin ointment (gr. xx to Si). 158 THE TREATMENT OF SKIN DISEASES N/EVUS PIGMENTOSUS A pigmented n^evus or mole occurs in its simplest form as a small yel- lowish-brown or blackish patch, and results from an excessive deposit of pigment in the skin (n^evus spilus). It may be single or numerous, and is usually of small size, differing from a freckle (lentigo) in being permanent, in some cases the pigmented nsevus is raised, and presents a rough, fissured, and warty surface (nsvus verrucosus). The surface presents occasionally an aggregation of small rounded fibrous tumors (nsevus papillomatosus). There is sometimes a foul-smelling secretion from a verrucous or papillary nsvus, and such a growth may become the seat of malignant disease. A pigmented n^vus is often covered with fine or coarse hair (n^evus pilosus.) The treatment of a pigmented nsevus depends upon its size and character. The small smooth nasvus may be permanently removed by any caustic which will destroy the epidermis and the superficial portion of the corium. Corrosive sublimate, ethylate of sodium, trichloracetic acid, and lactic acid have been recommended for this purpose. Any blistering agent will remove the pigment temporarily, but the dark color returns in a short time if only the epidermis is removed. The smooth pigmented nsevus upon the face of children can best be treated, according to my experience, by dotting the surface carefully with nitric acid applied by means of a wooden toothpick. Care should be taken that the minute yellow dots caused by the action of the acid should not coalesce and produce ulceration. The little crusts which form will fall in a week or ten days, and repeated application of the acid will remove the dark spot, leaving no permanent scar, or one so slight as to be scarcely noticeable. The verrucous form of n^vus can best be treated by a more free use of acid or by the electrolytic needle. The growth cannot be removed and a per- fectly normal skin left by any method of treatment, and the patient should understand in advance that a slight and inconspicuous scar is the best result attainable in such a case. N/EVUS PILOSUS. N^vi or "moles" of a yellowish or brown color and smooth surface often appear upon the skin in youth or adult life, and seem like permanent freckles. These pigmentary nsevi are some- times raised above the surface of the skin and often present a rough or warty surface. In most cases they are covered by a growth of fine or coarse hair, and constitute the hairy mole or n^evus pilosus. They are congenital, most frequently found upon the face and back and often cover a large extent of surface. The patient represented by the plate had a raised warty growth upon the right cheek, involving the lower eyelid and ex- tending up to the ridge of the nose. It was of a very dark hue and covered by a growth of coarse hair which the patient frequently trimmed with the scissors. In the center of the patch was a dry, blackish friable tumor resembling a cutaneous horn. The treatment of this case by means of the electrolytic needle was slow and tedious but productive of a most satisfactory result. The growth was entirely removed, leaving a smooth and scarcely perceptible scar with not the slightest deformity of the eyelid. The small portrait at the lower left hand corner of the plate shows the appearance of the face at the close of the treat- ment, while the other portrait shows a still further improvement, which was simply the result of time. Copyright, igoo, by G. H. Fox. N/EVUS PILOSUS. N^VUS VASCULARIS i59 N/^VUS VASCULARIS Naevus vascularis is the result of a permanent dilatation and increased growth of the cutaneous blood-vessels, and is usually congenital. In its simplest form it occurs as a small red punctate lesion with a few capillary vessels running from it in various directions (nasvus araneus). In the form commonly known as "wine mark" it appears usually upon the face, and presents an irregular patch of a hue varying from bright pink to dull purplish red (naevus fiammeus). It is unilateral in most cases, and has been known to extend over one half of the body. Small tumors of a cherry or grape color sometimes develop upon the surface of a wine mark, or independently. In infancy such growths often tend to increase rapidly in size (nsvus tuberosus). A subcutaneous vascular growth of venous character often involves the skin and forms a large compressible tumor of a faint bluish tint (naevus cavernosus). The treatment ot the vascular n^vus depends upon its size and char- acter. In the punctate form often seen upon the faces of children as well as adults, the use of the electrolytic needle is without doubt the very best method of obliterating the dilated vessels. With a current of two or three milliamperes so little pain is occasioned that most children can be induced to bear it for a few seconds by a promise of candy or other reward. The needle attached to the negative cord must be sharp and quickly intro- duced into the centre of the red spot. The sponge electrode attached to the positive cord should now be gently and slowly pressed against the palm. The effect of the electrolytic action will be noted in the gradual blanching of the tissue around the needle. When this is withdrawn, there should be no hemorrhage if the current has been of proper strength and continued for a sufficient length of time to occlude the dilated vessel. The small vascular tumor often seen upon the scalp or face of an infant may be destroyed by nitric acid or the galvano-cautery. The treatment of wine mark has long been and is still considered by many as a hopeless task. From time to time new methods have been i6o THE TREATMENT OF SKIN DISEASES recommended with more or less enthusiasm, but none has as yet been found capable of producing any brilliant therapeutic result. The most that can be said is that a wine mark can be greatly improved in appearance, if not satisfactorily removed, and the more disfiguring the mark the more successful will be its treatment. Cauterization will readily destroy any wine mark if vigorously em- ployed, but the scar which is apt to be left would generally be considered more disfiguring than the mark itself. Nothing short of a miracle will remove a large vascular nsvus and leave a perfectly normal skin. The main object of treatment should therefore be to destroy the new growth of vessels with the least injury to the skin. In the small red patches upon the face of children, and in the light- hued n^vi of older patients, the safest and least painful application which is likely to do good is pure carbolic acid. This should be applied with patience and persistence to limited portions of the red area and at intervals of one or two weeks, in order to give time for the outer layer of skin to peel and leave a smooth surface. The acid can be used in drops to dot the affected skin, or applied in the form of stripes running across the patch. Care should be taken not to cover too large a portion of skin, as some susceptible patients are apt to become dizzy, or even intoxicated, from absorption of the acid. Ethylate of sodium and various powerful acids are more effective in destroying the dilated vessels, but, at the same time, are more likely to cause ulceration and subsequent roughness of the skin, even when employed with the utmost care and skill. The operation of linear scarification as proposed by Squire consists in first freezing a portion of the affected skin by means of ether spray and then making parallel incisions with a thin scalpel or an instrument com- posed of a dozen or more blades and called the "multiple scarifier." The cuts should be no more than a sixteenth of an inch apart, and as long as they can be made quickly and straight. The bleeding is slight if the cuts are not over a sixteenth of an inch in depth, and can easily be ar- rested by applying a piece of blotting paper with slight pressure. This N/EVUS VASCULARIS NaevLis vascularis results from a permanent dilatation of the blood vessels of the skin and presents four clinical forms : 1. N^vus araneus is a small red spot which usually appears upon the face in early life. It presents radiating vessels which suggest the legs of a spider. 2. NcEvus flammeus or "port wine mark" is a congenital affec- tion commonly located on one side of the face or body. It varies in size from a very small patch to one affecting half the face or a large portion of the trunk. The color is sometimes rosy, but generally dull red or purplish. 3. Naevus tuberosus may occur as a vascular excrescence often seen upon the surface of a port wine mark, as a small rounded tumor, or as a raised lumpy birthmark of irregular shape. It varies from a bright red to a dull bluish tint, according to the arterial or venous char- acter of the tumor. 4. Ngevus cavernosus is a sub-cutaneous tumor, in which is a mass of dilated veins or arteries surrounded by firm connective tissue. The overlying skin is often normal in hue. The plate shows an extensive wine mark upon the right arm and lower scapular region with a few outlying patches of the same nature. Here and there are the small vascular excrescences which frequently develop upon the surface of a large naevus. Upon the arm near the axilla is seen a patch of ulceration and crusting, a condition which is very unusual in vascular naevus. j'S©, Copyright, igou, l)y I", H. Im.x N/EVUS VASCULARIS. N^VUS VASCULARIS >6i piece of paper should be gently peeled off before it has dried, and in the direction of the incisions. Squire says : " If the little operation be executed cleverly, that is to say, if the skin is well frozen, the instrument exquisitely sharp, the incisions made with perfect regularity of spacing and with uni- form equality of depth, and a special care be taken to avoid any acci- dental dragging of the strips apart, so that no clot is formed in the inci- sions ; if such details be well cared for, it will be found that the cuts heal with surprising rapidity, and become within a few days quite invisible. The process of scarification must be many times repeated, at intervals of a few days — that is to say, as soon as the last cuts are healed. At each operation the direction of the parallels of the second operation should be oblique to those of the first operation, and so on. The process is a tedious one, but the result of it is highly satisfactory, for the stain is made to disappear without the production of a scar." This operation appears to have failed to accomplish the desired result in the hands of others, and my own limited experience with it leads me to the belief that it is inferior to treatment by electrolysis. An operative procedure recommended by Frederick Churchill, of Lon- don, (''Face and Foot Deformities," 1885,) consists in puncturing the skin with the needle cautery and thereby causing the formation of hundreds of microscopic equidistant scars vertical to the surface. A coating of collo- dion is spread over the portion of the n^evus which is to be operated upon, and a thin metal plate perforated with holes about one-eighth or one- fourth of an inch apart is firmly pressed upon this hardened surface. With a series of rapid punctures through the skin the effect of arresting the blood current in the dilated vessels is attained. A square inch may be treated at one sitting, and the skin covered with a carbolic oil dressing. In a case illustrated by two chromo-lithographs a notable improvement is shown in the condition of a girl's face, but as this result involved a weekly operation under anaesthesia for a space of three months, the method of treatment seems hardly worthy of approval. The treatment of vascular nasvus by electrolysis is one which 1 have i62 THE TREATMENT OF SKIN DISEASES employed during the past twenty years, with results of a more or less satisfactory character. Although it has not accomplished as much as might be desired in the removal of wine mark, it is certainly of much greater service than the methods advocated by Squire and Churchill. Its object is to create numerous minute cicatrices upon the surface of the purplish patch, which will tend to reduce the color of the nsvus to such a degree that it will present comparatively little contrast with the surrounding skin. I have often used an instrument containing a dozen or more needles, with points upon the same plane and about two millimetres apart, but a single needle attached to the negative cord of a galvanic battery, such as is used in the treatment of hypertrichosis (page 115), will answer the purpose. Wine mark has been treated by Sherwell by means of a cluster of needles dipped in pure carbolic acid and thrust into the skin. While this may prove more or less successful in destroying the superficial vessels, and thereby lessening the dark hue of a nsevus, it is certain that the galvanic current is more active and at the same time more manageable than acid adhering to the point of a needle, and better adapted to produce the speediest results and with the least injury to the surface of the skin. ONYCHIA Onychia, or paronychia, is a term which implies an inflammatory condition of the matrix and soft parts adjoining the nail. In most cases the fold of skin rising above the lateral border of the nail is the part affected (onychia lateralis), but the root of the nail or underlying tissue may be the seat of the inflammation. An augmentation or deformity of the nail substance often takes place, and loss of the nail with more or less ulceration is a common result. Onychia may be idiopathic and occur alone or in connection with an eczematous condition of the finger ends. It is frequently traumatic in its origin, and may result from a cut, prick, or blow upon the fingers, or from the pressure of a tight shoe upon the toe nails. It may be due to the growth PAPILLOMA LINEARE Papilloma lineare (or n^evus verrucosus linearis) is a pigmented and warty growth, either congenital or acquired, which develops in lines or elongated patches, usually upon one side of the body. The patient whose back is partly shown in the accompany- ing plate was a girl of fifteen, in fair health though thin and nervous. She stated that her skin had been smooth at birth and that the warty patches had first appeared when about six months old. Since puberty they had increased in extent and become much darker. Her skin was smooth and normal except where patches of dark warty excrescences appeared. These were chiefly upon the left side of the breast and back and upon the anterior surface of the left thigh. These groups of papillomatous lesions were irregular in form but showed a marked tendency to a linear distribution, especially upon the extremities. They were raised considerably above the surface of the skin and of a deep brown or blackish hue. The few patches upon the right side of the trunk were removed by the curette with considerable difficulty, owing to their firm con- sistence, and left a notable contrast in the condition of the two sides. The patient represented in the lower corner of the plate was a young man who presented a vertical line of dark, slightly pedun- culated, fibrous excrescences running down the right side of the neck. His skin was elsewhere quite normal. Owing to the dense charafter of this warty growth, an attempt to remove it by means of the curette proved a failure and it was found necessary to excise it with a pair of sharp curved scissors. Copyright, ir/j, by G. H. Fox. PHTHEIRIASIS CORPORIS. PHTHEIRIASIS 167 When the head is swarming with pediculi, as is often the case with patients in our public dispensaries, it is advisable to cut the hair, especially in the case of children, and in summer time. The scalp may now be rubbed morning and night with an ointment of sulphur or carbolic acid, with kero- sene oil, or with the tincture of staphisagria or cocculus indicus, and sham- pooed every second day. A corrosive sublimate lotion (i-iooo) may be cautiously used when no excoriations or eczematous lesions are present, otherwise it is better to apply equal parts of oil of cade and olive oil. Sulphur or staphisagria in powder form may be rubbed well into the scalp with good effect. In the case of girls and women with long hair, cutting the infected tresses renders treatment much more convenient, but this is never abso- lutely necessary, and should generally be avoided. Soaking the hair over night in kerosene by means of an oiled silk cap will kill the pediculi and most of the nits, and repeated applications will effect a cure. "The dead nits or shells of the ova often remain upon the hairs in spite of ordinary treatment. They can best be removed by rubbing each affected hair from root to tip with a soft cloth dipped in alcohol or hot vinegar. In all cases the head-covering should be carefully examined, and old hats and caps baked in a hot oven or thrown away. Phtheiriasis corporis, caused by the clothes louse (pediculus vestimen- torum), is usually indicated by peculiar lesions upon the body and thighs. These consist of hemorrhagic specks, or so-called "bites," excoriated pap- ules, and numerous parallel scratch marks, especially across the shoulders and over the hips where four finger-nails have been used to tear the skin. In no disease is the pruritis so intense as in pediculosis of the body. The treatment of phtheiriasis corporis is usually a simple matter, except in cases where the patient is possessed by the idea that the eruption is due to impure blood, and not the direct result of the lice in his clothing. Many ignorant patients actually believe that the eruption breeds the lice, and such cases can only be treated satisfactorily in hospitals where enforced cleanliness is possible. i68 THE TREATMENT OF SKIN DISEASES The two aims of treatment should be to remove the pediculi and to soothe the excoriated skin. A complete and repeated change of clothing is necessary, and while the shirts and drawers are being boiled, the outer gar- ments should be baked in a hot oven in order to destroy both the pediculi and their ova. This having been accomplished, the irritation of the skin will be greatly lessened, and any pruritus remaining will quickly yield to daily hot baths and the use of a zinc lotion or carbolated vaseline. Phtheiriasis pubis, caused by the crab louse, is attended by severe itch- ing of the pubic region, and, in time, by a papular eruption. The lice, being much smaller than those already mentioned, are not readily dis- covered if unsuspected, but a careful examination usually reveals a num- ber of minute dark specks adhering closely to the roots of the pubic hair. In the treatment of this disease mercurial ointment has long been a favorite remedy, especially among the laity. While it is extremely effica- cious in removing the parasitic cause of the eruption, it is very disagree- able, and often excites an acute eczema of unexpected severity. The use of the ammoniated mercury ointment, either alone or diluted with an equal part of cold cream, will usually effect a cure without injury to the skin. The following have also been recommended : ? Hydrargyri chloridi mitis 5 Vaselini ad 100 TTl 5 Naphtholis 10 Olei olivse ad 100 m Covering the pubis for a few moments with a cloth saturated with a small quantity of chloroform (according to Van Harlingen) will kill all living crab lice instantly. The hair may then be washed with hot soap-suds, sponged with vinegar, and combed. The sponging with vinegar may be continued once or twice daily for a week, to get rid of all nits. When patients will permit it, shaving the pubis shortens the cure greatly. PITYRIASIS MACULATA Pityriasis is a superficial inflammatory affection of the skin, occurring either in small rounded discs, in rings, or in diffused patches, and is characterized by a light roseate hue and a branny desquamation. It is often classed with eczema, but differs from this affection in several important features. It usually runs a self-limited course, and never presents any notable thickening of the skin nor manifests any tendency to moisture. It differs from psoriasis in beginning as an erythema, in presenting only a slight degree of scaling, in usually running an acute course, and in showing no. tendency to recurrence at certain seasons. In the case of the patient who was the subject of the accom- panying illustration, the eruption appeared suddenly over the trunk and in less degree upon the extremities, and for a few days bore a slight resemblance to an erythematous syphilide. Many of the discs or roseate macules soon began to desquamate, and in a few weeks the eruption disappeared without any vigorous treatment. The general resemblance of the eruption to a guttate psoriasis, as well as the characteristic points of difference, may be readily seen by a comparative examination of the plates illustrating these two affections. While all of the guttate lesions of the psoriatic patient were covered with thick silvery scales, most of the lesions in the case of pityriasis were simply erythematous at the outset and the desquamation was slight and secondary. i ■%■ Copyright, iqoo, by G, H. Fox. PITYRIASIS MACULATA. PITYRIASIS CIRCINATA To the circinate form of pityriasis a variety of names have been applied. When it occurs upon the anterior portion of the chest, which is a favorite location, it is often designated as pityriasis rosea, lichen circinatus, or seborrhoea corporis. Upon the extremities or other portions of the trunk it is frequently called eczema seborrhoicum, despite the fact that it is not an eczema and has no relation whatever to the sebaceous glands. In patients with a marked eczematous tendency, however, a part of the eruption may become irritated and a secondary eczema develop, as it often does upon a patch of tricho- phytosis. Although the eruption is undoubtedly of internal origin, many believe in its parasitic nature, and some have regarded it as disseminated ringworm (herpes tonsurans maculosus). In the case of the female shown in the upper illustration the eruption, as is frequently the case, occurred in both the macular and circinate form. Many of the patches, as they increased in size, assumed a circular or oval outline and presented a central area of a dull, yellowish hue surrounded by a scaly margin. The disease ran an acute course. In the lower illustration the eruption upon a male chest is seen to be more confluent and to present a slightly papular character. When such an eruption occurs over the sternum it may run an acute course of one or two months, but in many instances it shows a tendency to relapse and to become chronic. •» Copyright, i~^oo,by G. H. Fox. PITYRIASIS CIRCINATA. PITYRIASIS DIFFUSA In the case of the patient who was the subjeft of the accom- panying illustration, the eruption was of four months' duration, having begun in the form of numerous small, scaly, punftate and guttate patches. These coalesced and formed diffused marginate patches of a purplish red hue and with a very slight amount of mealy desquamation. The eruption was found upon the scalp, face, arms, axilte and pubis, and especially upon the sterna! and spinal regions. There had been considerable scaling and itching at the outset, but there was little at the time the photograph was taken. The diagnosis in this case was perplexing. The peculiar purplish hue was a notable feature and was strongly suggestive of lichen planus, but there were no angular, flattened lesions typical of this disease. The eruption presented certain features suggestive of both eczema and psoriasis, but there was no tendency to exudation, no evidence of scratching, nor any formation of silvery scales. A diagnosis of eczema seborrhoicum, eczema marginatum or sebor- rhoea pityrjasiformis might have been made, but after a careful study of the case it seemed evident that the smaller lesions were essen- tially the same as those found in cases of pityriasis maculata seu ro^ea, and hence the diagnosis of pityriasis was made and a de- scriptive adjeftive appended which would suggest the occurrence of large, smooth patches, instead of the branny discs and rings which are more commonly observed in this disease. Copyright, 1903, by G. H. Fox PITYRIASIS DIFFUSA. PITYRIASIS PITYRIASIS, a name as old as Hippocrates, has long signified a branny desquamation of the skin. With certain adjectives appended, it has been applied to a number of eruptions presenting a variety of clinical appearances. Most of these are identical in origin and nature, while a few of them are distinct diseases to which the name "pityriasis" has become unfortunately attached. For instance, the pityriasis rubra of Hebra is a well-defined and generally recognized disease. Pityriasis rubra pilaris is a name given by French and some other writers to lichen ruber. Pityriasis versicolor, the name used in Germany for chromophytosis, has come into use as the result of an unfortunate attempt to classify skin dis- eases according to genera and species, and thus to bring all pityriasic erup- tions under one head, regardless of their origin and nature. The pityriasis rosea of Gibert, the pityriasis maculata, circinata, and marginata of Vidal and Duhring, the pityriasis simplex of older writers, and most cases of so-called eczema seborrhoicum, or dermatitis seborrhoica, may be conveniently and justly classed together. They are simply clinical forms of one disease which bears a strong resemblance to eczema on the one hand and to psoriasis on the other, but may be readily differentiated in most cases from either of these diseases. The clinical forms of pityriasis may be designated by the adjectives maculata, circinata, diffusa, and marginata. Pityriasis maculata usually occurs as an acute affection and may present a few small scaly discs upon the trunk or extremities, or an eruption which within a few 'days involves a large portion of the body. The discs are at first erythematous in- character and the desquamation- which rapidly follows 170 THE TREATMENT OF SKIN DISEASES may be confined to the central portion. The eruption may last a few weeks or several months. Pityriasis circinata bears the same relation to the form just described that the circinate psoriasis bears to the guttate form. The lesions may be rounded or elliptical in shape, with a pale yellowish centre and a raised border, which may be continuous or punctate in character (lichen cir- cinatus). They generally appear upon the upper portion of the chest, but may be numerous upon the back, loins, and thighs. According to Brocq, a single primitive plaque or circle usually develops a short time before the general or secondary eruption. This, beginning on the neck or breast, gradually extends downwards. Discs and circles are usually found to coexist in this eruption. The disease is always of internal origin, al- though the annular character of the lesions has led many to regard it as of parasitic origin and some to class it with ringworm (herpes tonsurans maculosus). Pityriasis diffusa may occur in a mild form upon the face (pityriasis simplex), or it may appear in large patches upon the breast and back, where, owing to the free glandular secretions, the desquamation may have an unctuous character, which has given rise to the names sebor- rhcea corporis and eczema seborrhoicum. Upon other portions of the body the eruption is quite dry and resembles a superficial eczema. The term seborrheic eczema, which is applied to it by many writers, following the lead of Unna, is certainly a misnomer, since many of those who use this name admit that the eruption is not a true eczema, and few, if any, will claim that it is at all seborrheic in character; i.e., due to a flow of sebum. A diffuse eruption, long known as pityriasis capitis, often occurs upon the scalp, it appears in a variety of forms (known as dandruff), varying from the dry, white flakes which fall readily, to the thick, asbestos-like mass which adheres and mats the hairs together, it is often associated with an erythematous condition of the scalp, and in certain subjects is prone to run into a typical eczema. Pityriasis marginata is found usually in the folds between the scrotum PITYRIASIS '71 and thighs (eczema marginatum), and is sometimes regarded as a ringworm or other parasitic disease of this region. It may also affect the axilla and the umbilicus, and is commonly regarded as an eczema. The eruption, if un- treated, is usually chronic. The treatment of pityriasis of a mild type consists in some bland inunc- tion calculated to soften the skin, remove the scales, and to lessen whatever itching or irritation may be present. Meanwhile the internal condition causing the eruption should be remedied or allowed to disappear spontane- ously, as it usually does in due time. For slight roughness of the skin a little cold cream may be used, or the following lotion applied frequently : 5 Sodii boratis 3 iii lo Glycerini f3 iss 5 Aquae rosae ad f § iv ad 100 m For slight pityriasis capitis frequent shampooing and the use of a two per cent, salicylated oil will usually keep the scalp clean and in time effect a cure. Jackson recommends the application of sweet almond or other oil at night, and in the morning an ointment composed of one drachm of washed sulphur to one ounce of vaseline, the scalp being shampooed every second or third day. When grease is objectionable, as it usually is to ladies with thick hair, the following lotion is a pleasant substitute, the amount of castor oil being. increased or diminished according to the dryness of the hair: 5 Acidi salicylicl 3ii 5 Olei ricini 3iv 10 Alcoholis ad 3 vi ad 100 Olei rosae q. s. m The general treatment of dandruff will be found discussed at length under the head of alopecia (page 34). The treatment of the macular and circinate forms of pityriasis consists in general measures suited to the needs of the patient, and the local use of baths !72 THE TREATMENT OF SKIN DISEASES and emollients. The following ointment will prove of service when the skin is not too irritable : 5 Hydrargyri ammoniati gr. xx 4 Hydrargyri chloridi mitis gf- xl ^ Petrolati mollis ad § i ad loo -"[ (Bronson.) In cases of pityriasis diffusa (dermatitis seborrhoica), sulphur, resorcin, and chrysarobin in ointments of gradually increased strength will prove of service, and some experimentation wiH often be required to determine just how much stimulation the eruption will bear. In pityriasis marginata, also, the same remark holds true, and the eruption is often aggravated by too strong an application. If marked congestion of the patch is evident, a zinc lotion will prove most agreeable and serviceable, while in other cases the most brilliant result can be obtained from a chrysarobin ointment (two to five per cent.), or the tincture of benzoin, containing one-half per cent, of corrosive sublimate, may be cautiously painted over the patch. PITYRIASIS RUBRA The disease to which Hebra limited the term pityriasis rubra is fortunately as rare as it is fatal. It runs a slow chronic course, and after it has existed for a year or two is characterized by redness and extensive desquamation of the whole body. In time the bright red hue grows duller and the skin becomes atrophied and tensely drawn. The hair falls, the nails become brittle, general emaciation occurs, and the patient succumbs to exhaustion or to some inter- current disease. The treatment of pityriasis rubra is intended chiefly to render the patient more comfortable, since in most cases there is but slight hope of a cure. It consists in the frequent use of emollient baths and soothing inunctions. Internal remedies have little effect. Kaposi mentions one case of recovery PITYRIASIS SEBORRHOICA The disease portrayed in the accompanying plate is one to which has been applied a bewildering variety of names. It is most frequently found upon the scalp in varying degrees of severity, and in its mildest form is commonly recognized as "dandruff." _ The dermatologists have called it pityriasis, seborrhoea, erythema squa- mosum, eczema squamosum, eczema marginatum, eczema sebor- rhoicum, dermatitis seborrhoica, etc., etc., and differ widely in their descriptions and views as to its precise nature. It is essentially a branny desquamation of the skin, associated with slight superficial inflammation, running an acute, subacute or chronic course, and presenting rounded discs, rings or diffused patches with either a