rrr.%o j V'-^'V* "V^'V V^'V % .* * * % v v y » * • •- 'ck **- w : imM° ^ ; JBir ^ :,J ' o » o ' 1 - C.J ? *+ -SIP/ A v *^ V c°. ^0^ *bV" ^\ & ;* .v ,♦* '•"V /^W, >°-v x-s ***** -Mak' ^ * -4 o •V" * ! ^* . vv DISEASES OF THE SKIN DISEASES OF THE SKIN WITH SPECIAL REFERENCE TO PRINCIPLES OF TREATMENT TOR THE USE ADVANCED STUDENTS AND GENERAL PRACTITIONERS BY HENRY M. DEARBORN, M.D. I'rofmsor Late SECOND EDITION REVISED, ENLARGED AND EDITED BY FREDERICK M. DEARBORN, A.B., M.D. [Jem ..».ira Pran pita WITH ONE HUNDRED AND THIRTY-FIVE ILLUSTRATIONS INCLUDING NINETY-EIGHT FUl.l PAGE ENGRAVINGS BOI Kl< Kl A RUNYON \l W YORK 19 ^LIBRARY ot CONFESS? IwoCoB'e* riectiv-a. ' WAY 8 1908 <>LA»S» M* Nu - j ooky a. IXc Nu. j »=-■ J Copyrighted, 1906 By BOERICKE & RUNYON Received from Copyright Office. !7Je'08 The Outing Press deposit, n. v. Cfjis *5>rronb Coition is brbiratrb t»» tfir <£ tutor tEo tl)f mrinorp of fjrr tofjo toitl) loumg interest toatcljrb ttjr progress of this fcuorb PREFACE TO THE SECOND EDITION While every attempt has been made to bring this edition up to date in all departments, none of the original feature- have been shelved, and conciseness and brevity arc as before, coupled with a self-evident system of simplicity. No better explanation of tin- objects in view in the prepa- ration of this treatise can 1m- offered than the following paragraph from the preface to the first edition: "The besl method of studying disease is that which yields the mosl practical information a- to the causes, nature, course and symptom- of a given malady and the therapeutic measures required for it- -afe and speedy relief or cure. The aim in the following pages ha- been to furnish the entials of skin diseases in such form as to be clear and accessible to the -indent and general practitioner- especially a- indicating principles or mean- of treatment. Hence etiology, symptomatology and diagnosis are given more prominence than pathology, not because the latter is lacking in interest, bul rather that it i- of leasl importance in a work not designed for the use of specialist In the preparation of this edition, every page ha- been revised ami many portion- rewritten, particularly those sections dealing with pathol- and treatment. Tin eneral classification is retained, although a number of di- igned to different groups because further in\ tigation ha- established their real nature or because original research has demonstrated something specific in their character. Possibly one of the most important addition- to this edition will he found under the general remark- on treatment iii Pari I. and ileal- with phototherapy, radiotherapy and other physical agents. A further discussion of these subjects will be found in the sections devoted to the treatment of those diseases which call for these method-. Part III i- added to embrace a brief consideration of internal therapeutics, a- shown by a discussion of the action of drugs. The remedies are arranged alphabetically, and being all grouped together make the matter of reference much simpler and obviate the necessity of frequent repetition. Again quoting the preface to the original edition: "It is hoped that a brief statement of the general sphere of action of drugs may .-how the adaptability of some remedy to one of the varied assem- blages of the phenomena of disease presenting from time to time: most of the indications given have been verified, many of them by the author. 8 mc of the illustrations of cutaneous diseases serve the double purpose \ iii PREFACE TO THE SECOND EDITION of depicting objective lesions and the principles of treatment related to their cure. An ideal in therapeutics has been striven for, though far from attained, yet sufficiently demonstrated in practice to justify the belief in its practical utility in the art of dermatology." Seventy new illustrations are presented in this edition, the majority being from photographs taken by the editor, and the following new sub- jects are introduced: Radiotherapy, Phototherapy, High Tension and Frequency Currents, Becquerel Rays, Vibration and Mechanical Vibratory Massage, Monilethrix, Lepothrix, Tinea Nodosa, Rontgen-ray Dermatitis, Dermatitis Gangrenosa, Varicose Ulcer, Atrophia Cutis, Atrophia Senilis, Kraurosis Vulva?, Echinococcus, Demodex Folliculorum, Dhobie Itch, Blastomycosis, Myringomycosis, Colchicum, Cuprum Arsenicosum, and Fagopyrum, while many other sections have been completely rewritten. The editor desires to acknowledge the courtesy of those colleagues who have assisted in any way in the revision of this work, especially the resident physicians of the metropolitan hospitals which the editor attends. Frequent reference has been made to the standard works on diseases of the skin, both of foreign and American authorship, also to the current medical journals, especially to the Journal oj Cutaneous and Venereal Dist-ases. It is hoped that the form and appearance of this volume, the mechan- ical changes, and such additions as a lapse of three years demands, will meet the approval of the profession. FREDERICK M. DEARBORN. New York City, 146 West 57th Street. CONTENTS TART I GENERAL PRINCIPLES ANATOM* '■'• avu ... 4 Erancsiua ............. 5 6 Si douf ' II mi:- s 11 Blo 1- Li M-ii LTioa 12 Ni I 13 Mi 14 COLOB . 15 rin 8101 1 16 16 Ih 17 1" I s M MI'KiM kTOLOOl 18 Mai J'» I'M -'I Will M- _'J \ i 88 23 _'i l\ cm - i - 25 1~> ■2:> I . • ...... 26 i i, 26 i \ --ii in. I.i -i<'\- 26 X CONTENTS GENERAL FEATURES OF LESIONS PAGE Patches 26 Size and Shape of Lesions •. 27 Eruption 27 ETIOLOGY Predisposing Causes 28 Direct Causes 32 DIAGNOSIS Patient's History 35 Symptoms of Disease 35 Lesions 35 Effects 37 Causes 37 TREATMENT Causal 3S Physiological 39 Pathogenetic 39 Mechanical 40 Operative 42 Instruments 42 Electricity 44 Radiotherapy • 44 Phototherapy 40 Becquerel Rays 48 High Tension and Frequency Currents 49 Vibration and Mechanical Vibratory Massage ; 51 CLASSIFICATION Class I. Diseases of the Cutaneous Appendages 54 A. Sweat Glands 54 B. Oil Glands 54 C. Hair : .14 D. Nails •">."> Class II. Idiopathic Affections 55 Class III. Diathetic Affections 55 Class IV. Neuropathic Affections 56 Class V. Parasitic Affections 57 A. Animal Organisms 57 B. Vegetable Organisms 57 Class VI. New Growths 58 A. Benign Connective Tissue Growths 58 B. Benign Epithelial Growths 58 C. Malignant Epithelial Growths 50 D. Malignant Connective Tissue Growths 59 CONTENTS xi PART II SPECIAL DISEASES CLASS I. -DIS] OF THE CUTANEOUS APPENDAGES A.— DISl ! I UK n\\ EAT GLANDS i-i.. i \mi>H"-i~ 80 Hyfbbidbosu til Bbomidbosu 82 I i: <;:i i Ihbokidwmu 64 Hi mm ii>ici-is (i:> Pbmphoh -< i m Sweai Bnw ! BTOM \ 68 Mm iu; i una t;t; Mii.iaui k Rl BBA liT llvi>li U>l il-i BATH v i: Hi- 1 HE "II. GLANDS Ibteatosih 70 -i BOBBBa \ 7 • » '.'•iciciih n Di ii\i \ 1 1 1 1 - 7:> IIDO 80 Mi i.i i \i \< M \ i I -. \Kl- 84 \i M \ tBIOl DOBMU 91 i»i-i USES OF i hi: h \ii; llvriitiun BOB] 92 Tick hi \~i- 95 Dim H HIASU 95 1'it \.. ii [TAB i i:i mi \i . . . 95 I HOttBBXIB MOOOH \ '■"'> m«pmi etrbix 97 i.iimiiiuix . 98 Tim \ NfODOfl \ 98 I'ui'itv .... 98 I \MMI- 99 Plica . i<»<> An. ii i i \ LO] \i "ii I I \ \i:i v i \ l""i Poi 1 1« i litis Decalvahs . 1 n» Di i;m \ I II Is Pun I LBIB i M-ll.l HIT 112 iikmi StTPUBATin Pebdoixm 113 xii CONTENTS D.— DISEASES OF THE NAILS PAG E Onychauxis 114 Pterygium .- - 115 Onychomycosis 115 Atrophia Unguis 116 Spoon Nails 117 White " 117 Reedy " 117 Onychia 118 CLASS II.— IDIOPATHIC' AFFECTIONS Lentigo : 119 Chloasma 120 Erythema Simplex 124 Erythema Neonatorum 124 Erythema Intertrigo '. 124 Erythema Traumaticum 126 Erythema Caloricum 120 Erythema Scarlatiniforme 127 Erythema Exudativum 130 Erythema Multiforme 130 Erythema Iris 132 Erythema Nodosum ' 133 Dermatitis 136 Dermatitis Calorica 137 Dermatitis Traumatica 141 Ron'jgen Ray Dermatitis 141 Dermatitis Medicamentosa ' 142 Drug Eruptions 142 Vaccination Eruptions • 150 Dermatitis Venenata 152 Feigned Eruptions 153 Trade Eruptions 1 54 CLASS III.— DIATHETIC AFFECTIOXS Eczema 156 Psoriasis 177 Dermatitis Exfoliativa 1S7 Dermatitis Exfoliativa Epidemica 191 Dermatitis Exfoliativa Neonatorum 192 Dermatitis Gangrenosa 194 Multiple Gangrene 194 Hysterical Gangrene 194 Diabetic Gangrene 104 Dermatitis Gangrenosa Infantum 195 Varicose Ulcer 190 Pityriasis Rosea 198 Lichen 200 Lichen Ruber 201 CONTENTS xiii PAG! LlCIIK.V Pl.ANl'S 205 Pakakkka tonis VaRXEOATA 208 KERATOSIS Pilaris 209 Ki.I'.ai :us 210 Keratosis Pauubu bi Pla.ntakis 211 icbthtosis 21:5 si i.kk1 ma nconatordm 217 (Edema Neon itori m . 218 • LASS [V.— NEUBOPATHIC AFFECTIONS BT Dim i RBAXI BS . 220 Hyperesthesia 220 AJMMtheaia 221 I'm 221 matalgia 221 Pki BXTtJS 222 l*Ul RUM 22li Urticaria 229 - \ *A 233 Pi IF) U 239 III RPBS 242 - I \i LAXJfl 211 Hi mi 245 roams 260 I Mil I I .ii III R|>| l II ORMIfl 264 D 265 i km \i ii i- Pn 256 Pi i i LORA 2.">7 ■i \i \ IIVI.U >\ Pomphoi \ \ 200 Pi mii 2H1 s« 1 1 booi i:m \ 268 Dn i i -i ii Btmhetu i \ 268 I lid I USCBIOl D I 271 2 7:i ism 274 Vim mo 27 1 276 277 Atrophia Maculosa n Striata 277 Kit A I HUMS Vl |A I 278 27s or the Fooi 279 Trophic Ulcers . 280 SVMMIIItKM 1 ,li;iMIMI> 280 A I Ml I M 28] Sybini 282 XIV CONTENTS CLASS V.— PARASITIC AFFECTIONS A.— ANIMAL PARASITIC DISEASES PAGE Scabies 283 Pediculosis Capitis 288 Pediculosis Corporis 290 Pediculosis Pubis 292 Pulex Irritans 293 Pulex Penetrans 293 Cimex Lectularius 294 Culix Pipiens 294 Apes Mellifer.e 294 Simulia 294 Yespid^e 204 Leptus Autumnalis 294 Ixodes Ricinus 294 Dermanyssus Avium 295 fllaria medinensis 295 Cysticerus Cellulose Cutis 296 Echinococcus 296 Demodex Folliculorum 297 B.— VEGETABLE PARASITIC DISEASES Favus 297 Tinea Trichophytina 302 Tinea Circinata 303 Tinea Tonsurans 303 Tinea Barbae 305 Tinea Versicolor 315 Tinea Imbricata '. 318 Erythrasma 320 Dhobie Itch 321 Blastomycosis 322 Myringomycosis 323 Pinto Disease 323 Actinomycosis of the Skin 325 Mycetoma 32S Impetigo 330 Impetigo Contagiosa 332 Ecthyma 334 Sycosis 336 Furunculus 341 Carbunculus 344 Anthrax 347 Dissection Wounds 350 RlIINOSCLEROMA 351 Oriental Boil 352 Phaged.ena Tropica 353 Elephantiasis 3.54 Tuberculosis Cutis 358 Tuberculosis Cutis Orificialis 359 CONTENTS xv PAGE TCBEBCULOSIS VSBBUOOSA .ilil Li Ft B \'l LOABU3 363 Scbofi LODEBMA 369 I.K MhN >( BOl i 382 Ebytiikma Imh KATL.M 383 Syphilis -42!! *> A.W8 .... 4411 Kyi ima 442 B*T«P1 LAS 444 PELOID 447 CLASS \ [.—NEW GROWTHS A.— BENIGN CONNECTIVE TISSUE GROWTHB I tnOM v 44!» J\i I'.iu 451 ( l< ATMX 152 JLuri boh v 453 XAHTuOMA iMI-lil ll« 5;5<) 1 Iabso Vegetabxus ... 539 001 [0 At lii .")40 ' Al Ml. 1 M ........... .">41 1 IIi.UDo.Ml h .... 542 ( MINIM M Si I.IMIl UH I M .-,4.°. Cm.oKAi.1 m ;,44 \ :,4."> :>4.") LATIS . ."itli :>4i; i '•> ■ .".47 i iih i m 548 I • i • Hi' ink . ;,ts 10 LABIA 549 I'M :>4!i M . \ . ... ."i.'ill ' IIIUWU ."l.'ll - IllUCIillil I ."l.'ll i i'. i mm ....... "i">:> 563 < i FBI v. "i">4 t I HAH! ."..")4 I 111 UIIN 555 Dn.i i LLM 555 Di I < AMABA 558 ion \i U)t a iii i si . 557 Bl PHOBHl m ... 557 I LOOFYBI m 557 li i OUd M At ini If ........ .... ... 558 < ;i(\i-iii ii - 550 in 1 1 1 noil - Nun k ... . 561 IIh-mi Si i.i'in it . . 561 IIyiu; 1Mb 564 llvmiu. on i i A-i vi u a 565 HViiSi V AMI - 566 llvi'i iiu i H ... 567 [an lob . :,(;s .1 ami in win 569 ■li 0LAK8 I IM in A 569 JUQLAHB lU'.l \ . 570 K.vi [DM 8AI.T8 ... 570 Kai.i BICHBOHK i M . 571 xviii CONTENTS PAGE Kali Bromatum 572 Kali Caebonicum 573 Kali Iodatum , 574 Kali Mleiaticum 575 Kali Phosphoricum 570 Kali Sllphuricum 577 Kalmia 578 Keeosotum 579 Laciiesis 580 Ledum 581 Lycopodium 582 Manganum 584 Meecueius • 585 Mebcleils Biniodidus 587 Mebcueius Cobrosivus 588 Mezeeeum 588 Mleiaticum Acidum 590 Nateum Salts 591 Natrlm Arsenicatum 592 Natrlm Muriaticum 592 Natrl m Piiosphoricum 595 Natrlm Sulphuricum 596 Nitrlm Acidum 590 Nux Moschata 598 Nux Vomica 599 Oleander 599 Opilm 600 Osmium 001 Paris Quadrifolia 001 Petroleum 601 Phosphorus 603 Phosphoricum Acidum 605 Phytolacca 606 Picricum Acidum 607 Populus Candicans 608 psorinlm 608 Pulsatilla 609 Ranunculus Bulbosus Olo Rhododendron 011 Rhus Toxicodendron 011 Rlmex C'rispus 013 Sabina 014 Salicylic Acid 615 Saesapaeilla 615 Secale 010 Selenium 617 Sepia 617 Silicea _. 019 Spigelia 022 Staph ysagria 022 Stillingia 024 Sulphur ci-24 Sulphueicum Acidum 627 CONTEXTS xix PAGK Tabexti i.a Clbexsis 02S Telia bum 628 Thlil KIMHIXA l!2!l Thuja 629 Ubtica Ubexs 631 Vespa 632 VlXCA MlXOB C33 \ ioi a Tbicolob C33 \ II-l.KA (134 II 634 LIST OF ILLUSTRATIONS FIO. 1 Section <>i mi. hi man skin page 2 2 Buaoi ta.neoi B i ai H88DI page 3 - QLAJfDfl 01 tiil BBOOHD class page 7 4 BV i BOB "i Bfl N \ I iiaib and ns koi.lici.e page 9 5 Ei'iLATi.NG i "H< Wn page 42 6 Elk( tkoi.yth Kirm page 42 7 liniwi'miM ii Minu page 43 9 1'iiiabd's OBAl-riiM. KM page 43 9 PlVTABD'fl ■ 'iB page 43 10 Milium page 43 1 1 Scabikvi.no sim u page 43 12 NEEDLE h>b bkmowng iiaib R ki.i ci bi>i.y-i> page 43 IS N i u page 43 14 Pin abii'.-, dkbmai. o bi in page 43 15 Hi iitviMiiiK page 43 16 Aim i. vmii \m> OOMEDON1 i x i u v< i< >it paye 43 17 Ei.m title iaiumi page 44 1« Fbii hi vsi'i.ii inxpi) page 45 19 CBOOI page 46 ( boom page M _• 1 (bimiki's ii in page 4«; _'_' s aim'abatls page 47 II QLAM \ aci i m ELaonooM page 49 !i:ai. -ii mi i. olam rAOOtm Btaunon page 50 ii ui.ab A' bay ii be* page 51 lii'iiiic KOTO! page 51 ■J7 M.niiBiiini:ir i>ibm\iiii-. facing page 72 "Uuiki.m in km m in- facing page 73 BnOMHOW I'MtMMlii- .... facing page 70 BnOSUKHI imummiii- . facing page 77 31 Acne WUUMU facing page 84 : 47 Eczema facing page 159 48 Eczema facing page 162 49 Eczema facing page 163 50 Eczema ' facing page 166 51 Eczema facing page 167 52 Psoriasis facing page 178 53 Psobiasis facing page 179 54 Psoriasis facing page 180 55 Psoriasis facing page 181 56 Psoriasis facing page 184 57 Psoriasis facing page 185 58 Hysterical gangrene facing page 194 59 Lichen ruber facing page 202 60 Keratosis of the sole facing page 210 61 Keratosis of the palm facing page 211 I 62 Ichthyosis simplex facing page 214 63 Ichthyosis hystrix facing page 215 ^~~~ 64 Prurigo facing page 226 65 Purpura simplex facing page 234 66 Purpura simplex facing page 235 67 Herpes zoster facing page 246 68 Herpes zoster facing page 246 69 Herpes zoster facing page 247 70 Dermatitis herpetiformis facing page 250 71 Dermatitis repens facing page 255 72 Pomphoxyx facing page 260 73 Pompholyx facing page 261 74 Pemphigus facing page 261 75 Leucoderma facing page 274 76 Leucoderma ' facing page 275 77 Acarus scabiei (female) page 285 78 Acarus scabiei (male) page 285 79 Pediculus capitis page 289 80 Pediculus corporis page 289 81 Pediculus pubis page 289 82 Favus facing page 298 83 Favus facing page 299 84 Favus fungus page 299 85 Tinea circinata facing page 302 86 Tinea tonsurans facing page 303 87 Tinea tonsurans facing page 304 88 Trichophyton fungus page 306 89 Tinea versicolor facing page 315 90 Fungus of tinea versicolor page 316 91 Fungus of erythrasma page 320 92 Actinomyces page 326 93 Actinomycosis of the skin facing page 326 94 Actinomycosis of the skin facing page 327 95 Impetigo contagiosa facing page 332 96 Impetigo contagiosa facing page 333 97 Ecthyma facing page 334 98 Ecthyma facing page 335 99 Sycosis facing page 336 100 Sycosis facing page 336 LIST OF ILLUSTRATIONS xxm FIG. 101 Elephantiasis facing page 354 102 Tuberculosis okukiaus et verrucosa facing page 360 103 Lupus vulgaris facing page :>oi 104 Lupus vulgaris facing page 304 105 LUPUS vulgaris facing pagt 365 106 Lupus vulgaris facing page 308 107 Lupus vulgaris facing page 369 108 Scrofuloderma facing page 370 109 Scbohloi . s i.aciyi.uis facing page 371 110 Secondary BTFHUUDIi facing page 394 111 Secondary sypiulide facing page 395 112 Moist papular sypiulide facing page 398 113 Purpuric sypiulide facing page 414 114 Tertiary syphilide facing page 415 115 Leprosy facing page 430 110 LCFBOn facing page 431 117 Leprosy facing page 434 118 Leprosy .... facing page 435 119 Leprosy . facing page 438 120 Leprosy faring page 439 121 Fiiikoma M'h.i.i BCUU facing page 448 122 Fibroma PDTD1 l.i M . facing page 449 123 Kii.oid ...facing pu 124 Cicatrix facing pa* 12.~> l.i ii I i KYiiu.MAloM - . lacing page 466 120 LUfllS miJUMATOBUI .. facing page 467 127 NSUBOPATHIO papilloma facing pa> 128 Ki-ii in LION ^ facing pu • 129 KPIIHU.IOMA facial/ pa- 180 Kin in. i.ioMA . facing page 487 131 I'M.i r> i. . . facing pw 132 Cam i- } ii,\iuj paj 133 Primary in. mi i page 496 ■ '- 135 IfTOOaa n mm I facing page 499 PART I GENERAL PRINCIPLES ANATOMY The skin is an organ complex in Structure ami with active ami passive functions. As a fibro-elsstic membrane it affords : and protection t" ti • s with which it is intimately related 00 one 6ide, ami receives impressions from the outer world to which it is ever exposed on the other. The skin beantinea the human fori' roundness b and curves of the body, ami for this ami m thickness in dilTi us. It buttock*, the palms of the hand- ■ad !id thinnest on • ml pre; • nerally ir tissue is i se deposit normally riant of d t-> tin- par' !i is close and firm, and mobility is limited. Where mobilit and tin there is litt Cat, and The most external thelial i The i in al, also pigment, which ^ivea color to the .-kin in var liferent indiridu and under d hith, a- Dp into ]»dvimirphou8 mtlv. and U6uall> invisibly, thrown "!T, ami ai otly in within. Thus the epithel :in in health is ■air by it.- own in-dwelling protoplasm, but l>y tl jiarative impermeability by a uatui of the fkin. wh: Dually ai a ! < tibly in the - :iuni. thus formed are filled with fat S queni to birth, t! is gradually absorbed mobility, such as over the d, or firm attachment, n* tin- larger portion of tin- ear, are •itial. The inu-r-fascic-ular spaces rtitute tin- paw The fat globules are clustered in ma--.'-, forming lobuli - of ..irious Bach lobuli- is supplied witli a capillar} an afferent artery and an efferent vein. In some thicker por- tions "i the skin columns of fat pass obliquely into the lower two-thir tlio curium. They are believed increased support and elasticity to the I'm- the passage of blood- and lymphatics, and at in the nourishment of glands. Imbedded in the subcuutnc-ou the sudoriferous -land- and the deeper-seated hair follicles. The blood- vessels supplying the* are large and send off branches to the corium. The Bubcutaneous tissue contains lymphatics and nerves. Some of the latter terminate in the Pacinian corpuscles, The Bubcutaneous t in its normal condition gives form and plumpness to the body and serves as Fi< H. bundles of filirou;. connective ■ globules with mxli i. M giuued about 500 diameters. (Diar niiiKitic after H< itzrnuiin. ) 4 ANATOMY a double cushion — first to the parts beneath which are liable to pressure, and, second, to the more delicate corium externally, as well as the appendages seated within and passing through both layers. In starvation and wasting diseases the contents of the oil globules disappear, leaving the cell-wall intact. These rapidly refill again with the return of nutrition. An abnormal pro- duction and deposit of fat leads to obesity, so that the subcutaneous tissue may become an inch or more thick. Corium. — The corium (2, Fig. 1) is the most important portion of the skin. It is composed of a closely arranged network of white fibrous tissue, with yellow elastic and muscular fibres in intimate association. The inter-fascicular spaces are smaller than in the subcutaneous tissue, and lessen in size towards the surface. They contain lymphoid corpuscles, connective tissue cells and oil globules. The corium is abundantly supplied with blood-vessels, lym- phatics and nerves. Its thickness varies in different individuals and on different parts of the body. In the thickest portions, as over the soles of the feet and the nates, its substance is penetrated by columns of fat heretofore mentioned. An arbitrary division of the corium is usually made into two layers, the lower or reticular layer and the upper or papillary layer. The reticular layer (R, Pig. 1) is composed of white fibrous tissue, which, in the deepest portion, separates in bundles without division, forming a distinct net; but, as they proceed upwards, the bundles of tissue divide and subdivide, until they reach the upper layer and there form an interlacement by numbers of single fibrilla?. The larger spaces in the reticular layer are filled with fatty tissue, blood- vessels, nerves, lymphatics, the outwardly opening sudoriparous ducts and deeper hair follicles. The smaller spaces contain connective tissue, corpuscles and wandering cells. The papillary layer is distinguished from the lower layer by its more intricate structure. The inter-fascicular spaces are so minute in places as to present a homogeneous appearance. The superficial surface is made uneven by countless projections called the papillae (P, Fig. 1) of the corium, which dovetail with the downward growths from the epidermis. The papillae are simple when there is one tuft or compound, when two or more projections spring from a single base. They may be conical, club-shaped, or square. They vary also in number and size in different regions. They are most highlv developed and numerous on the tips of the fingers, palms of the hands, soles of the feet, the nipples, clitoris, glans penis, and labia minora. Meissner found four hundred in a square line at the tip of the finger, and it is estimated that the whole skin contains one hundred and fifty to two hundred millions. The importance of the papillae is due to their being the residence of the terminal expansions of the cutaneous nerves and vessels. The vascular papillae are supplied with afferent arterioles (plexus) and an efferent vein. The nervous papillae contain medullated nerve fibres and one or more tactile corpuscles. Occasionally a papilla is provided with both blood-vessels and ANATOMY 5 nerves. The papillae of the corium are separated from the epidermis by a thin basement substance. Epidermis. — The epidermis, cuticle or scurf skin (3, Fig. 1), is the most external layer of the skin. It is entirely cellular in structure and contains no blood-vessels, and only a few nerves in the innermost part. The junction between the corium and epidermis is nearly a straight line at about the middle period of foetal life. During the latter part of foetal life the epidermis grows flown ward by linear processes into the corium and, as the capillaries in the papilla? develop, centre.-; of nutrition are established for the epidermis. The full development and inter-relations of the papillae and epidermis, however, are not attained until after birth. The minute furrows on the surface of the skin illy noticeable on the back of the hand, are due to the depres- sions of the epidermis between the papilla?. The coarser furrows, as seen upon the back of the ne. -or surfaces of the joints, forehead and other pan face, are due to repeated tensions or muscular tractions of the skin. In origin the epidermis is quite independent of the corium. It has its own ectoderm, and is not re_ omplete loss of this matrix. The epidermis if 1 into three layers, the mucous layer, the granular . and the corneous la; The stratum m the mucous layer, the prickle layer, rate Mal- phigii (M. Fig. I), is situated immediately above the papillary layer of the corium, and is moulded by its inter-papillary projections accurately to the roughened surface of the cerium. It is composed of layers of nucleated cells. The lower strata of eel all and oblong with oval nuclei, which are surrounded by granular pro! their !