n A PRACTICAL TREATISE DISEASES OF THE SKIN", FOR THE USE OF STUDENTS AND PRACTITIONERS. JAMES KEYINS'HYDE, A.M., M.D., PROFESSOR OF SKIN AND VENEREAL DISEASES, RUSH MEDICAL COLLEGE, CHICAGO ; DERMATOLOGIST TO THE MICHAEL KEESE HOSPITAL, CHICAGO ; AND ONE OF THE PHYSICIANS TO THE INFIRMARY OF THE CHICAGO HOME FOR THE FRIENDLESS. ■/ v7 PHILADELPHIA: HENEY C. LEA'S SOK & CO. 1883. Entered according to the Act of Congress, in the year 1SS3, by HENRY C. LEA'S SON & CO., the Office of the Librarian of Congress, at Washington. All rights reserved. PHILADELPHIA : COLLINS, PRINT! TO THE MAN LOOKING ACROSS THE ATLANTIC, VIEWS "with satisfaction the zeal and fidelity with which the doctrines of THE VIENNA SCHOOL OF DERMATOLOGY ARE CULTIVATED IN AMERICA, AKD THE RICH AND RIPE FRUIT WHICH FROM YEAR TO YEAR THEY BEAR," MOEIZ KAPOSI, PROFESSOR OF DERMATOLOGY IN THE UNIVERSITY OF VIENNA, AUSTRIA, WHO, BOTH BY WORD AND PEN, HAS SHOWN HIMSELF TO BE A WORTHY LEADER OF THAT SCHOOL, AND FITTEST TO WEAR THE MANTLE OF HIS RENOWNED PREDECESSOR, THESE PAGES ARE, WITH HIS GENEROUS CONSENT, RESPECTFULLY S»i8iai&*fl. PREFACE. The increasing recognition of the gravity of many cutaneous disorders and of the importance of their accurate study, is shown by the rapidly augmenting number of observers in this depart- ment of medicine and by the numerous valuable contributions constantly made to it, both in this country and abroad. For the convenience of the general practitioner it therefore becomes necessary at shortly recurring intervals that some one should attempt the task of presenting in a comprehensive form the results of the latest observation and experience. The author is aware of the degree to which he must claim indulgence in the present effort to perform this duty. The extent of the subject and the limitations of a single volume, require the omission of much detail of secondary importance. With regard to that which it has seemed propel" to include, he has endeavored to write concisely, to set forth only what can be held as the truth, to be frank in the admission of the weak- ness with which the most skilful physician stands in the pre- sence of many grave and not a few benign disorders, and to cultivate a wholesome doubt of that which has not been shown to be worthy of trust. How far he ma}' have fallen short of attaining this end these pages will declare. He has to express his indebtedness to the standard works on dermatology of foreign authorship, especially the exhaustive and invaluable work of Hebra, and the Lectures on the Dis- eases of the Skin lately given to the profession by Professor Kaposi, which contain the mature conclusions of his vast expe- rience. With these should be named the writings of Sir Eras- mus Wilson, Dr. Tilbury Fox, Dr. Neumann, Dr. McCall Ander- son, Dr. Behrend, and the syphilographers, to whose works special reference is made in the chapter devoted to their theme. Among the books of American authorship, he is under special obligation to the sterling work of Dr. Duhring, of Philadel- phia, and to the excellent treatises of Drs. Pift'ard, Fox, and Bulkley, of New York. All these are named by title in the brief, and selected biblio- graphy appended at the close of the volume. No less valuable (v) VI PREFACE. aid lias been obtained by consulting tbe papers of American and foreign authors contained in the journals specially devoted to diseases of the skin, among which, as tbe representatives of tbe English tongue, tbe Archives of Dermatology, lately edited by Dr. Bulkley, and the current Journal of Cutaneous and Venereal Diseases, edited by Drs. Pitfard and Morrow, deserve special mention. The author is also very greatly indebted to Dr. Charles Heitzmann, of New York, not merely for the information gathered from tbe study of his original researches in pathology, but particularly for bis kindness in furnishing advanced sheets of the chapter on the skin, in his work on Microscopic Mor- phology, which has just issued from tbe press. From this work, with Dr. Heitzmann's permission, several illustrations have been borrowed, which appear in the chapter on anatomy, the details of which subject are also very largely drawn from the same rich store. Tbe first of tbe drawings representing sections of tbe skin, is from the faithful pencil of Dr. H. D. Schmidt, of Xew Orleans, who, in order to produce it, interrupted, without hesi- tation, his arduous labors in connection with the subject of pa- thology. To bis colleague, also, Dr. Frederick W. Mercer, of Cbicago, the author is glad to express his indebtedness for the skill with which a number of pathological specimens have been prepared and mounted for special study, and original drawings produced for tbe first and several subsequent chapters of tbe book. To Dr. Dubring, of Philadelphia, be is further indebted for valuable suggestions made during the course of preparation of tbe manuscript. Medicinal measures are, in these pages, expressed in terms of both tbe apotbecaries' scale and the metric system. It is to be noted, however, that the latter are not in all cases literal trans- lations of the terms of the former, many of tbe formula?, espe- cially those for preparations designed to be topically employed, being metrically composed the relative proportions of the ingre- dients remaining unchanged. The changes which it has been advisable to make, in tbe matter of nomenclature, classification, and other equally im- portant subjects, are concisely explained in tbe chapters devoted to each. ago, No. 240 Wabash Avenue, February, 1883. CONTENTS. Anatomy and physiology of the skin 17 The epidermis 18 The corium 22 Bloodvessels 24 Lymphatics 25 Nerves 26 Pigment 27 Muscles 28 Hairs 28 Hair-follicles 30 Sebaceous glands 35 Sudoriparous glands . .37 The odorous emanations from the skin 39 The nails 40 Subcutaneous tissues 42 General symptomatology 45 General etiology 56 General diagnosis 61 Prognosis 67 General therapeutics 68 Classification 77 DISEASES OF THE SKIN. CLASS I. INVOLVING PREDOMINANTLY THE COMPONENT PARTS OF THE EPIDERMIS AND DERMA,' AND INCIDENTALLY THE APPEN- DAGES OF THE SKIN. PAUE 1. Hypersemic 83 Erythema simplex 84 Idiopathic erythema 84 Symptomatic erythema 85 Erythema intertrigo 86 2. Exudative Sd Erythema multiforme 90 Urticaria 94 Urticaria pigmentosa 95 Eczema 102 Erythematous eczema . . 103 Vesicular eczema 104 Pustular eczema 106 Papular eczema 1U7 Eczema intertrigo 109 ( vii ) 11 CONTENTS. Eczema vcrrueosum . Eczema Bclerosum Acute eczema Chronic eczema . Eczema of the scalp . Eczema of the face . Eczema of the lips Eczema of the nos< Eczema of the ears Eczema of the lids Eczema of the beard (e. barbae) Eczema of the genital organs Eczema of the anus and anal region Eczema of the nipple and breast of the fe Eczema of the umbilicus Eczema of the superior and inf< Eczema of the hands and feet Eczema as it affects the nails Dermatitis Dermatitis calorica . Dermatitis traumatica Dermatitis gangrenosa Dermatitis venenata . Dermatitis medicaments Herpes Herpes facialis . Herpes progenitalis . Herpes iris . Herpes zoster . Impetigo .... Impetigo contagiosa . Ecthyma .... Furunculosis Anthrax .... Psoriasis .... Pityriasis maculata et circinata Pemphigus vulgaris . Dermatitis exfoliativa generalis Pityriasis rubra . Pemphigus foliaceus . Impetigo herpetiformis Lichen ruber Lichen ruber acuminatua Lichen ruber planus . Prurigo .... Zoonoses .... Equinia (glanders, farcy, malii Pustula maligna Hypertrophic .... Molluscum epitheliale Keratoses .... male mitics r.i"E 109 110 110 111 140 143 14-, 140 147 148 149 151 154 155 158 1.17 159 161 162 10-2 164 165 165 16S 176 177 177 17!) 180 183 184 188 190 193 198 214 214 218 219 221 223 224 224 224 226 228 226 226 230 230 285 CONTENTS. IX PAGE Callositas (tyloma) 235 Clavus (corn) 236 Cornu cutaneum (cutaneous horns) 237 Verruca 238 Multiple cutaneous tumor accompanied by intense pruritus . 241 Ichthyosis 242 Elephantiasis 246 Dermatolysis 250 Sclerema neonatorum 251 Scleroderma 253 Morphcea 256 4. Atrophic 259 Atrophia cutis 259 Xeroderma 259 Blanching atrophy of the skin 260 Atrophia senilis 261 Striae et maculae atrophica * ■ . 261 5. Neoplastic 263 Lupus erythematosus 263 Lupus vulgaris 267 Keloid 273 Molluscum rlbrosum 276 Xanthoma 279 Adenoma 281 Myoma cutis . . 281 Rhinoscleroma 282 CLASS II. OF THE SEBACEOUS GLANDS AND PERIGLANDULAR TISSUES. 1. Anomalies of secretion 284 Seborrhcea . .284 Seborrhcea sicca (or squamosa) 285 Seborrhcea oleosa 2S8 Comedo 294 Sebaceous cysts 300 Milium . 300 Wen 302 Asteatosis 304 2. Exudative 305 Acne 805 Acne artificialis 306 Acne atrophica and acne hypertrophica 306 Acne cachecticorum 306 Acne indurata 306 Acne papulosa 307 Acne punctata . 307 Acne pustulosa .... 307 Acne varioliformis 308 Acne vulgaris 308 Acne rosacea . 314 X CONTENTS. CLASS III. OF THE SWEAT GLANDS AND PERIGLANDULAR TISSUES. PAS! 1 Anomalies of secretion 318 Hyperidrosis 318 Bromidrosis 320 Anidrosis 321 Chromidrosis 329 Budamina 324 2. Exudative 325 Miliaria 325 Miliary fever 328 Dysidrosis 329 CLASS IV. OF THE HAIRS, HAIR FOLLICLES, AND PERIFOLLICULAR TISSUES. 1. Atrophic 330 Alopecia 330 Congenital alopecia 330 Senile alopecia 330 Premature alopecia 331 Alopecia areata 339 Alopecia furfuracea 337 Pityriasis capitis 337 Atrophia pilorum propria 337 Trichorexis nodosa 398 Piedra 340 Canities 340 2. Exudative 341 Sycosis non-parasitica 341 Dermatitis papillaris capillitii ....... 345 3. Hypertrophic 346 Keratosis pilaris 346 Hypertrophy of the hair 348 CLASS V. OF THE NAILS. Hypertrophy of the nail 351 Atrophy of the nail 352 CLASS VI. OF THE BLOOD- AND LYMPH -VESSELS AND PERIVASCULAR TISSUES. l. Hemorrhagic 353 Cutaneous hemorrhages 359 Purpura hemorrhagica (morbus maculosus Werlhoffii) . . 354 Purpura pulicosa 354 Purpura rheumatica (poliosis rheumatica) .... 355 Purpura scorbutica (scurvy) 356 Purpura simplex 858 Purpura urticans 356 CONTENTS. XI PAGE 2. Neoplastic 358 Angioma 358 Narvus vasculosus 359 Telangiectasis 359 Angioma cavernosum 360 Lymphangioma cutis 363 CLASS VII. OF THE NERVES. 1. Anomalies of sensation '. 364 Pruritus 364 Pruritus hiemalis 369 Hyperesthesia 370 Anaesthesia 370 Dermatalgia 371 2. Neoplastic 373 Neuroma 373 CLASS VIII. OF THE PIGMENT. 1. Hypertrophic 376 Lentigo 376 Chloasma 377 Melanoderma, or chloasma, cachecticorum .... 378 Nsevus pigmentosus 381 2. Atrophic 382 Albinism 382 ■ Vitiligo 383 CLASS IX. OF THE SKIN WITH INVOLVEMENT OF OTHER ORGANS. 1. Exudative 385 The Exanthemata 385 Rubeola (measles, morbilli) 386 Rotheln (rubella, German measles, hybrid measles, French measles) 389 Scarlatina (scarlet fever) 390 Variola (smallpox) 395 Vaccinia in man 406 Erysipelas 410 2. Neoplastic 416 Scrofuloderma 416 The papular scrofuloderm (lichen scrofulosorum) . . . 418 The small pustular scrofuloderm 418 The large pustular scrofuloderm 419 Tuberculosis of the skin 420 Lepra . 423 Lepra tuberosa 424 Lepra maculosa 426 Lepra ansesthetica 427 XII CONTEXTS. PA'iE Pellagra 482 Frambcesia 4:!4 The Parangi disease of Ceylon ...... 43.) Syphiloderma 486 Chancre 486 The Syphilodermata 438 Syphiloderma maculosum 449 Syphiloderma papillosum 445 Syphiloderma vesiculosum 4.V3 Syphiloderma pustulosum . 452 Syphiloderma hullosum 455 Syphiloderma tuberculosum 455 Serpiginous tubercular syphiloderm 45G Syphiloderma gummatosum 458 Syphiloderma infantile, acquisitum et heereditarium . . 45!) Chancroid 483 Carcinoma 488 Epithelioma (epithelial cancer) 4ss Cancer of the connective tissue 496 Tuberose carcinoma 497 Melanotic or pigmented carcinoma 497 Myeloma cutis (sarcoma of the skin) 498 Inflammatory fungoid neoplasm 502 CLASS X. OF THE SKIN AND ITS APPENDAGES, ALL PARASITIC. 1. Of vegetable origin 503 Tinea favosa 503 Tinea trichophytina 510 Tinea circinata 510 Tinea tonsurans 518 Tinea sycosis 525 Tinea versicolor 531 Myringomycosis 535 2. Of animal origin 536 Scabies 536 Demodex folliculorum 544 Pules penetrans (rhinocoprion penetrans) .... 545 Filaria medinensis (filaria sanguinis, Guinea vvorm) . . 545 Cysticercus cellulose 547 Leptus 547 Dipterous larva? in and beneath the human skin . . .548 Ixodes (wood-tick) 549 Pediculosis 549 Pediculosis capitis (parasite, the head louse) .... 550 Pediculosis corporis (parasite, the body louse) . . . 552 Pediculosis pubis (parasite, the pubic louse) .... 551; Cimez lectularius (acanthia lectularia, bugs or bed-bugs) . 558 Bibliography 561 IM'KX 503 LIST OF ILLUSTRATIONS. FI3. PAGE 1. Vertical section of the skin of the thumb, partly diagrammatic . 19 2. Scalp of a colored man — horizontal section 20 3. Vascular and nervous papillae 23 4. Pacinian body, after silver staining, showing superimposed endothelial layers 25 5. Section of Pacinian body, from a duck's bill 25 6. Transverse section of hair and follicle .... 30 7. Upper portion of hair-pouch from the human skin .... 32 8. Lower portion of hair-pouch from the lip of a kitten .... 33 9. Section of hair-follicle during the formation of a new hair ... 34 10. Sebaceous gland of the second class from the ala of the nose . . 36 11. Duct of the sweat-gland within the epithelial layers of the skin . . 37 12. Coil of the sweat-gland 38 13. Vertical section of one-half of nail and matrix 40 14. Implantation of the nail at its border ....... 41 15. Subcutaneous fat tissue, the fat having been extracted by turpentine . 43 16. Columnar adiposes . 43 17. Vertical section of skin after injection, from beneath, of areolar tissue with Berlin blue 44 18. Chronic eczema — vertical section of the skin of the forearm . . 115 19. Longitudinal section of the third spinal ganglion of the right lumbar region from a case of lumbo-inguinal zoster 182 20. Section of anthrax 194 21. Vertical section of anthrax 195 22. Vertical section of skin from a patch of psoriasis of long standing . 201 23. Molluscous corpuscles 232 24. The author's case of molluscum epitheliale 234 25. Varieties of cutaneous horns 237 26. Varieties of cutaneous horns 237 27. Vertical section of the summit of a pointed wart .... 240 28. Ichthyosis hystrix, vertical section 245 29. Elephantiasis of the foot and leg 247 30. Section of a lupous nodule . 269 31. Keloid growths 273 32. Molluscum fibrosum 276 33. Large single fibroma .......... 276 34. Section of a comedo 296 35. Sebaceous tumors of the scalp, one of them being laid open to show its cysts and contents 303 (xiii) LIST OF ILLUSTRATIONS, no. 36. 37. 38. 39. 40. •11. ■VI. •i::. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66. Tricliorexis nodosa Painful neuroma of the skin; external appearance Microscopic structure of neuroma Vertical section of pustule at the beginning of pustulation Vertical section of one-half of an undeveloped pustule in v Lepra tuberculosa Larynx of leper affected with lepra tuberculosa Larynx of leper affected with lepra tuberculosa Larynx of leper affected with lepra tuberculosa Byphiloderma papillosum .... Vegetating condylomata of the vulva. Palmar syphiloderm Ulcerative tubercular syphiloderm Syphilitic gammata of head and face . Lea's lamp for fumigation .... Epithelioma, vertical section The author's case of myeloma (sarcoma) cutis Achorion Schi'mleinii Epidermis invaded by the trichophyton Hair invaded by the trichophyton Filaments and spores of the trichophyton from patient affected with tinea sycosis . Microsporon furfur Female acarus, fecundated ; ventral surface Acarian furrow, from the lumbar region Dcmodex folliculorum (Estrus ....... Leptus Pediculus capitis — male Ova of head-louse attached to hair Pediculus vestimenti — female Pediculus pubis .... the beard in variola ariola of lale PAOB 339 374 375 401 401 424 425 426 426 447 449 450 456 458 477 491 499 506 514 520 527 533 539 540 545 548 548 550 551 553 557 DISEASES OF THE SKIN. I. ANATOMY AND PHYSIOLOGY OF THE SKIN. The skin of the "human body is its living envelope, intimately associated with underlying structures, and by its situation brought into intimate relation also with the external world. It is a complex, elastic, and sensitive organ, varying greatly in different conditions of climate, age, sex, health, and race; and differing also in the characteristics exhibited in different locali- ties upon the same individual. Thus in color there is a wide range between the fair skin of the blonde and the black of the negro, between the rosy pink of the infant's palm and the dark brown hue of the genital region of the aired. The skin varies also in pliability and thickness, being delicate and lax over the lids, the lips, and the prepuce; and much thicker and more firmly attached over the palms and the soles. It is important to note that the appearance of the skin, even in conditions of health, also changes within appreciable limits. It is the exposed parts such as the face which the eye of the physician most frequently searches, and which betray evidence of mental emotions, physiological fluxes, sedentary or active habits of life, and fatigue or unusual conditions of vigor. Viewed externally, the skin is seen to be traversed by super- ficial and deeper furrows, dotted by numerous depressions repre- senting the mouths of its follicles, and provided very generally with coarse or fine downy hairs which are in some parts repre- sented by a growth sufficient to conceal the skin from the view. By its extraordinary sensitiveness to different degrees of tem- perature and to the physical properties of the bodies with which it is brought into contact, it becomes, even when unaided by the eye, a valuable means of preserving the human frame from ex- ternal injury. The skin is provided with a natural unguent, the sebum, by which it is continually anointed in health, a fact readily appre- ciated when the fingers are passed over its surface. It is capable of exuding sweat in various amounts, from the aggregate known as insensible perspiration to several pounds in the course of twenty-four hours. It is capable in a limited degree of acting as a respiratory agent, by eliminating carbonic acid gas and ab- sorbing oxygen, though the reverse of this may at times be ob- served. Aliments, medicaments, and toxic agents of gaseous, 2 18 ANATOMY AND PHYSIOLOGY OF TH B SKIN. liquid, and even Bolid consistency arc also by it. under favorable circumstances, absorbed. The complex organ which is called the skin is essential to the life of the individual. The Bexual, and possibly other organs of the human body, may have their functions arrested or be even obliterated by destructive processes, and life still continue, but it' the fuuetions of the skin were all suspended for a sufficient period of time, the result would be fatal. In its important rela- tions alone to the complicated processes by which the heat of the body is maintained at a relatively fixed standard, the skin ex- hihits its importance to the general economy. It is thus seen to be, not an isolated membrane stretched mechanically over an artificial machine, but one of several living and potential sys- tems of the body, each of which is in intimate union with all Ot ImM'S. Anatomically considered, the integument proper, including under that term the outer or scarf skin and the inner or true skin, which lies immediately beneath the other and is superim- posed upon a layer of fatty and connective tissue, may be studied apart from its appendages. The latter are perspiratory and seba- ceous glands, and the hairs and nails. These four appendages are properly considered in such connection, as they are all, not only accessory to the perfect function of the skin organ, but also histologically derived from it. The Epidermis. 'fin-: Scarf-skin, Epidermis, or Cuticle is the most external of the several membranes of the body, being in contact on one side with the true skin, or corium, and exposed on the other to the atmosphere by which it is surrounded. The latter surface is therefore relatively the drier, while the former is constantly moistened by fluids from the vessels which ramify beneath it. Three separate strata are recognizable in its structure ; the outer, called the horny layer or stratum corneum ; a layer intervening between this and the deepest, known as the stratum lucidum ; and lastly, next to the true skin, the mucous layer or stratum mueo-um. Like the entire integument, the epidermis differs in thickness in different portions of the body, that over the palms and soles being greatly superior in vertical section to the epidermis which covers the dorsum of these same organs and that found in yet more sensitive situations, as in the lids, lips, temples, and prepuce. The Horsy Later, or Stratum Corneum of the epidermis, is relatively the largest of the three, and is made up of superim- posed Beriee of flat, imbricated, many sided, dryish and whitish epidermal plates, uniformly and closely packed together, which are spindle shaped on vertical section. They are unprovided THE EPIDERMIS. 19 with bloodvessels, pigment or nuclei, though according to Heitz- raaun a nucleus is often faintly indicated in the lower portion Fig. 1. Vertical section of the skin of the thumb, partly diagrammatic. «., stratum corneum, traversed by ducts of two glands ; b, rete mucosum with prolongations extending between papillae beneath ; between a and b is seen the stratum lucidum ; c, papillary layer of corium. Near the centre of the figure is seen a nervous papilla ; d, reticular layer of corium with vascular plexus, nucle- ated connective tissue and interspaces ; e, coils of four sweat-glands ; /, fat-globules in the meshes of the connective tissue. of the stratum corneum. The outermost plates are more wrin- kled and curled than those which are typically flattened and seen in the deeper portions, being also in such situations com- ■20 ANATOMY AND PHYSIOLOGY OF THE SKIN. pletely lifeless, and moreover proportionately destitute of lil they me found at a greater distance from the rete. The exact source of these bodies has not been determined. The Septum Lucidum, of Oehl, is recognizable under the raicro- . as h delicate, brightly colored line, consisting of a double layer of transversely disposed, glistening epithelia, differing in tran R lucency from those found on either side of it. It thus marks with tolerable distinctness the boundary lines of the strata immediately above and below it. The latter iscomposed of flat- tened occasion ally granular or nucleated epithelia. whose charac- teristics resemble chiefly those of the epithelia in the mucous layer, and are disposed for the most part in a transverse direc- tion. This Beries of epithelia has been termed also the granular layer of the epidermis (stratum granulosum i. but its distinction from the others does not seem to he sufficiently constant to jus- tify its consideration under a separate title. Fi<'. 2. -*~/c $Wv Scalp ofa colored man— horizontal section. -/.'. rete mucosum ; Pi, row .if columnar epithelia, cut obliquely, supplied with dark-brown pigment granules; Pa, papilla, cui transversely; I>, derma. Magnified 500 diameters. (After Heitzmann.) The Mucous Later, Stratum Mucosum, Rete Mucosum, Rete MaLPIGHI] or MALP1GHIANUM, is the deepest of the epidermal layers, and rests upon the corium below. The latter is inti- mately united with it by a series of interdigitations which are commonly described as prolongations of the derma into the sub- stance of the rete, hut it is equally true that the rete sends down prolongations into the derma. The two, for reasons which doubtless originate in the need of im intimate union to resist friction and to insure vascular supply, arc thus closely locked together. The studies of ffeitzmann have clearly shown the essential character and relations of the epithelia in the mucous layer of THE EPIDERMIS. 21 the skin. According to the latter the epithelia represent irreg- ularly polyhedral and diffusely colored lumps of living matter — protoplasm, or, as it is termed by Beale, bioplasson, which, by their relations to each other, constitute a layer of living mat- ter on the outer surface of the body, and on all cavities and elongations which are in direct or indirect communication with that outer surface. These elements are flattened by reason of their apposition, and separated from each other by a lifeless cement-substance. All are, however, uninterruptedly united to each other by means of delicate spokes, formerly known as " prickles," spines, or thorns, which traverse the cloak of cement- substance. The living matter, which produces a delicate reti- culum within each protoplasmic body, its points of intersection being termed nuclei, nucleoli, and granules, furnishes the spokes already described, which thus produce continuity through all the living layers of the epithelial elements, as well as through the underlying layers of the connective tissue.. The epithelia are unprovided with either blood or lymph vessels ; but, when living, are supplied with a large number of nerves, which, in the shape of very minute, beaded fibres, traverse the cement-sub- stance, and are here in direct communication with the fibrillse of living matter; indirectly, therefore, with the reticulum of living matter within the protoplasmic bodies themselves. Deli- cate excavations in the cement-substance, analogous to the bile- capillaries of the liver, and evidently designed to carry the nutritive material to the epithelia, have been discovered by Arnold, of Heidelberg. The cement-substance also exhibits small protoplasmic masses or lumps in those situations where the threads which traverse it are most distinct. The epithelia next the corium are columnar in form, of a dif- fuse brownish hue, and arranged with their long axes nearly at right angles to the plane of that portion of the corium upon which they are superimposed. More externally they have pro- nounced polyhedral outlines, and the so-called nucleus of each is large and distinct. A contrast is thus presented to the flattened plates of the stratum corneum, which do not exhibit this feature, and are besides not pigmented, except in the case of the negro, where the intense staining of the deepest part of the mucous layer is partially extended to the external strata. Such staining in the colored race is produced by granules of pigment arranged about an unaffected nucleus. The living lumps of protoplasm, just described, play the most important part in all the pathological and physiological pro- cesses observed in the skin. It is probable that, in the embryo, all the appendages of the skin are formed directly by their as- similative and reproductive processes; and it is certain that, in health and disease, they furnish the organic matter of all secre- tions. ■I'l ANATOMY A XI) PHYSIOLOGY OF THE SKIN'. It was at one time taught that the living epithelium of the mucous layer was nlso the source of the lifeless?, horny plates of the stratum corneum. According to this view, the polygonal plates of the horny layer represent dried, effete, transformed epithelia, which have been gradually removed by growth of new elements beneath, from the deeper layers of the si rat um mucosum. But at presenl it is generally conceded that this is at least not certain, recenl writers, including Langerhans, Duhring, Pittard, and others, having failed to establish Buch a fact. Those authors point to the absence of intermediate forms between the two varieties of epithelial elements, as also to the remarkable stratum lucid um which seems to serve as a dividing line between the layers of the epidermis on its either side. The Corium. The Corium, Derma, Cutis Vera, or True Skin, is composed of bundles of iibres, whose decussations produce a dense teit- work, coarsest toward the subcutaneous fat-tissue, upon which it rests interiorly, and finest superiorly in the outermost portion, which is in contact with the epidermis already described. Its general characteristics are well described by Heitzmann as fol- lows: "The bundles are bounded in many instances by a very dense basis-substance, representing the elastic fibres, and sepa- rated from each other by narrow layers of a cement-substance (Thomsa), which, in its chemical features, is kindred to the glue- giving basis-substance of the fibrous connective tissue in gen- eral. In this cement-substance there are imbedded delicate for- mations of protoplasm, greatly varying in amount in the derma of persons of different age. They represent formations analogous to nuclei, formerly so-called 'connective-tissue cells,' at present considered as compact masses, or delicate reticular layers of liv- ing matter, which, with a power of five hundred diameters of the microscope, look finely granular. The whole glue-giving basis-substance of the bundles is traversed by a delicate reticu- lum of living matter, in direct union with all protoplasmic formations between the bundles, with all blood and lymph ves- sels, with all nerves, and with the columnar epithelia, nearest to the capillary layer. Only the meshes of the network of the living matter contain the glue-giving basis-substance, which, as the history of development of the connective tissue demon- strates, is produced by a chemical alteration of the lifeless pro- toplasmic fluid itself. The bundles of the connective tissue of the derma accompany all elongations of an epithelial character. They produce the follicles around the root-sheaths of the hair, the capsule around the sudoriparous gland, and the layers which surround their ducts. The bundles of connective tissue are tra- versed in an oblique direction by bundles of smooth muscular fibres, by relatively scanty bloodvessels in the derma, by nu- THE CORIL'M. 23 merous capillaries in the papillary layer, by a perfectly closed system .)f lymphatics, and by numerous medullated and non- mednllated nerves." Pars Papillaris. — -The papillary layer of the corium lies in contact with the rete above, and is connected below with the deeper reticular portion of the true skin. Between the rete and the papillte of the derma a hyaline and structureless membrane is often interposed, though its recognition in every section of the skin is a matter of difficulty. Fig. 3. e J Vascular and nervous papillfe. a, vessel ; 6, nervous papilla ; c, vessel ; d, nerve- corpusculum tactus ; /, transversely divided nervous filaments; y, epithelia of lete. Biesiadecki.) fibre ; (Aft The name of this portion of the derma is intended to describe its chief characteristic, the existence of numerous digital pro- longations of the corium, made up of delicate tibres of connective tissue, which do not interlace, and are abundantly provided with nuclei. The papillae spring each from a single, or several from a common, ovoid base; their bulbous, conical, or blunt apices reaching into the rete, which also dips down between them. They differ in size in different parts of the body, and also in their disposition and shape, being in places arranged in linear series, and in others in concentric whorls, with definite centres, producing thus crossing furrows, visible to the naked eye, as markings upon the outer surface of the epidermis. 2 I A X A T M Y AND I> H V S I 1. G Y OF THE S K I X . Tn horizontal sections of the skin, the papillae, being trans- versely divided, appear as circular or ovoid areas, in which can lie recognized centrally a transversely or obliquely divided capil- lary loop. Between these areas the inter-papillary reticulum of tie' mucous layer is seen. Two varieties <>!' papillae are distinguished — the vascular ami the nervous; the former containing the terminal loops of a minute artery and vein ; ami the latter, the ultimate filamentous termination of a non-medullated nerve-fibre. It is probable that there are minute nervous filaments which enter the vascular papilla? in connection with the vessels; and i1 is certain that minute capillary vessels ramify in the nervous papilla', the distinction between the two being based upon the prevailing characteristics of each. By this mutual interdigita- tion of rete and corium, not only is the union between the two insured against trivial external accidents, hut an immensely larger superficies of bloodvessels is obtained than would have been possible by a mere juxtaposition of the two membranes. The importance of this provision tor vascularization of tin' sur- face of the body is apparent in connection with the regulation of its temperature. Pars Reticularis. — The reticular layer of the corium is made up, as has been seen, of interlacing connective tissue bundles, with interspaces increasingly larger from without inward. The fineness of the bundles increases, on the contrary, from within outward, being finest where the minute papillae of the corium project into the rete, and coarsest near the subcutaneous tissue. Bloodvessels. The Arteries and Veins supplying the skin spring from sub- cutaneous branches which penetrate the fasciae beneath, and pro- ceed by subdivision to be distributed to all portions of the in- tegumenl below the epidermis, the distribution being especially abundant about the glands ami follicles of the skin, and the inferior and superior parts of the corium. They are always more abundant upon the flexor than the extensor faces of the extremi- ties, dust beneath the papillary layer of the corium there is a minutely ramifying plexus of fine capillaries, whose loops extend into the papilla? above, as already described. This and the coarser plexus in the deeper portion of the derma are so well defined that they might well be designated as superior and in- ferior partes va-'cularcs of the corium Still a third vascular district is found in the subcutaneous connective tissue where the ve88els arc numerous. The arterioles, which supply the sweat-glands, surround the coils of the latter in an elegant plexus (compared by lleitzmann to a basket), and terminate in two or three veinlets, one of which LYMPHATICS. 25 always accompanies the duct of the gland upward as far as the papillary layer, where it anastomoses with the vessels of that [•art of the skin. The ascending arterioles supply also the seba- ceous glands and hair-follicles ; and finally, breaking up into smaller and yet smaller branches, furnish a single or double capillary loop to each papilla. The capillaries of the papillary layer anastomose freely with those transversely arranged in the upper portion of the hair-follicle, loops from which also pass to the sebaceous glands. The hair-papilla has a vascular supply similar to that of the other papillae of the corium. Vaso-motor nerves are twined around these vessels in all their ramifications. The whole vascular system, as thus ar- ranged, plays a most important part in all the healthy and morbid processes which occur in the skin, as well as in the sud- den physiological changes distinguishable to the eye in the phenomena of blanching and blushing. Fig. 4 Pacinian body, after silver staining showing superimposed endothelial lay- ers (After Renaut.) Section of Pacinian body, from a duck's bill. g.L, lamellar envelope ; g.h, hyaline zoue of the lamel- lar envelope; bt, terminal bulb of the nerve; g.p, n.g.p, layer investing the cavity of the body. (After Renaut.) Lymphatics. The skin is supplied with a perfectly closed system of lymph- vessels. These are distributed to the subcutaneous tissues, where they form a deep layer; a superficial plexus lying also immedi- ately beneath the superior pars vascularis of the corium. From the latter loops are presumably given off to the papillae, as well 26 ANATOMY AND PHYSIOLOGY OF THE SKIN. us ti) the pilary, sudoriparous, and sebaceous follicles. In tlie mucous layer of the epidermis, Heitzmann has also described deli- cate <'\-c;iv;iticiis in the cement-substance between the epithelia, which Berve as lymph-conduits. The formerly described lymph-spaces, with which it was thought the lymphatics were in open communication, are now known to have no existence. Nerves. Non- medullated and medullated nerve-fibres are supplied to the skin from subcutaneous branches. The Non-Medullatbd Fibres form a delicate sub-epithelial plexus beneath the mucous layer, from which proceed the very minute and abundant beaded filaments which traverse' the cement-substance between the epi- thelia. They are supposed to form finally an intimate connec- tion with these bodies. Reference has been already made to the tine vaso-motor nerves discovered by Thomsa, which are dis- tributed to the sheaths of the bloodvessels, and finally lost in the latter. Besides these, motor filaments arc sent to supply the muscles. Lastly, trophic nerves supply all the secreting organs of the skin, and all the protoplasmic formations in every part, including the hair follicles. Tin: Medullated Xerve-fibres of the skin terminate in the Pacinian and tactile corpuscles. The Pacinian Corpuscles, named from the anatomist Pacini, exist suhcutaneVnisly only upon nerves intended for cutaneous supply, and an- small, oval bodies, two or more millimetres in diameter. Each consists of a series of concentric, nucleated, and vascular capsules, arranged after the manner of the capsules of the onion, more closely united at the periphery than at the centre, and surrounding a protoplasmic core. The medullated nerve, to which the body is attached, gradually loses its myeline envelope, and terminates in the centre of this core, alter travers- ing the greater part of its axis, in one or several, minutely club- shaped, nervous filaments. The myeline sheath is lost in the tissue of the concentric capsules. The precise function of the Pacinian corpuscle is unknown. Its connection with the tactile sense is suggested by its location, since these bodies are most numerous in the subcutaneous tissue of the nipple, the penis, the digits, and parte similarly sensitive. It bears an evident analogy to the organ of vision, each body having a capsular character; each being provided with a special nerve-filament, which enters the corpuscle at one pole; each also receiving its impressions at the extremity of the capsule opposite that where it receives its nervous supply. PIGMENT. 27 The Tactile Corpuscles (corpuscles of Meissner, or Wagner,) are other oval-shaped bodies found in about one of four of the papillse in the pars papillaris of the corium. They are made up of finely interwoven spiral connective tissue fibres with minute nuclei, which are so spun together as to form a spindle-shaped mass, occupying the greater part of the papilla in which each is found. A somewhat" denser connective-tissue capsule incloses each. Each is penetrated by one or more medullated nerve- fibres whose myeline sheath is lost in the fibrous tissue of the corpuscle. The axis-cylinder divides into numerous delicate nervous threads which are irregularly distributed over the surface of the corpuscle and also penetrate within, where they possibly have an ultimate distribution, though this is not clearly understood. Dr Robinson has latel}' shown that the nerve does not terminate in the tactile corpuscle but passes beyond it to the rete. 1 The office of the tactile corpuscle is without question connected with the sense of touch. Pigment. The hue of the living integument is due in part to the degree of vascularity and distension of the vessels in the corium, and in part also to pigmentation of the epidermis. This pigmenta- tion depends upon a distinct and uniform coloration of the epi- thelia, chiefly those found in the lower strata of the epidermis, and also to minute granules of pigment entangled in the reticu- lum of living matter in the same part. These pigment-granules are carbonaceous compounds, their ultimate chemical composi- tion resembling that of the pigments used by the artists in oil. Extreme variation in the distribution of pigment is noticeable both in health and in disease and in individuals and races, being at times certainly proportioned to climatic and similar influ- ences. This is well illustrated by the wide range between the flaxen-haired and pink-eyed albino, and the blackest specimens of the negro, each with small exception of African descent. The relation existing between the two sources of the skin coloration, viz., the blood and the pigment, are interesting and suggestive. The eye unaided, looking at the outer surface of the body, detects no distinction between these two color sources. It is indeed probable that the pigment originates from the color- ing matters of the blood. It is certain that solar heat exerts a manifest influence upon both, and that in extravasations of blood into the substance of the skin every shade of color which can be detected in the spectrum can be at times distinguished. 1 At the sixth annual meeting of the American Dermatological Association, Dr. Robinson read a valuable paper, illustrated by numerous drawings of sec- tions prepared by himself, demonstrating clearly that both the Pacinian and tactile corpuscles are provided with afferent and efferent nerve-fibres. 28 ANATOMY AND PHYSIOLOGY OF THE SKIX. Muscles. Striated Muscular Fibres extend from the subcutaneous tis- sue into the derma, and in the case of man are found chiefly upon the face and neck, where they are the analogues of more power- ful skin moving muscles possessed by Beveral of the lower ani- mals. Some, as those in the region of the face, serve to give expression to mental emotion by the production of movements in the features. Non-striatbd Muscular Fibres exist, either as minute oblique fasciculi in connection with glands and follicles of the skin; or as flattened fan like Bheets, such as those found in the integu- ment of the scrotum; or as annular bands, such as those which surround the nipple. In connection with the hair-follicles, where these muscles fulfil an important function, they are attached at one extremity to the papillary layer of the corium near its upper surface, possibly also to the structureless membrane which occasionally may he seen to divide it from the rete; and at the other to the outer layer of the hair-follicle, somewhat above the plane in which is the apex of the hair-papilla. They are said by Tlionisa to be connected with the tissue of the derma by elastic fibres twined around the mus- cle-bundles. The direction of each is oblique, and the arrange- ment such as to include, in a somewhat acute angle made with the hair, the sebaceous gland which is connected with the fol- licle. These muscles are termed ERECTORES (or arrectores) pilo- RUM, from the fact that in the lower animals they serve to produce erection of certain hairs or bristles. Such action in the human skin is exceedingly limited, though by contraction these muscles undoubtedly exert an influence upon the sebaceous gland which they include in the angle subtended by the mus- cular fibre. They thus aid in the extrusion of the contents of the gland; and it is worthy of note that the greatest develop- ment of these muscles is in those parts where the sebaceous glands are largest and of the racemose variety seen in the scalp and scrotum. Hairs. Hairs are elongated and pointed epithelial filaments, derived from the stratum corneum of the epidermis, and implanted in depressions in the rete and corium, known as hair sacs, or hair- follicles. They are found in all portions of the body except the palms and soles, the dorsum of the distal phalanges of the hands and feet, and the skin of the penis. Hairs occur in three toler- ably distinct classes. There are the fine downy hairs, or lanugo, covering the face, trunk, and limbs; the long and soft hairs, such as are implanted upon the scalp, pubes, and axillae; and HAIRS. 29 the short hairs, including the soft variety seen upon the brow, and the stiff' hairs of the lids. The shaft of the hair is that portion which extends from its exit at the surface of the skin to its extremity. The latter, when uncut, always tapers to a perfectly acuminate point, as is illustrated in the uncut hairs of the lids, and of the lower ani- mals. The shaft is either straight, curled, wavy, or alternately varied in diameter, producing the peculiar character of the growth seen upon the scalp of the negro, these variations being due to the different degrees of flattening of the shaft in a trans- verse direction. In consequence of the variability in the pig- ment which they contain, hairs differ also in color, from a snowy whiteness to the darkest black. The membrane which invests the shaft of the hair is called the cuticle, and is composed of numerous flattened plates, regu- larly overlaid so as to resemble fish-scales when viewed under the microscope on the flat side, and the overlapping shingles of the roof of a house when seen on the edge. The cortical, or main substance of the shaft of the hair, is en- wrapped by the cuticle, and is composed of flat, nucleated, fusi- form, epidermal scales. The strength, elasticity, and extensi- bility of the hair are chiefly due to the cortical substance, and in particular to the firmness with which these epidermal scales are attached to each other. The medullary substance of the hair is found best developed in the short and strong hairs of the beard and eye-lashes, being wanting in the lanugo hairs. It consists of a loosely packed mass of epidermal elements, differing in shape, developed in the centre of the axis of the shaft, often after extraction of the hair intermingled with air bullae. This part of the hair contains also the pigment and fatty matters which are here developed as in the rete of the epidermis. Seen under the microscope, the medulla appears as a continuous or interrupted longitudinal band, extending from the bulb, or the part implanted in the fol- licle, to the extremity or point. The purpose of this difference in the constitution of the cortex and medulla of the hair is doubtless to insure, on well-known mechanical principles, a maximum of strength, flexibility, extensibility, and elasticity, with a minimum of volume. The coloring matter of the hair is stored in both its horny and medullary portions, and is distinct both within and between the epithelial elements of which it is composed. This pigmentation corresponds, as Heitzmann has shown, in great part to the amount of pigment distributed to other parts of the integument, and sustains a close relation to the general nutrition of the body. Its subjection to the influence of the trophic nerves is well demonstrated by the phenomena of rapid blanching of the hairs. Excessive sweating, whether physiological or induced :;o ANATOMY AND PHYSIOLOGY OF THE SKIN, by the action of pilocarpine, has also a distinct influence upon the shade of color of the hair. On transverse Bection hairs present an ovoid or ellipsoidal outline, occasionally suggesting an ir- regularly com pressed circle. The de- gn f this flattening differs in different races, and, as has been intimated, is the cause of variability with respect to straightness or curliness. As hairs are to a marked degree hygroscopic, and not only absorb but can be deprived of a portion of their water, these states of curliness or waviness are Buhject to variation according to the aqueous con- dition of the media by which an indi- vidual is surrounded. The bulb or root of the hair is that portion which is imbedded in the skin, toward which the shaft gradually in- creases in thickness as it descends. It is implanted below at the base of the sac upon a nipple-shaped projection of the corium, which repre- sents one of the vascular papillae of the pars papillaris. The latter is the chief source of the nutrition of the hair, and, like the other digitations of the papillary layer, is made up of delicate fibrous or myxomatous connective tissue, traversed by a number of capillary bloodvessels, with accompanying vaso-motor nerve- fibres. The bulb of the hair which embraces the papilla is a knob composed of living elements which, according to Ileitz- mann, resemble those of the inner root sheath, to be presently described. 'I i a i averse section of hair follicles. Hair-Follicle. The hair-follicle is a sac-like depression in the corium, in which the ha ir-ti lament is implanted by its hull) and there firmly secured. The direction or set of this follicle is always at an oblique angle with the plane of the cutaneous surface where it opens; and thus is determined the set of the hairs, which is al- ways fixed and at a similar angle. Viewed as a whole, the in- tegument of the body over its entire area exhibits determinate whorls of both short and long hairs with definite centres, such as those which may he recognized at the vertex of the seal}), the centres of the lips, the umbilicus, etc. By this disposition the symmetrical appearance of the hairy parts is preserved, and, as a consequence of the same provision, physiological loss of the hair is not productive of deformity, but rather adds dignity to the aspect of the elderly man. The description which follows of the anatomy of the hair-fol- licle and of the relation which the hair sustains to it, is con- HAIRFOLLICLE. 31 densed from the observations of Heitzmann, based upon his late original and accurate studies of this part of the skin. 1 If the hair-pouch were made artificially by thrusting into it from without inward a blunt-pointed pin, before which the tis- sues were gradually pushed, it is evident that the external layer, the stratum corneum, of the epidermis would be first depressed and finally cover the inner surface of the pouch. This repre- sents the inner root sheath of the hair. Next to this the pin would carry before it the mucous layer of the epidermis, which then would form the outer root-sheath of the hair. Outside of both would lie the connective tissue of the corium ; this is the hair-follicle. In this artificial conception, some modifications are required by the relation of the parts as actually determined by observa- tion. Thus the stratum corneum of the epidermis, as it turns downward to form the inner root sheath, loses gradually in width till, in the middle of the pouch, not more than two strata are visible. At the bottom of the follicle, on the contrary, it in- creases in width till it is composed of three or four layers which have lost their horny character and acquired protoplasmic fea- tures. Here, indeed, is a transitional stage between the lifeless stratum corneum and the living rete mucosum, which may well arrest the attention of the student of histology, as it may yet furnish an explanation of the relation of the one to the other in the exposed portions of the integument. The rete mucosum enters the pouch in its full width, the epithe- lia retaining their protoplasmic character, though gradually re- ducing in number till they are represented by but a single layer, this last disappearing completely at the bottom of the follicle. Supposing that a blunt-pointed pin were now pressed from within outward against the base of this epithelial pouch, in a line corresponding with the direction observed by the connective- tissue bundles, it is clear that the pouch would be again turned upward, and that the inner root-sheath would be exclusively involved. The resulting epidermal elongation, agreeing in main features with the inner root-sheath, represents the hair. The hair, therefore, is a solid elongation of the hollow inner root- sheath, and is produced by the latter exclusivelj r . If now the rete mucosum, or its representative, the outer root- sheath, were pushed by the same pin downward and in a lateral direction on the side of the acute angle of the obliquely im- planted pouch, a smaller depression would result, representing the sebaceous gland. The latter is found to be produced exclu- sively by the outer root-sheath, and the inner root-sheath to take no part in its formation. Viewed somewhat more closely, the innermost portion of the » 1 Heitzmann's Microscopic Morphology of the Animal Body in Health and Disease, New York, 1888, chapter xiv. the Skin, p. 553 ; also a paper entitled "A Contribution to the Minute Anatomy of the Skiu," Chicago Med. Jour, and Exam., Dec. 1881. 32 ANATOMY AND PHYSIOLOGY OF THE SKIX. connective-tissue bundles, which constitute the outer invest- ment of the pouch, are found to exhibit cross-sections of smooth muscular fibres; and the papilla itself is seen to he a product of the follicle. The inner root-sheath also of the hair widens as it approaches the bottom of the pouch, and exactly at the lower level of the latter is reflected, producing first the hull) of the hair, then its root, finally its shaft; the innermost layer of the inner root-sheath, in the same process of reflection, forms the Fig. 7. - •^ <¥.| FG-;- JiTA >uv Upper portion of hair-pouch from the unman .skin B, epidermis ; R.3f, rote mucosum ; P /.. papillary layer; /', derma; F, follicle ; It, arreetor i>ili muscle; S. O, sebaceous gland; U.S, outer root-sbeath ; T.8, inner root-sheath ; C, cuticle ; B, root of hair. Magnified 150 diameters. (After Beitzmann.) hair-cuticle, a layer singly investing both the root and the shaft of the hair. Between the outer root-sheath and the follicle is the homogeneous, structureless membrane, which may be also HAIR-FOLLICLK. 33 recognized at times between the corium and rete of the skin above. The arrector pili muscle connects with the muscle layer of the follicle, and surrounds the bottom of the sebaceous gland. The pouch at its free extremity is funnel-shaped, and lined with stratified epidermal scales, directly traceable to the inner root- sheath, which begins in the neck of the pouch. It is composed of two layers, that in this situation being named after its dis- coverer, Henle. Within, the inner root-sheath is in contact with Fiar. 8. Lower portion of hair-pouch from the lip of a kitten. F, follicle ; T, transverse sections of con- nective-tissue bundles of derma ; M, arrector pili muscle ; IS, inner root-sheath ; OS, outer root- sheath ; P, papilla; O, cuticle ; R, root of hair; H, hyoline, or so-called structureless membrane. Magnified 500 diameters. (After Heitzmann.) the delicate cuticle of the hair, the latter ensheathing both root and shaft. The duct only of the sebaceous gland is lined with flat horny epithelia. Its acini, like those of other acinous glands, exhibit cuboidal epithelia. The duct opens into the funnel-shaped widening of the pouch in the space between the 3 34 ANATOMY AND PHYSIOLOGY OF THE SKIN. inner root-sheath and the cuticle of the hair. The several strata of the outer root-sheath are also composed of cuboidal epithelia, columnar-shaped elements resting only upon the structureless membrane. The inner Burface of the latter is covered by deli- cate, flat end othelia, connected by protoplasmic threads with the columnar representatives of the deeper rete in the skin above. Studying in detail the lower extremity of the hairpouch, its upper portion exhibits the light, horny llenle's layer of the inner root-sheath. In an oblique line appear polyhedral epithelia; in the upper portions pale, and finely granular, with indistinct nuclei; deeper down, coarsely granular, and slightly elongated. This part of the inner root-sheath repre- sents what has been termed "* Hux- ley's layer." This, at the bottom of the pouch, is reflected over the papilla, and constitutes the bulb of the hair-root. On the lower periphery of the papilla are co- lumnar epithelia, which are grad- ually transformed into first cu- boidal, higher up into elongated, spindle-shaped elements, and final- ly into the horny spiudles, which produce the main bulk of the hair. The boundary line between the inner root-sheath and the root of the hair is represented by a thin, apparently structureless layer, on one side of which is the inner root-sheath, and on the other the hair cuticle. The latter, on the upper portion of the root, as well as on the shaft, is composed of thin, imbricated scales, described above. The epithelia of the cuti- cle of the root gradually assume a columnar shape and become nu- cleated. At the height of the bulb they are large, pale, granu- lar, and supplied with large and distinct nuclei. A characteristic row of these is seen in the middle between Huxley's layer and the bulb; and this at last blends with the cuboidal epithelia on either side. Outside of the cuticular row another thin layer of pale, flattened epithelia corresponds to the innermost struct ure- Section of hair-follicle during the forma- tion of a new hair. (After Ebner.) a, ex- terna] and middle root-sheaths ; b, vitreous membrane ; c, papilla, with va.-c-ular loop; .'i root-sheath ; e, internal root- sheath ; /, cuticle of hair-follicle; g, cu- ticle of hair; /», i, young hair; /, bulb of .ilil hair ; ft, debris of external root-sheath of hair recently ex pi I Led. SEBACEOUS GLANDS. 35 less layer of the inner root-sheath. The middle portion of the bulb is often tilled with globular, indifferent, or medullary cor- puscles, pigmented in various degrees, which also fill the central portion of the root. Even in strong hairs, however, this may be wanting. The upper portion of the outer root-sheath is composed of epithelia in strata, of which the external layer is columnar. This is the last left, as the outer root-sheath approaches the region of the bulb, and, becoming thinner, is lost finally at the level of the height of the bulb, into whose formation it does not enter. External to the follicle is the fibrous connective tissue of the derma, in longitudinal and transverse bundles. At its base a fibrous connective tissue pedicle is often seen extending to the subcutaneous tissue. Heitzmann shows, furthermore, that the new growth of a hair takes place exclusively within the inner root sheath. The latter, below the bulb of the old hair (which is fringed by torn epidermal scales) widens, is again involuted, and forms a new bulb, com- posed of embryonal corpuscles. The boundary between these two portions of the inner root-sheath is established by the cu- ticle, which, below the bulb of the old hair, is composed of columnar epithelia. When pigment is discovered, it lies exclu- sively in the central portion of the inner root-sheath, from which the new springs. In this the outer root-sheath takes no part. The hairs are developed in the third month of intra-uterine life by budlike projections from the epidermis downward, the bottom being subsequently projected upward by connective tissue extension. The epithelia, originally medullary in character, elongate, flatten, and are finally transformed into the hair and its root-sheaths. Sebaceous Glands. The sebaceous glands are pyriform bodies, usually racemose in development, situated in the corium, never in the subcuta- neous tissue, and designed to furnish the natural unguent of the human body. The plan of their development from the outer root-sheath of the hair - follicle has been already described. Externally, each is limited by an outer coat of connective tissue, within which is a layer of nucleated cuboidal epithelia flattened by juxtaposition, continuous with and. similar in character to those constituting the mucous layer of the epidermis. Several layers of these can be recognized in each acinus of the gland. In this situation the epithelia undergo a fatty metamorphosis, by reason of which the semi-fluid, amorphous, greasy substance is produced w r hich is known as sebum, or sebaceous matter. Three classes of sebaceous glands, as they are divided by Sap- pey and Piffard, are readily distinguished. There are, first, those which serve as appendages of the hair-follicles and hairs. These 36 ANATOMY AND PHYSIOLOGY OF THE SKIN, occur in connection with the long and soft hairs, as of the scalp and axillae, several at times grouped around a Bingle hair-sac. They are usually found lying along the upper third of the fol- licle and, in such case, the Bebum is extruded into the latter before arriving upon the free surface of the skin. Fie. 10. Sebaceous gland of the second class from the aire of the nose. (After Sappey.) The second class includes the large and complex glandular structures to which the lanugo or rudimentary hairs seem accessory, the orifice of their ducts opening directly upon the cutaneous surface. These are chiefly found' upon the so-called non-hairy portions of the skin, as the face in both sexes, and portions of the trunk and extremities. The third class, em- bracing by far the smaller number, are the sebaceous glands entirely unconnected with hairs and their follicles. Such are the glanduls odoriferse of the male and female genitalia, and those seen in the areola of the nipple of the female breast. No sebaceous glands exist upon the palms, the soles, and on the dorsum of the distal phalanges of the hands and the feet. SUDORIPAROUS GLANDS. 37 The office of the sebaceous glands is evidently the protection of the human body both from undue loss of water by evapora- tion and the consequent desiccation of the surface, as also from undue absorption when immersed in the same fluid. This latter office is well illustrated by the action of the vernix caseosa of the foetus, in consequence of which the new being is for a period of several months, so long as life is sustained, preserved from the macerating influence of the liquor amnii. In chemical constitution, the sebum is found to consist of olein, palmatin, cholesterin, and the saline constituents of the other animal products. It has been already shown that the extrusion of the secreted sebum from its gland, is greatly favored by the action of the arrectores pilorum muscles, by which on the one side the latter is compressed against the hair-follicle on the other. Sudoriparous Glands. The sweat, or sudoriparous glands, are elongated tubules ex- tending obliquely from the surface of the body to the deeper Duct of the sweat-gland within the epitheiial layers of the skin. BP, papilla with injected bloodvessels ; V, valley between two papillaj ; D, duct in the rete mucosnrn ; E, E, epidermal layer ; PL, coarsely granulated epithelia, deeply stained with carmine ; P, duct with corkscrew windings in the epidermal layer. Magnified 200 diameters. (After Heitzmann.) portions of the corium, or, in certain localities, to the subcuta- neous tissue, terminating in the latter situation in a glomerulus or coil. They serve for the excretion of sweat. The sudoripa- rous glands are found in all parts of the body, being developed more abundantly and in larger size in certain special regions, as the axillse, the groins, the palms, and the soles. The long duct of this small reddish-yellow body, beginning 38 ANATOMY AND PHYSIOLOGY OF THK SKIN. as a coecal pouch within the coil or glomerulus, ascends in a nearly vertical direction to the surface, a very gentle spiral direction being assumed in this ascent. The excretory duct of the gland has a funnel-shaped terminus, and opens at the free surface of the integument, often at an angle with the plane of the latter. s<> that a Bpecies of minute valvule is formed hy those plates of the horny layer superimposed upon the superior portion of the duet. The orifices of the sweat-glands called "pores" are in places visi'nle to the unaided eye, in the furrows between the papillary ledges. Under the microscope, the anatomical differences between the coil and the duct are seen to depend upon the existence in the former of cuboidal, and in the latter, as tar as the rete, of columnar epithelia, both attached to a deiicate hyaline membrane. In the empty condition of the gland the calibre of the tubule is narrow, and the cement ledge of the epithelia is plainly visible at the surface bounding the calibre. A basket-like plexus of vessels has been already de- scribed as surrounding each in the connective tissue capsule of the gland. Here also are smooth muscle iibres, chiefly conspic- uous in the axilla?. The diameter of the duct at its outset does not, according to Ileitzmann, exceed that of the lobule within the coil. It soon, Fig. 12. Coil of the Bweal gland. S, tubule lined by cuboidal epithelia; T, central calibre of the tubule; Z>, beginning of the duct ; C\ connective tissue with injected bloodvessels. Maguified meters. (After Heitzmann.) however, widens and shows a single stratum of columnar epi- thelia. Delicate longitudinally arranged bundles of connective tissue accompany the duct, though no smooth muscle bundles THE ODOROUS EMANATIONS FROM THE SKIN". 39 are present. The latter leads in a slightly devious course to a depression between two papillae, and is here composed of strati- fied epithelia representing a formation of the rete prolonged within it to a varying depth. After reaching the epidermal layer, the duct is lined by a single row of flat epithelia, its calibre widening considerably at its orifice upon the surface of the skin. The sudoriparous glands of the foetus are seen about the fifth month of intra-uterine life, and, like the sebaceous glands, appear first as flask- or bud-like projections from the columnar epithelia of the rete mucosum. As they extend further toward the corium the skein of the coil is formed by convolution of the originally straight cylindriform column, an axial canal simultaneously developing. The total number of the sudoriparous glands in the bod} 7 is estimated to be between two and three millions, and the total length of the uncoiled glands about eight miles. These figures serve to give an approximate idea of the immense importance, physiologically, of the sweat excretion, and of the extent to which violation of the hygienic rules of cleanliness possesses interest from the pathological standpoint. The sweat excreted by the body differs under varying condi- tions of temperature, humidity of the air, and the amount and character of the articles ingested by the individual, either as food, drink, or medicament. Nearly ninety-eight per cent, of the secretion is pure water, the remaining proportions represent- ing the saline constituents of the other fluids furnished by the animal in life. In all chemical analyses of the sweat, a source of error lies in the difficulty of securing the fluid secretion un- mingled with that produced by the sebaceous glands; and the same, it may be said in passing, is true of the chemical analysis of the sebum. According to X)uhring, the iodide of potassium, benzoin, succinic and tartaric acids are excreted with the per- spiration. The Odorous Emanations from the Skin. The skin of the human body in health is the constant source of odorous emanations, which, in pathological conditions, may be greatly increased or otherwise changed. The nature and ex- act sources of these emanations are as yet imperfectly under- stood. Were these exclusively of a volatile, gaseous, or vaporous composition, even though such volatile fluids were capable of condensation upon external bodies, this could be scarcely held as compatible with the well-known fact that the lower animals are, many of them, capable of tracing the track of the human being for miles over a wind-swept path, till the soil pressed by the foot is covered with water. There is strong reason to be- lieve that these emanations are the sole sources by which several 40 ANATOMY AND PHYSIOLOGY OF THE SKIN". of 1 1 1 o contagious and infective diseases are communicated from one individual to another, a fact which Buggests that they, at times certainly, contain living matter derived from the proto- plasmic masses of which the body is built up. These emanations are properly regarded as having their origin in the secreting Bystem of the skin, but in what proportion the several secreting glands participate in the product, is difficult to establish. The sweat at times, even to human nostrils, exhales a distinct odor, though, as before intimated, to what extent this is due to its admixture with the Bebaceous material, it is difficult to deter- mine. Peculiarly fetid and disgusting odors occasionally origi- nate in chemically altered sebum, where the influence of the sweat secretion must lie, from the locality under examination, practically eliminated. The entire subject is one of great interest, as promising to throw light in the future upon many questions connected with contagion and infection. Enough is certain to justify the view that the human body in health is perfectly enveloped in an odorous medium, constantly perceptible to keener nostrils than our own at a considerable distance from the surface of the indi- vidual and having its source in the secretions of the integument. The Nails. Nails are concavo-convex plates or shells of horny tissue, placed upon the dorsum of the terminal extremities of the distal phalanges of the fingers and toes. Each has a free border at the Fig. 13. & if ¥ Vertical section of one-half of nail ami matrix, a, nail substance; h, horny layer; c, mucous layer ; ■/, papilla of corium : e, nail furrow destitute of papillae : /, horny layer of the ungual furrow rising above the nail ; g, papilla of skin of dorsal Burface of the finger. distal portion of the pulp of t lie digit, with sides and proximal borders let into distinct furrows of the skin. The convex sur- laee of the nail is exposed, the concave regarding the phalanx, and being implanted upon the matrix beneath. THE NAILS. 41 In the substance of the nail proper are recognized tissues analogous to the stratum corneum and rete raucosum of the epi- dermis, the main portion of the nail substance being horny in character, the lower elements exhibiting indistinct nuclei. Its growth in thickness is provided by increment from the epithelia of the matrix ; and its forward progression over the pulp of the digit, by a species of gliding movement in the elements, necessi- tated b} r the relatively rapid increase of the horny layer above in a longitudinal direction. The nail, therefore, is not physiologi- cally pushed forward en masse from its lunula to its free edge, but describes in its growth a gentle curve whose outline is indi- cated by the projection of the uncut nail over the pulpy extremity of the digit to which it is attached. The free border of the nail is distinguished by its elasticity and its semi-transparency. The ungual folds in which the attached edges are confined, are so arranged that an overlapping of the epidermis occurs above the nail tissue which it is designed to secure in situ. This overlapping is marked by an exquisitely rounded ledge, which is itself, in turn, separated from the gene- ral surface of the skin of the phalanx, by a delicate furrow. Fi£?. 14. Implantation of the nail at its border. P, papilla? decreasing in size toward the middle line ; S, rete mucosum, which broadens toward the border of the nail, and forms irregular prolonga- tions; B', E, epidermal layer ; N, plate of the nail. Magnified 500 diameters. (After Heitz- mannj The matrix of the nail is composed of the rete and its subja- cent eo ri lira, the papillae of the latter being projected somewhat forward in the direction in which the nail is to be pushed. They are absent in the lateral portion of the nail. The papillae here are well developed, arranged in parallel rows and unpro- 42 ANATOMY AND PHYSIOLOGY OF THE SKIN. vided with t';it. but richly supplied with vessels and nerves. According to Kaposi, the ungual substance is produced exclu- sively by the pars papillaris of the corium, which would thus seem to be assigned the rule formerly supposed to be played by the papilla at the base of the hair-follicle. But the demonstra- tion by Ileitzinann that the hair is formed from its inner root- Blieath and not from the papilla, suggests the inference that the analogy so faithfully observed by nature in other parts of the body, may here also become evident. The nail and the hair are alike nourished by their papillae, but do not seem to be formed from them. It would he unwise to conclude, for example, that the undeveloped foetus of the kangaroo, which is for weeks sus- pended at the maternal nipple, was originally developed from that organ. The whitish disk of define 1 crescentic contour, its convexity directed toward the free border, exists in each nail, but is best recognized in those of the toe and thumb. It is called the lunula, and is produced by the papillae beneath the disk, forming rela- tively bloodless laminae of tissue. According to Toldt, cited by Ileitzmann, the lunula is caused by diminished transparency of the tissues, owing to a broad, uniformly distributed layer origi- nating in the rete. Subcutaneous Tissues. The structure immediately beneath the skin is built up of loose connective tissue bundles, prolonged from the aponeuroses, the fuscia?, and often from the membranes beneath. It is firing attached to the skin over the extensor surfaces of the articula- tions, the palms, the soles, and the groin by short and coarse bundles, between which are single or multilocular spaces lined with endothelia, secreting a mucoid fluid. These are the bursae mucosae. Elsewhere, as in the eyelids, the penis, the scrotum, and the auricle of the ear, the attachment to the skin is by loose, delicate connective tissue, containing no fat globules. All other fibrous tracts are arranged obliquely, admit, by their ex- tension, of various degrees of pliability, and inclose rhomboidal spaces containing more or less numerous fat globules. These are lobulated, bounded by a delicate, fibrous connective tissue, and abundantly supplied with bloodvessels. This is termed the panniculus adiposus. The anatomy of the thick cutis vera has been carefully studied by Dr. J. Collins Warren, of Boston. 1 The back and shoulders of. a vigorous adult are seen to furnish an integument much thicker than the hide of many pachydermatous animals. The papillae are imperfectly formed, and represented by an undulat- ing line. The follicles of the lanugo hairs penetrate only the 1 Batterthwaite'fl Manual of Histology, New York, 1881, p. 420. SUBCUTANEOUS TISSUES. 43 superficial layers of the cutis. From the bases of the hair- , follicles, nearly vertical clefts, or slender, columnar shaped Fiff. 15. Subcutaneous fat tissue, the fat having been extracted by turpentine. B, bundle of fibrous connective tissue, carrying injected blood-vessels ; C, capsules of fat globules, with oblong nuclei. Magnified 500 diameters. (After Heitzmann.) Fig. 16. Colurause adiposse. (After Warren.) a, epidermis ; b, erector pili muscle ; p, horizontal prolonga- tions of the column; c, coil of sweat gland suspended in the latter; /, fibrous bundles of corium; g, panniculus adiposus ; lc, band of fibrous tissue extending to the latter. 44 ANATOMY AM) PHYSIOLOGY OF THE SKIN. Bpacea extend obliquely to the panniculus adiposus, which have been fitly termed by Warren, " fat columns or fat canals," as they are entirely occupied by adipose tissue. These columns are about four mm. in length, and are slightly wider than the hair-follicles above. Their long axes form a slight angle with that of the follicle, hut they are nearly parallel to that of the erector pili muscle. Two horizontal prolonga- tions are given off on either side of the middle of this axis, partly fat-filled. Near this point is suspended the coil of a sweat gland, held in place by a few delicate fibres. The duct of the gland runs to the top of this space, whence it may be traced to the side of the hair-follicle. The connective tissue fibres seem to terminate abruptly at the edges of these columns. The cleft, slightly widens below, and on the side toward which its axis leans, the fibres of connective tissue form a bundle pen- Fi". 17. 3 I lection of skiu after injection, from beneath, of areolar tissue (After Warren.) ", epidermis ; /, corium ; g, panniculus adi etrating below to the subcutaneous fat. The erector pili muscle is inserted partly into the base of the follicle, and partly into the apex of the fat canal. T hese columns correspond in number to the hairs. The blood- vessels which they contain, springing from the subcutaneous plexus, bifurcate at the lateral clefts. GENERAL SYMPTOMATOLOGY. 45 II. GENERAL SYMPTOMATOLOGY. In cutaneous, as in other diseases, the clinical signs or symp- toms of the morbid process are those by which it is recognized alike by the patient and the physician. It is usual to divide these into subjective and objective: the former those appre- ciated by the patient alone in consequence of his sensations, the latter by the eye and the touch of another who undertakes the investigation of the disease. It should be remembered, however — and this is a matter of some importance in this connection — that many objective signs are made manifest to the eye and touch of the patient himself, and liable to be inter- preted or misinterpreted by him, with consequences which should not be ignored. Subjective Symptoms. — The purely subjective symptoms of a disease of the skin are those manifested to the patient by sensa- tions other than those connected with vision and his own sense of touch. They include sensations of itching, smarting, tingling, pricking, and burning; sensations as of increased or diminished susceptibility to the contact of foreign bodies ; of increased or diminished temperature; pain in various grades of severity; and disordered sensations, as of the crawling of insects over the part, currents of hot or cold vapors or liquids, and compression of portions of the skin by either cords, bands, or closely fitting plates. The character of the subjective sensations experienced by a patient often proves an aid to the physician in recognizing the nature, not merely of a present disease, but of one also which has preceded. Thus the sensation produced by an attack of erysipelas is rarely an itching, while the latter is highly char- acteristic of eczema and scabies ; the pain of zoster and the tingling of urticaria being distinctly different, not only from each other, but from the subjective symptoms named above. Objective Symptoms. — The study of the objective symptoms of a cutaneous disease is of paramount importance, hi no re- spect does the skilled physician so distinguish himself from one who is inexpert as in the recognition of the typical or atypical objective characters presented in diseases of the skin. The study is one which can be neglected safely by no diagnostician, and its rewards are precious in every department of medical science. These symptoms are spread before the eye, and their legibility increases with every hour of careful attention. 46 GENERAL SYMPTOMATOLOGY. These Bigna of skin disease — or, more literally, skin injury — arc called lesions, and if is usual to classify them as primary and secondary. Such a division is, however, open to criticism, since, viewed from the standpoint of time merely, some of the so-called primary lesions of the skin become in turn secondary and even tertiary. Thus a papule which might at one moment he called primary, may he transformed wholly or in part into a vesicle, which thus becomes a secondary lesion; and such vesicle again, in the evolution of a disease, may become a tertiary pus- tule. The latter finally may result in a quaternary crust. In the following pages these elements of skin diseases will be described as lesions and lesion-relics. LesIons. — In describing the average size of cutaneous lesions, it is less convenient to state their measurement in fractions of a line or millimetre than to convey an approximate idea l>y a comparison with familiar objects of relatively fixed dimensions. The objects usually selected for this purpose are, beginning with the smallest, the seeds of poppy, mustard, and rape; the coffee- bean; the pea; the bean; the cherry; the finger-nail; the chest- nut; the horse-chestnut; the egg of the hen and of the goose; and the orange. To these may also be added the point and the head of a pin. The student will find it useful to familiarize himself with the size of the small seeds mentioned, that then- names may at once suggest to him the relative size of the lesions to which they are compared. Maculae, spots or stains, are generally circumscribed al- terations in the color of the integument, differing as to the size, shape, hue, and duration of the dyschromia. Examples of macula; are to be found in the exanthematons rashes (measles); in localized hyperamiise of the capillary plexus of the corium, disappearing in various degrees according to the pressure exerted on the part (rosacea); in visible acquired devel- opment of bloodvessels in the skin (telangiectasis); in congenital vascularization of the surface (nsevi); in variously colored blood extravasations and stases (purpura); in stains produced by con- tact with dyes (hand-workers in aniline); and in pigmentary changes such as those produced by solar heat (freckles), or by leprosy. Extensive non-circumscribed changes in the skin color are seen in the course of several general disturbances of the economy, as in yellow fever, cancer, chlorosis, albinism, Addison's disease, argyria, and icterus. Spots of various color and device are also produced by the intentional or accidental introduction of pigmented particles beneath the skin, as by the process of tattooing, of gunpowder, etc. lesions and lesion relics. 47 Papula are soltd or compressible, ephemeral or persistent, circumscribed projections from the surface of the skin, vary- ing in size from a poppy seed to a coffee-bean. These exceedingly common skin symptoms vary greatly in their shape, color, location, career, and significance. Thus they may be flattened at the apex, acuminate or pointed, conical, rounded, or depressed at the summit to form an umbilication. They may be pale, rosy, dark or lurid-red, purplish, or even blackish. They may develop in transitory or persistent pro- cesses ; they may be transformed into lesions containing fluids ; may desiccate and furnish scales either at apex or base; may degenerate into ulcers, or enlarge into tubercles or tumors. They may be scratched, torn or rubbed so as to lose their typical ap- pearance; they may come and go; be sensitive to sudden changes in the blood-current, and yet be themselves persistent. The mixed forms described above are generally named vesico-papular or papulo-vesicular, papulosquamous, papulo- pustule, etc. Lesions which simulate the papule and which, though described under that title, really belong to another category, are the small, semi-solid elevations of the surface which occur at the orifices of the ducts of the cutaneous glands and follicles. Thus they may consist of little heaps of epidermis about the hair follicles (lichen pilaris, keratosis pilaris), or of inspissated sebum collected in one or all of the acini of the sebaceous glands (milium, comedo). The concomitants of an eruption of papular type also vary. Thus there may be a febrile process, or extensive infiltration or' the skin about and beneath the papules (prurigo); or itching of the most intolerable character (eczema papulosum) ; or produc- tion of trifling sensations of annoyance, as a slight burning without other subjective symptoms (acne, lichen planus). Papules which are transformed into moist lesions become covered with a crust. Papules which are scratched or torn by the finger nails usually betray the fact in the minute and flat blood-scale dried upon their surface. Papules which ulcerate may be followed by scars. Papules which have undergone the process of involution may be followed by macular sequelae. Wheals are more or less transitory, rosy-red and whitish, irregularly shaped and sized elevations of the surface of the skin, produced by blood-stasis in spasm of the vessels, accompanied by a tingling or pricking sensation and charac- terized by rapidity of evolution and frequency of recurrence. The typical wheal is seen in the disease known as nettle-rash (urticaria), where closely packed, shining, roundish and whitish pea to finger-nail sized elevations of the skin are visible, sur- rounded by a slightly rosy border. They are firm to the touch, and occur in patches, circles, bands, gyrations or striations, often 48 GENERAL SYMPTOMATOLOGY'. disappearing in a brief time and recurring with or without a renewal of the cause. They are occasioned by a rapid exudation of serum into the rete or pars papillaris of the corium. This is supposed to be due to clonic vascular spasm, producing irreg- ularities in the lumen of the skin capillaries, under the influence of the vaso-inotor nerves which supply a small area of the superior pare vascularis of the derma. The sensations produced by the wheal arc particularly stinging, burning, pricking, and itching. " Giant" wheals are such as enlarge to the dimensions of an egg or a tomato, or cover extensive areas of integument, as for example the entire surface of the buttock or shoulder. Relics of disappeared wheals are usually transitory erythema- tous maculae, but in rare cases a more or less deep pigmentation is left, which slowly disappears (urticaria pigmentosa). It should be borne in mind that at times the wheal-like con- dition is assumed by the papule, as also the lesions resulting from such traumatism as the bite of insects, reptiles, horses, dogs, etc. Tubercles are solid, generally incompressible and persis- tent, NODOSITIES OF THE SKIN, VARYING IN SIZE FROM A COFFEE- BEAN TO A CHERRY. They may be largely projected from the free surface of the integument, or be deeply seated in the skin, and but a small portion become evident to tbe view externally. Their varieties as to shape, color, size, and other features, correspond in great part to those described in connection with papules. They may be attached by a broad base to the skin, or be pedunculated or even pendulous. Their seat is usually in the deeper portions of the corium or the subcutaneous connective tissue. Degener- ating and ulcerating tubercles are followed, as might be sup- posed in view of their volume, by considerable destruction of tissue, and in cases of repair by correspondingly extensive cica- trices. Tubercles are seen in such diseases as molluscum tibro- sum, molluscum epitheliale, syphilis, leprosy, myeloma, and cancer. Tubercles are often described as merely enlarged papules; but the distinction between these two forms of lesion will be better recognized when attention is paid to the particular portion of the skin in which each takes its origin. Papules spring oftenest from the superficial layers of the derma; tubercles, on the other hand, from the deeper. This being remembered, it will be clear that at times a tubercle may project from the surface to a less extent than a papule, though its larger volume is evident as soon as the skin within which it has developed is handled. Tumors are masses of solid tissue, or of solid tissue more or less commingled with fluids of variable consistency, dif- fering in size, shape, color, and in the benignity or malignity LESIONS AND LESION- RELICS. 49 OF THEIR CAREER, EITHER LOCATED WITHIN OR BENEATH THE SKIN, OR, BEING ATTACHED TO THE LATTER, PROJECTING FROM IT TO A VARIABLE EXTENT. The mere fact that, a lesion of the skin approaches in dimen- sions the size of a tumor is in itself an element of gravity. Tumors may originate in mere hyperplasia of the living matter ; may consist of new formations of greater or less danger to the vicinage, or the general economy; may be formed of blood or lymphatic vessels, or both in the same lesion; may embody large fluid-containing cysts; may be built up of nervous tissue, fat, bundles of connective-tissue fibres, glandular elements, and indeed of any of the elements which exist physiologically in the human integument. Examples of tumors are seen in molluscum fibrosum, myeloma, wens, cancer, and rhinoscleroma. Vesicles are elevations of the horny layer of the epi- dermis WITH LIMPID, LACTESCENT, OR SANGUINOLENT FLUID CON- TENTS, VARYING IN SIZE FROM A POPPY-SEED TO A COFFEE-BEAN. Typical vesicles are seen in the minute and transitory lesions occurring in the vesicular form of eczema. They are usually filled with a clear serum. Variations from this type are, how- ever, common. Thus, they may be flattened, acuminate, round- ish, umbilioated, or conical ; may be fully distended or partially collapsed upon their contents; may have a short or long dura- tion; may be distended with milky, chylous, or a blood-stained fluid; may be opalescent, yellowish, reddish, or blackish in color; several may coalesce to form a many-chambered lesion ; and a single one or several such may undergo transformation into pus- tules or bullae. Vesicles may terminate by accidental or spon- taneous rupture, their contents freely flowing forth upon the surface of the peripheral integument; or they may desiccate to a crust, or may even terminate by one of the ulcerative pro- cesses. They may or may not be accompanied by pruritus. Minute vesicles, which are merely the external apices of large- chambered accumulations of fluid beneath, occasionally form upon the surface of the skin. Such are seen in the course of lymphangiectasia. Blebs, or bullae, are superficial or deep-seated elevations of the skin having fluid contents, differing in color, shape, and career, and varying in size from a coffee bean to a goose's EGG. Blebs have been described as large vesicles; but this fails to define exactly their pathological character. Like vesicles they may contain serum, lymph, blood, or pus; and be variously colored in the degrees according to which their contents become visible through a semi-transparent roof-wall. They may be glo- boid, hemispherical, oval, crescentic, semi-crescentic, conical, and 4 50 GENERAL SYMPTOMATOLOGY. even exhibit angles. They may be seated upon an apparently unaltered or evidently morbid integument; and may or may not present a peripheral areola. Bullae may persist or rupture; ma} T desiccate or degenerate into ulcers; 'may collapse after tlie escape of their contents, and the roof-wall become glued to the base from which it was origi- nally raised. Bullee usually occur in extremely debilitated states of the Bystem, and are, as a rule, of graver portent than other fluid- containing lesions of the skin. " They occur in scalds and burns, in pemphigus, leprosy, erysipelas, syphilis, and moist gangrene. Pustules are circumscribed cutaneous abscesses, covered WITH AN EPIDERMAL ROOF-WALL, AND VARYING IN SIZE FROM A MILLET SEED TO A FILBERT. The typical pustule contains pus, and is colored yellowish, yellowish-green, or brownish green, according to the admixture of its contents with blood. The pus being an inflammatory product, it necessarily indicates the occurrence, at the base of the pustule, of an inflammatory process. Pustules, like vesicles, may be roundish, acuminate, globoid, conical, umbilicated, sur- rounded by an inflamed or normal integument; may be super- ficially or deeply seated; may terminate by rupture or desicca- tion; may or may not be followed by an ulcer and ultimate cicatrix. They may be seated either upon the free surface of the skin, or at the orifice of a follicle, in which case they repre- sent an inflammation with purulent product in the duct or gland beneath. Pustules are seen in syphilis, variola, eczema, scabies, acne, and many other cutaneous diseases, including several forms of dermatitis medicamentosa. Excoriations are superficial solutions of continuity, usually involving portions of the skin affected with pruritus, and resulting from mechanical violence. Excoriations, in appearance among the most trivial of skin lesions, possess a value from the diagnostic standpoint which can scarcely be overestimated. They occur as striated, linear, punc- tate, circular, or irregularly shaped furrowed wounds, at times involving areas of flat surface, oozing with serum or blood, cov- ered with dried blood or crusts, yellowish or reddish in hue, and for the most part both induced and accompanied by severe pru- ritus. They may coexist with hyperemia and infiltration of the skin beneath, brought on by the irritative character of the con- tinuous, or more frequently interrupted cause by which they were begotten. Excoriations become significant according as they indicate scratching, tearing, or other species of wounding by the finger nails, and rubbing portions of the integument with foreigu LESIONS AND LESION-RELICS. 51 bodies. Tn the former case they are significantly recognized in those portions of the body most accessible to the hands, though in the case of eczematoos children and infants they may origi- nate by the rubbing together of the knees ; or the leg of one side by the feet and toes of the other. The loss of tissue may extend deeper than the rete, — at times invading the papillae of the corium, which bleed in consequence. Excoriations may occur without the appearance of other lesions, as in the disease called pruritus; but where itching is severe and induced by a cutaneous exanthem, the lesions con- stituting the hitter may be intermingled with, obscured, or even obliterated by excoriations and the pathological processes to which they give origin. Thus maculae, vesicles, pustules, and papules may undergo change ; and the recognition of the type of the existing disease be correspondingly difficult. Excoriations are common in skins wounded by lice, bed-bugs, and gnats; in the subjects of eczema, scabies, intertrigo and prurigo; and in individuals with special sensitiveness of the integument to the action of a medicament employed either inter- nally or externally. Fissures, or rhagades, are linear solutions of continuity, usually occurring in previously infiltrated portions of the SKIN. They may extend to the derma, and even invade yet deeper structures; may be painful, or the reverse; dry, secretory, or incrusted; are often hemorrhagic, and usually formed with sharply-cut walls. They are- of frequent occurrence in the vi- cinity of the articulations, in which situations they are in- duced or aggravated by the joint-movement, stretching or tear- ing tissues whose extensibility has been diminished by any morbid process. Fissures may terminate in ulceration. They are for the most part lesion relics; and are observed in syphilis, eczema, psoriasis, and dermatitis. Scales, or squamae, are attached or exfoliated epithelial lamellae, which have become appreciable at the surface as the result of some morbid process in the skitf. A physiological desquamation is constantly in progress over the superficies of the body, whose evidences are not pronounced in skins properly cleansed by ablution. In disease processes, how- ever, desquamation may occur as a distinct symptom in various forms. Thus the scales may be minute, fine, branny, dirty-white, or yellowish ; they may be larger, pearly-white, shining; dry or fatty; aggregated so as to resemble flaky pie-crust; exfoliating in extensive sheets, as from the entire sole of the foot or palm of the hand ; or in glove finger-like sheaths, as from the surface of a digit. They may be scanty, scarcely perceptible, and so 52 GENERAL SYMPTOMATOLOGY. attached as to require force for their removal ; they may fall spontaneously in a pulverulent shower, being so abundant as to till the garments or bed-clothing of the patient. Furfuraceous desquamation is that form in which fine bran- like scales are shed from the surface. Scales occur in eczema, psoriasis, pityriasis, ichthyosis, syph- ilis, and iu several of the parasitic diseases of the skin. It should not he forgotten that scales are frequently inter- mingled with other lesions, often they succeed the latter, ami become lesion-relies. Thus a papule may scale at its apex, or surround its base with a collarette of loosened epidermal plates, beneath or between which a macular stain is visible. Again, they may develop from the macule, the tubercle, or the tumor. Though generally conceded to be evidences of a dry and non- discharging disease of the skin, they are at times accompanied or succeeded by moisture of the part affected. The term " scales" is sometimes applied to the flattened plates of dried sebum which form on the scalp and portions of the trunk in seborrhcea sicca. Crusts upon the skin are relics of the desiccation of its pathological products. Crusts are of the number of true lesion-relics, never occur- ring as primary symptoms of disease. When formed by the desiccation of serum only they are of a yellowish, straw-yel- lowish, or reddish-yellow hue; when composed largely of dried pus they are colored greenish, or greenish-yellow; and, when there has been an admixture of blood, they are usually brown- ish or blackish. At times they suggest in appearance gum, honey, or Venice turpentine; in shape they may have the form of the concavo-convex lid of a watch-case; in color and shape they may resemble the half-shell of the oyster, or the cara- pace of a small turtle. They may be delicate and thin; bulky and thick ; friable or mealy ; may be firmly attached to the sub- jacent tissues, or readily separable; may cover a sound, though tender and reddened epidermis; may conceal a superficial, or deep, foul-based ulcer, by whose secretions from beneath they are raised above the plane of the skin and increased in thick- ness. They may be circumscribed and no larger than a small finger-nail ; may envelop an entire limb or organ, as the leg or the penis; or, finally, may be so irregularly disposed among other lesions, papules, pustules, excoriations, and open ulcers, that it is difficult to define their outline, and even to recognize ther identity. Crusts formed of dried sebum are greasy to the • touch, dirty-yellowish in shade, and usually seated upon a non- infiltrated base. Crusts are common in eczema, syphilis, leprosy, seborrhcea, and a large number of other diseases of the integu- ment. lesions and lesion- relics. 53 . Cutaneous ulcers are losses of substance resulting from a previous pathological process involving the derma, and, IN cases, the subcutaneous tissue. Ulcers also are true lesion-relics. They differ greatly in size, shape, color, edges, base, career, and, indeed, in all their charac- teristics. Every ulcer has an outline, base, floor, edges, and secre- tion. The outline may be circular, crescentic, reniform, ovoid, serpiginous, or with horse-shoe-like contour. The base, or un- derlying tissue, may be soft, supple, indurated, or in a state of active inflammation, with consequent infiltration. The floor may be glazed, shallow, deep, excavated, cup- or funnel-shaped, "worm-eaten," crateriform, sloughy, covered with a tenacious or readily removed secretion, granular, puriform, or hasmorrhagic. The edges may be clean-cut, having a punched appearance, un- dermined, everted, ragged, regular, or contracting, with a whitish inner border of advancing cicatrization. The secretion may be scanty, limpid, puriform, profuse, ichorous and odorless, or ex- haling an offensive stench. They may be so crust-covered as to be invisible, or so exposed and. erosive in action as to render the affected surface in the highest degree unsightly. They may be acute or chronic, insensitive or productive of intense pain ; may heal by cicatrization, remain open for a lifetime, or prove fatal by either destruction of parts essential to life, or by exhaustion of the vital forces. Scars, or cicatrices, are new formed substitutes for lost connective tissue. Scars are essentially lesion-relics. They never succeed, ex- coriations, fissures, or other solutions of continuity in the skin, which have not penetrated, as far as the derma, and resulted in destruction of a portion of the elements of which the latter is built up. They possess the highest importance for the diagnostician, since they point invariably to a patho- logical process whose career is terminated, the characteristic features of which they frequently embody. They may be re- garded as the special and persistent imprints upon the integu- ment of the serious disorders from which it has suffered. To a certain extent, as already intimated, scars retain traces of the special peculiarities of the lesions, and even of the dis- eases, which they succeed. The identification, however, of the individual predecessor in each instance is, in the present state of our knowledge, not always possible from a study of cicatrices alone. The extent of knowledge in this direction is, however, rapidly increasing, and in many cases the certainty thus acquired is of incalculable value to the diagnostician. Scars are remarkable for their tendency to contraction and gradual decoloration. They may be minute, punctate, extensive in area, attached to underlying tissues, depressed, raised above the plane of the peripheral skin, seamed with furrows, pliable and 54 GENERAL SYMPTOMATOLOGY. soft, indurated, traversed by ridges, knotted, and as irregular in contour ns the ulcers already described. They may extend in digital, linear, or annular prolongations toward contiguous portions of the skin, and by subsequent contraction induce con- siderable distortion and deformity. Thus they may drag down an eyelid, and ectropion ensue; may glue the lobe of the ear to the cheek ; may evert lip or nostril. When recent, they are usually reddish in tint ; when older, be pigmented in centre or circumference, or, as is common, exhibit a gradual decoloration, centrifugal in its progress. They may be the seat of pain from an entrapped nerve-filament ; may reopen to ulceration, or be accompanied by no subjective sensation. Not rarely they be- come the origin of the disease known as keloid. Scars are unprovided with hairs, papillae, or the orifices of sweat and sebaceous gland ducts. As implied in the definition given above, scars may result from any disease or injury of the skin which involves loss of connective tissue elements in the corium. In addition to the names of the lesions of the skin just enumerated, certain peculiarities of cutaneous symptoms are described in qualifying terms, which here require definition. They relate chiefly to the color, shape, distribution, and method or period of evolution of lesions as they are observed in individ- ual' cases. The more important of these terms, as used by modern writers, are arranged below, alphabetically, with a brief explanation appended to each. A much larger list of obsolete adjectives, employed by older authors, is purposely omitted. Abdominalis. Located on the abdominal surface. Acumixatcs. Having a pointed apex. Acuttjs Of acute course. Aiultorum. Occurring in adult years. ^EsriVALis. Occurring in the season of summer. Aggregatus. Collected in patches. Agbiub. Acute, or angry in appearance. Albidus. Of whitish color. Annularis. In the form of a ring. Annulatus. In t lie form of a ring. Apyketicus. Unaccompanied by fever. Areatus. Occurring in anas. AhtIficialis. Producible artificially. Asymmktricalis. Of different distribution on the two lateral halves of the body . Autumxaris. Occurring in the fall of the year. Buachiaeis. 'Occurring on the surface of the arm. CachECTICORTJM. Occurring in debilitated subjects. Capitis Occurring on the head, usually the scalp. CHRONICUS. Chronic in course. Circinatus. Of circular outline. Circumscuiptus. Having a definite contour. CONFERTTJS. Arranged in close proximity, with coalescence of lesions. Coxflcens. Arranged in close proximity, with coalescence of lesions. Contagiosus. Capable of communication by contagion. Corporis. Occurring on the surface of the body ; employed usually to desig- nate an eruption upon the trunk, as distinguished from that on the head or extremities. GENERAL SYMPTOMATOLOGY. 55 Dippdsus. Irregularly disposed. Discretus. Having isolated lesions. Disseminatus. Disseminate, without regularity of distribution. Eruption. Is used of the totality of all patches and lesions upon the person of one individual. Erythematosus. Having a reddish blush. Exfoli\tivus. Having a tendency to exfoliation or shedding from the surface of the body. Exulcerans. Is employed by French writers to designate superficial ulcera- tions, or lesions with a tendency to such a process. By English and Ame- rican authors it is used to designate unusually deep ulcerations. Facialis. Located on the face, usually as distinguished from the scalp. Febrilts. Accompanied by a febrile process. Femoralis. Occurring on the surface of the thigh. Fibrosus. Composed of fibrous tissue. Figuratus. Having a figured appearance. Flavescens. Of yellowish hue. Foliaceus. Resembling a leaf or leaves. Guttatus. Of the size of a drop of water. Gyratus. Having a serpiginous or gyrate outline. This is usually the result of a coalescence of imperfect circles or semicircles. Hismalis. Occurring in the winter season. Humidus. Accompanied by moisture. Hypertrophicus. Characterized by hypertrophy. Infantilis. Occurring in infancy. Intertinctus. Distinguished by color. Iris. Occurring in more or less distinctly defined concentric rings. Labialis. Occurring upon the surface of the lip. Lenticularis. Of the size of a small bean. Madidans. Characterized by moisture. Marginatus. Having a defined margin. Medicamentosa Produced by external or (more commonly) internal medi- cation. Melanodes Of blackish color. Miliaris. Of the size of a millet seed. Mitis. Of mild, benignant type— the reverse of agrius. Multiformis. Exhibiting simultaneously several types of elementary lesions. Neonatorum Occurring in the newborn. Nigricans. Of black or blackish color. Nodosus. With development of nodes or tuberosities of the surface. Nummularis. Of the size of small coins. Olecsus. Accompanied by an oily secretion. Palmaris. Occurring on the palms. Parasitarius. Produced by an animal or vegetable parasite. Parasiticus. Produced by an animal or vegetable parasite. Patch. The aggregation of several isolated or confluent lesions. Pigmentosus. Accompanied by pigmentation. Pilaris. Related to the hair. Plantaris. Situated on the soles of the feet. Planus. Flat. Polymorphous This is the Greek equivalent of the Latin multiform. Pr^eputialis. Situated upon the prepuce. Progenitalis. Situated on the exposed mucous surfaces of the genitalia. Pruriginosus. Accompanied by itching. Pubis. Located upon the skin or hairs of the pubis. Punctatus. Occurring in dots or points. Rosaceus. Having a rosy or pinkish hue. Ruber. Red, usually dark red in color. Scutiformis. Having the shape of a shield. Senilis. Occurring in advanced years. Serpiginosus. Literally, creeping — advancing in irregular gyrations. Siccus. Dry, unaccompanied by moisture. Solitarius. Having an isolated lesion, or with isolated lesions. Symmetricalis. Similarly distributed on the two lateral halves of the body. 56 GENERAL ETIOLOGY. I'niiokmis. Exhibiting lesions all of one type. I'mvkksai.is. Affecting the entire surface of the body. VaRIEGATTJS. Exhibiting several distinct colors. Vasi dlosus. Accompanied by vascular development. Vernalis. Occurring chiefly in the spring of the year. Versicolor. Exhibiting Beveral shades of the same color. Yi i G \jiis. Of the usual or commonly observed type. III. GENERAL ETIOLOGY. The study of the causes of diseases of the skin ogives us a glimpse of the etiology of diseases in general. In the lowest representatives of life, the greatest dangers to existence origi- nate in exposure to assault from other and stronger representa- tives in search of their prey, in other terms an external danger. In man, the highest representative of the animal scale, the perils of existence are complicated hy his social necessities and his arti- ficial methods. He can never, however, at any period of his existence, divest himself from the necessity of exposure to exter- nal peril. The plan of his organs and the play of his normal activities are perfect, even to the recovery from all hut mortal injury and the repair of moderate loss. The struggle for exist- ence of the ideal man is intended to he with that which is with- out ; his body meanwhile furnishing him with a comfortable tenement and a fair fortress. In the purview of nature there should he no internal revolt. When such occurs, it is usually the result of his ignorance, his folly, or his vice. Viewed in this light, the causes of the diseases of his skin will be seen to differ but little from those which induce disease in his other organs. Exposed to cold, he suffers from a pneu- monia ; to injury, a fracture or a dislocation ; to the contact of poisons, lie vomits or purges; to contagion from his fellow-man, lie has the cholera or plague; all these are capable of producing diseases of his skin. But meantime his organs have a tender care for themselves and each other, compared with which the solicitude of a mother for her child becomes insignificant. The stomach refuses to digest itself; the lung, unwounded, admits no air to the pleura ; the bladder, so long as it is unruptured by violence, permits no drop of urine to pass into the peritoneal sac. In the same proportion and under the same general law, do the viscera refuse to generate a poison which will injure the integu- ment; and the fluids of the body, a vicious u humor" which will damage the bones. GENERAL ETIOLOGY. 57 Reasoning thus from analogy alone, it will be seen that the prevalent doctrines respecting blood-poisons of internal origin must be greatly restricted. Eczema alone, in its manifold forms, furnishes more than one-half of all the diseases of the skin ; and yet every one of these several forms can be produced at will and artificially upon the integument of man. Again, it is not to be forgotten that the body is really invested with a continuous skin which not only is extended over its outer surface, but is also reflected so as to line all passages by which it is traversed within. This inner investment, called the mucous membrane, is as truly a part of the skin as the epider- mis and corium of the face or hand. This is clear: first, as shown from the facts of evolution, because representative ani- mals of the lower scale are found capable of complete inversion, by which the outer skin becomes the inner or digestive, and the inner, in turn, the outer or protective organ; second, as shown by histology, the anatomical characters of the skin and mucous membrane being similar; third, as shown by pathology, the ex- troverted mucous membrane rapidly undergoing the transforma- tion which causes it to resemble the skin ; while the inverted skin, as when the thighs are by disease kept in continuous con- tact and moistened, assumes the characteristic features of mucous membranes. In the study of cutaneous etiology, it is manifestly proper to regard as of external origin all causes which operate from without upon either the outer or the inner skin of the body. This much premised, it can be said that the large proportion of all diseases of the integument originate either from the ac- tion of solar heat and light ; temperature changes at the surface of the body; contact with various fluid and solid substances with the production of either frictional, traumatic or toxic effects; or the development upon and within the skin, of vege- table parasites. It remains merely to consider these causes somewhat in detail, remembering that at times several influences cooperate in the production of a given effect. The action of solar light upon the skin is usually coincident with the operation of another mode of motion called heat. To the former are to be attributed the production of freckles, " tan," and other pigmentations of the surface; to the latter, the ery- thema, eczema, and various grades of dermatitis which may fol- low exposure to the direct rays of the sun. Other temperature effects, including those produced by extremes of both heat and cold, are to be classed in the same category. According to ITebra, exposure of the skin to a temperature over one hundred degrees Fahrenheit, produces merely a transient erythema, which under a further elevation of sixty-five (65° F.) degrees will not subside for several days. At a temperature of two hundred and twelve (212° F.), all grades of acute dermatitis are awakened with the production of bulla?, up to the point where complete destruction of the integument occurs. 60 GENERAL ETIOLOGY. integument, and conic in contact with toxic agents, without exhibiting a disease of the skin. Often there is a marked decree of sensitiveness of the integument peculiar to the individuals who suffer, which may exhibit itself in several members of one family, or exist in one person for hut a hrief period of time. Again, an individual idiosyncrasy may he exhibited, in conse- quence of which an article, harmless to all others, becomes to him alone a source of serious discomfort. The various physiological changes of the human body are never the causes of diseases of the skin, hut at times furnish special opportunities for the operation of such causes. Thus in the rapid tissue evolution of early life, eczema and lupus are relatively common — carcinoma and tinea versicolor rare. At puberty the hairs of the heard of the male are liable to the incursions of the trichophyton; and the nipple and breast of the female become the seat of eczema from epiphora of milk. The old man and the old woman may become the victims of cancer, aggravated forms of pruritus, and horny growths. Dentition, menstruation, pregnancy, and the menopause disturb the physi- ological equilibrium, and at times render the access of other disturbing forces exceptionally facile. The sexual appetite leads to excesses which bear fruit in attacks of herpes, pruritus, and syphilis. And the unceasing excretion from the skin surface, with constant deposit there of effete material, may, when there is prolonged disregard of the laws of cleanliness, induce a lia- bility to disease of the skin which is especially marked in the case of infants and children. The power to transmit skin disease by heredity is of less im- portance than is generally supposed. It is most conspicuous in the instances of hereditary syphilis; but even here the trans- mission of the disease is not without singular exceptions, and is limited to certain periods of the disease in the progenitors. The transmitted disease is also most, common in the foetus, which is in direct communication with the mother, and rapidly dimin- ishes in frequency with every month of separate existence, till late and very late instances of hereditary syphilis have come to be received with suspicion. Many of the examples cited of hereditary transmission of cutaneous diseases are, without doubt, cases of coincidence, which, considering the number of patients affected annually with eczema and psoriasis for example, should not be regarded as of very rare occurrence. The list of causes recognized as directly productive of dis- eases of the skin are, without question, under special circum- stances, capable of operating as indirect etiological factors. Temperature changes, contacts Avith the external world in all harmful degrees, and toxicants are prime agents in the produc- tion of diseases of internal organs; and these in turn may in- duce changes in the skin of the nature of disease. The uterus, the stomach, the liver, the kidney, the heart, the nervous ceu- GENERAL DIAGNOSIS. 