. LIBRARY OF CONGRESS. TV m — ®m*W ^ Shelf ..ji.SLfc UNITED STATES OF AMERICA. I WM WORKS BY CONDICT W. CUTLER, M.S., M.D. Manual of Differential Medical Diagnosis. — (In Students' Manuals Series) i6mo, cloth . . . $1.25 Differential Diagnosis of the Diseases of the Skin. — (In Students' Manuals Series) i6mo, cloth 1.25 Essentials of Physics and Chemistry, Written Especially for the Use of Students in Medicine. Third edition, revised and enlarged, 8vo . . 2.00 Practical Lectures in Dermatology. — Compri- sing a Course of Fifteen Lectures Delivered at the University of Vermont, Medical Department, during the Session of 1892 and 1893. 8vo . 2.00 G. P. PUTNAM'S SONS, New York & London PRACTICAL LECTURES IN DERMATOLOGY COMPRISING A COURSE OF FIFTEEN LECTURES DELIVERED AT THE UNIVERSITY OF VERMONT MEDICAL DEPARTMENT DURING THE SESSION OF 1892 AND 1893 /' CONDICT W. CUTLER, M.S., M.D. PROFESSOR OF DERMATOLOGY, UNIVERSITY OF VERMONT ; PHYSICIAN-IN-CHIEF AND DERMATOLOGIST TO THE NEW YORK DISPENSARY ; FELLOW OF THE NEW YORK ACADEMY OF MEDICINE ; MEMBER OF THE AMERICAN DERMATOLOGICAL ASSOCIATION; AUTHOR OF "DIFFERENTIAL MEDICAL DIAGNOSIS," " DIFFERENTIAL DIAGNOSIS OF THE DISEASES OF THE SKIN," ETC. 'MAY 6 1894'. J) T^z. ^ G. P. PUTNAM'S SONS NEW YORK LONDON 27 -WEST TWENTY-THIRD STREET 24 BEDFORD STREET, STRAND ®be ^nicktrbockcr ||ttgg 1894 Copyright, 1894 BV CONDICT W. CUTLER Electrotyped, Printed, and Bound by Ube Iftnicfecrbocfcer press, IRew ]t>or& G. P. Putnam's Sons DR. J. H. WOODWARD, M.S., M.D. PROFESSOR OF DISEASES OF THE EYE IN THE UNIVERSITY OF VERMONT MEDICAL DEPARTMENT, AND SECRETARY OF THE FACULTY THIS WORK IS DEDICATED IN ADMIRATION OF HIS ABILITY AS A SURGEON AND CLINICAL TEACHER PREFACE. Having been requested by the students in the Medical Department of the University of Vermont to publish my lectures on Disease of the Skin, delivered to them during the sessions of 1892 and '93, I offer this as my excuse for the creation of another work on Dermatology. The following pages are prepared from stenographic notes and represent with substantial accuracy the lectures as they were delivered to the students. As the subject was large and the number of lectures small, I endeavored to make the course as practical as possible and considered only those diseases of the skin which every physician in general practice should at least be able to diagnose and to treat in an intelligent manner. If I have succeeded in making such a presentation of the subject these lectures should be found of service not only to the student but to the physician engaged in general practice. 260 WEST 57TH ST., NEW YORK. CONTENTS. PAGE LECTURE I. Anatomy of the Skin ; Lesions of the Skin ; Classification and Diagnosis 1-14 LECTURE II. General Therapeutics 15-30 LECTURE III. Acne ; Alopecia, and Alopecia Areata .... 31-48 LECTURE IV. Asteatosis ; Chloasma ; Clavus ; Comedo ; Dermatitis Venenata ; and Ecthyma 49-64 LECTURE V. Eczema 65-79 LECTURE VI. Epithelioma ; Erysipelas ; Erythema, Erythema Multi- forme, and Erythema Nodosum 80-98 LECTURE VII. Feigned Skin Diseases ; Furunculosis ; Herpes ; Herpes Zoster ; and Hyperidrosis 99-115 vii viii CONTENTS. PAGB LECTURE VIII. Hypertrichosis ; Impetigo, Impetigo Contagiosa ; Keloid ; Keratosis Pilaris ; Lentigo ; Leucoderma ; Lichen Planus; and Lichen Tropicus 116-131 LECTURE IX. Lupus Erythematosus ; Lupus Vulgaris ; Milium ; and molluscum contagiosum 132-i43 LECTURE X. Njevus ; Pediculosis ; Pemphigus ; Pityriasis Rosea ; and Pruritus 144-156 LECTURE XL Psoriasis and Purpura 157-168 LECTURE XII. Rosacea ; Scabies ; Seborrhea ; Sudamina ; and Sycosis 169-184 LECTURE XIII. Syphilodermata 185-199 LECTURE XIV. Tinea 200-215 LECTURE XV. Tuberculosis of the Skin ; Urticaria ; Verruca ; and 100 Dermatological Don'ts 216-230 INDEX 231-238 PRACTICAL LECTURES IN DERMATOLOGY. LECTURE I. ANATOMY OF THE SKIN, LESIONS OF THE SKIN, CLASSI- FICA TION A ND DIA GNOSIS OF SKIN DISEA SES. Gentlemen ; Many of you have doubtless heard that skin dis- eases were formerly divided into three grand divisions. In the first division were those which could be cured by mercury ; in the second were those which could be cured by sulphur ; and in the third were those which the Devil himself could not cure. If you start out with any such idea it will not be long before you discover that the largest number of skin diseases belong to this third class, and that the Devil must have neglected his studies in der- matology. You may be successful practitioners without much knowledge of diseases of the skin, but I can tell you that it will be very comforting one of these days when called upon to treat some skin affection, to be able to call it something besides eczema, and to prescribe some other remedy than zinc ointment. 2 LECTURES IN DERMATOLOGY. The skin is a very much neglected organ, and at the same time one frequently the seat of disease. It is the largest organ in the body, and upon the proper perform- ance of its functions the health and comfort of the indi- vidual depend. It is, therefore, but right that we who study the healing art should not be entirely neglectful of so large and important a part of the human body. With this object in view I will endeavor to quickly bring to your notice a few points pertaining to the study, diagnosis, and treatment of some of the most common skin affections. I will not burden your memories with the names of the large number of skin diseases, many of which are so rare and unimportant that you will seldom be called upon to treat them, but I will ask you to give close attention to these few lectures, which we will call your introduction to dermatology. ANATOMY OF THE SKIN. It will be necessary in the first place for you to under- stand a little something about the anatomy of the skin. The skin is composed of two principal layers. The lower or deeper one is called the corium, cutis vera, derma, or true skin ; the outer one is named the epidermis, cuticle, or scarf skin. The derma or corium is that portion of the skin which constitutes the leather of commerce. It is composed of connective-tissue fibres, which interlace and form a texture resembling felt. At the deepest part of this corium the fibres are spread, and between them are found masses of fat globules consti- tuting adipose tissue. In the outer portion the fibres are closely matted together, the surface externally rising into ANA TOM Y OF THE SKIN. 3 minute prominences called papillae, and sometimes de- scribed as the papillary layer of the skin. The epidermis or scarf skin is composed of roundish elements called cells. The deeper cells are rounded or many-sided, succulent, and composed of what is known as the rete mucosum or rete Malpighii. This rests directly upon the papillae, and dips down in the inter-spaces between them. In the cells of this deeper layer is found the pigment or coloring matter of the skin. In patho- logical conditions this coloring matter may be very much increased or diminished in amount. In negroes it is normally present in large amount. In the outer layer of the epidermis, called also the horny layer of the skin, the cells are flatter, hardened, and lifeless, and are thrown off or removed by friction. In the corium or true skin are found blood-vessels, nerves, lymphatics, muscular fibre, hair follicles, sebaceous glands, and sweat glands. The hair follicles may be considered as prolongations downward into the corium of the epidermal layers sur- rounding the penetrating hairs. At the bottom of the hair follicle thus formed the fibrous elements of the corium rise and form what is known as the hair papilla or bulb, from which the hair is supposed to take its growth. The hair itself is composed like the epidermis of cells. With- in the follicles these cells are succulent, round or polygo- nal in shape. Outside they are flattened and elongated, appearing like fibres, and these constitute the entire length of the hair. The sebaceous glands are almost always connected with hairs, of some size, and discharge their secretion's into the hair follicles. Generally there are two sebaceous glands to each hair, situated on opposite sides. They are very 4 LECTURES IN DERMATOLOGY. minute affairs, situated in the outer portion of the corium, and their main function appears to be to keep the skin and hairs in a flexible state. The muscles of the skin, which are connected with the hair follicles and sebaceous glands, are attached to the lower portion of the hair follicle, and running diagonally are inserted in the upper portion of the corium, so that each time they contract, pressure is made upon the glands, and their contents are forced out. When these muscles contract under the influence of cold or mental excitement the surface presents minute elevations called cutis anserina, or goose skin. The sweat, coil, or sudoriparous glands are in the form of minute tubes coiled up in the deepest portion of the corium, or even in the subcutaneous tissue. Their ducts extend through the entire thickness of the skin, and after making several spiral turns open directly upon the outer surface. The action of these little glands is continuous, and sweat is incessantly exudated in the form of sensible or insensible perspiration. The nails are altered portions of the epidermis. Each nail grows from a root, just as each hair starts from its root. It only slides over its matrix or bed, so that injury to the matrix need not cause a disfigured nail other than of the portion directly injured ; whereas injury or disease of its root, or where it starts, will generally cause the destruction or a deformity of the whole nail. SKIN LESIONS. The lesions occurring in skin diseases may be either primary or secondary. The primary lesions are eight in number, and are mac- SKIN LESIONS. 5 ules, papules, vesicles, blebs, pustules, wheals, tubercles, and tumors. The secondary lesions are six in number, and are crusts, scales, excoriations, fissures, ulcers, and scars. Macules are colored portions of altered skin, neither elevated nor depressed. Papules are circumscribed, solid elevations of the skin, and are described according to their shape as acuminated, rounded, flat, or umbilicated. Vesicles are circumscribed, non-purulent, fluid elevations of the epidermis, and named like the papules according to theii shape. Blebs are irregular-shaped, fluid elevations of the epi- dermis larger than vesicles. Pustules are circumscribed, fluid elevations of the epi- dermis containing pus, and like the papule and vesicle may be acuminated, rounded, flat, or umbilicated. Wheals are flat, raised, solid elevations of the skin of an evanescent character. Tubercles are circumscribed, solid elevations of the skin, firmer, deeper, and usually larger than the papule. Tumors are of various sizes. Usually they are large prominences of the skin extending into the subcutaneous tissues. Crusts are dried products of the diseases of the skin. Scales are laminated epidermis separated from the skin. Excoriations are superficial losses of tissue from the skin. Fissures are cracks in the epidermis or skin. Ulcers are excavations in the skin, the result of molecu- lar death. Scars are formations of cicatricial tissue in the skin taking the place of the normal integument. 6 LECTURES IN DERMATOLOGY. CLASSIFICATION OF SKIN DISEASES. If we could classify diseases of the skin according to the lesions presented, it would very much simplify their study ; but this is impossible, for very few of the diseases are distinctly macular or papular in character — that, is the lesions are not of one kind, but multiple. Then again, many of the skin lesions in a particular disease change in character from day to day. That is, the eruption may be macular to-day, papular to-morrow, and pustular the next day, so you can readily see how difficult it would be to classify skin diseases in any such simple way. The best dermatologists, both in this country and abroad, no longer classify skin diseases or divide them into groups, as was formerly done, but simply treat them as en- tirely distinct diseases. The American Dermatological Association have named and classified alphabetically the diseases of the skin as follows : Diseases of the Skin. Acne Atrophia pilorum propria Actinomycosis Atrophia senilis Albinismus Atrophia striata Alopecia (Baldness) Atrophia unguis Alopecia areata Bromidrosis Alopecia furfuracea (Dandruff) Callositas Ancesthesia Canities Angioma Carcinoma Angioma cavernosum Chloasma (Liver spots) Anidrosis Chromidrosis Anthrax simplex (Carbuncle) Cicatrix Anthrax maligna Clavus (Corn) Asteatosis (Xeroderma) Comedo (Black-heads) Atrophia maculosa Cornu cutaneum CLASSIFICATION OF SKIN DISEASES. Dermatalgia Dermatitis calorica Dermatitis exfoliativa Dermatitis gangraenosa Dermatitis herpetiformis Dermatitis medicamentosa Dermatitis papillaris capillitii Dermatitis traumatica Dermatitis venenata (Ivy poison) Ecthyma Eczema : a. erythematosum b. papillosum c. vesiculosum d. madidans e. pustulosum f. rubrum g. squamosum Elephantiasis Epithelioma Equinia Erysipelas Erythema multiforme Erythema nodosum Erythema simplex Erythrasma Feigned Skin Diseases Fibroma Frambcesia Furunculus (Boils) Granuloma fungoides Herpes simplex Herpes zoster Hyperesthesia Hyperidrosis Hypertrichosis (Hirsuties) Ichthyosis Ichthyosis congenita Impetigo Impetigo contagiosa Impetigo herpetiformis Keloid Keratosis follicularis Keratosis pilaris Keratosis senilis Lentigo (Freckels) Lepra Leucoderma (Vitiligo) Lichen planus Lichen ruber Lichen tropicus Lipoma Lupus erythematosus Lupus vulgaris Lymphangioma Melanoderma lenticularis pro- gressiva Miliaria rubra Milium Molluscum (Epitheliale) con- tagiosum Morphoea Myoma Myxcedema Naevus fibrosus Nsevus- pigmentosus (Moles) Naevus pilosus Nsevus vascularis (Birth mark) Neuroma 8 LECTURES IX DERMATOLOGY. (Edema circumscriptum acu- tum Onychauxe Pachydermatocele (or Derma- tolysis) Pediculosis capillitii Pediculosis corporis Pediculosis pubis Pellagra Pemphigus Pemphigus neonatorum Phlegmona diffusa Pityriasis maculata et circi- nata (P. rosse) Pityriasis rubra Pityriasis rubra pilaris Pompholyx Pruritus Psoriasis Purpura : a. simplex b. haemorrhagica Rhinoscleroma Rosacea : a. erythematosa b. hypertrophica Sarcoma Scabies Sclerema neonatorum Scleroderma Scrofuloderma Seborrhcea : a. congestiva b. oleosa c. sicca Steatoma Sudamen Sycosis vulgaris Syphiloderma Tinea favosa Tinea trichophytina (Ring- worm) : a. circinata b. tonsurans c. sycosis Tinea versicolor (Chromophy- tosis) Trichorrexis nodosa Tuberculosis verrucosa cutis Uridrosis Urticaria (Hives) Urticaria pigmentosa Vaccinia Verruca (Warts) Xanthoma Xerosis Among these many skin diseases, only the following can be distinctly classified in groups according to the character of their lesion : CLASSIFICATION OF SKIN DISEASES. MACULAR SKIN DISEASES. Chloasma Erythema Lentigo Morphoea Nsevus simplex Purpura Scleroderma Chromophytosis Vitiligo PAPULAR SKIN DISEASES. Lichen tropicus Lichen acuminatus Lichen planus Lichen scrofulosorum Keratosis pilaris Acne Comedo Milium Prurigo Psoriasis TUBERCULAR SKIN DISEASES. VESICULAR SKIN DISEASES. Carbuncle Epithelioma Keloid Lupus vulgaris Molluscum Rhinoscleroma Xanthoma Herpes Sudamina Dermatitis venenata Zoster Impetigo contagiosa Dysidrosis PUSTULAR SKIN DISEASES. Acne vulgaris Impetigo Ecthyma Sycosis Furunculosis BULLOUS SKIN DISEASE. Pemphigus TUMOROUS SKIN DISEASES. Fibroma Sarcoma Carcinoma DIAGNOSIS OF DISEASES OF THE SKIN. In making a diagnosis in skin diseases a good history of the case must first be obtained, and then a carefuL 10 LECTURES IN DERMATOLOGY. examination of the lesions presented. In obtaining this it would be well to follow some such systematic plan as here presented : I.- —HISTORY OF PATIENT. II. EXAMINATION OF LESION. I. Age i. Extent and distribution of 2. Sex lesions 3- Occupation 2. Color of the lesions 4- Previous attacks 3. Acute or chronic character 5- Time of present attack of lesions 6. Constitutional disturbance 4. Individuality of lesions 7- Local symptoms 5. Configuration of lesions S. Hereditability History of the case. The age of the patient is very often an important factor in making a correct diagnosis, for many diseases of the skin occur exclusively in children and others in adults. Thus, scarlet fever, chicken-pox, measles, impetigo, some forms of eczema, occur almost exclusively in children, while psoriasis, pruritis, tinea versicolor, epithelioma, etc., never occur in infants. Sex. Although sex is less important than the age in diagnosing skin affections it is nevertheless of some aid, for such a disease as sycosis occurs only in the male, while other affections, as epithelioma, occur more often in the male and lupus in the female. Occupation. A disease is often known by the cause that produces it. By ascertaining the occupation of the patient the cause of the disease may be determined, and the diagnosis made or confirmed. Thus washerwomen and others whose hands are frequently in water suffer from eczema, workers in chemicals from dermatitis, etc. Previous attacks. Many skin affections, especially those caused by the exanthematous diseases, as measles, DIAGNOSIS OF DISEASES OF THE SKIN. II small-pox, etc., a person has but once, while of other erup- tions, as eczema, psoriasis, etc., one attack is quite sure to be followed by others. Thus it is of the greatest import- ance to obtain the previous history of the patient. Many of the syphilitic lesions are so obscure that without a history of chancre it would be difficult to make a positive diagnosis, while with such a history the treatment is at any rate very satisfactory. Length of time of the present attack. By determining this history we arrive at the acute or chronic character of the eruption. Acute diseases, such as measles, erythema, urticaria, etc., are of short duration, lasting for hours or days. Subacute eruptions, as eczema, are of longer dura- tion and last for weeks, while in the chronic affections, as lepra, lupus, psoriasis, acne, etc., the eruption lasts for months or years. By obtaining this history many dis- eases may be eliminated and the diagnosis be selected from a few. Constitutional disturbance. With most of the inflam- matory contagious affections of the skin the constitutional symptoms are pronounced. In such affections as erythema and urticaria there is nearly always some stomach disturb- ance. In more chronic affections, as psoriasis and eczema, the general health suffers but little, while in lepra, syphilis, epithelioma, etc., the constitutional symptoms and general impairment of health form one of the marked features of the disease. Local symptoms. A snap diagnosis can frequently be made of a skin disease by the local symptom as repre- sented by the patient. Thus in psoriasis, eczema, and the parasitic skin diseases, itching is a constant symptom. In urticaria there is burning and smarting. In herpes zoster burning and lacerating pains, some of the symptoms being 12 LECTURES IN DERMATOLOGY. almost diagnostic of the disease in which they occur. But if the history of the case is important, much more so is the personal examination of the lesion presented. Extent of lesion and distribution. Some skin diseases are limited to certain portions of the body, others have a predilection for particular parts, others occur on any part of the body, while still others extend over the whole surface. Thus, sycosis affects the hair follicles, acne ap- pears on the face and shoulders, lupus on the face, pso- riasis on the elbows and knees, eczema may attack any portion of the body, while the exanthemata may extend over the entire surface. Color of lesion. The color of the skin lesion will fre- quently throw much light on the diagnosis. For instance, the later syphilitic lesions are of copper color; the keloid, pinkish ; chloasma and lupus vulgaris, a yellow or reddish purple ; leucodcrma, a dead white, etc. Acute or chronic character of lesion. The appearance of a skin eruption will frequently show whether it is acute or chronic, whether on the increase or decrease, without obtaining a history from the patient. This is of import- ance, for frequently it is impossible to obtain a history, or else the patient may purposely give a wrong one to mis- lead the physician. In the acute affections we may expect to find the primary lesions present with more or less signs of active inflammation, and in urticaria, the exanthemata, and erythema, some acute constitutional disturbance, as fever, vomiting, and general malaise. In the chronic affections the symptoms are much less active in character; some of the secondary lesions are usually present with or without the primary ; there is frequently, especially in the syphilides, pigmentation of the skin, and the constitu- tional symptoms are seldom active although there may be, DIAGNOSIS OF DISEASES OF THE SKIN. 1 3 as there is in lepra, syphilis, and cancer, great impairment of the general health. Individuality of lesions. Each separate lesion must be examined carefully to see of what character it partakes, whether the lesions are all of one kind, or multiple. It must not be forgotten that two or more skin diseases may make their appearance at the same time, or occur togeth- er in the same person, and although this may complicate matters so that the diagnosis is uncertain, still the char- acteristic lesions and symptoms of each are usually dis- tinctly present, and can be made out by careful study. At the New York Dispensary I have seen as many as seven distinct skin diseases upon the same man, each of them being so distinct as to be easily recognized. Configuration of lesions. The lesions of the skin form themselves often into a great many figures or patterns, some of them being diagnostic of the disease. When the patch is circular it is called circinatus, or in ring form annulatus, and seen frequently in syphilitic lesions and ringworm. If occurring in concentric rings the term iris is employed, as in herpes iris. When one margin of the lesions is elevated and sharply defined against the sound skin the term marginatus is applied, and occurs in ring- worm about the genitals. Where the lesions are winding or gyrate the term gyratus is used, and occurs in psoriasis and syphilis. Tubercular and ulcerating lesions are called serpiginous when they spread in a creeping manner, and are often syphilitic. Hereditability. Before leaving this subject of diagnosis I wish to say a few words as to the hereditary tendencies, or predisposition. As some skin diseases, the most com- mon examples being syphilis, leprosy, psoriasis, eczema, and scrofulosus, are undoubtedly hereditary, it is not only 14 LECTURES IN DERMATOLOGY. necessary to obtain a good history of the patient, but often extremely important to obtain a family history as well. Some rare forms of syphilitic eruptions in infants would be most difficult to diagnose if it were not for the syphilitic history of the mother. LECTURE II. GENERAL THERAPEUTICS. Gentlemen ; Skin diseases so far as their treatment is concerned may be divided into three classes. First, those having a natural tendency to pursue their course to a final termination without any treatment what- soever, but are, in fact, often made worse by applications intended for their cure. Second, those cases having but little tendency to run a favorable course, but become chronic, extend and reappear from time to time, yet are cured by proper treatment. Third and lastly, those diseases ot the skin which al- ways terminate fatally, or last during the life of the patient, are not curable, but are usually relieved by treat- ment. In the first class our treatment should be directed tow- ard the comfort of the patient, and by wise counsel pre- vent the use of therapeutic measures which would retard rather than hasten recovery. In other classes of cases the therapeutic agents employed may be administered internally or applied externally. Almost all diseases of the skin require for their successful management external treatment, and on the other hand very few seem to be materially benefited by internal 15 1 6 LECTURES IN DERMATOLOGY. medication. So you can readily understand that as der- matologists we must deal principally with drugs which are used externally. The remedies which are used internally and have undoubtedly some value in curing or relieving diseases of the skin are, in the relative order of value, prep- arations of mercury, arsenic, iodide of potassium, cod- liver oil, alkalies, ergot, and quinine. I have not mentioned in this list tonics, which are often very serviceable in skin diseases by improving the general health, but have named only the most important drugs, which are known by repeated use to possess some direct influence on the skin lesions, tending to cause them to disappear. MERCURY. The value of mercury in almost all the syphiloderma is acknowledged by dermatologists, and it is almost wholly among this class of cases that the drug is now employed internally. Few non-syphilitic affections are benefited by this drug, so mercury is frequently used internally as a means of diagnosis between syphilitic and non-syphilitic diseases by those who are in doubt as to the nature of the disease, claiming that if the eruption is cured by mercury, it must necessarily have been syphilitic. This seems to me a very unscientific way of making a diag- nosis—in fact, it is very much like having some one else step in and make a diagnosis for you, and even then an uncertain one. There are a number of other skin diseases besides syphilis that are benefited by mercury, and although per- haps not acted upon so promptly will eventually cure the trouble. Mercury seems specially indicated in chronic papular, scaly skin diseases, as psoriasis, lichen planus, GENERAL THERAPEUTICS. \J and those tubercular skin affections as lupus vulgaris and scrofuloderma. I do not want you to understand that mercury will cure these diseases I have just named, for sometimes you may give it without any beneficial effect ; but usually you will find an improvement, and sometimes a cure. The best preparations of mercury to use are the iodides, and preferably the proto-iodide. Mercury may be given in connection with iron and arsenic, a very valuable solution being Donovan's solution of the iodide of arsenic and mercury. ARSENIC. There is no drug which has been so extensively em- ployed in skin diseases as arsenic. It is a custom with almost every physician who knows little about diseases of the skin to prescribe arsenic in almost every skin dis- ease he is called upon to treat, no matter what the lesion may be. Such then is the reputation of the drug as a specific in skin diseases, and yet no remedy is more abused, for its beneficial action is very limited. In skin diseases characterized with the formation of bullae arsenic is indicated, and may be given with excellent results. Especially is this true in acute pemphigus where it may be said to act as a specific. Arsenic by many is considered a specific also in sarcoma cutis, and it certainly does seem to have a marked beneficial effect in most all cases of this disease by retarding the development of the new growths, and even causing some ®f them to entirely disappear. As a general rule you may consider arsenic as counter- indicated in all acute affections of the skin, and indicated in the chronic papulo-squamous diseases, especially 1 8 LECTURES IN DERMATOLOGY. psoriasis, squamous eczema, and lichen planus. Skin diseases in persons suffering from chronic malarial poison- ing may be treated advantageously with arsenic. Nine out of ten cases of acne are treated by the internal ad- ministration of arsenic, and, when occurring in anaemic and debilitated persons, with the greatest success ; but the good result is probably due to the tonic action of tin- drug rather than by any direct influence on the skii? lesion. Arsenic is best given in the form of Fowler's 01 Donovan's solution, well diluted and after meals. It i£ usually necessary to give large doses, and continue it?- use for some time. IODIDE OF POTASSIUM. Iodide of potassium is used very frequently in skin dis- eases by physicians, but less frequently by dermatologists. Its use more often does harm than good, by its tendency to set up inflammatory action in the sebaceous glands. Skin diseases, the result of syphilitic eruption, especially those occurring late in the disease, are cured by the iodides, while scrofuloderma and lupus are undoubtedly benefited by its use. COD-LIVER OIL. Cod-liver oil may be employed in a large number of skin diseases. Hebra considered it a remedy of special value, and one which could be given with advantage in most skin diseases. Its special value is in the cutaneous affections of children and infants, and in the chronic skin diseases of adults accompanied with wasting, such as lupus, syphilis, scrofula, sarcoma, etc. Seborrhcea or greasy conditions of the skin are not counter-indications for its use. GENERAL THERAPEUTICS. 1 9 ALKALINE DIURETICS. The alkaline diuretics given before meals are not only indicated in the more acute skin affections, as urticaria and erythema but also in eczema, both acute and chronic, in psoriasis, in lichen planus and in acne occurring in the plethoric. The best of these diuretics is potassium acetate, given in twenty-drop doses before meals, either in water or, if constipation exists, in the rhubarb and soda mixture. ERGOT. Ergot may be used with great advantage in acne, especially acne rosacea, and in all the hemorrhagic skin affections, especially purpura. QUININE. Quinine is curative in the neurotic skin affections, as herpes, and in all skin diseases complicating malarial poisoning. Phosphorus, carbolic acid, tar, ichthyol, resorcin, and hundreds of other drugs are given in skin diseases for their direct influence on the skin lesion, but only those I have named have stood the test of repeated trials. I do not wish you for one moment to think that these few drugs I have mentioned are the only ones you will be called upon to use with your patients affected with skin diseases, for you will frequently be obliged to treat the general health of your patient, and unless you do so, poor results will follow all your efforts. HYPODERMATIC MEDICATION. Before leaving the subject of internal medication, I wish to say a few words to you of hypodermic injections 20 LECTURES IN DERMATOLOGY. of medicine for the cure of skin diseases. Fowler's solu- tion of arsenic is used with good result injected into sar- comatous tumors. It may be used at full strength, but had better be diluted with four or five times its volume of water. Mercury in various forms has been used by injection for the cure of syphilitic eruptions, but the pain and danger of producing abscesses is an objection to its use. It may, however, be used in infants with good result, or in adults where emergencies demand heroic treatment. The bichloride of mercury well diluted may be thus em- ployed, or calomel or yellow oxide may be used held in suspension in either water or gum arabic in the propor- tion of three parts to thirty, and about fifteen minims, of this injected at one time and repeated in five days. The injection should be deep in the cellular tissue, or in the muscles of the gluteal region. Pilocarpine is now used by hypodermic injection to stimulate the growth of the hair in alopecia, with good result. EXTERNAL MEDICATION. It is unfortunate that we have very few drugs which are specific in skin diseases — that is, in themselves have a direct influence in curing the disease, as mercury has in syphilis. In other words, we must treat the majority of skin diseases with external treatment, in the same way we treat scarlet fever or pneumonia with internal medi- cation. As we cannot say that this drug or that drug would cure pneumonia, neither can we say that this application or that application will cure eczema. We must treat very largely the symptoms, and by reliev- ing the conditions present cure the disease. We must GENERAL THERAPEUTICS. 21 therefore divide our external remedies into groups, ac- cording to their physiological or mechanical actions. Thus, they may be either soothing, astringent, stimulating, protective, drying, antipruritic, parasitic, antiseptic, or specific. To be in accord with the more recent progress of der- matology we must understand the various methods of applying medicaments to the skin, and know what proper- ties the medicines or the bases with which they are com- bined must possess to obtain the best results. First. The drug must be either in soluble form, or so minutely divided as to pass into and through the outer layers of the skin. Second. The preparation must be protective against external influences, especially where the outer skin is broken or removed. Third. The base should be readily soluble to carry the drug with it. These general rules just mentioned are not without ex- ception, but they answer very well for the treatment of most skin diseases. Drugs for external application may be used in the form of ointments, plasters, powders, lotions, baths, caustics, and soaps. OINTMENTS. The best success in treating skin diseases is obtained by the use of ointments. In many respects these are disagreeable and nasty means of applying treatment, soil- ing the patient's clothing and making them feel very un- comfortable and dirty, but nevertheless efficacious. They are usually made by incorporating the drug or drugs to be employed in some fatty base, as lard, vaseline, or lanoline 22 LECTURES IN DERMATOLOGY. Benzoitic lard is usually used for the bases of all oint- ments, as it keeps nicely, is about the right strength, is protective, is quite readily absorbed by the skin, and is cheap. Lanoline, a fat made from the oily matter obtained from sheep's wool, may be more readily absorbed by the skin than is lard, but in other respects it is inferior. Vaseline is cheaper than lard, keeps longer without spoiling if pure, but is not readily absorbed, and if not properly prepared contains impurities which are very irri- tating to many skins. In parasitic skin affections vase- line seems to act as itself a parasiticide, so that I should advise you to use it as a base for your ointments in all skin affections of this nature. Remember that mercury and vaseline do not mix well together. Ointment mulls. Unna has overcome the objectionable features of ointment applications to a great extent by leaving the ointment spread on mull so that it is really in form of a plaster and applied as such. Ointment of the water of roses of the U. S. P. is some- times used as the base for ointments, and Dr. Bulkley considers it the best. Where protection is required to the skin it is certainly a very valuable preparation to use as a base for other ingredients. It is very important that you should see your ointment is free from any coarse parti- cles, for frequently poor results of treatment are due to poorly prepared ointments. In 1891 two excipients were produced which very nicely take the place of fatty sub- stances in making ointments. These are called bassorin, which is made from gum tragacanth, and plasmcnt, made from Irish moss. They are easy and simple in applica- tion, requiring only to be spread upon the skin with the finger or a brush. They dry in the space of a few minutes GENERAL THERAPEUTICS. 2$ if so applied, adhere closely, and do not rub off and soil the linen, but form a flexible coat which does not inter- fere with the movements of the body. When its removal is desired the preparation can be washed off with a little water, or a damp cloth or sponge. They remain in situ without change for a variable length of time, depending upon the condition of the surface on which they have been applied. With these pastes almost any drug can be incorporated ; those which exist in the form of powders, or in solid forms in any amount desired ; the tars, ichthyol, and oily sub- stances in smaller percentages, but sufficient for all practical purposes. The properties possessed by these pastes render them superior to ointments for the reasons, among others, that it is difficult to keep the latter in constant contact with the diseased surface ; that salves soil and stain the linen, and offer such other objectionable features as greasiness, risk of becoming rancid, etc., to say nothing of the dis- comfort entailed upon the patients using them. GELATOLE OINTMENTS AND PLASTERS. As most of these drugs are only incorporated in the fatty bases used in preparing the ointments, it has been thought that better results could be obtained by having the drug in solution. To this effect gelatole ointments are now made by first dissolving the drug in a suitable sulpho- oleate salt, combining it with a fatty base, and adding enough gelatine to give consistency and form a protective film. A wide range of drugs may thus be brought into condition to readily penetrate the skin. The unofficial gelatole plasters are the ones now some- times used in the place of ointments. These are prepared 24 LECTURES IN DERMATOLOGY. in the same way, by dissolving the drug to be employed in sulpho-oleate of sodium (a solvent for at least a small percentage of almost any drug), and combining with a fatty base. Gelatine is then added to give strength, and the mass spread on cloth either pervious or impervious as desired, in the form of a plaster ready to be applied to the skin lesions. The action of these preparations when applied to the skin is largely due to their affinity for liquids, whereby the layer of air upon the surface of the skin is displaced, and a close contact established between the compound and the glands and follicles, and absorption rapidly fol- lows. By the slight saponifying of the sulpho-oleate acid the fatty exudatets of the skin, dirt, and other matters, are emulsified, and their power to prevent absorption removed. Some druggists keep these plasters and ointment mulls already prepared, and they are named from the drug dis- solved in them. Thus, you may ask for a 5 per cent, salicylic gelatole plaster, or an oxide of zinc ointment mull. The- oretically these plasters should be all that is desired for the treatment of skin diseases, for the full and continued action of the combined drug is fully presented to the diseased surface. They are clean, adhesive, light, applied easily and do not have the objectionable feature of extreme adhesiveness — or the complete envelopment of the drug by the base that prevents the use of resinous or rubber plasters in dermal practice. Practically these plasters have not taken the place of ointments. They are expensive, not always easy to ap- ply, are not adapted for use where a large extent of sur- face is to be treated, often produce more irritation of the skin than ointments, and in many cases the sulpho-oleate GENERAL THERAPEUTICS. 2$ of sodium will not dissolve a large enough percentage of the drug to be serviceable. Where small areas of sur- face are to be treated, and you wish to get a continued and penetrating action of the drug, as in cases of scaly and thickened lesions of the hands and feet, these plasters are very serviceable. GLYCO-GELATIXES. These are composed of a combination of glycerine and gelatine with oxide of zinc or water, in nearly equal propor- tions. Nearly all the medicaments used in the treatment of diseases of the skin are miscible in proportion from 5 to 15 per cent, and are added as required. The method of application of this form of dressing is excessively sim- ple. The solid glyco-gelatine is melted in a hot-water bath. It is then applied with a paint brush to the affected region, and dabbed over immediately after with a roll of absorbent cotton. Thus a sort of skin is formed, which acts as a protector and as a medium, by which the medi- caments may be kept in constant contact with the skin. Besides this, it acts beneficially by its slight compressing effects, producing a localized anaemia, also favoring the absorption of inflammatory products. TRAUMATICIN AND COLLODION. Liquor guttapercha^ (traumaticin) and flexible collo- dion are sometimes used as excipients for drugs. They give us cleanly fixed dressings, which exert a certain amount of pressure on the skin that is very useful in many cases where we have chronic thickening of the skin, as in psoriasis ; but in acute diseases when there is more or less exudation they cannot be used. I warn you to be 26 LECTURES IN DERMATOLOGY. very careful, in making applications to the skin, never to confine sero-purulent or purulent secretions under your dressings, for it always causes mischief. I have frequent- ly seen deep ulcerations of the skin following applications of collodion and other impermeable substances in skin diseases accompanied with purulent or sero-purulent exu- dation. LOTIONS. Lotions, although not as important as ointments in the treatment of skin diseases, play an important part and should be carefully prepared, so that their ingredients are thoroughly pulverized and mixed. Lotions may be applied occasionally to the diseased skin, or they may be kept continually in contact by means of thin cloth wet in the solution, but not covered with oil silk as they then have a poulticing action. Glycerine is usually added to the lotion as a demulcent, but you must remember that some skins cannot stand glycerine, it acting as an irritant. Lotions are more cooling and astringent than ointments, and are easier to apply to the face and scalp. The same drugs may be used in the same proportion, and to fulfil the same indications in lotions as when used in the form of ointments POWDERS. Powders are more frequently used in skin diseases by the laity than by dermatologists. When used they should be very fine and free from any gritty particles. Care must be taken that powders be not allowed to cake upon the skin, or to be worked into a paste. If in this condi- tion they frequently do more harm than good. Powders are more drying than other forms of application to the skin, and seem to possess a cooling influence on inflamed GENERAL THERAPEUTICS. 2J skins, and are therefore indicated in erythematous and vesicular eruptions. Among the powders used for such conditions may be mentioned buckwheat flour, calamine, fuller's earth, lycopodium, and magnesia. In case there is a tendency to the formation of pustules salicylic acid or boric acid may be added as an anti- septic in acute exudative inflammations of the skin, as weeping eczema. These powders may be used for their drying and astringent properties, but care must be exer- cised to prevent the caking of the powder and the reten- tion of the secretions under them. BATHS. Hot- or cold-water baths are occasionally used as a remedy in skin affections, but their use is very limited. In chronic inflammations of the skin where there is much crusting and scaling, these crusts and scales may be removed by continual applications of hot water. Hot water, by its relaxing effects on the tissue, is frequently used with good effect to hasten the resolution and ab- sorption of inflammatory thickenings in the skin. You should remember, however, that water in acute inflamma- tion of the skin, especially accompanied with exudations as in eczema, is counter-indicated. Turkish and Russian baths you will seldom prescribe for your patients. Medicated baths should be taken hot or tepid, the patient remaining in the bath from ten to thirty minutes. Among the best medicated baths are the bran, alkaline, and the carbolic acid, and sulphur. Bran baths are especially serviceable in all cases requir- ing a soothing application to the skin, and where the subjective sensations are itching, burning, or pricking, such as occur in erythema, exanthemata, urticaria, sub- 28 LECTURES IN DERMATOLOGY. acute or chronic eczema, psoriasis, etc. A pound of bran may be added to a bath of fifteen gallons of tepid water. It may be simply mixed with the water, or confined in a cheese-cloth bag soaked in it. Starch or gelatine is sometimes used in place of bran in about one half the quantity. Alkaline baths are used for very many of the same conditions as the bran baths, but are especially service- able in the scaly skin diseases. The water may be first made demulcent by the use of bran or starch, and then half a pound of washing soda added to the bath. Carbolic acid baths, from four to eight ounces to fifteen gallons of water, are especially serviceable as antipruritic remedies in the conditions of the skin already mentioned, and may be used without fear of absorption if the skin is not excoriated. The bath has undoubtedly some anti- septic properties, and you will find it very serviceable in the parasitic skin affections, and in the exanthemata when desquamation is progressing. Sulphur baths are sometimes employed for the cure of parasitic skin affections, especially scabies, and, used as a help to other treatment, may be highly recommended. Two ounces of precipitate of sulphur, and one ounce of the hyposulphate of sodium may be added to fifteen gal- lons of water. In seborrhceal affections and when the skin is very oily these baths are serviceable. CAUSTICS. Caustics are not often required for the treatment of skin diseases, except in cases of lupus and epithelioma and naevi. Those most frequently employed are arsenic, chloride of zinc, nitrate of silver, carbolic acid, and sodium ethylate. When arsenic or chloride of zinc is employed, it is best GENERAL THERAPEUTICS. 