• ndicular to the surface of the corium: they have no (ell-wall, and BOmetin -trata ajppear a mass of protoplasm with scattered nuclei. The cells of the next few rows are la' n form, with well-defincd nuclei and a distinct cell- wall. They contain granular and pigmentarj matter. The more superficial n.ws of the muo p of still larger cells, mere granular, and flattened; and. generally, their axes assume a horizontal position to the cutaneous sue All ■ Qucous layer have chs c protoplasmic processes, which unite the cells to ■ died prickli s. Hence the nai prickle-cells or prickle I authorities to this part of the epidermis. The prickle irmly, but at the same time the body of epithelia are kept separated from each other by the so-called itance of the skin; which subs permits the free passage of nutritive material from the papilla of the corium, the ingrowth of nerve- threads, the immigration of white bi I corpuscles, and the counter-flow of lymph inwards to the inter-papillary depressions, thence to the lymph vessels of the corium. The epidermis contains no lymph proper and no blood-vessels. During oic life the appendages of the skin are formed by the nutritive pi. talixed protoplasm of this part of the epidermis; 6 ANATOMY and, after birth, they are the source of the organic material of all physiolog- ical or pathological secretions. The stratum granulosum, the granular layer (67, Fig. 1), is made up of one to three rows of granular cells arranged next to the prickle cells of the mucous layer. In disease this layer may be increased to four or five rows of cells. They are attached to each other by short threads, which make the inter-cellular spaces much narrower than in the mucous layer, hence, nutritive material is only sparingly supplied to these epithelia. The cells of this layer are filled almost entirely with granular matter, to which "Waldeyer has given the name of kerato-hyalin. This substance, which first appears in isolated granules near the nuclei of some of the cells of the prickle layer, is greatly increased in and characterizes the granular layer. TJnna believes that to this layer the white race owes the color of its skin, and supports this belief by the fact that, before the appearance of the granular layer during foetal life, the outer portion of the skin is transparent, so the blood-vessels of the corium can be seen through it, and also, that the color at the border of the lips and the nail beds is due to the absence of the granular layer in these parts throughout life. The changes which occur in the cells of the granular layer, as they are progressively forced outward from the mucous layer, are necessary to further changes in the external layer of the epidermis, known as cornification. The stratum corneum, the corneous layer, the horny layer (C, Fig. 1), is the external layer of the epidermis and of the skin. By rapid changes the outermost cells of the granular la3 r er are transformed (by apparent meltino- of their granules into the surrounding cell protoplasm) into clear, transparent epithelia. The first two or three rows of cells, owing to their appearance under the microscope, are sometimes called the stratum lucidum. But, as they represent a stage in cornification, it does not seem wise to distinguish them as a separate layer. More externally, the cells are arranged in po- lygonal plates, with shrivelled nuclei and rudimentary threads, which still serve to connect the frame-work of cells with each other. Still nearer the surface the cells become lifeless, horn-like shells, lying parallel to the cuta- neous surface, the outer rows wrinkled and curled up, preparatory to being shed. According to Unna, cornification of the epidermis is not a complete process, but consists of an alteration of the periphery and connecting threads of the cells into horny tissue, which, after digestion of the central part of the cells, presents a honeycomb-like structure. No traces of the inter- cellular canals are found in the corneous layer. The hard, dry character of the cells of this layer is due to the presence of keratin, which is a verv hard and resistant substance. Sebaceous Glands. — The sebaceous glands originate during the third month of fcetal life from the mucous layer of the epidermis, which, from multiplication of the epithelia downwards, form the gland (S, Fig. 1). Thev are found imbedded in the corium everywhere except in the soles of the feet, palms of the hands, and the dorsal surfaces of the last phalanges of the fingers ANATOMY - and toes. They are racemose glands, simple or compound, and lined with round cell epithelia. They secrete an oily substance called sebum, which is produced by the simple process of slow fatty degeneration and rupture of the cells lining each acinus. The ducts are short and end in the hair follicles or open directly on the surface. They are divided into three groups accord- ing to their distribution. The first group, or "the glands of the hair follicles," are found in the skin of the hairy parts of the body, where they are very abundant and are connected with the hair follicles into which they discharge. Each hair is provided with two or more glands. The second group are chiefly found in the so-called non-hairy parts of the skin, or those portions supplied with lanugo hairs. These glands are larger in size and more complex than those of the first class. Their dm directly on the cutaneous surface. In the duct the rudimentary or lanugo hair follicle appears to be placed inda <>f tin- ><•<•<. ml Cla-vs. appendage to the gland A third group are Limited in number and are uncon- l with tin- hair follicles. They an' found in the areola of the nipple, labia minora ami vestibule in the female, and on the interna] Burface of the prepuce and corona in the male. The diachai sebum i- facilitated by the contraction of thi llorum a Tin: SuDORiPAfl glands. — The sweat gland (T, Fig. 1) consists "f B minute tube with a blind extremity coiled several » ANATOMY times upon itself and imbedded in the subcutaneous tissue; thence the tube passes as a spiral duct through the other layers of the skin to the surface- of the epidermis, terminating in a funnel-shaped opening or pore, which in many places can be seen with the naked eye. The sweat glands appear to originate subsequent to the third month of foetal life, by solid growths of epithelia from the mucous layer of the epidermis downwards into the deeper tissues, where they coil upon themselves; and, in the course of development, the central part liquefies, forming a tube. Unna believes that the true duct ends at the surface of the corium (or about the plane from which the solid growth began), and that the remaining portion of the tube outward is a com- mon outlet for exudations from the interstices of the epidermis and for the sweat. The sudoriparous glands are simple in structure. The outer coat is continuous with the basement membrane of the corium; the middle or epithe- lial coat is continuous with the deeper layers of the stratum mucosum; the inner coat, or lining, is a delicate cuticle. The sweat glands are each sur- rounded by a sheath of connective tissue and fat cells, which support and hold the tubes in position. The sudoriparous glands are present in great numbers in all parts of the skin, except the colored border of the lips, the glans penis, the inner surface of the prepuce, and the clitoris. They are most numerous in the skin of the soles of the feet and palms of the hands, where Krause estimates their number to be nearly three thousand to the square inch. The largest glands are found near the anus and in the axillae. The average length of a straightened tube is about one-fourth of an inch, and it is estimated that the total length of the coil-tubes of the whole adult skin is upwards of nine miles. The function of the coil glands is the secretion of sweat, which varies in quality in health from a clear watery fluid of the smaller glands of the general surface to the more consistent fluid containing fat globules and granu- lar matter from the glands of the axilla?, the meatus of the ear, and at the verge of the anus. The Hairs. — The hairs (H, Fig. 1) originate about the beginning of the fourth month of intra-uterine life by cylindrical, knob-like growths downwards of the mucous layer of the epidermis. Later, these solid epithelial growths are met by extensions of the connective tissue from beneath, and the papilla? are formed in cup-shaped excavations in the epithelial bodies. In the papillae are fine protoplasmic cells and loops of capillaries which supply nutriment to the hair-root or bulb. Continuous with the tissue of the papilla? and with fibres from the subcutaneous layer, bundles of connective tissue surround the root of the hair and run parallel with it in an oblique direction through the entire thickness of the corium. This tissue is interspersed with circular muscle-fibres, is supplied with arteries, veins and nerves, and is lined with a structureless homogeneous membrane, which does not contain either blood- vessels or nerves. The whole forms a fibro-elastic pocket known as the hair follicle, in which rests the hair, to the base of which is attached the erector- pili muscle. anatomy 9 With the development of the papillae, the elements of the hair are formed by growth of the medullary epithelia about the papilla?. Gradually, by elonga- tion and compression of the epithelia, the hair is pushed outward to the sur- face, where it first emerges at about the sixth month of intra-uterine life. The portion of the hair in the skin is called the root, and the portion external Stratum Malpighii of outer root-sheath. I Cuticle of hair. -Cuticle. - Huxli v- Henle'a layer \ \ Inner } - root- layi r ' sheath. -v layer. ! cells of the outer rool- ith. Medulla of hair Cortical ■ub- : hair. Hair-bulb. - Hair papilla. .. Blo...|-ves8eL -\ layer of hair-bulb. Conni of th>- Mil Fig 4 Longitudinal Section >>f Human Hair and Its Follicle. in mi'l Muvi'li.fl: x about 300.) 10 ANATOMY from the skin is called the shaft. The root of the hair is provided with two coverings, the outer root-sheath and the inner root-sheath. The outer root-sheath is composed of epithelia, which are continuous with similar epithelia which form the sebaceous gland. It extends from the inner border of the pouch of the latter downwards, and ends near the bulb of the hair. The inner root-sheath is made up of granular polyhedral epithelia (for- merly divided into Henle's and Huxley's la}^ers), which, in the inner part, become somewhat elongated. The protoplasm of the cells of this sheath con- tain Tcerato-hyalin, which promotes the cornification of the hair tissue. The inner root-sheath covers the papilla, forms the bulb of the root of the hair, and extends upwards to the neck of the follicle. According to Heitzmann, the hair is produced by this sheath alone, by a solid elongation of the epithelia. The inner root-sheath is separated from the outer root-sheath by a thin mem- brane. Between the inner root-sheath and the main mass of the hair, TJnna says, there is found the matrix from which is formed both the cuticle of the root- sheath and the cuticle of the hair. The cells forming the cuticle of the root- sheath are arranged with their axes on a line with the circumference of the hair, while the cuticle of the hair is composed of cells which gradually become columnar in shape and lie parallel with the length of the hair. As the root nears the surface the cuticle of the hair appears to be formed of imbricated scales with elevated edges, which, in the shaft of the hair, gives it the charac- teristic serrated appearance. The central or cortical portion of the root of the hair is composed of delicate fusiform scales, firmly attached to each other, which give to the hair its great strength and elasticity. These qualities are further assured in the larger hair by a central marrow or medulla, which is composed of loosely packed embryonal corpuscles, f atty and pigment matter, and extends through the root of the hair to its point. The hair, after it emerges from the skin, has the same structure as the root, minus the root- sheaths. The color of the hair is due to the granules and diffused pigment which is deposited in and between the scales of both the cortex and marrow of the hair. The degree of pigmentation usually corresponds with that of other parts of the skin. It varies widely in different races and individuals, and, to some extent, in the same person, under changed states of nutrition, from sudden or slowly acting influences on the trophic nerves. Blond and grav hairs contain no pigment granules. Hairs are found everywhere in the skin, except upon the soles of the feet, palms of the hands, the last phalanges of the fingers and toes and the penis. They are sometimes divided into three classes: The fine, downy, or lanugo hairs, found upon the general surface; the long and soft hair of the scalp, beard, axilla? and pubes; and the short hairs, as found upon the eyebrows and eyelids. Each hair, normally, has a limited existence, and is shed by a process of separation, which takes places about the bulb accompanied by a contraction of the hair follicles at this point. The new hair is regenerated from the ANATOMY 11 inner root-sheath about the papilla, and, as it grows, pushes the dead hair before it until it is shed or accidentally removed by traction upon it from without. It will be seen that the hair is not only derived from the epidermis, but that its production is a process of cornification under conditions which form a cornified cylinder, which is projected from the cutaneous surface and is very analogous to the cornification which takes place in the epidermis itself. The Nails. — The nails are concavo-convex, horn-like, elastic plates firmlv imbedded in the 6kin of the dorsum of the last phalanges of the fingers and toes; fully exposed on their upper surface and terminating in free border. which, if uncut, extends beyond the ends of the fi] The nail consists of horny epithelia like the corneous layer of the epidermis, only more dense in structure. According to Bowen the nail is a modified growth of the innermost row6 of cells of the corneous layer, or. as it is frequently called, the stratum lucidum. About the third month of festal life two or tlm > epithelia from the mucous layer appear at the site of the future nail-root. In the fourth month one or two additional rows of epithelia are pro; \- the! mature they are gradually forced forward between the rete mucosum and the horny layer of that part of the epidi which is to be the nail-bed. By the '.h month the nail - way through thi layer, and at intra-nterine life is usually well d( The wiil-fu -kin in which rests the border of the nail not bj the pi iwth. !• continuous at the root of tin- nail with the nail-n • with the nail-bed. The ads from the floor of ail-fold at tl border of the lunul • bt-COlored part of the nail. The derma of the matr which is blended with the : th and rises aboTe into mIIh parallel with tl; tpilhe ward, and ai it the lunula. On the papilhe and in the fm the mm ■ ie horn] nail. According bo ' or part of the matrix produces the horn; plates of the surfae middle of the matrix, iddle of the nail, and rior part of the lunula, the andermoet part of the nail. The niiil-li- 1{, or the I i hich supports the nail, as it is pue forward from the matrix. from the am. -rior border of the lat: the bt of the free part of the nail. I- subcutaneous steam beneath, high i papilla? from "rium running the full length of the nail-bed. and over the papilhe and their interspaces prick of the mucous layer so arranged as to pr a grooved appearance of the upper surface of the nail-bed. Into these grooves ding ridges on the m nail lit. thus giving firm attachment nf the nail to the nail-bed. 12 ANATOMY At the junction of the nail-bed and the free border of the nail the granular and corneous layers are united again with the mucous layer, so that at this point the nail rides over a complete epidermis instead of over the cells of the mucous layer in the nail-bed. This junction can be seen through the nail, as a yellowish-white line just behind the free border of the nail if the ball of the finger is pressed against a hard substance. The matrix and nail-bed are freely supplied with arteries and veins which, according to Hoyer, have direct communication without intervening capil- laries. This provision permits a temporary stoppage of circulation in these exposed parts without liability of injury to them. The transparency of the nail over the nail-bed allows the color of the blood to show through the nail, while the opacity of the visible part of the nail over the nail matrix (the lunula), due to the changes in the superficial cells of the mucous layer under- going cornifieation, entirely shuts off from sight the color of the blood in the vessels of the matrix. Blood-vessels. — The skin is supplied with abundant and freely distrib- uted blood-vessels in all its parts, except the epidermis. The arterial supply is derived from subcutaneous branches which pass through the fascia and, by division and subdivision, form, as Tomsa has shown, three separate vascular districts. The deepest supply the subcutaneous fat with numerous capillaries in a net-like arrangement inside and between the fat lobules (A, Fig. 1). The middle district sends off arterioles to form a capillary plexus for the coil glands (B, Fig. 1). The capillaries supply the tubule and end in small veins, one of which passes upward with the duct of the sweat gland and anas- tomoses with the veins of the papillary region. The third or upper district is supplied from an ascending artery (F, Fig. 1), which sends off branches to form capillaries for the hair follicles, the sebaceous glands and the papillae. Each papilla is furnished with one or two capillary loops. The papilla of the hair has its own arteriole and capillary similar to those of the papillae of the corium. The capillaries of the papillary layer anastomose freely with those of the upper part of the hair follicles from which loops pass to supply the sebaceous glands. The most superficial veins of the skin are derived from the capillaries of the papillae (V, Fig. 1) and form narrow meshes, which, together with the deeper and circular veins, form venous branches which anastomose with branches from the hair follicles and sebaceous glands. These unite into larger vessels, and with the veins from the coil glands and fat lobules merge into the venous sinuses which end in the subcutaneous veins. Vaso-motor nerves accompany the capillaries of the skin everywhere. Under their domination the capillary circulation is largely concerned in the physiological functions of the skin as well as in pathological changes in its functions or tissues. A sudden dilatation of these vessels produces the common phenomenon of blushing; and a sudden contraction the equallv marked blanching of the surface. Lymphatics. — The lymphatic vessels proper are relatively few, and com- ANATOMY 13 monly are appendages to the blood-vessels, their contents flowing from the papillary portion of the coriura inward to communicate directly with the subcutaneous blood-vessels. There are, however, according to Unna, juice spaces or lymphatic channels in every part of the skin which usually do not have independent walls nor absolutely free out-flow of lymph into the lym- phatic vessels. These lymph channels are uniformly present in the papillae of the eorium and converge near the middle of the base where a lymphatic -el usually begins. From the apices of the papilla? lymph flows into the mucous layer of the epidermis in all directions through the inter-epithelial spaces and between the prickle threads which unite the epithelia. The return flow of lymph to the eorium occurs slowly by way of the inter- papillary di - of the epidermis through minute openings, or, possibly, through the ducts of the sweat glands which emerge at these points. Juice spaces similar to those of the epidermis exist in the hair follicles, in the sebaceous glands, and in the ducts of the coil glands, and form a sheath-like ig about the connective tissue bundles, the oblique muscles and the fat-cells. The course of the lymph in the eoriun rly downward to the lymphatic vessels. The passage of lymph from the spaces of the coil glands and fat tissue is by slow filtration into the neighboring veins or lymphatic vessels. This an I peculiarity facilitat nnation of subcutaneous fat. No lymphatic Tea* md either in fat or in subcu- ie free from fat. :\is. — The skin is abundantly supplied with medullary and non- medullary nervi of branchei from the cerebral and spinal oei which enter the .-kin and form horizontal bundle! QtaneoUS tissue. tai upwards with th<' blood-vessels through the eorium, and divide into QUI ons in i ary layer, some assum- ing a horisontal position t" the surface, and an- disposed about the sui>- papillary vessels and capillaries of the papilla?. Other short narv< up lidermis into non-medullated fibrills?, which send <>tr nume branches, of which a smaller number end with free extremities in the com ti\. or "ii the endothi I a larger Dumber penetrate into the epidern i n the basal cells. The nerves of the epidermis, after many divisions, and. possibly, reunions i" form plexus.-; (1'nna) in the intcr- capillar . finally send o)T from different points tine threads for each prickle cell, as far as the granular layer. These Derve-threada penetrate the cell protoplasm and terminate in minute bulbs <>n or about the audi Borne branches end in bulbs between the epithelia, hut without any regularity of distribution. Non*fMdvUary nerve fibres are also supplied to the cells of the hair-sheath and the ducts of the coil glandi ■ding to Crause all rve filaments ultimately terminate without medullary sul.stance ami in minute enlargements. A- these nerve terminations are found in largest part, and uniformly in the cells of the epidermis up to the corneous layer, they would appear to he the transmitt Deral sensation. The muscles of the skin and the sheaths of blood- ire supplied 14 ANATOMY with motor-nerve fibres, while to the secreting structures and protoplasmic formations trophic nerves are distributed. Eegarding the latter little, how- ever, is positively known. Medullary nerves of the skin terminate in the Pacinian and tactile corpus- cles, and according to Eobinson, some branches pass into the papillae, then change their direction downward to the deeper part of the corium, to reascend to the papillary region to adjacent papillae. Similar loops are given off from the nerve-bundles before they reach the papillary layer. Pacinian corpuscles or corpuscles of Vater are small oval bodies mostly situated in the subcutaneous tissue, in some parts visible to the naked eye and measuring two or more millimetres in width by three or more in length. Each corpuscle consists of capsules made up of a large number of concentric- ally placed hyalin and connective tissue lamellae, resembling the outer struc- ture of an onion, and enclosing a central space or core of transparent proto- plasmic material, in the centre of which is a single mcdiillary nerve fibre. The medullary sheath of the nerve is lost in the tissue of the capsules before it reaches the central space. In the central space the nerve-fibre continues to the distal end and there divides into two or more club-shaped enlargements. Eanvier claims that after supplying one corpuscle the nerve may pass on to penetrate a second or even a third; and Eobinson says the nerve may form a loop or loops, and then pass out at one or the other pole of the corpuscle. In such cases the nerve regains its sheath from the capsules at the point of exit. The tactile corpuscles; corpuscles of Meissner or of Wagner (X, Fig. 1), are found in the papillae of the corium, usually filling the greater part of the non-vascular papillae. They are roundish or oval bodies of about one-tenth the size of the Pacinian corpuscle. They consist of connective tissue cells with small nuclei interwoven into vertical or spiral rolls, which go to form one to three lobules, and are surrounded by a denser connective tissue or capsule. Each corpuscle is penetrated at one extremity by one or two medullary nerves, which lose their myeline sheaths in the fibrous substance of the corpuscle. A nerve branch passes to each lobule where it divides into delicate fibrillae, which ramify between the connective tissue cells, anastomose with each other and terminate in slight enlargements; or, according to Eobinson, they may pene- trate the capsule at the distal extremity and emerge therefrom as one or more efferent nerves. Delicate nerve-threads encircle the corpuscle and pass up- wards with other nerves to the rete. The afferent nerve of a corpuscle may be supplied from an adjacent papilla, or one nerve may supplv two or nioro corpuscles. Muscles. — The voluntary muscles of the shin are chiefly limited to the face and neck. They consist of striated muscle fibres, which pass obliquely from the subcutaneous tissue into the corium. Their action under the influ- ence of the emotions or the will aids in giving various expressions to the features. In some of the lower animals analogous muscles are large and abundantly distributed. ANATOMY 16 Involuntary muscles of the skin are found in the eorium occupying hori- zontal and oblique positions in relation to the surface. The horizontal layers are found chiefly in the scrotum, penis, areola and nipple of the breast, and the eyelids. The contraction of these muscles forces the skin into folds and changes its external appearance. The oblique muscles are found in nearly all parts of the eorium, either as minute fasciculi, without attachment to the hair follicles, or as more dis- tinct muscular bundles with multiple attachment to several adjacent hair follicles below, and a similar attachment to the papillary layer above, and known as the erectores pilorum. The erectores not only have fixed points of attachment to the papillary layer of the eorium and fixed points of insertion into several hair follicles at of the hair papillae; but by means oi fibres, which surround and mingle with them throughout their length and at their to the elastic- work oi the eorium. Their dir- oblique. The direction of the hair ■ a less oblique angle, a powerful isclea pulls the hair of the lower animal - •i in a mark' portant which follou i of the oblique "f the eorium are the expulsion of sebum bj -sion of the ■ebsceoui glands, a l e s sene d circu- lation of blood in the papillary layer. Slid miration from the a of the upper | the eorium. The compressi<.' upon the skin in 1 ••* produces an sppsn d* the surface, or cuds a ral effect is to prevent loss of bodily tern] om of the oblique in of the sk . ■ rnal cold stimulates their m. r of the -kin d< (piantit -sels of • in, snd to tl at "f pig present in the layers of tl '*hat by to the heat of the sun ither diffi In the whib in ■■ usually • and limited ithelia of the epidermis. Deep* 'is of t! e (as the scrotum and general in te gu m e n t of the er or di in the prickle cells and their DUcleL In the Di tation SI to the granular layer, and a dark coloration <>f the skin results. There is pigmentation "ft!' -. and only in abnormal conditions is it found in I m. 16 PHYSIOLOGY PHYSIOLOGY The functions of the skin have been already mentioned, and the general office of the skin as a protective covering of the other tissues, etc., briefly stated. The active functions of the skin are of much importance in relation to many of its diseases. Secretions and excretions of the skin are furnished by the sudoriparous and sebaceous glands. Sweat. — The sudoriparous coil glands produce perspiration or sweat, which is ordinarily rapidly evaporated from the surface in the form of vapor or insensible perspiration. The quantity of vapor of water given off by the skin is nearly double that eliminated by the lungs. The quantity varies with the season, occupation, etc., from one to two pounds daily. If evaporation from the surface is retarded, or the excretion markedly increased, sweat accumulates on the surface in drops, sensible perspiration. The secretion of sweat is largely under the control of the perspiratory nerve centres, located probably in the spinal cord and medulla. These centres may be directly or renexly stimulated, and act, through the local nerve fibres, directly on the epithelia of the coil glands. Sweat is increased by heat, changes in the blood, by certain drugs, such as camphor, pilocarpine, and toxic doses of strychnine, etc. Pilocarpine and some other alkaloids are believed to stimulate the secre- tion of sweat by acting directly on the peripheral nerves. The secretion of sweat is diminished by cooling the skin, by suspension of the blood supply, and by such drugs as atropine, morphine, etc. The normal increase of per- spiration is attended with increased activity of the local circulation, but in abnormal conditions the perspiratory nerves may act independently of the vaso-motor system, and a free secretion of sweat occur when the skin is pale and cold. The normal perspiration is composed of about ninety-nine per cent, of water and one per cent, of organic and inorganic constituents. It is saltish to the taste, alkaline or neutral in reaction, and lias a characteristic odor. The organic matter consists of urea, fat aud various fatty acids. The quantity of urea in the sweat is small and varies but little in health, but in pathological states of the kidneys, with suppression of excretion of urea by those organs, it may be enormously increased. The kidneys and skin hold compensating relations normally to each other; the lessened perspiration from the skin in cool weather is compensated for by an increase of urinary fluid, and vice in warm weather. The chief inorganic solids of the sweat are the chlorides of sodium and potassium and some phosphates and carbonates. The sweat aids in removing effete material from the system, in preventing, by surface evaporation, a rise in bodily temperature, and helps to lubricate and protect the cutaneous surface. Sebum. — The secretion of the sebaceous glands is a semi-fluid fat, which is insensibly discharged from the sebaceous glands upon the skin, and varies PHYSIOLOGY 1< considerably in consistency and quantity within the limits of health. Its chemical constituents have been found to be water, fats, saponified fats, caseine, albumin, cholesterine and a small proportion of the salts of sodium. The function of the sebum is mainly preservative. It protects, in a measure, the surface of the skin from external infection, from the softening effect of long-continued moisture, and, at the mucous outlets, from the con- tact of irritating excretions. It may prevent too rapid evaporation from the cutaneous surface and consequent undue loss of heat. It probably contributes to the nutrition of the hair, and presei Eternal surface Unlike the secretion of swt tied in the production of sebum. 