V <6 V EPITOME OF SKIN DISEASES, WITH FORMULAE, FOR STUDENTS AND PRACTITIONERS. BY TILBURY FOX, M.D., F.E.C.P., PHYSICIAN TO THE DEPARTMENT FOR SKIN DISEASES IN UNIVERSITY COLLEGE HOSPITAL, AUTHOR OP VARIOUS WORKS ON SKIN DISEASES, ETC. AND T. C. FOX, M.B., B.A. (Cantab.), t V PHYSICIAN TO SAINT GEORGE'S AND SAINT JAMES'S DISPENSARY. ; SECOND AMERICAN EDITION, ENLARGED AND REVISED BY THE AUTHORS o. 331.LJ0 PHILADELPHIA: HENRY O . LEA. 1879. Entered according to the Act of Congress, in the year 1879, by HENRY C. LEA, iu the Office of the Librarian of Congress. All rights reserved. COLLINS, PRINTER AMERICAN PUBLISHER'S NOTE. In printing this work from the MS. kindly furnished by the Authors, the press has been supervised by a com- petent professional gentleman, to secure the necessary accuracy of the text ; and there has been introduced on page 50 the Classification of Dermal Diseases adopted by the American Dermatological Association. Philadelphia, March, 1879. PREFACE TO THE SECOND AMERICAN EDITION. In preparing this edition of our "Epitome" for pub- lication in the United States, we have increased the matter to about three times its original amount. The kindly appreciation manifested for the work by the American profession has stimulated us to spare no pains in render- ing it more worthy of their approbation, and in its en- larged form we believe that it will be found of enhanced value. About two-thirds of the work is newly written, and we may direct attention particularly to the section regarding the Pathology of the Skin, which has been entirely recast, and now contains a concise account of all the important changes taking place in the dermal textures in disease. The clinical descriptions of diseases also have been amplified and occasionally remodelled. Lastly, we may say that in adding material to the book we have selected such as bears on the practical side of 1* VI PREFACE TO SECOND AMERICAN EDITION. Dermatology, to the exclusion of that which is as yet hypothetical or merely of interest to the curious student. The favorable reception accorded to the work on both sides of the Atlantic would seem to show that it has realized the object with which it was prepared — to afford assistance to the student in his early study of derma- tology, and to serve as a manual for ready reference by the practitioner in his daily practice. For this latter purpose it has been specially adapted, by means of the references made in the sections on treatment to the formulae at the end. TILBURY FOX, THOMAS COLCOTT FOX. 14 Harley Street, London, W., January 1, 1879. CO 1ST TENTS. PART I. PAQB General Observations on Skin Diseases . . 13 SECTION I. The Mode of Observing Skin Diseases : — 1. As to the General Character of Skin Eruptions . . 13 2. As to the Mode of Examining Skin Diseases . . 14 3. As regards Complications ...... 17 4. Modifications of Eruptions ...... 18 SECTION II. The Pathology of the Skin : — 1. Elementary" Lesions ....... 21 2. Secondary Changes ....... 32 3. General Observations on the Pathology of the Skin . 34 SECTION III. Classification or Diagnostic Chart of Skin Diseases : — 1. Eruptions occurring in Connection with the Acute Specific or Zymotic Diseases . 2. Eruptions connected with Diathetic Conditions 3. Local Inflammations ..... 4. Hypertrophic and Atrophic Diseases . 5. New Formations 6. Hemorrhagic Disorders .... 44 45 45 46 46 46 Vlll CONTENTS. 7. Neuroses 8. Pigmentary Alterations ... 9. Parasitic Diseases .... 10. Diseases of the Glands and Appendages . 11. Peculiarities of Skin Diseases in the United States 12. Classification and Nomenclature of American Derma- tological Association 50 PAGE 46 46 47 47 48 SECTION IV. The Causes of Skin Diseases 54 SECTION V. Diagnosis 60 SECTION VI. General Principles of Treatment . . . .62 PART II. The Description and Treatment of Skin Diseases. Acne 69 Alopecia, or Baldness 75 Anthrax, or Carbuncle .....<. 76 Area, see Alopecia. Atrophia Cutis .77 Bakers' Itch 79 Baldness, see Alopecia. Barbadoes Leg, see Bucnemia. Boils, see Furunculi. Bricklayers' Itch ........ 79 Bromide Eruption 79 Bucnemia Tropica, see Elephantiasis Arabum. Bug-eruption ......... 81 Cacotrophia folliculorum ...... 81 Cancer, see Epithelioma and Rodent Ulcer. Carbuncle, see Anthrax. Chloasma, see Tinea versicolor. CONTENTS. IX Comedones Condylomata . Contagions Impetigo Dermatitis exfoliativa Dysidrosis Ecthyma Eczema . Elephantiasis Arabum Elephantiasis Graecorum Elephantiasis Telangiectodes . Epithelioma, or Epithelial Cancer Erythema .... Favus, see Tinea favosa. Fibroma ..... Fish-Skin Disease, see Ichthyosis. Follicular Hyperemia Fungi, see Tinea. Furunculus .... Grocers' Itch .... Guinea-worm Disease Gutta rosacea, see Acne rosacea. Herpes . Hydroa . Hydradenitis Hyperidrosis . Ichthyosis Impetigo Impetigo contagiosa Intertrigo, see Erythema. Iodide of Potassium Rash Itch, see Scabies. Keloid Kerion, see Tinea kerion. Lepra Leucoderma .... Lichen ..... Lichen urticatus, see Urticaria. Lupus ..... Maculae ..... Medicinal rashes PAGE 82 82 83 83 83 85 86 97 103 105 106 106 110 110 111 112 112 113 117 121 122 123 126 126 129 130 130 130 132 135 139 139 CONTENTS. PAGE Miliaria 140 Molhiscum contagiosum . . . . . . . 141 Morplicea 143 Nails . . . .145 Pediculi, see Phthiriasis. Peliosis Rheumatica, see Purpura. Pemphigus ......... 147 Plitliiriasis ......... 149 Pigment Increase ........ 150 Pityriasis . . 153 Porrigo .......... 154 Prickly Heat, or Lichen Tropicus 154 Prurigo .......... 155 Pruritus, or Itching . . . . . . . 156 Psoriasis . . . . . . . . . 158 Purpura .......... 1G4 Ringworm, see Tinea. Rodent cancer . . . . . . . . .165 Roseola 166 Rupia . 167 Scabies, or Itch ........ 167 Scabies in private practice . . . . . .169 Scleroderma . . . . . . . . .170 Scrofuloderma . . . . . . . .173 Seborrhoea ......... 174 Strophulus, or Red Gum 175 Sudamina ......... 176 Sycosis 176 Syphilis of the Skin 178 Tinea . .184 Trichorexia Nodosum, or Trichoclasis .... 189 Urticaria, or Nettle-rash ....... 190 Vitiligo . . . .192 Vitiligoidea 193 Xanthelasma 193 Xanthelasmoidea ....... 196 Xeroderma, see Ichthyosis. Zoster, see Herpes. CONTENTS. XI PART III. Cutaneous Pharmacopoeia. PARE Baths 199 Fumigation ......... 199 Caustics 200 Astringents ......... 201 Sedatives . 202 Absorbent Powders 205 Stimulants and Absorbents ...... 205 Plasters . . 208 Mixtures 208 Pills 210 Remedies for Scabies and Phtliiriasis .... 211 Remedies for Vegetable Parasitic Diseases . . . 212 Diet in Skin Diseases 214 EPITOME OF SKIN DISEASES. PAET I. THE GENERAL PRINCIPLES OF CUTANEOUS MEDICINE. SECTION I. THE MODE OF OBSERVING SKIN DISEASES. In order to pursue the clinical study, and to prosecute the treatment, of maladies of the skin with the best chances ot success, attention should be primarily directed to one or two important considerations ; relating, on the one hand, to the general character of cutaneous changes, and, on the other, to the mode of examining patients attacked by these diseases, as well as to some general facts concerning the complications and modifications of the disorders themselves. First. As to the General Character of Skin Diseases Really, there is nothing specialin the pathological changes occurring in the textures in these disorders. When the student approaches the study of cutaneous maladies, he is apt to imagine that he is about to encounter a new set of pathological phenomena, different from those with which he has been made acquainted in morbid alterations in other parts of the body, which in reality is not true. Recent researches in cutaneous pathology have cleared the way to a more correct knowledge of the changes taking place in the skin in disease, and, as a consequence, it is becoming more 2 14 MODE OF OBSERVING SKIN DISEASES. and more apparent that these morbid processes are identical with those occurring elsewhere in the body ; whilst a propo- sition to group skin diseases according to their pathological affinities, upon a plan like to that on which other maladies are classified, is now seriously entertained. It is a noteworthy and satisfactory circumstance that the student of to-day, who is compelled to acquire pathological knowledge over a wide field, is beginning to discover that his study of skin diseases is rendered comparatively easy, because of the complete simi- larity which has now been demonstrated to exist between the facts of general and of skin pathology. The reader does not find himself dealing with strange topics or data, but recognizes familiar appearances, changes, and causes in morbid action, when he turns from his study of the diseased states of other organs to deal especially with those of the in- tegument in its several parts. It is all-important, then, to understand that there is nothing essentially peculiar in the principles of cutaneous pathology. The misconception which has so long prevailed on this point, it is not difficult to account for. The student has been bewildered and often misled by the prominence given to the mere external form and aspect of eruptions, whilst the multi- tudinous names, too, which have from time to time been coined with great prolixity as designations for the infinite varieties of these external appearances, have been so unlike those applied to diseased states in other parts of the body, that they have materially supported the belief in an essential difference and peculiarity in the nature of cutaneous dis- orders. Secondly. As to the Mode of Examining Shin Dis- eases — In examining eruptions with the object of ascertain- ing their specific characters, error is frequently committed in attempting to decide upon these characters from a too partial or superficial examination of the phenomena they disclose to MODE OP OBSERVING SKIN DISEASES. 15 the senses of the practitioner, and without due inquiry into their antecedents. Many persons are wont to content themselves with making a diagnosis at sight, judging from mere aspect alone. In many cases, without doubt, the nature of the dis- ease under scrutiny can be correctly made out at once by an expert, simply from inspection, even when that is of a very partial kind, wherever the eruption assumes from the out- set, and preserves throughout its course, its typical charac- ters. But in other instances, on the contrary, it is difficult or impossible to make an accurate diagnosis without careful inspection of many parts of the disease in several localities in a given patient, and an inquiry into the previous history of its course. For many skin diseases have definite stages, and at the time of observation these may vary considerably in different parts of the body. The typical phenomena of a given eruption may be only in progress of development here, or be lost there, or modified by scratching in another locality. But an examination of the disease in several regions of the body will often disclose the existence of its earlier characters as well as the later changes, by means of which the general nature of the disease may be determined. Typical features may be discovered, in some cases, in a region of the body which, perhaps, comes last under inspection, when they have been absent in several other parts examined. But sometimes it is necessary to go carefully into the history of the case to discover the evidence of the existence of diagnostic features which formerly existed, though lost at the time of actual observation by the practitioner. Further, in reference to the necessity of a thorough examin'ation of patients suffer- ing from cutaneous troubles for the purpose of diagnosis, it is important to add that parts, or stages of different mala- dies often resemble one another, and may convey a very imperfect picture of a disorder. To avoid error then the diagnosis should be based upon a careful estimation of the phenomena or features presented by any given disease as a 16 MODE OP OBSERVING SKIN DISEASES. whole, and not upon the data afforded by any particular por- tion of the history, or distribution, of that disease. The foregoing observations may be summed up in two car- dinal principles, or to put the matter in another form, we may say, from what has been mentioned about the mode of ex- amination of cases of skin disease, that there are two im- portant rules which should be observed in attempting to make a proper diagnosis of a disease of the skin : — The first rule is this : — All diseased places, or as many as possible, should be care- fully examined, and not one only, or one here and there: for the simple reason that the eruption may be at very different stages of development, and therefore present diverse aspects, in different localities upon the same patient. The second rule is as follows : — Where in any given case the earlier stages are not present so as to be recognizable, careful inquiry should be made by interrogation of the patient, as to the changes that have occurred before the disease came under observation, with the view of determining its nature. The object of the examination prescribed by the first of these two rules is to trace out the origin and course of the dis- ease, and to link together the various stages into a complete history which will correspond in its clinical features with an authoritative standard description of the disease, whatever it may be. During this examination special attention should be directed to the character of the newest developments of the eruption with the intention of determining the " initial or elementary lesion," as it is called (to be presently referred to), or if there really be no new spots of eruption, the ob- server should carefully note the features presented by the extending edges of patches, which always constitute the most recently developed parts of the disease, and which, therefore, often portray the primary lesion. Complications are also more likely to be recognized by attention to this point. MODE OF OBSERVING SKIN DISEASES. It The use of the second of the two rules has been cursorily referred to in a previous paragraph, but requires further dis- cussion. Very frequently no fresh developments of the eruption are taking place at the time of observation, and no exten- sion of a given patch has occurred for some time. The malady has in fact become chronic and indolent, and more- over has lost its typical features oftentimes. The only way of making a diagnosis under these circumstances is by ob- serving this second rule. For example, eczema is charac- terized mainly by a peculiar discharge, but the discharging stage, frequently, has passed before the case comes under medical observation, and the affection may present a dry and scaly appearance and be readily mistaken for psoriasis — a not infrequent error. Again, a disease essentially papular may have become inflamed and encrusted, and its true nature may therefore be overlooked, unless its history be carefully inquired into. By the observance of these two rules the student ascer- tains what is the elementary lesion, as well as the cha- racters of the several stages of different eruptions; and he should form with these materials a picture of the malady and so make an accurate diagnosis, just as the child with his dis- sected puzzle puts together the animal or landscape bit by bit to form the desired whole. Thirdly. As regards Complications. — It should never be forgotten that two or more eruptions may occur together. When this is the case the different features of the concurring diseases will be mingled in varying proportion, and the ob- server will find himself dealing with characters and pheno- mena which, theoretically at least, he has learned are exhibited by different maladies. Examples of such commingling are to be found in the common coexistence in the same patient of urticaria and scabies, of syphilitic rash and chloasma, lichen 9* 18 MODE OP OBSERVING SKIN DISEASES. and urticaria, of ecthyma and scabies, of purpura and urti- caria, of eczema and scabies or fur •an cuius, and so on. The possibility of the coexistence of two diseases should never be lost sight of. Multiformity of eruption is, however, by no means sufficient evidence, although it is suggestive, of the coexistence of two or more distinct diseases, because certain uncomplicated diseases of the skin possess this feature. Practically it may be said, however, that there are only three diseases, which are essentially multiform in eruptive charac- ter. They are scabies, eczema, and syphilis. Supposing, therefore, that scabies, eczema, and syphilitic disease can be said to be absent, multiformity of eruption usually indicates the coexistence of two or more distinct eruptions. Fourthly. As regards Modifications of Eruptions There are many influences which modify the aspect and the general character and behavior of skin diseases, which should be taken into account in dealing with their treatment. It is not only necessary that the physician should recognize any particular kind and form of skin eruption, but that he should appreciate the part played by a number of concomitant con- ditions in each individual, which modify the character and the duration of the particular disease present. There are various diatheses, special states of the blood, of nerve influence, and of tissue change, which specially tend to induce an unusual amount of inflammatory action, or favor undue cell activity or pus formation, or disorder of sensation, and the like, to which due consideration must be given. The evil influences of such conditions must be dealt with, so as to pave the way for the due action of curative measures directed against the disease more directly. A few useful particulars or hints may not inappropriately be given here. Diseases of the skin are made to spread or take on an inflammatory character, and changes in the skin are exaggerated, by exposure to irritating agencies, such as MODE OP OBSERVING SKIN DISEASES. 19 heat, cold, scratching, and by the contact of acrid substances of all kinds, as the handling of lime, sugar, and soda respec- tively, by bricklayers, grocers, and washerwomen. So, too, an inflammatory aspect is given to eruptions by acridities in the blood, as in gouty or rheumatic subjects, in dyspeptics ; and in those in whom the bile acids, sugar, or retained effete matters are present in undue amount in the blood. Erup- tions in strumous subjects are attended by an amount of pus formation which is unusual in non-strumous subjects. Undue chronicity is occasioned, oftentimes, by the existence of ner- vous or general debility : for nature then lacks the normal recuperative power which it always tries to exert in aid of the cure of disease. The questions of age, sex, occupation, mode of life, and the general medical history of the patient have to be con- sidered, and will be incidentally referred to in other places. Attention to the four indications already discussed will, however, be found of essential importance in the successful study, or in determining the treatment, of a skin disease. It may be observed, however, as regards age, that one essen- tial difference between the cutaneous diseases of the young, as compared with those occurring in the middle-aged and old, consists in the fact that the former are often the result of imperfect digestion and assimilation, whereas the latter are induced by mal-influences connected with the habits and occupations and wear and tear of adult life, and degeneration of structure in the old, and are modified by a number of functional and organic diseases of internal organs, which are conspicuous by their absence in the young. The modifying influence exerted upon skin troubles by the strumous diathesis, however, is infinitely more common in the young. 20 THE PATHOLOGY OF THE SKIN. SECTION II. THE PATHOLOGY OF THE SKIN. Recent research in the field of dermatological pathology has advanced this branch of medical science to a reputable position ; and dermatologists are beginning to describe with no little accuracy, and with an increasing general agreement amongst themselves, the minute tissue changes that go on in the various disorders of the skin, and to define with more approach to the truth the exact anatomical limits and locality within which these morbid processes begin and go on. It has been the custom, since, indeed, the days of Plenck and Willan, to divide diseases of the skin according to their general aspects or naked-eye features, such as lumpiness, and redness, or pimples, vesicles, etc, and it has hitherto been found convenient to make certain groups according to these various types of -aspect, or " elementary lesions" as they are called. But some better method will assuredly be devised before very long, and probably it will have a pathological basis ; for the old Willanian system, however useful, cannot be regarded — taking account, as it does, only of the mere outward aspect or appearance of eruptions — as anything but a tentative arrangement, roughly outlining the physical characters of cutaneous disorders. An accurate knowledge of elementary lesions, however, is still needed by all stu- dents of dermatology preliminary to the fuller study of the subject. We shall, therefore, first describe these primary lesions, and then proceed to make a few general remarks upon the nature of the changes that individually occur in the different component textures of the skin. THE PATHOLOGY OF THE SKIN. 21 ELEMENTARY LESIONS. These elementary lesions, as before indicated, are the types of external form and aspect presented by eruptions of the skin. These are nine in number, bearing the designa- tions respectively of macules, or stains ; hyperemia, or red- ness ; pomphi, or wheals ; papules, or pimples ; vesicules, or little bladders ; bullce, or blebs (*". e., bladders larger than vesicles) ; pustules, or pustules , squamce, or scales ; and tu- bercula, or tubercles (little solid lumps). These several le- sions we shall now briefly describe in detail. Maculae or Stains For all practical purposes these may be said to be of four kinds, viz., pigmentary, chemical, parasitic, and hemorrhagic. I. Pigmentary stains are usually due to the presence in the rete mucosum, and more particularly in the lower strata of its cells, of altered coloring matter of the blood in the form of pigment granules, or minute dark particles. They may be divided into two groups, viz., primary and secondary maculae. The primary or idiopathic pigmentary stains are few, and consist chiefly of such things as freckles and the discolorations left after hyperemia induced by local irritants of various kinds. The majority of pigmentary maculae belong to the group of secondary stainings, that is to say, they do not constitute the sole, or primary, or main condition present, but follow in the course of other morbid states of importance. They, for instance, occur in and are secondary to syphilitic eruption, and in association, in like manner, with certain cachexia, such as Addison's disease and leprosy. They are left behind by such eruptions as lichen pla- nus, and the vitiligo of Willan (xanthelasmoidea of ourselves). They are sometimes strictly physiological in character, as seen in the bronzing of the forehead, and other parts of the surface, in connection with pregnancy and uterine activity of 22 THE PATHOLOGY OF THE SKIN. other forms. Maculae of this kind are not raised, they are unaffected by pressure, and are not the seat of any morbid sensation. There may be an entire absence of pigment, when the skin, of course, looks white. II. Chemical stains are seen in the instances of dis- colorations from iodine, silver compounds, bile products, and the like. III. Parasitic maculae are usually of a fawn color, and are caused by the presence of fungous elements growing between the cuticular cells, as seen in tinea versicolor. IV. Hemorrhagic stains are due to the actual extrava- sation of blood, or the escape of its coloring matter alone, into the skin textures, and the varying hue is accounted for by the changes which have taken place in the transuded material, as typically portrayed in an ordinary bruise. Pur- pura is the chief disease in which extravasation of blood into the skin occurs, but an hemorrhagic aspect is assumed by variola, by herpes, by lichen planus, the bites of insects, and the petechice of febrile states. Hyperaemia or Redness may be active (arterial) or passive (venous). Active hyperemia consists of redness removable by pressure. It may be punctiform, patchy, or consist of circles. It mostly is accompanied by swelling from effusion of serosity, and the escape of leucocytes ; by disordered sensation (pruritus and burning); by a slight rise in temperature ; and it is followed by desquamation. It is caused by local irritants, by changes in the blood, and by excitation of the nerves. It may occasionally exist alone as the sole disease, as in the erythemas ; or, as is usually the case, it may be a stage or part in the development of more complicated changes, as in the inflammatory disorders of the skin. All active morbid alteration in the skin is attended by hyperemia, more or less pronounced. Passive conges- tion of the skin may be said to be the result of some cause THE PATHOLOGY OF THE SKIN. 23 retarding the flow of the blood through the veins towards the heart, or, in fact, to be of mechanical origin. Pomphi, or Wheals, are raised hyperasmic swellings, which vary much in size and shape. They have a palish centre, and a red areola in varying proportions. They very rapidly form, to as rapidly disappear. Attended by a certain feeling of heat in the part together with tingling or itching, they are typically portrayed in the sting of the com- mon nettle, with which every one is familar. The fugitive and capricious character of the wheal is the most charac- teristic feature in its behavior. The wheal is significant of urticaria. The wheal may be oval, or round, or linear, or band-like in form ; the latter generally are the result of scratching in a particular direction, and when so produced are said to be factitious. In children they are often quite small, resembling bug-bites, and are followed by the de- posit of lymph in the form of minute, solid, pale papules, which may run on into slight vesicles, as the "lichen urti- catus" of children, which is a phase of urticaria. Wheals are caused by sudden irritation with immediate contraction of the capillaries, but this contraction is speedily followed by free dilatation and escape of serosity into the tissues, which accounts for the redness and the swelling; but the vessels beyond the area of dilatation, that is, away from the imme- diate seat of the irritation inducing the wheal, are probably in a state of spasm ; as soon as this gives way the wheal begins to disappear, and as this happens speedily, the wheal is essentially fugitive. During the formation of the wheal the serosity finds its way to the rete cells, and more particu- larly the lax tissue of the papules outside the vessels. It exerts, as it augments in amount, some pressure by its dis- tending influence, and as the greatest effect is felt about the centre or apex of the wheal, the paleness at the corre- sponding point on its surface, which is in strong contrast 24 THE PATHOLOGY OF THE SKIN. with that of the bulk of the wheal, is most likely due to the emptying of the capillaries at this point by this pressure, and the masking of them by this fluid. This is proved by the gradual reappearance of the pink blush over the centre of the wheal as the effusion and swelling lessen, the white as- pect going and the red reappearing pari passu with the absorption of the fluid and the diminution in the tension of the tissues. Some think that the pale centre is due to spasm of the vessels, but facts are clearly against this view. In exceptional cases the effusion is so decided and rapid that the serosity uplifts the cuticle, and produces a vesicle or bulla ; but this is not a common occurrence. In other rare instances the effusion of serosity is very great and deep, so that large tuberose swellings are induced. These are more or less fugitive in character, and are attended by heat and itching, but naturally where much fluid is transuded, it takes longer to become absorbed. Wheals cannot be said to be inflammatory in character, because no new products are produced in connection with their formation. They are rather developed as a conse- quence of an alteration of the calibre of the vessels, induced by disordered nervous influence. It is a vaso-motor, and not a local, tissue disorder. Papulae or Pimples These are small, circumscribed, more or less firm elevatious of the surface. The word pimple sufficiently expresses their general character. Papules are of several kinds, however, and are produced by a variety of causes ; for instance, they may result from the presence of effused serosity in small amount, or lymph, or a new growth in the derma itself; or by swelling, thickening, or plugging the follicles. They vary in size somewhat, and in color, according to the amount of congestion by which they are attended. If very vascular they are small, red, and soft ; if due to the presence of solid material in the textures, THE PATHOLOGY OF THE SKIN. 25 they are paler, and, of course, firmer. It is important to distinguish true from what may be termed false papules. True papules are such as assume and retain the aspect of papules from the beginning to the end of their career. In other cases what seems to be a papule — but which is false, as it were, to its character at the time of observation — may be in reality an early stage in the formation of a vesicle or pustule. That is to say, when in the development of a vesicle there is but slight effusion, the dermic structures are raised into papules ; but this is succeeded, as the fluid increases in amount and the inflammation progresses, by uplifting of the cuticle, the formation of pus, and other changes. It is manifestly wrong to designate the papular stage of a vesicle as a true papule. It is a potential vesicle, as seen in eczema, hydroa, etc. It is of no little moment to remark the dis- tinction here pointed out in diagnosing cutaneous eruptions. Patches may be and often are formed by the aggregation of pimples. Papules are often attended by itching. True papules may, clinically, be conveniently regarded as of six chief kinds : — a. They may be due to hyperemia of the papillae, form- ing bright red points, as in strophulus, or the papules of certain of the acute specific diseases. b. They may consist of turgescent and erected follicles, the hair, the sweat, or the sebaceous, as in cases of follicular hyperemia, induced by scratching, and in slight acne and the early stage of miliaria respec- tively. c. They may be caused by the deposit of lymph, or by cell infiltration about the walls of the follicles, as in lichen planus. d. They may be actual lymph formations, or cell growths in the derma proper, as in lichen, prurigo, and syphilis. 