29 mixed with equal parts of starch or pulverized acacia, and enough water added at the time of using to make a thick paste. This is to be kept on the diseased surface for twelve hours or more, and then poultices applied until the slough separates. Nitrate of silver is especially serviceable in the treat- ment of tubercular forms of lupus, each tubercle being punctured by the solid stick sharpened at the point. Carbolic acid is a superficial caustic usually applied with a brush, and especially useful in the treatment of ery- thematous forms of lupus and mucous patches and ring- worm. Equal parts of ethylate of sodium dissolved in alcohol is the best superficial caustic in the treatment of capillary and pigmentary nasvi. The solution should be applied to the naevi with a brush. Tincture of iodine is a superficial caustic to use in cases of ringworm, either of the body or of the scalp. SOAPS. Soaps are of two kinds. The hard or soda soap, and the soft or potash soap. Hard soap is neutral in reaction, and used chiefly for the purpose of ablution. Soft soap is decidedly alkaline in reaction, due to an ex- cess, of the potash present, and has a much larger thera- peutical action. It is usually dissolved in alcohol in the form of tincture of green soap. It has the physiological property of cleansing the skin, removing the oil or grease from its surface, causing a superficial destruction of the horny layer of the epidermis, acting as a direct stimulant or irritant to the skin. Its therapeutic properties are especially marked in treatment of the chronic scaly diseases of the skin. 30 LECTURES IN DERMATOLOGY. Besides these two varieties of soaps we have a large number of medicated soaps made by adding some drug to a hard soap. Most of these preparations are worthless things. The best of them are the sulphur, corrosive sublimate, tar, ichthyol, and carbolic acid soaps. These medicated soaps should never be relied upon in the treatment of skin diseases, but are sometimes useful when used as adjuncts to other forms of treatment. Thus, if you are treating a case of psoriasis in which tar is indi- cated, it would be well to tell your patient in washing to use tar soap. In conclusion I would again warn you to be careful, in making applications to the skin, never to confine purulent secretions under your dressings, for it always causes mischief. INSTRUMENTS USED IN DERMATOLOGY. You will find it convenient in the treatment of skin diseases to possess the following instruments, besides those usually found in pocket-cases. I. Small and medium-sized dermal curettes for remov- ing new formations in the skin. II. Small and medium-sized dermal burrs for destroying diseased sebaceous glands and removing lupus nodules. III. Single and multiple scarificators for treating naevi, lupus, and acne rosacea. IV. Epilatory forceps. V. Comedone extractors for treatment of acne. VI. Small and medium-sized dermal punches for re- moving small epithelioma, warts, moles, powder grains, etc. VII. Dermal spear for opening skin abscesses and for puncturing papulo-pustular lesions, especially those occur- ring in acne vulgaris. VIII. Galvano-cautery battery with electrolysis needles for removing hairs and for treatment of naevi. LECTURE III. ACNE, ALOPECIA, AND ALOPECIA AREATA. Gentlemen : Having gone over with you in a general way the classi- fication, diagnosis, and thereapeutics of skin diseases, I will now call your attention to the consideration of some of the most common skin affections. ACNE. Probably among the first of the skin diseases which you will be called upon to treat will be acne. This is the most common of all skin diseases, and there are but few people in our climate who have not at some time or another suffered more or less with it. Pathology. The disease is an inflammatory one, and has its seat in the sebaceous glands and follicles of the skin, and not only involves the gland structure but the tissue about it. The first stage in the disease is a retention of the glandular secretion, which is followed by a hyper- aemia and cellular exudation in and about the walls of the glands, which usually goes on to suppuration, and may be so extensive as to result in scar formation. Etiology. The causes for acne are numerous, and may be constitutional or local. There is no question that there is often an hereditary disposition, making certain persons very susceptible to the disease. It occurs about 31 32 LECTURES IN DERMATOLOGY. equally in the sexes, most frequently making its appear- ance about the sixteenth year. It is more common in persons with fair skin than those with dark, although some of the worst attacks occur in brunettes. Among the most common causes are functional derangement of the stomach, bowels, and generative organs. Diseases of the blood, as anaemia, chlorosis, and general cachexia produce the worst forms of acne, known as acne cachecticorum. Medicines, especially the iodides and bromides, fre- quently are the direct cause of the disease, producing as one of their physiological effects inflammation of the sebaceous glands. Exposure of the skin to certain irrita- ting influences will frequently produce acne, as decided and sudden changes of temperature, and the application of certain substances, as tar. Symptoms. Acne usually shows itself in the form of either papules, tubercles, or pustules about the opening of the hair follicles. All three of these lesions exist together, but usually one or the other is predominant, and the disease is then called either papular, pustular, or indurated acne. These lesions usually exist in all periods of development, some of them disappearing as others are making their appearance. The symptoms which usually attract the patient's attention when a new lesion is ap- pearing are first a hyperaemic spot on the skin, then a little, hard, shotty nodule felt in or under the skin, and accompanied by pain on pressure over the spot. Within twenty-four hours the lesion becomes distinctly papular, raised above the skin, and surrounded by an inflamma- tory areola. The papule remains in this condition for a variable length of time. It may within a few hours sup- purate, a papulo-pustule forming, which either ruptures ACNE. 33 or dries up, or it remains as a papule for two or three weeks and is gradually absorbed. When the inflamma- tion is deeply seated in the glands suppuration may go on for days before the pus reaches the surface. In these cases the suppuration usually extends to the surrounding cellular tissue, occasioning considerable swelling and pain. This condition is frequently spoken of as a blind boil, but is more properly a cutaneous abscess, and usually results in the formation of scar tissue. The affected skin in many cases is oily and shiny, and in nearly all cases pre- sents many black-heads or comedones, which I will speak of at another lecture. The number of acne lesions present at one time varies considerably. They seldom appear in groups, but often in crops, several making their appearance at one time. They may occur on any portion of the body except the palms of the hands or the soles of the feet, but have a decided preference for the face, shoulders, back, and buttocks. Acne leisons may disap- pear entirely or result in atrophy of the skin, in hyper- trophy of the glands and tissue about them, or in the production of scar tissue. Diagnosis. The diagnosis of acne is seldom difficult. The only diseases with which it is liable to be confounded are small-pox, papulo-pustular eczema and syphilis, sycosis, and rosacea. For these differential diagnoses of acne and other skin diseases I would refer you to a little work which I have written upon this subject, entitled Differential Diagnosis of the Diseases of the Skin. Treatment. The treatment of acne, however, requires for its successful management both internal medication and external applications. The cause of the disease should first be ascertained if possible, and treatment directed towards curing or relieving it, for otherwise if 34 LECTURES IN DERMATOLOGY. the cause still exists and your remedies are employed only on the external lesions, you cannot hope for a per- manent result. In almost every case of acne the diet should be carefully regulated. In the cachectic a more generous diet is required that when acne occurs in the full-blooded. In all cases patients suffering from acne should not eat hot breads, pickles, spices, cheese, pastry, nuts, or candy ; nor drink coffee, chocolate, or other stimulating drinks. Alcoholic liquors of all kinds, ex- cept in the cachectic cases, should be prohibited. The bowels should be kept very thoroughly open by the use of hot water taken before meals, and if necessary sprudel salts or hunyadi water before breakfast. Besides the internal remedies which may be required for the treatment of the functional disturbances or of the cachexia accompanying the acne, certain drugs seem to possess a greater or lesser influence independent of the local skin treatment. Arsenic, perhaps, heads the list of valuable internal remedies, and in many cases it does seem to be especially beneficial. You will find that it acts better in those cases that have lasted for a long time where the induration is marked, where the disease is very extensive, and where the blood is in a very poor condition. Iron and cod-liver oil are also indicated in these sort of cases. Donovan's solution of the iodide of arsenic and mercury has proved a better agent in many hands than other preparations of arsenic, probably on account of the mer- cury it contains, although Fowler's solution is the prep- aration usually given. Sulphur and molasses is an old- time remedy in acne, especially useful in those cases where the bowels are sluggish, and where pustulation is extensive. The sulphide of calcium is now extensively used to lessen the amount of pustulation, and given in ACNE. 35 one-tenth-of-a-grain doses every two hours, seems to act very much more satisfactorily than if given in larger doses less frequently. Acne occurring in the plethoric is fre- quently greatly benefited by the use of sulphur spring waters. In the papular form of acne, glycerine given in tablespoonful doses two or three times a day seems to hasten the resolution of the papules and prevent their further development. Local treatment. There are three drugs that I can recommend to you most highly in the local treatment of acne. They are sulphur, mercury, and resorcin ; but you will get very little good result from their use if you do not employ them in a scientific manner. I have never seen a case of acne in which very hot water was not of decided benefit if used thoroughly. By thoroughly, I mean for half an hour three times a day ; but cold water, or luke- warm water, should never be used unless necessary. If there is but little oiliness of the skin, a very satisfactory treatment consists in the use of hot water for half an hour three times a day, and then applying the following lotion : 5 Resorcini 3 ss Hyd. chlor. corr. ...... gr. i Glycerini 3 ii Aq ad 3 ii Sometimes the glycerine, even in small quantities, will not be well borne by the skin, and you will have to leave it out of the lotion. If the disease is very sluggish and slow to respond, the following ointment 5 Resorcin 3 ss Ung. hyd. ammon., Ung. aq. rosse aa § i m 36 LECTURES IN DERMATOLOGY. may be applied at night. If this treatment causes a der- matitis, the application may be made less severe. Where the face is specially oily and greasy, sulphur lotions and ointments are better than the mercury. Such a lotion may be prepared as follows: 5 Gum. tragacanth gr. v Camphor gr. x Sulphur sub 3 ii Aq. calcis ad 3 ii This is very serviceable to use two or three times a day after the hot-water applications. Do not use the sulphur and mercury preparations together on the face, for a chemical reaction will take place, staining the skin. In chronic, indolent cases that do not respond to treat- ment, where the skin is greasy and muddy-looking and the circulation sluggish, it is often necessary to stimulate the skin pretty thoroughly and get up some reaction be- fore a cure is effected. To do this, nothing is better than to scrub the face every few days with the tincture of green soap, together with the frequent use of the following lotion : J} Pot. sulphuret 3 i Aq ad I ii Solve et adde solutionem subquentem : Zinc sulph 3 i Aq ad § ii One word in reference to the surgical treatment of acne. The contents of all comedones should be ex- pressed. All pustules should be freely opened and their contents squeezed out ; the deep collections of pus should be evacuated by a deep incision with the dermal spear, which should be turned round a few times in the skin to ALOPECIA. U destroy the glandular structure, otherwise you may have a collection of pus forming again in the same location. These little surgical operations should be done before the hot water is applied, for the bleeding is then encouraged, which is beneficial. ALOPECIA. The next subject to which I call your attention is in- teresting to us all, but evidently to some more than others for personal reasons. Although baldness is much more common in the male sex, it is none the less noticeable, for woman's uncovered head is usually covered, thereby not attracting attention. Since that terrible punishment received by the children who gave Elisha the unasked for advice to " go up, thou bald head," we have been accustomed to look upon bald heads with reverence, and as a sign of old age and natural decay ; but now times have changed, and even ballet dancers are apt to look down upon them. In the past few years, alopecia occurs so frequently in comparatively young persons that it may be considered as a disease when occurring in those under forty years of age. That a bald head is not a desirable possession is evidenced by the enormous sale of nostrums warranted to restore the natural covering to the scalp. To every hair is given a length of life varying from four months to four years, and it is estimated that the daily average loss of hair from a healthy scalp varies from 13 to 200. In the natural condition of the scalp, every hair which dies is replaced by another that usually grows from the same papilla, but sometimes from a new papilla developed by the side of the old one. If this growth of hair did not take place, every one would be bald within four years. 38 LECTURES IN DERMATOLOGY. These new hairs should be the same size as the old ones, and have the same length of life. The thicker the hair, the longer its life, so if the new hairs which make their appearance are smaller in calibre than the old ones, it is a pretty sure indication of approaching baldness. The term alopecia is a very general one, and should be used to describe a symptom rather than a disease. Just as we use the term headache to designate the symptom of a disease, so should we speak of alopecia as a symptom present in certain affections of the scalp. You can no more cure the diseased condition of the scalp by simply treating the symptom alopecia, than you can cure pneumonia or typhoid fever by remedies used to lessen the headache. There are so many varieties of alopecia, each variety depending upon different causes, with different symptoms, and demanding different treatment, that I will only have time to call your attention to the most important disease of the scalp which is accompanied by baldness — namely, seborrhoea. To perfectly understand how a seborrhcea of the scalp will result in alopecia, it will be necessary for me to call your attention to the very close anatomical and physiological relation between the hair follicles and the sebaceous glands. Each hair follicle may be considered as a prolongation downward of the epithelial layer of the skin into the corium, which is its deepest layer. In the bottom of the sac thus formed the fibrous elements of the corium rise and form a papilla, which is called the hair bulb, and from which the hair is supposed to take its growth. On either side of each hair follicle thus formed is situated a seba- ceous gland with its duct opening directly into the fol- licle, so that the secretion from such glands finds its way ALOPECIA. 39 to the surface of the skin through the mouth of the hair follicle. The secretion from these glands supplies pabu- lum to the growing hairs, thereby nourishing them, so you can readily understand from these close relations existing between the hair follicles and the sebaceous glands that any disease, or even disturbance of function, of these glands must necessarily, if long continued, affect the growth and condition of the hairs. There are several forms of seborrhcea which may result or terminate in alopecia, but there is one variety which, from its great frequency of occurrence, its insidious man- ner of approach, the apparent insignificance of its early symptoms, and its certainty of termination in permanent baldness if not properly managed, is a disease of much importance, and the only one which I will speak of this evening. The disease which I refer to is termed alopecia furfuracea, or eczema seborrhoicum of the scalp, also sometimes called alopecia pityroides, or dandruff. The disease always begins in the sebaceous glands as a fatty, metamorphosis of the glandular cells. This degen- eration extends into the hair follicles, which eventually results in an atrophy of the hair bulb and a permanent loss of hair. Of late the opinion is gaining ground that alopecia furfuracea is a contagious disease, and the ex- periments of Lassar and Bishop would seem to prove this. They have succeeded in producing typical attacks of this disease in guinea-pigs by rubbing into their backs a pomade composed of the scales taken from the head of a student suffering from dandruff. A number of observers have found micro-organisms present in the scales pro- duced in alopecia furfuracea, but it is not absolutely demonstrated that these parasites are the direct cause of the disease. 40 LECTURES IN DERMATOLOGY. Symptoms. The disease usually begins between the ages of fifteen and twenty-five years, and the first symptom noticed is dandruff. In the beginning this desquamation of fine, branny scales from the scalp is so slight as to pass unnoticed, but after a time they become so abundant as to fill the hair and fall over the clothing. All parts of the scalp are not equally affected, the disease appearing most markedly about the edges of the hair and on the vertex of the head, sparing the occiput and sides. Ac- companying this desquamation there are few if any sub- jective sensations attracting the patient's attention to the diseased condition of the scalp, a pruritus or itching of greater or less severity being the only symptom present. Sooner or later, however, the patient will notice a con- stantly increasing number of hairs combing out, and that loose hairs will be found on his clothing during the day, and on the pillow in the morning. At first there does not seem to be any thinning of the hair, as each hair is reproduced, but it will be noticed if a careful examination is made, that the new hairs are smaller in calibre, which is a pretty sure sign that an atrophy is already taking place in the hair papilla. About a year or more after the disease is first noticed a marked thinning of the hair will be found, usually beginning in two spots, one just back of the anterior border of the scalp, and the other near the vertex. This is the beginning of the end. Unless proper treatment is begun at once, " Good-bye, fond hopes of future greatness," for there will soon be left no hair (heir) to the crown. Treatment. Now for a few words regarding the treat- ment of this affection. As the skin is in an apparently healthy condition under the scales, it seems a very easy matter to remove these scales with soap and water or with ALOPECIA. 41 oil ; but, unfortunately, the removal of the scales in no way removes the disease, as they will form again in even greater abundance in a few days, sometimes in a few hours after they are removed. The remedies which are recommended and advertised for the cure of this affection are only exceeded in number by those given for the relief of the vomiting in pregnancy. The question then arises, which of these remedies are we to use, and how are they to be applied? If you will take your Bible and read the twenty-third and twenty-fourth verses of the second chap- ter of II Kings, you will find when Elisha had his atten- tion attracted to his bald head he immediately looked around for some means of relief. He found that bears afforded a remedy which was wonderfully and rapidly effectual, for we do not hear of any further reference made to his bald head. Since then " bear's-grease " has been one of the many remedies applied to the scalp for the cure of alopecia. It acts well, especially with children, to prevent baldness. Some dermatologists claim that as the original prescrip- tion called for only the she bears, this preparation should be made from the female animal. The importance of this, however, I think is doubtful. Of late years we have found other agents acting to better advantage. The scientific treatment of the dis- ease differs somewhat according to the extent to which it has progressed. If we see the disease in its early stages when the only symptom is dandruff, and when the loss of hair is very little, if any, we can do a great deal in the way of prophylactic treatment. In the first place, the constant application of water to the scalp is bad. It undoubtedly tends to produce dan- druff, and if the disease already exists it always aggra- 42 LECTURES IN DERMATOLOGY. vates it. The same is true of irritating applications to the scalp, such as tincture of cantharides, capsicum, and all strong alcoholic preparations, for they not only tend to set up an inflammatory condition, but by dissolving the natural oil of the skin, produce a dryness of the scalp which in the end does more harm than good, in fact may be the direct cause of the disease. The hair should be shampooed once in ten days to two weeks with the yolks of three eggs beaten up with lime water. After thoroughly rubbing this into the scalp, it should be washed out with a solution of borax in hot water, the hair thoroughly dried, and the following oint- ment rubbed into the scalp and allowed to remain over- night : 5, Pilocarpin. hydrochlor 3 ss Vaselin 3 v Lanolin § ij Ol. lavandulae gtts. xv m In the morning, after the hair is thoroughly rubbed dry, its greasy condition will not be noticed. Moistening the hair every day with water will do no harm if neces- sary to keep the hair smooth, but daily sousing of the hair should be prohibited. Deep brushing of the hair every day with a long-bristled brush, stiff enough to warm but not scratch the scalp, is stimulant enough for a healthy scalp. If we do not see the patient until the hair has already begun to fall out to a considerable extent, a different plan of treatment is to be recommended. Once in every five days to a week the patient should take a shampoo, using the tincture of green soap to form a lather ; after ALOPECIA. 43 thoroughly drying the hair, a pomade, as just recom- mended, is to be thoroughly rubbed into the scalp and allowed to remain overnight. In the morning this should be washed out with the tar soap, and the following lotion rubbed into the scalp : ^ Hydrarg. chlor. corros gr. iv Resorcin 3i Aquae destil § iv TTl This lotion is to be applied to the scalp night and morning, rubbing it well in about the roots of the hair with a small sponge. Usually in three or four weeks a marked improvement will be noticed by the absence of dandruff and the hair no longer falling out. As the im- provement continues the treatment may be less vigorous. The shampoo may now be used once in ten days or two weeks, and the lotion applied only at night ; but treat- ment should be continued for at least six months. Re- lapses are very common, and especially so if all treatment is discontinued too early. After the hair has stopped falling out, you may find that the new hairs which replace those that were lost are weak and need stimulation. There is but one drug, taken internally, which seems to possess the power of stimulating the growth of the hair, and that is pilocarpin. It must, however, be taken in quite large doses to have an effect, and even then it is often disap- pointing. In some cases better results are obtained in giving it by hypodermic injection. Externally there are many irritant applications to the scalp which are recommended to stimulate the growth of the hair. If these applications are used while the sebor- rhcea is still present, only harm can come by irritating a 44 LECTURES IN DERMATOLOGY. scalp which is already inflamed ; but if the disease is first cured, then such applications may be used with advan- tage. The following is the one I usually recommend to stimulate the growth of the lanugo hairs after all traces of the seborrhcea have disappeared : 5, Tine, cantharides, Tine, capsici, Tine, nucis vomicae, Ol. ricini aa § ss Aquae coloquiesis, or bay rum . . ad § iv m This lotion may be rubbed into the scalp every night for several weeks, and then continued less frequently for several weeks longer. In the third stage of the disease, when baldness has fairly won the crown, do not despair. Your work is not yet done. You may somewhat dim its shining glory still by one more prescription — for a wig. ALOPECIA AREATA. There is another form of alopecia to which I would call your attention, and that is alopecia areata. Cause and Pathology. This disease has been variously regarded by dermatologists as the result of perverted en- ervation, a tropho-neurosis, or a parasitic skin affection. If the hairs be examined microscopically, they will be found to terminate at the root abruptly in a club shape, the hair bulb being contracted and atrophied. The shaft of the hair near its free extremity will be found swollen, and then tapers into a broken extremity. These condi- tions are all due to the fact that the hair does not receive its proper nourishment from the papillae. The lesions ALOPECIA AREATA. 4$ seem limited to the hair, for besides the pale, atrophic condition of the affected area, the skin and its glandular appendages seem normal. In some cases there is found a micro-organism, which has been considered by many observers as the cause of the trouble. I can advance very few arguments to prove the correct- ness of my opinions, but personal observations, from a purely clinical standpoint, convince me that I have seen but one form of alopecia areata, and that is the neuro- pathic. If the disease is parasitic we could expect to find it contagious, but I have yet to see one case where a careful investigation of either the history or circumstan- tial evidence surrounding it would point toward its con- tagious nature. On the other hand I have found in the great majority of cases evidences of well-marked nerve disturbance in the affected area. I have one patient un- der observation at the present time in whom the disease was preceded by the most frightful attack of tic douleureux that I have ever seen. A few days before each patch of alopecia makes its appearance this woman will suffer the most agonizing neuralgic pains in the area where the lesion is about to form. Several of these patches have made their appearance from time to time, and were invariably preceded by these sharp neuralgic pains. In almost all patches of alopecia areata careful examina- tion will disclose some nerve disturbance in the affected area. Subjective sensations as tingling, formication, or itching are not uncommon, while a careful examination by the aesthesiometer will show that there is usually some hyperesthesia or anaesthesia of the skin as compared with a symmetrical area on the opposite side of the body. But not only does this tend to prove the neuropathic form of the disease, but the so-called nerve tonics, especially 46 LECTURES IN DERMATOLOGY. arsenic, phosphorus, and strychnine, if used early in the disease and pushed to their therapeutical limit will in many cases prevent the spread of the disease and hasten the return of the hair. The only one argument which I can hold forth in sup- port of the parasitic nature of the disease is the good effect resulting from the local use of such germicides as iodine and carbolic acid ; but I believe these agents act not by virtue of their antiparasitic properties, but by stimulating the sensitive nerves to better conductivity, which in turn stimulate the trophic centres, and an in- creased nourishment to the hair bulb is a result. Symptoms. The disease may attack any hairy portion of the body, but most commonly the scalp, and next most frequently the beard. The disease usually makes its ap- pearance suddenly, often within twenty-four hours. The patient may go to bed with a normal head of hair, and wake up in the morning with several bald patches. In other cases the baldness comes on less rapidly, it taking several days to a week or more for the bald patches to form. These patches when formed are about the size of a silver dollar, some smaller, others larger, round or oval in outline, except where several unite together, producing irregular patches. Any portion of the scalp may be attacked, but over the parietal bones most fre- quently. Around the margins of the patches the hair is normal. The baldness is generally complete in the affected area, the skin being unusually white, soft, smooth, and more or less atrophied. Sensation in the skin is often diminished. Subjective sensations are not well marked. They are sometimes absent altogether, and when present consist of a little burning or itching. Usually not more than one ALOPECIA AREATA. 47 patch begins at a time, but they follow each other till there is often two or more lesions present. Course. The disease is a very slow one, lasting for months, but gradually ending in recovery of young sub- jects, lanugo first making their appearance in the bald area. In older people the prognosis is not so good. Months or years may elapse before recovery takes place. If no hairs appear in these lesions after five years, the baldness will remain permanent. Relapses are common. Diagnosis. The clinical symptoms of this disease are usually so clear that you will seldom have any difficulty in diagnosing a case of alopecia areata. The only diseases with which you are at all liable to confound it are syphi- litic alopecia and ringworm of the scalp. Treatment. The treatment of alopecia areata is unfor- tunately not always attended with a good result. As the disease is considered by most dermatologists due to ener- vation, internal treatment is recommended in the way of cod-liver oil and nerve tonics,especially strychnine, arsenic, and phosphorus ; but I have seldom seen any good re- sulting from the use of these drugs except in cases where the general health was run down. Cases of alopecia areata accompanied by severe neuralgic pains at the seat of the lesions, are often very much benefited by large doses of quinine. We must depend almost entirely upon external agents to effect a cure, and you will be wasting your time in the employment of all remedies which are not stimu- lating in character. One of the best agents to use every few days when the lesions are not very extensive is a lotion composed of equal parts of tincture of iodine, car- bolic acid, and chloral, which should be applied with a camel's-hair pencil. This will set up a certain amount of dermatitis, which must be controlled by the use of some 48 LECTURES IN DERMATOLOGY. oil or mild ointment. Occasionally blistering the scalp in the affected area with cantharides is a very useful method of treatment. Some dermatologists prefer the use of stimulating lotions, and those containing ammonia and tincture of cantharides yield the best result. They should be used once a day, and strong enough to produce some redness and smarting. LECTURE IV. AS TEA TO SIS, CHLOASMA, CLA VUS, COMEDO, DERMA TITIS VENENATA, AND ECTHYMA. ASTEATOSIS OR XERODERMA. Gentlemen : I will first call your attention to-day to a disease which, in its milder form, is not uncommon, and called asteatosis or xeroderma. Patliology. Xeroderma must not be confounded with the rarer skin affection ichthyosis, with which it is very closely related, the two terms being often used synony- mously. The pathological conditions existing in the disease xeroderma are found confined to the epidermis, and consist of an hypertrophy of the horny layers with an excessive proliferation of the cells of the epidermis. If the hypertrophy extends to the deeper layers of the skin other changes take place, and the disease is then properly an ichthyosis. Etiology. True ichthyosis is usually a disease born with the patient, although it may not become apparent until the second or third year. Xeroderma, however, although frequently noticed in early childhood, may not show itself until later in life. It is supposed by some to be hereditary. The direct cause is very obscure, as those suffering from the disease are often in the best of health. By some dermatologists it is considered a deformity of the skin rather than a disease of it. 50 LECTURES JN DERMATOLOGY. Symptoms. Harshness and dryness of the skin with fur- furaceous and bran-like desquamation are the most marked symptoms. Upon the lower extremities, below the knee, the scales are often thin, large, and polygonal or diamond- shaped, resembling^ fish-scales. The scales are usually whitish and gray in color, and their abundance varies greatly in different patients. In those who do not bathe frequently or make applications to the skin they often accumulate in large quantities, giving the skin a white appearance. The disease is usually extensive, covering the whole or greater portion of the body, but it is most marked on the extensor surface of the extremities and in the lumbar and gluteal regions. The disease is always worse in winter than in summer, although persons affected with the disease sweat but slightly in the affected regions. The subjective symptoms are not very severe. There is a sense of abnormal dryness in the skin and some itching. The disease is a very chronic one, and not very amenable to treatment. Treatment. A residence in a warm, moist climate is always to be recommended. Internal remedies do not seem to have much effect. The prolonged use of arsenic, cod- liver oil, and alkalies seem to have some beneficial action. We have to depend mostly on external applications. Alkaline and bran baths should be employed every night, and the skin then thoroughly rubbed with turtle oil or cod-liver oil. Vapor baths and tincture of green soap should be used once a week. A 10 per cent, ointment of iodide of potash is recommended by some dermatologists as a serviceable remedy in this complaint. CHLOASMA. A disease which you will all be called upon to treat is chloasma. CHLOASMA. 51 Pathology. This hypertrophic skin affection has its seat in the pigmentary layer of the skin, and consists simply in an increased deposit of normal pigment. The patho- logical progress is undoubtedly under the influence of the nervous system, but in what way we do not know. After the pigment is once deposited it may be slowly absorbed, or remain for an indefinite period. Etiology. The disease is much more common in women than men, and usually results from some functional or organic derangement of the internal organs, as the uterus or suprarenal capsules. Sudden shock to the nervous system and various neurotic disturbances not infrequently are the direct cause of chloasma. Pigmentary deposit in the skin secondary to other skin lesions, should not be confounded with primary chloasma, the affection we are now considering. Symptoms. The tissues of the skin are not altered in structure, the only change being the pigmentary deposit, and this is not associated with any subjective symptoms. In the majority of cases this discoloration comes on gradu- ally, in patches of rounded or irregular shape. When first noticed they are usually about the size of a small coin and not very distinct, but gradually increase both in size and color, and with a well marked line of demarca- tion in some cases. The color of these patches varies from a yellow to a dark brown, often having a muddy appearance. The patches seldom become larger than the palm of the hand, although several may run together, covering a large surface. These patches are several in number and may appear upon any portion of the body, but are especially apt to appear upon the forehead, neck, face, and hands. This usual form of the disease is associ- ated frequently with uterine disorder. When chloasma 52 LECTURES IN DERMATOLOGY. results from some general disease, as malaria, cancer, Addison's disease, etc., the pigmentation is more general and of a bronze tint. This is more pronounced, however, upon those regions having a disposition to normal in- crease of pigmentation, as the hands, face, axilla, nipples, and genitals. The color of the hair is also sometimes changed to a deeper shade. Diagnosis. There are three diseases for which you are liable to confound chloasma. They are tinea versicolor, pigmentary syphilide, and leucoderma. Leucoderma, which is an abnormal whiteness of the skin, is often asso- ciated with chloasma. Treatment. The treatment should consist both in internal medication and external applications. The internal treatment depends entirely upon the cause of the disease, for by removing it the pigmentation will frequently entirely disappear. Frequent examples of the disappearance of chloasma, the result of pregnancy, of uterine disorders and of malaria, after the cause has been removed, have been recorded by many observers. It has been claimed by some that these pigmentary stains can be removed by the internal administration of certain drugs, as mercury, arsenic, and the iodide of potash, and in certain cases it does seem to hasten their absorp- tion. For external application there are four drugs which seem to hasten the disappearance of these pigmentary stains. They are bi-chloride of mercury, resorcin, acetic acid, and sulphur. The following combination is a very good one: B Resorcini 3 ss Hyd. chlor. corr gr. Ac. acetic, dil 3 Aq ad ? m CLA VUS. 5 3 and should be applied over the patches two or three times a day with a camel's-hair brush. At night an ointment composed of one drachm each of ammoniated mercury and subnitrate of bismuth to the ounce is favorably spoken of by Neumann. Remember, whatever plan of treatment you adopt, the result is always slow and often very un- satisfactory. For the more rapid removal of the patches the following method has been suggested by Hebra : A solution of corrosive sublimate, five grains to the ounce of alcohol, is applied continuously by means of compresses. The compresses are to be kept moist by the addition of the fluid from time to time, and are to be retained in position for about four hours, when the skin will be blis- tered. The epidermis is to be removed, and the surface dressed with starch powder. The newly formed epider- mis will be devoid of pigmentation, but the discoloration is apt to return after a certain period. Another method which is not quite as heroic but yields just as good results, consists in painting lightly on the pigmented patches every two or three days with the following application : 5 Acid, carbolic, Chloral, hyd., Tinct. iodi aa 3 ii m If no benefit results after six or eight applications there is no use of continuing with it. CLAVUS. Synonym — Com. Avery common and painful disease of the skin, and one which is too frequently looked upon by the physician either as too trivial or else beneath his dignity to treat, is clavus, or corn ; consequently the chiropodist or " corn doctor " thrives and gets wealthy 54 LECTURES IN DERMATOLOGY. for relieving, but seldom curing his patient. Let me im- press upon you the fact that a corn is not such a trivial matter. It is one of the most painful of all skin diseases, and one of the hardest to cure. Many a patient would give more to get rid of his corn than his eczema, yet we send one often to a quack for treatment of his greater evil, while we attempt to cure him ourselves of the lesser. If any of you have ever been the referee in a conflict be- tween a sensitive corn and a tight shoe, I am sure no words of mine can express too forcibly the importance of that position. Try as you will to become interested in other matters, nothing can distract your mind from the painful interest you feel in that unequal contest. The knowledge of a corn on the little foe of a philanthropist will cause him much more sorrow than the news that a thousand Chinamen have been drowned in the floods which invade that country. Pathology. The growth consists of a circumscribed hypertrophy of the epidermis, usually of horny consis- tency, containing an inverted cone-shaped centre or core, the apex of which rests upon the corium, often causing atrophy of that structure, which results in a cup-shaped depression into which it fits. In structure it is composed of concentric layers of epidermic cells. The pain is pro- duced by this sharp-pointed core, which presses upon the nerves in the true skin, these nerves often being inflamed or in an excitable condition. Etiology. Corns are almost always the result of pres- sure, but may come from friction. Tight-fitting shoes will produce corns from pressure, while loose-fitting ones may produce the same result from friction. Symptoms. Corns most frequently appear upon the feet and over the joints of the toes where friction and CLA vus. 5 5 pressure are usually the greatest. They first appear as callosities upon those portions of the skin which are naturally most exposed, or when seated upon sensitive moist skin, as that between the toes, the lesions, although made up of the same pathological elements, are soft. Hence we use the term hard and soft corn to express the clinical features which they present. The lesions are from a pin-head to a split pea in size, and very painful on pressure. Sometimes there are present sharp, shooting, intermittent pains in the lesions where no pressure exists. This is especially apt to occur after patients have gone to bed at night. Not infrequently, if the irritation to a corn is continuous, it will set up an inflammation in the corium about the core which terminates in suppuration. When this occurs on the sole of the foot the destructive process sometimes extends in form of a sinus deeply into the tissues of the foot, and the disease is then known as perforating ulcer. This ulcer and sinus is surrounded by hard, callous tissue and very difficult to heal. These conditions sometimes simulate very closely the forms of ulceration found in the feet, the result of spinal-cord disease. Treatment. The treatment of corns is always local, and may be palliative or curative. In the first place the cause must be determined and removed. The palliative methods of treatment have the same objects in view in removing the core, which will always give immediate re- lief but will seldom cure, for the core will grow again in a few weeks or months unless all pressure and friction are removed from the affected area. To cure the corn, not only must the core be removed, but the callous tissue about it. To do this we may either resort to the knife, or to various applications. 56 LECTURES IN DERMATOLOGY. Surgical treatment. By a cutting operation all the core and callus surrounding it may be removed, and the edges of the wound brought together with sutures. This may be done without pain if a little cocaine be injected about the core. There are some objections to thus operating on a corn. In the first place, as the lesion is apt to be over bony prominences it may be difficult to bring the edges of the wound together after the incision, or to keep them together, in which case the wound heals slowly by granu- lation. In the second place, the scar is apt to remain sensitive, owing to the friction and pressure, which it is almost impossible to keep from the diseased area. In the third place, many patients object to a cutting operation of any kind, and you will be forced to resort to other means. However, in many cases this simple operation is followed by the best results and a complete and perma- nent cure. Medical treatment. The medical treatment of corns would fill a book the size of a dictionary, and I shall not attempt to go all over the subject. I shall give you the plan of treatment which I consider the best. The treat- ment for a hard and soft corn is a little different. For a hard corn paint over the centre of the lesion with liquor potassi, which will in a few minutes so soften the core that it may be removed with very little difficulty, which will give the patient relief from pain. Then tell your patient every night before retiring to bathe the corn in hot water for fifteen minutes, dry thoroughly, using con- siderable friction, and then apply on a bit of lint some diachylon ointment, containing 5 per cent, of salicylic acid, and bind on snugly. In the morning this may be removed, and a corn plaster applied to keep the part from pressure. This treatment should be continued for a COMEDO. 57 week, after which a strip of mercurial plaster should be applied, and worn continually for some time. With this treatment, and attention paid to the removal of all further cause of the trouble, a complete cure usually results. If all pressure is removed from a soft corn, it usually heals very rapidly without much treatment. They also heal very rapidly if painted over with a 5 per cent, solution of aristol in flexible collodion. This application should be made every day or two until the corn is healed, which usually takes place in a week if all irritation and pressure be removed. After a cure is effected, great care must be taken to prevent a relapse by separating the toes with a little cotton wool, when the lesion grows, as it usually does, between the toes. When it occurs on the sole of the foot, a corn plaster may be used with advantage, or a strip of mercurial plaster, applied continually. This is one method of treating both the hard and soft variety of corns. The only other method which I would recommend to you that may be better in a certain per- centage of cases is a continued application every day or two of the following solution : IJ Ac. salicyl. . . Ext. can. ind. . Alcoholis . . yEtheris . . . Collodion flex. . gr. xv • gr. x . ffl xv • 3 i ad 3 iii m COMEDO. You will remember that in my lecture on acne I re- ferred several times to the term comedo or comedones. Closely allied to and almost always occurring with acne is a disease of the sebaceous glands, resulting in the produc- tion of what is termed comedones or black-heads. 58 LECTURES IN DERMATOLOGY. Pathology. The disease has its seat in the sebaceous glands, and consist of an accumulation of sebum and epithelial cells in the glands and follicles, dilating the ducts to such an extent as to produce a point of elevation on the skin. These elevations are usually black; and, according to Unna, the color is the result of pigment deposit in the epithelial cells, but it is probably most frequently a mixture of dust or dirt with the sebum. The inflammatory process is seldom an active one, but when it is, it may result in the production of acne pustules. Etiology. The disease is usually due to an inactivity of the sebaceous glands, either the result of improper care of the skin, or to some functional derangement of the digestive or generative organs. The idea held by many, that the disease is due to a flesh-worm, is, of course, erroneous, although a little microscopic parasite, known as the demodex folliculorum, is sometimes found mixed with the sebum of the comedo. Symptoms. Comedones appear as little black elevations in the skin, usually pin-point in size, although frequently larger. They are attended with no subjective symptoms, unless active inflammation is set up in the gland, when acne results. The skin about the comedone is usually dirty, muddy, and greasy-looking. The disease occurs most frequently in young people under twenty years of age, and attacks the face, back, and chest in preference to other portions of the body. They may occur singly, but usually in numbers, even to such an extent as to be disfiguring. Course. The lesions come and go from time to time, but the disease is very sluggish, and lasts for years. Even under treatment they often prove rebellious. Treatment. The mechanical treatment consists of DERMA TITIS. 