marginate or an indistinft border. From a clinical aspeft it should be differentiated from both eczema and psoriasis, to either of which it may bear a strong resemblance. Although pityriasis is always a dry eruption, it may become the seat of a secondary eczema, especially upon the legs and when occurring in patients with a disposition to the latter disease. Upon the scalp and also about the nasal, sternal and interscapular regions, where the skin is naturally oily, the desquamation is frequently of a greasy charafter. From this faft originated the erroneous idea that the eruption resulted from a perverted function of the sebaceous glands. The affeftion may be accompanied by moderate pruritus and usually yields to the application of mildly stimulating ointments. Copyright, 1900, by G. H. Fox. PITYRIASIS SEBORRHOICA. PSORIASIS GUTTATA This illustration shows a mild type of the disease, although there was an unusually large number of small, dry, scaly papules covering the trunk and limbs. The silvery scales could be readily scratched off by the finger-nail, leaving a number of bleeding points upon the surface of the denuded corium. The patient was in good physical condition, and complained of nothing save the eruption. In this respect he was like the majority of psoriatic patients, since the disease seems to manifest a predileftion for robust and well- nourished subjefts. it will be noted that the eruption is symmetrical, as is usual in psoriasis, but the guttate lesions are not as rounded as they often appear in this disease, and consequently bear a resemblance to pityriasis maculata. Indeed, it is difficult in some cases of mild psoriasis to distinguish the eruption at first glance from pityriasis (seborrhoeic eczema), but the charafteristic tendency of the psoriatic eruption to recur at certain seasons, year after year, will usually settle the question of diagnosis. It will be further noted that in this case there are no erythematous spots. While congestion exists beneath the patches of thickened epidermis, all that can be seen of the eruption are white silvery scales with a line of redness at the border. Under a restrifted diet and an alkaline diuretic taken before meals, with cold baths and the inunction of salicylated vaseline, the eruption speedily disappeared. Copyright, ].,.,(,, by C, H. Fox. PSORIASIS GUTTATA. PSORIASIS '73 following the internal use of carbolic acid after all local measures had made the cutaneous affection worse. In other cases this remedy, like arsenic, has failed utterly to do good. A decided improvement will sometimes follow the internal use of citrate of potash and the external application of a weak salicylic ointment. In two cases observed some years ago, the disease being in its latter stage, with skin atrophied, inelastic, and tender, no emollient employed seemed to give as great relief to the patients as pure vaseline. PSORIASIS Psoriasis, though not seen as frequently as eczema, is still a very common disease in this as in other countries. On account of its frequency, its characteristic chronicity, and its occasional severity, it constitutes one of the most important of the inflammatory group of skin diseases. The eruption is always dry and scaly, contrasting in this respect with the moist exuding patches which characterize eczema in its most typical form. Unlike eczema again, the eruption always exhibits a notable tend- ency to a symmetrical distribution. In both mild and severe cases one side of the body is almost the duplicate of the other. No region is ex- empt from the eruption, although the scalp, back, and extensor aspect of the extremities are the parts which are usually first and most affected. The palms and soles are usually free, even when the scaly patches are elsewhere abundant, but in rare cases these may also be the seat of the disease. The lesions of psoriasis present a striking and a varied appearance in different cases, but they are always rounded and sharply defined, never fading off gradually into the surrounding healthy skin, as do the patches of eczema. When at their height of development they are always cov- ered with an accumulation of .silvery or yellowish-white epidermic scales, which can be readily scraped off with the finger-nail, leaving the pink corium exposed and a number of bleeding points representing the torn capillary blood-vessels in the cutaneous papillse. Various clinical forms of psoriasis have been long since described and 174 THE TREATMENT OF SKIN DISEASES are still recognized as the punctate, guttate, nummular, circinate, gyrate, diffused, and exfoliative varieties. The disease affects both sexes and all ages, having been observed in patients of three months and of eighty- five years. One of the striking peculiarities is a tendency to a recur- rence or an exacerbation of a persistent eruption at some certain season of the year. In most cases the eruption undergoes improvement during the summer and increases with the cold weather of the autumn or win- ter. Occasionally a respite of one or more years will be noted. The cause of psoriasis is a very interesting study, and yet in the past years, during which the pendulum of scientific opinion has slowly swung from the vague humoral pathology to the modern and more defi- nite germ theory, little, if any, light has been thrown upon the subject. The facts are these : Certain persons in nearly every community show a marked tendency to become psoriatic just as others become rheumatic or tuberculous. The disease often affects several members of a family and appears in successive generations. Those manifesting this psoriatic diath- esis or predisposition are usually robust, well nourished, and above the average perhaps as regards physical strength and vigor. The disease runs a remittent or an intermittent course, increasing at certain seasons and partly or wholly disappearing in the meantime. Every psoriatic in- dividual, though often presenting the eruption when in apparently good health, is certain to suffer more intensely when his or her general condi- tion is impaired through dissipation of any sort, insufficiency or excess of food, overwork, anxiety, gestation, lactation, or whatever may exhaust the vitality of either mind or body. From a careful study of these clinical facts it becomes evident that psoriasis is no more to be considered as simply a scaly eruption on the surface of the skin than rheumatism is to be regarded as merely a local affection of certain joints. It matters little whether we call psoriasis a constitutional disease, like syphilis, of which the eruption is simply an external manifestation, or say that, like urticaria, it is a cutaneous dis- ease of internal origin. It is sufficient to remember that, while local treat- PSORIASIS NUMMULATA The psoriatic eruption presents a great diversity of appearance in different patients, although rounded and circumscribed patches covered with silvery or yellowish white scales are characteristic of all cases. The eruption is nearly always symmetrical, whether the scaly lesions be punctate, guttate or nummular in size or occur in large diffused patches. Although the extensor surface of the ex- tremities, and particularly the region of the elbows and knees, is most frequently affected, the trunk in some cases may be the principal seat of the disease. The boy who was the subject of the illustration presented an eruption of the nummular or coin-like form. Both trunk and extremities were the seat of numerous rounded and scaly patches, varying somewhat in size, but bearing a sufficiently strong resem- blance to silver coins stuck upon the skin to warrant the use of the descriptive adjective. All of the larger lesions show an elevation of the border and a corresponding depression of the central portion of the patch. Upon the thigh a portion of the thick whitish scale has evidently been scratched off from some of the patches, leaving exposed a red and slightly elevated surface. The boy was admitted as a patient at the Skin and Cancer Hospital, and in a few weeks was quite free from the eruption— the regularity of sleep, diet, etc., doing as much for him perhaps as the special treatment employed. Copyright, i9'>3. by G. H. Fox. PSORIASIS NUMMULATA. PSORIASIS n5 merit will sometimes remove the eruption, it can never cure the disease— i.e., the almost constant tendency to the outbreak of a characteristic eruption. Hyde rejects the idea that psoriasis is hereditary or that it has any relation to gout, rheumatism, struma, or dyspepsia, and is inclined to regard it as a deformity of the skin (like ichthyosis) rather than a disease. The parasitic origin of psoriasis, which was claimed at one time, has been given up since the micro-organisms discovered by Lang have been found by Qtiinquaud in all scaly affections of the skin. The treatment of psoriasis, like that of nearly all inflammatory affec- tions of the skin, may be conveniently divided into general or hygienic, internal or medicinal, and local measures. The best results can only be obtained by a combination of all three therapeutic agencies. In every case it is well to remember that, however well and strong the patient may appear to be, it is possible, in a slight degree at least, to improve his condition. The very fact that he has psoriasis is sufficient proof that something is wrong, and from my point of view that indefinite ''something" which predisposes to the cutaneous eruption is to be found invariably beneath the skin. I have known a professional pugilist to suffer from psoriasis, though at all times a picture of health. Whenever he went into training the eruption invariably disappeared without resort to arsenic or local remedies. 1 believe firmly that a professional trainer could quickly cure nearly every case of psoriasis who would undergo the strict regime which is enforced upon every aspirant for athletic honors under such control. This being the case, why should not the physician adopt a somewhat similar plan in treating cases in which the customary treatment has failed, and which he is inclined to consider as unusually obstinate, if not incurable ? I know that many physicians, in addition to their Latin prescriptions, give excellent advice. They tell the patient to be careful in his diet, to take plenty of exercise, to drink less or to smoke less, and what is the result ? The patient takes his Fowler's solu- tion faithfully, but after a day or two eats what he likes and ' exercises or 176 THE TREATMENT OF SKIN DISEASES smokes when he feels like it. The trainer, on the other hand, not only gives the good advice, but makes it his business to see that it is followed out in every slight particular. Many patients with psoriasis are clerks, teachers, and others upon whom long hours of exhausting indoor work are obligatory, and for whom much outdoor exercise seems an impossibility. But these are precisely the ones who most need the exercise which is lacking, and by utilizing Sun- days, holidays, and early and late half-hours, even they can manage to improve their physical condition to a considerable degree, if a man has no time to eat, starvation is unavoidable. If a patient lacks the opportunity or the inclination to obey the fundamental laws of hygiene, he is bound to suffer, and medical treatment, in spite of a too prevalent medical belief, will rarely suffice to ward off the penalty of disobedience. Many other patients who have time to exercise, and do take a moderate amount of it, have fallen into the pernicious habit of eating far more than they actually require. While many eczematous patients are weak and poorly nourished and need an increased supply of nutritious food, the majority of psoriatics can restrict their diet with great benefit, not only in amount, but in variety. An excessive addiction to meat favors the development of the eruption and keeps the patches in a congested condition, which renders them rebellious to local applications which might otherwise do much good. A poor circulation often makes psoriasis more difficult to cure, and a cool tub bath every morning, in addition to vigorous exercise, will tend to overcome this condition. In all cases, and especially in inveterate ones, re- sort to the Turkish bath is beneficial. Unfortunately, the public baths ex- tend no welcome to patients with an extensive eruption, and the private box bath, involving, as it does, an extra room and more or less expense, cannot well be prescribed in a large number of cases. Among the many internal remedies which have been employed in the treatment of psoriasis, arsenic is usually placed at the head of the list. In no other skin disease is it capable of producing such a brilliant therapeu- tic effect. And yet, when administered in every case regardless of the PSORIASIS GYRATA The pioneers in dermatology were accurate observers and carefully noted the variations in clinical form which the common skin diseases are liable to present. While they may have laid undue stress upon certain peculiarities of configuration, we are certainly indebted to them for many descriptive adjeftives which are still in use and which convey to the mind a clear impression of the most striking clinical features of an eruption. Psoriasis is always of the same nature whatever form the eruption may assume, but for descriptive purposes, terms like punftata, guttata, nummulata, cir- cinata, gyrata, and diffusa are of great convenience. While in many cases of psoriasis the lesions may retain a punftate or guttate form, there is usually a tendency of the scaly discs to enlarge peripherally. In this manner are produced the num- mular or coin-like and the large rounded diffused patches. When small rounded patches coalesce an irregular patch with a scalloped border is formed. Frequently the psoriatic disc manifests a notable tendency to heal in the centre, like ringworm and syphilitic lesions. In this manner is produced the circinate form of psoriasis, and when the ring develops iil a serpiginous or creeping manner, part of the circle is apt to disappear, leaving a gyra or curved line of silvery scales. In the illustration may be noted guttate, diffused, circinate and gyrate lesions, and also the pigmentation of the skin which is fre- quently left after the disappearance of a psoriatic patch. i Copyrighl, 1900, by G. H. Fox. PSORIASIS GYRATA. PSORIASIS '77 condition of the skin, it usually does harm in ten cases where it bene- fits one. Arsenic is contraindicated in psoriasis when the eruption is increasing or when the patches are in an irritable or highly congested state. On the other hand, when the disease is tending to improve spontaneously, or in any chronic case in which the patches do not present a reddened and angry appearance after the scales are removed, arsenic may be prescribed with great benefit. Small doses should be given at the outset, and in- creased steadily until the eruption yields, unless a toxic effect is produced which calls for a diminution of the dose or a complete cessation of the remedy. When the eruption is extremely obstinate and no unpleasant effects are produced, the administration of the drug may be continued for many months. Indeed, when a notably beneficial effect is obtained in psoriasis, it is advisable to continue the arsenic even after the last trace of the eruption has disappeared. But when impairment of digestion results from its use, as frequently happens, the continuance of the drug is liable to injure the stomach far more than it can possibly benefit the skin. Arsenic is most frequently given in the form of Fowler's solution (Liquor potassii arsenitis, U. S. P.), well diluted, after each meal. The dose may be gradually increased from five to thirty drops if the patient is found able to tolerate the larger amount without unpleasant symptoms, such as puffiness of the eyelids, a burning sensation in the stomach, looseness of the bowels, or pigmentation of the skin. Some patients may be able to take even larger doses, but permanent harm has often resulted from "pushing" the remedy in accordance with the advice of former writers. The solution of arsenous acid (Liquor acidi arsenosi, U. S. P.), as well as the solution of sodium arsenate (Liquor sodii arsenatis, U. S. P.), are of the same strength as the solution of potassium arsenite (i-ioo). Tablet trit- urates of arsenous acid containing from one-fiftieth to one-tenth of a grain may be found more convenient for patients to take, and, in my experience, are no more apt to disturb the digestion. 178 THE TREATMENT OF SKIN DISEASES In cases where the psoriatic eruption is irritable and liable to be aggra- vated by the use of arsenic, the alkaline diuretics will invariably prove of the greatest service. Potassium citrate or acetate, given in a dose of twenty grains or more in a glass of water before each meal, will increase the renal secretion and speedily lessen the congestion of the patches. In all plethoric patients, and especially in those with a rheumatic or gouty tendency, this remedy is one of the most reliable at our command. If it does not alone effect a cure of the psoriasis, it will put the patient in a condition which will greatly enhance the value of any subsequent arsen- ical treatment. Potassium iodide in large doses has been found by Haslund and others to be an efficient remedy in psoriasis, but my experience has led me to the belief that it acts simply as an alkaline diuretic and has no advantage over the citrate or the acetate. In acute forms of psoriasis, and in cases in which the subjective symptoms are very pronounced, Malcolm Morris has found antimony to be very useful. He gives from five to ten minims of the wine of antimony three times a day. Carbolic acid has been advocated by Kaposi for internal use, and an action analogous to that of arsenic has been claimed for it. Ten or fifteen drops of the acid may be administered daily in the form of pills made with the extract of liquorice as an excipient. Crocker speaks highly of turpentine, stating that under its use the hyper^emia of the skin is reduced, the scales fall off, and many cases get quite well in about two or three months. It may be given in the form of an emulsion, the oil of turpentine being rubbed up with mucilage of acacia. The dose may be gradually increased from ten to thirty minims after each meal. Barley water should be taken freely during the treatment, to avert the possibility of unpleasant urinary complications. Cantharides, copaiba, and gurjun oil have also been praised for their efficacy in the cure of psoriasis, but all remedies which may produce only a slight improvement in a psoriatic eruption at the risk of possible injury to the urinary organs may well be discarded. Mention might be made of many other internal remedies which at various times have been highly recommended, but it will suffice to say that none of them can compare in value with the alkalies and arsenic. PSORIASIS CIRCINATI The circinate form of psoriasis results from a tendency of the rounded, marginate patches to heal in the centre while the border remains thickened and scaly. This is noted in certain cases par- ticularly of the nummular or diffused type. The small lesions do not develop in a circle and enclose a healthy area, as sometimes happens in the tubercular syphilide, but as the patch enlarges in a serpiginous manner the raised scaly border often breaks into small guttate segments. The accompanying plate shows a case of psoriasis which had lasted for many years, increasing in extent at times and then almost disappearing. This increase and decrease of the eruption, which is a charafteristic feature of psoriasis, is due partly to the change of seasons and partly to the change of food which this involves. It also depends upon accidental conditions which exert an influence upon the health and vigor of the patient. The eruption is com- monly worse in winter than in summer, and many patients note a marked tendency to an exacerbation in either the spring or autumn months. While it is true that the victims of psoriasis are, as a rule, robust and well nourished individuals, it is also to be noted that in a given case the tendency to the outbreak of new lesions depends largely upon conditions which tend to impair the health or to pro- duce mental or physical exhaustion. ^^5'V -V Copyrig''ht, igoo, by G. H, Fox. PSORIASIS CIRCINATA. DERMATITIS VENENATA Dermatitis from the local use of chrysarobin in the treatment of psoriasis, chronic eczema and other skin diseases is an incidental effeft which is as unavoidable as it is undesirable. When used in the form of an ointment and well rubbed into infiltrated patches it seems almost impossible to prevent the surrounding skin from becoming inflamed if the best results of this most valuable remedy are attained. A diffused redness is first noted and this often spreads to parts beyond the area to which the ointment has been applied. In certain cases an unexpeded and painful congestion of the skin is occasioned with severe itching, swelling of the glands, slight fever and loss of sleep. When the application of the drug is discontinued the bright scarlet hue of the inflamed skin gradually changes to an Indian red tint. In a few days more or less desquamation occurs and soon a skin of normal whiteness is left. Upon the face chrysarobin should be used with great caution, if at all, owing to the danger of exciting a severe conjunftivitis. Even when used elsewhere the patient should be cautioned against rub- bing the eyes while any ointment remains upon the fingers. Upon the scalp the remedy is usually objeftionable on account of the pur- plish color of the hair which is apt to result from its continued use. The plate shows all that is left of numerous discs of psoriasis after the use of a chrysarobin ointment. Instead of red or scaly spots upon a white background of normal skin, the reverse is seen. The infiltrated discs have become smooth and white and present a strong contrast with the red staining of the surrounding skin. Copyright, pj.-.., by ^- H- Fo DERMATITIS VENENATA. (EX USU CHRYSAROBINI.) PSORIASIS 179 The good repute which some remedies have attained is doubtless due to the fact that psoriasis, as has been remarked, is so frequently intermit- tent in its course. It increases and decreases at certain seasons and with varying conditions of the patient. When a chronic case of psoriasis is taken from a dispensary clinic and put in hospital, the regularity of the diet, the enforced rest, and the continuous warmth of the bed will usually benefit the patient in a marked degree, and the eruption will tend to improve and sometimes to disappear in a few weeks. If thyroid extract, clover tops, or some other useless remedy is administered during this period, an enthusi- astic paper is very apt to be published on the remarkable effect of the remedy in the cure of psoriasis. In the local treatment of the eruption many remedies have been recommended and used, and a score or more of them are usually mentioned in every text-book. But there is one local remedy the therapeutic action of which so far surpasses that of every other known remedy that, if it is desired to remove psoriatic patches from the skin in the shortest possible time, no other application should be thought of That remedy is chrysarobin. its capabilities in the cure of psoriasis, or at least in the removal of psori- atic patches, is simply marvellous. Such a remark is not infrequently made by some enthusiastic writer commenting upon a new drug or preparation which he has tried but a few times, but it is rarely made concerning a remedy which one has been constantly using for a quarter of a century. The brilliant therapeutic effect of chrysarobin cannot be obtained, however, by one who has had little or no experience in its use and who is ignorant of how and when to use it. Frequently it does harm. It often inflames the skin of a patient until he looks like a boiled lobster, and suffers perhaps even greater agony. It invariably stains, and usually ruins the patient's un- derwear and his bed-linen. And not infrequently, when the patient receives no caution as to his danger, it is inadvertently rubbed in or about the eye, and sets up an intense conjunctivitis which is usually far more dis- agreeable, if not more serious, than the eruption for which it has been prescribed. But the great point in its favor is that it always produces an i8o THE TREATMENT OF SKIN DISEASES effect. If it fails to do good, it is certain to do harm. Unlike the many vaunted remedies which we have carefully used and finally failed to discover whether they were of slight value or perfectly inert, the remedy in ques- tion is one which never can be accused of producing a doubtful result. In cases of psoriasis in which the skin is irritable and the congested patches are tending to increase in number and extent, chrysarobin, like arsenic, is contraindicated, and likely to increase the eruption if applied. But when the eruption is tending to disappear, or when chronic, thickened patches have remained unchanged in appearance for a long time, an oint- ment of varying strength, suited to the requirements of the case, will speed- ily remove the scales and lessen the infiltration. A curious effect is usually produced. The healthy skin surrounding the patches becomes reddened, partly from inflammation and partly from the staining effect of the drug. Around the scaly discs or patches a whitish line is commonly produced, and gradually the psoriatic eruption, instead of appearing as red, scaly spots on a background of light normal skin, is converted into smooth white discs or patches upon a background of a dull indian-red hue. The ointment may now be discontinued, and the reddened or stained skin will gradually return to its normal appearance. When a considerable degree of inflammation has been occasioned, more or less desquamation is apt to occur, as after an attack of scarlatina. The best effect of chrysarobin can always be obtained by the use of an ointment. This should be thoroughly rubbed into the scaly patches by means of a swab or tooth-brush, as it stains the nails badly when the pa- tient uses his fingers for this purpose. Old or discarded underwear may be advantageously worn night and day during this treatment by inunction, and only such bed-linen used as can be cheerfully sacrificed in behalf of the cure. No amount of washing will remove the purplish-red stain occasioned by the use of this drug. The Unguentum Chrysarobini of the United States Pharmacopoeia is of ten per cent, strength, and well suited to the majority of cases. It is often advisable, however, to commence with an ointment of from three to five PSORIASIS DIFFUSA. Psoriasis of long standing usually assumes the diffused form, in rare cases the first attack may affect a large portion of the skin, and not infrequently the disease may retain the guttate or nummular form for many years either continuously or in recurring attacks. Still it may be regarded as a rule that the more chronic cases are the ones which present large rounded or irregular patches of diseased skin. These are formed by the gradual confluence of smaller lesions and are generally characterized by an excessive accumulation of epidermic scales. Such patches are not only intensely pruritic but often extremely painful, owing to the fissures produced by motion of the body. Sometimes large masses of dried scales become loosened and are finally torn or rubbed off, leaving a dull red and tender skin exposed to view. The accompanying illustration shows many guttate spots upon the trunk and region of the elbows as well as diffused patches upon the back. The patient had suffered from the disease for many years and the localization of the eruption around the waist was doubtless the result of his wearing a tight belt, since it is frequently noted that pressure or local irritation of any kind is apt to determine the site of psoriatic patches. The eruption is quite typical over the sacral region, which is a favorite site of the disease, but the unsym- metrical appearance presented by the scapular regions is somewhat unusual. Copyright, icjotj, bj' G. H. Fox. PSORIASIS DIFFUSA. PSORIASIS i8i per cent, in strength, watching its effect, and increasing the percentage if it seems advisable to do so. In chronic, thickened patches, especially upon the legs, it is often necessary to use a twenty per cent, ointment. in order to use chrysarobin, and at the same time to lessen its disagree- able effects, many devices have been suggested, such as incorporating the powder in plasters and varnishes. These are less likely to produce extensive dermatitis and staining of the clothing, but they are inferior to an ointment in quickly removing the psoriatic patches. One of the best of these is a solution of gutta-percha containing five or ten per cent, of chrysarobin. A combination of salicylic acid with chrysarobin in collodion 1 have used for many years, and found it extremely serviceable. The following is the formula : ^ Chrysarobini lo Acidi salicylic! lo Etheris 15 CoUodii flexilis ad loo m This may be painted over the patches every day or two until the scaling has disappeared and smooth white spots are left. Another method of confining the effect of chrysarobin to the diseased skin is to rub it into a soft paste with water and smear it over the psoriatic patches from which the scales have been removed. When this has dried, a layer of thin collodion should be allowed to flow over each patch and to harden into a protective coating. This will remain for several days or longer, according to the location of the patches. it is inadvisable to use chrysarobin upon the scalp or face, as it discolors the hair and is very liable to get accidentally rubbed into the eyes, and thus cause conjunctivitis. In psoriatic patches upon the head the ointment of ammoniated mercury may be conveniently used in its stead. Although this ointment has little effect upon, psoriasis of the body, it will often suffice to remove the eruption from the face and scalp. Before the introduction of chrysarobin, tar was the chief remedy in the treatment of psoriasis, and the oil of cade is still an efficient, though disagree- i82 THE TREATMENT OF SKIN DISEASES able remedy. Upon the scalp it may be applied diluted with alcohol or almond oil. On the body it may be used mixed with five parts of glycerole of starch. Pyrogallic acid, aristol, and various other remedies have been highly recommended and extensively used by many in the cure of psoriasis. None of these remedies can compare in efficacy with chrysarobin, and since some of them possess qualities almost as disagreeable, 1 have failed to find any occasion for their use. Baths of various kinds and soap frictions are commonly advised for the purpose of removing the psoriatic scales, but usually they occasion more trouble than benefit. When the skin is highly inflamed or extremely itchy, prolonged hot baths, followed by the inunction of vaseline or almond oil, will often give relief. But when the skin is in a condition which will permit the use of a mild chrysarobin ointment, this will be found to remove the scales far more quickly than any amount of soap and water. To sum up the treatment of psoriasis in a few words, it may be said that at the outset in most cases, while the general health of the patient is being improved by a judicious system of exercise and diet, the best remedies are alkaline diuretics internally and vaseline locally. When the patient is in his or her best physical condition, and the irritability of the skin has been lessened by the treatment mentioned, then arsenic can be given internally and chrysarobin applied locally, with an excellent prospect of effecting a speedy cure. By a cure is meant a restoration of the skin to its normal condition. The tendency to psoriatic outbreaks, like the tendency to gout or rheumatism, is not a mere local affection of the skin or of the joints, in either case it is constitutional, and occasionally seems to be ineradicable. Psoriasis may be cured, i.e., the eruption may be forced to disappear, but, as experience teaches, it may be confidently expected to return as soon as the patient resumes his former mode of life. PSORIASIS EXFOLIATIVA The scales of psoriasis are usually adherent except in cases where, from the severity of the disease or from lack of daily ablu- tion, they have become unusually thickened. Under such circum- stances the scales tend to disintegrate and fall to such an extent that when the patient removes his clothing a considerable quantity can be gathered from the floor. An extensive psoriatic eruption occasionally becomes the seat of an acute inflammatory process. The scales then form rapidly and tend to become less adherent. To this condition the term psoriasis exfoliativa may be properly applied. The acute inflammation often involves the whole body, the imbricated and adherent scales give place to large flakes of peeling epidermis, and the psoriatic eruption gradually loses its distinftive charafter and finally merges into an affeftion of the skin known as dermatitis exfoliativa, and which is illustrated in the following plate. The accompanying plate portrays a confluent nummular erup- tion which covers the greater portion of the back. The patient was of intemperate habits and an extensive eruption was certain to fol- low every prolonged debauch. f, I -i fer*^.