Qass. Book COPYRIGHT DEPOSIT Skin Diseases THEIR DESCRIPTION, ETIOLOGY, DIAGNOSIS. AND TREATMENT ACCORDING TO THE LAW OF THE SIMILARS. BY M; E. DOUGLASS, M. D., Baltimore, Mb., LEcxrRER ON Dermatology in the Southern Homceopath Medical College of Baltimore, Md. PHILADBlvPHIA : BOERICKE & TAFEL. '*• '■ ■ 1900. TWO COPIES RECEIVEO. library of CGiBsr§8% Offlee of tli« APR 7 - 1900 H9Kl9t«r of Gopyrlg|fi% 60024 COPYRIGHT BY BOERICKE & TAFEL, 1900. T. B. & H. B. COCHRAN, PRINTERS, LANCASTER, PA. SECOND COPY, Uo-^fc. ^ PREPACK. Man is a composite being. We have the skeletal man ; the muscular man; the arterial man; the nervous man; the venous man; and enclosing and protecting all these the skin— or outer man. This outer man is the one in whom we all take a greater or lesser pride; the one that receives the greatest amount of attention; the one that more pains are taken to beautify and adorn than all the others; the one in which any imperfection is soonest noticed, and for which relief is most promptly sought. The physician who can soonest remove the disfiguring blemishes, heal diseased conditions, smooth and beautify the skin is the one whose praises are the loudest pro- claimed by the gratified patient. In no other department of medical science is a reputa- tion so readily made as in the department of dermatology, for the reason that patients can speedily judge whether the physician is likely to do them good or harm. What not to do in treating skin diseases is an import- ant thing to know. The physician must have a thorough knowledge of the general course and behaviour of skin diseases, and it is essential that he should be proficient in the principles of general medicine, in order that he may treat affections of the skin intelligently and success- fully. The reason for this statement will become ap- parent as we study the etiology of the various lesions. We will then find that it often is necessary only to treat the cause to remove the lesion; and in this branch of IV PREFACE. medical science, more than in any other, perhaps, we will find Hahnemann's rule to treat the totality of the symp- toms complained of by the patient, the only method by which we may cure our patient. " The highest aim of healing is the speedy, gentle, and permanent restitution of health, or alleviation and oblitera- tion of disease in its entire extent, in the shortest, most reliable, and safest manner, according to clearly intel- ligible reasons. ' ' '* When the physician knows in each case the obstacles in the way of recovery, and how to remove them, he is prepared to act thoroughly, and to the purpose, as a true master of the art of healing." The author has been prompted to prepare this work by a conviction of the existence of an urgent demand for a work on Dermatology in our School of Medicine, which should embody the advances recently made and set forth the distinctive characters of our therapeutics in a rational and practical manner. The work has been written in the first instance with the view of meeting the wants of the homoeopathic prac- titioner in his daily dealings with diseases of the skin; at the same time the needs of the medical student in pre- paring for his examinations has been kept constantly in mind. The author has endeavored to present his subject in the most practical manner and with the fewest possible words consistent with an intelligible presentation of the same. To this end he has avoided all theoretical and con- troversial discussions, which are of interest to the special- ist rather than to the general practitioner or student. 7 W. North Ave. May, 1899. CONTENTS. CHAPTER I. Thh Anatomy of the Skin, 9 Blood Vessels, 10. Epidermis, 11. Subcutaneous Cellular Tissue, 17. The Sweat Glands, 17. Sebaceous Glands, 20. Hair. 22. Muscles of the Skin, 23. Nails, 24. Nature and Amount of Perspiration, 28. CHAPTER II. Some General Observations, : . . . 33 Rules for Studying Skin Diseases, 41. CHAPTER III. Classification of the Elementary Lesions, ...... 48 Macule, 49. Vesicle, 50. Bulla, 51. Pustule, 51. Papule, 52. Tubercle, 54. Scales, 55. Fissures, 56. Ulcers, 56. Drug Eruptions, 57. Pathology, 59. CHAPTER IV. Etiology, . 60 CHAPTER V. Local Dermal Inflammations, 70 Erythematous Diseases, 72. Erythema, 73. Erythema Mul- tiforme, 73. Erj'thema Nodosum, 75. Roseola, 79. Urti- caria, S2. P^ollicular Hyperaemia, 93. Medicinal Rashes, 94. CHAPTER VI. The Eruptions of Acute Specific Diseases (Zymotic), . 96 Variola, 96. Varicella, 107 Typhus Rash, 108. Typhoid Rash, 108. Measles, 109. Scarlatina, 114. Erysipelas, :i5. Rubella, 125. Frambcesia or Jaws, 126. VI CONTENTS. CHAPTER VII, Papular Infi^ammations, 129 Lrichen Planus, 129. Ivichen Ruber, 133. L^ichen Simplex, 135. lyichen Scrofulosorum, 141. Strophulus, 142. Prurigo, 143- CHAPTER VI n. ECZRMA, 148 CHAPTER IX. Buivi^ous Diseases and Anomalous Forms of Bullous Eruption, i/<2;z^'<2r surfaces, frequently accompanied with great thickening of the epidermis and with fissures, requires special treatment. The thickened epidermis must be removed mechanic- ally with knife, file, or sand-paper. After all that is pos- sible has been removed in this waj^, a five per cent, solu- tion of salicylic acid in flexible collodion should be applied. After several daily applications have been made, it will be found that still more of the epidermis may be easily removed. If infiltration be present, liquor potassae should be applied, taking care not to let it get into the fissures, if any be present. The fissures them- selves should be dressed with graphite, and white pre- 172 SKIN DISEASES. cipitate or citric ointment applied to the entire diseased surface. If, however, there be Uttle infiltration or epidermic proliferation, tar or its equivalent is indicated if the sur- face is dry and scaling ; while some of the less stimulat- ing ointments should be applied if the surface be moist and exuding. At best, eczema of the hands, if already chronic, is an exceedingly obstinate affection, and one difficult to remove. Eczema of the leg is very frequently dependent on pre- existing varicose veins, and when such is the case is difficult to manage, unless the diseased veins can them- selves be brought under control. If the varicose condi- tion be at all severe, the general nutrition of the skin of the leg seems to suffer greatly, and a slight wound from scratching may degenerate into an ulcer. The cutaneous tissues, which are the site of the lesion, and for a consid- erable space around it, may be greatly thickened, and the surface present a bluish tint from impeded circulation. When this condition exists, the utmost benefit will be secured from the systematic use of the rubber bandage applied so as to bring firm but even pressure to bear upon the parts. The bandage should, in the first instance, be applied by the physician, and the mode of its application taught the patient. The bandage should, when practic- able, be applied morning and night, and, if it becomes soiled by discharges of any kind, should be replaced by a fresh one, while the first one is permitted to soak in cold water till again needed. After the leg has been restored to its natural size, the bandage may be discarded, but an ordinary eclastic stocking should be worn habitually. The direct applications to be made will depend on the stage of the eruption and condition of the lesion. TREATMENT OF ECZEMA. 173 Eczema of the leg, however, is not always of varicose origin, but sometimes presents itself as a chronic subacute circumscribed lesion, with or without much infiltration. If scaling be a notable feature — that is, with decided epi- dermic thickening and proliferation — a few applications of salicylic acid will prove of great service as a prelimi- nary application, and a ten or fifteen grain solution in flexible collodion should be painted over the spot. This may be repeated a few times until the tendency to scale formation has notably diminished. If there be but little infiltration, tar, or some of its preparations, is indicated ; but if infiltration is marked, potash or scarification should be employed and afterward zinc or white precipitate ointment. Acute eczema of the leg requires different treatment. If the greater part of the leg or both legs are involved, rest in bed or on a lounge, with the limbs elevated, is a sine qua non. The parts, being inflamed, hot, red, swollen, and exuding, need rest and soothing treatment. Absolute rest must be insisted on, and when secured apply a diluted solution of peroxide of hydrogen. The best method of applying it is with an atomizer. Purulent exudation is brought under immediate control, and of- fensive odors are destroyed. After two or three days, as a rule, the inflammation will be lessened, the area of de- nuded surface diminished, and attempt at healing be apparent. Now, some of the medicated plasters contain- ing oxide of zinc or ammoniated mercury should be ap- plied. These may be left undisturbed for several days, and if covered with an elastic stocking the patient may be permitted to take moderate exercise. If no indiscre- tions be committed, steady progress toward cure may usually be expected. 174 SKIN DISEASES. Eczema of the inner surface of the thigh not unfre- quently appears in the papular form, and may best be treated with permanently attached dressings containing zinc or white precipitate. Eczema of the anus is an insiduous affection, and is frequently of long standing before it is brought to the notice of the physician. Thickening and fissures often coexist, and should first be treated and healed by cau- terization, peroxide of hydrogen, graphite ointment, or powder, etc., before any attempt is made to reduce the infiltration by strong alkaline applications. One of the most effective applications to the fissures is the fine point of a Paquelin cautery at a white heat. Eczema of the mammae and nipples is a very frequent accompaniment of scabies in the female, and when met with the latter disease should be suspected and sought for, and the scabies, if present, receive the first attention. In obese persons an eczema may arise from the irrita- tion produced by the confinement of the cutaneous secre- tions by overlapping folds of skin, as under pendulous breasts and in the groin between the thigh and genitals. In these, simple dusting powders, with separation of the parts by linen, will often accomplish all that is required. We now come to the consideration of the most import- ant of the means of cure of eczema, and one in which Homoeopathy has won some of her brightest laurels, — the internal treatment. Indications for the remedies are as follows: Aconite. — Acute eczema in plethoric persons. Al2imina. — Dry, thin subjects and old people with constipated bowels ; the slightest bruise of the skin smarts ; brittle nails ; much itching with no relief from scratching ; the patient feels as if the white of ^%% had dried on the surface ; itching aggravated in the evening TREATMENT OF ECZEMA. 175 and from the heat of the bed, and every other day ; and, in the open air. Ammon. carb. — Eczema in the bends of the extremities ; excoriations between the legs, and about the anus and genitals ; violent itching relieved by scratching. Aggra- vated by either cold applications or hot poultices ; in children. Ammon. mur. — Eczema on the face and across the loins ; intense burning, somewhat relieved by cold appli- cations ; constipation ; in fat, sluggish individuals. Anacardium. — Acute eczema on the face, neck and chest. Tubercles on the scalp, sore when touched ; vio- lent itching, worse at night, and after scratching ; redness of the skin with eruption of small vesicles ; rough, ex- foliating skin around the mouth, burning around the lips as from pepper ; sensitiveness to draught. Antimon. crud. — Eczema with gastric derangement ; violent thirst ; white coated tongue ; yellowish, tenacious discharge ; violent itching ; aggravated from wet poul- tices, from bathing and working in water, from alcoholic drinks and in the sun. Antimo7i. tart. — Pustular eczema with bronchitis ; vio- lent itching, suppurative rash, particularly on the occiput, chest and arms ; sleepiness with nausea ; rattling cough ; irritable ; wants to be carried ; complains when touched. Apis. — Eczema with renal troubles, scanty urine, no thirst; tendenc}^ to dropsical swellings; burning and stinging in the skin ; aggravated from heat, ameliorated from cold water and scratching. Argent, yiitr. — Eczema on the genitals ; urging to urinate ; in children who eat too much sweets. Arse?!, alb. — All forms accompanied by intense burn- ing of the skin ; fetid or purulent discharge or dry, scaly eruption ; falling out of the hair in patches here and 176 SKIN DISEASES. there, leaving the skin dry and dirty looking ; dry, parchment-like skin ; thirsty, drinking little and often ; aggravated after midnight, from cold, in open air and from scratching with bleeding afterward ; ameliorated from heat. Arundo Maui'it. — Eruption on the chest, upper ex- tremities and behind the ears. Intolerable itching, crawling sensation, especially over the loins and shoul- ders ; in young children. Astacusfluv. — Thick crusts on the scalp ; enlargement of the lymphatic glands ; clay colored stools. Aurum. — Old persons with mercurial symptoms; sui- cidal tendencies ; constant desire to be in the open air even in bad weather. Baryta carb. — Eczema capitis, wdth falling out of the hair and swelling of the adjacent glands ; fat, dumpy children ; timidity in the presence of strangers ; chronic disposition to swelling of the tonsils or glands of the neck ; takes cold easily ; aggravation at night and from scratching ; ameliorated when walking in the open air. Bellad. — Eczema on the face with scarlet redness, burning, itching eruption, sensitive to the touch ; in teething children, with tendency to convulsions ; over- sensitive, excitable persons. Borax. — Eczema on the face and scalp ; red, papulous eruption around the cheeks and chin ; excoriating secre- tions ; aphthous difficulties ; slight injuries suppurate ; dread of slight downward motion. Bovista. — Eczema about the mouth and nostrils ; gen- eral lassitude, especially in the joints ; patient wants to urinate immediately after micturition ; constipation ; perspiration smells like onions ; aggravated from warmth ; grocers' itch; moist vesicular eruption with formation of thick crusts; eruption on the thighs and bends of the TREATMENT OF ECZEMA. 177 knees; on the back of the hand; swelling of the upper lip; burning, itching; no relief from scratching; symptoms worse during hot weather; the skin of the fingers becomes dented by the use of the scissors or other instruments. Bro7nine. — Profuse oozing of a dirty, nasty-smelling discharge; eczema covering the head as with a cap; crawl- ing sensation beneath the scalp, with sensitiveness to the touch; glands of the neck hard and swollen; high-colored urine. Bryojiia. — Eczema capitis when the scalp is ver)^ tender to the touch, and there are pains and aches worse from motion; eczema all over the body, especially on the back ; eruption slow in making its appearance; symptoms worse from exposure to the heat of the fire; stools dry and hard as if burnt. Calcarea carb. — Chronic and squamous eczema in scrofulous persons; skin inclined to ulcerate; itching and burning in the skin; thick crusts with oozing; parts affected — nape of neck, head, face, on and behind the ears, genital organs, region of umbilicus, hands and bends of the extremities; chalky stools; menses too soon and too profuse; takes cold easily; cold feet, as though there were damp stockings on them; no dread of water, but the disease is aggravated by water; aggravated in the open air and from water and from drinking milk; ameliorated in a warm room; in big-bellied children with light hair and blue eyes; profuse sweating of the head. Caladium. — Eczema alternating with asthma; great disinclination to move; vertigo on going to sleep; eczema of vulva, chest and forehead; ameliorated when pertjpiring. Cantharis. — Eczema with urinary difficulties; much burning and smarting or burning itching; aggravated from touch; ameliorated from lying down. 178 SKIN DISEASES. Carbo veg. — Eczema with hemorrhoids and flatulency; the most innocent food disagrees; cachectic individuals; aggravated from warmth and water. Carbolic acid. — Moist vesicular eruption on the hands and all over the body. Itching better from rubbing, but leaving a burning pain. Causticum. — Eczema in rheumatic or gouty individuals; moist eczema on the neck and around the nipple; thick crusts on the nostrils; great restlessness; child is afraid at night in a dark room; aggravated in the open air and in the evening; ameliorated from the warmth of the bed. Chamom. — Excoriations between the thighs in children and infants; unhealthy skin, every injury suppurates; severe itching of sweating parts; child fretful, must be carried about. Chelidofi. — Eczema rubrum of the scrotum, or ankle; heat, swelling and redness of the parts; bitter taste in the mouth when not eating or drinking; pain in the hepatic region ; chronic affections of the abdominal organs. Cicuta. — Thick, whitish scurfs appear on the chin and upper lip; they secrete a dampness; sometimes affect the nose; no itching; the exudation dries down into a hard, lemon-colored scab. Clematis. — Red and humid eruptions when the moon is increasing, growing pale and dry with the decrease; scaly spots with yellowish corrosive ichor; pustules over the whole body; eczema, following suppressed gon- orrhoea; sticking sensation when touching the skin; ag- gravated from washing and from the heat of the bed. Conium. — Eczema of old people from being overheated; on face, arms and mons veneris; urine flows, and stops and flows, and stops at each emission; vertigo when turning the head, when looking up or when turning TREATMENT OF ECZEMA. 179 over in bed; gluey, sticky discharge; aggravated from scratching. Cornus alternifolia. — Dr. Lutze reports on the use of the swamp wahitit, and sums up the following as indica- tions for the remedy: Eczema when the skin was cracked everywhere, but especially where it had a fold or crease, exuding a sticky, watery fluid from these cracks; use locall}^ and internally. Creosote. — Eczema capitis and mammae, with violent burning after scratching; heavy scabs. Crotalus. — Vesicular eruption on the septum narium; sour, acrid eructations; painful retention of urine. Croto7i tigl. — Any form of eczema uncomplicated with disease of other organs; watery diarrhoea gushing out forcibly; excessive itching, but the patient cannot bear to scratch very haid as it hurts; a mere rub sufi&ces to allay the itching. Co7idurango. — Especially when rhagades are present, oozing out a fetid fluid; cachectic or syphilitic dyscrasia. Cuprum. — With convulsions, or when convulsions fol- low the suppression of eczema. Cyclamen. — Eczem.a faciei; when there is stinging itch- ing, aggravated in the evening in bed by eating fat food, and ameliorated by scratching or by wiping with the hand. Dulcamara. — Eczema on the face and extremities preceding the menses, oozing a water}^ fluid and bleeding after scratching; after its disappearance, faceache and violent asthma; desire for cold drink, eructations, vomit- ing in the morning; persons who get angry easily; ag- gravated in cold weather, after taking cold, from cold, and evening when at rest; ameliorated while moving in warm air. 180 SKIN DISEASES. Fluoric acid. — Eczema on the face, scalp, neck and chest; dry eruption with itching and burning; painful rhagades after washing; brittle nails. Graphites. — Thick crusts and a raw surface with deep rhagades; eczema of fat people, of blonde complexion who take cold easily; on and behind the ears with con- stant profuse oozing of a sticky fluid; thick crusts some- times ; falling out of the hair; on the face and chin, with considerable itching and increased discharge after scratch- ing; on genitals and in bends of limbs, especially of women with delayed and scanty menses; humid eruption with secretion of corrosive serum smelling like herring brine; great soreness of the skin, after scratching, with oozing of a sticky moisture; on the hands, with sticky and profuse secretion; itching worse in the evening and at night; skin dry, never perspires, and is inclined to crack; disease apt to become purulent; aggravated from cold and in the evening; and, when at rest. Helleb. — Eczema of the fingers, lips or head, continuing moist for a long time and then covered with scurf. Ag- gravation of symptoms from 4 to 8 p. m.; in the evening, in cold air, ameliorated in warm weather. Hepar. — Eczema pustulosum, with glandular enlarge- ments, severe itching and scratching, oedematous swell- ings; eczema behind the ears and on the scalp, burns and smarts after scratching, and is very sensitive to the touch; after the abuse of mercury; sleeplessness after midnight; aggravated at night, from cold air and from contact; ameliorated from wrapping up warmly. Hydrocya7iic acid. — Itching, burning vesicles on neck and arms; weakness and anaemia; constant drowsiness. Hydrastis. — Eczema along the border of the hair in front; aggravated on coming from the cold into a warm room; oozing after washing; constipation with hemor- rhoids. TREATMENT OF ECZEMA. 181 Hypericum. — Eczema on the face and hands; yellowish- green crusts with violent itching; excessive itching, espe- cially in the sacral region when undressing; the eruption is sometimes dry, and at times fiery red; roughness of the skin. Iris vers. — Eczema on the face; pustular eruption around the nose and lips, and on the cheeks; worse in the evening and at night; gastric and bilious derange- ments. Juglans cin. — Vesicular eruption on the upper and front part of the chest with burning and itching; violent itching over the whole body, in spots, worse when being heated from over-exertion; stitch-like pain under the right scapula. Kali carb. — In persons inclined to pulmonary difficul- ties; take cold easil}^- sensitive to cold; sticking pains all over; eruption dry at first, but when scratched exudes a moisture; comes on in warm weather; puffy and baggy swelling of the upper eyelids (Ars., lower lids); great dryness of the skin; deficient perspiration (Graph.; Alum., Led.); yellow, scaly, violent itching spots over the body, especially over abdomen and around the nipples. Aggravated between 2 and 3 A. m., from cold air {Hep.), from becoming cold. Ameliorated in warm air and on getting warm. Lachesis. — Very obstinate cases when seated on the legs; ulcers on the lower extremities; pricking, pulsating tearing pains; variable appetite; burning in the palms and soles; often useful in women during the climacteric period. Lappa maj. — The lesion is at first vesicular, then a scurf, and afterward a greenish-yellow crust, and is always accompanied with such intolerable itching that the child has to be tied or mittened to keep it from maim- 182 SKIN DISEASES. ing itself; sometimes the crust comes off in large patches, leaving the surface raw and exposed; the eruption smells offensive; swelling and suppuration of the axillary glands; disposition to boils. I have cured some very bad cases with this remedy, used as follows: Internally I use the IX three times a day, and apply locally the following lotion: ^. Lappa major, ^ij. Glycerine, ^j Aqua destillata, q, s. ad ^iv. M. Sig. : Apply to scalp on retiring. Ledum, — Eczema only on covered parts; eczema of rheumatics or drunkards; gnawing, itching of the skin; the pain commences in the feet and goes up; aggravated from heat and motion, and heat of the bed. Lycopodiiim. — Obstinate cases when the eruption bleeds easily and has a thick, badly smelling discharge; parts affected — back of head, face, neck, hands and right fore-finger; bowels constipated; no appetite, a few mouthfuls satisfy him; great debility while at rest; bleed- ing after scratching; humid suppurating eruption, with thick crusts and profuse fetid discharge underneath; ag- gravated from 4 to 8 p. m. , after getting heated, and from wet poultices; ameliorated from cold, from uncovering one's self. Mercurius sol. — All forms of eczema, especially of the hairy parts in persons who perspire easily, but obtain no relief from perspiration; tendency to inflammation of the lymphatic glands; increase of saliva; enlargement of the tongue, showing the imprints of the teeth; scorbutic gums; after scratching, bleeding and smarting; sleepless- ness before midnight; aggravated at night; after getting warm in bed; after scratching; ameliorated in the morn- ing. TREATMENT OF ECZEMA. 183 Mercurius iodat. — When other remedies fail and there is a decided syphilitic taint; swelHng and induration of the glands; troublesome itching over the whole body; all symptoms are worse at night. Merc, precip. rube7\ — Eczema of the hairy parts, and of the anus with fissures; eczema of the umbilicus; pustular eruption with slight itching: oozing of pus from beneath the crusts; glandular swellings. Mezeretim. — Eczema crusts with white scabs, itching intolerably, bleeding and burning like fire on being scratched; honey-like scabs around the mouth; dis- charges profuse, excoriating the surrounding parts; head covered with a thick, leathery crust, under which pus collects and mats the hair; constant chilliness; pale urine; thirst, but drinks only a little at a time. Scrofulosis. Natrum mur. — Eczema behind the ears, back of head and neck about the edges of the hair, anus, bends of the knees and elbows; humid eruption, with gluey discharge, matting the hair; raw, inflamed surfaces, with constant corroding discharge, which eats away the hair; craves salty food; difficult expulsion of stool Assuring the anus, with flow of blood; morning headache; cutting in the urethra after micturition; white, coated tongue; lips and corners of the mouth ulcerated and cracked; eyelids raw and ulcerated; aggravated in the forenoon and from exercise; ameliorated after lying down. Natrum sulph. — Very moist eruptions, with much oozing of fluids, the secretions more watery than sticky. Nitj'ic acid. — Eczema of gouty origin, about the head, ears and genitals; pustular eruption of the face, with large red margin, and heavy scabs; vesicles on the inner side of the left hand; soreness of the feet from profuse, offen- sive perspiration ; dry, scaly skin; moisture and itching in the anus; syphilitic ulcers after abuse of mercury; 184 SKIN DISEASES. swelling of sub-maxillary glands; strong smelling urine; in dark-complexioned old people; aggravated at mid- night. Nux juglans. — Burning itching vesicles upon a cracked surface, with a greenish discharge which stiffens the linen; numerous, large, painful boils; itching worse in the evening and at night. Oleander. — A humid, scaly eruption of the scalp, with gnawing itching, temporarily relieved by scratching, soon followed by burning and increased itching; smooth, shin- ing surface, with drops of serum standing out here and there; humid fetid spots behind the ears, red, rough spots in front; very sensitive skin; it becomes sore, raw and painful merely from friction of the clothes; aggravated when undressing. Marked weakness of the lower limbs, and a gloomy irritable mental state. Oxalic acid. — Exceedingl}^ sensitive skin, with vesicu- lar eruption. Suffers from the use of sugar, and sweets in general. All symptoms worse while thinking of them (reverse, Camph.^. Petroleum. — Eczema with red, raw, moist surface; burns like fire; great itching; oozing after scratching; ulceration after scratching; small wounds spread and ulcerate; obstinate dry eruption on genitals and peri- nseum, inside of thighs; skin of the hands cracked and rough; eruption between the toes; skin heals with diffi- culty; aversion to open air; aggravated in the open air and during a thunder-storm; ameliorated from warmth and warm air. Phosphorus. — Dry eruptions, burning and itching; the gums separate from the teeth and bleed easily; ecchy- mosed spots on the body; slight wounds bleed much, ag- gravation at night before midnight; during a thunder storm; ameliorated after scratching; after sleeping. TREATMENT OF ECZEMA. 185 Piper methysticum. — Skin dry, scaly, cracked and ulcer- ated, especially where it is thick, as on the hands and feet. Piper nigrum. — Eczema on the lips. Psorinum — Dry and scaly eruption, with little pointed vesicles around the reddened edges, disappearing during summer, but reappearing when the cold weather comes on; violent itching, worse by heat of bed and scratching; dirty, greasy-looking, foul-smelling skin. This remedy should be thought of in cases which do not yield to the well-selected remedy and compared with Sulphur. Ranuncuhis bulb. — Vesicular eruption on face in clus- ters, as from a burn; smarts as if scalded; aggravated in the evening, from change of temperature, from touch and motion. Rhus tox. — Eczema inner side of thighs, particularly after vaccination, with much itching and thirst; the erup- tion is generally moist, the surface raw, and the parts swollen; a red, inflamed, swollen rim from subcutaneous infiltration surrounds every portion of the eruption {Ars., black rim around the eruption); white, thick, moist crusts form, which smell offensively, and itch, especially at night; cheeks, face, and scalp affected; falling off of the hair; milk crust on face, humid, angry- looking, with hard, brown crusts; eczema of the scrotum, with intolerable itching. The child is restless, wants to be moved continually, especially after midnight, when the itching is intense, but this is relieved for a time by scratching; the cold fresh air is not tolerated on the head; it seems to make the scalp painful; hence the child likes to have its cap on in the open air (compare Silicea'). Rhus venenata. — Fine vesicular eruption on the upper extremities; groups of watery vesicles on the fingers; fissures on the ends of the fingers; upper lip swollen and covered with vesicles. 