61 tres, and the intestinal tract may become disordered, and the result be declared not only in disturbance of the function of these organs, but in an attack of urticaria, pruritus, jaundice, or erythema. Passive congestions of the surface, leading to oedema and violaceous blush of the skin, often result from circu- latory changes ; and, in fine, any constitutional disease, by im- pairing general nutrition, arresting repair, hastening waste, or in other directions impoverishing the protoplasm of the body, is capable of inducing disorder in the skin as in other organs. Thus in cancer, chlorosis, anaemia, and cholera there are signifi- cant alterations in the hue of the integument which possess not merely a diagnostic value for the clinician, but attest the sym- pathetic unity of each organ of the body with all others. IV. GENERAL DIAGNOSIS. The establishment of an accurate diagnosis in a cutaneous disease is essential to its successful management. This state- ment is rendered necessary in this connection by the preva- lence of a belief among the uneducated that the disorders of the skin, exhibited for the most part in visible symptoms, can be safely treated on general principles, without a recog- nition of the nature of the malady. By many practitioners the demand for an accurate diagnosis is ignored in consequence of a too general impression that the desired end is to be pursued through great and perplexing obscurity. Yet with patience, method, a habit of careful observation (without which no physician is successful), and a reasonable degree of skill, both the practitioner and student can attain their purpose in the large proportion of all cases. It is a popular error that the sole requisite for establishing a diagnosis is the exhibition of the affected portion of the integu- ment to the eye of him who is consulted with a view to its relief. The physician is supposed to inspect this surface at- tentively for a few moments, and then to pronounce definitely upon the nature of the disease present and the therapeutic measures to be adopted. But far more than this is requisite, and, indeed, fully as essential here as in the investigation of a disease involving any other organ of the body. It is first necessary to secure a history of the physical and mental condition of the patient in the past ; then should follow the special history of the disorders of the skin; lastly, an 62 GENERAL DIAGNOSIS. examination of the affected integument. For the purpose of methodically arriving at these facts, and of preserving them tor future reference, they should he systematically recorded. The following are some of the points upon which it will gene- rally be found useful to secure information : — The name, residence, age, sex, occupation, and married or unmarried state of the patient should be known, as also, when- ever practicable, the health-history of parents and children. In the case of women it is not only necessary to learn of the per- formance of the menstrual function in the past, but of the highest importance to he informed as to the previous occurrence of abortions and miscarriages, and, if such have occurred, the order observed by these with relation to the birth of viable infants. The significance and value of several of these facts have been described in the chapter on etiology. With respect to the history of the products of conception, it should never be forgotten that these have a most important bearing upon the question of syphilitic infection ; and the absolute exclusion of syphilis in any obscure case is a long step in the direction of an accurate diagnosis. In the case of male patients, questions will usually elicit either admission or denial of the fact of a precedent or present venereal disease, and the answers should be recorded as valueless or trustworthy according as they are or are not substantiated by corroborative clinical facts. Then should follow some record of the habits of the patient, as to active or sedentary employment, bathing, food and drink, including under the latter term the use of beer, wine, and spirits. The history of any previous disorders, whether of the skin or other organs, should be satisfactorily clear ; and, with respect to the latter, the dates of occurrence, recurrence, and convalescence be at least approximately discovered. The patient should also make known whether he has had refreshing sleep; whether he lias undergone mental anxieties (domestic, financial, etc.); whether he has suffered in his digestive, respiratory, cir- culatory, gen i to- urinary, or nervous system. This much ascertained, the patient should be encouraged to narrate as succinctly as possible, and as far as may be in his own terms, the history of the present cutaneous disorder. He should give the subjective sensations it has produced, as also the objective features presented to his own vision and touch. In the case of infants this information will of course have to be obtained from the mother or nurse. The treatment to which the disease has been subjected should then be detailed. This frequently furnishes a key alike to the diagnosis and therapy of the disorder. In an incredibly large proportion of all cases, ignorantly directed and vicious internal or external medica- tion has either begotten or aggravated the disease of the skin. This much ascertained, the physician is ready to examine the affected suriace for himself. GENERAL DIAGNOSIS. 63 During, however, the verbal interrogations which are required for this first part of the exploration of the case, the watchful and observant practitioner will probably have secured for him- self some useful information of which the patient is totally un- conscious. Much of this is difficult to describe, as it is the rich fruit of a wide experience and careful scrutiny. With a gentle, courteous, and sympathizing manner, the diagnostician must combine the art of a detective and the skill of a swordsman. Glancing occasionally at the face of his patient while making record of the answers given, he will of course have observed any eruption upon that portion of the body. lie will have made a mental note of the temperament of the sufferer, or any movement made by the latter indicating a tendency to scratch or rub any portion of the skin. He will have noticed the posture, clothing, and head apparel ; the existence of hair on the scalp or extensive baldness; the condition of the exposed hands, as indicating manual labor or the reverse ; and, in the absence of facial lesions, will have observed the general tint of the skin of the face, as indicating anaemia, chlorosis, or a gen- eral condition of cachexia. The facial expression, as indicative of anxiety or placidity, habits of debauch, sexual excesses, etc., will not have escaped his attention. All this and much more will have possibly enabled the questioner to direct his inter- rogatories into the channel where they would elicit the most useful responses. The posture, cries, facial expression, and gen- eral condition of nutrition of the infant will have been no less carefully noted. Proceeding to the examination of the affected integument, the physician must assure himself of a good light, as colors are best distinguished by daylight, and artificial illumination should be reserved for exploration of the cavities of the body. The air of the apartment should be sufficiently warm to permit of ex posure of the person without discomfort. Adult males and children of both sexes should have the clothing completely re- moved, so that all portions of the skin may be inspected. One portion of the body may, however, be examined, and then re- covered, if desired, while the examiner proceeds to direct his attention to another. In the case of women the investigation should be conducted with all the tact and delicacy to which the sex is entitled. The examination, whenever practicable, should extend over the entire surface of the integument. The importance of this point can be scarcely exaggerated. It must be remembered that the physician should be very much wiser than his patient ; and the assurances of the latter are always to be accepted with re- serve. Thus one who exposes his leg merely, stating that this is the only part of his body affected, may have concealed be- neath his clothing extensive varicosities of the veins of the thigh, a typical syphilitic exanthem over the belly, a significant scar 64 GENERAL DIAGNOSIS. on his elbow, an extensive patch of tinea versicolor on the sur- face of the chest, or a blennorrhagic discharge from the urethra, the medication of which has induced the rash for which he seeks relief. These are not the rare, but the common cases of a daily experience. Observation should be had at this time of the general and special features of the eruption. As to the former, the following considerations should be borne in mind : — A symmetrical eruption, one equally distributed over the two lateral halves of the body, is rarely the result of an etiological factor operating upon the outer skin. It more often points to an efficient cause of so-called internal origin, one influencing the inner skin or the internal organs. An eruption affecting the covered integument, never creeping out upon the exposed sur- faces, suggests the operation of the clothing; as the latter may chance to prove the nidus or protector of a parasite, the fabric which has been colored by a noxious dye, the recipient of a chemically-altered secretion, which has proved irritating to the surface, the instrument of friction, or the source of increased temperature at the surface by its non-conductivity of heat and unseasonable thickness. An eruption, accompanied by excoria- tions and scratch-lines, is that usually most severe in the parts most accessible to the hands, and least developed where the latter have the least ['lay, as over some parts of the back. An eruption limited to the hands is likely to be one induced l>y an agent to which the hands alone have been exposed, as those originating in the trades and domestic occupations; while in the latter, an eruption more distinct on the right hand, and especially about the right thumb and index finger, tells its own story when the hand-worker is not ambidextrous or left-handed. Artificially and intentionally produced eruptions, as in malingering, hys- teria, mental depravity and insanity, usually occur also in parts to which the right hand finds easy access. Eruptions occurring on the face, hands, and genitalia of the male, or face, hands, and mammae of the female, point to exter- nal contact or contagion (poison-ivy, scabies, croton-oil, etc.); since, next to the face, the hands are more commonly brought in contact with the parts named in the sexes respectively, as the wearing apparel of each suggests. An eruption, limited to the forehead, suggests an inspection of the hat-hand, the veil, or the overlying false hair; to the ears of the female, a glimpse at her possibly cheap ear-rings; to the centre of the root of the neck, before or behind, a scrutiny of the collar-buttons and collars; to the anus of the baby, an inquiry as to the changing of its napkins; to the wrists of the adult, a question as to the cuffs worn ; to the feet, information respecting gaiters, varicose veins, recently cut corns, and ill- fitting shoes. Eruptions springing from each of these causes have been long and vainly treated as " diseases of the blood." GENERAL DIAGNOSIS. 65 Eruptions markedly asymmetrical are indicative of asymmet- rically operating causes — that is, the accidents of the outer world contact, or else influences exerted within the body unequally on its two lateral halves. Thus an orthopaedic apparatus, worn to correct talipes, excites an eczema in the affected leg only ; and zoster of the trunk is evident on that side supplied by the intercostal nerve which has been inflamed. The greater stress may be laid on this peculiarity, as the law of symmetry, in erup- tions not occasioned by causes operating on the outer skin, is faithfully observed in nature. The earlier syphilides, the qui- nine exanthem, rubeola, and even lupus erythematosus, are remarkable illustrations of this fact. Proceeding next to the special visible characteristics of the eruption, the physician will not fail to note an acuteness or chronicity of lesions; their color, size, distribution, tendency to become aggregated in patches, or the reverse ; and the evi- dence presented as to change in type, the sequence or coexistence of several lesions at the same time,— that is, the multiformity (polymorphism) or uniformity of the eruption. He will observe whether the limit of the affected skin is well-defined against that which is normal, or scarcely to be outlined with a pen or pencil. He will rupture a bleb, pustule, or vesicle, should such be found, to discover the nature of its contents. He will re- move one or several crusts in sight, to expose the surface on which they rest. He will remove a few scales with the dermal curette for a similar reason. He will as carefully inspect the skin where the disease has existed, as that where it does exist. He will pinch up between his thumb and finger a small portion of each, in order to determine its infiltrated condition ; its atrophy ; or its attachment to the tissues beneath. He will pass his hands over the surface to recognize the firmness or softness of the lesions, their dryness or moisture, and the existence of sebaceous or perspiratory secretion. He will look at the mouths of the follicles, where such secretion is retained or abund- antly exuded. He will discover any ova or lice on the hair; any ascarides at play about the anus ; any unnatural forma- tion of the nail, or deformity of its matrix. He will examine for inguinal, post-cervical, axillary and epitrochlear adenopathy, and will thus be often greatly aided in his task. This done, he will question in turn for himself, and by the methods recognized in medical science, the organs of the body other than the skin. He will inspect the tongue carefully, and then, if he is through with the mouth, he will be guilty of great error. The gums rarely deceive the questioning eye; the inside of the lips, fauces and tonsils are all to be searched. A mucous patch here will often echo the story of a palmar or plantar syphiloderm. The laryngoscope may be called for in syphilis, cancer, lupus and leprosy. The degree of distension of the belly, and the region of hepatic dulness, should not be overlooked. The genitalia of 5 66 GENERAL DIAGNOSIS. the male, and of children and infants, can usually be explored. For women unaffected with syphilis or disease limited to these parts, an exception in this particular should usually be made. With the necessary reserve of all very obscure cases, it may be said that the diagnostician who has conscientiously con- ducted an examination after the manner described above, is in possession of the diagnosis for which he seeks. If the facts thus acquired have been properly recorded, and yet do not spell out the diagnosis to his eyes, they are probably legible to others with a wider experience or riper judgment, to whom such a record is shown. It is not claimed that this exhaustive method of examination is requisite in every case, as, for example, in order to recognize an acne or to differentiate erysipelas from erythema. But it is certain that few obscure cases of skin disease will remain such under severe scrutiny, and the estab- lishment of a thorough and exhaustive method of examination is important in the earliest experience with disease. Let the student or practitioner conduct such an examination in the first few cases of eruption upon the surface of the body for which his advice is sought, and he will establish a habit of observa- tion in comparison with which his pecuniary or professional success in the management of the same cases will be indeed of trivial worth. Upon one special point should the inexperienced physician be guarded. It relates to the acceptance of a diagnosis which is not based upon such an examination as that given in outline above. The diagnosis of a patient is usually faulty, and the verdict of even skilled practitioners may be founded upon an error. The careful diagnostician should commence his task in a spirit of skepticism, and pronounce definitely only upon ascertained facts. The man who says he has an " eczema" ma} T be louse-bitten; the woman who has been "overheated" may prove syphilitic. The patient recognized as suffering from ringworm of the heard may not have been infected under the hands of the barber. Finally, the eruptions upon patients un- mistakably syphilitic are often of other than syphilitic origin. They are men, women, and children exposed daily to the acci- dents from which the non-infected suffer. They exhibit acne, physiological alopecia, and dermatitis medicamentosa equally with those who have not sinned sexually. For the diagnosis of special diseases of the skin, the reader is referred to the chapter in which each is considered. The microscope is an instrument whose aid in establishing a diagnosis of cutaneous disease can rarely be dispensed with. The contributions it has made to the knowledge had on the subject of pathology are of inestimable value ; and as a means of diagnosis it can be used with advantage both at the time of the first examination of a patient, and afterward for the more PROGNOSIS. 67 leisurely examination of hairs, scales, crusts, or portions of tissue. Those unable to secure the costlier and elaborate in- struments sold by the makers, should take pains to provide themselves with a fairly good "student's stand," and a fifth and half inch objective for diagnosis in skin diseases. V. PROGNOSIS. The prognosis of most diseases of the human body is formu- lated with a view to the decision of the serious question of life or death. Occasionally this question arises in connection with skin diseases. Many of the latter are trivial ; some are grave ; a few, inevitably fatal in their termination. Thus general ex- foliative dermatitis, leprosy, myeloma, carcinoma, at times lichen ruber, and variola in the unprotected, are of grave por- tent ; while the ordinary hypenemise and exudations, the great majority of all cases of acquired syphilis in adults, and the entirely curable diseases induced by parasites do not excite alarm in the breast of the average patient with respect to his longevity. The questions, however, as to his future, which are urgently pressed by the victim of cutaneous disease, are both numerous and important. He is anxious as to the time during which he must suffer; as to the possibility of conveying his disease to his progeny or other members of his family; as to the disfigure- ment of his person which might result; as to the scars which he may have to carry for the remainder of his life; as to the possible recurrences of his malady in the future. The responses to these questions will be largely influenced by the prognosis of the physician. Some diseases of the skin are acute, rapidly pursue their course, and are then prompt to disappear. Others are chronic, rebellious to treatment of the most energetic and skilful char- acter. Others, again, though not shortening life, are never re- lieved while life is continued. Some disappear, only to reappear at more or less regular intervals. There are cutaneous diseases which affect one individual but once in his lifetime; others which reappear at the instant the patient is again exposed to their exciting cause. There are cutaneous diseases so distort- ing and destructive in their effects, that their victims have committed suicide under the influence of the morbid emotions which they have as a consequence experienced. 68 GENERAL THERAPEUTICS. The mental distress occasioned by oven an insignificant cuta- neous disorder is often out of all proportion to its exciting cause; and this should always be regarded in establishing a prognosis. The sexual hypochondriac has been made insane by an acne ; and the man or woman affected with syphilis has been made wretched for years by a recurrent erythema. Again, a disease of the skin may coexist with grave lesions of internal organs, and the prognosis of the disease of the one be greatly influenced by that demanded by the other. Thus there is occasional coexistence of syphilis and phthisis. Pru- ritus may be associated with Bright's disease of the kidneys ; and the eczema of an infant starving for want of breast-milk may hasten its marasmus to a fatal termination. Upon the answers given to his patient inquiring as to the prognosis of the disease of the latter, will largely depend the professional success of the physician. Scrupulous honesty should be here welded with all the skill that science can com- mand. That a. disease does not endanger life, is not an argu- ment in favor of its amenability to treatment. The practitioner should never suffer himself to be pushed by his patient to the position that an obstinate disease is readily manageable. It is the height of folly to lightly estimate that zoster of the forehead, the scars of which the patient will exhibit to all who afterward look upon his face both in life and death. He who engages to relieve an alopecia areata in the month, may have a year in which to repent his precipitancy. There is no way in which the conscientious physician can so readily secure the confidence of his patient, and with it that willingness to submit to appro- priate treatment, which is begotten of such confidence, as by demonstrating his ability to forecast the future of a disease ; in other words, to describe accurately its prognosis. VI. GENERAL THERAPEUTICS. A consideration of the subject of the methods of treating skin diseases in general, suggests at once the intimate relation which subsists between the integument and other organs of the body. The etiology of one, largely explains the causes of the disorders in all. The pathological processes in each are subordinated to the same general laws. The principles of treatment are very similar, in all the disorders of the body. The object to be attained by treating a cutaneous disease is, GENERAL THERAPEUTICS. b\) first, its complete relief; second, where the latter is impossible, such a management of the morbid process as will mitigate its severity and render the victim of the disease more comfortable. A higher and more scientific achievement than either is the prophylaxis by which man is enabled to escape the disease alto- gether. He can by his wisdom largely diminish the danger to which his integument is exposed. He can, to a certain extent, shelter himself from extremes of temperature, traumatism, toxic agents, and the contagious diseases. He can, by observing the simple rules of hygiene, fortify his skin against the lesser evils which may befall it. If it be true that "the people perish for want of knowledge," it is certain that once in possession of it, they can greatly enhance their comfort and prolong existence. Here, however, the subject under consideration involves disease which is actually present and in progress. Like all other diseases of the body, those of the skin may be divided into three classes with relatively fixed limits. The first embraces all the diseases which have a natural ten- dency to pursue their course to a favorable termination. It em- braces all those affections which, either mild or severe, require absolutely no treatment of an active character. It is the duty of the skilful physician to watch the evolution of these mala- dies, and to discharge a most 'important duty by refraining from all therapeutic measures which in such cases might prove hurt- ful. By his judicious counsel also, he hinders patients and their friends from pursuing a course which might prove prejudicial to the disease. The second class embraces all those affections of the skin which are either inevitably fatal or hopelessly remediless while life is prolonged. Fortunately this includes but a small pro- portion of the large list. Here the duty of the physician is plain. He should assuage pain, attempt to relieve deformity, administer to the comfort of the afflicted in other ways, and, by his patient courage, inspire confidence and hope. It must not be forgotten that the skill of man has not yet reached the acme of human need. In the presence of many diseases of the body, he stands absolutely helpless ; and the speediest way to success in such cases is to begin by an honest admission of the plain fact. The third class of affections naturally embraces all not in- cluded in the other two. Here disease may be prolonged or shortened in its course, rendered acute or chronic, made more or less endurable, permitted to become inveterate, or be abso- lutely relieved, by prompt and energetic measures, according as it is, or is not, judiciously and skilfully managed. Here are gained the most brilliant successes of the dermatologist ; here also occur his most humiliating failures. In the presence of a cutaneous disease which requires treatment, a question naturally arises as to whether this treatment shall Hi GENERAL TH K R A PEUTICS. be internal, that is, by medicaments ingested; or external, that is, by local therapeusis ; or by a combination of the two methods nt the same time. With regard to the first question, which is one of pressing importance, it can be safely said that there are no remedies to be given by the mouth which can be described as certainly and specifically curative of the diseases of the skin. The number of medicinal ageuts employed with this end in view is incredibly large, by far the greater part being obtained from the vegetable kingdom. With the few exceptions given below, not one of these is known to exercise the slightest reme- dial action upon the surface of the body, though it can scarcely be doubted that the list will be enlarged as experiments in this direction multiply. Other so called remedies are, for the most part, utterly without value of any sort; but will continue to lie vaunted as specific, so long as credulity on the one hand, and avarice on the other, move the masses of mankind. The remedial agents employed internally and recognized as possessed of some value in diseases of the skin, are arsenic, mer- cury, iodine, cod-liver oil, quinine, ergot, and carbolic acid. Of them all, it may be said that while each possesses a wide range of usefulness, no one of them in any case can be certainly trusted to produce a given effect; and each in many cases is either posi- tively prejudicial or without efficacy of any kind. Arsenic, which properly stands at the head of this significantly short list, is known to exert its effects almost exclusivel}- upon the epithelia of the skin, and upon these, so far as therapeutic effects are concerned, only when they are in indolent conditions, subacute and chronic pathological states. It is known to exert an unfavorable influence upon the epidermis when the latter participates in a condition of active inflammation. Operating in this limited class of cases favorably, it also operates slowly, requiring months for the production of its curative effects. Its administration is at all times attended with the hazard of pro- ducing toxic effects, which, however, when the result of the ex- hibition of the drug in medicinal doses, are usually limited to a mild exanthem upon the skin, moderate coryza and some redness from congestion of the vessels in the eyes and eyelids. It is used chiefly in psoriasis, acne, squamous eczema, pem- phigus, and lichen ruber; its dosage in cases of children being relatively large. It should be invariably administered only after eating, and a minimum dose be first employed in order to test the susceptibility of the patient to its action. It should be re- membered that the toxic effect of this, as also of several of the other drugs mentioned below, is often speedily noticed after the first exhibition of a relatively small dose. Toleration once established, the dosage may be cautiously increased. The forms in which it is usually administered are the prepa- rations of arsenious acid, such as the liquor potassii arsenitis GENERAL THERAPEUTICS. 71 (Fowler's solution); the liquor arsenici et hydrargyri iodidi (Donovan's solution); the liquor arsenici chloridi, and the Asiatic pill. Duhring's modification of this pill is obtained by making two grains (.13) of arsenious acid, and thirty-two grains (2.2) each of black pepper and liquorice powder, into thirty -two pills by the aid of a sufficient quantity of mucilage. Arsenic is also at times advantageously combined with other indicated medicinal substances, such as iron and the iodide of potassium. As already intimated, an unprejudiced view of its action, even, in cases properly selected for its administration, will justify the statement that it is a remedy of uncertain effect, and, in that proportion, disappointing. The value of Mercury in the syphilodermata is incontestable, and its injudicious employment in many cases springs from that precise fact. The vulgar prejudice that many disorders of the skin, really not syphilitic, are obscure manifestations of lues in a preceding generation, and amenable to mercurial treatment, is a striking illustration of the necessity of accurate diagnosis in cutaneous diseases. Few non-syphilitic affections are bene- fited by continuous courses of mercury, though the value of the metal as an alterative in this small proportion of cases must be admitted. The corrosive sublimate is well nigh superseded, in consequence of its irritative effects, by the compounds of the metal with iodine. The gray powder is useful chiefly in case of infants and children, though its not infrequent development of the corrosive chloride has largely limited its favor with Americans. Calomel and the mercurial pill should be employed only for transient effects, as, when administered for long periods, they are much more apt to produce ptyalism than the other preparations mentioned. Iodine and its compounds are also chiefly used by the derma- tologist in syphilitic disorders of the skin, but they possess a wider range of value than the mercurials in the treatment of other cutaneous affections. Here too the abuse of the drug fur- nishes the clinicien with a long list of cutaneous disorders either originated or aggravated by its employment. As in the use of arsenic, toleration should be established before large doses are exhibited. The compounds chiefly used are the iodides of potas- sium, sodium, lithium, and ammonium, and, quite recently, iodoform. It has been administered for the relief of the scroful- dermata, the two varieties of lupus, keloid, and the syphilitic affections of the skin. As to the latter, it may be added, that in the earlier skin symptoms of lues, it is often a source of positive injury. Cod-liver Oil is a remedy of special value in diseases of the skin, and was for that reason held in high favor by the dis- JO GENERAL THERAPEUTICS. be internal, that is, by medicaments invested; or external, tliat i.-. by local therapeusis ; or by a combination of the two methods at the same time. With regard to the first question, which is one of pressing importance, it can be safely Baid that there are no remedies to be given by the month which can be described as certainly and specifically curative of the diseases of the skin. The number of medicinal agents employed with this end in view is incredibly large, by far the greater part beiii^ obtained from the vegetable kingdom. With the few exceptions given below, not one of these is known to exercise the slightest reme- dial action upon the surface of the body, though it can scarcely be doubted that the list will be enlarged as experiments in this direction multiply. Other so called remedies are, for the most part, utterly without value of any sort; but will continue to be vaunted as specific, so long as credulity on the one hand, and avarice on the other, move the masses of mankind. The remedial agents employed internally and recognized as possessed of some value in diseases of the skin, are arsenic, mer- cury, iodine, cod-liver oil, quinine, ergot, and carbolic acid. Of them all, it may be said that while each possesses a wide range of usefulness, no one of them in any case can be certainly trusted to produce a given effect; and each in many cases is either posi- tively prejudicial or without, efficacy of any kind. Arsenic, which properly stands at the head of this significantly short list, is known to exert its effects almost exclusively upon the epithelia of the skin, and upon these, so far as therapeutic effects are concerned, only when they are in indolent conditions, subacute and chronic pathological states. It is known to exert an unfavorable influence upon the epidermis when the latter participates in a condition of active inflammation. Operating in this limited class of cases favorably, it also operates slowly, requiring months for the production of its curative effects. Its administration is at all times attended with the hazard of pro- ducing toxic effects, which, however, when the result of the ex- hibition of the drug in medicinal doses, are usually limited to a mild exanthem upon the skin, moderate coryza and some redness from congestion of the vessels in the eyes and eyelids. It is used chiefly in psoriasis, acne, squamous eczema, pem- phigus, and lichen ruber; its dosage in cases of children being relatively large. It should be invariably administered only after eating, and a minimum dose be first employed in order to test the susceptibility of the patient to its action. It should be re- membered that the toxic effect of this, as also of several of the other drugs mentioned below, is often speedily noticed after the first exhibition of a relatively small dose. Toleration once established, the dosage ma} r be cautiously increased. The forms in which it is usually administered are the prepa- rations of arsenious acid, such as the liquor potassii arsenitis GENERAL THERAPEUTICS. 71 (Fowler's solution); the liquor arseuiei et hydrargyri iodidi (Donovan's solution); the liquor arsenici chloridi, and the Asiatic pill. Duhring's modification of this pill is obtained by making two grains (.13) of arsenious acid, and thirty -two grains (2.2) each of black pepper and liquorice powder, into thirty-two pills by the aid of a sufficient quantity of mucilage. Arsenic is also at times advantageously combined with other indicated medicinal substances, such as iron and the iodide of potassium. As already intimated, an unprejudiced view of its action, even in cases properly selected for its administration, will justify the statement that it is a remedy of uncertain effect, and, in that proportion, disappointing. The value of Mercury in the sypbilodermata is incontestable, and its injudicious employment in many cases springs from that precise fact. The vulgar prejudice that many disorders of the skin, really not syphilitic, are obscure manifestations of lues in a preceding generation, and amenable to mercurial treatment, is a striking illustration of the necessity of accurate diagnosis in cutaneous diseases. Few non-syphilitic affections are bene- fited by continuous courses of mercury, though the value of the metal as an alterative in this small proportion of cases must be admitted. The corrosive sublimate is well nigh superseded, in consequence of its irritative effects, by the compounds of the metal with iodine. The gray powder is useful chiefly in case of infants and children, though its not infrequent development of the corrosive chloride has largely limited its favor with Americans. Calomel and the mercurial pill should be employed onl}^ for transient effects, as, when administered for long periods, they are much more apt to produce ptyalism than the other preparations mentioned. Iodine and its compounds are also chiefly used by the derma- tologist in syphilitic disorders of the skin, but they possess a wider range of value than the mercurials in the treatment of other cutaneous affections. Here too the abuse of the drug fur- nishes the clinicien with a long list of cutaneous disorders either originated or aggravated by its employment. As in the use of arsenic, toleration should be established before large doses are exhibited. The compounds chiefly used are the iodides of potas- sium, sodium, lithium, and ammonium, and, quite recently, iodoform. It has been administered for the relief of the scroful- dermata, the two varieties of lupus, keloid, and the syphilitic affections of the skin. As to the latter, it may be added, that in the earlier skin symptoms of lues, it is often a source of positive injury. Cod-liver Oil is a remedy of special value in diseases of the skin, and was for that reason held in high favor by the dis- VI GENERAL THERAPEUTICS. tinguished EJebra, though its action is almost exclusively that of a nutrient of the general system. It is employed chiefly for its roborant effects, and these are similar to those of the digestible aliments. Its special value in the treatment of infants and children affected with cutaneous disease cannot he questioned. It is. however, of great use also in maturer years, and is ad- vantageously exhibited in eczema, lupus, scrofula, syphilis, morphoea, scleroderma, and in all the disorders of the integu- ment accompanied by wasting. Quinine, administered both as a tonic and anti-periodic, is largely employed in cutaneous medicine for its generally recog- nized systemic effects. It produces, in certain susceptible individuals, a peculiar smoothness and softness of the skin, which usually disappear when the drug is suspended. Like arsenic and iodine, it is occasionally the cause of a generalized exanthem, and is capable of producing other toxic effects, such as failure of the heart's action, dizziness, and tinnitus aurium, symptoms recognized under the designation of cinchon- isra. It will of course exhib t its happiest effects in malarial affections with coincidence of cutaneous symptoms, and in the forms of disease of the skin associated with a neurosis. Ergot, whether hy exerting an effect upon the muscle bundles or vessels of the derma, or the uterus of the female, or yet by its influence upon the general economy, is thought to possess some value in the treatment of several cutaneous diseases occur- ring in both sexes. Such are acne, purpura, and a tew other disorders. Tar, Carbolic Acid, and Phosphorus are remedies which have been employed internally with appreciable effect in certain cutaneous disorders, but the action of each is uncertain, and at times highly prejudicial. They have been used with advan- tage in some cases of lupus, eczema, psoriasis, and pruritus; but their value is exceedingly limited. The difficulty attending their internal administration has been to a great degree a bar to their general employment. The "perles" of phosphorus, and the elegant elixirs of the same drug, prepared by the Messrs. Fairchild and Wyeth & Bro., seem to have obviated this diffi- culty in the instance of at least one of these articles. Unpromising as is perforce this brief review of the in- fluences which internal medicaments are capable of exerting upon the skin, it must not be forgotten that, while the treat- ment of the patient and the treatment of the patient's skin are practically one, there is some distinction to be drawn between them. No one would claim that castor oil, for example, pos- sessed any efficacy in the fracture of a femur, yet such a cathar- GENERAL THERAPEUTICS. 73 tic is frequently ordered by the surgeon, with the happiest effect upon the condition of his patient in a splint. Such precisely is the inestimable value of a properly conducted internal medica- tion in cases of cutaneous disease. The consideration of this point introduces us at once and properly to the broad field of general medicine. He is totally unfit to treat cutaneous diseases, who is not qualified by educa- tion and experience for the general practice of medicine. The internal treatment of the patient suffering from a disease of the skin, is that which is in each case indicated by his general condition. Thus the aperients, cathartics, diuretics, and occa- sionally even the anodynes, are demanded, and, when judiciously employed, accomplish beneficial results. Few practitioners can afford to dispense with the use of the preparations of iron, for example, in cases of anaemia. Even the patient affected with a parasitic disease may need one of the bitter tonics, and the youth with vegetations upon the glans may require first to be rid of his blennorrhagia. J^or will he who accomplishes the largest success neglect con- sideration of the diet, hygiene, and social surroundings of the patient. The chief value of the various mineral springs and health resorts of this country lies in the change of the manner of living which they invite and necessitate. Sunshine, pure air, recreation after the care and toil of business, change of climate, of foods and drinks, and even of cooks, often decide the question of speedy recovery. Unfortunately, both in this country and abroad, many of the health resorts are peopled by unscrupulous charlatans, with a myopic tendency to attribute all the benefits to be derived from these sources to the medicinal virtues of this or that particular spring, aided always by treat- ment according to their own Very peculiar methods. Many patients affected with disease of the skin are thus made worse by a temporary residence at noted health resorts, and therefore it is often the case that a visit to the seashore, the mountains, or any healthful place in the country will be conducive to far greater practical results. In the external treatment of diseases of the skin, the indica- tions are, to hasten repair when this is possible; to alleviate dis- tress, if palliatives only are admissible; to absolutely destroy or excise the diseased tissue, when this is justifiable. The follow- ing are the principal substances employed as external applica- tions: — Water, either pure or medicated by holding other substances in solution or mechanical suspension, is applied either in baths or lotions. Baths, local or general, may be employed for days continuously, or but for a few moments at a time. They are given with water of varying temperature, cold, warm, or hot. Cold baths of short duration are generally followed by a sharp 74 GENERAL THERAPEUTICS. reaction, the skin hemming congested after the normal tempera- ture of the Burface is regained. Tims it is that cold sponging of the inflamed skin is usually grateful so long as it is contin- ued; and is succeed, m1 afterwards by sin aggravation of the symptoms which it was intended to relieve. Continued appli- cations of cold water are not open to this objection. Hot baths are followed by a more or less enduring relaxation of the integ- ument, while those given with tepid water are chiefly macera- tive of the surface. It should be remembered that the applica- tion of water to the broken surface of the skin, is liable to be followed by endosmosis, unless the specific gravity of the serum of the blood and that of the fluid of the bath or lotion are nearly the same. This imbibition of fluids by the broken skin is accompanied by slight swelling of the tissues and productive of disagreeable sensations. The most perfect of all methods by which water is applied to the surface of the body, is that which most resembles the water- hath in which the tender skin of the foetus is safely immersed for consecutive months. Here the bath is continuous; the tem- perature, that of the viscera of the living animal; the medica- tion, slight ; and the delicate skin of the unborn child, anointed with a fatty substance which actually interferes with the macer- ative action of the surrounding fluid so long as vitality is pre- served at the average standard. The comfort and therapeutic value of a bath prepared and administered in conformity with this rule, can scarcely be overestimated. Were it not for the difficult ies with which it is attended, so far as relates to many portions of the surface of the body, it would be possible with this single therapeutic measure to rob the exudative affections of the skin of a great part of their formidable features. Water for external application, is medicated by the addition of a large number of substances, such as marine salt, sodic and potassic salts, alum, tannin, the mineral acids, mucilages, gela- tin, bran, and, especially in the Southern States of this country, the orange leaf. When employed as a lotion, water is made to produce a seda- tive effect by the addition of opium, belladonna, glycerine, car- bolic acid, hydrocyanic acid, zinc, bismuth, mercury, lead, and the alkaline bicarbonates with the sodic hiborate. It is rendered stimulating by the admixture of alcohol, most of the acids and alkalies in stronger solution than in the soothing or sedative lotions; and by a large number of substances which operate upon the surface either mechanically or chemically. It is also ren- dered astringent when tannin, lead, and similar medicaments are dissolved in it; and by its union in various degrees with soaps and alkalies a solvent effect is produced, either upon the cuticle itself or upon pathological or foreign products upon its surface. Water is employed also, both in the form of the douche and vapor bath. When evaporation is prevented, by covering the GENERAL THERAPEUTICS. 75 wet surface of the body with an impermeable tissue, such as gutta-percha or rubber cloth, still further macerative effect is produced. The sweat alone is in the same way converted into a macerating; agent. Lotions other than those containing water are often service- able. The fluid in such case may be alcoholic, ethereal, or ole- aginous, and medicated to any desired, effect. Fatty and Oily substances are applied to the skin either directly by pouring; or by friction; or by the mediation of compresses, bandages, etc., which are saturated or spread with the material to be applied. The oils may be used for either soothing or stimulating effects. To the former class belong cod- liver, lard, olive, almond, linseed, neatsf'oot, castor, and similar oils; to the latter, the oil of tar, of cade, of white birch, of the cashew nut, and of juniper. Fatty substances are also applied in the form of Ointments or Pomades. They are compounded with various medicinal sub- stances, according to the requirements of each case, such as the salts of mercury, zinc, copper, lead, and sulphur; carbolic, pyro- gallic, chrysophanic, and hyposulphurous acids; tar, camphor, iodoform, balsam of Peru, hydrate of chloral, the extracts of opium, belladonna, etc. Glycerine and the products of petroleum refinement, known as Vaseline and Cosmoline, though not true fats, are increas- ingly employed for similar purposes, and have met with high favor in this country and abroad. Plasters are employed when it is desired to exert a more or less continuous effect upon the skin. Among those chiefly' used may be named mercurial, soap, and lead plasters. Powders are mechanically dusted over the surface of the skin for the purpose of protecting it, and occasionally in order also to produce an astringent or antipruritic effect. In order to be serviceable, they should generally be rendered impalpable by sifting them carefully through a fine silk bolting cloth. They are composed of starch, lycopodium, bismuth, camphor, tannin, oxide of zinc, salicylic acid, and similar substances. The arti- cles sold by the grocers as " Oswego Gloss Starch" and "Corn Starch Farina," are usually much more finely bolted than the dusting powders prepared by the chemists extemporaneously. As absorbent powders, the starchy substances are open to the objection of forming little pasty rolls or "cakes" when wet with serum or sweat. Lycopodium, which is seen under the micro- scope to consist of irregularly globular pollen sporules, never behaves in this fashion; and is, for that reason, deservedly pop- ular. lb GENERAL THERAPEUTICS. Son]- arc of great value when applied to the skin. The hard, or Boda, soaps are employed chiefly for the purposes of ablution. The Boft, or potash, Boap lias a wider therapeutic range. In consequence of the small excess of caustic potash which it con- tains it not only serves to cleanse the skin of any accumulations upon its Burface, native or foreign, but also to exert a mild, destructive effect upon the horny layer of the epidermis. Di- ed with rectified spirits of wine in the proportion of two parts of the soap to one of the alcohol, it forms the well-known '•spiritus sapouis kalinus" of Ilehra, a preparation which the modern dermatologist employs constantly with admirable results. Medicated soaps, containing carbolic acid, glycerine, tar, sul- phur, and various oils, are sold in the shops; but contain so small a portion of the individual medicament from which each is named, that they are practically worthless except for pur- poses of ablution. The author has had such [prepared under cold pressure, so as to contain medicinal substances in therapeutic proportions; but, after experimentation, lias concluded that other forms of administration are preferable. Many agents are employed upon the surface of the integument to produce in various degrees a caustic or destructive effort. Among these maybe named the thermocautery (Paquelin knife), gal- vano-caustic apparatus, the mineral acids and alkalies, ethylate of sodium, arsenic, chloride of ziuc, several mercurial com- pounds, acid nitrate of mercury, bichloride of mercury, chloride of antimony, sulphate of copper, and nitrate of silver. Several of these substances in weak solution are employed as milder agents for the production of irritative, or even various inflam- matory effects. To the latter class should be added iodine in tincture, chloroform, tartar emetic, castor oil and cantharides. These destructive effects are of advantage in the treatment of disorders of the integument due to parasites, either animal or vegetable. Of those employed for this purpose, and not men- tioned above, may be named petroleum and staphysagria, for the destruction of lice ; sulphur, styrax, and balsam of Peru, for the destruction of acari; sulphur and its compounds, and a number of derivates from tar, for the destruction of vegetable parasites. A variety of Surgical and other Appliances are found useful as adjuvants in the treatment of skin diseases. They may be employed to support, protect, or compress the surface, or merely to aid in the retention of dressings or external medicaments. Thus tlie ordinary roller bandage is applicable to many portions of the body; the suspender, or suspensory bag, over tlie scro- tum; elastic or inelastic stockings to the feet and legs; kid, rubber, and thread gloves to the feet and fingers; and various skull-caps, face-masks, and mittens are employed in the case of infants and children to protect affected surfaces from the dangers of scratching. CLASSIFICATION. 77 The instruments employed upon the skin for ordinary opera- tive, exploratory, or dressing purposes, need not be numerous. The author's case contains the following useful articles: — One set of variously-sized dermal curettes. These little sharp- edged spoons are for erasion of the surface, and should con- sequently have in each a fenestrum large enough to permit the escape of all collected substances from the floor of the spoon. One pair of epilating forceps with easy spring, and smooth blades meeting in perfect apposition. One pair of tine dressing forceps. One pair of fine curved scissors. Several comedone extractors. These should not be provided with piston and needle, but have a superior opening for escape of sebaceous accumulations. One half-inch lens for examining the surface of the skin. One set of needles in ivory handle. One set or* " gynecological" needles and needle-holder, for entering sebaceous and hair follicles, attacking small warts, etc. Two fine scalpels. One exploring needle. One set of fine probes. VII. CLASSIFICATION. TnE numerous attempts which have been made to classify diseases of the skin according to their nature and relations, have been a response to the generally recognized demand for a sys- tematic arrangement of all scientific facts. As regards derma- tology, not only have these attempts been numerous and based upon different principles, but the results which they have ac- complished have been in the highest degree divergent. No single classification yet devised has hitherto secured general ac- ceptance. While it is certain that no one of them has been per- fect and that each has exhibited defects, it is equally true that of the larger number each has possessed some merit of its own. It is probable that no perfectly satisfactory classification of cu- taneous diseases can be generally accepted till the knowledge of diseases of the skin has been greatly enlarged. The most satisfactory of alt the systems thus far proposed is that of Hebra. By it cutaneous disorders are arranged in the following nine classes : — CLASSIFICATION. CLASS I. Disorders of Secretion. ( Jlass II. Eypersemias. Class III. Exudations. Class IV. 1 hemorrhages. Class V. Hypertrophies. Class VI. Atrophies. Class VII. New Growths. Class VIII. Neuroses. Class IX. Parasites. This classification is essentially observed in the arrangement which is appended, the difference between the two resting upon the fact that in the latter the diseases are grouped primarily according to the regions involved, and secondarily upon the anatomico-pathological peculiarities which constitute the basis of Hebra's system. The chief reason for this change is the need of associating in a single group the disorders which naturally, that is clinically, either concur or undergo transformation the one into the other. Thus, for example, I have long found it a source of inconveni- ence and confusion to separate seborrhcea, which is named in the first of Hebra's classes, from acne, which, being essentially exu- dative, is described among the disorders included in the third of these classes. In the same way a somewhat unnatural divorce has been procured between the several disorders of the pilary system, some of which, as sycosis non parasitica, are found in one class, while the hypertrophies and atrophies of the hairs are found disassociated and each in a separate group. The subjoined system of classification, while it does not do violence to the arrangement of Hebra, is one therefore which I believe to be practically useful: — A CLINICAL CLASSIFICATION OF THE DISEASES OF THE SKIN. Class I. Involving predominantly Furunculus. the component parts of the epi- Anthrax, dermis and derma, and incident- Psoriasis ally the appendages of the skin. llvri II.EMIC. Erythema simplex. Erythema intertrigo. Exudative. Erythema multiforme Papillosum. Bullosum. Nodosum. Urticaria. Eczema. Dermatitis. Pemphigus vulgaris. Dermatitis exfoliativa ralis. Pityriasis rubra. Pemphigus foliaceus. Impetigo herpetiformis. Lichen ruber. Prurigo. Zoonoses. Pustula maligna. Equinia. Hypertrophic. Molluscum epitheliale. ,I, ; I I 1"' S - • Keratoses. Herpes iris Herpes zoster. Impetigo. Impetigo contagiosa Ecthyma. Of the epidermis chiefly. Callositas. Clayus. Cornu. CLASSIFICATIOiN'. b. Of the derma chiefly. Verucca. Ichthyosis. Elephantiasis. Dermatolysis. Sclerema neonatorum. Scleroderma. Morphcea. 4. Atrophic. Atrophia cutis. Atrophia senilis. Strise et maculae atrophica?. 5. Neoplastic. Lupus erythematosus. Lupus vulgaris. Keloid. Molluscum fibrosum. Xanthoma. Adenoma. PJiinoscleroma. Class II. Of the sebaceous glands and periglandular tissues. 1. Anomalies op secretion. Seborrhcea. Oleosa. Sicca. Comedo. Cyst. Milium. Wen. Asteatosis. 2. Exudative. Acne. Acne rosacea. Class III. Of the sweat glands and periglandular tissues. 1. Anomalies op secretion. Hyperidrosis. Bromidrosis. Anidrosis. Chromidrosis. " Secretion of otherwise altered sweat. Sudamina. 2. Exudative. Miliaria. Miliary fever. Dysidrosis. Class IV. Of the hairs, hair-fol- licles, and perifollicular tissues. 1. Atrophic. Alopecia. Alopecia areata. Alopecia furfuracea. Atrophia pilorum propria. Canities. 2. Exudative. Sycosis non-parasitica. Dermatitis papillaris capil- litii. 3. Hypertrophic. Keratosis pilaris. Hypertrophy of the hairs. Class V. Of the nails. Hypertrophy. Atrophy. Class VI. Of the blood and lymph- vessels and perivascular tissues. 1. HEMORRHAGIC. Purpura. 2. Neoplastic. Angioma. Nsevus vasculosus. Telangiectasis. Angioma cavernosum. Lymphangioma cutis. Class VII. Of the nerves. 1. Anomalies of sensation. Pruritus. Pruritus hiemalis. Hyperesthesia. Anaesthesia. Dermataltna. 2. Neoplastic. Neuroma. Class VIII. Of the pigment. 1. Hypertrophic. Lentigo. Chloasma. Naevus pigmentosus. 2. Atrophic. Albinismus. Vitiligo. Leucoderma. Class IX. Of the skin with involve- ment of other organs. 1. Exudative. The exanthematous fevers. Erysipelas. 2. Neoplastic. Scrofuloderma. Lichen scrofulosorum. Lepra. Syphiloderma. Carcinoma. Epithelioma. Myeloma (sarcoma). Inflammatory fungoid neo- plasm. Class X. Of the skin and its appen- dages, all parasitic. 1. Produced ry vegetable parasites. Tinea favosa. Tinea trichophytina. T. circinata. T. tonsurans. T. sycosis. Tinea versicolor. DISEASES OF THE SKIN. Class T. — INVOLVING PREDOMINANTLY THE COMPONENT PARTS OP THE EPIDERMIS AND DERMA, AND INCIDENT- ALLY THE APPENDAGES OP THE SKIN. 1. Hypsraemic. The hypersemic disorders of the integument are so termed because they are chiefly characterized by an excess in the supply of blood to the part affected. This increased vascularity, lasting for a longer or shorter period of time, is, as is well known, the first and necessary stage of every inflammatory process. If every condition of hyperemia were succeeded by the exudation charac- teristic of inflammation, it would be manifestly improper to con- sider its phenomena as separate from that process. Such, how- ever, is not the case. A large list of disorders are those in which hyperemia is not succeeded by exudation, and thus arises a clinical demand for their separate consideration. As hyperemia touches upon one side the pathological process of inflammation, so, upon the other, it extends to the physiologi- cal changes in the vascular currents constantly manifested in the healthy skin and illustrated in the phenomenon of blushing. Between these extremes, with ill-defined limits on either hand, occur the purely congestive affections of the integument. Hyperemie disorders are usually first classified into those which are active, characterized by direct increase of blood-sup- ply, and those which are passive, characterized by blood-stasis from interference with the return of the circulating fluid. Clini- cally, the distinction thus established is of minor importance. Active and passive hyperemias differ from each other chiefly in the intensity of the induced coloration, the elevation of the tem- perature accompanying the process, and the subjective sensations they occasiou. A more important distinction is that between idiopathic and symptomatic hyperemias. The former are properly disorders of the skin, and result from direct causes operating externally upon its surface. The latter are surface congestions induced by influ- ences operating within the body, with the effect of producing changes in the circulatory system. An idiopathic active hyper- emia of the skin can be induced by the action of mustard applied v i DISEASES OF THE SKI X. to its surface; ;>n idiopathic passive hypersemia, by encircling a finger with a closely-fitting rubber Btrap; a symptomatic active hypersemia is seen in the cheek of a child with frankly developed fever; and a symptomatic passive hypersemia, in the finger- nail of a patient suffering from a severe attack of asthma. Cutaneous hypersemias are generally distinguished by in- creased color, varying from a delicate rosy tint to a deep purple, occurring in points, patches, large areas, or in singular striatums of the surface. The colored portions rarehy project to an appre- ciable extent above the general level of the unaffected skin. They are never accompanied by infiltration of the tissues, and hence when a portion of the hypersemic integument is pinched up between the finger and thumb, it is at once felt to be un- changed in pliability and thickness. The temperature of the part may be normal, slightly increased, or, rarely, diminished. The subjective sensations induced are usually a trifling itching or burning, and may be wholly wanting. Pathologically, the hypersemias may be described as occa- sioned exclusively by an increased afflux of blood to the supe- rior pars vascularis of the eorium. The differences in the shade, contour, and extent of the coloration are due to the preponder- ance of arterial or venous blood in the vascular elements, its condition of stasis or rapid transmission, and the area of altered vascular supply. The vaso-rnotor nerves, in the production of this alteration, play an important part. Erythema Simplex. Deriv., Gr. ifu0«,u.*, redness. Erythema simplex is a coloration of the skin in various shades of redness, tem- porarily disappearing under pressure, the lesions differing in size and shape according to the extent and degree of the hyperemia by which they are in- duced. Idiopathic Erythema. Erythema Traumaticum. — Here the redness is the result of friction, rubbing, pressure, scratcbing, and similar external con- tacts. It is observed, for example, in the part pressed by the pad of a truss; in the colored circle left about the leg where a tight garter has been worn; on the sides of the nose where pres- sure is exerted by a newly-applied pair of eye-glasses. These traumatic hypersemias are readily converted into exudative affec- tions, if the traumatism be long continued. Intermittent pres- sure upon the skin permits restoration of the vascular equilib- rium, and the skin responds to the demand made upon it by increasing in thickness; continued pressure, on the contrary, admits of no such restoration; and the integument finally be- comes thinner and yields before the agent inflicting the injury. Inflammation resulting in ulceration may finally supervene. ERYTHEMA SIMPLEX. 85 Erythema Calortcum. — Solar heat in excess and extremes of cold; very hot and very cold water; and other heat-conducting substances, are also sufficient to induce transitory redness of the surface. In the erythemata induced b} 7 solar heat especially, there is frequently an increase in the pigmentation of the sur- face, as in the production of freckles and "tan" in persons whose skins are reddened by the sun. The darker, brownish and choco- late-colored stains of the hands and face are thus induced. Erythema Venenattjm. — A number of chemical substances, d} 7 es, and vegetable poisons are also capable of producing tran- sient hyperemia of the skin. Among these may be mentioned cantharicles, capsicum, mustard, aniline, chloroform, ether, ar- nica, and several of the essential oils. Symptomatic Erythema. A long list of phj'siological and pathological causes operating upon the system at large are capable of inducing active symp- tomatic hyperemia of the skin. This may be generally diffused, or occur in surface mottlings and markings of various sizes and shapes. Thus the skin of the face may be intensely reddened in a paroxysm of rage; and that of the limbs of a teething child covered with rosy maculations in consequence of the reflection to the surface, through the medium of the nervous system, of the irritation induced by a tooth. In consequence of the rosy tint assumed by several of these rashes, they have long been termed "roseola," a name which today is held to describe a symptom rather than a disease. The word "roseola" is still associated in the minds of many with the earliest syphiloderm; but that eruption is now designated by the best authors as the erythematous or macular syphilide. Several of the severer constitutional maladies betray their morbid influence upon the central nervous system by a speedy efflorescence of this character. A lurid erythema of the axillary or inguinal region may precede by several days the eruption of confluent variola. Cholera, cerebro-spinal meningitis, enteric and other fevers are thus at times accompanied, preceded, or followed by rashes. A study of these is of the utmost import- ance to the diagnostician. Children who are really susceptible to the disease are often supposed to possess an immunity from scarlatina, as the symptomatic erythema they previously dis- played was misconstrued. JDiagnosis. — If an erythema of the surface exists and is mani- festly unattended by exudative symptoms, the recognition of the condition of the skin is not difficult. A more serious prob- lem, however, concerns the significance of this symptom when it occurs in connection with grave constitutional maladies. A high temperature, severe lumbar pain, great gastric or intestinal 86 DISEASES OF THE SKIN. irritability, coryza, and injection of the ocular conjunctiva), are symptoms which should always put the practitioner on his guard in pronouncing upon the nature of an erythema. On the other hand, patients in a state of alarm, frequently seek relief for an idiopathic erythema, of the nature of which they are ignorant. Here the locality, contour, and general ap- pearance of the eruption, taken in connection with the history of the case, will usually suffice to establish a diagnosis. Treatment. — The symptomatic erythemata are usually of such trifling significance in comparison with the constitutional dis- order by which they are occasioned, that the removal or man- agement of the latter becomes of the higher importance. The idiopathic erythemata are usually relieved at once by the suspen- sion of the cause. Occasionally cold water, weak spirit lotions, dilute solutions of carbolic acid, or one of the dusting powders may he required. The ordinary rubher, adhesive, or lead plas- ter, may he applied to erythematous surfaces where the friction must necessarily be continued (surgical appliances, orthopaedic apparatus, etc.), and in those produced by constant pressure (nates and sacrum in low fevers or surgical confinement), it should never be forgotten that the hyperaemic is also a weak- ened skin. Here stimulating applications may be needed, alco- holic, camphorated, etc., with a view to the restoration of the tone of the weakened capillaries. Erythema Intertrigo. Derid. Lat. inter, between ; terere, to rub. Erythema intertrigo is an hypera?mic condition of those cutaneous and muco- cutaneous surfaces which are in constant apposition, and between which there is an hypersecretion or retention of sweat. Symptomatology. — The erythema which is limited to portions of the integument which lie in contact with each other, is sub- ject to certain modifications. The sites of such contacts in the human body are the axillas, the groins, the cleft between the nates, the inter-mammary and infra-mammary spaces in the female, the superior and inner faces of the thighs, the scroto- femoral and the labio-femoral clefts in the sexes respectively, the flexures of the joints, and in especially fat individuals, all those parts where the integument is thrown into fleshy folds, as about the neck of infants, and even over the crest of the ilia in fat women. In these localities the disorder, beginning as an erythema traumaticum, proceeds b} T its irritative effects to stimulate the secretion of sweat, which is freely poured out between the adjacent folds of the skin, and may there be tem- porarily imprisoned. The surface, heated and reddened, is also somewhat macerated by the effused perspiration; and the latter, when chemically altered, as it is frequently under these circum- ERYTHEMA INTERTRIGO. 87 stances, adds still further to the original disorder. The ground is thus well prepared for an exudative process, hut the disorder may be limited to mere hypersemia with hyperidrosis of sweat, and disappear before the supervention of actual inflammation. The sensations produced are those of heat and tenderness. "When the parts in contact are separated, the surfaces are seen to be reddened and chafed. Here and there very superficial abra- sions of the macerated epidermis become evident. One such is always especially significant. It is the linear and superficial excoriation which marks the line of deepest contact of the two apposed surfaces of the skin at the bottom of the angle formed by the two. An offensive odor usually proceeds from the part in consequence of the fluid secreted. Fox, of London, has called attention to the fact that the secretions of an intertrigo stain, but do not stiffen the linen of the patient, and thus differ from the serous fluid poured out in an exudative dermatitis. Etiology. — The disease is chiefly induced by heat, friction, and moisture, — these causes occasionally cooperating. The heat may be merely that of the natural temperature of the body, or it may be increased by that due to season and climate. The friction also may be merely that originating between the sur- faces in apposition, or may be increased by clothing or other articles worn next the skin. The moisture which produces maceration of the epidermis is that originating in the perspi- ratory follicles, their secretion being doubtless stimulated by the heat and friction. The interchange of operation of these three factors is, lastly, shown by the fact that the friction, if severe, is capable of increasing the temperature of the part to which it is applied. As aggravating causes may be named other physiological secre- tions and excretions, retained in contact with the surfaces affected with an intertrigo. Thus the faaces of the infant left in contact with its nates upon the napkin ; the urine of the old man with paralysis of the bladder, or with "overflow" from prostatic dis- ease; the milk of the nursing woman dribbling over the breast to the infra-mammary region; retained lochial, menstrual, and similar discharges, are all efficient in this regard, and particularly apt to induce that form of dermatitis to which the intertrigo then plays a subordinate part. Occurring in fleshy persons, these conditions find their most fertile field. Diagnosis. — The recognition of a simple erythema intertrigo is a matter of no difficulty, if regard be had to the exciting and aggravating causes enumerated above, and to the special locali- ties where such hyperemia generally originates. If an eczema or dermatitis supervene, the fact will appear from increased sub- jective sensation (usually a severe itching), from an infiltration of the affected integument, and from the appearance of those lesions and discharges which are significant of these forms of inflammation of the skin. 88 DISEASES OF THE SKIX. The special sites of preference of an intertrigo are tliose also of the disease named by Eebra "eczema marginatum," or ring- worm as it occurs upon the parts of the thighs covered by the " reinforced" patch in the trowsers of the cavalryman. The disease is properly named, tinea circinata cruris, though it is found also about the axilla?, buttocks, and groins of both sexes. Here the disorder is, however, of the exudative- typo, and, more- over, is distinguished by a characteristic "festooning" of the elevated border marking the advancing limit of the disease. The microscope, by revealing the existence of a fungus, will of course put an end to any doubt. In intertrigo the most marked evidence of disease is to be distinguished in the deeper parts of the cleft between the two adjacent skin surfaces, while in tinea circinata cruris the growth of the parasite is most active at the advancing border of the patch, which is, moreover, per- ceptibly elevated above the sound skin. Treatment — Erythema intertrigo is an exceedingly common affection of the skin, and occasionally proves of great annoyance to those suffering from it. The skill of the young practitioner is often tested early in his professional career by his management of just such cases; and not a little may depend upon the success witli which he may be rewarded. The affected surfaces should be gently cleansed by ablution with soap and warm water, and the offensive odor of the secre- tions remedied by the addition to the water of a weak solution of carbolic acid, or the dilute liquor sodas chlorinate. The parts are then to be carefully dried with a fresh ly-laundried towel or soft handkerchief, and afterward one of the dusting powders very thoroughly applied. To be of service these must be quite impalpable, and, if compounded by the druggist, be sifted through a miller's fine silk bolting-cloth. The articles chiefly used for this purpose are: Bismuth, starch, zinc oxide, French chalk, lycopodium, and, when an anti-pruritic effect is designed, cam- phor. Combinations of several of these are at times effective. The formula of M'Call Anderson is highly esteemed, and con- sists of: — R. Zinci oxid. pulv. §ss ; 16 Campbone pulv. ."jss ; 6 Amyli pulv. §j ; 32 M. Sig. Anderson's dusting powder. The following is the formula for a dusting powder recom- mended by Klamann. 1 R. Talc, venet. pulv. ^v ; 20 Acid, salicyl. gr. iij ; 2 Magnea. ust. subtil, pulv. 3jss; 5 31. Sig. Dusting powder. 1 Hebam. Kalend., Obstet. Gazet., March, 1882. ERYTHEMA INTERTRIGO. 89 The "Oswego gloss starch" and the "corn starch farina" sold by most of the grocers in this country, are finely bolted, and answer well alone, or in combination with some of the other articles named. The chief objection to the starch-containing powders is their tendency to form little "cakes" or rolls when wetted with the sweat, these masses further irritating the tender surface of the skin. Such an objection does not apply to lycopodium, which not only under the microscope exhibits no salient angles, but on account of the oil it contains is not mis- cible with water. 1 The affected surfaces of the skin must also be separated in order to prevent further friction. A thin strip of lint, or the antiseptic cotton now in the market, may be used for this pur- pose; and must be pushed well up to the deeper portions of the cleft where the secretion chiefly forms. Occasionally it will be found useful to anoint this absorbent layer with cold cream or vaseline. Where an astringent effect is desired, the lycopodium or other dusting powder may be compounded with tannin, alum, or similar substances. The list of lotions may be also at times consulted with advantage. Thus, cologne water, weak spirit lotions, tannin and aromatic wine, or carbonate of magnesium, may each be serviceable. Lastly, the charron oil (equal parts of lime water and linseed oil), spread thickly upon linen, will pos- sibly give more relief than the other articles named; the chief objection to it being the consequent soiling of the patient's clothing. The best treatment is that which is accomplished with a gentle and yet efficient dressing of all the parts. The care and nicety requisite, may be appreciated when one considers that in some very fleshy women there are several square feet of surface which may be at one time affected with erythema intertrigo. 2. Exudative. Under the title of exudations are classed all those affections of the skin, which on the one side are limited by the boundary lines of the hypergemise already described, and on the other are distinguished by the severest types of dermatitis. In the classi- fication here employed, only those exudations are now to be considered which affect the skin proper, and which, afrer involu- tion of the process is at an end, leave no persistent traces of their career in the integument. 1 I have been in the habit of illustrating this fact to my classes at the college, by sprinkling a thin layer of lycopodium over the surface of the water held in a. goblet nearly filled. The finger may then be thrust quite to the bottom of the glass through the water, and, when removed, will be found to be as dry as when it entered. It has been so completely ensheathed by the lycopodium that not a drop of the fluid has come in contact with its surface. 90 DISEASES OF THE SK IX. The diseases of this group will naturally differ according as the degree of exudation present justifies their assignment to <»ne or the other of the extremes named above. Thus, in erythema multiforme and urticaria, the exudative process is less distinct and exaggerated than in cither pustular eczema or bullous der- matitis. The presence of an exudation in the sense in which the term is here used, necessarily implies that the inflammation by which alone it can he produced, has either preceded or is actually pre- sent. The pathological processes implied by the term inflamma- tion of the skin, will he described fully in considering the nature of the most common disease in this category, viz., eczema. It is sufficient to note here, that the clinical signs of an exudative process in the integument are the occurrence of any lesions upon its Biirface which indicate that the hyperemia of its vessels has been succeeded by an exudation of serum, or any increase in the hulk of the skin in consequence of the multiplication of its pro- toplasmic elements. An integument which is the seat of an exudation is thus, clinically considered, either the field upon which are visible one or more of the elementary lesions of the skin other than macula?, or is with difficulty gathered up be- tween the thumb and finger in consequence of its augmented thickness and diminished suppleness. This group includes by far the larger number of all diseases of the skin of every kind ; and the necessity for its careful study is correspondingly imperative. Erythema Multiforme. Erythema multiforme is an exudative disease of the skin, in which appear flat or elevated lesions of an erythematous type in various forms, the exanthem being at times symptomatic of constitutional derangement. Symptomatology. — In this affection, which is usually of sym- metrical development, erythematous maculae, flattened papulae, and even large flat nodosities, very rarely vesicles, occur, usually upon portions of the extremities, the forearms, the legs, and the dorsum of the hands and feet. The eruption, which is much more generally recognized in clearly defined patches, usually commences with pin head to finger-nail sized macules of a dark- ish-red shade, losing their color under the pressure of the linger, which in the course of some hours exhibit tumefaction in vari- ous degrees, producing thus the papules, tubercles, and nodes already described. The disease may persist for but a few days, but in severer grades it lasts for several weeks. In the height of the exudative process, there is usually an efflux of the color- ing matter of the blood into the skin which is the site of the several lesions; and thus are produced the singular shades of reddish-black, purple and red, blue and red, yellow and orange, ERYTHEMA MULTIFORME. 91 which are so characteristic of simple bruises of the extremities when the injury has been sufficient to cause extravasation of blood. The lesions occur in various shapes, sizes, and shades, and a number of names have been used to designate their seve- ral appearances, which require explanation though they are without any practical value. Erythema Annulare is characterized by central paling of color and peripheral extension of the erythematous patch, in the form of a ring. Erythema Figuratum occurs in gyrations formed by coales- cence of two or more annular circles. Erythema Iris is the result of successive new erythematous centric colorations, by which at times several differently shaded concentric rings are formed. Erythema Marginatum is that form in which a distinctly ele- vated and denned marginal band is left as the sequel of an ery- thematous patch. Erythema Nodosum is regarded by several authors as a distinct affection. In it the characteristic lesions are of the dimensions of semi-globular pea to fist-sized tumors, pale red to livid blue in color, tender upon pressure, exhibiting in their involution the variegations of hue already described. They occur at times, not only in the localities named above, but also upon the trunk and face. Though occasionally becoming so soft to the touch that fluctuation may seem to be present, they never terminate by suppuration. Erythema Papulatum (or Papulosum) and E. Tuberculatum (or Tuberculosum) are those forms in which occur respectively lesions of a papular or tubercular type. Erythema Urticatum is that form in which there is severe itching, and, as a result, scratching of the lesions with crusts of dark dried blood at the summit of each. This crust is sur- rounded by the light red or bluish-red, flattened or elevated patch characteristic of the disease. Erythema Yesiculosum and E. Bullosum are rare and excep- tional forms where the exudation is sufficient to raise the horny layer of the epidermis into larger or smaller serum-con- taining chambers. These may be, as regards the erythematous patch, of central or peripheral situation; and may crown the summit of papule or tubercle. The fluid is usually removed by 02 DISEASES OF THE SKIN*. absorption, and is rarely set free by rupture of the vesicle or bleb. The name, multiforme, given to this disease by Hebra, is thus seen to be justified by the singular variety of lesions which it displays. The subjective symptoms, save in the urticarial form of the disease, are usually of a trifling character. The slight sense of heat and burning awakened by the lesions, is altogether out of proportion to the extent of development of the latter. The symptoms, however, indicative of a general disturbance of the system may be of a marked character. General malaise fever, inappetence, pharyngeal inflammation, chills, severe gastro- intestinal disorder, rheumatoid involvement of the articula- tions, and even organic changes in the heart (valves, endocar- dium and pericardium), lungs and kidneys (Kaposi), have all been noted as coincident or causative phenomena. In many of these caseB it is clear that the exanthem belongs to the list of symptomatic erythemata, and is of insignificance in comparison with the grave general condition. With these exceptions, how- ever, the prognosis is in general quite favorable, as the disease may terminate in a few days, and rarely exceeds a month in duration. Occasionally the mucous membranes are affected to a disagree- able or even painful extent. Thus a sudden tumefaction of the uvula may supervene upon the cutaneous s} T mptoms, even in cases sufficient to impede respiration ; or the lining membrane of the larynx be involved and the resulting aphonia in various degrees persist for two or three days. Etiology. — " We are in a state of complete ignorance as to the cause of these erythemata." — (Hebra.) We simply know that the affection is more common in the spring and fall of the year ; that it occurs in the young, or in the early periods of adult life; that the papular and tubercular forms are more common in the male, and the nodose forms in the female sex ; and that in many cases it occurs in those who are affected with rheumatism. There can be but little doubt that its etiology includes a list of varying and widely differing causes. I have seen severe manifestations of the disease in a young woman with extensive ulceration of the cervix uteri. Tilbury Fox noticed its frequency in young servants brought to town from the country. It is not rare in young female immigrants who have recently made a " steerage " passage to this country. Fathology. — Erythema multiforme is essentially an hyperemia of the integument which, under certain obscure influences, ad- vances more or less rapidly to the stage of a mild grade of in- flammation with consequent exudation. If, with Landois and Lewin, it be accepted that the process is the result of vaso-motor nerve influence, it cannot be determined whether these nerves ERYTHEMA MULTIFORME. 93 are centrically or peripherally irritated. In the case of erythema nodosum, Hebra advances what he admits to be an hypothesis, in saying that the morbid process is essentially an inflammation of the lymphatic vessels. In some cases it is evident that there is extravasation of blood from the vessels into the skin of the affected parts. Diagnosis. — Erythema multiforme is always to be carefully distinguished from the traumatisms producing bruises, especially upon the lower extremities. This is a point which may have an interesting bearing upon certain medico-legal questions, es- pecially in the case of young children. The tendency of the disease here considered to symmetrical arrangement, upon the two sides of the body ; the occurrence of lesions evidently dating from several periods, where successive crops appear; and the absence of all history of external injury, will usually suffice to establish a diagnosis. Among the precocious affections of the subcutaneous connective tissue in syphilis, Mauriac has described a lesion resembling somewhat the symptoms of erythema nodo- sum ; but in such cases, and especially in women, mucous patches of the vulva, anus or mouth, with coincident adenopathy, would point to the real nature of the disease. Treatment. — As the disease under consideration progresses naturally to a favorable termination within the course of a few weeks, the duty of the physician is usually limited to the ques- tion of diagnosis merely. He should remember that the larger lesions seen in erythema nodosum never suppurate ; and thus be not tempted to open them with a lancet. Local treatment is rarely called for ; and in any case should be restricted to the application of hot or cold water, as found most grateful to the patient, with possibly the use of a weak lead lotion. Internally such medication should be employed as is indicated by the gen- eral condition of the patient. Iron, quinine, strychnia, and the dilute hydrochloric acid will be found beneficial in many cases. Constipation and indigestion are to be corrected by appropriate measures. When the disorder is evidently purely symptomatic, the internal treatment is to be directed to the general condition present. In rheumatic cases, the indications for such treatment are clear. When the erythema produces extensive oedema of the uvula, incisions may be requisite to prevent dyspnoea and dysphagia. Prognosis. — It will be gathered from what has preceded, that the prognosis is always favorable. The fatal cases reported are usually those where the result was due to grave constitu- tional conditions, and where the erythema multiforme was an insignificant feature of the malady. The disease may relapse in susceptible individuals at those periods of the year when it is most frequently observed. 94 DISEASES OF THE SKIN*. Urticaria. Deriv. Lat. urtica, the nettle. Urticaria is an exudative affection of the skin in which appear ephemeral, whitish, or rosy tinted wheals surrounded by a reddish areola, giving rise to an intense pruritus. Symptomatology. — This disorder, popularly known as the "net- tle-rash" or the "hives," is characterized by the sudden devel- opment of wheals upon the surface, which frequently disappear with equal rapidity, leaving behind no traces of their existence Bave a slight and transitory hyperemia of the affected spot. The lesions may he as small as a coffee-bean, and are usually of this size ; but in certain rare instances " giant wheals " are seen, large tomato-sized projections or flat elevations of broad areas of the integument, covering the greater part of the belly or the buttock. In color, they are either rosy-red or whitish ; and are usually surrounded by an hypenemic areola. They may be iso- lated and few; or numerous and closely packed together; may even coalesce so that individual lesions are scarcely recognizable. They are usually firm and semi-solid to the touch. Rarely the horny layer of the skin is raised in fluid-containing lesions by the sudden effusion of serum beneath. In shape they are round- ish or ovalish ; but a variety of curious outlines may result from the irregularity of their development. Thus concentric circles, lines, bands, and even figures, are in this way produced. The finger-nail drawn across the unaffected portions of the skin, in a patient with urticaria, will often produce a linear wheal of ex- tent corresponding to the line of irritation. It is said that in this way the so-called "medium" with a sensitive skin exhibits written characters upon the surface of his body. The subjective sensations induced by these lesions are distress- ing in various degrees, according to the susceptibility of the indi- vidual. Every grade of pruritic, burning, tickling, crawling, pricking, and especially stinging sensations are thus engendered. The efforts of the patient, to secure relief by scratching^ not only serve to still further develop the eruption, but to irritate, tear, and otherwise wound those lesions already in full evolution. In this way the serous effusions are produced at the summits of the wheal ; and in this way, also, the lesions really transitory in their course may be changed to more persistent, deeply-colored, flat, lenticular papules. Where the skin is delicate and thin, as that of the lids and prepuce, considerable oedema may result. All parts of the body may become affected, and this irre- spective of age and sex, though children are particularly liable to the disease. There are few very young children with skins unwashed for an entire month, who will not exhibit urticarial symptoms, if there be an added irritation of the surface. URTICARIA. 95 The lesions may be numerically few, or so numerous as to cover the entire surface of the body. Though more frequently acute in course, they may recur frequently from apparently insignifi- cant causes, or even become chronic. In man} 7 cases trivial, the disease may become so aggravated as to make the largest de- mands upon the skill of the physician. The rapidity of appearance and disappearance of the lesions visible upon the skin is a characteristic feature of the disease. In some instances but a few moments are required after the operation of an efficient cause, to develop a large number of closely packed wheals upon the skin. Even while these are under inspection, it can be noted that there is a change in indi- vidual lesions, some fading or completely disappearing, while others are newly developing. A number of names have been employed to designate the several external peculiarities of the lesions as they are pre- sented to the eye. Thus u. annularis occurs in rings ; u. figu- rata in gyrations from union of several lesions or patches of lesions; u. vesiculosa and u. bullosa, where there is a vesicular or bullous development at the summit of the lesion ; and u. papulosa (or lichen urticatus), where there is a combination of the features of the wheal and the papule, the lesions being usually rape seed to coffee bean in size, and covered with blood crusts where their apices have been torn in scratching; u. tube- rosa, where "giant" wheals occur, some attaining the size of a hen's egg; u. hemorrhagica (purpurata urticata), where the urticarial element, is developed in a lesion produced by cutaneous haemorrhage ; and u. evanida, or perstans, where there is re- spectively a rapid or slow process ot involution in the character- istic symptoms. Urticaria Pigmentosa. In this form of the disease, characteristic wheals are succeeded by peculiar pigmentations of the surface in dark-brown, greenish- yellow, or chocolate-tinted spots, which persist from the date of one eruption to another. The skin is highly irritable, and the most trifling causes are sufficient to induce an attack. In Mor- row's case 1 the mere removal of the clothing and exposure of the skin of the little patient to the air were sufficient, at the time I had the opportunity of observing the phenomena, to pro- duce an abundant crop of wheals over the surface. The pig- mentation in these cases is probably due merely to the extraor- dinary sensitiveness of the integument, whereby repeated and rapidly repeated exudations occur in the skin, and the resulting maculations are proportioned in depth of color to the frequency and intensity of the process. 1 Archives of Dermatology, January, 1879. 96 DISEASES OF THE SKI X. Four cases of this same disease were exhibited at tlie Inter- national Medical Congress in London in 18S1, by Mackenzie, Cavafy, and Fox. Baker 1 report-; a ease of urticaria tuberosa characterized by the presence of persistent yellowish-red tubercles in various parts of the body which proceeded to ulceration. The parts most affected were the knuckles, elbows, and cars. These tubercles arc said to have begun in a manner similar to that which characterizes the onset of evanescent urticarial wheals and tubercles. Urticaria, like erythema, may be either idiopathic or symp- tomatic; and in either, the urticarial condition may underlie or be superimposed upon almost every elementary lesion noted in the integument. Its lesions may complicate (or be complicated by) the macule, papule, tubercle, vesicle, bulla, and pustule. It may Bpring from an excoriation, or result in a tissure. It is common in traumatisms, and is a prominent symptom in the skin bitten by insects, reptiles, and the domestic animals. Etiology. — Idiopathic urticaria is occasioned always by the action of external irritants. The enumeration of these would require a recital of all the external agencies which are capable of irritating the skin. Prominent among them are the bites and stings of lice, fleas, bed-bugs, flies, gnats, wasps, and bees. The wounds thus inflicted usually excite a stinging or burning sensation, by which the patient is excited to rub or scratch the part. Then a wheal is rapidly formed in the site of the injury, and the irritation thus set up is conveyed to other parts of the skin in the vicinity, so that, especially in children, a single trau- matism by an insect may excite an urticaria covering a much larger area. Many medicaments operate similarly; and it should be added that some of them, though applied externally without toxic effect to the mass of men, may produce urticaria in excep- tional cases. Thus a common flaxseed poultice when made to cover but a small portion of the body has produced violent symptoms of the disease under consideration. Symptomatic urticaria is chiefly of the variety named by authors, nb ingestis, since it most frequent!}' results from medici- nal or dietary articles taken into the stomach. Of the latter class maybe named cheese, pork, and confectionery; crabs, lobsters, clams, oysters, and fish generally; strawberries, gooseberries, rasp- berries ; canned fruits, meats, and vegetables ; pickles, sauces, sausage, mushrooms, salads, and spinach. Vinegar, champagne, beer, and alcoholic beverages in general are capable of inducing a similar effect. Of the former class (medicaments) are the bal- sams, the turpentines, quinine, chloral, valerian, arsenic, and some of the mineral waters. h\ the case of children, a severe urticarial efflorescence may 1 Lancet, August, 1881, p. 153. URTICARIA. 97 be occasioned by any undigested morsel of food, or indigestible material of any sort, which may have been passed into the stomach. Thus a bit of orange-peel or fragment of potato paring or the skin of grapes, may be discovered to lie at the root of the trouble. In the case of adults also who have suffered from repeated attacks of urticaria, and have a fully developed sensi- tiveness of the gastro-intestinal tract, almost any unusual ali- mentary substance, if ingested, will induce a return of their dis- agreeable symptoms. It must be borne in mind that this undue sensitiveness to the effect of ingesta or external irritants is often an idiosyncrasy peculiar to the individual either on special occasions or at all times, and that, given this susceptibility, the effect is often great with a relatively insignificant etiological factor. Thus I have seen cases in which a teaspoonful of beer, one grain of quinine, the smallest fragment of cheese, and but a single straw- berry would not only induce an urticarial rash of such extent as to cover the greater part of the surface of the body, but would do the same on every occasion when the articles named were swallowed in the quantities given. This, it may be use- ful to remember, is in general characteristic of the medicament- ous eruptions. The a -priori reasoning, that the greater the quantity of the toxic agent applied or swallowed, the graver, the effect, may lead to gross errors. It should always be re- membered, in seeking the explanation for an urticarial rash, that the smallest amounts of apparently innocent substances may be responsible for the largest annoyance. Other causes of urticaria may be cited, such as moral emotions (fear, shame, anger) ; gastro-intestinal disorders, where ingesta play no part ; malaria ; the erythematous fevers, particularly in their prodromal stages; disorders of the uterus, kidneys, and nervous centres ; pregnancy, dentition, and the irregularities attending the menopause ; and, lastly, the following special diseases: asthma, pemphigus, prurigo (of Hebra), rheumatism, and purpura. Pathology. — The wheal of urticaria is produced by an inter- change of play between bloodvessels, muscles, nerves, and tissues, under the operation of a principle which the French characterize as the choc en retour. There is first, most probably under the influence of the vaso-motor nerves, a clonic spasm of the capil- laries in a limited area of the derma, by which an acute oedema is produced with some serous exudation. The rapidity with which this occurs is greater than that with which the tissues of the vicinage can accommodate themselves to it either by imbibition or more diffuse tumefaction, and there results a counter-pressure upon the affected capillaries, by which their lumen is still further restricted. As the wheal is not a purely fluid-containing nor yet an entirely solid lesion, but is semi- fluid in consistency, the mechanical pressure is greatest at the . 7 98 DISEASES OF THE SKIN". centre and least at the periphery. Tims is explained the white and relatively bloodless appearance of the centre ot* certain wheals, and their rosy or reddened outer border. It is con- firmed also by the fact that generally the most acute lesions, those springing into view most rapidly, are chiefly characterized by this whitened centre, while those more indolent, or even chronic in their career, have been less subject to the interplay of the forces described above, permit of more general vascular injection, and have a light crimson or even at times a dull red centre. Wheals have been excised and examined microscop- ically by Neumann, Poncet, and others, with the result of dis- covering merely evidences of infiltration. According to the last named author, the lymphatic vessels are also choked with "lymph clots." Rone 1 explains the occurrence of the wheal by supposing that certain sensitive nerve-fibres of the skin possess also a vaso-motor function. The process described, occurring as an epiphenomenon after the traumatisms or other cutaneous lesions enumerated above, merely adds its characteristic symptoms to those previously apparent. Diagnosis. — The diagnosis of typical urticaria is so readily made that it is often recognized as such before the attention of a physician is called to it. As usual, the atypical cases are those in which confusion may arise. The chief points to be remembered are the rapidity of evolution of symptoms, their ephemeral character, and the characteristic sensations they awaken. The action of the animal parasites and insects not parasitic should not be overlooked, and the rash be closely examined for the minute wounds inflicted in this way, often covered with a minute pin point to pin-head sized dried "blood- scale." The various forms of erythema papulatum, tubercula- tum, and nodosum are liable to be mistaken for urticaria, but this is in many cases inevitable, as the intermediate forms between the two disorders are with difficulty assigned to either category. Absence of marked subjective sensations and persistence of lesions would generally imply the existence of an erythema, while marked prevalence of these symptoms would properly decide in favor of urticarial disease. In many cases the physician is consulted by a patient who gives a history of well-nigh intolerable distress at night or at other capriciously selected hours, who repeatedly and vainly endeavors to exhibit the lesions as they appear upon his skin. Being examined on occasions, scarcely a trace of cutaneous disorder is manifest. Here the practitioner has to practically decide upon the character of an eruption he never sees. The task is rarely a difficult one. No other than the urticarial eruption behaves in this fashion. Occasionally the physician 1 Maryland Med. Journ., May 15, 1881. URTICARIA. 99 will discover delicate, rosy, or deeper stained mottlings of the surface where the wheals have been but are not. At times also he will succeed, on the flexor aspect of the fore- arm, or in some situation where the skin is equally delicate, in exciting the occurrence of one or more typical lesions by the aid of his finger nail in scratching or rubbing. These cases are more frequently of the chronic or at least relapsing class ; and the victims of the disease may have a characteristic facies, a worn look from loss of sleep or mental emotion. One is apt to discover in this class those who are mourning over the death of relatives, loss of property, separation from home and friends, and those harassed by anxieties. Treatment. — Many cases of acute urticaria demand no treat- ment. The physician is summoned for a diagnosis. The patient and his friends are alarmed by the dread of variola or other severe affection, and learning that perhaps a pickled cucumber is alone responsible for the disorder, they wait with equanimity for the conclusion which is always reached. Fortunately the exceptionally severe and relapsing forms rarely begin with acute symptoms. Naturally the first indication to be observed is the removal of the cause, and this if possible accomplished, the exclusion of all aggravating agencies. The discovery of the cause, at times readily effected, is often the most serious problem which is pre- sented. An exhaustive and minute examination of the person and history of the patient, a study of his food, drink, medicine, regime, clothing, sleeping apartment, habits, occupations of life and mental state, are here essential. When the disorder is re- cent and is an urticaria- ab ingestis, a brisk emetic or cathartic may rid the stomach or bowels of offending matters. This done, it should be borne in mind that an idiosyncrasy of the patient may at this moment render the skin peculiarly sensitive to the action of other ingesta, and the diet, for a few days certainly, should be carefully prescribed. In many cases the alkalies are indi- cated by an acid condition of the stomach, and then the prepara- tions of sodium, potassium and magnesium are useful. Laxatives such as rhubarb, the cathartic mineral waters, and, in the case of children, small doses of castor-oil, are frequently indicated when there is no suspicion of irritating ingesta. At other times there is marked atony of the digestive organs, when the mineral acids, the bitters, and the ferruginous tonics may be needed. Again, lactopeptine, pepsine, the subcarbonate or the subnitrate of bismuth may be exhibited with advantage for the relief of the indigestion which may be the prominent feature of the attack. Other remedies found useful in the internal treatment of urti- caria, are, the arseniate of soda, employed by Blondeau in doses of from one-thirtieth (0.002) to one-fiftieth (0.0018) of a grain: the sulphate of atropia, given by Schwimmer in doses of one- 100 DISEASES OF THE SKIN. sixtieth (0.001) of a grain: the salicylate of soda, in scruple (1.33) doses; and either pilocarpine or the fluid extract of jabo- randi. This remedy is known to produce at times a powerful effect in relieving surface congestions of the skin, by means of the excessive hyperidrosis which it occasions, and in proportion to which it may become dangerous. The treatment of a symptomatic urticaria should have regard also to that disorder of the viscera or general system to which the cutaneous symptoms may he attributed. The uterine com- plaint of the female may require appropriate treatment, as also the diabetes of the patient with an affection of the kidneys. Quinine is of course indicated in periodical attacks, but its ac- tion in exceptional cases as a direct cause of urticaria should not be forgotten. The same, to a greater extent, is true of arsenic, the bromide and iodide of potassium, hydrate of chloral, and gelseminum. The larger number of patients are best treated without the employment of these drugs. In the local treatment of urticaria, which is chiefly intended to assuage the disagreeable sensations experienced in the skin, the greatest diversity exists in the methods employed. This is to be largely explained by the fact that a similar difference is to be noted in the relief experienced by different patients after the application of the same medicinal agent. Thus cold and hot water baths, baths medicated by marine salt, aromatic vinegar, alcohol, cologne, camphor, the alkalies, and sulphuric ether; compresses dipped in such solutions and laid over the part affected ; douches and vapor baths will, any of them, in the case of some individuals produce a marked alleviation of symp- toms; and in others be either inoperative or actually serve to aggravate the symptoms in the highest degree. Hebra asserted that several of the baths named above are quite useless, while Kaposi recommends cold lotions medicated with aromatic vola- tile substances. The alkaline bath, as prepared in England and America, usually contains the carbonate of sodium, the biborate of sodium, alum, or the bicarbonate of potassium, either singly or in com- bination in the strength of about six ounces (192.) of the salt to thirty gallons of water. One or two ounces ^32.-64.) of the sul- phuret of potassium may be substituted for these. The water is made demulcent by the addition of starch or gelatine, or by squeezing into it a bag of muslin containing bran. When it is desired to employ the acid bath, half an ounce (16.) of either the muriatic or nitric acid is added to the quantity of water given above. The bath of this size may be also medicated with one drachm (4.) of corrosive sublimate; or this drug may be used as a lotion in the strength of from one-fourth (.0016) to one-half (.OOoo) a grain to the pint. Carbolic, benzoic, boracic, and di- lute hydrocyanic acids in weak solution, are also employed with advantage in some cases. Other external applications are, thy- URTICARIA. 101 mol, carbonate of ammonium, bromide of potassium, etber, chlo- roform, and chloral camphor in the strength of half to one drachm (2.-4.) to the ounce (32.) of ointment. This last is pre- pared by rubbing together equal parts of camphor and chloral till a semi-liquid substance results. It is an antipruritic remedy of some value, but will increase the uneasy sensations produced, if not largely diluted. In other cases the oily or fatty substances will give more prompt relief, especially if the eruption has been much irritated by scratching and tends to persist. Among them may be named the linimentum calcis of the pharmacopoeia, and cold cream to which have been added a few drops of the fluid extract of grin- deli a robusta. Mention should also be made here of the dusting powders which the reader will find described in the chapters relating to general therapeutics and the erythemata. They are the most cleanly of all external preparations in urticaria, and are often the only local measures required. With internal medication, as each case may suggest, the practitioner will be careful to note that the clothing of the patient is of a character that will not aggravate the eruption, that sleep is secured without an excess of bed-covering, and that 'places where the temperature is for any reason elevated nre carefully avoided, as the proximity to a fire-place or drop-light, the opera-house, the kitchen, etc. Such is the empirical treatment of urticaria. It will be seen to be founded upon no rational method of procedure, and this be- cause the very capriciousness of the disease demands and secures relief in one instance by a treatment which should be reversed in another. It must be admitted that cases occur when all treat- ment seems absolutely valueless, often really injurious to the patient. These cases will usually be found to be of the relapsing or chronic type. The subjects of this form of disease are often plunged in morbid mental states ; dreading by clay the exacerba- tions of the night; brooding over misfortune experienced or anticipated; worn with loss of sleep; fearful of a generous regime at the table. Here the treatment is largely moral, and makes demands upon the tact and courage of the physician. Travel, change of climate, variation in the routine of life, new social surroundings, are here valuable. The widow must be made to lay aside the heavy crape veil beneath which her urticaria plays; the solitary patient must secure a companion capable of diverting the nervous attention for a few hours each day. Prognosis. — The prognosis of an attack of urticaria is, as has been disclosed in what has preceded, exceedingly variable in dif- ferent cases. Simple attacks of the acute sort are trivial, and in a few days the patient may retain but the slightest souvenir of his trouble. In the case of children, the attack is often at an end in the course of twenty-four hours. It should, however, never be forgotten that urticaria may tor- 102 DISEASES OF THE SKIN*. merit the lite of a patient to the utmost bounds of tolerance, and seriously impair the general health. Persistent and rebellious chronic urticaria may prove to be a more formidable affection than a mild attack of syphilis. Eczema. Deriv. Gr. I* £i*>, to flow forth. Eczema is an acute or chronic exudative affection of the skin, during the course of which one or several of the various elementary lesions appear upon the surface, either successively or simultaneously, and in either case accompanied by a characteristic sensation of itching, the involved tissues becoming mean- time infiltrated, resolution occurring in the natural termination of the disease "without leaving permanent relics of the process. Symptomatology. — Eczema is one of the diseases of the skin of most frequent occurrence. In the statistics gathered by medical men it would seem to rank first in the order of frequency. But this is only true as regards those diseases for which the physi- cian is commonly consulted. It is easy to become convinced that acne is a more frequently encountered affection than eczema, by observation of the faces of individuals on the streets of any large city, eczema being of more frequent occurrence in this situation than upon other parts of the body. Many persons are the subjects of acne who never deem it necessary to submit to treatment for its relief, and the records of such cases do not figure in dermatological statistics. This being noted, eczema may be regarded as the disease of the skin, for which most fre- quently the practitioner of medicine is consulted. By as much as inflammation is the most common accident of other organs of the body, by so much is its enveloping organ subject to the same pathological process. The surgical signs of inflammation of an} r given tissue are usually named as increased heat, redness, pain, and swelling. These are essentially the symptoms of an eczema ; and it will be necessary, in order to study the disease intelligently, to in- quire how these phenomena are modified by the anatomical pecu- liarities of the organ in this case affected. A typical eczema is always betrayed by an elevation of the temperature of the sur- face, and by a greater or less degree of swelling. Redness, in varying shapes, is also true of the eczematous skin. Pain here is represented by a sensation usually of itching, which may vary from slight annoyance to an almost intolerable distress. The variation in the sensation which accompanies inflammatory dis- orders of the skin and other organs, is merely due to the fact that the former is exposed to the air, and its increase in bulk is not opposed by other contiguous parts, as, for example, the inflamed bone in contact with periosteum, or the pathologically enlarged prostate within its fibrous capsule. Inflammation of the inner skin of the body, as of the lining membrane of the ECZEMA. 