1 1 \ : B —A variation of bodily temperature of ten degrees from normal, either above 03 apatible with continued life, yet vide atmospheric variations are endur- rat harm and with but slight, if any, change in n important part in ni;i tture by n-gulating loss of heat. It is ed that from seventy .1 loss of bodily I - a \vh< I heat. When the surface is cooled, the rant of blood sent to the skin is greatly diminished by shrinking of the «sels throng] r muscular by a time increased teni -vies as, and thereby diminishes the discharge of loss of a minimum require.: normal internal b • or of heat phyi relax the the : the skin. A lai tin- Mij.erlicies of the skin ai and loss of heat takes p] liation from II oat-loss is aided IT, and i • air. naturally In! epi- ''' rl " is - Wlt - Ldoriparons docti U --ous follicles, ofi n to absorption by fly '" ' ipidly. The absorption throu the epidermii ■ sontewl , ; t j, hoi, chloroform j„ B lb I Qg :.:• In this wav many ""'' i into i ; , and exert their only in grm than «i phthol, ml I in this manner. Arsenic and up by the skiii in sufficient quantity to Cfl Gases and volatile vapors • through the skin into the blood. nd nitrogen are absorbed by the skin is not known. Car l is e l iminated by th rant of two or three drachi {,ail - 8 BO-calll ratory fund 18 PHYSIOLOGY of the skin, which Scharling, at one time, estimated to be about one-fiftieth of the respiratory work of the lungs. It is altogether probable that all substances which are absorbed by the skin pass through the outer parts of the epidermis (sometimes aided by friction), by way of the gland ducts and hair follicles, whose walls are only lined with a single layer of epithelia, and thus present a comparatively slight barrier to absorption. Mercury in ointment is absorbed in this way in the form of vapor, or after being dissolved by the acid secretions of the skin. Watery vapor is readily absorbed by the skin from the surrounding air, and water in contact with the surface may enter the epidermis in considerable quantity, by soakage, without actual absorption. Bacteria may be absorbed by the skin. Furuncles have been produced by rubbing into the sound skin cultures of the staphylococcus pyogenes aurens. According to Wasniuth, bacteria do not enter the skin by the sweat or sebaceous passages, but by way of the opening between the hair-shaft and the sheath. Sensation". — An important function of the skin is that of general sensa- tion, and the special sensations of touch and temperature. General sensation is provided for every part of the skin, the thinnest portions of the skin being most sensitive, and the thickest portions the least sensitive. Ordinary contact becomes painful, if applied directly to the coriuin. The acuteness of tactile sensation depends on the distribution of the sensitive papillae of the corium. Where these are abundant, as in the skin of the end of the third finger, sense of touch exists in a high degree. Webber found, by experiment, that at these parts two distinct sensations of touch could be felt, only one twenty-fourth of an inch apart. The middle of the thigh and forearm appear to be the least endowed with the sense of touch, the distance at which two points of contact can be distinguished in these regions being upwards of two inches apart. The sense of touch not only makes known the size, shape and other properties of bodies, but with it may be felt the varieties of pain and differ- ences of temperature. Goldscheider believes there are two kinds of sensitive nerves of touch. The office of the tactile corpuscle, in the light of later investi- gations, appears to be to give greater mechanical protection to the nerve ter- minations. The quality of touch can be educated to a surprising degree. This is well illustrated in the blind, who, by their delicacy and expertness of touch, seem almost to supply a substitute for the loss of vision. The distri- bution of temperature sensation is very like that of common sensation, and varies in different parts of the skin; but is not modified by the relative thick- ness of the skin to the same extent as general sensation. Formerly, temperature perception was thought to be a variety of general sensation. The experiments of Blix and Goldscheider not only tend to disprove this, but seem to show that there is a separate nerve mechanism for cold, heat and pressure. Experimenting independently of each other, they found that the same irritant produced on some parts of the skin a sense of cold, on others heat, and on yet others only ordinary sense of pressure. It is well known that in some diseases attended with paralysis of ordinary SYMPTOMATOLOGY 19 -ation, sensitiveness to heat and cold may remain intact. The degree of temperature felt depends, in great measure, on the extent of surface exposed. One finger, for instance, can be comfortably borne in hot water, which would become painfully hot to the whole submerged hand. The tip of the tongue, the fingers and face are most sensitive to temperature change. From one-half to one degree variation can be appreciated by those parts. SYMPTOMATOLOGY Tin. manifestations of disease, by which it- ized, are known as symptoms. One class of symptoms are felt only by the patient, as disturbances of sensation, and are 1. - subjective symptoms. Another ay be observed I md person, with or without the aid of the patient, and are known as o The relative importance of -•■ tun i obably more nearly equal in ■ of the skin than in an 'it of medicine. may he limited to tin- .-kin ;> moid ;m\ other part of the I" atly the lathological relation- skin disease with ther functional or Such itionship itaneoui E cause and effect Most often the skin . internal distal a local or :. It i: 1. therefore, that usually the .-\mp- aplcte anless it ineludes all tin- symptom! a\ at the tin • itomy, .-.- -kin If. Study and anal; and therapeul Sir., ii . n\i -\mi-i. t. may lie of great elinieal "I'u an. <■. The] in intei !"rom t! of heat of a mild erythema to \l.<- m . malignant lional condition, a- the so-called "boi liilis; th< D furuncles', or r ma - in many ir f prurii of all sul.j«( tivr symptoms of the .-km. It may l»' present in modified form, as a i v or less pronounced Ktiglingj ,-j. ctsm »n), tickling, or a- a □ any degree up to an intolerable sensation, which cannot be borne without n - often occurs in prurigo and ec/ema. Total of pruritus aids greatly in d . syphi- litic from noii-syphilitii whicli objectively have a cL Not infrequently t! •> absence of subjective symptoms in the skin in benign cutai oe, for instance, they may he slight or want- of the digestive organs, the genito-urinaj the upper respiratory tract may be often found; or. again, a i i with debility, sensations of weakness, languor, headache, 20 SYMPTOMATOLOGY etc., may form a group of subjective symptoms. The sharp neuralgic pains which commonly precede an outbreak of zoster are characteristic of that affection. The chief value of subjective symptoms, whether in or apart from the skin, depends on their nature, location and behavior under varied influences, acting from without or from within the body. The nature of sensation, whether a burning, smarting, stinging, gnawing, aching, shooting, etc.; the location, whether limited to one part, a few parts, or generalized; behavior, whether unaffected, relieved, or aggravated by time of day, cold, heat, water, clothing, rest, exercise, eating, drinking, sleep, mental or physical occupation, etc.; all these give character to subjective symptoms and establish their value, especially in the therapeutic domain. No one, who has not studied the char- acteristics of subjective symptoms can comprehend that, contrary to the opinion of many dermatologists, subjective symptoms are nearly, if not quite, equal in importance to objective sjonptoms. Objective symptoms comprise pathological changes, which occur in the skin and are also known as primary and secondary lesions. These distinct lesions are few in number, and may be, in a degree, successive stages in pathological evolution; yet, in differences of grouping, modes of occurrence and other features, they form the many varieties of cutaneous disease. So- called primary lesions are not always first in order of occurrence, but may be consecutive to other elementary lesions. Again, some lesions are common to several diseases. One or more lesions presenting certain features and with or without the presence of certain subjective symptoms distinguish each disease and form the basis of dermatology. A knowledge of lesions is, therefore, most essential. They are grouped as follows : Primary Lesions. 1. Macules, 2. Papules, 3. Wheals, 4. Tubercles, 5. Tumors, 6. Vesicles, 7. Bulla?, 8. Pustules, 9. Scales. Secondary Lesions. 10. Crusts, 11. Excoriations, 12. Fissures, 13. Ulcerations, 14. Cicatrices, 15. Unclassified. PRIMARY LESIONS Mabules (spots, stains, macula?) are changes of color of the skin with little or no elevation, due to various causes, and are of various sizes, shapes and tints. In size they vary from a pin's point to patches of several square inches. In shape they may be irregular, ovoid or circular, bur. most often they have a roundish outline. The}' vary in color from a verv SYMPTOMATOLOGY 21 light red to a very dark brown, and their duration may be short or long. Their color may or may not temporarily disappear on pressure, and they may or may not be attended with subjective symptoms: usually the latter are wanting. Macules may be due to hypenemia, to extravasations of blood, to dilatation of blood-vessels, or to changes in the pigmentation of the skin, and are designated as follows: Erythema or roseola are the terms used to denote acute hyperemia of the skin. Their color is red, if due to arterial i i: bluish-red. if due to HOU usion; and they alu ;ipear on pr> - If a fluid exu- dation from the blood-vessels into the cells of the skin takes place, there is some swelling of the skin, and occasionally a alight elevation of the surf a m escape of the coloring matter of the blood occurs with the exudation, ami gives a yellowish shade to the patches. Brytki urs either in in or is more <>r less generally diffused tin' surface. It forms a or halo about an inflamed area of skin. Roseola occurs in round or oval-shape'! oring thi of >-re, rarely exceeding the -ize. Dii of blood into the superficial tissues of i. which reddiah-purple color at : n ging to various shades of so-ca! k and blue," as absorp- 1 ii partial ran ruction aes only the i >f the bl< es and Bhows in yellow- ish- When the mall and round, they are called P< UckUl ; V, I'urpur primary in occurra indary to inflammatory il dilatation of the m. and U !ar acquired ehai of the hlood-vessels. DOrmal of the skin may be due to increase or loss of pigment I of pigment, I vitiligo of diminution of pig may lie perma- ij< -lit "i- of -hort the latter, raising its surf. or i "in it in a rariable • . may become pedunculated or even pendnli it may not be attended with subjective symp- toms. Tumors occur in fibroma, carcinot tike) are elevations of the horny layer of the epider- mis, from a mustard seed to a coffee bean in size, containing a serous fluid exudate from the superficial or deep parts of the skin. Vesicles are usually of inflamn .: they may be, however. non-innammatoi the chief feature of an eruption and seated in the -km. U in I they may be secondary and rnal to othi at the ■ i papule no. Their fluid may be —purulent from the of pus, or -anions and •ero-sanguineous from admixture of blood. They are generally tense: round- ish at the base, if d and convex at the top, or pitied, as in varicella, ftaccid from collapse upon tl often formed in groups, or I patches; are usually single chambered, but may be multiloeular. a.- in mattpOX. \. of comparatively short duration; terminate by spontaneous or accidental rupture and discharge of fluid upon the adjacent surface; or they may dry in' may also be transformed into bulls by increase of size, or into pustules, or become the teai of ulceration. An eruption of inflammatory vesicles is usually attended with subjective sensations of itch- ing, burning or stinging. Hi. Kits (bullae, blisters) are vesicles of a pea size, or larger, and may be formed by a confluence of vesicles. Like they are most often formed in the deep and middle layers of the epidermis; may contain serum. pus. blood or lymph; may be tense or flaccid : and mav terminate in a similar manner as by rupture, desiccation or ulceration. They differ from vesicles in their having stronger roof-walla, less tendency to spontaneous rupture, longer duration, their more frequent seat in apparently normal skin, 24 SYMPTOMATOLOGY greater freedom from subjective sensations, and in indicating a graver sys- temic condition. In shape, bullae may be oval, hemispherical, erescentic, round or irregular from coalescence of a number of lesions. Single bulla vary in size from a pea to a goose egg ; but when confluent, they may sometimes form enormous lesions. Blebs are a diagnostic symptom in pemphigus, hydroa, herpes iris and pom- pholyx; and may appear in the course of cutaneous syphilis, erysipelas, urti- caria, exudative erythema, and exceptionally in almost any inflammation of the skin. Pustules (pustulae) are circumscribed elevations of the skin, of in- flammatory origin, containing pus and pus cocci, and varying in size from a millet seed to a hazel nut. Pustules may arise as such, but most frequently originate from vesicles or papules. Transitional forms are known as vesico-pustules or papulo-pus- tules. They may be roundish, globoid, convex, irregular, pointed, flat or umbilicated in shape; in color, yellowish or blood-stained, surrounded by the normal-hued skin, or by an areola; sometimes with induration, as in boils; or an indurated base, as in ecthyma. They may be situated around the sebaceous glands, as in acne; around the hair follicles, as in sycosis; deep in the corium, as in furuncles; or involve only the papillae and epidermis. The largest proportion of pustules arise in the papillary layer; and, if the destruc- tive process extend to several papillae or to the deeper parts of the skin, a scar may result. Epidermic pustules heal without cicatrix. The evolution of pustules is generally rapid; they usually rupture and form firm, yellowish, greenish or brownish crusts ; or dry without rupture into somewhat lighter colored crusts. They are frequently attended with soreness or tenderness, but rarely with any degree of itching. The pathological process in variola is different from other pustulous affec- tions, in that the exudation occurs within the cells instead of within a newly formed cavity. The distended cell-walls form a multilocular pock or pustule, which cannot be opened by a single puncture. Scales (squama) are dry epithelial matter exfoliated from the sur- face of the skin in appreciable quantity, as the result of an over-produc- tion of epidermic cells, generally without exudation. Scales are usually inflammatory in origin. They may be primary and characteristic, as in psoriasis; or secondary, as in scarlatina and eczema. When they are thrown off in fine, small scales, they are called branny or f urfuraceous ; and lamellae, when as large as the finger nail or larger. Thev mar be scantv and firmly attached; or they may be abundant and freely shed; they may be dry or fatty, white, pearly white, or yellowish. They may occur in single layers, or massed together in variable degree. The so-called scales of sebor- rhcea are made up of dried sebum and epithelial cells. Scales occur commonly in such diseases as squamous eczema, psoriasis, ichthyosis, squamous syphilide, ringworm and favus. SYMPTOMATOLOGY 25 SECONDARY LESIONS Crusts (crusts) are the remains of effete products of disease, more or less changed by desiccation. Crusts usually cons; rum, pus, or blood, intermingled with epithe- lium, and are seconda: 16 inflammation of subjacent parts. They may, it of fat ami epithelium, or of fungus growths, as in fains. They vary in color, with the nature of tbe exudation from which !. from the light yellow of serous products, the green- i.-h 01 i-vellow of i mulations, to the brownish or blackish hue due to the presence of blood. If the i ■ free and thin, they must Boon I n off ; if thick, the] n layers and raised above of the skin. They may be .-mall <>r large; firm or friable; thick or I or loot! skin. i>r a superficial or deep ulcer. In outline, tl • rally follow the lesions which produce : hut may l»e disposed among other D a way to obscure their lary or > . syphilis, I many o tnmon afl ire superficial solutions of continuity usually due to mechanical injury, and varying in size, shape, and depth with the nature and degree of the force which produced them. fly in dis.-a- ed with itching of the skin, and oommonlj result from k ; but may In- caused by ruhhin • •s. When due to tearing with the found only on ble to the lii •i pruritus, or be secondary in papular atfe< tions, Linear in phthiri with a superficial re a: and if due per injury, exud -. which dries into brownish crusts. •nations are found in ire linear solutions of continuity involving the epidermis and corium, due to either injury or disease. They occur chiefly to frequent movement, or inelastic, ■ ned or hard. Tim- mid from disease in the normal lines of the -kin, in th - of the join- d the I the body, and on the palms and sol, -. M..-t fissures an lent to the infiltration and thickening of the skin produced by that d or in syphilis, dermatitis, ty, or from any factor which in< on the skin, which has been rendered inelastic. If they involvi irium they are likely to lie painful on movement, may bleed • il : when irregularly scattered lurfaoe, disseminatt : when limited lo one or a few regions, "•■i l i:e,t: when occurring alike on both lateral halve- <.f the body, symmetrical j when limited to one ride of the body, umZaieroi. An eruption is called uniform when it c • onlv 01 ultiform, when more than one type of prin us are present at the same time. M.mi . other qualifying • ployed to describe certain peculiar .if in; eruptions, as to regional distribution, cause, clinical appearance, Their mean i ar, and therefore no extended explanation is ne cessa ry. The term capitis, occurring open the head, usually the scalp; itical, produced by an animal oi • camples of qualifying words used in describing eruptions. ETIOLOGY Tii - nf .skin disease arise from many and varied sources, and operate from within t ; a (internal) or from without (external). The same causative factors do not always produce, directly or indirectly, the same > specific causes. This varied relationship of many causes to disease, together with a want of knowledge regarding the etiology of 28 ETIOLOGY many diseases, stands in the way of the most practical system of grouping skin lesions or diseases according to their etiology. Causes themselves may be divided for convenience into predisposing and direct. Predisposing causes include states of the general system, which have come from hereditary transmission; acquired conditions of the fluids and tissues of the organism, often manifested by the presence of internal disease of a gen- eral or local nature. Cutaneous eruptions occurring under such conditions of the system may be incidental or essential symptoms of them, and hence are sometimes called symptomatic skin diseases. Direct causes are those agencies which act directly upon the skin itself, or appear to do so. Diseases produced by direct causes, together with diseases which begin in or are confined to the skin, but whose causes escape our obser- vation, are termed idiopathic skin diseases. It is possible that the same disease at one time may be symptomatic, and at another idiopathic. General etiojogy of cutaneous disease is, therefore, a principle with a large varying relationship, and frequently identical or mingling with the general or special causes of other diseases of the system, its organs or parts, which, moreover, must be practically learned in connection with individual disease. A brief review of the more general predisposing and direct causes will suffice here. Among the predisposing and general causal agents may be found : Age and sex. Life is measured by age, and certain events occurring at periods of life are qualified by sex. In the early part of life the more acute inflammations and hypertrophy are more apt to occur; in late life, less acute inflammation, atrophy and degenerations. Beginning with early infancy, strophulus, congenital syphilides, ichthyosis, etc., may appear. Intertrigo, impetigo contagiosa and ringworm of the scalp are common to childhood; during dentition, erythema, eczema capitis and urticaria are most frequent. Acne, seborrhoea and psoriasis seldom develop before puberty. Chromophy- tosis, rosacea, lupus erythematosus, etc., are diseases of adult life. Cancer and affections due to degenerative changes are rarely seen until middle life or in old age. Vaccination must now be reckoned as an event in the life of most children. While its causal relationship to subsequent disease is not clear, there can be little doubt that such relation exists as regards some cases of skin disease. It is probable that its influence in such instances is largely to arouse some latent tendency in the system, rather than a direct effect. The author has observed cases of psoriasis, eczema, furuncle and impetigo which appeared to have originated primarily from vaccination. Louis Frank has classified twenty- two skin diseases which have been attributed (1) to vaccine virus; (2) to mixed inoculation, and (3) as sequela? of vaccination. Sex alone exerts little influence until the approach of puberty. There- after, the greater divergence in the habits of the two sexes has a modifying effect only less pronounced than the physiological differences of the mature ETIOLOGY 29 male and female. These latter differences reach the point of exclusion in only two diseases — 6ycosis does not occur in the female, and Paget's disease of the nipple does not often occur in the male. As causal events peculiar to women, menstruation, pregnancy, lactation aud the menopause require notice. Menstruation more often a^ sting eruptions by the recurring disturbances of the circulatory or nervous systems; but, if excessive, it may lower nutrition and create a predisposition to cutaneous i Such disi ma, urticaria, acne and i ire frequently worse shortly ippeaiance of tl bale transient erythema, herpes and purpura may appear only at the monthly period. Bloody sweat (lueinati- droaia) baa been observed in amenorrhea; likewise, excessive local or general perspiration, with or without reenltu ma or eczema, is not uncommon, may be attended wiii _, r pruritis vulva?, or the itch- may I" i associated with urticarial Lesions. chloasma is quite common, herpes simplex is often seen, herpes gestationis • iuite rare, and impetigo herpetifon fortunately, ly rare. With t iptions incident then ar. tation, like d agia, may tend more to aggravate chronic erupt than to .s. This is probably due to a lack of cutaneous vitality from a rted nutrition. Tin. ma, which may ' I during pregnancy, are liable to return during Lacta- rate ah in in ua and ine e pronounced in f womai //■ r, ■■'■hi. Mai i ii. .n-i. lired inherit ,]y ichthyosis, am rematun and possibly . ' unlikely t! rid wholly due to in u of BOme dia- •>t uniformly pro of skin may family thr<- :it. It has K.