13 186 SKIN DISEASES. Sarsaparilla, — Eczema on the nose and face; thick scabs on the face; scabby eruption on the nose and face, like milk crust ; intolerable itching, worse at night, and after getting heated; child cries a great deal and is ex- tremely restless. Sepia. — Eruptions during pregnancy and nursing; itching of skin, changing to burning when scratched; sensation as of ants crawling over the skin; soreness of the skin and humid places in the bend of the joints and behind the ears; pruritus, with vesicles on a red base over all parts of the body. Dry ringworm, especially on the face of children; dry offensive eruption on the vertex and back of head, itching and tingling, with cracks behind the ears; pruritus, with vesicles on acrid base over all parts of the body, face, eyelids, hands, feet, armpits, vulva, anus, ears, hairy parts. Great indifference or sadness; wakes about 3 AM. and lies awake for hours; patient has dark hair, thin, delicate skin, brown discol- oration of the forehead, and passes putrid urine (compare Calc. OS., Benz. ac); aggravated in the open air, from application of cold water; ameliorated from warmth in general. Silicea. — Eczema capitis, with humid itching eruption in scrofulous children; pale, cachectic countenance; en- larged cervical glands; leucorrhoea, backache; menses too profuse; eruption on the back part of the head, either moist, or dry and scaly; offensive; scabby; itching during the day and evening, never at night; soreness after scratching; burns; pustules form and discharge copiously. Child cries when spoken to; big-bellied children, with weak ankles; emaciated frame, and irritable tempers, with perspiration about the head towards morning; offensive perspiration on the feet and genitals; aggra- vated during day and evening, and about the new moon; ameliorated from warmth in general. TREATMENT OF ECZEMA. - 187 Staphysagria. — Eczema with yellow, moist, offensive scales, with considerable itching, disappearing after scratching, but soon returning; oozing after scratching; humid scabs with bad smell; j^ellow acrid moisture oozes from under the crusts; scratching sometimes changes the locality of the itching; scalp painfully sensitive; skin peels off with itching, hair falls out; itching of the mar- gins of the lids. Face sunken; nose pointed and blue rings encircle the eyes; the child is irritable, and in- dignantly throws things away from it which were desired but a moment before. Aggravated from scratching, from touching the affected parts, from abuse of mercury. Ameliorated from walking in the open air. Sulphur. — Sequela of a suppressed eruption; voluptu- ous itching, with soreness after scratching; eruption on back of head and behind the ears, around the margin of the hairy scalp from ear to ear posteriorly; dry, offen- sive, scabby, with cracks, easily bleeding, burning and painful; or humid, and offensive, discharging thick or thin acrid pus, which forms into yellow crusts; chronic cases; the child cannot bear to be washed; is most comfortable when dirty; morning diarrhoea, or bowels moved regularly, but always with great pain. Aggravated from getting warm in bed, from washing, from wet poultices; ameliorated from heat, in dry weather; after rising. Sulphuric acid. — Moist eczema after suppressed gonor- rhoea, with pricking of the skin; on scratching the itch- ing changes locality; aggravated in the open air. Sumbul. — Eczema on the left side of the scalp in infants. Terebinthina. — Infantile eczema in front of ear, tending to affect the eyelids {Graph., behind ear), often alternat- ing with otitis. Thuja. — Itching vesicles, with shooting pains; skin 188 SKIN DISEASES. extremely sensitive to touch; burns violently after scratching; dry, scaly eruptions on head, extending to the temples, eyebrows, ears and neck, with itching, tingling and biting; dryness of covered parts; per- spiration of parts uncovered, smelling like honey; eruption only on covered parts; after vaccination the eczema is worse (SiL); eruption is white, scaly, and desquamating; offensive perspiration of the feet; wants head and face wrapped up warm (Stl.). Ag- gravated from cold, wet, heat of bed, about 3 a. m. ; ameliorated from gentle rubbing (itching); from warm wet (reverse, Lj'c. and Suipk.); from a development of coryza. Vaccinatio7i. — Several cases have been reported cured by vaccination; I have had no personal experience with this agent in this disease. Vinca minor. — Eczema on head, face, and septum of the nose; humid eruptions, itching at night, with burn- ing after scratching; offensive moist verminous eruption with biting itching; eruptions appearing in spots, moisture oozes therefrom and the hair becomes matted. Viola tricolor. — Eczema impetiginoides, exudation of yellow viscous pus; the eruption burns and itches, espe- cially at night; thick crusts form; swelling of cervical glands; urine smells like cat's urine; eczema capitis or facei, in scrofulous children. CHAPTER IX. BULLOUS DISEASES AND ANOMALOUS FORMS OF BULLOUS ERUPTION. Under this head we include the diseases which are especially characterized by the occurrence of the bullae as primary and essential phenomena. A bulla is a large portion of the cuticle detached from the skin by the inter- position of a transparent watery fluid. In fact, a bulla is a large vesicle. In the wide sense of the term several diseases are really bullous, such as erysipelas, herpes, pemphigus, rupia, eczema of the fingers, and impetigo contagiosa. But of these there are only two that really rank under the term bullous — i. e., herpes and pemphi- gus. Erysipelas belongs to the class of zymotic diseases; rupia is always syphilitic, and of course it is grouped un- der that head; the bulla produced by the coalescence of vesicles in eczema is an accidental and secondary phe- nomenon; and in impetigo contagiosa, the primary stage is a vesicle and not a bulla, the secretion subsequently becoming sero-purulent, whilst the general behavior and outward aspect of the disease are those of an impetigo. Besides, herpes and pemphigus are peculiar and like in regard to the influence of the nervous system in their production. Therefore, true bullous diseases, or those which are probably of neurotic origin, and in which the bullae are primary, with transparent contents, are herpes and pemphigus. Herpes and pemphigus might have been placed under 190 SKIN DISEASES. the head of neurotic diseases, but then many others must have been included, such as urticaria, pityriasis rubra, etc., with them, if we carried out the idea of collecting together under one head all those diseases which pri- marily originate in disturbance of the nervous system and arranged them upon a pathological basis As we have classified diseases, however, clinically, we place herpes and pemphigus under the convenient but most unscientific term, "bullous inflammation," because it is to changes implied by that term that the practitioner first directs his attention in the matter of diagnosis and treat- ment. Some anomalous forms of eruption will be noticed at the latter part of this chapter. Herpes. The term herpes, used b}^ itself, has little significance, but the expressions herpes zoster, herpes labialis, herpes prog e7iita lis , etc., refer to definite and distinct affections. The first of these we will describe under the name of Zoster, but the other two will be considered here. Herpes Labialis. Herpes is an affection of the skin, characterized by the development of small clusters of vesicles, usually situated on a slightly reddened or inflamed surface, and in the immediate neighborhood of the mouth. The vesicles appear unattended with any pain other than a slight burning or itching sensation, and last for a few hours or a day or two. They then rupture and give exit to a slight serous discharge, when they dry up and leave a surface which heals in a short time without scars. Herpes labialis usually attacks children or women, but is not commonly met with in men. It frequently comes HERPES PROGENITALIS. 191 on as a sequel of a cold, or slight febrile attack, and on this account has received the names " cold sore," " fever- sore," etc. There may be a single group of vesicles, or there may be several, each group containing four or five vesicles. The eruption may be confined to one side of the face, affecting either the upper or lower lip, or both, or just as frequently it may appear on both sides of the mouth. A true zoster ma}^ appear on the face and invade the same regions as herpes labialis, except that the eruption is almost invariably unilateral. The local treatment of herpes labialis involves nothing more than a little absorbent powder, or a sedative lotion — a little camphor- water being a favorite application. The internal treatment will be taken up in the next article. Herpes Progenitalis. The term hei-pes progenitalis includes the herpetic affections of the genital organs of both sexes, and, when occurring in the male, is called herpes preputialis , and in the female heypes vulvaris. Herpes preputialis most frequently occurs in young men between the ages of 20 and 40, and is not often met with as a first attack after that age. The vesicles may form on both the cutaneous and mucous surfaces. Owing to the anatomical situation of these parts, and to the friction to which they are more or less subject, the ves- icles last for but a few hours oxAy, breaking and giving rise to superficial erosions, which from neglect or un- cleanliness may run into slight ulceration. In herpes vulvaris the lesions may be upon the labia majora or the labia minora, or upon the prepuce of the clitoris, running the same temporary course as the other varieties of the affection. 192 SKIN DISEASES. Herpes progenitalis is not usually accompanied with much pain, unless the parts are subjected to undue fric- tion. As in the male, herpes of the female organs is most frequently met with between the ages of 20 and 40. A single attack lasts for a few days only, but with many patients herpes proves to be a relapsing affection, and causing on this account serious inconvenience to those who are subject to it. In men, relapses may occur after almost every act of sexual intercourse, but curiously is much less frequent in married men than in those who indulge promiscuously and at irregular intervals only. In women of the town the affection is by no means un- common, but is very rarely met with in married women or virgins, except when the attacks coincide with men- strual periods. In this connection I will quote from an article in the Journal, Cutaneous and Veneral Diseases, August, 1883, where Dr. Unna reports his experience. He has met with 200 cases in the female. He says: "In France, where prostitution is under surveillance, and where ex- cellent syphilographers abound, herpes progenitalis early attracted attention and was ascribed to an unnatural irri- tation of the sexual organs to w^hich prostitutes are sub- ject. Venereal diseases cannot be the cause, for in mar- ried women suffering from syphilis or gonorrhoea herpes is not found. In prostitutes, herpes occurs as often in those without as those with syphilis. Acute and chronic blenorrhoea often exist as factors in the development of herpes progenitalis, by the congestion of the parts which they induce. There are prostitutes who have an attack of herpes every time they menstruate. Less frequently pregnancy and the puerperal state induce a disposition to herpes progenitalis. Bruneau must be given credit for having shown that in women suffering with chronic HERPES PROGENITALIS. 193 metritis, cervicitis, etc., every herpetic eruption is pre- ceded by increased sensibility and signs of heightened congestion of the pelvic organs. While the vesicles are still intact, the diagnosis is easy. The vesicles are yel- lowish, translucent and arranged in clusters. When the epidermis has given way, the surface crusted over, erosion present, the surface must often be first carefully cleansed before we can say whether the disease be a superficial wound, a burn, eczema, chancre or herpes. Herpetic erosions are all well defined and of a bright red- dish hue. They are discrete, coalescent or confluent. In any case, the sharply defined contour and crescentic ar- rangement make herpes easy of diagnosis. The parts most liable to this affection, in order, are the labia minora, prepuce of the clitoris, labia majora, introitus vagina, and caruncula myrtiformis. The disease may be unsymmetrical when such organs as the prepuce of the clitoris, perineum, etc., are attacked. Pain usually pre- cedes the eruption by several days." The etiology of herpes progenitalis is obscure, and no adequate- explanation has yet been given to account for the attacks. Diagnosis. — The diagnosis of herpes progenitalis presents little difficulty, but care should be taken to dis- tinguish it from mechanical abrasions and from conta- gious venereal lesions. The treatment of this affection is simple. As a rule, nothing more is required than a little dressing-powder, or a sedative lotion; and if the parts are left at rest the erosions will be covered with new epithelium in a few days. Should ulcerations have occurred, they may be lightly touched with the solid nitrate of silver, and small pieces of linen may be placed between folds of mucous membrane that are lying in contact. These should be 194 SKIN DISEASES. frequently changed , and the parts kept clean with warm water and soap. When the affection assumes the relapsing form, pa- tients will go from one physician to another, seeking a permanent cure, which we regret to say they will rarely attain until they reach the age at which the trouble tends to disappear spontaneously. The internal treatment and the indications for the remedies are as follows: Acojiite. — In the earlier stages with catarrhal fever. Agnus castus. — Herpes on the cheeks with gnawing itching, worse from getting wet. Alnus rubra. — Chronic herpes. Apis mel. — Large confluent vesicles; burning stinging pains; vesicular eruption on the lips; cold sores. Arsen. alb. — Red herpetic skin around the mouth, with burning, worse from scratching and after midnight. Herpes iris. Aurum rnur. — Herpes on the prepuce and vulva. Herpes accompanied by intolerable itching. Bufo. — Herpetic eruption after a cold. Causticuni. — Burning vesicles under the prepuce, which become suppurating ulcers. Burning vesicles on the face which, when touched, exude a corrosive water, afterward they dry up to a scurf. Cantharis. — Large, burning painful blisters with ery- sipelatous inflammation of the parts. Burning, tearing ulcerative pains, worse on the right side. Urinary com- plications. Clematis. — Itching blisters on the lower lip. Gnawing itching not relieved by scratching. Worse during in- creasing, better during decreasing moon. Graphites, — Herpes in females with scanty menstrua- tion; burning blisters on the lower side and tip of the tongue; dryness of the skin. HERPES PROGENITALIS. 195 Hama7nelis — Herpes on the nose. Profuse epistaxis. Helleb. nig. — White vesicles on the lips; aphthae in the mouth; in scrofulous children. Hepar. — Herpes which tend to recur; herpes on the prepuce, exceedingly sensitive to the touch; small ulcers form around the large one; unhealthy suppurating skin, after mercurial poisoning. Kali bich. — Herpes after taking cold; fluent coryza; all the secretions are of a stringy and ropy character. Merciirius sol. — Herpes on the prepuce with a tendency to suppuration; ulcers on the glans; itching of the genitals. Moschus. — Herpes, with excessive burning, in hyster- ical subjects; menstruation too early and too profuse. Natrum mur. — Herpes occurring during fevers; erup- tion on the lips and flexures of the joints; vesicles on the tongue; itching and pricking in the skin. Petroleum. — Herpes on the perineum and genitals; itching worse in the open air. Rhus tox. — Herpes upon the hairy parts with burning and stinging; itching worse after scratching; rheumatic pains with great weariness. Sepia. — Herpetic eruptions around the lips; herpes during pregnane}^- circular form of epilepsy. Sulphur. — Herpes about the mouth and nose with itching and burning, aggravated by warmth. Hot palms and soles. Sarsaparilla. — Herpes on the prepuce; after abuse of mercury. Upas. — Herpetic eruption on the upper lip, on the left side. 196 SKIN DISEASES. Zoster. Zoster is an acute affection characterized by the devel- opment of one or more groups of large-sized vesicles. When there are several of these groups, it will be noticed that they are arranged along the course of one of the larger nerve-trunks whose filaments are distributed to the skin. The most frequent and perhaps the most typical seat of the eruption is on the chest, where it may form a semi- girdle corresponding to the area supplied by one of the intercostal nerves. Zoster, however, is by no means con- fined to the thoracic region, but may appear on the ab- domen, the face, in connection with the trigeminal nerve, on the shoulders and arms, and on the thighs and legs. The eruption may or may not be preceded by prodro- mal symptoms, which may partake of a mild febrile attack of one or two days' duration, or, instead, of a more or less, severe neuralgia, without fever; or neither of these phenomena may be present, the eruption itself being the first indication of the affection. Each group or patch of vesicles may consist of from four or five to a dozen separate, non-confluent lesions situated upon a reddened, raised, and inflamed base. Occasionally the vesicles themselves may be absent, and nothing is to be seen except the circumscribed reddened patch. The several groups of vesicles constituting the typical erup- tion do not usually appear at the same time, but the patches may appear in succession, so that several days may elapse before all the lesions have developed. The eruption having appeared, is accompanied with more or less pain of a neuralgic character, together with some soreness of parts if the vesicles rupture. As a rule, the lesions remain intact until after a week or so, when M-^^ I Zoster. ZOSTER. 197 the fluid contents become absorbed, and the upUfted epidermis desquamates, leaving a reddened macule, or in some cases a small cicatrix, to mark the site of the lesion. A striking peculiarity of zoster is the fact that it is strictly unilateral (with exceedingly rare exceptions). Cases of double zoster, in which both sides of the body have been involved at the same time, have been reported. Another feature of this affection is the extreme rarity of a second attack, resembling in this respect the eruptive fevers. The neuralgia which precedes or accompanies zoster may exhibit any degree of severity, and may indeed per- sist for an indefinite period after all symptoms of cuta- neous irritation have disappeared. Instead of neuralgia, a more or less intense pruritus ma}^ be present, confined to the affected region, and persist for a long time. As a rule, zoster is an affection of little gravity — that is, in persons who when attacked are in ordinary health. In those, however, who are aged or feeble, the prog- nosis is not always so favorable, as the vesicles may be followed by more or less severe ulceration. When the eruption appears on the head, and especially in connec- tion with the branches of the trigeminus that are dis- tributed to the eye, ulceration of the cornea, and even destruction of the sight, may ensue. Etiology. — It has been very clearly demonstrated that the majority, if not all cases, of zoster appear in connec- tion with irritation or inflammation of the ganglia at- tached to the roots of the sensitive nerves; but what sets up this primary irritation is not always clear. Zoster has been known to appear, after exposure to cold, in connec- tion with pleurisy, after traumatisms, and after the internal administration of arsenic. Quite recently, bacilli are said to have been found in the inflamed 198 SKIN DISEASES. ganglia, but how they got there does not appear very clearly. M. Fere reports four cases of herpes zoster, which oc- curred nearly contemporaneously among his 150 epileptic patients at the Bicetre. The first was a young man of nineteen, who had had a few violent epileptic attacks without any unilateral symptoms. The herpes was con- fined to the left side of the thorax and the left side of the face, and along with it he had some spasms of the left corner of the mouth, illusory impressions of persons ap- proaching him from the left side, and some contractions and sluggishness of the left pupil. The left side of the tongue also was much more thickly furred than the right. The temperature ran up to 107° F. at first, but all the morbid symptoms gradually subsided in a week. In the three other cases, in middle-aged men, the most promi- nent symptom was severe pain, with tenderness on pres- sure, down the spinal column. M. Fere is led to con- clude from these and similar observations that the most probable cause of the herpetic eruption is a slight epidemic cerebro-spinal meningitis, which may be widespread, but perhaps only of sufiicient irritative power to cause the herpes at the root of one or two nerves. Such a pathological condition would not be surprising in infectious diseases, for in them some forms of meningitis are not rare. Zoster may follow influenza; Dr. Finzi reports a case in a girl of fifteen, who, after recovering from a severe attack of influenza, was seized with neuralgic pain, accompanied with a pricking and burning sensation shooting from the back around the right side. On being seen five days later, a chain of herpetic vesicles was found extending along the seventh intercostal space, the lymphatic glands in the axilla being swollen and tender, ZOSTER. 199 and pressure along the course of the seventh intercostal nerve, making the patient scream with pain. In from eight to ten days the vesicles disappeared, the whole duration of the S3"mptoms having been about a fortnight. Another case is reported of a case of zoster correspond- ing to the eighth intercostal nerve of the right side in a girl of eighteen, in whom the disease appeared at the be- ginning of an attack of influenza and lasted a month. The writer had a case occurring in a girl of twelve cor- responding to the eighth intercostal nerve of the left side, in which the eruption made its appearance three days after the beginning of an attack of influenza of a severe form, and the eruption lasted two weeks. Treatment. — The chief indications are to preserve the integrity of the vesicles until their contents are absorbed, and to give relief to the neuralgic pain. We may at- tempt to carry out the first by the application of several coats of flexible collodion, or trauviaticin, or we may brush the lesions over with oil, and then cover them freely with some indifferent dusting-powder. The neu- ralgia is to be treated exactly in the same way as if it were not accompanied with the vesicular lesions. Zoster of the mucous membranes is not an infrequent affection. Three cases are reported in which the region supplied by the trigeminus was affected. In one of the cases the vesicles were located upon the mucous membrane of the left cheek; in the second case upon the conjunctiva of the right eye; and in the third case on the left half of the tongue. The galvanic current, from four to eight cells of a bat- tery of ordinary strength, has been found very beneficial if the pain is sharp, w^hen applied from fifteen to twenty minutes daily. 200 SKIN DISEASES. The principal internal remedies and their indications are as follows: Aconite. — In the earlier stages, when the neuralgic pain is accompanied by febrile symptoms. Apis. — Burning and stinging pains with swelling; large vesicles, sometimes confluent; better from cold applica- tions. Arsen. alb. — Confluent eruption with intense burning of the blisters; worse after midnight, and from cold ap- plications; neuralgia; in debilitated constitutions. Cantharis. — Large blisters, burning when touched; smarting and stinging; mostly on the right side; worse in the open air. Cistus. — Zoster on the back; neuralgic symptoms; in scrofulous subjects. Comodadia. — Zoster on the legs; rheumatic pains ag- gravated by rest; relieved by motion. Dulcamara. —Zoster after taking cold from damp air; moist, suppurating eruption; glandular swellings in neighborhood of eruption; eruption precedes the menses. G7'aphites. — Zoster on the left side; large blisters from the spine to the umbilicus, burning when touched; worse indoors; better in the open air; dry skin, tendency to ulceration; in blonde individuals inclined to obesity. Iris vers. — Zoster, especially on the right side; follow- ing gastric derangement; pain in the liver; neuralgic pains. Kali mur. — Zoster; vesicles encircling half of the body like a belt; white tongue. Kalmia lat. — Facial neuralgia remaining after zoster; worse at night; palpitation of the heart ; rheumatic pains. Lachesis. — Zoster during spring and fall; the vesicles turn dark and are very painful; all symptoms are worse after sleep. ZOSTER. 201 Mercurius. — Zoster on the right side, extending across the abdomen; worse at night, from the warmth of the bed; tendency to suppuration; easy perspiration without relief. Mezereum. — Zoster in old people; constant chilliness; neuralgic pains; worse at 9 p. m.; burning, changing lo- cation after scratching; in scrofulous persons. Natrum mur. — Eruptions occurring through the course of any disease. Pepperini7it Oil, when applied locally, rapidly allays the pain of zoster. Pru7i2is spinosa has succeeded in removing the very troublesome neuralgic pain which often remains when the eruption of shingles has disappeared, by means of Prunus spinosa 30X. Ranunculus bulb. — Zoster aggravated by change of temperature; neuralgic sequels; in rheumatic subjects. Rhus lox. — Burning and stinging pains aggravated by scratching. Small burning vesicles with redness of the skin; confluent vesicles; worse in cold weather; rheu- matic pains during rest; sleeplessness with restless toss- ing about; zoster brought on by getting wet, while over- heated. Seinpervivum ted. — In obstinate cases; may be used internally and locally. Thuja. — Zoster with eruption only on covered parts; better from gentle rubbing; in individuals of lymphatic temperament. Zincum. — Neuralgia following zoster; pains relieved by touching the parts; worse after dinner and towards evening. 'Zincum phos. — When other remedies fail; following brain-fag in literary persons. 14 202 SKIN DISEAvSES. Pemphigus. Under this name a number of widely varying diseases have been described, and one of the earlier writers men- tions upward of a hundred varieties of the affection. We will confine the name to a single disease, embracing- but two varieties — namely, pe^nphigtcs vulgaris and pem- phigus foliaceus . In childhood two forms are observed; pemphigus acutus neo7iatorum, appearing during the first two weeks. The whole body is covered with bullae, some of the size of a hazel nut, and its course usually benign. A second form stands in close relationship to acute exanthemata. In general pe77iphigus is characterized as regards erup- tion by the appearance of little separate blebs, usually grouped in threes or fours, seated upon slightly inflamed bases, which are quickly covered over by the enlarged bullae. These blebs ma}^ attain a size varying between that of a pea and a hen's ^z%. They are distended with fluid, which is at first very transparent, but soon becomes milky. The fluid may be quickly re-absorbed, or the blebs or bullae simply shrivel, the distended globe becom- ing flaccid. Very often the blebs burst in a few days, and then the contained fluid dries into crusts of lamellar aspect, beneath which is very slight ulceration. The contents are sometimes sanguinolent. The bullae gener- ally occur in successive crops; they develop in the course of a few hours; their outline is generally round or oval; they may be confluent, but are usually distinct. Now and then a species of false membrane is contained in the bullae. The reaction of the fluid is generally alkaline, but with the turbidity comes acidity. The local symptoms are, slight itching and smarting at the outset, and more PEMPHIGUS VULGARIS. 203 or less soreness. The healing process in pemphigus is sometimes tard}^, a thin ichor being secreted by the sur- face originally blebbed, and so a quasi-impetiginous crust is often produced. In rare cases, in cachectic subjects, sloughing may occur. The disease attacks all parts of the body — but rarely the head, the palms of the hands, or the soles of the feet. Sometimes the mucous surfaces — for example, the intestines, vagina, etc., are the seat of bullae in pemphigus. Pemphigus Vulgaris. This variety is characterized by an eruption of bullae of varying size, some of which may be as large as a pigeon's egg. They may exist singly or in considerable number, and successive outbreaks may prolong the affec- tion for an indefinite period. In pemphigus vulgaris the bullae are well distended with a thin, not ver}^ plastic fluid, and usuallj- remain in- tact for several days. Sometimes the fluid is resorbed, and the uplifted epidermis applies itself to the skin, with- out, however, becoming permanentl}^ attached, but ex- foliates as soon as a new stratum corneum has formed beneath it. More frequently, however, the bulla ruptures and be- comes detached, leaving a raw and reddened surface, giving rise to a slight serous discharge. This gradually lessens, however, until a newly-formed, horny laj^er re- places the old. Solitar3^ bullae ma)^ succeed each other at more or less regular intervals, or there may be crops of smaller bullae, appearing weeks or months apart. The disease may persist unchecked for several years, terminating in spontaneous recovery, or quite frequently ending fatally. 204 SKIN DISEASES. Pemphigus Foliaceus. In this variety the bullae, instead of being freely dis- tended and tense, are only partly filled with fluid, and are flaccid, and often attain a considerable size. As a rule, they are accompanied with more or less debility and im- pairment of the vital forces. Contiguous bullae may coalesce, thus forming a large, flat, watery tumor, con- taining a lymphy exudation. The prognosis of pemphi- gus foliaceus is grave, as the majority of cases go on to a fatal termination. In some instances pemphigus foliaceus is said to begin as a single blister, which continually enlarges until the whole surface of the body is skinned and covered with a brownish crust; it is always fatal. The causes of pemphigus are involved in obscurity. Prognosis. — The cure is not rapid, but slow; recur- rence of the disease is frequent. In old people, where the disease is general, and in children, when there is. ulceration, the issue of the case is often unfavorable. The general condition of the patient must be the guide, and in these cases a cautious opinion should always be given. Diagnosis. — Pemphigus can scarcely be confounded with anything else, the bullae are so diagnostic a sign. In eczema of the hands, bullae may be produced second- arily by the confluence of vesicles, but their origin is readily traced, and co-existent eczema is to be found elsewhere. Pemphigus is rare on the hands and fingers, per se. General eczema and P. foliaceus should not be confounded; in the latter abortive bullae are present, the scales are larger and peculiar, and the skin is not infil- trated. PEMPHIGUS FOLIACEUS. 205 In ecth3^ma cachecticiim the pustules contain bloody fluid; there are no true bullae in the disease; the crusts are also thick and dirty; whilst the ulceration is deep. In rupia, the bullae are smaller and flatter, the contents sanious, the crusts thick, dark, prominent — cockleshell like; the ulceration deep and foul. Pemphigus foliaceus resembles pityriasis rubra; but in the latter there is no history of bullae; the scales are altogether smaller, and they are imbricated in a peculiar manner. Sometimes in impetigo contagiosa, the bullae become somewhat large, but they are never distended as in pem- phigus, but flat; the contents soon become purulent, and flat yellow scabs form, which are characteristic. The disease is clearly pustular. Treatment. — The patient should be placed on a full animal diet, with plenty of fresh air and exercise. Means must be taken to bring the health up to a normal standard. Locally, bran, starch or gelatine baths are of decided benefit. The continuous bath, as recommended by Hebra.may be resorted to in some cases. The old school rely upon quinine, the mineral acids, and arsenic, as internal remedies. They recommend cod-liver oil, combined with either of the above, it is a favorite prescription with many. Dr. Cooper has cured pemphigoid eruptions, particu- larly those occurring in the ears, with an ointment of scrophulaida nodosa. The same medicine was very useful in bullae surrounded by an inflamed ring. Dr. Pope ameliorated a distinctly pemphigoid eruption with Cantharis 3X. Later in the case — one of dissemi- nated sclerosis — the eruption reappeared, and passed away without rupture under Phosphorus given on gen- eral indications for that drug. 206 SKIN DISEASES. The indications for the principal internal homoeopathic remedies are as follows: Ammo7i. miir. — Blisters the size of peas on the right shoulder with itching; burning at small spots on the chest; chilliness, especially when walking; fat body but thin legs. Arsen. alb. — Black blisters, burning and very painful; great restlessness and typhoid symptoms; pemphigus foliaceus or when gangrene sets in. Belladon. — Painful, watery vesicles on the palm of the hand sensitive to the touch; chill in the evening, mostly on the arms, with heat in the head. Ca7itharis. — Pemphigus presents a very exact image of the lesion produced by the external application of can- tharides; active inflammation, with blisters containing serum, burning more than itching; more on right side. Causticum. — I^arge painful blisters on the left side of the chest and neck, which become flattened; with the eruption, there is difficulty of breathing, fever, heat and sweat; very sensitive to cold; corpulent children, with tendency to enlargement of glands; involuntary urination when sneezing or blowing the nose. Chamo?nilla. — Extreme irritability of the nervous sys- tem and great sensitiveness to pain, or to wind or cur- rents of air; darting and lancinating pains. China. — Great nervous irritability; the contents of the vesicles becomes ichorous with a putrid smell; where there is a tendency to gangrene. Clematis. — Burning throbbing pains; yellow corrosive ichor; great emaciation. Didcajnara. — Burning pains, restlessness, thirst and emaciation; the bullse break forming corroding ulcers, Gumnii gutti. — May be used when other remedies fail. PEMPHIGUS FOLIACEUS. 