3 26 THE PATHOLOGY OF THE SKIN. e. They are caused by collections of sebum or epithelium, or both, in the follicular orifices, as in pityriasis pilaris, in which the hair follicles are plugged by epithelial exuviae, or in the acne sebacee cornee, in which the sebaceous glands are plugged, rasplike, by sebum. f. Papules are sometimes the result of mere hypertrophy of normal tissue, as in papillary warts. It will be noted that papules may be situated on three chief sites, viz. : the corium, the hair follicles, or at the sweat ducts, as in miliaria. Vesicles These have hitherto been described as little bladders, varying in size from a pin-head to small split peas, and caused by uplifting of the cuticle by serous fluid poured out by the vessels of the papilla? ; and, further, as either single or loculated in structure. But this definition, and especially the former portion, must now be regarded as affording "an altogether too limited representation of patho- logical facts. The part of the skin tissue distended into vesicles, and the nature of the fluid which causes the distension, vary essentially in different cases, but it may be stated that there are three principal kinds of vesicles : — a. Serous or inflammatory vesicles. b. Sweat vesicles, or vesicles formed in connection with the sweat ducts ; and — c. Lymphatic vesicles. a. Serous or inflammatory vesicles are the commonest, by far. They rise above the level of the surrounding skin, and tend to burst and discharge their contents and dry away. Some vesicles burst with difficulty, as in herpes, in fact, these often never rupture. Sometimes their contents become opalescent or opaque, which is due to the admixture of pus with the serosity, thus giving rise to vesico-pustules, which THE PATHOLOGY OF THE SKIN. 27 form yellowish crusts, when their contents dry up. These vesicles may be acuminated as in scabies, but usually they are more or less globular, as in eczema, or hydroa. They may be oval, and perhaps at one period of their course um- bilicated, as in varicella. Sometimes they are isolated, as in scabies and hydroa; at other times aggregated together into patches, as in eczema, or grouped in circular form as in herpes. They are usually attended by burning or itching. Such are their gross characters. In regard to their mode of formation and anatomical structure, it may be said that inflammatory vesicles answer to the ordinary ^description of vesicles, that is to say, they are due to the escape of serosity from the papillary and subpapillary vessels, which finds its way to the surface and uplifts the tissue which bars its exit. This may in its escape not disturb the rete tissue much, but find its way chiefly between the horny and mucous layers, raising the former up into vesiculation, as in pem- phigus, and mild cases of eczema, probably, in which this condition is associated with oedema and cell infiltration of the derma ; or in its passage through the rete the fluid may cause more or less stretching of these cells into fibres, which then form the walls of little loculi in which the fluid is con- tained, and in which, when the disease is inflammatory, cell- products make their appearance by migration from the corium vessels, as is the case in variola, herpes, pustular eczema, etc. The inflammatory vesicle, therefore, may be single, as in pemphigus, or, as in most of the cases, com- pound, as in the common vesicular affections. b. Siveat vesicles. In these the vesicles may be elevated and globular, as in sudamina, or imbedded in and below the level of the skin, as in the earlier stages of dysidrosis. The fluid present may be normal sweat, and collected between the layers of the epidermis, as in sudamina ; or the fluid may be sweat mixed with serosity poured out from the vessels of the sweat tubes; in this case the fluid first distends the portion 28 THE PATHOLOGY OF THE SKIN. of the sweat duct in the rete, which is the commence- ment of a globular dilatation that by its increase projects upon the surface, and may by continued development, col- lection of fluid, and junction with other cysts, produce bullce. Usually the duct bursts, and the walls of the large vesicle are formed in part by the stretched rete tissue, as in dysi- drosis. c. Lymphatic vesicles, that is to say, vesicles having the aspect of clean, transparent, little bladders, and not merely minute, soft, little reducible swellings, are observed in lym- phaugiomata and elephantoid diseases, and are distensions of the lymphatic spaces of the papillas and base of the papilhe. They are usually attended with hypertrophy of the fibro- cellular texture of the skin, and in fact may form part of and stud over a hypertrophic mass. The walls of these vesicles are formed not by the rete, not immediately at any rate, but by a layer of the tissue of the papillae, though the rete is just outside it, and is often thinned by pressure. The lymph vesi- cles are lined by endothelium. There is another aspect in which the features of vesicles may be summarized, and that is from the points of view of their single or compound nature. This arrangement affords a good general indication of the characters of different vesi- cles, and is as follows : — A. Single-chambered Vesicles are produced by — a. Sweat between the horny layers of the epidermis, as in sudamina ; h. By serum between the horny and mucous layers, as in pemphigus and mild cases of eczema; c. A mixture of sweat and serous fluid in a globe formed by distension of the sweat tubes and rete tissue im- mediately adjoining, as in dysidrosis ; d. By lymph distending the lymphatic tissue and its spaces in the papillary and subpapillary regions, as in lymphangiomata. THE PATHOLOGY OF THE SKIN. 29 B. Compound or Loculated Vesicles are produced by the presence of inflammatory fluid and cells, which uplift the cuticle and collect in loculi formed by the stretched out rete cells and the distended meshes of perhaps the upper corium layers, as in variola, herpes, severe eczema, and hydroa, or in a blister. Pustules. A typical pustule, as generally understood, is a small circumscribed elevation of the skin textures pro- duced by the presence of pus ; but there are two other forms, which must not be lost sight of, viz. the one produced by inflammation of the sebaceous glands, as in acne, and the other due to suppuration set up in a papule, as in syphilis. The vesicle and the pustule differ in the relative amount of leucocytes in each. Ordinary pustules vary in size from that of a pin's head to a sixpence or shilling, and their yellow color is due to the pus ; if dark, to the presence of blood coloring matter or actual blood. They are attended with more inflammation than vesicles, and by. a deeper affection of the tissues, and therefore have harder bases. They tend to dry up rapidly into dirty-looking crusts, and sometimes leave scars behind. True pustules are formed in the same way as vesicles, and the pus is contained in loculi, or meshes of the rete, similar in structure to those of compound vesicles already described. The vesi co-pustule has already been referred to in speaking of vesicles. The term is applied to the condition in which the aspect of a vesicle is first assumed, but in which pus is subsequently produced in distinct amount, so that the aspect of the pustule is more or less closely approached. The pus is not so freely nor so promptly produced as in the pustule. Bullae are really large vesicles or blisters. They are primary and secondary. The primary, or true bullae (be- cause essential parts of the disease), occur in pemphigus, hydroa, pycemic pemphigus, erysipelas, syphilis, and leprosy ; 3* 30 THE PATHOLOGY OF THE SKIN. and they are developed by friction in some people. The secondary, or accidental bullae, occur in dysidrosis, eczema, and urticaria. Primary bullae vary in size up to that of a large egg ; and bullae of different magnitudes may occur together in the same patient. They are seen not only in numbers over the body, but occasionally they also develop singly. They vary in hue according to their age and contents. At first they are trans- lucent, and subsequently become opaque or even hemorrhagic in aspect from the admixture of blood or its coloring matter with their contents, which generally contain albumen, with few corpuscular elements, the reaction being alkaline. Ordi- nary bulla? are at first tense, then become flaccid ; the walls, however, are firm, and do not readily burst, so that, as the rule, bullae gradually shrivel away, leaving a red mark and some crusting, except in cases associated with constitutional cachexia, when there may be more or less ulceration. From first to last bullae do not possess any decided areola ; excep- tionally when they crowd together very closely, as in pem- phigus foliaceus, the secretion of the bullae and a certain amount of discharge from the skin dry together into consi- derable crusts or flakes. Mostly they are unattended by any decided subjective sensations, but, occasionally, attendant burning and smarting, as in pemphigus foliaceus, and intoler- able itching, as in pemphigus pruriginosus, are present. The secondary bullae of eczema are accounted for by the non-rupture of several vesicles which join together. They are seen especially about the hands. In urticaria, occasion- ally small bullae are observed owing to very free and exces- sive outpouring of serosity. In dysidrosis bullae occur ; but whereas in other cases they are single chambered, in dysi- drosis, in their early stage, they are loculated or rather com- pound, being produced by the aggregation of a series of distended sweat follicles and adjoining rete tissue, projected upward bodily, as it were ; the walls of the separate little THE PATHOLOGY OP THE SKIN. 31 vesiculations forming so many partitions which may give way later on by the increasing distension of the parts by fluid, whereby the loculated is reduced to a single-chambered bulla ; the ruptured partitions, however, remaining more or less loose in the cavity. Ordinarily, in other diseases, the bullae are formed of a single chamber only, from first to last, except, perhaps, in early blister, but in this case the parti- tions are soon ruptured. Squamae or Scales are formed of dried flakes or thin layers of detached epidermic scales. They differ from crusts in the fact that they are not formed by the drying up of dis- charge. Scaliness occurs as a secondary consequence in all inflammatory skin diseases; but squamae also form as an essential part of squamous inflammation — e. g., psoriasis, and pityriasis rubra ; they occur also in hypertrophic condi- tions. They may be thin and fine, as in pityriasis simplex, or large and flaky, as in pityriasis rubra, in which disease they are often arranged like the tiles of a house, and are produced and thrown off in great abundance and rapidity. They are thin and greasy in seborrhea, and dark and horny in ichthyosis. Tubercula or Tubercles A tuber culum is a solid fleshy lump in the skin formed by the growth of new tissue. It is a term applied to any smallish lump which is not large enough to deserve the name " tumor," to which, on the other hand, the term papule is not applicable. A tubercle is, however, a big papule, and there is no real line of de- marcation between the two, for oftentimes a papule grows to a tubercle, as is seen in syphilis, or lupus. Tubercles occur under two main conditions — where there is a hyperplasic growth of connective tissue, as in fibroma and keloid, when they are said to be homologous ; or there is a formation of a new or foreign kind of tissue, as in cancer, lupus, syphilis, 32 THE PATHOLOGY OF THE SKIN. rodent ulcer, leprosy, frambcesia, etc., when the growth is termed heterologous. The tubercles in these diseases are, in their early stage, round, firm to the touch, and either possess the aspect of normal tissue, as in fibroma* or are reddish and more or less vascular, as in the other diseases before men- tioned. They undergo a variety of changes, such as en- largement, aggregation, absorption, softening, or ulceration ; but they may remain unchanged for years. When they degenerate they lead, after ulceration, to more or less scar- ring. Dr. Duhring makes a separate class of the large and more pendulous outgrowths from the skin, and terms it " tumores." It comprises " alterations in the sebaceous glands ; new formations in the corium, connective tissue, bloodvessels, and lymphatics." It is a useful clinical ar- rangement. SECONDARY CHANGES. Crusting This is a common condition. The crusts are derived mainly from three sources : — a. By the drying up of discharge — seroso-purulent fluid, or actual pus or blood. These fluids may be poured out free upon the surface from inflamed or ulcerated surfaces, as in eczema and syphilis, or derived from the contents of bullae, as in rupia. b. Crusts may also be formed by dried sebum, as in seborrhcea. c. From the collection together of the elements of pa- rasitic fungi, as mfavus. Crusts formed by the escape of serum are thin and light- colored, often ill-defined; from pus, thick, yellow and with definite borders ; from the drying up of bullae, thin and dark- ish ; from the drying of sanious pus from ulcers, thick, dark-colored, adherent and heaped up ; from collections of dried sebum, flat, easily detached and greasy; and from favous elements, sulphur colored, pulverulent and honey- combed. THE PATHOLOGY OF THE SKIN. 33 Ulceration. — This, like crusting, may be said to arise from three sets of causes : — a. The most common kind is the result of cachectic in- flammation, such as the strumous and syphilitic ; b. It may be due to the presence and softening of new- growths which replace and destroy the normal tex- tures, and which themselves decay in due course, as in lupus and cancer ; or c. It may result from the softening and decay of actual outgrowths from the skin, as in fibroma and yaws. Ulcers vary in size, shape, and depth. Strumous ulcers are indolent, unhealthy in aspect, with boggy edges and an offensive, dirty discharge, mixed with attempts at crusting. Syphilitic ulcers have sharp-cut, serrated, everted, but not undermined edges. Cancerous ulcers have everted and un- dermined edges. They leave behind decided scars. It must not be forgotten that superficial ulceration may follow common inflammation in ill-nourished people, especially in cedematous, congested, and dependent parts, such as the legs. Excoriations. — In these the true skin is more or less exposed, but it is not otherwise disturbed, and excoriations are due to scratching or rubbing of itching parts by the pa- tient, or to maceration of any part by fluid, perhaps its ow r n secretion, as in intertrigo. Excoriations are observed in a number of cases of disease of the skin which are attended by itching, for the relief of which scratching is practised, but chiefly in eczema, lichen, prurigo, hydroa, psoriasis, scabies, phthiriasis, and in cases also of pruritus of the surface with- out eruption. Excoriations, therefore, can be truly the sole visible condition present, or it may be a superaddition to other eruptions, a difference of some importance ; for if there be only the signs of an excoriated skin present, the cause of the pruritus must be sought for in some blood state or nerve disorder, and not in the skin itself. Excoriations are often 34 THE PATHOLOGY OF THE SKIN. seated around the hair follicles alone ; about an eczematous spot ; or in a given patch, as in psoriasis. In scabies they are found particularly on the front of the arm, the abdomen, and thighs ; in phthiriasis about the neck and shoulders, and in the form of linear scratching. Fissures are linear cracks which occur in parts that are rendered dry, hardened, and brittle by infiltration with lymph, or about the hands in eczema and psoriasis. Sears are left by traumatic injuries, caustics, and by cer- tain diseases which ulcerate, such as variola, furunculus, an- thrax, pustula maligna, and strumous and syphilitic disease. Scars need scarcely be described as regards their general appearance. They signify that the true skin has been re- moved or destroyed, and replaced by " cicatricial tissue." GENERAL OBSERVATIONS ON THE PATHOLOGY OF THE SKIN. In describing the " elementary lesions," the intention was to convey information regarding the types of form and the external aspects which skin diseases assume ; it may now be useful to add some few remarks upon the general nature and main anatomical seats of the changes that occur in these maladies : — The Cuticle. A. The horny layer — The changes in this structure may be said to be almost invariably secondary to changes in the rete and deeper tissues below. There are none of moment that are of primary origin if we except the results of trau- matic or toxic injuries, undue maceration of fluid, and the invasion by fungi. This will appear reasonable enough if it be remembered that the cells of the horny layer are merely the rete cells pushed upward from below, and which have undergone desiccation. THE PATHOLOGY OF THE SKIN. 35 The secondary changes are many and various. The cells are increased in amount whenever the rete is in a state of excitation from pressure and friction, as in corns, warts, or as in congestive conditions, especially in psoriasis, where the whole rete is eminently hyperplasic ; also in inflammatory diseases, as eczema and pityriasis rubra, where a hyper- production of scales marks the latter stages of the disease. A like condition may be part of a general hyperplasia of the tissues of the skin as a whole as in elephantiasis arabum, and is congenitally so in ichthyosis. The cells may be dis- posed more or less normally, there being only such an excess as to cause roughness, or their normal stratification may be altogether destroyed by their rapid production and heaping together, as in psoriasis. The horny layer is elevated in con- nection with portions of the rete cells by fluid issuing from beneath, and in some like fashion in the formation of vesi- cles as in eczema, or herpes, or it alone may form the walls of vesicles or bullae as in pemphigus, or the cells may be only swollen, oedematous, and closely packed together with fluid amid them as in oedema. The cells may be collected to- gether upon the skin and shed not only now and then en masse, as in psoriasis, but they may be also shed, again and again, in rapid and successive crops, as in pityriasis. Some- times they are shed once and for all, as in erythema. The cells of the horny layer again may be diminished in absolute amount, as in those cases where the nutrition of the rete is interfered with by such influences as pressure from below and substitution of the normal textures by new growths, as in syphilis and lupus. In these cases the cells are disposed in irregular scales upon the surface, the flakes .of which are often few and fine, but it is important to add that the appearance of scaliness is apt to convey at first sight the idea of an excessive formation of cuticle, whereas the amount of epidermis is less than normal in its total. The condition here is a minus ill-stratified, and not a plus ill-stra tified one, as it is in psoriasis. 36 THE PATHOLOGY OF THE SKIN. Again the cells may be altered in character more or less, retaining the characters of rete cells, from failure to undergo the horny transformations, in which case such failure may be due to a too rapid and imperfect formation of cells. Lastly, vacuolation may, now and then, go on in the cells of the horny layer. B. The rete Malpighii The changes which occur in this layer are very important ; they are primary and secondary, and, as before stated, are associated, in most instances, with others in the upper layer of the epidermis. Unquestionably, morbid processes originate in the rete, and are primary. The simplest instances of such primary alterations are seen in the hypertrophy of warts, corns, callosities, and notably, in our belief, in psoriasis, in which diseased state the two layers of epidermis are concerned. We have long taught, and our con- victions on this point are based in part upon careful micro- scopical observations, that psoriasis is to be regarded as due to an hyper-activity of the rete cells, which increase so freely as to be extended down beside the papilla? into the corium tissue, and also spread in undue proportion upwards. The nuclei of the cells are active, they freely multiply, and rapid cell division takes place, vacuolation being marked in many cells ; the vessel changes being probably secondary. Another instance of the origination of disease in the rete occurs, we believe, in epithelioma, large processes of morbid rete tissue being projected downwards, portions finding their way along the lax connective tissue and following, probably, the lymphatic tracts toward the glands, and developing into onion-like bodies en route ; the phenomena of congestion and inflammation being concurrent. A congenital hyper- plasia of the epidermis associated with papillary hypertrophy is illustrated by ichthyosis. Pigmentary deposit in the lower strata of the rete cells may be a primary change, but it is, as the rule, secondary to THE PATHOLOGY OF THE SKIN. 37 other morbid conditions, especially such as are associated with cachexia. The alterations in the rete tissue which occur in conges- tive and inflammatory diseases are very common and distinct, but it must be understood that the rete does not actively participate in these changes, but rather is altered as a con- sequence of the escape of fluid and migration of cells into it from the vessels beneath. Therefore the changes are, strictly speaking, secondary to the vascular disorder. As a consequence of the escape of fluid into the rete tissue, the cells swell and become loosened, separated, or put upon the stretch, as the fluid increases in amount, and travels to the surface. As has been explained in speaking of vesicles, loculi are often formed by the separate and stretched out rete cells. If these loculi open to the surface, the rete layer is more or less exposed, and may continue to give exit to a "discharge." The migration of leucocytes from the vessels of the papillae and their subsequent change account for the presence of pus in the rete meshes. If the inflammation be severe and continuous, the nutrition of the rete may be so interfered with that it is more or less destroyed. Such changes as the above described as are induced by the pre- sence of fluid occur in eczema, herpes, hydroa, blister, dysi- drosis in part, pemphigus, and such alterations as are de- pendent upon the migration of cells into the rete are observed in eczema, herpes, impetigo, variola, etc. It will be noticed that the primary seat of change is the vascular tract below, and that the cell migration and final transit may concur, as in eczema, or it may be mainly fluid escaping, as in pemphigus, whilst the cell activity is compara- tively insignificant or nil. Another principal alteration in the rete is the invasion, destruction, or replacement of its tissue by new or foreign tissue. In this case the production of rete cells is gradually interfered with, and the normal tissue becomes atrophied. Such change is seen in syphilis, 4 38 THE PATHOLOGY OF THE SKIN. lupus, and rodent ulcer. The rete, however, is not alone nor primarily affected ; the corium, in its superficial or deep layer, being the seat of the mischief in the first instance. The rete may be reduced to a thin layer, or be completely gone in parts, or small areas may remain isolated as it were by the new cell-growth around, the whole being finally replaced by cicatricial tissue where ulceration has occurred. Somewhat similar results are produced by pressure upon the rete below by molluscum tumors, cysts, lymphangiomatous vesiculations, which form in the papillary layer, etc. Vacuolation of the cells in psoriasis, and some other con- ditions, has already been referred to. The Corium. — The changes in the fibro-cellular struc- ture of the corium are also primary and secondary. The primary consist mainly in an increase — a plus state — of the connective tissue elements, and, as an independent condition, is seen in morphoea, keloid, fibroma. The relative amount of cells and fibres varies. In the one case the tissue is lax, and contains many cells as in fibroma ; in other instances the fibres predominate, forming a dense, tough mass of tissue, as in keloid. It is an open question whether the cells of certain new growths that invade the corium primarily, such as lupus, syphilis, elephantiasis, are derived from the cell- elements of the connective tissue of the corium, or from the blood-current, but probably the latter. In any case " neoplasmata" lead to destruction and atrophy of the corium tissue. In xanthoma the connective tissue undergoes a fatty change. The secondary changes in the corium have reference to prior changes in the vessels. The corium tissue is rapidly rarefied about the vessels by the escape of fluid from them, as in oedema, and this is specially so in the papillary layer. It is always more or less hypertrophied, as the result of vas- cular excitement of any decided duration. It is infiltrated THE PATHOLOGY OF THE SKIN. 39 with lymph, serosity, or cell-growths, first about and then beyond the vessels in inflammatory disease, and may suffer more or less injury or atrophy in consequence, especially in its papillary layer. The cells which escape from the vessels (leucocytes or wandering cells) into the corium are no doubt the source of a number of new growths, according to the influence exerted upon them by general and local conditions. In intense and long-continued inflammatory infiltration, the deeper layers are involved, and the occurrence of induration, fatty, and atrophic changes — some or all of these are said to occur. The effect of neoplasmata in inducing similar destructive changes has been already noticed. The papillae are enlarged to some extent in pso7*iasis, but, as Dr. Robinson points out, such an appearance is often de- ceptive, owing to the growth downwards of the interpapillary portions of the rete. The portion of the connective tissue adjoining the seba- ceous glands becomes specially involved in inflammatory and other changes in those glands, as in acne or sycosis, and especially in strumous subjects. The papillae too are enlarged and elongated where the lymphatic tissue and spaces augment and increase in size, as in elephantiasis arabum, but this is a secondary change, perhaps. Where lymphatic or blood cysts form either in the papillary or subpapillary localities, the tissue around may be pushed aside and thinned by pressure. The corium is also the seat of certain animal parasites, such as the Guinea worm, or parent filaria, and abscesses follow their presence. The Vessels The bloodvessels are primarily con- cerned and hyperplasic in teleangiomata, or vessel tumors, and naevoid growths. Also in most congestive and inflam- matory affections, except, of course, where the inflammation 40 THE PATHOLOGY OP THE SKIN. is secondarily induced by the irritation of morbid textural alterations. In inflammatory disorders, the vessels are en- larged or dilated, and frequently augmented in amount, the veins being especially numerous, and the capillaries of the papillae particularly prominent and active. The results of " vessel activity," viz., effusion into the tissues, and dis- turbance by the presence and results of cell infiltration in the rete and papillary layers, have been dealt with generally in the description of vesicles and pustules. It is necessary here to point out that the degree and extent of the arterial and venous excitement depend upon the nature of the ex- citing cause. It may be very temporary, as in urticaria, where there is spasm of the vessels of short duration. It is more prolonged, but still comparatively of short duration in other erythemata, due to the operation of temporary causes, such as chill, or excessive heat, or "rheumatic" disturbance. It is prolonged and developed with all its more serious consequences, when excited by blood disorders, or chronic nervous causes, or diathetic conditions. In some cases the vessels of the more superficial strata of the corium, and especially the papules, are mainly or solely affected, as in psoriasis, lichen, and prurigo ; in others those of the longitudinal plexus are chiefly involved, as in pity- riasis rubra. In other instances the vessels generally are implicated, as in severe eczema. It is important to distinguish between vessel excitement leading to secondary changes in the textures, as in the inflam- mations, and that which occurs as the result of tissue ac- tivity itself, as in psoriasis and cancer. No doubt the vaso-motor system of nerves plays a great part in determining the occurrence of various congestive states of the skin, as in lichen rubra and pityriasis rubra, but no facts are at present