59 squeezing out the contents of all the follicles. Instru- ments are made on purpose for this, but a watch-key usually answers every purpose. Hot applications and friction to the diseased surface with tincture of green soap are very serviceable. The lotions recommended for acne are also especially beneficial in cases of comedo. There is nothing to be done in the way of internal treatment, except regulating the diet, and giving atten- tion to any functional derangement which may exist and be the cause of the disease. Tonics may be of some service in cases of the disease occurring in the anaemic or debilitated. DERMATITIS. The next subject I will call your attention to to-day is dermatitis. Under this general term dermatitis is in- cluded all those simple inflammatory diseases of the skin which are mostly caused by external irritation, as heat, cold, caustics, poisons, etc., and also by the internal administration of certain drugs, all of which result in similar conditions as to their pathological anatomy, differ- ing only in the intensity of the inflammation. If the inflammation is slight a simple erythema results ; if more extensive the presence of wheals or vesicles or blebs or pustules, even gangrene of the skin, shows the severity of the skin affection, — the character of the lesion depend- ing entirely upon the grade of the inflammation. The usual signs of inflammation — heat, swelling, redness, and pain — are also always present. The terms given to the various forms of dermatitis are derived from the causes which produce them, and are as follows : Dermatitis traumatica, Dermatitis venenata, Dermatitis calorica, Dermatitis medicamentosa. 60 LECTURES IN DERMATOLOGY. DERMATITIS VENENATA. The only variety of dermatitis which I have time to describe to you is that form of dermatitis venenata which is produced by the poison-ivy, or rhus toxicodendron. This inflammation is due to an acid which occurs in the plant, called toxicodendric acid. As this acid is volatile it is not necessary for the plant to come in direct contact with the skin, but proximity to it, or the smoke produced by burning it, will in persons susceptible produce a der- matitis. All persons, however, are not susceptible to the influences of the acid, some not being affected at all by handling it. Symptoms. The eruption usually makes its appearance within twenty-four hours after exposure, and usually upon the exposed portion of the body, either the face or hands. Next in frequency it occurs about the genitals, being car- ried there by the poison on the hands of the individual. Sometimes it occurs only on the genitals, the sensitive skin there being more susceptible to the poison than the hardened epidermis of the hands and face. The eruption is either erythematous or vesicular, almost always the latter. It may begin as an erythema upon which vesicles form, or it may be vesicular from the begin- ning. In either case, the vesicles, when formed, are situ- ated upon an inflamed and cedematous surface. The vesicles are very irregular in shape, varying from a pin- head to a split pea in size, showing a tendency to group, and often running together, forming blebs. About the second or third day the eruption is at its height, and swelling, pain, itching, redness, and cedema are marked symptoms. At the end of three or four days the vesicles rupture, and the fluid dries into yellowish crusts. At the end of a week the inflammation gradually subsides. DERMATITIS VENENATA. 6 1 the crust becomes detached, leaving a reddened surface beneath. Course. The disease lasts about two weeks on an average, but some cases have a tendency to terminate in a chronic eczema of the affected area, which lasts for months. This condition is most often seen in persons who have an eczematous tendency, or as the result of in- judicious treatment. Diagnosis. The only disease for which you are at all liable to mistake ivy poisoning is vesicular eczema, which is, by the way, a very common mistake to make, and shoulcf always be guarded against. Treatment. Internal treatment by the administration of belladonna is well thought of by many, and does seem to lessen the symptoms and the length of the attack in some cases. Homoeopathic physicians use internally the same remedy which caused the disease, namely, rhus, and claim great results by this method of treatment. .. Usually external treatment is all that is required. If seen in the very beginning of an attack, before the vesicles are formed, dusting powders — as buckwheat flour and starch — seem to relieve the symptoms and check the severity of the disease. In the later stages, when the acute symptoms are well marked, soothing and astringent lotions give the best result. A lead and opium wash, as — B Liq. plumb, subacet 3 ii Tinct. opii 3 i Aq ad f ii m kept continually applied, acts very nicely ; but a little care must be exercised, especially in children, when the area is large, as poisoning may result from absorption of the 62 LECTURES IN DERMATOLOGY. drug. A much safer lotion to use, although not quite as efficacious, is the following, which must be kept continu- ally applied : I£ Calaminae, Zinc, ox aa 3 ss Glycerini 3 ii Liq. calcis ad ? ii m An application of grendelia robusta, one drachm of the fluid extract to four ounces of water, acts very nicely. After the inflammation has subsided, and the vesicles have ruptured, a soothing and astringent ointment should be used, such as diachylon. If the disease shows a ten- dency to run into chronic eczema the more stimulating ointments containing tar should be used, a drachm of the oil of cade to the ounce of diachylon ointment being a favorite remedy. ECTHYMA. If you practise much among the poor, especially in large cities, or among emigrants, you will frequently see a dis- ease called ecthyma. Pathology. This disease is a markedly inflammatory one, and affects the papillary layers of the skin. The exudation is largely purulent, and, collecting in the centre of the inflammatory area, forms a pustule, while the sur- rounding skin becomes infiltrated, congested, and swollen. The deeper layers of the skin are seldom affected, so that scarred or permanent lesions seldom result. Pigmentation at the seat of the lesion may, however, remain for some time. Etiology. The disease always occurs in those who are ECTHYMA. 63 physically in a poor condition. It is often called a ''poor-" or "tenement-house" eruption. The want of proper hygienic conditions is therefore the most common cause for the disease. It occurs in both children and adults, and is not contagious. Continued irritation of the skin may produce ecthyma in those disposed to it, and it is of frequent occurrence in persons suffering from scabies. Symptoms. The eruption begins as a small pustule situated on an acutely inflamed surface, which is reddened and infiltrated. These pustules increase in size, and also the inflammatory area around them, until they reach the size of a thumb-nail. At first they are yellowish, but soon acquire a red tinge owing to blood becoming mixed with the pus. The lesions are fiat and rounded, with their walls not fully distended, but exhibiting a sharp outline. After existing for a few days the lesions become more and more flaccid, the pustules forming into brownish or black crusts, which are easily detached, leaving an excoriated, ulcerating surface covered with a bloody crust.. If these crusts are allowed to remain on, the surface be- neath heals slowly, so that they do not fall off spontane- ously for two or three weeks, leaving a pigmented surface sometimes slightly scarred. New pustules appear from time to time. They mostly occur about the lower ex- tremities, but also appear on the back and shoulders. They are accompanied by considerable pain and much tenderness. Itching is present at times. The lesions are usually discrete. Course. The disease lasts indefinitely, so long as the cause is kept up by the reappearance of new lesions, which may appear singly or in groups. Diagnosis. The lesions of ecthyma may be mistaken for those of impetigo, large, fiat, pustular syphilide, pus- '64 LECTURES IN DERMATOLOGY. tular eczema, and furunculosis ; especially are they liable to be mistaken for the pustular syphilide. Treatment. Dietary treatment and tonics in this skin disease are more useful than external applications. Good, nutritious food, such as beef, eggs, milk, ale, porter, etc., should be allowed, and the patient placed in the best hygienic surroundings. Tonics of iron, quinine, arsenic, and strychnine should be given. Soothing ointments should be applied to the lesions. If crusts have already formed they should first be removed by soaking in oil or by poulticing. The whole affected area should be washed once or twice a day with a I : iooo bichloride of mercury solution, and the following ointment 5 Hyd. ammon 3 ss Hyd. chlor. mit 3 iss Adipis ad 3 i m applied under a snug bandage. Aristol powder over the lesions, after the crusts are removed, often hastens cica- trization, or it may be used in a io-per-cent. ointment with vaseline. LECTURE V. ECZEMA. Gentlemen : We now come to consider the most common of skin diseases in the point of frequency, for from an analysis of many thousand cases of skin diseases eczema was found to equal about one third of the whole number. This proportion is probably somewhat too high, for the ten- dency of many physicians to call all skin diseases eczema, as a loop-hole for their ignorance, is only equalled in frequency by their number of cases of malaria. There is some excuse for this, however, for, besides the frequency with which eczema occurs, it takes on so many different clinical forms that it may simulate almost every variety of skin disease. However, it is very unscientific to call a skin disease eczema simply because you do not know what it is. Pathology. Eczema is an exudative inflammation of the skin, which undergoes many rapid changes during its development. As we have exudative inflammation with the production of either serum or pus depending un- doubtedly upon the violence of the inflammatory process, so we find in like inflammations of the skin the same products of inflammation depending upon the variety of the eczema. The varieties of eczema possess, however, some features in common. There is, in the first place, a hyperemia or 5 65 66 LECTURES IN DERMATOLOGY. congestion of the skin, either general as in erythematous eczema, or in points as in the papular variety. In all cases, however, it is most marked about the follicles. The next pathological process is an exudation from the blood-vessels, great or small, fluid or plastic, serous or purulent, depending upon the variety of the disease. The exudation, consisting of serum and cells, mostly leucocytes, takes place in the deeper layers of the rete mucosum and the upper layers of the corium. If the process ends here and is general there will be an erythematous eczema with thickening of the skin, but if localized to papillae, a papular eczema is the result. When the fluid becomes more abundant it raises the epi- dermis in the form of vesicles, producing vesicular eczema. If the exudation is purulent rather than serous, pustules form producing pustular eczema. In some cases where exudation is general rather than localized, the skin be- comes bereft of its normal epidermis, the fluid exuding directly from the surface without any formation of vesi- cles. This variety is termed madidans, or weeping eczema. These pathological changes all take place in acute eczema, but the alteration found in the skin in chronic eczema is of another character. The skin becomes permanently hardened and thickened from serous exudation and cell infiltration, usually of the connective-tissue variety, which extends through the entire corium. The papillae become so enlarged as to be seen with the naked eye, and pig- mentation takes place in the deeper layers of the rete. The blood-vessels become distended, and a serous exuda- tion results which infiltrates the cutaneous tissues, espe- cially the epidermis, drying on the surface producing scales and crusts. The skin becomes weakened owing to the infiltration ECZEMA. 67 of products of inflammation into the corium, and, losing its elasticity, becomes dense and hard, especially liable to crack and become fissured, — lesions which are usually seen in chronic eczema. There is seldom any production of scar tissue in the skin, the result of eczematous inflam- mation. Etiology. Eczema is rather more common in males than in females. In certain cases it seems to be heredi- tary, or, more properly speaking, some persons seem to inherit a predisposition to the disease, as we find it occur- ring from one generation to another. Persons with light hair and florid complexions are more subject to the dis- ease than those with dark hair and skin. Causes which produce eczema in one person might have no effect at all upon another, showing that some persons are much more susceptible to the disease than others, and even at one time more than another certain causes excite an appear- ance of the eruption. Constitutional causes. Chief among the constitutional causes of eczema are functional derangement of the diges- tive organs, especially associated with a large amount of urates, or uric acid in the urine. Rheumatism and gout are frequently the cause of eczema. Impaired conditions of the blood, such as are present in anaemic and strumous persons, is a frequent cause of the disease, as is dentition in children. What is sometimes described as nervous eczema is a form of the disease occurring in persons suf- fering from nervous debility. Local causes. Eczematous eruptions, the result of local irritants, are very common, but some authors prefer to call all such eruptions, although eczematous in character, der- matitis. Familiar examples of such causes are heat, cold, poison vines, as rhus ; certain drugs and chemicals, as 68 LECTURES IN DERMATOLOGY. mercury, sulphur, zinc, etc. Continued applications of water to the skin will frequently result in eczema ; sudden changes of the weather will produce an attack, and the disease is more common in winter than summer. Pediculi of the scalp and pubis will frequently produce eczema, as will scratching of the skin from any cause. Please remember that simple eczema is not at all conta- gious, although the discharge may become at times so acrid an irritant as to set up inflammation on a sensitive skin with which it comes in contact, but does so simply by its irritating properties rather than by any contagious elements present. Symptoms. Eczema presents itself in so many different forms that it is very difficult to describe intelligently the disease as a whole, although they all have some symptoms in common. The symptoms which characterize an eczema- tous inflammation of the skin are heat, itching, thickening, and exudation, and remember you will seldom be called upon to treat an eczema that has not at one time or another presented these symptoms. The disease begins frequently as an erythema ; at other times in the form of papules, then again either in the form of vesicles or pustules. The characters of the lesions may remain as they begin, but more frequently they change into other forms, for there is no affection of the skin in which the lesions, both pri- mary and secondary, undergo so many and varied altera- tions, and so suddenly, as they do in eczema. This disease may begin as an erythema, and in a day or two the lesions become an excoriated patch terminating in thickened, dry, desquamating surfaces ; so the disease, beginning as papules, may soon become vesicles, and then pustules, thus changing in character from day to day. It will be well for you to remember this, otherwise your ECZEMA. 69 various varieties of eczema may seem to run a very erratic course. The varieties of eczema, which I will now briefly describe to you, are named according to the lesions which the disease assumes at its commencement. ERYTHEMATOUS ECZEMA. This form of eczema usually appears about the face or neck, or upon the genitalia. It usually begins as an ery- thematous patch about the size of a half dollar, and spreading gradually into the surrounding skin. The patch has an ill-defined border fading imperceptibly into the surrounding skin. The affected skin is slightly thick- ened, pale red, or bright red in color, sometimes viola- ceous, having a dry surface covered with fine scales. After the disease has lasted for some time the surface becomes dotted with bright red points, the deeply con- gested papillae. Itching is usually a very marked symp- tom. This form of the disease is more apt to occur in old people, especially men. Course. The disease may last but a week or two and then disappear, but is very apt to return and last longer each time it reappears, until it becomes chronic. Even when chronic it is apt to be better some days than others, the disease being easily influenced by changes in the weather or over-indulgence in food or drink. It may always remain erythematous in character, but frequently changes into a moist, weeping eczema with crusts, espe- cially when two affected surfaces come in contact. More frequently it terminates in desquamation, becoming eczema squamosum. VESICULAR ECZEMA. Vesicular eczema usually begins with an itching and burning in the part to be affected. This is accompanied 70 LECTURES IN DERMATOLOGY. by redness of the skin, which increases until after a few- hours minute pin-head-sized vesicles make their appear- ance. These are usually at first discrete, but run together, becoming confluent. They increase in size and become distended with a yellowish serum, rupture spontaneously or by scratching, the fluid spreading over the surface and drying in yellowish crusts. This process takes but a day or two, and may be succeeded by new crops of vesicles, but usually the epidermis being denuded new vesicles do not form, but the exudation of serum continues. The face and hands are especially apt to suffer from this variety of eczema, but any part of the body may be affected. The extent of surface attacked varies very greatly. This variety of eczema may occur alone, but is more apt to be associated with the formation of papules and pustules. The lesions fade gradually into the sur- rounding skin, but the line of demarcation is better marked than in the erythematous form. Course. The disease may last but a few days, drying up and getting well, but the skin may become more and more thickened, red, and weeping, the disease passing into a chronic condition known as eczema rubrum. ECZEMA PUSTULOSUM. Pustular eczema, or impetiginous eczema, as it is fre- quently called, most often begins as a vesicular variety, but it may be pustular from the start. Again, both lesions may be present at the same time. The early symptoms are the same as those described under vesicular eczema, but the pustules when formed are usually larger than the vesicles and firmer in consistence. When they burst the crusts forming have a greenish-yellow color, which are thick and bulky. The pustules have a tendency ECZEMA. yi to run together, and may thus cover a considerable extent of surface. They are more apt to occur on the face, scalp, and hands. A number of patches may form at about the same time, and uniting almost cover the face and scalp with disfiguring crusts, which dry up and fall off in a few days, leaving a reddened skin which very gradu- ally resumes its normal appearance. Burning and itching are present, but are not usually so severe as in vesicular eczema. The disease is most apt to occur in children, especially those of a strumous diathesis. Course. The disease usually runs an acute course, ex- cept when present on the scalp, when it lasts for a long time. The disease is especially apt to reappear from time to time. ECZEMA PAPULOSUM. Papular eczema or lichen simplex usually makes its appearance suddenly in the form of numerous, discrete, pointed papules of pin-head size, either in groups or dis- seminated. They usually remain as papules, but some of them may become vesico-papules or vesicles, both lesions being present at the same time. The disease is generally extensive, showing a preference for the flexor surfaces of the extremity. The itching is most intense, the patient scratching the summits off the papules, causing them to bleed and thus forming blood crusts. From the result of scratching a moist eczema may be set up in places. Course. This form of eczema almost always runs a chronic course, but is less apt than other varieties to undergo any change. It begins as papules and ends as such. Each individual lesion lasts for many days, and when it disappears it is apt to be replaced by others. Relapses are very common. 72 LECTURES IN DERMATOLOGY. CHRONIC ECZEMA. Any one of the acute forms of eczema just described may terminate in chronic eczema. The division between acute and chronic eczema relates not to the length of time that the disease has lasted, but to the pathological changes which take place in the skin when the disease becomes chronic, and to the symptoms which accom- pany these changes. ECZEMA RUBRUM. In one form of chronic eczema, called eczema rubrum, the disease is characterized by thickened, reddish, weep- ing skin with a denuded surface. This serous exudation, often tinged with blood, dries into greenish or brownish crusts, which adhere closely to the surface, and when re- moved leave a deeply inflamed surface beneath, which exudes freely and bleeds easily. This form of eczema occurs often in old people, and especially about the legs. It is often associated with ulcerations, which, from vari- cose conditions of the veins, are frequently called varicose ulcers. SQUAMOUS ECZEMA. The other form of chronic eczema to which I will call your attention is the squamous variety, and is most fre- quently the result of the erythematous form of eczema. It is characterized by the presence of smaller or larger dry scaly, reddened patches of skin, which are much thickened. The scales are usually easily removed, and leave a dry surface beneath. Itching is a marked symptom. Fissures and cracks are of frequent occurrence in chronic eczema, and are usually apt to form in regions ECZEMA. 71. subject to constant motion, as about the hands and joints. Occasionally a patch of chronic eczema will take on a verrucous form, the warty appearance being due to a hypertrophic condition of the papillae. This condition is most frequently met with about the hands and feet. Diagnosis. I told you in the beginning of this lecture, eczema occurs in so many clinical forms that it may simulate almost every variety of skin disease. You can understand, therefore, how difficult it is in many cases to make a differential diagnosis. Erythematous eczema is most liable to be mistaken for erysipelas, erythema, erythematous lupus, and erythematous syphilide ; papular eczema for pediculus corporis, prurigo, lichen planus, papular syphilide, papular urticaria, scabies, and lichen trophicus or prickly heat ; vesicular eczema for herpes, sudamen, scabies, and dermatitis venenata or ivy poison- ing ; pustular eczema for impetigo, impetigo contagiosa, sycosis, tinea sycosis, pustular syphilide, tinea favosa, pediculosis capitis, scabies, acne, and rosacea ; squamous eczema for psoriasis, seborrhcea, squamous syphilide, tinea trychophytina, and pityriasis ; while eczema rubrum is often mistaken for cellulitis and dermatitis. There are a great many other diseases which are often mistaken for eczema than those which I have just mentioned, but they are the ones which you must especially consider in making your diagnosis. Treatment. The treatment of eczema should be both constitutional and local. The diet should be especially regulated, for indigestion is frequently an exciting cause. The patient should be especially careful not to eat starchy or saccharine food, and avoid all sweet wines and malt liquors. If the case is a very acute one, a diet of bread and milk for a few days may aid materially in effecting a 74 LECTURES IN DERMATOLOGY. cure. If the disease occurs in the plethoric, a very low diet should be ordered and insisted upon until the disease is quite cured. The bowels should be kept thoroughly- open by drinking large quantities of hot water before breakfast, with a required amount of Hunyadi water. Alkalies should be taken before meals, and the one which seems to act uniformly the best is the acetate of potash in 1 5-to-20-grain doses. If there is much thickening of the skin, or much desquamation, a few drops of Fowler's solution may be added with benefit to the potash solu- tion. If the case is uncomplicated, this will be about all the constitutional treatment required. Eczema occurring in the strumous and cachectic, or in children, cod-liver oil is one of the best remedies you can use. In the anaemic and debilitated iron tonics are required, and perhaps stimulants in the way of sour wine or whiskey. Iron, when given, should be in some very digestible form, as ■Startin's mixture — Ferri sulph . . . gr. ii Magnesii sulph . . . gr. xv Acid, sulph. dil . . . TTl iv Tinct. gent. comp. . . . . . . m x Aq . . ad 3i m taken after meals. Stimulants are usually beneficial in moderate quantities when the disease occurs in the old •and enfeebled, but they should be strictly prohibited in the young and strong, for in such cases the disease is almost invariably made worse by their use. Local treatment. The external applications will de- pend very largely upon the kind of eczema you are called upon to treat. Remember, as a rule, water should not be ECZEMA. 75 applied to acute eczema, in whatever variety it may exist, for water, in the majority of cases, irritates the skin. The diseased surface must be kept clean, however. In the treatment of erytJiematous eczema powders, lotions, or ointments may be applied. Powders contain- ing oxide of zinc, talc, and camphor in the following proportions — 1$ Zinc, ox., Talci aa | ss Camphorae 3 ss ni are both cooling and antipruritic, and may be dusted over the eczematous surface frequently and with great benefit. If the diseased area is not very extensive, lotions of cala- mine, such as I recommended in the treatment of ivy poisoning, or lactate of lead, one drachm of lead water to an ounce of milk, may be applied frequently with good result, and allowed to dry on the affected surface. Lotions cannot be used, as a rule, longer than a few days at a time without producing irritation, when we must resort to ointments. The ointments should be soothing and astringent, but not too drying. The oxide of zinc oint- ment is a very good one for acute erythematous eczema, and may be used alone, or a half drachm of camphor or five grains of carbolic acid may be added to the ounce, to relieve the itching. Occasionally this variety of eczema becomes universal, covering almost the entire body. In this case it is neces- sary to keep your patient in bed, give an alkaline bran bath for fifteen minutes once a day, after which rub the skin thoroughly with the following ointment : 76 LECTURES IN DERMATOLOGY. Ac. carbolic 3 ss Glycerit. amyli § iv m In the treatment of vesicular eczema powders are of very little service. Drying and astringent lotions, such as were recommended in erythematous form, may be used for a few days with a good result, a 5 per cent, ich- thyol lotion being especially serviceable when the surface becomes denuded, but our chief dependence is upon oint- ments. Lassar's paste, which is compounded as follows, Acid, salicylic gr. xv. Amyli. Zinc, ox aa 3 ii Petrolat % i m is perhaps the best ointment I can recommend to you, but freshly prepared diachylon ointment is usually as good, and acts better in some cases, being more protec- tive. These ointments should be applied twice a day, and if there are any crusts on the affected surface they should first be removed by salicylated or carbolized oil. If the ointment is applied to a hairy surface the hair should be cut as closely as possible before the application is made. When the ointment is reapplied the affected area should not be washed, but the excess of oil ointment wiped off with a little cotton or lint. Should the eczema be pustular, we have to depend almost entirely upon the use of ointments, and as we have present the micro-organism which produces pus, antisep- tics are called for. The antiseptics which can be depended ECZEMA. yj upon and may be added to the ointments employed, or used as a lotion before applying the ointment, are salicylic acid 3 to 5 per cent., boric acid 2 to 4 per cent., carbolic acid 1 to 2 per cent., and ichthyol 4 to 5 per cent. It has recently been found very serviceable to thoroughly cleanse the surface of the diseased area with a strong solution of peroxide of hydrogen before applying the ointment. This is recommended in both the vesicular and pustular forms of eczema. Tar ointments are especially serviceable in this form of eczema affecting the scalp, the following being a very good one, especially in children : B Ol. cadini 31 Ung. zinc, ox f i m In the treatment of the papular form of eczema you will have your patience seriously tried if you are fortunate enough to keep your patients, for it is often exceedingly unsatisfactory. You must depend very largely upon the constitutional treatment. Mild applications of any kind seem to have but little effect, and stimulating lotions seem to act better than ointments. Lotions containing carbolic acid 2 per cent, or liquid tar 5 to 10 per cent., are those which seem to give the best result. A very good lotion to use in the papular-pustular form of the disease is the following applied two or three times a day : Gum. tragacanth gr v Camphor grx Sulphur sub 3 ii Aq. calcis ad § ii m 78 LECTURES IN DERMATOLOGY. Ointments containing tar (liquor picis alkalines) or sulphur, are the only ones you can put much dependence upon, their strength depending entirely upon the acuteness of the disease. The local treatment of chronic eczema is directed tow- ard relieving the itching and removing the thickening of the skin, for if these conditions exist we cannot cure the disease. We have, as you remember, simple thickening of the skin with the production of scales (squamous eczema), or the formation of crusts on a denuded and in- flamed surface (eczema rubrum), and in each the treat- ment is different. Eczema squamosum. In this variety of cases I should advise you once in four or five days to rub the affected area with tincture of green soap and hot water, thus re- moving all the scales, and then gently going over the surface with a solution of equal parts of carbolic acid, chloral, and tincture of iodine. Between these applica- tions, if an acute inflammatory process is set up by them, Lassar's paste or diachylon ointment may be kept ap- plied ; but if the reaction is not so marked the following ointment, 5 Ung. picis, Ung. ac. carb aa 3 ii. Ung. diachylon ad § i. m may be used. If the disease is not very chronic, or the skin not greatly thickened, this ointment, containing a greater amount of tar, may cure it without any appli- cations of the iodide solution. Eczema rubrum. In the other form of chronic eczema rest in bed may be necessary to effect a cure. The ECZEMA. jcy crusts must be carefully removed by soaking them in warm oil, or by poulticing. This leaves an actively in- flamed, raw, denuded surface, with a great deal of thick- ening of the skin. To this should be applied once a day an oxide of zinc or diachylon ointment, containing from 2 to 5 per cent, of ichthyol, and the part snugly ban- daged. Rubber bandages are recommended by many dermatologists, but muslin will usually answer if you can- not get the rubber. These chronic cases are rebellious, and do not often respond to treatment. Sometimes counter-irritation to this actively inflamed surface by the tincture of green soap once every few days seems to be attended with good results. A soothing ointment should be applied immediately after the soap is used. I have not time to dwell longer on the treatment of this very in- teresting disease. Every case must be treated on its own merit to a certain extent, but I have outlined a treatment of eczema to you which I trust will be of some service in guiding you in the right direction. LECTURE VI. EPITHELIOMA, ERYSIPELAS, ERYTHEMA, ERYTHEMA MULTIFORME, AND ERYTHEMA NODOSUM. EPITHELIOMA. Gentlemen : There are three varieties of epithelioma or skin cancer to which I wish to call your attention. First, the super- ficial ; second, the deep-seated ; and third, the papillary. Superficial epithelioma may make its appearance in the form of minute papules on the surface of the skin, or it may start from a sebaceous gland or wart, but more frequently it begins as superficial, flat, skin infiltration. After once starting it may remain quiescent for a num- ber of years, but sooner or later the tumor shows a dispo- sition to fissure or excoriate, and becomes covered with a yellowish crust, under which is a scanty, clear, or bloody secretion. These crusts are usually picked off or rubbed off a few times, and form again. After a while the in- flammatory deposits in the skin increase in size, and breaking down ulceration begins. This ulceration is very superficial at first, but gradually increases in size as the cancerous deposit becomes greater. The edges of these ulcerations are usually somewhat elevated, indurated, and have a rolled border, but not usually reddened. The base of the ulcer is red in color, and secretes a scanty, viscid, yellowish fluid. The surface is hard, uneven, and 80 EPITHELIOMA. 8 1 bleeds easily. The pain in this form of cancer is not so very great, as the deep-seated structures are not usually involved unless it passes into the second or deep-seated variety, as it sometimes does. The ulceration is often extensive as to the surface covered, but seldom very deep except in that form generally known as rodent ulcer, which appears upon the upper portion of the face, and implicates every tissue in the neighborhood, including muscles and bones. The general health remains good, and the lymphatic glands are not involved in this form of cancer. The deep-seated variety begins as a roundish, conical tubercle, having its seat in the skin and subcutaneous tissue. It may have its starting-place in a wart, but is always deep-seated. It is reddish in color, firm to the touch, and shows signs of extensive infiltration in the surrounding tissues. The growth is always elevated. After a few months of growth, which is very slow, this little tumor breaks down, usually upon the surface, in the form of ulceration, but occasionally in the centre, forming a little abscess. In either case the tissue disintegrates, and deep ulceration takes place. The edges of the ulcer are raised, inverted, hard, and infiltrated. The base of the ulcer is uneven, ragged, brownish in color, bleeding readily, and secreting a yellowish, viscid fluid. Around the ulcer the tissues are hard, infiltrated, and red. The destructive process progresses rapidly, and large and deep ulceration results, accompanied by severe, lancinating pains. The lymphatic glands become involved early in the disease, breaking down and suppurating. The general health of the patient suffers. They become anaemic and die from general exhaustion, or from some concurrent disease. This form of epithelioma progresses rapidly, terminating 6 82 LECTURES IN DERMATOLOGY. in the death of the patient in two or three years, some- times sooner. The papillary variety of epithelioma usually begins as wart-like growths, or as raised, spongy, papillary forma- tions the size of a coin or larger. In either case the tumors become covered with papillary growths, which are at first dry and scaly, but afterwards secrete a viscid fluid consisting of sebaceous matter, epithelia, and blood, which forms in crusts on the surface. After a time disintegra- tion takes place on the surface with ulceration. Exuber- ant, fleshy, and uneven granulations spring up, which bleed easily. The disease becomes more and more ex- tensive and the ulceration greater, involving the deep tissue as in the deep-seated variety, although the course of the disease is not so rapid. Seat of epithelioma. Epithelioma occurs most com- monly on the face, the lower lip being a very common seat. The mucous membrane of the mouth is also a common place for this form of cancer, which may be either the superficial or the deep-seated variety. On the face the superficial variety is much the more common. The papillary variety is apt to occur on the backs of the hands and on the glans penis. The superficial variety often occurs on the scrotum, and is called " chimney- sweep's " cancer. Etiology. Local irritation is undoubtedly an exciting cause for epithelial cancer. This form of cancer can hardly be said to be hereditary. It is much more com- mon in men than women. It not infrequently has its starting-point in a mole or wart, especially in those sub- ject to irritation. The disease seldom occurs before thirty years of age, usually after forty. Diagnosis. It is seldom difficult to make a diagnosis EPITHELIOMA. 83 of epithelioma, as there are but few diseases of the skin for which it is liable to be mistaken. Epithelioma is per- haps most often mistaken for a syphilitic lesion, either a chancre, or a late tubercular, or gummous syphilide. It must also be diagnosed from simple warts, seborrncea, and lupus. Treatment. Internal treatment does not seem to be of much service, except so far as it may improve the general health. Local treatment consists in the removal of the growth. This may be done by excision, by the cautery or by the curette, by caustics or by scarification. The superficial variety may be best treated by the dermal curette. This should be used thoroughly, until all the diseased tissue is removed. The raw surface should then be covered for two or three days with pyrogallic acid, which seems to have a selective action in destroying dis- eased tissue. After this, the ulcer may be treated with soothing applications until it is healed. The disease can be thoroughly destroyed by caustic applications, which will act sufficiently upon diseased tis- sue without destroying the healthy skin, so that there is almost an excuse for the fallacy that they exercise a posi- tive power of selection. The resulting cicatrix, when the deep subcutaneous tissues are not involved, is a smooth, white, and in every way healthy one, and far less con- spicuous than those remaining after operation. The only cases in which an operation should be preferred to a caustic are those affecting the mucous surface of the lip, the eyelids, and all others which might have involved a large surface, in which dangerous poisoning might result from absorption. The choice of a proper escharotic is of considerable importance. If the disease be a small warty growth, the 84 LECTURES IN DERMATOLOGY. potash and cocaine paste of Mr. Jennings is a good one, the composition of which is as follows : B Hydrochlorate of cocaine .... 3 i Caustic potash 3 vi Vaseline 3 iii m Acetic acid must be at hand to limit its action as soon as desired. Marsden's paste, or other strong preparations containing arsenic or chloride of zinc, maybe applied, but their action is slow, having to be kept applied for several hours, and intensely painful. Their action is, however, extensive, so that they may be used in the deep-seated variety or in the papillary form. The surfaces must be denuded, if not already ulcerated, by caustic potash, to render the action prompt and effective in the shortest possible time. Perhaps the safest and best paste is Bou- gard's, which is made as follows : ^ Wheat flour 60 grammes. Starch 60 " Arsenic 1 " Cinnabar 5 " Sal ammoniac .... 5 " Corrosive sublimate . . 0.50 centigramme. Solution of chloride of zinc at 52 F 245 grammes. m The first six substances are separately ground and reduced to fine powder. They are then mixed in a mortar of glass or china, and the solution of chloride of zinc is slowly poured in, while the contents are kept rapidly moved with the pestle so that no lump shall be ERYSIPELAS. 85 formed. A thick layer of this is spread on cotton and left in position twenty-four hours, and after they are removed poultices should be applied to hasten the absorp- tion of the sloughs produced, and then mild dressings applied. In the deep-seated variety, however, the best result is ob- tained by the excision of the tumor, and plastic operation. Whatever treatment is applied skin cancer is very prone to return within a few years, in or about the scar or the seat of the former growth. ERYSIPELAS. Synonym, St. Anthony s fire. Pathology. Erysipelas is regarded by some as a conta- gious, constitutional disease (as scarlet fever), with local skin lesions, by others as an infectious skin disease with constitutional symptoms. Dermatologists usually describe it as a skin disease. Certain it is that it differs from the general infectious diseases by the fact that one attack does not prevent another, but rather predisposes toward a second. Besides, we know that the general contagious diseases may be ac- quired by taking into the system, by means of the respi- ratory or alimentary ducts, the poisonous agents which produce the affection, while it is very doubtful if erysipe- las is ever produced except by direct inoculation through the medium of a wound or abrasion in the skin. The pathological conditions found in erysipelas may affect the skin alone, or the skin and areolar tissue beneath. When the deeper structures become involved abscesses are apt to form, and the disease is then known as phlegmonous erysipelas, to distinguish it from simple erysipelas of the skin. Under the microscope the skin and subcutaneous 86 LECTURES IN DERMATOLOGY. tissues are found to be infiltrated with serum and cells, which in some places lift up the epidermis in the form of blebs or bullae. The blood- and lymph-vessels are en- gorged, as are also the cutaneous follicles. The walls of the lymph channels and lymphatic glands in the neigh- borhood of the affected skin are infiltrated with products of inflammation, the glands not infrequently breaking down. Etiology. The disease is undoubtedly due to a micro- organism called the erysipelas coccus, which, coming in contact with some abrasion of the skin or mucous mem- brane, causes the disease. This coccus multiplies rapidly, and is found with the microscope in great numbers, especially in the affected skin about the edges of the lesions. Symptoms. The disease is almost always ushered in with a rigor or chilly feelings, soon followed by a high rise of temperature and frequently vomiting. The pulse is accelerated, tongue coated, lips parched, headache, frequently delirium, — in fact all those symptoms usually present in cases of severe disturbance of the vital organs, such as are found in acute constitutional diseases. Within a few hours the skin lesion makes its appearance, almost always about some wound, which may have been so slight as to escape notice. A crack in the lip, an abrasion of the mucous membrane of the nose, may be the starting- point. The eruption begins as a red spot or blush with a raised, sharply defined, irregular border, which gradually becomes larger by extension of its boundaries. The out- line always remains very well defined, the line of demar- cation being distinctly raised, red, and unusually irregular in outline. The color of the diseased area is a dusky red and often presents a number of bullae, which rupture ERYSIPELAS. 87 early leaving an abraded surface beneath. Occasionally portions of the skin become gangrenous. The lympathic glands in and about the diseased area are enlarged and painful, and the lymph channels are inflamed and can often be traced in the skin leading up to the glands as pink lines. You can never tell how far the erysipelatous process will extend if not checked, but always over a considerable area. The subjective symptoms present are heat, burning, and in a certain number of cases itching. There is always pain on pressure, but most acute in the phlegmonous form of the disease. The deeper structure of the skin may become involved, and a true phlegmonous cellulitis set up. In other cases the disease remains limited to the skin, and after a week or ten days both constitutional and local symptoms begin to disappear. Sometimes the redness begins to fade from the area first involved, other times from the margin of the lesion. As the redness and oedema of the skin disappear, desquamation takes place. The prog- nosis in the majority of uncomplicated cases is good. Most of the patients make a good recovery in about two weeks' time. Erysipelas which has passed into the phlegmonous stage is always more serious, and lasts a much longer time than the simple variety. It is always associated with con- siderable destruction of the deeper layer of the skin and cellular tissue, and with the formation of abscesses. This form of the disease, however, is one in which dermatologists are not especially interested, but belongs to the surgical class of cases. Diagnosis. Erysipelas is sometimes mistaken for derma- titis, acute eczema, simple erythema, herpes zoster, or an urticaria ; but the constitutional symptoms accompanying 88 LECTURES IN DERMATOLOGY. the marked skin lesions will usually make the diagnosis clear to a careful observer. Treatment. Internally such symptomatic treatment as the nature of the case seems to require should be given. There is but one drug which seems to have a specific action in erysipelatous processes, and that is the tincture of chloride of iron. This drug seems not only to lessen the severity of the case, but also to have an abortive effect. It should, however, be given in large doses as frequently repeated as the patient's stomach can bear. Twenty minims every two or three hours can usually be given with good results. The bowels should be thoroughly opened at the commence- ment of the disease with a calomel purge, and afterwards kept open with the use of saline cathartics. The headache, fever, and general listlessness can usually be treated by frequently repeated doses of phenacetin given in a little whiskey. Delirium may be controlled and sleep produced by the use of sulfonal and chloralamid combined in 15- grain doses. The recent discovery of erysipelas coccus as a cause of the disease has modified very much our management of it, which is based largely upon the antiseptic and anti- bacterial external treatment. The fact that the microbes are found in greater abundance upon the edge of the inflamed surface shows that the attempt to limit the spread of the disease by surrounding the patch with a line of Higgenbottom's solution of the nitrate of silver, or with equal parts of tincture of iodine and pure car- bolic acid, was correct in principle though not always successful in practice. In many cases, however, it does check the advance of the disease, and may be used with great benefit. Ichthyol dissolved in collodion, two drachms ERYSIPELAS. 