- --ii- <■ -<■' '*'-*?'-::S:i»i^ V _v Copyri'^'ht, I.J.-., by G. H. Fox. PSORIASIS EXFOLIATIVA. DERMATITIS EXFOLIATIVA Dermatitis exfoliativa is used by some writers as a synonym of pityriasis rubra (of Hebra). A distinftion should be made, how- ever, since the former disease runs an acute course in many cases and is always amenable to treatment, while the latter disease, although it may begin as an exfoliative dermatitis, tends to grow worse in spite of treatment and finally results in a smooth, reddened, atrophied skin and terminates fatally. The scaling in this disease is peculiar, the epidermis peeling in large papery flakes. These often curl at the free borders while remaining attached in the centre to the subjacent skin. There is never any moisture of the surface as in eczema, nor any accumu- lation of silvery epidermic masses as in psoriasis. In exceptional cases a few bulte may develop upon the surface and the eruption bear a strong resemblance to pemphigus foliaceus. The patient whose trunk and arms are well portrayed in the plate was sent to the Skin and Cancer Hospital by Dr. Martin Burke. The eruption had developed rapidly and involved the entire body in a few weeks. Under the administration of alkaline diuretics the redness of the skin faded, the scaling gradually lessened, and in two months she left the hospital with an almost normal skin. Copyright, 1900, by G. H. Fox. DERMATITIS EXFOLIATIVA. PRURIGO THE name prurigo has been applied by former writers to many eruptions of varied character, in which severe itching is the prominent symptom. It is now restricted to a definite disease which begins in early life, and persists usually in spite of treatment. It is characterized by a peculiar dryness of the skin, with pale shotty papules, chiefly on the extensor aspect of the extremities, and a pruritus so intense as to cause numerous excoriations, urticarial lesions, thickening and pigmentation of the skin, and often a notable enlargement of the superficial lymphatic glands. A severe form of the disease (prurigo ferox) is common in Austria and other parts of Europe, but in this country such cases are extremely rare. Even the mild form (prurigo mitis) does not often occur, and the few cases which are met with are apt to be regarded as instances of persistent papular eczema. The diagnosis must depend upon the early development of the disease, its chronicity, and the characteristic location of the lesions. The treatment of prurigo will usually ameliorate the condition of the skin, even if it fails to effect a complete cure. Hot baths, soap frictions, and stimulating inunctions are called for in most cases. Vlemingk's solution (page 20), applied either pure or diluted with from one to ten parts of water, is perhaps the best local application. If the skin is very dry, good results may be obtained from the use of Wilkinson's ointment, made according to the following formula : 5 Sulphuris prsecipitatl 3iss is Olei rusci f3iss 15 Cretse preparatae gr. xl 10 Saponis mollis 3 iis 25 Adipis ad 51 ad 100 m 1 84 THE TREATMENT OF SKIN DISEASES If eczematoLis patches complicate the disease, the use of vulcanized rubber underwear, worn with the rubber side next the skin, may prove of value. "Naphthol (two to five per cent.) in oxide of zinc ointment may be smeared upon pieces of muslin and applied to the limbs beneath a roller bandage. Kaposi has long used this remedy, and claims that it diminishes the itching at once, has no disagreeable odor, and does not soil the linen. The local treatment should be continued until the skin is smooth and all itching has ceased. Applications may then be made less frequently until the skin has remained smooth for a month or more. Arsenic, according to Zeisler, exerts little, if any. influence upon the eruption, even if given perseveringly and in full doses. Pilocarpin, used subcutaneously, will produce a profuse perspiration and thereby soften the skin, but its incidental effects require that it should be used with great caution. Antipyrin, in doses of one to three grains, has been found service- able by Blaschko and others in lessening the intense pruritus and controlling the urticarial symptoms. Crocker relieves the itching by giving full doses of the tincture of cannabis indica. For a child of eight or ten he begins with five minims, and increases it even to thirty minims, three times daily, directly after meals. An interval of a fortnight in its administration should be allowed about every six weeks, since when taken in large doses for a long period it may produce dullness of intellect and loss of memory, which soon passes off, however, when the drug is suspended. Since cases of prurigo here and elsewhere are usually found in the lower stratum of society, attention should be paid to the betterment of the patient's hygienic surroundings. Nutritious food, with cod liver oil, malt extract, and bitter tonics, will often strike at the root of the disease and enhance the value of local remedies. It is also important to continue general treatment, frequent hot baths, and inunctions long after the skin has become comparatively smooth and soft, as early cessation of the treatment is certain to be followed by a speedy relapse. PRURITUS 185 PRURITUS Itching is a prominent symptom of eczema, urticaria, scabies, phthei- riasis, and many other skin diseases. Often it occurs alone as the result of hepatic or renal disease, or of some obscure internal condition, and to this cutaneous disorder, with the resulting excoriations, the term pruritus is applied. It is, in fact, a neurosis of the skin. It may occur at any age, but is apt to be especially annoying and intractable in the decline of life (pruritus senilis). It may occur at all seasons, but is very frequently noted at the advent of cold weather, and persists in some cases only during the winter (pruritus hiemalis). It may affect the body generally, or be limited to certain regions, e.g., the nostrils, anus, scrotum, or vulva. Pruritus results from a great variety of causes, both predisposing and exciting. The source of the affection often remains obscure even after a most careful study of the case, and frequently it is much easier to remove this by measures which improve the mental and physical condition of the patient than it is to determine its precise location and character. Jaundice, diabetes, gout, malaria, dyspepsia, and neurasthenia are diseases which often underlie the cutaneous pruritus and demand therapeutic recognition. Improper food, excessive use of tobacco, coffee and certain drugs, intestinal worms, hemorrhoids, etc., must always be regarded as possible sources of the external irritation, and proper measures taken to arrest their detrimental action. Of all diseases of the skin pruritus is the one in which a routine plan of treatment is most certain to fail. Its etiology is so varied that unless great patience and skill are exercised in the examination of a case no treat- ment will be likely to accomplish any brilliant result. If the cause of the pruritus can be discovered and removed, the treatment of the cutaneous lesions becomes a simple matter. The general treatment of the patient who suffers from Intense pruritus is always of prime Importance. The treatment of the patient's skin can only be regarded as a palliative measure. i86 THE TREATMENT OF SKIN DISEASES The use of narcotics in the treatment of pruritus may sometimes seem advisable for a brief period, but they soon lose their effect when continued indefinitely and often do far more harm than good. Opium is especially objectionable, since it not only tends, like cocaine, to induce a pernicious habit of reliance upon the drug, but it usually aggravates the pruritus. Bulkley has recommended both cannabis -indica and gelsemium as internal remedies, and in general pruritus good results may be obtained from their temporary use. In my experience the bromides have proved quite as ef- ficient in the treatment of adults, and may be pushed v^ithout the danger of unpleasant toxic symptoms. Baths are of great service in cases of general pruritus, and may be plain or medicated. The cool tub bath in the morning will invigorate both the skin and the nervous system, and may be safely advised even for elderly patients and those who imagine that all sorts of evil may result from such a procedure. A hot bath at night usually has a sedative effect and tends to induce sleep, and when salt in large quantity is added, as recommended by Piffard, a decided antipruritic effect is attained. The underclothing of a patient suffering from pruritus may tend to irri- tate the skin, and the wearing of thin garments of silk or linen beneath the ordinary woollen underwear will often relieve the itching and any urticarial complications.' In the winter season, or in a climate where sudden changes of many degrees are frequent, the clothing should be regulated in such a manner as to keep the body warm at all times, and at an even temperature. External applications in the treatment of pruritus are often found to be of great service, since they alleviate the distress of the patient, even though they may not strike at the root of the disease. They may be used in the form of powders, lotions, oils, or ointments. Alcohol rubbed into, painted over, or, better still, sprayed upon the skin, relieves pruritus temporarily by virtue of the cooling effect produced by its rapid evaporation. Chloroform liniment is another remedy which, though seldom used for this, purpose, is capable of allaying itching in a marked degree. PRURITUS 187 Carbolic acid, on account of its power of inducing a certain amount of local anaesthesia, is one of the most reliable of all antipruritics. As com- monly used in a weak solution, it does but little good, but when a solu- tion is used of sufficient strength to almost burn the skin the relief of the pruritus is always marked, and only in cases where there is an inflamma- tory condition present is it likely to do harm. Over the whole skin, and especially in children, it should be used with caution in order to avoid the possible intoxication from absorption. The following lotion is a cleanly and most effective one, which 1 have used with success in many cases: 5 Acidi carbolici 20 Glycerini 20 Aquffi ad 100 m S. — Apply with caution, and dilute if necessary. A more lasting effect is produced when the acid is mixed with oil or fat, and the following formula is highly recommended by Bronson : B Acidi carbolici f3 i-ii 12-25 Liquoris potassii f3 i 12 Olei lini ad f5 i ad 100 m Menthol, thymol, cocaine, tar, corrosive sublimate, potassium cyanide, and hydrogen dioxide may also be found of service. A mixture of chloral and camphor, which forms a fluid, has been used with success by various writers. This may be incorporated in an animal oil or ointment and thor- oughly rubbed into the skin. In cases of intense general pruritus, when nearly all remedies have failed, 1 have found galvanism, applied to the skin by means of a metallic roller, to produce an almost magical, though temporary, effect. With each succes- sive application of the electricity the relief from the itching is apt to be more prolonged. THE TREATMENT OF SKIN DISEASES PURPURA Hemorrhage into the cutaneous tissue or from a mucous surface may result from a variety of causes. Upon the skin it occurs in the form of small, bright red spots (petechia), diffused bluish red patches (ecchymoses), or a dark tumor due to the rupture of a larger and deeper vessel (hematoma). The hemorrhagic lesion always appears suddenly, does not disappear under pressure of the finger, and usually exhibits a series of tints of red, purple, blue, green, and yellow, as the effused blood is gradually absorbed. The term purpura is not applicable to cutaneous hemorrhage result- ing from bruises or other external injury, or occurring in connection with eruptive fevers such as small-pox and measles, and in various ery- thematous and bullous affections. It should- be restricted to an idiopathic hemorrhage, which may involve the skin alone or the mucous membranes simultaneously. Several clinical forms of purpura are usually described. Purpura sim- plex usually occurs upon the legs, although the thighs, neck, and chest may also present the eruption. The lesions appear suddenly and in successive crops, so that notable contrast is often observed between the bright claret colored spots of recent occurrence and the dull purplish or livid hue of those which are a few days old. Purpura rheumatica is a less common form of the disease, in which pain and swelling of the knees, ankles, or other joints are noted in addition to the hemorrhagic eruption, which is apt to be elevated, and to resemble an exudative erythema. Purpura hemorrhagica is a severe form of the disease, in which there is fever and more or less general prostration. There are serious hemorrhages from various mucous membranes in addition to the cutaneous eruption, which usually assumes the form of large ecchymoses upon the trunk and extremities. Purpura scorbutica or "scurvy" is a term which has long been applied PURPURA Hemorrhage into the cutaneous tissues, when spontaneous and superficial, gives rise to an eruption of smooth lesions of vary- ing size known as purpura simplex. These are bright blood-red spots at the outset, becoming dull or purplish after a few days. In some cases they do not increase in size, but usually they enlarge and often coalesce into patches. When the hemorrhage occurs in the follicles the lesions may be elevated (purpura papulosa). In severe cases there is usually more or less bleeding from some of the mucous membranes (purpura hemorrhagica). When this hemorrhagic purpura is the result of a prolonged abstinence from vegetable food, the disease is commonly known as scurvy (purpura scorbutica). The accompanying plate shows a well-marked case of purpura in its most common form. The man was a patient in my service at the Skin and Cancer Hospital and had suffered from recurring attacks of purpura of the lower extremities. The present eruption began with numerous small bright-red spots, such as are seen around the popliteal space and above the ankle. Upon the middle portion of the legs they rapidly increased in size, coalesced into irregular patches, and assumed a dull purplish hue. With rest in bed and the administration of the tindure of the chloride of iron in full doses the eruption faded away in about two weeks' time, the patches passing through those gradations of color which are charafteristic of a disappearing bruise. Copyrig-ht, 1900, by G. H. Fox. PURPURA. PURPURA 189 to the same affection when occurring among sailors on long voyages, sol- diers on poor or short rations, prisoners in crowded jails, and others who are unable to enjoy the benefits of good food, fresh air, and outdoor exercise. The treatment of purpura depends upon the type and severity of the individual case; In the simple form a spontaneous recovery in a few weeks is often noted, and this may be favored by complete rest and the administra- tion of the tincture of the chloride of iron in full doses. Quinine, nux vomica, and the mineral acids, will often give tone to the patient's system and in- directly hasten the course of the eruption. Since the arthritic type of purpura frequently occurs in those who suffer or have suffered from rheumatic attacks, the salicylates and other anti-rheu- matic remedies will be found of service. Potassium iodide is especially valuable, not only for the rheumatic symptoms, but for the purpose of hasten- ing the absorption of the purpuric spots. Treatment of rheumatic purpura should be continued for some time after the cutaneous lesions and arthritic symptoms have passed away, as relapses are not uncommon. In the treatment of purpura hemorrhagica absolute rest in bed, with free- dom from all care and mental anxiety, is of prime importance. The most nutritious diet, with wine, unless a febrile condition forbids, is necessary to keep up the strength of the patient. Among internal remedies, iron, turpen- tine, and ergot have been used with probably the best results, although their administration has not always prevented a fatal termination. The iron tincture is best given in glycerin, and the turpentine, in ten to thirty minim doses, on lumps of sugar. The fluid extract of ergot may be given in carbonated water, one half drachm every three or four hours. When the hemorrhage is serious, its hypodermic use is preferable. Hamamelis, hydrastis, and arnica have also been recommended for internal use. For bleeding of the gums, the ordinary astringent mouth-washes may be used, or a three per cent, solution of cocaine applied by means of a camel's- hair brush. Small pieces of ice will sometimes relieve gastric or rectal hemorrhage. I90 THE TREATMENT OF SKIN DISEASES Local applications have little effect upon the cutaneous lesions. Eleva- tion of the limbs, with the use of light cheese-cloth bandages, may prove of service. Vidal recommends the application of compresses, soaked in a one to two per cent, solution of ammonium chloride. ROSACEA Rosacea is a disease which has long been associated with acne, and is still described by most writers under the name of acne rosacea. While often presenting inflammatory lesions which bear a strong resemblance to the pustules of chronic acne, it is also characterized by a development of super- ficial blood vessels, and an increase of connective tissue, which give it a place among the hypertrophic affections. Three clinical forms are recognized and described as rosacea erythematosa, rosacea pustulosa, and rosacea hyper- trophica. it is the pustular form which bears the strongest clinical resemblance to acne, but may be differentiated by the fact that it occurs in middle life instead of in youth, affects chiefly the central vertical third of the face, and is not associated with comedos and an impaired function of the sebaceous glands. ■ Rosacea usually presents dull red nodules on the nose and malar region, and sometimes on the forehead and chin. These may be due to some form of alcoholic indulgence, but all dietetic errors which cause irrita- tion of the stomach and a consequent flushing of the face will tend to pro- duce them. In fact, the term "dyspepsia blossoms" would be more com- prehensive and more applicable to all cases than the well-known name of "rum blossoms." in the treatment of rosacea the circulation and digestion of the patient should be carefully considered before any thought is directed to the cutane- ous condition. If a man saw another shivering with cold on a bleak corner, and wished to restore his pinched and blue nose to a normal condition, he would probably suggest to him to go indoors and get warm. If he saw ROSACEA ERYTHEMATOSA The three forms in which rosacea may appear are commonly- described as the erythematous, the pustular, and the hypertrophic. The accompanying portrait represents a combination of the first two types, although the erythematous element is the most marked. The nose and malar regions are the favorite seat of the affection, but in this case, one of long standing, the whole lower portion of the face is involved. The cheeks and chin present numerous indolent nodules some of which show a tendency to suppuration. Between and over these a persistent passive congestion gives to the skin its character- istic rubicund color. This affection is frequently described as a form of acne (acne rosacea), but it differs in several essential respects. It is not primarily of follicular origin. There are never any comedos or other evidence of follicular disturbance such as is invariably present in cases of acne, and the disease is usually noted at a more advanced age. Indeed, it commonly begins at about the age when the ordinary acne of youth begins to disappear spontaneously, and most patients over thirty who suffer from rosacea will be found to have shown little or no dis- position to acne during their teens. C'jpyright, iqoo, by G. H. Fox. ROSACEA ERYTHEMATOSA. ROSACEA PUSTULOSA The patient represented in the accompanying plate had suffered from rosacea for many years. This may be readily judged by the pitted condition of the malar region which had evidently been the seat of many suppurating nodules. The forehead was dotted with numerous large indolent pustules in various stages of development. The nose had gradually assumed a purplish tinge and at times was slightly increased in size. The cause of rosacea varies in different cases, but a chronic indigestion is usually present and is often associated with a feeble circulation. These conditions predispose to a frequent flushing of the face and a stagnation of blood in and about the nose. Though the lesions in this affection, especially in the pustular form, are sometimes justly spoken of as "rum blossoms," it must be remem- bered that the bright redness of the nose or the dull red nodules in its vicinity, or even a considerable hypertrophy of the organ, may sometimes occur in patients who have never been addicted to the use of alcoholic beverages. The most successful plan of treatment consists in a combina- tion of local and constitutional measures. While a radical change of habits and general treatment of the patient is usually necessary in striking at the root of the disease, a marked improvement can often be effected by vigorous curetting, soap frictions, and the application of the most stimulating ointments and lotions. Copyright, k/^j, by G. H. Fux. ROSACEA PUSTULOSA. ROSACEA 19' another one indulging in supernumerary cocktails or irritating his stomach in some one of many, other common ways, he would surely not expect to dissi- pate the resulting nasal blossoms by the mere application of a topical astrin- gent. And yet many physicians strive to cure rosacea by the local use of soap, sulphur, ergot, etc., without paying the slightest attention to the cause of the trouble. While it is true that stimulating local remedies often produce a notable improvement in the patient's appearance, they do not strike at the root of the disease, and are therefore incapable of effecting a permanent cure. In rosacea, as in many other cutaneous affections, the importance of judicious regulation of the diet, systematic outdoor exercise, and cold bathing as therapeutic agents can hardly be overestimated. In the erythematous form of rosacea the lower portion of the nose is often persistently reddened, and this condition, like the cold hands and feet with which it is usually associated, is simply due to a sluggish circulation. The patient's lungs are rarely expanded to their full capacity and the heart's action is weak. In. such a case simple gymnastic exercises, frequently repeated during the day, will serve to lessen the congestion of the head by drawing more blood to the lungs and quickening the circulation through the extremities. The patient, especially if a young girl, will do well to renounce corsets and tight collars. She should be made to acquire the habit of sitting erect at all times and walking with the chin never in advance of the breast bone. It is not generally known how much a correct posture, combined with frequent forced inspiration, will do in relieving facial congestion and improving a girl's complexion. This chronic redness of the nose is sometimes associated with an oily condition of the skin, which may be greatly benefited by the frequent application of sulphur in either powder or lotion. When gastro-intestinal irritation exists strict dietetic measures are called for. The only indication of this irritation may be a frequent flushing of the face or an increased redness of the nose after hot drinks or hearty meals. Tea and coffee, as well as alcoholic stimulants, and even soup, should be forbidden. Excessive use of tobacco, and especially cigarette smoking, is apt 192 THE TREATMENT OF SKIN DISEASES to weaken the circulation, to favor reflex hyperasmia, and thereby to aggra- vate an erythematous rosacea. In the pustular form of rosacea the same attention should be paid to the patient's general condition, while local treatment of the most vigorous character may be instituted. Soap frictions, strong sulphur lotions, and all stimulating applications, however they may irritate and redden the face temporarily, are certain to quicken the sluggish circulation and cause the affected skin to become smoother and whiter, in the local treatment of rosacea pustulosa, as in chronic acne, the curette will be found of great value. Once or twice a week the face should be scraped as energetically as the patient will permit. The bleeding excoriations left in place of the pustules grow less with each repeated curetting, and soon the instrument will merely redden the skin. The "bubuckles and whelks and flames of fire " which characterized the countenance of Sir John Falstaff will disap- pear very speedily from any other rosaceous face under the unsparing use of the ring curette or sharp spoon. After vigorous curetting an antiseptic lotion should be sponged over the face. This lotion or a soothing oint- ment may be used daily by the patient, although it is by no means neces- sary. The hypertrophic form of rosacea demands treatment of a surgical character, as the strongest ointments cannot remove the increased growth of tissue. Vigorous massage will often evacuate a large amount of sebaceous matter from the glands upon the tip and wings of the nose, thereby lessen- ing its size to a considerable extent and reducing its color in a slight degree. Multiple incision, deep linear scarification, or the use of the electrolytic needle, will serve to reduce the size of the nose and sometimes effect a brilliant result. But when soft, pendulous, lobular masses are present their removal by the knife is the simplest and surest method of treatment. Often the excision of one or more wedge-shaped masses of hypertrophic tissue will greatly improve the patient's appearance. The dilated and branching capillaries (telangiectasis) often seen upon the wings of the nose, with or without rosacea, can best be destroyed by ROSACEA HYPERTROPHICA The hypertrophic form of rosacea is not frequently met with, but when it does occur it usually presents a peculiarly strik- ing appearance. In most cases the increase of growth is limited to the tip and wings of the nose. Though red and swollen in appearance the nose feels cold and flabby to the touch. The mouths of the sebaceous follicles are abnormally patulous and dilated blood vessels often appear upon the surface. In time the increase of growth produces large lobular masses and the red color of the nose changes gradually to a dull purplish or livid hue. in rare instances the enlarged nose becomes pendulous, resting upon the upper lip and presenting a marked deformity (rhinophyma). When the whole nose is enlarged without the formation of soft lobular masses the surface presents a smooth red appearance, or is of a venous tint and often dotted with numerous follicular pits, which give the organ a worm-eaten appearance. The accompanying plate illustrates a case of moderate degree in which redness, swelling and incipient lobulation were the chief features. The sebaceous glands of the tip and wings of the nose were greatly distended by their contents. Just before the photo- graph was taken the nose was vigorously pinched and numerous masses of white, cheesy sebum forced out of the follicular openings. The patient was a gentleman in good general health who had never indulged in alcoholic beverages to an unusual extent. A N Copyright, igoo, by (\. H. Fox. ROSACEA HYPERTROPHICA. SCABIES 193 inserting the electrolytic needle at the point where the vessel first appears upon the surface of the skin. The small, tortuous veins upon a hyper- trophied nose may be made to disappear by inserting the needle at one or two points along their course. SCABIES Scabies, commonly known as "the itch," is a disease caused by the burrowing of an insect (acarus scabiei) in certain regions where the skin is thin, as on the web of the fingers, axillary folds, penis, and scrotum. The resulting eruption is characterized by numerous excoriated papules, and is found chiefly on the hands and forearms, the female breasts, the male geni- tals, the lower portion of the abdomen, and inner surface of the thighs. As the common name implies, the disease is an intensely pruriginous one, and the itching is especially severe at night when the patient is in a warm bed. It is contagious, and very apt to affect several in one family. It is usually acquired by sleeping with an affected individual, or in a bed which such a one has occupied. In the treatment of scabies sulphur has long been, and is likely to re- main, the standard remedy. Styrax, naphthol, and various other remedies have been recommended, and a number of formula of parasiticide ointments are usually given in every text-book, but nothing is simpler, cheaper, and more effective than plain sulphur ointment. A few suggestions as to its proper use will, therefore, be of more use than a discussion of other remedies which may be of undoubted value, but can lay no claim to superiority. The main object of treatment is to destroy the acari and to cure the eruption which has resulted from their presence in the skin. The official sulphur ointment (3 in 10) is well adapted to the accomplishment of both these ends. In the case of children or patients with an extremely delicate skin, or when a secondary eczema has resulted from persistent scratching, the ointment may be diluted with one or two parts of vaseline. 