forthcoming to enable the patho- logist to offer any satisfactory conclusions upon the subject. THE PATHOLOGY OF THE SKIN. 41 The Lymphatic System plays an important part in many skin diseases in our estimation. The lymphatic ves- sels may be primarily or secondarily affected. Primarily they may be enlarged and increased in number and size, both as regards the juice tracts and the actual vessels, where the tissues are generally hyperplasic, as in lymphangiomata. We have referred to this in speaking of vesicles, but the changes are mostly secondary to other conditions. The lymphatic tissue seems to be more or less in a state of ac- tivity whenever the corium tissue is specially involved in disease, according to our own observations, as, for example, when the connective tissue is hyperplasic, or involved in inflammation, or when it is the seat of new growths. In some of these cases the lymphatics are in a condition of ex- aggeration, and more or less dilatation in parts. It seems that the office of the lymphatics is to regulate the amount of nutrient material retained in the connective tissues, and where great change is occurring, or the supply of fluid and cell from the blood current is excessive, the lymphatics are in a very active condition, in order to be able, as it were, to successfully remove the overplus. This is observed in elephantiasis arabum, lymph scrotum, and other diseases where indeed new lymphatics even may form in the enlarged papillae. It is probable that it is along the lymphatic juice tracts that many diseases spread from the more superficial to the deeper parts, as in epithelioma, farcy, erysipelas, etc. Nerves Of the organic changes that occur in nerves we know far too little. We know that in herpes zoster, lep- rosy, syphilis, ncevus, and teleangiectasis, and some other diseases, they have been found diseased, but the field of in- quiry in this direction remains comparatively unexplored, although it is a rich one. The Glands. — These are subjected to a variety of changes, both primary and secondary. But it is important 4* 42 THE PATHOLOGY OF THE SKIN. to observe that whilst these organs are disturbed secondarily in several general affections of the body, or in common with like diseased conditions of the adjoining textures, many of the disorders to which they are liable are, on the other hand,- not only confined to them, but are of a special and different nature from those observed in other parts of the body. This is accounted for by the existence of a special structure in these glands devoted to the special functions they perform. A new set of conditions therefore is observed in glandular disorders. So long, of course, as the fibro-cellular texture of the walls, or even the epithelial linings of the glands, or their periacinous lymphatic tissue and spaces, and their ves- sels, are the seat of disease, in connection with or independ- ently of the affection of other structures in the skin, as in congestion, syphilis, lupus, and cancer, for example, a simi- larity in pathological appearances is observed, but when the true gland structure or any of its functions is involved this ceases. But even if in the former case the histological ap- pearances are alike clinically, there are differences observable to the naked eye in the case of the sebaceous glands, because these glands are mostly irritated by the morbid action about them, and pour out an excess of secretion which crusts on the surface, and forms like plugs on its extracting duct, the special amplification of, or localization of the disease to, the sebaceous glands being evidenced by this feature, as in lupus erythematodes ; disseminated follicular lupus; syphilitic acne. The sweat-glands, being more deeply seated, escape more usually. Examples of secondary disease are syphilitic and stru- mous acne, or cortical sudamina, or miliaria, or atrophy of the glands from the pressure of new growths and ulcerations. Examples of concurrent disease in the sebaceous glands are their enlargement in elephantiasis, and leprosy, and other diseases, attended with general textural hypertrophy of the THE PATHOLOGY OF THE SKIN. 43 textures, the infiltration of the gland with lupoid cell-growth, or cancer-elements, with a like state in the corium generally. The primary diseases are numerous. They have reference to augmented, or diminished, or depraved secretion of sebum or sweat, as the case may be, by which the skin is rendered dryer or moister, or more oily and greasy. The secretion may collect in the ducts or in the actual glands, and irritate and inflame, inducing acne or dysidrosis, or distend the structure into cysts. Congestive and inflammatory disorders may arise too from a variety of causes, even the use of particu- lar drugs, as in bromide and iodide acne. In undue activity of the fatty gland, as in molluscum, vacuolation and cell- division are admirably seen. In gland diseases a very inte- resting field of inquiry is opened in reference also to the congenital defects of gland function, as in ichthyosis ; the modification of function by constitutional peculiarities as exhibited by the hyperproduction of sebum by strumous subjects ; the results of undue stimulation by baths, and by medicinal substances used both externally and internally, the effects of blood-poisons, and the influence of defective or dis- ordered nervous influence. The Hair-follicles The contained hairs, the follicles themselves, and their linings and walls, are subject to a number of important changes, and these are mostly primary. The hairs may be hypertrophied, or atrophied, or be textur- ally changed, as in fragilitas crinium, or be invaded and ren- dered dull, dry, swollen, split up, and brittle by the invasion of fungi, etc. The epithelial linings are augmented as to their cell-elements in psoriasis, lichen planus, etc., and ro- dent ulcer probably takes origin chiefly from the outer root sheath of the hairs. The fibro-cellular texture and contained vessels of the walls participate in congestive changes, which also attack at the same time the non-follicular part of the skin, as in the inflammations ; and they are also at times the 44 CHART OF SKIN DISEASES. seat of primary congestive and inflammatory changes pro- duced under the influence of irritants of all kinds, such as scratching, heat, friction, becoming definitely inflamed in sycosis, and under special conditions of weak health. The periacinous lymphatic channels and tissue participate in the changes in lymphatic diseases generally. Such is a brief sketch of the general nature and character of the minute changes in the skin and its several textures. It is only intended as a sketch to convey to the student a general idea of the origin, connection, and sequence of such changes. We believe it will be useful to beginners in der- matology. But it is important to note, in making use of the pathological data of any given disease, that these must be estimated in the mass and as a whole, not piecemeal in short, and also in connection with clinical facts. There is a fashion in vogue of trusting too much to the microscope in dermatological research ; signal error is the result. SECTION III. CLASSIFICATION, OR DIAGNOSTIC CHART OF SKIN DISEASES. The following list, or semi-chart, conveys a good, general idea of the various eruptions met with in the skin, regarded from a clinical point of view. The list comprises : — 1. Eruptions occurring in connection with the acute specific or zymotic diseases, including the variolous rash, roseola variolosa, vaccinia and roseola vaccinia, the rashes of typhus, typhoid, rubeola, rubeola notha, scarlatina, glanders and farcy, and dengue. These are important in reference to the differential diagnosis of skin diseases. CHART OF SKIN DISEASES. 45 2. Eruptions, the local manifestations of dia- thetic states, comprise scrofuloderma, or scrofulous in- flammation; syphilodermata, or syphilitic eruptions; leprous eruptions; frambcesia or yaws; eruptions occurring in con- nection with endemic cachexice, such as Oriental Sore, the Paranghi disease of Ceylon, etc. 3. Local inflammations, comprising : — . Erythematous inflammation ; the chief feature consisting in the presence of hypersemia, mainly affecting the papillary layer, with or without some slight consequent effusion of serosity, swelling of the rete cells, rarely vesiculation, but subsequent desquamation. The chief erythematous diseases are : — Erythema, intertrigo, roseola, and urticaria. Catarrhal inflammation, characterized by vascular excite- ment, with serous effusion into the corium, together with the escape of leucocytes into the same tissue from which pus is subsequently produced, giving rise to sero-purulent dis- charge and crusting. Under this head rank : — Eczem,a and impetigo. Plastic inflammation, essentially papular, due to effusion of plastic lymph into the papillary layer, and sometimes the deeper dermic layer ; including — Lichen and prurigo. Bullous inflammation, the chief feature being the develop- ment of bullae as an essential phenomenon. It includes Herpes, pemphigus, and hydroa. Suppurative inflammation, characterized by the develop- ment of pustules, superficial and painless, or deeply seated and painful. It comprises — Impetigo contagiosa, ecthyma, and fur unculus. Squamous inflammation, characterized by hypersemia of the derma, and hyperplastic growth of cuticle, with a vary- ing amount of secondary thickening. This group includes — Pityriasis rubra and psoiHasis. 46 CHART OF SKIN DISEASES. 4. Hypertrophic and atrophic diseases : — A. Hypertrophic. I. In which the epithelial layers are mainly affected. Pityriasis, xeroderma, ichthyosis, warts and corns. II. When the connective tissues of the skin are spe- cially involved — Keloid, fibroma, morphcea, and scleroderma. III. Vessels of the skin affected primarily : — 1. The arteries and veins — teleangiomata. 2. The lymphatic vessels — lymphangiomata. B. Atrophic. Senile atrophy, linear atrophy, general marasmus. 5. New formations, the characteristic being the growth of new tissue made up of granulation cells, or altered and proliferating connective tissue of epithelial cells, cells which invade, destroy, and finally replace the healthy struc- tures, the new growth itself undergoing degenerate changes in due course. Lupus, cancer, rodent ulcer, and xanthoma (?) 6. Hemorrhagic disorders (cutaneous), consisting of effusion of blood, in points or patches, uninfluenced by pres- sure. Purpura. 7. Neuroses, in which the nerves are primarily dis- ordered, with or without organic changes at the outset. A. Functional. — Hyperesthesia, ancesthesia, and pru- ritus. B. Organic Neuromata, nerve ncevus, and secondary changes in other disorders. 8. Pigmentary alterations. There are two groups : (1) those consisting primarily of deposit or alteration of pig- ment in the rete, as in Melasma, leucopathia, etc. ; and (2) cases of pigmentation, secondary to other diseases, as in Addison's disease, and the like. CHART OF SKIN DISEASES. 47 9. Parasitic diseases, which comprise : — A. Animal, illustrated by scabies, phthiriasis, erup- tions due to gnat -bites, fleas, etc. ; abscess due to fila- ria, etc. B. Vegetable, including tinea favosa, tinea tonsurans, tinea circinata, tinea Icerion, tinea versicolor, tinea sycosis, tinea decalvans, and onychomycosis. 10. Diseases of the glands and appendages are divisible into : — A. Diseases of the sweat glands and follicles, as exces- sive secretion (hyperidrosis) ; diminished secretion panidrosis') ; altered secretion (such as chromidrosis, colored sweating, and osmidrosis, offensive sweating) ; and those which may be termed congestive and in- flammatory, as miliaria, sudamina, lichen tropicus, strophulus, dysidrosis, hydro adenitis, and sweat cysts. B. Diseases of the sebaceous glands, as excessive secre- tion (seborrhosa) ; diminished secretion (asteatodes) ; altered secretion, with or without retention (allostea- todes, exanthelasma) ; retention of secretion without inflammation (mollascum, horns) ; slight retention with inflammation (acne). C. Diseases of the hair and hair follicles, as excessive growth (hairy ncevi, moles, hirsuties) ; diminished growth, constituting partial or absolute baldness (alo- pecia) ; textural alteration (fragilitas) ; inflammation of the follicles (sycosis). D. Diseases of the nails, including changes occurring in syphilis, lichen ruber, general eczema, psoriasis, pityriasis rubra, and struma; inflammation of the matrix, as in onychia; or in the parasitic disease termed onychomycosis, caused by the favus parasite (the trichophyton) ; also hypertrophy, atrophy, and corn of the nail. 48 CHART OF SKIN DISEASES. There are, then, ten groups of skin disease, viz. : the Eruptions of the Acute Specific Diseases ; Local Inflamma- tions ; Diathetic Diseases ; Hyper- and A-trophic Diseases ; New Formations ; Hemorrhagic, Neurotic, and Pigmentary Diseases ; Disorders of the Hair and Glands and their Ap- pendages. Such is the clinical classification that may be given at an examination. Every skin disease must fall into one of these groups, and it soon becomes an easy matter to refer any disease before the observer to its proper class. [Peculiarities of Skin Diseases in the United States. It is a well-known fact that a malady often undergoes definite modifications under changed external conditions, such as altered climatic and hygienic surroundings. Indeed, the subject of the geographical distribution of disease has ever afforded an attractive field for the medical philosopher ; furnishing, as it does, data which, if thoroughly appreciated, may prove to be valuable evidence both as to the etiology and the claims for specific character of certain disorders. The medical profession in the United States have no reason to be ashamed of the labors and results of those of their number who have especially cultivated the subject of skin diseases ; for their recorded observations and careful investi- gations have contributed materially to the progress of modern dermatology and its establishment upon sound scientific principles. From their experience we learn that there are not only some generally recognized variations in type of certain skin affections, but also that there are others, which, though quite frequent in their occurrence in Europe, are rarely met with in America, and vice versa. A general agreement among dermatologists upon the sub- jects of pathology and nomenclature of skin diseases would alone enable such a rigid contrast to be made as would com- pletely satisfy the demands of science. Such an exact com- CHART OF SKIN DISEASES. 49 parison is not practicable at present, although a rapidly increasing consensus of opinion among systematic writers upon these subjects, more particularly observed in the last quarter of a century, warrants the hope that this may be accomplished in the near future. In the mean time we may, in a general way, formulate the prominent characteristics of skin disorders as they occur in this country. Prof. James C. White, 1 of Harvard, from a careful study of American statistics and extended personal observation, has arrived at the following conclusions : — I. Certain obscure affections the etiology of which is little if at all understood, even in those parts of Europe to which they are mostly confined* may be regarded as practically non-existent among us. Such are prurigo, pellagra, and lichen exudativus ruber. II. Certain diseases, directly connected with and depen- dent upon poverty and habits of personal uncleanliness, are less prevalent in the United States than in those parts of Europe of which we have sufficient statistical information for a comparison. Examples of this class are the animal parasitic affections especially. III. Some cutaneous affections of grave character, which are dependent upon or form a part of serious constitutional disorders, are of less frequent occurrence amongst us than in Europe in general, or those parts of it where they are endemic. Lupus, the syphilodermata (?), and leprosy are the most marked instances of this class. IV. Certain disorders of the skin, especially those of its glandular systems and those connected more immediately with its nervous system, are apparently more prevalent with us than in Europe. The most notable examples of the for- mer are seborrhcea, acne, and possibly the heat-rashes ; of the latter, herpes, urticaria, and pruritis. 1 Trans. Int. Med. Congress, 1876, Phila., 1877, p. 681. 5 50 CHART OF SKIN DISEASES. In addition to these valuable observations, it may not be amiss to call the reader's attention to the limitation of leprosy (elephantiasis graecorum) within particular districts. Existing in India, China, Egypt, certain parts of Norway and Sweden and the Sandwich Islands, true leprosy is only very rarely encountered in the United States, and almost never in the person of a native. It may be found among immigrants in the Norwegian settlements in the Northwest ; also among the Asiatics in California. It is also seen in Central America and Mexico, but is probably never endemic in this country. Syphilitic skin diseases are common in America as in Europe, and when neglected are doubtless equally severe in their manifestations ; but in this country they are less fre- quently accompanied by such profound degradation of the system under the influence of accompanying filth, poverty, and insanitary surroundings, than they are in foreign countries. Lupus vulgaris, according to Dr. Duhring, is much milder here than in Europe; and cases of lupus erythe- matosis are relatively much more common in America. At the last meeting of the American Dermatological Association 1 the following Classification and Nomen- clature was adopted : — CLASSIFICATION AND NOMENCLATURE OF DISEASES OF THE SKIN. ADOPTED BY THE AMERICAN DERMATOLOGICAL ASSOCIATION. Class I. — Disorders of the Glands. 1. Of the Sweat Glands. Hyperidrosis. Bromidrosis. Miliaria crystallina. Chromidrosis. Anidrosis. 1 Held at Saratoga, August, 1878. CHART OF SKIN DISEASES. 51 2. Of the Sebaceous Glands. Seborrhoea. Cysts. (a) oleosa. (a) milium. (b) sicca. (6) wen. Comedo. Molluscnm sebaceum. Diminished secretion. Class II Inflammations. Exanthemata. Erythema simplex. Erythema multiforme. (a) papulatum. (b) bullosum. (c) nodosum. Urticaria. Furuncle. Anthrax. Phlegmona diffusa. Pustula maligna. Herpes. (a) facialis. (b) progenitalis. Herpes zoster. Psoriasis. Dermatitis. x («) traumatica. (6) venenata. (c) calorica. Pityriasis rubra. Lichen. (a) planus. (6) ruber. Eczema. (a) erythematosum. (b) papillosum. (c) vesiculosum. (d) madidans. (e) pustulosum. (f) rubrum. iff) squamosum. Prurigo. Acne. Impetigo. Impetigo contagiosa. Impetigo herpetiformis. Erysipelas. Ecthyma. Pemphigus. Class III Hemorrhages. Purpura. (a) simplex. (b) hemorrhagica. 1 These indicating affections not properly included under other titles of this class. 52 CHART OP SKIN DISEASES. Class IV Hypertrophies. 1. Of Pigment. Lentigo. Chloasma. (a) locale. (h) universale. 2. Of Epidermal and Papillary Layers. Keratosis. (a) pilaris. (b) senilis. Callositas. Verruca. Clavus. Cornu cutaneum. Verruca necrogenica. Xerosis. Ichthyosis. Ichthyosis of nail. Hirsuties. 3. Of Connective Tissue. Scleroderma. Rosacea. Sclerema neonatorum. (a) erythematosa. Morphoea. (£>) hypertrophica. Elephantiasis Arabum. Framboesia. Leucoderma. Albinismus. Alopecia. Alopecia areata. Atrophia senilis. Class V Atrophies. 1. Of Pigment. Vitiligo. Canities. 2. Of Hair. Alopecia furfuracea. Atrophia pilorum propria. 3. Of Nail. 4. Of Cutis. Atrophia maculosa et striata. CHART OF SKIN DISEASES. 53 Keloid. Cicatrix. Fibroma. Class VI New Growths. 1. Of Connective Tissue. Neuroma. Xanthoma. Angioma. 2. Of Vessels. Angioma cavernosnm. Angioma pigmentosum et Lymphangioma, atrophicum. 3. Of Granulation Tissue. Rhino-scleroma. Lupus erythematosus. Lupus vulgaris. Lepra. (a) tuberosa. (b) maculosa. (c) ansesthetica. Scrofuloderma. Syphiloderma. («) erythematosum. (b) papulosum. (c) pustulosum. (d) tuberculosum. (e) gummatosum. Carcinoma. Class VII Ulcers. Class VIII Neuroses. Hyperesthesia. (a) pruritus. (b) dermatalgia. Anaesthesia. Class IX Parasitic Affections. 1. Vegetable. Tinea favosa. (5) tonsurans. Tinea tricophytina. (c) sycosis. («) circinata. Tinea versicolor. Scabies. Pediculosis capitis. 2. Animal. Pediculosis corporis. Pediculosis pubis. — Ed.] 5* 54 THE CAUSES OF SKIN DISEASES. SECTION IV. THE CAUSES OF SKIN DISEASES. In the previous section a general summary was presented of the different varieties of skin diseases in the form of a tabular classification. In this section a sketch of the causes of these diseases will be given ; they may be conveniently ranged under two heads : — 1. Those which act from within the system, or internal causes. 2. Those which act from without, or external causes. There are some who think that the latter are much more frequent in their operation and much more potent than the former, but it is very doubtful if such is really the case. It must be remembered that a combination of these may constitute the real cause of a skin disease. But it will be useful to consider the two classes separately for the moment. A. Internal Causes Amongst these the most impor- tant are : — a. Hereditary tendency to a given disease, such as in the case of ichthyosis or psoriasis. It may give rise to a purely local affection, or to a more or less general disease — i. e., one involving the skin locally and the general health as well. b. Blood poisoning, by certain animal or vegetable poisons, inducing specific eruptions, as in the acute specific diseases, syphilis, or disorders derived from eating shell-fish and some other articles of food. It often results from defi- cient excretion, or the undue retention of biliary, renal, or intestinal excreta, giving to the blood an acrid character. It may be also brought on by long-continued dyspepsia, either from dietetic errors or otherwise ; by the presence of THE CAUSES OF SKIN DISEASES. 55 medicinal substances in the blood (e. g., potassium bromide, belladonna, or copaiba) ; by the accumulation of lactic or uric acids, as in rheumatism and gout, which often excite eruptions or impart an inflammatory character to them ; by poverty, which depraves the blood and leads to cachexia ; by the imperfect fulfilment by certain organs of their natural functions, as menstruation, perspiration, and the hepatic or renal excretion. c. Nerve disturbance, which acts in one of four ways. Firstly, by inducing changes in the calibre of the vessels by which the blood supply and fluid transudation are affected, as in the erythemata. Secondly, by directly encouraging tissue change, as in herpes, hydroa, pemphigus, and prurigo. Thirdly, by the loss of control over the skin nutrition, which follows from nervous debility, allowing morbid action of all kinds in the skin to take place more readily. Fourthly, by the transmission of irritation through reflex action, by which eruptions may be excited or aggravated. d. An acquired, innate, or rather an actual, disposition in the shin tissues themselves to take on a diseased condition. This is a point on which special stress is laid. It is pretty certain that many diseases of the skin must originate in a disordered behavior of the tissues themselves, and do not necessarily depend for their cause upon any general defect of nutrition. For instance, cancer is a case in point; and so with warty growths of all kinds, such as fibroma, keloid, and perhaps lupus. In some cases there is simply an excess of growth, a plus state of the nutrition of the tissue and nothing more ; or it may be a minus condition. In other instances it is a perverted nutrition, a deviation in the type of the tissue, as in cutaneous cancer. In fact, Group 4, and many of the diseases in Group 10 of the classification given in the preceding section illustrate this point. It is asserted by most writers that hypertrophy and atrophy, the simpler and homologous changes, are, in reality, 56 THE CAUSES OF SKIN DISEASES. merely the consequence of the presence in the blood of a greater or less amount of the pabulum of the particular tissue affected. But if these pabula be in excess, which has not been satisfactorily proved, the hypertrophy would not occur unless the tissues were thus disposed to appropriate and use them more freely than usual ; and if such a disposition existed in a degree less than that in healthy nutrition, atro- phy would result. So that, after all, the formative capacity, or the assimilative activity, of the tissues themselves is an important element in these plus and minus states of growth. The explanation given above — viz., that the tissues them- selves are hyperactive in the diseases in question — may, therefore, be true, and certainly if the tissues themselves ex- hibit a tendency to hyperplasia, nature will answer the demand for an increased supply of pabulum. In the case of perverted nutrition or heterologous forma- tions, the changes it seems to us are as readily explained by a primary modification of the same "formative capacity" as by the supposition of an altered character of growth, the immediate consequence of the supply of a special kind of pabulum. e. Climacteric or endemic injluences induce skin disorder by depraving the nutrition of the body in particular ways, as in elephantiasis arabum, J'rambaesia, or by affording oppor- tunity for the operation of special endemic causes, such as special parasites, ex., the filariae, etc. B. External Causes Some of these influence the general health for evil, and so disorder the skin indirectly ; others act directly upon the skin. 1. Among the external causes acting directly upon the skin, the most important are : Scratching, which may excite and always aggravates disease, especially if it happen to be of an inflammatory nature ; and which may, in contagious cases, spread it from place to place, as in scabies and im- THE CAUSES OF SKIN DISEASES. 57 petigo contagiosa. Local irritants of all kinds — ex., cold, heat, friction, flannel worn next to the skin, irritants, plas- ters, fluids, and applications of all kinds ; irritating sub- stances, such as lime, sugar, flour, washing soda producing bricklayers', bakers', grocers', and washerwomen's itch ; un- wholesome handicrafts ; dyes, contusions, animal and vege- table parasites of all kinds ; medicinal applications and want of care of the skin in the dirty and ill-fed, are fruitful sources of disease. 2. Amongst the external causes that act indirectly upon the skin, through their influence upon the general health, may be mentioned : Neglect of cleanliness, defective clothing, unsanitary surroundings, climatic influences, and the like ; also animal poisons inoculated into the bodily surface, etc. Clinically, as before hinted, it is of the highest moment to be acquainted with the fact that, as a rule, these several causes not only vary in character, but do not operate in a solitary or individual way. To put it in another shape ; (1) these influences or agencies are, in reality, divisible into^re- disposing, exciting, producing, and intensifying causes ; and further (2) the true cause of the state of any given disease is made up of a number of phenomena or agencies in combined operation. These are points of great practical importance in reference to the treatment of skin diseases. In reference to the first, it may be said that many so-called local causes usually only predispose to, although they are thought to excite, eruption. For instance, debilitating occu- pations render a man much more liable to be affected by the handling of irritants ; in a bad climate, the system generally is disordered in addition to the skin, and the latter is so ren- dered more liable to become diseased. Other causes act as pure excitants, as when there is a predisposition to a disease — e. g., eczema, and the local irritant excites it, but proba- bly would not if acting without the existing predisposition. Some influences, however, are really producers of disease, as 58 THE CAUSES OF SKIN DISEASES. in the case of medical irritants, or circulated poisons — e. g., malignant pustule, or parasites. Other agencies again only aggravate existing disease, as in the case of the wearing of flannel, or exposure, or scratching. In reference to the second point, it is indisputable that, in most cases, several agencies or influences, external or in- ternal in origin or operation, combine to make up the true cause of a disease, and it is the duty of the physician to re- cognize this fact and analyze very carefully the composite cause of skin troubles. In fact, in such correct analysis lies the source of all successful dermatological treatment. From a therapeutical point of view, diseases of the skin are very different things as portrayed on paper and as seen in the consulting-room. A disease may answer most perfectly to the typical description, but the remedies ordered for its cure may signally fail, because the analysis of its causation is in- correct or incomplete, or some coexistent condition which exerts an antagonistic action to the operation of the remedies prescribed may have been overlooked, as is the case when neglected constipation so often defeats the proper action of tonics. Diseases are greatly modified as they occur in differ- ent subjects, and it is not the uncomplicated type that is to be dealt with in practice, but the disease modified and in- fluenced by the many concomitant conditions of age, consti- tution, occupation, etc. It may be useful to mention a few common combinations met with clinically, which illustrate the multiform character of the causation of skin diseases, as seen in the consulting- room. In the case of eruptions provoked by local irritants, referred to above, there is very frequently debility present in those who are attacked by these eruptions. This debility favors the development and tends to promote the chronicity of the disease, and must be removed if the eruption is to get well, and if it is to be cured in the best way possible. In fact, the skin of a healthy person will resist the action of THE CAUSES OF SKIN DISEASES. 