207 Kali carb. — Burning, itching and stitch pains; blisters with tendency to spread; pemphigus foliaceus. Iodine. — Gangrenous tendency, after mercury. Lachesis. — Gangrenous tendency; bullae and blisters; tossing and moaning during sleep, and aggravation of symptoms on awaking. Me7ruri2is. — The bullae have a tendenc}^ to spread, with discharge of burning ichor, worse at night, particu- larly from warmth of the bed; profuse sweat which does not relieve. Natrumcarb. — BHsters with oozing of purulent fluid; the whole skin becomes dry, rough and chapped. Natrum mur. — Fluid from blisters and blebs like water. Natrum siilph. — Watery vesicles or blebs all over the body. Phospho7dc acid. — Deep hard bullae on the ball of the thumb; blisters on the balls of the toes; great drowsiness and apathy; in debilitated individuals; after sexual ex- cesses. Phosphorus. — The blisters are full to bursting, painful and hard, but not itching; tall fair children with tendency to tuberculosis; languor and nervous itching; chilliness -every evening with shivering; arms and hands become numb; regurgitation of food; small wounds bleed much. Ranmiculus bulb. — Blisters on the fingers the size of a hazelnut, followed after healing by small deep transparent dark-blue elevated blisters the size of ordinary pin-heads; this remedy has cured pemphigus in new-born children. Ranunculus seel. — Vesicles, which emit a thin acrid, 3^ellowish ichor, and form obstinate ulcers; itching, boring, gnawing and biting pains; sleeplessness, with debility and anxiety. Raphanus. — Blisters full of water on the breast, with- out inflammation, redness or pain. 208 SKIN DISEASES. Rhus tox. — Acute form, with much itching and burn- ing; confluent blisters with milky or watery fluid and peeling of the skin. Sepia. — Pemphigus on the arms and hands; heaviness of the limbs; sensitive to cold air; arthritic pains in the joints. Tartar emet. — Vesicles filled with bloody serum, col- lapsing and bursting, turning blackish and changing ta malignant broad deep ulcers; gastro-intestinal irritation. Thuja. — Pemphigus foliaceus, with offensive odor, and formation of scales. Anomalous Forms of Bullous Eruption. Hydroa. Under the head of neurotic diseases, and in connection with herpes, attention may be directed to certain vesicu- lar or bullous forms of eruption, which have been de- scribed by Bazin under the term of arthritic hydroa. He distinguishes three varieties of hydroa: i. Hydroa vesi- culeux. 2. Hydroa vseciniforme, confounded with aphthae chronique. 3. H5^droa bulleux. Hydroa vesiculeux is generally confounded by authors with erythema papulatum. First, as regards Seat, "It is developed on the cutaneous and mucous surfaces. On the skin it exists ordinarily on the uncovered parts — back of the hands and wrists and on the front of the knees, etc In most cases the buccal mucous membrane is affected, and then the eruption occupies by preference the lower lip and the inside of the cheeks, and appears after its development on the skin. However, in one of our cases, the base of the uvula was surrounded by a cir- cle of vesicles. The conjunctiva may also be the seat of this eruption." Symptoms. — " It is sometimes preceded by malaise^ FORMS OF BULLOUS ERUPTION. 209 anorexia, and a slight febrile attack, but these prodromic symptoms are often wanting, or are so little marked that the attention of the patient is first attracted by the de- velopment of the vesicles. Whatever be the seat of the eruption, it presents the following characters: — There is seen at first spots of a deep red color, small, rounded, a little raised, and with their edges clearl}^ de- fined. These spots vary in size from that of a lentil to that of a twenty-five cent piece; they are sometimes sur- rounded by a rose-colored areola; the}^ show soon in their centre a small vesicle filled with transparent yellowish liquid. This vesicle appears the day following that of the red spot. It dries rapidly from the centre, which is occupied by a small blackish scab, whilst the liquid is absorbed from the circumference. The phenomena takes place towards the second or third da}' of the eruption. The subsequent phenomena are as follows: — The liquid in the circumference of the vesicle is reabsorbed, whilst that which occupies the centre becomes a blackish scab. At last it may happen, especially during cold weather, that the fluid exuded in tbe vesicle is absorbed rapidl3^ It will then have only a small whitish or yellowish macula, placed in the centre of a red disc, and formed by loosened epiaermis. In this case it is that the affec- tion has been confounded with erythema papulatum. On the mucous surfaces the vesicles are whitish and sur- rounded by a violet-colored areola — the scabs are detached sooner. The red discs and vesicles are more or less numerous. The}' are generally separated by intervals of sound skin; sometimes they are disposed in groups of two or three, touching at their circumference. They do not all appear at once, but b}^ successive crops during many days. The affected parts have scarcely any itch- 210 SKIN DISEASES. ing. The febrile symptoms which exist rarely at the commencement cease when the eruption is developed. The duration of hydroa vesiculeux is from two to four weeks; each element in the eruption taken by itself runs through its course in four or five days. The affection is prolonged for many weeks only by the eruption of fresh crops of vesicles. A relapse may take place. The disease is seen in both sexes, but more frequently in the male. It appears among adults from twenty to thirty years of age. It is more frequent in spring and autumn; cold and variation of temperature have a marked influence on its appearance and course. Finally it is always seen amongst people who have had still' symp- toms of gout." ''Hydroa vesiculeux," says Bazin, in continuing his description, which we have given above almost at length, " is essentially arthritic — at least we have always found it among arthritic subjects, and it has steadily presented clear relation to gouty manifestations." Prognosis. — "This affection is not grave; it disap- pears of itself in four or five weeks. It is subject to recur." Hydroa vacciforme is the same, only that the vesicles are varioliform. Hydroa bulleux (pemphigus with little bullae) is an arthritic affection which is generally little known. The eruption shows itself by bullae, which present one important character — the inequality of their size. Some are as large as a lentil; the largest do not go beyond the size of a pea. These bullae are rounded, arranged in an irregular manner, in groups of three or four; they are filled with transparent fluid, which grows thick quickly and takes a yellowish color; finally they are placed on a red surface, which extends from their base in the form FORMS OF BULLOUS ERUPTION. 211 of an areola. Whilst new bullae are developing, the old ones dry up and are replaced by a 3^ellowish scab; and if one of these is rubbed off by scratching there ap- pears a violet-colored, slightly excoriated surface In the interval of the crops of bullae there is no morbid phe- nomenon observed except the ordinary well-marked itch- ing. The patient preserves his appetite, and the nutrition is not at all altered. Bazin states that the course is chronic, that the disease appears in successive crops, and lasts generally from five to six months; that it is more frequent in men than in women, and appears in adults from twenty to forty years; that the seasons and varia- tions of temperature have a marked influence on its de- velopment; that it is most common in the spring, and is excited by gout. Diagnosis. — The characters of hydroa bulleux permit always of its being recognized. It is important to es- tablish well the differential diagnosis between this disease and pemphigus. In the former the bullae are small, and do not go beyond the size of a pea; they are further re- markable, for the inequality of their size, they occupy re- gions sufficiently well circumscribed. The bullae of pem- phigus are larger — they may attain the size of a nut, or even of a hen's ^gg; they exist in various parts, and ex- tend sometimes over the chief part of the skin. The diseases which it in a measure resembles are, ur- ticaria and the various forms of erythema, and perhaps mistakes might be made between it and the vesicular syphilide, varicella, and variola. As a rule, it has a defi- nite duration, and disappears spontaneously in a few days, and may be accompanied by slight fever. The first phenotnenon noticed is a faintly-marked, rosy spot, which is soon replaced by a single vesicle, which 7nay reniai7i intact or may become umbilicated, or may dry up and become a7i 212 SKIN DISEASES. umbilicated crust of a yellowish- white color. Around this vesicle i?iflammatory changes very soon take place; a zone of a color varying from red to violet^ with a well-defined, slightly elevated periphery, forms, and then around this perhaps a ring of small vesicles, which may coalesce and form a circumferential bullce. These spots vary in size from a line to four or five, or even more. There is no hypersemia between the patches, as the inflammatory ac- tion is sharply confined to them. This condition differs from that of herpes phlyctenodes, in which the inflamma- tory areola is not thus sharply defined. There is usually no pain or itching, merely a little heat or a feeling of ten- sion. The same appearances, somewhat modified, have been observed upon the buccal mucous membrane. The eruption disappears by the fall of the crust, which is formed from the vesicle, and is generally seen in the centre of each patch, and then there remains a more or less well- marked hypersemia with slight infiltration. The sites of election are the back of the hands, the forearms, face, neck, and also the trunk and lower limbs. It is generally symmetrically developed. The practitioner may meet with cases in which, with or without some slight antecedents, malaise, or pyrexia, a few scattered spots answering as regards eruptive features to Bazin's hydroa vesiculeux occur — that is to say, a few red irritable spots appear, having in the centre a small oval or roundish bulla, which may enlarge to the size of a split pea, but is generally not so large, and dies away in the course of a few days. These spots appear on the back of the hands, the arms, the legs, and the shoulders. The disease may last, by the development of successive crops of solitary vesicles, for ten days or more. The more exaggerated form of this disease is that in which small bullae are developed rapidly over a large ex- tent of surface, or even the whole body. FORMS OF BULLOUS ERUPTION. 213 In some instances in which this quasi-herpetic or pem- phigoid disease makes its appearance the eruption is pre- ceded by an unusual amount of irritation, and it is com- plicated or followed by true pruriginous rash. This is very probably the disease termed pemphigus pruriginosus. We may therefore sum up the foregoing remarks by saying that there is a form of disease which seems to stand midwa}^ between herpes and pemphigus, the features of which allay it, now to herpes, now to pemphigus. It may consist of solitary small bullae seated on a red base, and scattered here and there over the body, or the bullae may be surrounded by small vesicles; or these two dispositions of the bullae may be seen in one and the same case, the eruption being localized to a certain part of the body, or generally distributed and accompanied in severe cases by pyrexia and marked constitutional disturbances, which is often the result probably of malarial poisoning. The erup- tion may recur more or less periodically; and lastly it may be complicated or followed by prurigo, and in that case will answer to the designation of pemphigus pruriginosus. Diagnosis. — The characters I have given are sufficient for diagnostic purposes. The only disease with which they might be confounded is urticaria bullosa, and I do not know that any mischief would accrue to the patient from such a mistake. Treatment. — The first care of the ph3^sician is to at- tend to the general condition of the patients as regards their emunctory organs and their hygiene. Anxiety, worry, and depressing influences must be neutralized. The patient must be ordered to get good air, to take plain nourishing food, and to avoid luxuries of the table, over- work, and fatigue of all kinds Locally I know of nothing better than, first of all, va- por baths to encourage the skin to proper action, and the 214 SKIN DISEASES. use of a weak lotion made of liq. carbonis detergens 3jj to ^ss with aquae |vj applied night and morning. Subse- quently sulphuret of potassium baths may be regularly given for a long time, and followed up by the drinking of some sulphurous or iron waters. According to old-school authorities, the main remedy is quinine; iron, nux vomica and cod-liver oil are also re- commended. The principal internal homoeopathic remedies are: Po- tassium iodide, Kreasote, and Mag?iesia carb. CHAPTER X. SUPPURATIVE INFLAMMATION, OR PUS- TULAR DISEASES— IMPETIGO— CONTA- GIOUS IMPETIGO— ECTHYMA— FUR- UNCULUS— ANTHRAX, OR CAR- BUNCLE—MALIGNANT PUSTULE, Etc. General Remarks. In many very different diseases of the skin pus is pres- ent, and if the term pustular were used in its widest sense a large number of diseases would have to be in- cluded under it; for instance, acne; favus; scabies; pem- phigus; variola; farcy; varicella; and so on. But in the diseases just named the presence of pus is often not a pri- mary or even essential condition, and its importance is thrown into the shade by the prominence of other feat- ures. In those affections which may more strictly be called pustular, the suppuration is the leading and the primary condition, the particular morbid condition the practitioner has to recognize and to remedy. Now un- der the term pustular diseases, thus defined, are usually comprised impetigo, ecthyma, and furuncular affections, — the latter term including furunculus, or boil; anthrax or carbuncle; and pustular maligna, or malignant boil. Delhi boil would come under this division, but, owing to its rarity in this country, will not be treated of. 216 SKIN DISEASES. Impetigo Contagiosa. This disease is characterized by the appearance of mild pyrexial symptoms, followed in two or three days by the appearance of one or more small vesicles. They slowly enlarge, but soon dry into thin, light-yellow crusts, or scabs. These lesions may be few or numerous, and succeSvSive outbreaks may prolong the affection for several months. The affection is unquestionably conta- gious, and, when it once appears upon an individual, other members of the family, either children or adults, may contract it. In not a few instances the eruption has appeared within a couple of weeks or so after vaccination. If the crust, which has the appearance of being " stuck on," is removed, a slightly reddened but not eroded sur- face is revealed, from which but little or no moisture is exuded. The disease is seen amongst children of the lower orders especially, probably in great measure because the disease spreads by contagion freely amongst them. It occurs also in those who have all the advantages of social position and good hygiene. The eruption in the disease in the majority of cases appears first of all on the face, sometimes on the top or back of the head, and in the form of ''little watery heads " (vesicles) that enlarge into flat bullae if they are not injured by scratching. Sometimes the hands are attacked at the outset, and look as if burnt here and there; phlyctense may also arise out of and around the remnants of vaccinia, or about cuts or bruises. The dis- ease then extends to other parts, the back of the neck, but- tocks, feet, etc. The vesicles are always isolated. In five or six days the bullae may reach the size of a sixpence or p ..J Impetigo Contagiosa. IMPETIGO CONTAGIOSA. 217 shilling unless ruptured, and are then flat and depressed in the centre, their contents becoming turbid. Usually the vesico-pustule is the size of a large split-pea or there- abouts. The secretion consists of lymph-like fluid, gran- . iilar cells, and subsequently pus-cells. Scabs commence to form a few days after the appear- ance of the disease. They are characteristic of the -disease, varying in size from that of a split pea to a -shilling; they are flat, straw-colored, dry, and granular- looking, and appear as if " stuck on " to the part; they present, as a rule, no inflammatory areola around their circumferences, though this is the case in severer in- stances of the disease. If removed, little sores are observed beneath, more or less filled in by gummy-like secretion, or a little pellet of splastic lymph, and when the scabs fall off there is an erythematous base left behind, the hue of which gradually fades away. The disease may be spread from spot to spot by direct inocula- tion with its secretion in the act of scratching. The crop of vesicles is to some extent successive, though the majority of the places " come out " in the first week or so. In some instances the disease resembles vaccinia very slowly. There is always a uniformity about it; it always commences by vesicles; there are no papules present at the height of the disease. On the face the spots may be confluent, and then the disease resembles eczema impetiginodes; but the patches are made up of the elements described above. On the scalp the disease consists of circular, mostl}" isolated, flat-scabbed spots about the top and back of the head, the hair being matted by the crusts. Usually, no pediculi and no offensive smell are present. Now it is verj^ important to note that an eczema may be readily excited in fair children by scratching or the irritation of the discharge, in connection ^5 218 SKIN DISEASES. with impetigo contagiosa — and then the characteristic features of the latter disease are masked. The result of neglecting to attend to this point is that the practitioner regards the disease present as solely and entirel}^ an eczema. The error, too, is a very common one. The mucous membranes of the eye and the nose are sometimes implicated; then inflammation is produced by the development of little ulcers, that take their origin in the formation apparently of vesico-pustules, identical with those seen on the surface of the skin. The eye may look as though affected by slight purulent ophthal- mia, but soon recovers itself. The disease may complicate eczema, scabies, and other affections, and vice versa. Diagnostic features are — its apparently epidemic char- acter in many cases; the antecedent febrile condition; its attacking children; the origin from isolated vesicles, which tend to enlarge into blebs and to become pustular, the bleb having a depressed centre, and, it may be, a well-defined, slightly raised, rounded edge; the isolation of the spots; the u7iiform character of the eruption, and its general and scattered condition; its frequent seat and commencement about the face or head; the circular, fiat, granular, yellow crusts looking as if stuck on; its con- tagious nature and inoculability; its frequent follow- ing in the wake of vaccination; the absence of pain, and especially troublesome itching at night. Contagious impetigo may be confounded with eczema ; but the history is altogether different, and the isolation, the small scabbed patch, the characters of the crusts, and the facility of cure at once distinguish it. Impetigo sparsa does not arise from a vesiculation, but is primarily pustular, made up of aggregated pustules; it does not phlyctenoid; it is not contagious nor inoculable; it does IMPETIGO CONTAGIOSA. 219 not run a definite course; it is not confined to the young; it is not so amenable to treatment. Pemphigus. — In this disease the blebs are larger, more persistent, oval, and distended; the contents are watery and acid. Pemphigus is non-contagious; it does not occur especially on the face or the head; it is less in- flammatory, and wants the characteristic scabs. Ec- thyma. — This is primarily a pustular disease; it is seen also in adults; there are more induration and swelling, and a good deal of pain in connection with the formation of pustules; it is non-contagious; the scabs are heaped-up and dark. Pustular^ scabies. — This is the disease with which contagious impetigo is at times confounded. It must be remembered that the two diseases may coexist. In children both attack the buttocks frequently; both may exist about the hands and feet; but the distinctions are really very clear. In scabies there is no febrile condition; the eruption is multiform. If there be ecthymatous pus- tules, like impetigo contagiosa, they are covered by dark thick crusts; there are plenty of characteristic vesicles, with cuniculi and papules. If the impetigo contagiosa begins about the buttocks, it appears presently on the face or the head, or both. There is no irritation, nor are the effects of scratching visible about the body as in scabies; the bullous origin of the disease is distinct, and the scabs are characteristic. The hands are not specially affected in scabies in the child, but even impetigo contagiosa may attack the hands and feet markedly; still there is no mul- tiform eruption, and there are no cuniculi in the latter. When a correct diagnosis is made, the treatment is easy. The natural course of the disease is a short and defi- nite one The secretion is an active agent, by means of inoculation self-practiced by the patient in scratching, in transmitting the disease from one part to another. There- 220 SKIN DISEASES. fore it is of first importance to destroy the activity of the pus, and to alter the behavior of the surface that secretes it. A very active agent in procuring this result is an ointment containing five grains of the ammonio-chloride of mercury, and apply it to the surface beneath the scabs, which must be removed by poulticing or fomentation with warm water. A sulphur ointment is also beneficial. The patient must be well-nourished, and strict hygienic treatment adopted. Cleanliness is all-important. The old-school rely principall}^ upon the external ap- plications. The indications for the internal remedies are: Anti7}ion. criid — This is the principal internal rem- edy. Eruption forming thick, heavy yellow crusts, with burning; eruption about face; worse from bathing the parts; better in open air; chronic cases. Arsen. alb. — Black pustules, filled with black blood and fetid pus; painful sensation on scalp and face, as from cutaneous ulceration; worse from cold and touch; better from warmth. Baryta carb. — Especially old people; thick crusts be- hind the ears; fat dumpy children, with swollen lym- phatics; sore throat, with swelling of tonsils after the least cold; worse at night and when thinking of it; better in open air. Calcarea carb. — During dentition; dry crusts; sweat of forehead, particularly in the evening; sensitiveness of the roots of the hair. Cicuta vir. — Impetigo sparsa; eruption on chin and lower part of face, forming thick yellow crusts; honey- comb-like crusts, which fall off and leave a bright-red smooth surface; painful eruption on scalp. Clematis — Psoric constitution; pimples on forehead, root and sides of nose; pustules about lips, tender to IMPETIGO CONTAGIOSA. 221 touch; large pustules about loins; eruption changes char- acter during the changes of the moon; worse in bed, washing, and towards morning; feels exhausted on wak- ing. Conium — Sero-purulent eruption in aged people, old hypochondriac maids; vertigo when turning over in bed, looking up; old, weak, and feeble men; scrofulosis, with engorgement of lymphatics; eruption around mons ve- neris. Croton Hgl, — Pustular eruption upon an inflamed base, with itching and stinging pain upon septum nasi, plug- ging the nostril; eruption on abdomen; sore nipples of nursing women. Euphorbium is indicated when there is an irritable skin, with swelling of the face and pea-sized yellow vesi- cles. Graphites. — Scabby eruption, with excessive oozing; eruption around mouth and nose or the whiskers; hair falls out; corrosive blisters about extremities, toes, and fingers; dry skin; very sensitive to cold; cold hands and feet, with scanty menses; rhagades. Hepar. — Eruption after mercurialism; sensitive to touch; tendency to ulceration; humid scabs and pustules upon the head, oozing a fetid substance; swollen cervical glands; cracks behind ears; hands cracked and dry. Iris vers. — Impetigo capitis, with gastric complaints, nausea, and vomiting. Kali bichrom. — Dry eruption; pustules disappear with- out bursting. Stands next to Antim. cr. as a remedy. Kreasotum. — Painless pustular eruption all over body, especially on chin and cheeks; sticking pain, especially on points; sad and weeping; worse in open air. Lycopodium . — After abuse of mercury; itching and sup- purating eruption on head and face; full of deep cracks; 222 SKIN DISEASES. abundant and fetid discharge; fetid and moist scabs be- hind ears; humid tinea capitis. Mercurius. — Swelling and suppuration of glands; gas- tric derangement; moist scabs, with excoriation of the scalp and destruction of the hair; yellowish scabs on face, with fetid discharge; yellowish scabs, especially around mouth. Mezereum. — Deep inflammatory redness of face; erup- tion fat and moist; ichor from scratched places excoriates other parts. Nitric acid — Eruption on head, pricking on being touched; pustular eruption on face, with large red mar- gin and heavy scabs; mercurio-syphilis. Rhus tox. — Small pustules on black base; greenish pus, with violent itching at night; humid eruption, with thick scabs on face and head, destroying the hair, wnth fetid smell; eruption on nose, extending to face. Silicea. — Eruption resembling varicella; violent itching of scalp; moist scald head; growing pains; better warmth, worse from cold. Sulphur. — Dry, thick, yellow scabs on scalp, with pro- fuse discharge; great itching relieved by scratching; pur- ulent eruption on elbows. Tartar emet. — The remedy when the disease is exceed- ingly pustular. Thuja. — Eruption all over the body; itching and shoot- ing, especially at night; pustular eruption about the knee; better from gentle rubbing. Viola tricolor. — Pustules and scabs upon face, with burning and itching, and discharging fetid pus; sensa- tion as of tension of the integument of face; urine smells like cat's urine; worse at night. Recent cases. ECTHYMA. 223 Ecthyma. This disease is described as consisting of isolated phlyza- cious pustules — namely, those which are "large, raised on a hard base, of a vivid red color, and succeeded by thick, hard, dark-colored scabs, beneath which there is ulceration." The pustules are generally distinct, round, and isolated; they are mostly general, but may be par- tial, and leave cicatrices behind. The shoulders, but- tocks, and limbs are the parts usually attacked. There are two chief forms described — acute and chronic. Acute general ecthyma is rare. The ordinary scattered ecthyma is practically always the result of the action of some irritant upon the skin, in an unhealthy or badly nourished subject; and so ecthymatous pustules frequently occur in connection with scabies and phtheiriasis, and more rarely in pruri, or eczema, and other diseases. Acute ecthyma commences with slight febrile disturb- ances, and occasionally sore throat; locally, there is first a sense of heat and burning, followed by the appearance of reddish raised points, with hard, indurated bases, and •distinct vivid areolae; these points, which vary in size from that of a pea to that of a shilling, quickly pustulate, and are often accompanied by acute, sharp pain. In two or three days the pustules give exit to discharge, which dries into hard, adherent, dirty, discolored scabs, covering over circular ulcerations; the crusts fall off in a week or so, leaving behind dark stains. The ecthymatous spots may be few or man}^; in the latter case a good deal of ir- ritation is set up; the patient may be unable to sleep from pain, and the glands and lymphatic vessels may become inflamed, small abscesses forming subsequently. The disease is generally protracted by successive crops of pus- 224 SKIN DISEASES. tules, or it may relapse into a chronic state. The limbs^ shoulders, and trunk are chief seats of the disease. Chronic ecthyma generally results from the action of some irritation, as in scabies, in connection with pedi-- culi, and from scratching and badly nourished subjects. The ecthymatous pustules in the chronic disease are of similar character to those of acute ecthyma. They are painful, with hard, inflammatory bases and a small central collection of pus. When they occur on the limbs, espe- cially the legs, in old people they are followed some- times by troublesome ulcers. In ecthyma the seat of disease appears to be the upper- most layer of the derma, not unlikely about the glands of the skin, the depth of surface involved being less than in furunculus, and there is no "core," otherwise ecthyma would be well classed with boils. The tendency to ulcer- ation and sloughing, the lividity of the inflammatory areola, the disturbance of the general system, all point to a cachectic condition. Causes. — The predisposing causes are always such as lead to debility and an impoverished state of blood. They are, in infants, bad nursing, suckling by mothers much out of health, scabies, bad clothing, damp dwell- ings; in adults and others, over-work, fatigue, convales- cence from acute diseases, bad food, privations, various oc- cupations that induce irritation of the skin, as bricklay- ing, excesses of all kinds, debauchery, uncleanliness, night-watching, overcrowding in public institutions — workhouses, jails, and such like. The immediate excit- ing causes are scabies, phtheiriasis, the use of acrid medicinal applications, and scratchiiig. Prognosis is to be made according to the general con- dition of the patient. The ecthyma, per se, is of little gravity, save when it is accompanied by sloughing, as in old people; then it is grave. ECTHYMA. 225 Diagnosis. — The distinct, large, isolated pustules, with an inflamed areola and hard base, distributed over the body, are very distinctive of the disease. It may be confounded with impetigo sparsa, but in this disease there are rather sero-pustules than pustules, which are very superficial; the discharge is viscid, yellowish; these areas, dark scabs, no indurated, inflamed, and painful bases. Furunculus is deeper, it runs a slower course, and con- tains a central " slough " or " core," as it is called. It is more circumscribed, and there is little scabbing. Treatment. — lyocally a good application is an oint- ment made by rubbing together an ounce of lard, and half a drachm or so of Friar's balsam. The crusts may be removed after soakings with oil, and the affected parts dressed with an ointment made by adding five to ten. grains of white precipitate to the ounce of cosmoline. After the pustules burst, if the ulcers show but little tendency to heal, a weak carbolized wash may be used. The patient should be well hygiened and given a good generous diet. The appropriate internal remedy ma^^ be .selected from the following: Aiiacardium . — Hard, red pustules, itching worse after scratching; crossness and irritability with weakness of mind; sensation of a hoop around the affected part. Antimon. crud. — Pustules on the face in fat people;, yellowish or brownish scabs on the face; desire for acids. Arsen. alb. — Red or white pustules, with intense burn- ing; painful black pustules, gnawing, burning, and itching; eruption on the scalp, forehead, around the e5^es, cheeks, arms, shoulders, and upper part of the chest, terminating in thick crusts, and leaving well-marked scars. 