194 THE TREATMENT OF SKIN DISEASES The treatment should begin with a prolonged hot bath at night for the purpose of macerating the skin, so that the burrows of the insect may be more readily destroyed. The hands should then be scrubbed thoroughly with soft soap and the same applied more gently to the axillary region, genitals, and other parts where the acari are prone to burrow. After the skin is dried, the sulphur ointment should be rubbed well into the parts which have been scratched most severely, and the patient directed to sleep in tight-fitting underclothing. This may be worn constantly for three days, the ointment being reapplied rnorning and night. The patient may then take a second hot bath, and in most cases no further treatment is required. Should a return of the itching be noted the same programme, including the hot bath, soap friction, and sulphur inunctions may be repeated. In very chronic cases the period between the baths may be five instead of three days. Sulphur rarely produces any irritation of the skin when eczema is not present, but such a possibility must be borne in mind. If the pruritus persists after the above treatment has been carried out, it may indicate that either an error in diagnosis has been made or that the sulphur, and not the scabies, is now the cause of the itching. In either case its use should be discontinued. The use of sulphur powder in place of the ointment, as recommended by Sherwell, has found favor with some, and is certainly a more agreeable method of treatment in private practice. Though in chronic cases it may not be equal in efficacy to the ointment, it is capable of curing most patients. By the ease with which it can be dusted over the bed and underclothing it is well adapted to prevent a return of the disease from reinfection. SCLERODERMA Scleroderma is a rare disease in which an indurated or "hide-bound" condition of the skin is noted. It is usually chronic in its course and may affect a limited region, or involve the head, trunk, and upper extremities. At first there is an infiltration of the skin, imparting to the surface a characteristic SCABIES The eruption in a case of scabies is mainly artificial and results from the free use of the finger-nails. It may consist merely of excoriations, but in many cases, owing to the vulnerability of the skin, a secondary eruption of an eczematous type with papules, vesicles and pustules is induced. When, in addition to this, local infeftion of the numerous scratch marks occurs, efthymatous crusts and superficial ulcerations are frequently seen. The eruption in scabies often bears a close resemblance to a papular eczema and may indeed be justly regarded as such an erup- tion evoked by external irritation. The diagnosis of scabies, how- ever, may be readily made by noting the charafteristic location of the eruption. When excoriated papules or other lesions are num- erous upon the web of the fingers, the anterior aspeft of the wrists, the axillary region, the female breasts, or about the genitals in men and boys, the parasitic origin of the eruption is invariably indicated. The little girl portrayed in the accompanying plate had suffered from scabies for several weeks and presented an unusually extensive eruption. There were numerous pustules as well as excoriated papules upon both the trunk and extremities and a few efthymatous lesions upon the thigh. The free use of sulphur powder quickly allayed the intense itching and the skin was soon as smooth as ever. At the same time care was taken to have the other children in the family submitted to the same treatment. Copyright, 1900, by G. H. Fox. SCABIES. SCLERODERMA I95 hardness and pallor. Later this may disappear and leave an atrophied and tightly drawn condition of the integument. In some cases the infiltration disappears and leaves a normal skin. The cause of scleroderma is obscure. The affection is often associated v^ith the rheumatic diathesis, and exposure to cold and damp air may possibly give rise to it, as it certainly tends to aggravate it. It occurs in children as well as in adults, and women appear more subject to the disease than men. The treatment of scleroderma is rarely attended by any brilliant thera- peutic result, and often seems of little or no benefit. But since a sponta- neous disap'pearance of the disease has at times been noted, a persistent effort should be made in every case during the stage of infiltration to restore the skin to its normal condition. When the disease has progressed until the atrophic stage has been reached, all hope of a cure becomes delusive. The general health of the patient can often be greatly improved by systematic outdoor exercise and a nutritious diet, including koumyss, malt extract, and cod liver oil in large doses, if the patient's stomach will tolerate it. Internal remedies have been found to be of little or no service so far as their direct effect upon the hardened skin is concerned. But when a rheumatic condition is present, as often happens, the alkalies, salicylates, and salol may be prescribed with benefit. The patient should be removed to a warm and equable climate when this is practicable, or made to dress in such a manner that the skin will not be affected by any sudden change of temperature. The Turkish bath has been highly recommended in the treatment of scleroderma, and if taken frequently will improve the condition of the skin in most cases. In the local treatment of the disease, massage is of the first importance, and in no other affection of the skin is this remedy of greater service. In combination with massage the inunction of cod liver oil has been employed ; but the main object of the massage is to stimulate the cutaneous circulation in the ischaemic regions. Whether dry or oiled hands are used, the massage must be employed skilfully, frequently, and persistently. Galvanism is 196 THE TREATMENT OF SKIN DISEASES another agent which tends to stimulate the cutaneous circulation, and I have seen excellent results follow its use. Hyde advises brisk rubbing of the whole body with salt, partially dissolved in hot water, followed by warm bathing and finally cold affusion. SCROFULODERMA Under the name of scrofula or struma many cutaneous eruptions have formerly been classed, some of which were syphilitic, a few inflammatory or eczematous, and many of tuberculous origin. The chief symptoms of scrofula have been described as indolent inflammation of the skin, caseous degeneration of the lymphatic glands, with the subsequent occurrence of characteristic ulceration. Visceral disease, tumefaction of the belly, chronic keratitis coryza, otorrhcea, and chronic arthritis- or dactylitis are usually coincident indications of the peculiar diathesis. The chief cause of scrofulous lesions, which were formerly attributed to an inherited taint, has been found by modern research to be the tubercle bacillus or toxins in the tissues affected ; or a cachexia resulting from the tuberculous condition of some internal organ. Some, therefore, class scrofu- loderma as a tuberculosis cutis, or, if the bacilli are not present, as a para- tuberculosis. The treatment of scrofuloderma depends upon the extent of the disease. For the general condition of the patient cod liver oil and iodine have long been the favorite and most effective internal remedies. Combined with fresh air and a nutritious diet, these will often produce a decidedly beneficial effect. When glands have softened or ulceration is present, a surgical method of treatment is usually required, and the curette may be freely used. The healthy ulceration which results will usually heal speedily. When healing is slow the raw surface may be sprayed with an ethereal solution of iodoform. SCROFULODERMA Although the term scrofula has always had a somewhat vague significance and various skin diseases have been attributed to its influence, the name scrofuloderma has a more precise meaning. It is applied to chronic suppurative inflammation occurring in strumous or tuberculous subjefts, and usually in conneftion with glandular inflammation of the neck or elsewhere. Though often classed as a form of cutaneous tuberculosis, it presents clinical features which differentiate it from the common forms of this disease. In place of the small nodules which are charafteristic of lupus vulgaris and the papillomatous growth found in cases of tuberculosis verrucosa, we have -in scrofuloderma an indolent undermining ulceration of the skin with more or less of crusting, and a marked tendency to the forma- tion of reticulated or puckered cicatrices. The subjed; of the accompanying portrait, a boy aged twelve, of German parentage, was brought to the Vanderbilt Clinic by Dr. H. J. .Wallhauser. There was no evidence in the case of inherited tuberculosis, and the ulceration of the cheek and neck was attributed to a fall when four years of age. From this time the boy had been in delicate health, and extensive ulceration had occurred upon either side of face and near the elbows. He had suffered also from a dactylitis of the right index finger. The large patch upon the right cheek began as a suppurating tumor and the resulting ulceration pur- sued a charafteristic indolent and obstinate course, extending up ■beneath the eyelid and down across the anterior surface of the neck. The illustration shows an eftropion of the lower eyelid and a slight deformity of the ear, produced by partial cicatrization. i Copyright, 1900, by G. H. Fox. SCROFULODERMA. SYCOSIS SYCOSIS is an inflammatory affection of the hair follicles, usually of the bearded portion of the face. It is, therefore, almost exclusively limited to the male sex. The characteristic lesions are papules or pustules, each perforated by a hair. The disease is non-contagious, and has no more claim than acne to be considered as a parasitic affection, notwithstanding the presence of pyogenic micro-organisms. What has been termed by some writers a parasitic form of sycosis is simply ringworm (trichophytosis barbae). The presence of this disease may sometimes occasion a secondary sycosis, as it often does a secondary eczema, but in such a case we have two distinct diseases to deal with. The cause of sycosis may be either of a general and predisposing, or of a local and exciting character. In the great majority of cases both of these etiological factors are present. In the pustular lesions of sycosis staphylococci are readily found, and some have regarded these organisms as the parasitic cause of the disease. Occasionally a strong, robust man may suffer from sycosis as he may suffer from a furuncle, and it would seem as though some local infection, possibly of a contagious nature, were responsible for the affection. But in most cases, sycosis, like acne, depends upon, or at least is aggravated by, systemic conditions which predispose to the cutaneous inflammation. These produce what is commonly termed a favorable soil for the pyogenic germs, and are of prime importance in the development of most cases. I cannot agree with Crocker in regarding sycosis as a purely local disease, but would claim, with Robinson, that hereditary vulnerability of the skin, impaired nutrition of the body, and disorders of the intestinal tract, as well as all injurious local agents, whether acting mechanically, chemically, or thermically, can make the ground favor- able for a sycosis. 198 THE TREATMENT OF SKIN DISEASES Upon the cheeks local irritation, such as the use of impure or alkaline soap, does not play as important a part in the causation of the disease as some have alleged. But in that form which so often affects the central portion of the upper lip, local irritation is an important etiological factor. A chronic catarrhal rhinitis will almost invariably be found to exist, and the acrid discharge from one or both nostrils will keep up the sycotic inflamma- tion of the. lip immediately beneath. In such a case treatment of the nose must either precede or accompany the measures directed to the cure of the sycosis. In the treatment of sycosis local applications will sometimes effect a cure, but in many cases the inflammatory process will persist, in spite of either soothing or stimulating ointments. In such obstinate cases it is only after the patient's general condition has been carefully studied and some decided improvement occasioned by judicious hygienic or tonic treatment that the local disease will yield. Internal remedies have no direct effect upon the local inflammatory process, but, indirectly, they may be of service. Laxatives and alkaline diuret- ics will tend to lessen the acute hyper^emia which is often present. Bitter tonics will serve to tone up an impaired digestion, while cod-liver oil may be administered with a view to overcoming the nutritive debility which is often at the root of the disease. In the local treatment of sycosis, shaving or clipping the hairs, ai]d epila- tion of such as have been loosened by the follicular inflammation, is the first step. In most cases the bearded portion of the face can be shaved care- fully every second day, but if the inflammation is intense and the pustules numerous, the patient may object strongly to the use of a razor. If so, the hairs may be cut as short as possible with a pair of sharp, curved scissors. Another objection to shaving has been raised to the effect that when care- lessly performed it is apt to irritate and abrade the skin, and thereby to aggravate the disease through the increased opportunity thus offered for the multiplication of pus organisms. Epilation is called for in nearly every case of sycosis. When the in- SYCOSIS Sycosis, a disease peculiar to adult males, is the result of an inflammatory process in and around the hair follicles. Deep suppu- ration usually occurs and the pus reaches the surface of the skin between the hair and the follicular wall. The charafteristic lesion thus formed consists of a pustule in the centre of which is a loosened hair. The disease usually attacks the bearded portion of the face, although other hairy parts are sometimes affefted. It differs from eczema in causing a loosening of the hair, and in not ex- tending from the bearded portion of the face upon adjacent regions which are not hairy. It is always non-parasitic, and the disease which is sometimes called sycosis parasitica is an entirely distinft disease, vi^., trichophytosis, or ringworm of the beard. In the accompanying illustration the limitation of the disease to a hairy part is well shown upon the cheek and chin. An unusual amount of scaling and crusting is seen in this case (the patient having gone several days without shaving), but a few of the char- afteristic pustular lesions may be noted. The cause of sycosis, especially when occurring upon the cheeks, is not always readily determined, but on the upper lip it is frequently the result of a chronic irritating nasal discharge. Epilation of the loose hairs and such others in the inflamed area as will yield to gentle traftion is one of the most effeftive methods of treatment. It speedily relieves the tenderness and swell- ing in most cases, although the operation may prove extremely painful when a high degree of inflammation is present. Copyrij,''ht, tjoo, by G. H. Fox SYCOSIS. SYCOSIS 199 flammation is very acute only the loosened hairs should be removed, and even this is sometimes the cause of severe pain. Large and powerful men will sometimes shrink and protest after the forceps have accidentally made slight traction on a firmly imbedded hair. The pain of the operation may be somewhat lessened by first applying cotton dipped in very hot water to the inflamed skin, or rubbing over the surface a thin ointment containing menthol. When the inflammation is not so acute the hairs may be re- moved from all the pustules, and in a chronic case it is often advisable to thoroughly epilate a large patch. In the use of lotions and ointments in the treatment of sycosis, re- gard should always be paid to the grade of inflammation. Though the disease is usually chronic — i. e., of long standing — the inflammatory lesions are often so extremely acute and tender that any stimulating application is apt to do more harm than good. A mild zinc or boric acid lotion may be used when inflammation is intense, and later superseded by an astringent or parasiticide ointment. The following have been used with success : 5 Acidl tannici gr. xlv 8 Sulphuris praecipitati gr. xlv 8 Zinci oxidi 3 ss 20 Amyli §ss 20 Petrolati mollis 5 i ad 100 m (Rosenthal) 3 Hydrargyri chloridi corrosivi gr. i .20 Acidi carbolic! gtt. x 2 Unguenti zinci oxidi §i ad 100 m (Robinson) In the chronic thickened condition of the skin sometimes resulting from persistent sycosis, soap frictions and ointments of a more stimulating character can be employed. The vigorous use of a curette will often be found of service. 20O THE TREATMENT OF SKIN DISEASES SYPHILODERMA Syphilis is a disease concerning which enough volumes have been written to fill a large library. Its cutaneous manifestations consist of the chancre or initial lesion, which usually appears from two to four weeks after infection, and the characteristic eruptions, which first develop about two months later, and may appear after a lapse of many years. The syphilo- dermata, or cutaneous syphilides, may be conveniently divided into those which appear during the first year (usually during the first three months) and those which are liable to develop after the first year, and are usually called the late syphilides. The former are macular, papular, or pustular, and affect the greater portion of the body in a symmetrical manner. The latter are nodular or gummatous, and show a marked tendency to grouping and localization in a limited area in place of being symmetrical like their predeces- sors. Scaling, crusting, and ulceration may occur in both the early and late syphilodermata, and greatly modify their clinical appearance. The treatment of cutaneous syphilis is, in most cases, a very simple matter, in fact, the disease tends to run its course like the acute exanthemata, though much more slowly, and most cases occurring in those who inherit a good constitution, and who avoid all kinds of dissipation, would probably get well without any systematic treatment. The prevalent idea that the disease, if not treated vigorously, is certain to destroy the patient's health and to shorten his life, is not in accordance with the facts of everyday observation. it is true that in weak and strumous subjects, and those addicted to alcoholic excesses, the disease may occasion both disagreeable and alarming symptoms, but in the great majority of cases it presents a benignant form and tends to spontaneous recovery. The curability of syphilis has long been a subject of discussion, but the old idea that a man who contracts syphilis must live and die a syphilitic, and that even his ghost will be a syphilitic, has few if any sup- porters at the present day. Many men who contract syphilis, and are properly treated for a year or more, go through life without any subsequent SYPHILODERMA ERYTHEMATOSUM The erythematous syphilide when appearing as the first cuta- neous symptom of the constitutional disease presents numerous small, rounded, pinkish macules scattered over the surface of the skin, and showing no tendency to occur in groups or circles. The relapsing erythematous eruption, which is comparatively rare and occurs later in the course of the disease, presents, on the other hand, fewer but larger erythematous patches, and sometimes an eruption in annular form. The early erythematous syphilide is rarely observed to be as general and as distinft as in the case which forms the subjeft of the accompanying illustration. It is frequently seen only upon the abdo- men and flexor aspeft of the forearms, and often appears so faint as to resemble the mottling of the skin seen upon certain patients with a poor circulation when the body is stripped and exposed to a cool atmosphere. In most cases the macules do not exist alone but are associated with lesions of a more or less papular charafter. Indeed, the centre of a macule sometimes appears darker than its margin and is slightly elevated, and at this point a papule may develop. In this patient the macular eruption developed suddenly about two months after the appearance of the chancre. It was of a bright red color at first, disappearing under pressure of the finger, and dis- appeared in a few weeks, gradually becoming duller in its hue and finally presenting the appearance of a -faint, yellowish stain. Copyright, 1900, by G. H. Fox. SYPHILODERMA ERYTHEMATOSUM. SYPHILODERMA PAPULOSUM The papular syphilide may occur in several forms, presenting a variety of clinical features. The miliary eruption consists of pinhead sized papules usually occurring in small clusters and is comparatively rare. The lenticular eruption, which is the most common form, is characterized by disseminated papules of split pea size. These may be few or numerous and are symmetrically distributed over head, trunk, and extremities. The large papular syphilide usually consists of fewer lesions which may be scaly, simulating psoriasis, circinate and resembling ringworm or moist and appearing like mucous patches upon the skin. The unusually copious eruption upon the back shown in the illustration was of the ordinary lenticular variety. It had existed for about six weeks at the time the photograph was taken, and without treatment the lesions, especially upon the shoulders, were tending to flatten and disappear. Upon the lower portion of the back many of the papules were covered with scales, and some had softened and crusted so that the plate might have been designated as a papulo- pustular syphilide, although the papular element still predominated. It is rare indeed for an early syphilide to present throughout its course but one variety of primary lesion, and in many cases macules, papules and pustules will be found to coexist. w -*■ Copyright, 1900, by G. H. Fox. SYPHILODERMA PAPULOSUM. SYPHILODERMA PAPULO-SQUAMOSUM While the small papular syphilide usually disappears without any desquamation, the large flat papular syphilide is apt to present scaly discs which bear a strong resemblance to psoriasis and were formerly designated as syphilitic psoriasis. These scaly lesions when numerous are apt to occur in groups, forming irregular patches like the tuberculo- squamous syphilide seen in a later stage of the disease. The scales do not cover the whole of the papule as they do in psoriasis, but usually leave a reddish peripheral margin of infiltrated skin. Furthermore, while they may occur upon the extensor aspeft of the extremities, and even upon the elbow as seen in tha illustration, they are more likely to occur upon the thinner skin of the flexor surface, and frequently are seen upon the bend of the elbow and the popliteal space, where psoriasis never occurs. While the infiltration of the skin in the papulo-squamous syphilide is very marked, the scaling is usually comparatively slight. In psoriasis, on the other hand, the scaling is commonly found to be greatly in excess of the infiltration. The eruption shown in the accompanying plate occurred several months after infeftion, as may be inferred from the grouping of the lesions which is never seen in the early lenticular syphilide. While the eruption presents a notable resemblance to psoriasis, its syphilitic nature might be inferred 'from the existence of lesions upon the nucha, where psoriasis is not commonly found, from the faft that the scaling is limited to the central portion of the infiltrated patches, and from their charafteristic irregular border. In coalescing psoriatic lesions a circumscribed and scalloped border would be observed. C'jpyright, i-:/j.j,-;by l.. H. Fox. SYPHILODERMA PAPULO-SQUAMOSUM. SYPHILODERMA 201 manifestation of the disease. Those who marry a few years after Infection usually beget healthy children, and though cases do occur in which the disease occasions serious and sometimes fatal accidents late in life, or in which it is transmitted to offspring resulting from marriage many years after infection, these must be regarded as exceptions to the rule. There are few, if any, constitutional diseases so amenable to treatment as syphilis, and so certain to be cured by proper management. in the treatment of the chancre or "primary syphilis" attempts have been made to prevent, by means of thorough cauterization or excision, the occur- rence of the constitutional disease. The result has usually been unsuccess- ful, and even in cases where a successful result has been reported there always remains a doubt as to whether the lesion destroyed was a simple venereal sore or the initial lesion of syphilis. With this uncertainty as to any possible benefit, it is advisable to refrain from either cauterization or excision. The former practice does no good, and often tends to increase the induration of the lesion and render it more difficult to cure. In the case of an unmistakable hard chancre upon a redundant prepuce, circum- cision might prove advantageous to the patient, even if it failed to prevent the constitutional manifestations of the disease. In most cases simple measures are to be preferred. The penis, or other affected part, should be kept scrupulously clean by daily washing, and the surface, if raw, dusted frequently with calomel or boric acid. When deep ulceration is present iodoform is the best application. The question as to whether mercury should be given internally in the primary stage of syphilis has elicited much discussion, and most writers agree in condemning the practice. That it will tend to lessen the indura- tion of a persistent chancre is beyond all doubt. That it can do any direct harm in this stage of syphilis has been claimed by some, but never proven. If a patient has a lesion which is certain to be followed by secondary symptoms, the sooner mercury is administered internally the better effect will it have upon the course of the disease. But who can say with absolute positiveness in all cases that a given sore or induration is the primary lesion 202 THE TREATMENT OF SKIN DISEASES of syphilis ? Wiien mercury is given at this time for the healing of a chancre, the subsequent evolution of the disease is delayed and often modified to such an extent that an uncertainty may arise as to whether the patient really has syphilis or not, and in such a case the necessary treatment often fails to be carried out for a desirable length of time. On the other hand, when mercury is administered for a simple venereal sore, erroneously sup- posed to be syphilitic, the patient is often treated for months or years unnecessarily, and is doomed to go through life in constant dread of some manifestation of a disease which he has never contracted. The indirect harm which may therefore result from the early admin- istration of mercury far more than counterbalances the slight loss of time resulting from the postponement of internal treatment until the constitu- tional symptoms have appeared, and when doubt can no longer exist as to the nature of the patient's disease. When the constitutional infection has manifested itself in the form of a macular or papular eruption upon the skin, the systematic treatment of the disease may be said to begin. The patient should at once be made acquainted with the nature of the disease from which he is suffering, the impossibility of a rapid cure, and the necessity of continuing treatment, or, at least, remaining under careful observation for several years. Some physicians treat syphilis without even mentioning to their patients the name of the disease. Except in the case of innocent wives, to whom ignorance may prove blissful avoidance of a family jar, the custoni can only be con- demned, for without a knowledge of the contagious nature of the disease it may be readily conveyed to members of the family, or others. When mucous patches occur upon the lips a simple kiss may convey the disease. 1 have known four members of one family to contract syphilis in this inno- cent manner. Some patients of a reckless disposition need to be seriously admonished as to the gravity of the disease, its possible dangers, and the necessity • of submitting to a more or less prolonged treatment after the early symptoms have disappeared. Such patients are often willing, and even anxious, to SYPHILODERMA PUSTULOSUM Pustules of various size and form occur in the early dissemi- nate eruptions of syphilis and constitute the true pustular syphilide. The softening tubercles and suppurating dermatitis occurring in the later eruptions are conveniently described in accordance with custom as the pustulo-crustaceous syphilide, although well-developed pus- tules rarely occur at this stage. The pustular syphilide, like the papular form of the disease, may consist of small or large lesions. In the former case they are usually numerous and may be conical (acne-form) or rounded (variola- form). In the latter case they are fewer in number and manifest a tendency to increase in size and to become crusted (efthyma-form). The pustular syphilide may occur as a relapsing eruption a few months after the earliest secondary outbreak, but generally it develops from a small or large papular syphilide through suppuration of the individual lesions. Frequently macules, papules, and a few pustules are found to co-exist and constitute a mixed eruption. The accompanying plate shows an early pustular syphilide in which the lesions, instead of being small and rounded, manifest a tendency to remain flattened as they increase in size. The photograph was not taken until the eruption was beginning to disappear, and while a few lesions are still typical and efthymatous in charafter the older ones have mostly dried in the centre, leaving a crusted, serpiginous ring. ^ ..1- e Copyright, if^oo, by r,, H. Fox. SYPHILODERMA PUSTULOSU M, SYPHILODERMA TUBERCULOSUM The nodular or tubercular syphilide is one of the later mani- festations of the disease. While in rare instances it may occur during the first year after infection, it is commonly met with many years later. The tubercles or nodular lesions in this form of syphilis are not necessarily larger than the papules of the early syphilide, as the name might imply, but they are always arranged in groups and are unsymmetrical, while the lesions of the early syphilides (macular, papular and pustular), whether few or many, are invariably dissemi- nated, and one side of the body is almost a duplicate of the other. The accompanying plate represents a tubercular syphilide of the serpiginous or creeping variety. It is evident at a glance that the most recent lesions have developed at the periphery of the patch and enclose, an area from which earlier lesions have disappeared leaving more or less discoloration of the skin. Even the peripheral lesions appear to have become flattened and scaly and are evidently disappearing, as they frequently do, even without treatment. Such an eruption leaves no scars, but when nodules soften and ulcerate, small, smooth, whitish cicatrices remain as a permanent record. This patient gave no history of syphilitic infection, but with such a characteristic eruption the diagnosis was unmistakable. Copyn.i^ht, vjoo, by G- H. Fox. SYPHILODERMA TUBERCULOSUM. SYPHILODERMA ULCERATIVUM. In the early syphilodermata ulceration is uncommon, although in the large papular and pustular forms of the disease round superficial ulcers occasionally develop. - In the late syphilodermata, ulceration of greater or less extent may be considered as the rule rather than the exception. The tubercular or nodular eruption, appearing usually in groups, tends frequently to soften and to produce a number of superficial crusted ulcers. In some cases of serpiginous character a crescentic band of ulceration may be noted at the extending border of the patch. The gummatous syphilide almost invariably softens and often causes deep and painful ulceration, which is followed by a disfiguring scar. The borders of syphilitic ulcers, whether superficial or deep, are usually quite abrupt and differ in this respect from the sloping edges of simple ulcers and the undermined border of scrofulous ulcers. Their specific origin can sometimes be inferred from this feature, but more frequently from their tendency to a circular or curving arrange- ment, and their localization upon the scalp and face and about the elbow and knee joints where traumatic or eczematous ulceration is not very likely to occur. The accompanying plate shows an extensive patch of tubercular syphilis of the scalp of two years' duration. It had gradually spread at the periphery through successive development and ulceration of nodules. A large central area of cicatricial tissue had formed upon which the hair was destroyed, leaving a condition of permanent bald- ness. This ulceration healed rapidly under internal treatment. V. •^'■'V^ It'- Copj-right, 1900, by G. H, Frix. SYPHILODERMA ULCERATIVUM. SYPHILODERMA 203 take ten times the amount of medicine necessary during the persistence of an eruption, but are inclined to discontinue treatment just as soon as this has gone. On the other hand, many patients contracting syphilis are unduly alarmed, and, like children in the dark, quake at terrible evils which are by no means probable and scarcely possible. Such patients need to be soothed by assurances that the disease will run its slow course without interfering seriously, if at all, with their health, business, or pleasure, pro- vided they keep cheerful and follow simple directions. In some cases syphilis may, indeed, prove to be a blessing in disguise. A reckless and dissipated young man, after contracting the disease, will sometimes appreciate the necessity of leading a sober life in order to get well, and will be actually healthier, happier, and possibly will live longer than if he had never been so unfortunate as to become infected. In the treatment of constitutional syphilis, mercury is the chief remedy. While of value at every period in the course of the disease, in early syphilis it is the mainstay of treatment. It will lessen the manifestations and shorten the course of syphilis in the majority of cases. And yet it is not absolutely essential to the cure of the disease, as many imagine, for cases will get well by virtue of the vis medicatrix, even when no mercury is administered. The physician who believes that improvement is wholly dependent upon the drugs administered — and this belief is by far too common— is apt to neglect the hygienic and tonic measures which are of the utmost impor- tance, and thereby to do great injustice to his patient. The best effect of mercury in the treatment of syphilis can be obtained by the use of smaller doses than are commonly employed. From the time when the beneficial effect of this drug was estimated by the pints of saliva which dribbled from the patient's mouth there has been a constant tendency toward a diminution of the dose. Even now too many physicians are dis- posed to push the remedy in every case as far as possible without producing actual salivation. This common practice frequently does more harm than good. The protiodide of mercury is a preparation in common use, and while it may not be more efficacious than blue mass or mercury with chalk. 