59 many of the local irritants specified, but the skin cannot do so if the subject be weak and debilitated ; so that it is an important point to give tonics as the rule in cases of erup- tions excited by local irritants. This simple combination of causes, debility and local irritants, is often found to induce erythema, eczema, lichen, etc. Other examples of concur- rent causes must readily occur to the reader, such as eczema in a gouty subject, modified by neglect and scratching ; pso?*iasis in a strumous subject, in whom the tendency to the disease is hereditary ; erythema in a rheumatic subject, in connection with dyspepsia ; eczema occurring in cooks ex- posed to the irritating influence of the fire, whilst the patient also has a blood current charged with retained excreta, in consequence of inefficient bowel and kidney action ; lupus in a scrofulous subject ; tinea tonsurans in a boy with per- sistent anemia and a phthisical tendency ; pruritus in con- nection with senile atrophy of the skin, liver derangement, gout, or it may be in connection with diabetes. Indeed, ex- amples might be multiplied almost indefinitely. In estimating therefore the cause of any given cutaneous disease, attention must be paid not only to predisposing and exciting causes, but to coincident occurrences and accidental concomitants which modify such disorder ; for it is not in the abstract that the disease is to be regarded, but in its en- tirety, and in all its clinical features and behavior. The correct estimation of a disease after this fashion constitutes the true diagnosis, upon which a few remarks will be made in the next section. 60 DIAGNOSIS. SECTION V. DIAGNOSIS. Firstly — In making a diagnosis the observer should apply the important rules laid down (Section I.) for examining skin diseases — that is to say, he should examine the whole of the eruption and not a part only, and also trace carefully its history, to discover the nature of its beginning, the cha- racter of its stages, if any, and their transitional relation- ships, and the general course of the eruption up to the time of observation. Secondly The observer must proceed to determine to which class the disease belongs, according to the principles laid down in the chart in Section III. He should inquire in the first place whether the eruption belongs to one of the Acute Specific Diseases. If this be so, then the constitu- tional condition will be by far the most pronounced, the patient more or less prostrated, the temperature unusually high, whilst other pyrexial symptoms will be marked and out of proportion to the mere rash ; the access of the malady will have been comparatively sudden, and so on. If the eruption be essentially erythematous, then it must be one of four conditions — viz., erythema, intertrigo, roseola, or urti- caria. Is the disorder accompanied by sero-purulent dis- charge, by the development of bulke, by pustules, or by squamae alone ? Then the disease is one of those comprised under local inflammations. Is the eruption part of a cachexia, or some special diathetic condition present ? Then it be- longs to Group 2. And in like manner Hypertrophies or Outgrowths of Tissue, Atrophies. New Formations, Hemor- rhagic Spots, Neurotic conditions without organic changes, DIAGNOSIS. 61 Pigmentary Alterations, Parasitic Diseases, and Affections of the Glands, Hair, and Nails will be put under their re- spective groupings. In the case of New Formations, the diagnosis is singularly easy. The youngest student can readily distinguish the newly -formed fleshy mass of a neo- plasm in the skin from the ordinary, rapidly-formed, semi- hypersemic, inflammatory deposit of a similar size ; and he knows practically that he has a case of syphiloderma or lupus to deal with. Further, in making a diagnosis, the observer must remember to determine whether the disease is, or is not, complicated by another, as evidenced by an ad- mixture of different characters, and to thoroughly sift out the nature of any constitutional modifying influences. Thirdly. — An estimate of the immediate or exciting cause of any given eruption is of the first importance in a com- plete diagnosis. No doubt, when the observer has been able to put the disease before him into its proper class, a pretty correct indication is obtained of its causes, especially as re- gards Classes 1, 2, 4, 5, 6, 9 (Section III.) ; yet, unfor- tunately, the difficulty is greater with the eruptions of the commonest occurrence, comprised in Class 3, or the local dermal inflammations, and with those in Classes 7, the Neu- roses, and 10, the gland and hair disorders. Hence the observer must proceed on the lines laid down in Section IV., working out the specific cause, and inquiring into the pro- duction of the eruption from within or without. His object is to seek for the source in (see Section IV., A) an heredi- tary tendency, a condition of blood poisoning, nervous disturb- ance, a disposition in the tissues themselves to take on a diseased condition, or perhaps some climatic influence. If not, then the cause is to be sought for in local agencies as detailed under B (Section IV.). And at the same time the observer should bear in mind what has been said about the multiple character of the causes of skin diseases. By attend- 6 62 TREATMENT. ing to these several points the diagnosis will be worked out correctly and with facility. SECTION VI. GENERAL PRINCIPLES OF TREATMENT. If, as has been already stated, there is nothing essentially special in the pathological changes that occur in skin dis- eases, it follows that there can be little that is absolutely special in the treatment. The minor differences that do exist, arise from the fact that the skin can be irritated directly, and that the diseased parts become rapidly dry, harsh, cracked, etc., from the constant exposure to the air, so that they need to be kept protected and supple by the use of moistening applications. Otherwise the general princi- ples of therapeutics are applicable to the case of skin mala- dies, and it is necessary for the reader to mentally lay firm hold of this fact. A correct diagnosis must of course precede successful treatment. When in accordance with the rules already laid down a given disease has been placed in its proper clinical class, and the exciting and other causes discovered, the proper kind of treatment naturally suggests itself. It may be said, indeed, that the ten groups of skin dis- eases require three main methods of treatment — viz., a purely local one ; one almost wholly general ; or a mixed kind, i. e., one partly local and partly general. That is, in- deed, saying in other words that skin diseases are made up of those which are essentially local in nature, those essen- tially general, and those more or less local in their main features, but influenced by general conditions. In the first category may be placed Groups 4, 5, and 9, viz., the hyper- trophic and atrophic, the neoplasmata, and parasitic diseases; TREATMENT. 63 in the second Groups 1 and 2, the eruptions of the acute specific diseases, and the local manifestations of diathetic diseases ; and in the third Groups 3, 6, 7, 8, and 10, viz., local in- flammations, hemorrhagic, neurotic, pigmentary disorders and most of the glandular disorders. In dealing with the diseases in the first category, viz., Groups 4 and 5, absorbent or astringent remedies to promote resolution, or removal by caustic or surgical means, consti- tute the treatment. In Group 9, parasiticides are to be em- ployed to kill the insect or fungus which produces the particular disease present. In dealing with the components of the second category, viz., Group 2 — for we need not touch on Group 1 — specific remedies are used : in scrofuloderma, cod-liver oil ; in syphilis, mercury and iodide of potassium ; in leprosy and framboasia, hygienic measures and so-called " specifics." So far all is clear. When we come to the third or mixed class, or category, of cases indicated above, the principles of treatment are more varied. Groups 6, 7, 8, and most of the diseases comprised in 10 — for some must be dealt with as local inflammations — are consequent on what may be conveniently termed debility, and the treatment consists of the use of general tonics, etc. It is not necessary here to add more about them, as they are among the more infrequent of skin maladies. As regards, however, Group 3, viz., local dermal inflammations and cer- tain of the components of Group 10, such as sycosis and dysidrosis, the case is different, for the diseases comprised in it contain, as will be seen at a glance, almost all the ordi- nary forms of skin diseases, and it is amongst these the greatest difficulties are met with, owing to their many causes of excitation, aggravation, and modification. Now the dis- eases comprised in this Group 3, are essentially inflamma- tory, but some run a course of definite duration, as in herpes and roseola, and hence require only watching to prevent in- tercurrences ; or for the alleviation of special symptoms and 64 TREATMENT. conditions, such as pain or disfigurement. The majority, however, run an indefinite course, and are to be attacked by therapeutic measures, based upon a consideration of the varying combination of exciting, aggravating, or modifying agencies. The treatment, therefore, of the components of Group 3, and those of Group 10, before specified, consists in a careful combination of both local and internal remedies. As regards local remedies, there are three main rules to be observed, viz. : — (1) Whenever active hyperemia is present, be the disease what it may, applications of a stimulating nature should not be used, but the treatment should be essentially soothing, otherwise the inflammatory symptoms will be increased, and the disease aggravated and probably spread. The vessels, especially in the earlier stages of congestive diseases, are very sensitive to stimuli — and they readily contract and dilate under their influence. The tonicity of these vessels is soon lost with any great increase of dilatation, and its conse- quences, under these circumstances, whilst the area of the congestion is widened by the sympathetic action of the irri- tants upon the parts in the neighborhood of the original seat of disorder. Soothing remedies have contrary effects. (2) The action upon the skin of all external irritants — such as scratching — should be prevented, and the air even excluded from inflamed or excoriated surfaces, especially by oil- packing. (3) Not until the stage of active hyperemia has fairly passed should astringents, stimulating applications, or revul- sives be employed. These, and absorbents, are to be re- served for the stages of vascular sluggishness and inflamma- tory induration and thickening, when not only the capillaries, but the lymphatics require stimulation with a view to pro- mote the absorption of morbid products. As regards internal or general remedies, it is proposed to indicate below, in as practical and concise a form as possible, TREATMENT. 65 the conditions which should be taken into consideration in framing the treatment of such diseases as erythema, inter- trigo, urticaria, eczema, lichen, prurigo, pemphigus, hydroa, ecthyma, furunculus, pityriasis rubra, and psorias ; and inflammatory conditions of the glands and hair follicles, such as acne, dysidrosis, and sycosis, which are analogous in pathological nature to, and only differ in regard to their anatomical seat from, those preceding. The following short sketch or chart, inasmuch as it applies to the great majority and most common forms of skin diseases, should be used regularly in determining the treatment, which must neces- sarily vary with the different combinations of influencing agencies referred to. We may observe that we invariably mentally employ this analytical chart or summary in dealing with cases of in- flammatory skin diseases in our consulting room. Having first determined by inspection and interrogation the general origin, course, and symptoms of a disease — that is, having made a bare diagnosis, we proceed to discover the presence and degree of influence of one or many of the several modi- fying conditions which we are about to notice briefly in detail ; and then we prescribe not only the treatment appro- priate to the disease itself in the abstract, but so modified or amplified as to meet the necessities of each case in regard to the existence of any of these special conditions. We desire to treat the patient's disease in the light of the patient's pecularities, and the success of treatment so formulated is ample testimony to the importance of the rule laid down. The conditions here referred to are : — A Syphilitic Taint. — This tends to induce induration from the presence of syphilitic tissue ; or it leads to ulcera- tion, cachexia, and general debility — features which are unusual in the diseases which they complicate. This taint is sometimes in operation in cases of eczema, psoriasis, pem- phigus, ecthyma, acne, and intertrigo (of infants). 6* 60 TREATMENT. Constipation — This causes dyspepsia, liver torpor, and retention of excreta, and so leads to an impure blood current, by which eruptions are aggravated, and to debility. It occurs, of course, in all forms of skin diseases, and it is im- possible to overrate the importance of attention to it. Con- stipation, besides leading to an aggravation of existing eruption, prevents the due exhibition of remedies, as in the case of many tonics, which can often be given in combina- tion with aperients, but not otherwise, since, by their con- stringing effect, they, when unaided by aperients, give rise to dyspepsia, headache, and other symptoms. We mention these facts because they are of such frequent application in dealing with skin troubles. Debility, including anaemia This retards recovery from want of recuperative power in the system ; but frequently, important emunctory and assimilative organs perform their functions languidly or imperfectly as a consequence of the debility ; and so, as a consequence of the retention of un- oxidized or effete products, the blood becomes charged with irritating materies morbi. It is especially operative in furunculus, eczema, psoriasis, lichen, pityriasis rubra, pemphigus, urticaria, and ecthyma. Diabetes This increases inflammatory conditions, favors the occurrence of phlegmonous inflammation, and leads to freer development of disease, and tends to chronicity of eruption. Its influence is often seen in eczema, psoriasis, intertrigo in adults, furunculus, and anthrax. Dyspepsia — This induces debility. It also leads to liver disturbance, and impurification of the blood ; and it increases hyperemia by reflex action, as in acne. It is common in connection with eczema, urticaria, acne, and sycosis. Errors of Diet — These introduce special irritative sub- stance into blood, cause dyspepsia, lead to accumulation of nitrogenous matters in system, to liver disorder, etc., and are TREATMENT. 61 operative in all forms of inflammatory eruptions without ex- ception. Gouty and Rheumatic Diatheses — These cause accumu- lations of uric and lactic acids and allied compounds in the blood, which give an inflammatory character to disease. They influence especially eczema, psoriasis, lichen, ecthyma, sycosis, and urticaria. Lack of Hygiene This disposes to torpor of skin. It favors the occurrence of morbid action and disease, and greatly influences acne, sycosis, eczema, intertrigo, and erythema. Repression of the special normal eliminatory functions. This throws the necessity of compensatory elimination on the skin, which may fail to respond, and so become diseased. It favors increase of fluid in the tissues of dependent parts. It occurs in furunculus, ecthyma, acne rosacea, and eczema. Retention of Excreta, from kidney, liver, and bowel in- activity. This, a most fertile source of skin irritation, which it both excites and increases by leading to the accumulation of effete products or materies morbi in the blood, gives the blood an irritative quality, which aggravates hyperemia in all inflammatory skin diseases. It is a common cause of pruritus of the skin. It also leads, in the case of kidney torpor, to increase of watery fluid in tissues, as in eczema of the legs. Strumous Diathesis This imparts an unusual purulent character to eruptions, and favors the implication of the connective tissues. It operates powerfully and commonly in cases of eczema, psoriasis, acne, and sycosis. PAET II. THE DETAILED DESCRIPTION OF CUTANEOUS DISEASES, ARRANGED IN THEIR ALPHA- BETICAL ORDER. Acne. — This disease is an inflammation of the sebaceous glands, the ducts of these glands, and the periacinous fibro- cellular tissue to a varying degree. The upper part of the hair-follicle, into which the glands discharge, becomes neces- sarily involved in the inflammation. The varieties of acne are said, commonly, to be four in number, viz., Acne punctata, A. simplex or vulgaris, A. indurata, and A. rosacea, but the latter is a compound of acne and hyperemia of the face tissue generally. The first three of the four forms of acne arise directly from accumu- lation of sebum, more or less altered perhaps in quality, in the glands and their ducts. But besides these varieties, there are unusual or artificial phases of acne produced by the special irritation or stimulation of the glands by certain medicinal substances, including iodide and bromide of potas- sium when taken internally, and- tar when applied exter- nally. Acne of a special kind is also induced by the syphilitic poison in action upon the skin, and lastly there is a peculiar acne incident to a low condition of health, to which Hebra has given the significant term acne cachecticorum. Acne in the commoner varieties, as we have already indi- cated, results immediately from the retention of sebum, the retained plug which is discolored by dirt, being designated comedo. It is important to point out certain special con- ditions, which favor the retention or non-excretion of the 70 THE DETAILED DESCRIPTION sebum in acne. These are three ; the first is inactivity or torpor of the skin ; the second is undue production of seba- ceous material ; and the third is the formation of sebum of greater consistency than usual. This last is practically the most important of the trio ; for without this tendency acne would be uncommon. The disposition to the secretion of sebum of a less oily or more fatty character is met with in lymphatic and strumous subjects, especially about the time of puberty, when the hair follicles and their attached seba- ceous glands are in a state of physiological activity in con- nection with the free formation of hair, and are, in conse- quence, easily disposed to become the seat of disorder. The sebaceous plug, or comedo, which is the early and first sign of acne, may exist without much attendant change in the gland-wall, or tissue around the latter ; but as a rule it soon undergoes a chemical change, whereby the sebum acquires an acrid character, and thereby induces irritation and inflam- mation, which vary in extent and character according to the constitutional bias of the individual, and acne results. Acne, therefore, is a follicle plugged by an augmented sebum with a varying degree of attendant follicular and peri-follicu- lar inflammation. It should be mentioned here that ordinary acne attacks certain localities by preference, such as the face and the shoulders, but artificial, or syphilitic, or cachectic acne is more or less general in its attack. We now proceed to give a brief description of each va- riety of acne. Acne punctata In this form there is simple retention of more or less inspissated sebum forming comedo, whilst there is no decided inflammation of the follicle, but only a certain amount of prominence sufficient to form a pimple. It is common on the face, the shoulders, and front of the chest, and appears on young people of lymphatic and stru- mous temperament. The minute, discolored plug of sebum OF CUTANEOUS DISEASES. H may be readily squeezed from the follicle, and looks like a little grub. Acne simplex or vulgaris is that form in which slight perifollicular inflammation and occasionally suppuration are added to the phenomena of retention of sebum or plugged follicles. It is an exaggeration of, or an inflamed, acne punc- tata, and occurs under similar circumstances. Comedones are found intermixed with the inflamed acne spots. Occasionally acne is confined to the forehead and the re- gion of the temple almost exclusively; it may assume the simple form, but now and then the pustules are flattish and more or less umbilicated, and after crusting they disappear and leave distinct scars behind, something like those of smallpox. This form is often obstinate, and is apt to recur. In some cases the scalp is also affected by similar spots seated at the hair follicles, and scattered more or less gene- rally over the scalp, especially over the top and front parts. In consequence of the umbilication of the spots, the term acne varioliformis is applied to this phase of acne. It is not certain whether it is not syphilitic, at least syphilitic treatment is very efficacious with it. We reserve our opinion as to its exact nature. The term acne varioliformis has been also applied to molluscum contagiosum. Acne indurata is a more severe form of the disease. It is characterized by the large size of the spots, and by their possessing considerable inflammatory induration at their bases, together with a certain amount of pain, lividity or violet-redness, followed by suppuration, and, it may be, crusting. The spots may be painful, and, when large, they leave pits or scars after their disappearance. It occurs in the same situations as the other two phases of acne, but it is altogether more severe and extensive. In some cases the acne spots are very much indurated and as large as full-sized peas, or even larger. Acne rosacea is characterized by its bright red color, more *I2 THE DETAILED DESCRIPTION or less formation of Dew connective tissue about, with hyper- trophy of, the glands ; and by its occurrence in middle-aged persons oftentimes the subjects of menstrual disorder. The condition denominated acne rosacea, and called gutta rosea by Wilson, or simply rosacea by others, is, as stated before, scarcely a true acne. It consists of chronic hyperemia of the face, attended mainly by the formation of red papules, due to effusion of lymph into the papillary layer of the skin. These papules show out from the general reddened surface as minute elevations like non-suppurating acne spots, and they present no central opening. The occasional presence, however, or intermixture of a certain number of true acne spots leads to the inference that the disease is really acne, whereas it is a mixed condition. The hyperemia present in the above described varieties of acne is especially intensified by dyspepsia, by errors of diet, and by local irritants. The inflammation, too, is modified by the strumous and syphilitic cachexia?, which conduce to implication of the surrounding cellular tissue and to suppu- ration in struma, and to induration and ulceration in syphilis. As regards unusual forms of acne a few words may be added here : — Tar acne. — The use of tar to the skin externally is often followed by stimulation of the sebaceous glands, and the pro- duction of an acne-like eruption, but it has this peculiarity that the tar collects in minute amounts in the follicular orifices, so that the punctate points are black or treacly in aspect. Bromide and iodide acne A description of these will be found under the head respectively of Bromide and Iodide eruption. The disease presents the aspect of acne vulgaris or acne indurata of bright color. It is specially characteristic of these forms that they do not attack the face only, but many different regions of the body ; such as the back, the forearms, the lower limbs — a fact which should always excite suspi- OF CUTANEOUS DISEASES. 73 cion as to the cause of the acne. They alike appear and dis- appear with the exhibition . or withholding of these drugs. Syphilitic acne is widely distributed, it is attended by ulcer- ation of the acne spots, and forms part only of a series of syphilitic phenomena. Cachectic acne occurs as a general acne in badly nourished or half-fed or scorbutic subjects. It is indolent, painless, of livid hue. It does not ulcerate, whilst the skin which it affects wears an unhealthy or cachectic look. The differential diagnosis of acne is simple. The plugged follicle constituting comedo, and the simple forms of acne {acne vulgaris) are not liable to be mistaken for any other disease, for the comedones are peculiar to acne alone. Acne indurata and acne rosacea may be thought at times to be syphilitic, and may resemble hydroa, but syphilitic acne is not confined to the face or shoulders ; it ulcerates, and is attended by other readily recognized syphilitic phenomena. Acne in strumous subjects ulcerates and leaves pits, but it is a uni- form eruption, and not multiform or corymbose like syphi- litic rashes ; it attacks the ordinary seats of acne, and it is made up of indolent, livid, boggy -like indurations. Hydroa of the face may consist apparently of little indurations like acne indurata, scattered here and there, but they tend, if not scratched, to vesiculate ; they have no comedo, that is, they are not follicular, but dermic in origin, and they are very pruritic, even from their earliest stage. Treatment — The objects in view in the case of the com- moner varieties of acne, which we deal with alone here, are — -first, to promote the loosening and removal of the plugs of sebum from the follicle (in comedo especially) ; secondly, to lessen the hyperemia ; thirdly, to restore tone to the ves- sels and to the general system ; and, fourthly, to promote the absorption of inflammatory products. We now proceed to consider the several varieties of acne. In acne punctata the skin will often bear a good deal of stimulation with ad- 1 74 THE DETAILED DESCRIPTION vantage, and hot water bathing with friction with mild soap and the use of an alkaline wash (45), or a weak alkaline pomade may be employed, or if this fail (67), cautiously used, and tonics, constitute the proper treatment, as the rule (see Comedo). In acne simplex it is necessary in the first place to remove dyspepsia, if present, by (97) before giving tonics such as (90), (107), or (108), or in anaemic subjects (94). Cod-liver oil should be prescribed in the strumous. Occasionally there is a loaded state of system, which is im- proved by diuretics, especially if the face is much congested, and the urine be scanty and loaded with urates. Locally the affected parts should be bathed with hot water twice a day, and soothed with (14) or (74), to reduce the hyperemia, and presently stimulated with (64) or (66) diluted. In acne in- durata similar internal remedies are required at first ; or if the system be loaded (96) or (98) ; if there is much indura- tion (85). In gouty subjects a little colchicum wine — 5 drop doses — with a carbonate of magnesia and bitter infu- sion mixture will often be of value in the earlier congestive stages. Locally, it is best to soothe, as in acne simplex, and subsequently to remove the induration by the use of (47), (60), or (66) ; or, if necessary, each spot may be occasion- ally touched with acid nitrate of mercury. In acne rosacea it is necessary first to look to the state of the uterine func- tions, to remedy coexisting dyspepsia, debility, tippling habits, etc. Internally (95) may be given with advantage; locally (74) may be used, with the occasional application of acid nitrate of mercury to each spot, or (80) may be applied each night to very decided indurations. In some cases it is advisable to cut the vessels across with a lancet, and to ap- ply collodion regularly for awhile, and after the parts have bled, to allay irritation or excessive hyperemia in the first instance. This may be followed by (Q5) which is a very effective remedy. In indolent cases of extensive acne rosa- OF CUTANEOUS DISEASES. 75 cea and indurata (65) may be used every night or every other night. Alopecia signifies Baldness, and may be partial or general : it is either idiopathic, i. . circumscriptus). Often the lichen attacks the backs of the hands, which may, secondarily , become inflamed and give out a discharge (L. agrius). The disease in this situa- tion is excited by the contact of irritants, as sugar and flour, and then bears the name of Grocers' or Bakers' itch (vide these), and under these circumstances the eczematous com- plication becomes the chief trouble. If the lichen papules are seated at the hair follicles, giving the surface a dotted, or, even, on a small scale, a rasp-like appearance, the name L. pilaris is given ; but this term is also made to include not only inflammatory infiltration around the hair follicle, but also that condition in which papules are produced by the choking of the follicles by epithelial exuviee or sebum, which occurs in persons whose skin is inactive. So-called L. lividus is a purpura ; that is to say, there are little hem- OF CUTANEOUS DISEASES. 