89. to one ounce, painted over the patch and on the surround- ing skin gives the best result. This application may be applied every second or third day. It not only prevents the spread of the disease, but in many cases lessens the severity of the local symptoms and hastens a speedy cure. In some cases ichthyol is borne better by the skin if applied either pure or mixed with lanolin in equal parts. Before this is applied all the neighboring mucous membranes and skin should be cleansed with a concen- trated solution of salicylic acid, then not only the red- dened skin but the normal as well for a hand's-breadth around should be thoroughly rubbed for from ten to fif- teen minutes with this ichthyol ; this rubbing should be as thorough as the pain will admit. The drug is in this way absorbed, and seems to act as an antiseptic in de- stroying the coccus. Over the whole of this area a layer of absorbent gauze moistened with a solution of boracic acid is spread, and this dressing covered with a thick sheet of non-absorbent sterilized cotton. This dressing should be changed daily. Occasionally, when other means fail to arrest the spread of the disease, a band of adhesive plaster tightly applied around the margin of the lesion will prevent further en- croachment. Lately, instead of the use of adhesive plaster, crossed scarification of the skin has been resorted to with exceedingly good results. This treatment is service- able in either form of erysipelas, but especially in the simple variety. In facial erysipelas continuous applica- tions of ice-cold lead and opium wash will frequently be all the local treatment required. Relapses are common ; usually at the seat of the previous attack. This is espe- cially true when the point of inflammation is some chronic ulceration or lesion in the skin or mucous membrane. 90 LECTURES IN DERMATOLOGY. Erysipelas sometimes exercises a curative influence upon certain pathological formations, as sarcomatous tumors. In some cases these tumors have been inocu- lated with the erysipelas coccus with a curative result. The experiment is always dangerous, and should not be done without due appreciation of the severity of this method of treatment, for St. Anthony's fire not infre- quently burns unto death. ERYTHEMA. Under the general term erythema may be considered erythema simplex, erythema multiforme, and erythema nodosum, but it is to the first of these I now wish to call your attention. Pathology. The disease consists of an active hyperae- mia of the papillary layers of the skin, causing a dilatation of the blood-vessels, increased circulation and swelling of the skin, usually without exudation. Etiology. The trouble may be due to local irritation applied to the skin in the form of heat, cold, or irritating substances, or to some systemic disturbance. Gastro- intestinal disturbance will frequently cause an erythema, as will ingestion of some drugs, as quinine, antipyrine, and ipecac. Certain constitutional diseases, as roseola and scarlet fever, have erythema of the skin as one of the most marked symptoms, but these diseases properly be- long to the exanthemata. Frequently an erythema will appear without any apparent cause. Symptoms. In systemic erythema constitutional symp- toms are often present, but depend very largely upon the cause of the disease. In a large number of diseases gen- eral malaise with gastro-intestinal disturbance will precede the attack by a few hours, but in other cases the first ERYTHEMA. 9 1 symptoms are those produced by the eruption itself. The first local symptom which usually attracts the patient's attention is a slight itching or burning in that portion of the body to be affected. Soon afterward the disease usually appears in patches of irregular shape, very little if at all elevated, bright-red in color, disappearing on pressure, but returning when the pressure is removed. The affected skin is hotter than normal, and hyperaes- thetic. There is no well-defined line of demarcation, the color of the patch varying accordingly in the normal skin. The patches are not usually larger than the palm of the hand, but may become much larger by uniting with other patches. But a small area of the body may be affected, or the disease may be quite general, nearly cover- ing the body. The diseased areas are most frequently met with on the abdomen and thighs. Course. The disease usually lasts but a few hours to a day or two, and disappears without desquamation, al- though it may follow if the hypersemia has been very active. Relapses or return of the disease are common. Diagnosis. You will often have great difficulty in diag- nosing this simple erythema of the skin from the rash of scarlet fever. The mistake is often made, and I have no doubt that in nine cases out of ten when you hear of a patient having had scarlet fever twice that one of the attacks was nothing worse than a simple erythematous eruption. The other diseases for which it may be mis- taken are erythematous eczema and erysipelas. Treatment. I should advise you in the treatment of this simple affection to begin with an active purgative, either calomel or castor oil, and put your patient on a bread-and-milk diet for a few days. Acetate of potash or citrate of magnesia in 20-grain doses may be given 0,2 LECTURES IN DERMATOLOGY. before each meal. The external treatment consists of the application of soothing and cooling lotions, or pow- ders. If the disease is very extensive a bran bath may be given and then flour dusted over the surface. If limited in area, a calamine lotion or a lead and opium wash may be applied continually with very happy results. ERYTHEMA INTERTRIGO. Very closely allied to a simple erythema, yet taking on some of the character of an eczema, is a very common disease, occurring most frequently in young children, called intertrigo, or erythema intertrigo. Pathology. Like simple erythema, it is a hyperaemic affection of the skin, but one associated with a serous exudation, causing a maceration of the epidermis and an abraded surface as a result. Etiology. The disease is most frequently the result of heat, moisture, and friction, especially when combined. It may, like a simple erythema, result from some stomach or bowel disorder, or in infants as a result of teething. Symptoms. The disease usually makes its appearance suddenly, and occurs most frequently in fat people and infants. It occurs chiefly in those parts where the folds of the skin come in contact, and where moisture is pres- ent, as in the axilla, about the groins or nates, and under the breasts. The skin first becomes chafed, and feels hot and sore. It then becomes bright red in color, the sur- face abraded and moist, and secreting an acrid fluid. The abraded surface is considered by some due to friction, and by others to an exudation under the epidermis causing its exfoliation. The discharge is very irritating, and will cause the extension of the disease to the surrounding ER V THEM A M UL TI FORME. 93 skin. The affected skin becomes very sensitive and then painful, swollen, and hot, showing the presence of active inflammation. Course. The disease, if properly treated, usually recov- ers rapidly, but, if left to itself, lasts for a long time and may interfere with the general health. Relapses are common. Diagnosis. This form of erythema must be diagnosed from acute eczema, which it very closely resembles, and from tinea cutis or eczema marginatum, a parasitic affec- tion which attacks localities where we usually find inter- trigo. Treatment. Attention should be paid to the diet and bowels ; the affected skin should not be washed more often than is absolutely necessary, but should be kept perfectly clean. The abraded surfaces should be sepa- rated from each other and kept perfectly dry. Soothing and slightly astringent applications should be used. After the affected area is thoroughly cleansed and dried, a powder of oxide of zinc and starch, equal parts, should be dusted on, then Lassar's paste or diachylon ointment spread on a linen cloth and applied ; this should be repeated once or twice a day until a cure is effected. In some cases, especially with infants with intertrigo about the nates, a 5 per cent, ichthyol solution may be kept continually applied and acts like a charm. ERYTHEMA MULTIFORME. Another form of erythema which differs very much from the one we have just studied, is erythema multi- forme. Pathology. Erythema multiforme is an exudative in- 94 LECTURES IN DERMATOLOGY. flammation of the skin, closely resembling in some particulars urticaria, and in others herpes, and it is doubtless the result of some vaso-motor disturbance. Like the lesions of erythema simplex, the redness dis- appears on pressure, but returns when the pressure is removed. Etiology. This affection is most frequently seen in the spring and fall of the year. It is perhaps most fre- quently the result of rheumatism, but also may accom- pany digestive disturbances. It is not infrequently a complication of some chronic uterine disease, or other chronic, inflammatory conditions of the genito-urinary organs. Symptoms. The disease makes its appearance in a num- ber of different forms with a different variety of lesions, which have given rise to various terms used to express the clinical conditions and features presented. The lesions present themselves in the form of erythematous patches, in papules, and in tubercles. I. Erythematous forms. When the lesions are in the form of erythematous patches they nearly always present themselves in some peculiar configurations, which give rise to the terms erythema annulare, erythema iris, and erythema marginatum. Erythema annulare consists of circular, erythematous patches, most frequently occurring about the back and chest, fading at the centre and spreading peripherically. The circles are usually of small size, seldom more than half an inch in diameter, not scaly, but very chronic in their course, thus differing from ringworm for which they are often mistaken. Erythema iris. Occasionally the disease presents itself in a series of concentric rings, which are found possessing ERYTHEMA MULTIFORME. 95. variegated colors, as red, yellow, blue, etc., to which the term erythema iris is given. This form is doubtless closely related to herpes iris, there being more exudation in the latter disease producing herpetic vesicles on the erythematous rings. Erythema marginatum. When these erythematous patches spread over a considerable surface, having a sharply defined, irregular serpentine border, the disease is then termed erythema marginatum. As the redness disappears at the centre, this form of the disease often appears as irregular red bands. II. Papular form. The papular variety is that affec- tion originally described by Hebra as erythema multiforme. The lesions maybe either distinctly papular or tubercular, the latter to be viewed simply as an exaggerated form of the papular variety. This form of the eruption is almost always symmetrical, and is especially liable to attack the backs of the hands, wrists, neck, and feet, but seldom occurs on the trunk. The disease begins as little red- swellings in the skin, accompanied by some pain and burning. The color soon becomes a dusky red or viola- ceous, and afterwards yellowish, disappearing but slowly on pressure. The lesions are elevated, flat, circular or oval in shape, and vary in size from a pea to a half dollar. They occur in groups, and last from ten days to three weeks, but relapses are common. As the lesions disap- pear they often fade first at the centre, leaving circles or segments of circles. There is some desquamation. Oc- casionally vesicles or bullae form on these lesions, giving^ rise to the term erythema bullosum. The subjective symptoms are not so severe, notwithstanding the angry appearance of the lesions, there being but slight burning and itching present. Some slight constitutional symptoms g6 LECTURES IN DERMATOLOGY. are frequently present, as fever, headache, digestive dis- turbances, and pain in the joints. Diagnosis. As the lesions of erythema multiforme ap- pear in many different forms it is not always easy to make a diagnosis. The diseases for which it is most often mistaken are urticaria, pemphigus, papular eczema, pur- pura, erythema nodosum, and dermatitis herpetiformis. Treatment. Low diet, alkaline diuretics, and hot appli- cations of from 2 to 3 per cent, carbolic acid to the lesions for half an hour at a time several times a day, will usually hasten a cure in uncomplicated cases. If rheumatism is present io-grain doses of salicylate of soda seems to be beneficial in curing the rheumatism and the skin affection. If there is digestive disturbance it should be attended to. ERYTHEMA NODOSUM. Pathology. Erythema nodosum is closely allied to erythema multiforme, and by some dermatologists described as one variety of that disease. By others it is regarded more like a purpura rheumatica accompanied by an inflammatory process, which is probably nearer correct. The lymphatics and blood-vessels play an im- portant part in the disease, as the lesions are frequently found upon the lymph vessels, and the exudation which enters the inflammatory area of the skin is usually sero- hemorrhagic. Etiology. The cause of the disease is not known, but occurs most frequently in rheumatic patients, and in those especially who are anaemic and debilitated. The disease is more common in females than males, and in young adults. It is most frequently met with in the spring of the year. ERYTHEMA NODOSUM. 97 Symptoms. This skin disease is usually ushered in with some constitutional symptoms, as fever, headache, and pains in the joints. After these symptoms have lasted two or three days nodes make their appearance on the extremities, almost always over the tibia. These nodes vary in size from a hickory nut to a small egg, and are usually oval in shape. They are very firm to the touch and at first red in color, but afterwards a variegated yellow, greenish, or bluish in tint, looking very much like a con- tusion, such as would be produced by a kick. The color does not disappear on pressure, showing that there has been some hemorrhagic exudation in the skin, which undergoing chemical changes produces the different colors. The lesions often have a shiny, tense look, as if suppuration were going to take place, but it never does. These nodes are somewhat tender on pressure, and ac- companied by some burning sensations. Purpuric spots are also sometimes present. The lesions appear in groups ; not more than eight or ten are usually present at one time. Each node lasts from two to four weeks, and disappearing leaves some pigmentation which is slowly absorbed. New growths are apt to appear before the old ones are gone. Each crop is preceded by some febrile disturbance. Diagnosis. Erythema nodosum must be diagnosed from gummous syphilide, bruises, purpura or scurvy, urticaria, abscesses, and erythema multiforme. Treatment. Iron and ergot are indicated in almost all cases. They seem to- hasten the resolution of the nodes and prevent relapses. In cases complicating rheumatism salicylate of soda should always be given. Local applica- tions do very little good. Hot, alcoholic fomentations applied for two or three hours every day seem beneficial in hastening resolution. The bowels should be kept 98 LECTURES IN DERMATOLOGY. thoroughly open and the kidneys active by the use of salines. The following prescription given in teaspoonful doses every three hours has been very beneficial in my hands : $ Antipyrin gr ii Pot. iodid., Pot. bicarb aa gr iv Pot. acet gr viii Tinct. hyoscyami, Tinct. colch. sem aa lUiv Alcohol tt^x Glycerini 3 ss Aq. menth. pip ad 3 i m LECTURE VII. FEIGNED SKIN DISEASES, FURUNCULOSIS, HERPES, HERPES ZOSTER, AND HYPERIDROSIS. FEIGNED DISEASES OF THE SKIN. Gentlemen : I wish to call your attention to-day to certain conditions of the skin which are usually described as feigned dis- eases of the skin, and are often very difficult to diagnose. It must be remembered that various diseases of the skin may be closely simulated by artificial means, and that such deception may be kept up for months. In some cases, as skin diseases occurring in prisoners, malingerers, and others in whom we might suspect the artificial produc- tion of skin diseases, close watch may be rewarded by dis- covery of the deception ; but in other cases, happening as they frequently do among hysterical females of the better classes, the difficulties of diagnosis are heightened by the fact that the feigned eruptions may be caused by a sort of automatic, insane impulse without any possible object. These you can readily understand will be most difficult to detect. To aid, however, in the diagnosis, in the first place the disease is almost always anomalous in the time, place, and manner of its appearance, and in the course in which it runs. In the second place, it almost always shows some signs of having been artificially produced, and is usually in a position easily accessible to the manipulator. The face, forearms, chest, lower limbs, and mammary 99 lOO LECTURES IN DERMATOLOGY. region are most apt to be the seat of the eruption. Care- ful inspection of the lesion will very frequently show along the edges some trace of the irritant used, or the mechanical irritant applied. Among the diseases most frequently feigned are, first : Alopecia areata, which may be simulated by plucking the hairs from a circumscribed area, but close examination will show the result of this violent operation, and after a few days' watchfulness you will be able to detect the new hairs springing up before they are long enough to be epilated. Bromidrosis is also frequently feigned, especially among the French and Germans. In France bromidrosis will prevent a soldier from entering the army, and in Germany foul-smelling feet is a legal ground for divorce. It is usually practised by the inunction of animal oil, asafceti- da, decayed fish, or cheese. Frauds of this sort are easily detected if the suspected person can be kept under surveillance for a short time. First using a disinfectant — as permanganate of potash, and then causing the patient to sweat freely by the use of hot air, will immediately show that the perspiration has no odor whatsoever. Besides it is also noticed that bromidrosis of the feet is almost al- ways accompanied by a macerated appearance of the soles, which is never present where the disease is feigned. Dermatitis is perhaps more frequently produced by artificial means than any other of the eruptions. It is nearly always the result of tearing the skin with the nails, or by continual friction with the finger tips. This will produce lesions of the skin which appear very much like herpes, or like neurotic excoriations. Sometimes painful erythematous patches are produced in this way, which are succeeded by exudation on the surface of serum and FEIGNED DISEASES OF THE SKIN. IOI sero-pus, making the lesions appear very much as a case of eczema. Vesicular and pustular eruptions are usually produced by the application to the skin of some irritant, croton oil, mustard, and turpentine being the most frequent sub- stances used. All these substances give rise to confluent vesicles, becoming rapidly purulent or vesico-purulent, which may be readily mistaken for eczema, to papular eruptions, or urticaria. The latter is occasionally simu- lated by the application of nettles or by the ingestion of certain substances which the patient knows will produce eruption. As these eruptions are transitory, hysterical or malingering persons would hardly be likely to take the trouble f or a result lasting so short a time. Of all lesions of the skin ulcers are more frequently produced by malingerers than any other. Many substances, such as cantharides, nitric acid, and sulphuric acid, when applied to the skin and allowed to remain for some time, will produce an ulcer which will last for a time. These ulcers when having a tendency to heal will be kept in- creasing in size by continued application of the irritating substance. Erythematous patches, appearing at first glance very much like erysipelas, may be produced by applications of thapsia and numerous other substances, but as the erup- tion lasts for so short a time it is not frequently resorted to. The treatment of all these classes of cases, of course, is to prevent the patients from thus abusing themselves. FURUNCULOSIS. A disease which I hardly need introduce to your notice, as many of you have had its acquaintance thrust upon you, is furunculosis or boils. 102 LECTURES IN DERMATOLOGY. Pathology. A cutaneous boil always has its seat in the deeper layers of the skin, and has its starting-point either in a sebaceous gland, sweat gland, or hair follicle. The inflammation is an active one, and always accompanied with not only the production of pus, but also some cen- tral necrosis of the skin called the core, which is composed of the tissues of the gland in which the boil originated and the structure about it. The inflammation is always circumscribed about the central core, the inflammatory products being infiltrated into the tissues of the skin. After the necrotic tissue is separated from the living struc- ture by process of suppuration it is cast off, and the inflam- matory products about it are absorbed. A slight scar remains, showing the seat of the destructive process. Etiology. Although it is reasonable to suppose that boils are produced by a micro-organism, which gains access to a gland and there sets up an inflammatory process, there are certain conditions which must be present to admit of this pathological change. Certain lowered conditions of the system are seen in diabetes, anaemia, continued fevers, general debility, chronic metal- lic poisoning, etc. Boils may also result from the use of improper food and ingestion of certain drugs, as the bro- mides and iodides. They sometimes apparently result from local causes, as friction, contusions of the skin, etc., but it is doubtful if injuries of this nature would produce the disease if there was no predisposition. Boils some- times occur in epidemics, thus strengthening the theory that the process is the result of bacterial infection. Symptoms. Boils attack both sexes and at any time in life, but young adults are more susceptible to the disease. There are usually no more than two or three lesions pres- ent at one time, but these lesions are very apt to occur in FURUNCULOSIS. IO3 successive crops, so that the patient may not be entirely free from these " comforters " for many months. Any portion of the body except the palms or soles may be the seat of the disease, but certain portions of the body are more apt to be affected than others. Boils occur more frequently upon the neck, shoulders, and buttocks than all other portions of the body. When several lesions appear simultaneously they are usually grouped about the same locality, but always remain discrete. Sometimes a number of lesions are scattered all over the body, when the term " general furunculosis " is used. This form of the disease is very rare, but one of the few skin diseases mentioned in the Bible, for " Job was sore # afflicted with boils from the crown of his head to the sole of his foot." Each lesion first begins as a little red spot in the skin, which is hot and accompanied with burning or itching, painful on pressure. Within twenty-four hours it increases in size, becomes raised above the surface of the skin in the form of a papule, and presents considerable induration. The summit of this papule soon becomes pustular, and in the centre of the pustule a hair will frequently be seen to penetrate, while the skin about it becomes a purplish red color, shiny, indurated, and very painful and tender. The pustule if opened at this stage will secrete only a little pus, or serum, or blood, but the centre of the indurated skin will present a yellowish, neurotic mass, due to the death of its central portion. This mass is called the core. Within a day or two suppuration takes place about this core separating it from the living tissues, and the dis- charge of pus becomes very free. At the end of five days to a week the core is discharged with the pus, the indu- ration begins to subside, the discharge of pus becomes less, and healing takes place leaving a small scar, the result 104 LECTURES IN DERMATOLOGY. of the destructive process. The amount of throbbing pain experienced at the seat of the lesion is often very great. Occasionally the boil does not mature, there being little or no suppuration or formation of a core, simply a hard, painful, deep-seated, indurated swelling in the skin, which disappears very slowly. This condition is usually spoken of as a blind boil. Diagnosis. There is seldom any difficulty in recog- nizing a boil, as both the lesion and symptoms are so well marked. It is possible, however, to confound it with a carbuncle (anthrax), or with a malignant pustule. It is also possible to mistake a boil for a large pustular syphi- lids Treatment. Boils if treated in time, or before the core forms, may often be aborted. If the inflammation is about a hair follicle the hair should at once be re- moved. Counter-irritation and strong antiseptics are the local agents you must rely upon. One grain of bichloride of mercury to an ounce of flexible collodion painted over the lesion may abort it. Carbolic acid and tincture of iodine in equal parts has given me the best results in aborting a beginning boil. The point of a sharp-pointed wooden tooth-pick should be dipped in this solution and thrust deeply into the centre of the lesion, and then diachylon ointment applied. In some cases this treat- ment seems to be exceedingly beneficial. The actual cautery applied to a boil at its very beginning will some- times abort it. It is often customary among patients who are afflicted with styes, which are really boils affecting the eyelids, to ap- ply a hot ring, which acts slightly as a caustic application and may act as an abortive agent. Internal use of a calomel purge followed by frequently repeated doses of sulphide FURUNCULOSIS. IO$ of arsenic or calcium seems to prevent the formation of boils. This is about all we can do to prevent the for- mation of these lesions when seen in time. When once suppuration begins and the core forms, we should hasten its separation by the application of heat in the form of poultices. I know that poulticing is now considered by many as old-fashioned, but I know of no better appli- cation to make to hasten the maturation of a boil than a hot, old-fashioned flaxseed poultice, sprinkled over with laudanum. These poultices should be applied continually until the slough separates, when under protective dressing the lesion will heal rapidly. The surgical treatment of a boil is to open in and to apply wet, antiseptic dressing. The one good which can result from opening a boil is to relieve the tension and congestion of the skin, and in this way to relieve the pain and hasten the separative process. In some cases when the tension of the skin is great the knife should be freely used, and in all cases where the pus is confined in the skin. Constitutional treatment. The general health of the patient should always be considered and treated accord- ingly. Tonics are frequently called for, and one deserving of great praise in the treatment of debilitated conditions associated with the production of boils is Fellows' syrup of hypophosphites. The sulphides, especially of arsenic and calcium, certainly lessen the tendency to the recur- rence of boils if given for some time in large and fre- quently repeated doses. Bathing the skin once a day in some antiseptic solution, as bichloride of mercury 1:1000, on the theoretical grounds of destroying all disease germs which may be actively engaged in producing boils, has in some cases been satisfactory. 106 LECTURES IN DERMATOLOGY. HERPES. We come now to the consideration of a class of disease which is distinctly vesicular in character, and described under the general term of herpetic eruptions. The ones which I wish to especially call your attention to are known as herpes, the most common examples of which are herpes facialis, herpes progenitalis, and herpes zoster. HERPES SIMPLEX. Pathology. The vesicles in herpes simplex are formed in the same way as the vesicles in vesicular eczema, and as a result of an exudative inflammation, which is probably due to some nerve disturbance, the pathology of which is not at all well understood. Etiology. Exposure to cold, digestive disturbance, fever- ish conditions, and external irritants are the most frequent causes of herpes. Symptoms. The eruption is often preceded by malaise and fever, or, as is often the case, it occurs in the course of some severe febrile condition, as typhoid fever. The first local symptom is a heat and burning in the place where the eruption is to make its appearance. A few hours after, a group of vesicles, usually from four to ten in number, make their appearance upon a reddened surface. They are usually from a pin-head to a split pea in size, discrete at first, but may become confluent. Their con- tents, at first clear, soon become cloudy and somewhat purulent, which after a few days dry into small brownish crusts. These vesicles may or may not rupture sponta- neously, but, if broken, an excoriated and exuding surface is exposed, which crusts over and heals without leaving HERPES. 107 a scar. A number of groups of these vesicles may occur at one time, or follow each other. HERPES FACIALIS. When this eruption occurs on the face we often find it about the borders of the lips, where it is commonly known as fever- or cold-sores. The vesicles rupture spontaneously owing to the maceration soon after forming, so they often appear from the start as excoriated patches, which crust over and heal in a few days. When the vesicles appear elsewhere on the face, as about the alae of the nose, they are less apt to rupture, and remain as such, drying up and forming a scab which falls off in a day or two. HERPES PROGENITALIS. This variety of herpes in the male occurs generally on the inner surface of the prepuce, and in the female on the inner surface of the labia majora. The lesions, however, are not limited to these regions. It is a disease of youth and middle age, seldom occurring after forty, except in women at menopause, and, with this exception, it is almost always found in persons who have suffered some time previously with some venereal disease, especially gonorrhoea. There is nothing peculiar about the vesicles. They are preceded by pain and tenderness, appear on a reddened surface, usually in clusters of four or five ; they rupture easily through maceration, leaving superficial ulcers covered with a whitish deposit, and may heal in a few days. Relapses are common. Diagnosis. Great care must be taken in diagnosing these little ulcers from true chancroids. The following are some of the points of differential diagnosis between these 108 LECTURES IN DERMATOLOGY. two diseases, for it is of great importance that you should be able to distinguish between them : Herpes always begins as vesicles, chancroids as ulcers ; herpes appears in groups, chancroids do not ; herpes is always multiple, chancroids single or few in number ; the lesion of herpes is very superficial, those of chancroids quite deep ; herpes lasts but a few days, chancroids for a week or longer ; the lymphatic glands in herpes are not much enlarged, in chancroids they are enlarged and fre- quently suppurative ; repeated attacks of herpes are common, no relapses from chancroids; herpes usually preceded by burning and itching, and no premonitory symptoms to chancroids ; herpes not contagious or auto- inoculable, chancroids very contagious. It is also neces- sary to diagnose simple herpes from herpes zoster, vesicu- lar eczema, and hydroa. Treatment. The herpetic vesicles should be protected from rupturing by an application of some soothing or drying ointment, as the following: fy Camphorae . . . . gr. xv Ung. aq. rosae . . . . § i When they have ruptured, the oxide of zinc ointment, with half a drachm of camphor to the ounce, is an excel- lent remedy to use, especially about the face. When occurring about the genitals the part should be bathed frequently with hot water, dried thoroughly, and calomel dusted over the lesions. In some cases, the following ointment is especially serviceable : $, Hyd. ammon. . . . . 3 ss Hyd. chlor. mit 3 iss Ung. aq. rosae . . . . ad § i m HERPES. IO9 In other cases an astringent lotion, such as — ]$ Zinc, sulph. . gr. v Spt. lavandulae comp. 3ss Aq. rosae . ad 3 i m kept continually applied on a little cotton — will be found very useful. Recurrent attacks occurring in persons with a long prepuce, circumcision should be performed. HERPES ZOSTER. Herpes zoster, although properly classed as a neurotic skin affection, will be found more conveniently considered by us among the vesicular eruptions. Pathology. As the disease is one of neurotic origin, there is generally found an inflammatory condition of the nerves supplying the portion of skin affected, or of the ganglionic centres from which these nerves are derived. The spinal ganglia are the ones found most frequently diseased and softened. The disease is, however, not infrequently asso- ciated with disease of the brain or spinal cord. The cutaneous lesions are the same as those found in simple herpes, and formed in the same way. The papillae are considerably enlarged, due to cell infiltration, and may appear as papules. The nerves in the skin are swollen, the medullary layer softened, and the axis-cylinder increased in size. Etiology. Malarial poisoning probably causes more at- tacks of herpes zoster than all other causes put together. Sudden changes of temperature and exposure to severe cold may be the exciting cause. Injury to the nerves or ganglionic centres may be followed by an attack of herpes zoster, as may lesions of the brain and spinal cord. Some IIO LECTURES IN DERMATOLOGY. drugs have been known to produce the disease, especially arsenic. Symptoms. Herpes zoster, or shingles, as the disease is more commonly known, usually begins by neuralgic pains in the region to be affected for a day or two before the eruption makes its appearance, which in some patients are very severe, while in others, especially in children, they do not amount to much. The pains may be accom- panied by some fever. Next there appear, at the seat of the pain, several red patches of skin following the course of some nerve trunk. Upon this inflamed area soon appear groups of papules or vesico-papules, which have a tendency to form in groups. These lesions, within a day, however, become vesicles about the size of a split pea, at first discrete, but if crowded closely together soon become confluent. New inflammatory areas make their appear- ance from day to day, and upon them new groups of vesicles, until about the eighth or tenth day the disease is at its height. The vesicles, as a rule, do not rupture spontaneously, but are frequently broken by rubbing or violence, leaving a superficially ulcerated surface, which scabs over. The vesicles first contain a clear serum, which afterwards becomes cloudy and thick, often puri- form, and sometimes hemorrhagic. These vesicles usually dry up in about a week's time, forming brownish crusts, which drop off, leaving a reddened surface which gradually disappears without scarring. As new groups of vesicles continue to appear for about ten days, we find them in all stages of development. The neuralgic pain continues during the formation of these lesions, and, not uncom- monly, for some time after they disappear. The disease may attack any portion of the body, and almost invariably follows some nerve trunk. It has a decided preference to HERPES. 1 1 1 follow the course of some intercostal nerve, next to these the brachial and cervical plexus. The eruption is almost always unilateral, although occasionally bilateral. The popular belief, that if the disease is bilateral and entirely encircles the body death will follow, is erroneous. Course. The disease usually ends in complete recovery in about two or three weeks, but occasionally deep ulcera- tion takes place, which requires a long time to heal, leaving scar tissue. Relapses are common. Diagnosis. Herpes zoster must be distinguished from simple herpes, erysipelas, vesicular eczema, and herpes iris. Treatment. The treatment should be both constitu- tional and local. Quinine seems to be the only one remedy par excellence, and should be given in from 1 5-to-20-grain doses a day. The disease is frequently malarial. Perhaps this will account for the bene- ficial action of the drug. As the neuralgic pains are frequently very great, it had better be combined with either antipyrine or morphine. Quinine will frequently abort an attack, or greatly lessen its severity. To prevent recurrent attacks, which frequently come on at regular intervals each year, arsenic should be given in the form of Fowler's solution, three to five drops after meals. This may be given for several weeks before the expected attack. If you see the disease at the commencement of the eruption, or before the vesicles become purulent, the best local treatment consists of painting the affected area over with flexible collodion, in which are incorporated ten grains of morphine to the ounce. This not only eases the pain, but hastens absorption of the products of inflamma- tion. You should be careful not to make this application if the vesicles are puriform, for the confined pus may set 112 LECTURES IN DERMATOLOGY. up an ulcerating process which may be very extensive. In this stage of the disease, or if the vesicles have been rup- tured extensively, it is much better to apply some dry and soothing antiseptic ointment, such as Lassar's paste or I> Camphorne 3 ss Ung. zinc, ox ad 3 i which not only lessens the inflammation, but dries up the discharges, prevents the formation of pus, and heals the lesions. Should the neuralgic pains continue after the local symptoms have disappeared, the use of arsenic internally and electricity along the course of the affected nerves gives the best result. HYPERIDROSIS. I will say but a few words to you in reference to a disease of the sweat glands, the most important symptom of which is excessive sweating, called hyperidrosis. Pathology. The disease, so far as the sweat glands themselves are concerned, is purely a functional one, as the gland structure itself does not seem to be altered at all. The disease is undoubtedly one of the nervous system, but no organic lesions have ever been discovered which could be considered at all direct. Etiology. The secretion of the sweat glands is under the control of the vaso-motor system of nerves, whose nerve centre is in the spinal cord, just below the medulla. Any nerve lesion, disturbance of the nervous system, nervous impressions, or physiological action, as that caused by the ingestion of certain drugs, acting on the vaso-motor nerves or sweat centre, may affect the func- tional activity of the sweat glands. Thus, organic lesions of the brain and spinal cord, nervous debility, enervating HYPERIDROSIS. 1 1 3 diseases, severe mental impressions, shock, drugs like pilocarpin, are frequent examples of the cause of hyperi- drosis, either general or local. There are, however, many cases of local sweating especially, where no cause can be discovered, and must be considered as directly due to functional disturbance in the sweat centre or vaso-motor system. There is often found an hereditary predisposi- tion, but this is also frequently absent. Symptoms. The disease may be either local or general, but it is only the local sweating to which I wish to call your attention to-day. Local sweating may occur on any portion of the body, but it is most frequently encountered upon the soles of the feet, palms of the hands, the axilla, the face, or the genitals, and may be limited to one side of the body. This excessive sweating may occur con- tinually or in paroxysms, but even when continually it is worse at certain times than at others. The amount of secretion may be moderate or excessive, so excessive at times that drops of sweat will collect every few seconds, and roll off the surface. In one case I remember having collected a drachm of sweat from one hand alone in ten minutes. When so excessive as this, the sweating is usually limited to a small area. Usually other portions of the body, except the affected area, are supplied with sweat glands with normal functional activity, but in other cases the glands are either diminished in number, or their secretion is diminished. As the skin of the part affected is continually wet, it becomes yellow- ish or whitish in color, has a soggy appearance, with the surface temperature usually below normal. The macera- tion of the epidermis and the accumulation of the secre- tion, which undergoes a decomposition, often give rise to a most disagreeable odor, called bromodrosis. Bromodrosis 114 LECTURES IX DERMATOLOGY. is, however, frequently a disease occurring by itself, and not associated with hyperidrosis. Very frequently the macerated skin peels off, leaving the tender skin exposed, making the part very tender. This is especially apt to occur about the feet, making walking very painful. Some- times the subjective symptoms in the part, as tingling, pricking, or neuralgic pains, are quite pronounced, but are not usually present. Course. The disease is usually a chronic one, lasting for years. Although it may improve for a time, it is very apt to return. It is not very amenable to treat- ment, and some cases do not seem to improve at all under it. Treatment. In local sweating constitutional treatment does not seem to meet with the same success that it frequently does when the disease is general, for in the latter case the general health is very much run down, and tonic treatment is called for, but here tonics are not often required. Strychnine, ergot, and belladonna or atropia are the three remedies which may be used internally with advantage. If atropia is used, it had better be given hypodermically in or near the affected area in small doses once a day. Locally the use of the faradic electricity certainly is beneficial, the positive sponge electrode, soaked in strong brine solution, being applied to the affected area, and the negative to the upper part of the spinal cord. Electric baths also frequently give a good result. Electricity should be applied every two or three days, and continued for some time. In the way of drugs for external use salicylic acid, rubbed into the part and kept constantly in contact with it, is the best treatment that I can suggest. Diachylon ointment, containing 10 per cent, salicylic acid, is also very serviceable kept con- HYPERIDROSIS. 1 1 5 tinually applied. Astringent baths of alum or tannic acid may be applied, but they are not usually followed by any permanent result. Very hot applications of the following — B Plumbi acetat 3 ss Ac. acetic, Alcohol aa § ss Aquae ad § viii m may be applied every night for half an hour before the salicylic acid or diachylon ointment is used. This treat- ment should be continued for several weeks, and may be followed by a cure ; but your prognosis should be guarded, for in a short time the trouble is apt to return. LECTURE VIII. HYPERTRICHOSIS, IMPETIGO, lAfPETIGO CONTAGIOSA, KELOID, KERATOSIS PILARIS, LENTIGO, LET CO- DERMA, LICHEN PLANUS, AND LICHEN TROPICUS. HYPERTRICHOSIS. Gentlemen : Under the term of hypertrichosis, or hirsuties, I wish to call your attention to abnormal growth of the hair, either upon regions where no hair usually grows, or where it is ordinarily found. The abnormal growth of hair is a very common occurrence in connection with moles, when the disease is known as naevus pilosus. The treatment of this affection is limited to cases where the abnormal growth is confined to small areas. Undoubtedly the best treatment is by electrolysis. A galvanic battery of from eight to twelve cells will produce a strong enough current to destroy the follicles. A very fine gold-plated needle should be connected with the negative pole, while the positive pole with the sponge electrode should be held by the patient. The needle is to be introduced at the side of the hair into its follicle, and allowed to remain there until the hair is loosened, which usually takes about ten seconds. While the cur- rent is passing, a little fluid mixed with bubbles of air may be seen to pass out of the follicle by the side of the needle The pain is very sharp, but may be lessened considerably by introducing and extracting the needle 116 H YPER TRICHOSIS. 1 1 7 when the current is broken. It is better to let the patient make and break the current by grasping and letting go the sponge electrode. Many patients have told me that the pain is very much lessened when I make a strong ap- plication of cocaine before operating. When the follicle is destroyed by electrolysis the hair will never grow again. As the result of the treatment a dermatitis often results with pustulation, which lasts a few days, and until this subsides the agent should not be used again in the same area. To allay this inflammation, I have found that an application of hot water followed by an ointment com- posed of twenty grains of camphor to an ounce of water of roses very serviceable. Little or no scarring remains. The objections to this plan of treatment consist in the length of time it takes to effect a cure, the pain experi- enced by its application, the irritation and inflammation resulting, and the possible stimulation to increase the growth of the fine hairs in the neighborhood. Depilatories are of some service, the sulphides of the metals being usually employed, especially the sulphide of barium and sodium. Either one of these should be mixed with two or three times its weight of some sub- stance, as starch or oxide of zinc, made into a paste and applied to the hairy portions in thin layers for about ten or fifteen minutes. As soon as burning is felt in the skin it should be completely removed, and some bland oint- ment applied. These applications must be repeated from time to time, as they do not usually destroy the hair follicles. The following prescription is sometimes used with advantage : ^ Powdered air-slacked lime .... 