-en oed as ai proclivity to definite forms of disease. 'I n of diathes ted nic disease. In the cutaneous mon dial iich •iie rheumati - and exudative ery- thema ; the stnr ment of ma, aene and Lmp< tigo. ■i diseae ! to tropical 30 ETIOLOGY climates, e.g., leprosy, delhi boil, yaws, etc. Warmth of atmosphere seems to favor outbreaks of urticaria papulosa, miliaria rubra and intertrigo; in cold weather, eczema, psoriasis, seborrhcea, lupus, ichthyosis and pruritus are aggravated, or tend to recur; chilblains and dermatitis hiemalis originate in cold weather, boils and erythema are most frequent in the changes of spring and autumn. Sudden changes in temperature may cause greater activity in many existing eruptions or a fresh efflorescence. Occupation. Fissured eczema is common in plasterers, masons and wash- women, whose hands are frequently brought in contact with alkalies. Those who handle animals or animal substances, as herdsmen, tanners and butchers, are most liable to anthrax and ecthyma. Occupations necessitating exposure to heat, as with cooks, blacksmiths and firemen, are favorable to attacks of erythema, eczema and dermatitis ; while workers at oil refining, tar distillation and in aniline color making, etc., are peculiarly subject to the latter disease. The dwelling and clothing, often in connection with uncleanliness in various forms, are promoters of skin diseases. The air of houses and rooms polluted with sewer gas and other noxious emanations are favorable conditions for the occurrence of pemphigus in young infants, furuncles and strumous diseases; and, associated with uncleanliness of the person, largely diminish the resistance of the skin to the invasion and multiplication of animal and vegetable parasites. Soiled flannel and other underclothing, long worn, favors the development of seborrhcea of the body and eczema; while too light or too coarse garments, or the presence of irritating dyes in clothing, may excite excoriations, papular eruptions and pruritus. It is to be borne in mind, however, that eczematous eruptions are usually made worse by indiscriminate use of water, and that too much or too frequent scrubbing of the skin with poorly made soaps may excite some form of that polymorphous disease. Effects of existing disease: Oastro-intestinal disorders, dyspeptic or catar- rhal, nearly always accompany the early onset of rosacea, and only less often bears the same relation to urticaria. Erythematous, acnoid and eczematous affections also, at times, appear to originate from alimentary disturbances. The relation of food in quality and quantity to disorders of the digestive tract and associated skin eruptions is not to be overlooked. Infant foods, containing undigested starch, are frequent sources of cutaneous erup- tions in infants and young children; but, at all ages, food may be an im- portant factor. Certain individual idiosyncrasies in respect to one or more articles of diet may also have a direct causal relation. Diabetes mellitus pre- disposes strongly to the formation of boils, carbuncles, cachectic acne, urticaria and erythema. Glycosuria rarely produces a characteristic papulo-pustular eruption (xanthoma diabeticorum), unaccompanied with any subjective symp- toms, but which rapidly disappears with the relief of the diabetes. Pruritus. with or without secondary eczema, especially about the genital region, is fre- quently caused by diabetes. Of less practical importance is the superficial and terminal gangrene of the skin, which occurs sometimes in the advanced stages of the disease. Eczema, purpura, urticaria and general pruritus are ETIOLOGY • 31 occasionally observed in the course of chronic nephritis in old people. In the advanced stages there sometimes appears upon the skin an erythema, which, at first, may resemble measles or scarlet fever, but the patches of erup- tion soon coalesce and may become generally diffused. Desquamation in large flakes follows, leaving the skin infiltrated, red and sometimes eczematous. This uraeniic erythema is of grave prognostic significance. Spasmodic asthma is frequently enough observed in association with eezenja, acne, urticaria and ichthyosis to lie named as a cause. The author had a case of -pityriasis rubra pilaris under observation, in which the periods of aggravation were attended wit; asthma. LUhamia and jam are common causes of persistent pruritis, with or without an attendant erup- tion due to scratching. Chronic jaundice, from whatever origin, frequently stands in etiological relation ng multiple xanthoma; while simple xanthoma of t la, on the other hand, in the majority i ids in sequent relation to migraine. Incidentally, tfa how the same patho- logical disease, though clinically unlike, may arise from totally dil v causes. Chronic constipation may induce pigmentary deposits m the skin or chloasma. A rare affection named chromic 1 which I I and - the sebaceous s, , ., result of consti- pation. A theoretical explanation of tlored sweat is, that mdol lorhed from the : ee, and changed in its elimination into n and indigo. Bowever ft be, cure of t: pation h the in. Chloasma patches on the skin occur not infrequently in pi li. from tsionally they are symptoms of abdominal can- * a contracted liver. '1; the skin, from Add iphthalmic goitn known. In the and limit freckles ahout resemble leucoderma. In old aire pigment patch) i an son etimi n of the skin. istitutiur ly with characfa ehaoj those mentioned, i >fula, pyssmia, BCUTV] and malaria. I ''onus of malarial d frequently prod; the skin, herpes and urticaria: leas often, erythema and purpura -till less commonly, furuncles and lently determine the location and extent of eruption, hut the cutanci ly no niea 'ant. and the character of tin- eruption is far from uniform, if t the variel zoster which are 1 to !»«• always dm- to an inflammation of some part of th trunk or ganglion, having terminations in the affected area. nich as L r r«at fright, L r ri''f. etc.. do sometimes transmit to the trophic nerve powerful impressions enough to cause bleaching of the hair, baldness, eczema, severe pityriasis and psoriasis; hut all of these may follow quite different ca 32 ETIOLOGY Marked variation in the degree of nutrition resulting in plethora or debil- ity, while not strictly diseases, if persistent, establish a predisposition to disease. Plethora predisposes to superficial congestions and inflam m ations of the skin, and tends to make them less tractable to treatment. Such over-fed individuals are more liable to attacks of eczema, pruritis, etc., from trivial causes. The debilitated are much more prone to attacks of seborrhcea, furun- cles, carbuncles, ecthyma and impetigo than those who are well nourished. Defective nutrition and impaired functions of the skin probably also have much to do with the ease of lodgment and growth of parasites; the invasion of pathogenic germs or the absorption of contagion. Some persons are readily infected by contact, while others remain wholly immune after exposure. This difference can only be accounted for by constitutional or local loss of vigor, some anatomical peculiarity or change in quantity or quality in the protective secretions of the skin. Drugs in small or large doses produce nearly all the elementary eruptions of the skin. With few exceptions, drug eruptions are not a constant effect or uniformly characteristic. The eruptions which are caused by quinine, copaiba, belladonna, iodine, bromine, chloral, etc., will be referred to in detail under dermatitis medicamentosa. Thus far it will be seen that the general or predisposing causes of skin eruptions are both numerous and plainly related. Yet, in many instances, we are unable to demonstrate the direct connection between them and the cutaneous disturbances caused by them. This may be, in a measure, due to the operation of several or many factors at the same time to produce morbid conditions of the constitution or of separate organs or parts not under- stood or easily defined. The psora of Hahnemann finds little place in the modern etiology of dermatoses, and, in its narrow sense, deserves none. But, with a broad interpretation of its intended meaning, it might well stand for those indefinable states of constitution which underlie many chronic skin diseases, and, at the same time, prevent a too ready neglect of the relations of general pathology in the active search for the local or direct causes of erup- tive diseases. The direct causes of skin diseases are external in origin and do not neces- sarily bring about any disturbance in other organs; or, if they do so, such disturbances are secondary to the skin disorder. Some of these have been already named under the more general head of occupation, etc. Idiopathic skin lesions, unlike the symptomatic, have a distinct relation to the nature and action of the causes which produced them. These causal factors, accord- ing to their nature, may be chemical and toxic, mechanical or parasitic. Chemical agents may excite irritation, inflammation, or destroy the superficial and deep layers of the skin when brought in contact with it. The degree of injury will depend on the nature of the irritant, the duration of the applica- tion, and the sensitiveness of the part involved. Agents of this class are verv numerous; they include many plants which contain an active principle dele- terious to the skin, such as arnica, ivy, sumac, mustard seeds, etc. ; most of the ETIOLOGY ; ! ; ! ethereal oil> ami resins; the poisons introduced into the skin by the stings an 1 >* **.*> . mosquitoes and snakes; the various antiseptic preparations, when or over-used, such as iodoform, corr blimate, carbolic acid, and creolin; substances used in the pro* of manufacturing d aniline dyes; strong a< dtric, muriatic, sulphuric, acetic and lactic-: the stronger alka lustic potash; the effects of heat, from unusual exposure t<> the rays of the sun, from over-exposure j, or from the radiation from heaters or Barnes, or from actual con- tact, and ah oold. To these might be added the effects n chemicals used in the various trad< • tntly unavoidable, and espe- cially the many medicated applications, often unnecessary. It is to be borne in mind that chemical irritant- ma;, not l>e limited in effect to the area of the •i directly acted upon: hut. through their influence <>n innervation, ma\ sturhano mm points, or, from weakening the resistance of the ;. permit otl Regarding thi> relation medicinal irritant-. Kap irell said, "These relations are altogether too little known, for, it' they were, physicians would not use cutaneous irritants riniinatelv." Mechan ncidental to nearh tive employ- men! of mankind, and ma\ ait to produci the epidermis or deeper ch commonh promotes health, if too _ continued, without proti f the sui [ .ml con- ■ inflammation. Frequent or pn contact with water, m> the hand- of a laundress, ia apt to < as which constantly the hands to irrif - w n!i b ind ■ tend i eruptions. Intermittent pressure, in the work of shoemakers, bUu uing of the i us layer of the epidermis, known aa callus; while prolonged pressure over from ;i tight -hoe. in,i\ produce davi. Tightly encircling bands and itruct the local circulation, maj induce swelling of the skin or enlargement of the veins. B other causes of mechanical irritation not named, ami incident t cupation and habits, are the excori- ii- from scratching with the finger nails, and all sorts of accidental abra- ns, bruises and l . to wh one is more or liable. Pat iher ammal or vegetable in origin. Modern methods of investigation have demonstrated the etiological relation of parasites to a _-e number of f ringworm and tn The) are found in the lesions o irbuncle. furuncle, erysipelas, leprosy, tuberculosis cutis i lupus vulg i . and other Minion .1 They probably enter inl syphilis, molluscum epitheliale, po*wibl\ if eczema and some 34 DIAGNOSIS affections whose etiology is now obscure. It is but proper to say that scientific proof of the etiology of micro-organisms to skin lesions, according to the laws of Koch, is wanting except in a few diseases. On the other hand, observed facts in clinical history, curative and preventive therapeutics, justify the belief in such an etiology of wider influence, and emphasize its importance to der- matology. Animal parasites, comparatively few in number, are well estab- lished as essential causes of cutaneous lesions. Some dwell upon or in the .skin in a permanent way, as the itch mite, filaria, etc.; others, as the bedbug, body louse, etc., only seek the skin at intervals to obtain food therefrom. The lesions produced by animal parasites may be ephemeral wheals or ery- thema; sometimes vesicular and pustular inflammations of longer duration, or permanent and disfiguring, as in parasitic elephantiasis. The healthy and intact skin does not probably afford the proper soil for the habitat of most vegetable or animal parasites; hence, some predisposition may be the first element in the etiology of these diseases. DIAGNOSIS In the discrimination of skin disease it is not enough to say it is papidar, pustular, etc., but in each individual case it should be recognized broadly as a clinical entity, beginning with its earliest manifestations and ending with the evolution of its lesions. Knowledge, therefore, of general and special pathology, symptomatology and etiology, united with trained observation of minute details and sound judgment, are essential to accurate diagnosis. While special diagnosis will be considered in connection with separate diseases, there are general methods which are profitable to study by themselves, as illustrat- ing a system of collecting and grouping facts for the purpose of diagnosis. If it appears that an expert diagnostician arrives at a differentiation of disease by a rapid survey of symptoms, etc., it is a mistake to infer that his expertness was attained in any other way than by systematic methods of inquiry. An effort should always be made to see things as they are found, and not hunt for facts to fit a name, which is the last if not the least in importance. As sight and touch form the chief means of examination the patient should be seen in good daylight. Direct sunlight or artificial light modify color, especially the shades of yellow, to such an extent as to be at times misleading. The room should, if possible, have walls of neutral tint so as not to reflect their color upon the skin. The temperature of the room should be such as to permit the exposure of the skin, in whole or part, as may be necessary, without injury to the patient. The inquiry may now be con- ducted regarding facts which pertain to the patient, the disease and the lesions. The following grouping after Crocker, somewhat modified, will be found a useful guide for the student in this line of investigation : DIAGNOSIS : ^"> Patient. family history, occupation, mode of li ins, eeneral health. „ (Name, i DtstHse. —Symptoms, duratioi isation. its. — Kind and character, evolutii ibution, ,> ' ■ I rogn. The patient's family and personal b ige, sex, occupation, mode of livu plexion, general asp' or local disturbances are to be not mainly iiapter on etiology, to which student is referred. Family history may me hereditary influen personal history, the previous existence of other disease, or previous atta \he same disease, as is not ui d in psoriasis, eczema and urticaria. If ode of living may bare ^ed to plethora or mm. Local distnrbanoe in i is apt to : ia and ci The disease manift I by symptoms of a general which may iptiou. nstitutional disturb- fever in must of the innammato: tally in eczema and the para- n diseases; burning ->r tieiiraL 3 these set fit int'i the clinical history. The same : of the odor .dor in hilitic i) d variola and gangr. ration a An eruption lasting continu- !v two or n lude tli>- erupt r. of thema and urticaria longer, with remis- lasting for months or yet like the more usual chi •■. rossoi lepra, lupu- The rse of the disease the eruption appear all pemphigus; or continuously, resolving? Did it extend by more ma, ption primal d by the stages of evolutions, . multiforme; or i lined b] Qg or local methods of . tin.nt !- \- th< l* queries an anawi went by the patient, due all' g for inaccuracies of descrip- tion and misuse of terms. F ten required to elicit the ally in erratic history may be The lesions, t I titration, evolution, etc., ■ffOrd ' ' a lliell the III ! t)L r file |ia- ■1 and the disease ten or modify. The kind of lesion, whether pap and pi ; >>r papulo n acne, eczema; or v r multiple li : i i lis and many cs ema. The pn induration in <>r about them; signs inflamma heat, swelling and color, or color due to other pathological 36 DIAGNOSIS changes, as the yellow crusts of favus, the violet red hue of lupus nodules, etc. In the earlier stages of an eruption, lesions are most likely to show typical forms, unchanged by evolution or artificial means. Even when such changes have occurred, the edges of an active patch will frequently exhibit the original form of lesion. Secondary lesions may indicate the primary form, as the yellow scabs from previous pustulation, the light yellow to brown or blackish crusts from the drying of serous, seropurulent and bloody discharges ; the ulcers due to degeneration of infiltrating growths, as from syphilis and lupus vulgaris. Tims, also, is their pathological character and evolution partly ascertained. The identity of a lesion may be made clear by observing its peculiarity of evolution. Lesions may spread by peripheral extension, and, at the same time, clear in the centre, as seen in ringworm of the body, erythema iris, etc., or without tendency to clear centrally, as in seborrhceal eczema. When adjacent rings expand to meet each other, the sections in contact disappear, while the free border continues to extend, forming irregular curves and figures, as in some cases of psoriasis. The distribution and extent of lesions may be characteristic. Symmetrical arrangement of lesions is usually due to constitutional influences, or to the presence in the circulation of irritants or poisons; examples of which are the lesions of the eruptive fevers, and from the ingestion of the iodine salts. Unsym metrical distribution of lesions is largely due to agents primarily acting upon a local part, as the local infection in lupus vulgaris, or through the nerves of a part, as in zoster. Universal distribution of lesions may occur in pityriasis rubra, pemphigus foliaceous; and a general distribution in many erythematous affections, eczema and psoriasis. The lesions in some skin diseases commonly begin in certain regions; as. for instance, seborrhceic dermatitis upon the scalp, psoriasis upon the extensor aspect of the elbows and knees, and thence by preference to the other extensor surfaces. The general tendency of eruptive diseases to develop in certain regions is shown in the table below, from Pye Smith, as modified by W. A. Hardaway. Scalp. — Eczema, seborrhcea, alopecia, alopecia areata, psoriasis, steatoma. favus, syphilis, ringworm (in children), pediculosis. Face. — Forehead: Chloasma, acne, syphilis, psoriasis, zoster, epithelioma. Eyebrows: Seborrhcea, alopecia areata, alopecia syphilitica. Eyelids: Xan- thoma, eczema tarsi, milium. Nose: Lupus, syphilis, epithelioma, rosacea, rhinoseleroma, seborrhcea. Nose and cheeks: Bosacea. lupus erythematosus. Nostril orifice: Folliculitis, impetigo, herpes. Upper lip: Eczema, herpes, lupus. Lower lip: S3philis, epithelioma. Mucous membrane of mouth: Herpes, syphilis, measles, small-pox, lupus, leucoplakia. lichen planus, pem- phigus. Bearded face: Sycosis, pustular eczema. Ears. — Lupus erythematosus, syphilis, lepra, xanthoma tuberosum, eczema. Neck. — Eczema, scarlatina, intertrigo, furuncle, carbuncle, sveosis. Back. — Acne, tinea versicolor, seborrhcea, pediculosis, carbuncle. Chest. — Scarlatina, varicella, syphilis, keloid, seborrhcea, lenticular cancer. Breasts: Keloid, eczema. Nipple: Eczema, scabies. Pagefs disease. DIAGNOSIS H7 - of trunk. — Zoster, syphilis. Abdomen. — Typhoid and typhus rashes, tinea versicolor, scabies, syphilis. Umbilicus: Scabies, erysipelas, carcinoma. Scrotum. — Eczema, pruritus, syphilis, elephantiasis. Prepuce. — Herpes, scabies, syphilis, chancroid, eczema. Nates. — Furuncle, carbuncle, scabies, sypbJ Anus. — Pruritus, eczema, mucous tubercles. Elbows. — Flexor side: Eczema, xanthoma planum. Extensor Bide: Peon- is, xanthoma tuberosum. Forearms and backs of hands. — Erythema multiforme. Wrists.- Flexor ride: Bcabiee, lichen planus. Extensor side: Small-pox. II mills and j" t.— E dloaitas. Palms "nil soles. Syphilis, eczema, Fingers and toes: Chilblains, pom- pholyx. NTails: Hypertrophy, atrophy, onychomycosis, onychia, paronychia. In and groins.- -Intertrigo, eczema, ringworm, erythraama. Thighs. — Extensor side: Prurigo, ki pilaris. AV Flexor side: Eczema. Legs. Eczema, erythema nodosum, ulcer, purpura, ecthyma. • mi mi.- the line of in. pun can be carried farther and the 'tints of lesions noted, such as the pigment stains which may be left by the lesions of syphilis, lichen, ai the disfiguring rofuloderma and lupus vulgaris, the smooth, delicate ci< iperficia] syphilitic oleer- ations. ('are iim-i be Died to discriminate between lesions natural to the morbid process and those which result from external influences, such as the blood crusts, excoriations, wheals, etc., from scratching, or from changes iit aboui by soothing, -timulatn al treatment. borne in mind that two >>r more diseases may co-exist, in which oik- may more or less completely mask others; thus SCZCma may he fted on a lupus erythema! vphilitic ulceration disguised as lupus vulgaris; scabies complicate s ; or impetigo change the clinical .1 of 1 varicella. Certain lesions are pathognomonic whenever found in ac stion with other signs of s disease. Such are the sulphur-yellow cup of favu-: the broken "stubble" like hair in tinea capitis; the DUITOWS of the itch mite; tl ra on the hairy part-, and the hemorrhagic points on the non-hairy parte, in pediculosis; the flat, glistening papules in lichen planus; and the apple-jelly nodule- of lupus vulgaris. Tie "f a cutaie ise will frequently be learned during the collection of facts relating to the patient, the symptoms and the nature of the lesions found, aided by ■ knowledge of general and special etiology. The presence and nature of othei max be demonstrated by methods <»f examination adapted to such disease, as clinical analysis of the urine in affections of the nrinan organs, or laryngoscopic examination in of syphilis, cancer, lupue and leprosy. The microscope aids in the detection of parasites, and may further aid diagnosis in demonstrating the nature of aeopli . in doubtful cases Bacteriological has enabled 38 TREATMENT advances to be made in etiology and pathology. In no other branch of medi- cine has such strides been made in recent years; and this method of investi- gation may at times be available in establishing both the cause and the diagno- sis of obscure cases. A diagnosis should never be made without sufficient examination. Occasionally even the most expert dermatologist may require repeated examinations before arriving at a positive conclusion. The same facts which enable the physician to distinguish one disease from others furnish important indications for treatment (discussed below), and these again to- gether with a knowledge of the probable effect of treatment form a basis for prognosis, i.e., the probable course or termination of disease. TREATMENT No principles or art of therapeutics of the skin can be scientific or practi- cal which disregard the varied relations and the equally varied functions of the cutaneous structure. That therapeutic principles founded on such a basis alone can be wholly scientific is not claimed, because knowledge of function and the mode of operations of external and internal forces or influ- ences upon a part are far from complete, yet certain relations and needs are unmistakable and point to the advantage of classifying principles in accord- ance therewith. The value of a principle of therapeutics must depend on the stability of truth or facts which underlie it and its utility in the art, with or without strict regard to the details of its application. Therapeutic principles prevent hap-hazard prescribing, they conserve time, but they need not limit freedom of thought or abrogate common sense. To meet his own needs in treating diseases of the skin the author has classified treatment under five heads, each of which indicates a special purpose, but which may merge into another in application without loss of identity or conflict in action. Individually they stand for nothing new; collectively they may represent a convenient system of inquiry as to what is required in the treatment of a case, whether: Causal (antiparasitic, etc.^. Physiological, Pathogenetic, Mechanical. Operative, one or more. Etiology becomes at times a basis for a principle or treatment which may or may not fall within the sphere of other principles, therefore it is best considered by itself. Causal treatment implies the use of means to remove the obvious causes of disease. Perhaps its most common application is in the destruction of parasites. While the latter do not represent the whole etiological factors in such cases, neither prevention nor cure permits a disregard of their rela- TREATMENT 39 tions as exciters or disseminators of certain disea>e?