133 orrhagic papules formed. Of late years, dermatologists have with some approach to unanimity recognized two other forms of lichen, first described by Hebra, viz., Lichen ruber (which includes the Lichen 'planus of Wilson), and L. scro- fulosorum. L^ichen planus, as described by Wilson, con- sists of solid, red papules of very special features, which stud various parts of the surface symmetrically, the front of the forearms, especially the wrists, the flanks, the abdomen, the hips, and the legs below the knees. These papules attain the size of a large pin's head or more, and are dull red, an- gular at their bases, flat at top, with u peculiar shiny or glazed aspect, and umbilicated more or less distinctly. At first they are discrete, but they group together into patches by the springing up of new papules between the old. Then the patch becomes red, infiltrated, and slightly scaly, and presents the aspect of psoriasis, for which the disease is fre- quently mistaken, but it is distinctly papular at the edge. Dull, colored stains are left on the disappearance of patches or papules. The disease is accompanied by a severe burning sensation, or itching, and the patients attacked are usually much out of health. In some cases the surface of the body is more or less generally involved ; but as the rule, while the papules are not so large as in lichen planus, they are more confluent, or rather, patches occupying the whole regions are formed. Accompanying the rash there are also marked hyper- emia, itching, and more rarely considerable marasmus, ner- vous irritability, and like symptoms. There are all stages between lichen planus and lichen ruber, and the latter ex- hibits in places the characteristic discrete papular rash of the former. This severer phase is rare in England ; it is the L. ruber of Hebra, but the two conditions are different degrees of the same disease. Hebra has also correctly de- scribed a L. scrofulosorum, which occurs in those who ex- hibit decided signs of scrofula. The eruption is made up of circular groups of little pale papules the size of millet-seeds, 12 134 THE DETAILED DESCRIPTION each having in its centre a little exuvial plug. There is no itching. If the disease be severe, acneiform pustules may develop interspersed with the papular rash. It attacks, by preference, the trunk. Diagnosis — We need only refer to lichen ruber. Its itching and the presence of its papules on the forearm should not mislead to the idea of its being scabies. The papules are so very characteristic that they should be recognized at once by their flatness, irregularity, and glazed appearance. When patchy the disease may be thought to be psoriasis, but the presence of characteristic papules again, and the " papular" origin of the rash, and the presence of very thin pus, and not silvery scales, distinguish lichen planus or ruber. We have known the two aspects of the disease mistaken again and again for a syphilitic disease, but this arises from ignorance of the existence of such a malady as lichen planus. The papules of syphilis are wholly unlike those of lichen planus, which lack all concomitant evidences of syphilis. Treatment Lichen simplex and circumscriptus must be treated as simple inflammations. A loaded system, pyrexial condition, or debility should be attended to, but alkalies should also be exhibited in some form or other. Should the disease not speedily disappear, a mild mercurial course, or one of Donovan's solution, may be given together with cod-liver oil. Locally alkaline and gelatine baths, with remedies to allay irritation, are needed, as (14), (16), (20), (23), (24), (30), (32), (37), (38), (47). Lichen agrius must be dealt with as an eczema rubrum. In L. planus the indications, as re- gards internal treatment, are to improve the tone of the nervous system by rest, change of air, and general tonics, including arsenic, but especially the mineral acids and bit- ters ; to alleviate dyspeptic troubles ; to feed up the patient ; and lastly, to attempt to diminish hyperemia by astringents, such as perchloride of iron. As regards local medication it is needful to allay irritation by gelatine and alkaline baths OP CUTANEOUS DISEASES. 135 (la and lb), and by sedatives (23 et seq.); to diminish hy- peremia by the use of such remedies as (74), (14); and, finally, to promote the absorption of the papules, especially by vapor baths, and cautiously employed tarry compounds. In the severer aspect of the disease termed lichen ruber, arsenic may do good, but we have not found it efficacious. There is considerable nervous excitability, and sedatives may be required, but the general treatment is the same as that for lichen planus. Lichen urticatis, see Urticaria. Lupus is a disease characterized by the formation in the skin of a neoplasm or new growth, whose minute characters are those of granulation tissue, and which occurs in the form of a diffused infiltration, or of tubercles. This new growth tends to invade and destroy the true skin textures, the corium, the glands, and the vessels, etc., and to undergo, in effecting these changes, degeneration itself, so that all that is left be- hind where the disease has had full play is cicatrized tissue. There are two main varieties of lupus termed respectively L. erythematodes and L. vulgaris, the main difference being that in the former the sebaceous glands are especially and primarily implicated, whilst the new growth occurs in a dif- fused form ; and in the latter the growth arises in the corium tissue itself, and occurs in nodules or tubercles from the outset. L. erythematodes is the term applied, as just indicated, to the superficial lupus in which the sebaceous glands are especially implicated, and comedo-like spots, indicative of the irritation, infiltration, and choking of these glands and their ducts by secretion, stud the otherwise reddened and some- what raised surface, which is also affected by the new growth. The disease attacks by preference the face, and especially the nose and cheeks of young women of lymphatic tempera- ment, but it is also seen on the scalp, fingers, and, more rarely, 136 THE DETAILED DESCRIPTION in other parts of the body. It begins about the time of puberty ; it is more common in women than men ; runs a very indolent course, and is rebellious to treatment. In its most common seat, the face, it begins frequently like an erythema, or the disease may assume the aspect of a slight seborrhoea. The patches are often very small, and there may be one or several. Under the eye is the favorite locality. This erythema or seborrhoea may at first disappear, but soon returns, and then it assumes an obstinacy which does not belong to either of these two conditions above named, and this feature attracts attention. The patches are more or less circular, very well denned ; their edges raised, and thin ad- herent scales form upon them, or the comedo-like bodies make their appearance ; and at this stage, which is an early one, the deeper tissues of the affected part seem to have thinned a little — in fact atrophy sets in. This settles the diagnosis at once. As the disease progresses, the centre sinks from increasing atrophy, becomes paler, and now, if not before, the orifices of the sebaceous ducts are very patulous and distinct, the patches enlarge, and if near coalesce. Often there is a patch under each eye, and if these bridge together and form a junction over the nose, the appearance of a butterfly is pro- duced, hence the term butterfly lupus. When the hands are affected, the patches look like chil- blains in slight cases, but the disease may occur in summer. In marked cases atrophy is always present. When the scalp is affected, there is at first a red infiltration covered by adhe- rent scales, and then the tissues atrophy, and become white in aspect, like cicatricial tissue, whilst the hair is lost, and baldness of course results. The subjective symptoms are limited to itching and burn- ing. The general health is sometimes good, but mostly feeble and unsatisfactory. We have described a dissemi- nated, follicular lupus simulating acne (see Lancet, 1878). OF CUTANEOUS DISEASES. 131 Lupus Vulgaris. — In this disease the neoplasm takes the form of red, or at first yellowish, solid, more or less elevated, surfaces, varying in size from a small pea to very large areas, due to the growth or coalescence of different points or patches of disease. The morbid growth is elevated above the surface, and is a well-defined outline ; as the rule, it is covered over by a thin layer of adherent cuticle, which generally gives the growth a slightly scaly aspect, and ves- sels are seen to course over and about the tubercles before ulceration has set in. The neoplasm, which has a semi-gela- tinous aspect when fully grown up, originates in the corium, spreads upwards and outwards and more or less deeply, and destroys in its increase the normal textures so as to induce their atrophy and disappearance. Scarred tissue is left be- hind, it is thick, whitish, glistening, and shows little dispo- sition to contract. If the lupus tissue be removed by insen- sible absorption, commencing with its degeneration, there is no ulceration. If it break down freely, ulceration occurs prior to cicatrization. The disease is attended by itching at times, and perhaps some pain in the ulcerative stage. It begins at an early age, generally about puberty ; attacks the face by preference, especially the nose, cheek, and ears, but it also occurs on the trunk and extremities. It occurs in lymphatic and strumous subjects. There are no true varieties in reality, the so-called varieties are, clinically speaking, different phases of the same disease. If the lupus consist of tubercles scattered or crowded into a patch, the disease is termed L. tuberculosus, which may or may not in later stages ulcerate, hence the terms L. exedens and non-exedens. If the disease present the aspect of a general infiltration, followed by thinning of the textures and marked scaliness, it is termed L. exfoliativus. If there be much thickening and elevation, due to concomitant increase of the connective tissue elements, the disease is termed L, hyper- trophicus. In scrofulous persons the ulceration is free, and 13* 138 THE DETAILED DESCRIPTION large, dark, heaped-up crusts form, hence the unnecessary term L. scrofulosis. Diagnosis It will suffice to make an easy diagnosis, in a large number of cases where a doubt may exist as to the disease possibly being syphilitic, if it be remembered that in lupus the skin trouble stands alone as the total disease, and that there is an entire absence of any of the ordinary con- comitances of syphilis, nor is the skin mischief multiform in the character of its essential lesions. Treatment Lupus erythematodes is often difficult of cure. The lightest cases may be remedied by cod-liver oil, liberal diet, and iron internally, and painting constantly with liq. plumbi, or iodide of starch paste (vide formula). Severer cases are better treated with mercurial plaster, tarry appli- cations, tincture of iodine, or a strong solution used once or twice a day. If these fail a solution of caustic potash and water in equal parts, the fuming, acid nitrate of mercury, Vienna paste, and other caustics are serviceable, and they must be re-applied till proper cicatricial tissue re- sults after the healing of the caustic wound, which should be accomplished by dressings with unguentum diachyli after each application of caustic. Lately, scooping and scarification, or multiple puncturing of the diseased surface have been re- commended, but these do not, we think, offer superior advan- tages. In obstinate cases, perhaps, strong iodine 2 or arseni- cal caustics are the best, but must be used with due caution. In the case of lupus vulgaris the same principles of treat- ment apply, whilst the general health is to be improved in every way, and especially in strumous subjects, by cod-liver oil, iron, fresh air, seaside change, a full milk and fatty diet, and the like ; the essential point of moment is to destroy the new growth by caustics repeatedly applied, but not so as to produce unnecessary cicatrization. Great care is necessary in the application of these remedies, and judgment in the selection of appropriate times and cases. Whenever a lupus OP CUTANEOUS DISEASES. 139 is very tender, or shows a tendency to spread rapidly, or be- comes hyperasmic under slight causes, caustics should not be used, but they are particularly indicated when the disease is indolent. When the lupus is red, tender, and irritable, it is useful to exclude the air, and paint once or twice a day with liquor plumbi for some time. The caustics most suitable are (5) and (9), and it is best to use them to the edges of the patches in the first instance, and apply a poultice if there is much pain. The caustic may be repeated at intervals till an apparently healthy surface appears, and one that seems in- clined to heal. The surface should then be dressed with some simple astringent, as (74) or (35). When lupus patients are out of health, they should take appropriate tonics, iron, especially cod-liver oil, and quinine. The slighter forms of lu- pus may often be cured by the application of astringents only. Maculae. — There are four chief forms — viz. : (1) The pigmentary, occurring idiopathically as in leucoderma and melanoderma, or symptomatically in connection with uterine excitation, and certain cachexise, or after certain eruptions {see Pigment increase) ; (2) the parasitic, as in tinea versi- color ; (3) the chemical, due to the use of nitrate of silver ; (4) the hemorrhagic, as in purpura (see the special descrip- tions of the diseases here named). Medicinal Rashes. — Some medicines when taken in- ternally bring out on the skin an efflorescence, a fact which it is well to be acquainted with. Thus Arsenic is said to ex- cite in rare instances Herpes zoster, and to lead to indura- tion of the palms of the hands. Iodide of Potassium may induce an acne, and very rarely a bullous eruption, with fever and great constitutional disturbance (see Iodide of Potassium Hash). Bromide of Potassium excites a some- what similar acne, as well as other phases of eruption due to inflammation of the sebaceous glands (see Bromide of Potas- sium Eruption). It is not very unusual to meet, whilst ad- 140 THE DETAILED DESCRIPTION ministering Copaiba, with a raised, red, uniform, terribly pruritic, hypersemic rash, which now and then goes on to vesiculation. It attacks the arms in chief measure. Scarla- tiniform eruptions have been met with also during the exhi- bition of Chloral, Salicylate of Soda, belladonna, Morphia, but they must be looked upon as of very exceptional occur- rence. Quinine eruptions have been recorded a considera- ble number of times now, and they assume usually a scarla- tiniform or urticarial aspect. The external applications of various drugs and vegetable juices are well known to produce eruptions. We need not refer to the causation of blisters and ulcers by caustics, etc. Arsenic commonly excites an inflammation of the skin, and it is an active agent in giving rise to the erythema, papules, vesicles, pustules, and ulceration following the wearing of (a) articles of clothing brilliantly colored by the aniline dyes ; (b) green ball-wreaths, artificial flowers, etc. Many dyes, even apart from the arsenic, are capable of exciting a mild dermatitis. Stro?ig mercurial or tartar emetic oint- ments will occasion a pustular eruption, as will also Croton oil. Undiluted Arnica may cause very severe inflammation. Tar brings out an acne, and Sulphur a papular and then a vesicular eczema. Amongst the irritant juices of plants, which occasion an inflammation of the skin, that of the Nettle is well known. For America two species of Rhus (viz., the poisonous su- mach or dogwood, and the poison ivy or oak) excite in some persons, by contact or proximity to the plants, an erythema- tous though usually vesicular eruption of very extensive and often severe character. Miliaria is characterized by the formation in the skin of a soft, red, pruritic, pimply eruption, the papules of which it is made up rarely exceeding a pin's head or a millet seed in size. It is due to disordered action of the sweat glands, OP CUTANEOUS DISEASES. 141 i. e v either from the overtaxing of their functions, or from the irritation of abnormal secretions. The excessive or sud- denly increased amount of sweat may be due to the influence of temperature, a special excitation of the glands, or the de- rangement of the vaso-motor system from debility. The textures immediately surrounding the gland and its duct are irritated and become hyperaemic, so that a soft red papule is produced. It is possible that this papule may be vesiculate in certain cases, but the vesicles which are so frequently found capping the papules, or intermingled with them, are sudaminal in nature. It should be remembered that the contents of the vesicles may become purulent. A severe form of Miliaria has already been described under the term Lichen tropicus. Although all regions of the body may be affected, those parts more specially subject are the trunk and neck and then the arms. It may appear suddenly and as quickly disappear. The summer is the season when Miliaria is more frequently met with, but it may occur in winter — for instance as a complication of Dysidrosis — and is not uncom- monly seen at all seasons on the bodies of persons in states of pyrexia where there is excessive sweating, e.g., in Phthi- sis and Rheumatism. Treatment — When met with as an accidental occurrence in the sweating of pyrexial states, it is of little importance ; also when seen in the summer months, when the hyper- aemic spots may only require a soothing calamine lotion. But in other states the causation of the Miliaria is due to a debilitated nervous system, and nervine and ferruginous tonics, etc., are indicated. Molluseum eontagiosum is a disease of fairly com- mon occurrence, in w r hich the sebaceous glands are enlarged and distended by an excessive quantity of sebum, so that soft, sessile, pearly or pinkish-looking, little round tumors, which resemble white currants or pearl buttons in rough 142 THE DETAILED DESCRIPTION outline, are produced, which have the peculiarity of an um- bilication in the centre, disclosing the distended opening of the gland duct. They vary in size from a pin's point to a walnut, it is said ; but usually they average that of a good-sized pea. A white cheesy matter may be squeezed out from the opening, and the sac thus more or less emptied. The face is the chief seat of the disease, and it occurs mainly in children. There may be several or a great num- ber of these little tumors present in a given case. It is apparently semi-epidemic at times, and appears too to be contagious. If left alone the tumors generally suppurate, and then dis- appear, leaving cicatrices. The disease is of sebaceous origin clearly, and our own independent observations, recently made, have re-established this point. Lately it has been affirmed by Boeck, Lukowsky, and others, that the disease arises from a growth downwards of the interpapillary portions of the rete Malpighii, followed by degenerative changes in the central cells, and their ex- pulsion through a central aperture. We find that each tumor consists in hypertrophy of sebaceous glands, with increased rapid endogenous formation of cells, that become completely vacuolated and distended w r ith altered sebum, and form the concreted mass of contents. Diagnosis Molluscum contagiosum tumors are distin- guished from small fibromata by their central aperture, and the presence of sebum within them, which can be expressed readily. On the genitals they are commonly confounded with warts and condylomata, but the same points suffice for their distinction. Treatment., — This consists, in the early stage, of touching them with a point of caustic or the acid nitrate of mercury. If the tumors are of any size, their contents should be squeezed away, and the sac of the growth then touched with some mild caustic. OP CUTANEOUS DISEASES. 143 Morphcea Synonymes, Addison's Keloid, and Cir- cumscribed Scleroderma (Fagge). — Attention was specially drawn to this disease by Addison as a form of keloid, and a well-defined position was accorded it by the excellent descrip- tion of Wilson in 1868. In America it has since been pretty generally recognized, but in Austria it is still confounded partly with anaesthetic leprosy, and, in the more severe forms, with scleroderma. Wilson also and others are in- clined to regard it as a remnant of leprosy left with us. It is a somewhat rare disease, and its appearance is so striking that when once seen the disease will probably be never for- gotten. It occurs at first in isolated patches, either single or multiple, and often extensively distributed ; these patches may subsequently coalesce into large areas. The patches are usually more or less rounded, but occasionally occur in irregular bands or stripes or even in lines and spots. In the common form (M. alba) the disease begins as a delicate pur- ple or lilac blush, which is temporarily diminished by pres- sure. A pale, slightly depressed area then becomes apparent in the centre of the blush, which is not an " erythema" in the ordinary sense, and gets more and more defined, whiter, denser, smoother, and more polished. Occasionally the cuticle desquamates slightly or becomes wrinkled like tissue paper. The central white surface gets less and less mottled by straggling venules, whilst the dilated veins become more apparent and the amount of blood supply increased around its edges, forming the characteristic lilac fringe. The patch may attain a size involving the whole surface of the mamma. It is in this condition that the patient usually comes under observation with the dirty alabaster, or bacon-fat looking, circumscribed patches, giving the notion of a piece of white wax having been let into the skin. In the rarer form (M. nigra) the diseased conditions are similar, but there is a varying degree of dark pigmentation of the patches simulating leucoderma. Evidently there is an overgrowth and condensa- 144 THE DETAILED DESCRIPTION lion of the fibrous tissue, or an infiltration, which disturbs the circulation and causes the prominent superficial venules, and, as it increases and obliterates the bloodvessels, induces the condition seen immediately beyond the area of the dis- ease. As the disease progresses atrophic changes occur (M. atrophica), often to a considerable extent. The nerves of sensation are to some extent secondarily interfered with, producing differing degrees of anaesthesia. Whether the nerves play a more intimate part has not yet been demon- strated, but there is sometimes precedent pain, and, coinci- dently with the progress of the disease, generally either ting- ling, or burning, or slight itching, or numbness. The perspira- tory and sebaceous glands, and the formation of hair, are all interfered with in the patches. We have hardly material enough yet to argue as to its neurotic distribution, but it is rarely a symmetrical disease, and often confined to one part and one side of the body. Drs. Wilson, Tilbury Fox, and Duckworth have called attention to its situation over the course of the supra-orbital nerve, especially on the left side. In Wilson's cases the trunk, which includes the neck, was chiefly affected in 11 cases, the legs in 7, the arms in 6, the submammary region in 3. It may occur at any age except, perhaps, infants (Wilson mentions a case aged 4 years) and in old age. It is much more common in females than males, and is due to " a weakened trophic or nutritive power, and is a consequence of nutritive debility." It occurs in indi- viduals of weakly constitution, but may follow any debility, especially such as in women is associated with irregularities of menstruation, and pregnancy and lactation. Diagnosis Morphoea nigra may be easily distinguished from leucoderma by the textural changes. When occurring on the forehead and extending in the hair causing shedding of latter, it has been confounded with alopecia areata. In an- aesthetic leprosy the patches never present the curious wax- like condensation or infiltration of the skin, and the history OP CUTANEOUS DISEASES. 145 of the patch is different. It is exceedingly difficult, if not im- possible, to distinguish many forms of morphoea and scleroder- ma, and it is held in England that morphoea is only a peculiar circumscribed form of scleroderma ; that the former may pass into the latter condition, and that clinical experience shows that the two forms are connected by a complete series of cases. In America this view is not so generally held {vide Scleroderma). Treatment. — The disease is essentially a very chronic one. " Slightly more than half the cases are curable," says "Wil- son, but we have obtained rather more favorable results. The patches may spontaneously resolve, but the cure is gen- erally very slowly brought about. Some cases get well and relapse, and in others the patches rapidly get more and more numerous in spite of all treatment until the body is covered. We advocate the administration of cod-liver oil, preparations of iron, quinine, nux vomica, phosphoric acid, the mineral acids, etc. Locally we do nothing, but Wilson advocates stimulants, such as aconite liniment, bichloride of mercury in almond emulsion, cantharides, etc., whilst Bulkley likes a mild mercurial ointment. Nails are subject to a variety of diseased conditions. The clubbing and striation, as an effect of exhausting ill- ness such as heart disease and phthisis, are well known, and also the transverse notching indicating the cessation of growth in the part during acute illness. The nails are ill- formed, and rendered opaque and brittle, and possibly thickened, in psoriasis, pityriasis rubra, lichen planus, and sometimes in ichthyosis. They are likewise stunted, and more or less atrophied in some cases of syphilis, and very frequently in those who are weak and out of health. The nail-bed, or matrix, often gets inflamed, with pain, heat, swelling, and suppuration, occasioning perhaps the loss of the nail. This is called onychia, and it may be syphilitic, 13 146 THE DETAILED DESCRIPTION strumous, or erysipelatous in origin. Lastly, the nails may be thickened and rendered brittle, and raised from their bed by the attack of fungi, and then the disease is known as onychomycosis. A few words may be added as regards the diagnosis of these several conditions. In psoriasis of the nails, all or most of the nails, of the hands, and perhaps the feet, are affected. They become at first speckled, then opaque, un- even, dull, and brittle, and the free edge splits up into sev- eral layers. The clue to the nature of the disease is almost invariably given by the existence of psoriasis about the body, and one method of treatment for the nail and surface disease may be followed out. Onychomycosis mostly occurs together with some form of tinea of the head or body. It may arise by a tinea circinata travelling from the finger to the nail, or the nail alone may be affected in those who have been attending to ringworm cases. No psoriasis can be found, moreover, on the body in these cases. The nail be- comes opaque and brittle about the base and sides ; then it thickens, is loosened away from its bed, and breaks up into layers. Generally in onychomycosis — and this is a very important point — only one nail is affected, and more rarely two, and only exceptionally more than that. The nails of the feet are healthy, or, in other words, onychomycosis only attacks the nails of the hand. When scrapings of the nail are examined, fungous elements will be detected. The treat- ment consists in soaking the nail in a sulphurous acid lotion (one part to three or four of water) constantly, and applying acetic acid every day or every other day, but short of produc- ing irritation. Syphilitic disease of the nails may consist in general atrophy or indolent inflammation. In the latter condition the parts at the base of the nail become painful, swollen, and red ; suppuration follows, and unhealthy ulcera- tion, with loosening and perhaps loss of the nail. Several fingers may be affected at one time. The diagnosis is ren- dered clear by the concomitance of other evidences of syphi- OP CUTANEOUS DISEASES. 147 lis in the individual. The treatment consists in the applica- tion of black-wash externally and anti-syphilitic remedies internally. Onychia, when simple, is known by its acute onset and course, and the entire absence of syphilitic or strumous symptoms. The treatment is that of a sharp local inflammation ; nitrate of lead ointment is highly recom- mended for the disease. Pedieuli, see Phthiriasis. Peliosis Rheumatica, see Purpura. Pemphigus is a disease of very definite features, and needs no lengthened description. It is characterized by the occurrence of oval bladders or bullae, varying in size from a split pea to a pigeon's egg. These bullae are primary for- mations. Each bulla contains at first, and is distended by, a semi-transparent fluid ; soon, however, the fluid gets opaque, and the bulla becomes flaccid and dries up after a few days, leaving a slight scab, or giving rise to a superfi- cially excoriated surface, but no scars are left behind. The disease runs, as the general rule, a slow and chronic course, being prolonged by the development of successive crops of bullae. The disease, however, may be acute and pretty general, but in our experience the pemphigus is then connected with the development of a septicaemia or pyaemia, and in this case the skin trouble sinks into insignificance beside the graver general condition, but the skin eruption presents all the cha- racters of a freely disseminated pemphigus, hemorrhagic effu- sion into the bullae being a but infrequent accident. How- ever, in the great majority of cases, the disease is as stated, chronic and indolent. There are two main aspects of pemphigus, viz., P. vulga- ris and P. foliaceus. Pemphigus Vulgaris It may consist of a single bulla, which heals, to be replaced by another and another, 148 THE DETAILED DESCRIPTION generally about the ankle or the hand. This is sometimes called P. solitarius, an unnecessary refinement. Usually there are a number of bullae scattered over a limb, on the abdomen, or indeed any part of the surface, except the scalp. The bullae are of varying size, oval or round, and in different stages in any given case. Here is a bulla, here a slight crusted spot, and there a stain. Bullae are attended perhaps by a little burning or itching, and may be a little painful at times, but they are not surrounded, as the rule, by any de- cided inflammatory areola. They may cluster or coalesce. They prolong the disease by their successive outbreak, each crop lasting a few days only. They may appear on the mucous surface also. The general health is not specifically disordered, except in the young and feeble, who become irritable, feverish, and weak. Occasionally there is intense irritation, and a pruriginous state of the skin complicates the pemphigus, which has this peculiarity, that, although it may begin by large, yet has also in this variety small, bullae. This is termed P. pruriginosis by some, but we think it a phase of hydroa (which see). Pemphigus Foliaceus is a rare condition, first de- scribed by Cazenave, but is a well-marked clinical variety. It attacks the body generally, beginning in one spot, and gradually invading the entire surface. The bullae are more or less abortive, and of course flaccid, and give rise to flaky incrustations, like thin, pie-crust flakes, covering the surface of the body, and presenting the aspect of a crusted eczema, only that bullae are detected. It is said to begin on the front of the chest. There are exceptions to this ; we have seen it begin on the back, and in one case just like ordinary pem- phigus of the limbs, with well-marked typical bullae. We have seen aortitis with it. The general condition is one of extreme prostration, and patients are specially worn out and exhausted by the irritation, burning, and free discharge that accompany the disease. OF CUTANEOUS DISEASES. 