31 Orpiment (arsenic trisulphide) . . gr. ii Il8 LECTURES IN DERMATOLOGY. This should be made into a thick paste by adding water, and applied to the hairy surface for fifteen minutes and then washed off. This application should be made at first twice a week, and gradually less often until the hair no longer grows. This treatment usually takes a year to effect a cure. Very little irritation of the skin results from the use of this agent. IMPETIGO. Pathology. Impetigo is distinctly a pustular disease. It is due to a circumscribed, exudative inflammation of the papillary layer of the skin with the formation of pus, which raises up both the horny and mucous layers of the epidermis, thus accounting for the thick walls of the pustule. The inflammatory process is so circumscribed that the lesions are not surrounded by an inflammatory areola. Etiology. It is a disease of children under ten, and is rarely seen in adults. It occurs often in healthy children, and without apparent cause. Symptoms. There may be some constitutional disturb- ance ushering in the eruption, but if present is usually slight. The eruption begins as pustules on erythematous spots. These pustules vary in size from a split pea to a finger nail, and are prominently raised above the skin, with thick walls, which are very tensely distended with fluid. In two or three days they reach their full develop- ment, when the erythema around them disappears. The pustules are discrete, and have no tendency to rupture or form in groups. There are seldom more than a dozen on the body at one time, and they occur most frequently on the face and the extremities, especially the hands and IMPETIGO CONTAGIOSA. II9 feet. After the pustules reach their full development they are gradually absorbed or dry up, forming brownish crusts, which fall off, leaving a reddened surface without pigmentation or scar. New lesions make their appear- ance as the old ones dry up. When the pustules are ruptured they exude a whitish fluid, leaving an excoriated and exudative surface, which usually crusts over. These lesions are accompanied by few if any subjective symptoms. Course. The disease is an acute one, running its course in a few weeks, often without treatment. Diagnosis. You must be careful not to confuse this disease with impetigo contagiosa, which it sometimes resembles. It is liable also to be mistaken for pustular syphilide and ecthyma. Treatment. The lesions when fully developed should be opened, and their contents allowed to escape. The loosened epidermis should then be carefully removed, and some protective ointment applied to the reddened sur- face. Diachylon ointment, with fifteen grains of salicylic acid to the ounce, is a good application to use. If crusts have already formed they may be protected and not re- moved, as healing goes on very rapidly under them. As the disease always ends in spontaneous recovery, be care- ful you do not make matters worse by too active treat- ment. No internal treatment is necessary. IMPETIGO CONTAGIOSA. A much more common disease, similar in many respects to impetigo, and one which you will see quite frequently in your practice, is impetigo contagiosa. Pathology. The disease is undoubtedly contagious, and due to a germ or fungus. What this micro-organism is 120 LECTURES IN DERMATOLOGY. has not been definitely demonstrated, as observers differ as to its appearance. According to Piffard and to most observers of the present day, the same fungoid bodies found in impetigo contagiosa also occur in the pustules and crusts of vaccinia. The disease is distinctly a cir- cumscribed, inflammatory one, characterized by the formation of vesico-pustules by raising up of the horny layer of the epidermis by the exudation. Etiology. The disease is one confined almost exclu- sively to children who are uncared for and uncleanly. It is very contagious and also auto-inoculable. It so fre- quently follows vaccination that Piffard considers that it always primarily, is the result of the inoculation from a vaccine vesicle or crust. The disease usually occurs in epidemics. Symptoms. There frequently is a slight febrile disturb- ance preceding the eruption, which usually makes its ap- pearance about the face and hands, and often upon other portions of the body. The eruption begins as isolated vesicles, which are flat and increase in size until they are as large as a finger nail, still remaining flat however. As they reach their full size they become sero-purulent or purulent. At first they are surrounded by a slight in- flammatory areola, which disappears when the lesions mature. These vesico-pustules are round or oval in shape, with thin, flaccid walls, often umbilicated, which rupture in a few days, drying in yellowish crusts, easily detached and looking as if they were " stuck on." These fall off in a few days, leaving a reddened surface beneath. The lesions appear in groups, usually remaining discrete, but sometimes running together, forming patches, and appearing as bullae. The disease is one of short duration, not lasting usually more than a few weeks, in which time KELOID. 121 a number of successive crops of lesions may make their appearance. A slight pigmentation often remains at the seat of each lesion. Diagnosis. A differential diagnosis must be made be- tween impetigo contagiosa and scabies, impetigo, varicella, pustular eczema, and pemphigus. Treatment. But the mildest treatment is usually re- quired, as the disease is not one of long duration, and without treatment ends in spontaneous recovery. When the vesicles form they maybe opened, and the undermined epithelium carefully removed. The excoriated surface may then be treated with the following ointment : I£ Ung. hyd. ammon., Ung. zinc, ox aa § i m which not only heals the lesions, but prevents extension of the disease by auto-inoculation. If crusts have formed they may be protected by a little oxide of zinc ointment, as new epithelma seems to form more rapidly under them than it does when they are removed. In cases when re- lapses are frequent a 10 per cent, solution of ichthyol in water kept continually applied to the lesions not only heals them rapidly, but prevents them spreading by reinfection. KELOID. Surgeons perhaps more frequently than dermatologists are called upon to treat keloidal growths in the skin, but the frequency with which they are met warrant my saying a few words to you upon the subject. 122 LECTURES IN DERMATOLOGY. Pathology. A keloid has its seat in the corium, and •may cause an atrophy of the other layers of the skin and the glandular appendages. The whole thickness of the corium is occupied by bands of new connective tissue with few cells. These bands seem to start from the blood- vessels, and branch out into the surrounding skin. Etiology. Keloid may arise spontaneously, or spring from the site of a scar, the result of some previous injury to the skin. The latter is very much the more common. The disease is more common in negroes than in white people. Symptoms. The disease usually begins as a small, pale or pink nodule, deeply seated in the skin, and growing very slowly. From this central point the lesion sends out several firm, ridge-like prolongations extending into the normal skin. The central portion or body is usually round or oval while these prolongations are narrow, giv- ing the lesions somewhat the appearance of a crab with its claws extended. In other cases the shape of the lesions is extremely irregular, but in all cases the outline is well pronounced, the disease looking as if it was set in the skin. The lesions are always elevated, especially in the centre, of firm, elastic consistence, and varying in size from a pea to the palm of the hand, or larger. The color of the surface is pinkish or purplish, smooth and devoid of hair. The lesions are apt to appear singly, although a number may be present. They usually appear about the sternal region, the neck, or ears, but may occur upon any portion of the body. There may be a little pain present, but usually the subjective symptoms are not at all severe. The disease grows slowly, but after reaching a certain growth remains stationary for years, occasionally under- going a spontaneous involution in syphilitic patients. KERATOSIS PILARIS. 1 23 Diagnosis. You must not mistake hypertrophied scar tissue for keloid, but this is the only diseased condition of the skin which closely resembles it. Treatment. Internal treatment seems to have little or no effect. Mixed treatment, or Donovan's solution, may check the growth and lessen the size of the lesions. Occasionally anodynes must be given to re- lieve the pain. Externally lead and mercury plasters alone, or combined with belladonna, seem to be the only mild remedies having any good effect. The new growths may be excised or removed with cautery, but they are almost sure to return, and often with great rapidity, as- suming larger proportions than formerly. Occasionally good results are obtained by removing the growths by means of electrolysis. This plan of treatment is worthy of atrial in cases where the growth is disfiguring. KERATOSIS PILARIS. Pathology. A disease which is a very common one, and consists pathologically of an accumulation of epider- mic cells about the openings of the hair follicles, forming conical-shaped papules, is keratosis pilaris. Etiology. As the disease occurs most frequently in those who do not bathe often, the lack of cleanliness may be considered in some cases as the cause ; but it does oc- cur also in those who bathe every day, so that this cannot be considered as the only one. What other factors may produce the disease we do not know. Symptoms. The lesions are pin-head in size, and occur chiefly on the extensor surfaces of the extremities, espe- cially about the thighs, but also occur on the trunk. They are conical in shape, grayish or dull red in color, and 124 LECTURES IN DERMATOLOGY. made up of epithelial cells and sebaceous matter, con- taining in their centre a broken off, convoluted, or twisted hair. When the hairs are broken off each papule has a dark central point. The skin about the affected area is harsh, dry, and rough to the touch. When the hand is passed gently over the surface it feels like a nutmeg grater. It often has the appearance of " goose-flesh." The disease is usually not accompanied by any subjective symptoms, although there may be a little itching. The disease runs a chronic course, worse at times than others, and especially severe in cold weather. It lasts for years. Diagnosis. The diagnosis of this disease is seldom difficult, although it must be differentiated from cutis anserina, papular eczema, and papular syphilide. Treatment. The treatment of this affection is very un- satisfactory, and unfortunately you will frequently be called upon to treat it in young ladies who have it upon their arms, thus preventing them from wearing short- sleeved dresses. The same treatment which I have recommended to you in xeroderma or asteatosis, will in some cases give you a good result. After the use of the hot bath and friction with green soap, a lotion of one grain of bichloride of mercury to an ounce of cologne water is a very good application, and very agreeable to the patient ; but in any case do not promise your patients too much in the way of rapid improvement. LENTIGO. The most common skin disease with which you will meet is freckles or lentigo. In fact, it is so frequently met with that it is not often looked upon as a disease at all, but rather as a natural condition of the skin occurring under certain conditions. LENTIGO. 125 Pathology. Lentigo is a disease of the pigmentary layer of the skin, and consists of the deposit of pigment in numerous small areas, otherwise the texture of the skin remains normal. Etiology. The direct cause of the disease is unknown, but we do know that exposure to the sun sets up some physical or chemical change in these pigmentary deposits to make them much more pronounced and of a darker color. Symptoms. Infants and elderly people are not subject to the disease. It occurs in children and young adults of both sexes with equal frequency. It occurs most fre- quently in persons of a fair complexion, and almost always in persons having red hair. The pigmentary deposits are about the size of a pin-head, often very numerous and placed closely together, but seldom confluent. The color varies from yellow to black, and the lesions are always more numerous and pronounced on those portions of the body exposed to the direct rays of the sun, as upon the backs of the hands, face, and neck, where they may give the skin a dirty appearance. Lentigo is unaccompanied with itching or other subjective symptoms. There is no disturbance of the general health. The lesions are always much worse in summer than in winter, sometimes almost entirely disappearing in cold weather. In many cases although apparently gone, if the skin is carefully exam- ined the pigmentary deposit may be seen, although of a much lighter color. Even if they do disappear for a sea- son they are almost sure to return again. Treatment. There is very little I can say to you as regards treatment. Any physician that can cure freckles will not need for further practice. Counter-irritation seems to have the most influence in removing these 126 LECTURES IN DERMATOLOGY. blemishes. One patient whom I can recall had the dis- ease very badly, in fact it almost amounted to a disfigure- ment. The patient was entirely cured by an accident which resulted in a severe scorching of the face — a burn in the first degree. That was several years ago, and since then the patient has never been troubled with freckles on the face. I now treat all my freckled patients by severe counter-irritation of the skin with more or less benefit. This irritation may be produced by several methods, but the tincture of green soap rubbed in with a little bit of green flannel until the skin is reddened, is a favorite remedy with me. This can be applied every third, fourth, or fifth day, depending upon the amount of reaction set up in the skin. Bichloride of mercury seems to have some power of hastening the absorption of these pigmentary deposits, but it must be used in as strong solution as the patient can stand. You should advise your patients to bathe the face in hot water ten or fifteen minutes a day, and then apply the following solution : JJ Corrosive sublimate gr. vii Distilled water § vi Spirits camphor | ss Rose water 3 v m This treatment if continued for some time will give you the best results I can recommend ; but at best the treat- ment frequently fails, and you must not promise your patients to cure them of a trouble which although it in no way harms the general health or produces any unfavorable symptoms, yet they will certainly pay you well to get rid of. LEUCODERMA. 12 J LEUCODERMA. Pathology. Vitiligo or leucoderma is closely associated with chloasma, often occurring with it. The process con- sists in atrophy or absorption of the normal pigment of the skin in patches, and an hypertrophy or deposit of this pigment about the edges of these atrophic spots. Etiology. The disease is undoubtedly due to some nerve disturbance or innervation. As the general health does not suffer, the disease does not seem due to any ab- normal conditions affecting the body in general. Symptoms. The affection begins with the formation of several roundish or oval spots, which are white in color and surrounded by normal skin darker in color, the line of demarcation being well formed. These spots differ in size, but seldom get larger than the palm of the hand. New ones may continue to form, and uniting with the older ones produce large and irregular patches of whitish skin. These patches may appear upon any portion of the body, but are more apt to appear upon the trunk and backs of the hands. Hairs occurring in these spots usually turn white, but the glands, nerves, blood-vessels, and other skin structure, remain normal. There are no subjective sensations present, and the secretions are all right. The disease runs a chronic course. The spots gradually in- crease in size and number. The color seldom returns when once absent. Diagnosis. Leucoderma may be mistaken for lepra, tinea versicolor, chloasma, and pigmentary syphilide, but the diagnosis is not always difficult if you do not mistake the white color of the patches for the normal color of the skin. Treatment. The only success in treatment seems to lie in stimulating the patches. This may be done by 128 LECTURES IN DERMATOLOGY. keeping up constant irritation by frequent applications of tincture of iodine, or by occasionally painting over the patches with acetic acid, or pure carbolic acid, or collodion, or cantharides, or by the application of irritating or blister- ing plasters, or other modes of treatment which usually result in pigmentation of the skin, and thus cure the af- fection. Another way of treating these cases, is by remov- ing the pigmentary deposit found around the edges of the patches by treatment recommended in my lecture on chloasma. You may stain the white patches with walnut juice and thus artificially obtain the natural color of the skin, if your patient is very anxious to have something done, no matter if only temporarily. The internal administration of nerve tonics and bromides is recom- mended, but I doubt if you will derive any good result from their use so far as the condition of the skin is con- cerned. LICHEN PLANUS. Lichen planus has until recently been regarded as one variety of that very rare disease lichen ruber, but late in- vestigation, especially by Taylor, has established without doubt that this disease is distinctly different in patho- logical symptoms and course from lichen ruber, and therefore should not be described or classified with it. Lichen planus is a chronic, inflammatory disease of the skin seen quite frequently in this country. Etiology. Its cause is unknown, but it is seen most frequently in persons of a rheumatic diathesis. It attacks adults rather than children, and is more common in men than women. Symptoms. The lesions characteristic of lichen planus LICHLN PLANUS. 1 29 are papules, varying in size from a pinhead to a split pea. They are peculiar in shape, being angular, quadrangular or polygonal. They are often placed so closely together as to form patches or lesions, but when examined under the lens they are found seldom to lose their individuality, and around the edges of the patches the lesions are always discrete. The papules rise abruptly above the skin, but are flattened on their surface, and may present an umbili- cation. They are very firm to the touch, and slightly scaly. The color of the papules is very peculiar, they having a distinctly silvery, violaceous hue. When the lesions unite to form patches or ridges they seem to follow the natural lines of the skin or nerve trunks. Itching is usually severe. The lesions may appear upon any portion of the body, but are especially apt to attack the flexor surface of the forearm, wrists and ankles, and are almost symmetrical. The disease lasts for months or years, but eventually gets well, leaving pigmentation which lasts for a long time. Relapses are not very common. Diagnosis. The diagnosis of lichen planus is not always easy. It is very often mistaken for either psoriasis or papulo-squamous eczema. It must always be distinguished from lichen ruber and papulo-squamous syphilide, which it quite often resembles. Treatment. Treatment is not very satisfactory. The internal use of alkaline diuretics and the external use of ointments containing camphor in large quantities seems to act well in cutting short the disease and lessening the itching. Mud baths have in some few cases been followed by rapid and brilliant results. You can promise your patient a cure, but do not attempt to tell him when, or both you and your patient will be disappointed. 1 30 LECTURES IN DERMA TOLOG Y. LICHEN TROPICUS. Under the more general term miliaria are often de- scribed two diseases of the skin, lichen tropicus and sudamina. Pathology. Lichen tropicus or " prickly heat " is an in- flammatory disease affecting the sweat glands. Conges- tion first takes place about the ducts of the glands, which is soon followed by a serous exudation resulting in the formation of papules or vesicles, usually of both. These lesions have their seat about the orifices of the excretory ducts. Etiology. The disease is almost always the result of heat, either caused by hot woollen clothing or high ex- ternal temperature; it is also frequently the result of feverish conditions. It is more common in hot tropical countries, and in summer than winter. Fat people and those who perspire freely are more subject to the disease. Young infants and children are especially liable to suffer from it, on account of the superfluous amount of under- clothing and woollen bands which they are so often bur- dened with by over-anxious mothers. Symptoms. Miliaria papulosa or lichen tropicus, or still more commonly known as prickly heat, usually com- mences as small, pin-head-sized accumulated papules, of a bright red color. They remain discrete, although ap- pearing in great numbers and placed very closely to- gether, often covering a large area. Between the papules a few vesicles often make their appearence. When present in large numbers they are usually very small, situated on an inflamed skin, and frequently described as miliaria rubra. The eruption is often preceded by sweat- ing, and accompanied by considerable itching and burning. It often develops within a few hours, but disappears less LICHEN TROPICUS. 131 rapidly. It may occur upon any portion of the body, but is especially prone to attack the trunk. Relapses are common, and may be brought on by hot drinks or stimu- lating food. Diagnosis. This disease is most often mistaken for papular eczema, to which it has a close resemblance. It must also be diagnosed from scabies and eruptions of the skin the result of internal administration of medicines, as antipyrin. Treatment. As the principal cause of the disease is sweating, our first effort should be in controlling this activity of the sweat glands. A cool apartment and light clothing should be insisted upon. The patient should be fed on a light diet, avoiding all stimulating food, as meat, and hot or alcoholic drinks. The use of refrigerant drinks, such as the acetat and citrate of potash, should be given in lemonade, especially when occurring in infants and invalids. Aromatic sulphuric acid with some tonic is often serviceable. Atropine may be given in some cases to control the sweating. For local use mild dusting powders such as starch and lycopodium with a little salicylic acid added are very beneficial. Alkaline baths are also very agreeable and beneficial, taken once or twice a day. Lotions of sulphate of zinc or copper, or acetat of lead ten grains to the ounce, are frequently used in tropical countries for the relief of this affection. The following lotion I have used with great benefit : 5, Zinci sulph., Acid, carbol., Alumin aa gr. viii Aq |ii m LECTURE IX. LUPUS ERYTHEMATOSUS, LUPUS VULGARIS, MILIUM AND MOLLUSCUM CONTAGIOSUM. LUPUS ERYTHEMATOSUS. Gentlemen : It is both unfortunate and confusing that we have two distinct diseases of the skin called lupus, one lupus ery- thematosus and the other lupus vulgaris. It is to the former that I now wish to call your attention. Pathology. In which layer of the skin the disease first begins is a little doubtful, but it probably has its primary seat about the sebaceous glands and follicles. After a while all the structures and layers of the skin become af- fected. There is a cell infiltration of the connective tissue, and a cell proliferation in the glands, giving rise to sebor- rhcea. If these conditions last for some time a degenera- tive metamorphosis takes place, resulting in absorption and atrophy of the skin and glands, perhaps resulting in the formation of cicatricial tissue. Etiology. Females are more subject to the disease than males, and especially those having a tendency to functional derangement of the sebaceous glands ; so indirectly those causes having a tendency to produce the latter disease may be considered a cause for the former. The immediate causes for the disease are, however, very obscure. Symptoms. The disease first shows itself by the presence of a few, small, pin-head-sized erythemic spots, which are usually found clustered together, and running 132 LUPUS ERYTHEMATOSUS. I 33 into each other, forming one or more isolated patches. These patches, which are rounded or circumscribed, en- large very slowly by the extension of the disease from the centre towards the periphery, or by uniting with other patches, there often being several of such patches placed closely together. When two or more of these lesions have united, the patches become irregular in shape. The patches have a distinct and marginate outline separating them from the normal skin. Soon after forming, the lesions become covered with fine grayish or yellowish scales which are firmly adherent, but are not so abundant as to mask the color of the patches, which are distinctly violaceous in shade. Occasionally, however, they appear in the form of crusts, which completely cover the lesions, giving the appearance of a seborrhoea of the face. The scales or crusts are firmly attached to the openings of the sebaceous glands, sending a root-like pro- cess down into the ducts, which are distended and patulous. After the disease has lasted for a long time the central portions undergo atrophic changes, usually becom- ing paler in color and slightly depressed. Ulceration may take place with the formation of cicatricial tissue. Cica- tricial tissue may be, and often is, produced in the patches without ulceration first taking place. The seat of the disease is almost always about the face, affecting the cheeks and nose. As these regions are often invaded at the same time, a symmetry is produced which is likened to a bat with outspread wings. The scalp and ears are quite frequently attacked, but the rest of the body but seldom. The disease occasionally appears about the ankles and wrists. The subjective symptoms are not very marked. At times burning, itching, and pain are marked symptoms. 134 LECTURES IN DERMATOLOGY. Course. The disease is very chronic, lasting usually through life, without especially interfering with the general health. After the patches have reached a certain size there are periods, sometimes of years, in which they do not grow at all, but they may at any time take on a patho- logical action and grow rapidly. Diagnosis. Great care must be taken in not confusing lupus erythematosus with lupus vulgaris, which it oc- casionally resembles. It is also apt to be mistaken for eczema, seborrhcea — especially the so-called eczema sebor- rhceicum affecting the face, — psoriasis, rosacea, syphilis, and ringworm or favus of the scalp. Treatment. The internal remedies which seem to be of use in the treatment of this affection are iodide of potash, iodide of starch, cod-liver oil, and arsenic ; but it is the exception to find any beneficial result from the use of internal remedies alone. For external application sapo- viridis, carbolic acid, and diachylon ointment containing salicylic acid are the three remedies which yield the best result. If the disease is of recent origin the use of green soap applied in the form of a plaster or rubbed into the skin in the form of tincture of green soap may effect a cure without other applications. If the disease is of long standing more heroic measures must be adopted. Paint- ing over the lesions every few days with pure carbolic acid has for many years been a favorite method of treat- ment, and given good results. During the past few years I have used the following solution with even better re- sults : 1£ Acid, carbolic. Chloral, hyd., Tinct. iodi aa 3 ii m LUPUS VULGARIS. 1 35 After this treatment has been applied for a few times the lesions may be treated with diachylon ointment, or better with diachylon plaster containing from 5 to 10 per cent, of salicylic acid. If these superficial caustics do not cure, resort may be had to linear scarification, making a .series of " cross hatchings," not going very deeply yet deep enough to cause considerable bleeding, which may be checked by pressure over a saturated solution of car- bolic acid dressing. Electrolysis by means of multiple punctures and scarifi- cation have occasionally given very brilliant results. Do not resort to actual cautery or strong escharotics unless necessary, for you will have more scarring than the disease is apt to produce if left alone. Occasionally, however, you will meet with a case which from its severity and obstinacy to other plans of treatment will require such bold treatment. LUPUS VULGARIS. Having told you something of lupus erythematosus, I will briefly speak of the other variety of lupus, called lupus vulgaris. Pathology. It has only been in the past few years that the nature of this form of lupus has been at all understood. It is a true tubercular inflammation of the skin, and caused by or associated with the tubercle bacilli. The inflamma- tory process seems to start in the corium, but eventually attacks the whole thickness of the skin. After a time retrograde metamorphosis sets in, causing a destruction of the newly formed tissue, leaving ulcerations in the skin which heal by cicatrization. Part of the lupus tissue, however, does not die, but undergoes permanent organi- zation with the production of new connective tissue, thus 136 LECTURES IN DERMATOLOGY. causing hypertrophy of the skin. The epithelial and mucous layers sometimes become hypertrophied. The glandular appendages and follicles of the skin are fre- quently destroyed. Etiology. The disease seems especially apt to attack children, and particularly those of strumous diathesis. It does occur in persons of otherwise apparently perfect health. It is perhaps hereditary in some cases, but in all cases due to the presence of tubercle bacilli. The disease may be produced by inoculation. The reasons why the tubercular inflammation should attack the skin rather than other tissues of the body are obscure. Symptoms. Lupus vulgaris occurs most frequently about the face, but may appear upon any portion of the body, especially about the hands and feet. It usually begins as a number of small, round, reddish or yellowish points, situated beneath the skin. These points increase in size, resulting in the formation of papules and tubercles. They coalesce, forming a patch which is circumscribed, pronounced in outline, and dull red in color. The tuber- cles are usually firm in consistence, but so very soft that a probe can be thrust deeply into them with a very little effort. These nodules may undergo absorption, leaving an atrophy of the skin, but they may ulcerate, causing destruction of it. The patches grow from the centre towards the periphery by the addition of new tubercles, but have very little tendency to heal at the centre, al- though ulceration may go on at that point resulting in the formation of scar tissue. There are usually not more than one or two lupus patches present at one time, and these patches are usually not very extensive in area. When ulceration in these patches takes place, crusts form which are usually easily LUPUS VULGARIS. 1 37 removed, leaving unhealthy, exuberant granulations be- neath. Cicatrization does, however, usually take place, but the scar being of low vitality becomes the seat of the disease, and again ulceration may occur. At times the ulceration is so deep as to cause destruction of the tissues beneath the skin, resulting in great deformity, as the loss of the nose or ears. These deep ulcerations may event- ually heal, but leave frightful scars. Occasionally when the disease attacks the nose or ears it causes them to shrink up to half their size, due to absorption of the tissue and not to ulceration. There is one form of lupus vulgaris in which the individu- al lesions show no tendency to group or to form patches. This variety is called disseminated lupus. It occurs upon the face, and often is mistaken for acne. The destructive process is not very great, the tubercles terminating in small ulcerations or atrophied spots. This form of the disease is seen most frequently in young adults. Diagnosis. It is not always easy to diagnose lupus vul- garis correctly. There are two diseases especially which look very much like it, viz., tubercular syphilide and epi- thelioma. The disease must also be diagnosed from leprosy, erythematous lupus, and rosacea. Treatment. There are three things to be aimed at in the treatment of local tuberculosis or lupus. First, the removal of the morbid tissue ; secondly, that this removal be accompanied with as little pain as possible ; and thirdly, that the treatment should result in the least disfigurement. There are several plans of treatment, some of which are decidedly preferable to others. In the first place there is the removal of the tissue by excision. If the disease is limited in extent this can be I38 LECTURES IN DERMATOLOGY. •done thoroughly, and with very good result. If, however, it covers large areas, this plan of treatment should never be adopted. In the second place there is the cautery. This is a plan of treatment which is not now very much used. It is always painful, and is not accompanied by any specially brilliant results. Linear scarification by means of the actual cautery has been employed in certain cases with good results. The curette is an instrument well deserving a high reputation in the treatment of lupus. The curette in the form of a Volkmann spoon can hardly be improved. It removes all of the lupus tissue with little pain, and com- paratively little disfigurement. It has the advantage of removing only the diseased tissue and not, if a little care be exercised, any of the surrounding healthy skin. The dental burr, or dental excavator, can be used in certain cases with great advantage. When lupus appears in the form of disseminating nodules the dental burr will be found greatly superior to the curette. This little in- strument when thrust into the lupus nodule and screwed about removes all the lupus tissue without causing any deformity, and without producing much pain. It is, how- ever, far inferior to the curette, except in those cases where the nodules are disseminated. Scarification has frequently been employed in the treat- ment of lupus, and is now used very largely by all derma- tologists. This scarification is done by the linear method. A large number of parallel lines are cut through the lupus tissue very close together, this seeming later to destroy the lupus growth, permitting a new growth of connective tissue to take place, which tends to preserve the size and form of all the important features attacked. The lupus LUPUS VULGARIS. 1 39 cells seem by this method of treatment to greatly alter their configuration, and to assume the shape of fibres of connective tissue, in this way preserving the size and shape of the organs attacked, especially when the disease occurs about the nose. Caustics of various kinds are frequently employed in the treatment of lupus. Among them may be mentioned nitrate of silver, caustic potash, chloride of zinc, and ethylate of sodium. They possess no special value in the treatment of lupus, and are accordingly inferior to other methods of treatment. The application of pyrogallol, however, to lupus, after its surface has been thoroughly curetted, with a view to the complete destruction of the lupus tissue, has met with great favor. This is perhaps the best method of treat- ment, and may be carried out as follows : The lupus patch is first thoroughly curetted. A ten-per-cent. ointment of pyrogallol is then thoroughly applied twice daily for three or five days, when the surface appears swollen and of a dirty grayish hue. Iodoform is then plentifully applied to check the pain produced by the ointment. This is then covered with linen smeared with boric acid ointment, and bandaged for several weeks until the suppuration lessens and healing begins. Mercurial plaster is then applied, and the wound usually heals kindly. If any of the lupus tissue still remains, the same treatment is re- peated until the disease is entirely cured. Of recent years Unna has applied to lupus surfaces a strong ointment consisting of two parts of beech tar creo- sote and one part of salicylic acid. Before this ointment is applied, the epithelial covering of the lupus is first de- stroyed, either by scarification or by the curette. The pain produced by this ointment is very severe until the 140 LECTURES IN DERMATOLOGY. creosote has acted as an anaesthetic, so that it is first wise to apply a solution of cocaine, which deadens the pain until the secondary effects of the creosote will control it. This remedy leaves a smooth cicatrix, but according to Unna redness of the scar is apt to remain for some time, owing to a paralysis of the capillary blood-vessels. A one-per-cent. alcoholic solution of fuchsine has re- cently been employed painted over the lupus patch after it has first been superficially scarified. This may be done twice a week until the lupus is cured. It has one advan- tage, of being almost entirely painless. Koch's treatment by the injection of lymph has not been followed with the success which we all hoped for. The remedy does seem to possess some peculiar influence on the lupus patch. Its injection is always followed by a reaction, the patch becomes reddened, inflamed, and sometimes followed by suppuration. In a few cases the tubercles have flattened, and a decided improvement has been noticed. A cure, however, never results, and an improvement only in a certain number of cases. We must therefore depend almost entirely upon the local de- struction of the patch in one way or another. The one which I most highly recommend to you is the scarifica- tion followed by the use of the pyrogallol, and afterwards by the mercury plaster. While the local treatment is being carried on, internal or constitutional treatment should not be neglected. The patient should be placed in the best hygienic sur- roundings, and have the best of food and nourishment in the way of malt liquors, and should have the in- ternal treatment of iron, preferably the iodide of iron and the iodide of starch in as large quantities as can be borne. MOLL USC UM CONTAGIOSUM. 141 MILIUM. A very frequent disease of the skin, but one which you will not frequently be called upon to treat, as it does not often attract the attention of the patient, is milium. Pathology. The disease is due to the retained secretion of the sebaceous glands, caused by the upper layer of the corium growing over their opening ducts. The secretion not being able to escape, dries or becomes calcareous, and produces the following symptoms : Symptoms. The lesions are usually most numerous about the eyes, scrotum, penis or labia. When they occur in the eyelids they are called chalazions. They make their appearance as small, hard, white or yellowish raised papules, oblong or rounded in shape, and without subjec- tive symptoms. They are very firm to the touch, some- times almost stony in hardness, feeling like a foreign body in the skin. There may be only one or two of them, or they may occur in scores. They remain indefinitely, but sometimes disappear without treatment either by absorp- tion, or by the contents of the glands gradually reaching the surface of the epithelium and being thrown off. Milia usually occur with comedones, and must be diagnosed from them. Treatmeitt. The treatment is very simple. You may remove the lesions by electrolysis, or better still, scoop out the contents of the gland with a dermal spear and touch the cavity with a stick of nitrate of silver or car- bolic acid, thus destroying the gland and preventing the secretion from again accumulating. MOLLUSCUM CONTAGIOSUM. Pathology. Molluscum contagiosum is a disease whose pathology is not at all well understood. In later micro- 142 LECTURES IN DERMATOLOGY. scopical researches there has been found in the lesions the presence of little bodies called psorosperms, supposedly a vegetable parasite, which is now considered the cause of the disease ; but as these little bodies are also found pres- ent in other pathological conditions, as epithelial cancer, pityriasis rubra pilaris, etc., it is very doubtful if these bodies have anything to do with the cause of the disease. The older observers believed that the seat of the disease was in the sebaceous glands, but this is probably a mis- take, as all recent investigators hold that the process begins in the mucous layer of the epidermis. When the disease reaches its full development, and one of the little tumors is excised, the contents may be expressed as cheesy, fluid-like mass. On section these tumors pre- sent the appearance of a lobulated gland, the interior being soft and capable of being pressed out, while the wall corresponds to the Malpighian layer of skin, gradu- ally hypertrophied. The soft matter consists of altered or degenerated epithelial cells and psorosperms. Virchow considered the disease as beginning in the hair follicles. Etiology. The disease is undoubtedly contagious, and conveyed from one person to another. It seldom occurs in adults, but in children who for the most part are neg- lected and ill-fed. As it sometimes makes its appearance without any possible chance of infection, it is possible that it may develop from causes of which we know nothing. Symptoms. The lesions usually make their appearance upon the face, hands, or penis, but may occur upon any portion of the body. They may occur singly, but are usually seen in numbers and in various stages of develop- ment. When first noticed they are usually about the size of a pin-head, white in color, with a waxy appearance. They gradually increase in size until they are as large and MOLLUSCUM C0NTAG1OSUM. 145 about the shape of a split-pea. They usually retain their waxy appearance, but may become pinkish. Upon their summits they are flattened and often depressed, present- ing a dark point of opening, through which a sebaceous material may be squeezed in a thread-like form. These little tumors are firm to the touch and are not painful. All inflammatory symptoms are usually absent, and the patient seldom complains of any subjective symptoms. The lesions last for a variable length of time, but usually weeks or months, terminating eventually by disintegration and sloughing. Diagnosis. Molluscum contagiosum when occurring on the genitals is quite frequently diagnosed as a venereal disease. Be careful not to make this awkward mistake. Also do not confuse them, when seen on other portions of the body, with simple warts, milia, or small-pox vesico- pustules. Treatment. As the disease is purely a local one it may be cured by external means alone. If the lesions are small and of moderate size they are best treated by thrusting the sharp point of a probe dipped in pure carbolic acid deeply into the mass through the opening in the summit, and then applying white precipitate oint- ment or mercurial plaster. This method may have to be repeated once or twice to ensure a complete cure. When the lesions are quite large they may be excised with the dermal curette, and their bases touched with the nitrate of silver. A common way of treating these tumors is by making an incision across their tops, squeezing out their contents, and cauterizing the interior with pure carbolic acid or nitrate of silver. Be careful that your treatment is not too heroic, for you may leave a scar which would not result if you had allowed the case to end in spontane- ous recovery. LECTURE X. ■NjEVI, PEDICULOSIS, PEMPHIGUS, PITYRIASIS ROSEA, AND PRURITUS. NiEVUS PIGMENTOSUS. Gentlemen : There are several kinds of naevi or moles to which I would ask your attention, and the first of them is the naevus pigmentosus. Description. Pigmentary naevi may consist only of cir- cumscribed deposits of pigment in the skin without any other change, or there may be in addition an hypertrophy of all its structures. They vary much in size, from a split-pea to a silver dollar ; in shape from round or oval to irregular patches, and in color from a yellow to a black. Some are flat, others decidedly elevated above the skin. The surface may be soft and smooth (nsevus spilus), or rough, furrowed, and watery (naevus verrucosus). Some- times they consist of soft, fatty connective-tissue growths called naevus lipomatodes. Many exhibit a bountiful growth of hair, and are called naevus pilosus. Naevi may be either congenital or acquired. The hairy naevi always belong to the former variety. They occur upon any portion of the body, but especially upon the face, neck, and back. Naevi grow to a certain size and after- ward remain inactive unless irritated, when they may become malignant. Treatment. Moles, unless disfiguring or showing M4 CAPILLARY NMVUS. 145 a tendency to become malignant, as the warty variety sometimes does, require no treatment unless the patient insists upon getting rid of the lesions. They may be re- moved by the knife with a small, plastic operation, or they may be destroyed with caustics. If caustics such as nitric acid or potassi are used they should be applied thoroughly, for frequent irritation of the naevus may result in convert- ing it into a malignant growth. For a hairy naevus elec- trolysis gives the best result, and for other naevi the application of ethylate of sodium. This should be ap- plied with a glass rod, care being taken not to get the solution on the normal skin. A crust will form, which becomes detached in about three weeks, leaving a slight scar. If the mole is large, only a portion of it should be treated at one time. CAPILLARY N^VUS. Another variety of naevi is the capillary naevus, also known as birth-mark, strawberry stain, mother s mark, port-wine stain, teleangiectasis, etc. Pathology. Capillary naevus consists of a circumscribed and permanent dilatation of the capillary blood-vessels of the skin, often with pigmentary deposits. The surface is usually smooth, but may be furrowed, warty, and covered with hair. The patches are usually irregular in shape and vary greatly in size. Etiology. They are congenital, and undoubtedly often the result of maternal impressions upon the foetus in utero. Treatment. The various modes of treatment recom- mended in the pigmentary naevi are beneficial in this variety of the disease. When the lesions are large but a small area should be treated at one time. Multiple scari- 146 LECTURES IN DERMATOLOGY. fication of port-wine stain is employed with a view to dividing the small cutaneous blood-vessels, and thus les- sening the blood supply to the diseased area. This is best done by making a number of parallel incisions through the skin very close together, about one sixteenth of an inch apart. After these are healed a second set running obliquely to the first set are made, and so on until the whole area of the disease has been gone over. The skin can first be frozen with rigoline or ether spray, and then the incisions made with the multiple scarificator without pain. Another method of treatment which is superior to scarification is electrolysis by multiple puncture. The negative pole is to be connected with the needle holder, and the operation conducted as I explained to you in re- moving superfluous hairs. A needle-holder containing several needles set in a row or in a circle may be used in- stead of a single needle, although there is more danger of producing a scar. The punctures must be about one sixteenth of an inch apart. Multiple puncture may also be performed by first dipping the needle into nitrate of mercury or fuming nitric acid ; but in large capillary naevi electrolysis is undoubtedly the best plan of treatment. Small naevi may be cured by applications of caustics, especially nitric acid. PEDICULOSIS. You will be called upon so frequently to treat skin diseases resulting from the presence of lice upon some portion of the body, that I cannot pass by the subject of pediculosis without saying a few words. There are three kinds of lice which live upon the human skin. First those which attack the scalp, called pediculosis capites ; second, PEDICULOSIS CAPITIS. 