103 stomach or of the intestines, is generally characterized by the occurrence of increased heat, redness, swelling, and severe pain. Inflammation of tissues constituting other organs of the body, usually terminates either in resolution, in the free production of pus, or in the occurrence of gangrene. And so an inflammation of the skin may terminate either by resolution, or by the free production of pus on its surface, the living matter rapidly mul- tiplying as the intensity of the process may determine. Gan- grene is not a common result of eczema, chiefly because of the freely exposed position of the organ affected. The great variety of expressions assumed by an eczematous disease, and the frequent interchange of these, the one for the other, are to be accounted for in the same way. The atmosphere which surrounds the body is but one of many external influ- ences capable of affecting the skin. Thus it is rubbed and scratched, exposed to the friction of the clothing and the incur- sions of insects, and subjected to innumerable injurious contacts in all the various trades and occupations of life. If the inflamed skin could be as perfectly protected from the outer world as is the spleen, we should find the history of this affection much simplified. Clinically, four types of eczema can be recognized. These require separate description. It should not be forgotten, how- ever, that each may prove to be not a variety, but a stage of the disease, which may speedily give place to yet another. Erythematous Eczema. In this form of the disease the conspicuous symptoms are heat, redness, and swelling, with a variable degree of itching, usually less severe than in several of the othe. phases of the malady. The process may begin with acute and intense symp- toms, to be soon followed by one of the varieties of the disease to be subsequently described; or, what is perhaps more com- monly the case, may continue indefinitely as a subacute, or even chronic affection. In color the skin of the part involved varies from a light to a darker shade of red ; and inasmuch as the pro- cess is more frequently observed in middle-aged adults, with darker hue of the integument than in early life, the color of the part is frequently noticed to be of a dull shade. In consequence of the swelling the affected surface is notably elevated above the level of the unaffected contiguous skin, and the line of demar- cation between the two can be more readily traced than in sev- eral of the other varieties of eczema. The surface is usually uniformly and occasionally symmetrically involved. Lesions, other than the erythema, which is the prominent feature of the attack, are rarely observed ; and as a consequence, from the beginning to the end of the disease, there is commonly no his- tory of moisture. But in many cases minute poppy to rape seed- 104 DISEASES OF THE SKIN. sized papules become visible on close inspection, still more rarely with a very minute vesicular apex filled with a droplet of clear Berura. Tiie localities chiefly thus involved are the face, the palms, the soles, and the regions about the genitalia, though any portion of the body may be involved. Resolution is accom- plished after the occurrence of very fine superficial desquamation of the epidermis, or by very gradual diminution of the redness and swelling without the production of scales. In either event the termination of the process is often announced by significant changes in the involved surface, as by the fading of color, the appearance of islets of sound skin between affected patches, and by perceptible relief in the subjective symptoms. Such is the course of a typical erythematous eczema. Varia- tions from this type are, however, numerous and important. Thus the disease may be limited to a patch as small as a finder nail, or may extend over large areas, especially after subjection to irritation. At times the coloration is irregularly distributed, producing a mottled appearance, brighter at one point and darker at another; while again, as has been intimated, the variety described may coexist with, or be followed by, the weeping, excoriation and crusting which are characteristic of other manifestations of eczema. Scratching of the part in- volved produces a change in the symptoms which the skilled eye will promptly recognize. Minute superficial losses of tissue are then visible here and there upon the surface ; the fresher with a reddened floor possibly hidden beneath a thin blood- scale, the older surmounted by a light yellowish-red crust. The scratch lines so often recognizable elsewhere are here less frequently evident. Like all the other varieties of eczema, this is extremely liable to recrudescence and relapse. In advanced life, the traces of the disease may be visible for years. Vesicular Eczema. This variety of the disease is, as its name implies, character- ized at an early period by the formation of minute vesicles. It is a matter of importance, however, to recognize the fact that the vesicular, like the erythematous, is but one of several mani- festations of this singularly protean affection. Since the ap- pearance of the treatises of the early English dermatologists, the term eczema has been very generally limited by physicians to the vesicular phases of the disease; and it is to the Vienna school that we are largely indebted for the recognition of the fact that these simultaneous or successive features, presented often in the same individual, really belong to one and the same malady. To limit the name eczema to-day to the vesicular surface alone, would be to relegate the student of diseases of the skin to the misty uncertainties of the last half century of dermatology. ECZEMA. 105 The clinical features of vesicular eczema are chiefly due first, to the acuity of the inflammatory process present ; and second, as the result of the former, to the free exudation of the serum of the blood from the vascular plexus immediately below the pars papillaris of the corium. The involved surface usually feels at the outset hot, itchy, or particularly sensitive, and soon after becomes more or less intensely reddened, the hyperemia producing this effect in the course of a short time giving place to a true exudation which may last for one or several hours. Poppy- to rape-seed sized vesicles then become visible on this reddened base. The lesions may be closely packed together, or discrete, or may be so abundant as to coalesce, a frequent be- havior of all vesicular lesions. Each is filled with a droplet of clear serum, imprisoned beneath the most superficial layers of the epidermis. It is readily ruptured, and, if this does not speedily occur as the result of accident, it bursts spontaneously, and its limpid contents are then poured out upon the surface of the integument. The quantity of the fluid thus exuded is in excess of that originally contained in the small vesicular cham- ber. This is due to the fact that the elevated, macerated, and broken epidermis no longer presents an obstacle to the outflow of the serum from the engorged vessels beneath. Minute and even large drops of a clear fluid of syrupy consistencjr can be seen forming at the points where the solution of continuity has occurred. If with a slip of bibulous paper the first drop be re- moved, its place is visibly filled by a second. Crops of new ves- icles succeed the first, each followed by the train of symptoms described. The weeping at many points of the surface thus affected, is so prominent a feature of the disease that it has led several authors of note to describe eczema as a catarrhal disease of the skin, an error which is palpable to one who carefully studies the affection in each of its several varieties. There are, with- out question, forms of the disease where the history is through- out entirely different from that just described, where no evi- dence of discharge can be appreciated from first to last, and yet where, by artificial measures, the so-called catarrhal features can be readily produced. The subjective symptoms of the vesicular forms of eczema are more or less intense itching and often burning. In the very acute forms there is considerable soreness, the patient managing the affected part with as much care as a fractured limb. In exceptional cases, more frequently observed in children, there is sympathetic febrile disturbance of a mild grade. The discharge from the broken epidermis, whether directly from the vesicles or from the vascular elements, dries rapidly when exposed to the air, in light yellowish crusts, which are rarely bulky. The extent of surface involved is variable, and the contour of the affected patch or patches is seldom well de- fined, these portions imperceptibly shading into the sound skin. 106 DISEASES OF THE SKIN. The color of tlic area thus diseased varies according to the stage of tbe process, being at one time of a bright and vivid red. ;it another yellowish, and when covered with crusts or Bcales, undergoing a corresponding change of hue. Infiltration of the skin occurs rapidly, so that when a portion of the affected integument is pinched up between the finger and thumb, it is found to be thicker and less elastic than before. As resolution approaches, all the symptoms described above gradually decline in severity: the serous discharge diminishes, the redness fades, the limits of the involved area are less dis- tinct, the crusts loosen and fall, and it can be seen that be- neath the scales which have taken the place of the oozing and broken epidermis, a new and tender epithelial covering has been produced. As a rule, for weeks after the process has completely ceased, the newly formed epidermis has a slightly reddened and tender appearance, though complete resolution is followed by no permanent sequelae. Such, then, being the typical phases of vesicular eczema, it must not be forgotten that clinically the picture may be quite different from that described. The types here given are con- venient for analysis and study, however they may be com- mingled and obscured in the inflamed integument. Like the erythematous, the vesicular forms of eczema may precede the others, and becoming chronic, torment the suffering patient continuously for long periods of time, or yield, only to reappear at irregular intervals. Pustular Eczema. This variety of the disease may originate in one of the other forms of eczema, which, in consequence of the severity or acuity of the process, changes from an erythematous, papular, or more commonly vesicular type, or the pustular lesions may rapidly form at the onset. Usually a crop of minute vesicles is first seen of the sort just described, which, after enlarging to the size of a coffee bean, become distended with puriform contents. These either accidentally or spontaneously burst, and the fluid with which they were distended dries into yellowish-green or darker- colored and friable crusts. In aggravated cases the purulent matter seems to form directly upon the surface involved. If the process be long continued, infiltration occurs; and the itch- ing, which in all varieties of the disorder is a characteristic feature, is awakened as an accompanying symptom. It is, how- ever, rarely of the peculiarly aggravated type which accompa- nies the erythematous and papular phases. Pustular eczema is most frequently encountered in the regions of the head, and in constitutions where there is a pyogenic tendency. When exist- ing on the scalp and face there is most commonly an involve- ment also of the sebaceous glands, whose secretion, altered by ECZEMA. 107 the periglandular 'inflammation, is added to that naturally pro- duced by the exudative process. Singular shades of mixed, yel- low and green, and even black, are then to be distinguished in the resulting crusts, which later desiccate and fall, leaving a reddened and tender new epidermis beneath. Pustular eczema, as thus observed, has been described under a great variety of titles. Its identity as a form of eczema was first accurately distinguished by Hebra, in his experiments on the artificial production of the disease upon the surface by the external application of croton oil. It has been called impetigo figurata, mellitagra, porrigo larvalis, and other singular names, which suggest the attempts of the early astronomers to name the constellations by their resemblance to the figures of animals. These and many other useless terms have been finally dropped from the nomenclature of modern dermatology. Papular Eczema. Under this title are classed all those forms which have long been described as lichen eczematodes, eczema lichenodes, etc. " Observation of the natural course of an attack of eczema," says Hebra, "furnishes the most unassailable proof of the con- nection between its various forms. In one case an eruption of vesicles begins the series of symptoms; in another, it is preceded by the appearance of red scaly patches or groups of papules; or vesicles and papules are developed together, some of the former rapidly changing to pustules, and forming yellow gum-like crusts by the drying up of their contents." It is of the greatest importance that there should be a distinct and more general recognition of the fact, that eczema may exist from first to last as a dry infiltration of the integument, for there is perhaps no one of the various manifestations of the disease that is so fre- quently mistaken, and confounded with other widely different affections. The poppy- to rape-seed sized papules, which are developed in its course, are usually seated upon a reddened and thickened base, and are themselves colored in various shades of red to a dark lurid shade. They are usually discrete, though often closely set together; are accompanied by a severe form of itching when irritated by scratching; and of all eczematous lesions are most apt to be thus irritated. Their summits are torn, and often to such an extent as to bleed, the blood drying in reddish crusts over the area involved or limited to minute blood scales on the apices of individual lesions. The extent of surface affected varies, as usual in the other varieties, being in cases largely dif- fused in patches over various portions of the body, or limited to small and single patches no larger than a silver quarter of a dollar. Such patches covered with a single or several groups of reddish papules may continue to torment the patient for long 108 DISEASES OF THE SKIN. periods of time, or, being at one time relieved, recur with eaeh aggravation of the part by the exciting cause. Papular eczema is the dry manifestation of the disease, and is thus most fre- quently noticed upon the drier portions of the integument. These are the surfaces of the limbs, the back of the body, and. in particular, the scrotum. In the latter region the lesions o;iv- ing a name to this variety of the disease are most fully devel- oped. If the moist forms of eczema are most frequently seen in early life, it is none the less true that the dry forms are most common in adult life or advanced years. It should not, however, be forgotten, that the papules here described may develop into minute or larger pustules, or may exhibit minute vesicular summits when there is free exudation beneath the surface. It should be added, that a patch of papu- lar eczema, where no vesiculation nor pustulation has been observed, will, if sufficiently scratched, ooze with moisture, the serum escaping from the abraded surface. There are, in fact, few scratched eczematous surfaces which will not moisten a dry handkerchief applied to the part. This weeping condition attracts the attention of patients themselves, who will complain of it in describing their symptoms to a physician. A certain species of relief for the pruritus is thus obtained; and in aggra- vated cases patients will scratch or rub or otherwise irritate their diseased patches, not merely for the purpose of gratifying the intense desire to assuage this symptom, but alsoto induce the serous exudation for the sake of the relief it affords. The secretion when in contact with linen cloths stains and stiffens them, very much as seminal fluid leaves its traces upon the clothing. Resolution of papular eczema is accomplished after the for- mation of scales, the tissue beneath the latter assuming more and more the appearance of healthy skin. The four types of eczema considered above are, as has been stated, sometimes encountered in practice as distinct and un- mingled forms of cutaneous disease, some of them more com- monly than others. To present, however, a picture of eczema as it is seen clinically, it must be understood that these several forms, useful in the analytical study of the disease, often become, in actual observation, well nigh inextricably commingled. It is this untiring interchange of features which distinguishes all the results of manifold causes operating in nature at one and the same time; and it this which gives the inflammations of the human skin, exposed to almost every external influence, such a manifold physiognomy. Like all other inflammations, eczema may be acute or chronic. Like all others, too, the acute may precede, and the chronic fol- low ; or the reverse may occur, the disorder, originating in sub- ECZEMA. 109 acute or insidious forms, may become chronic, and then, as the result of fresh or more severe irritation, develop into the acutest symptoms. Thus the name eczema rubrum has been given to the red and angry form of the disease, which, because of the free exudation of serum from its surface, has been also termed eczema madidans. In this form, the intensely red and wounded integu- ment pours out freely upon the surface a thick gummy or syrupy fluid, which, if artificially removed, leaves behind it the swollen, angry, and still discharging skin, or, being permitted to dry where it has formed, concretes into the thick, dark-colored and often blood-stained crusts already described. Again, the scales which usually form on the eczematous skin toward the conclusion of the process just described, may prove to be the most characteristic feature of the case from the first. Thus on the back of the neck an eczematous patch may often be seen, where the skin is infiltrated, and covered with a stratum of thin, whitish scales, the latter having developed rapidly upon an erythematous surface, and continuing for a long period as a scaly disease. It is to this and similar forms that the term eczema squamosum has been applied. Again, in the regions about the hand, the movements of that organ develop often fis- sures or cracks in the inflamed and infiltrated integument, and to these fissured- forms the term eczema fissum has been applied. They are observed wherever an eczematous disorder has so im- paired the elasticity and extensibility of the skin, that its neces- sary movements, especially about the joints, tear and stretch the torn integument. It is thus seen not only in the hands, but also in the feet and about the ankles, the resulting rhagades being at times probably the most painful of all the complications of the malady. Occurring in the bodies and upon the hands of those who are. compelled to come into contact with irritating substances, this form of the disease finds its severest expression. Eczema Intertrigo Is a name applied by several authors to that form of intertrigo which, surpassing the limits of hypersemia, results in an exuda- tive process. Reference was made to this possibility in describing the symptoms of erythema intertrigo, in a preceding chapter. Here the symptoms are usually those of diffused redness of sur- faces of the skin in close apposition, macerated by previous transudation of sweat, and weeping with the serum which oozes from the several abraded points or patches. Eczema Verrucosum, Or the wart-like form of the malady, is occasionally observed, especially upon the lower extremities, in middle life or advanced years, as the result of long-continued disease. The integument 110 DISEASES OF THE SKIN. becomes thickened and so hypertrophied as to suggest the ap- pearance of warts closely packed together in a circumscribed patch. Eczema Sclerosum Is a form of the disease most frequently observed upon the palmar and plantar surfaces, a condition referred to in the para- graphs relating to asteatosis. Here there is present a densely thickened inelastic integument, suggesting the condition of tanned leather, without the occurrence of any of the other lesions of eczema described above. As a consequence the perfect extension of the digits is impaired. Most authors agree in considering eczema as it occurs in its acute and chronic manifestations. These are, as has been inti- mated, interchangeable conditions, the types of which possess, however, a clinical distinctness. Acute Eczema. In certain cases an acute attack of the disorder is ushered in by malaise, chilliness, or the recognized symptoms of the febrile state. With or without these prodromata, the affected portion of the surface speedily gives rise to a burning sensation, which is soon succeeded by redness and swelling. This may occur upon one or several portions of the body at the same moment of time, and the disease throughout be limited to this single area or those several spaces ; or it may extend from one or all to other regions. This process of extension may, by continuous devel- opment of the disease along the surface, or an eczema of the thigh, be suddenly followed by an eczema of the face, and this by an eczema of the scrotum. According to Kaposi, extension of eczema by the last-described method is due to the extraordi- nary sensitiveness of the skin when involved in an acute attack, in consequence of which the slightest friction and even reflex irritation of the bloodvessels produce a new focus of the dis- ease at a distant point. This seems to me a consideration of special importance. Pa- tients will frequently point to an acute eczema upon several [tortious of the body widely separated, the one from the other, and urge this as an irrefutable argument in favor of the fact that they suffer from some "poison in the blood." The tumid and erythematous surface already described soon as- sumes the features of either papular or vesicular eczema, which need not be again detailed. In this manner the evolution of the disease occurs, and may continue for weeks, the patient, if unrelieved, tormented by the itching; and, if the disease be ex- tensive, prevented from attending to his usual avocations. Acute eczema of severe grade will frequently prostrate a strong adult, contininor him to his bed-chamber, and often to his bed. When ECZEMA. Ill there is a simultaneous febrile process, the emaciation and adyna- mia are proportioned to its severity. Weeks, and even months, may elapse before recovery can be pronounced complete, sub- acute patches of the disease lingering here and there upon the surface, crust-hidden, scale-covered, occasionally oozing from recrudescence of symptoms. Recovery, even when complete, leaves the patient, it should never be forgotten, with a skin sen- sitive to irritation and more prone to a fresh attack of the dis- ease than one long virgin of an inflammatory process. Such is the course of an attack of acute eczema of severe grade, heedless to say that a circumscribed patch of the skin may ex- hibit all the features of vesicular eczema in an acute form; and, under the influence of appropriate treatment, be satisfactorily relieved in the course of a few days. Lastly, acute eczema may be followed by chronic forms of the disease, the one passing into the stages of the other by scarcely definable gradations. Chronic Eczema. The symptoms and pathology of chronic eczema are largely those of the acute form of the disease. The chief differences to be noted relate to diminished intensity of the inflammatory ac- tion, or marked tendency to persistence of the process, and a preponderance of scaling and infiltration as contrasted with the active secretion and crusting of the acute phases. It is, however, important to remember that chronic eczema is not only the fre- quent sequel of such acute phases, but is particularly prone to recurrent exacerbations of acute grade, during which the serous discharges, consequent crusts and angry aspect of the affected surface, do not fail to reappear. The itching so characteristic of the malady in all its manifestations is here also a tolerably constant symptom. Chronic eczema may involve a limited surface of the skin, or invade the entire surface of the body from the head to the feet. Rarely thus generally developed, it is more frequently observed upon circumscribed patches of the integument, as, for example, the scrotum or the flexor surface of a joint, in which situation it may linger for years, or even for a lifetime, now better and now worse, or disappearing for brief periods only to return with each recurrence of its cause. Etiology. — Eczema is a disease of both sexes and of all ages ; and is, moreover, neither contagious nor inherited. The study of its etiology is thus to a degree simplified. In many cases no cause of eczema can be discovered, beyond those which operate exclusively within the skin-organ and are proper to itself. These are necessarily obscure, and will remain so until we are in possession of far more knowledge as to the 112 DISEASES OF THE SKIN. complex mid inscrutably delicate processes by which innervation, nutrition, and new formation of the living matter of the skin, are both conserved and impaired. The autonomy of the integu- ment imi-i be conceded to the extent recognized in other organs of the body. There are diseases of the liver which are neither referred to the blood, the nerves, nor to the action of poisons. There arc diseases of* the heart which can neither be induced by rheumatism nor syphilis. When the etiology of the disorders of all the viscera is perfected, that of the skin displaying the lesions of eczema will be assuredly more distinct. These remarks are justified by clinical facts. Eczematous affections occur in the persons of individuals who are in every respect superb examples of good health, where the most thorough and careful examination fails to reveal for the disorder either an external or internal cause. Eczemas occur also in persons who are affected with wavy form of bodily ailment; those suffering from acute and chronic disorders of every viscus and system of the body; and even those affected with other disorders of the skin. This is only what a study of established facts would sug- gest, having in view the probable proportion of eczematous at- tacks in every thousand individuals. Such coincidences would, however, scarcely furnish a satisfactory etiological basis for the disease, unless a certain degree of constancy between eczema and these disorders could Jbe established. Thus eczema is often seen in patients affected with rheumatism, gout, dyspepsia, malaria, obstinate constipation, anaemia, scrofula, and pulmonary disor- ders, a list of affections exhibiting surely very wide pathological differences. Yet he would prove to be a physician of exceedingly limited experience who could not select from patients under his own observation, twenty individuals affected with any one of the diseases named, no single person of the entire number having ever exhibited symptoms of eczema. If figures alone were to decide the question, these and a larger list of maladies which have been named in similar connection, would be excluded in the study of the etiology of the disease. This much premised, it should be added that every phase of eczema can be artificially produced upon the surface of the skin by the action of external irritants. Several authors, notably those of French nationality, take exception to this view, claim- ing that the induced disease in such instances is an artificial dermatitis, but they fail to point out the distinctive objective differences between such dermatitis and eczema. They content themselves with observing the subsequent evolution of the malady, and pronounce that to be an eczema which fails to respond promptly to treatment; and that, a dermatitis which is capable of speedy relief. The climax of such absurdity is reached when they are shown obstinate cases of eczema of artificial origin, and the response is, that the induced dermatitis gave rise to an eczema in a predisposed subject. ECZEMA. 113 One step further and we are in position to estimate the approx- imate value of the etiological factors in eczema. The large majority of all generall} T recognized and externally operating causes of the complaint, fail to have such an effect in the mass of individuals. Whether any one of them be necessarily fol- lowed by the disease is open to some question. Even the poison ivy, a fertile source of the disorder in susceptible individuals, will fail to influence others. The late and eminent Professor Boeck, of Christiania, when he was last in America rubbed the tender leaves of this plant over his hands and face in repeated efforts to produce the disease in his own person, and utterly failed of the desired end. Respecting the numerous agencies operating thus externally, and capable of producing the disease under consideration, it is to be remarked that they can all be referred to either; solar light and heat; contact with foreign bodies in various vaporous, fluid, or solid states; toxic agencies of a widely differing nature; traumatisms in varying degrees; and the action of parasites. Many of these co-operate; some include others; and some be- come effective by aggravating a disease which others have en- gendered. The reader is referred to the chapter on general etiology for fuller consideration of this subject. It will be suffi- cient to note here that acids, alkalies, antimonial and mercurial compounds, mustard, sulphur, castor oil, capsicum, arnica, tur- pentine, chloroform, ether, alcohol, and a long list of other medi- caments are capable of producing eczema when applied to the skin externally. The same is true of articles manipulated in many of the trades, those, for example, handled by the grocer, the baker, the confectioner, the seamstress, the ink manufac- turer, the mason, the cook, the gardener, the laundress, the painter, the dyer, the printer, the tobacconist, and the chemist. Then, too, the eczema of the person exposed to intense cold, or intense solar light and heat, aided by reflection from the water, or even by excessive artificial heat, as the fire of a furnace, illus- trates the action of other causes named. Pressure and friction- effects are exhibited in the eczema produced by the contacts with gaiters, cuffs, trusses, saddles, crutches, and corsets. Scratching is a fruitful cause of eczema when the skin is affected with pruritus as a distinct disease, or as a symptom of other cutaneous disorders. Thus it is efficient in urticaria, scabies, and the prurigo of Hebra; in the skin bitten by lice, insects, bed-bugs, and fleas (which even without such interfer- ence are capable in many cases of inducing the disorder); and in the lower extremities where the skin is distended by varicose veins. Water is capable of exercising an injurious effect upon the skin to the extent of producing an eczema, whether it proceeds from the sudoriparous gland in an excessive exudation of sweat which is not duly removed by ablution ; or be applied externally 114 DISEASES OF THE SKIN". as a fluid in excessively cold or hot temperatures; or in the vapors of the popular Turkish and Russian baths; or yet again be ren- dered irritating by its saline or other constituents. The external sources of eezernqtous trouble named above should he regarded simply :is suggestive illustrations. It should be borne in mind that every contact with the external world, sufficiently severe or prolonged to awaken the resentment of the healthy skin, may be followed by the protest of the latter in the shape of an eczema; and the same may be true when even the most trivial external accidents occur to the sensitive skin of certain individuals particularly prone to the disease. Turning to the so-called internal causes of eczema, these must be, for reasons already detailed, considered for the most part as either coincidences or conditions which favor the development of diseases in general, eczema not excepted. By interference either with innervation, nutrition, development, excretion, or the performance of the important functions of the body, as well as by reflex irritation of the surface, they operate by inviting, aggra- vating, or prolonging an eczematous disease. Among these may be named: as diseases, rheumatism, gout, struma, gastro-intestinal derangements, including dyspepsia, constipation, and functional disorders of the liver, chlorosis, and menstrual disorders; as physiological states, pregnancy, lactation, and dentition; as associated with the habits of life, occupations necessitating in- ordinate fatigue of body or mind, especially with the exclusion of sunlight; and lastly, as originating in the irritative action upon the mucous surfaces, of substances foreign to the body, dietary, and medicinal articles capable of exciting cutaneous rashes, intestinal parasites, and instruments inserted and fluids injected into the mucous canals, as, for example, the male urethra. Pathology. — The pathological changes in eczema are those of in- flammation of the skin, varying somewhat with the acuteness or chronicity of the process and the character and career of the exu- date furnished in each expression of the disease. In all cases there is, first, a circumscribed or diffused hyperemia of the affected part. This results from a series of more or less rhythmical and alternate dilatations and contractions of the vascular capillaries, the apogee of which is persistent vascular distension, blood-stasis, and the condition generally recognized as engorgement of the affected parts. This engorgement becomes visible to the eye in various shades of increased redness. Then occurs an exudation, by which a material in various degrees of fluid or solid consist- ency is added to the tissues. This process is also coarsely appre- ciable, either by the free ooze of serum from the surface; or by the imprisonment of such exuded fluid in the chambers of the vesicles which it produces; or by an increased thickening of the various constituents of the skin, perceptible when these are pinched up between the finger and thumb; or, lastly, by the ECZEMA. 115 appearance of various solid or semi-solid projections concerning the skin proper, or, secondarily, its glandular appendages, which visibly spring from the involved area. Thus are explained the various erythematous, vesicular, pustular, and papular manifes- tations of eczema. A history of the many doctrines which have been held regard- ing the part played in these phenomena by the bloodvessels, the nerves, and the tissues would simply exhibit the several steps which have been taken in arriving at the facts now demonstra- ble. The researches of Heitzmann serve to throw light upon this inflammatory process in the skin in a highly satisfactory way. /_--_.- • - <<*&»" Chronic eczema — vertical section of the skin of the forearm, a, epidermis ; 5, thickened rete; e, hyper-pigmented layer of rete ; d, enlarged papilla;; e, atrophied sebaceous gland ; /, atro- phied hair follicle ; g, infiltrated corium. (After Kaposi.) As to the part played by the epithelium, Heitzmann 1 shows that the initial step of the inflammation is declared by an in- crease of the living matter, both within and between the proto- plasmic bodies; the former produces a coarse granulation of the epithelia due to increase of living matter. This increase is evi- dently due to augmented afflux of nutritive material in the stage of hypersemia. It is declared at the points of intersection of the protoplasmic network (the formerly so called granules) by their enlargement, and by the shining and solid condition of 1 Transactions Arner. Derm. Association, Fourth Annual Meeting. 116 DISEASES OF THE SKIN. that part of the network formerly called "the nucleus." The increase of living matter between the protoplasmic bodies is declared in a thickening of tlie threads traversing the cement- substance. Every particle of the living- matter, either within or between the epithelia, is capable of producing a new forma- tion of epithelial elements. Thus is explained the part played by the epithelium in the thickening of the skin, the production of scales in squamous eczema, etc. In connective tissue, the first, manifestation of the inflamma- tory process is the dissolution of the basis-substance and reap- pearance of the protoplasmic condition; by this process and the new formation of medullary elements which may start from any particle of living matter, the inflammatory infiltration is estab- lished. The sum total of the inflammatory elements which remain united with each other by means of delicate off-shoots, represents an embryonal or medullary tissue. In the case of erythematous eczema, the new formation of medullary elements is scanty, and resolution is accomplished by reformation of the basis-substance. In papular eczema the papilla? of the skin are enlarged in all diameters, partly owing to a dilatation and enlargement of their capillary bloodvessels, and partly to the peculiar connective tissue changes already described. Plastic formative inflamma- tion may be accompanied by the accumulation of a larger amount of serous or albuminous exudation in the epithelial layer as in vesicular eczema. Suppuration in the epithelial layer of the rete mucosum is produced by the accumulation of an albuminous or fibrinous exudation, in consequence of which a number of epithelia are destroyed, and by a new formation of pus corpuscles from the living matter of the epithelial elements themselves. Epithelial suppuration of this sort is not followed by a cicatrix. This is the pathology of eczema pustulosum and eczema madidaus. The elevation of the temperature in the inflamed skin is some- what proportioned to the rapidity of the process. In acute eczema such elevation may exceed 105.5° F. (41° C), while in chronic eczema it can scarcely be appreciated. The fluid exuded in eczema, whether taking part in tumefac- tion of any portion of the skin, as in vesiculation ; or in a free discharge from the surface, is always identical. It. is a yellowish- white sticky and syrupy liquid, feebly alkaline in its reaction, depositing albumen in abundance when treated by heat and nitric acid, and exhibiting the characteristic features of the serum of the blood under the microscope. Exposed to tlie air it desiccates in light yelloAvish to brownish, friable crusts, which resemble honey or gum. Increase in the pigment particles distributed to the epithelia of the rete is characteristic of the chronic forms of eczema, and more .especially of those where the circulation is somewhat ini- ECZEMA. 117 peded by the influence of gravity, {is, for example, in the lower extremities. This is true, however, of all diseases accompanied by an augmented afflux of blood to any part of the body, as, for example, over the surfaces of joints to which for many years stimulating embrocations have been applied. Diagnosis. — Eczema is such a protean disease in its manifesta- tions, and is, moreover, of such frequent occurrence, that it is necessary to establish a differential diagnosis between it and a large number of other cutaneous disorders. The more important of these are named below in alphabetical order for convenience of reference, the distinctive differences of each being briefly appended. It must be remembered, however, that the identity and characteristics of eczema are made clear only after a close study of all its features; and that this is the surest basis for an accurate diagnosis in every case. Acne. — Acne occurs chiefly on the face, neck, and back of the trunk, and its pustular forms might be mistaken for eczema of the same localities But pustular acne is usually accompanied by a deeper seated infiltration than the similar lesions of eczema; and this infiltration is also generally limited to the sebaceous glands or periglandular tissues. In eczema the itching is often severe, while in acne the subjective sensations are those of heat or burning; comedones intermingled with the pustules of acne will aid in distinguishing the two. Erythematous eczema of the face is to be distinguished from acne rosacea by its more generalized infiltration, its production of itching, and its greater diffusion over the face; while acne rosacea is more often limited to the face, nose, brow, and the re- gions adjacent to these parts. The patch of erythematous eczema is " hot ;" that of acne rosacea, "cold" to the touch. The former is seen in infancy ; the latter is rare in that period of life. Acne rosacea is also in many cases readily distinguished by the devel- opment of visible bloodvessels in the skin of the cheeks or nasal region. Lastly, in erythematous eczema the lids are apt to suffer, while in acne rosacea this is the exception. In severe forms of acne the sub-epidermic pus formation and the resulting sear will prove significant. Dermatitis. — Dermatitis, of artificial origin, is to be distin- guished from idiopathic eczema rather by its history than by special differences in the appearance or evolution of lesions. In many cases the two affections are indistinguishable. A history of traumatism or of the external application of irritant or toxic articles will often serve to distinguish the two. Dermatitis of artificial production is usually sudden in its onset, the date of which will nearly correspond with the time of the operation of the exciting cause. The subsidence of the symptoms after the withdrawal of the cause will also point to the nature of the 118 DISEASES OF THK SKI.V. affection. Eczema is also much more capricious in its distribu- tion and career. Erysipelas. — Erysipelas is generally accompanied by febrile symptoms, ;uie found useful to com- bine with these ointments the oxide of zinc, the mercurial com- pounds, <>r thi' diachylon ointment of Hebra, already described. The following formulae are illustrations merely of the manner of compounding these articles: — . 01. betull. alb. (vel cadini) 3ss-3jss ; i-fi Potass, subcarbouat. 9J-38S ; .66-2 Unguent aq. res. §j; 32 . et ft. ungt. f.3j-ij ; 32-64 fSJ ss 'U ; f§viij ; f.-ss ; 48-9(5 32 256 2 Fertile potassic Bubcarbonate one-half to one drachm (2.-4.) of the zinc oxide may he substituted, or from two to four grains (.133-.266) of the red oxide of mercury, or yet half a scruple (.0(30) of the mild chloride. The vehicle also of such ointments may he vaseline, simple cerate, or half an ounce ^16.) of either in combination with an equal quantity of diachylon ointment. Of the fluid preparations may he mentioned, alcoholic solu- tions of tar, half an ounce (16.) of the latter to the pint (512.) of alcohol; and, in cases where the detersive action of soap is also needed, the sapo viridis may he added as follows: — \i. Picis liquids Sapon. virid. Glycerin. Spts. vin. rectif. 01. rosraarin. f.^ss ; 2i M. Sig. To be rubbed gently into tlie skin with a flannel rag. Dr. Bulkley, of Xew York, has devised an alkaline solution of tar and caustic potassa, which is especially serviceable, as it is miscible with water in all proportions. It is constituted as follows: — B Picis liquid a? f§ij ; 64! Potassae causticre §j ; 32 Aq. destillat =v ; 160 M. Dissolve the potash in the water, and add slowly to the tar in a mortar with friction Big. " Liquor picis alkalinus." To be used diluted as a lotion A drachm (4.) or more of this solution may be added to a pint (512.) of water; and, as an ointment, the same quantity to the ounce (32.) of cold cream or vaseline. It should be remembered, however, that the caustic alkali renders it exceedingly irritating to a sensitive skin, and it should he employed with caution upon any untested surface. Hebra disclaimed any special value for sulphur in eczemas uncomplicated by the acarus seabiei, hut in Wilkinson's and other ointments, it has certainly served a good purpose. The following formula supplies an ointment much less severe and offensive to the nostrils than Wilkinson's, and which I can cer- tainly recommend for its practical efficacy in chronic eczema: — ECZEMA. R Picis liquid. §iv; 130 Adipis ?j; 30 01 olivce I ss ; 16 Misce et adde Terebinth. Canadeus } Sulphur, flor aa §j ; 30 Si g To be applied three times daily with a sr ft brush. 135 To this may be added the green soap, if a stronger effect is desired. Olive or cod-liver oil may be rubbed into the eczematous skin, after combination with equal parts of one of the tarry prepara- tions; and carbolic acid in lotion and ointment with the balsam of Peru, though less effective, answers well in many cases. Whatever article be selected, it should be thoroughly rubbed into the affected surface several times in the day, after a small portion of the skin has been attacked to test its susceptibility. IShould the redness, itching, secretion and infiltration be aggra- vated by such application, it will be needful, for a time at least, to exchange the local treatment for one less stimulating. Should, however, the tarry or other similar application be well borne, it should be reapplied till it is no longer washed away by the ooze from the skin. Sometimes it is well to permit the former to accumulate till it is naturally shed from the surface by exfolia- tion, a course which will be indicated by the absence of all local distress. The new epidermis, which forms beneath such a coat- ing, should be for a time protected by a dusting powder. Occa- sioning no further subjective sensation, it speedily loses its red- ness, and assumes a normal appearance. In other cases, indicated by local distress and exaggerated secretion, it will be found useful to remove the tarry application completely. After saturating it for a few hours with oil, the surface may be cleansed with a weak alkaline lotion, and the tar compound then reapplied to the oozing skin with flannel or camel's-hair brush, according as recourse is had to an ointment or solution. Hebra used to employ in chronic eczema of obstinate kinds a remedy which he claimed to be his ultimata refugium, and which "cures every case without exception," the concentrated liquor potassse. The objections to its use are, however, grave. It pro- duces severe pain, and in inexperienced hands it is dangerous. As a consequence, this distinguished dermatologist adopted two methods which he regarded as partial substitutes for it. The first was the inunction of the body thoroughly and firmly with green soap, which was not removed by washing, but left in con- tact with the skin for several days, while the patient was wrapped in blankets. The second was his well-known method of treating more circumscribed patches of chronic eczema with soap washing and ointment, the process being described below in nearly his own language: — ■ A piece of green soap as big as a walnut is spread upon a flannel 136 DISEASES OF THK SKIN. rag, and rubbed into the eczematous part for several minutes, pressing firmly the while, and from time to time dipping it into water in order to produce a better lather. The part is then washed free of suds with water, carefully dried, and the oil or ointment selected for topical use immediately applied on strips of muslin. These are neatly bandaged to the part. The soap must be rubbed in at least twice every day so lontr as an}' exco- riated points appear after its application. Soap rubbed into the healthy skin will not be followed by such effects; the part feeling clean, smooth and comfortable after it has been washed off with water. The contrast this offers to the eczematous parts is very Striking, the latter presenting numerous intensely red, raw and moist spots These are all caused by the action of the soap in softening and destroying the layer of cuticle which was before undermined by the eczematous fluid so as to form coverings for vesicles. Each, therefore, represents the floor of a vesicle, the roof being removed. The appearance of these red, shining, moist points after the first inunction suggests to the inexperienced eye, that the malady has been aggravated ; but they become fewer in number after each application, and finally entirely disappear, the eczematous surface being then no more affected by the soft soap than is the surrounding healthy skin. Frazer 1 speaks highly of the application of iodoform to ecze- matous patches. It is employed in the form of an ointment, containing from ten to thirty grains of powdered iodoform to the ounce of cerate. Other stimulating articles have been found useful in the treat- ment of eczema. Among these may be named cantharides, em- ployed as a blister, the nitrate of silver in crayon or solution, and iodine in combination with carbolic acid. The following formula should furnish a clear vinous-red fluid, which may be applied pure or in dilution : — R. Iodin tinct. 3ss ; 2 4 Iodin tinct. 3ss; Acid carbolic, (cryst.) sj; Glycerin., Alcoholis. aa 5'j ; Aq. dcsiillat. a.lt'sj; M. Iodized solution of carbolic acid. In cases where there is considerable pruritus, especially in obstinate patches of papular eczema, the iodized phenol of .Bel- lamy may be substituted for this. The formula is: — R. Iodinii cryst., ) ,, N Acid, carbol.; \ ** & <*■) Combine will) gentle beat and ndd an equal part of glycerine. Sig. Iodized phenol ; to be applied twice daily with a glass rod. Mr. Balmanno Squire, of London, has suggested a substitute for the diachylon ointment, in the glycerole of the subacetate ' British Medical Journal, July 16, 1881, p 80. ECZEMA. 137 of lead. It is certainly a valuable preparation, and I hnve em- ployed it with advantage in many cases, but am unwilling to admit its superiority over the other ointment named. The u stock" is prepared as follows: Take five parts of the acetate of lead, three and one half of litharge, and twenty of glycerine, heat for half an hour in a boiling glycerine bath, constantly stirring, and filter in a gas-oven or other kind of heated apart- ment. From one-half a drachm to two drachms (2.-8.) of this stock, added to the ounce (32.) of pure glycerine, are sufficiently strong for application to the oozing surfaces of eczema rubrum. Lassar? recommends that the part affected should be at first well soaked with antiseptic oil, of which a considerable quan- tity is absorbed by the skin. A muslin bandage, soaked in oil, is then applied and covered with oil silk. The oil may be ren- dered antiseptic by the addition of one to two per cent, of car- bolic or salicylic acid, or one and one-half per cent, of thymol. Sometimes the carbolic acid can only be borne for a short time, as it will of itself produce eczema. .Rape-seed oil may be used in place of the more expensive olive oil ; but drying oils, such as linseed oil, are to be avoided, as they may cause inflamma- tion. In chronic eczema, especially in infants, and in eczema of the face, he recommends an ointment. The formula for an ointment which cannot be rubbed off during sleep in eczema of the face is: — Salicylic acid Oxide of zinc Starch Vaseline gij ; 50 Mix. Wyndham Cottle 2 has employed chaulmoogra oil, or gyno- cardic acid, in a large number of cases of eczema occurring in persons with delicate skins, and over such exposed surfaces as the face, hands, and arms. In both acute and chronic forms he has employed these substances in the form of ointment, in the strength of from fifteen to twenty-five grains (1.-1.5) to the ounce (32.) of vaseline. The ointment is applied several times in the day, and, if possible, kept in contact with the part on rags over which it has been spread. Other mercurial preparations than those named above have long been in favor for application to localized patches of the disease. Among these may be named corrosive sublimate, the ammonio chloride, the iodide and biniodide, the two oxides, and the nitrate. Calomel, which is useful in the strength of a scruple to a drachm (1.-4.) to the ounce (32.) of ointment, can be often ad- vantageously employed also as a powder in full strength or diluted with bismuth or starch. In localized patches of papular 1 Annal. de Derm, et de Syph., Sept., 1881. 2 British Medical Journal, June 25, 1881. 3vj ; 25 3vj; 25 §U; 50 138 DISEASES OF THE SKIN'. eczema, where such a dressing can l>e tolerated, I have fre- quently found marked results follow this dry dusting of calomel over the part, followed by alternate superposition of neatly ad- justed strips of Maw's surgeon's plaster; the whole kept in situ by means of a neat bandage. If the itching is alleviated by Buch a dressing, it can he reapplied for a week as soon as it is loosened, when the redness ami infiltration will be found greatly reduced. Other surgical appliances used in the local treatment of eczema are Martin's solid rubber bandage, Fox's tubular bandage of rubber, and other dressings composed of starch, gutta perch a, and plaster of Paris, intended to support the extremities when the integument is weakened. None of these, in my experience, are equal to rest in the recumbent posture. The most useful purpose subserved by rubber in the treatment of cutaneous affec- tions is as an impermeable outer dressing for watery and oily applications. Here the mackintosh and silk protective of the Lister dressing answer all the indications. Constitutional Treatment of Eczema. — If the remarks which have preceded are justified by the clinical and pathological his- tory of eczema, it follows that there is no constitutional treat- ment of the disease, save that which excludes all sources of irritation, a point to which attention has been already called. Once fully persuaded of this important truth, the physician should be capable of managing the complaint without mental bias in the direction of futile experimentation with drugs. The treatment of the patient, however, may be in one sense regarded as the treatment of his disease, though I am thor- oughly persuaded that a very large number of eczematous pa- tients are, except as regards the skin, in conditions of health. Constitutional treatment, to meet any general conditions of ill- health, should be such as is made familiar to the physician in his experience as a general practitioner of medicine. It goes without saying, that the anaemic patient will be benefited by the chalybeates ; the dyspeptic, by the remedies calculated to relieve such a condition ; the rheumatic, by the lithium salts, the diuretics, and alkalies; the cachectic and strumous, by cod- liver oil, malt, and similar preparations. But this is merely the enumeration of a few disorders in the long list which may coexist with eczema. Many male patients with a gleet have an eczema of the thigh, kept up by the dis- charged secretion, which calls for treatment calculated in a very indirect manner to relieve also the cutaneous disorder. The same ma}' be said of an otitis externa with a purulent discharge, and of other local and constitutional ailments which the skilled physician should be competent to recognize and treat. Be it clearly understood the while, that all such treatment will not relieve an eczema. It simply places the patient in the most favorable condition for getting rid of local trouble. For several ECZEMA. 139 years past I have had the opportunity of observing a large num- ber of eczematous patients, of every social class, treated by internal medication of the character approved by those who still cling to a belief in the constitutional nature of the disease ; and the statements here made are based upon a conscientious study of this experience and of the results of personal experi- ments in the same direction. He who desires to build solidly will not lay his corner-stone upon the shifting sands, where so many have been disappointed before him. Bearing in mind the fact that an eczema will occasionally vanish under even the worst mismanagement, the value of arsenic administered internally for its relief should be duly esti- mated. It is an uncertain remedy in all cutaneous diseases; it is, if possible, more uncertain in eczema ; and has unquestionably aggravated more cases than it has relieved. Its value in chronic and persistent forms of the disease is attested by men of distin- guished reputation ; and upon such authority it may be conceded a position among the internal remedies for the malady, of pos- sible value. It has been my ill-fortune to observe so many ob- stinate forms of squamous and papular eczema aggravated by its employment, that I should consider an acquaintance with a dozen patients relieved by its use in a single year, a circum- stance suggestive of as much curiosity as congratulation. It is indeed not as remarkable that a few patients annually recover under its administration, as that more do not attain the same fortunate end. For it is the favorite dernier ressort, in chronic scaling diseases of the skin, with physicians of every grade of professional proficiency; and, having in view the large per cent- age of eczematous cases with which they are confronted, it is a curiously suggestive fact that the position of arsenic in eczema is yet open to discussion. If arsenic, which certainly does pos- sess an influence over the skin, cannot to-day be demonstrated to have any therapeutic value in the large proportion of all cases of eczema, what can be said of the host of other drugs too com- monly employed for a similar purpose, which are inferior to arsenic in their cutaneous effects ? Sunlight, fresh air, a properly selected diet, suitable clothing, and due regime as to pleasure and business; these must be, for many patients, controlled by the physician. They do not cure eczema. They may do much to aid in its management; they may do more, if neglected, to furnish sources of its aggravation. Prognosis. — The greatest uncertainty attends the prognosis of eczema, so far as regards the duration of the disease and the probability of the recurrence of a relapse. With respect to the questions most frequently asked, those relating to contagion, hereditability, and persistent lesion relics, naturally a favorable response can be made. But the fact remains, that some forms of the disease are insignificant, some persistent, and some peculiarly liable to relapse from very slight provocation. Only after careful 140 DISEASES OF THE SKIN. weighing of nil the conditions exhibited by the skin and by the other organs of the patient, can a reasonable probability as to the future be estimated. All this is unsatisfactory, and must be so. Eczema is truly a curable disease, but unfortunately one not only exceedingly common, but one open to aggravation by causes well-nigh innumerable. Were the physician always in position to absolutely insure his patient the exclusion of all sources of irritation, the prognosis would be much more satis- factory. In hospital patients, where such control is more per- fectly attained, the results of treatment may be predicted with some confidence. In general it ma}' he said that acute eczema is more readily relieved by proper treatment than the chronic forms of the dis- ease, that eczema with a discoverable cause is more manageable than one whose etiology is obscure. That eczema of the very young, and of the very old, is at times particularly rebellious. That the non-discharging phases of the disease are rather more persistent than those accompanied by secretion. That eczema lingering at the mucous outlets of the body (auditory canal, nostrils, mouth, nipple, anus, vagina) is more obstinate than when it affects the skin of other parts (shoulder, neck, lumbar region). That eczema with constant aggravation or complica tions (fissure of the hands, varicose veins of the leg, apparatus for anchylosis of knee) is more stubborn in proportion as those complications or aggravations cannot, from the circumstances of each case, be set aside. And finally, that an eczema which has long existed or repeatedly recurred, as for example with every season of extremely cold or hot weather, is after relief extremely liable to return. THE LOCAL VARIETIES OF ECZEMA. Eczema of the Scalp. When the scalp is affected with eczema, the symptoms differ somewhat, according to the age of the patient. In adults, the erythematous and srpuamous varieties of the disease are more common; in infants and children, the pustular. In the former, the eruption is usually circumscribed and in patches; in the latter, it is more diffused. In the same proportion also, the for- mer is generally asymmetrically and the latter symmetrically developed. In infants and children, the pustules rupture early; and their contents dry into dirty-whitish, yellowish, or greenish crusts, matting together the hairs, serving as foci for dust accumulation and nests for lice, superimposed upon a reddish, oozing, pus- covered or occasionally indolent skin, often foul-smelling, and usually complicated by a seborrhcea. The so-called " milk-crust " is usually a compound of dried pus and altered sebum. The itching is not so intense as in some other forms of the disease. ECZEMA. 141 Post-cervical, preauricular, and occipital adenopathy, are com- mon, and in strumous children suppuration of the affected glands may occur, though this is rare. The causes of this form of the disease are evidently associated with local conditions. The rapidly growing hairs of the scalp are in intimate associa- tion with the numerous and large sebaceous glands of the same part, which unquestionably respond at times to the physiological stimulus they feel, by an exudative process. The acne of the young man whose beard is growing, illustrates the same fact. Local irritants are not often wanting to push the disturbed equilibrium into the scale of disease. Dr. White calls attention to the common neglect in removing the " pre-natal cap of cheesy material," as well as to the rude and unskilful attempts to ac- complish the same end. Extremes of temperature, friction, ex- cess, neglect and want of skill in washing the scalp, all these contribute to originate or aggravate the disorder. The affection when complicated or induced by lice, is more common in children than in infancy, doubtless in consequence of the greater independence of the former and their gregarious habits. In female children with relatively long hair, the ova, or nits, of the parasite are readily distinguished, adhering closely to the hairs and accumulated especially about the occipital re- gion. The itching is usually more annoying than in pustular eczema not thus complicated. The erythematous and squamous forms of the disease, rather more common in adults, originate frequently in seborrhcea, when scratching or irritant applications have been made. The eruption here usually occurs in asymmetrical patches, or may be limited to a single patch tolerably well-defined in outline, and this often upon one side of the scalp, not as in infancy [(referring the vertex. Reference is made in the chapter on seborrhcea to a form of eczema of the scalp occurring in adults where finger- nail sized, circular, oozing or slightly crusted patches are gen- erally disseminated over the surface. They result, as a rule, from the scratching of an obstinate seborrhcea in "nervous" women; and suggest traumatism, in their reddish friable crusts, the color being due to exuded blood. The diagnosis of these forms of disease has been already con- sidered. In the treatment of the eczema of the scalp in infants and children, the first indication to be met is the removal of the accumulated crusts. When this is harshly accomplished, it be- comes a fruitful source of further mischief, it is therefore' neces- sary to proceed with great gentleness, and thus the thorough softening of the crusts is all important. For this purpose it is necessary to soak them in oil and to retain this substance in in- timate contact with the scalp. Olive or cod-liver oil may be selected, and, if needful to correct the odor or other purpose, one drachm (4.) of carbolic acid may be added to each pint (512.) 142 DISEASES OF THE SKIN'. with two drachms (8.) of the balsam of Peru. A neatly fitting Bkullcap should be then smoothly applied, constructed of the Lister protective or flannel, and fastened in place by a light bandage, never by elastic rubber hands. After several hours of soaking, the crusts should he removed by warm water an 1 soap washing, and the entire process be repeated till the crusts are completely detached. In selecting an article for subsequent medication of the scalp, it should always he remembered that. even infantile eczema will proceed to a natural involution if unirritated. Hence the oleated lime-water, or oil of sweet almonds alone, will often answer better than an ointment, and, even where there is considerable acuity of the inflammatory pro- cess, lime-water alone, with possibly a small quantity of glycerine added. In other cases the lime-water can he better medicated with calomel or the oxide of zinc. At times, also, it is well, even when these applications are kept in constant contact with the scalp, to order that a small pea-sized mass of one of the oint- ments descrihed above (such as the henzoated oxide of zinc ointment with cold cream, or medicated with a mercurial com- pound) he applied at the time of the dressing. This is to be gently rubbed in the surface with the tip of the finger, and the skin afterward protected as before. It is rarely needful to cut the hair unless nits he found, though in public Charities it certainly is a more expeditious method of arriving at the end, when a nurse has to dress the heads of several children in a single ward. In adults, especially in women, the hair should he spared, while the patient is warned that the loss of the growth upon the scalp may be considerable. As a sequel of obstinate sehorrhcea such an eczema may be succeeded by alopecia; in the absence of the former, the hairs are usually reproduced. I have never found it necessarv to emplo}^ the skullcap in adults, having succeeded in insuring the necessary applications by directing the attention of the patient to the necessity of care and thoroughness. As the disease in both classes of patients advances to a sub- acute or chronic stage, the treatment may be changed so as to include the various stimulating applications already descrihed, such as ointments and lotions containing tar, oil of cade, balsam of fir, alcohol, and sulphur. In the case of infants, however, such stimulating topical remedies are very rarely to be employed. An eczema of the scalp which has once entered upon resolution, in an infant or child, should be generalh 7 soothed and protected. Many little patients thus affected are in excellent general health, and require no internal medication. Others, however, demand the interposition of the wisdom of the physician to pro- tect them from the ignorance or folly of those to whose charge they are intrusted. Here is not space for a discussion of the pressing questions relating to the nutrition of the infant de- prived of the breast and starving on the " proprietary" diet pur- ECZEMA. 143 chased of a chemist, or an equally vicious aliment compounded by lime-water, and imbibed through a tube by which it is flavored with India-rubber and the chemically altered casein of milk several days old. A word to the wise is sufficient. Fresh pure milk, animal broths, cod-liver oil, must not be neglected. This, I remark in passing, concerns the health of the child, and has indirect connection with the eczema. A record lies before me of one hundred infants dead of artificial foods and marasmus in a public Charity of this city, and the list discloses not a single case of eczema. Lastly, patients of both classes are to be saved from mercury, arsenic, and the iodide of potassium. Eczema of the Face. Erythematous eczema of the face in adults is projected promi- nently among the varieties of the disease by its uniformity of type. It occurs in early and middle life and advanced years; and is a particular]}^ intractable ailment. In well-marked cases, the forehead, cheeks, eyelids, and nose of the patient are involved, exhibiting an infiltrated, usually dusky-red, often symmetrical patch of disease, the affected surface being slightly elevated above the level of the sound skin. This surface is uniformly smooth and reddened: occasionally, near the root of the nose and about the lower line of the forehead, minute, closeh 7 set papules are visible. Very slight oozing, especially after irrita- tion, may be noticed. At the height of the disease or in its involution, exceedingly line scales form, which are scarcely per- ceptibly shed from the surface. The lids, especially the lower lids, in advanced years become puffy. The line of demarcation is unusually distinct, and rarely invades the scalp-border or the region of the beard in the male. Itching is at times intense, the patient complaining of this bitterly, and usually preferring to rub the face with the hands or pieces of cloth. Sometimes, however, the face is well scratched with the nails, and excoria- tions and blood-crusts disfigure the countenance. Patients of intelligence usually describe the itching as paroxysmal, and starting at the root of the nose, whence it travels upward over the forehead, and laterally to the brows, often in the line of the supra-orbital nerves. Certainly at the root of the nose, the exu- dative process is of the most marked character. The eruption also is seen in asymmetrically disposed patches of various sizes, with islets of sound skin between. In resolution of the symmet- rical form, this is commonly observed. Patients thus affected are often those whose faces have been especially exposed to irritation, such as locomotive engineers, wheelsmen of sea-vessels, mechanics in trades where the hands are soiled with irritants and afterward applied to the face, and women spending hours of each day over the laundry-tub or the 144 DISEASES OF THE SKIN. kitchen-stove. In each class tlie operation of the cause is made manifest by the exacerbation of the disease after exposure. The affection is mosl commonly mistaken for erysipelas, a disorder from which it is readily differentiated by the ehron- ieity of its course. The latter feature is particularly character- istic of this form of eczema. It is rarely completely relieved utter the age of sixty within a twelvemonth; and, when it has existed tor a long period of time, is particularly obstinate under the best treatment, recurring with exasperating frequency upon exposure of the face to atmospheric changes. The great vascu- larity, abundant supply of sensory nerves, and necessary exposure of the face, probably explain this peculiarit^v. In its treatment the dusting-powders fulfil an important part. Soothing appli- cations should always be first employed. The more stimulating applications may be tried later. A very intelligent jurist of advanced years, whose face was thus affected, consented to aid me in some experiments, with a view to determining what ar- ticle of external application would give the speediest temporary relief for the local distress. He found that strips of cool, raw beef, neatly and closely applied over the forehead and cheeks, and renewed' as they become heated, were productive of the most comfort, an experiment I have since successfully repeated. In patients of younger years the face is apt to display vesicu- lar and pustular phases of the disease, forms more often of acute eczema, and correspondingly more manageable. The itching, and especially burning sensations, are apt to be severe; crusts form rapidly; and in infants the picture presented is often that seen in tne sealp, except that the hairs are not matted into the crusts; and there is often a reddish blush at the edge of the crust; or, when the latter has been removed, a redness of the oozing surface somewhat more marked than the similar patches on the less vascular scalp. The scratching in these little pa- tients is severe; crusts are torn off in part or wholly; blood- crusted excoriations are common The area of surface involved in this way clearly extended; sleep is greatly disturbed ; and the irritability and fretfulness of the child, thus produced, bear heavily upon its general nutrition. In some cases of longstand- ing the mental tone of the little sufferers becomes singularly perverted, and the character unquestionably changed. They will occasionally, when permitted, pick off and devour the crusts with voracity, and undergo nervous crises which are but a step removed from convulsions, and doubtless allied to the petit mat of the epileptic. This chain of formidable symptoms, well linked together, will often bid defiance to the most skilled efforts to impart ease to the tormented skin. In such cases the harness employed by Dr. White, of Boston, fills an important office. The skullcap, described above, and made of firm old cotton or linen cloth, is closely fitted to the calvarium, and a mask of the same material is shaped to the face with exactly ECZEMA. 145 placed apertures for the eyes, nose, mouth and ears. It is gathered in beneath the chin, and laps over two inches at the back of the head. This may be used only during sleep, or in aggravated cases, also during the hours of wakefulness. A species of strait-jacket is made by passing the head of the child through a hole in the closed end of a small pillow-case, which is then drawn down over the body and arms, and the latter confined at the sides by stitching the case together be- tween the trunk and the upper extremities, or accomplishing the same end with safety-pins. The jacket is finally secured by similar means between the thighs. When it is necessary to imprison the lower extremities, these are similarly secured by pins within the case; and the outer edge of such trowsers can be fastened to the bed or cushion on which the child reclines. Of course this treatment does not preclude the employment of the washes, ointments, etc., which are to be neatly applied next to the skin beneath the "trowsers" or "-jacket." The result is that rest is given to the tormented skin, which is not suffered to be exposed to a single scratching even during the dressing of the parts ; and its natural tendency to repair soon brightens up the case. Eczema of the Lips. Reference has been already made to the obstinacy of eczema occurring near the mucous outlets of the bodj-, a result due, I believe, to the secretion furnished bj' the adjacent mucous tracts. The lips furnish an illustration alike of this pertinacity and aggravation. Their frequent motions in mastication and articulation aggravate an eczema, which is, moreover, apt to be teased by a no less frequent thrusting of the tongue out of the mouth, where there is no beard, to wet the parts with mucus and saliva. One or both lips may be involved, vesicular, pus- tular, squamous, and erythematous lesions occurring at one point, or along the entire line of either, with frequently result- ing crusts and fissures. The vermilion border of the lips com- monly participates in the process. The lips become hot, some- times much thickened by the swelling and infiltration, their mucous faces being rarely implicated. Scarlet, dull red, and other peculiarly purplish hues of the vermilion border become visible. The parts are more picked than scratched, though the itching is at times severe. The pustular and vesicular forms are more common in children. The erythematous form, its red- dened outline roughened by scales, evenly projected beyond the vermilion border, is rather an affection of maturer years. In young children the affection is frequently aggravated by nasal discharges which flow over the lip, giving the latter an elephan- tiasic aspect, a condition noted also in later life. Occurring upon lips covered with the hairs of 'the moustache, the disease exhibits the usual symptoms of eczema barbae. In these male 10 146 DISEASES OF THE SKIX. patients, the pipe, the cigarette, the cigar, and the tobacco chewed and expectorated may aggravate the malady.' In all c;i-,.. it is obstinate, and calls for either emollient, stimulating, or protective applications. In cases displaying acute and pain- ful symptoms, frequent fomentations of the part with soft rags dipped m mucilaginous and alkaline hot waters, will aid in con- trolling the swelling and alleviating the pain. In chronic cases, where stimulation is demanded, this can be effected at the time of dressing, the parts being subsequently protected by collodion or other material. Carbolic acid and the nitrate of silver are often needed for Buch dressing. In eczema of the hairy lip it is often of great service to remove the moustache by shaving. The diagnosis is between sycosis parasitaria, herpes labialis, and epithelioma, the points of difference having been already suggested. The first is accompanied by loosening of the hairs and caused by a parasite; the second is vesicular in lesion, brief in duration, and trivial in severity; the third is a disease of advanced years, rather than of early and middle life, and is never accompanied by itching, but usually by more or less ulceration. Syphilis is fond of the angles of the lips; in most cases when thus limited, typical mucous patches of the mouth can be dis- covered. Eczema of the Nose Is naturally often associated with a chronic coryza. Inasmuch as one of the common symptoms of hereditary syphilis is the " snuffles" of the child, the physician should carefully exclude the possibility of such disorder in every instance when an infant with a coryza exhibits an "eczema" of the nose or lips. The age of the little patient; an inspection of its anal region (which should never be omitted in infantile eczema); and the history of the case will throw considerable light upon this important question. Whether occurring in the adolescent or child, the disease may linger only upon thealae in pustular or squamous forms, or block up the nares with crusts. In infants this enforces respiration with an open mouth, and the grasp of the nipple by the lips is thus interrupted either by respiratory acts or cries of agitation. The Schneiderian membrane participates in the inflammatory process, and pours out its secretion upon the eczematous skin. The membrane when inspected is seen to be either raw and suc- culent, or in a condition analogous to the pharyngitis sicca of authors, dry, glazed, and free from discharge. The nostrils are often thickened in consequence of the infiltration or fissured, especially at the line of the nares laterally and inferiorly. In severe cases, and when the lips participate in this process, the pouting, swollen, and distorted organs suggest the snout of the lower animals. Adults as a result frequently surfer from non- parasitic sycosis and furunculosis. ECZEMA. 147 Care should be taken to exclude syphilis in making a diag- nosis, bearing in mind the fact, that the pustular syphiloderrn (which see) frequently selects the furrow on either side of the nares for its evolution. In treating these cases all crusts should be removed, and the parts carefully protected. Picking the nose in children should be prevented if needful by the " strait-jacket." Pencillings with the compound tincture of benzoin, iodized phenol, nitrate of silver, and collodion will often prove serviceable. In softening crusts, oil may be freely used. For this purpose the warm car- bolized spray of the atomizer answers well. Eczema of the Ears. The ears are affected with eczema both in infancy and maturer years, the disease being limited to the whole or part of the organ, or extending backward over the post-auricular region or down- ward over the ramus of the superior maxilla. It may originate in chronic catarrhal discharges from the external auditory me- atus ; in exposure to temperature changes, especially when aided by high winds; in frost-bite ; in the irritation set up by the auricular limb of the frame of spectacles; in the toxic effect induced by the hook of cheap ear-rings and dyed bonnet rib- bons ; in the traumatism of ear piercing; and in the habit of unnecessarily picking the ear to relieve it of wax or trifling sensations of irritation. The pustular and moist forms are common at the superior, inferior, and posterior boundaries of the pinna, where a linear fissure is apt to form in the line of the angle made by the auricle with the plane of the adjacent integument. The motions im- pressed upon the ear by handling it, placing the hat on the head and tying hat strings over it, always tend to aggravate the dis- order. Long hairs worn over the ears may have a similar effect by the production of friction and the retention of heat. The lobules are apt to display the erythematous and scaly phases of eczema, becoming infiltrated, having a deformed appearance, a lurid red color and indolent course. The lobules alone of both ears in young women may be similarly affected, and exhibit these phenomena for consecutive years. Often the chronic in- flammation may laj^ the foundation for a keloidal growth, an accident of several inflammatory processes in other parts. At other times the entire auricles present a similar appearance, uni- formly dark red, infiltrated, alternately weeping and scaling, and projecting to a noticeable extent from the side of the head in consequence of their increase in bulk. The itching is usually more annoying than severe, being accompanied by a character- istic sensation of tenseness and fullness of the part. Like the eczema which occurs at the other mucous outlets of the body, the affection in these parts is particularly obstinate when it 148 DISEASES OF THE SKIN*. assumes the chronic form. Symmetry to the extent of involving both ears, though commonly to a different degree in each, is rather the rule than the exception; and is doubtless due to the simultaneous operation of a common cause. The diagnosis is between erysipelas, seborrhcea (which occa- sionally occurs in the concha of the auricle), erythema simplex and multiforme, and dermatitis calorica. The treatment should be at first soothing and protective; afterward stimulating. A firm bandaging of the ears to the head may he required to support the parts, to prevent irregular pressure (head upon the pillow), and to secure contact with ex- ternal medicaments. In chronic cases, stimulant applications are often well tolerated, and the tarry ointments here play an important part. Treatment appropriate to the otitis externa may be required. Bulkley recommends a tannin ointment, one drachm to the ounce, deeply and thoroughly passed into the meatus on a camel's-hair brush. French authors generally re- commend small tampons smeared with an ointment, and left in the canal. I have often found the greatest benefit from pencil- ling the indolent surfaces with solutions of the silver nitrate. The intractable forms almost invariably affect adults, and in them there is usually a history of improvement under treat- ment, then, in males, exposure, as, for example, to the wind, or, in females, excessive dancing, etc., and subsequent aggravation. Eczema of the Lids. Here the free edge of the lid, or the skin over the orbital mar- gin of the tarsal cartilage, may be chiefly affected; and either, both in children and adults. When the free edge of the lid is involved, there is a species of sycosis non-parasitica present, the hair follicles becoming inflamed and furnishing a purulent dis- charge which may agglutinate the lids. The latter are thickened and swollen, become'the seat of a moderate itching, are picked rather than scratched, and exhibit, minute crusts between, or glued to, the hairs. The disorder is often accompanied by a se- borrhcea of the Meibomian follicles, ami is described by oculists under the designation of " blepharitis" and "tinea tarsi." Inas- much as the facial expression is quite characteristic when the lids are thus involved, the patients exhibiting this form of eczema are usually set down as "scrofulous," though I am confident it occurs in many individuals with no other sign of struma, and eczema surely is not such a sign. Fissures occasionally form at the commissure of the lids. The disorder may complicate eczema of the other parts of the face. In the erythematous eczema faciei of adults, there is usually swelling with puffiness, especially of the lower lid. The con- junctiva may. or may not, be implicated. A chronic granular condition of the lids is not noted as frequently as might be sug- gested by a -priori reasoning. ECZEMA. 149 The edges of the lid should be carefully cleansed with a weak alkaline solution and soft camel's-hair brush, whenever the lid itself is involved ; then as carefully dried and anointed with cold cream. In acute cases, the closed lids may be frequently bathed with warm alkaline solutions; and strips of soft lint, soaked in the same material, or a very dilute glycerine and carbolic acid solution, may be laid over the closed lids for as long periods during the day as they are comfortably tolerated. In chronic cases, the red oxide of mercury ointment, half to one grain (.033-066) to the ounce (32.), has always been held in high esteem. The oculists, in the treatment of this affection, are fond of using an ointment of the yellow sulphuret of mercury. Epilation of the eye-lashes may be, rarely, necessary. Pencillings with solu- tions of the nitrate of silver in various strengths, are also useful in chronic cases, but these must be carefully confined to the lids and not suffered to come into contact with the conjunctiva. Excessive use of the eyes must be prohibited. In the diagnosis, care must be taken to exclude syphilis, lupus, and pediculi. I have seen but one instance of piedra of the eye- lashes, and do not recall any description of that disease in this locality. Instead of the ordinary nits of the lash, there were in this case, jet-black, small pin-head sized masses of ivory-like hardness, attached to the hairs. Eczema of the Beard. (E. Barbse.) Eczema may involve the region of the beard only ; or may spread to such parts from those in the vicinage ; or may, finally, extend from the beard to other parts of the face. The first is common, and furnishes, perhaps, the best type of the disease; the second is also common, but usually subordinate in importance to other trouble of the facial region. The last is decidedly the rarest. It is indeed a matter of surprise that an eczema should, as it often does, endure for years limited exclusively to the re- gion of the beard, and never once transgress these limits. In this last-mentioned fact, I find a convincing argument in favor of the local origin and of the frequency of local sources of aggravation of eczema. Rarely will one see a picture more sug- gestive to the uneducated eye of "scrofula" or "humors of the blood," than the face of a middle-aged man, with long standing eczema of the entire region covered by the heard. The hairs are thinned and fail to hide completely the reddened surface beneath ; covered here and there with pustules or floors of broken pustules, dried inflammatory products, scales and crusts. Beneath the crust the surface is smooth, not lumpy as in parasitic sycosis. The hair follicles are not solely involved, as in the non-parasitic form of sycosis, but evidently they and also the integument be- tween them. In recent eczema the hairs are not loosened in their follicles, but in chronic cases such loosening does unques- 150 DISEASES OF THE SKIN. tionably occur, and there is a true defluvium eapillitii. The disorder is evidently one primarily involving the skin of the re- gion of the heard, and secondarily the hairs, extending smoothly over that surface, as smoothly as an eczema on the cheek of a woman. There is commonly a certain degree of symmetry, to the extent at least of involving the beard in different degrees on both cheeks at once, or the chin on both sides; often the symmetry is perfect. This is rare in the parasitic affection of the aame part. The disease is accompanied by itching, rarely as severe as upon the smooth parts of the face, is particularly obstinate and ex- tremely disfiguring. When extending into the region of the heard from other parts, it is usually associated with eczema of the ears. When limited to the region of the moustache, it may be connected with an eczema of the nares and a chronic nasal catarrh. The explanation of the obstinacy of eczema of the region of the beard is, I believe, to be found solely in the hairs which cover it. Whether the latter be long or short, feeble or strong, each during the entire twenty-four hours, acts to a certain extent as a lever in motion upon the portion of the integument in which it is implanted. In conditions of health, the skin tolerates well this motion ; in disease it becomes a positive source of trouble. Multiply by thousands the impression produced upon the healthy skin when a single hair or group of hairs is moved by a strong current of air, by the fingers, by a brush, or by any other exter- nally operating cause, and some idea may be had of the extent to which this force may become effective. But the best evidence of the fact is to be found in the results which follow the removal of the beard. Clipping short the hairs of the face will not answer, though generally preferred by the patient as exposing to a less de- gree the unsightly surface beneath. Nothing short of shaving and continual shaving every second day, will effect the desired result in chronic cases. As soon as the disease is reduced prac- tically to an eczema of the non-hairy parts, it improves, in pro- portion to its distance from the mucous outlets of the body. When limited to the bearded cheeks, the most obstinate cases may be in the course of a single month robbed of one-half of their unsightliness. It may be needful to employ the usual methods, oil. hot water and soap, to remove the crusts before the first shaving, and any imprisoned pus should be evacuated. The pa- tient should be encouraged by reminding him that usually it is but the first step which costs; each succeeding removal of the beard is accomplished with greater comfort to himself physically and mentally. After each shaving, the skin should be bathed in water as hot as tolerable, and if at night, a lotion may be used or an ointment, or the latter after the former. Best of all, how- ever, is the dusting powder; and, as soon as practicable, the pa- tient should limit himself to this application. The shaving ECZEMA. 151 should be continued for months after the disease is at an end. It is indeed surprising to note in such cases how quickly the "scrofulous" look disappears, and the evidences of a " humor of the blood " are no longer evident in the face. The longer the limitation of the disease to the region of the beard, the more brilliant, as a rule, is the result. I have rarely found it neces- sary to resort to the tarry applications in this forn^of the affec- tion. When complicated by eczema of the post or infra-auricu- lar region, stalactite-shaped crusts depending from the infiltrated lobule in consequence of the unintermittent drip of serum from above, eczema of the region of the adjacent whisker is less readily managed. Flat epitheliomata of the bearded cheek are not to be con- founded with eczema barbae. The points of difference have been previously noted. It should be remembered, also, that the age of the patient, the career of the disease, the possible eversion of the neighboring lid, or agglutination of the adjacent lobe of the ear, distinctly high elevation, or ulceration of tissue, absence of itching, and distinct localization of the disease, are all characteristic of this form of carcinoma. Eczema of the Genital Organs. Here the disease is remarkable for the severity of the sub- jective sensations it occasions; for its tendency to persistence, recrudescence, and nocturnal exacerbation ; and for the liability to the production of the sexual orgasm by the act of scratching. In the male the surface most often involved is the anterior, pos- terior, or lateral faces of the scrotum where they meet the thigh, though the surface of the penis, as also that of the pubes and perineum, may be involved. In the female, the labia majora, more rarely the labia minora and vestibule of the vagina are affected, with occasional extension of the disease to the same contiguous parts as in the male. Eczema thus located is, as a French writer has well said, " a dry disease in a moist locality." Vesicular and pustular forms are much rarer than the erythematous, the papular, the papulo- squamous, and the erythemato-squamous. In the female, the moister forms are more frequent, doubtless because of the wider mucous outlet, and the more extensive mucous tract in the vicinage. The labia are then heightened in color, cedematous, agglutinated by crusts, and often torn viciously by the finger- nails. Blood-crusted excoriations are seen in most severe cases. An eczema intertrigo at the labio-femoral angle is common. Over the whole may be poured the secretions from uterus or vagina, normal or pathologically altered. The disease is, how- ever, sufficiently common after the menopause, when there is physiological atrophy of the uterus. The typical disease in the male is recognized in the thick- I'y2 DISEASES OF THE SKIN. ened, reddened, perhaps slightly scaling integument of the scro- tum, which may also be fissured, excoriated by the nails, or cov- ered by blood-crusts. Torn papules, often closely packed together, may be seen with a peculiarly lurid, even purplish bue. Tn exaggerated cases the infiltration is so great as to deform the pari-, increasing the thickness of the scrotal integument to many times its normal dimensions, producing thus an elephan- tiasic appearance. In eczema of the penis the prominent symp- toms are also oedema, itching and redness, with slight scaliness. In both sexes, :is before intimated, the attempts to relieve the itching are often as severe and prolonged as they are ingenious. Commonly no relief is obtained till a serous sweating or weep- ing of the thickened tissues is induced hy the friction. Inas- much as the latter is in severe cases frequently repeated, the physical dangers are obvious. Apart from this, however, the disorder has a marked tend- ency to disturb the mental tone and the general health. Shame deters many from seeking speedy relief, so that cases of long standing are those more commonly registered by the physician. Though entirely unconnected with venereal disease of every kind, there is, for the many, a special dread of an eczema of these parts, precisely because of its location. With Bleep dis- turbed, the mind agitated, and the nervous system teased by an intolerable pruritus, one can scarcely wonder at the eloquence with which many patients describe their sufferings. It is a disease of middle life and advanced years. I have never seen a well-marked, obstinate case in a child. The causes, exciting and aggravating, of eczema of the genital region, are to be sought in heat, moisture, and friction. These primary factors are favored, — first, by the effect of gravity, the organs in question being situated, when the body is in the erect position, at the inferior apex of the double cone forming the trunk, and being thus subject to the force of gravity; second, by the arrangement of the clothing in both sexes, by which heat and friction effects are heightened ; third, by uncleanliness, the secretions and discharges from the adjacent mucous tracts being suffered to accumulate upon the person ; fourth, by a long list of sexual errors which operate by obstructing what may well be termed the sexual ebb — that is, the natural reflux by which' each periodical physiological congestion of these organs is by a natural process relieved. That the skin of these organs partici- pates in such periodical congestion is a fact demonstrable to the eye. The abundant supply of bloodvessels, lymphatics, and nerves to the parts, furnishes all necessary elements for the ex- planation of the formidable series of symptoms often displayed in eczema genitalium. A curious illustration of the illogical method of drawing con- clusions, unfortunately too common in medicine, is furnished by the fact that in many eczemas of the surface, especially of ECZEMA. 153 the genital organs, the urine will be frequently found to contain albumen or sugar, and these conditions have been supposed to lie at the root of the eczema. One author has even gone so far as to prescribe a diet for the eczematous patient with saccharine urine. The explanation of the phenomenon is, however, suffi- ciently simple. It is the eczema which causes the elimination of the sugar or albumen, and not the reverse. The demonstration of the fact is readily made. Sugar and albumen are known to be producible in the urine by external irritants, and, among the latter, by cutaneous diseases. Merely varnishing a portion of the skin has been followed by these effects. If the patient with saccharine urine and severe genital eczema can be kept in bed, in the recumbent position, for a few days, while any soothing application productive of comfort is continuously applied to the tender and excoriated surface, the sugar will be found to rapidly disappear from the fluid excreted from the kidneys. I am in- clined to the belief that these renal symptoms are in part reflex, resulting from the extraordinary irritation of the nerves dis- tributed to the involved surfaces. The treatment is to be conducted on the general principles heretofore enunciated. Sponging of the genital region with alkaline water as hot as can be well tolerated, followed by the blander oils and ointments at night, and the use of anti-pruritic dusting powders in the daytime, must not be omitted. In eczema of the scrotum, the suspender lined with lint which is wet with a lotion, smeared with an ointment, or thoroughly covered with a powder, can be usually employed to good advan- tage. The habit of scratching must be broken up at all hazards. In chronic cases, the treatment by soft soap and diachylon oint- ment will be found useful. Caustics, solutions of the mercuric bichloride, and other mercurials, carbolic acid, and especially the tarry compounds, are often necessary. Finny, of Dublin, uses the following formula?, which I have found to be exceedingly useful in allaying the irritation: — M. i,. Liniment, calcis. f^iv ; Belladonn. extr. gr. xij ; Zinci oxyd. 3ij 5 Glycerini. f^ij ; Aq. calcis. f§iv ; ig. "Lotion, to be applied at night after water." 130 8 8 130 bathing V. Lin. calcis. f §iv ; Acid, hydrocyanic, (dil.) ^iv ; Liq. plurabi subacetat. f.^ij ; Glycerin. f5u ; Aq. ros. ad. fgviij ; 130 15 8 8 280 Sig. " Cream, for application on strips of old linen." Exceedingly obstinate eczema of the pubic region is benefited by shaving and subsequent appropriate treatment. When com- plicated by an intertrigo, the latter condition requires special relief by the interposition of soft lint spread with an ointment. 154 DISEASES OF THE SKIN. Tlio diagnosis is between ringworm of the genitals, acne, pruritus, pediculosis, the venereal disorders, and herpes progen- 1 talis. The 6rs1 named may occur alone, or induce, or be grafted upon the eczema. Ir will be recognized by the discovery of the trichophyton, and is clinically distinguished by the crescentic edge of the spreading patch, with its convex border looking away from the genital centre. The "follicular vulvitis*' of gynecological authors is a genital acne, and manifestly limited to the glands and peri-glandular tissues. The same is true of bromine and iodine acne, which I have seen developed in the same situation in both sexes. Genital pruritus may beget an eczema by scratching, hut is accompanied by no proper skin lesion. The pubic louse is visible to the eye, as are also its nits. The ulcers and sclerosis of the chancroid and primary syphilis are not accompanied bv pruritus, and though occasionally mul- tiple, never exhibit diffuse patches of disease. The syphiloder- mata are recognizable by their characteristic features, and by the history of an infectious disease. In herpes progenitalis there is precedent, burning, smarting, or neuralgic sensations, the occurrence of vesicles or groups of vesicles (lesions rare in eczema of the genitals), and frequent limitation of the disorder to the mucous surfaces or the muco-cutaneous lip by which such surfaces are bounded. In eczema such boundaries are usually respected, and the disease is much more strictly cutaneous. Eczema of the Anus and Anal Region In its etiology and characteristics is closely allied to the same disease in the genital region. The presence of ascarides and haemorrhoids occasionally induces or aggravates the disorder; though I believe this is rarer than is commonly taught, since multitudes of men and women who suffer from piles never com- plain of eczema. The eczema may occur in erythematous, squamous, or papular form, in the order named; thus exhibit- ing here, as in the genitals, "a dry disease in a moist locality." The redness, infiltration and itching may he limited to the verge of the anus, radiate from the latter in stellate lines, creep upward between the nates in the cleft, sweep forward over the perineum to the genital region, or extend laterally with inter- mediate intertrigo over the inner face of each thigh. Rarely the buttocks are covered with the same lesions. The disease is common in infancy, where want of care in the removal of the napkin is a fertile source of mischief; and also in middle life and advanced years, when it becomes particularly intractable. The itching is intense in the latter class, with fre- quent nocturnal exacerbation. Unfortunately the scratching is often reflex, and practised during the unconsciousness of sleep, from which the patient is often roused by his or her manipula- tions. Pollutions fully recognized, or occurring during pro- ECZEMA. 155 found sleep, or, more usually, in states of semi-consciousness, complicate certain cases. The harassed nervous system of the sufferer is often in a deplorably wretched condition. In cases of long standing the usual congested, thickened, infiltrated, and almost elephantiasic appearance is presented, with exaggeration of the natural furrows and occasionally fissures. The part may simulate in aspect the formidable conditions discovered in pas- sive pederasty. Excoriations are common around the anal verge. The diagnosis is that of eczema of the genital region. In the treatment of these cases the use of very hot water by sponging, and the subsequent application of ointments, bus yielded the best results. In the case of infants the dusting powders and blander ointments are alone to be employed; in adults, especially in chronic cases, the tarry applications are especially valuable. Here the tincture of tar may be freely painted over the surface, or one of the tarry ointments of suffi- cient firmness to retain its form as an unguent when subjected to the heat of the part. Caustics are useful when there are fis- sures. Corrosive sublimate, one-half to one-quarter of a grain (.033-016) in the milk of almonds; Squire's glycerole of the plumbic subacetate, half a drachm (2.) in two ounces (60.) of glycerine and water, or, as a substitute for the latter, the soft soap and diachylon plaster are here of special service. When defecation is painful the stools should be rendered soluble in order to insure non-aggravation of the local disorder; not, it need scarcely be remarked, with a view to eliminating any materies morbi by purgation. I have occasionally found service- able small tampons of cotton smeared with an emollient oint- ment, and gently inserted for a short distance within the anus. Kaposi recommends butter of cocoa suppositories, containing zinc oxide with belladonna or opium. When complicated by true fissure of the anus the sphincter ani must be stretched, divided, or dilated with medicated bougies. Eczema of the Nipple and Breast of the Female Is common in nursing women from either the irritation pro- duced by the mouth of the infant, or, more commonly, in con- sequence of a galactorrhcea. Eczema intertrigo is common below and between the breasts. The eczema here is vesicular, erythe- matous, or squamous in form, with fissures of the apex, side, or base of the nipple. The serous ooze from the infiltrated areas dries as usual into light-colored crusts. The disease may occur on one or both breasts, and, especially with a galactorrhcea in summer, may spread extensively, covering both breasts, the sur- face of the belly and the intermammary region. The circum- scribed forms occur also in pregnant or unmarried women, and are to be distinguished from scabies, which in the female is apt to occur upon the breast. 156 DISEASES OF THE SKIN. "Paget's disease," the Bo-called eczema of the nipple and can- cer of the breast, is designated by Thin 1 as a destructive or a "malignant papillary dermatitis." The mammary tumors here formed are found to originate in the epithelial lining of the lactiferous ducts, the elements of which undergo, at an early period of the disease, a cancerous transformation. Clinically, there is usually observed in such cases, a sunken nipple, its site occupied by a bright red infiltrated patch of distinct outline, differing thus from the irregular definition of the contour of the eczematous area. In all cases of subcutaneous tumor or coinci- dent axillary adenopathy, the physician should be especially careful in the matter of prognosis. The treatment is in general that described above. In severe cases with galactorrhcea nothing short of weaning the child, and a cessation of all demands upon the breast will insure relief. Every effort should be made in milder cases to avoid this dernier ressort. At first, scrupulous care; pencillings of fissures with a crayon of silver nitrate; gentle anointings with emollient zinc, thymol, or carbolic acid ointments, which should be carefully washed off before the child is put to the breast; and finally, dusting powders witli soft lint retained between and beneath the breasts, are measures to be tried. Later, the sublimate solu- tions, diachylon ointment or naphthol, two per cent, in alcohol, may be employed. Founder recommends a breast-plate of caoutchouc. When limited to the nipple and areola in nursing women the glass and rubber apparatus sold in the shops may be tried in the hope of saving the nipple from the mouth contacts in nursing. Sometimes they answer admirably; often they fail utterly. Eczema of the Umbilicus. This local variety of the disease is briefly described in the chapter devoted to seborrhoea. In most cases it is either in- duced or aggravated by a local seborrhoea fluida, which gives origin to the peculiarly nauseating odor characterizing the dis- ease. Generally a reddish and infiltrated, more or less annular patch surrounds the umbilical depression, which may be filled with crusts. Syphilodermata, pediculosis, and scabies in women {ire to be carefully excluded in the diagnosis. The liquor soda? chlorinate, carbolic acid solutions, and, in chronic cases, iodized phenol will be required in its management. Care should be taken that the dressing of the navel in the newly born infant, the improperly adjusted apparatus for retention of an umbilical hernia, and the corsets or " uterine supporters" of the female, do not occasion or aggravate the disease. 1 London Lancet, June, 1881, Amer. ed., p. 533. ECZEMA. 157 Eczema of the Superior and Inferior Extremities. The flexor surfaces of the extremities, especially in the vicin- ity of the joints, are particularly prone to exhibit symptoms of the disease. With these should be properly included the axil- lary and inguinal spaces. In all such localities the alternate tension and relaxation of the integument serve when the limbs are in motion, to increase the pruritus, and, correspondingly, to aggravate the disease. Often a certain degree of symmetry can be perceived, the two popliteal spaces, for example, being simul- taneously affected, though each to different degree. The parts most favorable for the complications of intertrigo are those nearer the trunk where the moisture and heat are greater, as the groins and axillae, while the elbow and popliteal spaces are more frequently dry, exhibiting papulo-squamous ridges in lines at right angles to the axes of the limbs, with hypenemic patches on either side. Upon the legs, where the force of gravity is more potent than in other parts of the body, exaggerated forms of eczema are found complicated with varicose veins and oedema, with dense infiltra- tions and indurations. In ancient cases the frequent elephanti- asic aspect is significant, one limb being by several inches larger in circumference than its fellow, covered from knee to ankle with enormous patches of eczema rubrum of an intensely angry appearance, moist and crust covered; or dry, glazed, and of a lurid reddish hue; or dry, horny, and ridged with irregular projections surmounted by scales resembling the rough bark of a tree; or again, with or without oedema, tense, inelastic, seamed with scars of old varicose ulcers, and deeply and irregularly pig- mented, an appearance with great difficulty to be distinguished from syphilitic ulceration of the same region. At its onset, eczema of these parts may assume any one of its known forms. In infants with long clothing, where the lower extremities are subjected to a higher temperature than in adults, the vesicular and pustular forms are common. The exceedingly obstinate forms of eczema of the legs, especially those complicated with varicose veins, are, of course, those encountered in middle life and advanced years. The diagnosis is in general to be established by considering the points heretofore discussed. The chief difficulty lies in dis- tinguishing the eczema associated with ancient varicose cica- trices of the leg, from syphilitic scars of the same locality, which have resulted from degenerating tubercular syphilodermata or gummata. In some cases when no distinct history can be ob- tained, there will be a necessary doubt, as the force of gravity upon the vessels, even without varicosities, produces certain common features, notably deep pigmentation, in both classes ot cases. In women, the sexual history is all-important, including the order of abortions, miscarriages, and viable infants. In both 158 DISEASES OF THE SKIN'. sexes, the discovery of other lesion-, and especially of character- istic cicatrices elsewhere, musl be attempted. It will be re- membered that the syphilitic ulcer tends to the shape of a circle or segment of a circle, and though occasionally existing as the sole lesion upon one leg, it is frequently multiple, or may involve both extremities, the pigmentation in old cases occurring chiefly at the periphery of the sear. Very extensive pigmentation about ancient cicatrices, especially disposed between irregularly defined seal's, is truer of eezematous forms, as the pigmentation due to syphilis, though long-lived, is yet the more ephemeral. With periosteal nodes the diagnosis is clearer. The treatment of eczema of the extremities does not differ from that described above, except as regards the indications to he met relative to support of the parts, thus counteracting the effect of gravity. Excellent results are here obtained by the use of the pure rubber bandage, applied immediately next the skin, especially in cases complicated by oedema, ulceration, and venous varicosity. The method of applying the well-known Martin bandage has been made generally familiar to the profes- sion ; and for details respecting its availability in eczema of the leg, I refer the reader to the essay on Eczema and its Manage- ment, by Dr. Bulkley, of New York, 1 who is enthusiastic in its praises. Such treatment, however, deserves only subordinate rank in comparison with the essential rest of the affected limb in the horizontal position. With a grave eczema of the lower ex- tremity, such rest should be enforced ; and patients whose limbs have proved rebellious under the rubber (for such there are) may thus be relieved The local applications to be made meanwhile are those adapted to the particular features in each case present. To a less degree, the same may be said of the arms. In these localities, I have never found it necessary to resort to elastic pressure. In all cases, however, a neatly-applied bandage over the dressings will add the effect of pressure and support, and generally contribute to the comfort of the patient. A favorite dressing with me, in dry, papular, erythematous and squamous patches of the disease, is applied as follows: — The parts are first bathed with hot alkaline water for several minutes till the itching is relieved, and then carefully and thoroughly dried. The^ patch is then completely covered with a dusting powder, which, according to the indications of the case, is either emollient, astringent, or stimulating. Finely pow- dered tannin with French chalk, or even pure calomel, or bis- muth, zinc and starch, may be thus used. Over the whole, strips of Maw's surgical plaster are alternately and neatly superimposed in the manner some years ago recommended by Baynton. A snugly fitting rubber bandage encompasses the whole. The • G. P. Putnam's Sons, N. Y., 1881. ECZEMA. 