149 Diagnosis Syphilitic pemphigus attacks especially the soles of the feet and palms of the hands of the newly born, and is associated with syphilitic cachexia and other evi- dence of syphilis. Bullae are secondarily formed in eczema of the hand, dysidrosis, and other diseases, but they are re- cognized to be not primary and independent, as are those of pemphigus vulgaris. Treatment -Local remedies play a subordinate part in the disease. The bullae may be punctured, and the affected parts treated with some soothing lotion containing oxide of zinc or Goulard's water with carbolic acid, or the surface may be dusted over with fuller's earth or some dusting powder, and when there are excoriations a mild, lead ointment may be used. In very severe cases, slight water packing or the continuous bath is recommended. But the internal treat- ment is of most good. Every possible source of debility must be carefully inquired after ; worry and excitement are to be avoided. The want of proper food, of fresh air, and of proper rest should be remedied, and the patient should be put upon a free and liberal course of quinine if there is any pyrexia or malarial condition present, though arsenic is preferred by many. In the foliaceous variety the patient should be dealt with as suffering from a rapidly exhausting disease. In children we have seen chemical food (solution of the hypophosphites of lime, iron, soda, and potassa) and cod-liver oil of great benefit. PhthiriasiSj formerly called prurigo senilis, is caused by the attack of the pediculus vestimenti. The disease con- sists, as we first pointed out some years ago, in the presence of certain peculiar hemorrhagic specks, together with the phenomena of secondary irritation induced by the pediculi and by scratching. It occurs chiefly in the aged, but it also is met with amongst younger persons, who are uncleanly. The pediculi attack the regions of the clavicles and neck, 13* 150 THE DETAILED DESCRIPTION first of all ; and it is there the first evidences of the disease must be traced. Pediculi do not bite as imagined. The characteristic lesion is easily overlooked. The hemorrhagic, mark is not raised like a scratched follicle, nor is it irregu- lar like an excoriation, but it is formed by the opening of a follicle dilated by the proboscis of the pediculis, showing in its centre a dried speck of blood which has welled up from its deeper part. It is a circular, cup-shaped depression about the size of the blunt point of an ordinary pin, and has an even and well-marked circumference. The pedi- culus inserts the proboscis into a pore, which it distends, and as the proboscis is withdrawn the blood wells up to fill the follicle. The irritation and scratching induce the develop- ment of papules, whose apices, when scratched off, become covered by scales of dried blood (pruriginous, as it is called). This condition, together with ecthymatous pustules, excori- ations from scratching, wheals, etc., constitute the secondary eruption of phthiriasis. At first the mischief is localized to the neck and shoulders, but presently it spreads over the back, abdomen, buttocks, etc. Treatment It consists in giving warm baths, smearing the skin with some parasiticide, as (114), (115), (124), to keep away the pediculi, and in carefully baking the clothes worn by the patients at a temperature of 220° F. Pigment Increase. — Moles; Lentigo; Chloasma; Melasma These terms include the states of increase of pig- ment in the skin which are unassociated with any textural alteration, and in the discussion of the subject it will be con- venient to follow Hebra, who has deduced something like order from the chaos of terms formerly in use. Moles are the pigmented areas of congenital origin. Those which are met with independently of any structural skin change are known as naevus spilus, and those associated with a slight amount of warty growth as naevus verrucosa. For other kinds of moles see the section on naevi. OF CUTANEOUS DISEASES. 151 Lentigo. — Under this term is included " all those pigmen- tary changes which are usually met with on the face and on the arms, but also on other parts of the surface of the skin, in the form of spots of the size of a pin's head or lentil, and of a yellow, or yellowish-brown color." They are met with in children under the age of 6 to 8 years, whether they are much exposed to the sun or not, and they disappear almost invariably after 40. The brown spots known as ephelides or freckles, so common in red-haired persons, which are popularly supposed to be present only in the summer, really exist, as Hebra has shown, also in the winter, though in cold weather they are usually of a much fainter color. Chloasma This term has been widely used to denote also the parasitic disease now known as tinea versicolor, and the student is warned not to be confused by this in his read- ing. The so-called " liver spots" which come under this heading were named so from their resemblance to the color of the liver. Chloasma consists of yellowish or yellowish- brown patches, as distinguished from the spots above de- scribed, of various shapes, sharply defined, smooth, not detaching scales on scratching, and occurring anywhere on the body. Such pigmentation may result from any pro- longed irritation of the skin, from pressure, injury, blisters, and in uncovered parts from exposure to solar heat. We may here call attention to an unusual state of pigmentation occur- ring in lousy people, which is mentioned by Hebra, but spe- cially called attention to by Dr. Greenhow. Cases of another class are those symptomatic of some states of peculiar physiological activity or organic disease. The C. uterinum et gravidarum of females is widely known. It occurs in pregnancy, at the menstrual periods, and in dis- eased states of the uterus or disorders of its functions, is situ- ated about the nipples, abdomen and face, arching over the forehead pretty symmetrically, and is limited to the child- bearing period. 152 THE DETAILED DESCRIPTION Apart from this special form there is a class of cases of in- creased pigmentation due to severe constitutional depression and more extensively diffused. It may follow or accompany severe illness, the cancerous cachexia, pellagra, etc. Melasma is the term applied when the pigmentation is very dark in color. A remarkable form is that met with in Addi- son's disease, and it is well to remember that it also occurred in the epidemic in Paris, some years ago, known as acrodynia. ^Etiology This may be ascribed to faulty innervation, but very frequently it must be considered as simply a " freak of nature." Treatment. — When the cause lies in any apparent disor- dered state of the body, the object must be of course to rectify this, but, in the many slighter cases where the " blemish" is of a purely local nature, the removal of the pigmentation is not often very satisfactory, and hence the excuse for the multitude of cosmetics, etc., professing their removal. As the pigment molecules are situated in the lower layers of epidermic cells, we may dissolve or otherwise destroy these with the hope that in the new cells the pigment will be diminished, or we may stimulate the part with a view to their absorption. For this purpose lotions of borax, the al- kalies, spiritus saponis alkalinus, tincture of iodine, and cor- rosive sublimate are the proper agents to use. Hebra gives tincture of iodine painted on every four hours for three days ; or spiritus saponis alkalinus (cotton-wool kept applied wet). He also uses the following formulae: — • $. Bismuth, subnit., Hyd. amraon. chlor., aa 5ij 5 Lard, ^j. M. S. To be applied on lint, at least at night. I£. Hyd. bichlor. gr. ^ ; Em uls. amygd. amarae, f§ij. M. S. Apply once or twice daily. I£. Hyd. bichlor. gr. v ; Sp. vin. rect. l'§j. M. S. To be quickly applied as a caustic. OF CUTANEOUS DISEASES. 153 Pityriasis consists essentially in an hyper-production and excessive shedding of epithelial cells in the form of small bran-like scales or of flakes, as a 'primary and essen- tial phenomenon. This state is attended with more or less hyperaemia. It must be distinguished from secondary des- quamation, which follows as a consequence of all disturbances of the cutaneous circulation, or the epithelial formation of new growths and the like. It should be also recognized as different from so-called pityriasis of the scalp (dandruff), which is in reality a seborrhoea. The term pityriasis in the designation pityriasis versicolor, as applied to the vegetable parasitic disease tinea versicolor, is misleading. Simple pityriasis, as above defined, is usually the result of simple hyperaemia induced by irritants, such as cold winds, heat, friction, and is quite an unimportant matter. But there is a second variety, which is a well-marked and severe disease. It receives the name Pityriasis rubra. Some think this a phase of eczema ; we do not. The disease begins at one particular part of the body as a red scaly spot, and then rapidly spreads so as to speedily involve the whole surface of the body. When the disease is thus fully developed the face looks more or less flushed, and is sometimes covered by minute scales, the scalp is in a similar condition, but the body and limbs show the disease in its most typical features. The skin is intensely red, but the hyperaemia is greatly di- minished or disappears under pressure. The skin itself is not thickened by infiltration in the earlier stages of the dis- ease, but only secondarily and exceptionally so in the later stage of chronic cases. The surface also does not weep, as does that of eczema, except again very exceptionally. Upon this reddened skin are disposed oftentimes in layers arranged like the tiles of a house, or more or less irregularly imbri- cated, thinnish scales of epidermis, loosely adherent to the surface, and varying much in size up to large flakes an inch or more in diameter. These flakes are adherent in part, 154 THE DETAILED DESCRIPTION but free at one or more points or edges. They readily curl up, and are easily, detached, and indeed large quantities are constantly and rapidly shed in some cases, so that two or three handfuls may be collected from the bed in the twenty- four hours, hence the term Dermatitis exfoliativa applied to the disease in this aspect. The patient suffers little discom- fort except in severe cases, when itching and burning and much stiffness are complained of, finally the disease is allowed to become chronic from want of proper treatment. In many cases it can be conducted through an acute course. Patients are usually much debilitated. Treatment — The slighter forms are relieved by internal tonics and the inunction of oil or some slight astringent. P. rubra must be treated as a disease consisting in general hyperemia of the skin due to nerve paresis. The patient must be wrapped in oil, and quinine and cod-liver oil must be given after the free exhibition of diuretics, to relieve the hyperaemic skin. Finally, perchloride of iron will be found very useful as convalescence approaches. Porrigo, a term now obsolete, but formerly applied in- discriminately to any crusted eruption or scaly incrustation, especially about the face or head. It included favus, ring- worm, eczema, etc. Prickly Heat, or Lichen Tropicus, occurs in the tropics mostly, but in a milder form elsewhere in the sum- mer months. It is seen as a minute, red, very itchy, pimply rash, due in part to inflamed sweat follicles and to hyperaemic papillae, which occur, we hold, secondarily to the other condi- tion. Lichen tropicus attacks the surface of the body, the limbs, and often the face, and is interspersed with sudamina, here and there. The itching is increased by heat, drinking hot liquids, etc. Much difference of opinion exists as to its anatomical seat. To those who are interested in the matter OF CUTANEOUS DISEASES. 155 we commend the clinical observations on the disease con- tained in the report of Dr. Farquhar and ourselves on en- demic skin diseases of hot climates. Treatment. — This consists in giving diuretics freely : avoid- ing all stimulants ; wearing thin clothing : taking light food : using alkaline baths ; and smearing the surface with whiting made into a thin paste, or some simple emollients. Prurigo must not be confounded with Phthiriasis, which is an eruption due to the attack of body lice. Prurigo is a rare disease, and is characterized by the development of small, hard, pale, or flesh-colored papules, which in their early stage are better felt than seen, accompanied by in- tolerable itching. The papular rash is primary in prurigo, and is not a secondary condition. The papules are due to chronic inflammatory changes in the papillary layer of the derma, and sometimes the deeper stratum of the skin. They occur mostly on the lower limbs, buttocks, lower part of the abdomen, and outer part of the forearms. The disease in its mildest form, when it resembles lichen simplex of chronic character, is termed P. mitis, since the papules are small or limited in extent, and the itching is not severe. When the disease is well marked, the papules crowd together in certain situations, and even form small patches, especially on the legs ; they are felt under the skin before being clearly dis- cernible to the eye, and the itching or disordered sensation, termed formication, is like creeping of ants. To this condition the term P. for mi cans is given. In certain cases where the disease is extensive, and more or less congenital and persist- ent, it is called P. agria or ferox. More acute inflamma- tory changes however supervene, and then more or less sup- puration occurs in this variety, with glandular enlargements in the groin, whilst the skin feels thickened and indurated in the chronic stage. In England the severer form is not common. The writer has only met with a few cases : and 156 THE DETAILED DESCRIPTION the disease of milder type has occurred in his experience in those exposed to alternate heat and cold in their occupation, and who have become debilitated. It is most important to thoroughly understand what is meant by the term pruriginous, which is so frequently used. In the first place it is most erroneously applied synonymously with the term pruritic. A consequence of pruritis is, that the skin gets scratched and excoriated, and, secondarily, the follicles become hyperaemic, and papules form, which in their turn get scratched and surmounted by a tiny blood crust. (See Follicular hyperemia.) Secondly, primary eruptions of various kinds are pruritic, and hence get scratched, and secondary lesions are formed. It is manifest that the term pruriginous is out of place as applied to these phases of dis- ease, and should only be used as denoting a distinct primary affection of a special nature. Treatment — Locally, to relieve the itching, our resources will often be severely taxed, and recourse must be had to the employment of vapor and alkaline baths, the use of sedative lotions, such as (23), (30), (34), (69), (71), (74), or to such applications as the lotio picis alkalinus. Internally, the ob- ject should be to improve the general health, and cod-liver oil and arsenic (90 et seq.), or (106) will be often found of especial service. Pruritus, or itching, is simply a disorder of sensation, and is an accompaniment of most skin diseases, especially eczema, lichen, prurigo, urticaria, scabies, and phthiriasis. Pruritus however may arise in the skin without any eruption, and then it is usually due to the circulation of some acridity, as bile products, urea, uric acid, etc. ; or to some local dis- order of the nerves ; or it is excited by some local irritant, as for instance, about the rectum by ascarides, about the head and pubes by pediculi, about the body by flannel, fric- tion, or scratching. It must be remembered that the ap- OF CUTANEOUS DISEASES. 157 pearance of the skin is always altered by scratching, which causes follicles and papillae to become hyperaemic and promi- nent, their apices get torn off, and a drop of blood sometimes exudes and dries as a speck. This pruritic rash is often most erroneously termed prurigo (which see). In old people pru- ritus senilis occurs as an hyperesthesia consequent upon the general atrophy of the skin ; but in such persons the causes mentioned above may also come specially into play. The following hints relative to the more common causes of itching may be found useful. Itching increased at night by the warmth of the bed, with a pimply rash about the front of the arms and the body, is suggestive of scabies, in which case cuniculi are to be looked for. Itching in old people about the shoulders and back, may mean phthiriasis. At the back of the head in children, the evidence of pediculi is often revealed by an abundance of " nits" on the hair. Itch- ing, with eruption about the fork of the thighs, may be due to parasitic disease and intertrigo (ex., eczema margina- tum). Itching of capricious character, suddenly coming and going, here and there, especially at night, and without visible eruption in the daytime, is suspicious of urticaria, and the occurrence of "wheals" affords the means of a speedy diagnosis. In the winter time especially, it is not uncommon for the skin in certain persons to be irritable, par- ticularly towards evening, or when the clothes are taken off, and the air obtains access to the skin. The itching in such cases has been termed pruritus hiemalis, or winter pruritus, by Dr. Duhring. It occurs in various parts of the body, but more especially about the thighs and legs. In some cases no eruption can be seen, but in others there is decided tur- gescence and prominence of the hair follicles, enough in de- gree, perhaps, to constitute lichen pilaris. The disease is supposed to be " neurotic," but it is probably due to inac- tivity of the perspiratory function in the majority of cases ; at the same time there is frequently defective excretion of 14 158 THE DETAILED DESCRIPTION nitrogenous matters and bile products, at least in our expe- rience in England. It is not exclusively a winter affection, though most common at that time, because of the inactivity of the skin. Scratching, it must be remembered, may excite lichen, eczema, ecthyma, and the like, whereby the primary disorder may be masked. Treatment A number of remedies for itching occurring in connection with particular diseases, will be found in for- mulae (18) to (44), and scattered elsewhere. Starch, borax, or alkaline baths should be administered when the skin is hy- perremic or irritable, and in the early stages of pruritic mis- chief. In the indolent aspect, or later stages, sulphuret of potassium or mineral acid baths are of decided efficacy, and we have found salicylic acid lotion of great service. As re- gards internal treatment, this varies with the case. Itching due to the circulation of retained excreta may be relieved by appropriate aperient and alkaline remedies, whilst nervine tonics will be suitable for the "neurotic" itching. In our experience a "gouty" tendency, constipation, rich foods, and the free use of wine, have much to do with a great num- ber of cases of itching of the skin. All parasites, and other local irritants, must be destroyed or removed (see 209 et seq.), and flannel especially should not be allowed in contact with the skin in severe pruritus. Further information will be gathered from the special descriptions of the several diseases mentioned herein, with which itching is associated. Psoriasis consists essentially in an overgrowth of the Malpighian and cuticular layers of the skin, occurring more or less generally and in patchy form, over the surface, in association with hyperemia and engorgement of the vessels in the more superficial strata of the corium, and particularly its papillary portions in the atfected spots. It has generally been held that the hypertrophy of the rete and horny layers is dependent upon the hyperemia, but we have been singu- Or CUTANEOUS DISEASES. 159 lar in maintaining for several years, in class and in our writings, the view that the changes in psoriasis originate, as regards the skin, primarily, or immediately, in the cell elements of the cuticle themselves. We were led to this conclusion by clinical observation, and an examination of the data afforded by the microscopic observations of Neumann especially ; interpreting these latter, however, in a different sense from Neumann himself, whose view is in accord with commonly received opinion. Recently Dr. Robinson, of New York, has published an admirable paper on the histol- ogy of psoriasis, in which, as the result of researches he has made, he comes to the conclusion so long held by ourselves. We may add that we have confirmed, during a recent inves- tigation, the correctness in the main of Dr. Robinson's his- tological data. In psoriasis as a consequence of the excessive growth of the cuticular layer of the skin, the surface of the psoriasis assumes a marked scaly appearance due to the accumulation and heaping together of the abnormal quantity of epithelial scales. And these scales have this characteristic, that they are dry and of very silvery aspect in the mass, which mostly enables the disease to be at once recognized. Psoriasis, therefore, is made up of elevated points or patches of hyper- aemic cutis, upon which are seated masses of silvery-white, dry scales. If these masses of scales are forcibly removed there is this peculiarity also observed, that the engorged vessels appear as little red points studding the surface, which is at once clearly seen when a lens is used, for generally the removal of the scales by the fingers tears open the vessels and they appear as little bleeding points. The disease may be acute or chronic, generally the latter. It may be hereditary. It is often general, but usually local- ized to several regions of the body. The chief seats of psoriasis are the elbows and knees and the head, but the body on both aspects and the limbs are frequently affected 160 THE DETAILED DESCRIPTION also. It attacks persons of all ages, but there is this re- markable distinction to be observed, that whereas as the rule in the young it is associated with nutritive weakness and even the lymphatic temperament, in the elderly it often oc- curs in those of gouty diathesis, and hence assumes a more inflammatory aspect. There are exceptions in the case of the young who inherit a gouty constitution. All conditions of debility favor the occurrence of psoriasis, especially about the time of puberty. But many persons attacked are appa- rently healthy and strong. A number of varieties of psoriasis have been made, but they are mostly only different degrees of intensity of the same essential condition — stages, not varieties — and several of these stages may be present in one and the same person. The disease begins by the development of small reddish or scaly points or spots, scattered here and there over a region, or the surface. This is termed psoriasis punctata. These spots gradually enlarge and then look like drops of mortar, hence the term P. guttata. Soon the places acquire the size of a sixpence or a shilling. They are mostly round, and being like pieces of money, the stage is termed P. num- mularis. These conditions may coexist in varying propor- tions. In some cases large patches are formed by the coalescence of the smaller or the continuous enlargement of original spots, so that a great extent of surface is covered, but at the same time smaller spots of the guttate or punctate character are perhaps present. This well-developed aspect is called P. vulgaris. Should patches take on a serpentine form the term P. gyrata is used, and if the affection is very chronic P. inveterata. Lastly, if the crusting is freer than usual and assumes a conical shape, the name P. rupioides is applied, the epithelial elements being in this case mixed with pus. This latter condition is dependent on a strumous habit. An important local phase is P. palmaris, likely to be confounded with syphilitic disease ; but the former is com- OF CUTANEOUS DISEASES. 161 monly a part of a more general affection, and it does not begin nor is it limited to the palm of the hand, as is the syphilitic disease as the rule. Diagnosis This is readily made in the great bulk of cases ; the silvery heaped-up scales, seated upon a hyper- asmic cutis, which readily bleeds on their removal, and the special affection of the elbows and knee-joints are very cha- racteristic of the disease. These features, together with the absence of any history of a " weeping stage," distinguish it from eczema, which in its squamous stage only resembles psoriasis. Seborrhoea of the scalp simulates psoriasis, but it is made up of soft, easily removable fatty plates. Squamous syphilitic eruption of the skin is distinguished from psoriasis by the presence of concomitant evidences of syphilis else- where, by the fine, few, adherent scales on the patches, which lack the silvery scales of simple psoriasis, by the ab- sence of the disease from the elbows and knees, and the presence of an infiltrated cutis beneath the scales which does not show the bleeding points on removal of the scales, as in simple psoriasis, etc. Treatment The treatment of psoriasis, if given in proper detail, would occupy considerable space. We can only indi- cate the main points of the matter here. In acute cases in young people, if the skin be hypera^mic, in the early stage diuretics, in our opinion, are very valuable, together with alkaline baths daily, or every other night, with free inunc- tion of oil afterwards. The same line of procedure applies to acute psoriasis, or to psoriasis of an inflammatory charac- ter in a chronic state in the adult ; but it is important to deal under these circumstances, with any gouty tendency or any loaded state of system due to torpid excretion which maybe present, and those " modifying influences" so commonly in operation, and which are mentioned under the head of gene- ral principles of therapeutics, at the end of Part I. of this book, should be carefully sought put and dealt with. We 14* 162 THE DETAILED DESCRIPTION may say by way of summary on this point, that whenever psoriasis is acute or hyperaemic, the action of the bowels and kidneys should be for the time augmented with the view of diminishing such hyperemia. But in ordinary indolent, typical, or chronic conditions tonics are needed, and certain local applications for the re- moval of scales and for checking of the hyperplasic growth of the cuticular cells. As regards tonics it may be said that children do best on cod-liver oil, quinine, and iron, though arsenic is indicated if the scales be very plentiful and silvery (see formulae 90, 92, 106, 107), which must, however, be properly proportioned in dose to the age of the patient. Locally alkaline baths may be used with the inunction of oil as long as hyperemia is decided ; subsequently mild tar applications as (70), or an ointment composed of five grains of white precipitate and a like quantity of nitric oxide of mercury, carefully levigated and mixed up with an ounce of lard and a little scent, may be firmly rubbed into the spots night and morning. In adults the general condition of health must be carefully estimated and dealt with accord- ingly ; but yet, in the weakest as well as in the strongest, the necessity of a due performance of the functions of excretion, the prescription of appropriate tonics, and the regulation of the diet in view of a gouty tendency, a scrofulous dia- thesis, under-feeding, over-nursing, and the like, are to be scrupulously observed. We think arsenic advisable, if at all, in indolent cases, with free, well-marked, silvery scali- ness (see formulas 90 et seq., and 106 et seg.). In anaemic women, iron is of essential importance. In the leuco-phleg- matic, and in women with leucorrhoea, the mineral acids, ix*on, and bitters, with cod-liver oil, have done us best ser- vice. Phosphorus sometimes does good. Locally, the first step is to remove the scales of psoriasis. Tepid baths act efficiently in this respect in a large number of cases. They may be used every, or every other, night, and OF CUTANEOUS DISEASES. 