147 those which attack the body, called pediculosis corporis; and third, those which make their appearance about the pubis and axilla and are known as pediculosis pubis or crab lice. They are splendid breeders, the young hatching out in seven days, and capable in eighteen days of propagating their species. A female louse may become the grand- mother of five thousand lice in eight weeks. PEDICULOSIS CAPITIS. Head lice first attack the occipital region, and although they may afterwards appear on other portions of the scalp, especially the parietal regions, it is here we find the most serious lesions. These lesions consist of a dermatitis very much like a pustular eczema, from which it is very difficult to diag- nose. The hair becomes matted together by a sticky secretion, often bloody and offensive, while the scalp is cedematous and covered with pustules, blood crusts, and scabs. These lesions are mostly the result of scratch- ing, caused by the irritation of the lice moving about and sucking the blood, although you must remember that they do not bite as a flea does, for instance. Diagnosis. Be careful not to mistake the lesions result- ing, from the presence of lice with pustular eczema, im- petigo contagiosa, or seborrhcea of the scalp. The presence of the lice themselves or their nits will always aid you in making the correct diagnosis. Treatment. Head lice can best be cured by saturating the head with petroleum, or with tincture of delphinium or larkspur, leaving it on overnight, and washing off with soap and water in the morning. Two or three applications of this will usually be sufficient. After thus getting rid of the cause you can treat the resulting dermatitis. The I48 LECTURES IN DERMATOLOGY. following ointment you will find very beneficial, applied once or twice a day : B Ung. hyd. ammon., Ung. zinc, ox aa § ss 01. rusci 3 i m It is only occasionally that you will be obliged to cut off the hair to cure the disease. PEDICULOSIS CORPORIS. There is probably no disease of the skin which causes so much suffering from itching as that resulting from the body louse. The little animal attacks any portion of the body or extremities, but directs its worst attacks on the back and shoulders. Its crawling over the skin and piercing it with its haustellum for feeding purposes pro- duces the most frightful desire to scratch, so much so that patients almost always tear the skin in trying to get relief, and from this irritation most of the skin lesions are pro- duced. These lesions consist of scratch marks usually parallel, minute blood crusts, and sometimes papules and pustules. An eczematous dermatitis may be set up in places if the irritation is long continued. Diagnosis. Pediculosis corporis must be diagnosed from papular eczema, prurigo, scabies, and pruritus. The pres- ence of the parasite or its nits, with the long parallel scratch marks, will greatly aid you in forming a correct opinion. Treatment. As the parasite does not live on the body but on the clothing, you can always cure the disease by removing the cause and the clothing at the same time. Never tell a patient that he is lousy unless you are able PEDICULOSIS PUBIS. 149 to back up your opinion quite forcibly. You had much better tell him that a change of under-clothing every day is very necessary to properly cure the disease. I know of nothing better than a strong solution of carbolic acid rubbed over the body two or three times a day to relieve the itching, and to prevent the lice from biting. PEDICULOSIS PUBIS. Pediculosis pubis or crab lice although usually affecting the pubic region, may attach themselves to the hairs or any portion of the body, and we very often find them in the axilla or eyelashes. Itching, excoriations, and eczema- tous lesions are the symptoms present, and although they are not so severe as in the other forms of pediculosis which I have given you, they are often more rebellious to treatment. Diagnosis. The diagnosis is not difficult. You are not liable to mistake this disease for any other, unless it is eczema or pruritus. Treatment. The following ointment will cure the dis- ease. It may be applied at night, and washed off in the morning. Two or three applications are usually sufficient : ^ Acid carbolici gr. x Bals. peru 3 ss Ung. hyd. nit., Sulphur sub aa 3 i Petrolat ad | i m PEMPHIGUS. There are several diseases of the skin usually described under the term pemphigus, but there is one variety quite 150 LECTURES IN DERMATOLOGY. commonly met with, which simply consists in the production of blebs. Pathology. A hyperemia of the skin may or may not precede an exudation which is poured out from the capil- laries of the papillary layer, lifting up the epidermis in the form of blebs. This exudation is usually serum, but may contain pus cells and occasionally blood. Etiology. The causes producing pemphigus are very obscure. It occurs more frequently in children than adults, and usually with those having bad hygienic sur- roundings and who are poorly nourished. It may accom- pany severe menstrual disorder and pregnancy. Symptoms. As I told you, there are several distinct varieties of pemphigus, but most of them are so very rare that I will simply call your attention to the only one you will probably ever see in general practice. This common variety is pemphigus vulgaris. The disease, although it may occur on any portion of the body, is more apt to attack the extremities, especially the lower extremities and the soles of the feet. The first symptom may be a little irritation of the skin where the lesions are to form, but usually the first thing noticed is the appearance of the blebs. They appear in groups of six, eight, and ten at a time, and upon a slightly reddened surface. They usually develop rapidly, reaching their full size — that of a walnut — within twenty-four hours, each bleb running its course in from three to six days without rupturing, drying up and falling off in the form of scales, leaving a reddened surface beneath. These blebs are round or oval in shape, rise abruptly from the normal skin, and are not surrounded by an in- flammatory areola. Their walls are thin and fully dis- tended with clear serum, yellowish in color, becoming PEMPHIGUS. I5I cloudy after a day or two. Sometimes the serum is stained with blood. They show no tendency to group, but appear in crops, one crop no sooner disappearing than another begins. The disease may run an acute course and be associated with acute constitutional symptoms, as fever. This is quite common in children, the disease lasting but two or three weeks ; but in adults it is almost always chronic, and not accompanied with constitutional symptoms. Diagnosis. Pemphigus is most apt to be mistaken for erythema multiforme, the so-called erythema bullosum, for hydroa and bullous urticaria. Occasionally in children the bullae of impetigo contagiosa may look like those of pemphigus. Treatment. As the disease is often associated with much debility, iron and tonics with cod-liver oil are usually required. For internal treatment directed tow- ard the cure of the lesions, we have almost a specific in arsenic. This is one skin disease in which arsenic has a decided and rapid action. It may be given in the form of Fowler's solution, and in as large doses as the patient can bear. For external treatment, the blebs should be opened as soon as formed, and the excoriated surface treated with some bland, antiseptic, and soothing ointment which is drying, such as the following : 5 Acid, boric gr. xv Amyli, Zinc. ox. aa 3 ii Ung. aq. rosae § i m Oxide of zinc ointment, or equal parts of this and diachy- lon ointment, are also of service after dusting- the lesions 152 LECTURES IN DERMATOLOGY. with aristol. Hebra has recommended for severe cases, where the disease continues after other means have failed, that the patient be kept in a continuous bath, the water kept at about the temperature of the body and changed every day or oftener. The patient is to be kept in this bath for weeks or months, eating and sleeping there. Some cases even then do badly. The general health fails, they have repeated febrile attacks, and eventually die from the disease or become so weakened that they die from some recurrent attack. The disease is more serious in adults than in children. PITYRIASIS ROSEA. Pityriasis rosea or pityriasis maculata et circinata is not a common disease, or one which you will often see, and, if it was not so frequently mistaken for ringworm or vice versa, I should not take up your time in describing it to you. Although rare, the disease is undoubtedly more frequently met with than reported, it being diagnosed as simple ringworm. Symptoms. An outbreak of pityriasis rosea is often pre- ceded by some slight constitutional symptoms, as head- ache or general malaise, but not always. The eruption is almost always confined to the neck, shoulders, chest, and back. When first noticed, it consists of small red papules surrounded by some redness, but soon enlarges into ele- vated, rosy-red macules, with a well defined border. In a few days they reach their full development, of from half to one inch in diameter, and begin to fade in the centre. The centre of each lesion turns a yellowish color, looking like parchment, and becomes scaly, while the border re- mains elevated and retains its red color. Later, only rings may remain, which are round unless two or more of PRURITUS. 153 the lesions unite, when the borders are irregular. New- lesions form from time to time, while others disappear, so that we find them in all stages of development. The lesions are quite numerous, each individual one lasting for a week or more. There are very few subjective symp- toms, slight itching being usually present. The disease ends in spontaneous recovery in about two months. Etiology. The cause of the disease is unknown, but it is probably parasitic in nature, only slightly contagious. Diagnosis. The disease is almost always diagnosed ringworm by those not acquainted with it. It is also mistaken for seborrhcea sicca, annular urticaria, psoriasis, and syphilis. Treatment. The disease tends towards spontaneous recovery, but I think you can hasten a cure by applying once or twice a day the following lotion : ^ Pot. sulphuret 3 i Aq |" Solve et adde solutionem subquentem. Zinc, sulph 3 i Aq. rosae § ii m PRURITUS. Pruritus is a functional, cutaneous affection manifesting itself solely by the presence of the sensation of itching without structural alteration of the skin. I wish you to remember that speaking of this disease I do not mean any of the numerous skin diseases in which you all know itching is simply a symptom accompanying the lesions. In this disease itching is the disease in itself, and is never associated with any primary lesions. Lesions may form secondarily, but if they do it is always the result of the 154 LECTURES IN DERMATOLOGY. scratching and never the cause of it. The intensity of the itching varies in different cases. In some cases it is so slight that it produces rather an agreeable sensation than otherwise, and it is a pleasure to the patient to scratch or have the skin rubbed. An example of this is the tendency which children have to wish their backs rubbed at night before retiring. In other cases the itch- ing is so severe that patients frequently prefer a pain to the intense itching. A pain in many of these cases is produced by the patient to take the place of that terrible sensation which is produced by the intolerable and continuous itching. Etiology. There are no lesions present which will account for the causes producing itching. It is supposed to be in many cases due to a cutaneous hyperplasia or excessive irritability of the cutaneous nerves. This con- dition results from a general neurotic condition, or is due to local changes in the skin. In some cases it is due to impaired conduction in the cutaneous nerves to the nerve centres. This has been termed hypo-pselaphesia. Among the exciting causes may be mentioned reflex irritation, the result of some disease or derangement of the inter- nal organs or nerve centres, or may result from external causes setting up irritation or structural change in the skin. Occasionally itching results from the ingestion of some obnoxious materials which are distributed to the skin by the blood, setting up an irritation of the cuta- neous nerves, resulting in the sensation of itching. Jaundice produces itching from some such cause, the bile pigment being deposited in the skin. Symptoms. The only direct symptom detected with pruritus is the irresistible desire to scratch and rub the skin. This may be associated with nerve symptoms, or PRURITUS. 155 secondarily by local skin lesions, the result of continued scratching, which generally expresses itself in roughened, hyperaemic and excoriated conditions of the skin. The itching is usually intermittent, and almost always worse at night. The sensation rarely invades the whole body at one time, though various regions may in turn be attacked. In most cases it occurs in certain localities, chiefly the scalp, genitals, and anus. Scratching relieves itching by one of two ways, either by substituting for the pruritus painful or voluptuous sensations, or by active irritation of the skin by counter-irritation, producing better conductivity in the nerves, thus removing the cause of the itching. Diagnosis. The neurosis pruritus must not be confused with other diseases of the skin that have itching for a symptom. You must also remember that the irritation of the skin by constant scratching will produce lesions which are not the cause but the result of the disease. Pruritus must therefore be diagnosed from prurigo, papular eczema, scabies, pediculosis, etc. Treatment. Treatment of pruritus must depend very largely upo-n the cause. In many cases where this cannot be determined, the internal use of salicylate of soda in 10- grain doses three or four times a day is followed by very beneficial results. In other cases the following prescrip- tion seems to be very satisfactory : IJ Antipyrini gr v Pot. brom gr x Aq. lauro-cerasi 3 i m Again in other cases you will find better results by ordering the following pill taken at bedtime, and if necessary once or twice during the day : 156 LECTURES IN DERMATOLOGY. 5, Gelsemin gr -^ Ext. cannabis ind gr \ Fiat. pil. no. 1 m If the digestive functions are deranged, attention to the diet will usually be followed by some relief. When there is some local irritation of the skin which results in itching, the treatment of the affection will usually result in a cure. For the immediate relief of itching local applications are numerous. The one which, however, has the best, and a more lasting effect, than any other is very hot applications of carbolic acid from 2 to 5 per cent. Tar in some cases, in the form of a tar ointment, is beneficial. When itching is about the mucous surfaces, the application of ointments containing cocaine relieve it for the time being ; but these remedies are all superficial in their result, relieving the symptoms but not curing the disease. Change of air and of hygienic surroundings will do more for the majority of these cases than any external or internal treatment. As the disease occurs more frequently in old people than in the young, general attention to the kidneys is always advisable, for not infrequently it occurs in those who have Bright's disease, or in those suffering from diabetes. At best you will have great trouble in curing your patient, for patients troubled with this affection travel from one physician to another, from one place to another, seeking aid from an affection which in itself is not dangerous, yet produces terrible results on account of the wakeful- ness and irritation to the nerves this disease produces. The danger of your patients resorting to the use of narcotics, especially morphine for relief at night, is very great, and you will do well to keep this in mind, for the opium habit can in this way be very easily contracted. LECTURE XL PSORIASIS, PURPURA. PSORIASIS. Gentlemen : To-day I will ask your attention to a very common, dry, scaly skin disease called psoriasis or dry tetter. Pathology. Psoriasis is a distinctly inflammatory disease of the skin, affecting the deeper layers of the epidermis. It begins as a hyperaemia, which results in an hyperplasia of the rete mucosa. The papillary layer, although seem- ingly thickened, is not much affected unless the disease has lasted for a long time. In the later stages of the disease the blood-vessels of the corium become dilated, and the corium itself infiltrated with cellular elements and serum, which, however, are entirely absorbed as the trouble disappears. The glandular elements of the skin are not affected, but there is a hyperplasia of the hair-root sheaths. As the disease is a superficial one, without many structural changes in the skin, after death the lesions are not very apparent to the naked eye, but seem like superficial collections of scales. Etiology. The disease never occurs in infants, and is seldom seen in children under ten years of age. It occurs in both sexes with equal frequency, and in both the well and the poorly nourished. It is more frequently seen in cold than in hot weather. A predisposition to it may be i57 158 LECTURES IN DERMATOLOGY. inherited, but in the majority of cases it cannot be said to be traced to either parent. Some dermatologists insist that psoriasis is always the result of some syphilitic taint, but this cannot be proven in the vast majority of cases, and probably has nothing to do with syphilis. Ingestion of certain articles of food and drink may precipitate an attack or aggravate it, but never seems to be the original cause. Psoriasis occurs more frequently in those who suffer from a gouty or rheumatic tendency, but the true causes of the disease have never been determined. Symptoms. Psoriasis always begins as small, red, slightly elevated spots, which immediately become cov- ered with white scales. These spots gradually increase in size until, in a few weeks, they may form large patches. As these patches assume different features as to size and shape, they are designated accordingly by special names. Thus, when the spots remain pin-head size, the disease is called psoriasis punctata; when they remain the size of drops, psoriasis guttata is the name given; when the spots remain the size of coins, the term psoriasis mum- ularis is given, which is a very common form ; when the spots clear up in the centre and continue to spread at the periphery, the disease is known as psoriasis circinata, or, if they unite with other similar lesions, thus forming broken segments of circles or festoons, it is called psori- asis gyrata ; when the patches are very large and irregular in shape, either the result of individual development or the union of several lesions, thus covering a considerable area, the term psoriasis diffusa is employed. The scales of psoriasis covering the patches, although superficial, are strongly adherent, requiring some force to remove them, and then leaving bleeding spots. They are usually very abundant, and of mother-of-pearl whiteness. The patches PSORIASIS. 159 themselves, when freed of scales, are usually of a bright red color, with a sharp line of demarcation separating them from the normal skin. The patches are usually not very much elevated above the skin, although they often seem to be very much so when covered with scales. The red color of the patches may also be almost entirely lost by the abundance of white scales upon their surface. The thickness of the patches varies very much. In most cases, when the disease has not lasted very long, after the scales are removed it will be found quite slight, and there is never as much thickening as the general appearance of the patch would indicate, as the lesions, you will remember, are mostly in the superficial layers of the skin and confined to them in the earlier stages. The disease may occur upon any portion of the body, but the extensor surfaces of the extremities are most apt to be affected. The back is more apt to be involved than the chest, and the scalp than the face. When it attacks the scalp, the disease usually extends slightly beyond the edges of the hair. When you suspect a case of psoriasis, always examine the elbows and knees, for these are points where the lesions are especially apt to appear. The number of patches found upon the body at one time varies greatly, but the smaller the size of the lesions, the greater their number, as a rule. There is but little tendency toward symmetry of the lesions, except when it attacks the palms or soles. The one subjective symptom which accompanies the lesion is itching, which is usually well pronounced. Burn- ing is sometimes present, but only when the lesions take on an acute inflammatory action, as they sometimes do as a result of irritation, etc. Diagnosis. A differential diagnosis must be made be- tween psoriasis and squamous and seborrhceal eczema* l6o LECTURES IN DERMATOLOGY. squamous syphilide, lichen planus, seborrhcea, especially of the scalp, pityriasis rosea, tinea tonsurans, and ery- thematous lupus. It is not always easy to diagnose psoriasis from these affections, but if you will carefully remember the group of symptoms I have just given, you will not often make a mistake. Treatment. The treatment of psoriasis is both internal and external. Arsenic, mercury, and the alkalies are the internal remedies in which we can place the most reliance. In the early stages of the disease, the alkalies, either given alone or combined with small doses of Fowler's solution of arsenic is usually followed by a good result. In the later stages larger doses of arsenic, or, better still, arsenic and mercury combined, as in Donovan's solution, is often curative without any external treatment at all. This bene- ficial action of mercury is claimed by many to be a proof of the syphilitic origin of the disease, but as this is often the only reason for considering it in any way related to syphilis, it does not seem to me to warrant such an opin- ion. We know of the beneficial action of mercury in diphtheria, undoubtedly curative in some cases, and yet no one for a minute would consider syphilis related to, or the cause of, diphtheria. Carbolic acid stands next to arsenic as an efficacious remedy, and should be given in two- or three-grain doses after meals, well diluted. Phos- phorus and tar are also favorite drugs with many for the cure of psoriasis. Whatever drug is used for its cure, you must remember that the disease disappears slowly, and that your remedies must be given for some time after all traces of the lesions have disappeared. Diet does not seem to influence the disease very much, but malt liquors have a tendency to increase the number of the lesions and to retard recovery, and should therefore be prohibited. PSORIASIS. l6l The same may be said of sweet wines. Animal food, fruit, and green vegetables are the best articles of diet for persons suffering from psoriasis. Persons drinking large quantities of alkaline waters seem to derive benefit by hastening the disappearance of the disease. Local Treatment. There are two drugs which you will find of more benefit in the local treatment of psoriasis than all the others put together. These are tar and chry- sarobin. You must use these drugs judiciously, however, if you wish a good result. Not all cases should be treated by these applications. For instance, when the disease is very extensive and of the punctate or guttate variety, chrysarobin should not be used, and the patients may often do better without the use of tar, depending entirely in these cases upon internal medication and the use of alkaline baths, with tar and sulphur soaps. In all cases, before any application is made, the scales must first be removed. This may be done by continuous applica- tions to the lesions for several hours of a 5 % salicyliated oil, and then giving an alkaline bath. If the lesions are not very extensive and are not situated upon the face and hands, chrysarobin without any doubt will give the best uniform results. It may be used either in a 5 or 10 % ointment or paint. The latter is neater and easier to use, but may not be as well borne by the skin, especially in the earlier stages of the disease. There are several ob- jections to the use of chrysarobin which you must always bear in mind. In the first place, if applied to the normal skin it will frequently set up a very acute derma- titis, which about the face is almost erysipelatous. It contains a dye-stuff which stains the skin, nails, and hair badly, also the clothing of the patient. If applied over a large area of skin constitutional symptoms may also l62 LECTURES IN DERMATOLOGY. manifest themselves, due to the absorption of the drug. For these reasons you must exercise some care and dis- cretion in using this drug, and never use it about the face or scalp, or apply it indiscriminately over the normal skir.. When you do use it, in either ointment or paint, apply it only to the diseased surface. In chronic cases with much thickening, the chrysarobin paint is a very elegant way of using this remedy. It may also be used with advantage when the lesions are small and numerous, for you can limit the extent of surface to which it is to be applied much better than you could with an ointment. A little salicylic acid added to the chrysarobin seems to increase its efficacy by softening the epithelma, removing the scales, and increasing its penetrating action. The paint may be made as follows: ty Acid, salicylic 3 ss Acid, chrysophanic 3i Liq. gutta percha § i A paint of this kind should be applied to the lesions every second or third day, carefully removing all the loose scales from the patches before the paint is re-applied. Chrysarobin should never be used if acute inflammatory symptoms are present in the psoriatic patches, as are occasionally seen. Should the disease have lasted for a short time or should it be very extensive, or should for any reason chrysarobin not be well borne we should resort to the use of one of the tarry preparations. An ointment which I have found very serviceable, especially in psoriasis of the scalp, consists of the following : 5, Ol. rusci 3 i Ung. hyd. ammon, Lanolin aa f ss m PSORIASIS. 163 In place of the oil of rusci, cade may be used in the strength of one or two drachms to the ounce. With these tarry preparations hot alkaline baths with the use of tar soap should be taken frequently. Tar is disagreeable to use, first, on account of its odor, and, secondly, if used very extensively and in strong preparations enough may be absorbed to cause some constitutional symptoms, as headache and fever. An application frequently made to psoriasis with good results is pyrogallic acid in ointment, half a drachm to the ounce. It acts very much like chry- sarobin, but more slowly and not so well. It is, however, free from injurious effects. Occasionally you will find old patches of psoriasis with much thickening that will not yield to the treatment just suggested. In these cases I advise painting over the patch every third or fourth day with equal parts of tincture of iodine, chloral, and carbolic acid, and if the reaction is not too great, keep con- stantly applied between such applications the following ointment : 5, Ung. picis 3 ii Ung. ac. carb 3 ii Ung. diachylon ad 3 i These chronic lesions disappear often quite rapidly under this plan of treatment. It requires patience to successfully treat psoriasis, but if you will carry out some such plan as I have just suggested to you, I am sure you will not be disappointed with the result. Remember that when an inflammatory action is set up by your vigorous treatment, stop all irritating applications and use some soothing ointment until the inflammation has subsided. 1 64 LECTURES IN DERMATOLOGY. PURPURA. Hemorrhages in the skin are named, from their form and size, petechiae, vibices, and ecchymoses. Petechia are small, round, or irregular-shaped hemor- rhagic spots. Vibices are long, narrow, streak-like hemorrhages in the skin. Ecchymoses are large, irregular, flat, and superficial patches of extravasated blood. Not all hemorrhagic affections of the skin are the result of extravasation, but are most frequently due to diape- desis of the red blood corpuscles or their coloring matter. When cutaneous hemorrhages are the result of injury they are called idiopathic, but when due to constitutional causes they are called symptomatic, and it is only to the latter I wish to direct your attention. Cutaneous hemor- rhages are common in certain constitutional diseases, as small-pox and typhus fever, and also as a secondary symptom of some skin diseases, as pemphigus and ecthyma ; but I wish now to call your attention to certain skin diseases which have hemorrhages into the skin as a primary and principal factor, and which occur independent of other cutaneous lesions. Such skin diseases are called purpura. There are three varieties of purpuric skin diseases, namely, purpura simplex ; purpura rheumatica, and purpura hemorrhagica. Pathology. The pathology of these three diseases of the skin is the same as far as the lesions go. The ex- travasation or diapedesis usually takes place rapidly. It may have its seat in the deeper layers of the corium, or about the glands and follicles. The size of the lesions and their shape depend entirely upon the permeability of the PURPURA SIMPLEX. 1 65 tissues and the amount of exudation or extravasation. Occasionally the blood is poured out through the sweat glands, and escapes through the sweat ducts upon the surface of the skin, producing hematidrosis or bloody sweat. Usually blood, once out of the vessels, remains in the tissues of the skin and must be absorbed before it disappears. This is generally a slow process, as the color- ing matter undergoes several changes, turning in the pro- cess of absorption from a red color to yellow, green, blue, and purple. Diagnosis. The diagnosis of purpura is seldom difficult. You must distinguish each variety from the others, and also from flea-bites, erythema multiforme, and scurvy. The only form of purpura which you will be liable to confound with scurvy is the purpura hemorrhagica, which is often called land scurvy owing to its similarity to the true disease. PURPURA SIMPLEX. Etiology. The causes of purpura simplex are very ob- scure, and differ somewhat according to the variety of the disease. Although it does occur in the well nourished it is more apt to attack debilitated subjects, and to occur more frequently in the old than in the young. Malaria is considered a frequent cause. Symptoms. Usually the disease begins suddenly with- out any constitutional symptoms, although it may be preceded by some general malaise, or not infrequently by some oedema of the extremities. The lesions may all make their appearance within twenty-four hours, or they may develop more gradually. They are about the size of a pin-head or larger, and at first of a bright red color, which will not disappear upon pressure. They usually ap- pear in large numbers upon the lower extremities, although l66 LECTURES IN DERMATOLOGY. other portions of the body may be attacked, and are dis- crete, having little or no tendency to form in groups. Usually subjective symptoms are absent, but if present the skin is usually very irritable, so that scratching may be followed by the formation of welts and wheals. Course. The individual lesions usually last two or three weeks, but as new crops then make their appearance the disease may last for months. Occasionally you will find the lesions very rapidly absorbed — in two or three days they may entirely disappear. Treatment. The internal administration of ergot and iron are the two drugs upon which you can place a good deal of reliance. The fluid extract of ergot and tincture of the chloride of iron are the two preparations which should be used. If the disease is produced by malaria, quinine and mineral acids are required. Rest in bed for the first few days seems important. Absorption of the blood may be hastened by hot baths and fomentations after the exudation has stopped, and by bandaging. PURPURA RHEUMATICA. Etiology. Rheumatism, or rheumatica diathesis, is always the cause of this variety of purpura. Symptoms. The lesions always follow an attack of articular rheumatism, usually an acute attack, but not always. Usually cutaneous lesions make their appear- ance after the rheumatic symptoms have lasted a week or more, and may attack any portion of the body, but most frequently the extremities. These lesions are scattered, rounded or irregular in shape, of a dark red or bluish color, and vary in size from a split pea to a finger nail. There is often considerable anaemia and depression present while the eruption lasts, but the rheumatic symptoms are PURPURA HEMORRHAGICA. \6j generally somewhat relieved. With the exception of some soreness in the skin there are no subjective symptoms present. The disease occurs more often in women than in men, and usually young adults. The lesions usually last for two or three weeks, gradually disap- pearing, but new crops may form from time to time if the rheumatic tendency continues. Treatment. The treatment consists in giving drugs for the cure of the rheumatism as well as for the external lesions. For the latter the same treatment as suggested for purpura simplex may be employed. Cod-liver oil and tonics are especially indicated. Iodide of potash is es- pecially serviceable, not only for the rheumatic symptoms, but to hasten the absorption of the purpuric spots. A change of climate and occupation are advisable to prevent return of the trouble. PURPURA HEMORRHAGICA. Etiology. The cause of purpura hemorrhagica, or land scurvy, is always the result of general debility or nerve exhaustion, causing the loss of tone in the vasomotor centres. Symptoms. The skin lesions play only a secondary part in this variety of purpura. They are always pre- ceded by debility, loss of appetite, general malaise, and anaemia. The spots always first make their appearance on the lower extremities, gradually extending upward in- volving the trunk. They are large and irregular in size, often uniting, forming patches the size of the palm of the hand. With these cutaneous hemorrhages bleeding from the mucous surface, as the nose, gums, mouth, bowels, etc., takes place, accompanied by a great loss of vitality, sometimes ending fatally. It occurs in both children and l68 LECTURES IN DERMATOLOGY. adults, but most frequently in females. There are slight or no subjective symptoms accompanying the skin lesion. Treatment. There is little to be said in the way of treatment except to employ those agencies recommended for the internal treatment of purpura simplex. The patient must remain in bed, and be given a nutritious diet of easily digested food and drink. Inhalations of oxygen seem to be beneficial in some cases. Hemor- rhages of the mucous surface must be treated according to their locality and the condition of the patient. The following prescription is very serviceable as a mouth wash in case of bleeding from the gums: 3 Tine, ratanhiae ... 3H Tine, iodine 3i Aquae ad § ii Remember the disease is always a serious one, and liable to end fatally. LECTURE XII. ROSACEA, SCABIES, SEBORRHEA, SUDAAIINA, AND SYCOSIS. Gentlemen : Rosacea is a disease in many respects resembling acne, and for that reason frequently called acne rosacea. Pathology. There are three stages to acne rosacea, the pathology differing somewhat in each stage. In the first stage there is simply an increase of blood in the skin, the result of capillary and venous stasis. In the second stage this stasis produces a prominent dilatation and hypertrophy of the walls of the blood-vessels, and the sebaceous glands become affected as in acne. In the third stage there is an hypertrophy of all the tissues of the skin, accompanied by a new growth of connective tissue and perhaps lipomatous growths, often producing a great deal of deformity. Etiology. This disease is more common in men than in women, but when occurring in the latter it is usually present at the climacteric period, and seems to result from menstrual disorder, but seldom passes beyond the second stage. Disorders of the digestive and generative organs seem to be a frequent cause of the disease. Constant use of alcoholic liquids, owing probably to their tendency to upset the digestion, and also to their physiological property of dilating the superficial blood-vessels, is the 169 I 70 LECTURES IN DERMA TOLGG Y. most common cause of acne rosacea, hence the term given to this disease, as " brandy nose " or " whiskey- nose," is not misapplied. Cabmen and others who are con- stantly exposed to all kinds of weather and changes of temperature often suffer from this disease, but are more liable to it if they are intemperate. Not infrequently no cause can be assigned for the trouble. Persons who suffer from seborrhcea seem especially susceptible. Symptoms. The disease may first show itself by a seborrhcea of the face and nose. At other times it be- gins as a passive congestion of the blood-vessels, as shown by a profuse redness of these parts, which feel cold rather than warm to the touch. After several weeks or months the second stage sets in. The redness is more prominent, and upon close examination the cutaneous blood-vessels are seen to be large and dilated, running a tortuous and irregular course. Acne papules and pustules manifest themselves, coming and going, but rarely absent. Active inflammation is present at times, associated with much heat and redness. The disease usually begins about the nose, and spreads gradually on either side and above, until both cheeks and forehead are attacked. Occasion- ally it begins on the forehead. After lasting in the second stage for a variable length of time, sometimes never advancing beyond this, the symptoms of the third stage appear. The changes usually begin in the nose, and often are limited to it. This organ becomes greatly enlarged, either keeping its normal shape or contorted into irregular shapes, being more or less lobulated and pendulous. This enlargement is due to hypertrophy of the sebaceous glands and the tissue about them. Course. The disease is a very chronic one. In the first stage it seems to improve for a time, and then gets ROSACEA. 171 worse again. In the second stage it often seems worse at times, due to the acute attacks of acne which are present, causing an active inflammation. In the third stage it remains about the same all the time, but gradually getting worse. Diagnosis. Rosacea is a disease usually quite easily diagnosed, but sometimes very apt to be mistaken for other skin symptoms. Perhaps it is most often confounded with a tubercular syphilide, which very often attacks the face and nose. It may also be mistaken for lupus vul- garis and lupus erythematous, which, you will remember, I told you most frequently occurred about the face and nose. In the first stages of the disease you must be care- ful not to mistake it for an erythematous eczema. Treatment. The treatment of the first and second stages is frequently attended with good results, but in that of the third stage we can only hope for some im- provement. The causes producing the disease should be sought for, and remedied if possible. The patient should be put on a plain diet, and all alcoholic liquors forbidden. Sugars also seem to be harmful. A more generous diet, with tonics and cod-liver oil, is required in those cases occurring in the young and anaemic. The mineral acids and nux vomica are almost always beneficial. As to the internal remedies used for their direct influence upon the skin lesion, ergot stands at the head. It is useful in all stages, with good results, and should be given in large doses after meals. In the second stage, where the acne symptoms are prominent, the sulphide of calcium, given in small doses frequently repeated, is very beneficial. For local treatment the continued and prolonged use of hot water is very serviceable in all stages, especially the second. After each application of the hot water a 172 LECTURES IN DERMATOLOGY. lotion of bichloride of mercury, I grain, and resorcin, 15 grains to the ounce, may be applied with benefit. In other cases sulphur seems to act to much better advan- tage. Early in the disease, or in mild attacks, the follow- ing lotion may be used with advantage : Pot sulphuret 3 i Aq |ii Solve et adde solutionem subquentem, Zinc, sulph 3 i Aq. rosae § ii m In later stages, or in more severe forms of the disease, the following lotion is to be preferred : Gum. tragacanth gr v Camphor grx Sulphur, sub 3 iss Aq. calcis ad 3 ii A 5- to 10-per-cent. solution of ichthyol has been used re- cently both externally and internally by Unna with good results in this disease. During the acute inflammatory attacks of the second stage a soothing ointment must be used, such as Lassar's paste. Much can be accomplished surgically for this disease to hasten the removal of pus- tules, and to destroy dilated vessels and hypertrophied tissue. The pustules are best removed by puncturing them with the dermal spear, and turning it around in the lesions to destroy their walls, or by use of the dermal curette. When the blood-vessels are permanently dilated. SCABIES. 173 scarification yields the best result by obliterating the ves- sels, thus lessening the redness and limiting the patho- logical process going on in the tissues of the skin. These vessels may be obliterated by electrolysis, but scarification is better. In the third stage, surgical treatment is about the only one that will be attended with any kind of a result. SCABIES. We now come to the consideration of another form of animal parasite which attacks the skin, producing a dis- ease called scabies, or more commonly the itch. Pathology. The little insects which produce all the lesions and symptoms of this disease are called the sarcop- tes scabiei, and are just visible to the naked eye. They are both male and female, and the female, as usual, causes all the trouble. The adult female has a convex back with several rows of sharp spines protruding from it. She has eight legs, four anteriorly and four posteriorly, and is armed with curved bristles. The male is only about half the size of the female, but his organs of generation are well developed. The young of either sex are recog- nized by having two hind legs. The female burrows through the horny layer of the epidermis to deposit her eggs in the skin, and after laying about a dozen eggs in a row, at the rate of two eggs a day, she dies, having faithfully performed her mission in life. These eggs hatch out in about eight days. The young burrow deeply into the skin until they are matured, and then come to the surface, where the female becomes impregnated, and burrows again into the skin to lay her eggs, while the male remains on the surface of the skin or is pushed off. The life of the animal is about three months, not longer — but long enough. 174 LECTURES IN DERMATOLOGY. Etiology. The disease arises from contagion, and from that only. It occurs among all classes, and at all ages. It is very contagious, and may be communicated by merely shaking hands. It is most apt to occur among the uncleanly and in crowded quarters. Symptoms. The first symptom which usually attracts the attention of the person who has contracted the disease is itching. Upon examination on the place of irritation will be found a few punctate spots, pustules, or vesicles. These lesions usually first appear about the hands and between the fingers, but spread rapidly, until at the end of three weeks or more the disease becomes general. A few days after the disease first makes its appearance in the form of puncta, papules, or vesicles, new lesions form which consist of burrows, excoriations, blood crusts, pustules, and crusts, seated on a more or less red- dened skin. The longer the disease has lasted the greater will be the number and variety of cutaneous lesions. These burrows are due to the raising up of the epidermis by the itch mite, as a mole will raise the earth as it burrows into the ground. They are usually about one quarter of an inch in length, and irregular, yellowish in color, and end abruptly in dark points. The primary lesion, namely, the papules, vesicles, and pustules, are all the result of the irritation produced by the mite in the skin, while the secondary lesions come from the scratching of the patient, and result in the form of scratch marks, blood crusts, excoriations, and crusts. Lastly, if the disease has lasted for some time a general dermatitis is set up, as is shown by the reddening, infiltration, and pigmentation of the skin about the lesions, where the disease is most active. Itching is usually very severe, especially at night. Seat of disease. The regions of the body attacked are SCABIES. 