226 SKIN DISEASES. Aurum. — Pustules on the face, neck and chest, with irritabiUty and melancholy. Bellad. — PUvStules surrounded by a whitish areola. Burning and itching with great sensibility to touch. Caladium. — White pustules with red areolae, sore to the touch and itching; better from sleep in the day time. Calcarea carb. — Heat, thirst and loss of appetite accom- pany the eruption. Scrofulous children and during den- tition. Cantharis. — Tendency to ulceration and gangrene, after or with the exanthemata; debility and emaciation. Ciciita. — Burning suppurating eruption about the face, with yellowish crusts. Croton tigl. — Confluent pustules with oozing and burn- ing; greyish-brown crusts on the abdomen; pustules with scarlet redness of the skin; itching followed by painful burning; pains relieved after sleep; intense itch- ing, but cannot bear to scratch on account of the pain it causes. Cyclamen. — Pustules on the feet and toes. Hepar. — Great sensitiveness of the pustules to the slightest touch; redness or little pimples around the ul- ceration. Kali bichr. — Pustules all over the body, in the early stage having a small brown scab on the top; pustules at the root of the nails spreading over the hand; pustules, with violent itching, which dry without bursting, form- ing scabs which sting and burn; pustules resembling small-pox, with a hair in the middle, leaving after the scab comes off a small dry ulcer, which heals in about a fortnight, leaving a colorless depressed cicatrix; eruption more in hot weather. Light-haired children inclined to grow fat. Kali hyd. — The eruption is profuse, over the body. ECTHYMA. 227 Great desire for the open air. Catarrhal fever with violent thirst. Kreasotum. — Large, fat greasy pustules, with violent itching towards evening; sensation in the skin as from ulceration, especially on face and chin. Larhesis. — Eruption more on the arms and left side; constitutional taint; feels worse after sleeping. Mercurius. — Suppurating pustules, which either run together, discharging an acrid humor, or which remain sore, become hollow, and afterwards raised and cicatrized; pustules bleed easily and are painful to the touch; itching and burning from the warmth of the bed; sweats easily without relief. Nitric acid. — Feeling as of a splinter sticking into the pustules when touching them. Petroleum. — Itching and burning pustules, with great weakness on exertion; great lassitude; worse in fresh air. Piper nigrum. — Large pustules leaving marks on the face. Rhus tox. — Pustules seated upon a red base; black pustules, forming hard scabs, with burning and itching; worse at night and in cold and stormy weather. Secale corn. — Cachectic females, with rough skin; pus- tules on the arms and legs, with tendency to gangrene. Silicea. — Pustules all over the body, especially on the back part of the head, sluggish, and do not suppurate or dessicate; sensitive to contact; burning and soreness after scratching; aversion to warm food; worse in cold. Scrofulous diathesis. Sulphur. — Dry, thick, yellowish scabs all over the body, especially on the scalp; always attended with great itching; painful to touch; aversion to washing. labacum. — Eruption most on neck and upper limbs; weariness, languor and debility; death-like paleness, nausea worse on least motion. 228 SKIN DISEASES. Tartar emef. — Eruption over the wbole body. Pustules are full, large, round, burning and painful with red areolae, soon drying up and leaving deep malignant ulcers. Pale,- livid, blackish, depressed pustules filled with blood or bloody serum collapsing on bursting and changing to broad, deep ulcers. Thuja. — Suppurating pustules, especially on lower ex- tremities; worse from touch; relieved by gentle rubbing. Furuncle. A furuncle, or common boil, needs little in the way of de- scription, the features being so familiar to all. Patholog- ically considered, it may be described as an acute and painful localized inflammation, differing, however, from a simple abscess by the fact that in the furuncle we find a central core of necrosed cutaneous and connective tissue, around which the inflammation is developed. Modern investigation leads us to the supposition that a micro- organism, having gained an entrance into one of the follicular openings, sets up changes which result in the death of the tissue in the immediate vicinity. This necrosed tissue acts as a foreign body and excites inflam- mation, as would a thorn, and after a few days the hard, painful, red tubercle exhibits a drop of pus at its summit, which gradually increases until the entire lesion softens, and finally breaks, with exit of pus, together with the core referred to. The pus which is discharged from a furuncle appears to be capable of exciting new lesions of a similar nature, and crops of boils may follow each other in an extremely per- sistent and disagreeable manner. Abortive Treatment. — If a furuncle comes under the treatment at the beginning, there is little doubt but that FURUNCLE. 229 it can be aborted; and one way to do this is to insert the sharp point of a PaqueHn cautery, or a lance-shaped galvano-cautery. If neither be at hand, a pointed stick of nitrate of silver should be thoroughly bored in. This is painful at the moment, but it saves pain later on, and may be the means of preventing the formation of new boils. Another method recommended is to scrape the skin over the threatened seat of invasion with a scalpel until a drop or two of blood exudes on pressure. Another: R. Hydrargyr. oxid., o. lo; lanolin, lo.o. S. To be well rubbed in three or four times daily. This will fre- quently be successful in aborting a boil. Sen recommends the following abortive treatment for furuncles: i. Carbolic acid in hypodermic injections. 2. The acid must be used early before suppuration appears, in which case the furuncle will be aborted without any connective tissue necrosis. 3. In advanced cases the adoption of the same treatment will prevent serious scar- ring. 4. A three per cent, solution is of more value than a weaker one. 5. Patients can follow^ their usual occu- pations during the progress of the treatment. Furuncles should never be opened with a knife until they are "ripe" — that is, until the accumulation of pus has been sufficient to loosen the central core. When opened, however, the pus should be evacuated as thor- oughl}^ as possible, and the central core removed. The parts should then be thoroughl}^ cleansed with mercurial solution, and an antiseptic dressing applied. The sul- phide of calcium given internally, in doses of one quarter of a grain, hastens the maturation of the lesions. When a boil is tense and hard, the best local treatment consists in applying hot, limited flax seed meal, or pul- verized slippery elm, or tomato poultices. Poultices 230 SKIN DISEASES. should not be continued after the boil opens, as if too long used they rather encourage the formation of new boils. Gelsemium or lappa cerate is a good after-dressing. The appropriate internal remedy will usually be one of the following: Absinthium. — Eruption of furuncles over the whole body. Aethusa. — Painful boil on the small of the back; he- patic derangement; intolerance of milk; in children dur- ing dentition. Ammon. carb. — Boils on the cheeks and around the ears; in scrofulous children and in old people. Antimo7i. rr/^^f.— Boils on the perineum; burning pain for some distance around; gastric derangement. Arctium lappa, — When crops of boils persistently oc- cur; hordeolum and ulcerated eyelids. Arnica. — Many small boils on the face; eructations bit- ter and like rotten eggs; general lassitude. Apis. — Boils on the pubis; burning, stinging pains; great sensitiveness to touch and pressure. Bellod. — In early stages, if boil is inflamed and pain- ful; red, hot, shining swelling; boils on the shoulders every spring; after measles. Bellis per. — Boils beginning as slight pimples, and in- creasing to large dark colored swellings, with aching pain. Mostly on the neck and lower jaw. Berberis vulg. — Hastens suppuration in boils, and pre- vents their recurrence. Bromide of potassium causes an eruption of small boilsy in successive crops, chiefly over the face and trunk, with troublesome itching. Bromine. — Boils on the arms and face. In light-haired, blue-eyed persons. Cadmium sulph. — Boils on the nose and buttocks. FURUNCLE. 231 Calcarea carb. — Boils on the forearms and hands, with lancinating pains; cramps in the arms; glandular swell- ings. In scrofulous persons. Calcarea mur. — As a preventative. Carbo afi. — Boils at the anus; burning, tearing pain. In scrofulous subjects. Ci7ia. — Boils on the head and face in children; child is very fretful; bores in the nose with the fingers; burning heat of the face with a glowing redness of the cheeks. Cistus. — Boils beginning with a blister. Gelsemiujn. — Large boils on the face and neck; great muscular prostration; sleeplessness from nervous irrita- tion; dizziness and blurred vision; heat of face and head. Hepa7\ — When boils mature slowly; violent throbbing gathering pain; stinging soreness; after injuries. Hepar low to promote suppuration, and /ilgk to prevent suppura- tion. Kaliiod. — Papular eruption, or other eruptions with strumous or syphilitic taint. Kalmia /<2^. — Red inflamed spots like incipient boils. Lappa?naj. — Boils on the face, eyelids and all over. Ledum. — Boils on the forehead, itching, pricking tear- ing pains worse in the evening before midnight. After mosquito stings. In drunkards. Lycopod. — Boils on the nates; periodical boils; aggra- vated by warm, wet poultices; after excessive wnne drink- ing. Manganum. — Small boils; every injury tends to sup- purate. Magnesia mur. — Boils on the nose which suppurate in one day; boils on the false ribs; menstrual derangements; diarrhoea in children. Merc. sol. — Boils on the ankles; coldness of the hands and feet; foetid ulcers on the legs, with gnawing itching; 232 SKIN DISEASES. shooting tensive pains, worse at night; especially when complicated with bilious or mucous diarrhoea. Natrum carb. — Boils behind the ears; ulcers on the limbs; burning in the feet when walking; sour eructions. Nitric acid. — Numerous large boils on the scapulae, nape of the neck, nates, thighs and legs; tensive pains worse in the evening and at night; aggravated by drink- ing milk. Nitrum. — Boils on the thumb. Nux juglans . — Boils on the right arm; indurated boils; blood boils; violent itching and burning. Nmx vom. — Boils on the knees; gastric derangement; constipation. Phos. acid. — Boils in the axillae, and on the nates; burning, stinging pain; skin feels sore all over. In young people who grow rapidly. Phytolacca. — Boils on the back. Rhus rad. — Boils on the face which do not mature; blind boils. Silicea. — Boils on the posterior portion of the thighs, and on the calves; disposition to boils; constipation. Stramon. — Boils on the feet; coldness of the limbs in children. Sulphur. — Boils in the ear; stinging itching with smarting after scratching; after suppressed menstruation; disposition to boils. Zinciun ox. — Boils on the abdomen, aggravated by use of wine; worse before and during menstruation. Hordeolum, or Stye, Is a small boil seated at the edge of the eyelids and in- volving a Meibomian gland. It is not an active kind of boil, but progresses sluggishly, the pustule centre being small. It is painful, and some time lapses before all ANTHRAX, OR CARBUNCLE. 233 traces of its existence go. There may be one, two, or more on one or both eyelids. Some persons are subject to repeated outbreaks of this furuncular inflammation. We find it most frequently in youthful individuals of rather delicate health with a tendency to acne, or in per- sons addicted to free living or dissipation. If by frequent relapses it induces inflammatory changes in the Meibo- mian glands, and is followed by fatty or chalky degener- ation of their contents, it is called Chalazion. Indications for the internal remedies are: Graphites. — Frequent recurrence of styes, ulcerations of the margins of the lids; biting lachrymation. Lycopod. — Styes on lids near internal canthus. Pulsatilla. — More in affections of lower lids, conjunctiva injected, agglutination of lids in the morning; much swelling of lids; burning, drawing pain, w^orse evenings, in warm room, and in a cold draft, better in fresh air; catarrhal states tending to suppuration. Staphisagria. — Affection of both lids, especially the upper ones; consequences of nervous exhaustion, the affec- tion does" not spread to the surrounding tissues; shooting, lancinating pains or tearing, mostly in paroxj^sms, worse during night; new ones form continually and leave small hard nodules at the tarsal edge. Anthrax, or Carbuncle, Is a multiple furuncle. It arises as a hot, hard swell- ing, not so conical as that of the boil — more indurated, however, the cellular tissue around being much more ex- tensively indurated; its color is dusky, the sensation burning, dull, throbbing; the carbuncle varies in size, the swelling becomes *' brawny," from the meshes of the cellular tissue becoming filled with a plastic lymph. The next step is the formation of a quasi-Qhs,ZQ.ss', the central i6 234 SKIN DISEASES. part of the swelling softens, and feels boggj^; the skin be- comes thin over the surface, and at several points open- ings occur, through which slowly issues more or less sanious pus; and the little holes are seen to be plugged up by small white cores, which presently loosen and come away; the apertures are red and papillated, the edges indurated and everted, particularly when several openings coalesce, so as to form one or more large open- ings. Gangrene may set in. The healing process is often indolent, the parts remaining undermined, brawny, dusky, shreddy, and also sloughy. Carbuncles are gen- erally solitary. The patient, if the attack be severe, gets into a very depressed state. The posterior aspect of elderly people is the selective seat of carbuncle. In carbuncles there are similar changes to those in boils, but a much severer degree of disease. Here a group of sebaceous glands is involved, and in conse- quence of the more cachectic state of the nutrition the reparative attempt is less perfect, the inflammation is of a lower type, and the cellular tissue sloughs and dies to a much greater extent. The nutrition is not only unequal to prevent the local disorder, but also incapable of putting repair in proper operation; and there is one disposition in carbuncular subjects that perhaps has a peculiar in- fluence in disposing to sloughing and gangrene of the cellular tissue; this is the tendency to, or an actual, diabetic habit. Sugar occurs in the pus of the carbuncle, and it is a curious fact that when anthrax develops the sugar is diminished or disappears from the urine. In summing up the conditions under which boils occur, it will not be difiicult to classify the main ones as follows: I. during seasonal changes in spring and summer; 2. from eating diseased meat (frozen); 3. when any special alteration is made in the ordinary habits and economy of ANTHRAX, OR CARBUNCLE. 235 the body, as in the training of prize-fighters; 4. from the influence of cadaveric poisons; 5. from sudden change of diet; 6. after fatigue of long duration; 7. during convalescence from debilitating diseases; 8. as a conse- quence of the action of septic poisons, as in fevers, etc. ; 9. in albuminuria; 10. in the diabetic habit; 11. dur- ing adolescence, and in the first stage of manhood. In most of these cases there are ' ' debility ' ' and an over- loaded state of system — for example, the circulation of urea, of sugar, of septic poison, or of effete matter which is plentiful during convalescence; and it only needs the action of some local irritant to determine the develop- ment of furunculi in the parts to which that irritant is applied. Diagnosis of Boils and Carbuncles. — No error can possibly be made in respect to these two diseases; in the former the hard, deeply-seated induration, the pain, the central suppuration, and the ''core," are distinctive. The manifold openings, the boggy feel, the sloughing, the grumous discharge, and the implication of the cellu- lar tissue in carbuncle are very peculiar. Furunculi are sometimes epidemic. Treatment. — I would add one word of caution in re- gard to the use of poultices: The poultices should be confined as much as possible to the exact seat of local in- flammation. Nothing is more common than the spring- ing up of fresh around old boils from the neglect of this precaution. The same local measures as recommended in furuncles are useful here. In addition consider the fol- lowing: The early application of ice and salt bags to the swell- ing is said to lessen the extent of the disease. If the sloughing is extensive charcoal and yeast poultices may be used. The sloughs should be picked out as fast as they 236 SKIN DISEASES. loosen, and the ulcer washed out once or twice a day with a weak solution of carbolic acid, or peroxide of hydrogen. Dr. Owen, of London, treats large carbuncles with ex- tensive sloughs by removing the sloughs, under an anaesthetic, scraping the sores and the diseased under- mined skin with Volkmann's spoon and trimming off the ragged edges. The wounds are then washed with a i-iooo sublimate solution, dusted with iodoform, and covered with moist perchloride gauze and blue wool. Do not use the knife to open a carbuncle. The indications for internal remedies are as follows: Aconite. — As an occasional remedy, when there is much inflammation with high fever. Anthraciyium . — When the burning pain is violent and not relieved by Arsenicum; cerebral or typhoid symptoms; evidences of blood poisoning; sloughing, abundant dis- charge of ichorous, terribly smelling pus. Apis. — Continued extension of the erysipelatoid inflam- mation with stinging burning. Arctium lappa. — Has great reputation; used both inter- nally and locally. Arse?i. alb. — Large, painful and malignant carbuncles; great prostration; great restlessness; great thirst, drink- ing but little at a time; all the symptoms are worse in the night, and better from external warm applications. Bellad. — Bright redness, with throbbing pain; when cerebral complications arise; erysipelatous inflammation around the carbuncle; drowsiness with inability to go to sleep. Biifo, at the commencement very efficient. Car bo veg. — Dark blackish appearance of the sore; fetid odor of the discharge; hippocratic face; blood poi- soning. Ciitchona. — When the asthenic character of the disease is well marked; debility from excessive suppuration. PUSTULA MALIGNA. 237 Hyoscyamus. — When there is great restlessness, caused by excessive nervous excitement; itching around the swelling; in nervous and hysterical individuals. Lachesis. — Bluish purpHsh looking carbuncles, with evidences of blood poisoning; nightly burning, obliging one to rise and wash parts in cold water; inability to bear any bandage around the neck; cerebral symptoms. Muriatic acid. — Carbuncles in scorbutic individuals, with ulcers on the gums; frequent desire to urinate with profuse emission of clear urine. Nitric acid. — When there is a predisposition to anthrax. Phytolacca. — Tendency to carbuncles, especially on the back and behind the ears. Rhus tox. — Great restlessness; feels somewhat relieved of the violent pain as long as he is in motion; burning itch- ing around the carbuncle, with vertigo; bloody, or serous, frothy, diarrhoea; typhoid symptoms. Secale corn. — Carbuncles on the arms; aggravated by warm applications; gangrenous tendency. Silicea. — During the process of ulceration, to promote healthy granulation. Pastula Maligna, Malignant Pustules, Also called Carbunculus contagiosus, is characterized by the appearance of an angry-looking pustule, associated with gangrenous destruction of the surro.inding pares which owes its origin either to a direct inoculation of the poison from an animal affected with the disease called Anthrax, or Charbon, or to a transmission by flies of the poison, or to inoculation of the poison from man to man, or to the eating of the flesh of diseased animals. It is there- fore most frequently found among persons wdio have to do with diseased animals, or who work in manufacturing establishments, where the products of such animals 238 SKIN DISEASES. (hides, horsehair, wool) are prepared for different uses. The infection 'takes place principally on the uncovered parts of the body which are exposed to the entrance of the poison. The eating of diseased flesh first causes gen- eral malaise and intestinal troubles, after which, in about eight or ten days, anthrax carbuncles appear, by prefer- ence on the arm, forearm and head. After an incubation of from a few hours to several days, there is at first felt on the spot where the poison took hold a slight burning and itching, as if from the bite of an insect, and one can see a little red speck with a black point in its centre. This soon becomes changed into an itching papule, capped with a small, generally reddish or bluish vesicle, which gradually enlarges. Af- ter bursting it discloses a dark red base, which becomes covered with a crust, while often, though not always, sec- ondary vesicles spring up around it, which contain a yel- lowish, reddish or blackish fluid. At the same time the surrounding parts swell oedematously over a considerable area, the cellular tissue underneath also becomes infil- trated, and in many cases discolored lines mark the course of the veins, or red stripes the course of the lym- phatic vessels in the oedematous region; the corresponding lymphatic glands also swell. The general symptoms cor- respond with the severity of the local affection; there is fever, great weakness, delirium, excitement, confusion; sweating, diarrhoea and pain in the extremities; in fatal cases collapse; in favorable cases after the dead masses have been removed by sloughing off, the wound gradu- ally heals by healthy granulation. The indications for internal remedies are few: Lachesis. — Bluish color of the pustule and red streaks along the lymphatic vessels. Anthi^acinum. — Blood poisoning. PUSTULA MALIGNA. 239 Mala7idrinum . — Blackish diarrhoea; pain in back and limbs; pustule similar to a badly-looking vaccine pustule. Compare the remedies given under Carbuncle. CHAPTER XI. SQUAMOUS INFLAMMATION. General Remarks. There are two important diseases of the skin with which we shall deal in this chapter — namely, pityriasis and psoriasis. In the former malady, in its typical form, the surface of the body is deeply reddened (hypersemic), and covered by large and freely imbricated scales or flakes; hence the term applied to it — pityriasis rubra. In the disease there is no real inflammation in the form of new products. Hebra allies it to eczema, and upon the ground that ' ' we occasionally find moist excoriated patches on other portions of the skin, especially in the flexures of the joints." But this is infinitely rare; from beginning to end, there need be nothing but hypersemia and scaliness present in the disease. There is not necessarily any change in the corium tissue or the connective tissue, though the hypersemia, if persistent, maybe followed by hyperplasia and thick- ening of these parts, but only as accidental epiphe- nomena. In psoriasis a somewhat different state of things obtains; there is hypersemia of the papillary layer of the skin, with hyperplasia of the epithelial elements, but I believe the latter to be the more important of the two; and in this respect psoriasis contrasts with pityriasis rubra — the former being essentially a disease of cell tissue, the latter rather an hyperaemia, primarily. PITYRIASIS RUBRA. 241 Pityriasis Rubra. Under this title two distinct types of disease have been described — the one by Devergie and the other by Hebra. They both possess certain marked features which would entitle them to the designations they have received; but, as there are also marked differences in their course, and prognosis, they must and should receive separate consid- eration. Pityriasis Rubra (Devergie). This affection is chiefly met with in persons between the ages of forty and fifty, and commences by the ap- pearance of well-marked redness, wath a sharply limited margin on the anterior aspect of the trunk and limbs. As it advances new surfaces are invaded, the skin slightly thickens, and the increase may be so rapid that the entire skin may become involved in from two to four weeks. Accompanying this diffuse redness we find free desquamation or exfoliation of medium-sized epidermic scales, with more or less watery exudation, resembling sweat rather than the l3miphy and plastic exudation of eczema. There is also an intense burning heat of the surface, so that the patient suffers from the warmth of his clothing and of the bed coverings at night. The acute symptoms mentioned are tenacious, and the affection m^ay persist in this condition for months, but in perhaps the majority of cases they gradually subside, and recovery takes place. On the other hand, the acute phase of the disease may be followed by one that is subacute, but more persistent, and continue to harass the patient for years, gradually breaking down his health and terminating fatally, 242 SKIN DISEASES. through the supervention of chronic diarrhoea or the de- velopment of pemphigus. The prognosis is in the main favorable, except when it occurs in aged or debilitated subjects, or assumes the dis- tinctly chronic form. Pityriasis Rubra (Hebra). Under this name Hebra has described a disease that is wholly different from the foregoing, and the principal characters of which are as follows: The skin presents a persistent deep-red coloration, dis- tributed over the entire surface, but without papules, vesicles, or any exudation. Scales are found in small numbers, but do not become a prominent feature of the affection. The local subjective symptoms are insignificant. The progress of the disease is remarkably slow, and in its early periods the general health is not notably affected; but little by little there is a gradual weakening of the vital forces, and fatal marasmus marks the termi- nation of the patient's sufferings. It will be seen from the foregoing that the affections described under the same name by the eminent French and German authors differ from each other in every im- portant respect, and are, in fact, quite distinct diseases. Dr. Piffard has met with a number of cases of Dever- gie's disease, but only a single undoubted example of the malady described by Hebra. - If, as asserted by Hebra, pityriasis rubra is always and unnecessarily fatal, treatment other than palliative is out of the question. In Devergie's affection, however, every effort should be made to cut short its progress, and benefit may be ex- pected from baths, emollients, and therapeutics. PITYRIASIS RUBRA. 243 Soothing local applications, such as bran baths or a de- coction of walnut leaves followed by oil}^ inunctions, and later by oil of white birch, are important aids. Lotions with corrosive sublimate i-iooo, or with hydrate of chlo- ral 1-50 or i-ioo, constitute an excellent application in pityriasis capitis. Sulphurated pomades have been ad- vised; flowers of sulphur 1-30 or 1-60. For pityriasis of the face a pomade of calomel i-ioo is often eflQcient. Arsenicum album is the principal internal remedy used by both schools. It produces pityriasis by its physiolog- ical action; its well known characteristics indicate its use; feverishness, with restlessness and thirst, for small quan- tities, etc. Natru7n ajsenicum. — This drug corresponds very closely to the leading peculiarities of this disease, and I have prescribed it successfully in several cases. Its skin symptoms read: "Squamous eruption, scales thin, white, and when removed leave the skin slightly reddened. If scales remain they cause itching, worse when warm from exercise." Arsen. tod. and Kali ars. are preparations that may be occasionally useful. I have had no trustworthy expe- rience with either. Other remedies may be indicated as follows: Antim. crud. — Brownish-red spots, like small hepatic spots, here anci there. Cajitharis. — Itching, followed by burning, when scratching; tendency to formation of blisters; most suit- able when the disease appears in children. Cocculus. — Red, irregularly shaped spots on the skin, over the whole chest, and on the sides of the neck, be- hind the ears, without heat or itching^ intolerance of both cold and warm air. Conium. — Frequently recurring red, somewhat itching, spots on the body. 244 SKIN DISEASES. Graphites. — Pityriasis capitis, dryness of the skin, with cracking; localization of the eruption; tendency to cold from draughts of air; pains from changes of the weather; abundant desquamation from the hairy scalp. Kreasotum. — Uneasiness during rest, with irritation throughout the body; child cannot sleep unless carried or fondled; scaly ulceration on face, elbows, wrists and fingers. Lachesis. — Small reddish spots on face, neck and chest, which increase in numbers, become scurfy, and then dis- appear. Ledum. — Aching, bruised feeling in the whole body; warm sweat of the hands and feet; bluish spots on the body like petechiae; eruption itching, with anxiety; cold- ness in affected parts. Mezereum. — Chronic pityriasis capitis, loss of hair and great itching, brownish miliary rash on the chest, arms and thighs; phlegmatic temperament, with light hair. Phosphorus, — Brown, bluish-red, or yellow blotches on abdomen and chest. Sepia. — Brown-red hepatic spots on the skin. Sulphur \?, advised by the two schools. Its pathoge- nesis contains the formation of furfur. Tartar e7net. — Eruption dependent upon gastric de- rangement, nausea and vomiting, with thick white coat- ing on tongue. Pityriasis Pilaris. Devergie, who was the first to describe this rare der- matosis, states that in its most benign form it consists of a more or less localized eruption on the external aspects of the members, and especially the forearms and legs. The essential seat of the eruption is at the pilous orifices of the general surface, but not on the scalp. The only lesion is a minute papule, with a small adhering scale. Psoriasis. PSORIASIS. 245 In more severe cases it may become generalized, with slight thickening of the skin about the follicle, forming a small, red pyramidal papule decked with a white scale. The skin between the papules is apparently unchanged. There is little or no pruritus, and it apparently causes but trifling inconvenience to the patient, except as it pro- gresses from bad to worse. It is exceedingly obstinate, and palliative and emoUient treatment is our only resource. When associated, as it may be, with pityriasis rubra, it presents a striking likeness to lichen, rubra and may pos- sibly be in reality the same affection. There is considerable discussion as to whether pityri- asis is not a parasitic affection. Some observers claim to have discovered a special parasite in this affection, con- sisting of very minute spores, averaging a thousandth of a millimetre in diameter. The extreme smallness of the spores and their irregularity in size have induced M. Vi- dal to name the parasite Microsporon' anomoeon or dispar. This is a point that has not been fully settled as yet, and I prefer to class the disease among the squamous in- flammations until further light has been thrown upon the subject. Sepia and Natr. ars. are the principal internal remedies for pityriasis pilaris. Psoriasis. Psoriasis is a constitutional disease, characterized by cutaneous lesions of the squamous type. This affection may appear in the early years of child- hood, or at almost any later period up to and including so-called middle life. It rarely appears at either of the extremes — that is, during infancy or old age. Its first manifestations usually take the form of small 246 SKIN DISEASES. red papules, soon decked with a white scale. These may- be few and scattered, or many and closely aggregated. The scaly papules increase at their periphery, becoming flattened patches from the size of a pea to that of a coin or even larger. When the progress of the disease con- tinues, neighboring patches encroach on each other, and in time coalesce, giving rise to irregular gyrate forms. Coincident with the peripheral extension there is an in- crease in the infiltration or thickening of the skin, and the scales become large, imbricated, and more or less ad- herent. On forcible removal of the scales, a red infil- trated patch is brought to light, on the surface of which minute droplets of blood may be seen. After the disease has attained its maximum development, which may in- clude the greater portion of the surface, it may remain stationary for an indefinite period, or may undergo a gradual involution and disappear. This is the course fol- lowed in not a few cases of mild type. A single attack of this sort, howeVer, is exceedingly rare. In almost every instance the eruption reappears after a shorter or longer interval. In not a few cases of mild type there will be an appearance of the lesions at the beginning of the cold and a disappearance of them at the beginning of the warm seasons. In cases even where the eruption is caused to disappear by treatment there is the same tendency to return, and this relapsing feature of the disease is one of its most im- portant and most annoying characteristics. To such an extent is this true, that even with the most judicious treat- ment there is no certainty of a radical cure. As a rule, if a person once has psoriasis, he may expect to have it al- ways — that is, with certain intervals of freedom. The reverse of this is rare, as it is extremely exceptional for a patient to recover permanently, or to enjoy immunity for a term of years. PSORIASIS. 