163 give great comfort. Two ounces of bicarbonate of soda or borax may be added to help the loosening of the scales from the surface. With baths it is usual to employ some tarry preparation. Several formulae containing tar are numbered 68, 69, 70, and 71. They should be applied cautiously to a small region at the outset, for, often where they a priori might be thought to agree, they do positive harm. When borne well they should be, as Duhring most justly points out, " used in small quantities and effectually worked into the skin." Hebra's favorite preparation is a mixture of equal parts of liquid pitch, alcohol, and sapo viridis, but it is often too irritating for English skins, except in the case of very indolent patches. Other good remedies are mercu- rial preparations, the citrine ointment diluted with one or several parts of lard or vaseline. The one of most general use is composed of five grains of white and five of red " pre- cipitate," and an ounce of lard. It is very efficacious in psoriasis of the scalp. To obstinate patches of limited ex- tent we often apply the strong mercurial (" blue") ointment, diluted with six times its quantity of lard. Lastly, we must mention the use of crysophanic acid in psoriasis, in the proportion of from ten to forty grains to an ounce of lard. This ointment often rapidly removes psoria- sis for a time, but in many cases the disease soon returns, and the remedy has its drawbacks in that it stains some people's skin a mahogany color, or excites so much irritation that patients get frightened and change their doctor. The remedy may be used in moderate strength to a few patches, and then the area of its application and the strength of the preparation may be gradually increased, but a few rubbings for a minute or two into a given spot or patch soon removes the disease, which is replaced by a whitish surface, the cir- cumference being stained dark brown. We have always employed the remedy with considerable caution because of the annoyance caused to some patients. 164 THE DETAILED DESCRIPTION Purpura is characterized by extravasation of blood into the cutis and sometimes internal parts of the body, and is usually attended by constitutional disturbance. The term does not include the extravasation due to mechanical causes, nor the occasional secondary occurrence of hemorrhage in lesions of the skin, such as Herpes, Pemphigus, Urticaria, etc., which especially occur in old and debilitated persons, though such names as Purpura urticans, Purpura hydroa, etc., have been applied, nor the hemorrhagic eruptions or purpuric conditions associated with malignant forms of the acute specific diseases and with scurvy. The spots of pri- mary purpura are at first of a deep red or scarlet color, and as they fade away they exhibit the usual changes presented during the absorption of blood in the skin. Three forms of purpura are usually described. In Purpura simplex the extravasations are of infinite variety, though attaining a large size. The eruption is sym- metrically arranged, general, though especially developed on the legs, it is often sudden, and usually unattended by con- stitutional disturbance, though debility is present. In Pur- pura hemorrhagica the conditions are altogether of greater gravity both as regards the number, of extent of the patches, of effusion, and the serious state of the patient ; hemor- rhages from the mucous surfaces being common. These purpuric conditions must be carefully distinguished from scurvy, which occurs principally amongst seamen who have been subjected to a deprivation of fresh food, and especially fresh vegetables. In scurvy also there are often inflamma- tions and ulcerations about the legs and gums, and consider- able constitutional disturbance preceding the eruption. There is a third variety of purpura which may be dis- cussed here, though it has been variously considered as a rheumatic affection, a purpura, a scurvy, and an erythema nodosum. It is complicated with hemorrhages and joint af- fection. It is known as Peliosis rheumatica or Rheumatic OF CUTANEOUS DISEASES. 165 purpura. The symptoms consist in the onset of some fever w:th pains in the joints, and the subsequent extravasation of blood in spots, after which the joint pains subside. Dr. Kinnicott considers the disease as distinct from erythema and purpura, whilst Dr. Liveing, who has also devoted espe- cial attention to the affection, considers it to be nothing more than erythema nodosum, E. tuberosum, etc., in which severe joint complications are known to occur, accompanied by an unusual degree of hemorrhage into the patches. Treatment. — The true forms of purpura require rest, care- ful dieting, and the administration of the mineral acids, quinine, perchloride of iron, turpentine (100), gallic acid, ergot, etc. Many cases, however, will be found to yield only with great difficulty. Ringworm, see Tinea. Rodent Cancer, or Ulcer, is in Europe generally not specially distinguished from epithelioma, but in England it has been regarded as a distinct form of cancer, though closely allied to epithelioma on account of its very slow growth, its appearance, and the non-infiltration of the lym- phatic glands. We have, however, recently demonstrated its true origin from the epithelial cells of the sheaths of the hairs and its essentially epitheliomatous nature. It is the least malignant form of cancer, and rarely begins before the age of fifty, though it has been met with as early as the age of twenty-five. It may commence in a pre-existent mole, or as a slightly crusted minute excoriation, probably made by scratching, or, more often, as a pale, solitary, indolent tuber- cle, with a distinct, slightly rolled, well-defined edge, some- where in the upper two-thirds of the face, and especially about the side of the nose. After two or three or several years, slow, and comparatively painless enlargement, the spot ulcer- ates in the centre, and the ulceration unequally follows the 166 THE DETAILED DESCRIPTION extending edge, so that there is a characteristic dry, glossy ulcer bounded by hard, rolled, sinuous or gnawed-looking edges, which are not undermined, as in ordinary cases of epithelioma. There is little if any cachexia, and the lym- phatic glands, in relation with the seat of the ulcer, are never infiltrated, as in the ordinary forms of epithelioma, though they may be irritated and temporarily enlarged. The disease progresses perhaps for four, five, or more years without at- taining the size of a sixpence, but its progress is slowly con- tinuous, and eventually the ulceration extends through every texture, even perhaps to the brain, leaving a. wide hideous cavern, with precipitous sides, sharply separated from the healthy skin around. Treatment. — Cauterization may be successful in the earliest stages of the disease, and in certain slight cases, but, after an extended experience of patients with rodent ulcer, we are convinced that the right plan is to excise freely, and to cauterize the surgical wound with the actual cautery or by the application of chloride of zinc paste. The line of incision requires to be made with judgment, so that it may really run sufficiently wide of all disease. Roseola is a hyperemia of a rosy hue, either sympto- matic, and then part of certain acute febrile disease, as rheu- matism, vaccinia, cholera, etc. ; or idiopathic, as seen mostly in children during change of season (R. infantilis), and in connection with slightest stomach derangement. It may be general and resemble measles, but there are no true catar- rhal symptoms ; the rash is not crescentric in character, and is more rosy than that of measles. Though it may be dis- tributed more or less wholly over the body, still it is deci- dedly patchy in character. It may occur in rosy circles and rings (R. annulatd), especially about the limbs, and in the autumn or summer (R. autumnalis and R. (Estiva). OF CUTANEOUS DISEASES. 16T Treatment In the idiopathic forms salines and laxatives should be exhibited and some simple ointment used. Rupia In this eruption small flattish bulhe are devel- oped, with contents which are at first fairly clear, but quickly assume the aspect of a mixture of blood and pus. The bullae dry into dark thick scabs, which hide unhealthy ulceration. The crusts increase by additional discharge, which " dries on," as it were, in layers from below as the ulceration in- creases. These crusts are consequently conical, stratified, dark, and adherent, and are termed "cockle-shaped" crusts. They are in fact diagnostic of rupia. Should the crusts be moderate in size the disease is termed R. simplex ; if large and prominent, R. prominens ; if the ulceration is excessive and phagedenic, R. escharotica. The disease is always syphilitic. Treatment This should be as for the tertiary syphilis, see (84 et seq.). The ulcers may be cleansed by iodide of starch, and dressed with black wash or (61), (81), (82), or (83). Scabies or Itch is caused by the burrowing in the skin ■ of an insect called the acarus scabiei. This burrowing ex- cites much itching and some hyperaemic rash ; the patient scratches for relief and so occasions much of the rash that is seen in scabies. Hence scabies consists of an eruption due to the presence of acari.in their burrows : together with a secondary rash, the result of the irritation of the skin. The appearance presented by the acarus in its burrow, which is characteristic of scabies, is as follows : Where the acarus enters a vesicle forms, and the animal's* course is traced by a slightly raised, straight, or tortuous line (cuniculus) from one to many lines in length, at the end of which the presence of the imbedded intruder is marked generally as an opaque spot; 168 THE DETAILED DESCRIPTION it may however be dark from dirt. The furrow or cuni- culus itself becomes discolored by dirt, and then has a dark tint w r ith darker dots along its course, probably, in part, the excreta of the acarus. Now these furrows are mostly seen in the adult, in the interdigits and about the wrists in the early stage of the disease, but subsequently about the penis at its upper line and more rarely other parts of the front of the body below the nipple level. In children the buttocks and feet may alone be the seat of scabies. Of course, the furrows lose their characteristic appearance after a good scratching, as they are torn open and the acarus frequently dislodged, a very common appearance then is a ragged line of torn cuticle indicative of the opened cuniculus and starting away from a spot, marked by indications of the shrivelled vesicle which formed at the place where the itch insect began to burrow, and observed to end sometimes in a small circu- lar, little depression, bounded by edges of ragged cuticle, from whence the acarus was dislodged by the fingers in scratching. If patients are cachectic both the vesicle and the furrow may suppurate, as in so-called pustular scabies. The " secondary rash" consists of hyperasmic follicles and papillae forming papules, of ecthymatous pustules excited by scratching, and sometimes of eczema, and urticaria. The results of irritation are seen in early scabies, in the adult on the front of the forearms and about the wrists ; in chronic scabies on the front of the belly and on the upper part in front and inner surface of the thighs ; in children about the lower limbs, buttocks, and abdomen. Scabies is accompa- nied by marked itching, which is always worse at night, and several members of a family are often the subjects of attack at the same time. Cuniculi are absolutely diagnostic, but if these cannot be detected, itching at night in persons who have a pimply rash in the interdigits or forearms or upper line of the penis is very suspicious, and much more so if several persons in the same family are similarly affected. OF CUTANEOUS DISEASES. 169 Scabies in Private Practice — It is important to remark that scabies often differs very much in aspect, according as it occurs in hospital or in private practice. Amongst the poor, and especially the uncleanly, the burrowings of the acari in the skin are attended with the formation of papules, vesicles, pustules, wheals, etc., in abundance. But amongst the well-to-do, and particularly those who observe great cleanliness, the ordinary results of the irritation produced by the acari may be almost, if not entirely, absent. So that if a student were to be guided by the ordinary descriptions given in books of scabies, he would certainly not be able to diag- nose the scabies present. The disease would not correspond in description to papular, pustular, or vesicular scabies, and yet true scabies might be present. We have seen several cases lately in which patients complained of itching intensi- fied at night in different parts of the body, and in whose skin nothing could be detected but a few cuniculi about the hands, or the penis, and an apology for a vesicle here and there. We have seen a multitude of acarian furrows about the hands, and other parts, in a case of scabies, and nothing else. In other cases we have observed just a few very fine, delicate, pale, flesh-colored papules, the result of irritation set up by acari present in the skin, and nothing more, and these, which were lichenous papules, were difficult to make out. In all cases in which a patient complains of itching aggravated at night, even though there be none of the ordinary evidences of scabies present, yet a diligent and active search for cuni- culi should be made about the hands and penis. We have known patients treated with powerful internal remedies for " prurigo," lichen, and the like for weeks, whilst scabies, which existed, was wholly unsuspected because there were no papules and pustules present. Papules, pustules, and vesicles are indeed accidental accompaniments of scabies. Scabies should be .looked upon as consisting essentially of the acari in their furrows (cuniculi) — i. e., the real scabies, and 15 170 THE DETAILED DESCRIPTION the phenomena of irritation (papules, pustules, etc.) super- added, which, under certain circumstances, ma)' be entirely absent. Two or three cases of scabies limited to the penis have recently come under our notice. In all of the cases careful search detected cuniculi. In two, suppurating buboes were produced by the irritation, and the disease was thought to be syphilitic. The diagnosis was rendered easy by the absence of any decided induration about the scabies spots, their vesico-pustular origin, pruritus intensified at night, the pre- sence of cuniculi, and the absence of any concomitant evi- dence of syphilis. Treatment — The majority of cases are cured by a free in- unction night and morning of (114) or (120) for three nights and mornings. The patient must thoroughly wash himself, and if free from itching on the fourth night may be regarded as well. It is important not to overdo the sulphur inunction, but discontinue it after a day or two, for it often sets up in itself irritation, and the continuance or increase of itching is taken for an aggravation of the disease. After three days' treatment the remedy may be lightly applied to any solitary vesicles that make their appearance. If any parts feel hot and tender (74) should be used to soothe. In chronic scabies it may be necessary to make freer and more potent applica- tions (110 et seq.). Often the free use of storax ointment will be found most effectual ; and ointments of iodide of potassium and carbolic acid are also efficacious. Scleroderma is known by the names of Sclerema, Scleriasis or Hide-Bound disease. This affection is usually considered under two heads, viz., S. adultorum, or true Scleroderma, and what is probably a totally distinct affection, the so-called Sclerema neonatorum. Scleroderma adultorum is a rare affection, characterized clinically by a shining, tense, inelastic, shrunken condition OF CUTANEOUS DISEASES. 171 of the skin, and extending usually over a considerable area of the body, and limiting the movements of the regions affected. In consequence of this condensation and shrink- ing, by which the underlying parts, over which, however, the skin is movable, are bound down and rendered immo- bile, the muscles, and even the bones may eventually waste, and whilst distortion may occur about certain apertures, as, for instance, those on the face, the parts about them being dragged out of normal position as by an extensive cicatrix. The aspect presented is very striking, and has been likened to a petrified, or frozen limb, or a corpse. When the change extends over nearly the whole body the patient becomes a helpless cripple, and the functions of deglutition and respira- tion may even be interfered with. The disease is usually very symmetrical, and may begin in one or more parts of the body ; the change is usually very extensive, and the dis- eased skin has an ill-defined border, with or without a velvet fringe, and passes insensibly into the healthy skin. Moreover, although the skin is dense and hard, it never ap- pears thickened, or as if infiltrated with a new deposit in the exact form seen in Morphcea, but thin and shrunken. It is necessary to pay attention specially to these points, because they are insisted on by such observers as Bulkley and Yan Harlingen, who deny that Morphcea is a circumscribed form of this affection (vide Morphcea), as held by Fagge, Tilbury Fox, Hutchinson, and Liveing, in England, and by Kaposi. Scleroderma commences more commonly at the back of the neck, and thence spreads to the face and trunk and even the limbs, or it may begin in the limbs and especially the hands and arms. It is far more common in females, and, though occurring at any age, from childhood upwards, is generally met wiih in adult or middle life. The affected parts usually feel cold, and are lower in temperature, and where the condensation is greatest the functions of the sudoriparous and sebaceous glands, of hair formation, and of 172 THE DETAILED DESCRIPTION the nerves of sensation, are interfered with, just as in Mor- phoea. So, too, irregularities of pigmentation occur fre- quently, and white patches may form, or more or less densely pigmented ones. The general health is often apparently good, and the patient may cease work simply from the increasing difficulty of motion in the parts ; or the health may be mani- festly bad, especially from rheumatism or heart disease, and there is frequently considerable anaemia. Apart from these influences, there is very little history of direct causation to be obtained, except, perhaps, a chill, exposure, or the sudden cessation of the menses. The onset may be pretty acute, but is nearly always very chronic. There is no febrile move- ment ushering in the disease, and no evidence of any inflam- matory action, but there may be some burning and stinging pains, and disturbances of pigmentation. As secondary effects, the constringing skin may cause some oedema 1 and even perhaps gangrene of the tips of the fingers and toes ; and further, the prominent knuckles, etc., may also become ill- nourished and ulcerated. In some of the records it is stated that the general health throughout was unaffected, but in the cases we have met with the general debility was great, and the functions of the stomach, etc., were much impaired. Indeed, Dr. John Harley regards the skin changes as a part only of a general affection of the sympathetic system of nerves. The course of the affection is very chronic, but it tends to get well after some years. Some cases end fatally, but usually from intercurrent disease, such as pneumonia, heart disease, phthisis, and Bright's disease. Pathology A good many microscopical examinations have been made of sclerodermatous tissues, from which it ap- pears that the epidermis is unaffected, but the cutis vera has its white fibrous and elastic tissues much increased in amount, 1 Some observers have described also a primary cedematous or brawny condition. OF CUTANEOUS DISEASES. 173 or at any rate the bundles are very densely packed in the corium. The fat cells become atrophied, and, in the subcu- taneous tissue, the fibrous elements become increased, and in well-marked regions of the disease the whole becomes welded into one dense felt. Kaposi 1 found the bloodvessels diminished in calibre, but here and there the perivascular sheaths distended with lymph corpuscles. He considers the disease as due to a generally abnormal state of the nutritive processes, which induces thickening and stagnation of the lymph, and consequent firm rigid infiltration of the cutis, and the subsequent overgrowth and shrinking of the con- nective tissue. Differential Diagnosis There are few conditions that could possibly be mistaken for Scleroderma by those who have seen the disease, but it is necessary where oedema exists to distinguish it from conditions induced by the latter, and from the brawny induration of diffused cancer and elephan- tiasis arabum. In the very young especial care must be used to discriminate it from the so-called Sclerema neona- torum. Treatment — We have always carried out the administra- tion of cod-liver oil, iron, mineral acids, phosphoric acid, nux vomica, and plenty of light nourishing diet, but it can- not be said that the immediate influence of this is very per- ceptible. Partial good effects have been obtained from electricity. Scrofuloderma — This disease must be carefully dis- tinguished from lupus, though there may be some difficulty w r hen the latter occurs in a scrofulous subject. It commences as indolent, painless, livid tubercles that very slowly soften up and give place to foul, ragged, unhealthy ulcers with pallid granulations, free secretion, and often much crusting. Occa- 1 Syd. Soc. Trans., p. 123. 15* H4 THE DETAILED DESCRIPTION sionally the ulceration is very superficial, and creeps along the surface. This is the form which usually results from the slow breaking down of chronically inflamed and strumous glands. Marked scrofulous features will be recognized in this disease in the family history, the physiognomy, the chronic glandular inflammation, the strumous affection of the eyes or ears, and the possible coincident disease of the spine or joints. Treatment Internally, this consists in endeavoring to counteract the strumous habit by giving cod-liver oil or some equivalent, the iodide or phosphate of iron, quinine, or the sulphide or chloride of calcium, and good food in variety. Locally, the sores must be cleansed by such applications as iodoform or the iodide of starch paste, and the pus produc- tion may require checking by a mild mercurial ointment. Later, the sore may require a more stimulating ointment or plaster, of which the mercurial preparations are the more suitable. Seborrhcea This consists in an excessive secretion of sebum. The disease attacks the scalp and the face chiefly, but may occur on other parts of the body. It is usually lo- calized to one region, such as the scalp or the nose, but not necessarily. In the newly born it may be pretty general, forming a fatty layer over the surface, a modification or rem- nant of which is seen in the caked incrustation that forms on the scalp of young infants. Seborrhoea may be slight and temporary, or obstinate and chronic. Patients affected by it are generally of lymphatic temperament and weak. Se- borrhoea is not usually accompanied by any local symptoms, except those due immediately to the presence or excess of sebum, but there may be decided heat, hyperemia, and swell- ing as about the nose and cheeks. There is always itching. The actual sebaceous secretion varies in aspect. It may be more or less soft, so that the skin of the affected part is oily ; OF CUTANEOUS DISEASES. 115 this is termed S. oleosa; or it may dry into fatty plates, consisting of dirty white flat scales that feel greasy, and are easily detached, exposing a very slightly reddened and non- excoriated skin, in which the sebaceous glands are more dis- tinct than usual. This is the common form of seborrhoea. It is termed S. sicca, and constitutes what is termed "dandriff " or "scurf" in the head, Thirdly, the fatty secretion may take the form of little plugs distending the orifices of the glands, and then the skin feels harsh like a file ($. cornea). The seats of seborrhoea are especially the scalp and the face. It is liable to be confounded with eczema, but in seborrhoea, although the skin is reddened, there is no breach of surface as is seen when the scaliness and crusting are removed. The follicles are seen also to be more patent than usual, and the incrustation is also soft and greasy, and not the result of the drying of " discharge." Treatment It is requisite to give tonics and arsenic, as (90), (93), (94), (103): locally to get off 1 the crusts by oily inunction, and to apply astringents, as (14), (25), (40), (51), (00), (73). Strophulus or Red Gum This term has been ap- plied to many different eruptions, consisting of soft red papules in infants ; in one case, to hyperagmic papillae, in another, to hypercemic sweat glands, and again, to distended sebaceous glands. So-called strophulus, characterized by bright-red points, seated on the face and arms of children, is, in fact, a hypera?mia of the papilla? or sweat glands, mostly induced by the child being kept very much wrapped up, and so overheated. S. albidus is the term given to the small pearly-white specks seen about the face of children, and due to distended sebaceous glands. The hyperremic states alluded to above are exaggerated by any stomach disturbance. Strophulus pruriginous is a modification of Lichen urticatus. When, in ill-nourished children, that disease be- 176 THE DETAILED DESCRIPTION comes very chronic, the "wheal" or "urticarial" aspect may give place to the " pruriginous" almost, if not entirely, and when the skin is covered pretty uniformly w r ith the pru- riginous papules only, then the condition known as Stro- phulus pruriginosus is present. At least this is the history of cases I have seen, though I notice Duhring states that Hardy recognized a case of true prurigo as one of S. pruriginosus. Treatment. — Some mild aperient and antacid should be given, with the adoption of a cool regimen, and the local use of some simple soothing lotion, as (74). S. pruriginosus needs locally simple baths, followed by inunction of oil, gen- erous diet, and cod-liver oil and iron internally. Sudamina are the tiny, rounded, non -inflammatory vesi- cles formed by the collection of sweat between the layers of the cuticle, and due to the excessive or suddenly augmented secretion of sweat. They are especially met with in the summer months, when the sweat glands are very active, and more particularly in the course of a febrile disease, such as phthisis or acute rheumatism, and during the critical sweats. The causes that lead to the formation of Sudamina may also excite some inflammation, and then the usually transparent contents of the sudamina may become opaque and puriform, and the vesicles may be complicated by miliaria. Sudamina seldom exceed a pin's head or millet seed in size, though, very rarely, they become confluent into bullae. The vesicles may crowd the surface or be sparsely distributed, and they are most often seen about the neck and trunk. Treatment — As with miliaria, when met with as an acci- dental occurrence in the pyrexial state, the presence of su- damina is of little importance, but otherwise it should be borne in mind that they may be evidence of debilitated health which requires tonics. Sycosis is the name given to inflammation of the hair follicles of the beard and whiskers. There are two forms. OF CUTANEOUS DISEASES. 17T In the one the disease is caused by a vegetable parasite, and is designated Tinea sycosis. (See that disease under the head of Tinea.) The other arises as an idiopathic inflam- mation of the follicles, and then is called simply sycosis. In this latter simple or non-parasitic form the disease consists in simple catarrhal inflammation of the follicles, character- ized by pain, heat, redness, and the speedy development of pustules, at first small, then larger, which have this pecu- liarity, that they are pierced by a hair and are scattered, here and there, about the hairy parts of the face. The pus- tules, which indicate that the whole hair sacs and their walls are inflamed, may become more or less indurated at their bases, forming quasi-tubercles. If the inflammation is severe, and the pustules are crowded together, there may be considerable discharge and crusting. The derma and con- nective tissue textures of the affected part may be involved, so that the parts are reddened, hot, swollen, and infiltrated, and the patient may suffer great pain. The disease, how- ever, differs very much in severity. It often occurs in the debilitated, the intemperate, the dyspeptic, and eczematous. It often, too, runs a very chronic course, especially in stru- mous subjects, and in such cases more or less atrophy and loss of hair may result ; in fact, as a consequence of the depth and severity of the inflammation, a condition simulating lupus may result. In some cases the upper hairy lip is the seat of the syco- sis, and the disease begins as a catarrh of the mucous mem- brane of the nose, the inflammation spreading down and involving the follicles of the lip. The characters in the main are those of sycosis, but there may be great swelling and infiltration, so that the disease looks like a mass of fleshy outgrowth, with considerable elevation. There are, however, usually, characteristic pustules. We presume this is the Impetigo sycosiformis of authors. The main thing to 178 THE DETAILED DESCRIPTION recollect about the disease is the necessity for soothing treatment. Treatment — It is generally considered that epilation rap- idly cures the disease, but this is a mistake, and, indeed, the procedure often does harm. Some say that sycosis is caused by the premature development of a new hair in the follicle, and so epilation does good. This is not true. Others think that epilation relieves the tension. In some cases the in- flammation does not extend to the deeper part of the folli- cle, and so the procedure can scarcely be of service ; but it no doubt is of use if there be much chronic inflammatory thickening involving the deep parts of the follicle with free suppuration, especially if there be much tension, and the pus has a difficulty in escaping. Sycosis should really be treated as a simple inflammation, locally by hot fomentations and soothing remedies in the early and acute stages, and subse- quently by the use of astringents, as (75), followed by weak mercurial ointments, and, lastly, tar or sulphur applications. Internal treatment consists in the use of aperient tonics, as (95), or saline aperients at the outset, in cases where there is much hyperemia and patients are gouty ; later on cod- liver oil and iron are needed, and lastly, a course of Dono- van's solution where there is much indolent thickening. Where there is. much thickening, painting with liquor po- tassae, followed up with the use of mercurial plaster, is often of service, but the disease must be in an indolent state for this treatment. We always find, where there is much infil- tration about the follicles and any tendency to atrophy of the textures, that antistrumous remedies internally and mild as- tringents externally do most good. Syphilis of the Skin is met with in connection with hereditary and acquiied syphilis. Hereditary syphilis is practically nearly synonymous with congenital or infantile syphilis. This form is uncommon OF CUTANEOUS DISEASES. 