-. Among the parasiti- cides ichthyol, thiol, rcsorcin, carbolic acid, naphthol, lysol, creolin, trikresol, formoiin (saturated aqueous solution of forty per cent, formic aldehyde). -ium permanganate, iodine, hydro >.cid'', corrosive sublimate and sulphur, may be mentioned. Causal treatment may call for operative measures, as in a case under my observation, where an intractable eczema of the face was easily cured after the removal of a nasal polypus. Chloasma, partly due to resorption of coloring matter from the intestines, may often be cured after sufficient removal of the effete intestinal accumulations, whether attended with constipation or not. A daily stool is not always a sign of efficient intestinal elimination. Faecal tumors may e\n. M : i r i . of i'. natural spring waters of this ...nun-, and the Continent due. bin with the relief from business and ■ in a bug ee for the marvelous one <>f t h<- health res However, the path irious mineral waters, adminis ile. Pathogenetic therapeutics is a ride field and beyond I contribution. Mam rathor in tin irity of homoe- opathic medication, and are rery likely thankful that it is not a question of doubt, but mally fin'l it difficult to correctly apply, because we di know enough about it. These difficult so great in cutaneous added t" subjective indications. The principles, however, s me and ..n which to hang a prescrip- 40 TREATMENT tion, i.e., location, sensation, aggravation and amelioration, are just as valuable here as elsewhere and there are no bodily limits as to location of symptoms. Pathogenetic therapeutics may be external, however, as well as internal. In this respect the exposed mucous surfaces and the skin cannot be viewed thera- peutically like other tissues, subject as they are to direct external influences. The indications from pathological change can sometimes best be met by local remedies which produce immediate pathological effects. This is the chief basis, I believe, for local pathogenetic treatment. ^Repressive measures are inadvisable and often dangerous, but substitutive irritation is often curative. Take a case of long standing eczema, for example, with pronounced changes in the structure of the skin. Such a case we may cure by internal treatment, but if not soon responsive to a remedy the immediate application of some sub- stance that will produce a similar irritation or inflammation may be of great service. It would seem that to produce a reaction is often the most scientific- way to cure a chronic skin disease. This may be achieved by the external application of such drugs as tar (crude or distilled), ichthyol, carbolic acid, pyrogallol, chrysarobin, anthrarobin, iodine, formalin, etc. ; or by the use of physical agents, such as heat, light, Rontgen rays, radium, high frequency currents, etc. ; or by internal medication in physiological doses of such remedies as mercury, or the iodides; or by the administration of serums or toxins, like streptococcus serum, tuberculin, thyroidin to produce reaction. Mechanical treatment is nearly always auxiliary to other methods. The nature, functions and exposures of the skin may call for protection, lubrica- tion, support, compression, etc., by the employment of non-medicated lotions, oils, ointments, pastes, varnishes, bandaging, posture, etc. The even com- pression of the skin from prolonged immersion in water is sometimes of marked effect, not only on the superficial surface, but as well upon the tissues beneath. Thermal effects may also be obtained through this medium. Mechanical treatment of the skin, if not alone curative, promotes comfort, which is no unimportant feature of most remedial measures. Cleansing, soothing (and practically non-medicinal) lotions may contain peroxide of hydrogen, one part of the ten volume strength to two to five parts of water; boric acid in saturated solution or reduced one-half with water; borax in two to six grains to the ounce of water : boro-glyceride (fifty per cent.), one part to five to twenty of water; carbolic acid, one part to sixty of water; benzoic acid, one to fifteen grains to the ounce of water; bicarbonate of soda, five to ten grains to the ounce ; electrozone, one part to four of water : enzymol, one part to one or two of water. Common salt may sometimes be added to water with advantage for general use, and alcohol can be used diluted with ninety per cent, of water, up to its full strength. A small proportion of glycerine may be added to lotions sometimes with advantage, but glycerine in large per cent, is seldom of value. Soft soap made by the addition of caustic potash in an excess of three per cent, to an animal fat. may be neces- sary for its detersive, stimulating or mildly destructive effects. Oils, such as the sweet almond, castor, cotton-seed or olive, can be em- TREATMENT 41 ployed alone, or more often combined with other substances, especially with more solid fats to lessen their consistency. Simple ointments may consist of fresh lard alone, or combined with wax to give it firmness; of lanolin com- bined with sweet almond or olive oil to lessen its adhesive qualities; and of vaseline alone or combined with paraffin in the proportion of two to one. Neither vaseline nor lanolin is adapted for application in acute inflamma- tion. The wide use of oxide of zinc ointment probably comes from its admi- rable protective qualities and its total medicinal inertness. It can be applied as freely a.- the simple fats; the benzoated ie occasionally preferable. Oxide or tubnUraie of bismuth in ten to twenty grains to the ounce is also protective and mildly antiseptic; salicylic acid in five to twenty-live grains to the ounce of simple ointment appears to have a purely mechanical effect on the thick- ened epidermis, loosening and separating the oornefied epithelia. Applied to non-hvpertrophic skin it may produce decided pathogenetic effects. Boric add in fine powder ..f ten to thirty grains to the ounce of lard or lanolin ointment is alone protective and gently antiseptic. The same may be said of gomenol (five per cent.), gallanol (one to three per cent.), calendula (five to twenty-live per cent.) and nmm //•// (one per cent.), each in a simple ointment For antipruritic effects carbolic acid, thiol, vchthyol, adrenalin, orthoform. iodoform, calamim in, etc, are used in simple ointment, in rose water, dilute alcohol, glj r m a combination of these, or in some alkaline vehicle like the milk of magnesia. Inert or hygroscopic powders may frequently serve to protect surfaces and nt parasitic invasion. The simple powders of finely pulverised starch. talc, leaolin, lycopodium, etc., will often suffice alone. When there is moisture to be neutralized the addition .if impalpable boric arid powder to anj of the above, except lycopodium, inc r e ase s their efficiency, and oxide of tine adds to their soothing qualities. OaUdnol in five to thirty grains t<» the ounce of simple powder L r i\e- to it sometimes increased efficacy when the skin is sensitive and tender. The compound ttearaU of :ini powder is of special mine on dry opposing surfaces. It maj be necessary to procure a mild stimu- lating, antipruritic, or antiseptic effect, and for this purpose iodoform, aristol. europhen, noeophen, ichthyol, reeorcin, bismuth, acetanilid, calamine, or car- bolic acid, in powder form, niav be added to the simple dolomol or stearate of zinc compound. Occlusive protection ie rarely adapted t" other than small areas of com- paratively immobile skin. Ordinary collod imetimes of service painted over a patch before exudation has begun, OT over dry lesions after removal of the Scales. I' the double purpose of hermetical protection and mechanical compressiori "ii the over-full hi l-vessels. Over the thickened horny tissue the addition of three per cent. Or less of Balicylic acid git it a special effect in removing the corneous epithelia. A ten per cent, solu- tion of gutts perchs in chloroform, known as troumaticin, is sometim* be preferred to collodion, especially when it is desirable t < ■ incorporate other 42 TREATMENT substances with it, as oxide of zinc or chrysarobin; the latter, however, is only used for its pathogenetic effect. Pastes are flexible applications which have little advantage over other mechanically acting applications. The soft pastes have moderate absorbing properties which may be of value in an occlusive dressing and the further advantage of ready application without heating. Lassar's paste consists of powdered starch and oxide of zinc, of each two drachms, vaseline one-half ounce. Ihle's paste is composed of equal parts of lanolin, vaseline, starch and zinc oxide. To these pastes other substances are added to give them medicinal powers. They are not essential to their protective function. Hard pastes contain gelatin and glycerine in some proportion. One of Unna's pastes is as good as any, perhaps. It consists of gelatin and oxide of zinc, each a drachm and a half, glycerine three drachms, distilled water four drachms. When used it has to be melted in a vessel placed in hot water ; it is then painted on the part and a layer of cotton-wool placed over it to prevent its adhering to the clothing. It is only adapted to dry surfaces, and then only in cool weather. It has been used as a vehicle for other substances, but is inferior to other vehicles where pathogenetic effects are desired. Varnishes, so-called, may be occasionally useful. One of the best is Elliott's oassorin varnish, composed of bassorin forty-eight parts, dextrin twenty-five parts, glycerine ten parts, water seventeen parts. It is more stable than some varnishes which have been recommended, and it serves the purpose of an impermeable covering for small, dry patches of skin. Adhesive plaster vaay be applied for support, for pressure or to forcibly stretch the skin as in its application to remove wrinkles. Operative procedures in cutaneous diseases are of the simpler sort and consist of incision, excision, enucleation, scarification, curetting, skin-grafting and the varied applications of electricity and other physical agents. Many of these methods are pathogenetic, causal or mechanical as well as operative, but for the sake of brevity they have not been mentioned before. Instruments. — The use of the curette, the lances, the comedone extractor. the najvus, milium, irido-platinum and electrolytic needles, the epilating and grappling forceps, the cutisector, the scarifying spud, the multiple scarifier. the needle holder, the pleximeter and the various lenses is well understood and needs no further description beyond what will be found in the text. Plastic surgery may be useful in a few cases, and the same may be said of shin grafting as recommended by "Reverdin and Thiersch. Fig. 5. — Epilating Forceps. Fig. 6. — Electrolytic Knife. TREATMENT 48 In,, 7. — Irido-platinum Needle. - — Piffard'x Grappling Forceps. '*. — Piffard'e < 'utiaector. .. 16 Piffard'a \ I and Comedone Extractor. 44 TREATMENT Electricity. — Every year notes fur- ther advances in the use of the physical phenomena, and to-day no one, engaged in the practice of dermatology, can afford to be without a complete electrical outfit. The cabinet, as shown in the illustration. is a convenient and space-saving contriv- ance, because from it the X-rays, high frequency, galvanic and faradic currents, electrolytic power, diagnostic lamp, sinu- soidal effects and cautery may be ob- tained. The galvano-cautery and the thermo- cautery (Paquelin-knife) are used for their caustic and destructive effect, espe- cially in lupus vulgaris involving the mucous membranes. General galvanism has been used as a sedative while it has been used locally for pruritus and Eay- naud's disease and for the relief of the pain in herpes zoster. Faradic and static electricity are not used for specific- purposes in dermatology, but on the same indications that would call for their use in general medicine. Electrolysis accomplished by the aid of a galvanic battery is a useful agent in Fig. 17. — Electric Cabinet for X-Ray, hvpertrichosis. telangiectasis, warts and High Frequency, Galvanic and Fara- 1, ,-, T - ■, .-, -,- • _ die Currents; Diagnostic Illumination, other new growths. I nder the discussion etc. of the first named disease will be found a description of the technique. Radiotherapy, or the application of the Rontgen, or X-rays, is probably the most-discussed and widely used method of physical therapy. It is to Freund and Schiff that we owe our earliest knowledge of the use of these rays in dermatology. The following diseases may be mentioned as having responded in some degree to its use — epithelioma, lupus vulgaris and other forms of tuberculosis cutis, acne, rosacea, sycosis, ringworm, favus, eczema, psoriasis, hypertrichosis, lupus erythematosus, keloid, sarcoma cutis and mycosis fun- goides. The X-rays are indirectly germicidal, through tissue reaction, as is shown by the cessation of purulent discharges in eczema and cancer after their application. Cells of embryonic type become degenerated without the surrounding healthy stroma being affected, and hence it is possible for hair follicles and sebaceous glands to become atrophied when subjected to the X-rays. For the clinical behavior and pathological action of the Rontgen rays, the reader is referred to the section on Rontgen Bays Dermatitis. TREATMENT 45 Apparatus. — One of two forms may be used — either the static- machine or an induction coil with electric current or storage batteries attached. The coil may have a double or triple winding in the primary, which should be connected in parallel or in scries and should furnish a .-park gap of 30 cm. Of the four interrupters that are in use, each ) individual advantage-, and are known as the turbine and the dip interrupters (both using mercury)., ectrolytic and the vibratory interrupters. A voltmeter, ammeter and tachometer may be used to indicate, respectively, voltage, amperage and fre- quency of interruptions. Lead plate is usually placed between the patient and the tube, an opening being mad.- Blightly larger than the area which is to be !. Ronl red that lead on d inch thick was impervious to till raj's, but in practice one thirty-second of an inch is -urti- ciently thick. The Friedlander Bhield, or bond (see illustration), is a con- venient method oi «rhen it tan be used. Aluminum screens have Fk. i^ I riedlander II i in the treatment of deep !• a- to intercept the rays which cause an earlj dermatitis. The subject of tubes admits of much honest difference of opinion. Tubes are known a- "hard" and "-oft." The former - marked ce to the pa the current, because the vacuum datively, men It- i penetrating, contain fewer of the superficial and hence the -km i> not affected quickly, but only after a Dumber of exposures. Naturally the characteristics of the -oft tube an- the i. this la-t variety that are better suited for fluoroscopic work, because the contrast between flesh and bones is more evident. When possible a regulating device Bhould be attached to all tube.-, because tubes become hard from u-.'. while rest will -often a hard tube to -nine d( - \ new tube will give out more .\-ra\s than an older one. It i- impossible t<> define any exact method applicable to all there i- ii. i mean- ■>( measuring the radiations of any single tube, and further individual susceptibilities must he expected. To offset this latter difficulty, preliminary exposures should always be instituted before •> regular course of rayii rted. These are given daily for three or four days, for about live minute-, at a distance of five inches. If no unusual tion occurs at the end of two or three week-" time, the regular treatment may 46 TREATMENT be instituted. Schiff and Freund have suggested that the coil should furnish a spark gap of 30 cm. ; that there should be a primary current of 12 volts and 1 1-2 amperes, with interruptions of 600 to 1,000 per minute; that the tube Fig. 19. Fig. 20. Fig. 21. Figs. 19, 20 and 21 show different types of Crooke's tubes, Fig. 21 showing a tube with automatic vacuum adjuster. should be placed 15 cm. distant from the lesion treated, gradually reducing the distance to 5 cm., and that the time of the first regular treatment should be five minutes, which may be increased gradually to fifteen minutes. Treat- ments should be given once, twice or three times in a week. As regards the choice of tubes, it may be said in a general sense that soft or moderately soft tubes are needed for the treatment of superficial skin lesions. However, a reac- tion should be anticipated and the treatment stopped, because a long continued raying is not necessary when a soft tube is used. For epithelioma, while a hard tube is preferred, its exact quality should depend upon the duration, depth and extent of the individual lesion. It is well to remember what Bontgen has stated, namely, that other conditions being equal, "the intensity of the rays varies directly with the strength of the primary current, and the effect varies inversely as the square of the distance of the tube from the surface exposed." Phototherapy.- — While' the bactericidal properties of light have been appreciated for many years, it remained for Finsen of Copenhagen in 1S9G to make the first practical use of light-therapy. His method may briefly be defined as the concentration of a large number of chemical rays of light on a small area, at the same time exehiding the heat rays. Exsanquination of the TREATMENT 47 part treated is necessary to ensure a deeper penetration of the light and to facilitate an acute inflammatory reaction. Compressors made of two quartz lenses, held together by a metal rim so as to leave space between, through which cold water constantly circulate* to prerent the heating of the lens are held ,n place by an attendant in Finse.rs Institute, but mechanical mean, are usually used by others to hold the compressors in place. Sunlight was used by Pinsen at first, hut later an an- light of 60 to 80 amperes and about .0 volts was condensed b - of lens. - ,1 m a metal tube which filled with distilled water to absorb the heat rays. The lenses are made of r "" ■ and the collecting lenses an- ; cm. in diameter. The rays are 1 about six ii nthel,. An outer compart g cold water surrounds the whole apparatus, thus affording additional pretention from over-heating, lour patients ma] tted by this lamp by placing a system of condensers In each quadrant oi . i THE KKY-SCHEEREft CO.H.Y. 1 ''■ -'-' I ,! kiatua Cor Phototherapy. For private work the small lamp devised by Fineen ai which end,,. -. but consists of one lent J dis- tance will [suffice. |„ this varietj the arc is so directed that the stronj *** ,i ' 11 ,lm " lv "" a» '»>< lens, and onlj 80 amperes and 55 rolbTare Decessary. ..'" i,n "f 8 ,|M ' li - 1 " "'"-« '■''I perpendicularly upon the affected area w, " d ' " ,l,M l,r constantlj exsanquinateA Lenses of condei 1 ,„ ln . pressors must be clean, and to this end they should be washed with antiseptic solutions after each treatment. Air bubbles should not be allow,,] on the lem and .ho distilled water should be free from duel and dirt. Exposures < 4S TREATMENT from fifteen minutes to two hours, and are repeated when the reaction has ■subsided, which takes from one to two weeks. The reaction usually develops in six to twenty-four hours, and may vary from an erythema to a vesicular or bullous dermatitis, which can be readily distinguished from the normal skin. No necrosis of healthy tissue results, hence scarring is minimized. Pigmentations and dilatation of superficial blood-vessels may persist beyond the ordinary time for resolution. The painlessness of actual treatment and the smooth, neat scars are points to be recommended. There are disadvantages attached to this use of actinic rays. For extensive diseased areas it is sure to prove tedious and expensive, because only small areas averaging less than an inch in diameter can be treated at one time. The parts to be treated must be free from exudation and capable of exsanquina- tion. Mucous membranes are inaccessible. .Further, it must be remembered the penetration of the rays is limited. A thorough and careful technique is the best element of success in the treatment of those diseases which are responsive to this method. Among these may be mentioned lupus vulgaris, for which it is specially effective, and some cases of lupus erythematosus, alo- pecia areata, rosacea, eczema, vascular naevi, etc. For the special treatment •of these diseases the reader is referred to their respective headings in Part II of this book. In order to decrease the expense and to obtain more rapid results, a number of modifications of the Finsen apparatus have been put on the market. While not attempting to lessen the virtue of these machines for some few purposes, the writer must enter his protest against the comparison of their work with that of the original Finsen apparatus, because such records are not trustworthy nor scientific, and hinder rather than advance the cause of phototherapy. Chief among these modifications are the Lortet-Genoud and the London Hos- pital lamps, in which the source of light can be brought within two inches •of the surface which is to be treated. Exsanquination is produced by pressing the affected part firmly on the face of the front lens. An arc light, having carbon electrodes, an amperage of 10 to 12 and a voltage of 55, is used. Many smaller, less reliable and less expensive lamps are made. In these, iron and other metal electrodes, or the high-tension condenser spark, are used to pro- duce the ultra-violet rays in varying quantity. Naturally these have no penetrating power, since the rays are absorbed by the epidermis and hence are suitable for superficial skin lesions only. Becquerel Bays. — Under this term are included those phenomena noted by Becquerel in 1896 when he demonstrated the radiating power of uranium and some of its salts. Also, we include the emanations and radiations given off by radium, which the Curies separate:! together with polonium from pitch- blende. From radium and its salts are derived at least three varieties of rays, one has bactericidal and slightly penetrating properties, while the other two seem similar to the cathode and X-rays respectively. The action of radium, clinically and pathologically, is similar in many respects to the Rontgen rays. and hence its use in all of the diseases which have been treated by the latter TREATMENT 49 agency. Good results have been reported from radium-therapy in lupus vulgaris, epithelioma, eczema, pruritus and other diseases, but the small supply of relatively weak activity that lias been obtainable has effectually prevented scientific research. The writer has used specimens <>f 5,000, 7,000, 20,000 and 200,000 radio-activity with results which will be mentioned in the following pag Inasmuch as recent investigations have proven that the so-called alpha ,md the emanation- of radium are lost if the radium i> sealed in a con- tainer, it seems reasonable that tin- radium should be in such a form that irroundii)"- wall.- will not intercept the alpha rays or the emanations. To this end Lieber of New York has produced what be terms radium coat- radium being dissolved and a celluloid rod. or disc, or other instrument dipped in th.- solution. Tin- solvent then evaporates and leaves the coat- radium, and this i- then fixed with a layer of collodion. The collodion film permits the | if both alpha rays and emanation-. A hollow tube can be similarly coated. This plan enables • to apply radium to any part ile. Variable results have followed th.- use of this method, and only recently a number of cases have been reported which were much aggravated such treatment It would seem, inasmuch a- after their use no radium could be discovered on the rods by the most delics hat the particles had actu- ally lodged in the parts and caused a radium dermatitis. WAPPl ER EXC0.NEW YORK. ■ Hum Electrode! for Administering the II igh In quency « Currents Hi.. ii Tension wi> Frequence Currents. — While these were first intro- duced into genera] therapeutics b\ D'Arsonval, Oudin that we owe our 50 TREATMENT initial knowledge of their use for diseases of the skin. There are a number of types known as high frequency currents of which the auto-condensation, the auto-conduction and the helioeoidal shunt of D'Arsonval, the resonator of Oudin and the hvperstatic of Piffard are the most important. The last two are chiefly used for skin lesions, and hence demand our attention. Of these the Piffard currents are less painful than the Oudin and their effect is nearly is great. Our personal experience has been largely with the Oudin resonator and as an adjunct to other measures in the treatment of seborrhcea, alopecia areata and prematura, acne, rosacea, urticaria, eczema, pruritus and the various parsesthesias, lichen planus, lupus vulgaris, varicose ulcers, etc., it should be regarded as indispensable. Splendid results have been achieved by its use in lupus erythematosus, and claims have been made for it in mam*- malignant skin diseases. These currents are administered through glass vacuum elec- trodes (see illustrations) which are held near the diseased area, but not in contact, for one to five minutes, daily or less often. Fig. 24. — Spiral-shaped Glass Vacuum Electrode for Administering the High Frequency Currents. The so-called unipolar X-ray tube, which is connected with the Oudin resonator, gives off X-rays when coming in contact with the surface, and has been of some service to the editor in cases of circumscribed eczema, and kindred disorders. For further clinical uses of these currents the reader is referred to the special diseases involved. TREATMENT 51 Vibration* and mechanical ""Ibbatohy massage by means of an elec- motor may be indicated for improving the circulation and assisting in the ^sm=^ No. 3. ►— TRIC CONTROLLER CO. So 1 Unipolar X-ray Tubes with ami without Handles. ption of inflammatory induration. In cat leroderma, acne indu- rata, etc., massage of this typ ly [i>n\. The indications • oeral or loca] hand-i are the Bame as are found in genera] raedi- i Fio. 26 Electric Motor with Attachments tor Vibratory and Pneumo-masi and ( autery. 