159 dressing is left in situ as long as it is comfortable, often for two or three days, when it can be removed. In properly selected cases, the itching is relieved, the infiltration reduced, and the patch soon loses its hypera?mic aspect. Occasionally no other treat- ment will be required. Nor should it be forgotten that with care and patience, the starch bandage of the leg, the plaster of Paris dressing over folds of Canton flannel arranged so that it may be removed at pleasure in the manner in which it is used by some surgeons in the treat- ment of diseases of the joints, these and other immovable dress- ings may accomplish even more in obstinate cases than elastic apparatus. Eczema of the Hands and Feet. E"o more striking illustration of the significance of the etiology of eczema can be adduced than that to be discovered in the hands. By these organs man toils to earn his bread, and the eczema they display is their protest against the rude contacts which are thus necessitated. Unfortunately, in too many of such patients, the imperative necessity of such bread-winning, forbids consent to the best method of relief, viz., temporary disuse of these organs. The feet may or may not be similarly attacked, and for similar reasons. All forms of eczema are here seen, erythematous, vesic- ular, papular, pustular, and squamous, involving the entire sur- face, or limited to the wrists, ankles, interdigital spaces, palmar or plantar surfaces, or one or more digits on either face. The motions of the part are so free, that fissures are common and often exceedingly painful. The itching may be severe, and the parts of one hand or foot extensively rubbed, torn, or abraded by the other. Vesicles are more frequently encountered upon the more delicate portions of the skin, as over the dorsum and interdigital spaces, while in the denser palm and sole they are represented by sub-epidermic points from which by puncture a clear serous or cloudy fluid may be evacuated. Usually, how- ever, in the regions last named', there is a dry, dead-whitish or hypereemic, uniformly indurated and thickened integument, which may be lissured or produce such a tense inelasticity of the surface that the fingers are semi-flexed into the palm, or, much more rarely, the toes rendered considerably less extensible. Circumscribed patches of eczema, with fairly defined outline, reddish in color beneath crust or scale, subacute in course and accompanied by paroxysmal itching, are of common occurrence on the dorsum and also in the' palm or sole. In the latter situa- tion, they may be traversed by one or more painful fissures, the same being true of the dorsum of the fingers and toes. Upon the back of the hand, these circumscribed patches are apt to as- sume an indolent course, improving temporarily under appro- 160 DISEASES OF THE SKIX. priate treatment, and becoming aggravated by every exposure to the causes by which they were first induced. The long list of etiological factors which may here be efficient can scarcely be enumerated. Several have already been considered in discussing the causes of eczema in general. The influence of all articles handled in the trades, occupations, and professions of life, as well as of the action of toxicants and dye-, must be remembered. Thus printers, bakers, and masons suiter in the hands; and the wearer of dyed stockings, and coarse, ill-fitting shoes and hoots in the feet. Because needle-women are often' overworked, nervous, pale, and thin, their digital eczema, really due to the implements and stutl's they handle, has heen erro- neously attributed to the general condition. I have seen the poor seamstress starving for sunlight, nutritious food, and open air exercise, return to her weary routine with her eczema quite relieved. The treatment demands, first, rest for the organs, and a simul- taneous discontinuance of the exciting cause. In the trades, the result of the latter can he usually demonstrated by the patient, who notices the difference between the condition of the skin on Monday morning after a Sunday's rest, and that which was dis- tressing on the preceding Saturday night. When practicable, protection during labor must be secured by the use of gloves, finger-cots, rubber-stalls, or bandages, neatly applied and retain- ing dressings to the part of the hand or foot which is the seat of the disease. For circumscrihed, non-discharging patches on the dorsum of the hand or foot, I can highly recommend the dressing described as employed by me in connection with eezema of the ^extremities. When the nature of the labor performed is such as to render it impossible to secure protection of the hand or fingers in this way, something may be accomplished in a few cases by directing that the hand be frequently dipped in a protective solution, or powdered during the hours of labor. Thus I have with success directed printers to dust their fingers with lycopodium, and those compelled to retain their hands in irritating solutions, to anoint these organs occasionally with an oily or fatty substance. Generally it may be said that an eczema of the hands is too frequently washed, and the ill effects of such practice are made evident not only in laundresses, but in mothers who personally attend to the dressing of young infants. The local applications made to each case may be those described above as suitable to each stage of the disease. When extensively involved, the hand should he carefully dressed, each linger being separately wrapped in soft linen rags smeared with camphorated or carbohzed, pure or diluted, linimentum calcis in acute cases; or, later, with a bismuth, zinc, or mercurial ointment. The tarry compounds are here very useful; and the caustics more than ever needful when there are fissures. Protective flexible collodion plays an admirable part about the nails where irritable seams ECZEMA. 161 and fissures form, with overhanging fringes of torn epidermis and ragged scales, bordered by reddened outlines. In all pain- ful eczemas of this region the immersion of the entire hand and foot in hot water should never be forgotten, especially at night, the misused member being subsequently carefully dried, and enveloped in vaseline or oleaginous compounds, with the Lister protective gauze as an envelope ; or a pair of rather large, white, kid gloves, which have the advantage of being bleached and not dyed. In the daytime, the organ may be dressed to meet the requirements of the disease or the species of labor. In the matter of diagnosis, it should be remembered that an eczema of the hands may be induced by the Rhus toxicodendron, the disease being then liable to a transfer by contact from the hands to the face and genital or mammary region. Scabies of the same region is in this country much rarer than eczema digi- torum or eczema manuum. In scabies the vesicles are fewer, more isolated, more intermingled with crusts, pustules, and even bullae, which latter are rare in eczema. The discovery of the parasite and a history of contagion will aid in removing doubt. Abundance of pustular lesions in young subjects is, however, according to Hebra, most commonly produced by the acarus. Psoriasis of the palms and soles is always accompanied by the presence of patches in other parts of the body, whose typical characters should throw light on the local disorder. Squamous syphilodermata of the palms and soles occur early and late in the disease, and usually after a distinct history of infection. The lesions in syphilis are usually isolated, slightly elevated, circular in outline, averaging in size the dimensions of a coffee-bean, and surrounded by dry, adherent, dirty-white scales, beneath which the brown and red hue of the persistent syphiloderm can be discovered. Superficial circular excavations of tissue are also visible, with punched or ragged edges. The eruption is rarely, like eczema, accompanied by itching or discharge; but painful fissures may form. It rarely extends to the dorsum of the hand or foot, favorite sites of eczema manuum. Eczema as it Affects the Nails. There is nothing characteristic of the disease in its effects upon the nails. These horny plates participate in the diseases which affect their matrices, and thus exhibit nutritional changes. There is, therefore, no eczema of the nail proper, but only an eczema of the digit by which the nail is affected. In well- marked cases one, several, or all of the nails of either hands or feet may become rough, furrowed laterally and clubbed, or present an appearance suggestive of worm-eaten surfaces. They lose their uniformly smooth attachment beneath, and become tilted on their beds, with marked friability of their tissue. h\ such cases an eczematous condition of the skin at the margin may 11 162 DISEASES OF THE SKIN*. be detected, where the usual redness, infiltration, and scaling, with a sensation of itching, point to the nature of the trouble. Rarely the nails are Bhed. The most misshapen will be suc- C led by Bmooth and natural growths of nail substance, if the disease of the matrix be completely relieved. The treatment, therefore, is the treatment of the cutaneous disease. Care must be taken to exclude ringworm of the nails, which end can be reached by microscopically examining the scales scraped from the nail-surface. Dermatitis. Dermatitis is an affection of the skin characterized by the phenomena of inflam- mation, including heat, redness, pain, and infiltration, terminating in resolu- tion, suppuration or the occurrence of gangrene. The milder forms of dermatitis disappear without leaving behind them persistent lesion relics. The graver forms may terminate in gangrene, or produce death by shock or exhaus- tion. Inflammation of the skin as distinguished from its other dis- eases, is generally recognized as that idiopathic morbid state whose phenomena are induced by the action of certain special agencies, such as heat, cold, poisons and traumatism. The in- flammatory process may involve the superficial or deep portion of the integument, or may extend to the subcutaneous tissues, or even deeper. The symptoms vary with the nature of the cause, the extent and degree of its influence, and the circum- stances attending its operation. Hyperemia usually precedes and may be followed by a fluid or plastic exudate, by the pro- duction of one or more of the several recognized cutaneous lesions, by diphtheritic deposits upon the surface, or by gan- grene. With these there may he general symptoms of mild or severe grade, due to the influence excited by the local process upon the general economy. Dermatitis Calorica. Under this title are included those affections of the skin in- duced by extremes both of heat and cold. Unduly high temperatures produce in the skin some redness and a slight degree of swelling, the color not completely disap- pearing under pressure. If the exciting agent be withdrawn before further effects are induced, the color first deepens, then becomes paler, and in twenty-four hours the process is usually concluded with a very delicate and transitory resulting pig- mentation. Rays of heat and heated objects at a temperature above 125° to 175° F. produce immediately, or after a brief interval, vesi- cles or bulla?, isolated or confluent according to the severity of DERMATITIS. 163 the exciting cause, seated upon a reddened skin which is usually intensely painful. These lesions are persistent or transitory, and generally rilled with a clear serum, which exudes and dries into crusts after rupture of the chamber in which it was imprisoned. At other times the serous exudation is so great that the epider- mis rises in broad plates, from beneath which the serum is exuded. This process may terminate by a free production of pus from the surface and gradual resolution. Adenopathy is a frequent concomitant symptom. In such dermatitis of exten- sive areas of the skin, the intensity of the process may awaken a violeut fever; or death may result from shock or exhaustion. In yet severer grades there is the production of an eschar, which is dry-brown, blackish, and destitute of all signs of vital- ity; or, as Kaposi describes it, dense, coriaceous, and as white as alabaster, upon which, nevertheless, some vesicles may appear, and by their presence suggest a false conclusion as to the vital- ity of the tissues upon which they rest. In from eight to ten days the eschar is removed by suppurative processes, and the scene is closed by the usual phenomena of granulation and cica- trization. The characteristics of the scar thus produced are, its great irregularitj 7 , its tendency to stellate radiation, and the production of ridges, folds, pockets, and bridles. The treatment of burns exhibiting hyperasmia of the surface is by the free use of dusting powders. In the cases where the serum is invited rapidly to the surface, with the production of vesicles and bullse, the latter should be gently punctured to give relief to the tension by the evacuation of their contents, but the roof-wall should be preserved, as it may subsequently form an attachment to the exposed derma beneath. The indica- tion then is to exclude the air as perfectly as possible and to prevent suppuration, indications admirably met by the applica- tion of carbolated oil and lime-water with the Lister dressing. Continuous immersion, in water of the temperature most agree- able to the patient, as practised by Hebra in cases of severe and extensive burning, produces speedy and certain amelioration of the pain, and a favorable condition of the wounds, though it does not avert a fatal issue in any dangerous case. Nitzsche 1 first disinfects the surface thoroughly with carbolic acid, having previously protected the blebs, after which it is covered with a thick varnish of linseed oil and litharge mixed by the aid of heat with five per cent, of salicylic acid. When this is dry, a second coat is applied, and the whole finally cov- ered with a thick layer of wadding retained in place by an elastic bandage exercising moderate compression. Cicatrization is said to progress beneath the dressing without changing the latter. When suppuration does occur the upper layer of the wadding is removed, and dried salicylic acid in powder is i Deutsch. Med. Zeit., 1881. 164 DISEASES OF THE SKIN. sprinkled over the surface, the wadding being afterward reap- plied. In dermatitis from congelation there are also usually, in the milder tonus, circumscribed erythematous patches or plaques, generally recognized under the name of pernio, or chilblain, seated upon the digits, or, more rarely, upon the face, and occa- sioning a disagreeable sensation of heat or itching, especially after the chilled part has become unduly warm. An ulcerative form is described by authors as the result of the congelation, Berum exuding within bulla?, the latter rupturing and the tis- sues beneath degenerating. When portions of the skin com- pletely lose their vitality in consequence of exposure to cold, a still more exaggerated condition results. Larger bulla? form, filled with sanguinolent serum, or the skin is smooth, marbled with bluish lines, whitish, cold, and insensitive. Mortification ensues, followed by the well-known phenomena of the "line of demarcation," suppurative separation of the dead part, granula- tion, repair, and cicatrization. As the injuries induced by con- gelation are more frequent upon the extremities, the bones largely participate in the losses of tissue, especially those of the digits. Septicaemia and a fatal result may follow. Chilblains are commonly treated by stimulant applications, such as those containing iodine, camphor, carbolic acid, and balsam of Peru. Kaposi recommends: — R. Pulv camphors gr. x ; 50 Cretse prseparat. §j ; 30 01. lini f§ij; 60 1 Balsam. Peruvian. rr^ xx ; 1] M. Frictions, with or without medication, are generally useful. The parts are to be carefully protected from pressure and undue friction effects. In cases of severe congelation the circulation is to be cautiously restored by friction in an apartment where the air is cool, in order to prevent too energetic reaction. Dermatitis Traumatica. External violence, various in character and severity, is capable of inducing dermatitis whose symptoms differ in degree, though their career is in general that described above. In this list are included the inflammations produced by surgical interference with the continuity of the integument; excoriations caused by scratching, by the friction of garments and other articles in- juriously acting upon the integument; by the various imple- ments handled in the trades; and by the bites and stings of beasts, insects, reptiles, and fishes. These injuries may be in the form of contusion, puncture, incision, or laceration ; and the consequences are declared in heat, swelling, redness, pain ; and in itching, burning, stinging, or pricking sensations, with sub- DERMATITIS. 165 sequent production of pus, granulation, and repair; or gangrene, and separation of the slough ; or finally, by repair without these consequences. Dermatitis Gangrenosa. Idiopathic and symptomatic cases of dermatitis terminating in gangrene, where no history of external violence or caustic application has been obtained, are reported by several authors. In most of these, single or multiple, circumscribed, erythematous or hsemorrhagic maculae have been followed by superficial gan- grene with sloughing, the process being at times attended with constitutional symptoms of such gravity as to result in some in- stances fatally. In certain other cases the affected patches pre- sented at an early period the mummified and alabaster white aspect, noted exceptionally in dermatitis calorica. In establish- ing a diagnosis in such cases, care should be taken to exclude the forms of senile gangrene occurring in the lower extremities as the result of vascular calcification, when the skin and deeper tis- sues are alike invaded ; as also the cases of simulated eruption, produced by caustics upon the skin with a view to deception. In the latter class, a distinguishing feature of the lesions will be their occurrence chiefly upon those parts of the body most accessible to the hands ; and, in persons not ambidextrous, upon those parts which the hand predominantly employed can most readily reach. Dermatitis Venenata. Certain medicinal and other substances applied to the external surface of the skin, are capable of exciting inflammation either by operating as caustic, irritant, toxic, or even traumatic agents. In this list are included most of the strong acids and alkalies; croton oil; cantharides; mustard; tartar emetic; the com- pounds of mercury ; arnica ; turpentine; ether; chloroform; the tarry compounds; many of the dyes; several members of the rhus family (the Rhus toxicodendron and Rhus venenata, poison ivy, poison oak); the nettle; the smart weed {Polygonum punctatum); cowhnge (Mucuna pruriens) and glass in fine powder or delicate ■filaments such as are thrust into the skin when handling certain articles of Venetian glass-ware. The list might be indefinitely extended, as there are few articles which are not capable of pro- ducing some irritation of the surface of the skin, if applied to it with sufficient vigor and for a certain period of time; and in some it is difficult to decide whether the effect is more traumatic or toxic. An almost equally long list of substances of animal origin might be also named having poisonous effects upon the integument, such as decomposed or ammoniacal urine, feces, ichorous pus, pathologically altered secretions from the uterus, eye, ear, nose, etc. 16'") DISEASES OF THE SKIN. The symptoms of dermatitis venenata are substantially such as have been already described. Numerous types of cutaneous lesions, maculae, pustules, papules, vesicles, bullae, wheal-. Bcales, crusts, free serous and purulent discharges, subcutaneous ab- 3,and cv.-n gangrene with sloughing, may result from the operation of Buch causes, the result being largely proportioned to the character of the agent producing the injury. A few of the more common sources of such accidents may he briefly considered. The use of soap for laundry, toilet, or other domestic purposes, containing an excess of alkali, or even minute particles of bone, is a frequent source of trouble, as are also several of the proprie- tary articles sold in the shops for similar employment. In these instances, the erythema, vesiculation, infiltration, or other symp- toms, will naturally he distinguished on the hands, or the hands and the face. Stockings and other undergarments dyed with aniline, the leather lining of the inside of the hat or the cap, and the painted toys to which the lips of children are applied, will beget mischief in the various regions of contact, for each. Duhring reports cases where the dye-stuff in the lining of shoes has penetrated the material of the stockings in women, and pro- duced dermatitis of the feet or legs. The tincture of arnica, an article unfortunately much used as a domestic application for contused and incised wounds of a simple character, has produced very serious annoyance in some cases, two such having been re- cently presented at my clinic in this citj\ An exceedingly common source of such dermatitis is urine retained upon underclothing in adults. A persistent dermatitis of the scrotum, perineum or inner faces of the thighs in either sex, always calls for a careful examination as to whether a few drops of urine are left in contact with such underclothing after each act of micturition. Fistula?, urinary incontinence, prostatic disease, "stammering of the bladder," imperfect finish of the coup de piston in males, especially after a gonorrhoea, and similar troubles, are all to be remembered. The eruption produced by the poison ivy and other varieties of rhus, is almost exclusively an American disease ; and from its frequency in this country has attracted a great deal of atten- tion. A certain degree of susceptibility to the poisonous action of the plant is requisite for the production of its effects, as some individuals can handle the leaves of the plant with impunity, and others are said to he affected by its exhalations within a circle hav- ing a radius of several feet. I have, however, never been ahle to demonstrate the truth of the last statement, suspecting, as I do, that such instances are usually cases of contact with other than the suspected plant. The parts commonly affected are the hands and the regions to which the latter are carried, such as the face, genitals, arms, thighs, and neck. Barefooted children suffer in the feet and legs. Usually the symptoms are developed in the DERMATITIS. 167 course of a few hours, and consist of erythematous patches, scanty or profuse vesieulation with abundant, serous weeping after rupture of the lesions, swelling, oedema, disfigurement, and intense burning and itching sensations. Serious effects are occa- sionally produced. I have seen deeply attached scars result from subcutaneous abscesses of parts greatly swollen. Occasionally, in particularly sensitive skins, the eruption spreads from the surface affected by the poison, to that where presumably none has been applied. It should be remembered, however, that arti- cles of clothing may, for brief periods of time certainly, furnish sources of further trouble, being worn at the moment of contact with the plant, then laid aside, and, the occasion being forgotten, being subsequently employed. Thus I have known a pair of undressed kid gloves to reawaken the disease after lying for two weeks untouched. Careful observation of a typical case, soon after the onset of sj-niptoms, will disclose the exact surface of contact, each being delicately outlined by a reddened, tolerably well-defined line, within whose limitations will be seen a slightly tumefied, ery- thematous surface, at times displaying closely packed, pin-point- sized papules, which may be embryonic vesicles, or may proceed to resolution without serous suffusion. The diagnosis of the eruption will be aided by recalling the features described in a careful monograph on the subject by Dr. White, of Boston. 1 According to this author, the lateral surfaces of the digits first exhibit the symptoms of the eruption ; later, the dorsal surfaces ; and latest, the thickened palms. The efflores- cence also is more irregularly distributed, more uniformly vesic- ular, and the vesicles less transparent than in eczema. These lesions are, moreover, more vesicular, and less papular at the onset ; and, though suggesting papules by their situation in the palm, are in that situation readily made to exude serum by puncture with a needle. Internal medication is not required. The local treatment is that of eczema. The application of an alkali for the purpose of neutralizing the poisonous volatile alkaloid in the leaves of the plant (toxicodendric acid, Maisch) should evidently be con- sidered solely with a view to prophylaxis, as it is difficult to understand how such neutralization could control the inflam- matory process after its inception. The black wash, solution of sugar of lead, or oleated lime-water, should be employed at first, and be followed later by the dusting-powders. The late Prof. Babcock, of this city, a frequent sufferer from the disease during his extended botanical excursions, first taught me the value of an ointment made by incorporating a decoction of the inner bark of the American spice-bush [Benzoin odoriferum) with cold 1 New York, D. Appleton & Co., 1873, from tlie March number of the New York Medical Journal of the same year. 168 DISEASES OF THE SKIX. cream. Tt certainly has afforded very prompt relief in the cases in which T have been able to employ if, the difficulty lying in securing the hark of the shrub in its young and tender state. Dermatitis Medicamentosa. The importance of recognizing the fact, that a given eruption is produced by an ingested drug, can scarcely he overestimated from the standpoint of the diagnostician. The errors committed in this connection are so frequent and so annoying to the patient that it is necessary for the physician to inquire very carefully, before treating any cutaneous disease, as to the medicaments previously swallowed by the patient; and also to he prompt to connect any aggravation of a cutaneous disease with remedies ordered by himself for internal use. The following is but an imperfect list of the drugs whose internal administration may be followed by an exanthetn ; imperfect, because without ques- tion many have yet to be recognized as possessing such an action. As to the modus operandi of such medicinal agents, for the most part our knowledge on the subject is purely conjectural. Some, for example the iodide of potassium, are eliminated in part by the glands of the skin, and presumably have thus a local effect upon such emunctories ; others, and in this class I believe should be included quinia, induce an urticaria scarcely distinguishable from an urticaria ab ivgestis. Some, possibly, operate in either or both ways at different times or in dif- ferent individuals. The absurdity of supposing that anj* dis- ease can be "driven out" by the ingestion of such drugs, should be relegated to the specious ignorance which first framed such an hypothesis. Aconite. — This drug is said to be productive at certain times of marked diaphoresis with the occurrence of vesiculation and considerable itching. If so, it is possible that the diaphoresis in an irritable skin may be responsible for the trouble. Arsenic. — Erythematous, vesicular, papular, and much more rarely pustular, bullous, and ulcerative lesions, occur upon the face, back, and hands, after the ingestion of arsenic. The well- known results of the administration of the drug in toxic doses upon the mucous membranes of the eyes, nose and mouth need not be described in this connection ; nor yet the grave, gan- grenous symptoms, with osseous necrosis, which have been observed in the workers with the metal. I have seen a bright red, scarlatiniform blush with few iso- lated vesicles cover both shoulders of a young woman with a delicate skin after taking three medicinal doses of Fowler's solu- tion, the eruption being present, but less distinct upon the face and hands. In two cases I have seen the rash in polymorphic type limited to the hands alone. DERMATITIS. 169 By far the largest number of such rashes are, however, pro- duced in those previously suffering from cutaneous disease, for whose relief the drug is administered. Here the toxic effect is declared either by — first, increased hyperemia of the skin visible in an erythematous patch, or beneath the scales of a squamous patch; or, as an areola of bright-red hue about any aggrega tions of lesions; second, by simple aggravation of the type of a disease already in existence (recurrence of acuity in a subacute eczema) ; third, by rapid peripheral extension of a disease which had previously been well limited in contour; fourth, by con- verting a disease exhibiting uniformity of lesion into one charac- terized by multiformity. Each of these results might be illus- trated by cases. In a series of eight cases of poisonous effects produced by arsenical paper hangings, and reported by Dr. F. H. Brown, 1 there were, curiously, no cutaneous symptoms. Belladonna, Atropia. — The well-known erythematous, scar- latiniform, or reddish efflorescence produced by belladonna and its alkaloids, is usually limited to the upper segment of the body, but may become generalized. It is said to occur more frequently in children, probably because it has been adminis- tered largely to individuals of that age under the superstition that it was useful as a prophylactic in scarlatina. Very disa- greeable and even dangerous results have followed the instilla- tion into the eye of atropia as a mydriatic, the rash being accompanied by constitutional symptoms. Boracic Acid. — Modadewkow reports a case in which the pleura was washed out with a five per cent, solution of boracic acid, a part of which was not removed. There occurred as a result an erythematous rash over the face, trunk, and extremi- ties. Bromine and its Compounds. — A full and valuable account of the cutaneous effects of this drug and its compounds, when ad- ministered internally, is contained in a paper on medicinal erup- tions, read by Dr. Arthur Van Harlingen, of Philadelphia, before the American Dermatological Association in 1880. Acneiform lesions, pustules, macules, maculo-papules, papules, eczema-form moist patches, furuncles, urticarial wheals, scales, and ulcers have been induced by swallowing the bromides of potassium, sodium, ammonium, and lithium. By far the most common are the acneiform and pustular lesions, occasionally accompanied by pruritus, which appear upon the face and upper portion of the trunk, though I have seen the rash very distinctly upon the genital region. Duhring reports an interesting observation of 1 Paper read before the Boston Society for Medical Observation, March 6, 1876. 170 DISEASES OF THE SKIN. a case in which the eruption simulated very closely the raaculo- papular syphiloderm, the patient having taken the remedy for three years. The eruption first appeared within tive or six days after decreasing the dose. Kaposi has observed a ease in a nine months old suckling, the mother having taken one hundred and twenty grammes of the bromide of potassium in two months, herself nol exhibiting traces of eruption. In one patient treated by myself the eruption was generalized, but in no part exagger- ated. It occurred in an adult male after three months' continual employment of large doses of the same salt. Mr. Browse, of Cambridge, Eng., recommends for relief of these symptoms the application of a solution of salicylic acid, one grain to the ounce of water, frequently applied on lint, having successfully treated in this way sores as large as the palm of the hand. Cannabis Indica. — The only instance thus far reported of an eruption produced by the ingestion of this drug was observed by myself in the case of an adult male, who was extensively covered with papulo- vesicular lesions after swallowing a grain of the extract. 1 Chloral. — An erythematous rash is the most common of the eruptions produced by chloral, though wheals, red and yellowish papules, vesicles, pustules, and petechial blotches have been ob- served. It occurs upon the face, neck, trunk, and limbs, the latter especially on the extensor surfaces. In a man of advanced years, totally deaf, who had slept only under the influence of chloral for four years, I observed discrete scaly patches as large as saucers over the lower extremities, hands, and feet. Martinet 2 reports an erythematous and scarlatinit'orm rash, occasionally commingled with urticarial and purpuric lesions, occurring upon the face, neck, trout of the chest, the extensor surfaces of the larger joints, and the dorsum of the hands and feet. There was no pyrexia nor indisposition, but in cases dyspnoea and cardiac palpitation. Cod Liver Oil. — According to Farquharson 3 cod-liver oil after being swallowed is capable of producing an acne. This can be true only of very inferior specimens, such as are not rarely found in the English market. Copaiba and Cubebs. — The ingestion of copaiba is occasion- ally followed by a vividly red rash, in the form of discrete macules, more rarely maculo-papules, invading chiefly the lower segments of the extremities and the skin of the belly, but often ' N. Y. Med. Record. May 11, 1878. 2 These de Paris. 1879. 3 Brit. Med. Journ., Feb. 22, 1879. DERMATITIS. 171 completely covering the surface. I have seen the rash occur in dark -mulberry-red petechias; and always in my experience accompanied by pruritus. Inasmuch as the drug is usually administered for the relief of a venereal disorder not syphilitic, care should always be taken not to confound the eruption it may excite with the early macular syphiloderm. Cubebs is much more rarely followed by a similar result. Cundurango. — Guntz 1 reports the occurrence of furuneular and acneiform lesions in twenty patients out of one thousand who were taking cundurango for the relief of syphilis. Digitalis. — In Behrend's treatise on diseases of the skin 2 ref- erence is made to cases where macular and maculo-papular rashes succeeded the ingestion of digitalis. Iodine and its Compounds. — Dr. Van Harlingen, in his very complete essay on the medicinal rashes, describes accurately the several lesions which iodine and its compounds are capable of producing in the skin. Naturally the iodide of potassium is responsible for the larger number of all. The frequent employ- ment of this drug and the very marked influence which it pos- sesses over the skin, render the study of these morbid results important. Unlike many of the other substances in the list, the iodine compounds are followed by some species of rash in probably the larger number of all persons who swallow them. The resulting lesions may be macular, papular, vesicular, bul- lous, pustular, petechial, or in the form of circumscribed, subcu- taneous abscesses. The macular rash is best seen full}' developed over the upper extremities, in discrete erythematous patches or in a diffuse blush. The cases in which I have studied it, all displayed sym- metry. The hands were chiefly affected and suggested in ap- # pearance the dyed hands of the aniline worker. It is said to assume at times the papular type, a transformation I have not noticed, though I have seen coexistence of papules upon the face. Berenguier describes a searlatiniform rash of sudden occur- rence upon the surface of which were numerous minute discrete vesicles. Eczema-form eruptions with abundant serous exuda- tions are also reported. A number of interesting cases are on record where the admin- istration of the drug was followed by the production of bullae. Bumstead, Taylor, Duhring, Tilbury Fox, and Finny, have described such in adults, and I have seen two cases in children, one only reported. 3 Hallopeau, 4 also, reports a case in which a bullous eruption followed the ingestion of the iodide of potas- i Vierteljahrschft. f. Derm. u. Syph., 18S2. 2 Braunschweig, 1879. 3 Arch, of Derm., Oct. 1870. « Union Med., Mar. 25, 1882. 172 DISEASES' OF THE SKIN. sium. The patient died, and the author reports in full the post- mortem appearances. The eruption occurred chiefly about the head, neck, and the upper extremities. I have called attention to the significant rarity of vesicular and bullous lesions in ac- quired syphilis, and suggested that at least sonic of the cases on record were those of rashes induced by the remedy given for re- lief <»f the disease. The pustules induced by the administration of the iodide are seen chiefly upon the face, neck, trunk, and arms. They are usually seated upon a firm base, and may be followed by cica- trices. Duhring has seen an annular patch upon the forehead, made up of minute vesico-pustules, which eventually developed into a globular violaceous mass, nearly two inches in diameter. On several occasions I have observed large, cherry-sized, tubercu- lar elevations abruptly rising from the surface of the integu- ment and presenting a cribriform appearance where showed the open ducts of several suppurating follicles (chin, cheek, nose). The purpuric rash occurs in petechial macules, discrete and miliary, situated chiefly on the lower extremities. In a case reported by Dr. Mackenzie (quoted by Van Harlingeif) a single dose of two and a half grains (.166) in an infant, was followed by a fatal result after the petechia? appeared. Mercury. — The statement that mercury when ingested is ca- pable of producing an erythematous rash upon the surface of the skin, is made by several authors of reputation. In view of the fact that the metal has been, in its various compounds, ad- ministered for so long a period of time and for so many various diseases without the production of cutaneous symptoms, it is a fair hypothesis that the few reported cases are those in which there was coincidence rather than causation. I have had the opportunity of observing a large number of individuals in whom .the drug had been both properly and very injudiciously employed for long periods of time, and have not heen able in a single in- stance to discover any evidences upon which to base a belief in its power to produce a cutaneous exantbem. A similar state- ment was made by Dr. White, of Boston, when this subject was under discussion in the American Dermatol ogical Association. Mercurials when applied to the external surface of the body are, as is well known, capable of exciting, in various degrees, cuta- neous irritation and inflammation. Opium and its Alkaloids. — Erythema, wheals, and occasion- ally intense pruritus with oedema and subsequent desquamation, have followed the ingestion of opium and several of its alkaloids, notably morphia. In its mildest expression this cutaneous effect is limited to a characteristic itching about the nostrils, which can be perceived in a large proportion of all patients as soon as the general effect of the opiate becomes apparent. In several DERMATITIS. 173 cases I have observed an intense and distressing general pruritus without efflorescence; and in some instances have been certain that the subseqent urticarial efflorescence was induced by the free diaphoresis which the medicament induced. This is a mat- ter of some practical moment, as the use of an anodyne for the purpose of procuring sleep for a patient tormented with a nocturnal pruritus, would seem to be occasionally indicated. Inasmuch as both chloral, the bromide of potassium and the opiates are capable of aggravating such distress, great caution is in such emergencies needful. In general, it may be said that the employment of these and similar remedies for such a pur- pose, should be interpreted as a confession of weakness on the part of the physician, who ought to be able to alleviate the distress of his patient by a judicious employment of topical remedies. Phosphorus. — Hasse (quoted by Van Harlingen) cites the case of a young girl who exhibited a pemphigoid rash after the in- gestion of phosphoric acid ; and, according to Farquharson, 1 phos- phorus itself is occasionally responsible for purpura with gastro- intestinal derangement and jauudice preceding a fatal issue. Podophyllin. — Wiuterburn 2 reports that those who work in resinoid podophyllin, are liable to suffer, as a consequence of this exposure, from a cutaneous disease of the scrotum. Quinine and its Alkaloids. — Morrow 3 has collected in an in- teresting paper, the record of over sixty cases of the quinine ex- anthem, and shows that its prevailing type is exantheraatous, the rash being of a bright vivid hue, disappearing on pressure and resembling scarlatina. Other lesions produced are wheals, papules, vesicles, petechias, hgemorrhagic purpura, bullae, and, in one instance, an intense localized dermatitis with commencing gangrene of the scrotum. In some cases the rash reappeared on repetition of the dose, and even after recourse to the other alkaloids. The subjects were mostly females. As with most of the other exanthern-producing drugs, small doses, where the idiosyncrasy existed, sufficed for the effect. I have seen the rash but in a single case, that of an adult male, who, after taking two grains of the sulphate of quinia for the first time in six years, exhibited an efflorescence over the entire surface of the body, of discrete, finger-nail-sized, salmon- and pinkish-tinted, scarcely elevated patches, accompanied by a moderate pruritus. A repetition of the dose was followed by a recurrence of the ex- anthem. In several cases desquamation is reported as resulting from 1 Loc. cit. z Louisville Med. News, April 21, 1882. 3 N. Y. Med. Jour., March, 1880, p. 244. 174 DISEASES OF THE SKIN. the rash. As to the occurrence of the general symptoms recog- nized under the title of cinchonisni (tinnitus aurium, etc.), these may and may not accompany the lesions. Morrow makes the pertinent suggestion, in view of the frequent similarity of the rash to that exhibited in scarlatina, that many cases hitherto recorded as recurrent attacks of that disease and measles with other anomalous cutaneous eruptions, may have been instances of the quinine exanthem. Salicylic Acid and the Salicylates. — Reports of cases where these substances after ingestion have produced cutaneous symp- toms, have been made by Ileinlein, Wheeler, and Freudenberg, all cited by Van Ilarlingen. The symptoms were diffused red- ness, urticarial lesions, vesicles, pustules, petechias, and vibices, accompanied by intense pruritus and followed by desquamation. Santoxine. — A generalized eruption of urticarial lesions seated upon a reddened surface, and accompanied by oedema, is reported by Sieveking as occurring in a child to whom santonine had been administered as a vermifuge. 1 Sodium Benzoate. — "Robe 2 reports two cases in which an ery- thematous rash, with well-defined border, accompanied by itch- ins: and slight desquamation, occurred during the use of the ben- zoate of sodium. The patients were a woman, aged thirty- five, and a boy with diphtheria. The eruption disappeared on the discontinuance of the remedy, and was made to success- ively appear and disappear by its alternate use and disuse. Sodium Biborate. — Gowers 3 reports the occurrence, especially on the arms, but also over the trunk and legs, of an eruption resembling psoriasis after the ingestion of tbe biborate of sodium. Some of the resulting patches were one inch and a half in diameter. Three cases in all are collated. In two the eruption faded, wheu a solution of arsenic was added to the sodium salt. Stramonium. — Deschamps (cited by Dub ring) reports an ery- thematous rash after tbe administration of the thorn-apple. Strychnia. — Skinner (cited by Van Ilarlingen) reports a case where an eruption of six weeks' duration ensued upon the ad- ministration of quinine and strychnia together; the former in the dose of one and a half grains (.10) ; the latter in the dose of one twenty-fourth of a grain (.0025). Tanacetum. — A varioliform eruption produced by the inges- 1 British Medical Journal, February 18, 1871. 2 Maryland Medical Journal, June 15, 1881, p. 91. 3 Lancet, September 24, 1881. DERMATITIS. 175 tion of a drachm and a half (6.) of the oil of tansy, administered for abortifacient purposes, is reported by Porter. 1 There were antecedent clonic convulsions. The result was not fatal. Tar and Turpentine — Erythematous, vesicular, and papular rashes are reported as resulting from the ingestion of these substances. The diagnosis of the various medicinal rashes described above does not, fortunately, demand a recognition of the essential pecu- liarities' impressed upon each by the exciting cause, since in many cases such peculiarities do not exist. The urticarias re- sulting from the ingestion of u head-cheese," quinine, and chloral, may be absolutely indistinguishable. But to establish the fact that a medicamentous eruption is present in any given case is a long step in the direction of reaching the precise cause that has been in that case effective. This latter must often be ob- tained from the lips of the patient. The medicinal rashes are in general remarkable for their sudden appearance, their sym- metry, their diffusion over large areas of the integument, the presence of pruritus, the absence of fever, and their existence alike upon exposed and protected surfaces of the skin, hinting thus at the action of some cause not operating externally. Ex- eluding syphilis and the exanthematous fevers, a generalized rash of sudden occurrence should always raise the suspicion of a dermatitis medicamentosa. Similarly in cases of pre-existing cutaneous disease, syphilis, eczema, or psoriasis, the sudden occurrence of lesions of a new type widely diffused, or of rapid aggravation in situ, or speedy extension as to area of those already in existence, should awaken suspicion, if there be fever of the exanthemata ; and, without a febrile process, of the medi- cinal rashes. Thus I have seen two patients with eczema ex- hibit rapid rise in temperature, and subsequently develop a gen- eralized variolous rash ; and it is a matter of common experience to examine patients on the eve of a macular syphiloderm, or even long past the eruptive stage of that disease, showing their faces, necks, and shoulders covered with an acneiform rash pro- duced by the potassium iodide. The practitioner cannot be too strongly urged to view with exceeding watchfulness the skin of any patient affected with either of the common disorders, eczema, acne, and psoriasis, when the eruption in any instance becomes auomalous as to type, distribution, or symptoms. An illustrative example has come under my observation since the first page of this chapter was written. A physician, on a trip from Colorado to Chicago, with a long standing eczema of the scrotum and thigh, suddenly exhibited tumefaction of both New England Medical Journal, October 15, 1881. 176 DISEASES OF THE SKIN. hands, with Bmall-egg-sized, discrete, dull-red plaques over the palms and dorsum ; and in the centre of nearly all such lesions a Whitish, firm, elevated wheal, the whole accompanied by sevei e burning, tingling, and pricking sensations. He had been Bwal- lowing " bromidia," a proprietary preparation, containing the bromide of potassium, the hydrate of chloral, and cannabis Indica, each single drug being capable of inducing an exanthem, and yet he had not the slightest suspicion of the real nature of his symptoms, having been questioned by a brother physician, to whom he exhibited the hands, as to the possibility of syphilis. The medicamentOUS rashes, as a rule, disappear rapidly after the withdrawal of the exciting cause, and require no further management. In exceptional cases the lotions, dusting-pow- ders, and emollient baths, useful in corresponding phases of eczema, may be indicated. It should never be forgotten that the patient who exhibits such a rash is usually one who has been suffering from the real or fancied disease, for the relief of which the drug was swal- lowed ; and this condition may call for appropriate recognition. Herpes. Deriv. Gr. ??*•«», to creep. Herpes is an affection of the skin characterized by the occurrence of one or more vesicles filled with a clear serum, disposed in groups, limited to a cer- tain region of the body, and pursuing a definite career within a relatively brief period of time. The term herpes is unquestionably responsible for a great deal of the confusion which has existed with respect to cutane- ous disease. By the ancients it was employed, as its etymology suggests, to designate a disease creeping or extending gradually over the surface or within the substance of the skin. By seve- ral more modern authors the term has been employed in a generic sense in the futile attempt to distinguish a series of so- called '-herpetic diseases" and even herpetic diatheses from those of a different complexion. The significance which attaches to the word in the minds of the leading dermatological authorities of this day, is exceedingly simple, and is limited to the features conveyed in the definition above given. It will be seen that the description thus embodied is largely that of herpes zoster, an affection which is here con- sidered separately in consequence of its marked characteristics. Symptomatology. — The disease is declared by the occurrence of millet-seed to coffee-bean sized vesicles, single or relatively few in number, and in the latter case grouped, occurring as epipheno- mena of a general febrile process, or as symptoms of an idiopathic disease. The lesions are usually short lived, surviving but for a few days, and are tilled with a clear, serous- tiuid which may become lactescent. After accidental or spontaneous rupture, HERPES. 177 there is left a slightly tumid, superficial excoriation, which at times is characterized by a circumscribed hyperemia, slight in- filtration, or oedema of the base and periphery. The subjective sensations are not usually severe, varying between moderate pain, itching, and heat. There is occasionally precedent chill and pyrexia, but no persistent lesion relics result from complete involution. Herpes Facialis. About the lips, mouth, and alse of the nose, rarely upon other portions of the face, lesions occur singly or in a single group, possessing the characters described above. Their frequency about the lips has determined the title herpes labialis, under which they are described by several authors. The tongue, buc- cal membrane, and palate may participate in the morbid pro- cess; and the lesions in such moist situations are represented by isolated or grouped, dark-grayish patches of epithelium, Avhich are sensitive and exfoliate. The functions of the mouth in articulation and mastication are thus rendered painful. The disease is common in acute pneumonia, malarial and enteric fevers. In these cases, as Kaposi has shown, the occurrence of the eruption by no means augurs favorably in every instance, as a fatal result may nevertheless follow. In other cases, trifling causes are sufficient to excite the pro- duction of the vesicles, such as a simple coryza, exposure to a cool draught of air, and temporary gastric disturbances. I have had under observation a patient who could produce the lesions at will by tickling the lips with a feather. There is in some individuals an unquestionable susceptibility to the disease. The disorder is always short-lived, though often recurrent; and the superficial crusts which terminate the process are never followed by scars. Herpes Progenitalis. Lesions similar to those seen about the lips occur, in the male, on the inner face of the prepuce, especially upon its upper limb, on the glans, the balano-praeputial sulcus, and the adjacent in- tegument; in the female, on the hood of the clitoris, the labia minora, the inner face of the labia majora, and adjacent surfaces even as far removed as the buttocks. The preference for the prepuce in the male has affixed the name herpes prseputialis to the disease as it occurs in several of the sites mentioned. There is usually precedent pruritus or a sensation of heat, fol- lowed by one or several, pin-head sized vesicles seated upon a tumid and hyperasmic base. Within the praeputial sac the lesion may either rupture at an early moment, or assume the features described as presented upon the mucous membrane of the mouth. The resulting oedema of the prepuce is often displayed in an 12 178 DISEASES OF THE SKIN. annular tumefaction encircling the glans, while the labia minora perceptibly project from the general vulvar plane. In these localities the floors of ruptured vesicles are particularly liable to be irritated (coitus, caustic, etc.), and then pus and even blood may be exuded with much angrier excoriation and resulting crusts of darker shade. In the course of a few days even these crusts fall, and the disease is at an end. Recurrence is common. In several cases under my observation, a first attack of herpes in the male resulted in an extraordinary sensitiveness of the balano-prseputial membrane, which persisted for more than a year. The patients were all middle aged men, married, and virgin of venereal antecedents. The membrane in question was tumid, tense, slightly glazed, and dark-red to dark-purple in hue. Upon any undue sliding of the prepuce over the glans, a very superficial fissure occurred, whence a drop of serum oozed. The membrane wa 8 so sensitive that the passage of the finger over it was resented, as though the conjunctiva bad been touched. Unusual friction by the clothing, or the use of a stimulating lotion, was followed by intense pain and aggravation of symp- toms ; and the price of coitus was a week's rest in bed. Naturally the diagnosis of herpes progenitalis is between chancroid and chancre. The latter will be manifested by its induration, its period of incubation, and its characteristic double inguinal adenopathy. The chancroid, whether in pustular form or inoculated abrasion, is ab origine ulcerative in tendency, capa- ble of auto-inoculation, and often accompanied by sympathetic, inflammatory, or virulent bubo of one side. Balanitis, with its puriform secretion and superficial patches of reddened epithe- lium, is readily distinguished by its symptoms, though the two disorders frequently coexist. The practitioner should never forget that the patient who exhibits an herpes of the genital region to-day, may have been inoculated at the site of these lesions which may to-morrow or later take on the chancrous modification. The rule to be fol- lowed, then, is very simple. Xo individual with a progenital herpes can be assured of immunity against syphilis, till the longest period of incubation of the syphilitic chancre has elapsed since the date of last suspected exposure. Herpes progenitalis is always, I believe, the result of naturally or unnaturally induced sexual erethism. I cannot recall the occurrence of a single case in an individual virgin of such ante- cedents. Treatment — The milder form of herpes, as it occurs about the lips and genitalia, requires no treatment. The lesions of the lips may at times need protection by flexile collodion, plaster, or ointments; those of the genitals, by the interposition of a pledget of lint or a dusting powder. As a rule, ointments are unsuited for the moist mucous surface of the genitals, the odorous emana- tions from most diseases of such parts being retained disagreeably HERPES. 179 by all grease-containing compounds. Lotions answer a far bet- ter purpose, and these may be made stimulant with alcohol ; astringent with tannin, the sulphate of zinc, or the sulphate of copper; anodyne with opium; and deodorizing with carbolic acid. Prophylaxis by the local use of aromatic wine, or tannin and. brandy, with continence, is a matter of importance. Herpes Iris. The behavior of the lesions in herpes iris differs somewhat from that just described; and this has led several authors to consider the affection as a separate and distinct disease. As there is, however, some doubt respecting the question whether herpes iris should not be relegated to the domain of erythema multiforme, I have preferred to assign it a provisional position in this connection. The symptoms at the onset are the occurrence of one or several vesicles or vesico-papules, which pursue their usual rapid career in two or three days. Upon the hypersemic ring which sur- rounds these, a second, and even a third and fourth circlet of similar lesions form, each pushing the areola further to the peri- phery of the patch. The older are in full retrogression while the newer are in process of evolution ; and the red blush which surrounds the earlier is undergoing color-changes from vivid to paler hues, while the zone of the latest vesicles is assuming its intensest shade. The lesions are pin-head to pea-sized, rather persistent, firm, and terminate more often by resolution than by rupture and crusting. The concentric and parti-colored rings may make up a single patch an inch or more in diameter, or several such patches may form upon the surface of the integu- ment. In the latter case the central disk of some of the patches will be seen to be made of confluent lesions. The eruption is most commonly situated upon the extremities, especially over the dorsum of the hands and feet, in which situation, especially when symmetrically developed, it is always, according to Kaposi, more nearly allied to erythema multiforme. It is, however, also rarely seen upon the face. The subjective sensations produced are usually trifling. Atypical forms occur where the lesions are imperfectly developed from papules, and also where, in conse- quence of an unusual exudation of serum, bullae appear. The points in which herpes iris most resembles erythema mul- tiforme are : the variegation of the tints in the peripheral integu- ment(whencethe name,iris); its localization upon the extremities chiefly ; its occasional symmetry ; its frequency in young adults ; and its tendency to occur in the spring and fall of the year. Per contra, herpes iris differs from other forms of herpes ; in the ab- sence of a precedent febrile state or neuralgic pain; in its avoid- ance of regions near the mucous outlets of the body (preputial orifice, vagina, mouth); and in the behavior of the vesicular lesions after attaining their full development. 180 DISEASES OF THE SKIX. The affection ia evidently one upon the border line between herpes and erythema multiforme; and might l>e properly con- sidered under either title. Its existence is another evidence of the impossibility of drawing hard and Cast lines between all the clinical Bymptoms presented by different diseases. It can scarcely be mistaken for other diseases, in consequence of the elegance with which its lesions are disposed. Pemphigus simplex and pemphigus foliaceus differ decidedly in their career, however much they may, at the onset of exceptional eases, pre- sent certain points of resemblance. The affection tends to spontaneous recovery, and requires no treatment. A dusting powder may he applied over the surface, if need he, to protect the lesions from accidental rupture. Herpes Zoster. Derio. Gr. %<»TTrip, a girdle ; Shingles, Lat cingulum, a girdle. Herpes zoster is an acute exudative affection, characterized by the occurrence of groups of firm and distended vesicles, preceded, accompanied, or succeeded by neuralgic sensations, usually mono-lateral in distribution, and followed in some cases by persistent cicatrices. Symptomatology. — The eruption is usually preceded, for a period lasting from a few hoars to days and even weeks, by neuralgic sensations of moderate or severe intensity. These sensations are usually limited to the area of the integument subsequently or coincidently displaying cutaneous lesions. The latter first spring from vividly tinted maculations, as minute papules which produce a sensation of heat, and more or less rapidly develop into typically perfect, isolated vesicles, varying in size from a rape-seed to a coffee-bean. These lesions appear in groups and successively, the individual members of each attaining maturity simultaneously in about one week, while the succession of others may prolong the period of efflorescence to an entire month. The lesions, when fully developed, exchange their earl} T limpid contents for those of a lactescent or puriform character. They project well from the widely hypersemic base from which they spring; are tense from complete distension ; and have no ten- dency to spontaneous rupture, so firm is their roof-wall. When abundant, they may coalesce. Involution is accomplished by desiccation, and the formation of yellowish-brown crusts, whose fall is succeeded in certain cases b}' indelible scars. Several variations from the type thus described require notice. The vesicles may be few and typical; numerous, abortive, and transitory; or differ in type as they may be transformed into veritable pustules or bullae, or become tilled with blood from capillary hemorrhage. In the latter event there is still further departure from type, in their tendency to spontaneous rupture and subsequent ulceration. According to Kaposi, it is in such HERPES ZOSTER. 181 cases only that cicatrices form, but this statement, in view of many clinical observations, must be accepted with reserve. The anomalies of nervous significance are, extraordinary per- sistence of neuralgia after the involution of the cutaneous lesions; neuralgia of an intense and intolerable severity at any period of the disease; paretic and paralytic phenomena with resulting muscular atrophy ; or, in zoster of the head, dehiscence of teeth and hair. The vesicles of herpes zoster are always produced in the areas of integument supplied by sensory nerves proceeding from the cerebro-spi nal tract, a circumstance which explains their limita- tion to a single lateral half of the body. This limitation is rarely observed exactly at the median vertical line of the body, as a few lesions will usually be seen surpassing this boundary. The terms zoster capitis, zoster brachialis, zoster occipito-cervicalis, etc., are used to distinguish the special regions involved in the disease. Zoster frontalis occurs in the area supplied by one supra- orbital nerve, extending from the upper eyelid to the vertex, with lesions spread in a fan-shaped figure over one-half of the brow, forehead, and scalp. It may be a severe and dangerous manifestation of the disease, being then complicated by agoniz- ing neuralgia, formidable involvement of all parts of the eye even resulting in panophthalmia, ulcerative keratitis, pyaemia, meningitis, and death. I have, however, treated typical cases of zoster of this region where not a single untoward symptom occurred. The cheek, side of the nose, lower lid, and palate are affected in zoster of the superior maxillary branch of the trigeminus, with consequent disorders of deglutition and dental losses. Other areas of special involvement are: the neck, the temporal region, the ear, the side of the jaw, and the tongue; the back, the side of the neck, the lateral half of the larynx, and the supra-clavicular region; the nucha, shoulder, postero-internal face of the arm, and the upper costal region of the trunk; the lateral half of the trunk along the lines of the intercostal nerves ; the lumbo-inguinal and lumbo-femoral regions; the buttock, sacro-perineal, and ano-genital tracts; and the lateral half of the progenital area. Individuals are commonly subject to but one attack of herpes zoster in a lifetime, though, as usual in all general laws, there are the few exceptions which prove the rule. The same may be said of double attacks, those involving simultaneously the two lateral halves of the body. The scars left by zoster are characteristic. Not only are they limited to the seat of the original disease, but they have a pecu- liarly indented look as if made by a nail-sett and hammer. They are particularly angular in outline, and do not exhibit the dead-white color of many cicatrices. 182 DISEASES OF THE SKIN. Etiology. — Herpes zoster occurs in both sexes, and in the young as well as the old, though it is very rarely seen among infants. It Been) a to be somewhat under the influence of the seasons, as cold and damp weather serves to increase its frequency in those susceptible to it. A large list of other depressing agencies are named as effective in its production; such as certain poisons (arsenic?); pyaemia; carcinoma; pulmonary inflammations (in- cluding phthisis); septicaemia; hemorrhages; traumatism; and malaria. Inasmuch as no one of these causes can he cited as certainly effective in all cases, it can merely be said that any influence sufficient to induce inflammation of a sensory nerve or its ganglion may he followed by the objective signs of the dis- ease. Pathology. — The researches of Barensprung, Raver, "Wagner, Charcot, Kaposi, and others have demonstrated with sufficient clearness that in zoster there is always, at some point in the corresponding nervous tract (cerebral or spinal centres, ganglia, or the nerves themselves), pathological changes. These are: enlargements, hemorrhagic effusion, separation, softening, or destruction of the nervous bundles, witli hyperemia, infiltra- tion and multiplication of the elements which surround the latter. Pig. 19. -f J Longitudinal section of the third spinal ganglion of the light lumbar region from a case of lnmbo-ingninal zosir-r. «.". ganglion, the black points correspond with pigmented ganglion cells, the dark linfs to engorged vessel- ; «.',.>■.,!., . fatty tis; observed chiefly in children and young adults of both sexes. In such patients, one to twenty or more isolated and often widely separated minute vesicles, usually acuminate, ap- pear upon the surface either simultaneously or in rapid succes- sion. They are speedily transformed into pustules, so rapidly in fact that often the early vesicular phase is not manifest, the lesions showing as minute pustules from the first. When fully developed, they are globular, yellowish-white in color, well dis- tended with their puriform contents, and projected clearly from the surface on which they rest. They may be surrounded by an erythematous areola, or be simply superimposed upon an in- tegument of unaltered color. They may persist as such, or burst, and their contents dry into a yellowish crust resembling honey, or into brownish tinted concretions which adhere with firmness to the superficial and circumscribed base, where a slight weeping can be determined. They are much more commonly observed upon the face, but are recognized elsewhere, always sparsely upon the trunk and extremities. The eruption is never IMPETIGO. 185 in any sense generalized : its characteristic features being the fewness of the lesions, which are scarcely ever grouped, and their occurrence in capriciously selected locations. The subjective sensations are slight, and the eruption is more picked than scratched. It is common in dispensary and hospital patients; and since these are often the victims of neglect and the subjects of vices of nutrition, it has been considered the appanage of scrofula. But the disease is also encountered in well-nourished, and rosy-cheeked children. In the latter, when well cared for, the eruption proceeds regularly to its natural resolution; while in the former, it is prolonged and often aggravated, thus attract- ing to a greater degree the attention of a physician. The pus- tules are never umbilicated, never followed by cicatrices, and. are incapable of transmitting the disease to another individual. Etiology. — The causes of the disease are not clearly recognized, but there is some reason to believe that it originates exclusively in local irritation. It occurs rather at the age of childhood than in infancy and adult life, a period when the hands are first brought into contact with the face ; and these are, quite sugges- tively, the two sites of election. The lesions are very rarely scratched, more often torn with the nail in picking, so that the crusts may be a little blood-colored. I am inclined to believe that the habit of picking the nose and other parts of the face and body with unwashed hands, is the sole source of the mis- chief. In later life the habit of refraining from carrying the hands to the face when the former are soiled, becomes instinctive. Before this instinct is well established, that is in childhood, the hands will convey to the head any particle of filth or dust with which they may have been brought into contact. Pathology. — The lesions have been examined, microscopically by Duhring and others, who have thus been able to establish clearly the purulent character of -the contained fluid. Plainly, each is but a distinctly circumscribed and superficial pea- to bean-sized abscess, the sources of the pus being the horny layer of the epidermis. Diagnosis. — In order to establish the identity of this affection, it is necessary to define its exact differences from eczema pustu- losum. These are, first, the absence of infiltration of the tissues affected ; second, the absence of itching; third, the failure of the lesions to form patches; fourth, the isolation and wide separa- tion, each from the other, of lesions distinctly pustular; fifth, the large development and rather persistent character of indi- vidual pustules ; sixth, after involution of the latter, the evident termination of the disease, which does not, as does eczema in many cases, progress to form a freely discharging and crusting surface, the pustular being but the initial stage of a distinct disease-process. Manifestly, however, an impetigo of the sort described, is not incompatible with an eczema which is often originated by less irritating causes. 186 DISEASES OF THE SKIN. From impetigo contagiosa, the disease is distinguished chiefly by the absence of the evidences of contagion. From ecthyma it is to be differentiated by the deeper excoriation beneath the pustules of the latter, and their engorge I bae Treatment. — The individual pustules are to be opened with a comedo-needle; the purulent contents gently removed by wash- ing with tepid water and soap; and the floor smeared with any mild ointment, such as live grains to half a scruple (.3S-.66) of ammoniated mercury to the ounce (32.) of cold cream. A dust- in-- powder containing calomel may be substituted for the latter or employed afterward. The disease tends to spontaneous re- covery, if the lesions are not irritated. When they are situated within reach of the tongue, which is constantly thrust out of the mouth to moisten them, they may linger obstinately, and require protection by flexile collodion. Impetigo Contagiosa. The late lamented Dr. Tilbury Fox observed and described in 1862, a form of the disease now under consideration, to which be gave the name, impetigo contagiosa. Several authors have agreed with him in recognizing this as an independent affection, a view which I am unable to reconcile with the opinions I have formed, after observation of the disease in its most pronounced features. The eruption, occurring in infancy, childhood, and early adult lite, is often preceded by a febrile process, and appears in the form of rarely numerous, isolated vesicles, vesico-pustules, pus- tules, or bullae, usually about the face, but also on the neck, but- tocks, or feet. The lesions are roundish, flat, have the average size of a split pea, and become covered in the course of a few days with dry, granular, straw colored crusts, which adhere closely to the slightly reddened base on which they rest. Very superficial erosions are to be discovered beneath, which become rapidly recovered with epidermis. They occasionally coalesce. When of the dimensions of bullae, a pseudo-umbilication may be observed at the apex, produced solely by flaccidity of the roof- wall, which is never tied down as in variola. The contents of the lesions are inoculable and auto-inoculable, the disease thus spreading from one member of a family to another, and also from one part of the body of an individual to another. The mucous surfaces are said to be occasionally invaded. The sub- jective sensations are mild, the itching being rarely severe. The disease runs a tolerably definite course, being usually at end in a fortnight. I have seen it recur. Kaposi states that it is at times accompanied by submaxillary adenopathy. Etiology ea, the itch. Psoriasis is a cutaneous disease, characterized by masses of whitish, lustrous, and adherent scales, exposed in pin head-sized agglomerations upon the surface of the skin, or in larger disks resting upon circumscribed and reddened patches of epidermis, which are readily made to bleed. Symptomatology. — The primary lesion in psoriasis is a puncti- form macule of reddish-brown tint, always, at the earliest moment of observation, covered with a delicate, whitish, epidermic scale. When this is removed even by gentle scraping, one or more minute droplets of blood exude from the points, beneath which lie as many vaseular papillae of the corium. When several or many such small points are visible upon the surface, the disease is called PSORIASIS PUNCTATA. Should the disease progress to fuller development, patches of larger size form, always with a definite contour, very slightly elevated above the general level of the integument, and covered with whitish, mother-of-pearl-colored scales in abundance. When these are about the size of drops of water, the disease is termed PS0RIA8IS GUTTATA. PSORIASIS. . 199 In yet more advanced conditions of the disease other names are employed, all from the external configuration of the patches, none having any pathological significance. Thus psoriasis num- mularis is characterized by coin-sized patches; psoriasis circi- nata or orbicularis, by patches where the disease is actively exhibited at the periphery of a circle, in the centre of which the scales have disappeared: psoriasis gyrata and pigurata, by co- alescence and extension of several patches, forming thus fantas- tic figures covered with grayish-white, inbricated. scales; and psoriasis diffusa, by much more extended and uniform involve- ment of the skin in large areas. The greatest variation is exhibited in the progress of the dis- ease, and to this point special attention should be directed. Thus, in a single individual the eruption may appear upon one or more regions of the body in the form of the punctate lesions described above, and thereafter regularly progress through the degrees suggested by the list of names given above till the entire surface of the body is completely covered, from the crown of the head to the sole of the feet. This is fortunately rare. More often the eruption tends to remain stationary when one or ano- ther of the less extensively developed phases of the disease has been displayed. Thus the patches may be at no time larger than a silver quarter of a dollar, and though very numerous, fail for years to extend beyond such a limit. They may even persist for a longer period in even smaller dimensions, or what is perhaps more common, occur in guttate forms upon the chest, and in patches as large as the palm over the knee or sacrum. The sites of preference of the disease, are over the extensor surfaces of the extremities, especially about the elbow and knee, where it is decidedly most common. After these locations should be named in order, the region of the sacrum (where often the largest patch upon the body can be discovered,) the upper surface of the chest, the scalp, the face, the belly, and the genitals; more rarely the hands and feet. The disease is essentially chronic in its course, is never con- tagious, and the efflorescence does not usually awaken any sub- jective sensation. Its features are so pronounced in typical cases that its recognition is facile, by appreciating the number and distribution of the patches, their clean-cut outline, the unaltered integument between, the lustrous and shining scales, and the red border of the skin which ma}' crop out from beneath the squamous thatch above, or be completely hidden by the latter. Rarely a single isolated patch betrays the existence of the dis- order. When the disease is acutely spreading over the surface it has occasionally a different expression. This is often seen in young adults. The patches are perhaps as large as the section of a hen's egg; dark or lurid-red over the whole; covered with a more uniformly constituted, thin, squamous film, or sheet of 200 DISEASES OF THE SKIX. semi-transparent delicate membrane, through which the red glare of the patch beneath is visible. T have Been this condi- tion also in young persons to whom arsenic had been adminis- tered For tlif relief of the disease, with the production of irrita- tive i fleets. In its indolent moods the color of the patch varies some- what with the hue of the patient'x complexion. Blonde women with flaxen hair and clear tint of the integument often exhibit singularly waxy-whitish patches, decidedly differing in color from those occurring upon the muddy and greasy integument of certain dark-skinned males. The scales are usually abundant, and may adhere with con- siderable firmness to the patch, or, more frequently, be shed freely from the surface, in pronounced cases powdering the cloth- ing of t lie patient or the sheets of the bed upon which he reposes at night. There is never at any time in the course of the disease, the appearance of other lesions or their sequela?, such as vesicles, pustules, crusts, papules, tubercles, ulcers, or any discharge fea- ture. The eruption is dry from first to last. Exception only may be made in the case of patches occurring where motion of the skin produces fissure, an accidental and by no means charac- teristic complication. The same may be said of certain acute symptoms, especially developed in young and tender skins, where considerable redness, occasionally with an erythematous halo, appears in and about individual patches, with the produc- tion of itching, heat, burning, [tain, or other disagreeable sensa- tions. The involution of the disease is evident in a gradual cessation of the scale-formation and the exhibition of a normal epidermis, which gradually spreads from the centre, or is at once perceptible over the entire surface of the patches. ISTo cicatrization results. Etiology. — The causes of psoriasis are not known. As no ex- ternal or internal factors can be demonstrated to be effective in its production, it is safest to conclude that these unrecognized sources of the affection are limited to the skin itself. The dis- ease is neither contagious, hereditary, nor limited to either sex, occupation, or social condition. It bears no relation whatever to syphilis, eczema, gout, rheumatism, struma, or dyspepsia. It appears in the feeble and delicate as in the most superb speci- mens of manly vigor and womanly beaut}'. Though not occur- ring in infancy, it yet usually first appears in early life. Kaposi reports a single ease in which the eruption appeared in the eighth month of lite. Under these circumstances, the question arises: Is this affection of the integument, when uncomplicated by the disagreeable symptoms named above, a disease or a deformity? Certainly in a very large number of individuals, displaying through life unchanging patches where the characteristic symp- toms are the same year after year, the ailment would seem to be PSORIASIS. 201 more properly classed with the deformities than with the dis- eases of the skin. In point of frequency the eruption ranks next after eczema. Dr. Gowers alone reports the artificial production of psoriasis by the internal administration of the biborate of sodium. Allu- sion has been heretofore made to this circumstance in the chap- ter on dermatitis medicamentosa (q. v.). Further evidence would be required to establish the fact that these results differed to any appreciable extent from those recognized in any squamous dermatitis produced by an ingested drug. Pathology. — The observations of Wertheim, Neumann, Aus- pitz, Kaposi, and Robinson, of New York, are substantially in accord respecting the general character of the changes occurring in the course of the disease, though they differ upon the question whether it depends upon an inflammatory or purely hyperplastic Fig. 22. Vertical section of skin from a patch of psoriasis of long- standing. MP, Malpighi prolongation; C, coriuni ; i, leucocytes. (After Janiieson.) process. So far as this problem is illuminated by clinical facts, it would seem clear that both views are correct, the disease being at times unquestionably the result of a circumscribed inflamma- 202 DISEASES OF THE SKIX. tion; al others associated with a simple overgrowth of the ele- ment of the epidermis ; and again at times with an inflammation which the hyperplasia lias awakened. There is always abnndaut development of the epithelia in the rete. and, in recently formed patches, distension of the blood and lymph vessels in the papil- lary layer of the corium beneath. In older plaques the rete either dips downward to an unusual extent between the papilla, or the latter push upward in the manner of wart-like prolonga- tions. It is reasonable to conclude that at times both hypertro- phies concur. The corium is thickened later by an increase of its elements which may involve its entire width as far as the connective tissue. In the older plaques also the connective tis- sue elements are often separated by a slight serous infiltration, Hyper-pigmentation is also noted. The external root-sheath of the hairs in direct connection with the rete participates in the same process, thus explaining the defluvium capillitii of certain cases, and the resulting transient or permanent baldness. The sebaceous glands are secondarily involved in the scalp only. Lam; - , 1 of Innsbruck, has lately attracted notice by his alleged discovery of certain fungous elements in psoriasis, which he claims to be the cause of the disease. These he finds in the whitish pellicle beneath the superficial squamous layer, to which Bulkley had already culled attention. After stripping this pel- licle, or a part of it, from the surface, and subjecting it to the action of a five per cent, solution of caustic potash, the epithe- lium becomes translucent, and upon and beneath the latter double-contoured and highly refractive spores become visible to him. Lang considers this to be a fungus of the lowest species, different from any previously recognized upon the skin. He terms this, a epidermo-phyton " In his treatment of psoriasis the author proceeds upon the principles which govern the man- agement of the other dermato-mycoses. He considers that the value of the remedies hitherto found most useful in the disease, such as tar, carbolic acid, chrysarobin, and the mercurials, owe their efficacy to their destructive action upon the fungus. He has used with advantage a topical application of rufigallic acid in a salve, one part in ten. All this, of course, requires confir- mation. Diagnosis. — The recognition of a pronounced case of psoriasis is made with, ease, and often by those unskilled in cutaneous disease. As usual, it is the atypical forms of the eruption which occasion doubt. It is to be distinguished from Eczema. — Eczema and psoriasis differ in a striking manner with respect to their sites of predilection, and their extension from such sites in progressive cases. Eczema, from the head to the toes, elects the anterior surface of the body, the neigh bor- 1 Volkinunn's Bammltms Klinisch. Yortr., 1881. PSORIASIS. 203 hood of the mucous outlets, the flexor faces of the joints and limbs, the crevices, folds, pockets, depressions, and protected angles of the skin. Psoriasis elects the posterior surfaces of the body, avoids the vicinity of the mucous outlets, spreads abun- dantly over the extensor aspect of the joints and extremities, and enjoys the region of pressure and friction, as the skin over the patella and the olecranon process of the ulna. Psoriasis, covering the vertex and scalp, lingers at the brow where its scaly thatch stretches from side to side close to the line of the hairs, and creeps more indistinctly down the face on either side in front of the ear, reluctant to spread over the cheeks, nose, and lips. Eczema easily escapes from the scalp to the nose, lips, or chin; or lurks in the folds of the pinna of the ear. Psoriasis will cover the back and reach forward in front by almost sj^m- metrically disposed parallels in the direction of the ribs, while eczema sweeps between and beneath the breasts or around the nipple. Psoriasis will cover the belly and spare the navel and pubes where eczema may originate. As before stated, the larg- est patch of psoriasis on the body will often be discovered over the sacrum, while eczema creeps upward with a diminishing vigor from the anus between the cleft of the nates. Psoriasis spares the hands and feet which eczema punishes. In individual patches eczema will be recognized by its severer itching; the scratching it excites; the history of moisture, dis- charge and crusting; its ill-defined outline ; its asymmetrical dis- position, except upon the similarly irritated hands and feet ; and the fewer, more yellowish, smaller, and less lustrous scales which characterize its squamous varieties. Favus of the scalp might be mistaken for psoriasis of the same region, but the occurrence of its sulphur-colored, cup-shaped crusts, the existence of the parasite, the lustreless and brittle condition of the hairs, and a possible history of contagion, will insure its identification. In psoriasis, too, the hairs are usually firmly attached in their follicles, while they are loosened in favus. Lichen Ruber, though a very much rarer disease than psoria- sis, must in eases be carefully recognized as distinct from the latter. In it the lesions are papular, distinct, covered by few scales, and these yellowish in color, never lustrous. There is always a constitutional impairment of health, and, when the whole epidermis begins to break up in scales, a condition of well marked marasmus. When scratched, the patches of the disease do not bleed. Finally, lichen ruber tends to a fatal termination. Lupus Erythematosus. — In any doubtful case where cicatricial tissue is discovered in the site of a patch where the disease has existed, the diagnosis is clear, since psoriasis never leaves a scar. 204 DISEASES OF THE SKIN. Lupus prefers the nose, the cheeks, and other parts of the face, commonly Bpared by psoriasis unless it he very abundant else- where. The lupus BCales are scanty, firmly adherent, yellowish, and attached to the orifices of the ducts of the sebaceous follicles; those of psoriasis are abundant, lustrous, and shed freely from the surface. Lupus is never like psoriasis, a generalized eruption. There is a bluish and violaceous tint to the reddish patch of lupus erythematosus, especially as it occurs upon the face, while the highly colored patches of psoriasis are rarely facial, being more commonly seen on the trunk and extremities, while the out-cropping disks on the face are the least-colored of any on the body. Seborrhea. — This disease could only be confounded with pso- riasis of the scalp. But in the latter ease the affection is, in the vast majority of cases, exhibited also in patches upon other por- tions of the body where seborrhcea is never seen. Seborrhoea of the scalp also occurs in usually diffuse forms, the surface beneath the crusts being rather anaemic and pallid in appearance, not bleeding readily, as in psoriasis. The crusts, too, in sehorrhcea, are distinctly fatty and greasy when rolled between the fingers, and have a dirty-yellowish hue, never recognized in the whitish scales of psoriasis. Lastly, seborrhceic crusts may fringe slightly the line of the hairs at the brow, hut never form a hand an inch or more in width, like a frontlet covering the upper half of the forehead, a not uncommon development in psoriasis. Syphilis. — Psoriasis does in many cases greatly resemble the squamous and papulosquamous syphilides. The necessity for a clear recognition of either disease occurring in suggestive patches, is often of the highest importance. In syphilis the greatest aid will he attained by a history of in- fection, adenopathy, mucous patches, and abortions, miscarriages, or still-births in the female. Psoriasis is a singularly uniform disease; syphilis decidedly multiform in its manifestations. The syphilitic patches are less symmetrical, more elevated at theedge, and the scales with which they are covered, fewer, smaller, and dirty-whitish, rather than lustrous in color. In syphilis, the eruption is less generalized, and shares with the other syphilo- dermata in the brownish and purplish hues of the skin beneath, lacking the vivid redness and pinkish-red of many non-syphilitic lesions. The scales of many of the syphilides, which resemble psoriasis, partake of the character of crusts, being agglutinated by pathological exudations from the patch; they are rarely so exclusively squamous as in psoriasis. In syphilis, the tendency of the patch is to exhibit an affected surface somewhat beyond the line of the scales; in psoriasis, the scales more frequently reach beyond the border of the affected epidermis beneath. The squamous sypbiloderm of the palms and soles may exist in these PSORIASIS. 205 localities only. Psoriasis is extremely rare in such situations, and is never, I believe, limited to that region exclusively. A psoriasiform circlet limited to the region of the mouth, nose, or chin, will generally prove to be syphilitic. The disease which has tor a long time persisted in the production of squamous patches can generally be demonstrated to be psoriasis ; as syphilis changes its type in the course of months. Tinea Circinata. — Here the discovery of the parasite, the his- tory of contagion, and the frequent limitation of the disease to a single patch (a feature exceedingly rare in psoriasis), will usu- ally suffice to establish a diagnosis. In ringworm of the body the scales are bran-like, aud more abundantly formed at the margin of the patch where the fungus is luxuriant; while in psoriasis, the scaliness is usually equally pronounced over the entire area of an invaded patch, unless the disease is in process of involution. The occasional occurrence of vesicles and vesico- papules at the peripheral border of the patch in ringworm, is never observed in psoriasis. Ringworm is never generalized symmetrically; and upon the scalp or beard the discovery of brittle and broken-off hairs should always suggest examination for the parasite. Treatment. — As the cause of psoriasis is absolutely unknown, all treatment for the relief of the disease must necessarily be limited to the removal of its objective features. Tins treatment may be internal, with a view to the indirect action upon the skin, of the drug selected; or topical, with a view merely to the reproduction of a sound epidermis in the patches of disease. Without full repetition of the remarks heretofore made, rela- tive to the efficacy of the drugs known to have an active effect upon the skin after their internal administration, it is proper to state in this connection that arsenic enjoys the highest rank in the internal treatment of psoriasis. What it is capable of accomplishing in other cases, it can with best effect accomplish here. Whatever failures must be charged to its account in the attempt to relieve other cutaneous eruptions, cannot safely be ignored here. The facts are these: Arsenic administered internally is assur- edly capable of relieving a certain proportion of cases of psori- asis. Given improperly in any case, it may be either powerless or manifestly injurious. In a certain proportion of patients, most carefully selected as fit subjects for its therapeutic action, arsenic will prove utterly valueless in the most skilled hands. It cannot be demonstrated to possess the power to prevent recur- rences of the disease, and yet the latter must be recognized as one exceedingly liable to recur. Unfortunately the proportion of cases in which it will and in which it will not, exhibit its happiest effects, is not known. 206 DISEASES OF THR SKIN'. The following rule-; for its administration are to be in general observed. It should be given with or immediately after the ingestion of food, so that it may be commingled with Bubstances in the Btomach. It should be given at first in small doses, which are to be cautiously increased. The possibility of the production of toxic effects should be remembered, and on the appearance of these the remedy is to Ik- given in a smaller dose, and not com- pletely discontinued unless such a course be imperative. If its administration is once determined upon, the arsenic should not In- hastily withdrawn and another remedy substituted for it, hut persistence for months should he enforced if no serious ob- jection exists, lest the time be wasted which has been already expended in the effort to relieve the disease. Arsenic is unsuited tor all cases of psoriasis occurring with rather acute symptoms, such as subjective sensations and unusu- ally vivid redness of the patches. It should not he given when the disease is in process of evolution, and therefore not in psori- asis punctata and guttata, unless the lesions have been long limited to patches of the sizes to which these names are given. For the same reasons it is often objectionable in the psoriasis of the young, for, though the drug is usually rather well tolerated in such periods of life, it is, unfortunately, in these also where the disease is most often encountered in its progressive stages. The remedial effect of arsenic, when such is obtained, seems to depend upon the impression it exerts upon the rete, and that pari of it especially which lies in connection with the derma, or rather with the structureless limitary membrane interposed be- tween the two. When the metal is injected suhcutaneously, its first ell'ects, according to Jamieson and Nunn, 1 are indicated by the appearance of a faint narrow band along the base of the columnar epithelia immediately next the basement membrane. This is due to a softening of the protoplasm which separates the epidermal from the dermal elements. Subsequently the remoter epithelia are involved, the protoplasmic threads becoming ob- scure, the characteristic arrangement of the epithelia less evi- dent, and the natural features of the rete distorted so that it remains attached to the derma by tags, and the prolongations which it sends down to the cutaneous glands. Jamieson sug- gests that arsenic stimulates the epithelia to exhaustion, that layer which lies next the bloodvessels containing the metal first appreciating its effects. The preparation usually employed is Fowler's solution, the most soluble of all, whose exhibition should be always begun in three dropdoses; this amount to be contained in a solution of fixed and relatively large dose, such as a teaspoonful of the infusion of peppermint; the wine of iron; or dilute syrup of gentian or 1 Bee the paper by the former on the Histology of Psoriasis, Edinburgh Med- ical Journal, January, lbT'J, p. 027. PSORIASIS. 207 of orange flowers; or the compound tincture of cardamom with water. When only remedial effects are obtained, such as dimi- nution of the scaliness, the dose may be steadily continued with- out change for long periods of time, and usually with advantage for some "time after the symptoms of the disease have entirely disappeared. When, without the production of toxic effects, the eruption seems quite unaffected by the treatment, the arsenic may be, very carefully and always under the direction of the physician only, pushed till twenty and even thirty drops of the Fowler's solution (the latter equivalent to one-third of a grain (.022) of arsenic) are administered at a dose. The constitution of the Asiatic pill has been given in the chapter on general therapeutics. The pill is less likely to be as well tolerated by the stomach as Fowler's solution, but cases are on record in which the psoriasis which proved rebellious under the administration of the liquor arsenicalis, Donovan's solution, and other internal remedies, yielded to the influence of the arsenious acid in pilular form. Hebra has given two thousand Asiatic pills to a single patient before the disease dis- appeared; and in no instance has he seen any ill effects pro- duced. With regard to the vulgar opinions respecting the arsenic habit which a long familiarity with this dosage has been sup- posed to beget, I consider it a curious circumstance that I have never yet encountered such an instance in a psoriasic subject who was consuming arsenic. Patients who for several consecu- tiveyears have,without interruption, pursued an arsenical course, thus barely succeeding in keeping their cutaneous ailment out of sight, will in many cases affirm that, apart from any trifling and accidental toxic symptoms, and those evident in the course of the eruption, they would not be sensible of the fact that they had taken the drug. Personally I may say, that with an enlarging experience, I view with greater distrust each year the benefits to he derived from arsenic in any untried case of psoriasis. The large possibilities of its failure, of the repeated recurrence of the eruption, of the necessity of continuing the medication for one or two years, and even after that period of time, of even then witnessing a general- ized development of the eruption to an extent quite equal to that exhibited at the outset, all these considerations should certainly have some weight in the mind of an ordinarily prudent man. 'Is the ultimate result in such cases worth the cost by which it is obtained? In such cases certainly it would seem not. In the others, wdiere, under a judiciously directed arsenical course, the eruption slowly disappears and fails to recur, the value of the treatment is incontestable. As before stated, the proportion in which these two classes of cases are related, is not known. Per- sonal observation and experience lead me to believe that the patients in the last named category decidedly outnumber the others. 203 DISEASES OF THE SKIN. The course which, under the circumstance, I prefer, is this: Instead of resorting first to the arsenical dose and afterwards to Other measures, the order should be reversed. That psoriasis which fails to respond to other treatment, may be finally sub- jected to the influence of arsenic, lie who having vainly tried other approved measures, essays at last the virtues of this medi- cament, ought certainly to exhibit no impatience while testing his case with it. He should he willing to try it fully and fairly, and he of all men least ready to exchange it for a less valuable substitute. I have purposely omitted to speak here of the effect of conjoined internal medication with arsenic and external treat- ment l>y topical applications. However desirable it may be, in the management of any individual case, to arrive at the desired end by the speediest method, it is evidently needful, in order to assign to arsenic its exact therapeutical value, to understand what it can accomplish unaided by topical measures. As to the other remedies employed internally for the relief of the malady, a very fair estimate of their value can be made by remembering that arsenic is superior to them all. If arsenic fails so frequently, what remains to be said of the other articles in the list? Phosphorus, copaiba, mid pilocarpine, have at times a feeble or transitory influence over the patches of the eruption, but their employment will disappoint far more often than satisfy. Iron, quinine, cod-liver oil, and the salts of the alkalies, will fill important indications in the treatment of certain classes of pa- tients, but these are in the minority, as the eruption is more often seen in perfectly vigorous and otherwise healthy subjects. I have been unable to discover, after the use of any one of these remedies, any decided effect upon the cutaneous symptoms, even when patients in whose case they were indicated, improved un- der their use. The same in general may be said of the use of dietary articles in psoriasis. As no ingesta save the substances already named are recognized as influencing the eruption to any perceptible degree, the diet suitable for a patient may be in brief described as that which is both wholesome and nutritious. The external or local treatment of psoriasis requires patience, care, and a certain degree of skill. Properly conducted, its re- sults are reasonably satisfactory in a large majority of cases. The first indication to be met is the complete removal of the epidermic scales from the patches, and this is accomplished in various ways. It is preferable to secure first their maceration in some fatty substance, such as one of the oils, or glycerine, or vaseline, after which they may be washed off by the aid of soap and water, in a general bath if the eruption be extensive. If it be localized, these oily or fatty substances may be spread upon pieces of lint or cotton, and thus retained by a bandage in con- tact with the skin. The scales may also be speedily removed with the dermal curette, if they occur in few patches, or if the latter are to be found in totality or part upon some portion of PSORIASIS. 209 the body where the disfigurement demands special attention, as upon the forehead and. cheeks. The squamous masses are also removable by water alone, as after maceration of the skin in a bath, or after profuse diaphoresis, or even moderate exudation of sweat, if evaporation of the latter be prevented by covering the affected part with oiled silk or rubber cloth. Usually there is no difficulty in removing these scales, patients often remarking to their physicians that they can themselves cleanse the surface, if they can be shown how to prevent the recurrence of the des- quamation. Baths play an important part in the subsequent treatment of the disease. They may be employed, as by Hebra, so that the patient remains in the water for from four to eight hoars in the day; or be medicated by the addition of sulphur, tar, or other substances, so as to combine a medicative with a macerative effect. In private practice, these baths are much less available than in hospitals. When the eruption is generalized and an excessive macerative effect is derived, the rubber clothing an- swers a better purpose. I am in the habit m such cases of order- ing an undershirt and drawers made of soft rubber cloth, of the size of the undergarments usually worn by the patient, the latter wearing these for several hours of the day. The sweating is often profuse and debilitating, to such an extent that the psori- asic skin will rarely tolerate the treatment for an entire day, or for even that part of it in which active labor is performed. By this means alone, it will at times be found possible to secure complete disappearance of the patches. In other more obstinate cases, or in those where for any reason such treatment is indicated, as upon the scalp and face, the sapo viridis may be employed with advantage in the soap and water treatment. The spiritus saponis kalinus (two ounces (60.) of the soap to one (80.) of alcohol) may be briskly rubbed over the patches by the aid of a piece of flannel or sponge, and then im- mediately washed off with the oil and scales in a surplus of hot water, or be left for a time in contact with the part. Hebra and Kaposi make use of a species of soap paste, made by rubbing into each patch a small quantity of the green soap to which a little water is added till the proper consistency is obtained. These inunctions are repeated twice daily for six days. The epidermis becomes then brownish-colored, and in three or four clays afterward exfoliates in lamellae. Then a general bath cleanses the surface. In the French hospitals, a somewhat speed- ier method is pursued. On the evening of the first day, the patient is anointed with the green soap which he retains upon the skin during the night. In the morning he takes an alkaline bath, and immediately after is thoroughly anointed with lard. This is repeated on the second and third days, after which the patient is usually ready for any topical medication of the dis- eased parts. 14 210 DISEASES OF THE SKIN F«>r the yet more obstinate cases in which the exfoliation of the epidermis is not readily induced, still more energetic meas- ures have been adopted, such as the local use of fan-tic acids and alkalies, scrubbing the patches with nail-brushes, floor- brushes, etc., and tlic use of clean, white sand. Once ready for topical medication, the patches may first be subjected to the local action of tar, a remedy which has long enjoyed the highest reputation for the relief of the disease. It should be remembered, however, that its value depends largely upon its application to patches where it will he tolerated. In very young patients, and in those whose skins are irritable, or who are suffering from what may well be termed acute phases *>\' \ soriasis. it may prove highly injurious by aggravating the disorder. The rule should be, to employ it at first tentatively over a relatively small portion of the surface, upon which the medicament should remain for several hours, as tar will not in all cases promptly produce its injurious effects. These are, sub- jectively, a sense of heat and pain, and, objectively, the other signs of inflammation, heat, redness, and swelling. Occasion- ally its eifeet upon the sebaceous -lands is manifested in what llehra has termed " tar-acne." Pix liquida, the oil of white birch, or, less preferably, the oil of cade, may lie used, generally in the proportion of a drachm (4.) to the ounce (oO.) of vaseline or lard. A thin stratum of such an ointment may be painted over or well rubbed into the patch several times in the day or merely at night. In Vienna, a still more energetic effect is secured by using the soft soap freely over the patches while the patient is in the bath, then anointing him with tar, and finally returning him to the bath where he remains for from four to six hours. For localized eruptions, the green soap in combination with tar and alcohol serves an ex- ceedingly useful purpose, either in the proportion of equal parts of the three ingredients, or by combining them in various pro- portions, as. for example: — li. Baponis viridis, 01. picis, f Glycerin., $ 01. rosraarini, Spts. Yin. red if., 'Oss ; 500 M. et Big. For external use. Other combinations oi' service are Bulkley's liquor picis alka- linus, the formula of which has been already given, 1 and Wil- kinson's ointment as modified by llehra, the latter combining the remedial effects of sulphur, lard, soap, and grease. The for- mula is as follows: — K. Sulphur. Buulimat. 01. cadini, Baponis \ iridis, i Adipis, $ Cretae praeparal . Sig. " Wilkinson's oil .~.i> s 130 30 I a § §ss ; 10 aaij; 30 tnent." B'jss; 3 1 See p. 134. PSORIASIS. 211 This is a remedy of remarkable value when employed exter- nally, not only in psoriasis, but in a long list of other cutaneous diseases. The chief objections to its use in private practice are its stench and its liability to produce chemical action upon met- als with which its vapor comes in contact. Absorption of any tarry compound applied externally may result in general toxic symptoms, including fever, vomiting, diarrhoea, strangury, and elimination of the toxic agent in secre- tions which are blackened by its presence. These symptoms are usually relieved in from twenty-four to forty-eight hours after the discontinuance of the drug. Next to the tars, as regards the treatment of psoriasis, ranks deservedly chrysarobin or chrysophanic acid, a crystalline pow- der of the color of old gold, insoluble in water, but readily dis- solved in hot alcohol, acetic acid, benzol, vaseline, and hot fat. It is derived from the "goa-powder" of the East Indies, or the " araroba powder" of Brazil, whose employment in psoriasis was first recommended by Mr. B. Squire, of London, Eng., in 1878. In 1880 I collected specimens of this powder from the leading chemists of Boston, ISTew York, Philadelphia, and Chicago, and finding these to vary greatly, both as regards the color of the preparation and the therapeutical effects induced, I have since exclusively employed the Brazilian araroba em po l with better results. The drug is best applied in the form of an ointment, varying in strength from half a scruple (.666) to a scruple (1.333) to the ounce (32.) of vaseline or cerate. It is used by others in greater strength, but with the pure specimen to which I have called attention, it is liable in larger proportions to produce disa- greeable effects. These are declared in a hot, itching, swollen, irritable, and erythematous skin, stretching from the surface of application, with tolerable uniformity, in every direction. It is, even in the strength named above, necessary to begin its use with caution, testing it by application first to a limited area of integument. These excessive effects usually subside in a few days. An ignorant woman to whom a chrysarobin ointment was given by me in 1879, with directions to test it carefully at first by application over the elbows of her daughter, stripped the latter before an open fire and rubbed the ointment over the entire surface for the space of half an hour. The result was an intense erythema lasting for six days with considerable distress, and the complete disappearance of the psoriasis, which did not fail to reappear in eight months. When the drug produces its most brilliant effects, the pso- riasic patch, previously denuded of its scales, assumes a whitish and normal aspect, contrasting thus somewhat remarkably with the chocolate to brownish-black discoloration of the normal skin 1 This article has been imported for me from Messrs. Silva, Limaos and Co., of Bahia, Brazil. 212 DISEASES OF THE SKIX. at the periphery. This coloration, when produced either by the ointment directly or by a frequenl transfer of its ingredients to other parts by the medium of the clothing and hands, involves also the nails, hairs, and under-linen of the psoriasic patient. Its employment upon the face and scalp is thus largely inter- dicted. The staining of the skin and its appendages disappears entirely in time, but always slowly. An improved plan of using chrysarobin externally, lias been recently suggested by Fox, of New York. 1 A soft paste is made by rubbing the chrysarobin with a suffi- cient quantity of water and smeared upon the psoriasic patches, the scales of which have been previously removed by one or more hot baths, with soap friction. As soon as the paste has dried, which it does in one or two minutes, a layer of collodion should he allowed to How over each patch and to harden into a protecting coating. This will remain in place for several days, or longer, according to the location of the patches; and when it tails or is washed off, the application of the powder and the col- lodion should he repeated. By this procedure the chrysarobin in full strength is kept in contact with the affected skin, and prevented from exciting undue inflammation of surrounding parts or staining the clothing. A mixture of the powder and the collodion may be used, hut it is less efficacious. A film of collodion doubtless interferes with the action of the aeid upon the skin. A somewhat similar plan consists in the use of gutta- percha tissue to retain a strong chrysarobin ointment in contact with psoriasic patches. The edges of this tissue will adhere tightly to the skin if a small camel's-hair brush, dipped in chlo- roform, lie passed rapidly beneath them. Contrary to the views of man}' dermatologists, I esteem pyro- gallic acid, first suggested as a remedy for psoriasis by Jarisch, 2 as inferior to chrysarobin. The fact that several deaths have now been reported as consequent upon its use, should deter many from making trial of it, in a painless and merely dis- figuring disease. It is used in a ten percent, vaseline ointment; is effective, though less rapid in its effect than chrysarobin; is cheaper; is odorless and painless; and discolors to a less extent the sound skin. Both remedies are capable of being absorbed from the surface and of producing constitutional symptoms, py- rexia, strangury, and blackish evacuations. But in the case ^t pyrogallic acid only, so far as is known to me, have these symp- toms resulted fatally. Kaposi' 1 has hee'n lately employing beta, naphthol in psoriasis, (as also in eczema), the formula of which is, (J )0 1I 8 0. It may he applied in alcoholic solution. Under tlie employment of a fifteen per cent, ointment, the author reports speedy disappearance of i Medical News, March 18, 1882, p. 289. * 8chmidt's Jahrb., 1880, No. ::. 3 Wien. Med. Woehenscli., May 28, June 4, and 11, 1881. PSORIASIS. 