204 THE TREATMENT OF SKIN DISEASES which some prefer, it certainly possesses the most desirable qualities. In the form of tablets made of a milk-sugar trituration, it is conveniently pre- scribed, and in doses varying from one-eighth to one-fourth of a grain, three or four times daily, it seldom produces any gastro-intestinal irritation. When ulcerations or mucous patches are present in the throat or oral cavity the tablets dissolved in the mouth produce a local as well as a general effect, and are far superior to coated pills. The duration of the mercurial treatment depends upon the severity of the case. The statement that syphilis should be treated two, three-and-a- half, four, or any number of years is quite as arbitrary as to say that every case of measles should be treated one, two, or six weeks, in the early period of syphilis it is advisable to continue the use of mercury for several months after the last symptom has yielded. During a relapse it should be given again, and continued for several weeks after an apparent cure, in late syphilis it need only be given until the eruption or other symptom of the disease has disappeared. The inunction of mercurial ointment in the treatment of syphilis is certainly efficacious, but its effect is not always easy to control and severe salivation may unexpectedly occur. While the use of ammoniated mercury ointment upon the face and hands is often advisable to hasten the dis- appearance of a disfiguring eruption, and the application of mercurial plaster is beneficial to all syphilitic ulcers, the use of inunctions in the systematic treatment of constitutional syphilis is an extremely disagreeable method, which is as unnecessary as it is undesirable in the great majority of cases. The same remark will apply with equal force to the treatment by vapor baths and hypodermic injections. Iodide of potassium is another remedy of great value. In early syphilis it relieves the cephalalgia and arthritic pains far more quickly than mercury, and in late syphilis it is indispensable in the removal of gummatous deposits and the healing of ulcerations. Large doses are sometimes required, espe- cially in cases of cerebral syphilis, but usually they are unnecessary, and when continued for months are likely to do more harm than good. SYPHILODERMA MANUS Syphilis affeds the hand both in the early and the late stages of the disease, and here as elsewhere its charafteristic features are observed. A variety of clinical appearances may be presented, four of which are shown in the accompanying plate. In the upper left illustration is seen the scaling papular syphilide. This usually coexists with one of the early disseminate eruptions. Owing to the thickness of the palmar epidermis it may develop slowly and not appear in full bloom until the papular or pustular eruption, of which it is a part,, has almost disappeared from other portions of the body. Unlike the. late squamous syphilide, it always affefts both palms. The large number and small size of the lesions prevent its being mistaken for eczema. The upper right illustration presents a scaling patch of syphilis occurring late in the course of the disease. The dull red hue of the patch together with its elevated and scalloped border constitute a clinical pifture which speaks unerringly of its specific origin. The lower left hand shows evidence of inherited syphilis in the osseous swelling affefting two of the first row of phalanges. Suppuration and ulceration often occur in such cases which are thereby brought within the province of dermatology. The lower right hand presents a charafteristic kidney-shaped and deep ulcer resulting from the softening of a gummatous deposit. 03 > a -0 > > 55g o CD c CO < "D I r O D m a o c m r rn o ^ m 12 > — < o ii SYPHILODERMA HEREDITARIUM Syphilis occurring in childhood is usually, though by no means invariably, the result of inherited disease. Infants at the breast may acquire syphilis as well as adults and the resulting eruption is not unlike that seen in later years. The inherited disease may develop in utero, in which case a large proportion of infants are born dead. It may manifest itself in an eruption at birth or this may develop any time during the first year. As a rule, however, the symptoms of inherited syphilis appear during the first three months. Emaciation is one , of the most common symptoms and the syphilitic infant with wrinkled face, sallow skin, and fretful cry often presents a tiny caricature of old age. A charafteristic coryza or "snuffles" usually develops and interferes with nursing and ordinary breathing. The inherited eruption in infancy may be macular or papular and, in the latter case, show a decided tendency to become moist and to ulcerate, especially about the mucous orifices, in the axillae, and on the buttocks. The palms and soles are often the seat of a bullous eruption. In childhood nodular and gummatous lesions may develop and cause destruftive ulceration coexistent with osseous and visceral lesions. The face of the young girl represented in the plate presents unmistakable evidences of the baleful legacy which has destroyed one eye, the nose, and a portion of the lip. In the lower illustration is seen the charafteristic notching of the upper central incisor teeth, described by Hutchinson. This occurs with the second dentition. Copyright, i o r > < m CO o c r O CO > < > 3D T3 C CO H c r O CO > VERRUCA 217 VERRUCA The term verruca, or wart, has been applied to various cutaneous excres- cences which develop at various ages, upon various portions of the body, and present various clinical appearances. They are all hypertrophic outgrowths of the papillary and epidermic layers of the skin and of a benign character. Verruca vulgaris, or the common wart, frequently seen upon the hands of children, usually appears as a dry, roughened, rounded growth, varying in size from a pin's head to a pea. it is often multiple, and sometimes warts may be counted upon the back of the hands and fingers by the score. In some cases they develop in the sulcus at the side of the nail and form a rough marginate patch. Upon the face the ordinary wart is apt to be conical or elongated, while upon the scalp it may appear either as a flattened growth or as a raised digitate mass of a reddened hue. Verruca plana occurs usually upon the hands or face, and appears in the form of one or many slightly elevated and comparatively smooth growths of a faint reddish or yellowish hue. Verruca filiformis (acrochordon) is most frequently seen upon the neck of middle-aged and elderly women. Threadlike pouches of skin, varying in length from one to five millimetres, are sometimes seen upon the eyelids as well as upon the neck, and look more like minute fibromata than warty growths. Verruca senilis (keratosis pigmentosa) is usually seen upon the face, trunk, and hands of old persons, often in connection with pigmented spots and other evidences of senile degeneration. The tumors are usually flat- tened, and sometimes pedunculated. They vary in hue from a dull yellow to a dark brown, and sometimes become the seat of epithelioma, especially upon the face and back of the hand. Verruca acuminata or venereal wart is a term applied to the bright red masses, of varying size and shape, which develop upon the glans penis and mucous surface of the prepuce in the male and about the vulva in the female, as the result of irritation from venereal or other secretions. 2i8 THE TREATMENT OF SKIN DISEASES In the treatment of warts, various internal remedies have been highly recommended, among which may be mentioned arsenic, thuja occidentalis, nitromuriatic acid, and magnesium sulphate. 1 have never seen any definite results occur repeatedly from their use, and doubt if their therapeutic value is any greater than the numerous "charms" resorted to by the credulous. These certainly produce so intense an impression upon the mind in some cases as to possibly cause a change in the nutrition of the skin. Leaving out of account the untruthful and exaggerated reports of their vir- tues, and overlooking the numerous cases in which they utterly fail, there still remain authentic instances where a large crop of persistent warts has disappeared suddenly after recourse to one of these vulgar methods of treat- ment, such as dipping the hand in rain-water collected in a hollow stump, spitting on the warts with some appropriate incantation, etc. The local treatment of warts is in most cases simple and effective. The use of acids is to be condemned, as in many cases only the projecting portion of the wart is removed, and its return speedily follows, while in other cases the acid acts too deeply and an unnecessary scar is left. When warts upon the hands are not numerous, the persistent application of a ten or twenty per cent, salicylic plaster may be conveniently used, and in time effect a cure. The use of a small dermal curette is the best method of removing the majority of warty growths, it - removes them quickly and permanently, causes but little pain when properly used, and leaves no scar. In the case of warts upon the fingers, the patient should be directed to "make a fist" in order to draw the skin tense. One or more quick scraping motions with a small sharp curette will remove the entire warty mass and leave a rounded, " punched-out " cavity in the skin. The hemorrhage, which is usually free and persistent, can best be checked by touching the bleeding surface with a cone of nitrate of silver. In the case of warty growths upon the scalp, the curette, skilfully used, will remove the excrescence without the destruction of a single hair follicle, while the application of an acid is very likely to occasion a small patch of baldness. VITILIGO The backs of the hands are the most frequent site of vitiligo, and in many cases the affeftion is confined to this locality. In other cases the white spots appear upfon the face and neck as well, and not infrequently are found upon the trunk and extremities. In the negro race the affection sometimes increases until the greater portion of the skin becomes white. In this patient, a man of nearly seventy years, the patches had existed for a long time and shown little tendency to increase in size or to appear elsewhere. As is usual, the skin around the white patches had assumed a slightly darker hue and, as the patient was naturally of a dark complexion and the photograph was taken in the summer time, when the hands were tanned through exposure to the sun, the contrast was exceptionally well marked. The patient suffered no discomfort whatever from the spots and no treatment was employed. In fad, there is little that can be done in such a case beyond lessening, the intense contrast of color by keeping the hands from exposure to the sun and by bleaching the darker skin by the frequent application peroxide of hydrogen. Aside from its disfigurement, the only disadvantage arising from vitiligo upon the hands is the marked tendency of the unpigmented skin to redden and blister when exposed to the rays of a summer sun. C'>pyri:^ht, igoo, by G. H. Fox. VITILIGO. VITILIGO 219 In warts situated at the border of a nail, the growth should first be softened by the application of acetic acid and then scraped by the curette. This may require several repetitions to remove the entire mass, especially when the patient is nervous and indisposed to bear a little pain. The electrolytic needle has been recommended in the treatment of ordinary warts, and may be successfully employed, but in my opinion it is far inferior to the curette, in the removal of senile warts upon the back and elsewhere it may be used to advantage. In removing the verruca filiformis, or soft threadlike outgrowths, from the neck or eyelid, a pair of delicate forceps and small curved scissors serve the best purpose. If slight traction be made the growth can be readily cut off at the surface of the skin, and when the minute speck of blood which may ooze out has dried and been removed the site of the excrescence can scarcely be found. In the treatment of venereal warts the curette is likewise simple and speedy, but when patients object to any treatment of a sanguinary char- acter, and time is not an object, the growths may be successfully removed by the use of nitric acid or equal parts of salicylic acid and starch. VITILIGO Vitiligo is the name applied to a partial or complete absence of pigment in one or more circumscribed patches. These are at first small and rounded, but as they increase in size they tend to coalesce and form large and irregular patches. The border of the patch is usually more or less hyper- pigmented, and in many cases, especially upon the face, the darker portion of the skin is far more striking in appearance than the abnormally white spots, and an erroneous diagnosis of chloasma is sometimes made. Vitiligo is most frequently seen upon the backs of the hands, face, and neck, but it may also occur upon covered portions of the body. In the negro it is especially common and most striking in appearance. In some cases the white patches have continued to enlarge from year to year, until 220 THE TREATMENT OF SKIN DISEASES finally little or none of the normally pigmented skin has remained. In white patients the affection is far more conspicuous in summer, when the normal skin is tanned, and thereby presents a stronger contrast with the whitened patches. The cause of vitiligo is unknown. It is held by some that it is due to a disturbance of innervation, an explanation which, as Shepherd remarks, tells us nothing, and is only a cloak to hide our ignorance, for nothing is known of its pathology. The treatment of vitiligo is most unsatisfactory, and no remedy, either internal or external, can be said to have any notable effect. As the disease tends to spontaneous recovery in some cases, it is possible that nerve tonics combined with cold spinal douches might have a beneficial effect. Brocq suggests the use of vigorous friction or irritating applications to the spinal column, combined with electric baths, or the prolonged use of the galvanic current. Besnier recommends the subcutaneous injection of pilocarpine. In the local treatment of vitiligo, curative remedies are lacking. Attempts have been made to increase the pigmentation of the white patches by the use of mustard and other stimulating applications which usually tend to darken the normal skin. However excellent this plan of treatment may be in theory, no satisfactory results are likely to be attained in practice. Other attempts have been made to lessen the conspicuous appearance of the white patches by treating the dark border with strong lotions of corrosive sublimate or hydrogen dioxide, as recommended in the treatment of chlo- asma. This plan has been productive of some temporary benefit, but not enough, so far as my experience goes, to yield much satisfaction. Fortunately vitiligo is not an affection which involves the patient's health or comfort. If the patches upon the face are regarded as a very serious disfigurement a simple pallia,tive measure is the use of a fine toilet powder tinted to suit the requirements of the case. A weak lotion of pyrogallic acid, or walnut juice, painted over the patches will also tend to partially conceal them, exerting a cosmetic if not a curative effect. XANTHOMA Xanthoma is a neoplastic disease beginning in the deeper layer of the corium and charafterized by circumscribed yellowish patches or nodules of varying size. The most common form of the disease, called xanthoma planum, usually affefts the eyelids and appears in the form of one or more rounded or elongated dull yellow patches near the inner canthus. They may be slightly elevated and are often symmetrical. Beyond the slight disfigure- ment they occasion no discomfort. This smooth variety of the disease sometimes occurs in streaks following the lines of flexure upon the palms (xanthoma striatum). The nodular form of xanthoma occurs chiefly upon the lower portion of the back and upon the extensor aspeft of the extremities. The lesions are usually numerous and vary in size from small rounded papules to lobulated masses as large as a hen's egg. They are of a dull yellow tint and firm in consistence. The cause of the disease is obscure in many cases and patients often appear to be in excellent physical condition. The nodular eruption, however, frequently occurs in diabetic subjefts and some writers regard this glycosuric xanthoma as a distinft disease. The upper illustration shows an exceptionally large tumor upon the elbow consisting of an aggregation of smaller tumors with a few outlying tubercles. The lower illustration presents a charaaeristic grouping of small tubercles over the hips and buttocks. This patient was suffering from diabetes mellitus and the eruption disappeared as soon as the glycosuria was successfully treated. Cu])yTight, iQoo, by G. H. Fox, XANTHOMA TUBEROSUM. XANTHOMA 221 XANTHOMA Xanthoma is an affection which occurs in the form of small yellowish, circumscribed patches, usually upon the eyelids (Xanthoma planum), or as an eruption of small yellowish nodules or tumors upon various portions of the body (Xanthoma tuberosum). These two forms are rarely associated, and by some writers are regarded as distinct affections. When the palms are affected, yellowish stripes are usually seen following the natural transverse furrows (Xanthoma striatum). The cause of xanthoma is in most cases quite obscure. A tendency of the disease to affect two or more members of a family has been noted, and in many cases a history of preexistent jaundice, or other hepatic disease, can be obtained. In most of the cases of xanthoma occurring as a general eruption, more or less sugar has been found in the patient's urine, and some writers have been inclined to regard these cases as constituting a distinct affection (Xanthoma diabeticorum). The lesions present no characteristic features which would serve to distinguish them from those seen in xanthomatous patients who do not suffer from glycosuria. The eruption in diabetic sub- jects, however, is apt to develop more rapidly and often to disappear spontaneously. It is somewhat inflammatory in character and responds quite readily to internal treatment. The treatment of xanthoma of the eyelids consists in the removal of the patches either by the knife, caustics, or the electrolytic needle. When the patches are not of large size, excision by means of sharp curved scissors is certainly the speediest method of effecting a cure. When a large patch upon the upper lid, near the inner canthus, is excised, the healing of the wound is liable to produce a puckered ridge, if not a slight ectropion. The use of the thermo-cautery after the yellow patch has been drawn through an aperture in a thin sheet of asbestos paper has been suggested, but is not to be commended. Acids, either nitric or monochloracetic, may be repeatedly applied by 222 THE TREATMENT OF SKIN DISEASES means of a wooden toothpick and a successful result obtained, but electro- lysis furnishes the simplest and safest method of destroying the growth, if a fine needle attached to the negative cord is inserted beneath the lax skin from one edge of the patch to the other, a weak current will suffice to destroy the tissue around the needle with very little pain, and with three or four insertions of the needle at one sitting, a patch of considerable size may be readily converted into a dark superficial crust, which will fall in the course of a few days, leaving a red mark like a slight burn in place of the yellow patch. Should any trace of the original disease be left, the point of the needle may be inserted again and the remnant destroyed, in this opera- tion the patient should be directed to touch the moist sponge connected with the positive cord with the tip of one finger after the needle has been inserted. Gradually the other fingers may be applied, and finally, if it is necessary, the sponge may be grasped firmly in the palm. This method tends to prevent a sudden and unpleasant shock at the outset and allays the patient's fear, which usually exceeds the pain of the operation. The tendency to the return of xanthoma palpebrarum after treatment may be due to the fact that complete removal of a patch does not prevent the development of the new growth in the neighboring skin. On the other hand, and especially when caustics are used, the destruction of the patch may be more apparent than real, and under such circumstances it speedily assumes its former yellow hue. Even the application of collodion will lessen the color of a patch for a short time. In a case recently treated, 1 noted the interesting fact that after a bright yellow patch had been removed by electrolysis from the left upper lid, a similar patch upon the right upper lid became spontaneously paler in hue. In the treatment of xanthomatous nodules a strong salicylic ointment or plaster (fifteen to twenty per cent.) has proved successful in the hands of Morrow, L. Heitzman, and others. When large isolated tumors are present, and occasion considerable annoyance, their removal by the knife is advisable. The frequent association of xanthoma with hepatic disease and glyco- ZOSTER PECTORALIS The gradual and even course which Zoster usually runs enables one to judge quite accurately the age of the eruption by the appear- ance of the lesions. As some of the patches, however, may develop a few days later than the primary patch, these will naturally be found to be in a less advanced stage of development. While some of the vesicles in a given case may be tense and filled with clear serum, the vesicles on patches a day or two older may appear flattened and of a milky hue. in the subjed; of the illustration the eruption had existed for six days at the time when the photograph was taken, but the boy had complained of pain for a day or two before the first red patch was noted. Upon the side the vesicles are seen to be at their height of development, while nearer the spine, where the eruption evidently first appeared, they show a tendency to confluence, and of a purulent character. At three points it is evident that they have been irritated or broken, doubtless by the friftion of the clothing, and small, dark, hemorrhagic crusts have formed. In the treatment of Zoster many of the applications in common use have no curative effeft and frequently add to the discomfort of the patient. If a simple dusting powder is used, and the inflamed skin carefully protefted by a soft linen cloth, the disease will run its course and the patient be more comfortable than when the affefted part is painted with collodion or smeared with an ointment. Gal- vanism applied by means of a metallic roller attached to the negative cord furnishes the best means of relieving the intense neuralgic pain which is often present in elderly patients. Copyright, 1900, by G. H. Fox ZOSTER PECTORALIS. ZOSTER 223 suria would naturally suggest the removal of these predisposing factors of the eruption. While little, if any, effect can be produced upon xanthoma palpebrarum or the chronic nodular eruption by any form of internal medication, the treatment of the diabetes which complicates other cases is usually followed by an immediate improvement, and often by a complete disappearance of the eruption. Dietetic measures are far more important than drugs in combating the diabetes. Besnier, who regards the xanthoma and the glycosuria as arising from the same general condition, recommends phosphorus, one-sixtieth to one hundredth of a grain daily for ten days, and then turpentine for a month, increasing the dose to two and a half drachms daily. ZOSTER Zoster (or Herpes zoster) is an acute, vesicular eruption occurring in patches which follow the course of one or more cutaneous nerves. It occurs, as a rule, upon one side of the body, and rarely affects a patient more than once. The eruption usually develops in from four to six days. The vesicles, which are then tense and filled with clear serum, gradually become purulent and flattened, and during the second week are transformed into thin crusts, which sometimes present a dark or hemorrhagic appear- ance. As the patches do not all develop simultaneously, some may appear in a more advanced stage than others. A burning or tingling sensation often precedes the eruption, and severe neuralgic pain usually accompanies it in advanced life. Upon the forehead the disease is apt to be most severe, and deep scars are not infrequently left in this location. As to the nature and cause of zoster, various opinions have been expressed by those who have carefully studied the subject. Some regard it as an acute, specific^ infectious disease on account of its occurring often in epidemic form in the spring and fall, running a definite course, and seldom occurring twice in the same patient. Others regard the disease as the result of a neuritis affecting either the cord, posterior spinal ganglion, or periphery of the nerve supplying the skin involved. 224 THE TREATMENT OF SKIN DISEASES arsenic, The eruption has been observed to occur frequently in those taking :, which in toxic doses may occasion a peripheral neuritis. Tender- ness of the nerve root upon the affected side of the spine can often be demonstrated, and in many cases 1 have elicited a history of some fall, blow, or other injury which may have caused the eruption. In the treatment of zoster, phosphide of zinc, nux vomica, gelsemium, quinine, salicylate of soda, and other remedies have been recommended, but I have never been able to convince myself that any drug has the slightest influ- ence upon the course of the disease. Antipyrin, phenacetin, or, better still, an injection of morphia may be used to lessen the pain and wakefulness in certain cases ; but, as a rule, no internal remedy is required. In the local treatment of zoster of the trunk, which is the most com- mon form of the disease, a soft linen handkerchief fastened smoothly to the underclothing will protect and soothe the inflamed skin as well or better than the ointments and lotions which have been recommended. If this is thought to be too simple, a ten per cent, solution of ichthyol (Zeisler), or a ten per cent, lotion of grindelia robusta (Duhring), may be painted over the vesicles. The use of collodion, either plain or containing morphia, the oil of peppermint, thymol, and other irritating applications are almost certain to add to the discomfort of the patient. A simple dusting powder will do no harm, even if it does little or no good. A strong galvanic current applied around and between the patches by means of a metallic roller attached to the negative cord will often relieve the pain for a short time, and possibly tend to abort the eruption if it be used twice daily at the outset. In cases of ophthalmic zoster, I have found this method to prove far superior to any other local treat- ment, and in the persistent neuralgia which sometimes follows zoster, in elderly patients, 1 know of no other remedy that can take its place. For this uncomfortable sequel of zoster the application of a small blister, or the actual cautery over the spinal ganglion upon the affected side has been recommended by some as a last resort. INDEX PAGE Acne 15 indolent and irritable . ... -15 general treatment of 16 internal treatment of 17 local treatment of . . • i7 Acne lance and curette . . ... 26 Acne cachecticorum ... 27 Acne varioliformis . 27 Advice versus drugs . . . . 5 Alopecia . . 29 congenital ... ... .29 premature . . . . ... 31 senile . . 30 idiopathic and symptomatic ... 32 etiology of 35 treatment of 36 Alopecia areata 39 parasitic and neurotic theories of causation ... 39 uncertain course of 39 treatment of 40 Anthrax 43 Anthrax benigna, or carbuncle .... 46 Bathing, stimulating effect of ... . 6 Baths, classification of 6 Boils loi etiology of loi treatment of 102 Burns 67 - treatment of 68 Canities . . Carbunculus . etiology of treatment of Chapped skin Cheloid . . Chilblain . . Chloasma . uterinum treatment of Chromophytosis treatment of Cicatrix . . Clavus ... Comedo . . scoop . . treatment of Corns . . . etiology of treatment of Cornu cutaneum Curette in treatment of acne in treatment of epithelioma in treatment of lupus Dandruff treatment of .... Dental burr, use in epithelioma use in lupus .... Depilatories . . ... Dermatitis . .... calorica 44 46 47 47 70 120 70 48 50 51 53 54 56 57 59 61 60 57 57 58 63 25 90 146 33 34 90 146 115 64 67 22; 226 INDEX PAGE Dermatitis medicamentosa 64 seborrhoica ... . . 169 traumatica . 64 venenata .... -65 Dermatitis lierpetiformis . ... 71 treatment of 72 Dermatology, a branch of general medi- cine -13 Dermatolysis 99 Diagnosis more than merely naming a disease . . 3 Diet, beneficial effect of change ... 9 importance of ... . value of rigid restriction Eczema internal treatment of . . local treatment of . ani . ... aurium ... barbffi .... capitis cruris ... genitalium manum et pedum . . . marginatum narium ... . . seborrhoicum . . . Electricity as a scalp stimulant Electrolysis in removal of hair Elephantiasis Epilation in favus .... Epithelioma forms of ... . etiology of . . . treatment of . . . Erysipelas . ... Erythema .... Erythema multiforme . . Exercise as a dermatological remedy 10 73 74 75 82 80 81 80 84 81 83 171 81 169 38 H5 85 98 86 86 87 88 91 93 95 7 Facial massage . Favus . . . Fibroma filiforme . molluscum . treatment of Filaria sanguinis hominis . Freckles Frost-bite . . . Furunculus Gelatin varnish for eczema General considerations Hair, abnormal growth of . Hair dyes . . Herpes . labialis . progenitalis . zoster . . . Horn, cutaneous . treatment of Hyperidrosis . . treatment of of axilla . . of hands . of feet . . Hypertrichosis etiology of . . treatment of Ichthyosis .... hystrix linearis neuropathica . treatment of . , . Impetigo contagiosa . . . In-growing toe-nail . . Itch _ . Intertrigo PAGE . 24 97 99 99 99 100 85 125 70 lOI 78 I 114 45 105 105 105 223 63 63 107 108 no no III 114 114 114 117 117 118 118 119 163 193 94 INDEX 227 of Keloid treatment of Keratoma diffusa Keratosis follicularis Keratosis pilaris . . Lentigo .... Lepra Leprosy, ana^sthetic macular . tubercular etiology of . . general treatment local treatment of prognosis of . Lichen pilaris . . Lichen planus . . etiology of . treatment of Lichen ruber . . treatment of Lichen scrofulosus . Lotio alba ... . . Lotion of calamine and zinc Lupus erythematosus . . treatment of Lupus vulgaris . treatment of . . . Malignant pustule . . . Miliaria Milium . Molluscum . . ■ treatment of . . . Molluscum fibrosum Morphoea ... . . relation to scleroderma treatment of . . . Mycosis fungoides treatment of . . . PAGE 120 122 117 124 124 125 127 128 129 127 129 130 131 133 124 133 134 135 137 138 140 19 18 141 142 144 145 43 150 152 153 154 99 155 155 155 156 157 Ncevus araneus .... cavernosus . . fibrosus ... flammeus . . papillomatosus . pilosus . . . spilus . . . . tuberosus . . unius lateris . . . Naevus pigmentosus Naevus vascularis . cauterization of . . electrolytic treatment of linear scarification of . Onychia . . parasitica syphilitica . Pachydermatocele Papilloma lineare Pediculosis . . Pemphigus Pernio . . Phtheiriasis capitis corporis pubis . Pigmentation Pityriasis . capitis maculata circinata diffusa marginata Pityriasis rubra Poison-ivy eruption Prickly heat . Psoriasis . . etiology of of skin PAGE 159 99 159 158 158 158 159 118 158 159 160 161 160 162 163 163 99 164 166 165 70 166 166 167 168 49 169 170 169 170 170 170 172 66 150 173 174 228 INDEX Psoriasis, general treatment of internal treatment of . . local treatment of . summary of treatment . Prurigo ... . . Pruritus . . . . use of narcotics in value of bathing in Purpura Purpura, simplex hemorrhagica rheumatica . Ringworm . . . Rosacea erythematosa pustulosa hypertrophica Scabies .... Scar . . Scar keloid Scarification of lupus Scleroderma . . . general treatment of local treatment of . . . Scrofuloderma . . Scurvy . . Shampooing and brushing hair . Skin, relation to other organs Soap, use in acne Specialism, natural tendency of . Special knowledge versus common sense Sycosis etiology of . treatment of . ... Syphiloderma Syphilis, curability of . . . objections to mercury in primary . 