52 CLASSIFICATION cine. The motor shown in the illustration has ■ attachments for cautery as well as for mechanical vibration and pneumo-massage, and hence is a conven- icnl type of apparatus. Other physical agents, such as radiant heat, freezing, liquid air, immer- sion in oxygen, etc., have been recommended for* ulcers of all types, lupus vulgaris, na?vus, warts, epithelioma and other diseases, but they cannot be said to possess any advantages over the more scientific methods heretofore men- tioned. CLASSIFICATION The test of any grouping of diseases is its practical utility for the pur- poses of study, diagnosis and treatment. It is not necessary that the classi- fication should be based upon one line of investigation, as pathology, etiology. etc^7~so long as it represents the greatest ensemble of facts and is in harmony- with scientific progress in its domain. Historical. — Attempts at systematic classification began with the regional, by Mer- curialis, in the latter part of the sixteenth century. He grouped skin diseases as they were situated on different regions of the body, without special regard for the nature of the lesions themselves. This arrangement seems to have sufficed for upward of a hundred and fifty years, when Turner divided cutaneous diseases into two general classes, — of the head, and of the body, — each with several divisions and subdivisions, intended to show the differences of the lesions as to shape and other qualities, while to eruptions of uncertain location he gave such names as syphilides, psorides, scrofulides, ephilides, etc., some of which continue in use at the present day. In 1776 Plenck made the first classification based on the objective character of the primary and secondary lesions, or the parts involved, as follows: (1) Macules, (2) Pustules, (3) Vesicles, (4) Bullae, (5) Papules, (6) Crusts. (7) Scales, ( 8 ) Callosities, ( 9 ) Excrescences, ( 10) Ulcers, ( 11 ) Wounds, ( 12 ) Cutaneous Insects, (13) Diseases of the Nails, ( 14) Diseases of the Hair. Willan, and, subsequently, Bateman, modified Plenck's classification, reducing the different classes to nine, as follows: Papules, Scales, Exanthemata, Bullae, Pustules, Vesicles. Tubercles, Macules, and Dermal Excrescences. Next in importance came the anatomical classification of Erasmus Wilson. He grouped skin diseases according to the part in which they originated, in four classes: (1) Diseases of the Derma, (2) Diseases of the Sudori- parous Glands, (3) Diseases of the Sebaceous Glands. ( 4)Diseases of Hair and hair follicles- A simple physiological plan of grouping cutaneous diseases was formulated by Barenspruns in three divisions: (1) Disturbances of Innervation, (2) Disturbances of Secretion. (3 ) Disturbances of Nutrition. Bazin and others of the French School sought, from time to time, to classify skin diseases according to their real or supposed causes. Bazin grouped all cutaneous diseases in three divisions: (1) Affections due to external causes, ( 2 ) Affections of internal origin, including those consecutive to some constitutional disorder, (3) Cutaneous deformities, congenital or acquired. In the effort to perfect this etiological system, a relation was assumed to exist between certain constitutional diseases and cutaneous eruptions, which had little foundation in fact. The increasing knowledge of the causes of skin lesions will probably permit, at no distant day, a practical classification of cutaneous diseases accord- ing to their principal etiological relations. Unna, Piffard and others have proposed classi- fications in this line, but without any general adoption by others. The classification of Hebra, published in 1845, marks the greatest advance in the method of grouping skin diseases. This plan classifies most diseases of the skin upon the evidences of their path- CLASSIFICATION 53 ological anatomy. In one group only the etiological factors are recognised: in disi caused by parasites. Some groups contain diseases which are wholly different in nature and development, and not related in causation. Nevertheless. Hebra's method, with various modifications, is the one adopted by most dermati : the present time be best framework for practical study. Hebra's system groups cutaneous diseases in twelve classes: (, 1 ) Hyperemia- Anaemias, (3) Anomalie- ) Exudations, S Hemorrhages, (•) Hypertrophies 7 Atro- phia 10 1 Ulcerations, li Neuroses, I 12 Diet caused by parai A- illustrating tin- great endeavor towards scientific classification of diseases -hould be mentioned the radical system of Auspitsi 1881 . as elaborated by Branson, in i vv ~ wherein the nn'tUitrurnl seat of th - taken as the basis for classes, and the pad of diseases is shown by subdivisions into order-, tribes, families, genera, sad this arrangement of diseases, while undoubtedly -cicntihe. is tOO COmplei anil extended in detail to serve the student as idy of skin di -cases. Leaving oaf deration the Last plan of grouping cutaneous affections, it will be found that no one furnishes a systematic classification of sufficient scope uiii.ii is bannonioua In all it.- details. Nearly all have contributed in Bonn to build op a working system, modified in one way ami another by different authors, but looked upon by all as largely provisional in character, subject to revision with the advancement >>f knowledge concerning the origin and nature ( .f morbid processes in the cutai to the unavoidable defects of all systems of i ition, - e writers hi contented tl les in alphabetical order. Bear- in mind the objects of cIj A system which can meet those requirements and follow the line of the greatest progress in medical science would seem to be tin- most desirable under conditions. a\i modern medical research is chiefly i in the inv< a of the . it follow- that, in sucl m, prominence must !*• given to the stiological element. The d in this work therefore, a simple rearrangement, designed to show, -.. far as practicable, the -. without losing the value of the anatomico-patho- "i commonly in vogue. I i test of it- utility in b Further strength ecision to incorporate it here. To avoid a confusion of nan some di s eases are included in a class not warranted by their etiology. Thus the erythemas are kept together under the general bead of idiopathii tions. though some are. without question, neuropathic in relationship. Dis- tbe appendages of the -kin and new growths an* each grouped in a js by themselves, it would be impracticable, if not impossible, to otherwise place th ;nd meet the requirement! on for clinical purposes. Where the etiology of ;i disea-e. characterized by a mw growth, i- clear, it has been placed in a different group. Although there are placed in one or another class whose relationship thereto is doubtful. to the author expedient t<> temporarily waive the doubt rather than form a non- nifiable group. It is hoped the -cope of the classification will be found sufficiently elastic to permit the transference of a dinrmac from one group 54 CLASSIFICATION to another, as increasing knowledge of its pathogenesis may warrant. Lastly. it is expected that this method of grouping skin diseases will also, in a measure, classify and simplify treatment, especially for students and practi- tioners who are accustomed to individualize cases for the consecutive choice of therapeutic methods. Class I. — Diseases of the Cutaneous Appendages. A. Sweat Glands. Anidrosis Hyperidrosis Bromidrosis Uridrosis Chromidrosis Hematidrosis Phosphorescent sweat '"Hydrocystoma Miliaria (sudamina) Miliaria rubra Hidradenitis suppurativa Nature. Absence 01 sweat, Excessive sweat Abnormal odor of sweat Abnormal odor of sweat Abnormal color of sweat Abnormal color of sweat Abnormal color of sweat Retained sweat Retained sweat Inflammation Inflammation Pathogenesis. Neuropathic, etc. Neuropathic, etc. Parasitic, etc. Neuropathic, etc. Neuropathic, etc. Idiopathic Symptomatic Symptomatic B. Oil Glands. Asteatosis Seborrhcea sicca Seborrhcea oleosa Seborrhceic dermatitis Comedo Milium Steatoma (wen) Acne simplex Acne indurata Acne varioliformis Absence of secretion Excessive secretion Excessive secretion Excessive secretion Retained secretion Retained secretion Retained secretion Inflammation Inflammation Inflammation Deuteropathic Idiopathic Idiopathic Idiopathic Idiopathic C. Hair. Hypertrichosis Trichiasis Distichiasis Fragilitas crinium Trichorrhexis nodosa Monilethrix Lepothrix Tinea nodosa Piedra Canities Plica Alopecia Alopecia areata Folliculitis decalvans Dermatitis papillaris capillitii Conglomerate suppurative perifolliculitis Excessive growth Anomalous growth Anomalous growth Defective growth Defective growth Defective growth Defective growth Defective growth Nodular growth Atrophy of pigment Matted hair Loss of hair Loss of hair in patches Inflammation Inflammation and keloid Inflammation Neuropathic Symptomatic, etc. Neuropathic Neuropathic Parasitic- Parasitic Parasitic Neuropathic Idiopathic Parasitic, neuropathic CLASSIFICATION .).. Parasitic Class I. — Diseases of the Cutaneous Appendages -Continued. \). Nails. \n f Fn I Onychauxis Excessive growth Pterygium Excessive growth of nail fold Onychomyco Fungus growth Atrophia unguis Deficient nutrition on nail- Deficient nutrition Reedy nail- ient nutrition White nail- Deficient pigment Onychia Inflammation CLASS II. — Idiopathic Affections. Lentigo Chloai Erythema nmpJex Erythema neonatorum Erythema intei I Erythema traumaticnm Erj thema ealoricum Erythema Bcariatiniforme Erythema exudativum I hema multiforme Erythema iri- • ma DOdoi Derma ti til Dermatitis ami Derm on is 1 lermatitii traumat gen-ray dermatitis I termatitis medican • l)ruj; erupt Illation ITU| ll !■ I termatitis vent tied erupt eruptions Hypertrophy of pigment Hypertrophy of pigment H\ penemic Hypenemic Hypenemic H\ penemic and pigmi ntary Hyperwniic Hyperamic Hj penemic Hj penemic Inflammator} [nflammal Inflammator} Inflai [nflammatory Inflammatory' Inflammal Inflammal Inflammatory Mirillc- ulea \ thema '. thema I thema thema Multiform N'odular Multiform Multiform Multiform Multiform Multiform Multiform Multiform .Multiform Multiform CLASS III. -Diathetic Affections. ma Paori I lermatitii exfoliativa Dermatitis exfoliatii ilcmii:i Dermatitis exfoliativa neo- natoruni Dcrmatil Multiple gangn . rene Diabetic g Dermatitis gangrem Ian turn Inflammatory [nflammatory Inflammator) Inflammatory Inflammator) Inflammatory Inflammator} Inflammator} [nflamma Inflammatory Multiple l< - scales < ■angrenoua uli i- ulcere renous uli 56 CLASSIFICATION Class III. — Diathetic Affections— Continued. Varicose ulcer Pityriasis rosea Lichen ruber Lichen planus Parakaratosis variegate Keratosis pilaris Keratosis senilis Keratosis palniaris et plan- taris Ichthyosis Sclerema neonatorum (Edema neonatorum Inflammatory Inflammatory Inflammatory Inflammatory Inflammatory Hypertrophic Hypertrophic Hypertrophic Hypertrophic Hypertrophic Hypertrophic Ulcers Patches, fine scales Papules and scales Flat papules Papules Papules Papules, warty growths Multiple Small and large scales Induration (Edema Class IV. — Neuropathic Affections. Nature. ^Hyperesthesia Sensory disturbances Anaesthesia Sensory disturbances Paresthesia Sensory disturbances Dermatalgia Sensory disturbances Pruritus Sensory disturbances Excoriations Prurigo Senso-motor disturbances Papules Urticaria Senso-motor disturbances Wheals Urticaria pigmentosa Senso-motor disturbances Wheals and pigmenta- tion Swelling Angioneurotic oedema Senso-motor disturbances Purpura Vaso-motor disturbances Extravasations Rosacea ' Vaso-mocor disturbances Multiform Herpes Tropho-sensory disturbances Vesicles Herpes zoster Tropho-sensory disturbances Vesicles Impetigo herpetiformis Tropho-sensory disturbances Grouped pustules Dermatitis herpetiformis Tropho-sensory disturbances Multiform Dermatitis repens Tropho-sensory disturbances Multiform Pellagra Tropho-sensory disturbances Multiform Acrodynia Tropho-sensory disturbances Multiform Hydroa Vaso-motor disturbances Bullae Pompholyx Vaso-motor disturbances Vesicles Pemphigus Vaso-motor disturbances Bullae Scleroderma Vaso-motor disturbances Induration Leucoderma (vitiligo) Trophic disturbances White patches Atrophia senilis Trophic disturbances Pigmentations Atrophia maculosa et striate Trophic disturbances White lines and spots Kraurosis vulva? Trophic disturbances Local atrophy Glossy skin Trophic disturbances Smooth skin Perforating ulcer of the foot Trophic disturbances Ulcers Trophic ulcers Trophic disturbances Ulcers Symmetrical gangrene of the extremities Trophic disturbances Gangrene Ainhum Trophic disturbances Circular atrophy Syringomyelia Trophic disturbances Multiform I LASSIFICATION .), CLA88 V. — Parasitic Affections. A. Animal ORGANISMS • ie- Pediculosis corporis Pediculosis capitis l'i .|ji hi..-!- pubis Pulix irritant Pulix- penetmi ( 'iiin-x leetulariua l bed Culix pipena (mosquito, gaai I.. I it u- aiitiinmali- 'hur- Lxodes rn-imi> Dermaoyasui avium 1'ilaria medini iinia norm i itieercus oelluloaas outis Echinococcu* I )i'i lex fiilliciilnriiiii Purls Aff* Skin Skin .lp Hairy gurl Skin Skin Skin Skin Skin Skin Skin Sul.. Sul ii Sul.. Multiple lesions He m orr h agic points and cxioriat I !xeoristiona Excoriations and papules Win Vari Wheals \\ beak Wheals, papules Wheals Papules Tumon Tumoi Papules and pigmentation B. Vegetable < taOANUMS . tricbopytina ' ringworm I - 'I'ii.. ilor ibrieata 'lira-ma Dhobis itoh 1 { I : t - 1 < > ■ ■ i \ I M> ringomj 1 1 Pinto disease \. i inomj raeis ni the -kin M\ cetoma Impetigo simplex Impetigo I'liiitairioKa I i i hyina 8) • ■ Paruneulm Cerbunculus Anthrax ection wounds Hhinosclirunia » trii-ntal boil Hair and -km Hair Skin Skin Skin Skin Skin Skin Skin and di< pel tissues Skin and deeper tissues Skin Skill Skin Hair follirlns foOidei and ad- jacent tissues Skin and deeper tissues Skin Skin Skill Yellow or «itli l.ranny Patches «itli a Papules in <-H. ipots Papulo-pustular 1'atcln - i pots N... i Nod Pustules pustules pustulss Papules, pustules I'u-tiilc- and Multiple ali-<<— Multiform Pustules Tumor Tubercles, ul< • .->s CLASSIFICATION Class V.— Parasitic Affections— Continued. B. Phagedsena tropica Skin and deeper tissues Pustules, ulcers Elephantiasis Entire skin Enlargement Pathological Character. Process. Tuberculosis cutis orificialis New growth Infiltrating Tuberculosis verrucosa New growth Infiltrating Lupus vulgaris New growth Infiltrating Scrofuloderma New growth Infiltrating Lichen scrofulosus New growth Infiltrating Erythema induratum New growth Infiltrating Syphilis New growth Infiltrating Leprosy New growth Infiltrating Yaws New growth Infiltrating Equinia Inflammation Infiltrating Erysipelas Inflammation Infiltrating Erysipeloid Inflammation Infiltrating Class VI. — New Growths. Chief Structure General Involved. Character. Benign Connective Tissue Growths. Fibroma Connective tissue Benign Keloid Connective tissue Benign Cicatrix Connective tissue Benign Xanthoma Connective tissue Benign Xanthoma diabeticorum Connective tissue Benign Lipoma Fat tissue Benign Myoma Muscular ; issue Benign Neuroma Connective tissue Benign Angioma Nffivus vasculosus Blood-vessels Benign Hsematangioma Blood-vessels Benign Telangiectasis Blood-vessels Benign Angioma serpiginosum Blood-vessels Benign Angiokeratoma Blood-vessels, etc. Benign Lymphangioma Lymph vessels Benign Lymphangioma tuberosum multiplex Lymph vessels Benign Naevus pigmentosum Pigment, etc. Benign Acanthosis nigricans Papillary hypertrophy Benign Multiple tumor-like new growths Glandular tissue Benign Colloid degeneration of the skin Connective tissue Degenerative Lupus erythematosus Corium Infiltrating Myxcedema Skin and subcutaneous tissue Hypertrophic Acromegally Skin and subcutaneous tissue Hypertrophic Benign Epithelial Growths. Callositas Epidermis Hypertrophic Clavus Epidermis Hypertrophic- Cornu cutaneum Epidermis Hypertrophic Keratosis follicularis Epidermis Degenerative Verruca Epidermis, papilla? Hypertrophic CLASSIFICATION 59 Class VI.— New Growths— Con tin Papilloma cutis Molluscum contagiosum Multiple benign cystic epithelioma Adenoma ikeratoeis bucealis Papillae Epidermia Epithelium Connective Papilla- Hypertrophic Degenerative Benign Benign Benign C. Malignant Epithelial Growths. Epithelioma - disease Rodent ul Carcinoma CUtifi Epithelium Epithelium Epithelium C'orium Malignant Malignant Malignant Malignant D. Malignant l nvE Tiasi i. Growths. Sarcoma cuti* mm Mycosis I i ium Xeroderma pigmentosum Blood-vi • Van ( !onnective : Malignant Malignant Malignant Malignant PART II SPECIAL DISEASES CLASS I.— DISEASES OF THE CUTANEOUS APPENDAGES A. DISEASES OF THE SWEAT GLANDS The perspiratory function is largely under the control of the nervous system. Whether there is one sweat centre or many, peripheral sweat ganglia or none, nerve supply from the spinal cord or from the sympathetic, a watery product only, or oily secretion also, remain undetermined. The quality and quantity of sweat may vary considerably within the limits of health, from differences of habits of living, exercise, etc. When there is a persistent departure from these limits of quality and quantity, functional disturbances exist; when an anatomical change in the glands or ducts is found, organic- disease exists. ANIDROSIS Definition. — A disorder of the perspiratory apparatus, in which the sweat is absent or notably diminished in quantity. This condition is nearly always secondary in character and may be local or universal in extent. It is common in the areas affected by such diseases as ichthyosis, psoriasis, scleroderma, anaesthetic leprosy, some forms of eczema, neuralgia, and forms of paralysis. The polyuria of diabetes and albuminuria naturally diminish the perspiration. Injuries to nerve trunks may cause anidrosis, and it is present in many tropho-neuroses, until elec- trical irritability is restored. Finally, there are individuals who, from some idiosyncrasy, perspire little or none at all, under conditions of temperature, etc., which induce profuse perspiration in most people. Pruritis is often associated with anidrosis, and in such cases may be aggravated in the winter (pruritis hiemalis) or after a bath (bath pruritis). Partial anidrosis occasions no disturbance, and the generalized type may lead to no discomfort, except under influences which usually occasion free sweating. Treatment. — In purely symptomatic anidrosis the treatment should be directed to the primary disorder. Physiological treatment, by the use of water internally and externally, by cold sponging or shower baths, or com- bined with mechanical measures, as in the Turkish bath, shampooing and HYPEKIDRUS1> 61 ge, tend to improve the innervation and nutrition of the skin and stimulate secretion. The introduction of vibratory mechanical massage has simplified the main object to be attained, stimulation. High frequency cur- bave ah en satisfactory for the same purpose. Idiopathic ani- - is rare and seldom marked enough to call for internal medication. See indications for Ahu, i. Lycopodium and Ntut motchata. HYPERIDROSIS (Idrosis, Sudatoria, Polydrotis, Hydr — / iting.) Definition. — A disorder of the perspiratory apparatus, in which the secretion is excessive. Miral or artificial warmth, a . libera 'ii of fluid-. . and other kindred itural pr active ration. In the abai stimuli, all due to diaeaee. Hyperidrosia ma era] or local, alight or - short duration or persistent. With I spiral ur in acute rheumatism, intermittent fever, phthisis and other wasting di- rned. They form a part of the symptomatology oi general practitioni The heal form- , ur in the axilla- and genital region, or on the palms of the hands and lually symmetrical, and on the irarmly o are apt to ated with offensive odor (bromidroeis), and. sometimes, with erythema, intertrig a. On the palms and soles th< tmmon in ) I pie, who suffer from cold extremities, due to :• rculation, ana more or leas ma i pidermis, which may be rivalled <>r flake off, leaving tin- part- tender to Bure. Hypertrophy of the outer layera of I f the palms, known aa tyh d by or of these surfaces. " ne lunli. or one-half of the bead supplied by the fifth i ■ at of the disordi Et j im' Pat Whatever tin- underlying causes ■ no doubt that d( e medium through which byperidrosie is produced, whether in the nal Emulation of the cerebro-epina] rmpathetic >>r peripheral cl ■ • ma\ be m th< mma and a the hrain: in the medulla, a- noted in ci jweat- e tumor- hare been found at the post-mortem; in the cord, from (rated refl om injury to peripheral nerves, aa rep by Weir Mitchell; from growl •■ kind which in nth the sym- pathetic. In women, disturbs] menstruation and hysteria may sive local sweating. In the Becond migraine tl ee perspi- 62 BROMIDROSIS ration. Symmetrical hyperidrosis of the palms or soles may be congenital, or very rarely hereditary. Usually, such cases are moderate in degree. The physiological experiments of Claude Bernard demonstrating that paralysis of the sympathetic produced hyperidrosis, and of Brown-Sequard, that stimula- tion of sensory fibres gave like results, are of special interest in relation to the pathology of this disorder. There does not appear any abnormality in the size of the glands or in their lining epithelia, in cases of hyperidrosis. The prognosis varies with the cause and the degree in which it is removable. Treatment. — Eemedial measures should be directed to the causal con- ditions which underlie abnormal sweating. If local defects of circulation or innervation exist, physiological and mechanical means may be employed, such as friction, exercise, cold baths, etc. Applications of very hot water to the parts, once or twice daily, followed by a dusting powder of starch and boric acid in equal parts, is very often beneficial. If there is a tenderness from a laceration and friction, simple cerate or mutton tallow may be used in place of a dusting powder. Compound stearate of zinc powder is occasion- ally useful as a mechanical protective dressing. Salicylic acid, one part to nix of talcum powder, may sometimes be used with advantage. When in- volving the feet only, daily foot baths of a one per cent, solution of per- manganate of potash continued for two weeks, are beneficial. The editor has achieved splendid results with the application of high frequency cur- rents to the axillae twice a week, in cases limited to that region. Unna recommends one-half ounce of the tincture of belladonna in three ounces of eau de cologne for sweating of the hands. Most local treatment is, how- ever, palliative, and we must look to general physiological means to remedy corresponding errors and to pathogenetic treatment to effect a cure. There are nearly always plenty of indications for a prescription, either in the general condition, in the peculiarity of the local disturbances, or in both combined. See indications for Agaricus, Aurum mur., Ant. crud., Baryta carb., Cocculus, Conium, Fluoric acid, Graph., Hepar, Hypericum, Jabor- andi, Nat. sul., N. mur., Nit. acid, Pet., Puis., Rhodod., Sepia, Sil.. Sid. and Thuja. BROMIDROSIS (Osmidrosis, Fetid sweat.) Definition. — Offensive odor of perspiration, either when secreted, or acquired soon after. Like hyperidrosis (which is frequently present at the same time) bromidrosis may be general or partial. The local forms are most common and usually affect the feet only, though the axillae and about the genital region may be the seat of the disorder. In most cases the odor is not markedly offensive, and a few cases have been recorded where abnormal odors of the perspiration have been agreeable, such as that of pineapple, violets, etc. Bromidrosis of the feet is likely to be most dis- IKIDROSIS 63 gusting, and, in extreme cases, has been compared to the odor of putrid cheese, penetrating through stockings and shoes to such a degree as to make the victims shun indoor society. The associated hyperidrosis renders the feet sodden, often red at the border- onally blisters form, and the tenderness may temporarily incapacitate the patient for walking. Etiology and Pathology. — Young people are most subject to local bromidrosis of the feet. Occupations which require much standing seem to favor it. A few cases are due to emotional influences: some to ba< ; and in others the causes are obscure. In nearly all he foul odor is due to decomposition of the fatty acids of the sweat after secretion. The sweat-soaked epidermis probably furn table soil for the growth of bacteria. Mi. an be usually found a the toes unaffected with offensive sweating, similar in those found in cases of bromidrosi- were cultivated by Thin, ami these he callB Bacterium fcttidiun,. Prom the presence ganisma be attributes the decomposition and con- sequent odor. The m can be readily found by drying some of the sweat on a cover glass and staining ii with methyl violet. Tim a i \n \ i. — As hyperidrosis nearly alwa with bromidro- sis, the indications foT treatment irly the - for the former. Antiparasitics and deodorisers are most effective palliative api - and employed after bathing with hot wi flic acid, one part t<> thirty of Kay nun or cologne; part to four hundred of ro