175, characteristic. Between the fingers, wrists, axilla, mam- mae, especially about the nipple, and penis, are the por- tions of the body almost invariably attacked, although all portions of the body may become affected. Course. The disease is sometimes called seven years' itch on account of the length of time it lasts if not treated. It will, however, in time, without treatment, undergo a spontaneous cure, but will last for months or years. Relapses are quite common from auto-infection, the disease not being completely cured. You will remember that I told you the length of life of each itch mite is about three months, so do not tell your patient that he is positively cured until he has passed this stage of proba- tion. Diagnosis. There is probably no disease of the skin so easily diagnosed, yet so frequently diagnosed wrongly as scabies. A differential diagnosis must always be made between scabies and prurigo, papular eczema, pediculosis, miliaria, and impetigo-contagiosa. The microscope will always aid you in the right direction. Treatment. There are two drugs that I can recommend to you in the treatment of this disease, sulphur and balsam of Peru. They may be used alone or in combination. I usually have my patient to take a hot bath every night if possible, then rub into the skin wherever the disease pre- sents itself the following ointment : 3, Bals. Peru 3 i Ung. sulph. alkal. ... % i After a few applications the treatment may be applied every second and then every third night, but continued for at least three weeks. This is usually all that is neces- sary. Flour of sulphur may be rubbed into the skin or 176 LECTURES IN DERMATOLOGY. plain sulphur ointment used, but the alkaline sulphur ointment seems to be more penetrating and efficacious. Occasionally the sulphur will set up a dermatitis when its use will have to be discontinued for a few days, and Lassar's paste used in its place. When sulphur cannot be used at all, or is unsatisfactory, you may employ in the same way the following ointment : B /?— Naphthol .... 3ii Sapo. viridis .... 3 iii Pulv cretae alb 3 i Vaseline § i m Be sure to see that your patients are very careful to change their underclothing after each bath, and that it is thoroughly boiled and ironed before again using, for the parasite will live in it indefinitely and cause reinfection. SEBORRHCEA. Seborrhcea is usually a functional derangement of the sebaceous glands, although after the disease has lasted for a long time structural change may take place in the glands and hair follicles, as atrophy and alopecia. This functional disorder results in an altered and increased flow of secretion from the glands, which is either oily or firm in consistence. This secretion consists of sebum and cells, sometimes one and sometimes the other predomi- nating. Etiology. Many cases of the disease occur without any known cause, but it is much more apt to occur in persons suffering from some debilitating disease as struma or anaemia, or those having functional derangement of the digestive or generative organs. The same constitutional causes producing acne will often result in seborrhcea. SEBORRHCEA. IJJ Symptoms. Seborrhcea may begin on any portion of the body, but its most common seat is the scalp, and the next in frequency is the face. It also appears on the sternum and the scapulae. It is usually not accompanied with any signs of inflammation, and itching is the only subjective symptom present. There are three distinct varieties of the disease depending on the character of the glandular secretions, viz. : seborrhcea oleosa, seborrhcea sicca, and seborrhceal eczema. I. In the oily variety, called seborrhcea oleosa, the secre- tion is decidedly oily, and usually attacks the non-hairy portions of the body, and is especially apt to appear on the face and about the nose and forehead. The skin looks as if it had been smeared with dirty yellowish oil, which when wiped off on a handkerchief leaves a grease spot and soon forms again on the affected area. It is almost always accompanied with acne and comedones. II. Seborrhcea sicca is a more common form, and ap- pears on either the hairy or non-hairy portions of the body. It consists of dry or more or less greasy masses of scales or crusts of yellowish color, and having a tendency to adhere to the skin. Seborrhcea capitis is the most common example of this variety of the disease, and is the most frequent cause of premature baldness. It is usually distributed over the scalp in the form of small, dry scales, easily detached, and called dandruff. Less frequently there is formed crust-like, greasy masses, which adhere to the scalp and paste the hair down to it. Under these scales or crusts the scalp will usually be found of a dull grayish color, but in some cases, especially when crusts are found, more or less hyperaemia is present. The hair gradually becomes lustreless and dry, and falls out. In does not grow again, 178 LECTURES IN DERMATOLOGY. as the hair follicles become atrophied. As the crown of the head is usually most seriously attacked, baldness be- gins in this area. When the process affects the bearded portion of the face, the scales are almost always dry, small, and easily detached. It occurs frequently about the chest. III. Seborrheal eczema. This third variety differs from the others in being accompanied by a varying amount of dermatitis, which is considered eczematous by some, and consequently called seborrhoeal eczema or eczema sebor- rhceicum. It occurs especially about the forehead and alse nasi, also on the scalp, chest, and back. It occurs most frequently in young adults, and is often accompanied by a distinctly inflammatory process. The affected skin is reddish and irritable, accompanied by burning and itching. The mouths of the sebaceous glands are patu- lous, secreting a thick, greasy material, which, drying on the surface in thick yellowish crusts, may form a mask to the part. When removed they will, in a few days, form again. This is especially common in infants, occurring on the scalp and perhaps extending over the face, and known as " milk crust." When eczema seborrhceicum occurs on the chest, over the sternum, or on the back, the eruption will often assume the form of circular patches covered with yellowish crusts, with the edges of a bright red color. These patches may run together, forming irregularly shaped patches with scalloped borders. The crusts may be removed with soap and water, or even by the irritation of the clothing, leaving circles or rings, slightly elevated and of a yellowish-red color. Although the skin in this variety of seborrhcea is red, it is not moist or infiltrated, as in ordinary eczema. Seborrhcea will run on indefi- nitely unless treated, and will often, when apparently cured, return after a time. SEBORRHEA. 1 79 Diagnosis. It is sometimes quite difficult to diagnose seborrhoeal eczema from a true eczema. It is also fre- quently mistaken for pityriasis rosea, ringworm, and tinea versicolor. Seborrhcea occurring about the face or scalp, must be differentiated from erythematous lupus, psoriasis, ringworm of the scalp, and favus. Treatment. Tonics and cod-liver oil are usually indi- cated for internal treatment. Tar, carbolic acid, green soap, sulphur, and resorcin are the drugs which may be employed externally with great advantage in seborrhcea. For the treatment of dry seborrhcea of the scalp, I will refer you to my lecture on alopecia. When the crusts are greasy, alkaline sulphur ointment rubbed into the scalp at night will be found more efficacious than any other remedy. In seborrhcea of the face and elsewhere, sulphur and resorcin are the two remedies which give the best results. The sulphur ointment, one half strength, may be kept applied at night and washed off with hot water and tar soap in the morning, and then a fifteen-grain solution of resorcin to an ounce of rose water applied once or twice during the day. Seborrhcea oleosa affecting the nose is often greatly benefited by bathing the nose once or twice a day with sulphuric ether and then dusting with a powder composed of equal parts of sulphur and lycopodium. An ointment of B Hyd. ammon 3 ss Hyd. chlor. mit 3 iss Ung. aq. rosae § i m is better borne by both the skin and the scalp in some cases than is the sulphur. In eczema seborrhceicum you will find the following ointment very serviceable : 180 LECTURES IN DERMATOLOGY. $ Resorcini gr. xx Ung. hyd. ammon., Vaseline aa § ss m SUDAMINA. Under the more general term miliaria are often described as two diseases of the skin, lichen tropicus and sudamina. Pathology. They are both inflammatory affections of the sweat glands. Congestion first takes place about the ducts of the glands, which is soon followed by a serous exudation, resulting in the formation of papules and vesi- cles, usually of both. These lesions have their seat about the orifices of the excretory ducts. Etiology. The disease is almost always the result of heat, either caused by hot woollen clothing or high ex- ternal temperature ; it is also frequently the result of feverish conditions. It is more common in hot tropical countries, and in summer, than in winter. Fat people and those who perspire freely are more subject to the disease. Miliaria vesiculosa or sudamina appears as small, pin- point-sized vesicles, which rise abruptly above the skin and often in great numbers. Thousands of them appear in one patch, but although placed very closely together they remain discrete, giving the skin a yellowish appearance. The skin from which they arise is usually of a bright-red color, owing to the fact that each vesicle is surrounded by a small areola. The eruption is preceded by considerable sweating, and accompanied by itching and burning. The trunk is usually the seat of the disease, but it often appears on the extremities. It may appear in patches, or generally diffused. The eruption often SYCOSIS. 181 appears suddenly and lasts for a few days, the vesicles drying up or terminating in slight desquamation. If the vesicles are ruptured, as by scratching, slight crusting may result. Relapses are very common. This variety of disease is more frequently seen in children, or in patients suffering from feverish conditions. Diagnosis. Sudamina must be diagnosed from vesicu- lar eczema, to which it bears a close resemblance. It is not apt to be mistaken for any other disease. Treatment. In the general treatment of sudamina I will refer you to my lecture on lichen tropicus. A very good lotion, however, to use for frequent applications, is the following : 5 Calaminae Zinc ox aa 3 ss Glycerini 3 ss ii Aq. calcis ad § ii m SYCOSIS. When we come to the study of the vegetable parasitic skin diseases, I will describe to you a parasitic sycosis or barber's itch. We have still another form of sycosis, called the sycosis non-parasitic, and one which is not caused by the ringworm, as in the other variety. To this variety I will now call your attention. Pathology. The disease begins as an inflammation about the hair follicles, and is therefore at first not a fol- liculitis, but the peri-folliculitis. As a result of this inflam- mation pus is formed. The inflammation soon extends to the follicles, softens and ruptures them, so that the pus may thus enter the follicles. The cells of the follicles and the hair roots undergo granular degeneration. The 1 82 LECTURES IN DERMATOLOGY. pus may reach the surface of the skin by either rupturing into the hair follicles, or through the rete mucosum. Except in some severe cases, the hair follicles do not become completely destroyed, the hair remaining firmly implanted ; but in cases where they are destroyed the hairs become loose, and the follicle sheath accompanies the hair when extracted. In these severe cases, alopecia results from the severity of the disease. Etiology. The disease is not contagious, and its cause is very obscure. It is not produced by shaving, for it occurs often in those who do not shave. It is not a disease due to a debilitated condition, for it occurs in those who are in perfect health. It is probably a germ disease. Symptoms. Sycosis is a disease of the hairy portions of the face and neck. It may attack all of these parts at one time, but more frequently begins at one spot, gradually extending to other regions. It first shows it- self as papules, or more commonly as pustules, surround- ing the hairs. They are usually at first few in number, but appear in successive crops until they are very numerous and cover considerable space. These pustules are about pin-head size and pointed, containing a yellowish fluid, and showing little tendency to rupture. These pustules remain discrete, although often crowded together, and are surrounded by an inflammatory areola", giving the skin a swollen and reddened appearance. If the pustules are not ruptured in shaving they dry up into yellowish crusts, which fall off without leaving scars. Besides the pustules, papules and papulo-pustules are usually present, situated immediately about the hairs. The hairs are not usually deformed, and are not easily extracted, and then with pain. The disease is usually accompanied by more or less pain and burning, but little itching. SYCOSIS. 183 Course. The disease is a chronic one. As some of the lesions disappear, new ones continue to form. This con- tinued inflammation of the skin leads to some chronic thickening, which may remain after the other lesions have disappeared. Diagnosis. Sycosis is most liable to be mistaken for barber's itch and for a pustulur eczema. It must, how- ever, also be differentiated from a pustular syphilide, lupus, and acne. Treatment. Internal treatment is not of much impor- tance. In cases which have lasted for a long time the internal use of Donovan's solution has a beneficial effect. In all cases, the bowels should be kept thoroughly active with the use of alkaline salts. If pustulation is very ex- tensive, sulphide of calcium in small and frequent doses may limit its amount. For local treatment you should advise your patients not to shave, but to keep the hairs closely clipped. If the disease is acute and accompanied by inflammatory symptoms, the soothing antiseptic oint- ment and lotions should be applied. The affected area should be bathed in hot water two or three times a day, and a calomel lotion applied. 3 Hyd. chlor. mit gr xv. Liq. calcis 3 ii m At night an oxide of zinc ointment, with a drachm of calomel to the ounce, or Lassar paste may be kept in contact with the lesions. After the disease has become chronic, and inflammatory thickening is present, a resorcin and bichloride of mercury lotion seems to have a better effect, and an ammoniated mercury oint- ment half strength kept applied at night. In some 184 LECTURES IN DERMATOLOGY. cases I have had very good success in using a sulphur lotion applied several times during the day, and the fol- lowing sulphur ointment once every three or four days for an hour or more : R Sapon. virid 3 iii Sulphur sub., 01. cadini aa 3 iss Petrolat i . 3 iii m Depilation is recommended by many dermatologists of all the hairs seemingly affected, but this does not seem necessary except in a few cases. It is well in all cases, when the disease seems to spread, to remove all the affected hairs in the periphery of the patch, for this seems often to check the extension of the trouble. If it does not, tincture of iodine or acetic acid may be painted about the borders of the patch every two or three days. LECTURE XIII. 5 YPHIL DERM A TA . Gentlemen : Syphilis, except so far as the cutaneous manifestations of it go, belongs to another chair than mine, and I will therefore not take up your time with the consideration of either primary or constitutional syphilis, but simply skin syphilis or syphiloderma. There are many varieties of syphilis affecting the skin, but they all present some symptoms and certain general features which we may first consider as common to them all. In the first place we usually have a history of an ini- tial lesion, and although this symptom should not be too closely relied upon, as the chancre may not be recognized either by the patient or physician as such, nevertheless the history of such a lesion can usually be obtained. In the second place we have certain constitutional symptoms present with the eruption. The most common of them are headache, muscular pains, pains in the bones, which pains are almost always worse at night, enlarged inguinal, epitracheal, and cervical glands, chronic sore-throat and alopecia, and after the first year bone and nerve lesions which are quite characteristic. In the third place syphilitic lesions are rarely accompanied by either itching or burning sensations, and unless irritated are not usually painful. This absence of subjective sensations is quite characteristic. In the fourth place the early syphilitic lesions are usually 185 1 86 LECTURES IN DERMATOLOGY. distributed and symmetrically arranged, while the later lesions are less numerous and symmetrical, and show a decided tendency to circular and concentric or serpigi- nous arrangement. In the fifth place all syphilitic erup- tions and lesions, are usually of a copper or dark brown color, which aids us in distinguishing them from any other lesions. Lastly, there is a great tendency to multiform- ity of the lesions, making their appearance at or about the same time, although one form is decidedly in predomi- nance. Polymorphism is, however, much more apt to be seen in the earlier manifestation of syphiloderma, although it does occur in the later stages. Thus you see we have a good many symptoms in common to all syphilitic erup- tions, and which aid us in making a correct diagnosis. The different forms of syphiloderma are the erythema- tous, papular, papulo-squamous, pustular, tubercular, gum- matous, and the pigmentary. The vesicular and bullous forms are occasionally met with, but so very rarely that I will not consider them at present. ERYTHEMATOUS SYPHILODERMA. Synonym — Macular Syphilide. The erythematous syphi- lide is the earliest of all the syphilodermata. It gener- ally makes its appearance in about six or eight weeks after the chancre. It is the only variety of syphiloderma ushered in with constitutional symptoms called syphilitic fever. These symptoms consist of general malaise, fever, general muscular pains, and headache, which last more than two or three days. There may be, however, no con- stitutional symptoms accompanying the eruption. The lesions first show themselves in the neighborhood of the umbilicus and from there spread all over the body, except on the face and backs of the hands and feet. • The trunk PAPULAR SYPHILIDE. 1 87 and flexor surfaces of the extremities are especially attacked. The lesions consist of macules usually about the size of the finger nail, round or irregular in shape. They are of a dark reddish color, more marked on ex- posure to the cold, giving the skin a mottled appearance. They usually last from three to four weeks, gradually fading with slight desquamation, and leaving a slight pigmentation, which entirely disappears after a time. Relapses are common during the first year, but occasion- ally seen during the second year of the disease, the erup- tion being generally less copious with each relapse. Diagnosis. The macular syphilide must be diagnosed from pityriasis rosea, simple roseola, tinea versicolor, ery- thematous eczema, and the medicinal eruptions. PAPULAR SYPHILIDE. There are several distinct varieties of the papular syphi- loderm which require separate description. They are : I. Small papular sypJiilide (synonym — miliary papular syphilide and lichen syphiliticus). This variety of syphi- loderm may occur early or late in the disease, but seldom before the fifth or sixth month. It runs a very chronic course, being the least affected of all the syphilitic erup- tions by treatment. It makes its appearance about the shoulders, trunk, arms, and thighs, either in a disseminate manner or in groups very thickly studded. The lesions consist of minute, confluent papules, pin-head or millet- seed size. They are hard, elevated, acuminated, and often scaly. In color they are dark-red or copper. They last for weeks before they disappear, leaving a pigmenta- tion which lasts for a long time. II. Large papular syphilide. This form of the eruption is very common, and usually makes its appearance early 1 88 LECTURES IN DERMATOLOGY. in the disease — third or fourth month — but relapses are common even after the second year. It usually follows immediately after the erythematous variety. The erup- tion may show itself upon any portion of the body, or the forehead, neck, back, flexor surfaces of the extremities, and genital regions are especially liable to be attacked. The lesions consist of large flat papules, varying in size from a split-pea to a finger nail. They are round or oval in shape, firm, and circumscribed. They are distinctly a raw-ham color, and disappear easily with treatment. These large papules are apt to undergo changes so that they become altered in appearance and form. (a) At times they become soft and spongy, showing- signs of excoriation and crusting over. When they exist about the corners of the mouth or anus, or other parts exposed to moisture, deep, painful fissures often occur. (b) The most common change in the papule, however, is into the moist papule (also called the mucous or condy- lomata). This change takes place where moisture natu- rally exists, as about the mouth, throat, genitals, breasts, and axilla. When moisture and friction exist between two opposing surfaces these lesions are very apt to occur, as between the nates or labia, or between the toes. The lesions differ from the large, dry papules by being moist, and covered with a gray, mucous secretion consisting of macerated epidermis. They are flattened, less circum- scribed, and often larger than the dry papules. They are also soft and spongy and often run together, producing patches of considerable size. Occasionally the surface becomes covered with hypertrophied papillae, when the term vegetating syphiloderma is applied. These often crust over, and are most frequently seen about the edges of the scalp or genitals. You must remember that the PAPULOSQUAMOUS SYPHILODERMA. 1 89 secretion from these moist papules is very contagious, often more so than the chancre itself. Although not auto-inoculable, the secretion coming in contact with an opposing surface is very apt to light up a similar lesion in that location. If properly treated they disappear readily in most cases. Diagnosis. The papular syphilide may be mistaken for keratosis pilaris, lichen planus, acne, psoriasis, lichen scrofu- losis, and possibly for papular eczema. The moist papule, or condylomata, is frequently confounded with simple stomatitis, hemorrhoids, epitheliomatous ulcers, and vene- real warts. PAPULO-SQUAMOUS SYPHILODERMA. Synonym — syphilitic psoriasis. These lesions, although they may occur elsewhere on the body, are especially apt to attack the palms or soles. When occurring on the body they consist of a number of grouped, flattened papules, covered with dry, greasy, adherent scales. The scales, although never so abundant as in psoriasis, give the ap- pearance of a single lesion, but when removed the patches will be seen to consist of a number of grouping papules of a distinctly raw-ham color. The eruption is rarely ex- tensive, and seldom symmetrical as in psoriasis. When the lesions are on the palms and soles the term palmar and plantar syphiloderma are used. The lesions are more like slightly raised macules than papules, of split-pea or finger-nail size, which show a decided tendency to coa- lesce into rounded or serpiginous patches. These patches are covered with scales, sometimes more abundant than others, but also more abundant on the borders of the patch. If the scales are removed the raw-ham color be- neath is very apparent, and often presenting painful, deep 190 LECTURES IN DERMATOLOGY. fissures. The disease spreads often from the centre toward the periphery by a distinctly elevated border, but not completely disappearing at the centre, which re- mains scaly. The eruption is almost always limited to the palms and soles, not spreading to the wrists or backs of the hands. If the lesions occur early in the disease the eruption is usually symmetrical, but if late in the dis- ease but one hand or foot is usually attacked. The dis- ease is very chronic, lasting months or years, not readily yielding to treatment. The disease is often difficult to diagnose from palmar psoriasis and eczema. PIGMENTARY SYPHILODERMA. You must not confuse pigmentary syphiloderma with the pigmentation in the skin the result of some syphilitic eruption. The majority of syphilitic eruptions are fol- lowed by pigmentary deposit at the seat of the skin lesion, but this is not true of pigmentary syphiloderma, which is never secondary to any other eruption. True pigmentary syphiloderma occurs almost exclusively in women, and in the second year of the disease. It seldom occurs elsewhere than upon the neck. The disease con- sists of circumscribed, delicate coffee-and-milk-color pig- mentations of the skin, in the form of irregular-shaped finger-nail-sized macules, often coalescing, giving the appearance of delicate network, sometimes described as the "queen's veil." It lasts for several months, and is not relieved by treatment. It is undoubtedly a form of chloasma influenced by syphilis, but must be carefully diagnosed from simple chloasma. PUSTULAR SYPHILODERMA. There are several varieties of pustular syphiloderma which require separate description. PUSTULAR SYPHILODERMA. ICjt I. Small or miliary pustular syphilide. This usually oc- curs early in syphilis. It may even be the first eruption noticed, but in the form of relapses it may occur late in the disease. The back and extremities are the favorite locations for the eruption, when it usually invades large areas of surface either in groups or disseminated. Oc- casionally it occurs in circles. The lesions are pointed and millet-seed in size, and situated on reddish, papular elevations. The pus, which is in small quantity, dries, forming small yellowish crusts, which fall off, leaving little pits lasting for some time. Slight desquamation takes place about the pits, forming a collar called by the French " collarette." The seat of this disease seems to be in or about the hair follicles, as most of the lesions are punctured by a hair. II. Large or acne-form pustular syphilide. This also is an early pustular eruption, and when it first makes its appearance is not infrequently accompanied by fever and headache. The lesions appear upon the face, scalp, and trunk, sometimes upon the extremities. The lesions be- gin as small, split-pea-sized papules, which within twenty- four hours or three days become pustular. This pus dries into brown scabs, which are situated upon superficial ulcers. These crusts fall off in a few days, leaving pits with considerable pigmentation. The lesions are quite numerous and often grouped. Not infrequently this form of syphilide is mistaken for small-pox, and vice versa. It runs a rapid and benign course. III. Small, flat, pustular syphilide or impetigo syphilitica. This eruption is usually about the hairy portion of the face and scalp. The lesions are small and flat, and grouped into irregular patches. Crusts form almost immediately, so that the pustular nature of the lesion can hardly be 192 LECTURES IN DERMATOLOGY. appreciated. These crusts are yellowish and thick, and when forcibly removed a superficial ulcer will be found beneath. The lesions look very much like pustular eczema, but may be diagnosed by the absence of itching and ulcer- ation. The lesions run a rapid course, but yield readily to treatment. IV. Large, flat, pustular sypJiilidc or ecthyma syphilitica. This eruption is seen in two varieties : (a) superficial, (b) deep. (a) This variety is very common, and usually occurs about the sixth month of the disease. The lesions are numerous, and especially apt to appear upon the back. They are finger-nail-size, pustular, flat, and seated upon a deep red base. Crusts form almost immediately. They are yellowish or brownish in color, flat and round, seated upon superficial ulceration. (b) The deep variety is a late manifestation of syphi- lide, and occurs upon the extremities. They are usually as large as a thumb nail, and surrounded by an inflamed, indurated area. The crusts are of a blackish color, conical and striated like an oyster shell, and constitute what is known as rupia. There is deep ulceration beneath the crusts, which discharge large quantities of greenish pus. These crusts when they fall off leave large scars deeply pigmentated. Diagnosis. There are so many varieties of the pustular syphilide that it is not always easy to make a diagnosis until you have carefully examined the patient several times. It is most apt to be mistaken for ecthyma, impetigo, small-pox, sycosis, acne, and pustular eczema. TUBERCULAR SYPHILIDE. Tubercular syphilide is a late manifestation of the ■disease, seldom occurs before the second year, and may GUMMATOUS SYPHILIDE. 1 93 be delayed for many years. It usually attacks the face, shoulders, and back. The lesions are usually not very numerous, and appear almost always in groups, forming rounded patches or segments of circles. Several of such segments may unite and form a serpiginous, tubercular syphilide. The individual lesions consist of solid eleva- tions in the skin of split-pea size. They are firm and circumscribed, deeply seated in the skin, and distinctly copper color. The lesions spread from the centre toward the periphery. They disappear either by absorption or ulceration. When ulceration takes place each lesion is completely destroyed, leaving unsightly scars, as the whole patch is apt to undergo destruction. The edges of the ulceration are irregular and uneven. The ulceration often runs a serpiginous course, spreading from the centre toward the periphery. As the ulceration spreads, cicatri- zation takes place, so that frequently there is a furrow of ulceration surrounding a patch of cicatrization. The pro- cess is a slow one both in development and spreading, but yields readily to treatment. Diagnosis. The diagnosis of the tubercular syphilide is usually much easier than the pustular form. When it occurs about the face, however, it often is mistaken for lupus vulgaris, rosacea, or for leprosy in countries where leprosy is a common disease. Occasionally it is mistaken for epithelioma. GUMMATOUS SYPHILIDE. Synonym — gumma, gummy tumor. This variety of the disease is usually one of the latest manifestations of syphilide, but occasionally occurs during the first year of the disease, when it is known as precocious gummata. The lesions are few in number, seldom more than two or three at a time. They most always develop in the loose, 194 LECTURES IN DERMATOLOGY. soft tissues, as upon the sides of the thorax and abdo- men, about the sternum, and upon the flexor surfaces of the extremities. The lesions begin as small, pea-sized, painless bodies, which are flattened beneath the skin. They increase slowly in volume, taking weeks before they are characterized as flat, circumscribed, subcutaneous tumors, about the size of a walnut, slightly raised above the surface of the skin. At first they are firm in consist- ence, but afterwards soft, owing to a destructive process. The skin then becomes involved, and appears pinkish or reddish. As the gumma breaks down it ulcerates and destroys the tissues in which it has its seat, leaving a circumscribed, deep excavation, rounded in form, with perpendicular edges. Its bottom is uneven and covered with a grayish, gummy deposit. Although the destruc- tive process is generally considerable, the ulcer heals by cicatrization, leaving often but a slight scar. Occasionally these gummy tumors heal by absorption without ulcera- tion. Diagnosis. A differential diagnosis must be made between the gummous syphilide and other forms of tumors, erythema nodosum, and abscesses. When syphi- litic lesions break down and form ulcers, it is very im- portant for you to distinguish them from other forms of ulceration. Treatment. The constitutional treatment of syphilis with mercury, iodine of potash and tonics belongs to another chair than mine, but I will say a few words as to the best forms of local applications in some of the syphilides. The macular syphilide may be hastened in its disappear- ance by taking a hot bath every day, or better still a Turkish bath, using the tincture of green soap in prefer- GUMMATOUS SYPHILIDE. 1 95 ence to any other. Immediately after the bath the erup- tion is frequently more pronounced, but it fades gradually and eventually disappears without any other external application. In the small papular syphilide there is nothing which will cause the disappearance of the lesion so rapidly as a mercurial vapor bath. If the eruption is confined to small areas, nightly inunctions of the ammoniated mer- cury ointment to these areas is followed by the best results. In the large scaly syphilide alkaline baths (one-half pound of bicarbonate of soda to fifteen gallons of hot water) every night, followed by inunctions to each lesion of the ammoniated mercury ointment, or better still, if possible, the continued application of the ointment spread on lint to these lesions, will give great satisfaction. After the papular character of the lesion has disappeared the stain will often remain for a long time. To remove the pigmentation the following lotion may be applied frequently: 5. Hydrarg. chlor. corros. . . . gr. iv Ammonii chlor gr. x Aquae rosae | iv m The scaly syphilides are often very rebellious to treat- ment, especially when they attack the palms or soles. The scales should first be softened by soaking them with a solution of caustic potash, half a drachm to the ounce of water, then thoroughly dried, and the ammoniated mercury ointment containing a drachm of the oil of cade to the ounce, kept continuously applied. This treatment should be repeated daily unless the lesions become in- 196 LECTURES IN DERMATOLOGY. flamed, when a soothing ointment, preferably Lassar's paste, should be applied for a few days. In those cases where the scaling is especially marked, often taking on the appearance of psoriasis, and consequently called syphilitic psoriasis, chrysarobim ointment in the strength of five to ten per cent, rubbed into the lesions or kept applied to them, will be followed by great benefit. Care, however, must be taken to limit the action of the drug to the lesions, otherwise a severe dermatitis may be set up. The small, pustular syphilide requires but little external treatment. Removing the scabs with an alkaline lotion, and applying a salve, composed as follows, will be all that is required : $ Ung. hydrarg. nit 3 ii Vaseline § i The scabs from the large pustular syphilide and other forms of ulcerating t?ibercular syphilide must first be care- fully removed by poulticing — or hot alkaline solutions — before any treatment is undertaken. After the scabs are removed, the base of the ulcers should be slightly touched with carbolic acid, and then dusted over with iodoform or calomel. If granulations exist they should be touched with a stick of nitrate of silver. If the ulcerations remain sluggish and show no disposition to heal, an ointment consisting of — # Bals. Peru 3 ss Ung. hydrarg. ammon., Vaseline aa § ss m May be applied with benefit. HEREDITARY SYPHILIS. 1 97 Do not excise a gumma. They frequently can be ab- sorbed by the continuous application of the mercurial plaster or ointment, even after they have softened and appear to be broken down. When the lesions do break down and ulceration exists, healing will not take place until the neurotic tissue is all destroyed. This can be hastened by frequently washing the ulcer with a solution of caustic potash, a drachm to the ounce, and dusting with iodoform and poulticing. After the granulations become healthy you may employ the same treatment recommended in the ulcerating syphilis. HEREDITARY SYPHILIS. It has long been a disputed question whether syphilis could be transmitted from a syphilitic father to the child without the mother being affected. Until recent years this has generally been considered as possible, but lately this fact has been questioned by most careful observers. The more the question is studied and investigated the more certain it becomes that true hereditary syphilis must be contracted through the mother. So confident am I that syphilis cannot be transmitted from the father to the child, that I now have no hesitancy in letting my male patients marry after all danger of communicating the disease to the wife has passed, and I have yet to see the first syphilitic child as the result of such union. A child, the subject of hereditary syphilis, may be born perfectly free from all appearance of disease, or the disease may be stamped upon it before it enters the world. In the majority of cases the child is born perfectly healthy. Before the end of the first month, however, the disease usually manifests itself, and almost without exception before the end of the fourth month, so that if there is no 198 LECTURES IN DERMATOLOGY. evidence of syphilis before that period the child is almost certain to escape the disease. When a child is born syphilitic the lesions are either maculo-papular or bul- lous, and the child shows the general signs of syphilitic cachexia, marasmus, and coryza, seldom living more than three weeks. When born healthy in appearance the syphilitic child soon begins to lose flesh, the skin assumes a muddy hue and becomes wrinkled, hard, and dry, giving the patient a pinched, weazened appearance of an old man or woman. The first specific symptom noticed is coryza, the acrid discharge stopping up the nostrils, giving the baby the snuffles. This discharge, after a time, becomes bloody and fetid, excoriating the surface with which it comes in contact. Do not mistake the snuffles of a syphilitic child for the ordinary cold in the head with which young chil- dren are very apt to suffer. If you do, and tell the parents that their child is syphilitic and it proves afterwards not to be so, you are likely to get yourself disliked by the family. If the coryza has lasted for some time, the bones of the nose may become affected and necrose. The inflammation may extend to the larynx and pro- duce a laryngitis. Soon after the coryza is noticed the skin lesions begin to form. The first one noticed is usually the macular syphilide, appearing as irregular, erythematous patches about the size of a finger nail upon the buttocks and genitals. They often run to- gether, producing a continuous patch of erythema ex- tending down the thighs, giving a distinctly copper color, which will help you to distinguish it from inter- trigo. The erythema surface often becomes excoriated, looking like eczema, but before long erythematous patches appear elsewhere, as upon the palms and soles, HEREDITARY SYPHILIS. 1 99 which are accompanied by more or less exfoliation. After a few weeks the lesions take on a papular character, the eruption becoming maculo-papular, which is the most common syphilide in infants. The papules are broad and flat^ becoming moist papules about the mucous surfaces, as the mouth, anus, and genitals, or wherever heat, moisture, and friction exist. The bullous syphilodcrma is most frequently seen at birth, but may occur later. It consists of flat, irregular- shaped bullae, showing a decided tendency to attack the palms of the hands and soles of the feet. They are sur- rounded by an inflammatory areola, and when broken down or ruptured show an excoriated, ulcerated base, which heals veiy slowly. New blebs form from time to time as the old ones disappear. The lesions do not usually appear alone, but associated with the papulo-macule eruption. The condition of the child's teeth, the diseases of the bones, as dachylitis, and other symptoms besides the eruptions on the skin, will all aid you in making a correct diagnosis. The treatment of syphilis in infants should always be heroic. Syphilitic children if left to themselves without treatment always die, and that within a short time. In- unctions of mercury in the milder cases, and the hypo- dermic injections of mercury in the severer cases, are the forms of treatment which should be most relied upon. The local treatment which I suggested in the treatment of syphilis in adults should guide you also for the local treatment in the syphilis of infants ; but remember that the skin of infants is very much more delicate than that of adults, and the preparations employed must conse- quently be milder, and you must be governed very largely by the local effect produced. LECTURE XIV. TINEA. Gentlemen : To-day we will study the so-called vegetable parasitic skin diseases, or tinea. There are undoubtedly a large number of vegetable parasites which attack the skin and produce well marked symptoms, but there are but three varieties which are recognized by all dermatologists, and to these I will ask your attention. They are named tinea favosa, tinea trichophytina, and tinea versicolor. These are all very contagious. TINEA FAVOSA. Tinea favosa, or favus, as it is generally called, is in this country the least often seen. It is, however, very common in Italy and Russia, and it is among these emi- grants that we most frequently meet with it. The disease is almost always limited to the scalp. Pathology. The disease is due to a vegetable parasite called the Achorion Schoenleinii. The fungus consists of mycelial threads 1-800 of an inch in diameter, and small, round, or flask-shaped spores. These gain access to the skin through the hair follicles, attacking the hair sac and spreading outward between the superficial layers of the epidermis. Afterwards it attacks the hair shaft itself. The growth of this fungus causes the loss of hair and atrophy of the skin. TINEA FAVOSA. 201 Symptoms. The disease either begins as scaly, erythema- tous patches, or in the form of small, yellowish, punctate spots appearing on the scalp. These develop into small, yellowish, cup-shaped crusts about the hairs, and are usually the size of a split pea. These crusts are first covered with a thin layer of the epidermis, and are conse- quently difficult to remove, and when torn off cause some bleeding. The hairs in and about these crusts are dry, brittle, and lustreless, falling out in places, leaving bald spots. The crusts may be few or many, usually discrete, although they may coalesce. They are very firm to the touch, dry and crumble like mortar between the fingers. If the disease has lasted for a time these yellowish cup- shaped crusts are sometimes obscured by the pressure of a thick, mortar-like substance, which surrounds and covers them. There is always a peculiar odor of mice about favus, which is so characteristic that you can often diag- nose the disease with your sense of smell. With this crusting there is always some itching, but not usually very great. The disease advances very slowly, new crusts forming from time to time, while the old ones drop or are torn off, leaving bald patches of atrophied skin, at first of a red color, but afterwards turning abnormally white like scar tissue, and covered with a loosely adhering epidermis, which is easily wrinkled under the finger. The irregular bald areas contain here and there a few hairs, which are dry, lustreless, and wire-like. When the crusts or scutula, as they are sometimes called, are removed, they usually form again in two or three weeks. The disease lasts for years unless treated, and sometimes even then. Although, as I told you, it is usually limited to the scalp, it oc- casionally attacks the skin or nails. Diagnosis. If you find the characteristic fungus with 202 LECTURES IN DERMATOLOGY. the aid of the microscope, of course your diagnosis is made certain. You should always use the microscope whenever you suspect the presence of favus, for the dis- ease is often mistaken for seborrhcea, eczema, psoriasis, and lupus erythematosus. You also must be able to diagnose the baldness resulting from this disease from other forms of alopecia. Treatment. Never pronounce a case of favus cured until all signs of the disease have disappeared for three months. In the first place you must get rid of all crusts by the aid of salicyliated oil or poultices ; after that you must every night rub into the affected area some strong parasiticide. The following is the one which I have found the most beneficial : 5 Acid, carbolici gr xv Bals. Peru 3 ss Ung. hyd. nit., Sulphur, sub aa 3 i Petrolat I i m If a dermatitis is set up you will be obliged to stop this active treatment for a few days, and employ some sooth- ing application as ointment of roses. TINEA TRICHOPHYTIXA. Tinea trichophytina, or ringworm, is a vegetable para- sitic disease produced by a micro-organism called the trichophyton, which may attack either the body, the scalp, or the beard. Although the cause is the same in the three affections, the appearance of the lesions, the symptoms, and treatment are so different, that they each demand a separate description. RINGWORM OF THE BODY. 203 RINGWORM OF THE BODY. Is usually described under the name of tinea circinata or herpes circinatus. It is due to a fungus which, alight- ing upon the skin, finds its way into the epidermis, but does not penetrate the true skin. Under the microscope the fungus is seen imbedded in the epidermic cells in the form of slender, ribbon-like formations or threads, called mycelium, containing granules called spores. These mycelium are long and branching, often forming a net- work. The spores may be isolated as well as joined to the mycelium. Etiology. The disease is very contagious, and fre- quently is communicated from one person to another. Domestic animals, as cats, dogs, and, horses, are affected with ringworm, and frequently the source of the conta- gion. Children are more susceptible to the disease than adults, and some persons very much more so than others. It is doubtful if the disease is communicated by mere touch, but probably the parasite is carried by means of damp towels, sponges, or clothing, and coming in contact with a skin susceptible to the contagion the trichophyton becomes implanted and multiplies rapidly. Symptoms. The disease usually first shows itself as a small scaly, rounded spot of a dull red color, slightly itchy, and occurring upon any part of the body, but most frequently upon the face, hands, and neck. The lesion gradually enlarges from the centre towards the periphery by a circular border, slightly elevated, well defined, and scaly. This border if carefully examined will be found to be attended with the formation of minute papules or vesico-papules. As these patches increase in size the centre of the lesion has a tendency to clear up, although they still remain somewhat scaly and dull reddish in 204 LECTURES IN DERMATOLOGY. color, and often containing a few pustules. It takes about a week or ten days for the patches to reach their full development, which is usually about the size of a silver half dollar. There are usually not more than two or three such patches present on the body and they remain discrete, but occasionally a number are present coalescing, producing irregular-shaped patches with curved outlines, assuming the form of serpiginous lesions. The scales, which are always most abundant about the margin of the lesion, are adherent and shreddy, and contain the parasite. The disease is accompanied by slight itching, more marked in some cases than others. Course. Ringworm, if not treated, usually lasts a few weeks and disappears. Occasionally it lasts for months or years, the lesions disappearing and returning again in the same locality, or on different parts of the body. When they last for months or years the lesions lose some of their characteristics and become small, superficial, less scaly, and irregularly shaped. Diagnosis. If there is any doubt as to the diagnosis of the disease scrape off a few scales from the suspected patch, mix with a drop of liquid potassae, and examine under the microscope for the mycelium and spores. They may be plainly seen with a power from 250 to 500 di- ameters. This will aid you very much in diagnosing ring- worm from pityriasis rosea, seborrhcea, psoriasis, squa- mous eczema, erythematous lupus, and syphilis. Treatment. As frequently ringworm occurs in debili- tated subjects internal tonic treatment may be required, especially if the disease shows a tendency to become chronic or to return. External treatment is usually all that is required. Hundreds of remedies have been pre- scribed for ringworm, but I will mention but three — chry- ECZEMA MARGINATUM. 