213 psonasic patches. It did not stain the skin, hair, or nails, and thus certainly bids fair to supersede the tars in the treatment of the disease, especially in patches upon the scalp and face. Balmanno Squire, 1 however, reports that the naphthol was, in certain experiments, conducted by himself, without appre- ciable effect when used in the strength of from ten to twelve per cent.; and that when he increased the quantity of the agent till the ointment was applied in the strength of twenty-five and even fifty per cent., there was the production of merely irritative effects. Crocker, of London, similarly uses thymol in ointment, half a scruple to half a drachm (0.666-2.) to the ounce (82.); and "Williamson advises turpentine, two drachms (8.) to the ounce (.30.) of olive oil with the odor corrected by the oil of lemons. Charteris treated thus a single limb of a psoriasic patient, which was subsequently wrapped in wool, with the curious result of relieving the psoriasis of the other limb, possibly in consequence of the absorption of the remedy. The danger of strangury in such cases must not be overlooked. The nitrate, as well as the iodides and oxides of mercury, are applied by many practitioners in the form of ointments to patches of psoriasis, usually few in number, and limited in ex- tent. The action of these agents is, however, inferior to those already named ; and, the range of their availability being quite limited, they should be esteemed lightly in the local treatment of the disease. Prognosis. — Inasmuch as no treatment will insure the perma- nent relief of psoriasis, such a result should never be either pre- dicted or promised. The disease is one which frequently recurs, and may do so for a lifetime. It, however, disappears completely at times, without subsequent recurrence, and when this alto- gether exceptional and fortunate issue is secured, both patient and physician can well congratulate each other on the result. In many cases, I am fully persuaded, heterodoxical though the belief may be, that the psoriasis calls for no treatment. " Such are the extremely indolent cases, where the patches exist in middle-aged adults upon the parts of the body entirely protected by the clothing. It is then harmless, painless, and in no sense annoying, save as it occasions unnecessary mental disquietude. It is far less burdensome than the spectacles which others have to support upon the nose; or the plate which may have to re- main in permanent contact with the palate ; or the suspender which is constantly demanded by a largely pendulous varicocele. It is, in short, in such cases, much more of a deformity than a disease, and, as compared with the uncertainties and discomforts of prolonged treatment, may often be better tolerated with a patient equanimity. 1 Brit, Med. Jour., Jan. 14, 1883. 214 DISEASES OF THE SKIN". Pityriasis Maculata et Circinata. Under this title Duhring in this country, as also Bazin and other French authors, have described a rare disease of exudative type, non-contagious, and benign in character, occurring sud- denly or gradually both in children and adults. It is character- ized by the conspicuous appearance over large surfaces of the trunk, especially the integument covering the clavicles, ribs, and scapulas, of numerous pin-head to small coin-sized, circumscribed, roundish or ovalish, Blightly elevated, macular or maculo-papu- lar lesions. These may be discrete, closely set together, or con- tinent, and instead of being elevated may he either on a level with the general surface, or even slightly depressed, with an an- nular border. They are dry, covered with furfuraceous scales, and vary in color from a yellow or tawny shade to a deep red. The infiltration is slight, the patch being superficially situated; and the subjective sensations insignificant, rarely more than a moderate pruritus. At times, Duhring has noted a central heal- ing and peripheral extension of the disease. The lesions accomplish a stadium of from one to three months, new crops meantime appearing, after which involution occurs, and is completed within a few weeks by desquamation, with the production of some pigmentation. The disease is distinguished, by the absence of a fungus, from all the affections of the skin induced by vegetable parasites. It should not be confounded with seborrhcea of the trunk, lichen ruber, psoriasis, and syphilis. Pemphigus Vulgaris. Deriv. Gr. wsu*^, a bladder. Pemphigus vulgaris is a disease characterized by febrile and other symptoms of constitutional disturbance, accompanied by the production of a series of pea- to egg-sized cutaneous bullae, irregularly distributed over the surface, and distended with serum or blood. S'lniptomalology. — The cutaneous lesions in this disease are usually preceded by febrile symptoms; and the disturbance of the economy is declared in cardiac, respiratory, and gastrointes- tinal derangements of function. The fever may he continuous, remittent, or intermittent ; and is usually exaggerated just before the appearance of a fresh crop of blebs. The eruption first appears in reddish maculae of rather vivid line, in the centre of each of which appears later a whitish ele- vation of the epidermis suggesting a wheal. Either upon these or unaffected points of the skin, tense, well-rounded bullaa sub- sequently form, varying in size from a pea to a lien's egg and even larger, and in number from three or six only, to a hundred and more. They are usually irregularly distributed (pemphigus PEMPHIGUS VULGARIS. 215 disseminatus), but may be clustered in groups; or very rarely be found, tbe younger encircling the older lesions, so as to form a circinate appearance (pemphigus circinatus); their contents are serous, bloody (pemphigus hemorrhagica), or later purulent, with color corresponding to these fluids. Whether ruptured or not, the involution of the lesion is accomplished by desiccation and crusting, the crusts being usually found to contain blood, pus, epithelial debris, and the exudate from the base of the bleb. Beneath such a crust a new epidermis forms, which is usually violet, purplish, or bluish-red in color; and, later, displays a brownish pigmentation which may for several weeks survive the disease. Occasionally the affection occurs with very mild and even in- significant phenomena (pemphigus benignus). There may be no fever, and a very few blebs appear; in some cases but a single lesion can be seen (pemphigus solitarius). In other instances the fever is intense; the eruption abundant; the skin cedema- tous, painful, pruritic, excoriated; and the underlying lymphatic glands enlarged. This general condition with exacerbations and remissions may persist for months, and the eruption then disap- pear never to return; or to recur, as it often does, in the future. Fortunately the disease is rare. The lines technically drawn between man}^ diseases are quite artificial, however useful and necessary for systematic study and classification. Clinically, many of these distinctions disappear. This is especially true of the varieties of pemphigus. Between the benign processes just considered and the grave form of pem- phigus foliaceus, described in another chapter, several interme- diate gradations can be observed ; and even the most benign may at times unexpectedl} 7 assume the most malignant phases. Pem- phigus malignus is a name given generally to those intermediate varieties of the disease, most of which are distinguished by per- sistent and prostrating fevers; cachexia, especially in infants; the occurrence of diphtheritic patches upon or about the lesions with infiltration of the derma and slouch of its superficial layers; or extensive crusting and even subsequent ulceration. A form is described by He bra and Kaposi, in which vegetations and fun- gosities rise from the base of the blebs. Pemphigus pruriginosus is another grave form of the disease, in which the lesions give rise to an intense pruritus, under the scratching induced by which they are torn, excoriated, and commingled with the crusts and exudations of an artificially engendered eczema. Sev- eral of these malignant and intermediate forms may terminate fatally. In all varieties of the disease, the lesions may be exhibited upon the mucous membrane of the accessible outlets of the body. Etiology and Pathology. — The cause and nature of pemphigus vulgaris are so obscure that they may be said to be unknown. The disease is more frequently encountered in infancy and child- 216 DISEASES OF THE SKIN. hood, because, if would seem natural to conclude, the powers of resistance al a tender age are inferior to f Lose of a mat urn- epoch. The disease is in general observed in debilitated patients, who are variously described as suffering from "nervous prostration," "mental worrv ami exhaustion," "neurasthenia," "general de- bility," visceral disorders, and impairment of nutrition. Occur- ring in a vigorous, rosy-checked, strong-limbed adult, the disease would certainly he regarded as a curiosity. It is therefore safe to conclude that those states in which there is marked impair- ment of bodily vigor, are particularly favorable to the develop- ment of the disease. In such, there is less tendency to the formation of a plastic exudate; and the protoplasm of the body, instead of reproducing itself in actively multiplying lumps dis- played regularly along its reticulum, produces a liquid in a con- dition of very languid activity. Diagnosis. — From what has preceded it will be inferred that pemphigus vulgaris is a name given to a disease, and not merely to bullous lesions upon the surface of the skin. It is of some importance to remember this fact, as several authors have used the term in a purely descriptive sense, the fact, being that bullae are manifestations of several disorders, including syphilis, lepra, pemphigus foliaceus, herpes iris, and erythema multiforme. At the outset, consequently, the blebs of pemphigus vulgaris can scarcely be differentiated from those of other diseases. It is necessary for its recognition that proper consideration be had of all the cutaneous and other phenomena present in the disease. In syphilis, such lesions are rare in the adult, and relatively more frequent in infants hereditarily diseased. With the latter, the blebs are usually seen at birth, often upon the palms and soles, and are frequently superimposed upon an exulcerated base. The coexistence of mucous patches of the mouth, vulva, and anus with the evident polymorphism of the lesions and signs of grave cachexia, will usually indicate the nature of the disease. The cutaneous symptoms of such infants are improperly designated as pemphigus. Such an eruption is a bullous syphiloderm. In the bullae of lepra, there is usually coexisting cutaneous anaesthesia, and the involution of the bleb is followed by a strik- ingly characteristic atrophic patch, usually pigmented and insen- sitive. In pemphigus foliaceus, the extraordinary and usually generalized desquamation which ensues, is sufficiently distinc- tive, though it must he home in mind, as heretofore stated, that the several varieties of pemphigus may he transformed, the one into the other, by well-nigh insensible gradations. Among its graver forms susceptible of such transformation may be named, impetigo herpetiformis, pemphigus cachecticus, pemphigus diph- theriticus, and pemphigus pruriginosus. In herpes iris, the Lesions are more vesicular; much more tran- sitory; subject to a concentric arrangement and variation with respect to color; and are situated more frequently upon the ex- PEMPHIGUS VULGARIS. 217 treraities, especially the backs of the hands. The bullous lesions occasionally seen in urticaria and erythema multiforme are to be recognized by the other characteristic symptoms of those dis- eases; in the former, more particularly, by their intermingling' with typical wheals; and in the latter, by the location of the eruption, and its climatic or seasonal significance. The so-called contagious forms of pemphigus, epidemics of which have been described by Besnier, Hervieux, and other French authors, were presumably, as Dnhring well suggests, instances of impetigo con- tagiosa. This inference is sustained by the frequent allusion of the writers named to the " varicella form" appearance of the lesions. Lastly, the external application of eantharides, mezereon, the stronger acids, alkalies, and other chemicals may be followed by blebs produced either by accident or intention with a view to feigning; disease. The intentional production of such symptoms is usually effected upon the anterior faces of the lower extremi- ties, regions within easy reach of the right hand. Erysipelas and. dermatitis calorica are also diseases in which blebs appear, always, however, of minor significance as compared with the other symptoms of disease present. The same may be said of the bullse which form upon a gangrenous integument. Treatment. — The internal treatment of pemphigus vulgaris is a matter of importance, as will be suggested by even a brief consideration of the constitutional states in which it occurs. Mr. Jonathan Hutchinson, of London, Eng., in his valuable Lectures on Clinical Surgery, 1 distinctly asserts his belief that " arsenic is a specific for the state of health upon which relapsing pemphigus depends." In many years' trial of this remedy, he declares that, in his own practice, he has never recorded a single failure, though he makes exception, properly, of many infantile cases supposed to be syphilitic. The remedy is certainly a valu- able one, but should be employed with the same caution and in accordance with the rules already prescribed in the chapter on psoriasis. Kaposi, however, declares that he has been unable to obtain favorable results from its employment. Iron, quinine, strychnia, and the mineral acids are certainly indicated in many cases, in conjunction with a particularly nutritious diet. Cod- liver oil and the malt preparations now in the market should not be neglected. ]STot infrequently the treatment should be directed to the relief of the anomalous performance of the sexual function in women, as the disease has been found to occur in the hysterical and chlorotic states sufficiently common as a result of such dis- order. The local treatment of the lesions should consist, first, in a puncturing of each bleb with a fine needle, in order to give exit ' London, J. & A. Churchill, 1878, p. 49. 218 DISEASES OF THE SKIN. to its contents, which should be carefully removed from the skin by the aid of cotton-wool. Then the parrs are to be thoroughly enveloped in an inert dusting powder. When there is consider- able pyrexia with heal and distress in the skin, the Burfaee may be treated as in acute eczema, with oleated lime-water, contain- ing als«. opium or dilute hydrocyanic acid in some such propor- tions as those already detailed. The ordinary lead and opium Wash, with or without the addi- tion of the oxide of zinc, will also answer a good purpose. In Vienna, the continuous water hath still enjoys the highest favor. Kaposi has kept one patient day and night for eight months with his body thus immersed, to the great advantage of the latter. Unfortunately such a course is well-nigh impracti- cable outside of a large hospital. Prognosis. — The prognosis in pemphigus vulgaris, though much less grave than in the malignant forms of the disease, should always be formulated with caution. Unlike several of the dis- eases heretofore considered, the affection is one not frequently encountered in persons of fair general health. The constitu- tional condition of the patient must be carefully considered ; nor should it be forgotten that the disease is not only one liable to relapses, but also one in which the graver may succeed the more benign manifestations. A flaccid summit of the bleb,san- guinolent or ichorous contents, an abundant efflorescence, and a rapid succession of new after t\\a involution of more ancient lesions, are in general unfavorable symptoms. The same be said of degeneration of the floor of the bleb, after rupture and dis- charge of its contents. The disorders next to be considered are mainly distinguished from those already named, by the gravity of their features, and the frequency with which they are conducted to a fatal issue. The distinction thus sought to be established, is of importance chiefly on clinical grounds. In the exceptional cases where a more favorable result is obtained, persistent lesion-relics rarely remain in the skin to mark there the traces of the ancient dis- ease-process. In this respect, the diseases now to be described, resemble those discussed in the chapters which have preceded. Dermatitis Exfoliativa Generalis. General exfoliative dermatitis is a disease characterized by erythematous, vesicu- lar, bullous, or pustular cutaneous lesions, involving the whole or the greater portion of the surface of the integument, succeeded by extensive desquama- tion, accompanied by febrile disturbance, and terminating often in marasmus and death. The condition which is now generally recognized under the title given above, occurs typically in two distinct forms, pity- DERMATITIS EXFOLIATIVA GENEKALIS. 219 riasis rubra and pemphigus foliaceus. It can hardly be denied to-day, however, that, clinically, intermediate forms can be recog- nized between the two extremes, thus justifying their considera- tion under a common term. Pityriasis Rubra. The disease which is recognized by authors under this title, is characterized throughout its course by a superficial hyperemia and inflammation of the skin, declared by a diffuse redness of a vivid or lurid tint, and an abundance of small, large, or lamellated, bran-like scales, which are continuously exfoliated from the epi- dermis throughout the course of the disease. Patients rarely present themselves for observation till a considerable portion of the surface is involved; but Kaposi states that in two cases ob- served by him the disease was first noticed in the neighborhood of the articulations. There are never at any time other lesions of the skin, betrayed in vesiculation, pustulation, moisture, or crusting. The palmar and plantar surfaces are usually less dis- tinctly reddened than the face and extremities, having at times even a pallid hue; but they are always covered with a distinctly scaling epidermis. Under pressure with the finger, the redness subsides or assumes a yellowish shade, while, as a rule, when the integument is gathered up betw r een the finger and thumb, no thickening and infiltration can be recognized. Exceptions to this have been, however, noted by several observers, by myself among the num- ber, in an interesting case made the subject of a clinical lecture. 1 The temperature of the skin is slightly increased. The exfolia- tion is, as the disease progresses, one of the most striking of its characteristics, the scales accumulating in large quantities about the coverings of the body of the unfortunate patient, who is en- gaged, as a French writer has it, in the labor of stripping him- self involuntarily of his epidermis. The disease persists for months and years, always more severe in expression as it advances, the papery scales being shed more abundantly and in larger flakes, leaving beneath them a smooth, shining, occasionally purplish or even cyanotic skin. In the cases observed by Jamieson, 2 of Edinburgh, and myself, the skin was soclark-hued as to suggest the color of the mulatto. Grad- ually the patient is conscious of an increasing sense of chilliness, as if deprived of sufficient bodily covering. The itching may be absent, moderate, or severe. Later, the integument seems to retract, as if insufficient to encompass the body, and becomes subject to fissure from extension and contact, while the lower extremities may even be oedematous. This retraction may be so marked that ectropion of the lid may ensue, and the wide open- 1 Pityriasis Rubra: Cliic. Med. Jour, and Exam., Feb. 1881. 2 Edinburgh Med. Jour., April, 1880, p 879. 220 DISEASES OF THE SKIN. ing of the mouth become difficult. The Lairs and nails lose their lustre and become triable, often falling, though at times escaping altogether. The influence of this gigantic, epidermal catarrh, involving, as if decs finally, wwy portion of the body, does not fail, toward the end, to be perceived by the vital forces. Alternating chills and febrile processes, pneumonias of a low grade, colliquative diarrhoea, tuberculoses, subcutaneous abscesses, bed-sores, and even gangrene of the skin, may close the scene. I [ebra and Kaposi have together had under observation " about fifteen" patients affected with pityriasis rubra who, with a single exception, died from its effects. It will be seen thus that the disease is exceedingly rare. A few interesting- cases have been reported by English authors. Among Americans, I believe that Duhring, Geo. II. Fox, of jSTew York, and myself, have alone published reports of c;ises. The disease is one of early or middle life, and preeminently of the male sex. Etiology. — The causes of the disease are absolutely unknown. It will be seen that the small number of cases which have been recognized, has furnished but an insignificant field for the study of the malady. It is interesting, however, to note in this con- nection, that the constitutional symptoms of each case seem to have been induced by the disease of the skin, and not the latter by any internal derangement of which the symptoms are made manifest. For not only do these visceral troubles occur chiefly at a late period of the malady, when common observation suffices to show that the cutaneous mischief alone is sufficiently exten- sive to induce them, but it is also clear, from the wide range of these disorders (bowels, lungs, etc.), that no special visceral malady has excited the cutaneous disease. Pathology. — The researches of Hans Ilebra 1 have demonstrated in two cases, that there is in the earlier period of the disease an infiltration of the integument moderate in degree, succeeded at a later period by cutaneous atrophy, in which the rete and pa- pilla- of the corium disappear. The connective tissue elements undergo sclerosis; and the glands and the follicles of the skin are destroyed. Pigmentation is abundant. Both he and Fleiseh- niiiii have discovered coincident pulmonary, intestinal, or cere- bral tuberculoses; and Kaposi, in one post-mortem examination, established an atheromatous condition of the uterus. Diagnosis. — It is scarcely necessary to add to the facts given above, that many cases loosely reported as instances of pityriasis rubra, are not really such. The misinterpreted symptoms are often those of an unusually extensive psoriasis or chronic squam- ous eczema, which commonly terminates favorably in the course of a proper treatment. I have been summoned to see several such eruptions, whose import has been misunderstood. 1 Vierteljahr. f. Derm. u. Syph., lift. 4, 1876, p. 508. DERMATITIS EXFOLIATIVA GENERALIS. 221 Psoriasis rarely extends over the entire surface of the body, but it will be at times thus generalized. In these very excep- tional forms, a long history of typical psoriasic patches ma} 7 usu- ally be obtained, while the bleeding surface beneath the scales and the character of the latter, will point to the true nature of the disease. Psoriasis occurs in healthy, pityriasis rubra in cachectic constitutions. Extensive erythematous or squamous eczema, apart from all other symptoms, can be recognized at once by the excessive distress occasioned by the eruption. The patient lies in bed nursing his or her tender limbs, back, or belly. In pityriasis rubra, the patient rises, dresses himself, and moves about with an expression, not of pain, but of listless apathy. His scales are not scanty and adherent, but abundant and exfoliating freely. There is, from first to last in his case, no history of moisture' In very generalized eczema, there will be always, at one point or another, a surface which weeps. In its early periods, pityriasis rubra can be distinguished from pem- phigus foliaceus by the absence of bulla?. When, however, there is present merely a generalized exfoliative dermatitis, the two disorders are, in my belief, often indistinguishable. Treatment. — Arsenic administered internally seems powerless in pityriasis rubra. Cases are on record of fatal results after the exhibition of this drug in prodigious quantities for long periods of time. Tar externally promises no better. Kaposi reports a single case relieved by the use of carbolic acid inter- nally. A roborant treatment, including the employment of cod-liver oil, iron, and quinia, is certainly indicated, with the simplest bland unguents externally. Of the latter, vaseline seems best tolerated. It should be employed, not merely to soothe, but also to protect the skin. The clothing should be ample and unirri- tating; and the diet carefully selected with a view to supporting the strength. The prognosis is necessarily grave. Pemphigus Foliaceus. In this disorder bullse form, which, instead of developing so as to freely project from the surface, as in pemphigus vulgaris, are flaccid, imperfectly distended, and, in cases, having a roof- wall scarcely raised from the tissues beneath. The relatively scanty, clear, or cloudy fluid which they contain, seems to push the limits of the chamber in which it is imprisoned, in a cen- trifugal direction, so that its mode of operation may be loosely compared to that of urine extravasated just beneath the skin. Below this elevated epidermis, no new tissue forms, so that the derma becomes exposed in patches as large as a saucer and even larger. The floor, thus exposed, is seen to be reddened and oozing. The exudate dries into friable and thin crusts, which 222 DISEASES OF THE SKIN'. become mingled with the effete epidermic plates forming the ancient roof-wall of flattened bullae; the whole producing finally a picture of generalized desquamation from the surface of the body. The extension over the entire surface is reached rather more slowly than in pityriasis rubra, but, once accomplished, the two diseases unquestionably merge by common phenomena. The hairs fall; the nails arc rendered friable; the integument becomes apparently insufficient for the covering, and certainly incapable of permitting the usual movements, of the body. Fis- sures open ; ectropion ensues ; a violaceous or deep pigmentation of the skin becomes perceptible. Emaciation, fever, diarrhoea, furunculosis, ulceration, gangrene, and death are the common chain of sequences. Grayish-hued, flattened blebs may also be seen in the mouth (velum, tonsils, epiglottis, and buccal mem- brane), the epithelium of which becomes detached in sodden masses, leaving behind a lurid-red, smooth, or ulcerated surface, which may interfere with articulation, deglutition, and even respiration. As has been stated in considering the subject of pemphigus vulgaris, the grave forms of the disease may originate in those which are commonly described as benign. The etiology, patho- logy, diagnosis, and treatment of the disease, have been practi- cally considered in the two preceding chapters. The prognosis is grave, as the disease, with i'ew exceptions, results fatally. General exfoliative dermatitis, when once fully developed, seems to present certain essential, definite, clinical features which have a character of their own. These are universal, progressive, epidermal exfoliation, and the consequent condition of maras- mus into which the patient falls. The accidents of this process seem to be fissures, infiltration, subjective sensations of pain, itching, etc., contracture of the integument, ulceration, subcu- taneous abscesses, gangrene, and visceral tuberculoses. If it be objected that pityriasis rubra and pemphigus foliaceus should be disassociated, because the former is a dry and non-discharging disease, and the latter a moist and exuding affection, character- ized always at first and often at last by the occurrence of blebs, the answer is sufficiently simple. The same arguments precisely which demonstrate the identity of erythematous, papular and ves- icular eczema, will indissoluble connect the two affections under consideration. The day in which diseases were classified by their elementary lesion has passed, [t is the occurrence of interme- diate forms which is the all-important fact. Jamieson 1 cites several Buch which are strikingly suggestive; and others are on record. The two diseases unquestionably merge, the dry ex- hibiting often a change to the moist or bullous form, and the 1 Loc. cit. IMPETIGO HERPETIFORMIS. 223 latter undergoing an inverse metamorphosis. When the causes are known which determine that one patient shall have a papu- lar, and another a pustular eczema, then it may be possible to explain why this general exfoliative dermatitis which destroys life is characterized by dryness; and that, by an ill-conditional fluid exudate forming an imperfect bleb. Impetigo Herpetiformis. Impetigo herpetiformis is a cutaneous disease of women, frequently compli- cating the puerperal state, characterized by the occurrence upon the skin and mucous membranes, of concentrically grouped pustules, and by a febrile con- dition which usually terminates fatally. Symptomatology. — Our knowledge of this rare disease is limited to the reports of eight cases observed in the Vienna clinic by Hebra and Kaposi; one in ISTew York, by Heitzmatm ; and a few scattered cases recorded by others. The patients were all women, and these usually in the puerperal state. Pin-head sized pustules, usually closely packed together in groups, tilled with an opaque or yellowish-green fluid, are discovered upon the sur- face of their groins, axillee, breasts, and several other portions of the body. A dirty-brownish-colored crust is formed by the rup- ture or desiccation of these lesions, and about this, single, double, or triple concentric circlets of new and similar lesions appear in succession, each series undergoing a similar process of involution. The eruption thus extends till the circlets from different foci of origin unite; and extensive areas of the skin are involved. Be- neath the crusts the skin is reddened, infiltrated, smooth, covered with a new epidermis, moist, as in eczema, or exhibits a denuded corium. It is never in a statu of ulceration. In the course of three or four months, the eruption is well-nigh universal, the skin being swollen, shining, and crust-covered, or seamed with excoriations here and there surrounded by circlets of pustules. The lingual mucous membrane exhibits grayish, centrally de- pressed patches, well-defined in contour. Alternate rigors and febrile accesses, mark the periods of recrudescence when new pus- tules form. Delivery seems to have had no favorable effect upon the course of the disease occurring in pregnant women. An endometritis with peritonitis was discovered, post mortem, in a single case. One woman only, of the eight Vienna patients, survived; and she suffered front a relapse after several weeks of improvement. The etiology and pathology of the disease are necessarily ob- scure, having in view the relatively small number of reported cases. Duhring describes a much milder malady of similar type, occurring in women not pregnant. Kaposi is inclined to asso- ciate the disease with a pathological condition of the uterus. Heitzmann thinks it related to pemphigus. Besnier and Doyon conclude the disease to have a septiceemic origin. In Vienna, 224 DISEASES OF THE SKIN. the treatment has been conducted by the aid of carbolated or alkaline baths, dusting powders, anodyne and carbolated oint- ments, and a mixture of plaster and coal tar. The prognosis is necessarily grave. Lichen Ruber. JDeriv. >«ix" v . moss. Lichen ruber is an exudative cutaneous disease, characterized by the appearance of firm, minute papules, conical, flat, or oven uinbilicated at the apex, whose evolution may be accompanied by a moderate degree of itching, the eruption, when unmodified by treatment, having a marked tendency to generalization and the induction of marasmus. Symptomatology.— Under the form lichen ruber, Hebra was first to describe one of the two forms of disease which are now recog- nized as equally entitled to the appellation. These are lichen ruber acuminatus and lichen ruber planus. In Lichen Ruber Acuminatus, pin-head sized, conical, reddish, scale-capped papules of con- siderable firmness, are disseminated abundantly over the surface of the skin, often in circles or lines, occasionally occurring first about the articulations, and in the course of a few months covering the entire surface in a well-nigh confluent eruption. The skin becomes then thickened, infiltrated, reddened, fis- sured, and scaling, the papules being at times no longer discern- ible. In unmitigated cases, the condition at this period resembles the later stages of general exfoliative dermatitis. The hairs fall, the movements of the body are accomplished with pain, and the extremities are maintained in a position midway be- tween flexion and extension. The integument is generally red- dened, covered with innumerable delicate scales, and, especially upon the palmar and plantar surfaces, thickened by dense infiltration. Over the deeper fissures, extending to the corium, blackish and blood-containing crusts form. The nails are thick- ened, friable, opaque, aud project from their matrices. Emacia- tion progresses pari passu with the invasion of the disease; and death results from exhaustion. In this country, the dis- ease is of exceeding rarity. Lichen Ruber Planus, occasionally seen in America, is the only form of the disease which I have had the opportunity of observing in this country. In it. the papules are glazed, waxy, umbilicated, scaling at the apex only alter they have existed for some time, pin-head to rape-seed in size, and roundish, angular, or oval in contour. They are usually firm and particularly well characterized by the LICHEN RUBER. 225 minute punetiform depression of the flattened apex, described as an " urabilication." They are at tirst irregularly disposed, but later tend to arrange themselves in groups about the flexor as- pects of the wrist and knee, the palmar and plantar surfaces, the lips, lids, cheeks, shoulders, penis, and other parts, as of the trunk and limbs. Often, as the lesions persist, they become flat- ter, assume a dark-brownish shade, and surround themselves with closely-packed, newer lesions in circlets or parallel lines. In this way distinct, sepia-tinted patches may form, whose pro- gressive involution leaves dark-brown atropine depressions in the skin, suggesting cicatrices. The itching may be moderate or severe. The eruption is chronic in its course ; tends to linger for years within distinctly circumscribed areas; and seems to exert upon the constitutional forces a much feebler influence than the acuminate form of the disease. As it is much more amenahle to treatment, it has been less studied in its unmiti- gated features, but Kaposi thinks that in the majority of cases it would, if unstayed, become generalized. In one ca.se only, has he noted the occurrence of emaciation and other symptoms of disturbance of the general economy. Etiology. — The causes of the disease are unknown. The sexes seem to suffer in equal proportion. The disease is neither trans- mitted by heredity nor contagion. In those who display the symptoms of the affection, external irritation is capable of aggra- vating the eruption. The disease is chiefly encountered in mid- dle life, but has been observed as early as the eighth month. Pathology. — The anatomical changes in the skin have been studied by Neumann, Biesiadecki, Obtulowic, and Kaposi. These seem to agree in pointing to the outer root-sheath of the hair and the perifollicular tissue, as the early seat of the disease. Here the hair follicle exhibits a bud-like prolongation, in conse- quence of hyperplasia of its elements, which involves finally the peri-follicular papillae and the rete above them. The umbiliea- tion is the result of central atrophy of the papillary layer. Pathologically, the two forms of the disease are discovered to depend upon a similar disease-process, a fact further borne out by the clinical evidence afforded by individuals displaying inter- mediate forms between the two extremes and even, at one and the same time, typical lesions of each variety. Diagnosis. — Lichen ruber is readity distinguished from moist forms of eczema by the absence of discharge and moisture, fea- tures present only in the most advanced stages of the first-named disease. Papular eczema exhibits lesions whose career, and whose ab- sence of umbilication and of angularity of outline, are sufficiently characteristic. From patches of psoriasis, the grouped papules of lichen ruber are distinguishable by the discovery in the latter of individual lesions of characteristic form. Pityriasis rubra and pemphigus foliaceus in their final stages might indeed be scarcely 15 220 DISEASES OF THE SKIN. excluded from lichen ruber acuminatus in a similar period. It yel remains to be determined whether the first may not represent the erythematous, the second, the bullous, and the third, the papular phase of a generalized exfoliative dermatitis, in which occurs a profound nutritive impairment of the tegumentary organ with a subsequent disturbance of the other organs of the body. Treatment — Arsenic is of greater value and can be employed with larger chances of success in lichen ruber, than in any other cutaneous disease. The drug is to he early given, persistently pushed in the face of new crops of lesions, till the desired result is obtained, and continued for several months after all signs of the disease have disappeared. Tonics when indicated, should always he exhibited. Kobner, 1 and others, have had remarkable success when using the metal by hypodermic injection, even after its failure by the mouth. The local treatment is naturally employed chiefly for the relief of any pruritic sensation. Here the dusting powders and oint- ments prove serviceable. The local remedies employed in cor- responding stages of eczema may, in brief, be here used with advantage. In Vienna, however, the tarry compounds have not been found as useful as in chronic eczema and psoriasis. Naph- thol promises better. Prognosis. — The prognosis of the disease, when it refuses to yield to treatment and tends to become generalized, is necessarily grave. Treatment after the occurrence of marasmus, will gene- rally be found ineffectual. The acuminate justifies a graver prognosis than the plane form of the disease. Untreated lichen ruber acuminatus will usually terminate fatally. Properly treated lichen ruber planus, fortunately the form well-nigh exclu- sively found in this country, may prove an obstinate but benign malady. Prurigo. Deriv. Lat. prurire, to itch. Prurigo is a chronic, exudative, cutaneous affection, common^ beginning in infancy or early childhood and continuing through lii'e, characterized by the occurrence of minute, pale or reddish papules with extensive infiltration and intolerable pruritus. Symptomatology. — In this affection, pin-head to rape-seed sized, firm, whitish or reddish-white papules form, chiefly and prima- rily upon the extensor faces of the extremities, hut from these localities extending gradually over the entire surface of the body. The itching they occasion is of the severest type. The earliest symptoms are usually displayed in the latter por- 1 Berl. Klin. Woch., Dec. 3, 1880. PRURIGO. 227 tion of the first year of life, in the form of an urticarial rash, which persists and is finally succeeded by typical papules. The latter are minute, often sub-epidermic, and become rapidly covered with blood-stained crusts in consequence of the induced scratching. Then ensues a long train of symptoms, including pustulation, fissures, excoriations, dense infiltrations, crusts formed of exuded serum and dried blood, oedema, diffuse dark- brown pigmentation of the surface in large areas, and consequent adenopathy. Fully developed, the disease presents in general the same physiognomy in different patients of different ages. The lower extremities always exhibit the severest manifestations of the disease, especially the thigh and leg as distinguished from the foot; though the trunk, forehead, cheeks, neck, arms, and head may be also involved. The protected surfaces, as of the axillae and groins, except as regards adenopathy, are free from the disease. The general health of the patient manifestly suffers from the insomnia and nervous agitation induced by the state of the integument. Emaciation, malnutrition, and cachexia are common sequelae. The mental and moral tone of the patient thus harassed from early childhood throughout an entire life, is necessarily profoundly impaired. Mild and severe forms of the disease are recognized in Aus- tria (prurigo mitis and prurigo ferox or- agria). Incessant care, judicious treatment, climatic influences, and the comforts of life commanded by wealth, seem to determine the difference between the two. Etiology. — The disease occurs chiefly in Austria, few eases being recorded elsewhere. A patient was, however, recently exhibited at the International Medical Congress in London, whom both Kaposi and II. Hebra recognized as affected with prurigo. "Wigglesworth and Campbell have reported cases in this country. It is needful to remember that the term prurigo is here employed to designate the disease recognized by some authors as the "true prurigo of Hebra." It should never be confounded with pruritus, which, under various usages, may be the title of a mere symptom of a disease. Prurigo is more often encountered in the male sex ; is never contagious, and never induced by lice; but, according to Hebra and Kaposi, may be grafted upon an hereditary predisposition. "Scrofula," tuber- culosis, malnutrition, " misery," poverty, anaemia, and filth, are held to be severallj r favorable to its development. Unquestion- ably the superior resources of the poorest classes in America will long protect them from the incursion of this inveterate malady. The only approach to the disease which I have seen in this country, occurred in the person of a male immigrant from Germany, whose skin was deeply pigmented and thickly set with minute papules on a densely infiltrated integument. He had suffered tor twenty years, but could not give a clear history of his condition in childhood. 228 DISEASES OF THE SKIN. Pathology. — Kaposi practically admits that, Btriking as is the clinical portrait of this disease, its anatomical features are indis- tinguishable from severe forms of obstinate papular eczema. The microscope reveals merely an hypertrophy of the various elements of the epidermis and derma, deposits of pigment in the corium, thickening of the root-sheaths of the hairs, enlargement of the cutaneous muscular elements (erectores pilorum), and a consequent atrophy of the integument which has long been the seat of the disease. Diagnosis. — Remembering the extreme rarity of prurigo in America, it is to be distinguished chiefly from the various forms of papular eczema by the location of its lesions and the course of the disease. From pruritus, it is readily diagnosticated by its general physiognomy and history; its peculiar pigmentations and infiltrations; and by the special region chiefly affected. But, both diseases may complicate prurigo, especially eczema, which is then ordinarily of artificial origin. In pediculosis vestimenti, the parasites will usually be found upon the under- clothing, while the lesions induced by the nails never form closely packed papules. There is something highly characteris- tic in the widely separated excoriations, puncta from wounds of the insects, and inflamed papules seen upon louse-bitten patients. Treatment. — In Vienna, sulphur, tar, green-soap, baths, and frequent anointings with oily and fatty substances have occa- sionally served to ameliorate the severe symptoms of the disease. Mercury, carbolic acid, salicylic acid, boracic acid, the diachylon and zinc ointments may also be employed upon different portions of the skin, when indicated. Internally, arsenic has proved valueless, while carbolic acid has occasionally seemed beneficial. Cod-liver oil and the ferruginous tonics with the bitters, will naturally be indicated in many patients suffering from mal- nutrition. Prognosis. — The disease usually persists through life. The most favorable conditions are those where the patient is quite young and surrounded by circumstances which permit of un- tiring provision for all his needs. Zoonoses. A number of diseases of the lower animals are transmissible to man, many of them with fatal result. Of these, some are attended with cutaneous symptoms, or display the latter as their chief morbid manifestations. Equinia (Glanders, Farcy, Maliasmus) is, as the term implies, derived exclusively from the horse. It is a contagious disease; manifested after a brief incubative period, either by grave constitutional symptoms which are not preceded but followed by an affection of the skin; or beginning with a ZOONOSES. 229 circumscribed phlegmon which rapidly passes through the stages of suppuration, gangrene, involvement of the lymphatic vessels and ganglia, and metastatic abscesses. Death usually results from septicemia, though recovery msiy occur after elimination of the poison, with great resulting prostration. The constitu- tional symptoms are, severe chills, high fever, and articular pains. When the cutaneous eruption succeeds the fever, there may be a generalized pustular eruption somewhat resembling the variolous exanthem, or numerous abscesses filled with an hemorrhagic pus. The mucous lining of the air-passages secretes an abundant, ichorous, puriform fluid. (Edema, erysipelas, ulcer- ation and gangrene are common complications. The disease is in a high degree contagious; and is said to be communicable to grooms and others who merely sleep in the stables where infected, animals are stalled. . Pustula Maligna. Tins is a disease of the same character as the preceding, orig- inating in those who have been brought into contact with the living or dead bodies, especially the hides, of animals infected with the "charbon." It is first manifested, usually upon the dorsum or other parts of the hands or face, to which the virus has had access, by the occurrence of an inflammatory and pru- ritic papule which is rapidly transformed into a blood-filled bleb, reposing upon a somewhat painful, engorged and often densely indurated base. One or more similar lesions may follow in the surrounding integument, coalescence of which produces a large, angry, cedematous and often gangrenous ulcer. The involved skin may be as large as a small coin, or of the size of the palm of the hand. The lymphatic vessels and ganglia enlarge and often suppurate; metastatic abscesses form; and the constitu- tional symptoms supervening are those described in connection with equinia. Death results from shock, septicaemia, or exhaus- tion ; though in cases where the lesion is circumscribed and unattended by constitutional symptoms, recovery may ensue. The attention and interest of the scientific world have been lately attracted to the experiments conducted by Pasteur and Toussaint with a view to securing immunity against these and similar disorders of the lower animals. By a so-called " vacci- nation" with " attenuated" fluids in which bacteria (supposed to be efficient in the transmission of these diseases) have been carefully cultivated, those gentlemen have unquestionably suc- ceeded in conferring a degree of immunity upon some of the animals experimented upon. It is probably too early to speak with confidence upon the brilliant results which many have thus been led to anticipate. In establishing a diagnosis of these and similar disorders, care 230 DISEASES OF THE SKIN. must be taken to avoid one source of error. These affections are, in this country, extremely rare, but occasionally various cutaneous eruptions are induced upon the hands, after contact with animals or hides upon which chemical solutions have been applied for the destruction of lice. These solutions usually con- tain arsenic, corrosive sublimate, and other substances capable Of exciting a localized dermatitis. The treat incur of these maladies is to be conducted on the principles of genera] therapeutics. Popper, 1 an Hungarian phy- sician with a large experience in malignant pustule, reports suc- cess by deep excision of the lesion, extending the operation to the subcutaneous connective tissue. This lias always proved suc- cessful when practised before the occurrence of general symptoms. Hebra was not in favor of the early cauterization of the ma- lignant pustule, and it may be considered as a questionable method of procedure. A grave case of malignant pustule is recorded, 2 in which re- covery ensued after the hypodermic injection of the tincture of iodine. Three syringefuls of the pure tincture were deposited beneath the skin at the periphery of the diseased surface, and lint soaked in the same was applied over the slough. Internally, fourteen drops of the tincture (1.) with three grains (.26) of the iodide of potassium, were also administered. Normal cicatriza- tion followed in this and six other cases recorded. 3. Hypertrophic. Molluscum Epitheliale. Deriv. Lat. mollusctis, soft. Epithelial molhisca are smooth, globoid, or acnmiiiiite bodies, situated either within or upon the skin, and in the latter case either sessile or pedunculated, varying in color from a yellowish-white to a dark-red, and in size from that of a pin-head to that of a bean. Symptomatology. — Molluscum epitheliale, a disease first recog- nized by Batcman, in 1817, under the title molluscum conta- giosum, is to be distinguished from another, known for a long time as molluscum fibrosum. The two disorders are perfectly distinct, and no longer to be confounded by a similarity in their names. Typical mollusca are firm, roundish bodies, averaging in size the dimensions of a pea, and in color varying from a waxy whitish hue, nearly that of the integument, to the dark-red tint of all injected masses. They are either imbedded in the skin, or project from it in semi-globular tubercles, sessile, or pedun- ' Cthltt. f. Chir., 1881. No. 33. 2 Archives Gen. de Med., Feb. 1882. MOLLUSCUM EPITHELIALE. 231 ciliated. Usually a dark-colored aperture can be detected at the apex or side of the lesion from which, on pressure, milky and curd-like, semi-fluid contents can be made to exude. Occasionally inspissated, or even horn-like masses project from these orifices, as though forced out by a vis-a-tergo. The disease is rare, and the lesion usually single and isolated, though hundreds may ap- pear upon the person of one individual. They consist of semi- fluid collections derived from that portion of the rete which either lines the sebaceous glands or penetrates between the pa- pillae of the derma, or transformations of the latter into corni- fied amorphous deposits, surrounded by thickened parietes. They may be artificially removed; or be shed spontaneously; or inflame, suppurate, and result in circumscribed abscesses; or terminate by ulceration. Most often they are insidious, and slow of development ; and may persist for years without producing annoyance or subjective sensation. They occur on the face, the sides of the neck, and the nucha: on the penis and scrotum of the male, and the breast and labia of the female ; on the trunk ; on the flexor surfaces of the extremities, and the dorsal surfaces of the hands and feet. They are most common in children. In consequence of the depression of the centre of the little tumors (which Hutchinson has aptly likened to small pearl buttons), they may suggest the lesions of variola, and are hence described by French writers under the term, varioliform acne. Etiology. — In England, where the disease was first recognized, and where, according to Hutchinson, it is far more frequent than on the continent of Europe, the belief in its contagiousness is quite generally accepted. Excellent authorities are, however, divided upon this question. At present, therefore, it can only be definitely stated that the contagiousness of moll use urn is not yet established. If contagious, the lesions certainly possess this power of transmission in a feeble and imperfect degree, one much inferior certainly to other lesions recognized as contagious. Retzius and Wigglesworth succeeded in producing the disease by the medium of the molluscous contents. I have expressed the contents of dozens of these lesions, and have never yet seen evidence of their contagious qualities. Experiments with inoc- ulation have been generally unsuccessful. The proofs of conta- gion rest chiefly upon the circumstance of lesions observed simul- taneously or successively on the breast of a mother and the mouth of her suckling child; or upon the successive development of mollusca in several members of one family. These are generally explicable as coincidences. Fox, of New York, has called atten- tion to an interesting relation which would seem to subsist be- tween mollusca and verruca, or ordinary warts. If ordinary warts are ever shown to be in a feeble degree contagious, it can scarcely be doubted that a demonstration of the contagiousness of mollusca will soon follow. In the absence of proofs of contagion, it can merely be said 232 DISEASES OF T II K SKIN. that the etiology of the disease is unknown It is as difficult to explain the origin of a molluscoii8 tumor on the face of a little girl, as to account for a wart <>n the hand of a boy. According to Kaposi, eczema, sweating, pruritus, and maceration of the skin, predispose to their occurrence. Pathology. — Upon section, a typical molluscous tumor is found to contain either a thick caseous fluid, or a mass of smooth, whitish and roundish bodies, which are often clustered aboul a short stalk. Microscopically, these are seen to he composed of epidermal masses, fat globules, and peculiar bodies of oval shape, partly or wholly contained in an epi- thelial pod, the so-called " molluscous corpuscles." The origin and significance of these corpuscles have been the subject of a great deal of careful investigation, and no little divergence of opinion as to the result. The disease by many authors has been consequently re- garded as one concerning the seba- „ ., ceous glands; and the fluid or more Molluscons corpuscles. 1 i • 1 ■ (After Kaposi.) or ' esS solid contents ot the tumors, as the result of the various metamor- phoses which the pent-up secretion of those glands underwent. By such authors the disease is termed " molluscum sebaceum," " contagiosum," etc.; and is classified with the sebaceous gland disorders. But the later studies of Retzius, 1 Lukomsky, 2 Renaut, 3 Vidal, 4 and Thin, 5 make it clear that, the disease is one which concerns chiefly the rete mucosum of the epidermis. Believing this- to be the real source of these tumors, I have, by agreement with Dr. Duhring, who also makes use of the same term in the third edition of his treatise, employed in the designation of the dis- ease the name molluscum epitheliale, first suggested in this con- nection by Yirchow, in the title epithelioma molluscum. Molluscous tumors may evidently take origin either in the portion of the mucous layer whose involution forms the lining membrane of the sebaceous gland, or in the prolongations of the rete downward between the papilla? of the corium where there is no follicle. In either situation, the molluscous elements are earliest recognized as simply enlarged epithelia which assume, as a consequence of this enlargement, a globular form. In the midst of these, there are certain individual elements which ac- quire a granular appearance, the granular masses finally giving ' Viertel. f. Dorm, und Byph. iv. lift. 3, 1877. 2 Virchnw's Archiv, Bd. lxv. s Lyon. MmL, July 25, 1880. ' 8oc. y the particularly waxy-look of genital mollusca with their depressed puncta. In such c Fig. 24. The author's case of nit.iiu.scum epitbellale. (From a painting in oil.) the inguinal glands should always be carefully examined, remem- bering, however, that a forcibly squeezed and cauterized mol lus- t-urn may be accompanied by a sympathetic adenopathy. KERATOSES. 235 Treatment — Molluscous tumors may be removed by ligature, scissors, knife, or curette, their contents having been previously expressed. When desired, the surface may be first chilled or frozen with the ether spray, to diminish the pain of the trifling operation. Bleeding is easily arrested by a pledget of lint. Occasionally the point of a crayon of nitrate of silver m&y be introduced after their removal, either to check hemorrhage or to insure destruction of the cyst. According to Hebra, the return or' the complaint, when it occurs at all, may be expected in points where no tumors have been removed. When the lesions are small and numerous, they may be made to exfoliate by the local application of green soap. Removal of the larger lesions may be followed by minute cicatrices. Prognosis. — The disease can always be terminated by removal of the tumors; the process to be repeated in cases of recurrence. Cicatrices, when these result, are of trifling moment. Keratoses. JDeriv. G-r. xipus, a horn. The disorders recognized as keratoses are due to an hypertro- phy which may involve preeminently either the epidermis or the corium. They are hence readily separable into two classes: — A. KERATOSES DUE TO EPIDERMAL HYPERTROPHY. Callositas (Tyloma). Callosities are superficial, circumscribed, dirty-white or yel- lowish-white, flattened, thickened, and horny patches of epi- dermis, dense in structure and usually insensitive. A section of the plaque shows it to he largest at the centre and least at the periphery. They vary in size from a finger-nail to a section of a hen's egg, being at times larger; and occur chiefly upon parts of the integument subjected to intermittent pressure, as the hands and feet ; also upon parts stretched over osseous promi- nences, as those over the ischia. They may be complicated by hyperemia, fissure, acute inflammation, or erysipelas; and read- ily serve as foci of cutaneous disease (eczema, psoriasis, etc.). They are commonly encountered among mechanics, carpenters, shoemakers, etc. ; among persons wearing ill-fitting shoes, stock- ings, or surgical apparatus; among workers in metals, acids, or heated substances; and among musicians (harpers, banjo-players, etc.). They are produced exclusively by external causes, pres- sure, friction, chemical agents, and heat. By careful considera- tion, they can be readily distinguished from eczematous, psori- asic, and ichthyotic patches, being always limited to the sites of external contact. Callosities require treatment only when they are sources of pain or discomfort. They may be removed; surgically, by the 23G DISEASES OF THE SKIN". knife: chemically, by the destructive action of acids or alkalies; rationally, by disuse of the part to an extent sufficient to inter- fere with the operation of the cause. When painful, they may be poulticed. A nightly soaking of the part with warm oil, kept in contact with the thickened epidermis during the hours of sleep, by a compress of flannel saturated with the same sub- Btance, will in the end always soften the induration. Clavus. (Corn.) Corns are similar hypertrophies of the epidermal layer of the skin, with the peculiarity of presenting inferiorly a coniform prolongation, which, being pressed from without inward upon the sensitive papilla? of the corium, excites pain in various de- grees. They vary in size from peas to large chestnuts, and are dense and callous when occurring upon those prominent parts of the foot where the hoot, shoe, or gaiter, exercises its greatest pressure. When occurring upon the lateral face of a toe in ap- position with another, the corn originates usually from pressure through the medium of the neighboring digits. It is then softer, from exposure to greater heat and moisture. Corns are often weather-sensitive, being unusually painful before, during, or after the occurrence of storms, ami should therefore not be confounded with gouty or rheumatic deposits below the skin. They are composed of superimposed, and often concentrically arranged, layers of epithelium, between which are occasionally found minute hemorrhagic extravasations. They are occasionally seen upon the palms of the hands. Corns are rationally treated by disuse of the feet, or the ad- justment of properly-fitted coverings for the same. They usually fall spontaneously after an attack of paraplegia, and in the case of the lower extremities confined for a few weeks in surgical apparatus for relief of a fracture. They may be softened by prolonged maceration in water, poultices, or, best of all, oil, as in the treatment of callosities. Erasion and excision may be prac- tised, if demanded by an exigency. Where the sufferer must necessarily continue to use the foot, the simplest and best treat- ment is as follows: The part is thoroughly macerated for half an hour, with water as hot as can be tolerated. Then the pro- jecting callous portion of the corn is gently removed by cutting or scraping, till, as nearly as may be. the surface is level with the plane of the adjacent skin. The part is then dried, and the entire surface, both of the seat of the corn and the adjacent in- tegument, is completely covered with many narrow, short, and nicely adjusted strips of Maw's moleskin plaster. When the trifling operation and dressing are complete, the patient should bear firm pressure over the corn without flinching, and walk witli perfect comfort. The plaster remains till it separates spon- taneously, which is usually in the course of a few days. The KERATOSES. 237 corn is then macerated at night with an oil poultice, as described above, and the dressing afterward reapplied, usually the second time by the patient. Persistence in this course is followed by complete relief if the coverings of the feet be properly fitted. Caustics, employed by many, are usually unnecessary when there is no ulceration of the hard corn ; and are in this situation fre- quent sources of great distress. They are chiefly valuable in the treatment of the soft variety ; but should always be applied with a skilled hand. Cornu Cutaneum. (Cutaneous Horns.) Cylindrical, conical, straight or twisted, angular, and other- wise irregularly shaped and sized corneous eminences, single or Fie. 26. Varieties of cutaneous horns. multiple, are occasionally seen projecting from the scalp, fore- head, nose, lips, ears, penis, and extremities. They are named 238 DISEASES OF THE SKIN. from their resemblance to the similar appendages in horned cat- tle, but widely differ from the latter, which are always im- planted upon osseous tissue. They are formed of dense mid massed columns of epithelin, often resting upon somewhat pro- longed papillae. Occasionally, on section, they exhibit the con- centric arrangement of the epithelia seen in corns, hut, unlike the latter, have reentrant basal depressions into which the pa- pillae below penetrate. At times they are implanted in a dilated follicle, in which case the glandular elements participate in their formation. At times also, they represent a corneous transforma- tion of the epithelia which constitute warts. They are seen in all colors, hut are often brownish-black, with a fissured or wrinkled exterior, like rough hark. They may lie painless, or, like the other keratoses, become the seat of inflammation in various grades. They may be short, or several inches in length. The largest specimen ever under my observation, was seen by nie in France, on the forehead of a male, where it had existed for fifteen years. It measured three inches in length. A few cases have been recorded in this city. They may be shed spon- taneously, never to return, or shortly to reappear. They occa- sionally develop into epitheliomata, as has occurred once under my observation, in a gentleman over sixty years of age, whose epithelioma developed from a horn on the dorsum of the right hand, projecting about three-fourths of an inch. Horns may be removed by extirpation, after which the surface upon which thej' were implanted should be carefully and com- pletely cauterized. B. KERATOSES DUE TO HYPERTROPHY OF THE DERMA. Verruca. Deriv. Lat. verruca, an excrescence. Warts arc cutaneous excrescences; sessile or pedunculated; pointed or flat; smooth, rugous, or having a cauliflower appear- ance; pigmented in various shades or of the natural color of the skin; congenital or developing after birth. They maybe single or multiple, and occur upon the hands, feet, face, scalp, neck, genital, and other parts of the body. They may develop slowly or rapidly, and persist for years, or disappear without apparent cause. They may be soft, dense, or even corneous to the touch. The several names given to the various manifestations of warts, have chiefly a descriptive value. Vkkruca acuminata (condylomata) are filiform, papilliform, or coxcomb like vegetations. They are single or multiple; at times hundreds coexist upon the genitalia and neighboring regions. In size they vary from a pin-point to a hen's egg, and may be larger. They are apt to be moist and secreting; being KERATOSES. 239 frequently covered with a puriform mucus of exceedingly nause- ating odor. Upon the genitals, they are encountered upon the glans, around the frsenum, and over the prepuce of the male; and in the female, about the clitoris, labia, vagina, and anus. They are usually of a bright red color in these situations. When occurring upon the integument, they are firmer, drier, and ex- hibit a feebler tendency to luxuriant vegetation. In this form they may be recognized about the axillary regions, the umbili- cus, the intercligital spaces of the feet, and even the face. Dr. Heitzmann once informed me that he had seen them covering the side of the chin. Verruca congenlta and Verruca acquisita are terms used to designate the lesions discovered at birth or later. Verruca filiformis. — This variety of wart differs somewhat from the others, not only pathologically, as is noted below, but in its clinical features. They are slender, thread-like, often pedunculated masses, usually covered with a smooth and appa- rently unaltered epidermis, occurring upon the neck, eyelids, chest, and ears of women. .Kaposi concludes that they represent minute fibromata. Verruca glabra is distinguished by its smooth surface. Verruca plana is the flattened or globoid, smooth or rugous formation like a plaque or button, usually pigmented, and occur- ring upon the back. Verruca senilis. — These are bean- to coin-sized growths developed upon the face, trunk, and extremities of persons of advanced years. They are fiat, usually pigmented, and have a granular aspect. They are readily separable by the finger nail, and are then found to rest upon a reddish granular base. As the result of external injury (caustics, traumatism) they may hecome the starting point of an epithelioma. Verruca vulgaris is the form most frequently seen upon the fingers and hands, pin-head to pea-sized, usually discolored, papilliform excrescences. Etiology. — The causes of warts are unknown; but in early childhood, a period in which they are most frequently encoun- tered, it is reasonable to conclude that they result from external contacts. It is when the child begins to handle everything within reach, that they usually first appear, and then about the hands. The acuminate or condylomatous warts are chiefly induced in parts moistened with a blennorrhagic secretion, but unquestionably may originate from contact with the leucorrhoeal 240 DISEASES OF THE SKIX. orpathological, oon-venereal discharges from the female genitals. I nave, however, never observed them in virgins of either Bex. The senile warts are more probably due to obscure changes in the nutrition of the integument. Pathology. — Warts on section exhibit, microscopically, an hy- Fi«r. 27. IP*** Vertical Bection of the summit of a pointed wart, a, papilla containing vascular loop : o, stratum corneum ; d, uypertrophied rete. (After Kaposi.) pertrophy of the papillary layer of the corium concerned in their iular loops mi. Above pertrophy ot the papillary layer of the corium concerne growth, with corresponding development of the vasci rising iron; the superior vascular plexus of the coriun: KERATOSES. 241 these papillae the rete is usually largely developed, the epithelia beiug multiplied not only on the sides of the prolonged papillae, but immediately over their apices. In all the dry varieties the stratum corneum is also hypertrophied, but this more especially over the summit of the excrescence. The filiform warts are composed chiefly of a slender fasciculus of connective tissue springing from the bundles below, and covered with an epider- mis which is not apparently altered. Beneath all forms of warts there may be a substratum of sclerosed connective tissue, con- stituting the firm base upon which they rest. Treatment. — Warts may be removed by excision, erasion, or caustics (nitrate of silver, alkalies, acids, perchloride of iron, cor- rosive sublimate, etc.). The larger growths upon the genitalia are often highly vascular, and may demand the prior application of a ligature when they are pedunculated. Even the slender filiform warts will be found to contain a small vessel in the pedicle which requires cauterization after the excision. "When the warts cannot be more readily removed by the knife or curved scissors, I prefer the Paquelin cautery to all other measures. The blackened eschar which is left prevents hemorrhage, serves as the best subsequent dressing, and, in my experience, is less apt to be followed, by a return of the growth. In some cases, it is a useful expedient to transfix the lesion in several directions with the long needles used in gynseco logical practice, previously dipped in a fifty per cent, solution of chromic acid. 1 Prognosis. — Warts are benignant growths; and in childhood and early adult life need not suggest grave sequelae. It is far different in advanced years, for, though these excrescences possess even then no malignant character, they are the too frequent pre- cursors of epithelioma. While it may be urged justly that the early lesions in such cases were really epitheliomatous and not verrucous ; the fact remains that many warty formations of appa- rently benign character do in advanced years, especially under the teasing of frequent cauterization, undergo a cancerous trans- formation. Multiple Cutaneous Tumor Accompanied by Intense Pruritus. Under this title Dr. W. A. Harclaway, 2 of St. Louis, describes a rare disorder characterized by the occurrence of about sixty pea- to nut-sized dense tubercles and tumors covered by a thickened, scaly, and excoriated, often hemorrhagic skin. In some situa- tions coalescence had occurred, forming thus, long and narrow plaques of nearly the width and half the length of the finger of an adult. The lesions were seen upon the outer aspects of the ! The following is the formula according to which are prepared several of the preparations sold in the shops for topical employment in both warts and corns : Salicylic acid, gss (2.) ; extract of cannabis indica, grs. v (0.33) ; collodion, §ss(16.). 2 Arch, of Derm., April, 1880, p. 129. 16 242 DISEASES OF THE SKIN. arms and legs, the palms and soles, the Bides of the fingers, and around the ankles, wrists, and elbows. The accompanying pru- ritus was intense and intolerable; and, having lasted for twenty- two years, was naturally associated with the degree of pigmenta- tion often observed under similar conditions. The patient was an unmarried woman, fifty-one years of age, and declared that the lesions first appeared as k> blisters." Specimens of these tumors, examined by Dr. Ileitzmann micro- scopically, exhibited hyperplasia of the epithelial and connective tissues. The papilla" were longitudinally elongated, branching, and provided with narrow capillaries. Numerous nests, greatly varying in size, and containing inflammatory elements with con- siderably enlarged bloodvessels, lay close beneath the papillary layer of the eorium. These elements showed all stages of transi- tion into basic substanee. The deeper layers of the derma were built up of very coarse bundles of connective tissue and numer- ous elastic fibres. Papilloma. — This term has been loosely applied to a large number of cutaneous growths widely differing from each other, both histologically and clinically. It has been made to include the vegetations of syphilis, the neoplasms of naevus, and even the tubercles of lupus. The designation, papilloma, is properly limited here to such cireumscrihed hypertrophies of portions of the skin as correspond with warts in their pathological significance. They may be de- fined as excrescences from the cutaneous surface, of a size con- siderably larger than all the varieties of the wart with the exception of the condyloma, usually presenting a luxuriant vegetation composed of elongated papillae, bloodvessels, and en- larged rete, covered externally with a smooth epidermis like a pellicle, or, more commonly, branched and tutted with the cauli- flower aspect, and then usually covered with a puriform mucus. The tumor inereases rapidly till it attains a maximum size, and then indolently persists. It is benign in character, and bears no relation to struma, carcinoma, syphilis, or lupus. It may occur upon any portion of the body. The cases observed by mo all occurred in women who were either pregnant or at the period of the menopause. Ichthyosis. Deriv. Gr. I^flt",-, a fish. Ichthyosis is .1 persistent disease of the skin, developed first in early infancy, and manifested in a general scaliness, in the formation of regularly outlined polygonal epidermal plates, or in the outgrowth of larger masses of a corne- ous consistency. Symptomatology. — The disorder briefly defined above, is one which displays a wide variation in its symptoms. To the ex- tremes in either direction two names are given, ichthyosis sira- KERATOSES. 248 plex and ichthyosis hystrix. These, - however, represent merely accentuated types of a disorder rare in its fullest development, and, in its slightest, much more common, I am persuaded, than is generally believed. Ichthyosis simplex. — In the simplest manifestations of the dis- ease the skin of the patient can merely be described as unusually harsh to the touch, moistureless, and covered with adherent or exfoliating, fine scales. The latter are not massed, imbricated, nor displayed in plaques, and are usually of a dull yellowish- white color. It is rare that the practitioner is consulted for the relief of this disorder; it is usually discovered when the skin is exposed for other purposes (exploration, vaccination, etc.). In a still more advanced degree, the scales are massed together, forming grayish and whitish, polyhedral elevations or plaques, regularly outlined and closely set together, especially upon the extremities and certain portions of the trunk. Elsewhere the scaliness described above may be present in a more marked de- gree. Variations occur, in consequence of which the plaques, bordered distinctly by the natural lines and furrows of the skin, are even depressed, centrally or completely, or assume darker shades of color than those described, brownish and greenish- brown. Ichthyosis hystrix. — With and without the symptoms de- tailed above, the hypertrophy of the skin may, in circumscribed patches or larger areas, produce irregularly-shaped, verrucous, corneous, corrugated, wrinkled, or rugous masses, usually much darker in color than the patches seen in the simple variety of the disease, and more often also discovered in adult years. The resemblance is here rather to the rough bark of a tree than to the scales of a fish. In other still rarer cases, the excrescences assume a spinous, acuminate, or horn-shaped form. The hand passed over the surface perceives not only the excessive rough- ness, but also the dryness of the skin. Perspiration is imper- ceptible in the parts affected. The, nails are friable and indu-. rated; the scalp, scaly and covered with hairs of exceeding harshness. The palms and soles are ofteti spared. Kaposi de- scribed certain diffuse callosities occurring in the palmar and plantar regions differing from the ichthyotic patches elsewhere. The face is usually spared, but, when involved, only the slighter manifestations of the disease appear there, minute, superficial, scaly patches of a grayish tint. Ichthyosis is accompanied by insignificant subjective sensa- tions. The skin, indeed, of these patients seems inapt for the eczematous and other complications of the less diffuse keratoses. I have treated four ichthyotic patients for syphilis, and noticed in all a decided tendency to the production of lesions of the 244 DISEASES OF THE SKIX. mucous surface without cutaneous complications. The extensor are usually more implicated than the flexor surfaces of the ex- tremities. Etiology. — Ichthyosis is unquestionably a congenital disease, though its first manifestations arc only apparent during the second year of life. It is said to be generally hereditary, but this should be accepted with some reserve for every individual case. One of ray ichthyotie patients was married to his own cousin, and had by her five children entirely free from cutaneous disease. None of his parents or grandparents were similarly affected. The disease occurs equally in both sexes, and is liable to aggravation in cold climates and the season of winter. The general vigor and development of patients thus deformed are, as a rule, quite unimpaired. Kaposi says : " The cause appears to be a local anomaly of the nutrition of the skin, especially involving its epidermic and fatty elements;" but this scarcely meets the requirements of etiology. Thost 1 describes ichthyosis occurring in four generations. Ac- cording to the ascertained genealogy, the ancestor first known to have suffered from this affection had five male children who inherited it, while one girl and one boy were spared. One of these diseased children had himself five children, of whom three males showed the disease, while one boy and one girl remained free. Another brother, of the second generation, had five male and three female children ; of these, four boj's and two girls be- came affected. One of the latter (of the third generation) bore four children, of whom three girls inherited the disease, while the fourth, a boy, escaped. It appeared that the affection always showed itself within a few weeks after birth, in the form of a roughness of the palmar and plantar surfaces. With the growth of the patient the condition constantly increased in severity, the epidermis shedding in large shreds until the disease reached its maximum by the fourteenth year. There was a marked dispo- sition to excessive sweating, particularly in the diseased locali- ties; the sensibility of the skin remained normal. Microscopic examination showed, in addition to the hypertrophied papillae, great development of the sweat, glands, with marked thickening of the ducts. Treatment failed to give more than partial relief. Pathology. — The diseased, or, better, deformed, skin is found microscopically to be hypertrophied in various degrees, accord- ing to the development of the malady; the proliferation of its elements occurring in connective tissue, papillae, stratum cor- neum, and bloodvessels. In well-marked cases of ichthyosis hystrix, the elongated papillae are surmounted by dense cones of the homy layer of the epidermis, more or less concentrically disposed, with sclerosis of the connective tissue, and a relatively unchanged rete. In this last particular, the dense plaque of ichthyosis differs in texture from the wart. 1 Inaug. Diss. Heidelberg, 1880; Cbl. f Chir., No. 10, 1881. KERATOSES. 245 Diagnosis. — Ichthyosis not only presents features which are so characteristic as to be unmistakable, but also those which can be well-nigh perfectly portrayed in plates. In this respect it differs from a long list of cutaneous maladies. 1 Were such necessary, aid of an important character can be gained in the history of the disease and in the entire absence of the lesions, lesion-relics and lesion-sequelse, common to all the exudative and scaling affections heretofore considered. Fig. 28. Ichthyosis hystrix, vertical section ; a, masses developed from the stratum corneum ; b, cones - formed by the rete ; c, hypertrophied papillae with dilated vessels ; d, dense connective tissue of corium, exhibiting numerous vessels transversely divided. (After Kaposi.) Treatment. — The younger the patient applying for relief, the larger are the chances of improvement and possible recovery. Ichthyosis hystrix of mature years is practically incurable. In- ternal treatment is valueless. External treatment is directed to softening, macerating, or anointing the skin, and, as far as prac- ticable, preserving it in a softer state. This is accomplished by frequent baths, alkaline, vapor, or combined with the use of soap or green soap, and generally followed by an anointing with 1 The admirable representation of the ichthyotic skin in plate F, of Duhring's Atlas, is faithful in its exactness. 246 DISEASES OF THE SKIN'. vaseline, dilate glycerine, or lard. The French, after the re- moval of the denser layers of the horny plates by the aih, nutrition. Atrophy of the skin is an idiopathic or symptomatic, diffuse or partial, diniinu- ■ tion of the mass of the integument, or its reduction, by loss or degeneration of one or more of its histological elements. The skin and its appendages, in common with the other organs of the body, may suffer from atrophy, either idiopathic or symp- tomatic in character, and general or partial in extent. It may result from either quantitative or qualitative, retrogressive changes, losing thus its normal dimensions, either from wasting of one or all of its normal elements, or from degenerative changes in the latter, or from their complete and final disap- pearance. Naturally these changes may be simultaneous. They are usually effected slowly, and the results are persistent. They are frequent concomitants of a long list of other pathological alterations. Usually, however, they succeed the latter. Under the general title of atrophy of the skin several rare forms of the disease have been considered. Xeroderma. {Deriv. Gr, £«?o?, dry ; and M^a, the integument. ) This term has been employed in the designation of several cutaneous disorders which differ in their pathological signifi- cance, but which are alike chiefly characterized by a dry and parched condition of the surface, including asteatosis, and the less pronounced forms of ichthyosis. In these pages the name is applied exclusively to the disease known as the " parchment- skin," or xeroderma, of Hebra. But few cases have been recorded, and these by Kaposi, Glax, 260 DISEASES OF THE SKIN'. and Geber, abroad ; and, in this country, by Taylor, of Xew York, in ;m interesting series of seven eases, and by Duhring, of Philadelphia. The disease results ultimately in a diffuse idio- pathic cutaneous atrophy, but this condition is preceded by a general hyperemia with vascular dilatation, and the production of numerous, punctiform, bright-red telangiectases and dissemi- nated, brownish and yellowish-brown maculae, varying in extent, between which form superficial, whitish and glossy, atrophic de- pressions, like the cicatrices of variola. The skin becomes fur- rowed, contracted, and as dry as parchment; and thus is readily developed an eczema or a superficial degeneration, including ul- ceration. A species of furfuraceous desquamation also occurs in patches. The faces of most patients exhibit a peculiar checkered appearance, from the uniform dissemination over the skin of the pigmented maculae. Ectropion, with ulcerative keratitis, epitheliomatous, sarco-carcinomatous and angio-myxornatous growths complicated several of the cases reported ; and in two, certainly, were the immediate causes of a fatal issue. Often, however, the general health seems, for long periods of time, to remain unimpaired, the subjective sensations being slight. Ob- servers of these cases differ somewhat as to the order in which the several lesions of the disease appear; and Duhring thinks it possible that no definite order is observed in the evolution of the symptoms. The etiology, pathology, and appropriate treat- ment of the affection are not understood. Blanching Atrophy of the Skin. Several instances of this peculiar degeneration of the integu- ment have been observed. It is characterized by an unnatural whiteness or pallor of the surface, with considerable tension and tenuity of the epidermis, usually limited to the extremities (the arms and palmar faces, ami the thighs and legs and plantar faces), moderate exfoliation occurs; and the latter, in connection with the tension to which the skin is subjected, is responsible for more or less painful subjective sensations. The disorder is chronic in its course, and may originate in infancy. The purest type of this atrophy is encountered in a well-nour- ished individual, one of whose limbs has long been affected with sensori-motor paralysis. The muscles waste, while the fatty elements may either persist, multiply, or almost wholly disap- pear. Over the whole rests a soft unusually whitened integu- ment, which in the paralysis of the aged often suggests the deli- cacy of childhood. Its hairs are relatively few; its pigment scanty; and its bulk manifestly diminished. In other cases, however, where there is trophic disturbance, the skin undergoes a shrivelling, with dirty yellowish coloration, and the exfoliation of dry epidermal plates. In these retrogressive changes, the nails may participate. STRIDE ET MACULE ATROPHICA. 261 The "glossy fingers," described by Sir James Paget, 1 are probably of the same general character. They are "tapering, smooth, hairless, unwrinkled, glossy, pink, and ruddy, or blotched, as if with permanent chilblains." One or several fingers are affected. The condition is associated with neuralgia or nervous impairment. Atrophia Senilis. This is the frequently recognized cutaneous degeneration pecu- liar to old age. The skin becomes colored in various shades of brown, either uniformly or in tolerably distinct maeulations over the face, dorsum of the bands, the genitalia and the anus, and. the lower extremities. It is seamed with furrows and wrinkles, often in various degrees desquamates slightly, and, losing the cushion of fat upon which it rested in earlier life, is either readily raised from the subcutaneous structures, or depends from them in loose folds. Pea- to finger-nail sized, verruciform, dirty- yellowish accumulations of epidermis become visible, often in numbers on the face and elsewhere, extending either as far as the deeper portions of the horny layer or the rete. The cutaneous atrophy in such cases may be characterized by unusual dryness, with failure of reproduction of the elements of the skin after the loss by physiological waste. The epidermis and derma, by their shrivelling, lose largely their characteristic interdigitations, while the elements of which they are composed, are impoverished in protoplasm. Vessels, relatively numerous before, disappear; pigment multiplies; the hairs are either pro- duced as lanugo, or fall as the papillae in the fundus of their sacs flatten; the root-sheaths encroach upon the follicle; while the sebaceous and sweat glands may either disappear or dilate and become filled with an epidermic detritus. In other cases the skin elements undergo a true metamorpho- sis, fatty, lardaceous, amyloid, colloid, waxy or vitreous. Striae et Maculae Atrophicse. Partial idiopathic atrophy of the skin occurs most frequently in linear cicatriform striae or streaks, an inch or more in length, developed chiefly about the hips, buttocks, and upper portion of the thighs in both sexes of adult years. Less frequently they are observed upon the neck, trunk, and extremities. They are insidious of development, indelibly persistent, and appear as sensibly thinned, glistening, and often depressed lines or fur- rows, having a whitish hue, with an occasional blending of a very delicate purplish tint. They are usually multiple, and at times abundantly displayed, running in various curves, for the most part parallel with the long axis of the body. They occa- sion no subjective sensation, and their etiology is unknown. 1 Med. Times and Gazette, March 26, 1864. 262 DISEASES OF THE SKIN. Much more rarely the atrophic areas occur in macular patches. Tlie lesions arc then fewer, more isolated, and are discovered more frequently upon the extremities, but also on the trunk, varying in size from a coftee-bean to a chestnut. This form of atrophy often succeeds cither an erythematous or pigmented condition, which very slowly changes till there is formed the dead-white, round or oval, often insensitive patch, resembling coarsely a vaccine cicatrix. Taylor, 1 and Atkinson, 2 have de- scribed some v<.-vy interest ing feat ures in this process; and I have been able to verify the accuracy of their ohservations in the only two cases of the affection I have had the opportunity of study ing. In both, the lesions occurred about the ankles of women with menstrual derangements, the largest spot of all attaining thesizeof the transverse section of a hen's egg. The patches were in various degrees insensitive, very slightly depressed, smooth, glistening, and scar-like, the condition being the sequel of brown- to choco- late tinted pigmentations, limited to the spaces which become afterward atrophic. Cantani 3 describes similar atrophic macula?, where there had been a bluish red color, evidently due to the development of minute vascular capillaries. The sensibility of the skin Avas unaltered. Under the microscope both the linear and macular lesions show separation of the fibrous fasciculi, effacement of the papillary layer of the corium, and diminution in the number of vessels and glandular appendages. In Taylor's and my cases, the macula? were quite hairless; in Atkinson's the hairs were relatively few 7 in number. Ftfre" ami Quemonne 4 have also described two singular cases observed in Charcot's clinic. In one of these, minute, whitish, elongated cicatrices appeared, about which there was marked pigmentation of the skin. They were abundant in the lumbar region. In a second case, brownish lines appeared over the hreasts of an unmarried woman which gradually grew paler, while others appeared over the skin of the throat. Those which were recent had a brownish or bluish-red color; others were of a dead white hue ; some appeared over the lumbar region and the upper part of the buttocks ; but there were none over the belly, the groins, and the thighs. In both cases the regions attacked were those in which there was no suspicion that the vergetures resulted from overdistension of the skin. These lesions are to be distinguished from the sequela? of morphcea, syphilis, and other diseases capable of leaving atrophic areas. A previous history of such pathological conditions would usually be needful ; but in the cases where there is precedent telangiectasis, hyperemia, or marked pigmentation of the spot, the diagnosis from morphcea will be, as several authors suggest, attended with some difficulty. 1 Archives of Dermatology, vol. ii. No. 2, 1867. 2 Rich, and Lou. Med. Jour., Nov. 1G. 1877. 8 II Morgagni, May, 1881. « Le Progres Med., Oct. 29, 1881, p. 837. LUPUS ERYTHEMATOSUS. 263 Partial symptomatic atrophy of the skin, in its simplest form, results from the traumatic action of tumors (ovarian, uterine, mesenteric, etc.), by which it is distended. The well-known results of a first pregnancy conducted to full term, are linear atrophies, at first of a violet tint, and later of a dead whitish hue, which are indistinguishable from the idiopathic lesions of simi- lar aspect, both clinically and pathologically. Partial symp- tomatic atrophy, with degeneration of the cutaneous elements (fatty, lardaceous, waxy, etc.), is the sequel common to a long list of cutaneous affections. 5. Neoplastic. Lupus Erythematosus. Deriv. Lat. lupus, a wolf. Lupus erythematosus is a cutaneous new growth, displayed to the view in well-defined, slightl}' raised, discoid patches, often with a depressed or atrophied centre, colored in various shades of hypersemia, covered with adherent, yellowish-gray scales, and terminating, after a favorable involu- tion, by the production of a persistent scar. Symptomatology. — The disease is first exhibited in one or sev- eral rape-seed to bean-sized, reddish macular, slightly elevated from the surface, and covered with a peculiar glistening epi- dermis, or with an adherent scale. When but a single patch is formed, the primary lesion de- scribed above enlarges its periphery, in the course of months or years, by a slowly continuous development. Its reddish outer rim is then distinctly elevated, while its centre is depressed, showing either adherent, yellowish-gray scales, or a glistening appearance of the unbroken epidermis. It ma}^ thus attain the size of a small coin or a large saucer, and occur in this form symmetrically or asymmetrically about the cheeks, nose, eye- lids, forehead, ears, scalp, mouth, hands, and feet. The disks or patches are very well defined in outline, and of a color vary- ing with the complexion of the patient, from a rosy-pinkish to a deep purplish hue. The shape is usuallj' circular, ovalish, or in figures representing combinations of these. The scales, too, vary in color, being at times of a clear white or whitish-yellow, and again, often from concurrence of comedones, of a leaden or brownish tint. The latter are usually scanty and adherent, but are also, rarely, abundant. They can be occasionally seen firmly fastened to the orifice of the excretory duct of a sebaceous gland. When such a patch spreads symmetrically over the brow and cheeks, its figure has been likened by Hebra to the open wings of a butterfly. The disease is never accompanied by the occur- rence of other cutaneous lesions; nor is it ever displayed in symptoms of moisture and discharge. 264 DISEASES OF THE SKIN'. When the maculae originate ns multiple lesions, the evolution of the disease may be accomplished by increase in the number of the farmer, rather than, as just described, by the peripheral extension of a single patch. The disease is then apt to be mani- fested, not only in the regions named above, but over the trunk and extremities, where it is likely to assume atypical forms, and be complicated by accesses of a febrile or neuralgic character, and by various cutaneous accidents, such as erysipelas, derma- titis, etc. The disease is remarkably chronic in its course, lasting in cases tor a quarter of a century, and throughout not interfering with the general health. So-called "galloping" cases are de- scribed by French writers, where visceral complications were the causes of a fatal result. The disease varies in the subjective sensations it produces; being at times accompanied by excessive itching, and often by no discomfort. It is much more common in women than in men, and is a disease of adult years. Kaposi reports a single case in one child three years of age. The scars left by the affection are indelible and characteristic. They are generally uniform and superficial; can be readily pinched up between the thumb and finger; are of a dull, whitish tint, and rendered punctate in a peculiar manner, sug- gesting the action of the engraver's tool in what is known as the "stippling" process. They are never pigmented, puckered, radiate, stellate, corded, or deeply attached. Etiology. — The causes of lupus erythematosus are unknown. Much has been said and written to prove that the disease is of scrofulous origin, but inasmuch as an immense number of scrofu- lous patients in all parts of the world never exhibit traces of the disease, it is needless to say that the proof has not been obtained. In by far the larger number of patients actually dis- playing characteristic disks of erythematous lupus, the usual concomitants of scrofuloderma (which see) are actually wanting. In many patients the most careful investigation fails to discover any other evidence of ill health. Yet inasmuch as many young women, after the puberal epoch, sutler from the chlorosis, anaemia, and menstrual irregularities, common to their sex and age, these conditions may concur. As for tuberculosis, aden- opathy, and malnutrition, no case of erythematous lupus yet presented at my clinic has chanced to occur in subjects affected with such symptoms. Considering the remarkable rarity of the disease, and the no less significant frequency of seborrhcea, the wonder is, not that they should occasionally concur or be trans- formed, the latter into the former, but that such phenomena are not more conspicuously and frequently noted. Pathology. — The disease process originates either in the peri- glandular tissues of the sebaceous or sudoriparous follicles and their ducts, or in some part of the pannieulus adiposus; in other words, from any point in the superficial or deep strata of LUPUS ERYTHEMATOSUS. 265 the cutaneous or subcutaneous structure. Under the microscope the elements of both the epithelia lining the glands and of the connective tissue without, are seen to be multiplied and largely commingled with the ordinary products of an inflammatory process. Thin 1 found enormous distension of the capillaries in the papillae, their loops of venules being choked with red blood disks, and in this state almost completely occupying the digitation. The same was observed in the perifollicular plexuses, while yet the rete and glands were quite unaffected. Such alterations would, without question, ultimately follow as the result of the vascular trouble ; but the observations are of interest as lending color to the supposition that the primary changes in lupus ery- thematosus are chiefly vascular. Similar vascular dilatations, papillary and perifollicular, have been noted by Kaposi and others as concurrent with structural alterations in other por- tions and appendages of the skin. In consequence of the new growth thus formed, there is mode- rate elevation of the initial macule of the eruption, and a thick- ened rim to its centrifugally developing patches. Central re- sorption or atrophy of the same material in the epidermis and corium of such a patch, explains the wasting and depression so frequently observed in each. By the destruction of the glandu- lar and connective tissue elements in the course of a retrograde metamorphosis, a loss is produced which is made good by the peculiarly punctate form of the cicatrix which results. Diagnosis. — The facies of the patient, with lupus erythema- tosus of that region, is usually so characteristic that the disease is there recognized with ease. When the hand and other por- tions of the body are involved, the diagnosis is somewhat less readily established. In the former situation, the disease has a predilection for the dorsum, and invades the palm usually only by extension to it from behind. From lupus vulgaris it may be recognized: by its occurrence originally at a later period of life; by its greater tendency to symmetry; and by the absence of nodules, ulceration, and ex- tension to the deeper portions of the skin, or underlying struc- tures. In eczema there is usually some history of moisture; in ery- thematous lupus, never. In eczema, also, the itching is a more persistent and distressing symptom ; but the acuteness of even chronic eczema, as compared with lupus erythematosus, will suf- fice to distinguish the two diseases. Psoriasis is rarely, if ever, limited to a single patch on the face; it is also characterized by more lustrous and more readily exfoliating scales. Its patches are, furthermore, uniformly well covered with scales, and of equal flatness in all parts, while those of lupus erythematosus 1 Medico-Chirurg. Trans., 1875. 266 DISEASES OF THE SKIN". are irregularly squamous, the scales being often clustered at the orifices of the ducts of the Bebaceous glands, while the rim of the patch is elevated and the centre depressed. Treatment. — The local treatment of the patches of disease is nt importance. Inasmuch as tlie affection is one whose invo- lution is occasionally accomplished under the influence of mild topical applications, and is succeeded very rarely by grave sequelsB, it is evident that the simpler measures should be first adopted. Of these, green soap, applied as a plaster, or in the form of the Bpiritus Baponis viridis, is most serviceable. It not only cleanses the patch of its scales, but stimulates the surface, often to the extent of inducing a reparative process. The patch may be briskly rubbed, either with the soap or the spirit, in combination with hot water, after which an ointment may be applied, preferably Bulphur, in the strength of two drachms(8.)to the ounce (32.) of petroleum ointment. When a decided effect is produced the spirit may be discontinued, and the hot water and unguent for a time employed alone. A decided and beneficial effect can be noticed at times after the topical application of very hot water alone, sopped on the part for twenty minutes at a time with a small sponge mounted on a handle. Other substances for local application are : the tars; iodized. phenol; iodized glycerine; the iodide of sulphur; iodide of potassium ; iodine in fine powder and tincture ; chrysarobin and pyrogallic acid. The two last named have a decidedly favorable effect, subject, however, to the inconvenience of stain- ing the skin, a prominent objection in the majority of cases where the disease is displayed upon the face. Upon the hands I have employed chrysarobin with the effect of producing a typical cicatrix in the course of a month when the disease had lasted for two years. In exceedingly obstinate cases, those especially where the ele- vated rim of the erythematous disk refuses to yield to the simple measures described, a solution of caustic potassa in distilled water, one part to two or four, may be gently applied with a eamel'8-hair brush, and the alkali immediately neutralized by the addition of dilute muriatic or acetic acid, as soon as the desired effect is produced. That effect, it must be remembered, is super- ficial cauterization only. When the serosanguineous exuda- tion and reactive effects disappear, the rim is seen to be flattened and to have lost in part its violaceous blush. After such severe application, which should never be trusted to the hand of one unskilled in its use, an anodyne cerate should be spread over the part, containing morphia or opium. Vesication with cantharides, recommended by Anderson, has been endorsed as valuable by several authors. The same may be said of the mercurial plaster, of which Kaposi speaks highly; while he and others agree that carbolic, salicylic, nitric, chromic, and sulphuric acids, the chloride of zinc, the other mercurial preparations, and arsenical pastes, are of less value. LUPUS VULGARIS. 267 Erasion by the dermal curette, in accordance with the method pr^aeed by Dubini, of Milan, and popularized by Volkmann, of Halle, has been successfully practised by many operators ; as also the treatment by multiple punctures. None of these have met with the favor in lupus erythematosus, which has been accorded them in lupus vulgaris; while multiple incisions by the lancet, or the instrument devised by Mr. Balmanno Squire 1 have been rewarded with greater success. The instrument of the latter makes sixteen simultaneous and superficial incisions in the patch previously frozen by the ether spray. Vidal 2 lays stress upon attacking in this way the peripheral zone of the lesions. The internal treatment of the affection is much less satisfactory. Often none is indicated or required. Anderson 3 highly recom- mends the trituration of twenty-four grains (1.6) of iodine with a little water, and adding to this one ounce (32.) of starch till a uni- form deep blue, almost black, color is obtained, after which the iodide is dried by gentle heat. A large teaspoonful is given in a little gruel three times daily. The administration of the iodide of potassium and iodoform has also been followed by remarkable results. In general, however, cod-liver oil and the chulybeates will be found most serviceable, in connection with such hygienic regimen and diet, as is in each case specially indicated. Prognosis. — A favorable opinion with respect to the future of the disease can never be safely given; though, as regards the general health and comfort of the patient, there can rarely be question. At the same time the affection is capricious in its course, and may on occasions, after long periods of obstinate persistence, very rapidly improve under the simplest treatment. It is liable to relapse though not to frequent recurrence. Lupus Vulgaris. Deriv. Lat. lupus, a wolf. Lupus vulgaris is a neoplastic growth iu the skin or contiguous raucous mem- branes, manifested in the production of slowly developing, reddish-brown nodules, whose involution, in certain cases, is succeeded by ulceration and the production of a cicatrix. Symptomatology. — The disease is characterized at its outset nnd throughout its career, by the development of numerous, isolated, sub-epidermic nodules, varying in size from a millet- seed to a hemp seed, encompassed by the derma, and betrayed to view in the epidermis by punctiform maculations of a reddish- brown color, which fade under pressure with the finger. It is the subsequent evolution of these elements in each lupous eruption, often indeed somewhat difficult to appreciate, which 1 British Medical Journal. May, 1880. 2 Le Praticien, Nov. 14, 1881. 3 British Medical Journal, May 1, 1880. 268 DISEASES OF THE SKIN. furnishes each variety of the disease. Tims they may be dis- seminated irregularly as in segments of circles (lupus dissemi- natus, lupus 8BRPIGIN08U8); or develop in bulk to the size of papules or tubercles (lupus tuberculosus); or proceed to involu- tion by atrophy and desquamation (lupus exfoliativus); or by ulceration (lupus vorax, lupus exedens); or be the seat of pro- liferating vegetation (lupus vegetans, lupus hypertrophic or of corneous and papillomatue growths (lupus verrucosus). A number of other names are employed to designate unessential features of the disease, according as its lesions appear in lines, with well-defined margins, or display elephantiasic, acute, chronic, and other phenomena. The disease is quite rare in this country, and when seen is usually in papular or tubercular phases. The lesions are then commonly agglomerated in patches; and vary in consistency, size, and depth of involvement of the derma and subcutaneous tissues, though often distinctly circumscribed in outline. If resorption occur the papulo-tubercles flatten by atrophy, and the shining, tense, and imperfectly formed epidermis by which they were covered, exfoliates, leaving a cicatrix beneath. When ulceration of the patch occurs, a suppurative and often painful inflammation precedes; the ulcer, if the secretion it fur- nishes be permitted to dry upon its surface, very slowly spread- ing beneath the crust. The lupous ulcer has a dirty, purplish- red, indolently granulating and hemorrhagic floor, a generally circular outline, soft neither elevated nor undermined edges, and a discharge which is sufficiently abundant to drip freely from an exposed surface, or to dry in peculiar, broad, flat, rather uni- formly homogeneous crusts. The nose is the most frequent seat of lupus, and this organ it may reduce eventually to a mere atrophied miniature of its former shape, or utterly destroy by extensive ulcerative invasion of its integument, mucous membranes, and cartilages. It occurs also upon the cheek, chin, ears, lips, lids, scalp, neck, genitals, buttocks, and extremities. At times, two or more distant regions are affected. I have at present under my charge a young Eng- lishman with a palm-sized lupous patch upon and beneath the chin, and a large platter-sized exulceration on the right buttock and thigh, both of which have tormented him from his earliest childhood. The ravages of the disease are at times frightful in severity; not merely in consequence of the destructive ulceration to which it tends, but from the deformity left by its ungainly attempts at repair. The entire head may be thus converted into a hideous travesty of humanity, while yet its possessor is left with all his vital organs and tunctions apparently unimpaired. Etiology. — The causes of lupus vulgaris are absolutely unknown. It is certainly in no way associated with either acquired or hereditary syphilis. From scrofula it is as widely separated in LUPUS VULGARIS. 269 its clinical features as is lupus erythematosus; and upon this point the statements made above in considering the etiology of the last-named disease are here equally pertinent. It is neither contagious nor transmissible by heredity; nor is it limited to either sex, nor to inviduals of any social grade. It occurs at times in the anaemic and the asthenic; but also in those otherwise possessing all the symptoms of fair health and even excellent vigor. It is much rarer in this country than abroad, occurring here with nearly the frequency of lupus erythematosus. It is Fie;. 30. Section of a lupous nodule. d d b, normal corium; a, reticulum with lupous eleme c, d, giant cells. (After Kaposi.) generally first seen between the third and sixth years of life; after the thirtieth year of life practically never, unless there have been prior symptoms of the disease. Pathology. — For a knowledge of the microscopic characters of lupus vulgaris we are largely indebted to the Germans, whose opportunities for the study of the disease are unequalled. Vir- chow, Auspitz, Billroth, Lang, Kaposi, Klebs, and Stilling, with Thin, of England, have amply contributed to the subject; and the result of their investigations may be concisely stated as fol- lows: — 270 DISEASES OF THE SKIN. The more recent nodules when divided exhibit at different depl hs of i he corinra roundish masses, comparable to a nidus or nest, above which spreads an unaltered epidermis. These foci of the disease are well defined in outline, and of a reddish-yel- lowisb tint. Around them is woven a network of connective tissue bundles; with larger and smaller interspaces containing vascular elements, and also so-called cells and nuclei, proba- bly masses of protoplasm originating in the reversion of the connective tissue elements to the embryonal state. Retro- gression is marked by a diminished vascularity; while the ele- ments disappear by resorption, or by the destructive process of ulceration followed by the cicatrix. Both Kaposi and Lang agree that the vascular and fibrous elements of the lupous mass are capable of developing new connective tissue which later un- dergoes retraction. This is curiously in accord with the clinical result of Squires' treatment by multiple linear scarification, in which the lupous growth, after replacing the normal elements of the derma, becomes itself the source of the new material of repair. When the disease is extending, the lupous growth, spreading along the vascular elements of the derma, involves finally the rete and the panniculus adiposus. The nest-like agglomerations disappear; there is in their stead an irregularly diffuse infiltra- tion, producing subsequently hypertrophic, atrophic, desquama- tive, suppurative, or ulcerative sequelae. Finally, the glands of the skin may become involved, the hairs falling from their fol- licles, the sebaceous glands either becoming obliterated, or leav- ing their acini stuffed with epidermal masses which distend them in milium-like bodies grouped about a cicatricial pedicle. When, as observed by several authors, there is coincidence of lupus vul- garis and epithelioma, the latter is developed from epithelial cones, described by Kaposi as penetrating downward and in other directions from the sweat glands and the root-sheaths of the hairs. Diagnosis. — Epithelioma, though rarely resembling lupus vul- garis, is more often designated by that than by any other false title. Great confusion lias arisen from the looseness with which several surgical authors have furnished illustrations of "lupus exedens," which were really pictures of cancer. JJut the latter is rarely a disease of early life, and when of such early occur- rence never persists to adult years; while lupus is such exactly in the vast majority of all cases. The nodules of lupus are absent in epithelioma; and the evolution of the disease slower, less painful, and, in its earlier periods certainly, of deeper situ- ation. The ulcer of epithelioma is more often defined and single; its edges, indurated and everted; its floor, uneven and glazed; its secretion, scanty and occasionally fetid; its base, a mass of indurated tissue. Lupous ulcers are often illy-defined and multiple; their edges, soft and inconspicuous, neither everted LUPUS VULGARIS. 