175 176 179 182 183 185 186 186 188 188 188 188 206 190 191 192 192 193 56 121 146 194 195 195 196 188 36 I 23 2 13 197 197 198 200 200 201 Syphilis, use of mercury in . . use of iodide of potassium in Syphilis hereditaria .... PAOB 203 204 205 Tan 49 Tinea trichophytina . . • 206 Trichophytosis . . .... 206 barb£e . . 209 capitis 207 corporis 21Q unguium .... 210 Tuberculin, use in lupus 150 Urticaria . . 211 etiology of 211 treatment of acute . .213 treatment of chronic . . . .215 Verruca . . 217 Vis medicatrix, main factor of cure . 4 Vitiligo 219 treatment of . 220 Vlemingkx's solution . . . . . 20 Vulcanized rubber sheeting . . . 79 Warts, treatment of 218 Water in treatment of skin diseases . 12 Wilkinson's ointment . . ... 183 Wine mark ... . . . 159 Xanthoma . . ... ... 221 diabeticorum .... . . 221 palpebrarum . . . . . 222 Xeroderma .... 117 Zinc and calamine lotion . .... 76 Zoster 223 treatment of . 224 PRACTICAL TREATISE ON SMALLPOX ILLUSTRATED BY COLORED PHOTOGRAPHS FROM LIFE BY GEORGE HENRY FOX, A.M., M.D. CONSULTING DERMATOLOGIST TO THE HEALTH DEPARTMENT OF NEW YORK CITY WITH THE COLLABORATION OF S. D. HUBBARD, M.D., S. POLLITZER, M.D., AND J. H. HUDDLESTON, M.D. PART i PHILADELPHIA AND LONDON J. B. LIPPINCOTT COMPANY 1902 Copyright, igo2 By GEORGE HENRY FOX PRINTED BY J. a. LIPPINCOTT COMPANY, PHILADELPHIA, U. H. A. PREFACE. WHENEVER a physician is called to a case of suspected smallpox, lie confronts a grave responsibility. If young or without special experience, he is apt to feel a sore need of assistance, and, although a book can never take the place of an experienced consultant, it is the object of the present work to render him as much aid as possible. The text aims to be practical rather than elaborate. The plates are reproductions of photographs from life, some of which have been obtained under great difficulty. While many articles on variola have been illustrated by a few photographs of cases, mostly of the pustular type, this work is believed to be the first which has presented illustrations of the smallpox eruption in each of its successive stages. It is sincerely hoped that the reader will find it of service in familiarizing him with the peculiar features of the disease. GEORGE HENRY FOX. LIST OF ILLUSTRATIONS. Note.— The names of the colored plates are in capitals. The letters H., P., and P. in hraekets indicate that the cases were photographed hy Hubbard, PoUitzer, or Fox. I. VARIOLA ERYTHEMATOSA. (First Day.) This shows the earliest eruption upon back and buttocks. The photograph was taken about seven hours after its first appearance. The patient was sent to Riverside Hospital, where she developed hemorrhagic smallpox, and died on the fourth day. [H.] II. VARIOLA PAPULOSA. (Second Day.) Showing numerous incipient papules upon the face. Those upon the forehead were the first to appear and are most prominent. The cheeks present a charac- teristic leathery appearance. [H.] III. Variola Hemorrhagica. Showing upon the face and cheeks a form of the disease commonly known as "black smallpox." Figs. 1 and 2 were photographed on the second day and show a profuse and dark eruption. The swelling and disfigurement of the face present a most striking appearance. Figs. 3 and 4 were photographed on the fourth day, when the patient was in a moribund condition. [H.] IV. VARIOLA VESICULOSA. (Fourth Day.) A case of moderate severity, with well-developed vesicles and characteristic grouping of lesions upon the face. [P.] V. Variola Vesiculosa. Fig. 1 shows a mixed eruption of papules and vesicles upon the right thigh. (Third day.) This condition is exceptional in Variola, though quite common in Varicella. [F.] Fig. 2 shows well developed umbilicated vesicles upon the fore- arm. (Fifth day. ) [H.] Fig. 3 shows a hemorrhagic effusion into the vesicles on the thigh and leg, a condition far less serious than the purpuric eruption of malignant variola. [P.] VI. VARIOLA SEMI-CONFLUENS. (Fifth Day, Sixth Day.) These illustrations show a partly confluent character which the eruption fre- quently presents, even in mild cases, and especially upon the legs. The influence of pressure in developing a more profuse eruption may be noted above the ankles, where shoes were laced, and below the knees, where garters were worn. [F.] LIST OF ILLUSTRATIONS. PLATE VII. VARIOLA CONFLUENS. (Seventh Day, Eighth Day.) Fig. 1 shows umbilioated pustules with an intense oedema of the foot, considera- bly increasing its size and causing much pain. Fig. 2 shows the epidermis raised in a large, irregular patch by the confluence of pustules. [F.] VIII, Variola Pustulosa. (Ninth Day.) Fig. 1 shows an eruption discrete upon the trunk and even upon the hand, while confluent upon the forearm. [H.] Fig. 2 shows a vaccine pustule coexisting with variolous pustules. The vaccination took place before the disease began, but too late to exert a decided prophylactic effect. [P.] Fig. 3 shows an eruption of large, flaccid pustules with swelling of the foot. [P.] Fig. 4 shows an eruption of discrete, tense, hemispherical pustules. [F.] LIST OF ILLUSTRATIONS. Note.— The names of the colored plates are in capitals. The letters H., P., and F. in brackets indicate that the cases were photographed by Hubbard, Pollitzer, or Fox, IX. VARIOLA DISCRETA. (Ninth Day.) A typical case of mild smallpox occurring after vaccination and sometimes called Variola modiflcata or Varioloid. [P.] X. VARIOLA PUSTULOSA. (Tenth Day.) A severe case, showing the characteristic aggregation of lesions on the face and extremities. [P.] XI. VARIOLA PUSTULOSA. (Ninth Day, Tenth Day, Eleventh Day.) These illustrations show the pustular lesions in the stages of complete distention, when they present a rounded appearance, and of incipient desiccation, when they appear flattened and with a central depression or "secondary umbilication." [P., F., F.] XII. Variola Pustulosa et Crustosa. (Tenth Day, Twelfth Day.) In Fig. 1 an occlusion of the nasal passages is indicated by the lips parted in , respiration. [P.] Fig. 2. shows a palmar condition which, in the adult, is found only in smallpox. [P.] Fig. 3 shows the desiccation of the facial eruption in advance of other regions. [P] Fig. 4 shows a mild discrete case in which a diagnosis of acne had been made. [F.] Fig. 5 shows the eruption in the stage of desiccation. [F.] XIII. VARIOLA CRUSTOSA. (Eighteenth Day.) Showing a few thick crusts remaining upon the face with numerous dull red spots from which the crusts have fallen. [F.] XIV. VARIOLA DESICCATA ET SQUAMOSA. (Twentieth Day.) Figs. 1 and 3 show the dried pustules remaining in the thickened skin of palm and sole after the crusts have fallen elsewhere. [F., P.] Fig. 2 shows the super- ficial desquamation which follows the falling of the crusts, producing rings of partly detached epidermis. [F.] PLATE XV. XVI. LIST OF ILLUSTRATIONS. Fig. 1 shows a peculiar pigmentation sometimes left after the eruption. The central portion, being darker, produces a "bull's-eye" appearance. [F.] Fig. 2 shows the hypertrophic condition of the soars which occurs in certain cases in place of the usual pitting, and which tends to disappear in time. [H.] Fig. 3 shows severe pitting, a partial loss of hair and eyebrows, and destruction of one eye. [H.] Fig. 1 shows the typical appearance of a successful revaccination. (Fourth day.) [F.] Fig. 4 shows a small, well-formed vaccination pustule at its height. (Eighth day.) [F.] Fig. 2 shows a large, irregular pustule resulting from scari- fication of an area of unnecessary extent. (Eighth day.) [F.] Fig. 5 shows an ulcer resulting from infection of the vaccination lesion. [F.] Fig. 3 shows a primary vaccination at its height (eighth day) with a characteristic areola. [F.] Fig. 6, a case of Varicella on the third day. [F.] SMALLPOX. CHAPTEK I. SYMPTOMS AND COURSE. VAEiIOLA, or smallpox, is an acute, contagious disease, characterized by an erup- tion upon both the skin and mucous membrane, with constitutional symptoms of greater or less severity. The eruption presents successively a macular, papular, vesicular, and pustular stage, the pustules finally drying into crusts, which fall and leave the skin temporarily discolored. Where ulceration has occurred it is perma- nently scarred or pitted. The lesions of the mucous membrane appear upon those parts more or less exposed to the air, — the mouth and eyes, for example, — but in exceptional cases they may be found throughout the entire intestinal tract, and in the uterus and bladder. These lesions do not run a course similar to those observed upon the skin, but appear as red macules, which rapidly change into ulcerations, covered with a whitish pellicle. The ulcers are imbedded in the substance of the mucous membrane and are not as superficial as in cancrum oris. The constitutional symptoms are most prominent during the periods of invasion and pustulation. There are various clinical forms of smallpox, which may be conveniently described as (1) discrete, (2) confluent, and (3) hemorrhagic, or malignant ; and then, according to intensity, as (a) very mild, (b) mild, and (c) severe. The few purpuric spots seen in the severe discrete and the confluent forms are not of great significance, as they are generally due to a peculiar diathesis, and as a rule the patient recovers. The malignant form is almost invariably fatal. The term discrete implies that the lesions are separate and distinct, not coalescent. If the lesions coalesce and form patches of various shapes and sizes, the eruption is called confluent. For the purpose of differentiating the various forms above men- tioned, it is convenient to first trace a normal, unmodified case of smallpox from the initial symptoms to recovery, and then to consider the severe forms, and finally the rare and obscure forms of the disease. 2 SMALLPOX. Period of Incubation. — This extends from the date of exposure to the occur- rence of clinical symptoms, a period usually lasting from twelve to fourteen days. Period of Invasion. — The disease is usually ushered in by fever, with a distinct chill or chilly sensations, headache, neuralgia, and a general malaise. Frequently the first symptom is a distressing backache. This is located in the lumbar region, but it may be as high up as the lower angle of the scapula, or it may be sacral and extend down into the thighs. The backache is an important symptom when present, but it is not always on hand to help one out in the diagnosis. The backache of smallpox is not peculiar or distinctive, but it is its severity which attracts attention. The headache is usually frontal and is an ache that is constant in character. The neuralgia is about the orbits, but may be facial, and is of a lancinating character. The fever may precede the backache or it may follow. It may be at first a rise of only a degree or two, or it may jump to 104° F., or as high as 106° F. The latter is most frequently seen in neurasthenic subjects and in children. The pulse rises in frequency and in tension. In children a convulsion not infrequently ushers in the disease. At this time con- vulsions are of little significance, but late in the disease they are of serious import. There are other constitutional symptoms, such as loss of appetite, vomiting, muscular pains, a dry, coated tongue, and at times an active delirium. The face is congested and swollen. The eyes are injected and present a bleared appearance, but the watery or weeping condition seen in measles is usually absent. The nose is dry, and a sore throat is not uncommon. Epistaxis is frequent. A very important symptom which sometimes occurs in this stage is a cutaneous efflorescence, which may resemble urticaria, scarlet fever, or measles. This latter resemblance is very close and often leads to diagnostic error. The efflorescence occurs most frequently in the young, and also in vaccinated adults. In some epidemics it is not at all uncommon, but as a rule it is rare. The duration of the stage of invasion varies from two to four days. Usually it is about three days. Period of Eruption.— Late on the third day or early on the fourth the eruption makes its appearance, and the constitutional symptoms subside to a certain extent. The rash appears first on the confined and moist portions of the skin or in irritated parts,— under a blister, for instance, which may have been applied for the backache. Normally, it is first seen upon the forehead at the hair-line, then behind the ears and down the tender part of the neck. It gradually extends down the trunk and arms, the hands and lower extremities being affected last. The eruption generally takes from SYMPTOMS AND COURSE. 3 twenty-four to thirty-six hours to cover the entire body. The best location to observe the rash for diagnostic purposes is on the back, where it cannot be obscured by scratching and where tlie warmth of the body causes the mildest congestion to appear at its best. The exposed parts are usually ill adapted for study of the rash, being obscured by the swelling and congestion of the face and by more or less dirt or staining of the hands. The rash consists first of small round or oval, rose-colored macules, which seem to be in the skin, coming up from beneath it, as it were. They disappear readily on pressure or on tension of the skin. When coalesence occurs, the lesions may resemble the blotches of measles. The macule at this stage is about from one-eighth to one- fourth of an inch in diameter, and its color is of an intense red which shows well at night, even by the light of a match. In less than twenty-four hours the centre of the macule becomes hard ; and as this hardness increases, the lesion gradually rises above the skin. It is now changing into the papular stage. The macular stage lasts usually from eight to twenty-four hours. The papules continue to increase slowly in size, the apex becoming flattened or indented in some lesions. While this change is going on the redness of the macule forms an areola about the hard portion or central papule. This areola tends to get smaller as the papule gets larger, and at last is completely lost. If the pulp of the finger is passed over the papule, especially in its early stage, the latter seems to roll beneath it, giving the sensation of a small shot buried in the skin. When the papule is fully developed, the surrounding skin is put on the stretch, and the rolling sensation is lost, but the papule is so dense and hard that it is frequently described as " shotty." The papule of varicella and of acne is not so dense and resisting as the papule of variola. The fully-developed papule in smallpox is rarely surrounded by a halo of congestion as it is in varicella, but in the modified form of smallpox this is not infrequently the case. The papule always arises from the centre of its halo like a bull's eye, whereas in chicken-pox it arises from within the circum- ference, but not always in the centre. The halo of congestion in chicken-pox is always very broad and extensive, and is best seen upon the back. When a halo is present in smallpox it is very narrow and insignificant. The papule is usually fully developed in twenty-four hours. At the end of another twenty-four or thirty-six hours the apex of the papule shows a further change. It appears to be transformed from a solid to a fluid. The color also changes as the fluid increases, and the lesion appears bluish or purplish. The fluid continues to increase in amount until the papule is converted into a little blister or vesicle. As the change is going on, the height of the papule grows less and less, and 4 SMALLPOX. when vesiculation is complete we have a broad, flat, umbilicated vesicle with a firm, dense base. To the touch these vesicles are firm and resisting, and the membranous covering is not easily broken, unless macerated by the perspiration due to heavy flannels. The vesicle is divided irregularly by little bands, or septa, which permit only a portion of the fluid to escape when one is punctured. Vesiculation is usually complete about the third day, and the stage generally lasts three days. It may be stated here that the reckoning in smallpox is usually from the appearance of the rash. The period of incubation and invasion are considered in reckoning the length of illness, but m descriptions of smallpox it is considered best to state the day of the eruption, and not of the disease. There is an old and oft-repeated statement that a uniform rash is a characteristic of smallpox and that a mixed rash indicates chicken-pox. This deserves to be promptly refuted. It is most unusual to find a case of smallpox with its eruption all in one stage. While it is a well known fact that chicken-pox runs a hasty course, — so that in from one to two days we may have macules, papules, vesicles, and even crusts, — in smallpox this is not likely to occur, as the disease never runs such a rapid course. In the early stage we may see macules changing into papules on the head and the neck, while there are simply macules on the trunk. Later in the disease the eruption may be vesicular on the head while still papular on the body. When vesiculation is complete, we have the distinct umbilicated appearance that has long been recognized as a characteristic of smallpox. The vesicles are broad, firm, flat, and hard, and are invariably indented or umbilicated. It is not until the stage of vesiculation that the constitutional symptoms diminish to a marked degree. In fact it is considered one of the landmarks of the disease for the fever curve to show a decline at this time. Late in the fifth or early in the sixth day the vesicle begins to assume a cloudy or yellowish hue, which denotes the commencement of pustulation. The fluid con- tinues to grow more yellow, and about the time that it has assumed a dense straw color the umbilication begins to disappear, so that in from one to three days the pustule loses its indented appearance and becomes globular in form. To the touch it appears to involve as much of the skin below the surface as it is high above it. It is during the stage of pustulatijn that the surrounding skin becomes swollen and oedematous, with an area of redness about the pustules giving the appearance of a bull's eye. It is also during the pustular stage that the constitutional symptoms become more intense and the fever rises in proportion to the severity of the attack. The i-)ustules are fully matured about the eighth day of the eruption. SYMPTOMS AND COURSE. 5 During the pustular stage the affection of the mucous membranes reaches its height. The eyelids, lips, and nose are often tremendously swollen. The tongue swells and deglutition becomes impossible. The voice is husky, and is sometimes lost, owing to the swelling of the glottis. About the ninth or tenth day of the rash another change appears in the pustule. In mild cases this change sometimes takes place several days earlier. In the centre of the pustule is observed a small, darker spot, which gradually grows larger. The mem- brane of the pustule becomes shriveled, and the little, dark spot continues to get larger and darker until it involves the entire area of the pustule. This is the drying stage, during which the fluid part of the pustule is absorbed, leaving the solid part behind to be exfoliated in the form of a crust. It is during this stage that, owing to the softening of its membranous covering, the pustule is broken by the movements of the patient or the contact of rough bed-linen. The pustules of the face are usually the first ones broken, and an ulceration frequently occurs which destroys the true skin and results in a pit or scar. Pustules do not rupture spontaneously and discharge their contents. Dessication lasts usually from five to twenty days, the exposed parts being the first to dry and shed their crusts. On the palms and soles the dessicated debris is left deeply buried in the skin, and often has to be removed by the aid of a lancet or other instrument. Sometimes there is a pustule under the nail, and the removal of the kernel or seed is quite painful, though necessary. The crust is usually thin, of a light yellowish-brown tint, but slightly adherent, and is shed or picked off without discomfort. The spot where the crust has been is of a deep purplish hue, and the many little stains here and there give the patient a pecu- liar spotted appearance, which in time disappears, except where the ulceration has left a pit or cicatrix. The pit soon loses its color and becomes of a whitish hue. As dessication proceeds the constitutional symptoms decline, the appetite returns, and the patient gains strength. Complications. — Sepsis is the one generally to be expected, and this may assume any form from a local affection, such as a furuncle, to a general septicsemia. Furuncu- losis is frequent and is often annoying, and no sooner is one boil healed than others follow. Bed-sores are also frequent if proper care is not used to prevent them. Bron- chitis from the affection of the mucous membranes may occur. When simple, this can be handled easily ; but when general pneumonia results, death is inevitable in the weakened condition of the patient. Ulcers and opacities of the cornea, laryngitis and croup (the latter generally fatal), zoster, sciatica, nephritis and gastritis, are all frequent complication^, especially in severe cases. 6 SMALLPOX. Confluent Smallpox.— In this form the vesicles coalesce or run together, form- ing variously shaped and sized blisters, which as pustulation proceeds are usually ruptured in some manner and become infected, forming large, thick scabs with extensive ulceration underneath. The inability to properly cleanse such cases causes a very fetid odor to be given off and makes the patient an exceedingly difficult one to treat. In the mild confluent form the disease is similar to the discrete form only that several lesions coalesce. In the severe confluent form the coalescence is extensive and laro-e blisters are formed. The swelling about them is intense, and with the extensive sepsis the patient rarely survives. The swelling of the face and extremities is some- times enormous, and the suffering is so severe as to make death a welcome visitor. Confluent smallpox runs a course similar to that of the other forms, except that it is not as rapid as the third and is usually more severe than the first. Hemorrhagic Smallpox. — This is recognized as the malignant form of variola, and is rapidly fatal in most cases. It runs its course precipitately, and at times most unexpectedly, — sometimes killing the patient in a few hours and in other cases not completing its career until the fourth or fifth day. Hemorrhages may come on sud- denly and the patient expire before any rash appears. In one case an efflorescence appeared and so closely resembled scarlet fever that it was mistaken for it. Suddenly hemorrhages set in, and within six hours the patient was dead. There was a question at the time as to whether the case was malignant scarlet fever or malignant smallpox. Later a room-mate came down with a typical case of smallpox and helped to clear the doubt. The hemorrhage usually occurs as the disease changes from vesiculation into pustulation. The severity of the hemorrhagic form of the disease is shown by the rapidity with which it passes through the various stages. Macules appear, and within a few hours rapidly change into papules, which almost as rapidly change into pustules ; and before pustulation is complete hemorrhage occurs, and death quickly follows. It is not unusual in these cases for the disease to run its course in from twenty-four to thirty-six hours. In many, severe constitutional symptoms mark the onset, hemorrhages occur immediately, and death results before the rash appears. The hemorrhages are from the mucous membrane of the eyes, nose, and mouth, and from the anal, vaginal, and urethral orifices, the membrane swelling enormously. Hemorrhage occurring in the skin causes it to become raised and of a livid purple or bluish tint. The eyes seem to bulge as if about to drop from the orbital cavity. On the abdomen the hemor- rhage is beneath the skin, causing raised lesions with a sharp border and a flattened SYMPTOMS AND COURSE. 7 top, feeling dense and firm to the touch. In the peritoneum the hemorrhages are extensive. The constitutional symptoms in this severe form are typhoidal in character. The mind appears at ease, quietly passing into a comatose state. The countenance is pinched and sunken, and the skin is dusky and purplish. The eyes appear bloodshot and list- less. The breathing is rapid and superficial. The delirium is of a quiet character, and death comes as a most welcome termination. Case I. — McD. Admitted to the hospital with a high fever (106.4° F.) and complaining of sore throat. One hour after admission there was noticed a very intense red rash, eyes bloodshot, and patient stupid. Patient isolated for scarlet fever. Hemorrhages came from eyes, nose, and mouth. Vomited blood in large quantities. Purplish spots appeared on the skin and spread rapidly over the whole cutaneous surface. Three hours after admission the patient died. Case II. — The patient, J. H., attended the funeral of a relative in New Jersey. Ten days after- wards he received a letter stating that the person had died of smallpox, but that they desired the matter to be kept secret. Feeling nervous, he got vaccinated. Three days from the receipt of the letter he did not return to work after his lunch, and complained of feeling weary. Went to bed, telling his wife to call him at four o'clock, as he had an important engagement. At half-past three his wife wont to call him, and found him bleeding profusely. She called a neighboring doctor, who noti- fied the Board of Health. The health inspector called at five p.m. Patient unconscious; face dark and dusky; eyeballs bulging and blood oozing from them. Hemorrhage from nose and mouth. Vomited a large quantity of dark, coagulated material. Pulseless at both wrists. Temperature 108° F., by rectum. Diagnosis, hemorrhagic variola. Ordered patient removed. Ambulance arrived at 7.15, just after the patient had died. No autopsy. Through the courtesy of Dr. A. H. Doty, the following cases may be quoted. They were reported to the Health Department of New York City with a diagnosis of malignant hemorraghic smallpox. Case I. — Mr. J. F., aged forty-four years. Eemoved to Eeception Hospital on suspicion of typhus fever, December 8, 1893, when the following history was obtained : Patient was taken ill on December 3. On the following day, December 4, great weakness was experienced. Gradually became worse. Epistaxis, etc. On December 7 an eruption appeared. On December 8 the patient pre- sented the following appearance : Face uniformly red, or of a dusky hue, and swollen ; on close exami- nation a faintly papular condition was apparent. Over chest, abdomen, and extremities was found a profuse papular eruption, of a very dusky or violet-colored hue. On the abdomen some of the papules had coalesced. Papules were noticeable on the hands and feet, particularly on the palms. On the inner Surface of the thighs the entire skin presented the appearance of a scarlatinous eruption, although darker in color. Pressure on the surface did not leave a white streak or spot typical of scarlet fever. In some parts of the body papules were found which were almost black. At this time, December 8, 8 SMALLPOX. there was no evidence of vesication. On December 9, the third day of the eruption, the latter pre- sented no particular change in its appearance or progress. It still remained papular. Intense depres- sion and delirium were present. At 3 p.m., December 9, the patient was removed to North Brothers Island. On December 10, the fourth day of the eruption, a few vesicles appeared for the first lime. These formed slowly about the lower part of the abdomen and thighs. At these sites were four or five typical umbilications. On December 11, the fifth day of the eruption, many more umbilications were found. The patient became rapidly worse, and died on the following day, December 12. Case II.— Mr. F. S., aged twenty-four years. Eemoved to Reception Hospital on suspicion of typhus fever. On December 8 the api)earance of this case was similar to Case I., inasmuch as the face was swollen and presented an erj^sipelatous appearance, although the color was more of a dusky hue. Large erythematous patches, suggestive of scarlet fever, were found covering different parts of the body. The same condition was present in this case as was noticed in Case I., — ie., the color of the patches was darker than in scarlet fever, and when the finger was drawn over the patch it did not leave a white line. No patches were found on the arms ; but at these sites were dark, almost black, papules, which slowly became vesicular and umbilicated. The eruption was confluent on the upper part of the thighs and the face, and the patient died on December 8. Case III.-^Mr. P. B., aged twenty-six years. Eemoved to Eeception Hospital, December 16, 1893, on suspicion of typhus fever. On December 17 he presented the following appearance : The face and the entire trunk and upper portions of the thighs and shoulders presented an eruption which could easily have been mistaken for scarlet fever. The eruption was dotted with dark or black papules ; some vesicles were noticed on the trunk. The eruption on the thighs was shotty and umbilicated and quite characteristic of variola. The face j^resented the same appearance as in Cases I. and II. On the legs and forearms, where the general redness was not present, the eruption had hardly gone beyond the macular stage, but was very dark, — almost black. As in the other cases, the finger drawn across left no white mark. It was stated that epistaxis had occurred. The patient became rapidly worse, without much change in the eruption, and died on December 17. Case IV. — Mr. L. E., lawyer, aged forty-three years. Eemoved from boarding-house, December 24, 1893, to Eeception Hospital. Seen at home previous to removal, December 24. Patient felt badly on December 17. On December 20 was quite ill; pains in different parts of the body; nausea and vomiting. This condition continued until December 23, when an eruption appeared. Diagnosis, scarlet fever. On December 24, with the exception of the legs and forearms, the entire body and face was involved in a general eruption resembling scarlet fever. However, as in the preceding cases, it was of a darker hue than that found in scarlet fever, and pressure upon the skin made no impression so far as changing its color. Over the legs and forearm was distributed a profuse papular eruption, very dark in color. On other parts of the body were scattered some dark or almost black papules, with a few vesicles ; typical umbilication was also present in some. A few small vesicles were noticed on the nose. These had the appearance of inflamed follicles, and were not as dark colored as the rest. The conjunctivae were very much congested, and the membrane of the mouth was so much swollen that it was impossible to examine the throat. Hematemesis was present, also great prostration from the outset. The patient died on December 25. DIAGNOSIS. 