247 The subjective sj^mptoms are usually unimportant, amounting at most to a moderate degree of pruritus^ though in man}^ cases this is not sufficient to be com- plained of by the patient. The eruption frequently exhibits a more or less sym- metrical disposition, and prefers the extensor surface, with a special predilection for the elbows and knees. The upper half of the body usually presents more lesions than the lower. It very rarely affects the palms or soles. When situated on the genitals it may excite an analogous condition of the mucous membrane. The features of the disease are the more characteristic if account be taken of its negative signs; for in it there is an entire absence of any discharge, vesiculation, or pus- tulation throughout the whole course of the disease. The characteristics above described constitute a primary condition . The eruption affects (by preference) certain parts of the skin whose epithelium is thick, especially the elbows and knees. It may be partial or general. At the outset the disease may be attended by more or less pruritus. The increase of the patches is by centrifugal growth, and there is oftentimes a slightly red margin; the scales are shed, to be again replaced by others; in chronic cases the derma itself becomes very distinctly infiltrated and thickened. The general health is often apparently good. The disease is non-contagious, runs a chronic course, and is very prone to recurrence. It is customary to make certain local varieties; they are: Psoriasis capitis. — The head is one of the commonest seats of the disease, next to the elbows and the knees; the whole scalp may be affected, or there may be only one or two small points of eruption; when extensive, the 248 SKIN DISEASES. disease travels on to the forehead, forming a kind of fringe along it at the upper part. There is co-existent disease elsewhere. The hair on the scalp thins out fre- quently when psoriasis attacks it. Psoriasis faciei. — In this local variety of psoriasis, the patches are often circular; they are less hypersemic, less thick, and less scaly than when the disease attacks other parts of the body, and they present consequently much similarity to tinea circinata, except that typical patches of the disease are seen in other parts of the body. Psoriasis palmaris ?indi psojiasis plantaris are important local varieties. These local varieties are infinitely rare. Of course, instances of so-called psoriasis palmaris and plantaris are common enough, but they are practically al- ways syphilitic. Non-syphilitic psoriasis may occur, though rarely, in connection with general psoriasis. But when such a condition exists as the sole disease, it is syph- ilitic and nothing else, and the concomitance of sore tongue and other evidences of constitutional syphilis at once make the diagnosis certain. The skin in the affected parts is generally thick, and dry, harsh, discolored; the scaliness is not very marked, but the superficial layers peel off from time to time. Presently the surface cracks and fissures, and healing is very tardy; occasionally the surface bleeds. The muscular movements of the hand may be painful. Psoriasis unguinum is mostly a complication of the in- veterate form of psoriasis, but it may exist alone. The nails (and several are usually affected) lose their polish, and soon become opaque, thickened, irregular, and brit- tle; they are then fissured and discolored in lines (from dirt), their matrix becoming scaly. Psoriasis also affects the scrotum and prepuce occasion- ally; the parts are swollen, red, hard, tender, scaly, fis- PSORIASIS. 249 sured more or less, and give exit to a thin secretion, which adds to the scaUness; there are pain and pruritus; and the local mischief may be the sole, or part only, of general disease. Psoriatic syphilides. — Nozo asserts that psoriatic syphi- lides always indicate the presence of a grave variety of syphilis and that they occur most commonly in cachectic subjects. In some cases they may appear as late mani- festations of the disease; and their development is fa- vored by old age, alcoholism, congenital or acquired dry- ness of the skin, and perhaps, also, by gout. Cases occur concerning which even the most expert diagnosti- cian may be in doubt as to whether the eruption is the ordinary psoriasis or a specific eruption. When psoriasis is in progress of cure, the scales lessen and the reddened elevated surface beneath comes more prominently into view; but this diminishes gradually till the eruption disappears, leaving oftentimes no trace of its former presence behind. It may leave, however, pig- mentary stains, the result of the congestion. It is in the disappearance of patches of psoriasis that the centre rapidly clears, and the ringed form or psoriasis circinata^ or the lepra of old authors is produced. Etiology. — We possess no certain knowledge as to either the proximate or remote causes of the disease. It is not uncommon to find an extensive eruption in those who otherwise appear to enjoy the most robust health; while, on the other hand, it may appear only during periods of temporary debility, as in women during preg- nancy and lactation. That the affection is constitutional and connected with similar conditions to those underly- ing eczema we have no doubt, and each year's experience more strongly confirms this opinion. Some have claimed that the eruption is purely local or due to the presence of 17 250 SKIN DISEASES. a parasite. Positive evidence of this is wanting. Others pretend that it is but a relic of syphilis handed down from a remote ancestor. This view also has little to sup- port it. Psoriasis is often hereditary. It attacks males more than females, and is most common between the ages of fifteen and thirty. Persons of sanguineous temperament are most liable to the disease perhaps, and it is seen in persons of all classes of society, and mostly in summer and winter. Prognosis. — The disease is mostly difficult of cure and has a tendency to recur. The most obstinate cases are those of psoriasis mummularis of the back and but- tocks, in which there is much elevation and thickening and deep redness; and psoriasis about the hands and feet. Diagnosis. — In well-marked and typical cases there can not be the least difficulty in diagnosis, especially to any one who has already seen an example of the disease. Unfortunately, however, cases are not always typical; and we must learn to distinguish psoriasis from syphilis, eczema, and dermatitis exfoliativa. As we have already stated, eczema may closely resemble psoriasis. In like manner the latter disease may closely counterfeit the former in its outward appearance; and in this particular case the diagnosis will be by no means easy, nor arrived at at a glance, but only by careful consideration of the case in all its bearings. A squamous syphilide may closely resemble psoriasis; but here the history will aid us greatly if we bear in mind a few fundamental facts. In psoriatic cases of long standing we will have the his- tory of repeated outbreaks of eruption, but they will all have presented the same general type — that is to say, a repetition of the same kind of eruption — a squamous PSORIASIS. 251 S3^philide will probably have been preceded by other eruptive attacks; but these have been in all probability a different sort of eruption — papular, pustular, or what not. Syphilis rarely repeats itself in its manifestations. If in addition we learn from the patient the prior exist- ence of the primary lesion, or if we find other co-exist- ing lesions, as alopecia, mucous patches, throat trouble, etc. , we should not long remain in doubt as to the nature of the eruption about which we have been consulted. The existence of squamous lesions on the palms and soles in connection with squamous patches on the general sur- face is evidence positive of syphilis. In psoriasis the epidermic proliferation or desquamation is much greater than in syphilis. We have known a case of exfoliative dermatitis to be mistaken for psoriasis; but if we recollect that the characteristic feature of the former disease is the exfoliation of quite extensive laminae, of not very greatly thickened epidermis, sometimes several square inches in extent, there is no excuse for mistaking the one disease for the other. Psoriasis and syphilis may of course coexist. There will be but little difficulty in differentiating the respective lesions. Psoriasis may coexist with eczema, both presenting typical lesions, or we may have lesions of mixed char- acter, in which it would be hard to say which disease predominated. Certain diseases of other organs appear to bear a close relationship to psoriasis. This is notably true of arthritic affections and also of asthma. As a rule, these do not coexist with the psoriasis, but manifest themselves during the time that the skin is free from eruption, alternating as it were with the cutaneous lesion. Treatment. — It is but a few years since the chief re- 252 SKIN DISEASES. liance of the old school in the treatment of psoriasis was the internal use of arsenic and the external use of tar. Slow and tedious was the cure. Now, however, they possess an agent which they claim exhibits a remarkable energy in the control of the eruption. We allude to chrysarobin. This is employed in various ways, but the one seemingly most satisfactory is a mixture of thirty grains of the drug with one ounce of traumaticin {liquor gutta-percha). This should be painted on the spots daily until a considerable degree of local irritation is produced. Sedative applications should then be applied for a few days, and the skin allowed to recover from the effects of the drug. A single course of this sort will cause most of the spots to disappear — that is, as regards scale formation and infiltration — and these spots will usually appear distinctly white and ansemic in comparison with the surrounding skin, which has been darkened by congestion produced by the chrysarobin. Unless the eruption was limited both as to size and extent of the lesions, we will find many patches in which complete recovery has not taken place. These will require addi- tional applications. Chrysarobin possesses the incon- venience of staining the surrounding skin (temporarily) and permanently staining the clothing; and a number of substitutes — naphthol, resorcin, antarobin, hydroxylamin, etc. — have been proposed. Some of these are dangerous, while others are inefficient, and none of them are equal in efficacy to chrysarobin. This drug, however, should not be applied to the face or scalp, and we must instead use milder applications, such as tar or some of the essential oils, as the oleum pini sylvestris, oleum eucalypti, etc. The following is an excellent aid : 9^, Chrysarobin, Acid Salicylici, aa gr. x. Unquent Resiuol, ^j. % PSORIASIS. 253 Sig. Apply thoroughly at night and bathe thoroughly next morning, or, 9^. Tar, Alcohol, Soft soap, aa Jj. M. Sig. Apply locally, with flannel or a coarse piece of cloth, and is firmly rubbed into the part night and morn- ing according to the effect. The following is a very good application for an ordinary case of psoriasis which is passing on to the chronic stage. ^. Nitrate of mercury ointment, 3J to gjj. Powdered oxide of zinc, 5jj- Solution of lead (liquor plumbi), ^ss. Carbolic acid, fl. drops, jj. Olive oil, ^j or ^j ss. M. Sig. Apply nightly. Another excellent application is made as follows : ^ Red precipitate, finely powdered, White precipitate, aa gr. vj. Lard, ^j. Mix. Sig. Apply night and morning. Dr. Stern recommends for psoriasis capitis : Precipit. alb., lo.o ; Sapon. nigr., 40.0; Lanoline anhydr., 50.0. M. Ft. ung., S. Rub in every evening a portion the size of a filbert. After four days all the scales are gone, and the affected parts become smooth and take on a natural appearance. It is usually advisable to continue the application of the lanoline alone for a time longer. Dr. Patterson reports a case of psoriasis of fifteen years' standing cured in one month by an ointment of vaseline, oxide of zinc and Sanitas oil. He fails to give the pro- portions. The pomade of tar is classical in the treatment of 254 SKIN DISEASES. psoriasis. Axunge or oil, with one-tenth part of tar. The pomade of oil of cedar has been employed in the same proportion. The immediate action of these pomades is a notable amelioration of this affection. But they never effect a cure. In obstinate cases, unless the skin is very irritable, the oil of white birch may be used in the form of an ointment, one drachm to the ounce of vaseline. The diet in psoriasis should be a generous one, and in it meat ought always to play an important part. Cod liver oil is generally needed. The indications for the internal remedies are as follows: It is better to commence the internal treatment with Sulphur. Afterwards one of the following remedies may be given : Ammon. carb. — White pea-sized spots upon the cheek, which continually exfoliate; skin very sensitive to cold; aversion to being washed; nose-bleed when washing the face in the morning; in weak, nervous individuals. Arsen. alb. — Eruption red or white and scaling; skin dry and scaly; great restlessness with weakness and pros- tration, worse about midnight; burning itching; oppres- sion of breathing; aggravated by eating fruit, ice cream, etc. Arsen. iod. — Dry scaly burning itching eruption on various parts; persistent itching on the back; in obsti- nate cases. Berber, vulg. — The eruption appears with itching, lymphatic swellings on the articulations; must scratch very hard. Calcarea carb. — Scurfy spots on the leg; burning and itching; skin cracks; profuse sweat from the slightest exertion; large abdomen; blue eyes, blonde hair, fair skin. PSORIASIS. 255 Clematis. — The eruption is chronic and long lasting, and becomes redder and more humid with the increasing, paler and dryer with the decreasing moon. Fluoric acid. — Roughness on the forehead like a rough line with its convexity upwards. Reddish spots above the eyebrows; desquamation on the eyebrows; nails brittle, edges bent in. Hydrocotyle — Circular spots with slightly raised scaly edges. Iodine. — Rough, dry and dirty 3'ellow color of the skin. Nervous irritation, and emaciation, with good ap- petite; psoriasis circinata. Iris vers. — Irregular psoriatic patches on the knees and elbows, covered w^ith shining scales; eruption becomes hard and dry; skin fissured and irritable; digestive de- rangement, with nausea, and debilit}^; starting during sleep; psoriasis diffusa. Majiganum. — In inveterate cases. Mercurius. — Psoriasis of the hands; psoriasis in spots all over the body; scaling off and exfoliation of the finger nails; the scalp is painful to the touch; easy perspiration without relief; recent cases. Mezej'eum. — Scurf- like scales on the back, chest, scalp and thighs; roughness and scaling here and there; pruritus increased by scratching or when undressing. Micriatic acid. — Psoriasis of the hands; great sensitive- ness to damp weather. Natruvi ars. — Thin whitish scales, which when re- moved leave the skin slightly reddened. Nitric acid. — Burning, itching or stabbing pains, worse at night, from change of weather, or during perspiration; strong smelling urine, like that of horses. Petroleum. — Skin of the hands cracked and rough; 256 SKIN DISEASES. unhealthy skin; aversion to the open air; extreme sen- sitiveness to sHght touch; falhng off of the hair. Phosphorus. — Psoriasis of the arms and hands, and on the knees and elbov^^s; arms and hands become numb; brownish or bluish-red blotches, with furfuraceous dry scaling; coldness of the knees at night in bed; falling out of the hair in large bunches; dry cough, with sore- ness in the chest; tall, fair children, with tuberculous tendency. Phytolacca. — Surface of the skin shrunken and of a leaden color; squamous eruption; rheumatic pains in the extremities. Psorinum. — Eruption dry and scaling, with itching, weakness, and debility; after acute diseases; profuse colliquative sweats. Selenium. — Dry, scaly eruption on the palms of the hands, with slight itching. Sepia. — Psoriasis on the face; red roughness of the skin; falling off of the hair; during pregnancy and nursing; dark complexioned individuals. Silicea. — Elevated scurfy spots near the coccyx; small white scales on the face and neck; white spots on the cheeks; sensation of numbness in the extremities; brit- tleness of the nails; in scrofulous, large-bellied children. Tellurium. — Psoriasis annulata, eruption over the whole body. leiicrium. — Psoriasis on the index finger of the right hand. \ CHAPTER XII. DIATHETIC DISEASES. I shall adopt the plan as outlined by Dr. Fox, and include under the head of diathetic diseases the strumous, the syphilitic, and the leprous diseases of the skin. There are some objections to this classification, but they do not outweigh the advantages of the arrangement. In struma, sj^philis, and leprosy the changes in the skin are but a small part of the whole disease, and only evidence of a disposition on the part of the tissues of the bod}^ as a w^hole, to become changed and disor- dered. Scrofuloderma. This disease does not require to be dealt with very elaborately. "It is scrofula of the skin," and only a part of the general diathetic condition, w^hich is evi- denced by the ordinary signs of struma in greater or less degree of expression. As regards the skin, scrofula is generally characterized by the appearance at the outset of indolent, dull red, soft, tubercular formations, that rapidl}^ suppurate, and are soon covered over with darkish scabs, from beneath which oozes an unhealthy pus. Ulceration to a greater or less degree takes place, with the formation of exuberant granulations at times, and the healing is accompanied by distinct scarring. The whole disease is of the most chronic character. One can scarcely mistake the strumous ulceration for any other disease; it may spread and cover a large 258 SKIN DISEASES. extent of surface, and in this case the ulcerated surface is half covered by darkish irregular crusts, whilst the ulcers discharge a thin disagreeable dark pus, and granulations are flabby and pallid, bleeding freely on being touched; the edges of the ulcers are livid, and various attempts at repair are made. The mucous surfaces of the nose or eye may be inflamed and slightly ulcerated and onychia may be present. There are old scars of former strumous disease, and the whole aspect of the patient is a sufficient tell-tale of the disease. The old school advises the use of cod-liver oil, iodide of iron, the phosphates of lime and iron, and locally an astringent ointment of tannin; or acetate of lead; or mercurial plaster; or iodide of lead ointment to the indo- lent ulcerated surfaces. Residence at the seaside is also advisable. These patients should be allowed an abundance of fresh air, plenty of outdoor exercise, and a generous diet. When the ulcers have formed, dress them with the iodide of starch paste. The indications for the homoeopathic remedies are: Alnus rubra. — Enlargement of submaxillary glands, strumous enlargement of tonsils; obstinate impetigo and porrigo, chronic diarrhoea; scrofulous disease of hip- joint; disease of mucous membranes, which arise from or alternate with eruptions of the skin. Arsen. zW.-— Diseases of mucous membranes, charac- terized by a peculiar and persistently irritating corrosive character of the discharges; constant susceptibility to take cold; excoriated nostrils and lips; swollen and cov- ered with scabs Arsen. 7net. — Great emaciation, clay-colored face, blue margin around the eyes; great weakness of all the limbs; want of disposition to do anything, and constant inclina- DIATHETIC DISEASES. 259 tion to rest; lax muscles; swelling of the cervical glands; distended abdomen; diarrhoea; scurf}' eruptions and ulcers; ophthalmia; carcinoma. Asafcetida. — Glands hard, swollen, hot, and throbbing, with shooting jerking pains; soft enlargement of bones, with curvature; ulcers with high hard edges, sensitive to touch, easih' bleeding, pus profuse, greenish, thin, offensive, even ichorous; psoitis when suppuration threatens; osteitis and caries; scrofulous ozaena; hard- ness of hearing, with thin purulent discharge of offensive odor; scrofulous, bloated, clumsj^ children, with phleg- matic temperament. Asclepias tub. — Strong tendenc}^ to tubercular develop- ment; sharp pains in different parts of the body, with muscular soreness, changing from one part to another; impaired strength, rather feeble digestion and assimila- tion; glandular enlargement about neck; vesicles; pim- ples and pustules all over the bod}'. Auriwi met. — Scrofula, rudd}" complexion, light haired, sanguine temperament; glands painfully swollen; ozaena, with caries of nasal bones; fetid otorrhoea from caries of mastoid process; caries of cheek bones; tearing, boring, burning stitches in zygoma; red and swollen ton- sils; profound ulceration in throat. Badiaga. — Dandruff or dry, tetter-like appearance of scalp, with slight itching; scrofulous ophthalmia, with hardening of the Miebomian glands; tonsils red and in- flamed; indurated inguinal glands; glandular swellings on left side of face, throat, and neck, some hard, some suppurating; small hard lumps along tibia; flesh feels sore as if it had been beaten, and ver}^ sensitive to touch or friction of clothes. Baryta carb. — Physical and mental debility; atroph}^, great weakness; face red and abdomen bloated, glands 260 SKIN DISEASES. swollen, indurated; fatty or encysted tumors; coryza, nose, and upper lip swollen, scurfs under the nose; chronic induration of tonsils; sensation as of a plug in throat, worse swallowing solids; crawling in rectum, ex- pulsion of ascarides; cannot retain the urine; chronic cough, with swollen glands and enlarged tonsils; worse after slightest cold, with soreness in chest when cough- ing; chronic torticollis; pimples, ringworms, humid sores. Bellad. — Hard, swollen, and ulcerated glands; muscu- lar debility, with difficulty of learning to walk; photo- phobia, inflammation of eyes and eyelids; cough, with mucous rales; otorrhoea; emaciation and atrophy; ulcers; inflammatory swelling of nose and lips; frequent epistaxis; frequent sore throat, with swelling; distended and hard abdomen; enuresis day and night; premature develop- ment of mind; blue eyes and blonde hair. Berberis aquifol. — This remedy is highly recommended by several physicians. Dr. Mallery uses the following prescription : 9^, Fluid ext. berberis, Syrup simplex, aa ,^iv. M. S. Teaspoonful every four hours. Bromium. — Swelling and induration of the glands; en- largement of thyroid, in children with Hght hair, blue eyes, and fair skin; pimples and pustules; boils on the arms and face; hard swelling of left parotid, edges of opening smooth, discharge watery and excoriating, swelling remaining hard and unyielding; tonsiUitis; swal- lowing of fluids more difficult than of solids; hard uneven tumor in right mammae, firmly adherent to its surround- ings, with lancinating pains, worse at night; stiffness of neck. Calcarea carb. — Malassimilatioii; tardy developmejit of DIATHETIC DISEASES. 261 bony tissue; large head with open fontanels; curvature of the back and vertebrae or other rickitic affections; herpes, tinea, crusta lactea; hard or suppurating glandular swell- ings; ulcers, exostosis, or caries; hard and enlarged abdomen, with swelling of mesenteric glands; emaciation and voracious appetite; thirst constant, even after drink- ing; profuse perspiration of head; thin and wrinkled face, with dim eyes; dry and flaccid skin; difiQculty of learning to walk; difficult dentition; red swelling of nose; bronchocele; swelling of upper lip; frequent bleed- ing of nose; feet cold and damp; craves eggs. Calcarea iod. — Tendency to alternate diarrhoea and constipation; no thirst; pustular eruption, sore and pain- ful, with desire to rub and scratch it, though it makes it worse; abdomen enlarged, breath offensive; cold sticky perspiration, feet cold and damp; restless, fretful, and irritable; pus from abscesses thin and ichorous; granular inflammation of membrana tympani; scrofulous oph- thalmia. Calcarea phos. — Emaciation, dirty- white or brownish complexion; skull soft, thin, crepitating when pressed, especially in occiput; craves bacon, salt meat, and potatoes; swelling of the epiphyses, difficult teething, slow closing of the fontanels; curvature of spine to the left, lumbar vertebrae bent forward; abscesses near lumbar vertebrae; incipient mesenteric tabes, with much fetid diarrhoea. Tendency to tuberculosis. Chimaphila. — Glandular enlargement, especially of lymphatics; enlargement of mesenteric glands; ulcers of an indolent and flabby character ; tumors in mammae. Cina. — Child feels uneasy and distressed, does not want to be touched, is not pleased or satisfied with anything, leaves his head side-ways all the time, rubs nose constantl}^ ; pale sickly-looking face ; hunger and 262 SKIN DISEASES. thirst soon after eating, with gnawing sensation in stomach ; abdomen hard and distended ; itching at anus; ulcers with scanty discharge ; inability to retain urine. Cistus Can. — Glands swollen, inflamed, indurated, or ulcerated; drawing tearing pains in all joints; itching all over the body, without eruption; herpetic erruption of various parts; chronic scrofulous ophthalmia, feeling as if something was passing around in the eye, with stitches; watery, bad-smelling pus discharged from ears; tetters on and around ears; swelling of parotids; eczema of nose; caries of lower jaw, with suppurating glands in neck; cool feeling in stomach and abdomen; cool eructations; chronic diarrhoea; swelling and suppuration of glands of throat; scrofulous ulcers on back; desire for acids and acid fruit, but they cause pain and diarrhoea. Conium. — Swelling of glands, with tingling and stitches; marasmus with frequent sour belching, worse during night; erratic itching of all parts of body; humid, burning, corroding, crusty herpes; blackish ulcers, with bloody, fetid, ichorous discharges, especially after con- tusions; ophthalmia with photophobia; blenorrhoea bronchialis; asthma; carcinoma. Cory dalis form. — Scrofulous cutaneous diseases, accom- panied by feeble digestion and poverty of blood; scrofu- lous syphilitic diseases. Cornus circin. — Scrofulous ophthalmia, herpes of eye- lids; ulcerations of tongue, gums, and mouth. Graphites. — Swelling and induration of glands; eczema capitis of entire scalp, forming massive dirty crusts, which mat the hair together; eczema beginning as a moisture behind left ear, and spreading over cheeks and neck; thick, yellowish, fetid discharge from nose; dry scabs in nose, with sore, cracked, and ulcerated nostrils; painful nodules on lower jaw; chronic catarrhs of DIATHETIC DLSEASES. 263 stomach and bowels; glandular swelling in groins; fissures and rhagades; turbid urine; unpainful swollen glands on nape of neck. Hecla lava. — Scrofulous ostitis or periostitis, resting on a syphilitic basis, and especially affecting the bones of face and of antrum highmori; difficult dentition; rachit- is; hip disease; white swelling; induration and infiltra- tion of cervical glands, studding the neck like a row of pearls; toothache from swelling about the jaws; abscesses of gums from decayed teeth. Hepar. — Glands inflame, swell, and suppurate; hard burning nodosities; unhealthy skin: slight injuries sup- purate; stinging burning of edges of ulcers, discharging bloody pus; humid eruption of fetid odor, feeling sore, itching violently; nodosities on head, relieved by cover- ing the head warmly and from sweat; discharge of fetid pus from ears; boils on face, lips, and chin; cancerous ulcers; disposition to phlegmonous sore throat, catarrh, or bronchitis; atrophy. Hydrastis. — Chronic catarrhs of mucous membranes wherever situated; cancerous cachexia; cancers hard, adherent; skin mottled; puckered, with lancinating cutting pains; atony of muscles. Hypophosphite of Lime — One of the best remedies we have for so-called scrofulous manifestations. It fully answers Hahnemann's indications for the use of Calc. carb. in scrofulous affections, especially when occurring in children, namely, the overgrowth, the large head and open fontanels, the distended abdomen, the tendency to swelling of lymphatic glands, the tendency to brain affections, to catarrhal discharges, abscesses, etc. lodum. — Emaciation, in spite of the necessity of eating every few hours; swelling and induration of glands, the whole of the lymphatic system being involved; swelling 264 SKIN DISEASES. of mesenteric glands; bronchocele; scrofulous women, with dwindling and falling away of the mammae. Kali bichr. — Scrofulous ulcers and skin diseases; dis- charges from mucous membranes tough, stringy, sticking to the parts; caries of the bones of the nose; strumous ophthalmia; pustular diseases of skin, secreting a watery fluid when broken or drying up into a yellow tough mass; fat, chubby children; fat, light- haired persons. Kali hydroiod. — It distends all tissues by interstitial infiltration; enlarged glands; tophi; exostosis; swelling of bones; necrosis; all worse at night; bronchial and submaxillary glands swollen, ulcerating, atrophied; goitre; papules on face, back; small boils on face, head, neck, back, and chest, leaving scars; pustules on cornea, without photophobia, redness, or pain. Lithium carb. — Skin rough as a grater, harsh, dry; dry itching eruption like ringworms; milk crust; whole body, bones, joints, muscles, sore as if beaten. Lycopodium. — Swelling and suppuration of glands; herpes and ulcers; humid suppurating eruptions, full of deep rhagades, breeding lice, itching violently; inter- trigo; raw places, readily bleeding; boils which do not mature, but remain blue; scalp covered with scabs; chronic enlargement of tonsils. Lapis albus. — Scrofulous affections, abscesses, and sores; enlargement and induration of glands, especially cervical; glandular tumors, where physiologically no glands are usually found; goitre; cretinism. Mercurius. — Glandular swellings, with or without sup- puration; cachectic affections; exostosis, curvature, caries, and other affections of bones; eruptions and corrosive herpes with crusts; tinea capitis; crusts in the face; suppuration, especially if too profuse; ulceration of tonsils. DIATHETIC DISEASES. 