205 sarobin paint, bichloride of mercury, and tincture of iodine, either one of which will usually cure the disease. Before any of these applications are applied the patch should be thoroughly scrubbed with soap and hot water. The chrysarobin paint is prepared as follows : # Acid, salicylic 3 ss Acid, chrysophanic 3 i Liq. gutta percha § i This paint should be applied every second day. Two or three applications are usually sufficient. If the corro- sive sublimate solution is used, it should be applied with a brush night and morning and allowed to dry on the surface. The strength should be about two grains to the ounce. If the iodine is used, the patch may be painted with it every second day for three or four applications. If this treatment sets up a dermatitis, soothing applica- tions of zinc salve may be required for a few days. After following out such a plan of treatment as I have sug- gested it is well to wait for a week or so and watch the result. Occasionally two or three more applications may be necessary, but not often. ECZEMA MARGINATUM. This is a form of ringworm of the body described by Hebra under the name of eczema marginatum, which occurs about the fork of the thigh, groin, and axilla, and differs in many respects from the lesions already de- scribed. The disease usually begins with a reddened, thickened patch of skin, with a marginate border, sharply defined and irregular. The patch increases in area from day to day, with very little tendency to clear in the 206 LECTURES IN DERMATOLOGY. centre, until they reach the size of a dollar or larger. Several of these patches usually make their appearance in the regions mentioned, and coalescing invade a large area of skin. The process is accompanied by an eczema, or more properly a dermatitis, as shown by the redness, thickening, exudation, and desquamation of the patches. There is a great deal of itching present, and sometimes burning and pain. The disease runs a chronic course, and is often rebellious to treatment. If the disease has lasted but a few days, you may be able to effect a cure with the treatment already given, but when the disease has become chrpnic, or will not yield to milder forms of treatment, we must resort to other measures. I have had good results during the past year in treating these cases as follows : After first cutting the hair off the patch I have it cleansed thoroughly with soap and hot water containing a little washing soda. After drying thoroughly, the border of the lesion is painted over with a solution of equal parts of chloral, carbolic acid, and tinc- ture of iodine, and the whole patch lightly gone over with the same. To relieve the pain caused by this application a 2 per cent, cocaine ointment is applied for an hour or so, and then an ointment kept on con- tinually composed of — IJ Ung. picis, Ung. ac. carb aa 3 ii Ung. diachylon ad 3 i m Every two or three days, occasionally not so often, owing to the irritation produced, this treatment is to be continued until a decided improvement is noticed, when the ointment alone can be applied. Usually six or eight TINEA TONSURANS. 2Q-] applications of the iodine solution will be sufficient. After a cure is effected, it is well to have your patients use a wash for some time to the affected area, composed of one grain of the bichloride of mercury to an ounce of rose water. TINEA TONSURANS. Tinea tonsurans, or ringworm of the scalp, is produced by the same parasite which causes ringworm of the body, and it not only involves the epidermis, but the hair and hair follicles as well. The hairs and their follicles become filled with the spores and a few mycelium, distending and rupturing them. The hair bulbs are also distended with spores, which are also sometimes found in the corium. Etiology. Ringworm of the scalp, like that of the body, is a highly contagious affection, and communicated from one person to another by means of towels, brushes, combs, caps, etc. It attacks only children, being seldom seen in persons over fourteen or fifteen years of age. A ringworm on the body of a mother will frequently communicate ringworm to the scalp of her child, the parasite in both cases being the same. Symptoms. The disease usually begins very much in the same way as does ringworm of the body, with the presence of an irregular, scaly, erythematous patch on the scalp. In a few days it begins to spread from the centre toward the periphery, with a raised, red, circular border, which is very apt to consist of small vesicles or pustules, which terminate in furfuraceous scales or des- quamation. These patches grow rapidly, usually attain the size of a silver dollar, and present the following characteristic features : each lesion is elevated, circular, circumscribed, of a reddish or bluish color, and covered with dry, furfuraceous scales. The hairs in the patch are 208 LECTURES IN DERMATOLOGY. scanty, broken, split, or deformed, and their follicles prominent, giving the surface a goose-skin appearance, especially marked if the disease has lasted for some time and most of the hairs have fallen out. The hairs are not only deformed, but are dull, lifeless, brittle, and very liable to drop out or to break off close to the follicles, producing baldness, and making the patch feel like a nut- meg grater. Some of the hair follicles undergo a sup- purative process, and then you will find pustules in the lesion, which rupture and form crusts. Occasionally the whole patch becomes acutely inflamed, red, and infil- trated, pitting on pressure and crusting, looking like an eczema of the scalp. This condition is known as kerion. Any portion of the scalp may be affected, but most fre- quently over the parietal region. There are usually not more than two or three lesions present at one time, but these may run together, producing large, irregular patches. Occasionally the whole scalp is attacked. The disease may spread to the side of the face, when it becomes tinea circinata. Course. If ringworm of the scalp is permitted to run on without treatment it lasts indefinitely, but frequently ends in spontaneous recovery. Diagnosis. Ringworm of the scalp may be mistaken for eczema, seborrhcea, alopecia areata, or psoriasis, but the history of the contagion, the deformity of the hair, and the presence of the parasite shown under the micro- scope will usually settle the diagnosis. The microscopic examination of the parasite is the same as for ringworm of the body. Treatment. The same remedies recommended for ring- worm of the body may be employed in ringworm of the scalp. The disease, however, is much harder to cure. The TINEA BARBAE. 20O, hairs in and about the borders of the patch should be carefully removed, and the scalp scrubbed with soap and water before treatment is applied. I have had the best success in treating these cases by applications, about every few days, of a solution of equal parts of pure car- bolic acid, tincture of iodine, and chloral. This should be painted over the lesions, and a little beyond the bor- der, with a camel's-hair brush. As dermatitis is usually set up for the next two or three days, the disease seems very much worse. I limit this inflammation by the con- tinued application of Taylor's paste, which is made as follows : 5, Camphorae gr. xx Ung. aq. rosae % i m which will be found very efficacious. Three or four appli- cations of the acid is usually sufficient to effect a cure. If the disease is very extensive, it is best to treat only a portion of it at a time with the carbolic acid solution for fear of causing too much inflammation of the scalp or absorption of the drug. While you are treating one patch with carbolic acid, you may be making application of the alkaline sulphur ointment to another. In young infants, care must be taken to use not too strong applications to the skin, and if carbolic acid or tincture of iodine is used, they had better be diluted with alcohol. To prevent in- fection to other portions of the scalp, a solution of bichlo- ride of mercury, two grains to the ounce of bay rum, is very serviceable. TINEA BARBAE. Tinea barbae, barber's itch, or parasitic sycosis are the terms used to distinguish ringworm when it attacks the 2IO LECTURES IN DERMATOLOGY. beard. The parasite is the same trichophyton that we have already studied incases of ringworm of the body and scalp, but its clinical features are very different, owing to the anatomy of the part which it now attacks. Pathology. The fungus attacks the hair follicles and hair shafts, producing a suppurative inflammation, not only of the follicles but in the subcutaneous tissue about them. Under the microscope the mycelium and spores are found abundant in and about the hair root and shaft, the hair bulb being often obliterated. Etiology. The disease is contagious, but apparently less so than ringworm of the body and scalp, and is not a very common affection. It occurs most frequently in persons between twenty and thirty years of age. The name barber's itch is given to this disease because it is supposed to be contracted some way in shaving, either from the razor, brush, lather, or towel of the operator. The probabilities are that the parasite is carried most frequently by means of the towel, although it has been found by microscopical examination in the shaving-brush, especially where the brush has not been used for some time and has become mouldy. When a damp towel which contains the parasite, by not having been properly cleansed and ironed after contact with the face of a person suffering from the disease, is used upon a recently shaved surface, you can readily understand why the parasite has a good chance to enter the hair follicles and start the disease. As the parasite is the same in all forms of ring- worm, it is not necessary for the fungus to be derived from tinea barbae to produce the disease, but it may come from either tinea tircinata or tinea tonsurans. Symptoms. The disease usually begins as a tinea cir- cinata in a reddish, scaly patch on the bearded surface of TINEA BARBAE. 2 I I the face. In a few days this patch becomes indurated and swollen, and the hairs are noticed to become affected, they becoming loose, brittle, and broken. In the course of a week or more the affected skin becomes distinctly nodular and pustules form about the openings of the hair follicles. The disease spreads by the presence of new patches and increase in size of the old ones. Often these lesions run together, producing irregular patches, and in- volving large portions of the chin and regions of the lower jaw. The upper part of the face and upper lip are rarely attacked. After the disease has lasted for some time the deeper tissues are involved, giving rise to thick, firm, irregular masses of induration called tubercles. The surface of the lesion has a purplish or dull red color, and studded with pustules. The amount of pustulation varies, but often enough to produce considerable crusting. If these crusts are removed, the surface beneath will be found excoriated and studded with yellowish points, dis- charging a glutinous material. The hairs in the affected area are brittle or bent, and can be extracted without pain. They are often seen to protrude from the centre of the pustule. Although the disease has the appearance of being very irritable, the subjective sensations are often very mild. There is some itching and burning present, but never in proportion to the amount of the cutaneous injury. Course. The disease without treatment usually spreads for several weeks, and then remains for months or years, then undergoing a spontaneous cure. Relapses are com- mon, especially if the disease is not properly cured. Diagnosis. The diagnosis of barber's itch is usually easy. It may be mistaken, however, for sycosis non-para- sitica, pustular eczema, vegetating syphilide, acne indu- 212 LECTURES IN DERMATOLOGY. rata, and seborrhoea. The history of the case, and the discovery of the parasite under the microscope will, of course, aid you in the diagnosis. Treatment. The treatment of barber's itch will require patience on your part and on the part of your patient. If you see the disease in the beginning, you may perhaps check its progress by suitable applications, but if it has lasted for weeks, it will take weeks before recovery is complete. If the disease has lasted only for a short time, you can frequently abort it by a few applications of the solution of carbolic acid, iodine, and chloral, that was recommended in the treatment of eczema margi- natum. This solution should be painted over the diseased surface every two or three days, and a soothing appli- cation, as Lassar's paste, kept continually on the patches to subdue the inflammation. If the disease has lasted for some time, you should direct your patient not to shave, but to keep his beard cut very close. Many dermatologists require that all the hairs should be pulled out of the diseased area, but this is painful, and often not necessary. All the hairs with suppuration about their follicles should be removed always, but more than this will seldom be required. Before any application is made, all crusts should be removed by means of soap and hot water, or by poulticing. Every night and morning the patient should bathe the surface for half an hour in very hot water. After this all loose hairs or those with pus about the roots should be removed. A lotion of IJ Resorcini 3 ss Hyd. chlor. corr gr. ii Glycerini 3 ii Aq ad | ii m TINEA VERSICOLOR. 213 should be applied and allowed to dry on. At night before retiring, an ointment composed of 3 Resorcini gr. xx Ung. hyd. ammon., Ung. zinc, ox aa 3 ss m should be applied to the lesions. Occasionally a dermatitis will be set up by this treat- ment, and if so it must be discontinued for a few days, and Diachylon ointment applied until the inflammation has subsided, when the former treatment may be continued. Other forms of parasitic ointment or lotions may be employed, but the treatment just recommended usually gives a good result. During the past few months, I have deeply punctured each tubercle in two or three places with a dermal spear every few days before apply- ing the hot water, and then painted them over with the solution of carbolic acid, iodine, and chloral, with most gratifying results. TINEA VERSICOLOR. Under the term tinea versicolor or pityriasis versi- color, I wish to describe a very common parasitic skin disease, which you have all probably seen a great many times, although you may not have recognized it as such. Pathology. The disease is due to a vegetable parasite called the microsporom furfur. It finds its way into the horny layer of the epidermis, and by its growth and development produces the symptoms of the disease. This parasite consists, as does that of the ringworm, of my- celium and spores. These mycelium and spores differ, however, from those of the ringworm, in that the my- 214 LECTURES IN DERMATOLOGY. celium are shorter, are usually empty, and contain very few spores and granules, and that the spores collect in groups. Etiology. The disease is contagious undoubtedly, but to a very limited degree. It never occurs in infants, and seldom in children. It is more common in persons who perspire freely, and in those suffering from wasting diseases, as consumption. Symptoms. The disease usually begins on the back or chest, or about the shoulders, as slightly elevated, yellow- ish spots, about the size of a pin-head, and slightly scaly. The spots increase in number and size, and running together produce large, irregular patches larger than the palm of the hand, but usually surrounded by the smaller pin-head lesions, thus giving the skin a mapped appear- ance, the patches being the mainland, and the smaller ones the islands. The larger patches are usually a little elevated, sharply defined, reddish-yellow, or buff color, and covered with a furfuraceous desquamation. The scaling is made more apparent by scratching the surface, but the scales are usually very fine, and not very abun- dant. The disease is attended by some itching, but frequently not sufficient to attract the patient's attention. There are so few symptoms connected with the disease that I presume some of you have it, and are not aware of your affliction. The disease is almost always limited to the trunk, never appearing on the hands, feet, or scalp, and very seldom on the face. Course. The disease usually spreads slowly, and lasts for months or years without treatment, but may undergo a spontaneous cure. Relapses, even when treatment is faithfully carried out, are common. Diagnosis. A differential diagnosis must be made between tinea versicolor and chloasma, leucoderma, sebor- TINEA VERSICOLOR. 215 rhcea, erythematous eczema, and erythematous syphilide. As in the other varieties of the vegetable parasitic dis- ease, the diagnosis is rendered positive by aid of the microscope. Treatment. As the disease is a very superficial one and confined to the horny layers of the epidermis, treatment is usually simple and satisfactory. Hot water, sulphur soap, and toilet pumice stone are usually all the reme- dies you will require. Form a lather with the soap and water and scrub the affected area with the pumice stone •every other night, which will usually cure the disease. Painting the lesion over with tincture of iodine a few times will have the same result. Lotions of sulphurous acid 10 per cent., or bichloride of mercury \ per cent., are satisfactory applications. It has been a matter of obser- vation with me that the parasite will not grow under an adhesive plaster of any kind, so if you cover the surface of the disease with a belladonna or capsicum plaster and let it remain for a week or ten days, on removing it you will find the trouble has disappeared. LECTURE XV. TUBERCULOSIS OF THE SKIN, URTICARIA AND 1 VERRUCA. TUBERCULOSIS OF THE SKIN. Gentlemen : There are four varieties of tuberculosis of the skin : I. Miliary, which runs a chronic course and is second- ary to phthisis ; II. Tuberculosis verrucosa cutis, and verruca necro- genica ; III. Scrofuloderma; and IV. Lupus vulgaris. I. The miliary form is rare. Usually appears about the corners of the mouth in the form of flat, very painful sores of irregular formation, the edges having an eaten-out appearance. -The cases are so few in number that it is not necessary for me to describe the lesions to you in detail. II. The second variety, tuberculosis verrucosa cutis, is very much more common, and the variety you will most generally meet with. The lesions are located on the hands and lower flexor of the forearm, most often on the backs of the hands or fingers, especially about the knuc- kles. They appear in the form of round, elevated plaques, varying in size, either single or multiple, on one or both hands. In a short time a bright red line develops about 216 TUBERCULOSIS OF THE SKIN. 2 1/ the plaque, and in it superficial pustules make their appearance. An erythematous redness extends from the healthy skin about the lesion. In the course of a few weeks the plaque becomes covered with warty growths or papillomata covered with horny scales. Between the papillary growths small pustules form from time to time and rupturing dry, forming scabs and crusts. After a time the formation of pus ceases, and the crusts consist only of epidermic scales. After lasting for some months the lesions may dry up and disappear, leaving superficial scars. Over the edges of these scars new plaques may make their appearance from time to time, giving a serpiginous form to many of the lesions. No general tubercular in- volvement occurs, but the tubercle bacilli are found present in the lesions. Etiology. The disease is always the result of inocula- tion of the skin with the tubercle bacillus, and is most frequently seen in men. The disease is purely local, and does not produce tuberculosis elsewhere in the body. Diagnosis. There are but two or three diseases which you are likely to confound with this variety of tubercu- losis. They are lupus vulgaris, tubercular syphilide, and possibly sarcoma of the skin. Treatment. The growth must be entirely destroyed, or it will return. There are two methods of treatment which I can recommend ; sometimes you may employ one, some- times the other. The growth may be entirely curetted away and then treated with pyrogallic acid, as was recom- mended in the treatment of lupus vulgaris, or it may be completely excised, the edges of the wound brought together, and healing made to take place by first intention. The only application which seems to be of any advantage outside of caustics in destroying the growth, is a 10 to 2Q 2 1 8 LECTURES IN DERMA TOLOG Y. per cent, salicyliated plaster containing I to 2 per cent, of beechwood creosote. Verruca necrogenica, a form of the second variety, is almost always the result of inoculation with tubercular material, and sometimes described inaccurately as "dis- secting wound." The changes produced are partly cutane- ous, partly subcutaneous. The changes consist in the formation of a tubercle, purplish in color, which goes on to suppuration, breaks down, discharging a small amount of pus, and then forms a warty growth. The subcutane- ous change consists in the formation of cold abscesses. An infiltrated area appears about these tubercles, which in turn breaks down, producing pus, and then grows warty in character. The process is apt to extend in the periphery while healing in the centre. It is purely a local process, which may end, in a few weeks or months, in recovery. Treatment. The best treatment for this variety of tuberculosis of the skin consists of the thorough use of the curette, and subsequent treatment with pyrogallic or applications of pure beechwood creosote to the diseased tissue. III. Scrofuloderma. There are two varieties of scro- fuloderma, {a) In the first variety, which is the most common, it begins in one or more of the superficial lym- phatic glands, especially under the jaw, about the neck, or clavicular regions. The glands become enlarged, and the process extends to the skin overlying them, which becomes red and infiltrated. The glands break down, forming a cold abscess, which discharges through the infiltrated skin, leaving an ulcer of slow progress with undermined, violaceous border, which heals very slowly, leaving often unsightly scars, which are very prone to degenerate and form ulcers. TUBERCULOSIS OF THE SKIN. 219 (b) The second variety is called scrofulous nodes, or scrofulous gummata, on account of their resemblance to syphilitic gummata. The most superficial of these lesions begin as little infiltrations in the skin, of a livid, red color, increasing in size slowly at first and later more rapidly. It extends in one or more directions, involving the whole thickness of the skin, softening at one or more points to form small ulcers, which burrow, leaving sinuses, they extending from one opening in the skin to another. The discharge from these ulcers is usually sero-purulent, occasionally bloody, and the skin of the affected region becomes undermined by numerous connecting galleries. Occasionally the disease takes on a diffuse, infiltrated form, spreading in an irregular patch over the skin, giving rise to serpiginous, shallow ulcers. The scrofulous ulcers never show any disposition to heal. It may look as though it were on the very verge of cicatrization, but it does not actually heal over, or if it does in a week or two the cicatrization breaks down and the ulceration continues. Diagnosis. Scrofulous ulcers must be carefully diag- nosed from other forms of ulcers, especially the syphilitic and the lupus ulcers, which not infrequently involve similar areas. Treatment. The treatment of scrofuloderma is both general and local. Cod-liver oil, iodides, usually in the form of iodide of potash, iron, or mercury, seem about the best internal forms of medicines. Locally the ulcers may be treated with stimulating ointments, preferably those containing mercury, the white precipitate ointment being a very useful one. Scraping and curetting of the ulcers with a sharp spoon and dusting with iodoform is often beneficial. Iodoform in glycerine or oil may be injected in scrofulous glands. Crocker recommends chaulinoogra 220 LECTURES IN DERMATOLOGY. oil in ten- to thirty-drop doses, with the external use of the same oil made in form of an ointment, three drachms to the ounce. IV. Lupus vulgaris. The fourth variety of lupus of the skin we have already studied under the term of lupus vulgaris. URTICARIA. A very common disease of the skin is urticaria or hives. Doubtless many of you have at one time or another suffered from it. Pathology. It is an acute, inflammatory process taking place in the papular layers of the skin, seriously affecting the circulation and nerve supply of the area attacked. In the centre of the lesion the blood supply is most diminished, but increases in the periphery, and also per- haps in the deeper layers of the corium beneath. The affected area of skin is cedematous, and the blood and lymphatic vessels near-by found surrounded by leucocytes. When the serous exudation becomes extensive the epi- dermis is raised up, forming a vesicle or bulla, when the disease becomes known as vesicular urticaria. Etiology. The cause of urticaria may be either external or internal. Among the most common external causes are insect bites and irritating substances, as cowhage or nettle. Among the most frequent internal causes are certain kinds of food, as shell-fish, strawberries, veal, pork, etc. Such articles of food, by setting up a gastrointes- tinal derangement in some persons, produce through the vaso-motor system an urticaria. Certain drugs, especially copaiva, cubebs, turpentine, chloral, quinine, and anti- pyrene, have frequently the same effect on the skin when taken internally. Other forms of intestinal irritation — as TUBERCULOSIS OF THE SKIN. 221 that due to worms — will frequently excite urticarial erup- tions. Agents acting directly on the nervous system are frequently the cause of urticaria. Sudden emotion or shock, especially in females, will be followed by an attack of this disease. Spinal irritation and various nerve lesions, especially with neuralgic symptoms, predispose towards it. Organic diseases of the kidneys or uterus, and general diseases of the blood, as purpura and rheu- matism, are frequently complicated by urticarial attacks, which often become chronic. Urticaria is one of the most frequent eruptions in early pregnancy. Symptoms. The first local symptoms noticed are burn- ing, stinging sensations in the skin, like those produced by the sting of nettles. This produces an itching, which the patient tries to relieve by scratching, and causes efflorescences to appear. The lesions make their appear- ance suddenly, and consist mostly of wheals of variable size, color, and shape. They are usually not larger than a dime and round, but a number may coalesce, producing large patches of irregular shape. In color they are whitish or pinkish, and surrounded by an areola. The lesions are usually elevated, flat, and hard. The skin becomes very irritable, so that slight irritation as by scratching will be followed by the production of a welt or wheal. The number of lesions and the extent of surface affected vary much in different cases, but generally the lesions appear suddenly in groups, and affect only a portion of the body at a time. After remaining on one part of the body for a few hours it may appear in a different locality. There are no regions of predilection, as the whole surface of the body and the mucous membranes are liable to its attacks, but it is more apt to occur on those parts most likely to become hypersemic from pressure or friction from 222 LECTURES IN DERMATOLOGY. the clothing. It comes at any period of life, but is more apt to attack children than aged adults. In children there is especially apt to be more constitutional symptoms accompanying the attack, as slight fever and gastro- intestinal disturbance.* In some cases of urticaria the exudation in the skin becomes so great as to form vesicles or bullae on the surface of the wheals. Course. The disease is usually one of short duration, the individual lesions lasting but a few hours, and the disease but a few days, during which time frequently exacerbations are likely to take place. Occasionally the disease becomes chronic, lasting for months or years. Here again the individual lesions do not last out much longer than a few hours or days, but new ones continue to make their appearance, so that the patient is seldom free from them. In these chronic forms, especially when occurring in children, the lesions may remain for some time, and assume a yellowish color, which, upon dis- appearing, leaves a brownish stain or pigmentation, which is permanent. Diagnosis. Urticaria is so common, and its symptoms and lesions so pronounced, that the diagnosis is seldom difficult. It has, however, been mistaken for erythema nodosum, erythema multiforme, erythema simplex, insect bites, erysipelas, and eczema. Treatment. The cause of the disease should be deter- mined, if possible, and removed. It is usually well to be- gin treatment with a calomel purge, followed by a dose of castor oil, and the patient kept on a bread and milk diet. When the disease shows a tendency to return, alkalies should be given before meals, and the diet restricted. To allay the irritability of the skin alkaline and bran baths are very serviceable, and had best be given hot. TUBERCULOSIS OF THE SKIN. 223 Acid, boracic, Acid, carbolic, Sodii bicarb aa gr. viii Glycerini 3 i Aq. picis ad 3 i m is a very good lotion to allay the irritability of the skin. Some patients are relieved by sponging the body with hot vinegar once or twice a day. When bullae form, the treatment should be very mild, and applications of some drying or astringent ointment applied. A diachylon ointment with a 5 per cent, salicylic acid in it is very beneficial. There is no special treatment for urticaria pigmentosa. Relapsing or chronic urticaria may be decid- edly benefited by giving large doses of jaborandi. VERRUCA. You will frequently be called upon to treat a very com- mon affection, called verrucas or warts. Pathology. The pathology of warts differs somewhat according to the variety, but they all consist of circum- scribed hypertrophies of the papillary layer of the skin. The epidermis on the surface also becomes hypertrophied. The blood-vessels supplying the papillary hypertrophies are increased in size and number, especially in some varieties of warts. Etiology. There seems to be in many cases an heredi- tary tendency to the formation of warts, for we find them more frequently in some families than in others. By many they are supposed to be directly contagious, and may be produced in this way. There is a superstition held by many that handling certain animals, especially 224 LECTURES IN DERMATOLOGY. the toad, will produce a crop of warts. Certain irritating substances when applied to the skin will set up an inflam- matory condition which may result in the formation of warts. The irritating secretion from moist warts will occasionally, whether from contagion or not I cannot say, produce warts of the same variety. Warts most fre- quently occur in persons of a strumous diathesis, but may occur on persons of healthy constitution. Symptoms. Warts most frequently occur in children and young adults, and are of five varieties. (a) Verruca vulgaris is the most common variety, and occurs most frequently on the hands. They are firm, circumscribed, round growths about the size of a pea, rough or smooth on the surface, but always horny. The color is usually darker than the surrounding skin, and may be nearly black. They often occur in large numbers, and grouped. They are frequently fissured or cracked, and then become painful and bleed easily. {b) Verruca plana differs from the vulgaris in being usually smooth and flat, but slightly elevated above the skin. They occur more frequently about the face, espe- cially in old people, and are then called verruca senilis, and not infrequently develop into epithelioma. (c) Verruca jiliformis is the result of the hypertrophy of a single papilla in the skin. They are thread-like pro- cesses about one sixth of an inch in length. They ap- pear about the face, eyelids, or neck, either single or in groups. (d) Verruca digit at a always appears upon the scalp. They are hard, slightly elevated, and marked at their base by a number of digitations looking like feet and giving them the appearance of insects. (e) Verruca acu?ninatis, or venereal zvarts, or moist VERRUCM. 225 zvarts, almost always make their appearance on the genital organs. In the male they occur on the inner surface of the glans or prepuce, and in the female on the surface of the labia. They are very apt to accompany venereal affections as a result of irritating secretion, but by no means necessarily so. By many they are considered erroneously as contagious. They may appear upon any moist surface, as about the anus or between the toes, where there are heat and moisture. These warts are of various size, from a thread to a hen's egg, or even larger. The smaller ones are usually pedunculated. Some appear as masses of vegetation, called cauliflower warts, others as flat, fleshy excrescences. They grow very rapidly, usually multiple, and may become confluent, producing large masses of cauliflower growths. They are usually vesicu- lar, pink or red in color, and when moist secrete a semi- purulent fluid, which decomposes readily, producing an offensive odor. This secretion may dry upon the surface, producing crusts. Diagnosis. The diagnosis of warts is usually very easy. Occasionally they are mistaken for epitheliomata or tuber- cular affections of the skin, but in the large majority of cases you will have no difficulty in distinguishing these diseases from simple warts. Treatment. The best and quickest treatment for hard warts when there are but two or three present is to snip them off with a pair of scissors, and touch the bases with a stick of nitrate of silver. If your patient objects to this surgical procedure, the best caustic to apply is nitric acid every second or third day. A slower but less painful way, and one especially to be recommended where the warts are numerous, is the application every second or third day of a 10 per cent, solution of salicylic acid in 226 LECTURES IN DERMATOLOGY. flexible collodion. Before each application the warts should be scrubbed and cleansed with soap and hot water, then thoroughly dried. The soft or venereal warts should be treated with applications of glacial acetic acid every day or two, and dusted over with calomel twice a day, after thoroughly cleansing with hot water and castile soap. If there are much heat and moisture the parts should be kept sepa- rated with lint or wool. Some of the large, flat excrescen- ces will not yield to this treatment, when chromic acid, or the galvano-cautery must be applied to remove them. The only internal remedy in which any confidence can be placed, is the thuya occidentalis. This remedy may also be applied externally at the same time. This, Gentlemen, finishes my course of lectures in derma- tology, which I have mapped out for you. In the few moments which I have left I cannot employ the time more profitably than to read to you some dermatological " Don'ts," to which I am indebted to my friend, Dr. G. T. Jackson, of New York. SOME DERMATOLOGICAL DON'TS. Don't make your diagnosis from the history of a case, because if you do you will often be led astray. Make it from the eruption that you see, and then substantiate or destroy this by the history of the case, if you will. Don't fail to think of the possibility of every case being either syphilis or eczema ; and Don't fail to master these two diseases as thoroughly as possible ; because, if you learn to recognize these two, you will have gone a long way in diagnosis. If they can be excluded, then the field of possible " might be's " is con- siderably narrowed. DERMA TOLQGICAL DON' TS. 227 Don't make the diagnosis of syphilis on account of a syphilitic history, because you can often get a history of syphilis in a non-syphilitic case. Don't expect much, if any, history of syphilis in a woman, because you very frequently will not get it. This is not because they are " gay deceivers," but because in them the early symptoms of the disease are often so slight that they are not observed by them. Don't throw out the diagnosis of syphilis on account of an eruption itching, because some syphilides, especially in the papular variety, do itch at times. The not itching of an eruption is better presumptive evidence of syphilis than is itching positive evidence against it. Don't make the diagnosis of lichen planus from the presence of flat angular papules with depressed centres alone, because identical lesions will at times be met with in eczema, syphilis, and psoriasis. Don't depend upon getting the bleeding-points springing out of the delicate pellicle after carefully scraping off the scales for your diagnosis of psoriasis, because you can produce the same thing in other diseases. In fact, Don't depend upon any one symptom, but make your diagnosis from the general make-up of the disease as a whole. Don't forget that many diseases of the skin are de- pendent upon disturbances in the general health of the patient. Therefore, Don't fail to inquire into the performance of the func- tions of the various organs of the patient, and to put him into as good a physical condition as possible. Don't tell your patient that it is dangerous to cure his skin disease rapidly, because it is not. If you 228 LECTURES IN DERMATOLOGY. Don't know how to treat the case, ask advice of some one who does. Don't encourage the popular notion that there is danger of an eruption striking in, because it never does. Don't give arsenic for every skin disease ; and, especially, Don't give it in acute eruptions. Its sphere is in the chronic scaly eruptions, such as chronic psoriasis. Don't forget that most cases of pruritus are due to in- ternal causes, and that in them external treatment is wasted ; and Don't forget the bed-bug and the pcdiculus as possible causes of the trouble. Don't forget that the greatest secret in the treatment of eczema, and many other skin diseases, is not what particu- lar drug or formula is "good for" the disease, but a knowledge of the great principle that acute diseases need soothing remedies, and subacute and chronic diseases need stimulation. Don't expect to cure an inveterate eczema with thick- ened skin by means of a soothing ointment, such as that of the oxide of zinc, because you will only waste your time and the patient's money. Don't use tar in an acute eczema, because it is a stimu- lant, and what we want at this time is to soothe the in- flamed skin. It is appropriate to a subacute or chronic case. Don't allow water to touch any form of eczema, because it always irritates in such a case. Don't use a thick ointment on the hairy scalp, because it makes a disagreeable mess of the hair and will not be " popular " with your patient. Even lard is not a pleasant vehicle for such applications. Vaseline and the oils are more elegant excipients. DERMA TOLOGICAL DON* TS. l2<) Don't order the hair to be cut from the head of a young or old woman in any disease of the scalp, because, except in the case of a peculiarly stupid or careless patient, it is never necessary, and always disagreeable to the woman. Don't allow a patient with ringworm to go to school, because if you do you will be responsible for the spread of the disease. Don't pronounce a ringworm case well and incapable of spreading the disease until you are sure that it is well ; and Don't be sure about it until there are no more "stumps " on the scalp, and you can find no more of the fungus in the hair. Don't use the name " barber's itch " for anything but trichophytosis barbae, because it is well not to use terms loosely to cover several different diseases. Don't use chrysarobin on the face or scalp, because it is very apt to cause a good deal of dermatitis with oedema, and to stain the skin a deep mahogany-red. Don't forget to caution a patient to whom you have given chrysarobin not to touch his face with his hands after applying the drug, because if you do you will have either a mad or frightened patient in your office. Don't pronounce a patient addicted to the excessive use of alcoholic beverages on account of his having rosacea, because there are lots of other things besides alcohol that will cause it. Don't use the positive pole of the battery for the needle in destroying hair by electrolysis, because if you do you will leave more or less permanent marks in the skin. Don't apply a sulphur preparation after using a mercu- rial upon the face, or vice versa, because if you do you will raise a fine crop of comedones. 230 LECTURES I.\ T DERMATOLOGY. Don't use a camel's-hair brush for making applications of corrosive sublimate, because if you do some of the salt will be left on the brush each time it is used, and you soon will have a stronger solution than you bargained for. Always use a little cotton on a wooden toothpick, or a splinter of wood. Don't allow a fine-toothed comb to be used on the scalp, because it scratches and irritates the scalp. Don't encourage or advise the use of pomades on the healthy scalp, because they are prone to become rancid and inflame the scalp. They are also unnecessary if the hygiene of the scalp is properly looked after. Don't forget that dandruff is the most frequent cause of premature baldness, because if you remember this you may be able to prevent the fall of some one's hair for some time. Therefore, Don't forget to treat every case of dandruff. Dr. Jackson neglected to add one more don't which is very important — Don't forget to study Dr. Cutler's " Differential Diag- nosis of the Diseases of the Skin," published by G. P. Putnams Sons of New York. INDEX. PAGE. 3 1 52 19 39 Achorion Schoenleinii Acne Addison's disease Alkaline diuretics Alopecia . " areata " furfuracea Anatomy of the skin Arsenic in skin diseases Asteatosis Barber's itch ...... 209 Bassorin 22 Baths 27 Birth-mark 145 Black-heads ...... 57 Blind boils 104 Body lice 148 Koils 101 Bromidrosis 100 Bullous skin diseases g " syphilide ..... 199 C Capillary nsevus ..... 145 Caustics 28 Chloasma 50 Chronic eczema 71 Classification of skin diseases . . 6 Clavus . 53 Cod-liver oil 18 Collodion ...... 25 Comedo ....... 57 Condylomata ...... 188 Corns ....... 53 Crab-lice 149 Dandruff. Dermatitis " venenata Dermatological don'ts . Diagnosis of skin diseases Diseases of the skin Dry tetter Ecthyma . 62 " syphilitica . 192 Eczema . . • 65 " erythematous . 69 " marginatum . 205 " papular • 71 " pustular . 70 " rubrum • 7 2 ' seborrhoeicum • 178 ' squamous . ■ 73 1 vesicular . 69 Epithelioma . . 80 Ergot in skin diseases • 19 Erythematous eczema . 69 " syphilide . 186 External medication . 20 231 232 INDEX. Favus 200 Feigned skin diseases . . -99 Freckles 124 Furunculosis ...... 101 Gelatine plasters Glyco-gelatines Gnmmala Gummatous syphilide Gummy tumor H Head lice Hereditary syphilis Herpes . . . " circinatus " facialis progenitalis " simplex " zoster . Hirsuties Hives Hyperidrosis . Hypertrichosis Hypodermatic medication Lesions of the skin Leucoderma Lichen " planus . " syphiliticus . " trophicus Lotions Lupus erythematosus ' vulgaris M Macular skin diseases syphilide . Mercury in skin diseases Microsporom furfur Miliaria papulosa . " vesiculosa Milium . Moles . Molluscum contagiosum Mother's mark Mucous patch . N Ichthyosis .... Impetigo ..... " contagiosa " syphilitica Instruments used in dermatology Internal medication in skin disease: Iodide of potash . Keloid . Keratosis pilaris Lassar': Ointment n Ointments 1 ] in I 1 eczema 70 " skin diseases .... 9 " syphilide . . . . 187 Papulo-squamous syphilide . 1S9 Parasitic sycosis 209 Pediculosis 146 " capitis 147 " corporis . .140 " pubis . . . '49 Pemphigus 149 Pigmentary syphilide .... 190 Pityriasis rosea 152 " versicolor .... 213 Lentigo ,24 Plasment . Powders . Prickly heat . Pruritus . Psoriasis . Purpura . " hemorrhagica rheumatica " simplex Pustular eczema skin diseases " syphilide . Ringworm " of the beard " " body " " scalp Rodent ulcer . Rosacea . Rupia INDEX. 233 PAGE. PAGE. . 26 Syphilide, gummatous . • »93 130 pustular . 190 '53 Syphilitic psoriasis . . .89 '57 Syphilis .... . 185 '9 Syphilodermata . • 185 71 Teleangiectasis '4i 9 Therapeutics of skin diseases 15 190 Tinea 200 barbae . 209 circinata 203 " favosa . 200 ?02 tonsurans 207 trichophytina 202 20.' versicolor 213 207 'I raumaticin . 2S 8l Tubercular skin diseases 9 169 " syphilide 192 Tuberculosis verrucosa cutis 216 Tumorous skin diseases 9 Scabies Scrofuloderma Scrofulous gummata " nodes . Seborrhcea " capitis . " oleosa Seborrhoeal eczema Shingles . Soaps Strawberry mark Sudamina Sweating Sycosis parasitica . " vulgaris Syphilide, erythematous " macular papular . papulo-squ; Syphilide, pigmentary " tubercular V Venereal warts 223 Verruca 223 " acuminatis 224 ' digitata ..... 224 1 filiformis ..... 224 " plana ...... 224 vulgaris 224 Vesicular skin diseases .... 9 Vitiligo ....... 127 W Warts 223 X Xeroderma 49