179 before the end of the second or beginning of the third week, and it is rare after the sixth month ; the usual period of its occurrence is when the child is about three weeks or a month old. No one can mistake the tainted infant : the general aspect is more or less marasmic ; the child presents a shriv- elled, " old man"-like aspect ; the skin is dirty and muddy, it has lost its elasticity, and hangs in loose folds ; it is dry, often exfoliating, and more or less erythematous about the buttocks. The cry of the child is harsh and cracked (cha- racteristic), and " the snuffles, produced by inflammation and ulceration of the nasal mucous membrane, are present." The disease is further characterized by the presence of mucous tubercles about the anus or mouth ; fissures at the angles of the mouth : ulceration of mucous surfaces ; a high arched palate ; inflammation of the thymus gland ; various eruptions over the body, especially about the feet and hands, in the form of erythemata or bullae ; a subacute onychia is possibly present ; and these, together with a family history of syphilis, are diagnostic. With regard, however, to the eruption, it is generally in the form of a dull-red erythema of the hands, feet, and peri- anal region, with or without tubercular formations ; but it may in cachectic subjects consist in ugly ulcerations arising out of tubercles, bullae, or pustules. The treatment consists in gently mercurializing the child by the use of gray powder or mercurial inunction (a small portion of blue ointment being rubbed into the soles of the feet each night), in keeping up the nutrition of the body by good food, by giving cod-liver oil and chlorate of potash, and, if the child is nursed, in giving the nurse a course of iodide of potassium [which the infant imbibes with the milk]. Acquired Syphilis. — When in the adult an eruption is due to this cause, there is usually imparted to it a coppery tint, and a more or less circular form ; the distribution of the eruption is general over the body and usually there is ab- 180 THE DETAILED DESCRIPTION sence of pain and itching ; there is also a polymorphism about the eruption, that is, it is made up of a variety of forms such as papules, tubercles, and ulcers (occasioning loss of substance), etc. "In addition, cachexia, ulcerated throat or tongue, alopecia, nocturnal pains in different parts are the usual concomitants ; and a history of the primary disease may be connected by different links with the existing con- dition by a series of syphilitic occurrences. Syphilodermata may be divided for all practical purposes into three groups : (a) those that are simply hyperamiic ; (b) those that have deposit (or new tissue formation) as the main feature ; and (c) degenerative lesions, the result of suppuration and ulceration of the syphilitic new tissue formed in the skin. The following sketch may throw light on this subject. The first effect of the syphilitic poison upon the general sys- tem is to give rise to syphilitic fever and transitory hyper- amiic lesions, as roseola and erythema, which are phenomena belonging to the early stage of syphilis. These occur with the syphilitic fever, in patches over different parts of the body, and in connection with many other evidences of the action of the syphilitic poison — i. water, 3iv. Used for warts, lupus, etc. 7. Powdered savin, perchloride of mercury, red oxide mercury, aa 3j« Used for condylomata and warts (Lang- ston Parker.) 8. Carbolic acid, 1 part; alcohol, 1-4 parts. Used in lupus, syphilitic ulcers. 9. Nitrate of zinc, 1 part ; bread mass, 2 or 8 parts. Used in lupus, spread thinly on the part. 9a. White arsenic, 10 grains; cinnabar, 3 SS > lard, jfss. To be used to small portions at a time of lupus erythema- todes, and to be re-applied if necessary. CUTANEOUS PHARMACOPEIA. 201 ASTRINGENTS. Alum and Zinc. 10. Alum, gr. xx ; sulphate of zinc, gr. x ; glycerine, 5j ; rose-water, ^iv. Used in erythema, intertrigo, eczema. Tannic Acid. 11. Tannic acid, gr. xl ; French vinegar, |§ss ; distilled water, ^viiss. Used in seborrhcea — (Neligan.) Myrrh and Zinc. 12. Tincture of myrrh, gtt. xxx ; zinc oxide, gr. xx ; cold cream, ^j. Used in prurigo, erythema, lichen — (Neligan.) Bismuth and Vaseline. 13. Trisnitrate of bismuth, 9ij ; solution of subacetate of lead, 30 drops ; vaseline, ^j. For intertrigo, eczema, etc. Zinc and Glycerine. 14. Zinc oxide, 3ij ; glycerine, J'j ; solution of subacetate of lead, 3iss ; lime-water, £vj to ^viij. Used in the secre- tory stage of eczema, in acne, lichen, foul ulcers, impetigo, herpes. Borax and Glycerine. 15. Borax, 9j or 3J ; glycerine, 3ij ; rose-water, *viij. Used in squamous diseases. Acid and Lead. 16. Dilute hydrochloric or nitric acid, 5 SS 5 l ea( ^ acetate, gr. v to x ; glycerine, 3iss ; water, g'vj. Used in eczema and lichen. Alum. 17. Alum, 3ij ; infusion of roses, ,^xx. Used in acne, pityriasis, and eczema (sine crustis) (Casenave.) 202 SELECTED FORMULA AND SEDATIVES. Soda. 18. Carbonate of soda, 5 SS > conium juice, ^j ; elderflower water, 3yj. Used in eczema, lichen, and urticaria, to allay itching. 19. Bicarbonate of soda, 5j > glycerine, 3i ss ; elderflower water, ^viss. Used as above, and in acne punctata. 20. Borax, Jrj ; cherry laurel water, ^j ; elderflower water, ^vij. Used in lichen. Morphia. 21. Borax, ^ss ; sulphate of morphia, gr. vj ; rose water, ifviij. Used in pruritus vulvce (Meigs.) 22. Solution of hydrochlorate of morphia, ^iss ; solution of potash, 3'j ; glycerine, ^j ; cherry laurel water, ^j ; elder- flower water, §xij. Used in pruriginous eruptions. Hydrocyanic Acid. 23. Bichloride of mercury, gr. j ; dilute hydrocyanic acid, 3j ; emulsion of almonds, ^vj. Used in itching, lichen, and prurigo. 24. Dilute hydrocyanic acid, Jj ; solution of acetate of ammonia, §ij ; tincture of digitalis, yi\] ; rose-water, ^v. Used in pruritus, prurigo, lichen, and urticaria. 25. Dilute hydrocyanic acid, 3\j ; borax, 5j ; rose-water, ^viij. Used in pruritus of old people — (Neligan.) Cyanide of Potassium, 26. Cyanide of potassium, gr. vj ; cochineal, gr. j ; cold cream, ,f j. Used in pruritus and urticaria — (Anderson.) 27. Cyanide of potassium, gr. xv ; water, ^viij. Used in pudendal irritation, lichen, and prurigo. It should be kept in a dark place (Hardy.) CUTANEOUS PHARM ACOPCEIA. 203 Chloroform. 28. Carbonate of lead, 3ss; chloroform, r^iv; cold cream, ^j. Used in pruritus. 29. Cyanide of potassium, gr. iv ; chloroform, n^viij ; glycerine, 5j '■> white wax ointment, 3 V J« Used in pruritus. — (Neligan.) 30. Chloroform, 3j ; glycerine, 3i y — (Duparc.) 31. Bichloride of mercury, gr. iss ; chloroform, n^xx; glycerine, ^ij ; rose-water, 3yj. Used in itching, papular, and vesicular diseases, and urticaria (Burgess.) Belladonna. 32. Extract of belladonna, ^ss; dilute hydrocyanic acid, ^ss ; glycerine, ^j ; water, §xiv. Used in papular and phlegmonous affections (Startin.) Benzoic Acid. 33. Benzoic acid, 40 to 60 grains to ^vj of water. Used in urticaria to allay itching — (Ringer.) Digitalis. 34. Tincture of digitalis, 3ij to 3iv; glycerine, ^ss; rose- water, ^vj. Used in pruritus of a purely neurotic character. Lead. 35. Carbonate of lead, gr. iv; glycerine, 3 j ; simple cerate, ^j. Used in erythema. 36. Glycerine, subacetate of lead, and vaseline. (Made by Squire, 277 Oxford Street, London.) In intertrigo, ec- zema. A convenient application is made by rubbing up from half to a drachm of solution of lead, with an ounce of vaseline. 204 SELECTED FORMULAE AND Acetate of Ammonia. 37. Solution of acetate of ammonia, ^ij ; alcohol, § ss ; rose-water, ^iv. Used in lichen — (Burgess.) Carbolic Acid. 38. Liquid carbolic acid, ^ss ; water to Oj. Used to allay itching in chronic eczema, or psoriasis. Zinc. 39. Oxide of zinc, 5ij ; solution of lead, 3j ; wine of opium, 5J » P°PP7 decoction, ^iv. Used in eczema, herpes, etc. 40. Oxide of zinc, 3j > carbonate of lead, 5j ; spermaceti, ^j ; olive oil, q. s. To make a soft ointment. Used in se- borrhcea, where the skin is inflamed — (Neumann.) Camphor. 41. Camphor, 3ss ; alcohol, q. s. ad solve ; oxide of zinc and starch, aa ^j. Used as a powder to allay burning heat of eczema (Anderson.) 42. Camphor, gr. viij ; tincture of conium, 3U '•> simple cerate, ^j (Neligan.) 43. Camphor, £ss or £j. alcohol, § j ; borax, 9*ij ; rose- water, ^ viij. Used in 'pruritus, eczema, and the erythemata. 44. Sulphate of atropine, gr. j ; borax, 3U ; glycerine, 3iij ; distilled water to §xij. Used to allay pruritus in various diseases where skin is not abraded. Borax. 45. Borax, 9ij ; carbonate of soda, 5j '■> glycerine, 3* ss ; dilute hydrocyanic acid, ni^xxx ; distilled water, gvj. Used in vesicular and sebaceous diseases. 46. Borax, 9ij ; oxide of zinc, 3j ; solution of subacetate of lead, 3\j ; lime-water, ^yj to ^ viij. Used in eczema and herpes. CUTANEOUS PHARMACOPOEIA. 205 47. Borax, 5j to 5U 5 glycerine, 5 j ; lard, ^j. Used in parasitic diseases, and in eczema, erythema, intertrigo, and lichen. ABSORBENT POWDERS. 48 (a). Powdered maize, §iv; oxide of zinc, ^j ; cala- mine, ^ss. Used to excoriated surfaces. 48 (b). Powdered maize, §iv; oxide of zinc, ^j ; orris powder, § ss ; essential oil of almonds, gtt. iij. 49. The white Fuller's earth, or Cimolite (prepared by Taylor, Baker Street, London). STIMULANTS AND ABSORBENTS. 50. Alcohol, oil of cade, soft soap, aa ^j : oil of lavender, 3iss. Used in eczema and psoriasis. — (Anderson.) 51. Soft soap, §ij ; spirits of wine, ^j ; dissolve, filter, and add spirits of lavender, 3'j- Used in seborrhosa — (This is the "Kalicreme" of Hebra.) Iodide of Starch Paste. 52. Powdered starch, 1 part ; glycerine, 2 parts ; water, 6 parts : boil together, and when nearly cold add solution of iodine, 1 part. Useful to cleanse and heal foul sores, espe- cially such as are syphilitic (Univ. Coll. Pharm.) Lead. 53. Lead plaster, ^ss ; almond oil, ,lss; benzoated oxide of zinc ointment, Jij. To be used in eczema as an astrin- gent dressing. Iodoform. 54. Iodoform, gr. xxx-lx ; lard, ]§j. Used to dress pain- ful bums, ulcers, chancres, and boils. 18 206 SELECTED FORMULAE AND Mercurial. 55. Calomel, 5j 5 lard, ^j. Used in herpes, psoriasis, and pruritus vulvce. 56. The oleates of mercury, 5 and 10 per cent. Useful in ringworm, syphilis, sycosis, etc. 57. Green iodide of mercury, gr. ij to gr. xv ; lard, ^j. Used in acne (Hardy.) 58. Calomel, 3j 5 camphor, 3 SS 5 spirits of wine, q. s. ; lard, ^j. Used in pruritus of the anal region, and in syph- ilitic ulceration. 59. Bicyanide of mercury, gr. v to gr. x ; lard, §j. Used for syphilitic tubercles. 60. Red oxide of mercury, finely powdered, and ammo- niated mercury, aa gr. vj ; lard, §j. (The " Unguentum raer- curiale comp.") Used in sebaceous, squamous, ulcerous, tubercular, and papular eruptions (Startin.) 61. Iodine, ^ss ; glycerine, ^ij ; olive oil, ^iijss ; strong mercurial ointment, ^ij. (The Linimentum hydrarg. et iodini of Startin.) Used in tubercular and cachectic affec- tions. 62. Ammoniated mercury, gr. v ; nitrate of mercury oint- ment, gr. xx ; acetate of lead, gr. x ; oxide of zinc, gr. xx ; purified palm oil, 5ss ; fresh lard, ^jss. Used in eczema oj the head, in children especially. 63. Nitrate of mercury ointment, Jj ; solution of subace- tate of lead, ^\ss ; oxide of zinc, 3j '•> carbolic acid, gr. v ; fresh lard, ^j. Used in inflamed or irritable psoriasis. Sulphur. 64. Iodide of sulphur, gr. x to 3j ; lard, 3j« Used in acne. 65. Milk of sulphur, 3ij ; aether, ^ss ; spirits of wine, 3iij ; glycerine 3"j ; rose water £vj. To be dabbed on once or twice a day to indolent acne indurata or rosacea, allowed to remain a moment or two, and then dried off with linen. CUTANEOUS PHARMACOrGEIA. 207 6Q. Hypochloride of sulphur, 5lj > carbonate of potash, gr. x ; lard, ^j ; oil of bitter almonds, gtt. x. Used in acne. —(Wilson.) 67. Sulphur, glycerine, rectified spirits of wine, carbonate of potash, sulphuric ether, equal parts by weight. To be rubbed on to the part affected with comedo, with friction. Tar. 68. Tar, alcohol, aa ^j. Used in psoriasis chiefly. 69. Pyroligneous oil of juniper, 3j to ^j ; mutton suet, 3ss ; lard, ^j. Used in eczema and psoriasis pal maris, etc. 70. Tar, 3j ; camphor, gr. x ; lard, 3x. Used in pruritus and in vesicular and papular diseases (Baume.) 71. Detergent solution of tar, 3ij to ^j ; glycerine, 5'j » rose water to Jviij. Used in chronic scaly, itchy conditions (dilute hydrocyanic acid may be added, itlxxx). Silver. 72. Silver nitrate, gr. ij to gr. x ; water, §j. Used in eczema and erythemata. Bismuth. 73. Bismuth nitrate, 3lj 5 mercury bichloride, gr. x ; spirits of camphor, 5 SS > water, q. s. ad ^xvj. Lotio bis- muthi nitratis. Used in sebaceous, pustular, and vesicular diseases, and in pityriasis. Use diluted with 1 to 3 parts water — ( S tartin.) Zinc. 74. Oxide of zinc, 5\i ; calamine powder, §ss ; glycerine, 3ij ; rose water, ^ v j- Used in eczema, especially where the surface is red and tender. A grain of the bichloride of mercury may be added. 75. Sulphate of zinc, 3 SS ; oxide of zinc, 3j '■> alum, 3j ; glycerine, 3\j ; r °se water to ^vj or more. Used in scaly stages of eczema, indolent intertrigo, etc. 208 SELECTED FORMULAE AND Hebrews Unguentum Diachylon. 76. This is made by boiling together olive oil, |xv, and litharge, ^iij et 3 v j> to ft good consistence, and adding oil of lavender, 5ij« Used in eczema, applied twice a day on linen. 77. Subcarbonate of soda, 3\j ; extract of opium, gr. x ; slaked lime, 5j ; liquor plumbi, ^ij. Used for severe itching in prurigo (Biett.) 78. Nitrate of mercury ointment, 30 > camphorated oil, glycerine, aa ^ss. Used in psoriasis. 78 (a). Solution of chlorinated soda, £ss ; carbonate of potash, gr. xx ; orange flower water, %x. Used for freckles. PLASTERS. 79. Camphor, 3ss ; black pitch, 3vj ; yellow wax, %ix ; red oxide of lead, ^ij ; olive oil, 3jiv. To be melted together till a little burned. Used in boils. (JEJmplastrum. fuscum.) 80. Mercury, %v ; turpentine, 3ij ; yellow wax, Jiij ; lead plaster, jfiss. Used in acne rosacea. — (Emplastrum hy- drargyri Neumann.) 81. Mercurial plaster, soap plaster, aa ^j. Used for syphi- litic papules, tubercles, and indurations generally. 82. Ammoniated mercury, 3ss ; soap plaster, ^ss. Used in syphilitic excoriations and ulcerations. (Sigmund.) 83. Red oxide of mercury, 3 SS '■> ammoniated mercury, 3ss ; soap plaster, ^ij. Used in syphilitic cracks and fis- sures about the hand, indurations, etc. MIXTURES. 84. Solution of bichloride of mercury, 5yj ; dilute hydro- chloric acid, 3 SS 5 water, ^vj. A sixth part to be taken twice a day in syphilis. 85. Bichloride of mercury, gr. j ; iodide of potassium, 3'j ; water, ^iij. A dessertspoonful three times a day. Used in acne (Burgess.) CUTANEOUS PHARMACOPEIA. 209 86. Solution of bichloride of mercury, 3 v j 5 iodide of potassium, 3j ; compound tincture of iodine, n^xv; water, 3 viij. A sixth part may be taken twice a day. Used in syphilis. 87. Bichloride of mercury, gr. | to T \ ; arsenious acid, gr. gV to ^q ; water, ^ss. For each dose, in chronic syphilis. 88. Iodide of potassium, 3ss-5iij ; sal volatile, 3iij ; syrup of orange-peel, 5 1V ; water to g viij . A sixth part with half a tumbler of water twice a day. The dose of iodide of po- tassium may be increased gradually still further, if required. Used in secondary and tertiary syphilis. 89. Iodide of potassium, 5ss or more ; potassio-tartrate of iron, 5j ; syrup, ^ss ; water, J vj. One-sixth part for a dose, in chronic syphilis in anaemic subjects. 90. Wine of iron, ^jss ; simple syrup, ^ss ; Fowler's so- lution, gtt. xlviij ; distilled water, to ^vj. Dose: a table- spoonful twice or thrice a day, in psoriasis and other chronic skin diseases. 91. Fowler's solution, rr^lxxx ; iodide of potassium, gr. xvj ; iodine, gr. iv ; orange-flower water, ^ij. Dose: a tea- spoonful with water three times a day. Used in eczema. — (Neligan.) 92. Cod-liver oil, ^ij ; yelk of one egg; Fowler's solu- tion, TTi,lxiv ; syrup, 5ij ; distilled water, q. s. ad Jiv. Dose : one teaspoonful three times a day — (Wilson.) 93. Arseniate of soda, gr. i. to ij ; distilled water, ^ viij. Dose : one tablespoonful twice daily. 94. Hydrochloric solution of arsenic, 3ss ; dilute hydro- chloric acid, 5J ; tincture of the chloride of iron, 3iss to 3iij ; water, g viij. Dose: a sixth part three times a day. In psoriasis and eczema in anaemic subjects. 95. Sulphate of magnesia, 3"j ; sulphate of iron, gr. xij; dilute sulphuric acid, 3ss ; infusion of quassia, q. s. ad J viij. Dose : one-sixth part twice daily. Used in acne, eczema, 18* 210 SELECTED FORMULAE AND impetigo, and ulcerous affections. Quinine may be added if desired. 96. Sulphate of magnesia, 5* v > carbonate of magnesia, 5j ; tincture of colchicum, n^xxxvj ; oil of peppermint, nijj ; water, o y ij« Dose: a sixth part. Used in erythematous, papular, and acute forms of disease in gouty subjects. 97. Bicarbonate of soda, 3"j ; tincture of calumba, %uj ; sal volatile, 3iij ; dilute hydrocyanic acid, rr^viij ; syrup of ginger, 5iij ; water, ^vj. Dose : a sixth part an hour before the two principal meals. Used in skin diseases accompanied by dyspepsia. 98. Acetate of potash, ^j ; acetic acid, 3ss ; spirits of ni- trous ether, ^iss ; fluid extract of taraxacum, ^ij. Dose: a teaspoonful with water before meals. Used in acne inda- rata (Bulkley.) 99. Iodide of sodium, 3j ; compound decoction of sar- saparilla, ^viij. Dose: a sixth part three times a day in obstinate syphilitic eruptions, where iodide of potassium disagrees or fails. 100. Turpentine, rectified, 3ss to %\ss ; creasote, n^iij ; spirits of rosemary, ni^xl ; water, q. s. ad ^iv. Dose : two teaspoonfuls every three hours. Used in purpura (Budd.) 101. Acid tartrate of potash, %uy, decoction of broom, Jfvj. Dose : one-sixth part three times day. Used as a di- uretic and aperient in eczema of the legs with oedema. 102. Acetate of potash, 3iij ; vinegar of squill, 3iij ; sweet spirits of nitre, n^xx ; compound decoction of broom, §viij. Dose : a sixth part thrice daily. Used as a diuretic, where the skin is very hyperaamic and the urine not freely voided. Digitalis may be added if desired. 103. Strychnia, gr. ss-j ; dilute phosphoric acid, 3iij ; tinc- ture of orange-peel, ^ss ; infusion of cloves, ^xj. Dose : half an ounce three times a day. Used in prurigo and lichen. CUTANEOUS PHARMACOPOEIA. 211 PILLS. 104. Red iodide of mercury, gr. j to ij ; extract of gen- tian, 9'ij. Make 12 pills. One pill twice a day. 105. Bicyanide of mercury, gr. j ; quinine, gr. xx ; extract of gentian, gr. xxx. To make 20 pills. One twice a day. Used in ordinary syphilitic eruptions. 106. Arseniate of soda, gr. ij ; water sufficient to dissolve it ; guaiacum powder, Jss ; sulphurated mercury, £)j. Muci- lage sufficient to make 24 pills. One pill two or three times a day. Used in chronic skin diseases. — (Wilson.) 107. Levigated arsenious acid, gr. v ; powdered acacia, 5ss ; cinnamon powder, 3iij ; glycerine, enough to make 100 pills. (Pil. arsenicalis comp.) Dose : one or two a day. 108. Arsenious acid, gr. j ; quinine, gr. 20-30 ; dried sul- phate of iron, or reduced iron, gr. xl-3j ; extract of hop, gr. x ; extract of gentian, q. s. To be well mixed and divided into 20 or 30 pills. One twice a day after a meal. Used in chronic skin diseases with debility. 109. Quinine, gr. j— ij ; reduced iron, gr. ij ; extract of nux vomica, gr. \ ; extract of chamomile, gr. j. To be taken twice or thrice a day. REMEDIES FOR SCABIES AND PHTHIRIASIS. 110. Sulphuretted potash, Jvj ; hard soap, ifeij ; oil of thyme, 5ij '■> olive oil, Oij. Used in scabies and prurigo. 111. Olive oil, £ij ; sulphate of potash, 5 XV 5 sulphate of soda, 5 XV '■> precipitated sulphur, 3 X « Used in scabies (Mollard.) 112. Sulphur, tar, aa §vj ; soft soap, lard, aa ,fxvj ; chalk, §iv. Used in scabies. — (Hebra.) 113. Lard, ^ij ; sulphur, 3v ; carbonate of potash, water, aa 3ij- Used in scabies — (Hardy.) 114. Sublimed sulphur, 3 SS > ammoniated mercury, gr. v; creasote, gtt. iv ; olive oil, 3U ; fresh lard, ^j. Used in sca- bies. 212 SELECTED FORMULAE AND 115. Olive oil, )§ss; lard, ^ss ; powdered stavesacre, 5»j ; Soak the stavesacre in hot oil and mix. Used in phthiriasis. 116. Quicklime, ^ xv j '■> flowers of sulphur, ^xxxij ; water, 20 pounds. Boil until 12 pounds remain, and then filter. Used in scabies (Vlemingk's Solution.) 117. Iodide of potassium ointment is very efficacious in scabies. 118. Sulphur ointment, ^ij ; oil of chamomile, gtt. xx. Used in scabies. 119. For phthiriasis the ordinary white precipitate oint- ment of the Pharmacopoeia is as good a remedy as any, diluted from 5 to 10 times. 120. Liquid storax, *j '■> lard, ^ij. Melt and strain. Used in scabies. — (Anderson.) A little sulphur may be added if thought desirable. REMEDIES FOR VEGETABLE PARASITIC DISEASES. 121. Bichloride of mercury, gr. x to xx ; elder-flower ointment, §j. Used in the early stages of favus and tinea tonsurans. 122. Carbolic acid, 3j '■> glycerine, §ss to Jj. Used in tinea tonsurans. Or, the same with rose water, ^ iv, in tinea circinata. 123. Hyposulphite of soda, ^iij; dilute sulphurous acid, 3ss; water, q. s. ad §xvj. Used in all forms of vegetable parasitic disease — (Startin.) 124. Bichloride of mercury, gr. ij to iv ; alcohol, $\v ; chloride of ammonium, 5 SS 5 rose water, q. s. ad ^vj. Used in scabies, phthiriasis, and tinea versicolor. 125. Officinal solution of sulphurous acid, 1 part; water, 2—4 parts. Used in all the tinece. 126. Pyroligneous oil of juniper, 3ij to 3iv ; lard, Jiiss. Used in tinea. CUTANEOUS PHARMACOPEIA. 213 127. Hyposulphite of soda, 5' v I glycerine, ^j ; distilled water, Jvj. Used in pruritus vulvce and tinea versicolor. 128. Ammoniated mercury, gr. vj-xxx : red oxide of mercury, powdered, gr. vj-xxx ; lard, ^j. Used in all forms of ringworm — (Startin.) 129. Strong ammonia liniment, ^ss ; castor oil, ^ss ; spirits of turpentine, purified, ^ss ; ammoniated mercury, gr. xv. Brush into the scalp with a hard brush until irritation is set up. For baldness. 130. Tincture of cantharides, ^j ; distilled vinegar, Hiss; glycerine, 3i ss ; spirits of rosemary, §iss; rose water, ^viij. To be well sponged into the scalp night and morning. For thinning or loss of hair in the scalp. 131. Blistering fluid (liniment, cantharides), 3J ; sulphate of zinc, gr. xx ; balsam of Peru, 3iss ; powdered galls, 3'j ; lard, 3j. For tinea tonsurans. 132. Subacetate of copper, gr. xxx ; birch oil, 3iij ; lard, 3j. Same. 133. Sulphur, tar, tincture of iodine, lard, aa ^j. Same. 134. Carbolic acid, 3j ; sublimed sulphur, 5"j '■> tincture of iodine, 3"j > vaseline (unguentum petrolei) or lard, 3j- In tinea tonsurans. 135. Blistering fluid, 3j ; sulphate of copper, 9ij ; pow- dered galls, 3j ; vaseline, ^j. For ringworm. 136. Iodine, 3j-ij > colorless oil of wood tar, §j. (This preparation is sometimes known as " Coster's paste.") 137. Tincture of iodine, 3 v j 5 iodide of iron, gr. xij ; ter- chloride of antimony (liquid P. B.), %lv. This solution should be used with care, and should not be used to sore or abraded surfaces ; but with this limitation, if painted over a limited area in ringworm, say to an inch square at a time, and repeated if need be, it is efficacious. An ointment made of 5 or 6 grains of the crystallized terchloride of anti- mony to the ounce of lard, with or without ammoniated mercury, and used freely to obstinate places, often acts well. 214 DIET IN DIET IN SKIN DISEASES. There are one or two observations to be made on this sub- ject that may be of use in the management of these diseases. First A distinction must be made between the diet of the private and hospital patient. The latter often only re- quires to be well fed up and his disease then speedily goes ; the former, on the other hand, often needs to have a check put on the quantity and quality of his food, but both need due attention to be paid to their excretory functions, that they be not sluggish. Secondly In young children, skin diseases often arise directly from defective alimentation, as in the case of eczema; and it is frequently the case that the child, the subject of eczema, intertrigo, or psoriasis, has not a sufficient supply of milk, either from excessive dilution or otherwise ; or the child is being nursed by a weakly mother. Thirdly The regulation of the diet, setting aside the question of quantity or quality, is, as a rule, needed not so much to directly influence the skin disease as certain states of the general health, which modify the particular disease present ; for instance to meet dyspeptic, gouty, and rheumatic conditions especially, but particularly the former ; and the mode in which these act prejudicially upon skin diseases has been referred to in Part I. of this work. In dyspepsia in connection with eczema, acne, psoriasis, lichen, or congestion of the face, it is advisable, especially if the urine be very acid, to avoid sugar, tea, coffee, alcoho- lics, beer, raw vegetable matter, unripe or uncooked fruit, veal, pork, seasoned dishes, pastry, cheese, pickles, and the coarser kinds of vegetables, but especially all articles whose use is followed by heat or flushing of the face, and by flatu- lence, or the like. Milk, the common meats, a light kind of SKIN DISEASES. 215 bread, and some very sound light wine should be the diet of dyspeptic patients, whose skins are at all in a state of irrita- tion. In very many cases the stomach is at fault at the outset, and a careful regulation of the diet is of the utmost importance as an aid to the other means adopted to correct faults in other parts of the system. This implies on the part of the practitioner the possession of an accurate knowl- edge of the characteristics of the various forms of gastric, intestinal, and hepatic functional diseases, which is indeed most necessary to a successful dealing with a great number of skin troubles. In the case of gouty subjects the above remarks apply Avith special force. As regards stimulants, a good light claret, or whiskey in Vals water, are the best beverages. In strumous subjects, the diet should consist of as much fatty matter as possible. Fourthly In children who suffer from ringworm, it is desirable to give as much fatty matter as possible, by means of milk, cream, eggs, and fat meat if they can eat it. Fifthly In syphilis, the greatest care should be taken to avoid anything beyond the most moderate use of stimulants ; their abuse in this 4isease is a source of the greatest aggra- vation ; otherwise the diet should be nutritious. Sixthly — In all cases in which the onset or early stage of a skin disease is accompanied by febrile disturbance, how- ever slight, or in which the. disease is very hyperasmic, stimulants should be avoided, and the plainest and simplest diet ordered. In marked cases of this kind, a milk diet for a while is often found to be very beneficial. Seventhly In some cases in which the skin is very hyper- cemic, this condition is much increased by the ingestion of food, especially if dyspepsia exists, in consequence of the sympathy existing between the stomach and the part of the skin affected. This state of things is especially marked in such diseases as acne, congestion of the face, and non-para- 216 DIET IN SKIN DISEASES. sitic sycosis. Stimulants must be avoided, except they be diluted with some alkaline water : the use of a diet appro- priate to the dyspepsia must be rigorously enforced. Eighthly It is said that psoriasis requires an ample meat diet ; but the patient must be dieted, and not his disease — *. e.j the diet should be plain and nutritious, and adapted to the constitutional peculiarities of the individual according to circumstances. Ninthly In all cases where a skin disease has become chronic, and where there is debility, the patient should be allowed a full, unstimulating diet. CATALOGUE OF BOOKS PUBLISHED BY ZE3I IB 1ST IFL 3T o. i_,:e].^. (LATE LEA & BLANCHARD.) The books in the annexed list will be sent by mail, post-paid, to any Post Office in the United States, on receipt of the printed prices. 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