ished appearance. This secretion may solidify in masses, as described in dry seborrhoea, but the oily condition of the .surface usually remains. In pronounced form, free drops of oil can be frequently wiped from the surface, and the ducts may be seen to be patulous or stopped with comedones, or the dust floating in the air may become attached to the oily matter and give the surface a dark or dirty appearance. If the ail'ected surface be at the ,-:ann time reddened and symmetrically distributed on the face, it might be mis- taken for seborrhoea congestiva, a designation given by Hebra to an early stage of lupus erythematosus, in which the ducts of the oil glands are plugged with adherent scales. The tenacious character of the latter serves to deter- mine the existence of that disease. The skin in seborrhoea is usually cool to the touch, but may be either reddened or pale. In the negro race a free oily secretion is more physiological, and may give to the exposed parts of the skin a pretty constant shiny look, without further evidence of the dis- order appearing. SEBORRHCEIC DERMATITIS A condition in which seborrhoea and an eczematous type of inflammation involve the same surface of the skin, has been described under different heads by several authors. Unna first described the disease as eczema sebor- rhoicum, taking the ground also that seborrhoea was often, or in part, due to an oily secretion from the oil glands. This claim has not been fully confirmed by later investigations by other observers. The disorder has been named Sudolorrhoea by Piffard, apparently for the same reason that Brocq named it "oily hyperidrosis." More recently the disease has been given the qualifying term of dermatitis, and, inasmuch as the inflammatory part is secondary to the seborrhoea, this seems the more appropriate name. The disorder nearly always begins as a seborrhoea of the scalp, which may have existed for some time; or, rarely, its starting point may be the axilla, genito-crural region, front of chest, and still more rarely on other parts of the trunk or extremities. Exceptionally, the distribution may become uni- versal. Seborrhceal dermatitis spreads slowly as a rule, and by peripheral extension, but may remain stationary for a long time; suddenly become active and spread in a uniform way, or more often appear at some new and distant point and pursue an irregular course. The lesions may be few or many; discrete, near together, or coalesce and form various shaped patches. The simplest form presents a more or less diffused scaliness, the color of the affected skin tinged with yellow or slightly reddened. The scales may be abundant enough to form adherent masses, varying in color and consistency with the character of the sebaceous secretion, from a dry gre) r ish white to a rather soft yellowish brown. This form is little more than a seborrhoea, with mild symptoms of irritation, such as itching, burning, etc. In the second degree, superficial macules with sharply defined borders are seen. They vary in shape, though often round or oval; in color, from 74 SEBORRHEIC DERMATITIS a yellowish-pink to a pronounced red. There may be found also near by reddish papules scattered about or aggregated together. lit women past the middle period of life it is not uncommon, to see a diffused redness of the whole or part of the scalp, extending down upon the neck or about the ears, with papular elevations here and there near the periphery. In such cases scales usually form abundantly and uniformly over the part of the scalp involved. Macular and papular lesions may, by peripheral extension and concurrent involution centrally, form circinate, concentric, or in union with similarly involuting lesions, band-like forms of efflorescence. The formation of scales may be scanty or abundant, and exhibit the same character as in the simple variety of the disease. When the scales are dry and whitish and sparsely distributed over the lesions, there may be a resemblance to the lesions of psoriasis, from which the scales have been partly removed, seborrhea psoria- sifgxjnis. So, also, may the thickly crusted lesions of similar shape to those of psoriasis closely simulate the latter disease. In other cases the surface of the lesions may be moist from admixture of sebaceous secretion, sweat arfct serous exudation. Sometimes there is a distinctly catarrhal discharge, which may dry into crusts; thus presenting some of the features of an eczema, seborrhea eczemaformis. In a third degree the inflammatory type of the disease is more pro- nounced, the skin is more deeply engorged and reddened, the greasy catar- rhal discharge more abundant, and the itching sufficiently marked to induce scratching. The squamous form of seborrhceic dermatitis is most common, but all degrees of the disease may commingle at the same time, or appear in slow or rapid succession upon the same person. On the scalp the disease may involve the whole surface (most often in women), or be chiefly limited to the vertex or occiput. There is commonly a greyish-white desquamation from a pale red and dry skin, pityriasis capitis. Sometimes the scales form in masses about the hairs, and when loosened appear as if strung upon individual hairs. The hair itself is lustreless and after a time becomes thinned out, alopecia pityrodes. Moist lesions may occur on the scalp; they are usually round or oval, sharply defined, yellowish red, and may become crusted over. At the margins of the forehead and occi- put the lesion may appear as well-defined curved bands or lines covered with scales or fatty crusts. Over the brow of these crusty circlets, "corona sebor- rheica," are frequently seen. When the process extends from the scalp down- wards it is more apt to spread down the forehead, temples and back of the neck, where there is produced a distinct redness of the affected surface, partially covered with fatty scales and occasionally moist lesions appear. The disease not infrequently appears upon the face without immediate extension from the scalp. The middle third of the face is most often affected, some- times the butterfly distribution is seen over the nose and outward upon the oheeks similar to lupus erythematosus. The area of reddened skin is quite SKBORRHCEIC DERMATITIS < » sharply defined; often heavily crusted, especially on and about the nose and eyebrows. Other parts may be reddened and greasy, and moist spots may be seen here and there; upon the cheeks yellow or reddish macules with less abundant scales are the most common lesions. The back of the ears may be affected with the moist or dry forms of the disease, and fissures may com- plicate the process. If the auditory canal is affected the meatus may become filled with the fatty accumulations and the hearing impaired. One case of total one-sided deafness from this cause has come under the author's obser- vation. The colored borders of the lips are rarely attacked, and in two cases under observation were secondary to the disease elsewhere. The lips affected are uncomfortably dry and stiff, from the presence of darkish crusts, which tend to separate and form superficial cracks into the moist denuded surface exposed. When the crusts are removed or shed, the lips very soon become dry and shiny, and the process of crusting is repeated. When involving the eyelids and the outer and inner angles of the eyes, it has been noted by the editor that the secretions of the eyes, especially when there is marginal trouble to complicate, serve to prolong the condition markedly; hence it is that seborrhceic dermatitis in this region is often of the pigmented, scaly, chronic type. In the axiila and genito-crural regions the disease usually occurs in red macular spots of various size, which are confined to those regions, show little crusting, owing to the presence of moisture; but if the disease spreads away from those regions, as it is apt to do by peripheral curve-like growth, scales and crusts form. Thus from the axillae the lesions may extend forward on to the border of the chest, or backward on to the scaprdar region; or from the inguinal region down upon the thighs and buttocks, over the external genitals and back upon the perineum. Where two surfaces of affected skin come in contact it may simulate an intertrigo. On the trunk the disease begins, as a rule, with small papules tipped with a smaller scale, or as macules more or less covered with scales; on the chest and back the papular form, seborrhoea papulosa, is most common. If iso- lated, they spread by peripheral growth, or if near together papules may coal- esce. In either case, a central evolution, sometimes including a portion of the circumference of a lesion, together with the mode of growth and mer- gence with other lesions, may result in figurate shapes of various degrees. The borders are sharply defined, scaly and often show raw exuding points. Thin, fatty scales may nearly always be found on the old portion of the patches. On other parts of the body and on the extremities the disease is of least frequent occurrence, the lesions are more macular in type, round or oval in shape, and less likely to merge together to form irregular patches. They may be bright red or have a . yellowish hue, with slight scaliness or thickly covered with fatty crusts, about which a reddish border may be seen. Solid papular lesions are sometimes present with the same variations in scaliness or crusting as the macular form. In both forms the crust mav 76 SEBORRHEIC DERMATITIS cover a moist or a dry base; they may remain roundish or change to coin-like, circinate or irregular shapes. Between the -fingers the disease may exhibit features similar to those seen in the axillae or groin. Lastly, it is well to note that seborrhoeic derma- titis may co-exist with other cutaneous diseases, such as the syphilides, rosacea, sycosis and acne. Etiology and Pathology. — Certain constitutional conditions of the system are said to predispose to seborrhoea, such as syphilis, gout, chlorosis, struma, chronic alcoholism, debility following fevers and malnutrition. Dis- orders of menstruation, of digestion, obstinate constipation, sedentary hab- its, excessive use of tobacco, and, in men, the wearing of stiff, heavy hats are causal factors. The fact that the disease occurs at all ages, and, in most eases, in persons of good or robust health, indicates that there must be a more direct cause than those enumerated. The not uncommon neglect of the scaip no doubt is often the first external beginning of a seborrhoeic dermatitis. Upon a surface where sebum and epithelial matters have accumulated to some extent, it is not unreasonable to suppose that micro-organisms may often find a suitable medium for growth. The clinical behavior of the disease favors this solution, as does the investigation of Taenzer, who isolated some eighty varieties of bacteria from the lesions of seborrhceal eczema. That the several forms of the disease occur in persons affected with some disturbance of health proves, as Morris has said, that, like other morbid processes, it flourishes best in a congenial soil. It has been thoroughly proven by TJnna, Brooke and others that the seborrhoeic process has a marked influence on the development and course of such diseases as acne, rosacea, eczema, psoriasis and syphilis. Despite the investigations of Sabouraud, who claims that seborrhoea is due to a micro- bacillus, there has been no satisfactory demonstration of the parasitic nature of seborrhoea or seborrhoeic dermatitis. Pathologically, seborrhoea is an epidermic disease showing an over-produc- tion of normal sebum and a dilatation of the sebaceous gland-duct openings. Normally, the sebum is produced by a fatty degeneration of the epithelia lining the pockets of the sebaceous glands. In the simple forms of sebor- rhoea there are changes in the secretion, as to quantity, fluidity, inspissation and sometimes a consequent tendency to decompose and give rise to super- ficial inflammation. Such results may then be wiped away; or cleansing with any toilet soap and water will clear the surface, after which it should be quickly dried and very lightly anointed with some non-medicated oil or fat. Some cases of seborrhceic dermatitis undoubtedly become parasitic, and local causal treatment is indi- cated. In mild cases alcoholic solutions may be efficient. Green soap may be combined with alcohol in equal proportions, which, after filtration and scent- ing with some perfume, if desired, may be employed in place of ordinary soap. This should be sponged over the affected part, and then sufficient warm water used to make a free lather; finally washing off with clear water, drying, and anointing as before directed completes the measure. Brandy or whiskey with ordinary soap may sometimes be substituted for the green soap. Or, again, following the first method of cleansing, the following lotions may be em- ployed : Sulphur one drachm, alcohol and rose water of each two ounces, gtycer- ine half an ounce; or sulphuric ether and biborate of soda, each three drachms dissolved in ten ounces of distilled water. The latter lotion can be used without first cleansing the part, when the scales are not abundant; and it may be followed by the light application of a non-medicated oil, such as lanolin one part and sweet almond oil four parts. In persons with delicate or sensitive skins mildly alkaline aqueous solutions, such as ammonia, car- bonate of potassium, bicarbonate of soda and borax, may be used for cleansing purposes, followed, after washing off and drying, by some mild anti-parasitic ointment in place of the non-medicated oils. The following combinations, perfumed if desired, will be found in a variety of cases useful: calomel in the strength of five to twenty grains to the ounce of fresh lard, or the ammoni- ated mercury in the same proportions; sxdphur one-half to two drachms to the ounce; salicylic acid, resorcin or beta naphlhol, ten to twenty grains to the ounce. In seborrhceal affections of the genitals, umbilicus and axilla, especially in stout individuals, ointments shottld be seldom used. Here lotions or dusting powders are better, when any medicated or anti-parasitic applica- tions are needed after cleansing. Of the latter, finely powdered boric acid SEBORRHEIC DERMATITIS 79 one part to four of starch or talc; powdered salicylic acid one part to ten of starch; and the compound stearate of zinc are among the best. All powders should be finely pulverized. Choice of the foregoing local measures may be made for individual cases of seborrhcea and seborrhceic dermatitis occurring on the hairy or non-hairy parts. The effect of these applications is almost purely mechanical or anti- parasitic. They act to remove a maintaining cause (the causa occasionalis of Hahnemann), and do not remedy an internal condition, but remove external obstacles to a cure. Rarely is stimulating (pathogenetic) local treatment required beyond that incident to the medicated applications already named. When needed in obsti- nate cases, to aid in bringing about the functional tone of the skin, resorcin or the tincture of pilocarpine, caniharis, capsicum, nux vomica or ergot incorporated in cold cream or other soft ointment, in the proportion of ten to thirty drops to the ounce; or, still better in many cases, in lotion of five to twenty drops to one drachm of boroglyceride and seven drachms of rose water may be employed. All local applications should be graduated in strength and quality to meet the local needs and the sensitiveness of the skin in each case. Stimulation applied to the spine of the patient by the regular application of the large, flat vacuum electrode attached to the high frequency apparatus, or applied directly to the seborrhceic area from the D'Arsonval apparatus with or without the Oudin resonator, will often obviate the need of strong local ointments. Physiological attention to the whole skin may be important. A daily cold bath invigorates the skin as well as the general system. Rock salt may be added to the water, in a proportion of a half ounce to an ounce to the gallon, to increase the effect of the bath. Other physiological treatment con- sists in the correction of habits which may have caused or aggravated the disease, and which were briefly named under etiology. Regulation of diet and exercise so as to promote healthful nutrition, and the relief of other disorders of the economy which may have had a causal relation to the sebor- rhceal disturbance are sometimes essential steps in a cure. Internal pathogenetic treatment is always important, and when the con- stitutional indications are clear, often the only treatment required. This I have been able to demonstrate over and over in patients coming to the clinic, who could not or would not carry out systematic local measures. See indications for Agar., Am. mur., Brij., Cal. acet., C. carl).. Chel., Colch.. Hydr., Kdli orom., K. mur., K. Sulph., Kresot., Merc. viv.. Mez., Nat. arsen.. N. mur., Nit. ac, Pet, Phos., Selen., Sepia, Sul. and Vinca. 80 COMEDO COMEDO (Black-head; Acne punctata.) Definition. — A disorder of the sebaceous function in which the inspissated secretion plugs the ducts of the sebaceous gland. Comedones are seen upon the surface as small blackish points or papules, which may be depressed, on a level with, or slightly elevated above the surface of the skin. They are readily pressed out of the ducts, and, from their resemblance to small maggots, have been vulgarly called "skin worms." When examined they are found to be whitish masses of sebum, and the black extremity, which presented at the surface, due to dirt and cornefied epidermic cells. The usual location of comedo is upon the forehead, nose, chin, cheeks, neck, back and penis. In number they may be few and scattered, or many and near together. They, are unattended with any local subjective symptoms, and may remain for years without apparent effect on the surrounding tissues; they are, however, frequently associated with seborrhcea, and they may, by mechan- ical or other irritation, give rise to acne. They are most common, also, at the same period of life as the two latter diseases; that is, the puberal epoch of both sexes, but they may appear at any age. Thus they have been observed in children, on parts of the skin subject to heat and moisture; and in older persons subject to dyspepsia, on the "flush area" of the face. Here they are smaller than in the usual form and tend to become grouped together. Smaller comedones are also seen sometimes upon the trunk, but not grouped. The double or multiple comedo, usually upon the back, consists of closely grouped black-heads having a common glandular cavity. Etiology and Pathology. — Comedo usually begins at an age when the oil glands and hair growth are active. The disorder in the majority of cases is probably due to a general or reflex cause. Often there seems to be a con- nection between constipation of the bowels and constipation of the sebaceous gland; but dyspepsia, scrofula, chlorosis, menstrual disturbances and cachec- tic conditions are at times plainly related, as proved by the. good effects upon the skin of treatment of those disorders. The fact that the disorder may occur in seemingly vigorous young people indicates there may be a local cause. Those subjects who work constantly in dust or dirt and who do not use soap and water freely may develop comedones from the nature of their habits. However, the pathology is suggestive. The sebaceous glands chiefly affected by comedo are those which contain the lanugo hairs, whose growth is espe- cially active at puberty. The follicles of these rudimentary hairs, according to Biesiadecki, often rest at an acute or even right angle to the duct of the gland, and as the hair grows its point meets the wall of the duct and occa- sionally turns downward upon itself ; thus acting as a foreign body to produce irritation of the duct and increased proliferation of the epithelial elements, which go to form the outer covering of the comedo. Hair filaments are frequently found in the contents pressed out of the sebaceous duct. The small mite, known as the acarus folliculorum, found sometimes in the ex- COMEDO HI ternal part of the comedo, and which excites a follicular inflammation in dogs, has no etiological weight in the human species, since it is also found in healthy follicles. Unna's opinion that the dark point which marks the comedone is due to pigment derived from the secretions, changed, perhaps, by exposure to the air and light, seems the true explanation, although fine parti- cles of dirt are doubtless the causes in specific instances. Diagnosis. — Comedones are easily distinguished from all other lesions. Grains of gun-powder imbedded in the skin may closely resemble them. The history of a gun-powder accident and the impossibility of removal by pressure alone will serve to differentiate the latter. Occasionally cases of unusual char- acter or distribution are seen. In the absence of diagnostic lesions of other cutaneous disease, the expression from the sebaceous ducts of moulds contain- ing more or less greasy matter will enable one to recognize the nature of the disease. The association sometimes of comedo in few or large numbers with seborrhcea and acne needs to be kept in mind. The frequent application of pigments to the face, or medicated preparations of sulphur, mercury, tar, etc., may leave minute deposits at the orifices of the gland ducts and give an objective likeness to comedones. A slight examination will reveal the lack of any real comedo. Prognosis. — The disease is always curable by appropriate measures of treatment, and tends to spontaneous resolution after a variable period of delay. With great rarity the site of a comedo continuing through middle life may become the starting point of a warty epithelioma. Treatment. — Mechanical measures may be employed to give temporary relief from the disfigurement of comedones, especially when situated, as com- monly, upon the face. The affected surface of the skin should be well moist- ened with glycerine and water, or a more agreeable lotion may consist of glycerine one-half ounce, rose water two ounces, and oil of eucalyptus twelve drops. Then the Kippax comedo extractor can be employed to remove as many comedones as is thought advisable at one sitting. This little instru- ment, which consists of solid metal with an acne lance at one extremity and a curette at the other end, in which an aperture has been cut on the reverse side and slightly rimmed out to fit around the point of the comedo, should always be used by making firm pressure in place of the more convenient watch key or thumb nail, but which give rise to more pain and liability to bruise the skin. Sometimes the point of a fine needle can be used with advantage to loosen the epithelial rim of the comedo before making pressure with the extractor. After treatment consists of bathing the parts with hot water, fol- lowed, if needed, with an application composed of the above glycerine lotion, to which three times the quantity of dilute alcohol has been added. If there is much sense of soreness, ten drops to the ounce of arnica tincture can be added with benefit. These procedures for removal may need to be repeated occasionally, as the plugs reform. When, for any reason, extraction of the retained secretion is not at- tempted, other mechanical means will accomplish some good, such as a thor- 82 MILIUM ough daily rubbing with a soft fat or oil, followed by friction with a nail brush, and soap and water, ending with the light application of the lotion last named. In obstinate cases, a thin paste made of kaolin one ounce, glycer- ine six drachms, and vinegar one-half ounce, may be used to loosen the seba- ceous plugs, or one-half drachm of precipitated sulphur in glycerine and rose water, half ounce of each and milk of magnesia, three ounces, may be used as a stimulant. Local massage by competent operators or with an electric vibratory or mild treatments with high frequency currents, also serve to give better tone to the parts affected. When possible external treatment of the face should be done in the evening, so its immediate effects may be the least apparent. Unirritated comedones on the unexposed parts of the skin need not be treated locally, as they are nearly certain to disappear spontaneously or from general treatment. Physiological measures of treatment suggested for seborrhcea are applica- ble to comedo, and, ^together with the internal pathogenetic remedies, often render local treatment beyond simple mechanical cleanliness unnecessary. See indications for Dig., Juglans reg., Nit. acid, Pet., Sabina, Selen., Sepia and Sulphur. MILIUM (Acne albidia; Strophulus albidus; Grutum.) Definition. — Pearly white, millet seed to slightly larger sized seba- ceous cysts, situated under the epidermis, generally located on the face where the skin is thin and devoid of much subcutaneous fat. Milia are occasionally congenital, but are most common in young adults, and may occur at any age. Their ordinary situations are about the eyelids, cheeks, temples, the external genitals of men, and the internal face of the labia minora of women. They are not infrequently found about scar tissue. They usually appear to be just within or upon the skin, but occasionally pro- ject from it and look as if filled with a milky fluid. They develop very slowly and may persist for a long time; very rarely reach a larger size — grape seed to a small bean — and finally, if not removed by artificial means, disappear with the normal desquamation of the epidermis. They are unattended with any subjective sensations, and are of slight clinical importance otherwise than the disfigurement they produce. Etiology and Pathology. — Whether milium is due