265 Mercurius biniod. — This is one of our best remedies. It is especially in the relief of those tardy engorgements and ulcerations which follow the discharge of the soft- ened scrofulous matter. It may be given during the growth or swelling of the gland with the hope of disper- sion, as we cannot always surely know whether the en- largement is attributable to the presence of scrofulous matter or to simple congestion and engorgement. Natrum carb. — Swelling and induration of glands; emaciation, with pale face, dilated pupils, dark urine; skin dry, rough, and chapped; suppurating herpes, with yellow rings; goitre; swollen cervical glands; humid herpetic eruptions and ulcers on nose, lips, and around mouth; burning fissures on lower lips. Oleum jec. ars. — Only indicated inpatients of a slender and lean figure, thin, transparent skin, with a frequent pulse, great excitability of the nervous system, and high specific gravity of the urine — all signs of an accelerated metamorphosis. Petroleum. — Swelling and induration of glands; un- healthy skin; small wounds ulcerate and spread; polypi; salt rheum on arms and hands, red, raw, burning, moist, or covered with thick crusts; herpes on knees and ankles. Phytolacca. — Swollen tonsils; indurated glands; glands and bones inflamed and swollen. Psorinum. — Pale, sickly, delicate children, whose body always has a filthy smell, even after a bath; deeply pene- trating, ichorous ulcers; skin dirty, greasy-looking, with yellow blotches here and there, at times itching; scratch- ing gives temporary relief; hair dry, lustreless, tangles easily; pustules and boils on head; scalp looks dirty and emits an offensive odor; wants to have the head covered i8 266 SKIN DISEASES. even in hot weather; purulent offensive otorrhcea; sub- maxillary and lingual glands swollen, sore to touch. Rhus tox. — Swelling of glands; herpes in the face and other eruptions discharging pus or forming crusts; emaci- ation; hard and distended abdomen. Sarsaparilla. — Great emaciation, skin shrivelled or lies in folds; herpetic circular ulcers, forming no crusts, red granulated bases, white borders; deep burning rhagades; milk-crust; ophthalmia after checked tetters; marasmus of childreji; neck emaciated, Silicea. — Swelling and suppuration of glands; exos- tosis; curvature, and caries of bones; pale and bloated; disposition of skin to ulcerate; eczema, impetigo, herpes; tendency to boils, which leave indurations; carbuncles; malignant pustule; blepharitis; otorrhoea; canine hunger, with nervous irritable persons; desires only cold things; swelling and induration of cervical glands and parotitis; imperfect ?i2itrUion, not from want of food, but from imper- fect assimilatio7i. Spongia. — Swelling and induration of glands; skin and muscles lax; light hair; fevers; yellow scabby erup- tion; suppuration of external ear; insatiable appetite and thirst. Sulphur. — Scrofulous and rickety complaints; emacia- tion of children, face has a very old look; dry flabby skin; glandular swellings, indurating and suppurating; ulcers, with raised swollen edges, bleeding easily, dis- charging fetid pus, surrounded with pimples; humid of- fensive eruptions, with thick pus, yellow crusts, itching, bleeding, and burning; ophthalmia and blepharitis; puru- lent offensive otorrhcea; painful eruptions around chin; lips dry, rough, and cracked; curvature of spine from softening of vertebrae; hangnails; burning of soles, wants im Syphiloderma Pustulosum. DIATHETIC DISEASES. 267 them uncovered; children dislike being bathed; especially- suitable for lean stoop-shouldered persons. Theridi07i. — Scrofula, rachitis, caries, necrosis, when other remedies fail to reach the root of the evil, and destroy cause; itching on scalp; itching behind ears, she would like to scratch them off; chronic catarrh of nose, discharge offensive, thick yellow or yellowish- green; phthisis florida, in beginning. Syphilis. Syphilis is a disease that involves, not only the skin, but every other organ and tissue of the body. Its cutaneous relations, however, are those which chiefly concern us. The first visible lesion of syphilis usually appears in from ten to twenty days after an infective intercourse, as a small papule or erosion, going on to ulceration, and most frequently situated on the genital organs. Extra- genital chancre, however, may be met with in a variety of locations, more frequently, perhaps, about the mouth than elsewhere. This lesion is termed a chancre. In a short time a limited induration of the subjacent tissue occurs, so that the chancre when taken between the fingers appears to have a hardened base. This indura- tion may be, and frequently is, absent in genital chan- cres in women, and the lesion may be altogether over- looked. In the course of two or three weeks after the appearance of the chancre certain of the lymphatic glands become involved, and take on enlargement and hardness. The glands chiefly noticeable in this respect are the inguinal, cubital, post-cervical, and post-auricular. About this time, or a little later, we may expect a generalized outbreak upon the skin. The various manifestations of syphilis on the skin, or 268 SKIN DISEASES. syphilides, as they are commonly called, present different types and degrees of severity, and involve the skin either superjScially or deeply. We may, however, classify them to a certain extent, and in doing so will find that they partake of one or the other of the following characters, namely : macular, papular, tubercular, pustular, squa- mous, bullous, and gummatous, together with ulcera- tion, occurring with, or following, any of the five types last mentioned. The appearance of the first cutaneous eruption ushers in what is termed the secondary period of the disease. As a rule, the first eruption is macular, and consists of small, rosy points or spots usually called syphilitic roseola. These present little or no elevation, and disap- pear under pressure, showing that they are little more than points of congestion. They usually pass away within a few weeks, with or without treatment. They are chiefly met with on the trunk and extremities. Another and much rarer macular lesion is the pigmen- tary syphilide, which appears as dark-colored spots on the neck, and almost w^holly confined to j^oung females. After a time a portion of the pigmentary deposit fades away, producing a somewhat characteristic appearance some- what resembling vitiligo. After the macules of syphilis have disappeared, or even before they are quite gone, a generalized eruption of papules may appear. These are solid elevations, and not unfrequently present minute scales at their apices. Should the patient be broken in health, a tendency to pustulation and ulceration may be developed; and we may have the papules becoming purulent at their sum- mits, or we may have a frankly pustular eruption from the outset. As the disease progresses there is a tendency to deeper involvement of the integument and larger size DIATHETIC DISEASES. 269 of the lesions, so the papules are not uncommonly fol- lowed by tubercles, not perhaps as numerous as the papules, but still freely distributed over the entire sur- face. These not infrequently undergo ulceration and become covered with greenish-black crust. In addition to the foregoing, we may have the appear- ance of reddish and not greatly elevated patches, covered with white scabs, constituting the so-called squamous syphilide. These various manifestations may occupy a year or more in their evolution, and embrace the secondary period of the disease. After the disappearance of these various eruptions, there is not infrequently a de- cided halt in the progress of the disease, and the patient may go on for a considerable period, for years even, without a fresh outbreak. When it does come, however, it ushers in what is known as the tertiary stage of the disease. In the tertiary period of syphilis the eruptions are usually of a tubercular or ulcerative character, and, in- stead of being generally and somewhat evenly distributed over the surface, they are usually collected into groups; for instance, half a dozen or more tubercles may form a group or patch, and there may be one or several such patches. As a rule, the number of patches is limited. The individual lesions sometimes disappear b}^ absorption, but very frequently undergo ulceration, and in either case leave indelible scars. In this stage of syphilis we meet with the lesion known as the gumma. It consists of a small tumor, which usually undergoes softening throughout its entire substance, and terminates by ulcera- tion. This lesion is not confined to the skin, but niay in- volve almost any organ of the body. Concomitants of Syphilis. — The disease we are describ- ing does not vent its entire energy upon the skin, but 270 SKIN DISEASES. early in its history it exhibits its presence on the mucous membranes by the development of rather large, flattish tubercles in the mouth and about the genital organs and around the anus. It is in females especially that the mucous patch or condyloma reaches its highest develop- ment. Early in the disease, too, the hair may fall out, so that an almost complete alopecia of the scalp may occur be- fore it is checked by treatment. This early alopecia, however, is not permanent, as the hair begins to grow again as soon as the patient is brought under the in- fluence of proper constitutional treatment. During this period, also, inflammation of the iris is a not infrequent complication. Ulcerations, more or less extensive, of the soft palate and tonsils, may supervene among the early or late symptoms of the disease. In the tertiary period painful swellings are met with along the course of the long bones, especially the tibia and in the flat bones of the skull. These nodes, as they are called, are due to an inflammatory deposit beneath the periosteum, which is usually accompanied with con- siderable pain, worse at night. The gummy deposit, separates the periosteum from the bone, and, by depriv- ing the bone-tissue of its proper nourishment, produces necrosis. An interesting case is reported of ulcerating gummata of the scalp forty-four years after infection, as occurring in a man aged 63, who contracted syphilis when between eighteen and twenty years of age. Typical syphilides followed, relapsed a number of times and finally disap- peared without treatment. When he was twenty-four years old (about five years after infection) he married. His wife miscarried once, but remained healthy, dying DIATHETIC DISEASES. 271 at sixty. His eldest son developed psoriasis palmaris when seven yearsold and again when eighteen, which was caused by anti-syphilitic treatment; in other respects, as well as his younger sister, remained well. The patient himself was affected by herpes zoster in 1878. In 1886 a gumma appeared on the left parietal bone, which ulcerated and exposed the bone and caused necrosis. Gradually the bone was cast off, and necrosis of the •diploe appeared. As, however, demarcation proceeded slowly and symptoms of pressure on the brain set in, trephining was decided upon, which exposed a collection •of pus under the necrosed bone. Improvement set in on anti-syphilitic remedies. Soon, however, an attack oc- curred during which he lost consciousness; then the functions of the brain becam^e disturbed, intelligence gradually waned, oedema of the extremities set in, new gummata appeared on the scalp, and the patient died. Post-mortem there were found thrombosis of the iliacs, caries and necrosis of the left parietal bone, thickening of the meninges, beneath it, but no pathological changes in the brain. The ulcerations of syphilis are somewhat peculiar, and, once seen, can hardly be mistaken afterward. The}^ are usually round, and with clean-cut margins, as if punched out, differing in this respect from the overhanging walls of scrofulous ulcers, or the sloping margins of the simple variety. Late in the disease, and among the tertiary group of symptoms, w^e meet with a peculiar deformity of the phalanges, commonly known as dactylitis syphilitica^ the appearance of which is so peculiar and characteristic that it should not be mistaken for anything else. This lesion is rare, however, and perhaps unknown to man}^ physi- 272 SKIN DISEASES. cians, and the illustration best shows its characteristic features. Necrosis of the nasal and palatal bones may occur late in the disease. Syphilis is an all-pervading disease, and may involve the viscera as well as the more superficial organs The liver, kidneys, lungs, brain, spinal cord, etc., may be- come the seat of gummy tumors, which, according ta their location and size, may do more or less damage^ even to the extinction of life. Dr. Marchiafava thus describes the lesions found by him in the kidney in two cases of hereditary syphilis r " The organs were of normal size, but the cortical sub- stance was of a grayish color, and dotted with minute whitish nodules, corresponding to the glomeruli. Under the microscope, the lesions w^ere seen to proceed from a diffuse arteritis of the glomerular and afferent vessels. The arteries were contracted, and finally obliterated, and became converted into a hyaline mass The vascular loops of the glomeruli were thus destroyed, as was also,, at a later period, the epithelium of the convoluted tubules which derives its nourishment from the afferent vessels. ' ' Dr. Ingram has observed, in twelve cases of congenital syphilis, concentric enlargement of the wrists. This en- largement has more the appearance as if two fine silk ligatures had been tied around the wrist immediately above the joint, the strands being placed about half an inch apart and tied tight enough to hide themselves in the flesh. To the touch they have all the dense hard feeling that callus does when thrown about a fracture. Etiology. — The original first cause of syphilis is un- known. We know, however, that at the present time it is propagated from one to the other by contact. The DIATHETIC DISEASES. 273 blood and the secretions from early syphilitic lesions are the medium of contagion, and the contact of these with an abrasion of the skin or with an even unabraded mucous surface is sufficient to transfer the disease. Whether a bacillus is an accidental or an essential feature of the process may as yet be considered unsettled. In the vast majority of instances syphilis is contracted during sexual intercourse; occasionally, however, the buccal cavity is made to serve the ordinary purposes of the vagina, and the disease is transferred from or to the mouth. There are, however, many innocent wslys of contracting the disease; for instance, using drinking- glasses, cups, spoons, pipes, etc., which have been previously used by a syphlitic, etc. Sternback reports a severe attack of syphilis in an army surgeon, acquired in a peculiar manner. While attending a case of blenorrhoea of the eye he was at- tacked by the same disease and had leeches applied ta the temple to combat the acute inflammatory sj^mptoms. One of the leech-bites became the site of the initial sclerosis of syphilis, to be followed later by the usual secondary manisfestations. After bix months iritis de- veloped, and shortly afterwards svmptoms of severe cerebral syphilis. How the leech-bite was infected by the syphilitic virus is unexplainable. It is altogether probable, however, that in tertiary S3^philis, especially if a considerable number of years have elapsed since the first contraction of the disease^ neither the blood nor secretions are contagious. Syphilis may also result from hereditary transmission. Should the father alone be syphilitic, the offspring usually escapes; but if the mother be affected, the child will almost certainly suffer. In the majority of cases, when infection of the mother occurred but a short time 274 SKIN DISEASES. before conception, the foetus will die in utero, and be ex- pelled before time. A second or third abortion may suc- ceed, but ultimately the mother may give birth to a liv- ing child, which, however, may soon succumb to the disease. As the period of time from the date of infection becomes greater, the less does the poison affect the off- spring, until a time arrives when the offspring of parents who have both been previously syphilitic may be born without apparent taint and grow up healthy children, reaching adult life without mishap. The symptoms of hereditary syphilis may be manifested shortly after birth by erythematous blotches, bullae, coryza, and marasmus, or may be deferred until about the period of puberty. In this event, interstitial keratitis, or various ulcerations, may be the chief features presented by the disease. An interesting case was reported in 1889 of a child four months of age, whose parents had acquired syphilis fourteen years before. Though anti-syphilitic treatment had been insufficient, their syphilis ran a very mild course, and they experienced very few syphilitic manifestations. Their first child, born three years after their marriage, died from meningitis at the age of seven years; the second had a syphilitic eruption at the end of the second month; the third succumbed to cholera infantum; the fourth died in its first month, of broncho- pneumonia; the fifth had an interstitial keratitis three days after its birth. This, the sixth child, showed an extensively distributed papular syphilide. At the time of conception, the parents did not show any syphilitic symptoms. Other cases have been met with of syphilitic infection from parents to children even twenty years after the primary infection in the parent. Dr. Mackenzie gives the history of a case of congenital syphilis in which ulceration of the throat was a marked DIATHETIC DISEASES. 275 phenomenon. This progressed in spite of the remedies employed to check it, until the child was taken with a mild form of scarlatina, when the ulceration at once "began to heal. When the stage of desquamation was reached, cicatrization was complete. In his remarks on the case, which is but typical of a class, he says that frequently specific ulcerations in children stubbornly refuse to cicatrize. Under such circumstances when remedial measures are apparently of little or no avail, thej^ sometimes cicatrize, as if by magic, on the accession of an acute disease. While congenital syphilis affords no absolute protection against certain acute infectious diseases, its existence in the individual seems often, other things being equal, to mitigate their severity and exert a favorable influence on their course. Certain acute diseases, accompanied by an exanthem, favor the dissipation, at least temporarily, of the throat and other manifestations of syphilis. While at no period of the disease is the child exempt from these affections, they are more liable to be contracted during the period of latency, that curious interval of apparent health in congenital syphilis, which Cazenave has poetically called the sleep of the virus. These remarks are limited to scarlet fever, measles and chicken-pox, but they could doubtless be ex- tended to embrace others of the exanthemata; or, in other words, to those diseases which present a certain analogical resemblance to syphilis. They do not apply, for obvious reasons, in the case of excessive virulence of the syphitilic cachexia or malignant epidemic influence of the inter-current disease. Of special interest is the effect produced by acute febrile disease upon the throat lesions of congenital syphilis. Chronic inflammatory conditions and ulceration of the larynx, pharynx, and nasal passages are often influenced in a remarkable manner through the 276 SKIN DISEAvSES. presence in the individual of an inter-current febrile affection. This is, moreover, eminently true of those acute blood diseases with special tendency to local mani- festations in the throat, such as scarlet fever, measles, diphtheria, etc. According to personal experience, scarlatina and measles exert, as a rule, a favorable influence on the course of the throat affection, their sup- ervention being of itself sufficient to cause its complete disappearance. The poisons of the two diseases, in their circulation in these regions, appear to be mutally destruc- tive and the throat escapes by virtue of such reciprocal antagonism. The cure here may be permanent, or relapses of the inflammatory or ulcerative process may follow the removal of the antagonistic influence of the inter-current disease. These remarks do not apply to diphtheria. When this affection supervenes during the existence of lesions in the throat, the patients rapidly succumb to the disease. The existence of syphilis in the child apparently increases the tendency to membranous formation; indeed in some instances, apart from the presence of the diphtheritic process, there seems to be a special tendency to fibrinous formation in the nose and retronasal space. Diagnosis. — To commence at the beginning, the initial lesion or chancre is to be distinguished from the soft venereal ulcer (chancroid) by its long (two or three weeks) incubation, its plastic character, its indurated base and its slight tendency to secretion, and the single or very limited number of lesions. The soft chancre, on the other hand, appears a few days after intercourse, presents a necrobiotic or ulcerative character, is not accompanied with the hard, infiltrated base, and may exist to the number of a dozen or more on the same patient. DIATHETIC DISEASES. 277 In syphilis the initial lesion is usually accompanied with a number of moderately enlarged hard inguinal glands, while the chancroid may be accompanied with one or more very much enlarged and greatly inflamed and painful glands, which not infrequently go on to sup- puration. In addition, we have in syphilis the other glandular indurations already noticed. There are very few cases in which the earlier syphilitic eruptions cause any great trouble in diagnosis. Taking the history into consideration, neither the macular nor tubercular eruptions are liable to be mistaken for anything else. The papular eruption of lichen planus, however, may sometimes closel}^ resemble a syphilide. The squamous syphilide may in like manner be mistaken for ordinary psoriasis. In most cases, however, we will learn (if the case is psoriasis) that the patient has had previous attacks of the same form of eruptions, while in syphilis the previous eruptions will have been of a different type. In late syphilis a patch of tubercular lesions may be mistaken" for lupus. The history, however, again helps us, for a lupus patch will have been many months, per- haps years, in forming, while the syphilitic lesions might have reached the same development in a few weeks. The real difficulties that surround the diagnosis of syphilitic eruption, however, do not so often occur in simple, uncomplicated cases as in those where a syphilide coexists with some other eruptive affection. Thus we have seen at the same time a syphilide and an eczema, a syphilide and a psoriasis, a syphilide and leprosy, a syphilide and scabies, etc., and each of these separate eruptions pursued its own course apparently unmodified by the presence of the other. Treatment. — In former times it was a question 278 SKIN DISEASES. whether the disease or its treatment caused the greater inconvenience or suffering to the patient. The treatment of a given case of syphilis will, of course, depend on the stage of the disease and the condition of the patient; but if the case comes at the beginning — that is, during the period of the chancre — the early or sub- sequent treatment ma}^ be pretty clearly mapped out in advance. When a patient presents a venereal sore, the question of diagnosis must be settled at the outset, and settled in the most definite manner prior to the institution of a direct anti-syphilitic treatment. If the diagnosis cannot be made with absolute certainty, defer the specific treat- ment until the secondary eruption appears. Granting, however, that the diagnosis of syphilitic chancre has been made, let us first consider what shall not be done. Some have fancied that they could produce an abortion of the syphilis by early destruction of the initial lesions; and, to this end, the chancre was ex- cised or cauterized. Experience shows that this hope can not be reahzed. Neither excision nor cauterization, no matter bow early they are practiced, will prevent the further development of the disease, while they do add very materially to the discomfort of the patient. What, then, shall be done? There is but one drug, so far as known, that is positively and directly curative in this dis- ease — namely, mercury; and the sooner the patient is brought under its influence the better. The two schools employ it in different ways. We will first look at the method employed by the old school, and afterwards the method as employed by the new school. An eminent writer of the old school, in speaking of the treatment of syphilis, uses the following language: " My own practice is to use this agent (mercury) both DIATHETIC DISEASES. 279 internally and externally, believing as I do that the drug acts by virtue of its particles being brought into direct contact with the lesions, externally by means of lotions, salves, or other applications, internally through the medium of the blood and circulation. To the chancre, then, we may make a mercurial application, and the old black wash answers admirably, except that it should con- tain about four times as much calomel as the officinal preparation allows. This should be applied two or three times daily. At the same time mercury should be given internally. Before commencing treatment, however, it is m}^ custom to have a distinct understanding with the patient on two points —namely, the use of tobacco and alcohol. If the patient is in a fair state of general health, and will consent to the absolute abandonment of these two substances, it will not be going too far to promise him a very easy time in connection with his disease, pro- vided, of course, that he pursues the direct medical treat- ment with persistence and regularity. " The choice of the mercurial preparation to be given is not a matter of indifference. During the early period of the disease — say, for the first six months or a year — metallic mercury or the protosalts are to be preferred to persalts. Later the persalts seem to be more useful. Metallic mercury, either in the form of blue-pill or in trituration, may be given, so that the patient receives a half-grain of the metal three or four times a day. The dose, however, should be pushed until the patient is on the verge of salivation, but never in the slightest degree beyond this. When this point is reached, we have a guide to the patient's tolerance of the drug, and omission of treatment for a day or two is recommended. It should then be resumed in somewhat smaller doses, and, with the gums and salivary glands for a guide and warning, 280 SKIN DISEASES. the drug should be administered with scrupulous regu- larity for weeks and months. In former times salivation was considered the sheet-anchor of safety. Now, we know that it is a danger to be avoided. Under this treatment many a patient will go on for a j^ear or more with only the slightest inconveniences from his disease. Instead of metallic mercury, the protoiodide may be em- ployed; and this, indeed, is the favorite with most vene- real surgeons. After this period, if all has gone well, I prefer to give either the bichloride or the biniodide. Some cases, however, will not go well, and, instead of superficial and not very serious eruptions, we find a tendency to ulceration developing quite early. This opens the gate for another drug — namely, the iodide of potassium. There are physicians who appear to be afraid of mercury, and who, believing the iodide to be compara- tively a benign and innocent drug, give it in even the earliest stages of the disease. Personally I regard the earl}^ administration of this drug as harmful. The iodide of potassium, in the writer's judgment, does not exert the slightest curative influence on the disease itself, or tend in the slightest degree to eradicate it from the system. It does, however, possess a wonderful power over certain manifestations of the disease. In syphilitic ulcerations, in gummatous lesions, and in periostitis, the effects of the iodide are not only positive but marvelous. Pe? contra^ in early superficial lesions and in late necrotic af- fections of the bones, it is not only useless but harmful. In syphilis we have two types of ulceration. In one the process is sluggish, and in the other active and rapid in its destructive effects. In both of these the iodide should be employed. In the former it should be given in small doses —say, five to ten grains three times a day— and com- bined with small doses of either the bichloride or binio- ii DIATHETIC DISEASES. 281 dide; while in the rapidly destructive forms of ulceration the mercury should be omitted, and the iodide given in full and increasing doses. " As soon, however, as the particular lesions for which the iodide is given are brought under subjection, the drug should be given in diminished doses and soon dis- continued, and mercury in small doses substituted for it. * ' In the sluggish ulcerations of cutaneous syphilis there is no question as to the benefit to be derived from local mercurial applications, and a favorite with the writer is fifteen grains of the protoiodide to an ounce of simple ointment. " Instead of administering mercury by the mouth, it may be used in the form of blue ointment rubbed into the groin or axilla. Or it may be given in hypodermic injec- tion, employing either a soluble or an insoluble prepara- tion. There are, doubtless, occasional cases in which these methods may be preferred; but as habitual or routine methods of treatment they are mentioned only to be condemned. " There remains one drug, however, that is useful in certain syphilitic conditions, but of which very little mention is made in modern text-books. I allude to gold. In necrosis of the bones, especially the nasal and pala- tine, gold unquestionably hastens the separation of the sequestrum by promptly determining the line of demark- ation between the healthy and the diseased tissues. A grain of the chloride of gold and sodium may be dis- solved in an ounce of water, and five to ten drops be given once or twice a day. No advantage, we believe, will be derived from increasing this dose. It should be continued for a short time after the separation and re- I moval of the bone, as it seems to decidedly promote the I healing process." ; 19 282 SKIN DISEASES. In contrast with this heroic treatment comes the recom- mendation of Hahnemann to use Mercurius vivus in the 30X potency, one dose of which will usually be suflScient to establish a cure. Later, we will give the indications for the homoeo- pathic remedies indicated in the different forms of syphilis. Just here I wish to call attention to the mechanical treatment of the syphilitic affection of the tongue and mouth known as keratosis or ichthyosis linguae, or as leukoplakia specifica, which is due to unequal develop- ment of epithelium over different papillae, and which is by no means a very easy affection to treat successfully, caustic, astringent, and disinfecting applications hav- ing but little effect upon it; according to Dr. Horwitz, it is best managed by mechanical scraping. He uses a sharp spoon, with which he removes the thickened epithelium; in order to accomplish this, several sittings may be required. He scrapes away the indurated tissue until the surface presents the appearance of a multitude of minute-bleeding points, showing that the vascular loops in the papillae of the dermis have been reached, lodo- glycerine, glycerine of borax or a ten per cent, solution of sulphate of copper is applied to the raw sur- face. The pain is usually not severe, but in the case of sensitive persons cocaine can be used. Indications for the homoeopathic remedies useful in syphilitic affections: Arsenicum. — Inflammation and swelling of genitals; phagedenic and gangrenous chancres; copper- colored eruptions on genitals; burning pimples or pustular erup- tions on skin. Asafoetida. — Tertiary syphilis, especially after abuse of mercury; ulcers, particularly when affecting the bones, DIATHETIC DISEASES. 