271 nor undermined; their floors, granulating and flattened; their secretion, relatively profuse and generally odorless; their bases, soft and pliable though occasionally indurated. Tubercular, serpiginous, and ulcerative lesions of syphilis may at times resemble certain forms of lupus. In any doubtful case a history of infection, of other types of cutaneous disease, of mucous patches, of adenopathy, of abortions in the female, etc., should aid in the recognition of syphilis. The suspected lesions should be carefully examined for the purpose of distinguishing characteristic lupous nodules in the patch itself, or the periphery of any exfoliating area. In the case of an adult, a long history of lupus can be often obtained; and it is worthy of note that syphilis with exceeding rarity displays for long periods of time a single exanthematous lesion or aggregation of such lesions in one part of the body exclusively. The lupous ulcers, often mul- tiple and isolated, insensitive, rarely of well determined outline, never reniform or horse-shoe shaped, with supple edges and granulating Moor, covered with crusts like soiled parchment of uniform thickness, do not resemble those of syphilis. The latter are often painful, single, circular, and clean cut in contour, with offensive greenish and blackish crusts resembling oyster shells. The cicatrices of syphilis are elegant, smooth, delicate, super- ficial, circular, and, after pigmentation has disappeared, dead- white in color. Those of lupus are irregular, indurated, deform- ing, yellowish-white, and reddish-yellow. Lupus erythematosus is even more readily distinguished by its characteristics; including the absence of nodules, ulcers, and crusts, and the superficial character of the disease process, the scaliness, and occasional symmetry of the patch. Cases are de- scribed of intermediate forms between lupus erythematosus and lupus vulgaris, but I have never been able to persuade myself that these really occur. The two diseases, unfortunately some- what similar in name, are unquestionably distinct in character. The so-called intermediate forms shown to me have been in every instance cases of flat and. scaling epitheliomatous infiltrations going on to ulceration. Treatment. — Without question the local treatment of lupus vulgaris by a modification of the Dubini-Volktnann method (that namely by multiple linear scarification) deserves first men- tion; as it is claimed with some justice to have changed the prognosis of the disease. It is somewhat doubtful whether any- thing is to be gained by either a preliminary freezing of the part, or the use of the cutting instrument of many blades devised by Squire, of which mention is made in the preceding article. The incisions are best produced with a delicate bistoury held in the fingers like a pen. They should be in parallel lines, closely set together, and crossed; should extend completely through the depth of the lupous growth ; and this is determinable after some practice by the cessation of the creaking resistance which the 272 DISEASES OF THE SKIN. blade fails to discover in normal tissue. Further, they should extend laterally beyond the borders of the lupous patch into the Bound peripheral zone. The bleeding is trifling and readily arrested by firmly pressing small pieces of fine sponge, lint, or absorbent cotton over the part. The edges of the incision unite either by granulation or first intention; and in both cases seem to serve as starting points of the reparative process, the material for which, as already pointed out, seems to be supplied from the lupous nests themselves. Subsequent operations, when needed, require a previous freezing of the affected surface. Less efficacious, more painful, and much move disfiguring in its results, is the method of erasion by thedermal curetTte. This instrument is a sharp-edged spoon with a fenestrum in the howl to permit escape of the debris. With it, the frozen lupous growth may be completely scraped away, and, if necessary, caus- tics subsequently applied. The method of treatment by multi- ple punctures instead of incisions, is efficacious, though less satisfactory. Schilt', 1 and Auspitz, have combined puncture with the introduction of iodized glycerine (one part of the former to twenty of the latter), the first named operator using a tubular needle filled from a rubber pipette. I have on several occasions, both in public and private, em- ployed the Paquelin knife without anaesthesia and with good results. The finer blades, especially manufactured for the pur- pose, are thrust at a red heat again and again through the lu- pous tissue until it is destroyed in its depth. Over the whole, the lower blade is firmly passed and pressed, the blackish coal resulting being the best subsequent dressing after the serous ex- udation ceases. Americans are generally credited, abroad, with a preference for erasion followed by tne galvano- or thermo- cautery. Inferior, I believe, to all these methods, is the now somewhat obsolete treatment by chemical cauterization alone. The various acids and alkalies, nitrate of silver, arsenical, mercurial, and zinc compounds, have all been thus employed, and each, in suitably selected cases, may be productive of fairly satisfactory results. For the cases which do not require surgical or other operative interference, simple local applications may be made, such as oil}' and fatty substances for the softening of crusts; stimulating dressings of tar, iodated glycerine, carbolized glycerine, iodized phenol, napbthol, chrysarobin, pyrogallic acid and iodoform ; as also the carbolated unguents appropriate for the reparative phases of the ulcer left after the destruction of the lupous growth. The internal treatment of lupus vulgaris is practically that indicated by the condition of the patient ; inasmuch as no medi- cament is known to be capable, alter ingestion, of relieving the victim of his local ailment. Of the articles in this category ' Viertel. f. Derm. u. Syph , Nos. 2 and 3, 1880. KELOID. 273 none will be more often indicated than cod-liver oil, the chaly- beates, the bitters, the preparations of iodine, and possibly phos- phorus. Arsenic and mercury are powerless to prevent the extension of the disease. With these, it is needless to add, a diet of the most generous character is to be supplied, and the rules of hygiene enforced. Keloid. Deriv. Gr. ^i*?. a claw. Keloid is a benign cutaneous neoplasm, occurring as one or more elevated, whitish and reddish, firm and elastic nodules, plaques, ridges, radiating strife, or as several of such forms in combination, resembling an hypertrophied cicatrix. Symptomatology. — The' term Keloid, first given to this disease by Alibert, should be restricted to it exclusively. The symp- toms are, dense, generally elastic, nodules embedded in the corium Fig. 31. Keloid growths. and firmly attached to it. They are generally very slow of evo- lution, and, having ouce attained their full development and assumed one of the several shapes which they affect, usually per- sist for a lifetime. These forms are globular or semi-globular 18 274 diseases or THE skin. nodules, buttons, or plaques, with roundish or ovoid outline; linear elevated striae, bands, ridges resembling cords, ribbons, or tapes, in irregular outline and disposition; or combinations of two or more of these figures. A common form over the sternum, and in other situations where the development of the growth in every direction is unimpeded, i9 that of a larger central mass with two or more diminishing and declining prolongations hearing a remote resemblance to the body and claws of a crab. The lesions vary in size from a small pea to a large saucer, the largest including the outlying points of the limbs or radiating ridges. Over it the skin is reddish or whitish in color, smooth, hairless, and occasionally hyper-sensitive to pressure and heat. The growth is also at times the seat of spontaneous pain. The most frequent site of the disease is the anterior surface of the chest, but it is observed also upon the face, neck, ears, breast, hands, between the scapula?, and on the extremities. It may be encountered indeed upon any portion of the body. I have seen it upon the penis of the negro. A case of scar-keloid undergoing involution, has been described by Dyce Duckworth, in a man, aged fifty, who sutfered from rheumatic fever, on two occasions, ten years before the date of report. He had pericarditis, and was blistered over the prsecor- dia. Nine months afterward, lines of keloid growth began to form in the scar left by the blister, and they extended rapidly. In two years' time they were still enlarging. In seven years, some subsidence was noticed, and, when exhibited ten years after their first formation, involution was markedly progressing. The case illustrates the frequent, origin of keloid in scar tissue, its common occurrence over the sternum, and the fact of the subsidence of the new growth in the course of time. 1 Etiology. — The disease occurs both spontaneously and as an hypertrophic development from a simple scar, in persons of all ages and sexes, but with a decided preference for the negro race. It is often the result of traumatism, as from piercing the ears for ear-rings, the operations of surgery, leech-bites, the deeper burns from lire, and wounds inflicted by accident. I have seen it in several instances follow cutting the hands with glass; and once, in the same situation, from the wound inflicted by the spur of a cock. It is sufficiently common after the occurrence of aene indurata, but the latter is of all its forms the least persistent. In general it may be concluded, however, that it occurs chiefly in those whose skins have a special tendency to such develop- ment. Pathology. — Kaposi has demonstrated a. difference, rather of disposition than of kind, between keloid, hypertrophied cica- trix, and cicatricial keloid. In the first, the epidermis is intact, while the corium at one level exhibits whitish, thickened, and ) Brit. Med. Jour., October 8, 1881, p. 597. KELOID. 275 closely packed bundles of fibrous elements, lying parallel to tbe long axis of the tumor and the surface of the skin, traversed here and there diagonally by similar bundles, all probably de- rived originally from the sheaths of the bloodvessels. In the second, the papillary layer of the corium has been destroyed by the process of which the cicatrix is a resultant, and the latter does not surpass its original limits by invading the unaltered peripheral tissues. The connective-tissue bundles are here also much less closely aggregated. In the third, the two forms de- scribed above can be seen combined, the papillary layer being- destroyed, and the peripheral parts invaded by the connective- tissue new growth. Diagnosis. — The features of keloid are readily recognized by its peculiarities described above. It can only be confounded with cicatrix; and in any doubtful case a distinction between hypertrophied cicatrix and keloid would be needless from any point of view. Keloid following the piercing of the lobule of the ear for the insertion of ear-rings, is distinguishable by pinch- ing the part between the fingers, when a globular, pea to cherry- sized mass will be felt firmly imbedded in the derma between the reflected folds of the integument. Upon the face, after the occurrence of acne, it can be usually seen as a puckered ridge, often transverse in direction, occupying the region of the cheek. Treatment. — Removal of keloid by cauterization and excision is not to be practised, as the growth does not fail to reappear. Vidal 1 has successfully employed multiple linear scarifications. Various stimulating applications may also be made with a view to promote resorption, such as the spirit of green soap, iodated glycerine, iodine in ointment and tincture, mercurial and lead plasters. Where there is pain, anodyne unguents may be em- ployed topically, such as the freshly prepared belladonna plaster, or the ointments of belladonna, stramonium, and opium. By far the most elegant of these, and one which also is capable of producing an alterative effect, is the oleate of mercury and mor- phia, manufactured by Squibb, of Brooklyn. Internally, quinine, strychnine, arsenic, and the iodide of potassium have been exhibited with varying success. I have never happened to see a case where internal medication had been followed by appreciable results in the diminution of the growth. Prognosis. — As regards the general condition of the patient the prognosis is favorable. Very rarely there is spontaneous resorption of the nodule or tumor. Generally the latter may be expected to persist, after full evolution is attained, for an indefinite period of time. Keloid of the cheeks following acne is usually smoothed down in the process of time, after the dis- appearance of the sebaceous gland disorder, till the deformity is greatly lessened, and often scarcely noticeable. Gaz. Des. Ilopit., January 29, 1881, p. 94. 276 DISEASES OF THE SKIN". Der Molluscum Fibrosum. Lat. molluseua, soft; and libra, a fibre. Molluscous fibromata are cutaneous or subcutaneous neoplastic tumors, pro- jecting in different degrees from the surface, single or multiple, of several grades of density, distinctly circumscribed, covered either by a sound and attached, or rarely by an ulcerated integument, and varying in size from a small pea to a foetal bead. Symptomatology. — Molluscum fibrosum is a disease character- ize. I usually by the occurrence of numerous roundish, sottish, semi-solid, or Bolid growths, varying in size from that of a small ]>ea to tumors of several pounds weight, though more rarely the neoplasm is single. They are situated, when quite small, within Molluscum Hbrosam. (Gross ) siugle fibroma. (From a photograph.) MOLLUSCUM FIBROSUM. 277 or beneath the skin, where they can be distinguished as dis- tinctly circumscribed nodules, buttons, or plaques often slightly projecting. When more fully developed they become sessile, pedunculated, or largely pendulous tumors, hanging from the part to which they are attached so as to resemble in shape a cherry, a nipple, a pear, or a sausage. They are commonly cov- ered by an iutegumeut which is natural in color and suppleness, though the latter may be traversed by bloodvessels ; sprinkled with comedones or patent orifices of sebaceous gland-ducts, thinned or thickened, or in a. state of ulceration ; the last named being usually the result of externally operating causes in tumors of large size. They are productive of no subjective sensation beyond the more or less uncomfortable tension produced by the weight of those attaining a great development. When mul- tiple, they may be seen in various degrees of development, cov- ering in hundreds the entire body, especially the scalp, face, trunk, genitals, and extremities. Upon the lids, they may inter- fere with vision by the production of ptosis. To the touch they may be felt as softish, somewhat elastic, firm, or lobulated masses, though at times nothing but a double fold of skin can be perceived, or a cordlike contained body. Etiology. — The disease is peculiar to neither sex ; and, though observed in adults, is commonly first developed in childhood. It cannot be claimed as peculiar to any race, though in this country the negroes have probably furnished the largest field for its observation. Hebra called attention to the low standard of physical and mental development of the subjects of the dis- ease seen by him, a fact well illustrated in a case presented at my clinic during the past winter, the patient being an exceed- ingly myopic, poorly nourished, white, male dwarf, whose body was literally covered with fibromata from the scalp to the feet. In view of this well-established clinical fact, the hereditability of the disease, which is rendered probable by recorded observa- tions, seems capable of explanation. It has been noted in three successive generations and in several children of one family. The precise cause of the disease is unknown. It is, however, reasonable to conclude that it is due to a vice of local develop- ment under the influence of a constitutional predisposition. Pathology. — Fibromata originate in gelatinous connective-tis- sue elements, which undergo metamorphosis into bundles of fibres, the tumors always exhibiting more of the formed mate- rial in the outer, and the formative or protoplasmic material in the central parts of the mass. The fibrous bundles pass down- ward, and unite with those of the derma or subcutaneous tissue, forming thus a firm attachment for the pedicle of all peduncu- lated tumors. There is some question as to whether these growths originate in the deep interspaces of the corium, or in the connective tissue about the hair follicles or fat lobules. 278 DISEASES OF THE SKIN. Heitzmann 1 divides the fibrous tumors of the skin into two classes: "a. I 'ciisc. fibrous, connective-tissue bundles with rela- tively few spindle shaped protoplasmic bodies or solid nuclei running in all directions, apparently without any regularity, thus producing a hard and dense felt-like tissue. This is an imitation of the structure of aponeuroses or inter-articular liga- ments, if scantily supplied with bloodvessels; or of periosteum and perichondrium, if holding a larger number of bloodvessels. 6. Dense, ■fibrous, connective- tissue bundles, holding in their meshes a jelly-like hasis substance, with a small number of pro- toplasmic bodies. This variety is an imitation of the structure met with in the valves of the heart mainly upon their insertions. The supply of bloodvessels, as a rule, is scanty. Both varieties are common tumors of the skin, in the shape of hard, sessile nodules and nodes (hard fibroma); or tumors of greatly varying size, but softer consistence (soft or myxo-fibroma); or shallow, as a rule pigmented, elevations of the skin (nsevi); or scar-like, irregularly branching, sometimes freely vascularized new forma- tions (keloid)." Diagnosis. — The tumors of molluseum tibrosum are to be dis- tinguished clinically from multiple cutaneous sarcomata, by the violaceous or reddish color of the latter, the absence of peduncu- lation, their greater tendency to ulceration, and their evidently malignant character. From the tubercles of lepra, they are dif- ferentiated by the entire absence of constitutional impairment and their general development in far greater multiplicity. The tumors of molluseum epitheliale differ in their contents, super- ficial location, and in the frequent presence of the dark punctum at their summits. Neuroma is usually painful; lipoma less frequently multiple and pedunculated, and more suggestive, when handled, of the "pillowy" sensation to the touch. Warty growths are readily distinguished by their vegetating summits; and the gummata of syphilis, by the concomitant or prior symptoms of the exist- ence of lues. Treatment. — The treatment of large single fibromata is surgi- cal; involving the employment of knife, ligature, ecraseur, or galvano- or thermocauterization. Multiple lesions are often so numerous as to forbid such interference. When there is a dis- tinct vice or development of inherited tendency to the disease, little can be accomplished in the way of treatment. Prognosis. — Rarely, one or more of these lesions disappear by spontaneous involution. More commonly they persist after their evolution is completed. Marasmus, tuherculosis, and a fatal re- sult may occur. One or several of the tumors may become sources of danger from the occurrence in them of an active in- flammation with resulting degeneration and septicemic conse- 1 Archives of Derm., Oct. 1880, p. 378. XANTHOMA. 279 quences. The disease, however, does not, in many cases, shorten life. In general, the prognosis of multiple libromata may be regarded as unfavorable. Xanthoma. Deriv. Gr. ^avdog, yellow. Xanthoma is a cutaneous neoplasm, exhibited in one or several, isolated or grouped, occasionally symmetrical, flat or slightly elevated, yellowish ma- cules, papules, plaques or tubercles, which arc most commonly situated upon the eyelids. Symptomatology. — The macular symptoms of the disease are bean- to finger-sized plaques, either quite fiat or with slightly elevated borders, often constituted by an aggregation of millet- seed-sized lesions, and covered with an apparently normal in- tegument. In color they vary from light and chrome-yellow to the '• coffee and milk" shade; and in shape they may be puncti- form, roundish, ovalish, elongated, or quite irregularly grouped. They are distinctly circumscribed, and when gathered between the thumb and finger do not produce the sensation of the pres- ence of a foreign material. They are most often seen upon the eyelids near the inner canthus, where they may be symmetri- cally disposed about the two orbits. But they may invade also the peri-orbicular region, as also, rarely, the cheeks, the nose, the ears, and the nucha. They are rarely productive of subjec- tive sensation, being occasionally the seat of slight pruritus. This is the commoner form of the disease, and is termed xan- thoma planum. The tubercular lesions of the same affection, known as xan- thoma tuberculosum, may coexist with the plane lesion de- scribed above, and scarcely differ from the latter save in their greater development. They are whitish or yellowish papules, plaques, and tubercles, circumscribed in contour, covered with an unaltered epidermis, and determinable by palpation as having greater consistence than the flat macules. They are less fre- quently seen upon the lids, but occur upon the scalp, cheeks, palmar and plantar surfaces, the genital regions, and about the joints of the digits. Other exaggerated forms are described. Thus sessile or pe- dunculated tumors, cutaneous or subcutaneous in their attach- ment, nut- to hen's egg in size, and originating in one or an- other of the lesions named above, are described by Gary 1 and Chambard. 2 To these the name xanthoma tuberosum should be limited. Xanthoma multiplex is the form in which the lesions, usually first manifested in the sites of election and in their simplest development, proceed to a gradual invasion of 1 Ann. de Derm, et de Syph., 1880, p. 75. 2 Archiv. de Phys. norm et path., Sept. and Dec. 1879. 280 DISEASES OF THE SKIX. the trunk and extremities. Occasionally the mucous surfaces of the mouth, of the respiratory, and ^astro-intestinal tracts are involved ; as also of the surfaces of the peritoneum, endocardium, and larger nrteries. In a proportion of eases, the disease is accompanied by a generalized coloration of the skin in a yellowish shade, which has been variously interpreted as a xanthomatous dyschromia, and as a true icterus. The former is the more probable explana- tion of the fact, as in such cases the urine and viscera have been found normal. Korach 1 has described the interesting case of a twenty-five- year old woman suffering from chronic icterus, produced by closure of the ductus eholedochus. Besides the typical patches of xanthelasma on the lids, the skin surface was generally and similarly affected. Thus the extensor faces of the extremities, the palms of the hands, nates, and other parts, were extensively covered with sago-grain to pepper-corn sized papules and tuber- cles of xanthoma, both flat and elevated. Etiology. — The causes of the disease are unknown. In many cases the lesions are first observed in early childhood, though they are encountered also in middle and later life. Pathology. — The latest pathological studies of the affection have been made by Chamhard, 2 whose conclusions are briefly these: "The three forms, plane, tubercular, and tuberose, are the results of two processes, irritative and retrogressive; the first prevalent in the tubercular and tuberose forms, the last in 1 be plane variety. " In xanthoma planum, the irritative process is represented by an albuminous tumefaction of the connective-tissue elements, with proliferation of their nuclei; the retrogressive process, by a fatty degeneration of their protoplasm. In the other forms, the irritative process is distinguished by the new formation of connective tissue; the retrogressive, by a fatty infiltration of the old and newly formed connective-tissue elements. In both forms, not only the connective tissue of the derma, but also the vascular, glandular, and nervous organs, within and about the sclerosed nodules, are invaded. The sclerotic process involves also the fibrous envelope of the sebaceous and sudoriparous glands (peradenitis); the internal and external sheaths of the vessels (peri-arteritis, endarteritis obliterans); and the lamellar sheath and intra-fascicular connective tissue of the nerves (peri- neuritis, endoneuritis). The nervous involvement is thought to explain not only the pain, but also the tenderness peculiar to the xanthelasmic tubercles." Diagnosis. — Milia are occasionally associated upon the lids in the form of oval plaques, but are distinguishable from xanthoma by the possibility of expressing their contents. 1 Dfutsch. Med. Wochensch., No. 23, 1881. 2 Loc. cit. XANTHOMA. 281 Treatment. — Erasion and excision are the sole recognized means of removing xanthoma. Care should be taken in such opera- tions to avoid a consequent ectropion when the operation is per- formed upon the skin of the eyelids. The Paquelin knife, which I have employed for this purpose, is objectionable, on account of the radiation of the heat to the globe of the eye. With the tumor slipped through an aperture in a thin sheet of asbestos paper, such as is now found in the markets, this inconvenience might be avoided. Prognosis. — The lesions, when not removed, are liable to per- sist through life Spontaneous involution is not known to occur. The French authors, who have given considerable attention to this subject, are disposed to believe that some cases of xanthoma tuberosum, with permanent xanthochromia and involvement of the inner coats of the larger vessels, may prove serious. Adenoma. Certain whitish or j-ellowish, pin-head sized, rounded and iso- lated lesions, with gelatinous contents, scattered over the face of persons in middle life and advanced years, are occasionally seen either flattened or slightly elevated above the level of the integument. They have been described under the title of " col- loid degeneration of the skin," but are probably instances of adenoma of small acini of the sebaceous glands, the epithelium of which has undergone colloid degeneration. According to Heitzniann, the distinguishing feature of them all is a wreath of cuboidal or short columnar epithelium, inclosing a distinct cavity. Besnier, 1 however, concludes that the connective-tissue elements of the derma are primarily involved in the colloid de- generation; and the glandular epithelia, secondarily. Myoma Cutis. Tumors of the skin composed of smooth muscular fibres are known as myomata. or lyomyomata. But little attention had been attracted to these new growths up to a recent date. Jullien, 2 however, in a review of the latest contribution to the subject made by Messrs. Brigidi and Marcacci, of Florence, and pub- lished by them in the Imparziale, in 1881, gives a full capitula- tion of the bibliography of the subject. 3 From these reported cases it appears that the tumors originate as usually single, though occasionally multiple, elevated, dis- seminated, small pin-head to orange-sized, macular or tubercular lesions, the skin covering which is smooth, stretched, and glis- 1 Ann. de Derm, et de Syph., t. x., Nov. 5 and 6, 1879. 2 Anuales de Derm, et de Syph., t. iii. 2me Ser., Fev. 25, 1882. 3 1854, Yirchow ; 1858, Forster, Verneuil ; 1864, Klob, two observations ; 1871, Challand, two observations; 1873, Marcano Sokoloff; 1878, Axel-Key, Sau- tesson ; 1880, Besnier ; 1881, Arnozan and Vaillard ; Brigidi and Marcacci. 282 DISEASES OF THE SKIN. ten ins:, with n rosy or dark reddish tint, paling or not under pressure. The developed lesions may l>e sessile or pedunculated, and cither intensely painful, pruritic or remarkably sensitive to cold. Under the influence of muscular contractions, there may he, as in the cases of Challand and Axel-Key, slow vermicular motion and frequent, changes of volume, or other evidences of contractility. They occur either as generalized lesions, or limited to the thorax, scrol urn, mammae, labia majora and the hands and feet, including the palmar and plantar surfaces. The ages of the patients varied from the twenty-fifth to the sixty-fifth year of life. Of thirteen persons whose sex was given, five were males and eight females. Pathologically, these cases were reported as either pure myo- mata or highly vascular types of myoma telangiectodes, and FIBRO-MYOMA. Verueuil's case resembled a neuroma, as it con- tained not only smooth and striated muscular elements and blood- vessels, but also nerves. The case ot' Axel-Key is recorded as Olie Of LYMPHANGIECTASIA FIBRO-MYOMA. The disease is a benign new growth, and is not to be con- founded with prurigo, lepra, syphilitic gumma, neuroma, mye- loma, and molluscuin fibrosum. Rhinoscleroma. Deriv. Gr. pi;, or p«, the nose ; and s-xXuse'c, hard. Rhinoscleroma is a new growth of the skin and mucous membranes of the nose and contiguous parts, characterized by the formation of exceedingly- dense, elastic, and painful, flattened or elevated, plaques, nodules, or tuber- cles, which may be isolated or confluent. Symptomatology. — A knowledge of this rare disease, first de- scribed by Ilebra and Kaposi in 1870, 1 has been obtained solely from a study of some thirty-five cases observed by these au- thors. The following is a concise statement of their description of the malady : — The disease commonly begins in the septum or a single ala of the nose without inflammatory symptoms. The involved parts slowly enlarge, and become finally as dense as ivory. The in- dividual lesions are flat patches, or elevated and circumscribed nodules, papules, and tubercles, painful upon pressure, movable to a certain extent over underlying tissues, and covered by either a normal integument, or a light or dark-red, shining, vascular epidermis. Neither hairs nor glands are discernible over the lesions. As the disease progresses, the ala? become enlarged, flat- tened, and so indurated that they cannot be pressed together, while respiration may be impeded by stenosis of the nares. The process may extend to the neighboring parts, involving thus the upper lip, gums, velum, epiglottis, and larynx, the teeth 1 Wien. Med. Wocb., No. 1, 1870. RHINOSCLEROMA. 283 meanwhile falling from their sockets, and the soft palate be- coming in some cases perforated. Involution of the process has not been observed, as the lesions do not degenerate by ulcera- tion. Max. Zeissl, 1 however, reports a single case in which there had been ulcerative destruction of the entire left nostril, as well as the tip and right ala of the nose. Occasionally superficial excoriations have occurred, but very rarely a diminution in the consistency of the mass. The disease is exceedingly chronic, requiring years for its development ; and though the affected parts are painful on pressure, they are otherwise not the seat of subjective sensation. Etiology. — The cause of the disease is entirely unknown. It is observed between the fifteenth and fortieth years in persons of all social conditions and individuals of both sexes, free from syphilitic, strumous, tubercular, and other cachexiee. Pathology. — Kaposi has observed, as anatomical lesions of the disease, a dense infiltration of the corium and its papillary layer, with small, closely packed elements, which he recognizes as a true new formation. He considers this as analogous to the small-celled sarcoma (small globo-myeloma, of Heitzmann), inas- much as Mikulicz, G-eber, and Billroth have seen some of the elements of the neoplasm transformed into osseous formations, transformations sufficiently common in sarcomatous tumors. Diagnosis. — The disease can hardly be mistaken for another in consequence of its situation, the disfigurement it occasions, the ivory-like elasticity and induration of the affected parts, and the rarity of ulcerative degeneration. As distinguished from syphi- lis, it is known to be entirely unaffected by specific medication. From the variety of acne rosacea of the nose, known as rhino- phyma, it is readily differentiated by the softness and compres- sibility of the latter, and its evident vascular and glandular composition. Treatment. — The method of relief thus far employed is a total or partial extirpation of the neoplasm. Kaposi speaks of dila- tation of the nares by means of laminaria and compressed sponge, where there is actual or threatened nasal occlusion. Both excision by the knife and destruction by caustics have, however, been found to secure merely temporary benefit, as the growth is reproduced with some rapidity. Prognosis.— The future of the patient is grave. The disease not only persists and recurs after operative interference, but may endanger life by obstruction of the nostrils. Zeissl's case 2 proved fatal in ten years after the disease first appeared. 1 Wien! Med. Woch., 1880, p. 621. 2 Loc. tit. 284 DISEASES OF THE SKIN, Clasb II.— of the sebaceous glands and periglandular TISSUES. 1. Anomalies of Secretion. The disorders named in this class all depend upon functional derangements of the sebaceous glands, whose office, it will be remembered, is the supply of the physiological unguent of the skin. This derangement may be true of the secretion itself, or of the mode of its excretion. Seborrhoea. Seborrhoea is a functional disorder of the sebaceous glands, exhibited in an abnormal condition of tbe secretion as it collects upon the surface of the skin. Symptomatology. — Seborrhoea occurs in two varieties, accord- ing t<> the condition of the excreted product. These are known as seborrhoea sicca and seborrhoea oleosa. The two forms are recognized clinically as of separate occurrence; and also as ex- isting occasionally at the same time in one person. Either form of the disease may be limited to certain sites of preference, or he generalized so as to extend over all portions of the body pro- vided with sebaceous glands. The most common seats of the disease are: the scalp, the face, the genital region, the dorsum of the body between the scapulae, and the anterior surface of the chest. As a physiological state, its features are seen in the ver- nix caseosa of the newly born infant; and in pathological symp- toms, it appears in all subsequent periods of life, and in both sexes. As the sebaceous glands are mainly appendages of the hair follicles, the lesions of the disease differ somewhat, according as they occur in regions covered with long or lanugo hairs. In the same proportion, a difference exists in the career of the dis- ease. At times it is a trivial and short-lived affection ; at others it is persistent and intractable, lasting for years, and possibly for a lifetime. The individuals thus affected exhibit a difference also with respect to the general condition of their health. Some are anaemic, chlorotic, or asthenic; some are of the sanguine temperament, fleshy, red-faced, and thick-skinned ; others again are absolutely healthy, so far as can be discovered, except for the local sebaceous disorder. This last fact is one of some sig- nificance. I have seen exaggerated types of seborrhoea in vigorous men who had worn for one mouth merely, a skullcap, to which was fastened an apparatus for relief of fracture of the lower jaw. The skin affected with a seborrhoea is usually anaemic, and either dry or humid. In such cases the subjective sensations SEBORRHEA. 285 are either slight and limited to a moderate degree of itching, of which the patient does not complain till he is questioned upon the subject, or altogether wanting. At other times the glands, or periglandular tissues, are affected with a mild form of inflam- mation, and then the involved surface may be reddened and become the seat of a considerable pruritus. Seborrhoea Sicca (or Squamosa), is the most common of all forms of the disease, and occurs upon both the hairy and non-hairy portions of the integument. In the former situation, where it is vulgarly known as " dandruff," it is called — Seborrhea capillitii, in consequence of its limitation to the hairy scalp. In its ordinary manifestations, the affection is recognized in the adult, by the formation in this region, of greasy, whitish or yellowish pellicles of dried sebaceous matter, which may be freely shed from the surface and cover the shoul- ders of the individual whose scalp is involved. At other times these fatty plates are more or less adherent to the scalp-surface, or piled up in laminae one upon another. These may closely mat the hairs together, perceptibly near the exit of the latter from their follicles; or be abundantly disseminated through the mass of the hairs, some of which penetrate a flattened greasy scale, as a twig might be passed through the centre of a leaf. In consequence of their deprivation of unguent, the hairs to which, the affected glands are accessory, become dry and lustreless, and fall from their follicles. If the process he not arrested, atrophy of the hair follicle ensues, and the resulting alopecia is perma- nent. Fortunately, the seborrhoea is usually symmetrical, and, cor- respondingly, the baldness which it occasions. The disfigure- ment then resulting is of the character of symmetrical senile alopecia, and is chiefly annoying as the loss of hair is premature. When the loss is asymmetrical, which is decidedly the excep- tion, the disfigurement is greater. The affection may be circumscribed and in conspicuously selected patches where thin, mealy, grayish, or whitish scales cover the patch ; or thick yellowish masses may paste the hairs firmly to the surface of the scalp. The disease may also extend over the entire surface of the scalp uniformly; or, as is fre- quently noticed, fringe the brow 7 at the line of the hairs, and thence extend chiefly over the vertex, being conspicuous at the line where the hairs are parted from vertex to brow r . Beneath the scales or crusts of dried sebum, the scalp is usually lustreless, and of a slate-gray color. As the disease does cer- tainly occur at times in types intermediate between functional and inflammatory forms, the subjacent tissues may present an hyperaemic or even exudative feature, with true epithelial des- 286 DISEASES OF THE SKIX. qua mat ion nnrl considerable itching. One group of cases, assign- able to tlii? class, deserves attention. In them there is a toler- ably well-diffused seborrhcea sicca of the scalp, and, here and there, irregularly distributed over the surface, are. filbert-sized, generally circular, dark-reddish patches, covered with a moist secretion or a triable, granular, reddish and yellowish crust. These are scalp excoriations produced by the finger-nail. They are most common in "nervous" patients, who cannot resist forc- ibly digging the seal]) on slight provocation. Occurring in infancy, the disease is well known as "milk crust " or crusta lactea. This may be merely persistence of the dried vernix caseosa about the vertex in the newly born, or it may occur in scalps which have been perfectly cleansed after birth. The crust differs somewhat in color with the tint of the child's complexion ; and may vary from a light yellow to a dark brown. It may be thick, greasy, and mat the hairs together ; or be thin, dry, and friable. It is a frequent complication of the eczematous disorders of this regio/i, and, as a consequence, more often in the adult, every variety of hyperemia and inflam- mation may characterize the tissue beneath the crust. In in- fants and children, however, the resulting alopecia is never per- manent, as the rapidly growing follicles hasten to reproduce the hair. The disease is also neither contagious nor followed by cicatrices, points upon which mothers are usually solicitous. The regions of the brow, the surface covered by the beard of the male, and the pubic hairs may be involved in the disease. Seborrhcea of the non-hairy portions of the body may exist upon the face (forehead, cheeks, chin, and nose), trunk, and genitals. Seborrhcea faciei is characterized chiefly by the accumula- tion of thick, dirty -yellowish, and even yellowish-black, accu- mulations of sebaceous matter, often adherent to the surface and disfiguring the features by the artificial mask produced. This is exceedingly conspicuous about the nose, where the disease is at times symmetrically disposed. I lately exhibited to the medical class at the clinic, a young woman with a complete cast, covering the nose uniformly from root to aire, composed only of yellowish-gray sebum. Such masses once removed, the skin beneath is generally found to be pallid or slightly reddened, with the orifices of the sebaceous ducts patulous; while the under surface of the separated crust is seen to project downward in corresponding delicate prolongations, which Kaposi compares to stalactites. The crusts are rapidly reformed when the disease is not arrested. They are found in the furrows on either side of the nostrils, on the brows, the cheeks, and the pavilion of the pinna of the ear. They are most common about the puberal epoch in both sexes, when the sebaceous glands of the skin undoubtedly sympathize with the changes occurring at the be- ginning of the sexual life. SEBORRHEA. 287 Seborrhea trunci is chiefly noted about the clavicles, scap- ulae, sternum, and umbilicus. Its features are less pronounced than those of some other localities, probably because the friction by the clothing, even in persons who neglect the care of their skins, serves to stimulate the sebaceous glands of these regions to a moderate degree. The disease occurs here in circumscribed or, more frequently, illy-defined patches which by confluence may describe irregularly-reticulated figures of reddish tint, when, as is usually the case, the few loosened fatty plates have been re- moved by friction. According to Duhring, who has carefully studied these features, the chest patches are circular, pale-reddish in color, defined in outline, separate or associated in large groups, and covered with withered, greasy, grayish-yellow pellicles, the eruption here much resembling ringworm of the body. About the umbilicus, the fatty matters are remarkable for their ten- dency to speedy decomposition, with the production of an ex- ceedingly fetid odor, which may prove to be the source of a mild grade of inflammation. In the latter event, a reddened halo surrounds the umbilical depression, which may be the- source of a thin, sero-purulent discharge. Seborrhea genitalium is usually located in the male in the sulcus behind the corona glandis, though in individuals with a tight or redundant prepuce it may be more extended. In the female, the accumulation occurs about the clitoris and vestibulum, though the external labia may be covered with the secretion in various degrees of fluidity. The smegma preputii, supplied by the glands of Tyson, may be thus the source of trouble either by its retention, or secretion in abnormal quantity or quality. In either event the tendency, as in umbilical sebor- rhcea, is to decomposition, fetid odor, and subsequent irrita- tion, which may provoke inflammation of severe grade. The retention of this smegma beneath a tight prepuce in the male may provoke a long list of reflex symptoms, such as incoordina- tion of movements in the lower extremkies, nocturnal enuresis and pollutions, hernia, and irritability of the testis. In some cases the secretion forms a ring as hard as the rind of cheese encircling the glans. It should be remembered that the young of both sexes as well as adults are liable to be thus affected ; and that in young female children these symptoms may have a medico-legal interest in connection with suspicion of criminal attempts. Seborrhoea generalis, affecting the entire surface of the body, is an exceedingly rare disorder. It has been described by authors as ichthyosis sebacea, cutis testacea and pityriasis tabescentium. In the infant, the skin is universally spread with a greasy layer, rapidly renewed after removal, beneath which the skin seems to be varnished in reddish-brown sbades. The. consequent stiffen- ing of the integument produces painful fissures, inability to take 2K8 DISEASES OF THK SKIN". the nipple, and consequent marasmus. In adults, there is noticed the same marasmus; with greenish to blackish crusts covering the trunk and extremities, mil desquamation of lamellae of the Bebaceous accumulation, corresponding, for the most part, to regions of the skin mapped out by its normal furrows and folds. Seborrhcea Oleosa Is in its pronounced features rarer than seborrhcea sicca ; but to a less distinct degree is a condition sufficiently common in many forms of the disease. Here the sebaceous secretion is poured out as an oily fluid upon the surface both of the hairy and non-hairy parts of the skin. In the former situation, both in adults and' infants, the free oily substance is seen to cover as a coating both skin and hairs, and, especially in bald adults, to produce a glistening and shining appearance of the scalp. It often concretes into masses which are described above as the crusts of seborrhcea sicca, The same greasy layer can be seen in the non-hairy portions of the skin, especially about the nose, forehead, and cheeks. Free drops of oil can be occasionally wiped from such surfaces with a handkerchief. The ducts of the sebaceous follicles are here either patulous or plugged with comedones ; the surface may be reddened or pallid, but is usually cold to the touch. The oily substance serves to entrap particles of dust, soot, etc., floating in the air, and often thus a peculiarly dirty or even blackish hue of the face is produced. Some of the forms of seborrhcea described above in connection with the um- bilicus and genitalia, are of this variety. In the negro, where the sebaceous glands are usually well developed and active, the oil}' forms of seborrhcea are common; and the flux, at times, almost physiological. Even in the absence of their frequent anointing with palm-oil, I have seen the naked blacks in Africa with exposed skins shining from exuded grease. Etiology. — Seborrhcea may be due to local or general causes. This is a point which should be clearly understood, as llebra, with his superb powers of observation, noticed that the majority of his cases occurred in young male and female subjects affected with chlorosis or conditions analogous to that state. It is a clini- cal fact of ready verification ; but I am persuaded that many- cases are essentially of local origin ; and, as before intimated, am convinced that a seborrhcea can be artificially produced in a healthy individual in the course of a few weeks by very simple local measures without interference with the general economy. Females with long hair are usually disposed to take special care of the scalp, upon which it grows. Males with short hair are more apt to attend chiefly to' its disposition upon the head, and to neglect the care of the scalp. For the seborrhcea sicca of the hairy parts, I would name neglect of the scalp as the most SEBORRHCEA. 289 frequent cause ; for the same disease of the non-hairy portions of the skin, in by far the greater number of all cases, chlorosis, struma, malnutrition, obstinate constipation, disorders of diges- tion and menstruation, and sedentary habits of life, are unques- tionably responsible. The exanthematous and other low fevers are often followed by asthenic states in which the same condition prevails. Hebra has pointed out the fact that the sebum of in- dividuals who have fatty livers from chronic alcoholism, is pecu- liarly fluid and oily; and it will be observed that few of all the disorders of the sebaceous glands characterized by inspissation of the secretion occur in such persons. Pathology. — It will be remembered that the sebaceous secre- tion is produced in consequence of a fatty transformation of the epithelia lining the acini of the sebaceous glands ; it is therefore directly derived from the living matter of the protoplasmic ele- ments of the rete. A seborrheal is therefore, strictly speaking, a catarrh of the epidermis; and the name is in this connection properly used, since most of the so-called catarrhs of the skin are in reality not such, the effused fluids being furnished by the bloodvessels. Typical forms of seborrhcea are strictly anomalies of secretion only, unaccompanied by inflammatory processes in either the glands or periglandular tissues. While other excep- tional forms are without question thus complicated, the varia- tions in the sebaceous product as to quantity, inspissation, fluidity, tendency to rapid decomposition and exhalation of fetid odors, may be due to variability in the transformation of the epithelia into fat under the influence of the trophic nerves, but this is a matter of conjecture. It is certain that these con- ditions are largely under the influence of external agents, such as friction, temperature, and air currents. In many cases the product of the disorder is composed, for the greater part, of epi- thelial masses mingled with a relatively small quantity of sebum, thus justifying further the view explained above regarding its catarrhal nature. The unguents naturally found in excess upon the body or parts of it, such as the vernix caseosa, are of course physiological in character. Diagnosis. — Seborrhcea is to be distinguished from : — Eczema. — The objective points of difference between eczema and seborrhcea depend upon the inflammatory character of the tirst named disease, easily recognized, whether upon the face or scalp, by the reddened, infiltrated, or discharging skin, and the considerable degree of itching which it occasions. In squamous eczema, the scales are rarely so abundant as to be shed freely from the surface, and are not greasy. It should be remem- bered, however, that the two diseases may and do coexist. Eczema of the scalp in infants is especially apt to be accom- panied by a seborrhcea, a fact which clearly shows that the 19 290 DISEASES OF THE SKIN. technical distinctions between many diseases, useful though they be for analytical study, arc not always capable of clinical demon- stration. ICHTHYOSIS. — This is a congenital disease, usually involving the entire Burface of the body, while Beborrhoea is generally acquired, and rarely universal. The distinction between ich- thyosis and the rare generalized forms of Beborrhoea, described above, might involve a difficulty. But in the latter, the greasy character of the crusts, their color, and the marasmic condition of the subject of the disease, would sufficiently distinguish the two disorders. Impetigo and Impetigo contagiosa. — Here the only possibility of error would originate in the discovery of either of the two diseases named, in the stage of crusting, especially upon the scalp. But both are acute disorders, with crusts much bulkier than the sebaceous matters formed in Beborrhoea, and beneath such crusts the integument is reddened, and evidently the seat of an exudation. Keratosis pilaris. — In this disease, also, there is a chronic accumulation of matters, partly sebaceous, on the hairy and non-hairy portions of the skin. But, unlike Beborrhoea, the sebo-epithelial heaps are aggregated in pin head sized masses about the hair follicles only, and never accumulate in such quantities as to paste the hairs to the surface. The disease is also most common on the extensor surfaces of the extremities. Lupus erythematosus. — Hebra, in 1845, described a sebor- rhea congestiva, which it would be indeed difficult to dis- tinguish from lupus erythematosus, as the two are practically identical. Typical cases of the two diseases are widely different and readily distinguished ; the atypical forms might lead to confusion. But lupus erythematosus, though occurring on the face, is rare on the scalp; it is accompanied by infiltration and the production of a new growth, and is followed by a charac- teristic scar. Its lesions are darker red than the congestive patches beneath certain seborrheas of the non-hairy parts. The scales of lupus are tenacious ami dry, and require scraping for their removal ; those of seborrhcea are readily detached, greasy, and often cover the shoulders of the patient. The contour of the seborrheic patch is illy defined, while that of lupus is very distinct, exception being made of the mask-like crusts seen in certain of the facial seborrheas when the greasy character of the layer is very evident. Lastly, seborrhoea is a disease of puberty chiefly, while lupus erythematosus is likely to be first seen in the earlier years of childhood, when facial seborrhea is rare. SEBORRHCEA. 291 Psoriasis. — Psoriasis of the scalp may resemble seborrhcea sicca. But the latter is rarely developed in such a universal exanthem as is frequent in the former. Few doubtful cases will come under observation, when a psoriasic patch on the elbow, knee, leg, or sacrum, will not point to the nature of the disease. The scales of psoriasis are lustrous, larger, and not greasy, unless fatty applications have been made to soften them; and they cover, moreover, a reddened and exuding patch of integument. Psoriasis of the scalp and face prefers the areas of the forehead adjacent to the hairs of the scalp, and rarely departs boldly to the nose and the furrows beside the nostrils, favorite sites of a seborrhoea. Syphilis. — Some forms of the pustular syphilodermata located upon the scalp and face, if observed only in the stage of crust- ing, might be confounded with seborrhcea. Here the history of the case, the discovery of other signs of syphilis (adenopathy, mucous patches, etc.), and the puriform character of the secre- tion beneath the crust, should point to the identity of the dis- ease. In syphilitic crusts about the angles of the nostrils, there is often a peculiar reddish-brown tint of the skin at the edge of the patch, the so-called "copper" color, which is significant. Crusts of the hairy scalp in syphilis are very often accompanied by post-cervical adenopathy, and especially by indurated enlarge- ment of the occipital glands. Tinea circinata and T. tonsurans. — In ringworm of the hairy parts, as also of the body, the microscopical discovery of the parasite will always point to the nature of the disease. Upon the scalp, the affected patches are seldom as diffuse as in seborrhcea; are usually circular; are often accompanied by fragility of the hairs ; and, in the latter case, the discovery of stumps of hairs is significant. There is also a history of contagion and absence of the greasy conditions .of the scales, characteristic of seborrhoea. Treatment. — The indications to be met by local treatment in seborrhoea are : first, the removal of the crusts and fatty mat- ters accumulated upon the surface ; second, the restoration of the deranged function of the glands. Upon the scalp, it is always well at the onset to warn pa- tients, especially if the disorder is aggravated and occurs in young females with apparently luxurious tresses, that a consid- erable loss of hair will result. Many of the latter are so im- poverished by the chronic course of the disease, and so loosened in their follicles, that a complete cleansing of the scalp surface will bring them away in quantities sufficient to threaten a speedy baldness ; and it is not rarely the case that patients attribute this to the treatment rather than to the disease. The fatty accumulations are first to be soaked in some oily fluid to facili- 292 DISEASES OF THE SKIN. tate their removal ; and for this purpose olive oil, cod-liver oil, or lard are usually employed. The article selected should be used in excess and iii quantity sufficient to permeate ;ill crusts. It may be poured over or rubbed into the seal)) several times in the twenty-four hours; and at night a flannel or other cap be worn to still further insure success. In the case of children and infants, considerable gentleness is required in thus treating the Bcalp, especially in the subsequent washings, lest the surface be irritated. In young women, it is rarely necessary to cut the hairs. As soon as the soaking with oil is insured, the crusts are to be removed by washing with soap and water, though when the accumulations are bulky, masses may be gently re- moved with fingers or comb. When the scalp is quite tender, ordinary toilet, or Sarg's imported glycerine soap, may be ap- plied with warm water; but it is usual in the case of adults to employ the spiritus saponis kalinus, of Hebra, two ounces (60.) of green soap digested in one (30.) of alcohol, filtered and flavored with lavender or bergamot. The surface should be thoroughly sponged with the spirit, and then warm water added till the foam of the lather is abundantly produced over the scalp, when an excess of water is finally used to cleanse the part of both crusts, oil, and soap. The scalp and hairs are then thoroughly dried and anointed with some bland, fatty substance if the sur- face exposed is tender and irritable; if not, with some stimu- lating pomade. The last-named precaution is an important one. However extensive the seborrheic crusts, it is possible to remove these complete^ by the measures described above in every case; and with the first experiment patients are often delighted. Their disappointment is correspondingly great when they discover that the seborrhcea is not yet at end, and that, in the course of a few days, the fatty plates are as freely as ever deposited on the scalp, disseminated through the hairs, and showered upon the shoulders. Some will even declare that .the soapy applications aggravate the disorder by increasing the seborrhcea. It should therefore never be forgotten, that having got rid of the extra- neous matters accumulated upon the surface, there is still to be remedied a functional disorder of the sebaceous glands of the part. In every case, then, after the use of the soap and water, which may be repeated as often as need be, daily, at intervals of several days, or once in the week, the scalp is to he thoroughly anointed. For this purpose olive oil, cod-liver oil properly scented, almond oil, vaseline, or glycerine and water, may be used. In the course of a few days, in most instances, a more stimulating plan of treatment may be adopted; and, in that event, alcohol may be combined, for example, with the oil of sweet almonds, half an ounce (16.) of the latter to five ounces (160.) of the former, to which half a drachm (2.) of carbolic acid may be added, the whole flavored with the oil of bergamot. SEBORRHEA. 293 Repeated applications and patient care of the scalp are neces- sary to secure complete relief' in the case of a disease as essen- tially chronic as seborrhcea. At times the local treatment may be changed with advantage. Sulphur enjoys a high reputation in the treatment of all sebaceous gland disorders; and in the form of an ointment, one to two drachms (4.-8.) to the ounce (32.) of cold cream, it is often of service. I have used with success the hypochloride of sulphur, which has lately come into our markets from the English laboratories. But it is open to objection on account of its odor, which can scarcely be disguised. Besides these, the tinctures of cantharides, capsicum, and nux vomica are frequently incorporated with advantage into lotions and pomades for use upon the scalp. Most of the latter can be made sufficiently fluent for use in this situation, by adding a drachm (4.) or two (8.) of glycerine to the ounce (32.) of lard or cold cream. The alterative effect of the mercurials is also as evi- dent here as in many other cutaneous disorders. At the head of the list, for this special purpose, stands the red oxide of mercury in the strength of from two to four grains (0. 133-0. 2t>6) to the ounce (32.) of ointment; but the white precipitate, the ammo- niated mercury and calomel, in the proportion of five to ten grains (0.333-0.666) to the ounce (32.) may be often substituted for the former with advantage. Solutions of corrosive sublimate, in the strength of two to four grains (0.133-0.266) to the ounce (32.) of fluid, may prove of use in obstinate cases. Hillairet recommends a lotion containing from two to four fluidrachms (8.-16.) of sulphuric ether and two to four drachms (8.-16.) of borax dissolved in eight fluidounces (256.) of distilled water. The treatment, described in outline above, may be used with success also for the relief of seborrhcea of the non-hairy portions of the body, especially the face. Here, it will be observed, the crusts have a singular tendency to re-form; and the most per- sistent care is necessary to secure permanent relief. Occasionally, after cleaning the surface by soap and spirit lotions, according to the indications of each case, it may be of advantage to apply the ointment selected for subsequent application, not only by gently smearing it on the part with the tips of the fingers (always the most effective method), but also by spreading it on a compress, which, for the night at least, may be fixed in con- tact with the part. When this tendency to re-formation of the crust is abated, one or more of the dusting powders may be at times employed with advantage for the purpose of protecting the skin or exercising upon it an astringent effect. The local treatment of seborrhcea of the genitals is somewhat different. Ointments rarely answer well in disorders of the mucous surfaces; and the green soap is too irritating for similar employment. Here washing with a good toilet soap and warm water is sufficient for the purposes of cleanliness, and diluted lotions containing alcohol, in the form of whiskey, brandy, or aromatic wine, suffice to procure relief. These can be made 204 DISEASES OF THE SKIN. astringent with tannin, alntn, or the zinc sulphate, and, when there is pain or tenderness, opium can be added. In this form of the disease, as also in seborrhcea of the umbilicus, carbolic acid or the chlorinated soda may be necessary to correct fetor. In the generalized varieties of the disease the surface is to be thoroughly anointed with oil. The body, especially that of infants, is to be swathed in flannel or other good non-conductor of heat: and a roborant treatment directed to the general ady- namia. The internal treatment of seborrhoea is often of the highest, importance. The preparations most often indicated are: Iron in anaemic yount; women; cathartics in sluggishness of the bowels; and cod-liver oil when there is impairment of nutrition. Duhring recommends the sulphide of calcium in doses of from one-tenth (.0066) to one-fifth (.0133) of a grain. Arsenic, em- ployed in the manner suggested by Sir Erasmus Wilson, is praised by Hebra: — . Vin. ferri fijss ; 501 Syrup. si m pi. ) Liq. potass, arseuit. ) aa f"3ij ; 8 Aq. destill fSU; 60 M. S. A teaspoonful to be taken three times daily with the meal. The preparations of malt and maltine, now largely employed by the profession in the treatment of wasting diseases, will be found available in eases where the cod-liver oil cannot be well taken. Lastly, the bitter tonics may be needed. Throughout the treatment, the physician should insure a careful observance of the laws of hygiene. Sunlight, nutritious food, and open air exercise are not to be disregarded. In the large cities of this country, many young women of indolent habits are greatly benefited by sending them to the riding schools for an hour's equitation daily. Prognosis. — In forming a prognosis in cases of seborrhcea, it must be remembered that the disease is frequently an obstinate one ; and the resulting loss of hair, if symmetrical, may be reme- diless. Much may be done in the way of saving that which is left. Facial seborrhoea is much more amenable to treatment ; and seborrhoea of the genitals and umbilicus is an entirely man- ageable disease. When the affection is generalized, the prog- nosis is in the highest degree unfavorable. Comedo. Comedo is a disease in which an inspissated secretion, lodged in the excretory ducts of the sehaceous glands, becomes visible upon the surface in yellowish- white or brownish-black points. Symptomatology. — Comedones occur exclusively in the ducts of the sebaceous glands, and consist of a whitish fatty plug formed by the inspissation of the secretion of these glands, one extremity of which is visible at the surface when the plug is in situ. Oc- COMEDO. 295 casionally they project to an appreciable distance above the general level of the integument; but often careful inspection will suggest that the extremity of the plug is slightly depressed below that level. There may be but two or three upon the face, which is their most common seat, or the nose, forehead, cheeks, chin, the front and back of the neck, and the back of the trunk and the penis may be thickly studded with them. The visible extremity of the comedo varies in size from a needle-point to a pin-head. They are readily expressed from the follicles in which they are lodged, and when thus examined are seen to be whitish moulds of inspissated sebum, one to two lines in length, the ex- posed extremities of which have become blackened by the dust and dirt entrapped at that point. In consequence of this sugges- tive appearance of the mass, the disease has been vulgarly known as "black heads" and "skin worms." The deformity produced in the face when these lesions exist there in large proportions, is strikingly conspicuous; and it is for the relief of this chiefly, that the practitioner is consulted. The subjective symptoms awakened are of trifling moment. The disorder is essentially chronic in its course. Isolated comedones may be observed for years in one situation without apparent change or modification of any sort, and without producing the slightest local or consti- tutional derangement. Others appear, only to disappear under the influence of the usual hygienic regimen of the skin of the face. Others again serve to irritate the skin in which they are implanted, precisely as though they were foreign bodies; and the sebaceous glands and peri-glandular tissues, with and without the operation of such cause, exhibit grades of hypersemia and inflammation. Comedones may occur as the sole lesions of the skin, even to the extent of very great multiplicity ; or they may coexist with other diseases of the glands, chiefly acne. They may occur at any period of life, but, like seborrhcea, are most frequently observed at the puberal epochs in both sexes. Ac- cording to Kaposi, the disease tends to disappear in the female earlier than in the male, in whose case it may be prolonged to the twentieth or thirtieth year. Etiology. — Much has been written with reference to the im- proper care of the skin as a cause of comedo, the neglect of soap in washing the face, and the influence of the trades, as in the case of those who work in metals, dust and tar. But observa- tion shows that these are exceptional causes. I have seen very obstinate and generalized lesions in the skin of intelligent young men and women of the upper social classes, who regularly washed their faces with toilet soap, were rarely exposed to dust, and whose habits and recreations were of the most healthful character. Similarly I have for some time past observed the grimy faces of coal heavers, machinists, masons, and certain ink manufacturers, and have been impressed with the singular rarity of the disease in such laborers. The cause of the disease is unquestionably to be sought for in the gland itself. It is true that young chlorotic !_".<.; DISEASES OF THE SKIN". females, affected also with dyspepsia and constipation, may ex- hibit the disease ; ;ui* n't,: d__. ^■^■'-V%j:;: ;■'■,'.''■:'' Section of a comedo, a, excretory dnct of a sebaceous gin nd filled with a comedo ; it contains also two small hair* with brush-like inferior extremities. : into it open* a small hair-follicle, c, whose contained hair, !' the macular syphilide, and also with surprising frequency masks the latter by a commingling of lesions. Simple acne is common also among those who are veterans of syphilis. Acne does certainly at times resemhle variola, and I have seen several cases of the former actually mistaken for the latter. En most instances, the absence of fever and a brief delay will soon put an end to any doubt. Treatment — Acne is, I believe, an entirely remediable disease in every case properly managed from the first. Sears of ancient ravages of the affection are, it is true, indelible; but even these arc smoothed down in the progress of time, so that they become yearly less conspicuous and disfiguring. An' important consideration, at the outset of treatment of a patient affected with acne, relates to any local or internal medi- cation which has been previously employed. A very large pro- portion of all cases first claim the attention of the physician, after ingesting drugs or making topical applications which have decidedly aggravated the original trouble. With or with- out the advice of others, such patients have often been engaged lor months in swallowing the iodide of potassium, "red clover," and various nostrums calculated to "drive out" the disease; or in rubbing over the skin equally noxious "proprietary" sub- stances. In every such instance, the skilled physician should delay active treatment of the affection until the artificial acne has subsided, and the real condition of affairs can be clearly lecoguized. The patient should be directed to discontinue his or her former practice, to bathe the affected part in hot water at night, and after it is dried to apply any bland unguent. By these simple measures alone, many cases can be very greatly im- proved, and some completely relieved. Their simplicity should commend them to every reader of these pages. It is a good thing to know what not to do. In cases, whether previously treated or not, which have been purged of all suspicion of an artificial element, the local treat- ment is of prime importance, and in the perfection with which its details are observed, lies the key to success. What personal experience I have enjoyed, has produced the conviction that it is not the selection of several remedies of the many advocated for the relief of the disease, nor yet the successive substitution of one for another to meet any transitory indications in each case, which conduces to the happiest result. It is rather the use of a single method of recognized value, and its skilful adaptation to the changing conditions of the disease. ACNE. 311 It is first necessary to evacuate the contents of all pustules, to express from the summits of papules where are the orifices of sebaceous ducts, all densely inspissated plugs of sebum, and to remove any comedoues which are present, by the aid of the comedone-extractor. For the purpose of opening the superficial and smaller purulent collections, the long needles used by the gynecologists are decidedly preferable; and for the larger and deeper furuncular lesions, a bistoury with a delicate and very narrow blade. A slight degree of skill will here repay the ope- rator. By gentle compression with the fingers, the whitish, yellowish, or blackish orifice of the duct may be detected, and at that point preciselj' the needle or bistoury should be thrust sufficiently deep to insure the removal of pent-up pathological accretions. Should blood flow in droplets from any of these slight wounds, it is rather to be encouraged than repressed, as relieving the hyperemia and engorgement of the small peri- glandular phlegmon. In one or several sittings, all lesions re- quiring such interference should be carefully attacked, and im- mediately after each, preferably while the pus and blood are still oozing, the part is to be bathed for several minutes in water as hot as can be borne with comfort. For many reasons, the hour before retiring is preferable, though not always practicable, in treating such cases, as then a bland ointment can be thoroughly applied and permitted to remain till the following morning. When one or several of such operations have completely re- lieved the skin of its engorgement and retained inflammatory products, a systematic use at night, of the spiritus saponis viridis with hot water, should be for a time practiced. Let it be noted here, however, that man}- cases which do not require the minor surgical operation described above, should be from the first treated in this manner. As the face is the most common seat of the disease, it may be, for the purpose of description, con- sidered as the affected part. The patient is seated befoie a basin of water, as hot as can be tolerated with comfort, and with a pad of white flannel or soft sponge, bathes the face till the skin is thoroughly moistened and softened by the heated water and steam. From ten minutes to half an hour may be well employed in this way, and it is a fertile source of the improvement which follows. Then, while the face is still wet, all pustules which have formed are emptied, and a sufficient quantity of the spirit of green soap is poured over the flannel or sponge, and the face thoroughly scrubbed with it. Finally the surface is cleansed with a surplus of the water, carefully dried, and anointed with a sulphur ointment. Some range may be observed in the employment of the two articles named. Thus the spirit may be diluted with cologne or rose-water, one half or more; or the soaps employed, in less im- perative cases, may be the best toilet, Sarg's glycerine or sul- phur soaps. The ointment, too, may be compounded by adding 312 DISEASES OF THE SKIN' half a drachm to two drachms (2.-8.) of the flowers of sulphur to the ounce (32.) of cold cream or vaseline. In the morning, the face is to be washed with cold water. This operation of Bt earning, soaping, and anointing, is to be continued, according to the severity of the case and the toler- ance of the patient, nightly, twice in the day, or on alternate nights, till the face is free from papules and other inflammatory lesions. It. at this time, is usually unsightly, reddened, slightly tumid, and often moderately furfuraceous, lint free from acnei- form lesions. To the patient, it feels tense, slightly painful, and as it made of leather. This accomplished, the spirit or other preparation of soap may he for the time discontinued, and the nightly bathing with hot water and subsequent anointing with the ointment regularly continued. The improvement which fol- lows is marked and speed} - ; and usually cpuite satisfactory to the patient. When this point is reached, a wider latitude of treatment is presented. Gradually the hot ablutions may -be withdrawn, and the use of lotions and ointments other than those containing sulphur, may he advised. The last-named substance, having the highest reputation in the disorders of the sebaceous glands, is a constit- uent of many of the lotions thus employed. Taylor 1 advises the following: — Sulphuris loti o'ij ; 12 Caraphorse spts. iSi'J ; 12 Sodse biborat. 3U; 8 Glycerin. t'5vj ; 2.-» Aq. fon tan. ad f.^iv ; 130 M. . Shake well and apply freely, leaving a thin film of powder over the face. Various combinations of sulphur with alcohol will be found useful. Thus Kaposi recommends a paste composed of: — R. Sulphur, prrecip. 3ijss ; 10i Spts. vin. rect. f§jss; 50 Lavand. spts. . f3'J ss ; 1 0] Glycerin. n\,xx ; 1 1 M. Sig. To be spread over the face and retained during the night. Or, 14 Sulphur, ftor. 5'.iss ; 10 Spts. sapon. virid. 15v; 20 Lavand. tr. f§u ; 60 Peruv. bnls. n\,xx ; 1 3 Camphor, spts. n\ xv ; 1 Bergamot. ol. "lv ; 5 Sig. To be applied over the face at night. Duhring recommends the following: — Sulphur, praccipit. 3ij ; 8 Glycerin. f-i.i ; 8 Alcoholis m ; 30 Aq. calcis t'i.i ; 30 Aq. ros. Qtt ; 60 Sig. Shake the vial befor e using. ' Amer. Clin. Lectures, vol. III. No. 10, N. Y. 1878. ACNE. 313 The English hypochloride of sulphur, in ointments of the strength of those given above, and the sulphnret of potassium, half to one scrupfe (0.66-1.33) to the ounce (32.) of lotion or ointment, are effective, but objectionable on account of their odor. Various cosmetic ointments will be found useful in superseding those described above, as the case progresses. Among these may be named, the oxide of zinc, the subnitrate of bismuth, and freshly levigated calamine in the strength of from one half to one drachm (2.-4.) of one or more of these substances to the ounce (32.) of cold cream, to which, as required, the tincture of benzoin, glycerine, oil of roses, or bergamot, may be added in suitable proportion. The other substances employed topicaltyin acne, are certainly inferior to those named above. The bichloride of mercury is very generally employed in the strength of from one-eighth to one-half a grain (.008-033) to the ounce (32.) of lotion ; and the protiodide, biniodide and ammonio-chlorideof the metal are similarly applied in both lotions and unguents; the first two, in the strength of from five to ten grains (.33-66) to the ounce (32.); the last named, in the strength of from half a scruple to a scruple (.66-1.33). One should be careful not to make use of the mercurials at the same time with a compound of sulphur, lest a chemical combination occur by reason of which the sul- phuret of mercurj- is precipitated upon the skin and produces the appearance of the comedo. Heitzmann highly recommends the solution of Vlemincx, which I have never had the courage to employ in acne. 1 Kaposi recommends also mercurial plaster applied on strips of linen, in obstinate cases, for which may be substituted iodated glycerine, five parts each of pure iodine and the iodide of potassium to ten of glycerine, applied with a brush twice daily till from six to twelve applications have been made. I believe that the use of caustics in acne, though recommended by several authors, should be discountenanced as quite needless. In extreme induration of the lesions, they may be rubbed with fine pumice stone till the desired effect is produced. The powders employed in the milder forms of the affection, are finely powdered sulphur, which may be freely dusted over the face; and those compounded, in various proportions, of starch, rice-flour, zinc-oxide, and the subcarbonate of bismuth. As regards the internal or constitutional treatment of acne, very often none is required, since many of the individuals who are subjects of the disease enjoy good health. Acne is, to a 1 The formula is : — fy. Calcis gss ; 16 Sulphur, sublim. §j ; 32 Aq. fx; 32U Coque ad §vj (200.) deinde filtra. Sig. "Vlemincx's solution." 814 DISEASES OF THE SKIX. satisfactory extent, remediable by local measures alone, and it is clear that they who employ a combination of constitutional and local treatment, if only the latter is skilfully managed, will have some difficulty in assigning to each its relative therapeutic value. The internal treatment of acne, therefore, may he prop- erly described as that which is indicated to the general practi- tioner of medicine, by the condition of his patient. Dyspepsia and constipation are, without doubt, to he corrected by medi- cinal measures, or even better by judicious attention to the diet and habits of the patient suffering from such disorders. The cathartics, saline and alterative, will often prove serviceable. I have rarely found it necessary to resort to arsenic, though it is highly recommended in acne papulosa, by both Duhring and Taylor. The internal employment of ergot in full doses for the relief of acne, as suggested by Ilardaway and Heitzmann, has, without question, been frequently followed by excellent re- sults. Cod liver oil, iron, the mineral acids, and the hitters will prove valuable in chlorosis and cachexia. The sulphide of calcium, in quarter of a grain (.016) doses, has proved of some benefit in obstinate cases. I have no question hut that the tem- perate gratification of the sexual instinct in a happy marriage, is conducive to good results; and such a change of condition, when anticipated, should generally he encouraged as favorable for the future of young adults. Uterine disease should receive proper treatment when such complication exists; and this, far less by topical applications, than by attention to the general health, as the patients of this class are more often chlorotic young women with menstrual derangements, leading sedentary lives, or overworked at the school-desk, the sewing-machine, or the shop-counter. The diet should be carefully regulated, and the rules of hygiene enforced. Acne Rosacea. Acne rosacea is a chronic disease of the skin, chiefly of the face, often devel- oped from, or associated with, the lesions of acne vulgaris, characterized by hyperaemic macula?, telangiectases, inflammatory papules, or vegetating masses, which may attain the size of a hen's egg. It is usual to describe three grades of this disorder, which is most often displayed upon the nose, though it may also affect the cheeks, lips, chin, and, rarely, the lateral regions of the neck. In the first grade, there is a more or less diffuse and uniform, pinkish or dusky redness, involving the extremity of the nose and its contiguous parts, which may extend from this point in a somewhat symmetrical figure over the cheeks and chin. The parts give rise to little or no subjective sensation. Under the finger, the color disappears upon pressure, the surface seems cool rather than hot, and the sebaceous glands are seen to be affected, as there is usually present either a seborrhcea oleosa or an accumu- ACNE ROSACEA. 315 lation of yellowish-white, moderately inspissated sebum, in the patulous orifices of the gland duets. When the redness has existed for some time, minute bloodvessels can be seen ramify- ing over the erythematous surface. In the second grade, firm, purplish-red, painless, pin head to pea-sized nodules or papules rise from the erythematous surface, and either display minute superficial and tortuous bloodvessels in the integument by which they are covered, or project from a base about which such a telangiectasis has been very irregularly de- veloped. The lesions are apt to be intermingled with those of acne vulgaris. When fully developed, this stage of the disease, though generally not productive of marked subjective sensation, produces an exceedingly conspicuous deformity. In the third stage, which is the most, pronounced of the three, roundish, sessile, or pedunculated, lobulated, or pendulous, firm, elastic, pinkish-red, bluish, livid, or violaceous vegetations, tra- versed by finer or larger networks of bloodvessels, slowly de- velop about the affected part of the face, chiefly the nose. These may be single or multiple, and, in the latter case, isolated, or so closely united as to be scarcely distinguishable- from each other. The acneiform lesions seen in the second grade of the disease, may here also be apparent. In other cases, there is a uniform, symmetrical, and elongated hypertrophy of all the soft parts of the nose, which may thus attain colossal proportions. It is these consequences of acne rosacea to which the term rhinophyma 1 has been applied. The course of the disease is very slow, and in by far the largest numher does not produce the exaggerated types of the second and third grade. The lesions may persist indefinitely as indolent symptoms of the malady in any one of its stages, or, in the cases where there has been no new growth of vessels or tubercles, proceed to spontaneous involution. Etiology. — The first and second grades of acne rosacea are common in women either at puberty or near the period of the menopause, in those who are pregnant, or who suffer from utero ovarian disease, frequent miscarriages, sterility, irregular performance of the menstrual function, and chlorosis. It is, however, seen in males of early and late adult life. In both sexes, it may occur in ansemic and asthenic states. In both, also, its association with dyspepsia and the immoderate use of alco- holic drinks, beer, wines, and spirits, is a matter of common ohservation. According to Kaposi, the rosaceous nose of the wine drinker is bright red; of the beer drinker, cyanotic or violet; of the spirit drinker, smooth, supple, fatty, and dark blue. The new-growth of vessels and tubercles, with the rhino- phyma of the advanced grade of the disease, is much more 1 For a full -discussion of this subject, consult a valuable paper by Hans Hebra, in the Viertelj. f. Derm. u. Syph., 1881, 4 Hft., p. 603, illustrated by cuts giving the gross and microscopical appearances of the disease. 316 DISEASES OF THE SKIX. common in men than in women. Tn those whose faces are bronzed by exposure to the weather, the telangiectasia condition of tlic cheeks rather than of the nose, is of frequent occurrence. Veteran sailors and soldiers are thus commonly affected. Per- sona who have frozen the nose or cheeks on one or more occa- sions,are similarly liable to the telangiectasia development. Any externally or internally operating cause which tends to retard the capillary circulation in the superficial portion of the skin, is capable of inducing the result. I have seen it conspicuously displayed in the mulatto. Pathology. — Tn the first stage of acne rosacea, there is merely passive hyperemia. The circulation of blood in the superficial capillary plexus of minute vessels, is retarded. Persistence of this condition for long periods of time, results in paresis of the capillaries, with their consequent dilatation and hypertrophy, phenomena which characterize the second stage, the sebaceous gland disorder being a complication of the process. In the third stage, the nodules are found to be composed of new formed gelatinous elements, which become formed by organization. According to Biesiadecki, there is also dilatation and hyper- trophy of the sebaceous glands with dilatation, hypertrophy, and new-growth of the superficial vessels, and enlargement also of those trunks which ascend from the corium. Diagnosis. — Acne vulgaris is distinguished from acne rosacea by the absence of telangiectasis, and of the hypertrophic growths which characterize the developed lesions of the last-named dis- ease. The tubercular syphiloderm is recognizable by its ten- dency to ulceration and crusting, and by the entire absence of telangiectasis. When the tubercles of syphilis are limited to the extremity of the nose and are unusually small in consequence of the influence of treatment, they often degenerate into charac- teristic, split-pea sized, irregularly circular ulcerations, superfi- cial in seat and frequently isolated. They leave similarly shaped and sized, depressed cicatrices, at the tip and neighboring parts of the nose. As the process is much more rapid than in acne rosacea, these lesions, considered in connection with the absence of telangiectasis, furnish the most significant diagnostic symp- toms of the disorder, for they often occur late in the history of syphilis, in individuals of middle life, and in varying shades of a dull reddish color, circumstances particularly favorable for confusion regarding the identity of the two diseases. I have seen a single case of zoster from involvement of the superior maxillary branch of the trigeminus with diffused red- ness of one side of the nose and efflorescence of vesicles over its tip and ala, which certainly strongly resembled acne rosacea with pustular lesions. Here the painful character of the disor- der, its limitation to one side, its transitory career, and its vesicular lesions were sufficiently characteristic. Lupus vulgaris, like syphilis, when occurring upon the nose, is to be recognized by the tendency of its papulo-tubercular ACNE ROSACEA. 317 lesions to ulceration and crusting, the absence of vascularity, and the frequent presence of characteristic cicatrices. Unlike syphilis and acne rosacea, however, the history of lupus vulgaris usually extends to early childhood. Lupus erythematosus is yet more readily different' ated, as it is not only unaccompanied by vascularity and ulceration, but is characterized by scaling and symmetrical diffusion over much larger areas, commonly extending from the bridge of the nose well on to the cheeks. Treatment. — The local treatment of the first grade of acne rosacea, is substantially that of acne vulgaris. Stimulating lotions of green soap, alcohol, bichloride of mercury, or sulphur in connection with ablutions by hot water, are of the highest value. In addition, the various ointments containing sulphur, the mercuric oxide and iodides, and the continuous applications of mercurial plaster, should be employed if necessary. When the diseased condition is that of the second grade, the indication is the destruction of the superficial capillaries, as well as the removal of the other lesions present. Hardaway, of St. Louis, destroys the vessels by single or multiple puncture of each with a fine cambric needle attached to the negative pole of a galvanic battery, with six to ten elements in the circuit. This is better than the knife which, in my hands, has repeatedly failed. Brushing the part cautiously with solutions of caustic potash, ten to thirty grains (.66-2.) to the ounce (32.) of water; and the local use of pure carbolic, chromic, and glacial acetic acids, acetum cantharidis (Taylor), iodide of sulphur, and the pernitrate of mercury are also available. Before any of these, however, is employed, an effort should be made to produce exfo- liation, by spreading over the part a plaster made of green soap. Kaposi highly recommends the solution of iodated glycerine employed by him in acne vulgaris (q. v.), which is painted over the part eight to twelve times daily for three or four successive days, and immediately covered with gutta percha paper. Multiple scarification of all new growths after the manner of attacking lupous nodules; erasion with the dermal curette; and surgical ablation of tumors by ligature and knife are also avail- able. After any destructive attack upon the diseased portions of the skin, the soothing lotions, fomentations, or ointments should be regularly applied. As far as there can be said to be any internal treatment of acne rosacea, it is that of acne vulgaris, but in neither disorder can such be confidently described as effective in the dispersion of the local lesions. The treatment is that of the patient rather than of his disease. Where alcohol has been in any degree pro- ductive of the local effects, the use of spirits, wines, and beer is to be interdicted; but as regards confirmed rosacea, this will prove to be of but little avail. I have seen the disease when resulting from brandy-drinking, persist after five years of total abstinence. 318 DISEASES OF THE SKIN. Prognosis. — A favorable prognosis can be established only in 3 where the disease is presented in its milder forms. In those complicated by marked telangiectasis and hypertrophy, the results of treatment are not in the highest degree encourag- ing. In spite of the most energetic procedures, the visa-tergo of passive hyperemia, involving often the deeper and unassailed bloodvessels, works its slow progress. For women, the future is in general more promising than in the ease of men. With the most unfavorable prognosis, however, it is to be remembered that, after all, the disease is one of deformity rather than of physical discomfort. Class III. —OF THE SWEAT GLANDS AND PERIGLANDULAR TISSUES. 1. Anomalies of Secretion. The functional disorders of the sweat glands are characterized by a quantitative or qualitative change in the secretion of sweat. Hyperidrosis. By this term is designated an exaggerated effusion of sweat, the secretion accumulating in visible drops upon the surface of the skin. The condition may be physiological as the result of active exertion in a medium of high temperature; or it may become pathological in character, and in the latter case be either general or partial. General sweating to a pathological extent occurs chiefly in the obese, but also in those who are the subjects of constitutional disease (phthisis, the various febrile disorders, etc.). It is the fertile source of the various forms of intertrigo, sudamina, and miliaria. Local hyperidrosis is the exaggerated effusion of sweat limited to certain definite portions of the skin, as the palms, soles, dorsa of the hands and feet, the interdigital spaces, the genitals, the axillae, and temples. In such cases the secretion occurs moderately or greatly in excess, varying in this respect somewhat in different degrees of temperature and of rapidity of the circulation ; is occasionally but not commonly accompanied by fetor; and always occurs to a marked extent. It may invlove one or both sides of the body, being generally symmetrical at the extremities and asymmetrical upon portions of the face. Its typical expression may be studied in the hands which are continually moistened, clammy, or dripping with fluid within a brief time after the most careful drying of the parts. In the case of a woman, the instincts of whose sex prompt her to take HYPER1DR0SIS. 319 such precautions, the dress is constantly protected from contact with the macerated palms by a handkerchief or similar article which is always in readiness. The disadvantages thus arising in individuals of both sexes who are engaged as tradespeople, artists, hand workers, etc., can readily be understood. In women of social position, no small complaint is made of the disagreeable result produced after wearing kid gloves for even a short time, the material of which is soon soiled by its complete saturation with the secretion from the skin. With and without this local excess, occurs the hyperidrosis of the feet, aggravated by the mechanical force of gravity and the need of constant covering. The stockings and the leather of the boots, shoes, or gaiters are saturated with the secretion, and be- come rapidly subject to chemical alteration. There is usually an offensive odor of the region, originating partly in the primary fetor of the secretions themselves, and partly in the subsequent chemical decomposition of the latter, rapidly progressing under the influence of the soiled and often stinking investments of the feet. The integument, constantly macerated, may become both pain- ful and tender; very rarely there is vesiculation or exfoliation of patches of sodden epidermis. When the genitals are involved, especially in the male, erythema and intertrigo are the frequent results. The causes of the disease are obscure, authors being divided as to the relative etiological influence of the nervous, muscular, and the vascular systems. The disease is encountered in individ- uals of both sexes, and in all ages and degrees of general health, as also in those who are and those who are not, careful as to cleanliness. I am inclined to believe, as a result of observation, that the facial symmetrical hyperidroses associated with migraine, neuralgias, hemicrania, etc., are etiologically and pathologically distinct from the similar symmetrical affections of the hands and feet. The latter certainly do occur with conspicuous frequency in young adult women who are the subjects of chloro-angemia, some form of dysmenorrhcea, or cardiac trouble. In one young female under my own observation, I discovered an habitual pulse of fifty-five to the minute without dicrotism, the patient being in other respects well. In her usual household avocations, she was generally provided with a towel for the absorption of sweat from the hands. The disorder usually lasts for years, but may spontaneously disappear. Hyperidrosis is locally treated by the diligent application of the dusting powders, lycopodium, zinc oxide, salicylic acid, bis- muth, or magnesia, the starch-containing compounds being here subject to the disadvantage, when commingled with the sweat, of forming minute rolls or cakes which irritate the skin. In the interval of applying these or alternately with such applications, astringent lotions or baths may be used, consisting of solutions in alcohol or water, of tannin, alum, corrosive sublimate, per- 320 DISEASES OF THE SKIN. manga n ate of potassium, sulphate of zinc, or the preparations of sea-salt now found in the American market. For byperidrosis of the feet, the treatment by the method of Hebra has, deservedly, the highest repute. It consists in neatly and completely enveloping the entire foot and toes separately, after thorough washing and drying, in strips of cotton cloth over which is spread to the thickness of the blade of a common knife, the unguentum diachyli albi already described. This hitter, it will be remembered, is made by boiling one part of the best litharge with about four parts of pure olive oil, to which a little water is added while the materials are stirred together over a slow fire. (For Duhring's modification of this ointment see page 132.) The parts are well bandaged, and the patient either remains subsequently at rest or pursues his avocation, wearing over the feet, shoes and stockings which have not been previously used. In twenty-four hours, the feet are redressed without washing, after dry rubbing with charpie and a dusting powder. This is repeated daily for ten to twenty days, after which a dusting powder may be substituted for the local dress- ing. A parchment-like desquamation of the epidermis in thick, yellowish-brown lamellae occurs, beneath which an epidermis is formed, new and at first tender, hut apparently normal. When the latter has lost its tenderness, the feet are for the first time washed with water. In case of failure, the routine of the treat- ment is, as often as necessary, again carried out. It is scarcely necessary to add that no ill effects are known to have resulted from the therapeutic measures adopted for checking a local byperidrosis. Internally, the use of chalybeates, quinine, strychnine, bella- donna, ergot, and the vegetable and mineral tonics, may be indicated, and, in the mild and fugitive forms of the disorder, possibly prove of service. In the confirmed and symmetrical varieties of the disease, they will scarcely do more than benefit the general condition of the patient. Bromidrosis. In this variation from a normal standard of the sweat func- tion, the secretion is either effused in such a state that it can be immediately perceived to possess an unusual odor, or, as Hebra taught was the case with the majority of patients, rapidly changed to that condition. It may be, and often is, associated with hyperidrosis, or may occur quite independently of the latter, and like the latter also be either general or partial. The odor may be either agreeable or disagreeable, having been in various cases compared to that of several flowers and fruits, as well as to that of various stench-emitting animals. In this respect the sweat presents a striking analogy to the urine, with which it sustains a close and well recognized physiological relation. ANIDROSIS. 321 General bromidrosis may be physiological, as in the case of individuals of the African race, or in those of dark skins who are profusely sweating during labor or in exalted temperatures. General pathological bromidrosis is rare. The odors emanating from the person in ulcerating syphilodermata, smallpox, and other general disorders, may, in certain cases, be associated with the sweat secretion, but in others doubtless are connected with the decomposition of pathological products of the inflammatory process. The local varieties of bromidrosis affect the regions in which the sweat is oftenest secreted in excess, and its immediate evap- oration prevented, as in the axillge, groins, feet, ano-genital, in- ter- and infra-mammary regions. In a qualitative sense, every degree of odorousness is noted, from that which is merely slightly agreeable or offensive, to the most intolerable stench. When complicated by a seborrhcea in situations where the parts are not only warm, moist, and covered by clothing, but also subjected to friction and long uncleaused, the most intolerable and nauseous fetor is perceived. Treatment. — The treatment of bromidrosis is in general that of hyperidrosis already described. Thin 1 has successfully em- ployed stockings and cork soles dried thoroughly, after satura- tion for hours in a jar containing a solution of boracic acid. The efficacy of this, he ascribes to the fact that the odor is the result of the development in the secretions of the bacterium foetidum. An ointment is also employed by him for similar purposes, produced by making a solution of the acid in glyce- rine, and incorporating it with a fatty basis of white wax and almond oil, making thus a "glycerated cream of boric acid." Armingaud, of the French Academy, has reported excellent results following the subcutaneous injection of three grains (.20) of the nitrate of pilocarpine, eight of which operations were suc- cessful in reducing the abnormal sweating and fetor. Clement Hawkins 2 finely triturates fifteen grains (1.) of the red oxide of lead, and to this adds gradually one ounce (32.) of Goulard's extract. This is used as a lotion following a nightly foot-bath containing an ounce (32.) of alum. Anidrosis. Diminution in the quantity of sweat excreted or its complete suppression, whether general or local, is a symptom of several disorders, but as a separate cutaneous affection has no existence. It is sufficiently common in many cutaneous diseases as, for ex- ample, ichthyosis, psoriasis, and some forms of eczema. But in these, the symptomatic character of the anomaly is illustrated by the well-known fact that when the skin is relieved of these ' Practitioner, Dec. 1881, p. 401. 2 Brit. Med. Journ., May 7, 1881. 21 322 DISEASES OF THE SKIN. cutaneous troubles, the function of sweat secretion is restored. Similarly, in neuralgias and certain forms of paralysis, a circum- scribed and temporary anidrosis may be the local expression of the nervous disturbance, precisely as in the case of the asymmetrical hyperidroses. Lastly, there arc individuals exhibiting the idio- syncrasy of sweating either not at all or quite imperceptibly in elevated temperatures, phenomena which I should prefer to as- scribeto peculiarities in the. equilibrium of the heat-exchanging forces, than to congenital deficiency of the sweat glands. Treatment — The measures capable of stimulating the sweat secretion are; the ingestion of water in quantity by the mouth, the external application of heat in a dry or moist atmosphere, and the use of jaborandi or pilocarpine by the mouth or hypo- dermic injection. In the anidrosis accompanying cutaneous dis- ease, the indication is always primarily for the relief of the latter. Chromidrosis. Cases are on record in which effused sweat has been variously colored in shades of red, yellow, green, black, and blue. In these there has been usually a copious secretion of fluid. Au- thors have variously attributed the color to the presence of com- pounds of phosphorus, iron, cyanogen, indican, Prussian blue, and even to parasitic vegetations upon the surface. Women, much more than men, are apt for the free deposit of pigment upon the skin, and, in view of the admitted rarity of chromi- drosis, the suspicion arises that in some of the cases reported, there was free pigmentation of the surface by which the fluid exuded was immediately stained or colored. Duhriug reports a single case of red sweating in a vigorous male patient. Usually, however, the phenomena occur in persons who betray some evi- dence of impairment of other organs than the skin, or who are debilitated in general health, thus furnishing an indication for their treatment. Babesiu, 1 of Pesth, reports some interesting cases of this dis- order, which appear to have been produced by the presence of bacteria. A woman, twenty-six years of age, presented pale- red sweat in the right, axilla, where the skin and hairs were also slightly reddened. From time to time the perspiration became blood-red in color, associated with hysterical and nervous dis- turbances. A sister, who slept with her, was affected in a simi- lar manner, the perspiration in the right axilla becoming red. A third case presented itself in a young, healthy man, who complained of occasional blood-red sweat; and a fourth, in a young woman. In all, the symptom was associated with trouble- some itching. Microscopical investigation yielded in all the 1 Lancet, 1882. CHROMIDROSIS. 323 cases a similar result. The hairs of the axilla? were thin, pale- red, brittle; and surrounded with a colloid-looking;, rusty, or bright red sheath, in places, of considerable thickness, and having a rough surface. It consisted of red masses, presenting a radiat- ing striation, more or less confluent, apparently proceeding from fibres of the cortex of the hair, or from some broken part of its surface. The radiating striation was found to be due to the aggregation of round or ovoid bacteria, scarcely a micro-milli- metre in diameter, which were united in zoogloea masses by a reddish, intermediate substance. Modular swellings on the hair were produced by the infiltration of the organism between the separated fibrils. The roots of the hair were free from bacteria. The red tint of the sweat was found to depend upon numerous roundish masses of zoogloea. T. C. Fox 1 also has reported two cases in which a deep bluish- black pigment was exuded upon the skin of the circum-orbital region. The amorphous granules were found insoluble in al- most all hot or cold reagents, but displayed a deep blue color when moistened with glycerine, and a purplish hue when dis- solved in hot sulphuric acid. The hypothesis, that certain cases described as chromidrosis are really instances of mechanical washing of pigment to the surface in the profuse sweating of the debilitated, is strength- ened by the phenomena of simultaneous hair coloration. Thus Prentiss 2 reports the case of a young woman affected with acute cystitis and purulent urine, whose hair, under the influence of profuse sweating induced by the action of pilocarpine, changed speedily from a light blond to a nearly jet black hue. At the meeting of the American Dermatological Association, in 1881, I exhibited hairs of a middle-aged man which had changed in a night from a grayish-white to a greenish and yellowish-brown hue ; and, in commenting upon these, Dr. White, of Boston, stated that he had observed several similar cases of hair color- ation as the result of profuse sweats. Abnormal conditions of excreted sweat, other than those de- scribed above, have been from time to time noted by various observers. Some of these are supported by a reasonable basis of fact, others not. Hasmatidrosis, for example, the so-called sweating of blood, is, in general, a pathological exudation of that fluid upon the free surface of the skin without the occur- rence of traumatism, and quite independent of the action of the sweat glands, in patients affected with haemophilia. Under these circumstances, it is not surprising to find that at times the sweat secretion is commingled with blood, which, by diapedesis ; enters 1 Med. Press and Circular. Jan. 1, 1881. 2 Phil. Med. Times, July 2, 1881, p. 609. 324 DISEASES OF THE SKIN". the sudoriparous gland from tlie delicate vascular plexus which surrounds it, as Parrot 1 and others have shown. In the effort to eliminate certain substances, accidentally or otherwise introduced into the system, the sweat may possibly become charged with iodine, turpentine, tar, arsenic, phosphorus, ami other articles. After the ingestion of the last-named sub- stance, the secretion is said to have occasionally become lumi- nous. Douhtless several of the eruptions described in the chap- ter on dermatitis medicamentosa are due to a similar eliminative effort, especially those accompanied by excessive sweating and the production of vesicnlation. With equal reason it may he inferred that the sweat is at times charged with excrementitious and other products of the human body; as, for example, the principles of the bile. During the late civil war, I observed several patients affected with yel- low fever whose skins exhibited the characteristic hue of that disease, and whose sweat was similarly colored. The so-called " galactidrosis," from supposed metastasis of milk, does not occur. Cases thus described have been instances of pathological sweat in the puerperal state. The fact of the occurrence of urinary sweat, uridrosis, is, how- ever, based upon positive proof, that, viz., of the discovery of urea and urinary salts deposited upon the skin surface after evaporation of the exuded fluid. Such symptoms have usually occurred either as the result of grave constitutional affections, such as cholera; or of organic renal disease, accompanied by anaemia; or of the ingestion of jaborandi. In a few cases, the symptoms have been presented in individuals who were appa- rently in good health. The salts of the urine appeared upon the skins of these patients, in the form of minute lamellae, or a fine powder of whitish color and crystalline aspect. In some cases reported, the symptoms have been noted to precede by a few days a fatal issue. Uridrosis, then, cannot be properly designated as a disease of the skin. Sudamina. Deriv. Lat. sudor, sweat. Sudamina is a disease characterized by the occurrence of discrete, superficially- seated, millet-seed sized, translucent vesicles resembling seed-pearls The lesions in sudamina are very thickly agglomerated, but discrete, transitory and translucent, pin-point sized vesicles, re- sembling minute sweat drops, or seed-pearls, upon the surface of the skin, often requiring the touch to define their real character. They are usually limited to certain regions of the body, as the trunk, and here more generally upon the face and sides of the 1 Etude sur la sueur de sang, etc., Gaz. de Med. et de Chir., 1839, t. vi. p. 633 et seq. MILIARIA. 325 belly and the iliac regions, though they may occur upon any part. Their course is rapid both in evolution and involution, and their sequelae are exceedingly delicate desquamative flakes, the thin roof-wall which originally covered the sweat-drops lifted from the superficial stratum of the horny layer of the epidermis. They contain each a droplet of sweat, which is removed by evapo- ration. The disease is a mere incident of profuse sweating, in debilitated conditions of the system, accompanied by the febrile process, as in enteric and other fevers, phthisis, and inflammatory rheumatism. The lesions are the result of the accumulation of sweat between the most superficial layers of the stratum corneum, in high tem- peratures of the body or of the medium by which it is sur- rounded, and usually in states of adynamia. They may hence occur at all ages of both sexes. The disease is not inflammatory, nor yet can it be described as purely functional in character. It occupies a middle ground between the two, sustaining thus the relation which is observed in several diseases, assignable with difficulty to the exact limits of artificial classes. The treatment is that of the diseased condition in which the lesions are produced. 2. Exudative. Miliaria. Deriv. Lat. milium, a millet-seed. Miliaria is an acute exudative affection of the sweat glands and periglandular tissues, characterized by the occurrence of numerous, discrete, whitish or reddish, millet-seed sized vesicles, papules, or vesico-papules, productive of sensations of heat and pricking, and often accompanied by hyperidrosis. Symptomatology. — Under this designation, it is intended to class all those lesions which occur as inflammatory symptoms in connection with profuse sweating. The terms lichen tropicus (or prickly heat), miliaria alba, miliaria rubra, miliaria papu- losa, miliaria vesiculosa, and miliaria crystallina, are merely descriptive of certain shifting characters of the eruption ; and, it must be confessed, have engendered some confusion with regard to its features. The disease is characterized by the occurrence of pin-point to pin-head sized vesicles, papules, vesico-papules, or the two as coincident and commingled lesions. They are exceedingly nu- merous, and may in severe cases cover almost the entire so-called non-hairy surface of the body, though they may be much more limited in their diffusion. They are usually acuminate and discrete, though often very thickly set together. They are rapid of occurrence, but may, in consequence of persistence of the cause, 326 DISEASES OF THE SK1X. be Bomewhat Blow in disappearing, or lie succeeded by crops of new lesions. In tbe white form (miliaria alba) opalescent ilea alone exist, and constitute thus an exaggerated sudamina, decidedly the rarer phenomenon. Much more frequently there is a decided and vivid redness, either as a halo about the base of the minute vesicles or of the pure papules, or of the papules at whose summit a minute vesicle Las formed (miliaria rubra). The eruption is seen upon the trunk, extremities, and lace, and is almost invariably accompanied by hyperidrosis, though the latter may be absent in high temperatures. The marked tingling, pricking, and burning sensations by which it is accom- panied, are often in the highest degree distressing, and may so- licit rubbing of the affected part, though the scratching elicited by severe pruritus is not common. Minute crusts may form after vesicular rupture. The attack may be mild or quite severe; and last for a few days, or for as many weeks or months, as the result of continuous aggravation, or of the production of new crops of lesions after each recurrence of the cause. It is not rarely complicated in obese individuals, by all varieties of inter- trigo and eczema. Etiology. — The disease is induced by stimulation of the sweat glands under the influence of heat; and is, therefore, most fre- quently noted iu elevated temperatures of the atmosphere. It is aggravated by all internal and external irritants, including alco- holic beverages, opiates, flannel, or other coarse under-garments, and friction of every sort. Excessive exertion on the one hand, and excessive prostration on the other, are equally effective. It Las seemed to me, after a somewhat extended observation of the white races in Africa, that the disease is more common in those subjected to rapid and intense fluctuation in the temperature of the atmosphere, than in those long accustomed to a relatively hot climate. It is thus exceedingly common in the northern parts of our own country, where the absence of the regulating gulf stream ushers the inhabitants suddenly from the rigors of a severe winter to the prostrating heats of summer. It attacks alike individuals of both sexes and all ages, being often particu- larly severe in the obese, and in infants, whose delicate skins, no less than their bowels, resent sudden and severe thermometrie changes. It moreover affects equally those who are vigorous and the debilitated. Pathology. — Miliaria is occasioned by afflux of the blood in excess of that which is physiological, to the periglandular vas- cular plexus of the sweat follicle. In various degrees, from transitory hyperemia to active exudation with the formation of vesicles, tli is pathological afflux may be exhibited in the symp- toms of the disease. When, however, as is usually the case, the exciting cause of the trouble is withdrawn before the production of excessive effects, the disorder does not advance to the grade of pustulation and active discLarge from the surface. Continu- MILIARIA. 