primarily to causes which interfere with the expulsion of sebum or to some interference with the transformation of epithelium lining the gland into fat, is not determined. In milia occurring in the neighborhood of cicatrices, following loss of tissue from injury or disease, the cause is purely mechanical and results from either the severance of one or more acini of an oil gland from the main portion, or from compression by a contracting band of cicatricial tissue. In some cases the pathology of milium would indicate an origin from some primary defects in the normal transformation of the epithelia of the gland. Thus, calcareous. w i;\ B8 horny and colloid changes have been found. Robinson suggests that milia which do not contain fat ma}' originate from misplaced embryonic cells from the hair follicles or mucous layer of the epidermis. Ordinarily, a milium is composed of a fatty nucleus and a covering of several thin envelopes of cor- netied epithelia. As this mass, from some part of a superficial sebaceous ^land, approaches the surface it is covered by a thin layer of the supra-im- posed corium containing papillae and the transparent epidermis. After in- cising the external cover, a spherical shaped body can be pressed or lifted out. appearing of nearly the same size as when seen in situ. Rarely can the opening of the sebacious duct be found. Diagnosis. — rMilia can hardly be mistaken for any other lesion. Vesicles of the same color may be recognized by their fluid contents and usual acute- ness of development. The minute growths of xanthoma simplex, which com- monly are found about the inner part of the eyelids, may be distinguished from milia by their yellow hue, and, in case of doubt, by the inability to re- move them by the means generally employed to remove milia. The black- ish points of comedones, their situation in the sebaceous duct, and their shape on removal, are sufficiently unlike milia. Prognosis is invariably good. Treatment. — Most individuals afflicted with milia endure the slight cos- metic disfigurement, or in a rude way treat themselves. A milium may be easily removed without leaving any blemish by opening the outer covering with a milium or acne knife and gently pressing or turning it out. Immediate application for a few minutes of very hot water is the only further local treat- ment needed; though touching the sac-like opening with iodine tincture, fifty per cent, solution of chromic acid, etc., have been advised. Electrolysis is a satisfactory method of treatment and especially as applied to milia of the male external genitals. Internal medication should be directed to any peculiar features of the local lesions or constitutional condition if present. WEN (Steal o ma : Atheroma; Sebaceous cyst.) Definition. — Wens are tumor-like sebaceous cysts, larger than milia, sometimes reaching the size of a hen's egg. Wens are most commonly found upon the scalp and neck, but they may occur in any part of the skin supplied with sebaceous glands. They usually grow slowly, give rise to no pain or change of color in the external skin over them unless they become inflamed. There may be one or several cysts, but they are rarely numerous. They are usually round in shape, sometimes flattened on top, and occasionally ir- regular in outline; situated beneath, within or upon the skin, but seldom attached to the deeper tissues. Occurring on the scalp, they may be covered by the longer hairs or protrude to an unsightly degree ; and if baldness exists, lead to considerable disfigurement. The duct of the glands is generally closed, but may be found in some cases patent enough so that some of the contents of 84 ACNE VULGARIS the cyst can be pressed out. To the touch wens impart a doughy or elastic quality, as they are either rather flaccid or tense. If they become inflamed they feel softer as a rule, and are then liable to result in suppuration and ulceration. Etiology and Pathology. — In most cases wens are caused by a reten-' tion of the product of the sebaceous glands and a counter thickening of the glandular envelope from pressure, forming the cyst wall. The contents of the cyst are made up from masses of more or less changed sebum and broken down epithelia, and as a result may vary in consistency from a granular, cheesy, semi-solid to a milk-like fluid; sometimes, also, they contain a rudi- mentary hair. Other pathological changes occur in some cases, such as a con- nective tissue new growth, forming a large part of the tumor; and atheroma- tous and calcareous degenerations. Diagnosis. — Fatty tumors may be distinguished from wens by the lobu- lated and "pillowy" sense to touch of the former, their different location, being situated about the shoulder blade, loins and buttocks in nearly all cases, while wens are seldom found other than on the scalp and neck ; from syphilitic nod- ules, by the evidences of other lesions or history of syphilis, and their usual pain and tenderness to pressure. Broken-down wens may be differentiated from boils and circumscribed abscesses by the history of long-standing tumor, previous to suppuration. Treatment. — Operative treatment only is indicated. Excision under strict antiseptic precautions is probably the best. The parts over the cyst having been incised, the cyst wall is carefully dissected out with or without rupture and evacuation of its contents. The wound may be evenly closed without sutures, dusted over with iodoform, thickly covered with antiseptic gauze, and held in place by a bandage. Unless some disturbance arises this dressing need not be removed for several days or a week. The author has never seen other than good results from this method. Owing to the danger from wound infection on the scalp other methods of treatment have been advised. Of these, caustics are usually too painful to be generally employed, and the ether injection method or the application of fuming sulphuric acid have no decided advantage. Small wens may be incised, their contents ex- pressed and the electric needle (electrolysis) applied at several points of the cavity. ACNE VULGARIS Definition. — An inflammation of the sebaceous glands and of the follicles of the lanugo hairs situated therein. Acne is one of the most com- mon and intractable of skin diseases. It is usually a folliculitis, less frequently a perifolliculitis, and probably is a direct result in some cases of decomposi- tion of the retained sebum. The characteristic features of acne are: (1) Loca- tion on. the face, neck, shoulders and chest, rarely appearing to any extent on any other part of the cutaneous surface. (2.) Period of occurrence coincident Fig. 31— ACNE VULGARIS Patient is a young man of twenty-three. Comedones, papules and pustules are scattered about the face and numerous scars bear evidence of deep seated pustula- tion. Duration, five years. He complains of soreness and pain in and about the lesions when pressed. Cured under the use of he par sulphur third decimal for over a year and arsenicum brom. sixth decimal'^ for two months. ACNE VULGARIS 85 with the development of sexual life of both sexes. (3.) Its perpetuation, if not origin, from some irritation (physiological or pathological) of other near or remote organs or tissues. (4.) Primary lesions of small, red, solid eleva- tions of the skin, followed by spontaneous resolution, or by central pustulation, without subsequent scar if superficial, with pitting if deep seated or involv- ing the true skin and successively appearing singly or in groups of a few or many. Simple acne, which is chiefly a blemish of youth, untreated, is a self- limited disease of from five to eight years' duration. Acne occurring in mid- dle life is of uncertain duration, and usually of a more pronounced inflam- matory type, attended with the formation of tubercles, and in many cases with marked induration of adjacent tissue. In such cases, if the lesions are per- mitted to mature (suppurate) scarring follows. Pathologically acne may be divided into acne papulosa and acne pustulosa, but as the smaller lesions occur chiefly in youth and the larger in middle life a better division seems to be into acne simplex and acne indurata. All skin diseases, with secondary acnoid eruptions, or clinically different, should be excluded, or qualified by other titles, such as bromine acne, acne varioli- formis, etc. Acne simplex. — The location of acne simplex is most often on the fore- head, cheeks and chin, but it is quite common on the back of the shoulders and upper part of the chest, and sometimes occurs on the extremities. The eruption is usually bilateral without symmetry. While nearly always develop- ing about the age of puberty in both sexes, it may occur at an earlier or later period of life. The lesions consist of comedones, papules and pustules, and vary in size from a pin's head to a split pea; they vary in number from one or two to hundreds. Frequently a comedo forms the centre of the papule and can be seen also after the transition into a pustule. Papules often appear independent of the comedones; and in some cases many papules re- solve without passing into pustules. Usually the lesions may be found in all stages of evolution in the same individual — from the blackish pointed comedo, the bright to dusky red papule, to the yellowish white pustule with a more or less red areola. The effects of previous lesions — stains and scars, may be found also. The former disappear gradually and the superficial scars become much less distinct in time. A negative feature of acne is the absence of subjective sensations, except a sore feeling when pressed upon and sometimes a slight burning. Acne simplex is essentially a chronic disease, and untreated it may last from the advent of puberty to the period of full maturity, when it is likely to spontaneously disappear. Occasionally it passes gradually into the deeper seated acne indurata and in a small proportion of cases the two forms co-exist in youth. Acne indurata. — Acne indurata occurs in the same localities as acne simplex, but is more frequently found upon the neck and back than the latter. It pursues a still more chronic course, rarely or never entirely disappearing without treatment. The lesions may be few or many, isolated or close together. They originate as deep seated round, ovoid or flatfish indurations; vary in size 8G ACNE VULGARIS from a pea to a cherry, and a s they slowly enlarge, the skin becomes a dark reddish color. Some suppurate quickly, more are indolent and contain little pus, which, if let out by incision, is apt to form again. If not opened there is no tendency to spontaneous rupture, and resolution may be dela} r ed for weeks. Comedones are not usually present, and when found have no direct pathological relation as in acne simplex. Scars are a frequent effect of acne indurata, at first of a purplish color they remain stationary, or very slowly fade away. Keloidal transformations sometimes follow, and rarely the acne induration may pass on to fibroid degeneration without the occurrence of sup- puration. Seborrhcea and seborrhceic dermatitis ma}' complicate either form and give rise to symptoms common to those affections. The term acne has been used freely in giving title to cutaneous diseases little or not at all related to true acne. A few need be named here in explanation only : 'I. Acne cachecticorum lesions are pea to cherry sized, flattened, flaccid, vivid red formations, containing a little sero-purulent fluid; located chief! y upon the trunk and extremities and occurring in persons poorly nourished, depressed, strumous, or scorbutic, and is frequently associated with lichen scrofulosum. Though it may resemble acne indurata of a low type, it is prob- ably partly or wholly tubercular in nature (see scrofuloderma). B. Acne artiftcialis, drug eruptions (see dermatitis medicamentosa). ' C. Acne rosacea and acne hypertrophica (see rosacea). D. Acne d'ecalvanS (see folliculitis decalvans). E: Acne keloid' (see dermatitis papillaris capillitii ). F. Acne moUvscum (see molluscum contagiosum) . G. Acne adenoid (miliary lupus, etc.) (see lupus vulgaris). Etiology. — The causes of acne are varied if not numerous. It has been viewed as a local disease, and when due to local stimulants or irritants, as the tar preparations, for instance, this is true. Here it is an artificial disease, how- ever, and quite different in origin from the true disease arising from a vital source more or less remote from the skin. A predisposing cause is no doubt the greatly increased activity of the sebaceous glands in the few years subse- quent to the advent of puberty. From the hypersemia of physiological activity it is only a step to congestion, if some influence intervenes to prevent the normal intermission in physiological hyperemia of a part. The flushing of the face from moderate mental emotions is a common illustration of a reflex effect on the skin. Gastro-intestinal reflexes are known to affect the cir- culation of blood in the face. Flatulent dyspepsia and constipation are often apparent factors. Abnormalities of menstruation appear to be the underly- ing cause in nearly fifty per cent of cases in girls and young women. Genito- urinary disturbances, masturbation, and affections of the mucous membrane of the nose and throat may be occasional causes. In many cases the pre- disposing influence is probably a general one. Anaemia and debility of various kinds in the young, too rapid growth, a weakened circulation, as manifested by cold extremities; the scrofulous type of constitution, etc.. may be men- ACNE VULGARIS *7 tioncd. Such causes operate to lower nutrition, which precedes the local im- pairment of function in the sebaceous glands. In middle life sedentary living, the gouty diathesis, diabetes and struma, together with functional disturbances in the digestive, urinary and upper res- piratory tracts, uterine and ovarian diseases in women and intemperance of one kind or another in both sexes arc the most frequent causes of acne. In a lew cases the causes seem to be entirely local. Whether the invasion of the sebaceous follicles by the staphylococcus pyogenes is an immediate cause, or a degree of inflammation from changed sebum first arises is not deter- mined. The surface of the skin is nearly always subject to the presence of pus cocci, and the possibility of their being local exciters and disseminators of acne under favoring systemic or surface conditions may be a reasonable basis for some of the modern local treatment of this disease. Pathology. — The pathological changes in acne result from inflamma- tion, frequently carried to suppuration and destruction in some degree of the sebeceous follicle. According to Elliot, the inflammation begins in the tissue around the folicle, or as a perifolliculitis and only subsequently is the follicle invaded. Under lowered vitality or changed nutrition ordinary causes may excite the inflammation. Thus temporary or reflex hyperemia, the elimina- tion of some virus poison or effete material by the glands, retained secretion, mi- cro-organisms, etc., may be the link between primary etiology and pathology. One or more follicles may be involved and may be partly or wholly destroyed. Pus-filled pockets ma}' also form in the adjacent tissues, ultimately discharg- ing into the gland cavity. In the contents of the gland numerous micrococci can be found, and recently Unna and Gilchrist have found a special bacillus in the acne pustule. Though this microbe has definite pus producing prop- erties, its shape has been variously described as thick, rod-like, straight or curved. Diagnosis. — Bearing in mind the characteristics of acne, mentioned at the beginning of the chapter, its usual association with comedones (in acne simplex) and frequency of occurrence, little difficulty will be found in diag- nosis. It might be confounded with papulo-pustular eczema, rosacea, the pustular syphilide, small-pox and sj^cosis. Papulo-pustular eczema may be known by its smaller lesions, occurring in patches, unconnected with comedones and showing signs of exudation and crusting. Itching is also a prominent symptom of eczema. Rosacea occurs usually in mature life; begins with temporary, followed by more permanent redness of the skin of the face, and dilatation of the superficial blood-vessels. Acne lesions, if present, are secondary in occurrence. The pustular syphilide appears generally in groups, and underneath the crusts which cover the base of the lesion small excavated ideers may be found. A history of the case and the presence of other forms of syphilide, with a wider distribution than is common to acne, may further aid the diagnosis. The tubercular or gumma- tous syphilide of the skin is apt to occur in groups, and degenerate into ulcers, which often spread by one-sided extension. When the nose only is affected. 88 ACNE VULGARIS the resemblance to acne may be very close, and other evidence of syphilis, or the effects of treatment, may need to be known in order to determine its nature. Small-pox can be excluded by the absence of constitutional symptoms, or the duration of the eruption longer than that eruptive fever. Sycosis oc- curs only in adult males, is strictly limited to the bearded part of the face, and a hair occupies the centre of the lesion instead of a comedo, as in acne. Prognosis. — Acne is a curable disease under proper management and treatment. In making any forecast of the probable duration of acne, allow- ance must be made for the uncertainty of the patient following the directions of a protracted therapeutic course especially if the causal treatment involves continued self-denial. Treatment. — In the treatment of all diseases it is of the first importance to remove the learnable cause or causes, original or secondary. In acne it is almost the sine qua non to success. Moral perversions are to be met by moral remedies; the pride evoked in some, in others fear aroused by exag- gerated pictures of evils yet to come in disfigurement of skin and in other directions. In the correction of onanism there is no auxiliary treatment equal to physical weariness or exhaustion, and in acne from this cause abundant exercise is an efficient aid. Sources of irritation in the genito-urinary sphere should be sought for when suspected. A contracted prepuce or meatus, ad- hesions in both sexes, and uncleanliness in the sometimes otherwise cleanly are conditions to be corrected. Cool or cold water should always be used to bathe these parts, and, as a rule, for the daily bath. Frequent or long con- tinued disturbance of function in any part of the digestive tract is often the hidden fire which flames forth in acne and its related disease, rosacea. The art of dietetics pertains here. In the plethoric, reduction and more or less substitution of vegetable for animal food is usually indicated. In the anaemic increase of quality or quantity of nitrogenous food, frequently of the animal kind is needed. Idiosyncrasy sometimes plays a part. So simple a food as boiled rice may cause congestion of the face, and it is not uncommon for such effects to follow the use of fruit jellies, beef, shell fish, etc. In nearly all cases too little liquid is taken. The skin is an important organ of excretion as well as secretion, and few realize the necessity of a full supply of water to maintain these functions in healthful activity. Attention to regimen and habits of exercise will often cure the very usual constipation. An indicated drug may, however, be needed for this lack of function. Massage, mechanical or otherwise, general or local, and the general tonic use of static electricity and of the high frequency currents have proven of great value in improving the general tone. Local treatment, if employed, should be on well defined principles. In acne these may all be embraced under (1) absolute cleanliness; (2) patho- genetic irritation or inflammation; (3) depletion, and (4) radio- and photo- therapy and the high frequency currents. The first may be obtained by the use of soap and water, or a medicated soap having solvent properties, such as salicylic acid or ichthyol, and the occasional use of a saturated solution of ACNE VULGARIS 89 boric acid applied hot, or the same in strong alcohol applied cold. Some- times cleanliness and artificial irritation may be had from the same agent, as in the use of soft soap or green soap applied with friction. The use of very hot water alone dissolves and washes away the secretions to some extent, and at the same time produces a temporary congestion which is more or less curative in its reaction. This simple measure may be pushed too far, however, and defeat rather than aid a cure. As a rule, local applications to the face should be made at night shortly before retiring, giving time in the interval before morning for the temporary aggravation, if any, to subside. When the skin is sensitive, a mildly antiseptic ointment may follow the bath- ing, to be washed off in the morning. Boric acid, twenty to forty grains to an ounce of cold cream, or salicylic acid or resorcin, five to twenty grains to an ounce of the same vehicle, may be employed. If needed, a dusting powder composed of boric acid, one part to eight parts of finely powdered starch, or stearate of zinc can be used. Calendula, bismuth, calomel, ichthyol or aristol can be applied likewise. More decided pathogenetic effects (stimulation, etc.) may be needed in cases of acne of a severe type, or occurring in persons who have thick and sluggish skins, and remedies of an antiseptic character are usually chosen. A simple formula for this, purpose is : 1$. Hydrarg. bichlorid srr. 8. Spr. vini rect 5 2. Aquae distil : o A. M. Whenever the above or similar prescription is prescribed for local use, the patient should be told that it may excite irritation, and then it should be discontinued temporarily for milder measures. When employed, cleansing treatment should precede its application and a mild ointment (before named) follow, if needed. Ichthyol soap and lotion will be found serviceable in some cases of acne for cleansing and stimulating purposes. Stiefel's (10%) ichthyol soap may be first used to thoroughly cleanse the surface, twice daily, followed im- mediately by the following lotion, recommended by Unna: 1$. Ammonia- sulph. ichthyolat gr. 12-120. Alroholis (90%), Etheris aa 3 4. M. The strength of the ichthyol may bear a relation to the degree of the disease or the texture of the skin. It is advisable to always begin with a mild strength and increase it subsequently as required. Numerous applications containing sulphur have been recommended for acne pustulosa, and among these the following has given the most satisfaction : R. Sulphuris precipitati 5 t. Glycerin i, Aquae rosea aa 5 J. Milk of magnesia q.s. 5 4. M. 90 ACNE VULGARIS Acne of the trunk calls for more energetic treatment and stronger lotions or ointments. A thirty per cent, solution of formaldehyde has proven satis- factory for acne of the back. Depletion is effected by the use of the acne lance. This is inserted in the centre of the papule or pustule, to give free exit to retained sebum or pus, which may be gently pressed out with the comedo extractor or with the dermal curette. Afterwards hot water can be applied to the parts for a few minutes to further depletion and discharge. The lancing is only slightly painful and may be repeated every few days. The cases in which depletion is indicated are those which do not yield to other well-directed treatment, and when the lesions are large or deep seated. Puncture in selected cases hastens cure by relieving the follicles of retained matter, the capillaries of stagnant blood, by limiting the formation of pus, and by preventing rupture of the epidermis. In the deeply situated suppurating lesions it is an essential procedure to pre- vemSscarring. After puncture of acne lesions the surface should be cleansed with alcohol or some alcoholic preparation. For many cases of mild acne (without pustulation) the regular applica- tion of the high frequency currents has proven most beneficial in the editor's hands. Nearly one hundred cases have received this method of stimulation, once or twice a week, for about five minutes. The particular form of high frequency currents used should depend on the exact nature of the case, the resonant (Oudin) and the hyperstatic (Piffard) being suitable when exces- sive stimulation is needed, while the helicoidal shunt of D'Arsonval suffices ior the large majority of mild cases. The Rontgen rays have been of marked benefit in the chronic, obstinate indurated and deep seated acne, especially when the pus infection is para- mount. The editor makes his exposures at a distance of eight to twelve inches, and for four to ten minutes' duration. This is repeated every three to five days, and it has seldom been necessary to go beyond ten treatments to secure permanent results. The Friedlander hood is used to cover the tube, and parts not to be treated are also protected. It is seldom necessary to carry the treatment beyond a point Avhere a mild erythema develops. In no disease is there better opportunity to watch and estimate the therapeutic effects and value of drugs and the relation of internal subjective phenomena and objective lesion thereto than in the treatment of this cuta- neous disease. A clearly indicated drug often benefits promptly and progres- sively. Not a few cases of acne, however, are unattended with subjective symptoms; either the causes were never apparent, or. having ceased to mani- fest symptoms, the momentum of the disease perpetuates itself, possibly from the presence of local conditions. In such cases drugs which produce papulo- pustular lesions, especially in the regions affected, are to be considered. See indications for Agar.. Alum.. Aloes. Am.