2S3 discharging ichorous, fetid, thin pus; syphilitic caries and necrosis, with fetid and bloody suppuration: ulcers very st"sitive to touch: rs:re~e nocturnal pains. \ — Secondary syr :. 5 low-spirited; bones of 5^_-. _:_:nful when lyinr in zztm: exostosis on head; A.r: :: sodii ^^ — S; ^^^i.is a::er azuse :f mer- c;:: :r ^htn, during st: -iir; :r .tr: ary stages :he bcnes ;: :iie nose are ize::ei ;r :J:e :hroat is ulcer- ated. Badiaga. — ^Syphilitic bubo, as hard as a stone, uneven, ragged at night violent lancinations as if with red hot £!i ~ T .-. r^i.^- -11 _i osis ! erysir-c-ir _ .i:r z s..mins; pamiu. eru-^- Bc juifolium. — ^Inve:tra:e cases 0: :er:: = ry syphilis. Calcarea fluar. — Chancres nari ml incnra'.ef. Calcarea sulpk. — In en:; :; c:n:r;l sn^rnra.in. Chronic suppurating s : : t 1 ^ - ' s . Car bo an. — ^Indurarei. ciit; - -:n lancinating or cut- ting pains; chancre n = s = l syrhilis Carbo veg, — Syrli: : : trs ~ :n lii^n :ri- : : :e- come irritable from :;; :a' ::-i::nrn: niir^n^ :: sires sharp, raggei nnierminei i ~:iir^e chin ache chen- sive; ulcer ranee' ene he he :: 'tre freely ~hen 284 SKIN DISEASES. touched; vesicles or blisters on prepuce; burning of labia; burning eruptions on skin. Cinnaharis. — Swelling of penis; redness and swelling of prepuce, with painful itching; violent itching of corona glandis, with profuse secretion of pus; small shining red points on the glans; blenorrhoea of glans; sycotic excrescences; violent erections in the evening; small ulcer on roof of mouth, on the right side of tip of tongue, and on tip. Coral, rubr. — Chancre and gonorrhoea of glans. Corydalis. — Syphilitic nodes on skull; ulceration of fauces; profuse morbid secretion of mucus; tongue coated, with fetid breath. Ferriim phos. — Bubo with heat, throbbing or tender- ness. Hecla lava. — Destructive ulceration of the nasal bones. Hepar. — Mercurius-sj'philitic diseases of gums; pains in bones; chancres not painful, but disposed to bleed readily; margins of ulcers elevated and spongy looking, without granulations in their centre; buboes after mer- curial treatment; phimosis, with discharge of pus, accom- panied by throbbing; itching of penis, glans, and fraenum; ulcers like chancres on prepuce; humid sore- ness on genitals, scrotum, and folds between thigh and scrotum; humid, suppurating herpes praeputialis. Hydrastis. — Ozsena, with ulceration, bloody or mixed purulent discharge; mercurial salivation. Kali bichr. — Syphilitic affections of mouth and fauces; bone pains, with stitches as if from sharp needles; period- ical wandering pains all over the body; pustular syphilo- derma; indurated chancre. Kali hydroiodicum. — Secondary and tertiary syphilis; abuse of mercury. Kali mur. — Soft chancre, 3x tr. internally, and also DIATHETIC DISEASES. 285 externally as a lotion; chronic stage of syphilis. In bubo for the soft swelling. Kali phos. — Phagedenic chancre and bubo. Kali sulph. — Syphilis, with yellow, slimy coating; tongue coated yellow; aggravation in the evening. Chronic syphilis. Lachesis. — Phagedejiic chancre; gangrene of glans and mons veneris; ulcers in throat and inflamed tonsils; caries of tibia; flat ulcers on lower extremities, with blue and purple areola. Lycopodiu7n. — Chancres with raised edges; indolent chancres, with thick, rounded, prominent margins, granu- lations flabby or absent; eruptions on glans; condy- lomata; syphilitic ulcers in mouth. Mercurius corros. — Excessive pain, swelling, and inflam- mation; regular indurated Hunterian chancre with lar- daceous bottom; swelling and redness of nose, ozaena; margins of soft chancre dark-red, painful, and easily bleeding; neighboring parts oedematous, hot, and painful; chancres on inner surface of prseputium or corona glandis; chancres with ichor adhering to the bottom of ulcer so firmly that it cannot be removed by washing; ulcers with thin pus, leaving stains upon the linen, as from melted tallow; phagedenic ulcers in mouth, gums, and throat, with fetid breath; tonsils swollen and covered wnth ulcers; bubo and swelling of glands generally. Mercur. iodat. rubr. — Hujiterian hard chancre; threat- ened gangrene of glans in paraphimosis; soreness of bones of face; sharp shooting stitches in the end of penis through the glans; old buboes, discharging for years. Mercur. vivus. — Red chancre on prepuce; spreading and deeply penetrating ulcer on glans and prepuce; pale- red vesicles, forming small ulcers after breaking, on glans and prepuce; painful bleeding chancres, with yel- 286 SKIN DISEASES. lowish, fetid discharge; small chancres, with a cheesy bottom and inverted red edges; ulcers of glans and pre- puce, with cheesy, lardaceous bottom and hard edges. Mezereum. — Syphilitic periostitis; constant headache from tophi of skull; pains through whole body, with nightly pains in the bones, brought on by syphilis, mercury, or both combined; bones inflamed, swollen, especially shafts of cylindrical bones; fainting sort of vertigo; weary of life. Natrum mur. — Chronic syphilis, serous exudations, etc. Natrum sulph. — Condylomata of anus, syphilitic in origin, externally and internally. Nux vom. — Chancroid; shallow and fiat-bottomed ulcer- ation, showing a disposition to spread irregularly and indefinitely, exuding a thin, serous discharge. Nitric acid. — Phagede^iic chancres; ulcers in urethra, with purulent or bloody mucous discharge; ulcers bleed when touched, with exuberant, but pale and flabby granulations, irregular edges; moist condylomata, like cauliflower, or on thin pedicles; ulcers in vagina, looking as if covered with yellow pus, with burning pain or itch- ing; copper-colored spots on anus; syphilitic ulcers in mouth; syphilitic epilepsy and melancholia. Phosphoric acid. — Chancres with raised edges; chancres like an indolent ulcer, edges thick, rounded, and promi- nent; granulations pale and flabby, or absent; corroding, itching herpes praeputialis; blisters and condylomata on glans; sycotic excrescences, chronic, with heat, burning and soreness, when sitting or walking; figwarts, compli- cated with chancre; painless swelling of glans; interstitial ostitis of mercurio-syphilitic origin, with nocturnal pains, as if bones were scraped with a knife. Phytolacca. — Secondary syphilis; ulcers in throat and genitals; syphilitic rheumatism and syphilitic eruptions; \ DIATHETIC DISEASES. ' 287 pains shift; joints swollen, red; periostitis; pains in middle of long bones, or attachment of muscles, worse at night, and in damp weather; glans inflamed, swollen; ulcers with appearance as if punched out, lardaceous bottom; weakness and prostration, but no paralytic symp- toms. Sepia. — hidolent chancre; burning itching, humid, or scurfy herpes praeputialis; chappy herpes, with a circular desquamation of skin; eruptions on glans and labia; itch- ing and dr}^ eruptions on genitals; chancres on glans and prepuce. Silicea. — Chancres with raised edges; inflamed, painful, irritable chancres, with discolored, thin, and bloody dis- charge, granulations indistinct or absent; painful erup- tions on mons veneris; itching, moist or dry eruptions of red pimples or spots on genitals; chronic syphilis with suppurations or indurations; ulcerated cutaneous affec- tions where mercury has been given to excess, nodes in tertiary syphilis; caries and necrosis with discharge of offensive pus. Staphisagria. — Soft, humid excrescences on and behind corona glandis; dry, pediculated fig- warts; excrescences and nodosities of gums; female sexual organs painfully sensitive, especially when sitting; mercurialism. Stillingia. — Secondary syphilis ; extreme torture from bone-pains; nodes on head and legs. Sulphur. — Inflammation and swelling of sexual organs, with deep rhagades; burning and redness of prepuce; deep suppurating ulcer on glans and prepuce, with puffed edges; phimosis, with discharge of fetid pus; glandular swellings, indurated or suppurating. Thuja. — Chancres, with pain as from a splinter stick- ing; sycotic moist excrescences on prepuce and glans; moist mucous tubercles; itching ulcers with unclean bottoms, or whitish chancres with hard edges. 288 SKIN DISEASES. Condylomata, Sycosis, Fig- warts. These excrescences are a morbid growth of the skin and mucous membrane, or, better defined, of the subcutaneous and submucous cellular tissue. They are of different ex- ternal appearance, according to their coating. When they are covered by the epidermis they appear dry, hard, horny, like common warts; when covered with thin epithelium, or when they are entirely bare and excoriated, they appear soft, moist and secrete more or less of a slimy, acrid, badly-smelling fluid. These latter are the geyiuine syphilitic condylomata or tubercula mucosa. Their forms are likewise various; some are flat, upon a broad basis; others are conical, growing on a pedicle; others appear like a cock's comb. The flat fig- warts are chiefl}'' found around the anus, between the glutens muscles; on the perineum, scrotum, external skin of the penis, glans penis, and on the external surface of the labia in women; whilst the conical and pediculated are usually found in the entrance of the vagina, on the clitoris and even far back in the vagina, and on the neck of the womb; in males on the interior surface of the prepuce; also between the nates. They sometimes grow so luxuriantly that the whole vagina and interior surface of the prepuce is covered by them. A third kind is quite small, in the shape of pin-heads, which are generally found around the corona in men, and on the interior surfaces of the labia in women. In secondary syphilis they appear also in other localities, especially on the tongue, corners of the mouth, chin, face, forehead, eyelids, iris, scalp, meatus auditorius, axillae, nipples, and between the toes. Soon after the outbreak of this pest in the middle ages we read of condy- lomatous excrescences in the face, which were of a finger's CONDYLOMATA. 289 length, and which caused, for their bearers, more ridicule than compassion. Treatment. — Keep the parts clean and dry. If the excrescences are troublesome, excise them with the knife and afterwards appl}^ a mercuric bichloride lotion, strength one to two grains to the ounce of water. The principal internal remedy is Thuja. Therapeutic Hints. — For the mucous tubercles the main remedies are: Cinnba., AHtr. ac, Thuja. Fig-warts, when complicated with gonorrhoea^ require Thuja, Cinnba., Nitr. ac, Sulph., Lycopodium. When complicated with chancre, Cinnab., Nitr. ac.^ Phos. ac, Staph., Thuja. When jlat, Magnes , Nitr. ac. When exuberant, like cauliflower or mulberries, Thuja, Staph. When fan-shaped, Cinnab. When growing on pedicles, Lycopod. , Nitr. ac. When conical, Merc, solub. When dry, Thuja, Staph., Merc, solub., Nitr. ac, Lycopod: When moist, S2ipp2irating , Nitr. ac, Thuja, Sulph., huphras^ When soft, spongy, Sulphur. When intolerably bunmig and itclmig, Sabina. Cinnabar. — Fan-shaped fig- warts accompanied by tetter. In scrofulous infants and children. Euphrasia. — Fig-warts at the anus. Mercur. cor. — Dry fig- warts, or else fig- warts accom- panied by acrid discharges. Soft, flat condylomata. Mercurius nit. — Filiform fig- warts. Mercurius prcBcip. ruber. — Fissured condylomata. Mercur. sol. — Conical fig-warts; small, itching pimples which ulcerate and become incrusted; mild types. 290 SKIN DISEASES. Nitr. ac. — Pediculated and pen-shaped, moist condy- lomata; fig- warts on the glans. Sabina. — Condylomata attended with itching and burn- ing. Sarsaparilla. — Flat fig -warts. Staphisagria. — Cock' s-comb-shaped fig-warts. Sulphur. — Soft, spongy fig- warts. Thuja. — Cauliflower excrescences. Condylomata on the penis, vulva and about the anus; broad, flat condy- lomata; after iritis, tubercles or warty excrescences on the iris. Leprosy. lyCprosy is a disease that has been known from the earliest ages, and has prevailed among all races and in all climes. At present it is most wide-spread in countries lying both to the north and to the south of the temperate zone and among the less enlightened people of the earth. To a limited extent, however, it is met with in Europe and the United States. The disease manifests itself in three chief forms or phases of development, known as the macular, tuber- cular, anaesthetic. The first is characterized by the de- velopment of brownish discolorations of varying size and number. These, after an existence of months or years, may lose their heightened color and become pigmentless, and the cutaneous nerves in the affected parts lose their sensibility. The tubercular form is characterized by the develop- ment of tubercles upon various parts of the body. These exhibit a slightly heightened color, becoming later somewhat copper-colored, and affect a preference for the face, especially just above the eyebrows and upon LEPROSY. 291 the nose and ears, but may, and usually do, appear upon the extremities. In the anaesthetic form, bullae, usually solitary, de- velop upon various parts of the integument. They per- sist for a short time only and leave behind them discolora- tions, which in time may become whitened and anaesthetic. In this form of the disease there is grave implication of the principal nerve-trunks of the ex- tremities. This is notably the case with the ulnar nerve, which in cases moderately advanced may be readily per- ceived as a thickened cord just above the head of the bone whose name it bears. In this form, especially, pain in the extremities is a more or less prominent feature. Connected with the development of the disease, anaes- thesia of the integument, chiefly of the extremities, be- comes a prominent feature. The gradual destruction of the ulnar nerve leads to impairment of its functions and atrophy of the more distant parts to which it is distributed. This atrophic action is most distinctly manifested in the fingers and toes. Fissures occur in the integument, and absorption of the phalanges takes place and leads to loss of these parts. The separation usually occurs at some point between the joints rather than at the joints them- selves. A continuance of the morbid action may result in loss of all the phalanges, and even of some of the metacarpal and metatarsal bones. Leprosy is essentially a chronic disease. Before the appearance of cutaneous or nervous lesions there usually exists a prodromal period of several years' duration, with- out definite symptoms other than impairment of the gen- eral vigor. During this period it is hardly possible to make a diagnosis of the impending trouble. After the disease, however, is fully developed, ten, fifteen, or twenty years may pass before the fatal termination. 292 SKIN DISEASES. After careful investigation Drs. Fox and Graham arrive at the following conclusions concerning leprosy: 1. Leprosy is a constitutional disease, and, in certain cases, appears to be hereditary. 2. It is undoubtedly contagious by inoculation. 3. There is no reason for believing that it is transmitted in any other way. 4. Under certain conditions a person may have leprosy and run no risk of transmitting the disease. 5. It is not so liable to be transmitted to others as is syphilis in its early stages. There is no relation between the two diseases. 6. Leprosy is usually a fatal disease — its average dura- tion being from ten to fifteen years. 7. In rare instances there is a tendency to recover after the disease has existed many years. 8. There is no valid reason for pronouncing the disease incurable. 9. Judicious treatment improves the condition of the patient and often causes a temporary disappearance of the symptoms. 10. There is a ground for the hope that an improved method of treatment will in time effect the cure of leprosy, or at least that it will arrest and control the disease. Dr. Perry has arrived at the following conclusions, after years of study and residence in India: 1. Leprosy is an endemic disease, malignant, constitu- tional, progressive; evidenced by tubercular degeneration of the tissues, and accompanied by anaesthesia, ulcera- tion, and gangrene; terminates in death from exhaustion, pyaemia, or rupture of the arteries. 2. That it is due to a specific bacillus he considers an unsettled point. 3. That leprosy is contagious only by inoculation, the LEPROSY. 293 direct transmission of the virus into the blood of healthy persons. This assertion does not exclude the transmis- sion of the disease by clothing, tools, etc., which have been used by lepers. 4. The disease is practically limited to people living upon a fish diet along the sea coast. 5. It is incurable. The best treatment is only pallia- tive. His experience with iodide of potash, iodoform, mercury, and other so-called antisyphilitics having been as satisfactory as with chaulmoogra oil and other rarer and costlier drugs. 6. The average life of the leper, after the full develop- ment of the disease, is from ten to fifteen years. This does not include the prodromal stage. Some cases die sooner, and some live much longer. 7. The period of incubation is less than one year; the prodromal stage may last for five or more years. Leon- tiasis may develop in twelve months, and may be the only hint of the latent disease for years, until some exciting cause brings it out. 8. Hereditary leprosy does not usually develop until the age of puberty, unless there be some exciting cause. This exciting cause may be inflammatory skin disease, suppurating wound, or prolonged illness. Etiology. — If we may judge from Holy Writ, the an- cient Jewish lawgivers regarded the disease as contagious. Modern science declares that it is not. The discovery in recent times of a peculiar bacillus by Hansen gives a clue to the medium of contagion, and corroborates the results of careful clinical observation. While we cannot doubt the possibility of contagion, we must admit that within the temperate zones the direct transfer of the disease from one person to another has been very rarely observed. It is by no means unusual for a Caucasian to 294 SKIN DISEASES. contract the disease when dwelling among the natives where it is endemic; but it is extremely rare for him, on returning to his native country, to convey the malady to those with whom he associates. During the past several years there have been a large number of lepers who have passed months and sometimes years in the hos- pitals of New York, and yet not a single case of leprosy has developed in this city. Fox says: "The causes of propagation are mainly these: 1. Intermarriage of the leprous or with the leprous. 2. Hereditary transmission, 3. Inoculation and cohabitation. 4. Vaccination (?). As to intermarriage, little need be said. It sufficiently accounts for the occurrence of a large number of cases of leprosy in the offspring of lepers, and the continuous intermarriage of people of the same caste in India, en- forced rigidly by custom and superstition, tends greatly to the spread of leprosy hereditarily. Secondly. — As regards hereditary influence, this is most marked in children who are begotten by lepers far advanced in the disease. Thirdly. — As to cohabitation and inoculation. Of course, these are not such potent causes as intermarriage and hereditary tendency in spreading leprosy, but still it is probable that they may account for a certain number of cases. It has been said that leprosy may be communicated by vaccination, but if so it must be infinitely rare and scarcely worthy of being taken into account. Prognosis. — The prognosis is uniformly unfavorable — that is, when the disease is left to its natural course. Spontaneous recovery, if it ever occurs, is extremely LEPROSY. 295 rare. A few cases of cure have been reported, but a shade of doubt hangs over them. Mitigation of the affection, and even abeyance of the symptoms for a time, are by no means uncommon. Treatment. — Good food and good hygienic surround- ings are of the first importance in the treatment of leprosy. Strychnine and chaulmoogra-oil are highly recommended by the old school. They claim that with these four means at command the majority of cases of leprosy can be greatly benefited. They give the drugs in full doses, the oil being applied externally as well as internally. Surgeon-major Peters gives as the result of two years* experience at a leper asylum in India, with twenty-nine cases, improvement in all the cases by the following plan: The patients had to rub the body for two hours early in the morning with Carbolic oil, i to 40; then bathe in warm soap and water. Afterwards an emulsion composed of Gurgium oil and lime water was rubbed into the affected parts only, any ulcerations being filled with cotton smeared with the same. Under this treatment the ulcers healed rapidly, while the anaesthetic parts and nodules remained unimproved They, however, were benefited by Cashew-nut oil rubbed on to blistering. Internally, the remedy administered was as follows: ^. Chaulmoogra Oil, m. v. Sodas Bicarb., gr. v. Aquae Menthae Pip. , ^ j . M. Size of dose not stated. Locally, warm baths with Gurgium oil are highly recommended. The principal homoeopathic internal remedies are Hydrocotyle^ Hoang nan and Piper methysHcum. Others may be indicated as follows: 296 SKIN DISEASES. Anacardium. — Numbness and feeling of pins and needles in affected parts, which are cold; patches of raised and hardened skin on face and arms; perfect anaesthesia of affected parts; weakness and prostration. Alumina. — Copper-colored tubercles in face; leprous spots on legs; lips swollen; nose heavy; husky voice; hypersesthesia; ulcers on planta pedis. Arsenicum. — Yellow or white spots; tubercular swell- ing in nose; burning ulcers at the ends of the fingers, at the toes, soles of feet, navel, cheek; raised up tubercles; loss of hair and eyebrows; livid tubercles on any part of the body; hyperaesthesia and anaesthesia alternating; general prostration. Arsen. iod. — Pricking sensation in the skin; loss of the voice; enlargement of the glands; hoarse cough; fall- ing off of the fingers and toes; ozaena; tubercles dirty looking. Aurum. — Melancholy disposition; discharge from the nares very offensive; absorption of the bones of the nose; has no desire to talk about sickness. Calotropis gig. — Tubercular leprosy; lassitude, indis- position to move; loss of energy; apathy and obstruction of the capillaries; intolerable itching over the whole body. Carica papaya. — Tubercular leprosy. Colocynth. — Desquamation of the whole epidermis; ab- scess of axilla. Crotalus. — Swelling of the limbs or body ; spots appearing like gangrene. Cupmm. — Leprous eruptions ; cramps ; suffocating spells. Graphites. — Leprous spots, coppery, annular, raised on the face, ears, buttocks, legs, and feet ; ulcers on toes. LEPROSY. 297 crusts in nostrils ; skin cracks and discharges a sticky fluid. Hydrocotyle, — Well-marked cases of tubercular leprosy; leonine face ; nose flattened and swollen ; lobes of the ears pendulous and swollen ; ulcers in the alse nasi and corners of the mouth ; ears discharge ; hands and feet swollen so that fingers and toes spread apart ; itching of any part of body ; feeling of lassitude ; yellowish or reddish spots on the trunk and extremeties. lodujn. — Emaciation marked ; swelling of the glands ; when mercury has been taken in large quantities ; loss of voice and hoarseness ; voracious appetite. Kali bichrom. — Brownish colored spots ; ulcers with an unhealthy look ; blisters on the extremities ; little boil or pustules on any part of body ; thick, tough discharge from nose ; hard plugs in nose ; thick, ^^ellow, putrid discharge from the ears ; ulcers on tongue and on cornea. Kreosote. — Soreness on the nose ; swollen gums ; painful ulcers ; wheals like urticaria ; numbness in different parts of the body. Lachesis. — Spots yellow, red, green, lead and copper colored, pale livid ; hard and pale swelling ; large boils ; ulcers surrounded by nodes and vesicles ; the muscles fall off in shreds from the bones ; bloody serum discharge from the nose, ears and mouth ; obstinate ulcers wdth black spots in the granulations. Madaru albuin. — The whole surface of the skin becomes leprous ; livid and gangrenous tubercles ; thickening of the whole skin. Mercurius. — Falling out of the teeth ; absorption of the small bones ; swollen gums ; sore tongue ; flat indolent ulcers. Natrum carb. — Spots and tubercles all over the face, 20 298 SKIN DISEASES. arms, thighs, legs, which ulcerate ; ulcers in the nostrils and on the heels. Petroleum. — Tubercles on the face; herpetic and tuber- culous spots on the body; ulcers of fingers, tibia; unhealthy skin with brown spots; skin dries and forms deep cracks; falling out of hair; hypersesthesia of scalp and ears followed b}^ anaesthesia; hoarseness, suffocating cough, numbness of extremities. Phosphorus. — Later stages of the disease; brown spots on an even base; boils; spots like blood blisters on the body; tubercles on the trunk, buttocks; thick patches on face and arms; discolored borders around the white spots; hair falls out; tension in the fingers, and dullness towards the end; great debility with increa.se of sexual desire. Rhus tox. — Scalp sensitive, cannot bear to have the hair touched; pulsation in the ears; loss of smell; swollen face so that patient is not recognized; tubercles with sharply defined margins; bright red skin, violent itching; hardness and thickening of skin on any part of body. Secale. — Can hardly talk, the tongue will not respond to the will; fingers and toes drop off; falling out of the hair; eyes look sunken; cold, dried-up-looking skin. Sepia. — Swelling of forehead, around temples; face thick, covered with tubercles; leonine face, pendant ears; eyes red, dull, weeping; purulent discharge from nose; tubercles and spots all over the body; gnawing ulcers on fingers and toes; excoriation at the tip of tongue; discharge from the swollen ears; nose and lower lip swollen; red herpetic spots at the elbow and hip; herpetic sores; white spots and ulcers on the articulations of the fingers; coppery tubercular spots all over the body, especially on the buttocks, arm-pits; tubercles on the face, trunk, buttocks, prepuce; brownish spots on face; morvan's disease. 299 skin peels off from hands and feet; nails look dried up and deformed; falling out of the hair and eyebrows; loss of smell; breath offensive. Silicea. — Induration of nose, with ulceration and discharge; palsied hands; white spots on cheeks; coppery spots and hard tubercles on testicles and buttocks; ulcers at tips of fingers; shortening of the hamstrings. Sulphur. — The usual antipsoric indications. Woorali — Obstinate boils^ that will not heal; slowly forming and suppurating pimples; dirty looking skin; blood oozes through the skin; tubercles on nose; stoppage of nose, with swelling of parts; falling of the hair; swelling of the lobes of ears; falling out of the teeth; discharge of matter from the ears; tonsils inflame and suppurate. Hura Bras.y Guano, Helleboi^ous foetidus and Veronica may be compared. Morvan's Disease. Morvan's disease must be differentiated from Sclero- dactily, from Lepramutilans, and from symmetric gan- grene of the extremities. The analgesic paresis with panaris of the superior ex- tremities was first described by Morvan. The patient complains at first of neuralgiform pains in the fingers, which are soon followed by a paretic state with muscular atrophy, more or less pronounced, in the hands and forearms, sometimes spreading through the whole arm and other parts of the body. There is at the same time analgesia and anaesthesia, especially for the touch, for pain and temperature (here it is necessary not to mistake it for syringomyelia, where there is no anaesthesia, but only a relative analgesia and especially thermo-anaes- thesia). This state is followed by panaritiae, which start. 300 SKIN DISEASES. like any other plain panaritium, with redness, heat and swelling, but it soon shows its malignant character, as necrosis of the bone follows, destroying not only the upper phalanx, but sometimes also the others, resulting in mutilations. We meet here also multiple panaritiae, attacking nearly all the fingers, which may follow one another at shorter or longer intervals, so that years may intervene between them. Though the first panaritium may be painful, the subsequent ones are usually painless. Trophic troubles are more or less observed, as more or less deep rhagades, ulcerations in the folds of the skin, extending to the tendinous sheaths, which are bathed in suppuration, but all is of an indolent character. The nails fall off or become deformed as in no other affection. Finally the whole hand becomes livid and its temperature below the normal. Prognosis in relation to the use of the upper extremi- ties is bad, as the disease leads to incurable deformities and mutilations. It attacks more often males than females, of all ages, and whether traumatism is to blame for it remains more than doubtful. It is easy to differentiate it from Ball's sclerodermitis, for here one never meets necrosis of the bone, nor are bone pieces discharged; the mutilations take place grad- ually by a kind of absorption of the tissues of the fingers; nor is there any paresis or anaesthesia. Finally the sclerodermic mark is specific, and can never be mistaken for anything else. In relation to anaesthesia with its atrophy the patient's hands become very similar to those of the monkey, and the lesions are mostly symmetric. The same trophic troubles may be found anywhere on the body and ulcera- tions are frequent, and the leprous spots on the skin of such patients are characteristic and known as morphea 301 alba or rubra. Lepra is an exotic plant and so far con- fined to few countries. Nor can Morvan's disease be mistaken for syringo- myelia, characterized, as it is, by more extensive mus- cular atrophy, and though the sensation of contact is pre- served, the sensibility to heat and cold is abolished over large surfaces of the body, a characteristic which is only partially met with in hysteria. The rhagades, the arthropachies and the scoliosis belong to both, but a panaris is an exception, while in Morvan's disease it re- mains the predominant phenomenon. Abnormal sensitiveness of the fingers, painful at first, with redness and swelling, then bullae which break and dry up, followed by atrophy of the upper phalanx, which becomes deformed and absorbed. Nobody as yet has discovered the origin of the malady, and none has yet given a treatment for it. We may claim that constitutional treatment may eradicate the poison and Homoeopathy is rich in resources. Thuja, Fluoric acid, Silicea, Sulphur and others are of great assistance. Thuja. — Erysipelatous swelling of the tips of the fingers and of the fingers; nails are crippled, discolored, crumbling off; twitchings of the muscles of the arms; coldness and sensation of deadness of the fingers and tips of the fingers; stinging pains in the arms and in the joints; emaciation and deadness of the affected parts dirty and brownish color of the skin. Silicea and scoliosis go hand in hand, and according to some authors it is found in nearly half the cases of Morvan's Disease. It is also complementary to Thuja, and in most cases where Silicea suits there is a tendency ^to chronicity of the disease; emaciation and atrophy of affected parts; paretic states; nails rough and yellow; 302 SKIN DISEASES. pain as if panaritium would form on left index; dryness of tips of fingers; ulcers about nails; felons with violent shooting pains deep in the fingers, with great restlessness and irritability. Sodium sulphate is also correlated to Thuja. Perhaps it may come in at a later stage when the paronychia sets in painless or with hardly any pain. Among its symp- toms we read twitchings of the hands, trembling of the hands on waking, and also when writing; loss of strength of the hand, is unable to hold anything heavy; tingling, ulcerative ])ain under the nail; internal coldness; with yawning and stretching. Graphites has emaciation of the hands, distortion of the fingers, gouty nodosities on the finger-joints; thick and crippled nails; soreness between the fingers; sensa- tion of debility without pain and liability to take cold. Cracks and fissures anywhere are often the key-note to the use of this drug, and as it has a long action, it ought certainly be of benefit in such a chronic affection as Morvan's Disease. Sepia also has diseased and crippled nails with painless ulcers on the joints and tips of the fingers and paralytic drawing and tearing in arms and fingers. Venosity and stagnation is the red thread which goes all through the pathogenesis of the drug; it is also a long lasting remedy, hence the neuraesthenia and the paretic condition, and the more we consider all these diseases, except lepra, of constitutional origin, the more will we be able to prevent the deformities which, when once present, are out of the pale of therapeutic measures. CHAPTER XIII. HYPERTROPHIC AND ATROPHIC AFFEC- TIONS. Under the terms h^^pertrophy and atrophy ma}' be in- cluded all cases of development in excess of the normal tissues of the skin on the one hand and wasting on the other; the atrophy and hypertrophy being in each case primary conditions. The maladies ranking under these two classes may be arranged as follows: A. Hypertrophic diseases, com^rismg: — i. Diseases of the epithelial layer of the skin, including callosities, corns, and horns, in which the epithelial tissue is specially affected. 