327 ation or repetition of the cause (as in long exposure to very high temperatures, or aggravation of the surface affected with miliaria by friction or macerative action) is sufficient to beget a troublesome eczema of any type, a fact I have frequently observed in the tropics. It is by no means certain that the congestive effect of the heat and sweating, is limited to the region of the sudoriparous duct, at even an earlier period than this. In the heated and sensitive skin of the patient suffering from the dis- order, it seems reasonable to conclude that other portions of the epidermis and corium would exhibit a sympathetic hy perse mia or exudation, and such, certainly, is suggested to the careful observer by the clinical features of a well-marked ctise. Diagnosis. — The diagnosis of miliaria rests chiefly upon: the recognition of the cause of the disease, viz., exposure to high temperatures of the atmosphere ; the pricking and tingling rather than the severe itching sensations which it occasions ; the rapidity of its course; and the usually distinct isolation of its lesions, however closely they may be set together. From the very superficial vesicles of sudamina, those of miliaria can be recognized at once by their evident involvement of portions of the skin deeper than the horny layer. From papular and vesi- cular eczema, the similar forms of miliaria may be distinguished by consideration of the features described above. Should the case be doubtful, in consequence of a commingling of the symp- toms of the two disorders, no difficulty need arise. That the one may merge into the other by insensible gradations, cannot be denied. Heat and sweating are the fertile sources of eczema as well as of miliaria, and it would not be unphilosophical to conclude that the latter is simply one of the many approaches to the former by the avenue of the sweat glands. Certain it is, that every miliaria can be artificially transformed into an eczema. Dermatitis medicamentosa may be readily confounded with miliaria, and is indeed at times clinically merged with that dis- ease. There are few practitioners who have not seen patients affected with "prickly heat" in summer, their symptoms inten- sified by the drugs they have swallowed in the hope of securing relief. In tiie latter event, the eruption is often widely gene- ralized and quite symmetrical, accompanied by unusual degrees of papulation, vesiculation, erythema, and intensely annoying subjective sensations, without recent undue exposure to heat. Sometimes a history of ingesta can be obtained. Duhring calls attention to the difficulty of recognizing the disease when its vesicular lesions complicate mild forms of scar- latina ; and the same might be said of papular urticaria, which in a teething, fretful child, bathed in perspiration, would be indeed almost indistinguishable from it. The recognition in any such case of the exact source of the cutaneous hypersemia and mild exudation, papular or vesicular, would involve merely a question of etiology. 328 DISEASES OF THE SKIN. Treatment. — Tin* local treatment of miliaria is, in brief, that of the corresponding Btage of eczema. Unguents are to l>e scrupulously avoided, a8 the skin cannot tolerate them, and the Bame may be said of plasters and very cold baths. Baths or lotions, tepid, warm, or moderately cool, as the feelings of the patient may decide to he most grateful, medicated with alkalies, bran, gelatine, or starch, will be found useful. After each, the skin is to be dried, not by rubbing, but by gently pressing dry cloths over the surface, and is then to he thoroughly protected by a free use of one of the dusting powders. When large tracts of the skin are involved and general baths have, been ordered, a package of "corn-starch farina" will often he found sufficiently well suited for Buch topical employment. Lotions may also he employed, composed of lead, or lead and opium, or alcoholic and ethereal solutions containing camphor and glycerine in the proportions given when considering the subject of acute eczema. I have also found modifications of the oleated lime-water serviceable in severe cases with eczematous features; as, for example — $. 01. lini flu; 65 Paraffin. 1 Sapon. Castil. f aa §ij ; 65 01. bergamii q. s ; q. s. Aq. calcis ad Oj ; 500 Sig For external use. This makes a demulcent creamy solution which often proves exceedingly grateful to the skin; and to it may he added the zinc oxide or dilute hydrocyanic acid, as may he required. After all, however, the general treatment of the patient is a matter of importance. The cause must he removed if possible. Withdrawal from the light, heat, and lahorof the day; unstim- ulating food and drink, nnirritating apparel, and rest, are of the greatest importance. The saline and acidulated heverages are usually acceptable to the palate, and useful if not drunk too cold. The chief value of Apollinaris water, lemonade, Vich}-, ami Tvissino-en, lies not in their action as medicaments, but as supplying the water demanded by the cutaneous loss through evaporation. Prognosis. — The disorder may he trivial and severe, and last hut for a few hours or as many months. It is usually relieved without difficulty, and often by domestic measures alone. It is most annoying and severe when complicated by the exudative process in other parts of the skin than the sweat-ducts and their immediate vicinage. Miliary Fever, Or the mette miliaire of the French, is an epidemic disorder of grave character, accompanied by sweating and a cutaneous ex- MILIARIA. 329 anthem. Pineau, 1 one of the latest writers on the subject, gives a description of the disease as it occurred lately in epidemic form in the island of Oleron, where, of one thousand patients affected, between one hundred and fifty and two hundred perished. The eruption appeared in the form of hypersemic macula?, disap- pearing under pressure, after which there formed rapidly myriads of reddish or whitish projections, grouped, unequally sized, and acuminate papules, rising from a whitish and macerated surface. Among these were interspersed lesions of sudamina. The re- gion of the face was not spared, and the conjunctivae were ex- ceptionally affected. In the course of from two to four days, pin-head to bean-sized, varioliform but non-umbilicated pustules formed in the site of some of the papules, the contents of which disappeared by resorption, the final lesions presented being large, flat, reddish papules, the skin, of the face particularly, becoming generally reddened and swollen. In the course of from ten to twelve days, general desquamation ensued with large palmar and plantar losses. Relapses occurred in some cases with general redness of the surface, or with crops of reddish plaques, or yet again with the occurrence of furuncles. The sensations were tliose of myriads of needles thrust into the skin. The exanthem was accompanied in some cases by fever, and in others not. In fatal cases death resulted from exhaustion. Bysidrosis. Under the names dysidrosis and cheiro-pompholyx, Tilbury Fox and Hutchinson, of London, respectively, have described cases in which deeply -imbedded, pin-head sized, acuminate, pri- marily translucent vesicles, occur upon the palmar and inter- digital surfaces. Both in consequence of coalescence and in- crease in size, bullae may subsequently form, an inch or more in height, filled with an alkaline or slightly acid fluid supposed to be sweat. Partial absorption occurs if the lesions be undis- turbed, after which desquamation ensues from a reddened, non- discharging surface. The cuticle about the lesions may be sodden and macerated or reddened; it is usually painful and swollen. There is often produced a sensation of pricking, burn- ing, or itching. The eruption is most commonly discovered upon the hands and, less frequently, the feet; though other portions of the body may be involved. No little controversy has arisen respecting the exact nature of this disease, Fox and Crocker, on the one hand, 2 claiming a sudoriparous origin for the malady, while Robiuson, 3 of JSTew York, concludes, from a careful study of a single case, that 1 Arch. Geuer. de Med., Jan. 1882, p. 25. 2 The Histology of Dysidrosis, London, 1878, from Trans of the Path. Soc. of London, vol. xxix., 1878. 3 Pompholyx, Arch, of Derm., vol. iii., No. 4, lb77, p. 289. 330 DISEASES OF THE SKIN. pything points against its being an affection of the sweat glands." Mj <>\vn conclusions are based upon a careful study of some interesting cases under my personal observation. It is probable that in some of them the disease originated in the sweat follicles, as the appearance and behavior of the vesicles certainly indi- cated. In others, the eezematous features were more pronounced; and the latter, in two instances, seemed to have been exeited by the former. If the remarks heretofore made relative to the absence of a strictly defined dividing line between disorders of the Bweat glands and eczema be based upon fact, here surely such an explanation of these differences may be urged. But a point of special interest in this connection is, it seems to me, the occurrence of the affection chiefty among the cachec- tic. Fox says " I never knew any patient who had this disease . . . well." lie describes a condition of well-marked cachexia in all bis cases. Robinson's patient was sickly for years, had twice suffered from fracture of the femur, had lost three of six children, and was "-depressed." The severest lesions exhibited by my pa- tients, were those of a woman who had chronic enlargement of the spleen; and of a man who was profoundly cachectic, suffered from night-sweats, had a sallow hue of the skin, and subse- quently died paraplegic. Class IV.— OF THE HAIRS. HAIR-FOLLICLES, AND PERI- FOLLICULAR TISSUES. 1. Atrophic. Alopecia. Deriv. Gr. x\virr,%, a fox. Alopecia is a physiological or pathological, symmetrical or asymmetrical, partial or complete, deficiency of hair. Congenital Alopecia. In rare cases, there is a partial or complete absence of hairs at birth, in consequence of an arrested development of the pilary system. Generally, however, these appendages of the skin n re merely of tardy appearance, their eruption being extraordinarily delayed, as in cases of retarded dentition. Senile Alopecia. The baldness of old age, whether occurring upon the vertex so as to produce a tonsure like that of the priest, or whether limited to the frontal region, or so extensive as to involve nearly ALOPECIA. 331 the entire calvarium, leaving; a fringe of hairs at the occiput and temples merely, is always remarkable for its symmetry. There is hence a certain degree of dignity added to the appear- ance of the head, which an asymmetrical loss of hair could not produce. It may occur at varying ages of advanced life, and is quite frequently traceable to an early seborrhcea sicca. It is much more common in men than in women; and this, I believe, partly, because of the difference in the manner of covering the head in the two sexes, women usually wearing an exceedingly light covering for the head, while men encase the latter with tight fitting caps or hats which interfere with proper aeration of the scalp. Individuals of the male sex also, in consequence of their usually wearing the hair short, bestow far less time upon the care and dressing of it. In uncivilized races, where these differences are less marked, and where males pay great attention to the ornamentation of the scalp, senile baldness is of less fre- quent occurrence. The bald surface is, as a rule, smooth and shining; it is occa- sionally the seat of a seborrhcea oleosa. The hair follicles, with their accessory sebaceous glands, and occasionally the skin itself, are often in a state of atrophy, though there may be dilatation of the sebaceous glands. There is commonly some blanching of the hairs which are gradually shed, as also of those which re- main, though this is not constant. These conditions are much less frequent upon the surface covered by the beard, and pubic and axillary hairs. Premature Alopecia, Or premature calvities, is that form of acquired baldness which occurs in individuals who have not attained advanced years. It may be either idiopathic or symptomatic. The idiopathic variety does not originate in the diseases of the scalp or of the general economy which are recognized as effective in the production of other forms of baldness. It is, as with senile alopecia, more common in men than in women, and is, in the former sex, decidedly prevalent among those leading seden- tary lives. The loss of hair may be produced either rapidly, or, more commonly, slowly; and at any period after the puberal epoch. The pilary growth may gradually and evenly recede from the forehead, or, what is more frequent, recede on either side of the median line, leaving a more vigorous crop extending centrally toward the root of the nose, or produce the effect of the tonsure described above. It is always symmetrical, and usually remediless, partial calvities being the permanent result of the process. In many families, there is a predisposition to this premature loss of hair, which may be recognized in the males of succeeding generations. Symptomatic premature alopecia is the frequent result of a series of local and general disorders which vary in their gravity. 332 D1SKASES OF THE SKIN. Sudden and gradual symmetrical thinning: of the hairs or com- plete baldness, is sufficiently common as the result of seborrhoea sicca, psoriasis, and other cutaneous affections of the scalp; the asymmetrical tonus being more common in asymmetrical scalp diseases, such as those resulting; from the destructive action of the vegetable parasites. Rarely, however, asymmetrical sebor- rhoea, occurring in patches upon the side of the head, may pro- duce such disfigurement. Among the systemic disorders which have this effect, may be named almost all severe fehrile pro- cesses, including the exanthemata, profound disorders of the nervous centres, lepra, and syphilis. In the last-named disease it may occur as a precocious or tardy symptom, the former being always symmetrical, variable as to the degree of loss, rarely so severe as to cause baldness, and occurring, as it does usually, in early adult years, generally quite remediable The tardy form, on the other hand, is usually associated with the evolution or destructive involution of gummata of the scalp, and the resulting baldness is often permanent. The forms of alopecia described above as encountered upon the scalp, may involve also other hairy portions of the body, as of the axillae and pubis; and these also in variable degrees. Treatment. — The treatment of alopecia in general, is that which stimulates the nutrition of the hair follicle by producing in its periphery a species of transitory and artificial hyperemia. This is usually accomplished by friction of the scalp with a brush, aided by the local employment of alcoholic, oily, alkaline, and other stimulating applications. The general health must in such cases receive special attention. I am strongly impressed with the fact that a large number of individuals suffering from pre- mature baldness have a distaste for fat; and the ingestion of cod-liver and other nutritious oils, fat meat, or linseed and lin- seed oil, as recommended by Sherwell, is for such patients ad- visable. Under the most favorable circumstances, however, the prognosis of idiopathic premature alopecia is well-nigh as hope- less as that of the senile forms. A scanty crop of short, soft, downy hairs may push for a time to the surface, but soon yield before the inactivity of the follicles in which they are implanted. Inasmuch, however, as exceptionally brilliant results are occa- sionally obtained by treatment, the latter is always deserving of a trial. When the alopecia is symptomatic of some local disease of the scalp, the latter of course is first to be relieved by the measures, appropriate for each, as, for example, the use of para- siticides in those of parasitic origin. The total or partial sym- metrical losses of hair occurring in the course of systemic disorders, have a much more hopeful prognosis. Exception, however, is to be made of the tardy syphilitic alopecia asso- ciated with local scalp lesions or profound cachexia. In all forms of syphilitic alopecia, local as well as constitutional treat- ment is indicated. ALOPECIA AREATA. 333 Alopecia Areata. Deriv. Lat. area, a vacant space; (arere, to wither, Fox.) Alopecia areata is a disease of the pilaiy follicles characterized by the sudden oc- currence of general and symmetrical, or partial and asymmetrical baldness, the latter exhibited in distinctly circumscribed, smooth, whitish patches, which are, in typical cases, completely destitute of hair. Symptomatology. — The disease commonly begins by the sudden and complete loss of hair over a circumscribed patch, usually upon one side of the scalp, so rapidly effected that patietits often describe a first discovery of the fact at the toilet of the morning. After a variable period of time, other patches of baldness may occur, all of the hairy portions of the body being liable to the affection, the scalp first in order, next the beard of the. male, then the genitalia, axillae, brows, lids, and the general surface of the body. I have seen a female child twelve years of age, where the closest scrutiny with a glass could not detect a single filament of hair upon any portion of the skin. The patches may be roundish, ovalish, or irregularly shaped, and may vary greatly in size, from that of a small coin upward. They may be so numerous as to greatly disfigure the entire scalp; and though these touch at the borders when thus numerous, they can scarcely be said to coalesce, as the individual elementary areas are usually recognizable. Their surface is smooth, whitish, and often perfectly destitute of hairs; it is rarely tumid and slightly reddened. The hairs at the periphery are usually of full length and fixed in situ, but are occasionally fragile, and readily with- drawn from their follicles. Stumps of such friable hairs may be at times seen at the margin of the patch. In point of abnormal subjective sensations, temperature, or disease of the surface from which the hairs have fallen, there is, as a rule, complete absence of symptoms. The skin, when the evolution of the disease is complete, is usually natural to the touch, and pliable. In in- complete evolution, and in periods of repair, downy hairs may appear upon the surface, at times considerably differing in color from those springing from unaltered regions of the scalp. The loss of hair from the surface may be: rarely, gradual; preceded by mild pruritus (Besnier et Doyon); or followed by anaesthesia (Neumann). Its apogee once attained, the course of the disease is variable; it may persist for periods without appa- rent change; or new patches may form while those of an older date either proceed to reproduce wholly or in part the pilary growth ; or, this latter accomplished, suffer a fresh loss by relapse. [Shifting areas of the disease may without question in this man- ner invade the entire surface of the scalp, which yet at any one moment of time may exhibit a loss of but the half of its hirsute covering. There is some reason for believing that the disease has a rela- 334 DISEASES OF THE SKIX. tively fixed period of evolution, though the exact limits of tlie latter are no1 known. Few individuals suiter less than one year; the moat arc relieved within a period of two years. These remarks, however, apply to the asymmetrical forms of the dis- ease in the relatively young. The symmetrical alopecia areata of the middle-aged is,' in my experience, a far more formidable affection. Few discuses are the source of greater mental distress than those of the Hass now under consideration. The prominent deformity thus occasioned debars the subject of the malady from social relations of many kinds, and this intensifies the morbid feeling which every reflected view of the head awakens. This is particularly true* of women. The successful management of these cases calls often for the supporting assurances of the practitioner. Etiology. — The causes of the disease are unknown. It is not transmitted by heredity nor by contagion ; and is not due to the presence of a parasite. It occurs with equal proportion in the two sexes ; and among these, irrespective of social condition. Of the partial and asymmetrical forms, I am persuaded that the larger number of cases occur in young subjects, from childhood to 'early adult life. The severe and generalized forms, I have more often encountered in middle-aged persons. In the latter elass especially, it is occasionally observed to follow the obscure disorders of the nervous centres due to sudden or prolonged undue excitation. In young subjects, I have repeatedly disco- vered a peculiar repugnance to the ingestion of fat and meat, a point to which attention is called in considering alopecia simplex. Collier 1 cites two cases in which the disease followed a blow upon the temporal region. Pathology. — The anatomical lesions which produce alopecia areata have not been recognized. The hairs fallen from the sur- face, when examined with the microscope, are seen to be atro- phied in the bulb and shaft, though Rindfleisch describes in certain cases a node-like enlargement of the hair-shaft after its escape from the follicle. Fracture of the shaft is in some cases also noted, evidently an accident of the process. No parasite can be discovered in uncomplicated cases. I have in one instance detected spores and mycelia of the trichophyton in the hairs, a coincidence of two disorders which has been observed by others. In default of all positive knowledge on the subject, the ma- jority of dermatologists have assumed the disease to be a tropho- neurosis, a view sustained by the etiological history of certain cases. I am inclined to believe that future investigation may establish some difference other than that of degree, between the partial asymmetrical disease of the young, and the more general symmetrical affection of middle life, in which the entire scalp, ' Lancet, Am. ed., Aug. 1881, p. 130. ALOPECIA AREATA. 335 lids, brows, pubis, and axillae, are completely shorn of their filaments. Diagnosis. — Alopecia areata is to be distinguished from vitiligo of the hairy portions of the surface, by the preservation of the pilary growth in the disease last named, the filaments moreover having usually a blanched and whitened look, due to the absence of pigment. From ringworm and favus of the scalp, the disease in question is readily differentiated, by the suddenness of its onset; the absence of all stumps of hairs, scales, crusts, and evidences of irritation in the involved area ; the whiteness, smoothness, and complete baldness of the latter; and, above all, by the failure to detect with the microscope the evidence of the presence of a vegetable parasite. The rare asymmetrical patches of seborrhcea of the scalp, are recognized by the presence of the fatty plates pasting the hairs to the surface, as well as by the slow and very gradual onset of the disorder. Other forms of baldness than those named above are all of gradual and, in their early stages, of symmetrical development. Those resulting from traumatic injuries of the scalp with cica- tricial results, are easily determined as having such an origin. Treatment. — One must necessarily view with some distrust all treatment for that disease which in the course of months or years usually terminates in spontaneous recovery, and in the mean time seems to bid defiance to each and eveiw therapeutic measure. Nevertheless, persistent and hopeful management of even the apparently desperate cases, is occasionally rewarded by such brilliant consequences that, however slight may be the foundation for a belief in the value of the therapy employed, it deserves recognition and trial. The indication for local treatment is to increase the physio- logical afflux of blood to the hair-follicles. With this end in view, the affected parts are to be bathed daily in water as hot as can be tolerated, then dried, and scrubbed with a stimulating lotion. The articles usually employed are alcohol, ether, tur- pentine, ammonia, camphor, cantharides, carbolic acid, oil of mace, croton oil, tincture of mix vomica, tincture of capsicum, tincture of aconite, castor oil, tar, iodine, sulphur, and the mer- curials. All frequently fail. Several of these in combination seem at times to be of service. The following are formulae, th varied to suit the indications in different cases: — . 01. ricini fgss; 16 Acid, carbolic. 3j; 4 Cantharid. tinct. gss; 16 01. rosmarin. gtt. xv ; 1 Spts vin. rectif. adfgiv; 130 S. For external use over the scalp with friction. 336 DISEASES OF THE SKIX. r. Oi. terebinth., ] ..- f - . 1fi 01. ricini, s' 1,1, lb Origani tinct. f 3j ; 4 01. caniphorat. f ;j ; 30 ' Liniment, volatil. ad f giij ; 100 11 Sig For external use with a brush till the scalp is irritated. Repeated blisterings of the scalp with cantharidal collodion, the Bpirit of green soap, and petroleum have also been employed externally with success. I have used with satisfactory results in a lew eases, an ointment of chrysarobin, which has the dis- advantage of staining not only the remaining hairs, hut often the face in consequence of its transmission to that locality by the medium of the hands. When patients, however, consent to its use, it is worthy of a trial, as its application has been speedily followed by a vigorous growth of new pilary filaments. Andre 1 employed ten hypodermic injections of muriate of pilo- carpine in one-eighth grain (.008) doses, which resulted, in the ease of a middle aged woman affected with total symmetrical baldness, in an abundant growth of hair. The disease, when limited to the regions of the beard in the young male, usually concludes its stadium in the course of about one year, with a favorable termination. Shaving should be regularly practiced, as the deformity is thus rendered some- what less conspicuous ; and the bald surface should be frequently stimulated with one or several of the topical applications named above. Alcoholic solutions of the mercuric bichloride, half to one grain (.033-.066) to the ounce (32.) are to be well rubbed over the patch or patches, once or twice daily. I have seen the disease in this locality coexist in two cases with benignant syphilis, the latter disease pursuing a career considerably short- ened by vigorous treatment, while the former, none the less, endured for twelve to fourteen months, long after the syphilitic cachexia had been relieved. At the end of this time, recovery' occurred precisely as in those cases which had presented no his- tory of infection. In all cases of implication of the head, where the scalp is in- volved in either sex, and where the peculiar hypochondriasis of the disease is developed, a wig should be worn for the sake of its moral effect upon the sufferer. For such, however, its use should be limited to social occasions, visits, etc., as the persistent wearing of a perruque in-doors, has seemed to me to lengthen somewhat the course of the disease. Internally, the use of fats and oils, especially cod-liver oil, is generally to lie advised ; and the chalybeate tonics with arsenic, quinine, and strychnia will often serve an important end. Prognosis. — From what precedes, it will justly be inferred that, as regards the relief of the baldness, the asymmetrical de- velopment of the patches in youth is much more favorable than I Rev. M§d. Fran, et Etranc. ATROPHIA PILOKUM PROPRIA. 837 the symmetrical general disease of middle life, the latter being often hopelessly remediless. The prognosis of the same affection of the male beard, is quite favorable. In all cases, the practi- tioner should actively persevere to the end. In no case should any encouragement be given as to complete relief within the year, though such exceptionally short careers of the disease are at times observed. Alopecia Furfuracea. Pityriasis Capitis. Under this title, is included that loss of hair, varying greatly in degree from moderate thinning of the growth to considerable symmetrical baldness, usually of the vertex, which, at the onset, results usually from seborrhcea. The scalp symptoms of this disorder have been described in the chapter devoted to sebor- rhoea. Later, however, as a consequence of long-continued ca- tarrh of the sebaceous glands, there is secondary involvement of the epidermis, whose elements are produced and shed in pathological frequency. The scales are then true squamae; dry, corneous, and epithelial, rather than fatty and seborrhceic. The subjective sensations are usually marked ; the scalp is often scratched and torn by the nails, and is in some eases reddened and thickened. There is, as a rule, decided general cachexia. Thus seborrhcea of the scalp is often associated with a general condition of excellent health ; alopecia furfuracea, never. The patients are often nervous, sallow women, with a long history of distressing headache, uterine hemorrhage, or hepatic disor- der. These are simply states in which there is malnutrition of the scalp. The treatment is that of seborrhcea and alopecia, as already described, with the internal remedies indicated by the general condition of the patient. Atrophia Pilorum Propria. Atrophy of the hair may be either symptomatic or idiopathic. Illustrations of the first named condition are observed in phthisis, syphilis, seborrhcea, ringworm of the scalp, and almost all general diseases interfering with the nutrition of the pilary growth. The filaments then become dry, lustreless, friable in both longitudinal and transverse diameters, and diminished in each dimension. There are several recognized forms of idiopathic atrophy of the hair. One of these exists in those long hairs which are seen to be irregularly thinned or flattened in the shaft, and split at the point into two or more recurving fibrillse, a condition noted, for the most part, in few hairs scattered among those of full development aud vigor. This especially localized atrophy seems 22 338 DISEASES OF THE SKIN. to be peculiar to one or more follicles merely; and is quite anal- ogous to the condition in which there appears among the vigor- ous pigmented haira of early life, a single blauched filament. Under the title of " An Undescribed Form of Atrophy of the Hair of the Beard," Duhring 1 gives the details of an exceed- ingly interesting case, in which either at the bulb or at a variable distance fr >m it hut within the follicle, there was fission of the hair filament into from two to four stalks with coincident atrophy of the bulb itself, and consequent irritation of the sur- face. The patient exhibited to a marked degree the species of hypochondriasis, to which the subjects of disease of the hair seem specially prone. Through the kindness of the author, I had the opportunity of privately examining under the microscope some specimens of these hairs, the appearances of which are admirably portrayed in the woodcut which illustrates his paper. This dis- order is not induced by a parasite. Trichorexis Nodosa, first described by Wilks and Beigel, is a condition in which the baits display "nodose swellings along the shaft at irregular distances, the beard and moustache being most often affected, thoush rarely there is involvement also of the hairs of the scalp. Sherwell, 2 in this country, has described one such case. The hairs are brittle; and fracture usually occurs through the node, leaving a broom-like mass of filaments projecting there, while the internodular portions of the shaft, appear normal save for some enlargement of the medulla. The fragility of the hair at the centre of the node, seems to depend upon the tension and consequent fissure of the cortical layer which is greatest at that point. No parasite has been discovered in hairs thus affected, their bulbs, moreover, being firmly adherent in their follicles. Little is known as regards appropriate treatment of the disease, which is, it must be said, persistent and disfiguring. Shaving has been followed in some of Kaposi's cases by good results; while Roeser 3 advocates the local employment of dilute tincture of cantharides. Smith, 4 of Dublin, has also reported a curious case of nodose SWELLINGS of the shafts of the hairs, differing somewhat from those described above. Through the kindness of Dr. Duhring, I have been enabled to exhibit some of these hairs in Chicago, photo-micrographs of which were, at my suggestion, taken by Dr. Belfield, of this city. Here there was no fragility at the nodes, which commencing near the scalp were quite regularly displayed along the shaft, the fracture being always internodular. The ' Amir. Jour, of the Med. Sci., July, 1878. « Arch, of Derm., July. 1879. » Annal. de Derm, el de Syph., 1877-78, pp. 185 et seq. * Brit. Med. Jouni., May 1, 1880. ATROPHIA PILORUM PROPRIA. 339 spherical swellings along the shaft were also pigmented in a brown hue, and these, contrasting with the non-pigmented color Tricliorexis nodosa. (After Schwimmer.) of the unaffected portions of the shaft, gave the hairs a singularly "checkered" appearance. ]S"o parasite is discernible iu any of the specimens. 340 DISEASES OF THE SKIN. Piedra "ense is described as still another condition of the hairs in which d .. node-like masses are attached to or surround the hair Bhaft. Mon-is 1 describes these as containing masses of spores. In a single case, thai of a young girl Bent to me by my colleague, Dr. Holmes, of the Eye and Ear Infirmary, I discovered there were numerous, jet-black, horny, and dense spherical masses attached to the liaii-sot' the eyelashes of each lid of both eyes. I \v;is unfortunately prevented from securing some of those hairs for microscopical examination. Canities. •ees Canities is that condition of the hairs in which they become in various deg decolorized as the result of atrophy of their pigment. Symptomatology. — Hairs appear in all shades of whiteness, from dirty-gray to silvery white, and this either as a general or par- tial, congenital or acquired, physiological or pathological, pre- mature, rapidly or gradually acquired condition. General con- genital whiteness of the hairs is seen in albinism, where pigment has never been supplied to the filaments. Partial congenital whiteness is occasionally seen, in meshes limited in size, varying in color from a pure white to a deeper hue, which from birth refuse to receive pigment in due proportion, and thus contrast strangely with the pigmented filaments by which they are sur- rounded. Physiological decoloration of the hairs in variable shades, is the well-known result of advancing years. When premature, it may he considered as resulting from pathological causes, or due to other individual or inherited peculiarities. It may occur gradually or suddenly; in the former case, the hairs usually pass through variable shades of gray to white, and this at any period after puberty, though usually after middle life is reached. Recurrence to the darker shades is rarely noted. Leonard, of Detroit, 2 cites a number of curious instances in which changes of this sort have occurred. Generally, however, canities of ad- vanced years is progressive and permanent, occurring earliest on the temples, then involving the vertex of the head. Finally, the hairs of the entire surface undergo a similar pigmentary loss. It should be remembered that the coloring of the hairs of the head is, to a greater extent than is commonly appreciated, sub- ject to variation from the operation of external causes. Thus washing the hair with alkaline solutions has a bleaching effect, while profuse sweating, inunction with fats, subjection to smoke, 1 Lancet, Dec. 7, 1878. 2 The Hair, etc., Detroit, 1880. SYCOSIS NON-P ARASITICA. 341 and the temperature changes of the summer, have the contrary effect, the last named being possibly due to the increased sweat- ing in the hot season. Treatment. — The sole means of remedying premature canities is by the action of dyes, and these are, in the main, compounded of solutions of nitrate of silver, acetate of lead, and the sulphate of iron. The chief objections to their use are the disagreeable coloring of the scalp which results from incautious use of the dye, and the consequent liability to irritation of the surface. When applied to the hair alone, these substances are not known to have a deleterious effect upon the health. Kaposi gives the following formulae for hair dyes: — To obtain a black color — Argent, nitrat. Amnion, carb. Unguent, adipis or, ty. Argent, nit. Plumb, acetas Aq. Cologn. Aq. ros. To obtain a brown shade- 1$. Acid, pyrogall. Aq. Cologn. Aq. ros. gr. xv ; grs. xxij ; Sj; 33; gr. xv ; gtt. xv ; ad f.%iij ; gr. xv ; p;ss ; SJss ; 01 II 1 100 M. M. 2. Exudative. Sycosis Non-Parasitica. Derio. Gr. s-Skov, a fig. Sycosis non-parasitica is an acute or chronic inflammatory affection of the sur- faces provided with relatively long hairs, in which the follicles and perifollic- ular tissues are involved in an exudative process, producing papules, pustules, tubercles, infiltrated patches, and crusts perforated by hairs. Symptomatology. — This affection usually occurs upon the face, involving one or both cheeks successively or simultaneously, the chin, upper lip, eyebrows, scalp, axillae, and pubes. The first symptoms are usually the occurrence of several discrete, flattened or conical, reddish and painful papules or pustules, whose ana- tomical seat is recognized to be the hair follicle by the penetra- tion of each by a filament of hair. These lesions may persist, and when typically discrete and visible at the part where the hair makes its exit from the duct of the follicle, have suggested the appearance of the surface of the tig, whence the disease has its name. They are apt to occasion a burning and at times a decidedly pruritic sensation when, being picked or torn open by the lingers, the pus concretes into a crust at the base of the hair. 342 DISEASES OF THE SKIN. Involution of Beveral lesions may be followed by fresh crops and, :i> a rule, Booner <>r later distinct patches of disease are thus formed. When fully developed, the surface of the skin is red- dened, swollen, infiltrated and thickened, covered irregularly here and there with papules, pustules, crusts, scales, ana" often with excoriated surfaces. The disease is apt to lapse into chronic conditions, usually as the result of improper treatment; and in ancient cases the deformity is characteristic and totally unlike that produced by the vegetable parasites. The hairs are usually fixed firmly in their follicles, hut from those where active sup- puration is in progress, they may be plucked without occasioning much pain. In the eases which have been treated for years, the hairs are thin and decidedly lacking in vigor. There is no par- asite to he discovered. In typically neglected cases of longstanding, where the region of the male heard is involved, an important clinical feature is the symmetrical, general ami uniform involvement of the entire surface. The picture of one cheek is very nearly that of the other. The thin hairs scarcely serve to disguise the reddened, tumid, painful surface beneath, displaying the several lesions of the malady. Furuncles, abscesses, cicatrices, vegetations, and eczema of the ears may complicate the process. It is occasion- ally acute in its course, but more often chronic and rebellious. I have never seen a typically chronic and untreated case of the malady terminate by spontaneous involution. Etiology. — The exciting causes of the disease are often obscure. It is encountered chiefly among males after puberty, and these in all social conditions and grades of health. It is non-parasitic, non-contagious, and not transmissible by heredity. Shaving is not known to produce it. At times, the immediate cause of the disease can lie recognized; as when the upper lip is constantly irritated by the discharge from a profuse nasal catarrh. I have treated one such patient, two years after Ilebra first assumed charge of his case. In others again, all the causes of eczema may be invoked in explanation of the result. A careful study of many of these cases has, however, con- vinced me that the hairs themselves are the aggravating causes of the disease and the sources of its peculiar obstinacy. In health the motions of the free shaft of the hairs do not irritate the follicle in which it is set. In conditions of disease it is quite different. Each free hair operates like a lever upon the inihuned ring of tissue which encircles it on its escape from the follicle beneath, and this whenever by the touch of the hand, by the action of brushing, by currents of air, or by any agency whatever, a movement is imparted to it. Every such movement must tease to a variable degree the surface beneath already irritated, and when estimate is made of the hundreds of such movements to which each hair is subjected during a period of SYCOSIS NON-PARASITICA. 343 twenty-four hours, the relative importance of this apparently insignificant factor may be appreciated. Pathology. — The disease is due to an inflammatory process, which, whether originally follicular or peri-follicular in its seat, may extend unquestionably either toward or from the follicle. Sometimes the extraction of the hair is followed by a drop of pure pus, which exudes from the follicle; and the root-sheaths of the hair are seen to be altered in consequence of the circum- scribed follicular abscess. At other times, the follicle itself is free from disease, and the exudative process has evidently ex- pended itself upon the peri-follicular or even the inter-follicular tissues, in which case the papillary layer of the derma exhibits the usual phenomena of hyperemia, infiltration and multiplica- tion of protoplasm, with abundant vascular dilatation. Diagnosis. — The most important consideration here, is the distinction between the parasitic and the non-parasitic forms of the disease, upon which naturally the microscope finally decides. Still the clinical features of the diseases are quite distinct. The non-parasitic form is recognizable by, (a) the greater redness of the involved surface; (b) by the extension of the disease in advanced cases to larger areas of sj^mmetrical involvement; (c) by the more superficial character of the lesions, and (d) by the firm implantation of the hairs in their follicles in the earlier periods of the disease, and their relative freedom in all cases from fracture and relics in the form of stumps. The parasitic disease of the hairs is peculiar, in consequence of (a) decidedly less redness of the surface attacked ; (b) its frequent limitation to a circumscribed area, or to several such, irregularly dispersed over a large region; (c) the peculiar "lumpy, tubercular, nod- ular, and uneven" characters of the patch, upon which Dun- ring has laid significant emphasis; and id) the earlier loosen- ing of the hairs in their follicles, as also of the occurrence of fractured hairs and stumps, exhibiting, usually at the bulb, un- mistakable evidence of the nature of the disease. The malady is often mistaken for syphilis, chiefly on account of its deformity, but the pustular syphiloderm is very much less chronic in its course, is never limited for years to the face exclusively, and when long persistent in one locality, is characterized by ulcera- tion and the production of very characteristic crusts. Eczema may complicate non-parasitic sycosis ; but typical in- stances of the two disorders may be recognized by the occur- rence, in the former case, of a discharging disease not usually limited to the region of the beard, characterized by a more in- tense itching, and with marked absence of the papulo-tubercular lesions described above. Treatment. — In all cases of non-parasitic sycosis, the essential and important step is the continual removal of the hairs which, as indicated above, are the chief sources of aggravation of the disease, f This is best accomplished by shaving, an act which, 344 DISEASES OF THE SKIN. though often painful at the onset, is soon well tolerated by tlie Bufterer. The majority of patients, however, object to the re- raoval of the beard, far more on account of tin- consequent greater cxi osure to view of the deformity induced by the disease (then no longer partly masked by the whisker) than on account of the dish..-- occasioned by the operation. To these objections, there is hut one response. The shaving is essential; the deformity is rapidly reduced alter its successful initiation; the discomfort diminishes with each repetition of the process. For the die in patients positively refusing to have the beard removed, whose cas< - are bo severe as to require it, the practitioner will do well to decline to he responsible. There is no limit to the tedious and obstinate course of the malady in the one case ; and in the other, the results are speedily satisfactory, often in the course of a few weeks. When there is much tenderness, pain, swelling, pustulation, or crusting, the hairs may first be clipped short, and a bland poultice applied, of oil, elm-bark, or bread and milk. The prac- tice in Vienna, is to substitute for the latter, strips of soft mus- lin or linen spread with diachylon ointment and firmly bandaged over the cheeks, chin, or lips, for from twelve to twenty-four hours, after which the razor is passed over the entire surface. The integument which thus becomes visible, is usually a red- dened infiltrated area, with pustules, papules, pustulo-papules, and some crusts dispersed here and there over it. This is best treated by very hot water lotions, pure or alkalinized, after exit is given to all purulent collections; and then a bland ointment is to lie applied at night, and a dusting powder in the morning. The subsequent treatment is largely that of eczema of equal grade of severity. In the more acute periods, the oleated lime- water, medicated with calomel or zinc oxide, half to one drachm (2.-4.) of either to the pint (500.1 may often be employed with hen. lit; or for this may be substituted two ounces (64.) each of linseed oil, castile soap, and paraffine, to the pint (500.) of aqua calcis. Later, ointments may he used, particularly cold cream, to which either sulphur, the zinc oxide, or, less preferably, one of the mercurials may be added. Lotions of the mercuric bichlo- ride, sulphur, alcohol, Cologne water, or iodated glycerine, may lie useful in stimulating any indolent patches of infiltration. The treatment of these is indeed that of chronic eczema. In Vienna, epilation is successfully practised for relief of the disease ; and, by many, severer met hods are employed, including the use of green soap, tar, cauterization with acetic, and even nitric acids. Erasure with the curette is to be named in the same category. It is possible that these measures have been employed in much more aggravated cases than those commonly observed here; but as the disease is certainly curable in a ma- jority of cases without having recourse to these heroic methods, they are to he regarded in the light of ndcrnier ressort. I never SYCOSIS NON-PARASITICA. 345 find it necessary in non-parasitic forms of sycosis, to either epi- late or employ caustics. By repeated and frequent use of very hot water, and the milder stimulants, with constant shaving, the desired result is always within reach. Shaving should be continued for nearly one year after all traces of the disease have disappeared ; and it is a point of some importance to substitute a continuously applied dusting powder for a fatty application, so soon as the skin will tolerate the persistent use of the former. Internally, treatment is of minimum value, and when indi- cated, should be of the kind demanded by the wholly accidental constitutional condition of the patient. It is a matter worthy of special attention, however, to purge every previously treated case of all suspicion of an artificial element, by withdrawing for a proper time all internal medication. The disease is so dis- figuring that many patients swallow the iodide of potassium, arsenic, and other deleterious drugs for months before consult- ing one who is wiser than they in these matters. Exposure of the face to dust, smoke, wind, and other sources of irritation should be for a time avoided. Prognosis. — The disease is entirely curable, and will, in the large majority of all cases, either disappear entirely or be very greatly improved by judicious treatment. The latter requires the personal supervision of the physician and close attention to details. Dermatitis Papillaris Capillitii. Under this title Kaposi describes a disorder characterized by pin-head sized, isolated or confluent elevations of the surface, with interspersed pustules, which finally form cicatriform plaques over which the hairs are either clustered in tufts or totally ab- sent. The pilary filaments are atrophied, yet firmly fixed in their follicles, and suffer elongation or fracture before with- drawal. The disease is encountered chiefly upon the nucha, occiput, and vertex. Papillomatous vegetations, crust-covered, hemorrhagic, and with a foul-smelling secretion, sometimes form, and eventually retract into a sclerotic tissue. I have seen two typical cases of this disorder, 1 and each concluded with the production of a keloid-like, cicatriform, ir- regularly shaped, but circumscribed elevation of the surface. This feature is that by which it specially differs from all other sycosiform disorders. The disease is, I believe, due fully as much to inflammatory processes in the subcutaneous tissues between the unyielding pericranium and the thick scalp, as to the derma proper, and is not, therefore, strictly speaking, a dermatitis. Puncture, for example, of one of the pin-head sized pustules, usually gives exit to the usual quantity of pus, but pressure upon the scalp in the periphery will at once be followed by the appearance of a still larger quantity of similar pus, which 1 See a paper on this subject by the author, published in the Joum. of Cuta- neous and Venereal Diseases, vol. i. No. 2, p. 83. 346 DISEASES OF THE SKIN. evidently is expressed from a circumscribed subcutaneous ab- When by Bucb pressure the abscesa cavity is emptied, it Blowly tills with venous blood, and produces a firm, semi-solid elevation of the Burface, which subsequently undergoes sclerosis, and the Btarved hairs above behave in the manner well described by Kaposi. The papules and plaques arc formed in a similar way, by the abundant supply <>t venous blood. The case of one of my patients (presented at the clinic) had been erroneously diagnosticated by a Burgeon ;is aneurismal in character. Punc- ture of all Buch semi-solid, cicatriform lesions, is invariably fol- lowed by oozing of venous blood in abundance. The disease is chronic in character, particularly liable to relapse in crops of pilary or peripilary pustules and papules, and extends from nucha to vertex, curiously avoiding the frontal and temporal regions. Over the bald or partially bald, keloid-like elevations, there is occasionally seen a species of seborrha-a in the form of more or less adherent, fatty crusts, with occasional characteristic tufts of hairs. None of these hairs were invaded by a parasite, though repeatedly examined with the microscope with a view to such discovery. I believe that the disease owes its peculiar character to the anatomical peculiarities of its location. It occurs preferably at the points where the venous supply of the scalp is not only greatest, but in most direct connection with the large vessels beneath, and where an inflammatory process in the derma or subcutaneous tissues, invites with readiness a pathological afflux of blood. Such a focus, limited beneath by the dense calvarium, and with the relatively thick scalp above, readily undergoes organization and sclerosis; the subsequent behavior of the hairs and hair-follicles being an accident of the process. The method of treatment to be employed in this rare disease, the exact nature of which is, indeed, not yet appreciated, can scarcely be said to be established. Sangster (in a paper read before the International Medical Congress in London, 1881) described a pigeon's egg-sized tumor of the scalp, which Kaposi, who was present, recognized as a case of dermatitis papillaris capillitii. 3. Hypertrophic. Keratosis Pilaris. Keratosis pilaris is a disorder, chiefly of the extremities, characterized by multiple, millet-seed sized, whitish, grayish, or slightly reddish aggregations of epithelium, about the orifice of the hair-follicles. Symptomatology. — This condition, termed also lichen pilaris, may he a mere temporary and functional disturbance of the skin, awakening no subjective sensation, inappreciable by the patient, and apparent only to the careful observer, or it may KERATOSIS PILARIS. 347 realty constitute a disease. Its symptoms are the occurrence of pin-bead sized, pointed elevations of the surface, which may be described as papules, though, strictly speaking, they are not such, constituted by an accumulation of horny epithelia, and a small quantity of inspissated sebum about the lanugo hairs of the extensor surfaces of the extremities and trunk. These aggre- gations of material are usually of a dirty-whitish or grayish hue, and pierced by a lanugo hair implanted in the follicle, about which the abnormal condition exists. Occasionally, however, the hairs are of the finer and shorter kind, and are often coiled in or otherwise covered by the little heaps of epithelial debris. The skin of the individual thus affected is generally harsh, squamous, and dry to the touch ; being also, in the majority of cases, long unwashed. The color of the quasi-papules also differs with the complexion of the individual ; at times they have a distinctly reddish tinge. They are often surmounted by a scale. The condition is sufficiently common in skins long uncleansed by ablution, and can thus be artificially produced. In some in- dividuals it persists for long periods of time, and awakens no concern. In others, and especially in children, it speedily be- comes the source of a pruritus, and each lichenoid papule may be then transformed into an urticarial wheal, with distinct and sometimes very annoying, pricking and tingling sensations, the entire trouble being at once relieved by a bath in warm water with soap. In other cases, especially in adults, an exaggerated form of the disease can be recognized, the skin presenting a roughness to the touch suggestive of the nutmeg-grater, and ex- hibiting numerous fine, conical, grayish, horn-tipped filaments, which several dermatologists are disposed to regard as a form of ichthyosis. Here, there is doubtless a true hypertrophy of the epidermis. In the former case, there is scarcely more than a mechanical accumulation of effete organic material. There can be but little doubt that the malady, simple though it be in character at the onset, may become the first stage of a series of chronic cutaneous disorders. Tilbury Fox 1 has reported four cases in which the disease was well marked, under the title cacotrophia folliculorum, the name being employed to desig- nate its peculiarities as to wide distribution over the body, im- plication of the deeper portion of the follicles, and its congenital history. In these cases, the reddish tint of the lesions is dis- tinctly shown. The disease should be readily recognized by the peculiarities of its seat, its course, and the nature of its symptoms. From ichthyosis, it can be distinguished by its limitation to the orifice of the hair follicle; from the transitory condition known as "■goose flesh," by its persistence after the surface of the skin is thoroughly warmed ; from papular eczema and the other lich- 1 Clin. Society's Trans., vol. xi., with illustration in color. 348 DISEASES OF THE BKIN. enoid eruptions, by the relatively insignificant character of the lesions, and their evidenl association with follicular inertia. The disease is besl treated locally by warm water and soap bath 8, followed, in the more argent eases, by inunction with the fats or oil 8. In the congenital and severer cases, such as those described by Fox, doubtless cod-liver oil internally should be advised. Hypertrophy of the Hair. Hypertrophy <>t' the hair is a development of the pilary filaments, exaggerated as to Bize or number, <«r unusual either with respect to the location of the growth, or the age, <>r sex. of the individual in whom it is displayed Hirsuties ma} - he congenital, and this in various grades. It is sufficiently common to see infants at birth provided with ex- tremely long hairs of the hairy parts of the hod}-, such a growth being usually replaced later by shorter filaments. Universal congenital hirsuties is a rare deformity, the entire body being then covered with longer or shorter downy hairs of various colors. Acquired hirsuties ma} 7 be partial or universal ; much more commonly the latter. Thus the hairs of the scalp or heard may acquire an enormous vigor and length, reaching fully to the ground when the ligure is in the erect position ; or the hyper- trophy of the hairs may affect the face of the female, and in this sex, either the upper lip, chin, cheeks, or all portions of the face usually covered by hairs in the male, be provided with a vigor- ously and symmetrically developed pilary growth. Dubring 1 has reported one such case, which is illustrated by an excellent lithograph representing the face of a woman provided with a superb beard. In such cases, the growth may he variously colored, and the hypertrophy of downy hairs be purely numerical, or result in increase in the actual size of the shaft of individual filaments. In neither case do the hairs present any anatomical peculiarities of structure. The localized congenital and acquired forms of hirsuties, are often characteristic of certain moles, known as N.Kyi pilosi ; and are also at times seen to cover the surface of pigmentary moles (n/evi plcmentosi). Under the name plica poloxica, was formerly described a condition supposed to l>e a disease peculiar to the Poles (whence its name!, but which has long been recognized as a result merely of persistent neglect, filth, the invasion by parasites and conse- quent exudative disorders, of the scalp. When it exists, the hairs form a huge matted mass on the crown of the head. Hebra has devoted some interesting pages to the superstitious awe with which this accumulation of hairs and tilth has been regarded. .Dr. II. M. Bannister, lately connected with the U. S. " Arch, of Derm., April, 1S77. HYPERTROPHY OF THE HAIK. 349 station in Alaska, informs me that be has seen a number of cases of plica among the inhabitants of that region. That is probably the sole territory of the United States where it exists. Etiology. — When congenital or acquired, the causes of hirsuties are practically unknown. It is clear that whatever determines the blood in excess to any one portion of the body, may be in- directly the cause of hypertrophy of the hair, a fact demonstrated in many patients of middle life who, after applying sinapisms or liniments for many years to the skin over the seat of a rebellious neuralgia, exhibit an abundant growth of hair, often several in- ches in length, over a scapula or a buttock. In women, whose sex renders the anomaly most deforming and distressing, it is chiefly noted at the beginning and end of the sexual life. At times female patients of this class suffer from disorders of the sexual apparatus, but I believe this to be quite unconnected with the disease. It is decidedly more common in brunettes. Treatment. — To Hardaway, of St. Louis, Americans are in- debted for the popularization of the method of removing super- fluous hairs by electrolysis, first devised by Michel, of his city. After him, White, of Boston, Duhring, of Philadelphia, Heitz- mann, Fox, and Piffard, of New York, and others have with success removed thousands of hairs, and without subsequent reproduction of the growth. A fine needle is introduced into the hair-follicle and pushed well down to the papilla at its base. This instrument is connected with the negative pole of a gal- vanic battery containing from six to twelve elements, the posi- tive pole of which is in connection with a sponge electrode held in the patient's hand ; the latter being thus enabled to make or break the circuit at will. When the current is passed, a few minute bubbles of gas escape from the orifice of the follicle, and, when the hair papilla is destroyed, the hair itself is readily extracted. The dexterity acquired by practice is requisite for the proper performance of the operation, with a view particu- larly to the insertion of the needle at the proper angle into the follicle. Few patients complain of pain. The number of hairs removed at a sitting varies with the sensitiveness of the patient's skin. The resulting scar is much less disfiguring than the hir- suties, suggesting the appearance of the male beard after shaving. Transitory maculae, papules, pustules, and wheals occur at the site of puncture. Care should be taken not to insert the needle too deeply in the particularly vascular regions of the face, as an aneurismal tumor might be produced as a consequence. A special instrument for the removal of superfluous hairs has been devised by Duhring. 1 It is of the shape of a thin lead- pencil or penholder, and is about four inches in length. The handle or stem is of hard rubber, through which passes a metal- lic rod, acting as a conductor for the transmission of the current. 1 Arner. Jour, of the Med. Sci., July, 1881, p. 142. 350 DISEASES OF THE BKIN. The needle is inserted into the needle-holder proper, which is slotted, the needle being clamped immovably by means of a Bcrew nut. On the other end of the stem, there is an insulated inserting-pin attached to the curd leading to the battery. The instrument is of proper weight, convenient to handle, and alto- gether well adapted for the operation. 1 Hairy nsevi are best removed by complete, excision. Depilatories for the removal of superfluous hairs operate by the destruction of the filament without obliteration of the papilla. The consequence is that the hairs are reproduced in the course of about a fortnight. Most of the compounds used lor this purpose contain either the sulphate of calcium, sulphate of arsenic, or sulphate of barium, made into a species of paste with hot water. This is applied over the surface with a spatula, and permitted to remain till it dries, a period usually requiring ten minutes. It is then rapidly removed by scraping with the spatula, and the surface thoroughly cleansed with warm water, after which it is anointed with cold cream, or other similar unguent. Of these depilatories Duhring recommends the following: — R. Barii sulphis. 5'j ; 8 Pulv. oxid. zinc, ) -- „••• . 10 Pulv. amyl., $ aa 3llJ ' l4 M. The following are formulae devised by French authors: — ■ R. Sodii sulphat. Siij ; 12] ? lci r' , I aa 3 x; 40! Ar Amyh pulv., ) J ' M. To be finely triturated, and, when used, to be made into a thiu paste with water. (Boudet.) R. Calcis 5j ; 41 Sodii carbon. 5J SS ; ,; Cerat. adipis .^j ; 321 M. To be applied as a depilatory in the manner of a paste. All of these require caution in their use, and should never be intrusted to unprofessional hands. Shaving may be practiced upon the hirsute face of the female, and, with a similar end in view, epilation also; the latter, par- ticularly in cases of hypertrophy of the hair, limited in extent. Partial success has attended the thrusting into the follicles of needles, previously dipped in various caustic solutions, or heated in various degrees. 1 The battery and needle-holder employed by the author in this operation, ■were constructed for him by Messrs. A. M. Leslie & Co., of St. Louis: the admirable working of the apparatus having been demonstrated by him to a num- ber of physicians. HYPERTROPHY OF THE NAIL. 351 Class V.— OF THE NAILS. Hypertrophy of the Nail. Hypertrophy of the nails is declared by an abnormal development of these appendages of the skin in any diameter. Symptomatology. — The nail substance may be developed to an unusual extent either as an idiopathic or symptomatic affection, and in either case may be either simply increased in volume or extent, or exhibit such increase in connection with secondary changes. Thus the nail may develop to an extraordinary length or breadth, preserving its general character as regards texture, color, and position ; or it may also be changed in either par- ticular, becoming opaque, discolored, and blackish or brownish ; rugous, furrowed, horny, and ridged ; thickened in one part and thin, vitreous and extremely fragile in another; tilted to one side or another on its bed ; or projected backward in recurved, irregular lines; finally the matrix may be inflamed, suppura- ting, hsemorrhagic, and the seat of an excruciating pain. One or more of the nails may be affected ; in some cases the entire twenty are similarly involved. The diseases in which these changes occur as symptomatic lesions are numerous, since it is evident that the matrix, from which the nail is produced, would scarcely enjoy immunity in the case of a profound alteration of the skin in its vicinage. Thus eczema, lepra, psoriasis, lichen ruber, syphilis, scarlatina, variola, and other diseases are attended by changes of various grades of severity in both matrix and nail. The condition termed paronychia, is that in which one or both lateral borders of the nail bury themselves deeply in the tissues adjacent, producing thus an exquisitely tender and painful state of the soft parts, which may suppurate or surround the attached limb of the nail with exuberant granulations. This is more frequently observed in the nails of the toes, as these appendages of the skin are liable to injury from the pressure of ill-fitting boots, gaiters, and shoes. In the condition described as onychia, the matrix is not only inflamed, but the nail substance is, as a consequence, texturally changed. No strict line of demarcation, however, can be described between the two conditions. The term onychogryphosis, has been employed to describe the con- torted deformities which cause it to resemble a claw. Onychomycosis is the name given to that condition in which the nail substance is invaded by vegetable parasites. In such cases, the nails become opaque, discolored, and thickened, with a noticeable friability at the projecting border. 3-32 DISEASES OF THE SKIN. In SYPHILITICA onychia, one or Beveral of the nail- may be- come affected, though it is quite characteristic of the disease to exhibit limitation to the extremity of a single digit. In Buch cases, there is usually a very marked involvement <>t' the periph- eral soft part8,which may be infill rated with gummatous material. The bullous syphiloderra, of the congenital manifestations of the disease, will at times form beneath or quite near the nail, and thus endanger its integrity. In both forms, ulcerative results are common, with secretion of a hail discharge. The prognosis in these disorders of the nails, rests entirely upon the nature of the malady in which they occur. Idiopathic and localized changes, as also those occurring in transient cuta- neous diseases (r.. g. the exanthemata) often terminate favorably. In severe constitutional or grave cutaneous diseases, the outlook is less promising. The diseases of the nail are usually more obstinate and less amenable to treatment than the similar affec- tions of the softer parts. In cases where there is congenital disease of the nails, a prognosis should he given with reserve. Treatment. — The treatment of the disorders of the nail de- scribed above, is largely that of the maladies in which they occur. Arsenic and iron are often indicated in these affections; and their influence upon the nutrition of the nail cannot be questioned. In syphilitic onychia, the constitutional treatment of the disease is essential. The cutting, scraping and trimming of the nail by the aid of the useful instruments found in the chiropodist's case, supplied by most surgical instrument-makers, are important' measures in many cases. The treatment of in-growing toe-nail varies with the extent of the disease. In mild cases, soft threads of charpie are insin- uated between the offending border of the nail and the tender granulating surface upon which it presses. Counter pressure by plaster and the local use of the crayon of nitrate of silver, may be at times employed with advantage. In severer cases, the nail may be removed, though this is generally unwise. The method of treatment devised by Agard, of California, often produces the speediest results. The soft parts are by him completely re- moved from the side of the nail by means of a thin-bladed bis- toury; and the nail permitted to grow down upon one side of the extremity of the distal phalanx, thus protecting the cicatrix and radically preventing the recurrence of the disease. Atrophy of the Nail. This is a congenital or acquired condition, in which there is deficient or defective production of the nail substance. The congenital forms are usually observed when the digits are poorly developed, and there is at the same time a deficiency of the pilary growth. In the acquired forms, the causes and symptoms are often those of hypertrophy, the nail substance undergoing CUTANEOUS HEMORRHAGES. 358 changes in color, bulk, elasticity, firmness, form, and position, having the general characters described above. Thus the nails may be seen to be expanded and thinned, narrow and acuminate, friable, laminated, furrowed, ridged and distorted. An excellent illustration of localized symptomatic atrophy of the nail, can be distinguished after convalescence from such wasting diseases as enteric fever, in which the deficient nutrition of the nail during the febrile period, is declared in smooth or rugous transverse furrows in its substance. The condition recognized as hypertrophy, is often a mere sta- dium of the process which results in remediless atrophy; and thus after many cutaneous affections accompanied at one period by enlargement or abnormal development of the nail substance, an atrophic condition may be the final result. Class VI.— OF THE BLOOD- AND LYMPH-VESSELS AND PERI - VASCULAR TISSUES. 1. Hemorrhagic. Cutaneous Hemorrhages. Cutaneous hemorrhage is characterized by the issue of a part or all of the con- stituents of the blood from the cutaneous or subcutaneous capillary vessels, with and without rupture of the vascular walls. Hemorrhage into the skin may be active or passive, idiopathic or symptomatic, and may vary greatly in extent. It may be limited to but a small area of the integument; or be symmet- rical and universal ; or coexist with similar blood extravasations in the mucous membranes, and the investments and parenchyma of the viscera. It may result from undue intra-vascular pressure, as in violent effort with extraordinary demand upon the circu- latory system. It may occur with a normal intra-vascular pres- sure when there is lessened extra-vascular atmospheric pressure, as after ordinary exertion in high altitudes. It may result from disease of the vascular walls, as in malnutrition. It may occur after traumatism of the latter; or by diapedesis through the walls of uninjured capillaries. It may result also from lack of support of the vessels due to various disorders of peri- vascular tissues, as in the cases where the epidermis is artificially removed ; or where an abscess cavity is evacuated of pus and the sac im- mediately fills with blood. Idiopathic hemorrhage into the skin and neighboring tissue, is usually the result of traumatism, and accomplished through rent of the vascular wall. The discolored patches which result from contusions of the surface of the body, are illustrations of 23 854 DISEASES OF THE SKIN'. ibis condition. Examples of symptomatic cutaneous hemor- rhage*, are to l>e found in the course of Buch general disease septicaemia and variola, and of such cutaneous disorders as herpes, pemphigus, and erythema multiforme. Bulla b.bmorrhagice Hre globoid, bean- to egg-sized eleva- tions of the epidermis, filled with a sanguineous or sero-sanguin- eous fluid, giving such lesions a reddish, brownish, or purplish ghade. Ecchymomata are nut- to egg-sized and even larger, firm or fluctuating, flattened or elevated tumors, tilled with blood and having a cutaneous envelope. ECCHYM08ES are small coin- topalm-sized and even larger, light- red to dark purplish, irregularly shaped, macular colorations of the skin, not fading under pressure, and due to circumscribed cutaneous hemorrhage. Petechia are pin point to small coin sized, light-red to dark- purplish macular colorations of the skin, not lading under pres- sure, and due to circumscribed cutaneous hemorrhage. Purpura Hemorrhagica (Morbus maculosus Werlhoffii). This disorder, called also land scurvy, is usually ushered in with phenomena of a febrile character, accompanied by symp- toms of genera] depression. Subsequently, ecchymoses appear upon the extremities and trunk, both spontaneously and at points where the integument has been specially subjected to pressure and friction. Usually petechias appear simultaneously upon the nasal, laryngeal, buccal and other mucous surfaces, which may also be the seat of exhausting hemorrhages resulting rarely in fatal collapse. A symptomatic fever is usually awak- ened. The disease occurs equally in the robust and feeble of all ages, and though usually as a sporadic affection, it may assume an epidemic form. The disease is slow in its course, but com- monly terminates favorably after the lapse of several months. It is distinguished from purpura scorbutica, or "scurvy," by the distinctive premonitory symptoms of the latter disease, and its invariable occurrence among those suffering from improper alimentation, vitiated air, and lack of exercise. Purpura Pulicosa is the result of the traumatisms produced by fleas, lice, and bugs. The lesions are puncti form, and due to the welling up of blood into the minute punctured wound, surrounded usually by an hyperaemic halo, which is the result of the irritation. When the latter fades, the central hemorrhagic point, usually for a CUTANEOUS HEMORRHAGES. 355 brief time persists. The disease is characteristically manifested upon the filthy skins of individuals long bitten by bugs, and covered with excoriations and dark-colored crusts, the result of scratching. I have known several such cases to be pronounced, scorbutic. Purpura Rheumatica (Peliosis Rheumatica). This is a variety of purpura which has a striking analogy to erythema multiforme, and is probably an exaggerated form of some of the conditions recognized under that title. It is pre- ceded by the usual febrile or other premonitory symptoms asso- ciated with arthritic pains, especially of the knees and ankles, which may become swollen, or be affected with an hydrarthrosis. In a few days, petechial to ecchymotic, light-red to dark-purplish maculations appear upon the extremities, trunk, or the entire surface of the body, fadeless under pressure, and usually with coincident relief of the arthritic pain. The subjective sensations are ordinarily trivial. In a fortnight, the eruption may subside, its color undergoing the usual variations from greenisb to orange and light yellow ; but relapses are common in the course of weeks, with recrudescence of the fever, return of the rheumatoid symptoms, and progressive asthenia. Kaposi describes cases in which there was coincidence of purpura rheumatica with renal hemorrhage, albuminuria and gangrene of the soft palate, in consequence of its over-distension with blood. Cases are also on record where there was cardiac involvement and grave disorder of other viscera. According to Mackenzie, 1 the disease occurs in both sexes, more frequently in women, however, and between the ages of twenty and thirty, though also at earlier periods of life. The purpuric spots observed by him usually made their appearance regularly in the afternoon or evening, sometimes daily, and often with several days' interval, accompanied by pain, stiffness, and swelling of the joints. The maculae w r ere at first of a bright reddish hue, but became purplish by the ensuing day. The site of predilection was the extremities, but the erup- tion in his cases was sometimes more generalized. The lesions displayed this amount of symmetry; if they oc- curred on one extremity, upper or lower, they would generally be found on the other. As a rule, there were not profuse sweats, unless the attack occurred with rheumatic fever ; the joint affec- tions and pyrexia, though distinct, were not severe. Sometimes there was a certain amount of erythema accompanying the hemorrhages; often the eruption was purely hemorrhagic. The attacks were frequently very protracted, lasting even some months, and w r ere liable to recur. The disease occurs in both sexes, though more often in young women, and is to a certain extent influenced by the changes of 1 Brit. Med. Jour., March 18, 1882, p. 383. 356 DISEASES OF THE SKIX. climate and Beason. Ita diagnosis, in consequence of its marked characteristics, coincidence of petechia? and ecchymoses with rheumatoid pains, is readily effected. Duhring calls attention to tin- danger of confounding it with the macular sypihiloderm, the lesions of which, however, fade under pressure. The prog- nosis i> in general favorable, though the disease may persist for long periods of time, and may, in rare cases, terminate fatally. Purpura Scorbutica (Scurvy). This disorder is peculiar to those who are compelled to subsist for lengthened periods of time on improper food, more particu- larly that from which fruit and fresh vegetables are excluded ; to respire a vitiated air; and to endure such confinement as pre- cludes the possibility of duly exercising the body. The disorder is hence more common among sailors, prisoners, Arctic voyagers, and men similarly situated. The hemorrhages which result are quite like those of purpura hemorrhagica ; and the cutaneous lesions are petechias, ecehy- moses,and painful ecchymomata, which may fluctuate, open, and result in offensive ulcerations reaching to the bone. Simulta- neously with the cutaneous eruption, the gums become involved, and show as tumid, hemorrhagic, or ulcerative fungosities, smeared with a dirty -yellowish secretion, and having a fetid ex- halation. The subcutaneous connective tissue, muscles, fasciae, and viscera, become also involved. The disease is accompanied by febrile and other general phenomena of asthenia, and, when the causes are persistent, results fatally. It is, however, reme- diable by proper treatment, though convalescence is usually tediously prolonged. Purpura Simplex. In this form of cutaneous hemorrhage, light red to dark purple petechias and small ecchymoses, usually multiple and symmetrical, of slow or sudden occurrence, appear upon various portions of the surface, chiefly over the lower extremities; and here doubtless by preference, because of the greater effect of gravity upon the column of blood. They usually awaken no subjective sensation, and may occur in persons of apparently un- altered health, though rigid examination will often disclose some facts having a bearing upon the etiology of the disease. The subjects of the disorder are frequently asthenic, and complain of unwonted lassitude and malaise. The disease may last for a fortnight, and in exceptional cases is accompanied by a febrile rise of temperature. Purpura Urticans is that form in which there is an irritability of the skin sufficient to produce wheals, urticarial lesions accompanied by itching in CUTANEOUS HEMORRHAGES. 357 various degrees, which have the purpuric hue iti consequence of circumscribed cutaneous hemorrhage. Vibices are linear maculations of various lengths, due to the diffusion in the skin of extravasated blood in the form of streaks or bands. They are often commingled with petechias and ec- cbymoses. Tlie symptoms of cutaneous hemorrhage are also observed in other conditions besides those named above. Thus a form of purpura medicamentosa has been produced by the ingestion of the compounds of iodine, tar, and chloral. Petechia and ecchy- moses are also in cases noted upon the lower extremities of the subjects of tuberculosis, cancer, and the plague. In Haemophilia, a disease occasionally of hereditary origin, and characterized by the facility with which trivial traumatisms of the surface are followed by incoercible hemorrhages, purpura may be the first signal of the predisposition. A young man with purpuric lesions of both lower extremities and otherwise in apparently good health, lately presented himself at my clinic for the relief of the difficulty. There was at the time no suspicion of haemophilia, but two weeks later, as the result of a vaccination, he bled con- tinuously for eight days. Pathology. — Many cutaneous hemorrhages, not resulting from traumatism, however manifestly and immediately due to morbid conditions of the vessels, are by many authors believed to have a neurotic origin. Purpura basmorrhagica, for example, is by Wagner, Henoch, and others explained by either abnormal ex- citation of the sympathetic system, or paresis of the vaso-motor centres, in consequence of the frequent absence of lesions of the vascular walls sufficient to explain the phenomena. Cavalier 1 reports a case of purpura alternating with paralytic symptoms. The frequent symmetrical disposition of the lesions has received a similar interpretation. Tyrrell 2 reports cases induced by marsh-miasm ; and lately Satterth waite, 3 of jSTew York, a similar case in which the eruption followed a chill lasting three-quarters of an hour. The hemorrhages occur in all these cases, chiefly in the derma, though often in the subcutaneous connective tissue, a fact well illustrated in the drawings made "by Variot, 4 of sections of the purpuric skin of a patient dead of haemoptysis. In this case there was numerical diminution of the red blood-corpuscles in 1 Bull. Gen. de Therap., 1879. 2 Pacific Med. and Surg. Journ., June, 1876, cited by Duhring. 3 Med. Gazette, Jan. 14, 1882, p. 14. 4 Jour. d. l'Anatom. et de la Phys., No. 6, Nov.-Dec. 1881, p. 520. 358 DISEA8E8 OF THK SKIN. life, iis demonstrated by tlie hemati metre, without any change in their form, volume, or color, [nflammatory complications in these conditions arc rare. The color of the several lesions in- duced is, without question, derived from the hsematine, which not only stains the environing fluids, hut also the tissues them- selves where the extravasation occurs, and appears, when absorp- tion of the fluid portions of the clot has been accomplished, in the form of variously sized crannies. In this way the color- changes between red, orange, yellow, purple, and violet in the resolution of petechia' and ecchymoses are to he explained. The persistence of their pigmentations varies with the quantity of the effused blood and its seat. In mild cases, especially of lesions involving the upper half of the body, all traces of the hemorrhage may be removed in the course of a few weeks. I have seen dark pigmentations resulting from purpura scorbutica affecting prisoners at Andersonville during the late civil war in this country, which are still perceptible upon the lower ex- tremities. Treatment. — The treatment of these various forms of cutaneous hemorrhage will clearly depend upon the nature of the cause in each case. In general it may he said that internally the use of ergot, of the perchloride or other salt of iron, and of quinine is advisable. Hypodermic injections of Bonjean's ergotine, one part to two of distilled water, repeated every second day have been speedily followed by favorable results. A generous diet, the use of wines, malt liquors, and even spirits, and strict ob- servance of the demands of hygiene, are often essential methods of relief. In the way of local treatment, rest in the recumbent position is advisable, and, if hemorrhage be actually in progress, the free use of haemostatics will he required with local application of ice. For those who are convalescent from systemic disorders ac- companied by purpuric lesions of the lower extremities, re- sorption of the extravasated blood may be hastened by stimu- lating spirit lotions with friction; and the pressure of the blood column partly relieved by elastic bandaging of the extremities. The prognosis lias been given, as far as might he, in connec- tion with each disorder named. 2. Neoplastic. Angioma. DeriV. Gr. iyy^ov, Vessel. Angioma is that pathological development which is constituted wholly or in part of dilated or new-formed blood- or lymph-vessels. The angiomata are naturally divided into those composed of bloodvessels and those formed of lymphatic vessels. The former are much more frequent and variable in character. ANGIOMA. 359 Blood-vascular new-growths occur in three forms: nsevus vasculosus, telangiectasis, and angioma cavernosum. Naevus Vasculosus. This term is limited to those vascular anomalies of the skin, which are either visible at birth or become developed within a brief period thereafter. They commonly occur as irregularly outlined or distinctly circumscribed, smooth spots, patches, or maculations, varying in color from "light red to deep violet and port-wine, either flat or very slightly elevated above the gene- ral level of the integument. From this type wide variations are noted, from the development of pea-sized papules, or tubercles, to tumors even of large size; pulsating and. aneurismal in char- acter; spongy or relatively firm; fading or more rarely persist- ent underpressure; superficial or deeply seated; venous or arte- rial in their connections; single or numerous; and in either case limited to a small area or involving a relatively large surface. They are of most common occurrence upon the head, but are seen also on the trunk and extremities. Often they are the sole lesions of the skin present in a single individual; in other rarer cases they complicate moles, warts, and lymphangiomata. The course of these lesions varies with their essential charac- ter. Of the simpler varieties, the larger number increase some- what in extent and development till they have attained a maxi- mum size, and then either persist indefinitely or accomplish a species of involution after agglutination of the vascular walls, leaving a whitish, cicatriform, occasionally pigmented surface. Others extend indefinitely, involving the neighboring mucous surfaces, subcutaneous tissue, and deeper structures, forming vast tumors, destructive not only by their tendency to extension, but by their mechanical effects. Fortunately these extreme devel- opments are rare. Much more commonly they are observed in the form known as the "port-wine mark" or " claret-stain," which awaken no subjective sensations, and are usually of clini- cal importance in consequence of the marked disfigurement which they occasion. Telangiectasis. Telangiectases are acquired blood-vascular new formations, which appear at periods of life other than at birth or a few months later; and are, therefore, distinct from the congenital forms of the disease. They are commonly first observed in adult life, and occasionally multiply with advancing years. They occur in diffuse and localized forms. Diffuse, generalized telangiectasis is exceedingly rare. Hil- liaret and Vidal have each observed one such case in individuals of both sexes; the condition being apparently due to systemic disturbance. 300 DISEASES OF THE SKIN. The localized tonus are betrayed by the occurrence of flat or slightly elevated, pin-head to pea-sized maculae; diffuse patches; linear ramifications of individual vessels ; or contorted cqngeries of a plexus of the latter, all exhibiting the variations in'color of lwevi vasculosi, hut usually of pinkish or violaceous hue. They are unaccompanied by Biibjective sensations, are evidently non-inflammatory in character, and are seen as single or multiple lesions chiefly upon the face, but also upon the neck, the hacks of the hands, the thighs, and other parts of the body. They are not rarely observed in connection with other diseases. Thus they occur in the vicinity of lupus erythematosus, morpboea, acne rosace;,, cicatrice*, and about the contour, or over the sur- face of many malignant tumors. Thus they may have either an idiopathic or symptomatic character. The term rosacea, as distinguished from acne rosacea, is em- ployed by some authors to designate that condition in which the skin, of the face particularly, exhibits a circumscribed or diffuse redness, due to dilatation of the capillaries, unassoeiated with acne or other sebaceous gland disorder. Angioma Cavernosum is distinguished from the lesions described ahove by the pecu- liarities of its formation. It consists of a dense frame-work of new-formed connective tissue, inclosing loculi or chamhers of varying capacity containing blood, and communicating not only with each other but with the larger vessels in the" vicinity. Whether they originate in the fibrous felt-work of the derma, which later establishes a vascular connection ; or in the vessels themselves; or are constituted by a mechanical dilatation of the latter in consequence of new-formed connective tissue in the adventitia, has not been determined. Etiology and Pathology. — The causes of the several pathologi- cal conditions named ahove are obscure. The symptomatic telangiectases are undoubtedly to be explained by obstruction to the circulation occasioned by the tumor or other lesions to which they are accessory. The foundation for the vulgar belief that maternal impressions are responsible for the "so-called "mother's marks" is very slight. The reputed resemblance of the latter to various flowers and fruits, generally requires for its recognition a stretch of the imagination. Anatomically, these lesions are recognized as due to dilatation and formation of venous and arterial capillaries in the superior portions of the derma, the vessels of the newly formed plexus freely communicating with each other. Generally there is a simultaneous new formation of connective tissue constituting the frame-work of the growth, which varies considerably in the different forms of the disease. Lobules constituted of/coils of ANGIOMA. 361 capillary vessels are often separated by it into distinct masses. According to Heitzmann, the large spaces of angioma cavernosum imitate the structure of the corpora cavernosa of the penis, and are filled with venous blood, being separated from each other by a scanty fibrous connective tissue. Treatment. — The treatment of telangiectasis and nasvus is the same; and is limited to a series of local surgical procedures. These all have in view either the destruction of the new growth, or the artificial production of an inflammation in order to ob- literate the lumen of the capillaries of which it is composed, to an extent sufficient to interfere with the transmission of the blood-current. First among these is electrolysis. One or a set of several fine cambric needles with their points at the same plane, are connected with the negative pole of an ordinary zinc and carbon battery of ten to twelve cells. The points of the needles are quickly passed into the tissues and there held for a period of between ten to thirty seconds, according to the effect produced after completion of the circuit. The new growth is thus blanched in the vicinity of the needles, this effect disappearing in the course of a few moments. In about three weeks, the curative result of the operation becomes apparent. According to Fox, 1 of New York, who has offered the latest contribution to this subject, the objections are that the operation is sometimes pain- ful and tedious, and may occasionally result in the production of suppuration, superficial sloughs, minute, keloid-like eleva- tions, vascular nodules, depressed scars, or superficial ulcers. The method of Sherwell 2 is by multiple puncture with a set of fine needles in a holder similar to that described above. These are dipped in a twenty-five to fifty per cent, solution of chromic acid, and then made to penetrate the part to be attacked. The bleeding is readily arrested by pressure ; and then the patch is to be covered with several superimposed layers of flexible col- lodion. I regard this procedure as of value in circumscribed patches of superficial character and relatively limited area. By it, I have succeeded in removing port- wine marks in three pa- tients, with the result of producing a somewhat irregular cica- triform tissue much less disfiguring than the original blemish. One of these patients was repeatedly exhibited at the clinic during the progress of the case. Squire's operation is done upon previously frozen patches, by the aid of an instrument which destroys the vessels by making numerous crossed and closely spaced linear incisions, parallel to each other and in a plane obliquely directed to that of the integ- ument. Here also bleeding is arrested by pressure, exerted before the circulation is restored. The operation has been, in hands other than his own, attended at times with unsatisfactory results. 1 New York Med. Rec, Feb. 18, 1882, p. 188. 2 Archives of Derm., Oct. 1879. 362 DISEASES OF THE SKIN. Sodium ethylate, a compound in which the radical ethyl in ethylic alcohol is united with sodium, is a caustic recommended by Richardson, 1 in the treatment of nsevus. It is applied by means of a glass rod. A first application usually results in the formation of a dense crust under which the mcvus contracts; and repeated applications are made at intervals of a few days till the desired result is obtained. The sodium ethylate should be pure, and the crusts should not be disturbed till they fall spontaneously. In one ease observed by myself, there was a persistent redness of the resulting sear which was decidedly open to objection. Other methods employed are the ligature when practicable; puncture with hot needles; the topical application of caustics other than those named above, such as potash, nitric and carbolic acids and corrosive sublimate; and total excision, the latter be- ing practicable in relatively small growths. The galvano-cautery and the thermo -cautery are both valuable in the destruction of the capillaries, and have repeatedly proved successful in my hands. For telangiectases and nsevi no larger than a pea, I regard the Paquelin knife as the most efficient resort. The old method of multiple vaccination about and upon the involved area, is frequently followed by the best of results; and whether in con- sequence of the retraction of tissue under the influence of the inflammation excited, or of the destructive results of the sup- puration induced, or of an indefinite caustic effect is not, as Kaposi suggests, quite clear. These results may be {tartly imitated by the induction of su- perficial pustulation and suppuration through the medium of tartar emetic and croton oil, methods which certainly should be considered clumsy in the light of recent successes, obtained by more manageable expedients. In that light certainly, all injec- tions of angiomatous growths should be condemned. Combs- has lately modified somewhat the method most in vogue, by passing fine silver wires through nrevous growths, and connecting the extremities with a Bunseu's battery. When the wires are heated, the circuit is broken, and the ends of the wires disconnected from the battery and united to each other, being then left in situ and covered with lint and plaster. The current can then be passed repeatedly without reinsertion of the needles, and the latter need be withdrawn only when the cure is complete. The treatment of angioma cavernosum manifestly requires surgical interference. The prognosis in any case of angioma will evidently rest upon the method of treatment adopted for its removal. In the larger number of cases, the lesions having attained a maximum devel- opment, persist without further pathological change, constituting 1 Lancet, Nov. 9, 1878. 2 London Lancet, 1881. LYMPHANGIOMA CUTIS. 363 a deformity rather than a disease. Physiological alterations in the color of such lesions, occur under the influence of changes in the circulation. Lymphangioma Cutis. New growths of lymphatic vessels in the skin have heen noted as constituting a cutaneous disease proper, only by Hebra and Kaposi, Pospelow, 1 and Van Harlingen. 2 By the authors first named the disease is termed Lymphangioma tuberosum multi- plex. The lesions in these several cases were multiple, pea- to bean-sized, smooth, roundish, reddish lilac-tinted or bluish, firm or compressible tubercles, implanted in the skin, and occurring first in early life, about the neck and trunk. Some of these were quite reducible under pressure, and transparent. In Van Harlingen's case, the lesions were destitute of fluid contents and also interspersed between telangiectases. Anatomically, round- ish or oval spaces appeared in sections, recognizable as distended lymphatic vessels by the characteristic endothelium with which they were lined. Kaposi distinguishes these tubercles from all subcutaneous cavernous tumors constituted of new-formed di- lated lymphatic vessels reaching toward the skin, by the limita- tion in the former of the neoplastic growth to the superior parts of the corium. In comparing these with the large number of cases of con- genital and acquired dilatation of the lymph channels, collated in the valuable monographs on these subjects hy Dr. S. C. Busey, 3 of Washington, D. C, a further special difference between the two becomes apparent. In the latter, when the lymph-filled vesicle, papule or tubercle, which appears upon the integument is ruptured, there at once supervenes an exhausting drain from the bodj% of pure coagulable lymph, a feature which is not described by the dermatological authors named, as of occurrence in their cases. ' Viertelj f. Derm. u. Sypb., Hft. 4, 1879. 2 Paper read before tbe Am. Derm. Ass., Sept. 1881, Pbil. Med. Times, Sept. 24, 1881. 3 Congenital Occlusion and Dilatation of tbe Lymph Channels (Amer. Journ. of Obstet., Jan. 1877, etseq.}; Narrowing, Occlusion, and Dilatation of Lymph Channels, Acquired Forms (New Orleans Med. and Surg. Journ. No. 3, 1876, to No. 8, 1878, inclusive). See, e. g., history of Berkley Hill's patient, p. 101 ; of Zambuco's, p. 120; of Carter's, p. 103; of Cholmley's, p. 136; of Jackson's, p. 173, and many others. 3G4 DISEASES OF THE SKIN. Class VII.— OF THE NERVES. I. Anomalies of Sensation. Pruritus. Deriv. Lat. prurire, to itch. Pruritus is a functional disorder of the skin, characterized by the sensation of itching in a part or a whole of the body, unaccompanied by objective symp- toms of disease, and evoked primarily by no exterior cause. Symptomatology. — Pruritus is to be distinguished not only from prurigo, a rare disease of the skin already described, but also from the symptomatic sensation of itching which is occa- sioned by a number of cutaneous disorders, such as eczema, scabies, and those produced by pediculi. Hebra was first to recognize the independent character of the disease here con- sidered ; and it is perhaps to be regretted that he did not give to it a name distinct from that which is also applied to a symp- tom common to several maladies of the skin. Pruritus is characterized by a sensation of itching not pro- duced originally by cutaneous lesions, or by exterior causes. It may he general or partial. In either form, it begins usually by a tickling, pricking, crawling or itching sensation in the skin, which solicits the sufferer to rub, press, scratch, or otherwise irritate the affected integument. It usually occurs by accesses in the day or night, much more often the latter, occasionally both; and these accesses manifestly occur under the immediate stimulus of some internal or external cause. Thus moral emo- tions, a cool draught of air, the warmth of the bed, the pressure of clothing, and often the substances applied externally with a view to the relief of the pruritus, suffice to determine a crisis. However firmly the sufferer may determine to avoid injury to the person, in well-marked cases the impulse to scratch becomes well nigh irresistible, and, in the highest degree, tormenting. From the milder, the patient will thus be frequently teased to inflict the severer injuries upon the skin. Brushes, combs, coarse cloths, and even metal instruments, will be employed in exagge- rated cases, for the purpose of assuaging temporarily the local distress. The objective cutaneous symptoms which may be presented are all secondary, and invariably result from self-inflicted injury. In some cases they do not appear, the statements of the patient being the sole basis for a recognition of his disease. This may be the consequence of unwonted self-control, or of the mildness of the malady, or of the transitory character of the lesions pro- duced. Thus the skin may be reddened during a nocturnal paroxysm under the manipulation of the sufferer, and the trail- PRURITUS. 365 sitory hyperemia disappear in the daytime when the skin is submitted for inspection. Not rarely, however, the integument resents the treatment to which it is subjected, by displaying wheals, hypersemic blotches, reddened papules, excoriations, characteristic " scratch lines," and the minute blood-crusts which indicate that the papillary layer of the derma has been reached and slightly torn. As these are among the recognized causes of eczema and dermatitis, it is not surprising to note that such disorders of the skin may be in this way originated, and still further add to the subjective distress. The localized forms of pruritus, albeit the abnormal sensation is in them limited to certain regions of the body, may occasion fully as much distress as those in which a larger part of the in- tegument is affected. They are of more frequent occurrence than the generalized forms. Pruritus of the anus, of the scrotum, of the vulva, of the vagina, of the scalp, of the nose, of the mouth, of the axillae, are all localized forms of the disease, two or more of which may coexist or develop in succession. In all exaggerated forms of pruritus cutaneus, the general health perceptibly fails. Whether from prolonged insomnia arising from the nocturnal exacerbations to which there are but few exceptions; or from the perversion of nutrition incident to the continuous teasing of the nervous system; or yet from the hypochondriacal state into which some patients are plunged by their sufferings, such an issue is often to be expected. It is in fact a complication which may merit, as much as the disease itself, the attention of the physician. Etiology. — The causes of pruritus are numerous, and the neces- sity for the discovery of the particular cause in each patient, often makes the largest demands upon the practitioner. The disease may occur at all periods of life, and in both sexes, but its exaggerated forms are peculiar to middle life and advanced years (pruritus senilis). It is frequently a reflex symptom of one of several internal disorders. Among the latter may be named, malarial affections, disorders of the liver or kidneys, (especially jaundice, Bright's disease, and diabetes), and dis- turbances of the alimentary canal, including those due to intes- tinal worms, haemorrhoids, and dietetic or medicinal ingesta. It may be associated with almost every one of the functional, and not a few of the organic, disorders of the uterus and ovaries. The same may be said of its dependence upon the genito-urinary diseases of the male sex, including stone in the bladder, stricture of the urethra, disorders of the testis and epididymis, and per- verted sexual hygiene. Lastly, the moral emotions of a depressing character play an important part in the etiology of pruritus. Mental distress, oc- casioned by bereavement, separation from relatives, misfortune of all sorts, and anxieties as to the future, often find physical expression in the disease. 366 DISEASES OF THE SKIN. Pathology. — The disease is essentially a functional disorder of the nerves of sensation supplied to the skin, and is of itself in- capable of producing objective Bymptoms. This fact can, in some eases, l>e eli ideally demonstrated, as the Beal of the pruritus, even though exhibiting nrtificially produced lesions, will, when protected from all external injury, speedily regain its normal appearauce, the pruritus no less continuing. It is probable, though not certain, that the nerves also in this disease undergo no structural change, hut merely convey to the periphery a per- verted sensation which is often reflected from some point of centric disturbance. Diagnosis. — The recognition of general pruritus is usually not difficult, as the secondary results of the disease are apt to be less marked than in its other forms. The complaint of the pat ieiit , the failure of cutaneous disease sufficient to explain his symptoms, and especially the discovery of such a sufficient cause in some visceral or systemic disorder, are all significant. It must lie admitted, however, that when the disease is localized and complicated, as it frequently is, by an eczema or dermatitis, obscurity often arises. Attention should then be paid to the history of the disorder, which may reveal the fact that the pruritus preceded for some time the cutaneous symptoms, and may reveal even more. Intelligent patients will often assure the physician of the real nature of their malady, by voluntarily remarking, that the skin symptoms disappear upon the region which is not scratched, though the pruritus continues. In all cases the operation of exterior agencies should be carefully eliminated. Prurigo, with its infiltrated skin, its primary papules, and its severe itching, beginning in early infancy and commonly per- sisting through life, can scarcely be confounded with pruritus cutaneus. Treatment. — The degree of success to be obtained in the treat- ment of pruritus cutaneus, is largely proportioned to the skill with which the cause of the disease is recognized and remedied. Taking into consideration the number of systemic and visceral disorders which may be, in different cases, responsible for the skin symptoms, it is clear that an exhaustive study of the mental and [physical history of each patient, will be essential at the onset of treatment. The cause once recognized, the treatment should be directed to the special disorder discovered ; and this largely requires the skill of the general practitioner. The gastrointes- tinal tract, the kidneys, the liver, the bladder, the uterus, the prostate gland, the rectum, and indeed any one of the viscera, may require therapeutic management. For the frequent gastric disorders, the alkalies and alkaline waters, with occasional ca- thartics and strict regulation of the diet, are often useful. At- tention should be particularly directed to any medication to which the patient may have been subjected with a view to a PRURITUS. 367 therapeutic effect, and which may have aggravated the com- plaint. The mineral acids, chalybeates, pepsin, lactopeptin, quinine, strychnine, phosphorus, arsenic, or atropine may be indicated in individual cases and productive of favorable results. The substances which have been topically employed for the relief of pruritus cutaneus are almost without number, a fact warranting the conclusion that each occasionally fails to afford the desired relief. This is corroborated in every wide clinical experience; that preparation, moreover, which is at one time of the highest value, will disappoint at another period in the his- tory of a single case. Attempts to secure relief by such topical applications should, however, be always made, and will often be followed by gratifying results. First in order of value are baths and lotions of water, hot, warm, or cold, and medicated by the addition of the sodic bicarbonate or biborate, the potassic carbonate or sulphuret, varying in strength from one ounce (32.) of the last-named to six ounces (200.) of the first-named suhstance, in thirty gallons of water. Gelatine or bran may often with advantage be added to these, as suggested in the chapter on general therapeutics. Alcoholic, ethereal, camphorated, and carbolated lotions are to he regarded as of equal value. Du bring specially recommends solutions of carbolic acid, in the strength of from five to twenty grains (0.33-1.33) to the ounce (32.) of water, to which a half drachm (2.) of glycerine has been added. Robe similarly em- ploys boracic acid, one drachm (4.) to the pint (500.). Baths and lotions of this character usually procure merely temporary relief; and the treatment in the interval of their application demands the wearing of soft linen, or other unirri- tating material next the skin, and the free use of a dustino-. powder. Those of pure starch are here less useful than those compounded with oxide of zinc and bismuth, as in the "Ander- son powder." Gorecki 1 mingles the starch with perfectly pure boracic acid. Dr. B. W. Taylor, of JSTew York, in a valuable paper, 2 gives the following formulae : — $. Potass, sulphuret. Camphor, spts. Glycerin. Aq. font. q. s. ad 13 vj ; 200 M. S. For external use as a lotion, and to be applied by the medium of saturated strips of lint. I£. Spts. camphor. f §ss ; 16 Boracis. 51 j ; 8 Glycerin. f 31J ; 64 Aq. fluv. |vj ; 200 M. S. To be well shaken and applied externally. ! Le Praticien, Oct. 3, 1881, p. 473. 2 On the Various Forms of Pruritus Cutaneus. and their Treatment, Arch of Clin. Surg. : Rutledge & Co., 1877. S"j ; 12 fgss; 16 *'?j; 32 q. s. ad f.^vj ; 200 368 DISEASES OF THE SKIN'. Morphia, in the Btrength of one grain (.066) to the ounce (32.), may be added to this and other lotions. Chloral-camphor, u pungent, syrupy liquid obtained, as BUg- 1 by Bulkley, of New York, after triturating an equal amount of the two substances in tine powder, is an antipruritic remedy of value in certain cases when properly diluted, thus : — i:. Chloral-camphor. 5 SS ; 16 Glycerin. »'5.i ; 32 A(|. ros. ad f.^viij ; 250 S. For external use. M. Other lotions may be made to contain corrosive sublimate, one-quarter of a grain (.016) to the ounce (32.); dilute hydro- cyanic acid, a drachm (4.) to the half pint (250.); Goulard's ex- tract, a drachm (4.) to the {tint (500.); chloroform; sulphur; alum; dilute nitric, aeetie, or salicylic acids ; tannin ; or the zine Bulphate in due proportions. Often the aqua calcis, medicated with calomel, zinc oxide, bis- muth, or calamine, answers well; and, if tolerated at all, the addition of linseed oil, four ounces (130.) to the pint (500.), with a drachm (4.) of one of the inert substances named, flavored with rosemary or bergamot, will aid in relieving the local distress. Ointments and fatty substances in general are usually not well tolerated in cutaneous pruritus. Occasionally, however, they are of more value than lotions, and may be made to contain one or more of the substances named above, such as carbolic acid, live grains (0.33) to the ounce (32.); subnitrate of bismuth, a scruple (1.33) to the ounce (32.); chloral-camphor, five minims (0.33) to the ounce (32.); and calomel, five to ten grains (0.33- 0.66) to the ounce (32.) of cold cream, petroleum ointment, or lard. Tarry substances are usually not well tolerated in the disease, and are, as a rule, when the skin is sound, objectionable as liable to irritate. Duhring, however, speaks well of the liquor carbonis detergeus, in the strength of a drachm (4.) to two ounces (64.) of water. This alcoholic solution of coal tar has been for some time in the market of our large cities. Special attention has been directed by many writers to the treatment of the local forms of pruritus, the principles of which have been in the main described above. For pruritus of the vulva, Wiltshire 1 recom- mends decoctions of almond meal, marsh-mallow, slippery elm, and rice; and in case of failure of the latter, an infusion of tobacco, two ounces (64.) to the pint (500.). Vaginal injections of hot water and tampons or cocoa-butter suppositories medi- cated with opium, belladonna, or carbolic acid are also available. Many of the medicaments named above are also useful in pruritus of the ano-genital region. The application of very hot 1 British Medical Journal, March 5, 1881, p. 328. PRURITUS. 