9 CHAPTER 11. DIAGNOSIS. There are few diseases the prompt recognition of which is of greater importance to the physician than variola. On the one hand, failure to recognize the disease may subject the family of the patient and the community at large to the danger of contagion, and thus even be the starting-point of a widespread epidemic ; on the other hand, to pronounce a case smallpox when it is not, entails so much needless pain and anxiety that the physician guilty of so grave an error merits the severe condemnation which will certainly be visited upon him. The recognition of a case of smallpox may be simple, difficult, or even impossible, depending on the case and on the stage of the disease. In general the disease is readily recognized when the case is typical and the eruption has reached the vesicular or pustu- lar stage. The diagnosis is difficult in atypical and complicated cases. It is impossible with any degree of positiveness in most cases in the pre-eruption period, — the stage of invasion. The initial symptoms of smallpox resemble the first symptoms of so many infec- tious fevers that it is only through a consideration of the prevalence of an epidemic and the opportunities for infection in a given case that the physician may be put on his guard. It is important in this connection to notice whether the patient has been successfully vaccinated within a recent period. The physician who during the prevalence of an epidemic finds an unvaccinated subject suffering from a febrile disease of acute onset, with severe lumbar and dorsal pains, may, in the absence of definite symptoms pointing to some other disease, suspect smallpox ; but a positive diagnosis at this stage is, of course, impossible. Prodromal Rashes. — The occurrence of the prodromal rashes, the roseola vario- losa, — a more or less diffuse scarlatiniform, morbillic, or urticarial rash which may appear on the second day of the fever, — has a certain diagnostic value ; but this roseola occurs in only a small percentage of the cases, and, unfortunately, sometimes appears in other acute toxsemic conditions, — typhoid, for instance. The scarlatiniform rash may lead to a diagnosis of scarlet fever and the morbillic roseola be mistaken for measles ; but these diseases would be excluded by the absence of the angina and the strawberry tongue of scarlatina in the one case and of the catarrhal symptoms of measles in the other, aside from other considerations. The appearance of the eruption on the second day of scarlatina is followed by a marked defervescence, while the 10 SMALLPOX. scarlet rash of smallpox is not accompanied by any change in the temperature curve. The eruption in measles occurs on the fourth day of the illness, a circumstance which alone suffices to differentiate it from the morbilliform roseola of smallpox. The charac- teristic and pathognomic " Koplik spots" on the buccal mucous membrane in measles are, of course, absent in smallpox. Furthermore, these prodromal eruptions of variola are of extremely evanescent character and usually disappear within eight or ten hours. Of somewhat greater diagnostic value in this stage is the appearance of small hemorrhages, or petechife, varying in size from a pin's head to a pea, in the brachial and crural triangles of Simon. This form of prodromal eruption, however, is extremely rare, and, it may be added, is of grave prognostic significance, as it is usually the precursor of hemorrhagic smallpox. Meningitis. — The intense headache, vertigo, delirium, and coma of meningitis, especially meningitis of the convexity without localizing symptoms, may be mistaken for severe prodromal symptoms of smallpox. As a rule, pulse and respiration are slow in meningitis, while in smallpox respiration and pulse are both markedly rapid. Cerebro-spinal Meningitis.— In cerebro-spinal meningitis, in which an erythe- matous or purpuric rash appears, the difficulties of diagnosis are often such as tux the skill of the most expert clinician. It is important to remember that the rash of cerebro- spinal meningitis usually develops gradually or in successive crops, and that its distribu- tion over the cutaneous surface is irregular, while the eruption of smallpox makes its complete appearance within the space of a few hours and is localized chiefly on the face and extremities. The stiffness at the back of the neck and the retraction of the head are symptoms that do not belong to smallpox. Septicaemia and Pyaemia. — Acute septicaemic and pysemic conditions in which there are hemorrhagic and bullous lesions in the skin sometimes present grave difficulties in making a differential diagnosis from smallpox. In general, however, a careful elucidation of the history of the case will bring out some points that serve for differentiation. It must be admitted, however, that the diagnosis between cryptogenetic septicjemia and hemorrhagic smallpox is sometimes impossible intra vitam. A case of this kind may be cited which occurred in New York during the epidemic last year. A woman of thirty, not vaccinated since childhood, living in a house adjoining one from which a case of smallpox had been removed, was reported to the authorities as a possible case of smallpox. It was the sixth day of her illness, which had begun abruptly with headache, backache, vomiting, and fever. On the third day of the illness there was a profuse hemorrhage from the uterus, and thereafter metrorrhagia was almost constant. DIAGNOSIS. II On the fourth day a scarlatiniform eruption was noticed on the legs and abdomen. The rash rapidly extended and was soon interspersed with hemorrhagic points. When seen on the evening of the sixth day the patient was semi-comatose. The skin was literally covered with a dusky scarlet rash in which were noted countless hemorrhagic macules, from a pin-point to a bean in size. The conjunctivae bulbi were chemotic, the tongue was swollen, and the fauces were deeply congested. The post-mortem examina- tion made the following morning, six hours after death, revealed a septic endometritis, and streptococci were cultivated from the blood and the peritoneal serum. Grippe. — An attack of grippe may simulate the early symptoms of smallpox very closely. The onset may be sudden, the muscular pains severe, the pyrexia decided, the general prostration as marked as in smallpox. In grippe, however, the muscular pains are, as a rule, more general than in smallpox, there is rarely profuse sweating, and symptoms referable to the respiratory tract soon develoj), if indeed they are not present from the beginning. Rheumatism. — The severe lumbar and sacral pains of smallpox have been mis- taken for rheumatism, but such an error can be made only where the use of the clinical thermometer is unknown. A febrile movement in lumbago is absent or but slight, while in smallpox the pyrexia is usually pronounced. Typhoid and Typhus. — Typhoid and typhus fevers have at times been con- founded with smallpox. But errors of this kind can be made only where the history of the case is completely ignored. In typhus, it is true, the eruption, petechial and almost papular in character, may suggest hemorrhagic smallpox ; but the eruption of typhus rarely appears before the fourth or fifth day of the illness and is located chiefly on the trunk, sparing the face. The rash of malignant smallpox develops usually on the third or even the second day of the illness and is not limited to the trunk. Upon the appearance of the rash in a typical case of smallpox the febrile diseases with which it is most frequently confounded are measles and varicella. It is interesting to note that until the time of Sydenham, in the latter part of the seventeenth century, measles and smallpox were regarded as manifestations of the same disease, and that the Vienna school of dermatologists, even to this day, insists on the etiological unity of variola and varicella. Measles. — As a matter of fact the early papular eruption of measles bears a considerable resemblance to the first stage of the eruption of smallpox. In both the eruption is noted first in the face. In smallpox, however, the papules have a firm, "shotty" feeling on palpation, while in measles they are smooth and velvety to the touch. In measles the eruption, viewed at a little distance, seems to present a distinctly 12 SMALLPOX. corymbose or crescentic grouping, an arrangement whicli is absent in smallpox. The eruption of smallpox appears at the end of the third day, that of measles on the fourth day. The temperature in smallpox undergoes a rapid defervescence upon the appear- ance of the rash, while in measles it continues to rise after the eruption appears. The pronounced pain in the back is absent in measles, while the very marked catarrhal symptoms, coryza, conjunctivitis, etc., are lacking in smallpox. The subsequent course of the eruption will leave no room for doubt, since within twenty-four hours the papules of smallpox will have developed into characteristic vesicles. Varicella. — In varicella the stage of invasion is usually much shorter than in smallpox, the prostration less marked, and the lumbar pains of the latter disease are absent. The eruption in varicella comes out in successive crops and runs a shorter course, so that lesions in various stages of development may be seen side by side. The temperature does not necessarily fall on the appearance of the eruption, and there may be a more or less marked rise with each fresh crop of vesicles, the temperature curve presenting thus a remittent character. The eruption itself presents marked differences in the character and the course of the individual lesions, as well as in their distribu- tion. The clear vesicles shoot up from the surface, as it were, without warning ; or there may be for a brief period only a circumscribed erythema like that which usually precedes the appearance of an urticarial wheal. The vesicles of varicella have usually a somewhat obtusely conical shape, while those of smallpox are distinctly hemispherical. The characteristic umbilication of the smallpox vesicle is wanting in varicella. It is true the varicella vesicle often shows a depression at its apex ; but this false umbilica- tion, as it is called, is due to the rupture of the vesicle and the escape of some of its fluid or to a partial drying of its watery contents, and occurs only after the vesicle has existed for some time. The vesicle of varicella appears much more superficial in its seat, and its roof is much thinner, so that it ruptures readily. Very moderate pressure with the finger sufiices to break it. When ruptured in this way the vesicle usually collapses completely, contrasting in this respect with the smallpox vesicle, from which, owing to the multilocular character of the lesion, all the fluid does not escape. In varicella the distribution of the lesions over the surface is far more erratic than in smallpox. The very decided tendency to grouping of lesions upon the face and about the wrists so characteristic of smallpox does not occur in varicella, in which the vesicles may appear even more extensively on the trunk than upon the face. In vari- cella the palms and the soles, except in infants, are almost never affected ; while in smallpox these regions are practically never exempt. It is true that in the extra- ordinarily mild cases of smallpox, such as have constituted the majority of cases during DIAGNOSIS. 13 the past two years throughout the West, lesions may or may not be present on the palms and soles ; but in the severe and moderately severe cases, such as have character- ized the recent epidemic in New York, the soles and especially the palms have practically without exception shown the lesions. The localization of smallpox lesions on the palms and soles deserves far more emphasis than is generally accorded it in the text- books, many of which even fail to mention it all. It may be put down as a safe rule that a case showing an extensive eruption of vesicles or pustules, however suspicious in other respects, is not smallpox if the palms and soles are free. Acne. — Among the skin diseases proper there are a few whose appearance upon hasty examination may occasion some confusion with smallpox. Acne pustulosa pre- sents only a superficial resemblance to variola, but in cases where it is accidentally associated with an acute febrile disease, like grippe, for instance, it may give rise to some diagnostic difficulty. In these cases, however, inquiry will develop the fact that the acne lesions have been present before the inception of the febrile disease ; and the presence of comedos, the limitation of the lesions to the face, chest, and back, together with the absence of any lesions on the palms and soles, will serve to exclude smallpox. Impetigo Contagiosa. — In impetigo contagiosa there might under similar cir- cumstances be a momentary doubt as to the nature of the illness. Impetigo lesions have no typical distribution on the surface, the mucous membranes are always exempt ; the vesicle itself is extremely superficial, ruptures very readily, and is at once replaced by a crust, so that lesions in various stages, vesicles, pustules, and crusts may always be seen at the same time. Zoster. — Zoster is, as a rule, readily distinguished by the definite grouping of the lesions in the tract supplied by one or more nerves, its asymmetrical distribution, and the more or less severe neuralgic pain that precedes or accompanies the eruption. It must be remembered, however, that in zoster, in addition to the typical grouped lesions, there are occasionally seen a few isolated vesico-pustules scattered promiscuously over the entire surface ; and the difficulty of diagnosis may be increased by the occurrence of a moderate temperature movement. In these cases, to which attention was first called by Teneson, the history of the case, the presence of characteristic herpetic groups, and the evolution and course of the individual lesions will suffice to clear the diagnosis. Drug Kruptions. — The ingestion of bromides, iodides, and quinine is sometimes fol- lowed by an eruption which may create some confusion in diagnosis. In general the drug eruptions may be distinguished by the absence of fever and of the subjective symptoms of smallpox. The bromide and the iodide acne never occur on the palms and soles, where there are no sebaceous glands, and the lesions lack the evolution and course of 14 SMALLPOX. the variolous eruption. The erythematous and purpuric eruption of quinine may be confused with the hemorrhagic form of smallpox ; but here, too, the history of the course of the illness and the absence of fever will obviate the difficulty. Syphilis. — Of all the diseases of the skin it is the pustular syphilide which most resembles the lesions of smallpox. Dermatologists and experts in variola are agreed that the pustular syphilide may be absolutely indistinguishable from smallpox so far as the appearance and distribution of the lesions is concerned. Furthermore, the pustular syphilide is frequently accompanied by a decided febrile movement. The diflferential diagnosis can be made in these cases only by the closest inquiry into the history of the case and by careful observation of the course of the disease. The characteristic history of an acute illness of short duration followed by a remission on the appearance of the eruption will of course be wanting in syphilis. The syphilitic eruption is more slug- gish in its evolution as well as in the course of its subsequent changes ; and though there may be lesions of syphilis on the mucous membrane of the mouth, they will lack the characteristic appearance of the vesicles and pustules of smallpox in this region. The palms and soles are not apt to show any lesions in this form of syphilis ; and finally some other forms of syphilitic manifestation are very often present in this polymorphic disease, to give the clue to the real nature of the eruption. In conclusion, the fact should be emphasized that there are cases of smallpox of so mild a character, with general symptoms so slight and eruption so sparse and ill- defined, as to make a positive diagnosis extremely difficult. It is a good plan to employ vaccination in such cases as a test. Within three or four days the experienced observer will be able to determine whether the vaccination is successful or not : a neo-a- tive result will of course have but a moderate value, but a positive result will serve to definitely exclude the diagnosis of smallpox. In all cases of doubt, whether before or after the eruption has appeared, the physician owes it to himself not less than to the patient and the commnnity to frankly explain to the patient or his family the difficulty in arriving at a diagnosis, and to express his suspicions that the case may be one of smallpox. It need hardly be said that such a case should be as strictly , isolated as if the diagnosis of smallpox were already established. TREATMENT. i5 CHAPTEE III. TREATMENT. In the treatment of smallpox the therapeutic measures employed must necessarily vary with the severity of the disease and the condition of the patient in its succes- sive stages. No remedy or plan of treatment will apply to all cases and at all times. As in the other exanthemata, there are cases of variola in which the disease runs so mild a course that a little nursing or simple attention to the personal comfort of the patient is all that is absolutely necessary. Such cases occur in those who have already had the disease, — for a second attack of smallpox must always be considered as a possibility, although it is a more rare occurrence than some writers would lead us to believe. Such cases also occur and with the greatest frequency in those who have been rendered more or less immune by a previous vaccination. But mild cases of smallpox may alSo occur among the unvaccinated ; and in the present epidemic I have noted a few cases where, in spite of the lack of any protection from vaccination, the eruption and other symptoms of the disease were quite as mild as in some cases of so-called varioloid, or smallpox modified by previous vaccination. In contrast with these cases which require no special medical treatment, there are others of marked severity with unexpected complications which tax the physician's skill to its utmost capacity. Still another class of cases, fortunately rare in most epidemics, are those to which the name of variola maligna has been given, and in which medical treatment seems to be almost as unnecessary as in the mild cases, since all attempts to avert a fatal termination have so far proved utterly futile. In the successive stages of a typical case of variola a marked change in the character of the treatment is demanded both by the peculiarities of the eruption and the accom- panying general symptoms. Instead of considering the various types of variola from a therapeutic stand-point, therefore, it would seem more practical to discuss in their natural order those measures which are adapted to the successive stages of the disease, beginning with the Period of Incubation. — During this period, which extends from the date of infection to the appearance of the earliest symptoms of the disease, treatment is rarely demanded, since in the great majority of cases the outbreak of the disease is a surprise, and in no case can it be positively known that a patient has smallpox until the initial symptoms appear, and often not until the characteristic eruption has developed. In many instances, however, it is quite certain that an individual has been exposed to the i6 SMALLPOX. contagion of variola ; and when such a one happens to be unvaccinated, or has not been vaccinated in recent years, the assumption is strong that the disease may have been contracted and will manifest itself in due time. The question as to whether vaccination can have any notable eflfect in modifying the course of variola when performed after a person has been exposed to and has contracted the disease is one concerning which a considerable difference of opinion is expressed by modern writers. While some contend that even if vaccination fails to prevent the development of variola it is quite certain to modify its severity, others claim that it can be of no more advantage than locking the barn after a horse has been stolen. The precise effect which vaccination during the stage of incubation may exert upon the subsequent course of the disease is very difficult to determine in one or even a small number of cases, since it is almost impossible to predict in any given case what the severity of the disease will be. In the opinion of Curschmann it is very doubtful whether vaccination can even render the course of smallpox milder. He states that in many instances where vaccination has been performed after exposure to smallpox infec- tion the pustules of vaccinia and variola have been seen developing side by side, the former having apparently no effect upon the latter. In the opinion of Welsh, on the other hand, vaccination after infection often modifies the disease, and not infrequently prevents it altogether. He believes that when vaccinia has advanced to the stage of the formation of an areola around the vesicle, about the eighth day, it begins to exert its prophylactic power against smallpox ; and as the period of incubation in variola is usually twelve days or more, an early vaccination may exert its protective influence in advance of the time when the variolous eruption should appear. Welsh reports one hundred and ninety-four cases of vaccination performed during the stage of incubation, in which thirty-eight were perfectly protected against smallpox, sixteen almost perfectly protected, thirty-one protected to a well-marked degree, thirty partially protected, and seventy-nine were unprotected. Of these one hundred and ninety-four cases the death-rate was 12.90 among those vaccinated early in the stage of incubation ; it was 40.98 among those vaccinated from one to seven days before the eruption of smallpox appeared ; while among the unvacci- nated cases the death-rate amounted to fifty-eight per cent. As it is well known that a secondary vaccination runs its course more rapidly than a primary one, it is evident that if an exposed patient has been already vaccinated a secondary vaccination is more apt to exert a protective influence. Since vaccination with humanized virus is more speedy in its effect than when bovine lymph is used, it TREATMENT. i7 is advisable to employ the former when readily obtainable and to make several inser- tions in order to increase the probability of success. Even a late vaccination in the stage of incubation may be of value, as it sometimes happens that this period lasts fourteen days or more. Early in the nineteenth century Waterhouse claimed that two days after infection vaccination would save the patient. Good results from the subcutaneous injection of vaccine lymph have also been claimed by Farley and others, but the efficacy of this method of treatment appears to have been assumed rather than proven. The speedy vaccination of all those who have been accidently exposed to smallpox infection will do no harm, even if it fails to modify the disease when contracted. Indeed, it is always advisable, since the persons exposed, even if not already infected, are liable to contract the disease through possible subsequent exposure ; and in the case of a threatening epidemic no precaution should be neglected which might tend to lessen the number of possible cases. Since no drug nor specific remedy exists which administered during the period of incubation will abort or modify the subsequent eruption, the only thing to be done is to prepare the patient by means of a rigid regimen and all possible hygenic measures to withstand the impending attack. When the fact of exposure is certain, forewarned should be forearmed. Period of Invasion (Initial Stage). — At the outbreak of the initial symptoms of smallpox a correct diagnosis is rarely made, owing to the fact that headache, lumbar pain, chills, fever, and nausea are not sufficiently pathognomonic to always suggest the true nature of the disease. In those cases, however, where it is known that the patient has been exposed to infection and an attack of variola is consequently antici- pated, the diagnosis is comparatively easy. In such a case the patient should be put to bed, or at least confined in a large, airy room, from which all draperies and super- fluous articles, capable of absorbing infectious germs, should be at once removed. The temperature of the room should be kept as low as possible in summer and should not exceed 60° to 65° F. in winter. An extra bed or couch should be provided, to which the patient can make a convenient and agreeable change later in the course of the disease, especially if it proves to be of a severe type. At the outset the bowels should be freely opened by a dose of calomel and soda, followed in the morning by a saline purgative ; and since constipation is apt to persist in most cases throughout the course of the disease, it is advisable to administer a little cold citrate of magnesia or some other agreeable laxative from day to day. i8 SMALLPOX. A warm bath should be taken and the skin from head to foot thoroughly cleansed by vigorous soap friction and the application of an antiseptic lotion. If the disease proves mild, a daily bath can be taken ; or when this does not seem advisable, the daily sponging of the whole body with cool water will usually lessen the fever and add greatly to the comfort of the sufferer. If the patient happens to belong to the class of the unvaccinated, or has not been vaccinated for many years, and there exists conse- quently the prospect of a severe attack, the hair and beard should be closely clipped. In most cases, however, this jarocedure can be left until the eruption has appeared, and if this is moderate in amount, the cutting of the hair, especially in the case of young girls and women, may not be necessary. The diet, which throughout the course of smallpox is a matter of the greatest importance, should be light and nutritious during this stage, consisting mainly of milk, broth, or gruel. The medicinal treatment of smallpox in this stage and throughout the course of the disease must be mainly symptomatic. Upon careful nursing and the prompt treat- ment of the various symptoms as they p)resent themselves we must depend in great measure for the fortunate termination in any case. The remedies and special methods which have been vaunted by some as tending to abort or modify the eruption and to lessen the severity of the disease, have been tested by others and found wanting. A specific for variola comparable in its action to that of mercury in syphilis or quinine in malaria is at the present time unknown, although, in view of the recent advances in antitoxic medication, the discovery of such is a hope that may possibly be realized in the near future. A high degree of fever in the initial stage of smallpox with intense headache and backache are symptoms which call loudly for relief, although they may not betoken a corresponding severity of the disease in its subsequent stages. Aconite, quinine, phenacetine, and other antipyretics are remedies which , may now be advantageously given, and the daily cool bath, although it may not have the notable effect so often observed in typhoid fever, will assist in lowering the temperature. If the fever is combined with extreme nervousness, the old and reliable Dover's powder will be found of service. In some cases delirium is present during the initial stage, and occasionally a suicidal tendency is manifested, which makes it necessary to have a watchful nurse in constant attendance upon the patient. Potassium bromide in full doses, chloral, or sulphonal may be advantageously employed as a sedative, but the most effective remedy is probably the hypodermic injection of the sulphate of mor- phine (gr. i). TREATMENT. I9 If tlie headache, which is ahnost invariably present, is very severe, an ice-bag or cold cloth applied to the scalp will afford relief. The fear which has been entertained by some that such a procedure might tend to suppress the eruption is utterly ground- less. For the lumbar pain, of which the patient often complains, a hot application will usually feel more grateful. The custom of applying mustard-plasters to the lower part of the back is not to be recommended, since the irritation of the skin which is caused thereby is liable to increase the eruption in that region and add to the subse- quent discomfort of the patient. The theory that the eruption can be lessened upon the face by increasing the number of lesions upon some other part of the body has never proved successful in practice. The sensation of thirst which is always present, and is often intolerable, can be alleviated by frequent sips of cold milk or by weak lemonade, either hot or cold. If there is extreme nausea and vomiting, as is usually the case with children, small pieces of ice dissolved in the mouth will relieve it together with the excessive thirst. Peri'od of Eruption. — With the outbreak of the papular eruption of smallpox, which usually appears upon the face on the third day of the disease, a notable decrease of the fever occurs with a decided improvement in the general condition of the patient. In a mild case, when a diagnosis of variola is not promptly made, the patient often returns to his business or pursues his or her customary duties with no thought of the danger to which others are exposed through contact or association. But the rapid development of the eruption soon leads to the discovery of its true nature and a reali- zation of the importance of continued isolation. During the papular and vesicular stage little or no internal medication is required, Gayton, an English writer on smallpox, who evidently shares the popular belief that the main duty of a physician is to give medicine, remarks that " we may also pre- scribe a little effervescing saline, for unless something is given in the form of medicine, the impression on the sick man's mind is that you are doing nothing to assist him." An intelligent public, in this country at least, is gradually awakening to the fact that skilful medical treatment cannot longer be measured by the number and size of the apothecaries' bottles. Although the appetite may now return, a restriction of the diet to simple and nutritious articles of food, such as milk-toast, eggs, oysters, and jellies, should be enforced. The daily bath should be continued, and there is no objection to its being made ■ antiseptic by the addition of carbolic acid or bichloride of mercury. It is simpler and 20 SMALLPOX. safer, however, to employ a plain bath and to disinfect the skin later by sponging with some antiseptic lotion, such as peroxide of hydrogen or permanganate of potassium. It has been claimed by some enthusiast, though never demonstrated, that carbolic soap will abort the disease. The local treatment of the eruption during the papular and vesicular stage has been a subject of experimentation for centuries, and the prevailing opinion at the present time is that little or nothing can be done to arrest its development. Most of the local applications, like the mercurial and other plasters of former days, though doubtless of some value, have proved generally to be more uncomfortable than beneficial to the patient. Tincture of iodine, pure or diluted, with an equal part of alcohol, nitrate of silver solution, collodion, picric acid, and more recently iclithyol, have been advocated by some and rejected by others after a careful test of their merits. Gayton recom- mends the use of the old itch lotion of sulphur and quicklime when cases present them- selves before eruption or during the jDajsular stage. He claims that if the lotion is rubbed over the whole body every four or six hours it will prevent the papules from reaching the pustular stage and thus avert the severe secondary fever. This surprising statement he bases on the observation of hundreds of cases. The effect of light upon the development of the smallpox eruption is a subject of considerable interest, and in recent years it has become one of therapeutic importance. As long ago as the fourteenth century John of Gaddesden and other physicians of his time were in the habit of excluding both light and fresh air from smallpox patients. The walls and furniture of the sick-room were painted red, on account of a peculiar virtue supposed to reside in this color, and the unfortunate occupant was nearly smothered by red curtains hung around his bed. Ever since that time it has been a common custom to darken the room of a smallpox patient, partly on account of the photophobia present during the course of the disease and partly on account of the idea that sunlight would aggravate the eruption. The fact that the face and hands are most intensely affected would seem to substantiate this idea, but the argument fails when we consider that the feet are usually the seat of an eruption scarcely less profuse. It was claimed by Black, in 1867, that the complete exclusion of light from the eruption of smallpox, even when occurring in unvaccinated persons, effectually pre- vented pitting of the face. Barlow, Gallivardin, and others, have expressed a similar belief. Experimentation by Finsen, Unna, and others having demonstrated that it was not the heat of the sun but the ultra-violet or chemical rays which cause solar eczema and pigmentation of the skin, it was suggested by Finsen that in place of the complete TREATMENT. 21 exclusion of light in the treatment of variola, it was only necessary to eliminate the chemical rays of sunlight by means of red glass windows or red curtains. Acting upon this suggestion Lindholm, Svensen, Day, and others, treated small- pox by this new method, and made most favorable reports of their results. The red light proved agreeable and soothing to the eyes of the patients, frequently caused the vesicles to dry without becoming purulent, and lessened the suppurative fever. The patients, it is claimed, passed directly from the vesicular stage into convalesence, and neither pitting nor pigmentation of the skin was observed. Some less enthusiastic experimenters with the red-light treatment of variola have been more moderate in their praises, and in some smallpox hospitals it has been tried and given up. My own experience with this method is limited to the observation of a few cases treated at the Riverside Hospital in 1893. Under the direction of Dr. Cyrus Edson, health commissioner, one ward was fitted with red glass windows. The cases treated were of a mild type, and although no deaths occurred, the disease appeared to run its usual course and the experiment was negative as to results. In reply to a letter of inquiry. Dr. Edson writes me that " if the results had not been negative a very careful report would have been made." For the advancement of therapeutic knowledge it is indeed unfortunate that while the enthusiast is always so ready to write, the sceptic or unsuccessful experimenter is usually inclined to remain silent. Period of Suppuration. — With the transformation of the smallpox vesicles into pustules a rise of temperature occurs which is commonly known as the " secondary fever," and in severe cases the swelling of the face, hands, and feet usually occasions the most intense suffering. The chief dangers of this stage arise from the possibility of septic poisoning and the probability of a greater or less degree of exhaustion. A nutritious diet is now of the utmost importance, and in severe cases bouillon, malted milk, or other pre2:)ared foods which can be readily swallowed should be given every two or three hours. If the patient is in a stupor, he may be awakened in order to receive the necessary nourishment, but the calm, refreshing sleep which sometimes follows a period of wakefulness and complete exhaustion should not be disturbed. Alcoholic stimulants are usually of great service in this stage and may be given freely, especially at night and in the early morning hours when the patient's vitality is at its lowest ebb. In case of delirium, rectal alimentation will often be found necessary as a substitute for or a supplement to oral feeding. The rectum should first be thoroughly cleansed by an enema of soap and water and then from four to six ounces of milk and brandy or eggnog may be injected. 22 SMALLPOX. As the eruption of smallpox attacks the mucous membrane of the mouth, nose, and throat, as well as the skin, difficulty in swallowing and considerable discomfort in breath- ing is often present, especially during the suppurative stage. If the patient is able to sit up and gargle, peroxide of hydrogen or some other antiseptic solution should be used at regular and frequent intervals. In case of extreme prostration, when any effort by the patient or the mere raising of the head might lead to syncope or symptoms of collapse, it is advisable to wash out the patient's throat and nostrils with a large swab of ab- sorbent cotton, dipped in a saturated solution of boric acid. Pyrozone, borolyptol, lis- terine, and other liquids may be conveniently used for this purpose diluted with one or two parts of water. Small pieces of ice or ice-cream given at frequent intervals with a small coflfeespoon will usually be found extremely grateful to the suffering patient. For a purulent conjunctivitis which may sometimes result from the presence of pustules on the lids, the saturated solution of boric acid should be frequently used in the form of a spray. When delirium occurs in this stage the patient must be closely watched, and, if necessary, the limbs may be kept quiet by linen sheets folded and carried across the bed and fastened at either end. Since chloral given by the mouth is liable to cause oedema of the glottis, it may be advantageously administered by the rectum, or in its place the bromides or a hypodermic injection of sulphate of morphine may be substi- tuted, although when the patient is suffering at the sam'e time from severe bronchitis the use of opium is objectionable. The treatment of the eruption in the suppurative stage is of the greatest importance so far as the comfort of the patient is concerned. A host of applications and peculiar methods of treatment have been recommended and tested in successive epidemics. Many of these have been found to have no effect save to intensify the patient's horrible appearance and to aggravate his discomfort. From time immemorial attempts have been made to prevent the pitting of the face after the disease by treatment of the indi- vidual lesions. The cauterization of the pustules with nitrate of silver after evacua- tion of the pus — the so-called ectrotic method — has been practised by many in the past, but the consensus of opinion at the present day seems to be that the procedure is as useless as it is painful. The ointments, plasters, pastes, and varnishes which have also been advocated are usually unpleasant or troublesome to use, and in the pustular stage are not likely to accomplish any desirable end. At this period it is too late to consider the possibility of preventing pitting, although the resulting injury to the skin may be reduced to a minimum by the use of all local measures which tend to reduce the grade of inflammation. TREATMENT. 23 For the highly inflamed condition of the skin which characterizes the suppurative stage of smallpox, especially in its confluent form, cold water is, beyond all doubt, the best antiphlogistic. The cold compresses advocated years ago by Hebra constitute the simplest method of local treatment and one which is most grateful and beneficial to the patient. They exclude the air, macerate and soften the lesions, and lessen the local inflammation. Although it cannot be claimed that they modify in any degree the development and course of the eruption, it is doubtful whether anything better in the way of local treatment has ever been suggested. Pieces of lint should be dipped in cold water and applied smoothly to the face and other portions of the body where the eruption is abundant and the skin inflamed. To prevent their drying too rapidly a little glycerine may be added to the water and the lint covered with gutta-percha tissue or oiled silk. Moore recommends covering the face with a light mask of lint and oiled silk, having holes for the eyes, nose, and mouth. The lint is wet with a mixture of glycerin and iced water (fsi-fgi). If preferred, a cold solution of boric acid may be used in place of plain water, and when there is an excessive and unpleasant odor present, thymol may be added to the solution. Immermann states that he used for a time sublimate dressings to the face (1-1000), but found that plain water did quite as much good and was safer to use. Next to the face, the hands and feet suffer most from the eruption of smallpox, and, owing to the fact that the skin is not as lax in the latter region, particularly upon the fingers and toes, the inflammatory swelling of these parts is always attended with extreme pain when pustules are numerous. Under such conditions it may be found advisable, in place of merely wrapping the hands and feet in lint and oiled silk, to immerse them in pans or pails of water, or to supply the patient with mittens and stockings made of vulcanized rubber cloth. Indeed, if the patient is not in too critical a condition, he may be immersed for hours in a bath, as recommended by Hebra for the treatment of extensive burns, pemphigus, and various ulcerating affections involving a large portion of the body. Period of Dessication. — When the distended, semi-globular pustules begin to dry, they tend to flatten, and often undergo a secondary umbilication from the shrivel- ing of the central portion of the pock. In favorable cases the general condition of the patient improves as the fever subsides, and a more substantial diet may now be allowed. The symptom which usually causes most local discomfort at this stage is the itch- ing which invariably accompanies the drying of the pustules. This is often intolerable, and much of the pitting left after an attack of smallpox may be due to the tearing of the crusts from the face and other parts. 24 SMALLPOX. The best application which can now be made to the skin for the double purpose of softening the crusts and allaying the pruritus is a solution of carbolic acid in olive oil (five or ten per cent.). When the itching sensation of the face and hands is intense, it can be greatly relieved if the nurse will frequently spray these parts with pure chloroform, or, if the crusts have an unpleasant odor, Avith a mixture of chloroform and some antiseptic solution. In the case of restless or unmanageable children the elbows may be put in splints so that the finger-nails cannot come in contact with the face. Period of Convalescence. — When the crusts have dried and fallen from the face and body and no unpleasant complications still exist, the patient may be considered as a convalescent. No treatment is now required except a liberal diet, the daily bath, and a continued application of carbolized vaseline or some antiseptic oil. When the discolored cicatrices left after the falling of the crusts appear elevated and hard, as is frequently the case upon the face and hands (variola verrucosa), it is customary with some to paint them with tincture of iodine. A j)l6asanter and more effective applica- tion is a twenty jDer cent, solution of resorcin in rose-water. When the skin has assumed its normal smoothness, and no indication of the dis- ease remains except the dull purplish-red spots where the.crusts have fallen, the patient may be regarded as well, and, after a careful disinfection of his body, he may be furnished with fresh or thoroughly disinfected clothing and discharged from the hospital or sick-room. In disinfecting a patient prior to his discharge, not only should a prolonged bath be taken, but the head should be thoroughly shamjjooed with carbolic soap, the nails cut and scrubbed with the same, and the mucous orifices of the body cleansed with peroxide of hydrogen. Prophylactic Treatment. — The prophylactic treatment of smallpox is of vastly more importance than any therapeutic measure, since it concerns a community and not merely an individual. In dealing with smallpox cases many physicians discover only too late that an ounce of prevention is worth many pounds of cure. When a case of smallpox is first recognized, or even suspected, the patient should be isolated in a room from which all unnecessary articles of furniture, especially of soft texture, have been removed. A sheet moistened with some volatile disinfectant should be hung before the door, and no one allowed to enter the room save the nurse and doctor. A change of clothing should be made outside by the former whenever leaving the room, and a gown should be ready for the latter to wear at each visit. Upon leaving the sick-room the physician should carefully disinfect his hands and remain for some time in the fresh air TREATMENT. 25 before making another call. When the diagnosis is positively made, all who have come in contact with the patient, unless manifestly immune, should be found and vaccinated without delay. During the course of the disease all discharges, such as faeces, urine, sputa, or vomited matter, should be received in glass or earthen vessels containing a five per cent, solution of carbolic acid. Handkerchiefs and soiled rags should be burned or with towels and soiled sheets placed in a carbolic solution and allowed to remain for twelve hours. The plates, knives, forks, and spoons used by the patient should be kept in the sick-room and washed in a disinfectant solution by the nurse, while any uneaten food should be treated in the same manner as the patient's discharges. When the patient has fully recovered, and, after personal disinfection, has left the sick-room, this should be thoroughly fumigated. The mattress and bed-coverings should be burned or, in large cities, sent to the Board of Health for disinfection. In case of death the corpse should be washed with a strong bichloride solution or painted with carbolized oil (twenty per cent.), and buried or cremated as quickly as possible. The clothing worn by the patient at the beginning of the disease should be destroyed or disinfected by baking for an hour in an oven at a temperature of 220° F., or steamed for five minutes at a temperature of 212° F. In disinfecting the sick-room, the furniture, woodwork, and floor should first be scrubbed with carbolic soap and hot water or a solution of bichloride of mercury (1-500). The windows, ventilators, and fireplace should then be tightly closed and the fumes of burning sulphur or formaldehyde gas used to comjjlete the disinfection. Sub- limed sulphur burned in a moist atmosphere (one pound to every thousand cubic feet of space) is effective, but is at the same time objectionable on account of its tendency to bleach or discolor all textile fabrics. In well-furnished rooms, containing articles liable to be injured by sulphur or steam, such as wall-paper, paintings, books, etc., it is advisable to use, whenever possible, a formaldehyde gas-generator, which can usually be obtained from the local Board of Health. 26 SMALLPOX. CHAPTER IV. VACCINATION. Vaccination consists in the inoculation of virus taken from the pock produced by vaccinia. Vaccine Virus. — Virus has been taken from vaccine vesicles on almost all animals susceptible to vaccinia, but throughout the greater part of the last century the material used in the vaccination of human subjects was taken generally from a vaccine vesicle on the arm of a previously unvaccinated healthy child. Such virus when collected at the proper time was found to take with great regularity, and vesicles resulting from its use were uniformily well developed and typical. Humanized virus was, however, open to the objection that it could communicate disease if the child were not perfectly healthy, and as a matter of fact it did communicate syphilis in a certain number of instances. The possibility of this infection was so serious an objection to the use of virus from this source that in the last quarter of the century calf virus, recommended and used in Italy many years before, was gradually substituted for human virus, and at the present time the use of animal virus is general in Europe and in the United States. In the production of virus, calves are for commercial reasons generally preferred to other animals. Calves take typically, and a large amount of virus can be collected from them, whereas all other animals either are comparatively expensive, or take poorly, or are able to furnish but little virus. Cows also are more expensive, are less easily handled, and develop vaccine vesicles less typically. In the practical production of vaccine virus calves are vaccinated much as human beings are vaccinated, but over a larger area. Usually the posterior abdomen and the insides, of the thighs are covered with superficial linear incisions, and into these incisions the seed virus is rubbed. In the laboratory of the New York City Health Department all operations relating to the vaccination of the animals and to the collection of the virus are carried on in an operating-room provided with a cement floor, glazed brick walls, and equipped with enamelled metal operating furni- ture, such as would be used in a hospital. The attendants wear sterile gowns and the technique of the operations is aseptic. The seed virus is either humanized virus collected by touching sterile pieces of bone to the serum exuding from ruptured vesiclfes on the arms of children, or in the great majority of cases bovine glycerinated virus which has been preserved two months. or longer. VACCINATION. 27 It is found that the crust of the vesicle, the serum issuing from the vesicle after the crust is removed, the pulp which forms the semi-solid contents and base of the vesicle, and the serum which exudes from the base of the vesicle after the pulp has been removed by a curette, all convey material capable of producing the vaccine vesicle in a susceptible person, and are therefore all different forms of vaccine virus. It has been shown, however, that if any of this material is filtered, so that all the solid particles are removed, the filtrate is inefficient. In other words, the serum is efficient as vaccine virus simply by virtue of the solid particles which it contains. It is also found that the pulp is so rich in the active principle of vaccine virus that it may be mixed with several times its weight of glycerin or other diluent and still maintain its efficiency. The different sorts of vaccine virus on the market are simply different ways of supplying this material coming from the vesicle. Most material is in one of three forms, — (a) The pulp diluted with some excipient, such as glycerin, vaseline, or lanolin. The emulsion, made by mixture with glycerin, may be contained in a vial or in a capil- lary tube, or may rest on some holder, such as an ivory or bone point. In the latter case the point is usually protected by some form of cap. Mixture with vaseline or lanolin makes a paste, which is usually issued in a box. This is in use in parts of Italy and in India. (b) The serum dried on a holder, as an ivory or bone point or a quill. (c) The serum mixed with some excipient, usually solid or semi-solid, until it becomes a paste, and furnished like dried serum on a holder. For a physician the choice among these three forms is governed by considerations of efficiency, safety, and ease of use. All the forms are under certain conditions effi- cient, but comparative tests show that the emulsion of the pulp issued by different laboratories is much more certainly efficient than the other forms, and the glycerinated emulsion is at present in most general use both abroad and in this country. It is also true that all forms may be perfectly safe. All forms contain bacteria when prepared, and the majority of these bacteria die within a few weeks or months after preparation. On account of the mildly antiseptic quality of glycerin the bacteria in the glycerinated emulsion usually die sooner than those in the other forms of virus, and so far as bacteria are objectionable in the virus the glycerinated form may therefore be said to be somewhat preferable. It should be added, however, both that glycerin- ated virus is usually put in the market before the bacteria have disappeared and that the bacteria present in virus issued by well-conducted laboratories are not found to be pathogenic to persons when inoculated by the customary method of vaccination. 28 SMALLPOX. The ease of use of any form of virus depends largely upon the custom of the physician. In vaccinating a large number at one time there can be no question that the use of a liquid virus supplied iu vials is more rapid than the use of a dried virus, as the latter has to be thoroughly moistened before it can be applied effectively. Methods of Vaccination. — The usual method of vaccination is to scarify a spot on the skin and to rub the virus on that spot. The choice of place depends partly on aesthetic reasons and partly on convenience. To avoid the formation of an unsightly scar on the arm, the leg may be used instead. If the arm is chosen, the insertion of the deltoid is the place of election on account of the small number of lymphatics there. If the leg is chosen, the area just below the head of the fibula presents the same ana- tomical advantage ; but a spot a short distance above the knee on the outside of the thigh is often thought to offer less opportunity for injury and infection. Choice between the sides depends in an adult on the use to which the vaccinated limb is to be put, and in a baby on the advantage of vaccinating the side which is carried away from the nurse. The size of the scarification is important. The vesicle is always somewhat larger than the scarification, and the larger the vesicle the greater danger that the surface may be broken, and the more opportunity there is for the introduction of extraneous infec- tion. A spot as large as the head of a medium pin is about as small as can be easily scarified, and vesicles formed on such scarifications are least liable to have inflammatory complications. If, as certain evidence tends to show, a larger area of scar guarantees greater protection, and if a larger area is therefore desired, it is better to vaccinate in two or three small spots than in one large one. It is somewhat difficult to rub the virus from a bone point on a spot of the minute size described, and as this form of virus is usually more dilute than glycerinated virus, a larger area may safely be employed. The scarification may be made with any sharp instrument, or with the point itself The only precaution necessary is that the instrument should be free from infection. As a scarifier the ordinary cambric needle presents the advantages that it is usually clean, is easily sterilized, and is so inexpensive that a fresh one can be used for every operation. It is not necessary that the scarification should draw blood, although blood is not objectionable unless it flows so freely as to wash away the virus, or unless the subject has haemophilia. Although with a notably susceptible subject or with especially active virus it may be sufficient simply to smear the virus on the scarified area, it is usually necessary and always advisable to rub in the virus with a wooden slip or with the point firmly and thoroughly. VACCINATION. 29 Other methods of introducing vaccine virus are by puncture, by deep injection, and by the mouth. In the method by puncture either a grooved lancet or a hollow needle may be used. A shallow puncture is made and the virus is deposited in it. The resulting vesicle is usually small and nearly circular, and generally remains free from infection ; but as the hole in which the virus is placed is small, it is possible that the issuing blood may wash it away completely, and the percentage of success with this method of inoculation is not quite so large, even in careful hands, as by the process of scarification with the same virus. Animal experiments with deep injection of virus through a hypodermic syringe and with administration of virus by the mouth show that there is no certainty of suc- cessful vaccination by these means, and that when success results there is no proof of it without a subsequent vaccination on the skin to test or to demonstrate the immunity. Care after Vaccination. — As vaccination is a surgical procedure, it should be conducted asejatically with a sterile instrument on clean skin, and the wound should be guarded against extraneous infection. It is well therefore to put either a sterile gauze cover or a clean shield over the wound as soon as the virus has been sufficiently absorbed, and to leave the protection on until the natural crust has been formed, — i.e., for a few hours. If the guard could be kept in position without motion and also without injurious pressure, it might remain until the process ended with the formation of a scar and the exfoliation of the crust ; but practically it is so certain that the guard will be moved that it is wise to remove it and to trust to the protection of a clean muslin or linen cloth attached to the loose sleeve or other undergarment. For a day or two at the time when the inflammation is at its height it may be well again to guard by a shield against injury from a blow or push, but the shield should always be regarded as itself a danger. If by any accident the vaccine pustule becomes infected, it should be treated like any other infected wound, — the crust removed, the ulcer cleansed with antiseptics and dressed surgically. The immunity given by the pock is not at all lessened by this treatment. Normal Clinical Course. — After primary vaccination in man there is a stage of incubation lasting for from forty-eight to seventy-two hours ; a papule then develops, and by the end of the third or fourth day this has begun to show umbilication and a vesicular structure. When fully developed, about the sixth day after vaccination, the vesicle is distended and pearly in color. On the seventh or eighth day the areola develops, — i.e., the skin about the vesicle becomes hard, sensitive, and red, the redness extending a variable distance, not usually more than two inches from the edge of the vesicle. In the course of the next day or two the vesicle loses its pearly appearance 50 SMALLPOX. and becomes opaque and often slightly yellow. With the development of the areola and of the pustule the adjacent lymph glands may swell and become somewhat pain- ful ; there may also be constitutional derangement,— some fever, pain, anorexia, restless- ness, and more or less prostration ; there is usually a moderate leucocytosis. About the eleventh or twelfth day the areola begins to fade, the constitutional symptoms to subside, and the pustule to dry up. A dark crust is formed which drops off usually between the eighteenth and twenty-fifth days, leaving a rosy depressed scar on which not infrequently a secondary scab is formed, to be shed a few days later. Variations in the Clinical Course.— The vesicles may appear on the second day, but it is more frequently delayed until the fourth, fifth, sixth, seventh, or even the eighth day, and cases have been observed in which the delay was even longer. The areola, which should be bright red, may be purple, and may extend a long distance from the vesicle. The pustule may be hemorrhagic or may be filled with greenish pus ; in this case there is probably a mixed infection. Sometimes instead of a vesicle there appears a hard elevated nodule, in color like a red raspberry. With this there is usually no areola, and no constitutional symptoms develop. The growth is usually an evidence of poor virus. It may persist for some time before absorption. The course may be abortive, — i.e., the vesicle does not develop completely ; pustu- lation comes early and the crust is shed and the scar formed before the end of the second week. This course is normal though not invariable in revaccinations. The scar may be poorly marked, even when the vaccination has run a typical course. Complications. — The most frequent complications are infections and eruptions. An infection may be, of course, of many sorts. It may be, for example, the streptor coccus of erysipelas, or the bacillus of tetanus, but it is oftenest a skin coccus. These infections may be introduced with the virus, with the instrument, or later through wounds in the vesicle or pustule. Erysipelas and tetanus following vaccination are exceedingly rare, and it has never been shown that in a case of tetanus the germ was inoculated at the time of vaccination. Eruptions are probably usually due to a chemical irritation produced by the devel- opment of the vaccinia ; they are analogous to the eruptions following the injection of antitoxine and the ingestion of various drugs. They vary in appearance, sometimes resemble the eruption of measles or of scarlet fever, and again are urticarial ; tliey are macular, papular, and vesicular. VACCINATION. 31 When a moist eczema is present there may be auto-inoculation of the pock on the affected area and a general confluent vaccine eruption appear. Immunity. — The immunity against smallpox, or vaccinia, produced by vaccina- tion is of gradual growth, and is not complete until the period of suppuration, about the beginning of the second week. Natural immunity is said to exist, and is probable, but it is exceedingly rare. Vaccination of a pregnant woman rarely, if ever, confers immunity on the foetus. Duration of Immunity. — Sometimes a single vaccination gives immunity for life. Usually, however, susceptibility returns at latest seven to ten years after vaccina- tion, and the second vaccination may give immunity for the rest of the lifetime, or sus- ceptibility may return again and again. Failure of active, properly inserted virus shows only that the person so vaccinated is at that time immune, but conveys absolutely no information about the condition a few months later. The appearance of the scar is not a trustworthy guide as to immunity. Susceptibility to vaccination returns fre- quently within one year, and has returned in three months from the time of a suc- cessful vaccination. Susceptibility to smallpox probably returns, as a rule, later than susceptibility to vaccinia. It is rare that a case even of varioloid occurs within five years of a successful vaccination. Conclusions. — Every child should be vaccinated at the time of election during the first year of life, and should be revaccinated before beginning school-life with its possibility of exposure. Every person, no matter at what age, should be vaccinated at a time of possible exposure to smallpox unless he has been successfully vaccinated within three months. 9 . ,;■» ' * , • % 4» \ Copyright, 1902, by G. H. box. VARIOLA ERYTHEMATOSA. (First day of eruption). Coj-yright, 1902, by G, H. Fox. VARIOLA PAPULOSA. (Second day). * . ^'.-w ■'%■■;■■ ^sszszmm vrV'-.v*-.J . K^ '.■■'". ^ •■ .Z^«l^/-f« Bfcwi-':'^ f.;-^p™ ^^KKM^m\ ; ^J'U ^ .v- '•■; !J *>■ '■ ^''' ' "^ ' M r/ , ' J \ m^u ''-'iH ■ ■ ) )"' ' "■. ,f^r^ N/^W . ■ ^ . , ' . t t '^ >- /^■.,*-/; ^j ■-. m '9 r': . '',' • ''■• ■ 9 , ':,.* WiSm ■ ■; P L: lH^gi F" T-"^! P'^" • ",- Cupyriyht, 1902, by G. H. Fox. VARIOLA HEMORRHAGICA. (Second day— Fourth day). Copyright, 1902, by G. H. Fox. VARIOLA VESICULOSA. (Fourth day). •t ^ -- ^ •■ p;--oifi*?~^ Copyri^^ht, 1902, by (,, H. Fox VARIOLA VESICULOSA Third day- Fifth day-Sixth day). Copyright, 1^)02, by G. H. Fux. VARIOLA SEMI-CONFLUENS. (Fifth da\— Sixth day). Copyrig-ht, igo2, by G. H. Fox. VARIOLA CONFLUENS. (Seventh day— Eighth day). V ^^ Copyright, 1902, by G. H. Fox. VARIOLA PUSTULOSA. (Ninth day). Copyright, igo2, by G. H. Fox. VARIOLA DISCRETA. (Ninth day). ^-^'^pyiyl'it, 1902, by G. H. Fox. VARIOLA PUSTULOSA. (Tenth day). .«> cP ^ ^^"^^ Copyright, 1902, by (,. H. Fc VARIOLA PUSTULOSA. (Ninth day-Tenth day-Eleventh day). Copyright, 1902, by G, H. Fox. VARIOLA PUSTULOSA ET CRUSTOSA. (Tenth day— Twelfth day). Copyright, 1902, by G. H, Fox. VARIOLA CRUSTOSA. (Eighteenth day). '^^^W^^'&^-^ gfK" Copyright, 1902, by G. H. Fox. VARIOLA DESICCATA ET SQUAMOSA. (Twentieth day). Copyright, 1902, by G. H. Fox. 1. PIGMENTATION AFTER VARIOLA. (30th day), 2. VERRUCOUS SCARS. (25th day). 3. CONFLUENT PITTING. (35ih day). 4 i Copyright, 1902, by G. H. Fox. 1. VACCINIA. (4tli day). 2. VACCINIA. (8th day). 3. PRIMARY VACCINATION. (8th day), 4. VACCINIA. (Sth day), 5. VACCINATION ULCER. 6. VARICELLA. (3d day).