369 water is of decided service. Exception should be made here to the rule with regard to the exclusion of tars generally from the treatment of pruritus; as in the distressing itching of the scro- tum and anus especially, they are often essential. The tincture of tar, oil of cade, and oil of white birch will here often be needed. Pencilling any existing fissures with the compound tincture of benzoin or nitrate of silver, is serviceable. The scrotum when attacked, usually requires the use of a suspender or suspensory bag, lined with soft lint or borated cotton, which may also be incorporated with a dusting powder, wetted with a lotion, or smeared with an unguent. Simon has successfully employed pilocarpine in cutaneous pruritus, both internally and by hypodermic injection. For the latter, the muriate of pilocarpine is used in doses of one-sixth of a grain (0.011). The same author has administered with good results a syrup of jaborandi, made in the proportion of three parts of the leaves of the plant to fifteen of water and eighteen of dissolved white sugar, of which two tablespoonfuls are taken as a dose. Lastly, it should not be forgotten that many cases of intract- able pruritus are best managed when the attention of the patient is diverted from the malady, by the distraction incident to travel, aided by change of scene and climate. Prognosis. — Pruritus senilis is usually an intractable disorder, and, when dependent upon senile alteration of the cutaneous tissues, is incurable. For all other forms of the disease, a prog- nosis should be formulated with reserve. Under the influence of S3'stematic and appropriate treatment, the happiest results are often obtained. Other cases, especially those associated with hypochondriasis, may bid defiance to all remedial measures. Relapse of the local forms of the malady, especially of .that of the ano-genital region, is sufficiently common. In many of these patients the treatment serves merely to palliate the disor- der which recurs with every renewal of the cause. Pruritus Hiemalis. Under this title, Duhring 1 was first to describe a harsh and pruritic condition of the skin, essentially unattended by struc- tural alteration, invading all surfaces of the body, but chiefly the inner faces of the thighs, the calves of the legs, and the neigh- borhood of the joints of the lower extremities, usually occurring in the fall of the year, and continuing until the following spring. It possesses many features in common with the forms of pruritus already described, including variability in the subjective sensa- tions awakened, nocturnal exacerbation, and the absence of a primary eruption. The secondary results are also similar, being 1 Phil. Med. Times, Jan. 10, 1874. 24 370 DISEASES OF THE SKIN". sequels of self-inflicted injury in the form of roughness, peri- follicular redness ami papulation, torn and fractured hairs, ex- coriations, blood-crusts, and. in severe eases, an induced derma- titis. It. however, abates in Beverity with a rise of atmospheric temperature, though the author has occasionally noted persist- ence of the distress alter such weather changes. The affection, moreover, is one which occurs in persons otherwise enjoying perfect health, in those of every social grade, irrespective of the character of the clothing worn, and of the habitual use or neglect of the hath. It is, without question, a disease of north- ern climates, and' more particularly, it seems to me, of climates like our own, where the variations of temperature hetween the extreme- of the summer and of the winter, range between one hundred and one hundred and twenty-five degrees Fahrenheit. The careful description of the author presents a picture whose accuracy is verified by clinical observation, and which justifies the recognition of the disease as a special variety of cutaneous pruritus. Its treatment is, in the main, that detailed above, the author himself laying- stress upon emollient unguents, glyce- rine in the form of lotion or ointment, and alkaline baths. In my experience the dusting powders, when employed after the tepid bath, have proved more serviceable than any fat-contain- ing substances. Hyperesthesia. This is a condition characterized by exaggerated sensibility unattended by structural changes in the skin. It may be idio- pathic or symptomatic, general or partial, unilateral or bilateral, and may also vary greatly in the degree of abnormal subjective sensation by which alone it is declared. In mild eases, there is unusual sensitiveness upon contact with foreign bodies, such as the clothing; in others, the distress occasioned by even the passage of a feather over the surface, is almost intolerable. The symptomatic variety of the malady is most common, occurring as one of the several manifestations of hysteria, tetanus, and other nervous disorders, including certain forms of motor para- lysis where sensation has been retained though in a perverted condition. The disease is properly classed with the neuroses of the skin, with respect to whose etiology and pathology much remains to be investigated. Anaesthesia. In this condition there is total or partial diminution of sensi- bility, with and without structural alteration of the skin. As in the affection just described, the disorder may be either idio- pathic or symptomatic, general or partial, unilateral or bilateral, and in varying grades of severity. Illustrations of the disease DERMATALGIA. 371 are furnished in the anaesthetic patches of leprosy which may and may not exhibit textural skin changes, the disorder result- ing from involvement of the nerves. Other diseases and condi- tions may he accompanied by partial or total loss of cutaneous sensibility, including centric and excentric paralyses ; syphilitic, hysterical, and ataxic disorders; partial or complete anaesthesia of artificial production ; the several toxic narcoses, traumatism of nerves by pressure, wound, or contusion ; the local anaesthesiae induced by cold, frigorific mixtures and substances capable of benumbing the sensitiveness of the skin ; coma, of whatever origin ; and a number of idiopathic cutaneous disorders, including certain of the atrophies, scleroderma, and morphcea. A curious divorce occasionally obtains between the elements which together constitute the compound sensory impression de- rived from the touch. The recognition of pain, of degrees of temperature, as also of the form, size, density, distance, weight, resistance, and other properties of foreign bodies, is accomplished largely by the sensory nerves: and the power to appreciate one or several of these objective qualities may be in different degrees impaired. In this respect several forms of what, for want of a better term, may be named cutaneous anaesthesia, are comparable to the conditions recognized in color-blindness. Thus, in some cases, there is appreciation of heat, but not of cold ; of form, and not of weight; of pain, and not of objective qualities; and the reverse. A curious illustration of this occurred in the person of a leper under my observation, whose hands were in all parts quite sensitive to the prick of a lancet and to contact with heated substances; who yet exposed them for hours, without protec- tion, to an atmospheric temperature of ten degrees below zero, without becoming aware of even slight discomfort. Dermatalgia. In this morbid state, the integument becomes the seat of pain- ful sensations, w T hich may and may not be associated with a byperaesthetic condition. The disorder is much more frequently sjnnptomatic than idiopathic, and partial rather than general, being in the larger number of cases a local expression of some disease of the nervous centres or tracts. It is observed usually in middle life, and in women more than men. Its symptoms vary in severity and in character. The pain is differently de- scribed as comparable to that produced by friction, incision, penetration, contusion or burning of the integument, as also to the passage over the part, of streams of very hot or cold water, or the electric current. With this there is commonly associated an undue sensitiveness to contact with foreign bodies. The skin presents no objective signs of disease. The disordered sensations may be limited to the scalp, the region of the spine, or the palmar and plantar surfaces. In the latter situation 372 DISEASES OF THE SKIN. it is often significant of some obscurely developed systematic disease, such as By philis, rheumatism, or locomotor ataxia. In a middle-aged woman, lately under my charge, a persistent dermatalgia of the interscapular region was associated with coft firmed gastric dyspepsia. In other cases the disorder is de- pendent upon disturbance of the uterine function. It is occa- sionally observed as one of the rare signals of the occurrence of tin- menopause. It is to be noted that the severe dermatalgia associated with disorders of the uterus in women, is occasionally succeeded by a cutaneous lesion. In a middle aged dysmenorrhceic patient under my charge, a pea sized hemorrhagic bulla appeared over the forehead alter several weeks of frontal suffering. Buck, 1 also, reports dermatalgia of the brow and wrists in a young woman who had frequently miscarried, followed by recurrent formation of a vesicle which accomplished its career of rupture, crusting, and erosion, in a stadium of from five to seven days. The disease is to be differentiated from pruritus and hyper- esthesia of the skin, as also from the affections of deeper parts, muscular, nervous, aponeurotic, and visceral. Severe pain, limited strictly to the skin of the lumbar region, with hyper- esthesia, may precede the occurrence of peri-nephritic abscess. The treatment is to be directed to the disorder, of which, in tbe great majority of cases, the dermatalgia is merely a local symptom. Temporary relief may, however, be afforded by the local application of the rubber bag filled with very hot or very cold water; sometimes by an alternation of the two, each for a few moments at a time. Sponging of the part with very hot water is also useful, continued for longer periods, and followed by swathing in cotton batting covered with the Lister protective. The anodynes may also be used topically with advantage; es- pecially the oils, combined with opium, aconite, belladonna, and stramonium. I have in some cases procured relief by paint- ing the part with Squibb's oleate of mercury and morphia, a preparation particularly well adapted to meet the indications presented. The skin should generally, in the interval of appli- cations, be protected by a dusting-powder; and the clothing worn next the skin be of an unirritating character. Care should be taken in dermatalgias limited to the trunk of women, lest the corsets be responsible for the mischief. The prognosis de- pends upon the nature of the cause of the abnormal sensations. In general it may be said, that these cases are less persistent and annoying than those of confirmed cutaneous pruritus with melancholia. A series of rare and singular cutaneous phenomena, due with- out question to abnormal conditions of the nervous system, are recorded by several authors. But little is known regarding ' Phil. Med. and Surg. Reporter, Jan. 18, 1881, p. G97. NEUROMA. 373 either the possible range of their clinical symptoms or their pathology. Of these isolated cases, it may be remarked, that they differ greatly among themselves. To this group belong the Neurotic Excoriations of Sir Erasmus Wilson, 1 an example of which was lately shown at the International Medical Con- gress of London. The Bleeding Stigmata which attracted the attention of the French and Belgian authorities in the years 1873-75 belong to the same category. Leloir and Dejerine pre- sented another similar case at a recent meeting of the Societe de Biologie, in Paris. A young girl of a family, several mem- bers of which were affected with nervous diseases, had, without any apparent cause, several patches of superficial gangrene developed on the cheeks; the small eschars soon separated, leav- ing a linear cicatrix, which gradually became transformed into cheloid elevations. The first happened three years since, and during this period she has suffered from several similar lesions on the trunk and arms. The lesion began on the skin, by a sensation of pricking, with slight redness and notable diminu- tion of sensibility at this point; in nine hours a white patch, not preceded by phlyctenula, formed and underwent, after a short time, superficial gangrene. Later the spot became brown- ish, detached at the edges, and was finally eliminated, leaving an ulceration and a cicatrix, the anaesthesia which existed around the part finally disappearing. 2. Neoplastic. Neuroma. Beriv. Gr. vsSpov, nerve. Neuroma is a disease characterized by the occurrence of single or multiple, pin- head to nut-sized, usually painful cutaneous papules or tubercles, constituted of a new growth of connective tissue and non-medullated nerves. Symptomatology. — But few cases of this rare disease are re- corded. The description appended is a summary of the symp- toms detailed in the reports of Duhring, 2 of Rump, 3 and of Kosinski. 4 The patients were all men of middle life or advanced years, who exhibited upon the shoulders, arms, thighs, or buttocks numerous disseminated and defined, pin-head to hazel-nut sized, roundish or ovalish nodules or tubercles. They were either painful, or painless at the onset and painful later. In Rump's 1 Lectures on Dermatology, London, 1875, p. 192. 2 Case of Painful Neuroma of the Skin, Amer. Journ. of the Med. Sciences, Oct. 1873 ; also Supplement to the same, with cuts, Amer. Journ. of the Medi- cal Sciences, Oct. 1881. 3 Arch, of Path. Anat., bd. Ixxx., hft. 1. « Ctblt. f. Chir., No. 16, 1874. 374 DISEASES OF THE SKIX. case, which was a sample of the false neuromata of Virchow (fibroid rumors of the nerve), there was no pain throughout the course of the disease. The nodules were not arranged along the tracts of nerves; were immovable, dense, and elastic; were fixed in the corium and extended below it. They were purplish to pinkish in color; and the -kin between them was unaltered, or like that envelop- ing the lesions, dry. uneven, and desquamative. The tubercles were both lender and painful, the pain being excruciating, paroxysmal, usually lasting in Duhring's case for an hour, and radiating. It was aggravated by temperature changes, mental emotion, and movement. Sections of the growth in Duhring's case showed anatomically a connective tissue stroma, interwoven with fibres for the most. part lying parallel with one another, each fibre composed of a finely granular central substance surrounded by a sheath con- Fig. 37. Painful neuroma of the skin ; external appearance. (Dnhring.) taining numerous, elongated, oval, somewhat granular nuclei. There was also yellow elastic tissue, bloodvessels with thickened and nucleated walls, and about the latter lymphoid, cell-like bodies. There was entire absence of unstriated muscular and fibrillar connective tissue. The specimen was certainly unique, representing the true amyelinic neuromata of Virchow. In Kosinsk'fs case, non-medullated nerve fibres and connective tissue NEUROMA 375 were also discovered. In both cases, exsection of a portion of nerve (brachial plexus, of the one; and small sciatic, of the other) was followed by considerable diminution of the pain, and almost entire disappearance of the growths. In Rump's case, which, as stated above, represented the fibromata and so-called tibro-nucle- Fig. 38. pic structure of neuroma, from the same case as Fig-. 37. (Duhring.) ated tumors of Virchow, the nodules were strung upon the same nerve, " like beads upon a rosary," and were similarly displayed upon its branches. Spinal, cerebral, and sympathetic fibres were all involved. Duhring, in commenting upon these interesting cases, calls attention to the distinction between these purely cutaneous lesions and the generally solitary, movable, and " painful sub- cutaneous tubercle." 376 DISEASES OF THE SKI. V. Class VIII.— OF THE PIGMENT. 1, Hypertrophic. Lentigo. Derir. Lat. lens, a freckle. Lentigo is tbat condition in which occur pin-head to bean-sized, yellowish to brownish, circumscribed, and usually multiple maculations of the cutaneous surface, due to an excessive deposit of pigment. nptomatology. — This condition, termed also ephelts, is due to excessive and irregular deposit of pigment in the skin, pro- ducing the pin-head to bean-sized spots of circulate or irregular outline, frequently grouped and even confluent, which are com- monly designated as ''freckles." They are most frequently seen symmetrically distributed on the parts of the body ordinarily exposed to the light and heat of the sun and atmospheric influ- ences, such as the face, the neck, and the hacks of the hands in persons of both sexes. In those whose bodies are to a greater extent similarly exposed, they occur upon the chest, the back, and over the extremities In other individuals, they may be seen upon parts not thus exposed, such as the penis, the scrotum, and the inner faces of the thighs', a fact which indicates that they are not always the result of the operation of the agencies noted above. They vary in color from light yellow, salmon, and red to the deepest brown; and are most noticeable in persons having red hair and a delicate skin. They occur rarely in in- fancy, partly, perhaps, on account of the infrequency of out-door exposure in tender years; and are usually seen first about the age of six to eight years. They are commonly observed in mulattoes, individuals of a race particularly disposed to the anomalies of pigment distribution. Once developed, the lesions may persist through life without marked alteration; or fade with each recurrence of the season of winter; or, in milder cases, entirely disappear. They usually share in the atrophic changes of old age, and, when persisting to that period, may then spon- taneously disappear. They are not the source of subjective sen- sation. Etiology.— Freckles are, without question, produced and ag- gravated at times by the action of the light and heat of the sun, as a common experience declares; but it is evident that these forces must act upon a susceptible skin. Of a hundred sailors exposed in precisely similar situations on a long cruise, some of the number will be uniformly "tanned," and others deeply "freckled." Attention has been called to the occasional CHLOASMA. 377 occurrence of lentigo in the protected parts of the skin. Dr. White, of Boston, in an interesting paper on melanoderma, 1 calls attention to the fact that exposure to sea-air and fog, with obscuration of the sun, is sufficient to produce the result. The pathology and treatment of lentigo are those of the dis- order next to be described. Chloasma. Deriv. Gr. x^H^i to possess a greenish color. Chloasma is that condition in which occur yelloAvish to blackish, finger-nail to palm-sized, circumscribed, diffuse, and ill-defined maculations of the cu- taneous surface, due to an excessive deposit of pigment. Symptomatology.— -In this affection the skin is either diffusely discolored in various shades, or the maculations occur in patches larger than those of lentigo, fairly well-defined, and irregular in contour. In color they vary from a scarcely perceptible staining of the skin, which requires a strong light for its detec- tion, to a deep yellow, a yellowish green, a chocolate-brown, or a blackish shade (melanoderma). They may be either, idio- pathic or symptomatic in character. The idiopathic varieties of chloasma are produced by all ex- ternally operating agencies, in consequence of which an undue afflux of blood is persistently determined to any portion of the skin. It is largely from the blood that the pigment is derived, and hence the stains produced by the latter are, to a certain ex- tent at least, proportioned to the hypersemia, stasis, or extrava- sation of the vascular fluid. Among these externally operating agencies may be named, pressure and friction (as over the part covered by the pad of a truss); traumatism (as after the severe scratching of the skin affected with lice, eczema, or scabies) ; heat (as in the diffuse "tanning" of the face, or "sunburn" fol- lowing exposure to the solar rays); and the toxic or irritating effect of externally applied substances, such as mustard, capsi- cum, cantharides, and other articles capable of producing either vesication or pustulation of the surface. The physician should always remember the possibility of producing long, persistent, or even permanent pigmentations of the skin upon the face, shoulders, and bosom of young women especially, by the re- peated operation of such topical medicaments. The symptomatic varieties of chloasma are the results of dis- orders either systemic or involving the internal organs. They occur as either circumscribed or diffuse, localized or generalized, spots, mottlings, stainings, or " masks" of the skin ; and vary in color from the lightest shades to the darkest. One of the most common, and at the same time the most marked of these, is chloasma uterinum, so called because of its frequent association 1 Boston Med. Journ., May 16, 1878, p. 624. 378 DISEASES OF THE SKIN. with certain physiological or pathological conditions of the ute- rus, both union-- married and single women. Thus in pregnancy, sterility, hysteria, chlorosis, ovarian disorders, and tumors and functional derangements of the uterus, there can be observed at times a facial discoloration extending equably over the forehead and reaching nearly to the line of the hairs at the Bcalp, in the form of a taint or decidedly yellowish, reddish-yellow, or deep brownish tinge. At other times, the discoloration is macular and asymmetrical, involving the lids, the cheeks, the lips, or the chin. When the chloasma assumes the mask-like form, it is usually most pronounced over the forehead, hut may involve the whole facial region, beiug less distinctly defined below than above. Similarly, the well-known changes occur in the areola of the nipple, along the linea alba, and about the external geni- talia. Melanoderma, or Chloasma, Cachecticorum, is another of the sj-mptomatic pigment disorders, characterized by the changes in the color of the integument of the subjects of tuberculosis, syphilis, cancer, chronic alcoholism, malaria (e.g., " Chagres fever"), and disorders of the supra-renal capsules (Ad- dison's disease). The peculiar tint in each may vary. That of the last-named disorder ranges from an olive-green to a dark mulatto shade, most pronounced upon the face and hands, the regions of pressure and exposure, and those of largest natural pigment supply. There is, however, nothing characteristic in this, as careful study of Addison's disease discloses the fact that its subjects are in many cases affected also with one or another of the several diseases exhibiting chloasma cachecticorum. Among the cutaneous disorders capable of producing skin pigmentation may be named scleroderma, lepra, xeroderma (of Hebra), eczema, especially e. venis varicosis; and general exfolia- tive dermatitis. From all of the discolorations named above, which are due solely to deposition in excess of coloring matters normally ex- isting in the skin, it is necessary to distinguish the various dys- chromia} which are owing to the introduction into the integu- ment of coloring substances, either supplied by other portions of the body or entirely foreign to it. Thus, in icterus, the bile may color the skin from a light yellow to a dark chrome color, the duration and severity of the cutaneous symptoms depending upon the nature and gravity of the hepatic disease. It is fre- quently accompanied by pruritus in various grades of severity, the exact causes of which are obscure. In arc.yria, the bluish, bluish-gray, slate-colored, or bronzed coloration of the skin, results from the introduction from with- out, of the nitrate of silver. It is most commonly the result of the administration of the drug in the treatment of epilepsy, but CHLOASMA. 379 is said also to have resulted from the topical application of the silver crayons to the throat, to the conjunctiva, and even to the skin. Under what form the silver produces this effect, whether as an albuminate, or other salt, is not known. The deposition, however, occurs in the form of minute particles of the metal in the connective tissue of the derma. The discolorations are most evident upon the parts of the skin exposed to the light, as the face and hands; but I have seen the chest and lower extremi- ties similarly stained. The connective tissue of the viscera is also at times involved, showing thus that the action of light is not essential to the production of the dyschromia. By the process of tatooing also, several mineral and vegetable substances are directly introduced into the corium by means of needles, for the production in the skin of various devices in colors. Individuals whose entire integument has been thus artificially covered with figures of different patterns by tatooing with indigo, vermilion, and cinnabar, have been from time to time exhibited in this country. The results are indelible. Post- mortem, these pigments have been discovered not only in the derma, but in the lymphatic ganglia nearest the site of their in- troduction. Pathology. — The lentigines, ephelides, and chloasmata, are all due to excessive deposit of the natural pigment of the body in the rete mucosum of the epidermis. Restoration of the normal color of the skin is usually proportioned to the extent and depth of the deposit, but the process is always very gradual. It can be well studied in the slow bleaching of the pigmentation of syphilitic cicatrices upon the lower extremities. In the dis- chromise due to the introduction of coloring matters foreign to the body or foreign to the skin, the corium and subcutaneous connective tissue are commonly stained. Diagnosis. — The diagnosis of the cutaneous pigment hypertro- phies, is readily effected by observing the persistence of the discoloration under pressure; the absence of all symptoms of hypersemia, inflammation, and secondary changes in the skin ; as also by the characteristic shades of color presented to the eye. In tinea versicolor, there is usually slight furfuraceous des- quamation ; and the existence of a vegetable parasite is readily demonstrable by the microscope. The rare pigmentary syphilide is usually seen upon the neck and shoulders of infected women in the form of yellowish to brownish maculations, often arranged in an irregular network. It is, indeed, one of the symptomatic chloasmata. Treatment. — In all the symptomatic pigment anomalies, the indications for treatment are presented by the disease which be- gets the cutaneous disorder. The local treatment of both the idiopathic and symptomatic varieties of the disease, demands the use of external applications which will hasten the physiological reproduction of the epi- 3S0 DISEASES OF THE SKIN dermis, substituting thus new and unpigmented for old and pig- mented epithelia. This must also be accomplished without the artificial production of such an hypersemia as will tend to add to the very coloration which it is attempted to relieve. The substances used for the slow accomplishment of this cud, are muriatic and acetic acids, borax, sulphur, tincture of iodine, potash, and soda (including the soaps of these alkalies), and the mercurials. None of these are more generally employed than corrosive sublimate, which constitutes the basis of most of the cosmetic lotions sold in the shops. The following are formulae given by Dr. White, 1 for use in the evening. The preparation in each case should he left upon the surface during the night, and removed by a soap and water washing in the morning. They are to he used for weeks in succession, but only after a cautious preliminary testing of the sensitiveness of the skin to their action. In order to avoid the possibility of error, the practitioner would do well to order a poison label upon all vials containing the sublimate: — K. Hydrarg. am. chlor. ? Bismuth, magistr. i Amyli, ) Glycerin, $ Amnion, muriat Aq. Colognien. Aq. Hydrarg. bichlorid. Acid. mur. dil. Glycerin. Alcoholis. ) Aq. ros. $ Aq. aa 3>j 3ss; m-, Oss; i'3J; & m ; 16 30 250| 4 30 60 130' The following are formulae for ointments given by Kaposi: — Hydrarg. amnion ) Sodse biborat. ) 01. rosmarin. Unguent, simpl. Acid, boracis. ) Cerae alb. $ Paraffin. 01. amygd. dulc. aa 5SS ; gtts. x ; sj ; aa 3j ; 5u; a; 8 30 M. The rapid removal of pigmented patches is accomplished, in Vienna, by covering the part with strips of linen dipped in an aqueous or alcoholic solution of corrosive sublimate of the strength of four grains (.26) to the ounce (32.) with which also the dressing is occasionally moistened. Vesiculation is usually accomplished in about four hours, when the serum is evacuated by puncture, and the detached epidermis covered with any inert dusting powder. The resulting crust falls in about eight days. Loc. cit. N^VUS PIGMENTOSUS. 381 The procedure is attended with the danger of producing, in the end, the precise deformity which it seeks to remedy, a danger explained above. The internal administration of the iodide of potassium recom- mended for the removal of argyria, has in my hands failed of any good results. YandelPs two patients, one completely and the other partially relieved, were both syphilitic. 1 One of my pa- tients was a veteran syphilitic, fifty years of age. Nsevus Pigment osus. Deriv. Lat. ncevus, a mask. Nsevus pigmenlosus is a congenital, circumscribed pigmentation of the skin, in single or multiple deposits, either without textural cutaneous change, or asso- ciated with the development of warts, tubercles, plaques, tumors, or pilary hypertrophy. Abnormal congenital pigmentations of the skin, vary in color from a light yellow or chocolate-brown to a blackish hue, and may be single or multiple and very numerous. The}' are com- monly termed pigmentary moles. They vary in size from a pin-head to tumors of considerable volume; and are either ovoid or circular in contour, or so irregularly shaped as to present a fanciful resemblance to parts of the figures of the lower animals, whence the popular belief as to their origin in maternal impres- sions. They occur in both sexes; and upon the face, neck, trunk, thighs, buttocks, and external genitals. The term n^vus spilus is applied to those which occur in a smooth and other- wise unaltered skin; n^ivus verrucosus, to those which are ir- regular and wart-like; islevus pilosus, to those surmounted by a growth of shorter or longer, stiff or downy, dark-colored hairs; and n^ivus mollusciformis, or lipomatodes, to the soft or firm, more or less elevated and projecting tumors. They may be, when multiple, symmetricall}' or asymmetrically developed upon the surface of the body; and in either case may confess in their arrangement to a supremacy of the nervous sys- tem. In a case reported by myself 2 there were multiple mono- lateral pigmentary noevi distributed over the left side of the trunk in the course of the intercostal nerves, and in such a manner as to strongly suggest to the eye their correspondence in site with the lesions of zoster of the same region. De Amicis 3 had previously reported a somewhat similar case. The course of pigmentary nsevi, after obtaining their full evo- lution, is to persist unchanged for a lifetime. Their increase in tender years is occasionally characterized by a relative rapidity. 1 American Practitioner, Sept, 1872. 2 Ch. Med. Journ. and Exam., Oct. 1877. 3 Lo Sperimentale, March, 1876. 382 DISEASES OF THE SKIN. I have Been a pilary naevus upon the chock of an infant extend n\-fv nearly doable its original area in the course of two years. They very rarely disappear spontaneously. Their removal may be accomplished by excision or destruction with caustics. 2. Atrophic. Albinism. Deriv. Dat. albus, white. Albinism is a congenital cntaneona achromia, characterized by universal or par- tial defect of pigment, unaccompanied by textural changes in the skin. Symptomatology. — The term albinism, or leucoderma, is limited to the congenital conditions of achromia induced by failure of cutaneous pigment. Universal congenital leucoderma is peculiar to individuals known as Alhinoes, isolated instances of this anomaly occur- ring in all races, hut more frequently among those having nor- mally a hyperpigmentation of the skin, such as the negroes. In the subjects of this deformity, the skin has a milky whitish, transparent, or rosy-tinted hue, and is usually of delicate tex- ture; the hairs are silky and yellowish, whitish or snowy-white in color; the iris, transparent or pinkish ; and the pupil, in con- sequence of the defect of pigment in the choroid, is also reddish or pinkish. There is, as a result, nyctalopia and heliophobia with frequent nictitation, pupillary variations, and the sem- blance of myopia. Partial congenital leucoderma also is seen in individuals of different races, but more commonly in those of African descent. When it exists, one or several whitish patches or bands unpro- vided with pigment may be seen upon any portion of the sur- face; and the hairs found upon such parts are equally destitute of normal color. Negroes thus marked are generally termed "piebald;" and the integument similarly affected in persons of other races has long been recognized as the "pied" or "piebald skin." These blemishes are occasionally symmetrical, and, like pigmentary naevi, respect in their distribution the areas supplied by certain nerves. In this particular, they exhibit a striking analogy with the symmetrical arrangement of the spots, bands, and stripes to be recognized in the furs of many of the lower animals. In both universal and partial albinism, the defective condition of the pigment is usually unchanged throughout life. Very rarely in the latter, there is a tendency to extension in area of the uncolored portions of the skin. Still more exceptional is the occurrence of pigmentation in previously achromic patches. The causes of the deformity are unknown. The few cases of inherited albinism on record are not sufficient to establish a law VITILIGO. 383 of inheritance in the face of many instances where such trans- missibility has not occurred. The union of a male or female albino with an individual of normal color has been repeatedly followed by offspring without pigmentary peculiarities. The condition is remediless; though it is probable that trans- fusion with the blood of a vigorous black-skinned African, would largely modify the color characteristics of the pure albino. Vitiligo. Deriv. Lat. vitium, a blemish. Vitiligo is an acquired cutaneous achromia, exhibited in single or multiple, variously shaped and sized patches, unaccompanied by textural chauge in the skin, and usually bordered by tissues exhibiting pigmentary excess. Symptomatology. — The disorder is one observed among the several races, often in the negro, and not rarely among those of Aryan descent. It commonly occurs without the slightest ap- preciable disorder, subjective or objective, save that betrayed to the eye in the discoloration of the skin. One or several round- ish, or very irregularly shaped, smooth, and well-defined, pale, or milky-white disks appear, often bordered at the periphery by an integument which assumes a light or dark brown or chocolate shade, this hue being by contrast most noticeable immediately at the contour of the patch, and imperceptibly fading into the normal color of the outlying integument. The hairs or lanugo growing from the affected area, may or may not be blanched. Most commonly they are ; a condition particularly conspicuous when, as is not rarely observed, a vitiliginous disk extends from the back or side of the neck, well into the scalp, in which case the outline of that portion of the scalp involved is clearly defined by the whitened pilary growth. The surfaces thus blanched are otherwise unchauged. In point of subjective and objective sensation, secretion from the follicles, and the condition of both epidermis and corium, aside from the dyschromia, there is no departure from a normal standard. The disease may progress by the coalescence of rela- tively small areas of involvement till a large portion of the trunk, thighs, or buttocks is involved. Hall 1 reports the case of a dark mulatto who became " perfectly white" with the excep- tion of a patch on the chin. It is then, as Kaposi has well shown, that the eye of the observer is struck no longer by the unusual whiteness of the involved patches ; but this whiteness being generalized and apparently that proper to the person, by the intermediate peripheral belts of a deeper and unusual color. The greater portion of the surface of the body may be finally thus involved. The most common seats of the disease are the face, the neck, the backs of the hands, and the extremities ; and 1 Louisville Med. News, 1880, x. p. 148. 334 DISEASES OF THE SKIN*. in these, since the coarse of the disease is exceedingly bIow, there may be for years no apparent extension of any involved area. Upon the hacks of the hands, the disfigurement is usually more conspicuous at Borne seasons of the year than at others, a cir- cumstance whi.-h probably explains the reported instances of recurrence and total disappearance of the disease in successive years. These changes are probably due to the influence of the 'sweat in washing the pigment to the surface. Such an effect would, of course, render the hyper-pigmented peripheral zone of a vitiliginous disk much the more conspicuous. The health of the subjects of this disorder is usually unim- paired. A morbid mental condition is often produced when the disfigurement involves the facial region, especially in women of middle life. . . Etiology.— Vitiligo occurs in both sexes, and in individuals of all complexions^ and ages; though it is commonly observed in early or middle life, ft is at tunes coincident with sclero- derma, morphcea, lepra, variola, and other diseases with similar cutaneous symptoms, though it occurs independently of all such. Its etiology must be regarded as obscure, unless the strong probabilities in favor of its occurrence under the influence of perturbed innervation be accepted as conclusive. I am strongly inclined to believe that the disorder is of more frequent occur- rence than dermatological statistics tend to show. Many per- sons who are the subjects of vitiligo of an inconspicuous part of the body, do not consult a physician with regard to the nature of the disease, as it occasions no physical distress. Close ob- servation of the people with whom one comes in contact in public will often verify this fact. Pathology.— The pathological anatomy of vitiligo may one day he described in the changes which occur in the trophic nerves supplying the skin. At present, the cutaneous changes alone are recognized ; and these are, probably, as regards the pigment, neither strictly atrophic or hypertrophic. It is true that there is an apparent atrophy in one portion of the skin, and an ap- parent hypertrophy in" another; but is not this merely a dys- trophia or ataxia of the epidermis, a disturbance ot arrange- ment and distribution, as of the blood in the face, m certain cardiac diseases, when the skin is temporarily streaked or mot- tled by the irregularity in the distribution of the circulating fluid? These are undetermined points. Diagnosis.— Mr. Hutchinson, of London, has devoted an en- tire chapter in his valuable Lectures on Clinical Surgery 1 to the importance of the diagnosis between leucoderma and white leprosy; yet it seems incredible that the symptoms character- istic of a systemic disease could be confounded with those de- scribed above, where there is no cutaneous anaesthesia or struc- 1 Churchill, London, 1878. THE EXANTHEMATA. 385 tural change in the integument. This latter is, in fact, the basis of discrimination between all purely pigmentary and all non- pigmentary changes in the skin color, separating them widely from parasitic diseases (tinea versicolor), morphoea, lepra, and syphilis. From the chloasmata, which are always accompanied by hyper-pigmentation, vitiligo is readily differentiated. Treatment. — lam strongly of the opinion that much chagrin will be saved both physician and patient, by practically regard- ing vitiligo as not amenable to treatment. Patients occasionally recover while under treatment; the latter has, however, gen- erally contributed but very little to the result. Arsenic and iron internally, recommended highly by some authors, have re- peatedly failed to accomplish any appreciable results as regards the dyschromia. By efforts directed to the removal of the hyper-pigmentation in the border of the achromic patches, the disfigurement may be somewhat lessened. The method of arriv- ing at this end has been described in connection with the treat- ment of chloasma. It is possible that further experimentation with hypodermic injections of pilocarpine, which have in a lim- ited number of cases been followed by disappearance of the dis- ease, may warrant a less unfavorable view of the results of treatment. Prognosis. — The health of the subject of the malady is not impaired. The disease is practically incurable, progressing usu- ally till it has obtained a maximum of development; and then, as a rule, remaining unchanged throughout life. Class IX.— OF THE SKIN" WITH INVOLVEMENT OF OTHER ORGANS. 1. Exudative. The Exanthemata. Deriv. Gr. I^ovflu^a, blossoming, flowering. The exanthemata are specific fevers, frequently occurring in epidemic form, com- municable by contagion, preceded by a period of incubation, and character- ized by systemic disturbance, with an efflorescence upon the skin of different type in each, as also by involvement of other organs of the body, a single attack usually conferring immunity, upon an affected individual during his oi- lier lifetime, against subsequent attacks of the same disease. For a detailed consideration of the phenomena of the exanthe- matous fevers, the reader is referred to the standard treatises on the subject, in the field of general medicine. Brief space is al- lotted here, merely to a description of the cutaneous lesions by which they are all characterized. These are unlike in each dis- 25 386 DISEASES OF THE SKIX. ease; and yet all exhibit certain common characteristics. In all, the eruptions arc symmetrical ; and in typical rases, general. hi each, the efflorescence i< succeeded by a desquamative or ex- foliating condition of the skin. In each there is. within rela- tively fixed limits, a distinct stadium of the pathological pro- cess, within which it is completed, and beyond which, however persistent may he its remote Bequelse, there is no chronic mani- festation of the disorder. Each also is produced solely by its own specific contagium, derived exclusively from an animal body affected with the same disease, being never, so far as known, generated from any other source, nor merging by imper- ceptible degrees, the one into another. Two of these may rarely concur, but under such circumstances the one is always pro- nounced in its features, which either closely precede or follow those of another. Finally, no specific medication is known to be capable of arresting any one of them, each pursuing its course uninterruptedly to a favorable or fatal termination, according to the intensity of the poison present in each case, and the more or less favorable or unfavorable conditions of the sufferer. Rubeola (Measles, Morbilli). This disease is preceded by a period of incubation, lasting from eight to twenty-one days, a period in which there may he no evidence of ill health, or merely a moderate degree of lassi- tude and inappetence. To this succeeds a prodromic fever, the temperature rising to 103°-l(H o F., occasionally alternating with chills or a sensation of chilliness, dryness of the skin, pains in the head, thirst, occasionally sweating, very rarely convul- sions in infancy; and, almost invariably, a serous catarrh of the mucous surfaces. By the second or third day, the tempera- ture begins to decline, while the catarrhal symptoms increase. These are manifested by sneezing, a secretion from the eyes and nose, and engorgement of the exposed mucous surfaces, espe- cially those of the conjunctiva, mires, and throat. Occasionally, the tongue and fauces exhibit a few isolated, minute, reddish puncta. In consequence of the implication of the larynx, trachea, and ultimately the larger bronchi, there is a hoarse, frequently an incessant and teasing, cough of a convulsive char- acter, accompanied by expectoration of a moderate quantity of mucus. This prodromic period lasts for from three to live days, but is, in exceptional cases, prolonged to twice that length of time. Upon its conclusion the exanthem appears, usually with exaggeration of the fever, the temperature rising to 104r°-106° F., and remaining at that point till the eruption has reached its apogee, wheu it commonly declines -pari passu with the severity of the skin symptoms. The eruption of measles appears usually first upon the face (the forehead and temples), and thence extends in about thirty THE EXANTHEMATA. 387 hours over the neck, upper portion of the trunk and superior extremities. Between the fourth and sixth days of the disease, it has usually attained its maximum of development over the entire surface of the body, including the palms and soles, and its deepest shade of color. This maximum attained, the erup- tion gradually fades; the tumid condition of the skin, most noticeable upon the face, also subsides; the catarrhal symptoms and cougb become less annoying; and the patient enters upon the period of desquamation. The eruption is characterized by the occurrence of reddish, yellowish-red, mulberry-red, deep raspberry-red, or, in extreme cases, violaceous-tinted, small finger-nail sized macula?, either not elevated or very slightly elevated above the general level of the integument; or by the occurrence of large-pin-head sized, discrete papules, much more rarely pin-point sized vesicles, cor- responding in color to the shades described above, and highly suggestive of the first efflorescence in variola. These lesions pale under pressure, exhibiting then a yellowish tint, and are often set together very closely in patches suggesting a crescentic outline. The term "suggesting" is here used purposely; as it is difficult by selecting a single patch to determine by the eye alone the existence of such a configuration ; while yet an examination of the eruption as a whole, may often very clearly convey this impression to the sight. In other words, the crescentic outline is far less distinct than, for example, in certain of the papulo- crustaceous syphilodermata, Usually patches of sound skin can be recognized, even when the eruption appears to be confluent, complete confluence never occurring so as to form a sheet or mask over an entire area of the skin. Individual lesions may so merge as to be well-nigh indistinguishable separately; yet, on the whole, the eruption deserves fully the plural character of its English name. It is made up in all cases of innumerable ele- ments, whose identity is never wholly lost. The subjective sen- sation awakened is occasionally a severe itching or burning; frequently this is a matter of insignificance in comparison with other disagreeable symptoms, e.g., the cough, coryza, and fever. Desquamation is accomplished usually with cessation of fever and the production of yellowish-brown pigmentations of the surface where the elements of the eruption have existed, invo- lution being first manifested in the site of the lesions which were earliest to develop. Gradually and simultaneously, the catarrhal symptoms of the respiratory passages diminish in severity. This final stage of the disease is usually terminated in- a fortnight from the date of invasion. The complications and anomalies of measles depend : upon the intensity of the poison, displayed in the most formidable symp- toms where human beings are crowded together, as in camps and prisons; upon the degree of physical vigor; and also upon the various hygienic surroundings of the victims of the disease. 388 DISEASES OF THE SKIN. Thug the period of efflorescence may be unusually prolonged : the eruption may disappear bu Idenly, and as rapidly reappear; the cutaneous symptoms may alone he wanting; the latter may be commingled with petechias due to cutaneous extravasation of blood, which may be also accompanied by severe epistaxis; and the catarrhal condition of the mucous surfaces affected may ter- minate in croupal or diphtheritic disease, may be followed by capillary bronchitis, catarrhal pneumonia, and even by pulmo- nary tuberculosis. Typhoid conditions may also supervene,and chronic inflammatory affections of the eyes and of the Schnei- derian membrane result. The pathology of the cutaneous lesions in measles, is that merely of acute hypersemia occasionally passing into exudation, limited for the most part to the vascular papillae of the corium and the perifollicular plexuses of blood vessels. Post-mortem, the eruption fades, as the result of the gravity of the blood, from the anterior aspect of the body as it reclines upon the dorsum. The disease is one of infancy chiefly, probably because at that aire there is always the largest number of individuals unpro- tected by -previous attacks. In every ease, the malady results from contagion, mediate or immediate, from an infected human subject. It spares no age nor sex, though much rarer in ad- vanced years than at other periods of life, probably because of the large number who, at such periods, enjoy immunity. The diagnosis of importance, is between scarlatina and variola. Typical cases with a well-developed eruption can be scarcely mistaken for either, if the symptoms displayed are assigned their full weight. It would be useless, however, to deny the fact that atypical forms occur, which have again and again confused the most expert diagnosticians; and in all cases of doubt, the prudent practitioner will refuse to decide as to the nature of the disease, till the symptoms have, in the lapse of time, bet n fully declared. The resemblance between illy developed measles and certain of the eruptions seen in varioloid, is in the highest degree striking; and it seems to be quite needful to remind the professional world that the greatest skill, at a given moment of time, will in cases utterly fail to make a decision between the two. A distinctly crescentic character of the eruption, the presence of catarrhal symptoms, the continuance of the fever after the efflorescence is completed, the color of the eruption, and the discovery of the nature of the disease from which the contagion was derived, will all point in the direction of the truth. From scarlatina, measles is much more readily differentiated by the macular or papular elements of its eruption ; by their color; by their appear- ance to a marked degree upon the face; and by the absence of the characteristic sore throat and usually intense febrile access of the first named disease. From the various forms of erythema accompanied by fever, measles can always be recognized by the irregularity of the temperature record, as well as by the charac- THE EXANTHEMATA. 889 ter of the eruption. The distinction between rubeola and ro- theln will be given later. The treatment of rubeola should be strictly limited to a careful hygienic attention to the invalid, including a restricted "fever diet," and the use of such medicaments only as are specially in- dicated by the complications or accidents of the disease. The skin should be anointed with a bland, oily or fatty substance, to relieve the pruritic sensations, especially after the sponging of the surface once daily with a weak alkaline solution, which may be used cool without fear of producing " repercussion" of the exanthem. The chamber of the invalid should be some- what darkened, for the sake of the eyes, but pure air should be constantly admitted. The prognosis is in general favorable All the complications named above increase, however, the gravity of the disease, which is also enhanced among men crowded together in camps, infant's in public charities, pregnant women, the cachectic and greatly enfeebled from other diseases, vevy young infants, old men and women, and islanders long unvisited by epidemics of the malady. Rotheln (Rubella, German Measles, Hybrid Measles, French Measles). Under these several titles has been described a disorder lately very prevalent in this country in epidemic form, accompanied by a cutaneous exanthem somewhat resembling that of rubeola, and manifestly contagious. Kaposi regards this disorder as a mild form of rubeola, since the latter, as is well known, may occur several times in the same person, and rotheln thus attacks those who have suffered from measles. Pie also lays stress upon the identity of the symptoms in the two disorders, and the occurrence of transitional forms between typical examples of the two, as admitted by G-er- hardt and other partisans of the specificity of rotheln. In dissenting from so high an authority, I believe that I am in accord with the larger number of those who have had the opportunity of studying the disease as it prevailed during the late epidemic so general in this country. My belief in the indi- viduality of rotheln, is based upon a somewhat careful observa- tion of more than one hundred typical cases. In the Chicago Home for the Friendless, more than sixty per cent, of those who suffered from the disease in 1880-1881, had also endured measles in 1879-1880. Both epidemics were severe in point of general prevalence, and furnished a large number of typical cases of the two disorders. The recurrence of measles in so great a propor- tion of children in two successive years, would furnish a very wide variation from the statistical facts of that malady. In the two epidemics, moreover, the symptoms were markedly different, and transitional forms did not occur. .Rotheln, then, occurs in those who have previously, and even 390 DISEASES OF THE SKIN. within relatively brief periodH of t i me. suffered from measles, without a prodroraic catarrh, this symptom when present, being coincident with the appearance of the exanthem. It is rarely a marked characteristic of the disease, and the affection of the eyes is. us ;i rule, much less pronounced than in measles. After a pyrexic period, rarely lasting longer than a few hours, and in many cases entirely absent, the eruption appears in the form of multiple, pin-point to small pin-head sized papules, occurring for the most part in the regions affected by measles, but smaller than the lesions displayed in that disease, and decidedly lighter in color. The shade is a rosy- to a crimson-red, rarely lurid, never of dark mulberry or violaceous hue. This color will, at times, lie perceptible beyond the line of the lesions, in a delicate halo, a circumstance which strongly distinguishes the exanthem from morbilli. The lesions, moreover, are seldom arranged in crescentic outline, being more often grouped in roundish or oval- ish patches. Often indeed the elements of the eruption are dis- crete and disseminated. The fauces are occasionally reddened in puncta. The eruption commonly hides in from one to two days, and there may or ma)' not be slight resulting cutaneous desquamation. The rash is to he distinguished from that of measles by the existence of the features described above, particularly by the color, contour, and date of occurrence of the exanthem, the transitory character of the fever when the latter is present, and the rapidity with which involution of the disease progresses. By the temperature record alone of the patient, it may he differ- entiated from scarlatina, though the rash is dissimilar in the two diseases. It is also not to be confounded with the erythe- matous affections of the skin. One of the most striking charac- teristics of the disease can be best recognized in a ward tilled with children, all of whom are simultaneously affected with the disorder. That characteristic is the remarkable mildness of the phenomena displayed in every case. I have thus bad under ob- servation at one time twenty little patients all exhibiting the exanthem, not one of whom presented the peculiar facies of the sufferer from measles. The disorder, consequently, should he treated by rest in bed, a supply of fresh air, and the usual diet of fever patients. I have never seen a case calling for medication by drugs. Scarlatina (Scarlet Fever). This is also a S} r stemic contagious disease, produced b} T poison- ous emanations from an infected human being, characterized by fever, a cutaneous exanthem, and involvement of other organs of the body. The period of incubation of scarlet fever varies between twenty-four hours and a month or more, the average duration THE EXANTHEMATA. 391 being about eight days. The reason of this wide variation is to be sought, not in any changeability in the mode of evolution of the disease, but in the fact that its poison is less volatile and less rapidly dissipated than is that of measles, the result being that it may remain potential for longer periods in connection with articles through the medium of which it is transferred from one individual to another. This incubative period, like that described in connection with measles, may he quite unpro- ductive of physical symptoms, or be associated with an ill- defined malaise. The prodrome of the disease in typical cases, is marked by the occurrence of a rapid and bounding pulse, an exceedingly dry skin, and a characteristic sore throat. When examination of the mouth is made, the tongue is seen to be thickly coated, and its filiform papillae reddened and prominent, producing the so- called " strawberry appearance." The velum, pillars of the fauces, tonsils, and all exposed mucous surfaces are engorged, tumid, reddened, and often covered with deep reddish puncta, which unquestionably represent hyperasmia of the perifollicular tissues. Thirst is great, and deglutition often in the highest degree painful. In severe cases, the mucous surfaces named may speedily exhibit finger-nail to pigeon's egg sized, ashy ulcera- tions with a lurid halo at the periphery. In children, there may be syncope, delirium, convulsions, vomiting, or, when the poison has been intense, fatal results from shock of the nervous cen- tres. This prodromal period usually lasts from twelve to twenty-four hours, though it may be prolonged for two days more. In this respect scarlatina is markedly distinguished from rubeola. It is terminated by the appearance of the exanthem, but the fever persists without abatement after the explosion : and the other symptoms of the disease are in no wise then ame- liorated. The eruption in scarlatina usually spares the face, however much the latter may display two damask-colored cheeks under the febrile flush, become tumid with the acceleration to it of the blood pumped through the throbbing carotids, or even ex- hibit a few scanty lesions upon the forehead and temples. About the mouth, the integument is always pallid. This is far different from the picture presented in measles. The eruption is first seen in the form of light or deep-red, pin-head sized puncta, so closely agglomerated as to produce upon the eye the impression of a diffuse reddish blush. It is first seen about the neck and clavicular regions, but rapidly spreads to the trunk and extremities, including the dorsal surfaces of the hands and feet, attaining complete development in the course of the second day of the eruption. It is then of a distinctly scarlet color, whence the disease has its name in the Latin, English, and Ger- man tongues, a coloration frequently compared to the appear- ance of a boiled lobster. Upon the limbs it is often developed 302 DISEASES OF THE SKIN. ill punctate form, while the occurrence of a diffuse scarlet blush is most distinctly perceived by the eve in the examination of the trunk. Here it is seen to fade under pressure; and the finger- nail drawn rapidly ever the surface of the skin is followed by the formation of a whitish line, which persists for an instant, a rime sufficient to enable one to describe a letter upon the skin. This period of efflorescence lasts for from one to two days to an entire week, during which, as stated above, the febrile and other symptoms persist unabated. The rash usually persists at its maxim of development for from one to three days, the concomitant symptoms continuing without noticeable abatement. Among the latter may be named the occurrence of albumen in a urinary Becretion of diminished gravity, with occasionally the presence of epithelium recogniza- ble under the microscope as derived from the lining membrane of the uriniferous tubules of the kidney. Having attained its apogee, the eruption in favorable cases begins to fade, the part first affected exhibiting earliest a lighter shade, while the other pathological phenomena diminish in sever- ity, the sore throat, especially in ulcerated conditions, alone per- sisting. In from four to ten days longer the eruption disappears, leaving a brownish-yellow pigmentation of the surface; and simultaneously the other symptoms of disease vanish. The desquamation which then ensues, as convalescence pro- gresses, is general and often proportioned in extent to the sever- ity of the preceding eruption, though it may be generalized after a well nigh i in perceptible exantheni. It is more pronounced and characteristic in scarlatina than in any of the other eruptive fevers. It may be superficial and furfuraceous in character; or the epidermis may fall in lamellated plates, the sheath of an entire finger, for example, with the nail; or that of the entire palm. In this way sheets, ribbons, and shreds of the horny layer of the skin may fall from its surface, and expose beneath a new and often tender epidermis. The hairs may be simulta- neously shed. When this desquamation is finished, the stadium of the disease may be regarded as concluded, the entire period lasting in uncomplicated cases from a fortnight to a month or six weeks. The complications, anomalies, and remote sequelae of scarla- tina are so numerous as to furnish a vast array of facts for the study of the pathologist. The reader need be merely reminded in these pages, that the usual incubative and prodromic Stages of the disease may be brief as to time, or so brusquely followed by eruptive phenomena as to be indistinguishable. The latter may also first occur upon the extremities or trunk, and later on the neck and over the clavicles; or at once cover the totality of the surface by a rapid explosion ; or be extremely short-lived ; or be altogether absent; or be unusually prolonged and visible for even a fortnight upon the surface of the body, appearing THE EXANTHEMATA. 393 and well-nigh disappearing: without appreciable causes. To a proportionate extent the stage of desquamation may be preco- ciously or tardily reached, and the exfoliating process be tediously prolonged and of intense type, jeopardizing in this manner the future of the convalescent prostrated by the fever which has passed, or the sympathetic fever which may thus be awakened. The anomalies of the scarlatinal rash are numerous, but de- pend, in general, less upon a variation in the intensity of the poison than upon the physical condition of the patient. Thus the affected surface may be slightly elevated above the general level; may exhibit irregularly disposed mottlings and macula- tions ; may be characterized by the occurrence of miliary papules, minute vesicles, or purpuric lesions well defined against the general scarlet color of the skin by their violaceous shade, and due to cutaneous extravasation of blood. The rare bullous, pustular, and urticarial lesions which may appear upon the skin, are accidental, and boar no relation to the specific history of the disease. Malignant anginose scarlatina is characterized by the gravity of the throat symptoms. In such cases, a parenchymatous in- flammation of the tonsils, velum, and fauces supervenes at an earl}- period, with enormous tumefaction, involvement of the submucous tissue and neighboring glands, and ulcerative, sup- purative and even gangrenous results, which may prove speedily fatal. Gastro-intestinal disorders may also prove dangerous. An otitis externa, media, or interna, may perforate the tym- panum, destroy the ossicles, induce caries of the mastoid process of the temporal bone, and prove fatal by the eventual produc- tion of meningitis or phlebitis. Another severe type of the disease is that in which symptoms of typhus are pronounced (scarlatiniform typhus). Here the patient may perish within a few hours after being attacked and before the eruption appears, exhibiting comatose or convulsive symptoms indicating the profound influence upon the nervous centres of the intensely intoxicated blood ; or the eruption may have time to appear, often livid, hemorrhagic, or petechial in type, and be followed by albuminuria, meningitis, diarrhoea, coma, and death Catarrhal and parenchymatous nephritis are justly dreaded during the desquamative period of the malady, when they may prove fatal after a relatively benignant mani- festation of the disease in its prodromal and eruptive stages. To this sufficiently grave list of disorders which may complicate scarlet fever, must be added pneumonia, pericarditis, pleuritis, peritonitis, chronic purulent nasal catarrh, which may result in caries of the nasal bones, destruction of the cornea as a result of severe keratitis, persistent adenopathy of the subcutaneous glands, and malnutrition in many forms, which may so impair the vigor of the constitution as to leave the sufferer a physical wreck for the remainder of life. 304 DISEASES OF THE SKIN. The cutaneous lesions of scarlatina, like those of rubeola, depend Upon byperaemia and a moderate decree of exudation. The latter, when it occurs, is limited for the most part to the rete and papillary layer of the coriura. The signs of the disorder are not apparent in the dead body, unless there has been exuda- tion <>f blood and the consequent formation of petechias. The disease is produced exclusively by contagion derived from the animal body affected with scarlatina, either mediately or immediately. It attacks individuals of both sexes and all ages, children and infants more frequently, the aged more rarely, probably in consequence of their respective conditions as re- gards immunity conferred by a previous attack, since in general the disease occurs but once in a lifetime. Individual idiosyn- crasy must account for the cases in which unprotected infants exposed to the disease fail to receive it, a fact noted occasionally in all the exanthemata. The contagious element is volatile in its nature, and seems to be most active during the eruptive stage of the disease. The diagnosis is between rubeola, rbtheln, erysipelas, and the erythemata ; and is, in general, readily established. The sore- throat, intense fever, the punetiform scarlet rash reaching to the border of the inferior maxilla, and the distinct, whitish-yellow line traceable by the finger-nail passed rapidly over the surface, are all characteristic. In rubeola, the macular character of the rash, and its crescentic arrangement, in connection with the catarrhal symptoms will usually be recognized. From ery- sipelas, scarlatina can always be distinguished by the absence of the peculiar, shining, smooth, or glazed and tumid condition of the affected area. From all other rashes, scarlet fever can be distinguished by the pyrexic symptoms and resulting desqua- mation. The modern treatment of uncomplicated scarlatina is purely expectant, after provision is made for an abundant supply of fresh air, disinfection, a proper regulation of food and drink, and the local use of baths, tepid or cool, for the purpose of re- ducing the bodily temperature. After each of these, the skin should be completely anointed with a fatty substance, such as cold cream, scented almond or olive oil ; or, what is most com- monly used in this country, vaseline. These inunctions are not only grateful to the patient, but, as I have again and again de- monstrated i.y the thermometer, reduce the temperature to a slight degree. All other treatment than that suggested above, should be limited to the special conditions presented in each case, and pertains to the field of general medicine. It includes the management of the disorders of the eye, ear, throat, kid- neys, and other viscera, whose involvement constitutes a compli- cation of the disease. The prognosis of the malady should always be established with reserve. It is largely based upon the relative intensity of the THE EXANTHEMATA. 395 symptoms, the vigor and age of the subject, and the presence or absence of serious complications. Albuminuria is rarely absent, and not per se alarming; but anasarca and other evidences of profound interference with the renal function, are to be assigned due weight. In general it may be said, that a high range of temperature ; early and ulcerative throat lesions ; tardy develop- ment, rapid and untimely disappearance or undue prolongation of the exanthem ; and its admixture with petechia to such an extent as to indicate extensive hemorrhagic extravasation, are all formidable symptoms. Finally, it must not be forgotten that the mildest and simplest forms of the disease, after the fastigium is passed and convalescence actually established, may terminate fatally by the supervention of urasmia, cerebral paraly- sis, or even meningitis, consequent upon secondary changes in the middle or internal ear. Variola (Smallpox). The variations of this malady as to the severity, character, and duration of its symptoms, are so great as to preclude its complete description within the limits here assigned to the subject. The following paragraphs are devoted to a brief sketch merely of its more commonly recognized characters. The period of incubation of the unmitigated disease varies between ten and twenty days, occupying usually a fortnight. It is characterized by the peculiarities of that period recognized in all the exanthemata, few and insignificant or no evidences of physical discomfort. The prodrotnic stage is ushered in gene- rally by a vespertine chill, succeeded by lever, with a tempera- ture rising to 104°-106° F., which is commonly associated with severe and characteristic pain in the loins, headache, nausea or vomiting, and occasionally, in young subjects, delirium and convulsions. The fever continues, with alternations of ex- acerbation and partial relief, or sensations of chilliness, on the second and third days. At the same time there may be faucial hypersemia and moderate dysphagia. Occasionally, before the cutaneous exanthem appears, minute reddish papules may be recognized upon the buccal membrane. On the second and third days there appears, in some cases, especially in menstruating women and in young subjects, a cu- taneous efflorescence, whose significance has been often misin- terpreted, and which has led to many errors in diagnosis. It is to Hebra that we are indebted for its distinct recognition as a cutaneous prodrome in variola. It has been termed variolous erythema, and variolous roseola. I regard its recognition as a matter of special importance to the diagnostician, having been myself, on the first occasion when it came under my observation, completely deceived as to its nature and significance. It is characterized by the occurrence of irregularly disposed, and dis- 396 DISEASES OF THE SKIN*. tinctly outlined, maculations, puncta, stria?, streaks, or a diffuse blush of bright or larid reddish hue; the invaded integument being at times Blightly tumid, and thus elevated above the general level. It may be also the seat of moderate pruritus. The blush may fade under pressure, but rarely does so perfectly. One cannot by the finger produce upon it a visible whitish spot. It. occurs most often about the groins, hypogastric region, pubes and inner faces of the thighs; and, examining these parts, the physician will usually discover the evidence, in adult women, of recent or present menstruation, or of the puerperal state. It occurs also about the axillae, the extensor faces of the larger and smaller joints, and the lumbar and clavicular regions. Often a broad area of the integument in these parts may exhibit a sheet or mask of dull crimson erythema, upon which pin-head to bean- sized dull-reddish papules may form, not losing their color under pressure, more rarely petechias, vesicles, and wheals. All these are precursory phenomena, and are not transformed into charac- teristic variolous lesions. They fade almost completely before the latter appear. Rarely, a few scattered papules may be dis- tinguished upon the face and arms before the variolous erythema fades. Often the former in full development are even less pro- fusely displayed in the site of the precedent efflorescence. The latter need not be necessarily regarded as a symptom of por- tentous gravity. I have seen the entire surface of the bell}* covered with a uniform erythematous blush of dull crimson hue, confluent variola follow, and the patient ultimately recover. The physician, then, in face of a deep-red erythema of the re- gions named, especially of the groins, lower part of the belly and thighs of a menstruating woman, affected with high fever, nausea, vomiting, and lumbar pain, should invariably suspect the presence of variola. The period of eruption is characterized, at its earliest, by punctiform, subcutaneous discolorations which photography alone can reveal. Commonly, after three days of prodromic symp- toms, the patient will be seen on the morning of the fourth with the face and scalp covered by pin-head sized and larger, firm conical papules, whose impression to the finger is compared by most English writers to the feeling of shot. Later, these de- velop upon the trunk and limbs; and in well-marked cases every portion of the surface of the body is invaded, including the palms and soles. The lesions may be surrounded by a narrow rosy areola upon the trunk. They may be unproductive of sub- jective sensations, or be slightly tender. As a rule, there is complete defervescence when the exanthera appears, the patient experiencing such relief that if an adult has chanced not to view the face in a mirror nor to be informed of his appearance by those in attendance upon him, he will often regard himself as completely relieved of his three days' illness. THE EXANTHEMATA. 397 In other cases, the febrile symptoms persist, with a lowered temperature. During the first two days of the eruptive period, the papules increase in number, and become correspondingly agglomerated; while those of earliest appearance become transformed into vesi cles containing a translucent serum, the roof- wall of many of them exhibiting an umbilication. This umbilication of the vesicle is characteristic, and slightly different from that observed in bullous and pustular lesions. The central depression is dispro- portionately large, and about it the yet undistended epidermis is often irregularly puckered or fluted. Even in this period, the lapse of a few hours will produce a lactescent appearance in their formerly translucent contents. From the eighth to the twelfth day, the transformation of these lesions into pustules is effected, the process beginning, as in all the metamorphoses, of the disease, in the vesicles of greatest ao'C ; those, namely, on the face and upper portions of the body. The lesions simultaneously enlarge till they are of the average size of a pea, and, being fully distended, rupture the centrally placed filament which held down the roof wall, in consequence of which the umbilication of the pustules is lost. With this process of suppuration, is awakened the so-called secondary fever, a pathological process evidently not essential to the disease, as it does not occur in mitigated cases. It is born of the extensive process of suppuration, occurring in the skin and other organs, and may be symptomatic, sympathetic, or septicemic in charac- ter. It thus varies in different cases with the character and severity of the processes by which it is excited, being transitory in mild cases, and in others terminating only with death. At this time the patient is usually in a most distressing condition. The skin of the face and other attacked regions is swollen, thickly covered with pustules, and the features indistinguish- able in the tumid and closed lids, the cedematous lips, disfigured nostrils, and pus obstructed mucous outlets. Deglutition be- comes painful and often impossible ; the saliva flows from the lips; and the mucus of the nares dries with the pus upon the exterior of the visage. The pustules recognized upon the in- tegument are represented also in the gastro-intestinal tract. In an autopsy of a patient dead at this stage of the disease, made by myself in company with Dr. McGill, of the United States Army, during the late civil war in this country, we discovered the entire canal from the mouth to the anus, as also the genito- urinary and respiratory passages, completely covered with closely agglomerated and well-distended pustules. The career of those within the mouth can be usually studied by observation with the eye. In this situation they rapidly lose their epithelial roof- wall by reason of the heat, moisture, and friction, to which the^v are subjected, and then exhibit a reddened and excoriated sur- 308 DISEASES OF THE SKIN. Face, over which then' is reformation of the epidermal layer. Gangrenous complications are rare. Between the thirteenth and fourteenth days, desiccation be- gins, and is usually completed within from ten days to a fort- night afterward ; the pustules rupture, and the exuded pus con- cretes into yellowish and brownish, rarely blackish ertists, or the latter are formed by th<> desiccation of the entire envelope and contents. The pulse usually at the same time diminishes in frequency; a secondary defervescence occurs; the tumefac- tion of the integument decreases; and at times the peculiarly characteristic and often intolerably fetid odor of the patient is less perceptibly exhaled. In from four to six weeks, the course of the disease is completed. The immediate traces of the erup- tion are purplish and violaceous pigmentations, which slowly disappear. When cicatrices result, they are slightly depressed, dead-white, lustrous, usually symmetrical in disposition, and most distinct upon the surfaces exposed to the light and air, as the face. Though persistent, they are rendered somewhat less deforming in the process of years. When closely set together, they produce a characteristic ridged and corded appearance, due to the elevation of narrow hands of unallccted integument be- tween the depressed surfaces of scars. The several departures from the pronounced type of the dis- ease, described above, present variations differing widely from the most benignant forms. Brief reference only can be made to these. Authorities differ respecting the nature of the disease known as varicella, or chicken-pox, and particularly with regard to the question of its relations to variola. My own convictions lead me to assent in part only to the doctrine held upon this point by Hebra and Kaposi, who recognize it as an exceedingly mild form of smallpox. Without attempting to present in these pages the arguments pro and con, which might here be urged, it will suffice to refer to the objection which will most readily be aroused by the proposition thus enunciated. That objection will naturally be based upon the mildness of the symptoms which characterize chicken-pox. The usual response is that every physician of large experience has seen cases of unquestioned varioloid much less severe than a typical case of varicella. The latter often leaves indelible cicatrices. I have seen varioloid in the course of which not more than one dozen papules appeared, all vanishing without the production of vesiculation. Hebra recognized three types of variola; first, that which lasted but a fortnight, or even less time, which lie termed varicella ; second, that concluded in three or four weeks, whether occurring after vaccination or not, which lie termed varioloid; third, that enduring for more than one month, true variola. In varicella, without and altera fever of moderate grade, which may last for from a few hours to three or four days, there is usually THE EXANTHEMATA. 399 complete defervescence and the coincident appearance of a few rosy macules or papules similar to those seen in variola. These rapidly become vesicular, and the vesicles are peculiar in being quite superficial, often phlyctenular in character, and either slightly or not umbilicated. In the latter case, they rarely pre- sent the well-marked puckered and "fluted" appearance of the variolous lesions. Their contents become lactescent rather than puriform ; usually desiccate on the third day in light-colored superficial crusts, presenting the " stuck-on" appearance described as characteristic of Fox's impetigo contagiosa; and usually fall on the sixth day. The general health is rarely seriously involved. The cicatrices in severe cases may he indelible. I have studied this disease in hospital, as it spread freely among vaccinated children when variola was raging side by side among the unpro- tected. No intelligent man to-day claims absolute protection from variola after vaccination. Valuable as that protection is, a recognition of the purely relative character of the immunity it confers cannot be safely disregarded. Varioloid, whether occurring after vaccination or not, is an- other modified form of the disease. With it should be classed all those forms of the disorder occurring in the human subject and described by authors under the titles, " swine-pox," " horn- pox," etc. In these cases, there may be severe prodromic fever and a scantily developed exanthem ; mild fever, abundant ex- anthem and rapid involution of lesions; abortion of the latter in any of their several stages from papule to crust; absence of secondary fever; transmission of the disease in a mild or miti- gated form, from one individual to another, so that an entire community, vaccinated and unvaccinated alike, may suffer from an epidemic disease of this moderate grade without the occur- rence among them of a single case of typical variola. This has been the experience of several small towns in the West, during the late variolous epidemic which visited this country. At the same time it is scarcely necessary to add that the patient with varioloid, especially during an epidemic, may transmit to the unprotected a malignant form of the disease. Much more formidable, viewed from every standpoint, is hemorrhagic variola, fortunately rare and too often confounded in the past with "black measles." When cutaneous hemor- rhages occur during the course of smallpox, they do not neces- sarily indicate that the case is one of this so-called varioliform purpura, since these may be accidents of the pathological pro- cess. In this malignant form of the disease, against whose ravages vaccination seems to present no barrier, the prodromic stage is followed by a deep purplish redness of the surface which is characterized by pin-head to split-pea sized, firm, closely set, papular lesions, suggesting the occurrence of measles in a pecu- liarly severe form. The febrile, nervous, and other symptoms of the disease are proportionately intense. Ecchymoses appear 4 00 DISEASES OF THE SKIN*. upon tlio conjunctival membrane. Gradually the color of the exautbem, which at first disappeared under pressure, refuses to thus yield, and assumes h bluish-black shade. Ecchymotic patches may be intermingled with these, rapidly spreading to palm sized and larger areas. The mucous surfaces share in these colors, being also infiltrated with effused blood, and the muco- cutaneous orifices are crust-covered and exhale an extreme fetor. Blood may escape from the bowels, bladder, mouth, and vagina. Signs of grave systemic and visceral complications are always present. Vesiculation, pustulation,and the typical transforma- tions of the variolous lesions are all wanting. In the few eases observed by me, death lias always speedily supervened, either from shock, coma, hemorrhagic infarction of the lungs, or rapid exhaustion. Intermediate forms between haemorrhagie and true variola are described, in which the pustules occurring in the latter form of the disease merely fill with blood in consequence of accidents possessing merely a local significance. The confluent is another severe form of variola, less malignant, however, than that just described. It is characterized by inten- sity of the prodromic fever which often scarcely abates with the appearance of the exanthem. The latter is developed in deeply implanted, firm papules, closely set together, succeeded by vesi- cles and pustules, which, as they enlarge, full)- occupy the entire surface of the integument, and accomplish a perfect coalescence. In well-marked cases there is scarcely a, pin-head sized area of the entire surface of the body which is not invaded. The tissues become enormously cedematous ; the deformity of the face renders the features indistinguishable. Hemorrhagic pustules and even patches of a gangrenous pulp may be intermingled with the sheets of suppurating surface. Phonation, respiration, and deg- lutition are proportionately impeded or absolutely subverted by the tumefaction and suppuration of the mucous membranes of the respiratory and gastro intestinal tracts. When the patient survives till the stage of desiccation is reached, the body presents an aspect as repulsive as that ever displayed by a living being. A thick, brownish, or blackish-brown mask envelops the swol- len head, trunk, and limbs, and the odor exhaled from the body is intolerably repulsive. All the systemic phenomena are pro- portionately grave, and accompanied by one or more of the complications of the malady, pneumonia, pleuro-pneumonia, albuminuria, diarrhoea, various motor and sensory paralyses, subcutaneous furuncles, and abscesses. The eyes may suffer from pustular and ulcerative changes in the conjunctiva, cornea, and deeper tissues, with resulting inflammation of every grade to panophthalmia, and resulting loss of vision. Often the patients, with surprising powers of resistance, will survive till extensive sheets of crusts have fallen from the surface, and then perish slowly in a typhoid condition with low remittent or continuous fever. Every such case does not, however, con- THE EXANTHEMATA. 401 elude fatally. I have seen children rally from the severest form of confluent variola, and enjoy afterward a vigor which illus- trates well the wonderful recuperative energy of the natural forces under the most adverse circumstances. Variola is always produced as the result of mediate or imme- diate contagion. It is a disease which is both contagious and Vertical section of pustule at the beginning of pustulation. a, umbilication at the site of an excretory canal ; b, reticulum within tho epidermis ; e, reticulum of smaller meshes containing lymph and pus globules. (After Rindtfeiseh.) F)£r. 40. --;?' ■if-STv-' Vertical section of one-half of an undeveloped pustule, n, old epidermis ; &, epithelia of rete above the alveoli ; c, new formed epidermis ; d, alveoli filled with pus globules ; g, flattened and infiltrated papilla lying beneath the pustule (After Auspitz and Basch.) infectious, being transmissible by volatile emanations from the victims of the disease. It is also artificially inoculable. When 26 402 DISEA8E8 OF THI SKIN. transmitted by the latter process, its period of incubation is Bomewhat shortened, and often ita successive manifestations become then less formidable. The history of inoculated human variola lias, however, received but little attention during the last decade, in which the practice has been properly forbidden by law. The disease is, to a certain extent, transmissible from man to the lower animal-, and the reverse. It attacks individ- uals of both sexes and ages, including the foetus in utero, which may be ushered at an untimely hour into the world, macerated or recently dead, and covered with the lesions of variola. The disease in the larger cities is decidedly more frequent in winter than in summer, possibly because in the colder months, the opportunities are greater for spreading the contagion in arti- ficially heated dwellings where numbers of individuals are crowded together. Islanders long unvisited by an epidemic, and unprotected by vaccination, may suffer equally in the sum- mer season. The pathological anatomy of the variolous exanthem has been most carefully studied by Ileitzmann in this country; and I append the results in his own language and in full, as an abridgment would fail to enable the reader to follow the dif- ferent steps in the process. 1 "First, the epithelial layer, termed rete mucosum. appears slightly thickened in cif en inscribed spots ; the swelling is due to a coarse granulation of the epi- thelia themselves. This mar.-'' granulation is produced by an increase of living matter within the protoplasmic bodies, evidently through an augmented afflux of nourishing material in the stage of hyperemia. The points of intersection of the network of living matter, formerly so called granules, become enlarged, many cf tin- nuclei shining and solid, and at the same time the threads traversing the cement substance, the formerly so-called "thorns," become thickened. The underlying papillae are slightly enlarged in all diameters, partly owing to a dila- tation and engorgemenl of their capillary bloodvessels, partly through a peculiar change in the bundles of the connective tissue and the protoplasmic bodies between them. The latter look slightly enlarged, and in many instances coarsely granular, the former are partly transformed into protoplasm. In other words, where before there were present bundles built up by a glue-giving basis substance, at present the reticulum of the living matter, formerly hidden in t he relatively solid basis substance, through a liquefaction or dissolution of this substance, became visible again. No other proof of the presence of an exudation in this stage is obtainable except the liquefaction of the gluey basis substance. This Btage of inflammation is termed "papular." Next, in the midst of the papule, on one or on several spots, the exudation make- its appearance; the outer or epidennal layer at no time participates in the morbid process. In some epithelia we notice an enlargement of the meshes of the living reticulum, the latter is first stretched, afterward lorn apart, the granules being now suspended in the liquid exudation. Where there were present epithelia before, a small, irregular cavity is visible. If several BUch cavities had formed in a papule through a continu- ously increased accumulate f the exudation and destruction of the epithelia, the separating layer.- of the epithelia become compressed and produce septa, traversing the cavities. Such septa greatly vary in number and width. The neighboring epithelia look very coarsely granular. Many of them have lost the inclosing cement substance, and are thus transformed into protoplasmic clusters, ' Proceed. Amer. Derm. Assn., 3d Ann. Meeting, Chic. Med. Journ. and Exam., Oct. is?;). THE EXANTHEMATA. 403 in which, through a considerable increase of the living- matter, new shining lumps of different size have appeared still in continuity with the neighboring reticulum by means of delicate threads, the so-called endogenous formation of new elements. The result of this process is the formation of an irregular cavity in the midst of the greatly widened rete mucosum, traversed by septa of compressed epithelia; filled with an exudation in which there are suspended numerous delicate gran- ules, generally termed coagulated albumen, and a varying amount of irregular threads in the shape of a felt-work, the coagulated fibrin. Scanty protoplasmic bodies are suspended in the exudation also, perhaps remnants of the destroyed epithelia, perhaps immigrated inflammatory or colorless blood-corpuscles." "In this condition of the rete mucosum also, the underlying connective tissue exhibits considerable changes. The papillae have disappeared, evidently through the pressure from above. The transformation of the connective tissue into proto- plasm has advanced, .in some instances to such a degree, that the uppermost layer of the derma are replaced by numerous indifferent, or medullary, or inflam- matory elements, as a rule clustered together. All these elements, however, are in interrupted connection with each other through delicate threads of living matter, fully analogous to those of the epithelia, and thus the inflamed tissue, though reduced to its medullary condition, still represents a tissue. The stage of the disease in which the changes just described have taken place, is known as the vesicular stage of smallpox." "Lastly, pus-corpuscles appear in the cavity within the rete mucosum; they doubtless arise in their main mass from the epithelia traversing and bounding the cavity. Through the increase of living matter in a large number of epithelia, shining lumps appear, first homogeneous looking, afterward through the inter- mediate stage of vacuolation transformed into nucleated protoplasmic bodies with a fully developed reticulum of living matter — the pus-corpuscles. The main sources of pus-corpuscles therefore, are the epithelia themselves, the endo- ■genous formation. How many of the pus-corpuscles have appeared through an immigration from below, from the inflamed connective tissue or from the blood- vessels, nobody can tell. The immigration is a sensible hypothesis only, without direct proof or foundation, while the endogenous formation can be directly traced in all its stages. The pus-corpuscles look coarsely granular, viz., are supplied with a large amount of living matter on the points of intersection of the living reticulum in persons of a good strong constitution ; on the contrary, they are finely granular, that is, scantily provided with living matter, in persons of a weak, so-called scrofulous or tuberculous constitution, or in persons debilitated by different acute or chronic diseases. In the former instance, the pus is thick and yellow ; in the latter instance, watery, serous, and pale. The subjacent con- nective tissue in many instances does not advance beyond its reduction into a medullary tissue. In some cases, however, the newly appeared and newly formed medullary elements, which produce the infiltration of the derma in a varying depth, are also torn asunder, and thus represent pus-corpuscles, which commingle with the pus sprung from the epithelia, and share in the formation of the abscess." "This stage of inflammation is known by the term pustular stage of small- pox, and represents the typical termination of the whole process. The pustule either bursts or its contents dry and produce the crust. So long as the inflamed derma remains in the condition of medullary tissue, so long, therefore, as the medullary or inflammatory elements remain connected with each other, the reformation of a glue-giving basis substance in the shape of bundles of fibrous connective tissue will be accomplished, without the formation of a scar. If, on the contrary, a part of the connective tissue has been transformed into pus, and thus completely destroyed, the result will be a cicatrix. Mere epithelial suppu- ration heals without, suppuration of the connective tissue always with, the forma- tion of a scar. The pigmentation of the skin, so common after smallpox, is due to the imbibition by the reticulum of living matter of the epithelia, of the color- ing matter of the red blood-corpuscles ; or by changes of directly extravasated red blood-corpuscles, both in the rete mucosum and derma. Such extravasations occur in all severe cases of smallpox, in the highest degree, of course, in htemor- rha«ic variola." 404 DISK ASKS OF Til K SKIN. The difficulty attending the diagnosis of variola in its pro- droraic and earliest eruptive stages, from rubeola, lias been already mentioned. I believe that the general demand upon the physician for an exact and definite diagnosis of every ease before its typical development, is founded upon an erroneous conception of possibilities; and that the sooner this is generally recognized, the better for all concerned. A delay of even a few hours will often verify or remove a suspicion, and I am confident thai I have seen fully as much mortification on the part of the physician and damage to the best interests of the patient, result from an error in the one direction as in the other. The widest course in every doubtful case is to admit the doubt and to fre- quently visit the patient for the purpose of observing the devel- opment of the disease till that doubt is removed. Typical cases of variola are recognized with ease from the character of the symptoms presented. Syphilis and acne are always distinguished by the absence of fever and their relative chronicity. Two cases of suddenly occurring medicamentous acneiform rash, have come under my observation during the past winter, where a diagnosis of variola had been previously made. In each, the absence of a prodromic stage and the subjective sensation excited, were suffi- cient to point to the nature of the disease when considered in connection with the peculiar character of the lesions. The treatment of variola should in general be limited to the indications presented in each case. No remedies can be employed which have the least power to abort the disease. Kaposi calls attention to the striking fact in this connection, that in syphilis, for many of whose manifestations mercury is a specific, we tind a disease whose second incubative period is measured by weeks, and yet neither by excision of its initial sclerosis nor by mercurials can the subsequent manifestations of the disease be completely prevented. Certainly no specifics are recognized as of value in variola. The patient should be kept in a relatively darkened room with an abundant supply of fresh air of a uni- form temperature; and antiseptic solutions should be constantly at hand into which all the ejecta of the patient are immediately received. He should be given ice when this is grateful to the palate, cool water ad libitum, and his strength should be sedu- lously supported by a liquid animal diet. The body may be sponged with or bathed in cool or tepid water, as often as is grateful to the patient. In severe or confluent cases, the constant immersion of the body in the continuous warm-bath as practised in Vienna, is followed by the most brilliant results in hastening the desiccation and fall of the crusts and the subsequent repair. A bath of this character given for merely two or three hours in the day, is often of great value. With and without these exter- nal measures, gargles of chlorate of potash, myrrh, honey, or carbolic acid, will be found acceptable to the mouth and palate. Indeed the constant attention of an efficient nurse bestowing THE EXANTHEMATA. 405 assiduous care upon the mouth, skin, and eyes, may be regarded as an essential part of all sound treatment. As regards the prevention of pitting it may be remarked, that no measures of a therapeutic character will prevent the occur- rence of a distinct cicatrix whenever pus has eroded or other- wise destroyed the integrity of the papillary layer of the corium. Every effort, therefore, should be exerted to prevent the exten- sion of the suppurative process to the true skin. The following are measures which have approved themselves to me as of practi- cal value: first, the sick room should be moderately darkened, and yet amply provided with fresh air ; second, a solution of the hyposulphite of sodium (Squibb's is superior to the ordinary preparations in the market) should be administered night and day in the dose of from fifteen to twenty grains (1.-1.3) every three or four hours. I have certainly seen the variolous lesions pursue a milder course under this internal treatment, and even, in cases, the vesicles shrivel before pustulation was fairly begun. Third, the skin of the face should be anointed with a bland fatty substance such as vaseline, almond oil, or fresh lard, and over this may be laid silk-enveloped compresses, dipped in tepid and weak solutions of carbolic or boracic acid, or thymol. I prefer the anointing of the surface before the application of the lotion, but when more grateful to the patient, the skin may be constantly moistened with the aqueous lotion alone. Here, again, the as- siduous attention of the nurse is a matter of importance. I have never employed the powder of iodoform topically in these cases, but believe that it might be often so used with advantage. The edges of the eyelids should be daily anointed with freshly prepared cold cream. Puncture of the cornea may be required for the relief of hypopion. Diarrhoea and other symptoms of visceral derangement should be relieved by appropriate medica- tion. As a rule, the administration of narcotics for the relief of pain is objectionable. Throughout all, the strength of the suf- ferer should be supported by a generous use of animal broths or milk; and in .typhoid conditions a judicious employment of stimulants may be necessary. The prognosis of variola is largelj 7 dependent upon the degree of protection conferred by previous vaccination. This aside, the age and vigor of the patient, the presence or absence of an epi- demic of severe or mild type, the extent of the eruption, and the character of the surroundings of the patient, are elements of prime importance. Very young and aged subjects, women preg- nant or in the puerperal state, and, as Hebra has shown, those who have suffered from a previous attack of the same disorder, are all unfavorably related to the final result. Confluent and hemorrhagic forms of the disease are, naturally, the gravest. Unmitigated variola is, under the most favorable circumstances,- one of the great scourges of humanity ; and as such will probably always destroy a frightful proportion of its victims. At the 406 DISEASES OF THE SKIX. Bame time, tlie conscientious physician needs to be impressed -with the tact, that often under the most discouraging circum- stances, the patient, disfigured to the greatest extent by an en- velope of blackened crust, and in a state of extreme physical prostration, with many of his bodily functions almost completely suspended, may often, even in the midst of apparently desperate peril, be won back to life and vigor. The assiduous attentions of a gentle nurse, guided by the inspiring presence and counsels of a physician who is himself fearless of the malady, will often achieve this result. Upon the latter point, it is interesting to note, that physicians in active practice who do not hesitate t<> ex- pose themselves freely to the disease in the discharge of the du- ties of their profession, rarely sutler in their own persons. In the course of four epidemics, during which I have had the oppor- tunity of observing the relations between many physicians and their patients, 1 have never known one of the former to he stricken down in the actual performance of his sacred office among the victims of the pest. Vaccinia in Man. The limits of these pages forbid a discussion of the interesting questions which concern the relations of cow-pox as it occurs spontaneously in the milch-cow, to human variola. A careful collation of the results ohtained by the large number of vaccini- culturists of later days, renders it clear that it is a matter of great difficulty to transmit variola from man to the heifer; that where this rare result is obtained, the lymph derived from the lesions on the udder or belly of the latter is liable to produce variola when retransmitted to man; and that spontaneous cow-pox alone seems to furnish a lymph which is safely inoculable in generations to the human race. Of greater importance is it to note here, that either by arm to arm vaccination, as was formerly extensively practised, or by the use of the animal virus, which lias of late been well-nigh exclu- sively employed in this country, there has been conferred upon millions of human beings a degree of protection against variola whose value is beyond estimate. In both methods, the lymph is derived originally from the female of the bovine race, prefer- ably in the puerperal state; and its sources are the vesicular le- sions of vaccinia spontaneously arising or artificially cultivated about the teats, udder, and adjacent, parts. The introduction of this lymph into the skin of the human subject, is termed vacci- nation. The simple operation of vaccination is performed in many ways, but that which especially commends itself to the prudent man is the method which eliminates to the largest extent the possibility of transmitting any other contagious disease than the one intended. With this object in view, no better instrument THE EXANTHEMATA. 407 can be devised than a clean needle, one which has not been pre- viously employed tor any purpose. The skin of the part selected for vaccination being subjected to slight tension by the left hand, the vaccinator should scratch or scrape off the epidermis with the needle, held in the right, by a series of parallel and crossed strokes, so as to make three or four superficial erosions, at a dis- tance of three or more inches apart. Each of these multiplex wounds should have the size of the little-finger nail, and. should in no case bleed, but merely ooze with serum slightly tinged with blood. At such points the lymph is to be thoroughly and slowly rubbed in, whether it be suppplied in a dry form upon ivory points which have been dipped in the serum oozing from vaccine lesions upon the heifer, or be a fluid obtained by crush- ing and dissolving in water the crust taken from the similar lesions on the arm of a child previously unprotected and recently vaccinated. In Public Charities, where, for the most part, such procedures are practicable, I have found it sufficient to dip a needle into the lymph flowing from the arm of the vaccinifer and to plunge it, thus charged, once or twice into the part se- lected for the operation. Between the third and fourth days after a successful vaccina- tion of the unprotected, a light reddish, pin-head sized papule rises at each inoculated point. Between the fifth and sixth days, it becomes transformed into a translucent, well-distended, occasionally umbilicated vesicle. This, when single, may attain the size of the finger-nail. Springing from the multiplex abra- sions described above, a minute papule usually forms at each point of intersection of the crossed lines produced by the scratch- ing with the needle, and the subsequent vesicles coalesce, form- ing thus a compound lesion of rather peculiar aspect. It appears often as a small coin-sized plaque, elevated to the extent of a line or more beyond the general level, with a rim formed of nu- merous discrete or confluent vesicles, which in either case are closely set together. The compound plaque seems to develop afterward as a single lesion, its centre being depressed. After ■the ninth day, the fluid becomes opalescent, and desiccates in a reddish-brown crust, which, examined in section by a good light after it is completely dried, exhibits a smooth, homogeneous, shining appearance, with a color having the shade of amber. Fully as important as any of these metamorphoses of this lesion, is its rosy-reddish areola, in the absence of which some authorities declare that there is not proper protection. It com- pletely encircles the compound vesicle in the form of a halo having a diameter of several inches, the tissue it invades being often slightly tumid. When the pathological process in the focus of this areola is intensified, either as the result of the irri- tant character of the virus, or from extrinsic causes (undue ex- ertion, of the vaccinated part), the areola may spread extensively down the arm, or over the thigh or leg, and eventually cover a 40S DISEASES OF THE SKIN'. dense, brawny, and deeply reddened integument. Dermatitis, erysipelas, and severe grades of inflammation of the subcutaneous tissues, may for similar reasons complicate the process, which may terminate by central sloughinsr, ulceration, slow repair, and the production of an atypical cicat rix. Ordinarily, the subjective phenomena arc limited to a mild or annoying itching of the vaccinated surface; in other cases, severe burning pain, a feeling of tension, and even sympathetic fever may be aroused. The acme of a successful vaccination is usually attained be- tween the tenth and the fourteenth days, after which the symp- toms of the disorder gradually subside, the crust falling, if un- disturbed, in the course of the ensuing week. When "animal*' virus is employed, the duration of each of these stages of the disease is usually somewhat prolonged. The cicatrix, at first slightly reddened or pigmented, gradually assumes the dead white appearance of scars in general. When typical, it is slightly depressed, circular, not irregular, nor de- formed by ridges, cords, or bands, and "foveolated," exhibiting a seriesof peripheral pits or depressions, each of which represents the site of a former minute vesicle of simple type. I am strongly disposed to believe that the degree of protection is based in part upon the multiplicity of typical cicatrices, and, having never chanced to ^ee a variolous patient with four such traces of suc- cessful vaccination upon the person, am largely prejudiced in favor of the English method of producing multiple scars. The complications of vaccination are due, first, to the character of the virus employed; second, to the character of the soil in which it is implanted; and third, to the external accidents to which the vaccine lesion is subjected. Respecting the first of these sources, I know of no contagious disease which may be transmitted by vaccination, save syphilis. When this accident occurs, it may be due either to the fact of syphilis in the vacci- nifer, or to the use of instruments soiled with infectious secre- tions. It is both asserted and denied, that the lymph from a typical vaccine vesicle in a syphilitic vaccinifer, will necessarily transmit syphilis, if it be accidentally commingled with either blood or the products of inflammation at the base of the pock. The demonstration of any such fact requires a mass of evidence exceedingly difficult to collect, inasmuch as the stage and intensity of the disease in the vaccinifer, are elements which cannot, be ignored in a decision of the question. When thus transmitted, it will be remembered that the vaccine lesion may complete its career during the incubative period of the initial sclerosis, whose existence at the site of vaccination is commonly declared later by induration, ulceration, pigmentation, and axillary adenopathy. The occurrence of a generalized syphiloderm before the chancre of vaccination is completely healed, is often the first symptom to arouse suspicion. Those further interested in the subject should study the cases collected and admirably illustrated by THE EXANTHEMATA. 409 Mr. Jonathan Hutchinson, 1 of London. It should be added, that the popular impression regarding the frequency of this accident is greatly erroneous. During my entire experience in this city, I have treated no less than nine physicians for extra-genital chancre of the fingers and eyelids, acquired during the dis- charge of their professional duties, while I have met with but a single unquestioned case of syphilis transmitted by vaccination. This occurred in a negro infant, who had a typical initial scle- rosis of the arm following vaccination, with axillary adenopathy, and a subsequent characteristic generalized exanthem. In all such cases, the possibility that the syphilis might be hereditary, and its symptoms simply coincident in point of time with those of vaccinia, should not be forgotten. Exceedingly dangerous is that virus, however good its early character, in which decomposition or putrefactive changes have occurred after exposure, in a liquid form, to the action of heat and the atmosphere. Vaccination with lymph thus changed has been rapidly followed by fatal results after the production of septicaemia or pyasmia. Complications of vaccinia, due to the character or predisposi- tion of the tissues in which the virus is introduced by the vac- cinator, are usually ascribed by the ignorant or prejudiced to the causes just considered. Post hoc ergo propter hoc, is the sole logic of the uninformed. In this way almost all other ills of the human family have been in turn ascribed to " impurities" and "humors" introduced by vaccination. The language and arguments used in support of these positions have been as ex- travagant as they were unreasonable, and have borne fruit in the refusal of many physicians of repute to perform vaccination, and thereafter to assume the responsibility of all the subsequent ail- ments of the vaccinated. The cutaneous symptoms which may thus be awakened, are numerous. It will be remembered that the contents of the typical vaccine vesicle are auto-inoculable, and that thus the scratching of young patients may produce an abundant crop of typical or torn vesicles Upon the arms, legs, thighs, hands, and fingers. In this connection, the reader is referred to the chapter on impetigo contagiosa, whose pathology is thus for the most part explained. But vaccination may also awaken in the patient, as explained above, a latent syphilis, as also a list of cutaneous disorders not contagious in character. Thus an erythema (roseola vaccinia, vaccinola, etc.), eczema in many of its forms, and other exudative processes may be first aroused in the integument by the turbulence of a successful vac- cination. I have seen several instances of typical psoriasis which first appeared in the young after the same harmless operation. Viewing the immense number of vaccinations annually per- formed throughout the world, the wonder is, not that such coin- 1 Illustrations of Clinical Surgery, Phila., 1875. 410 DISEASES OF THE SKIN*. cidences occasionally occur, but that they arc not more frequently observed and recorded. 1 Lastly, the com plications of vaccinia due to external accidents of the lesi