2. Diseases involving the dermic portion, in which the true skin is affected with or without the epithelium. In some cases the papillary layer is chiefl}^ affected, but in connection with augmented production of the epithelium also, as in ichthyosis and xeroderma. In other cases the fibro-cellular tissue of the corium proper is the special seat of change, as in the diseases termed scleroderma, keloid, fibroma, Elephantiasis iVrabum, and derma tolysis. 3. Diseases seated in the vascular structures, including such growths as vascular naevi. B. Atrophic diseases, including general wasting and senile atrophy, and local or linear atrophy, which will be incidentally noticed together with morphoea. 304 SKIN DISEASES. Hypertrophic Affections. We will first deal in detail with hypertrophic affec- tions. It will be understood that no reference is made in this chapter to secondary or accidental hypertrophy — the consequence of congestion or inflammatory conditions, but to those diseases in which hypertrophy is the promi- nent or only condition. Corns. These are composed of an accumulation of the cells of the horny layer, which, generally, are pressed together into a conical mass that dips deeply downwards. The papillae beneath may be enlarged, but are usually atrophied. The corn mass presses even upon the rete cells, and it also obliterates more or less the sweat glands. Corns are caused by pressure and friction; they are of two kinds — the hard ordinary corns, and soft corns. The soft corns occur between the toes, and being saturated with the secretion of the part, are moist and soft; gen- erally there is some serosity effused under the upper layers or the bursse normally found at the parts over the joints of the toes where the corns form, enlarge and pour out fluid, which is discharged from a little central aperture. Treatment. — The shoes or boots worn must fit the foot — neither too small nor too large. The corn may be gotten rid of by soaking it in warm water, after which the outer layers may be removed by a sharp knife, and a slice of lemon bound upon it, and worn during the night. This treatment continued for three or four nights, the corn can be removed with but little pain. Flexible or arnicated colloid may be used as a dressing for painful soft corns. HYPERTROPHY OF THE PAPILL.E:. 305 Ringed corn plasters will protect the corns from press- ure. If the corns are inflamed and painful, a veratrum viride or arnica lotion, one part to two, may be used. A lotion, composed as follows, applied once or twice a day with a camel's hair brush, has been used with great success in removing corns: 9^. Salicylic acid, drachm j. Ext. Cannabis Ind., grs. x. Collodion, ^j. M. S. Apply as directed above. Another excellent application is as follows: 9. Acid Salicylic, drachm j, Emplast. Saponat, Jjjj. M. f, empl. Sig. : Apply on lint. Antimon. crud. is the principal internal remed}^ for hard corns, and Sulphur for the soft variety. Dr. Berridge reports a case of soft corn between fourth and fifth toes of right foot; the corn shoots and burns; also, dull aching in outer side of right ankle extend- ing up to hip, as cured by the internal use of Wiesbaden 200, a dose every other day for fourteen days. Callosities are merely hardened conditions of the skin produced by pressure, differing from corns rather in the fact that they are on a larger scale than by any other feature. Hypertrophy of the Papillae and Epithelium Conjoined. Horns. — These may be sebaceous in origin; usually, however, they are made up of hypertrophied papillae, each containing one or more vessels and being covered by epidermis; on section they have a granular texture pierced with small orifices, and when dry, numerous con- 306 SKIN DISEASES. centric cracks. These orifices are the sections of little blood-vessels; a clear amber-colored circular area sur- rounding each of the vessels, which are separated by the general granular structure of the mass, incapable in the compact part of the horn of being reduced to its ultimate original elements. The central parts of the horn are more compact and less vascular than the outside. Verrucae, or Warts. These are little raised tumors, sessile or pedunculated, hard, generally round, rugose, and mammillated. They are made up of coherent and enlarged papillae, each con- taining a loop of blood vessels, and more or less nerve- tissue, especially at their base. The sessile warts, or the true hypertrophous papillae, are seen mostly on the hands in children; they may be multiple, solitary, or aggre- gated in clusters. They may form a fiat mass or present a digitate appearance. Warts are often the result of syphilis about the anus, vulva, penis, but they may also arise from simple irritation. Venereal warts are pinkish or reddish vascular vegeta- tions, and occur for the most part on the genitals, pref- erably on the penis and labia. They may also form about the mouth and anus, in the axilla and between the toes. They are apt to grow very rapidly, and may attain considerable size. They are caused by the contact of irritating fluids, and may be either dry or moist, accord- ing to their location. They may occur in connection with gonorrhoea, but are never like the condylomata, a sign of constitutional syphilis. The causes of warts are unknown; they appear some- times to be contagious. The local treatment consists in destroying the abnormal growth by caustics — the acid VERRUCA, OR WARTS. 307 nitrate of mercury, caustic potash, arsenical paste, perchloride of iron, or chromic acid. The smaller warts may be removed by the curved scissors, and the larger and more vascular ones by the curette, ligature or gal- vano-caustic wire. Venereal warts need the strictest cleanliness. The dry ones may be treated locally by thuja or mercuric bichlor- ide lotion. The moist ones respond best to dusting with the mercuric chloride. Thuja externally and internally has great reputation in removing all kinds of warts. Moles may be removed by the topical use of the acid nitrate of mercury. The following repertory of warts and condylomata, prepared by Dr. Olin M. Drake, is so complete and ex- cellent, that I transcribe it here: Warts, confinement, following, small: Calc. c. girls, upon young: Sep., Sulph., Thuja. horses, upon: Lach., Thuja. upon, about the head and ears; bell-shaped, small at the attachment and one to one-and-a-half inches long: Thuja. imagines w. upon the body: Mez. internal: Caust. isolated: Calc. c, Caust., Lyco., Natr. c. onanists, upon: Nitr. ac, Sep., Sulph., Thuja. salt, from abuse of: Natr. mur.. Nit. d. s. Locality. Anus, about: Aur., Thuja. Arms, upon: Ant. cr., Ars., Calc. c, Caust., Dulc, Ferr. ma.. Lye, Natr. c, Nat. sulph., Nitr. ac, Rhus tox., Sep., Sil., Sulph., Thuja, left forearm: Sulph. 308 SKIN DISEASES. bend of elbow: Calc. c. wrist (left) : Ferr. ma. Back: Nat. c. Body: Caust., Medor., Thuja. Buttocks, small, scattered, flat, grayish-brown: Con. Cheek (left): Calc. c, Sep., Thuja. Chest: Aur., Calc. c, Nit. ac. Conjunctiva: Thuja. Cornea, warty in appearance: Sil. Ears, behind: Calc. c, Thuja. | wart-like growths: Calc. c. j Eyeballs, sensation as though was studded with: Euphr. Eyebrows, upon: Anac, Caust., Thuja. Eyelids: Calc. c, Caust., Mag. s., Nit. ac, Sulph., Thuja. upper: Calc. c. , Mag. s. , Nitr. ac. Eyes, under: Sulph. Face, upon: Alco., Am. m., Calc. c, Caust., Dulc, Ka. bi., Ka. c, Mag. s., Natr. m., Nitr. ac, Sep., Thuja. Feet: Calc. c, Sulph. soles: Sep. Fingers: Ambra, Ars., Bar. c, Berb., Calc. c, Carb. an., Caust., Dulc, Ferr., Lac c, Lach., Lyco,, Nat. m., Nat. sulph., Nit. ac, Ox. ac, Pal., Petrol., Psor., Ran. b., Rhus t., Sars., Sel., Sep., Sulph., Thuja, Verrucinum. index finger: Caust. (right), Lyco. (left), Thuja. little finger: Caust., Lace middle finger: Berb., Lach. finger, back of: Lach. ring finger: Nat. sulph. back of: Dulc, Lach. YERRUC^, OR WARTS. 309 side of: Calc. c, Sep., Thuja. tips of : Caust., Thuja. joints, around: Sars. knuckles, on: Ox. ac, Pal., Sal. close to the nails: Caust. rudimentary: Berb. thumb: Lach., Ran. b., Thuja. left hand: Psor. Forehead, upon: Nitr. ac. Genitals, upon: Calc. c, Cinnab., Eucalyp., Nit. ac, Pho. ac. Sec c. Thuja. upon glans penis: Nit. ac. , Pho. ac, Thuja. OS uteri: Calc. c, Nit. ac. Sec. c, Thuja, stinging and burning, when urinating: Thuja. papilloma urethrae: Eucalyp., Thuja. prepuce, frsenum and inner surface, bleeding when touched: Cinnab., Eucalyp. Hands, upon back of: Ars., Dulc, Ferr., Nat. c, Nit. ac, Thuja. left: Ferr. ma. right: Ars. ball of the: Berb. inside of: Ruta. knuckles: Ox. ac, Pal., Sel. left: Ferr. ma., Psor., Thuja. onanists of: Nitr. ac, Sep., Sulph., Thuja. palm of: Anac, Nat. m., Ruta. wart-like induration in the palm, after a long con- tinued pressure on the part: Borax. right: Ars., Caust., Nat. sulph.. Thuja. Head, upon: Caust., Sep. Iris: Thuja. lyips: Caust., Con., Nat. m.. Nit. ac, Thuja. upper, smart and bleed on washing: Nit. ac 310 SKIN DISEASES. drawing pain in an old w.: Con. Mouth and chin, about the: Calc. c, Calc. ph., Cun., Ka. ca.. Ivy CO., Medor., Psor. , Sep., Thuja. thickly studding the mouths of sheep: Calc. c. Neck, upon: Ant. cr., Calc. c, Lyco., Nit. ac, Sep., Syph., Thuja. right side, filled with blood: Thuja. Nose: Alco., Caust., Laur., Nit. ac, Thuja. Sternum: Nit. ac. Thighs, upon: Medor. Thumb, upon: lyach., Ran. b. , Thuja. Toes, upon: Spig. Tongue, upon: Aur. m., Aur. m. n., Mang., Thuja. Objectively considered. Bleeding: Calc. c, Caust., Cinnab., Ferr. ma., Lyco., Natr. c, Nitr. ac, Pho. ac, Rhus t., Staph., Thuja. Breaking open: Calc. c Brittle: Ant. cr. Cauliflower, like: Nitr. ac. Ran. b., Thuja. on outer side of terminal phalanx of right thumb: Ran. b. Cleft. See jagged. Color, almost the color of the skin: Calc. c dark: Sep., Thuja, red: Ars., Bell , Calc c, Caust. size of a bean: Calc c and angry looking: Ars. circles around with: Caust. streaks with: Bell. Flat: Ant. cr., Berb., Dulc, I^ach., Ruta, Sep., Verru- cinum. Groups or crops, in: Dulc, I^ach., Nat. m., Psor., Sep., Thuja. VERRUCA, OR WARTS. 311 Hollow, become: Calc. c. Horny or hard: Ant. cr., Borax, Calc. c, Caust., Dulc, Fl. ac, Graph., Lach., Nit. ac, Ran. b., Sep., Sil., Sulph., Thuja. upper surface: Calc. c. Incipient or recent: Nat. c. Inflamed: Amm. carb. , x\rs.. Bell., Bovis. , Calc. c, Caust., Dulc, Hep., Lyco., Nat. c, Nitr. ac, Rhus t., Ruta, Sep., Staph., Sulph., Thuja. as if ulceration would set in: Hep. Inveterate or old: Calc. c, Caust., Cun., Ka. ca., Nat. m.,Nit. ac, Rhust., Sars., Sulph., Thuja. grow larger; Cun. Isolated: Calc. c, Caust., lyyco., Nat. c Jagged (cleft, divided or indented): Calc c, Caust., Euphr., L^'co. , Nit. ac, Pho. ac, Rhust., Sabi., Staph., Thuja. surrounded b}^ a hepatic areola, with bran-like desquamation: Lyco. Large or fleshy: Caust., Dulc, Ka. c, Lyco,, Nat. c, Nat.m., Nit. ac , Pho. ac, Rhust., Sabi., Sep., Sil., Thuja, Verrucinum. Malignant: Ars. Moisture, exuding: Calc c, Caust., Lj-co., Nitr. ac, Pho. ac, Rhus t., Sabi., Thuja. a fetid humor: Nitr. ac. Pedunculated: Caust., Dulc, Lyco., Medor.j Nit. ac, Pho. ac, Rhus t., Sep., Staph., Thuja. Small, all over the body: Caust. with pin-heads, like button mushrooms, on various parts of body and thighs: Medor. Recent or incipient: Nat. c Rough, upper surface whitish and horny: Calc. c Round: Calc. c 312 SKIN DISEASES. Rudimentary, on fingers: Berb. Scrofulous: Aur. Seedy: Calc. c, Caust., Medor., Nat. m., Sep., Thuja. small: Bar. c, Berb., Calc. c, Caust., Cun., Dulc, Ferr., Ferr. ma,, Fl. ac, Hep., Lach., Medor., Nit. ac, Psor., Rhust., Sars., Sep., Sulph., Thuja. Smooth: Ant. cr., Dulc, Psor., Ruta. Soft: Alum., Ant. cr., Calc. c, Nit. ac, Thuja. at the base, almost the color of the skin; upper surface hard, rough, whitish and horny: Calc c with thin epidermis, and moist: Nit. ac. to touch, like lipoma and pointed, on neck: Thuja. Solid body, with horny top: Caust., Rhus t., Sep. Spongy: Alum. See soft. Suppurating (see Ulcerating): Ars., Bovista, Calc. c, Caust., Hep., Nat. c, Pho., Sil., Thuja. then healing: Calc. c a previously existing wart, developed a red point, suppurated and disappeared: Bovista. sensation as if they would suppurate; in the evening in bed: Petrol. Sycotic: Alum., Aur., Cinnab., Medor., Mil., Nat. sulph., Pho. ac, Sars. Old, dry; after mercurial treatment for gouty pains: Sars. Syphilitic: Aur., Cinnab., Ka. iod.. Thuja. Ulcerating (See Suppurating): Ars., Calc. c, Caust., Hep., Nat. c, Pho., Sil., Thuja. Ulcers breaking out around warts: Ant. cr., Ars., Nat. sulph., Pho. having the shape of warts: Ars. orignating in warts: Thuja. turning into warts: Calc. c. VERRUCA, OR WARTvS. 313 Subjective Symptoms. Burning: Amm. carb., Ars., Ivyco., Nit. ac, Petrol., Pho., Rhus t., Sep., Sulph., Thuja. Itching: Calc. c, Carb. a.. Kuphr. , Hep., Ka. carb., Nit. ac, Pho., Psor., Sep., Sulph., Thuja. Painful: Ars , Amm. carb.. Ant. cr.,Bar. c, Bovis., Calc. c, Caust., Con., Euphr., Hep., Ka. carb., Lyco., Nat. carb., Nat. mur., Nit. ac, Petrol., Pho., Rhus t., Sabi., Sep., Sil, Staph., Sulph., Thuja, ameliorated on the appearance of menses: Thuja, preventing rest at night: Ars. like a boil: Calc. c cutting: Nat. mur. drawing, in an old w. on upper lip: Con. pricking: Ant. cr. , Calc c, Lyco., Nit. ac, Pe- trol., Rhus tox., Sep., Sil., Sulph. in the evening in bed: Petrol, pulsating (beating or throbbing): Ars., Calc. c, Caust., Hep., Ka. carb., Lyco., Nit. ac. Petrol., Sep., Sil., Sulph. shooting: Ars., Bovis. with pains, sticking: Hep., Nit. ac. stinging: Amm. carb., Ant. cr.. Bar. c, Calc. c, Caust., Euphr., Hep., Lyco., Nitr. ac, Rhus t., Sep., Sil., Staph., Sulph., Thuja, as if ulceration would set in: Hep. tearing: Amm. carb. throbbing: See pulsating. extending up the arm to the axilla, from a malig- nant wart on the hand, rendering the arm use- less: Ars. Soreness of: Ambra, Ars., Hep., Lach., Nat. carb., Nat. mur., Nit. ac, Petrol., Ruta, Sabi., Thuja. Tickling (see itching): Sulph., Thuja. 21 314 SKIN DISEASES. Condylomata, mercury; after the abuse of: Aur. , Lyco., Nit. ac, Staph, women, particularly in: Merc, d., Sabi. I.OCALITY. Anus, upon or about: Aur., Aur. m., Benz. ac.> Euphr., Lyco., Merc, c, Merc, d.. Mil., Nit. ac, Sabi., Sep., Staph., Sil., Thuja, a growth, like a w. , a quarter of an inch in height, and as thick as a pea, painless, itching, opening at the top and suppurating, in the ridge, close to the anus, lasting four weeks and gradually healed: Thuja. Clitoris, upon or about: Thuja. Eyebrows, upon or about: Thuja. Eyelids, upon or about; either on the internal or exter- nal surface: Cinnab,, Nit. ac. , Thuja, upon or about, lower: Nit. ac. Frsenum, upon or about: Cinnab. upon or about, oozing, especially during new moon: Thuja. Genitals, upon or about: Alum., Benz. ac, Lyco., Medor., Thuja. upon or about, female: Merc d.. Thuja. Iris, upon or about: Cinnab., Merc sol,. Thuja. Labium, upon or about: Sulph., Thuja. Larynx, upon or about: Merc c, Nit. ac, Thuja. Mouth, upon or about (inner): Phos. ac Neck, upon or about: Nit. ac. Penis, upon or about: Ant. t., Aur., Aur. m., Cinnab., Ka. iod., Ka. mur.. Lye, Merc c, Nit. ac, Nux v., Pho. ac, Psor., Sabi., Sanic, Sep., Staph., Sulph., Thuja. glans: Ant. t., Cinnab., Ka. iod., Ka. mur., Lyco., Nit. ac, Nux v., Pho. ac, Sanic, Staph., Sulph., Thuja. VERRUCA, OR WARTS. 315 Corona glandes, upon; after chancre: Ka. mur. around: Aur. upon and behind: Staph. surrounding: Sep. Prepuce, upon: Aur., Aur. m., Cinnab., lyyco., Nux vom., Merc, c, Nit. ac, Sabi., Thuja. edge of, itching and burning: Psor. Perineum, upon: Merc, d., Thuja. Scrotum, upon: Aur. m., Thuja. Tongue, upon: Aur. mur. Uterus, upon: Lach. cervix: Kreos. , Merc, sol.. Nit. ac, Tarent., Thuja. os: Calc. c. , Kreos., Merc. sol. vagina, in: Medor., Nit. ac. , Pho. , Tarent., Thuja. vulva, upon: Merc. d. Objectively Considered. Bleeding: Arg. n., Medor., Nit. ac, Sulph., Thuja. Broad: Ac. ac, Kuphr., Merc, d., Nit. ac, Thuja. Bulbous: Alum. Cauliflower or mulberry like: Staph., Thuja. Chancre, complicated with: Arg. n., Cinnab., Ka. bichr., Merc, sol., Nat. sulph., Nit. ac, Pho. ac, Staph., Thuja. after: Kali iod. Cock's comb shape: Euphr., Staph., Sulph. Conical: Ka. mur., Merc, v., Thuja. Dry: Ac. ac, Cinnab., I^yco., Merc c, Merc, v.. Nit. ac, Sars., Staph., Thuja. Fan-shaped: Cinnab., Thuja. Filiform: Staph. Flat: Ac. ac, Euphr., Nit. ac, Sars., Sulph., Thuja. Gonorrhoea, complicated with: Cinnab., Con., Ka. 316 SKIN DISEASES. mur., Lyco. , Merc, c, Nit. ac, Pic. ac, Puis., Sars., Sulph., Thuja. Moist ( discharging ) : Ac. ac. , Benz ac, Calc. c, Euphr., Graph., Hep., Ka. iod., lyyco., Medor., Merc, d., Nat. sulph.. Nit. ac, Psor., Sanic, Staph., Sulph., Thuja. discharging profuse: Benz. ac, Medor. greenish: Nat. sulph. offensive: Medor., Merc, d.. Nit. ac. smelling like fish-brine: Sanic herring-brine: Calc c, Graph., Hep., Thuja, old cheese: Calc c. Hep., Thuja, yellow fluid: Medorrh. Moon, worse with the increase of the: Thuja. Mulberry or cauliflower like: Staph., Thuja. Old, long standing, in cachectic subjects: Ka. iod. Pedicles, growing on. See pedunculated. Pedunculated: Lyco., Nit. ac, Sabi., Staph. Soft and spongy: Alum., Nat. sulph., Sulph. SpHt: Lyco., Nit. ac, Thuja. Strawberry-like: Medor. Suppurating (see Moist): Ka. iod.. Nit. ac. Thuja. Tubular: Thuja. Ulcers elevated, which have the appearance as if w. would grow out of them: Cinnab. Wart-shaped: Benz. ac. Nit. ac, Nux vom., Sars., Sulph., Thuja. White: Lyco. Subjectively. Burning: Kuphr., Pho. ac, Psor., Merc, d., Sabi. when touched: Euphr., Sabi. Itching: Cinnab., Euphr., Phyt., Psor., Sabi., Thuja. especially when walking: Euphr. about the joints: Cinnab. Ichthyosis. ICHTHYOSIS. 317 Painful: Euphr., Sabi., Thuja. even when free from contact: Sabi. Painless: Lyco. Pain in bones or bone pains, with: Pho. ac. Sore; Euphr., Sabi., Thuja. when touched: Euphr., Thuja. Stinging: Thuja. Stitches in: Euphr. especially when walking: Euphr. Ichthyosis. Ichthyosis is a chronic disease of the skin, in which the epidermis is developed in excessive accumulations, usually accompanied by more or less hypertrophy of the papillae, presenting a dry, harsh, and "scaly" surface, whence its name, and arising from a congenital or hereditary pre- disposition in the patient. This disease is usually divided into two forms, ac- cording to the degree of development. The mild form, called simplex, is more frequently found, and varies from a very mild xerodermatous to a decidedly scaly condition of the skin. The severe form, called hystrix, shows its most ad- vanced stage, with the papillae enlarged and the cones betweefi extended and capped with horny excrescences of various sizes and shapes. While the characteristics of this disease are marked, particularly the objective symptoms, the subjective symptoms are almost entirely lacking. Ichthyosis Simplex. In this, the mild form, the skin of a new born infant is free from any apparent symptoms. It is usually not until after the lapse of a few weeks or months, and some- 318 SKIN DISEASES. times years, that the disease is sujSiciently advanced to attract attention, when there is first noticed a dry, rough condition of the skin; its color, however, remains un- affected. The skin may be generally involved, or the affection may be confined to certain localities, such as the extensor surfaces of the limbs, and afterward extend over the whole surface of the body. By gradual devel- opment, the epidermis becomes slightlj^ thickened, and the natural lines of the skin begin to deepen, and those become apparent which ordinarily can not be seen. In its further development the epidemic scales become larger and more abundant. The scales enlarge in area and thickness, their outline being limited and conforming to the natural lines and furrows of the skin, and form plates of various shapes; those on the extensor surfaces of the extremities are the largest and resemble the scales of a fish. The well-developed scales are detached about their edges, but are quite firmly attached in their centres, and can be removed with little difficulty without abrading the surface of the papillae beneath, and blood following, as is the case in psoriasis. When the scales are thin and the skin kept clean, they present a white or pearly appear- ance. When more developed and thickened, this color is deepened, shading from yellowish to darkish-green or even brown or blackish. This is due partly to pigmen- tary deposits in the plates, but mainly to accumulations and incorporations of extraneous matter not removable by washing. Fissures or cracks are formed on the sur- face where it is thickest and most unyielding; but they extend only through the upper layer of the skin, and re- main dry, thus differing from those found in eczema, which extend deeper, giving exit to a serous discharge which dries into crusts. The anidrotic or dryish state of the skin, so markedly shown here, is probably due to ICHTHYOSIS HYSTRIX. 319 a sparse and defective development of the sweat glands and follicles and to their functional inactivity in the parts affected; the unaffected parts remaining in the normal state. Ichthyosis Hystrix. This form is the more severe and rare manifestation of the disease, and presents a variety of developments. It is characterized by the excessive growth and accumula- tion of epidermis in the form of thick, irregularl}^ shaped, variously colored, horny masses, which admit of being detached, exposing a dr}^ and rough surface; or by more marked hypertrophied papillary growths which are sur- mounted by variously sized and shaped horny projections. In some instances they take the semblance of the quills of the porcupine; hence the name, hystrix. Its distribution may extend irregularly over various parts of the body, or may be localized in one or more well-defined patches, as, for instance, about the axillary folds, the knees, elbows, neck, or other regions. This form is also of gradual growth, is the most advanced, and its degree of development increases with age. The eruption is particularly severe and annojdng in winter, and sometimes diminishes in summer, recurring again the succeeding winter. Course. — The disease is progressive as age increases, until the climax is reached, usually at adult age, where- after there is little change. A spontaneous cure has rarely, if ever, occurred. The two varieties of the disease may occur together. Diagnosis. — Ichthyosis is so distinctly characterized as to render its diagnosis eas}^ and certain. In its mild form it is to be differentiated from xeroderma, meaning dry skin, which properly refers to a condition not ichthyotic 320 SKIN DISEASES. in origin; from eczema, by the absence of pruritus; and from all other inflammatory disorders which tend to desquamation, by the absence of previous inflammation. Prognosis. — The simplex form may often be amelior- ated; but the hystrix form is rarely, if ever, more than temporarily improved. The general health is apparently unimpaired in either case; and there are instances where the mild form has decreased in development with increasing years; but it is a question if the disease once developed ever disappears or is cured radically. Etiology. — Ichthyosis is an hereditary affection, and usually transmitted in the line of sex; but there are man}^ exceptions to this rule, and numerous instances of the crossing of the sex. It is common to find several instances in the same family. Treatment. — This disease is seldom, if ever, radically cured, but the condition of the patient can be consider- ably bettered. The general health is apparently unaffected. The treatment should be directed to the relief of the symptoms present. The anidrotic condition of the skin may be improved by the employment of such agents as will increase the sweat-secretion. For this purpose the old school recommend jaborandi, in the form of fluid extract, taken daily, in drachm-dOvSes, and they claim that in some instances it has prompt effect, and at the same time loosening of the epidermic scales occur. The wet-pack has also been advantageously employed, or frequent washing and alkaline or other baths may be substituted with success for this purpose. After the removal of the epidermic accumulations, the newly exposed epidermis should be kept 'as soft and pliable as possible, by inunctions of some bland oil, to prevent a return to its former condition. Such treatment will afford relief, more or less permanent. ICHTHYOSIS HYSTRIX. 321 A generous diet should be allowed the patient. An infusion of quillaya saponaris bark sometimes works well as a local fomentation. Internal homoeopathic remedies are: Arsen. iod. — Dry scaly skin ; itching and burning in scrofulous subjects with swelling of the lymphatic glands. Clematis. — When there are fine scales wnth some itch- ing, worse when getting warm in bed; painful swelling and induration of the glands. Eruption changes charac- ter with the changes of the moon. Graphites. — Skin dry and inclined to crack; unhealthy skin; every injury tends to ulceration; thick and crippled toe nails; extremities go to sleep; itching of the genitals. Iodine. — The skin has a brown dingy color; ravenous hunger; swelling and distension of the abdomen; emacia- tion in dark-complexioned, scrofulous children. Mercurius. — Dirty, yellow color of the skin; itching, worse at night when warm in bed; dry, scaly spots; in syphilitic and scrofulous subjects. Natrum carb. — Skin of the whole body becomes dry, rough and cracked here and there; frequent empty or sour eructations; great prostration. Phosphorus. — Skin is dry and wrinkled; skin of hands is rough and dry; pains in the chest; desire for acids and spicy foods; falling of the hair; great indisposition; in tall, slender people. Potassium iodide. — Skin dried up; rough, like hog skin; sensitive swelling of the thyroid gland; oedematous in- filtration of the tissues; after mercury or syphilis. Plumbum. — Dry skin; absolute lack of perspiration; obstinate constipation; paralytic weakness of the limbs. Thuja. — Dirty, gray, cadaverous looking skin. Wart- 322 SKIN DISEASES. shaped excrescences; brittle or soft nails; lymphatic temperament. Hypertrophic Diseases of the Corium. Under this head are included all those diseases in which the fibrous tissue of the skin is in excess, and in which the disease extends to or involves the subjacent cellular tissue. These may be termed Jibro- cellular hyperplasicE . They are: Morphoea; scleroderma; keloid; fibroma; bue- nemia tropica; and dermatolysis. Morphoea. Morphoea, formerly called Addison's keloid, is a chronic cutaneous affection, characterized by the appearance of one or more discrete spots or patches, usually isolated and roundish in form, pinkish in color, and slightly elevated when hypersemic and hypertrophic, surrounded by a tinted or violaceous border, later becoming whitish, anaemic, atrophic, and slightly depressed; and upon their surface, in the early stage, may be seen small streaks of dilated blood-vessels. Forms. — This rather infrequent affection assumes various definite forms, according as the character of its development is mainly hypertrophic or atrophic. Patches of the first form, which are mainly hyper- trophic, enlarge until they are of the size of small or large coins, and are roundish in outline; after a prelimi- nary hypersemic stage, they gradually assume a lardaceous appearance, and later on show a distinct atrophic aspect. Lesions of the second form, which is mainly atrophic, manifest little or no tendency to hyperplasia, and occur in small, pit-like, or slightly depressed, cicatriform or telangiectasia, isolated or grouped spots or steaks, form- ing 7no,culcB et striiE atrophicce. MORPHCEA. 323 Symptoms. — A typical case of morphoea usually makes its appearance by the formation of one or more roundish, circumscribed, hyperaemic, slightly elevated macules or patches, varying in diameter from one-quarter to a couple of inches; the centre gradually whitens, and is bordered by a tinted circle of violaceous or pinkish hue, composed of dilated capillaries, and often there is to be seen a plexus of small blood-vessels extending upon the surface of the lesion. The hyperaemia of the patch is soon suc- ceeded by an anaemic state, which may be sometimes so decided as to cause a slight depression of the surface. The patch, from this time, undergoes a gradual change until it presents the characteristic smooth, lardaceous ap- pearance, resembling inlaid wax, or old ivory. The con- nective tissue of the skin is increased and becomes con- densed. The activity of its process of development becomes lessened during this stage of the disease and enters on a chronic course. The skin of the patch may be soft, or quite firm and inelastic. In its further progress the affection may manifest atrophic changes in the tissues as well as of the glands and vessels of the affected skin, resulting in contraction and also depression of its surface, together with a lessen- ing or cessation of the secretions of the sweat and sebaceous glands; and the skin feels stretched and thinned. These later changes may extend over a period of years and become permanent, or the affection, before it has become decidedly atrophic, sometimes dis- plays its tendency to recovery by the disappearance of the lesion. The distribution of the lesions is asymmetrical, and has been found upon various regions of the body, as upon the face, chest, back, buttocks, arms, and thighs. The shape of the patches, even in individual cases, is 324 SKIN DISEASES. irregular, and varies, being round or elongated, but usually roundish. In its early stage, morphoea develops usually without any or with but slight attending subjective symptoms; later there may be more or less anaesthesia. Diagnosis. — In its advanced stage, morphoea is so characterized that its diagnosis is readily made. Some- times, however, it is so very like scleroderma that it is difficult to differentiate between them. In scleroderma the patches are usually symmetrically distributed, and the affected skin is hide-bound, or can not be lifted up into a fold by the fingers, and feels hard. In morphoea the patches are asymmetrically distributed, and the affected skin feels soft or firm. In scleroderma the patches are not circumscribed, but show a tendency to spread over a large surface, and at their border merge indistinctly and gradually into the surrounding skin. In morphoea the patches are often distinctly circumscribed, and confined to a limited area; and in their earlj^ stage are surrounded with a tinted border of pinkish or lilac hue, or the surrounding healthy skin is more or less pigmented. When the pigmentless spots in vitiligo resemble the whitish spots of morphoea, it is only to be remembered that the former is due simply to the absence of pigment, while the latter is caused by an abnormal state of structure, and of vascular supply. Patches of morphoea sometimes present appearances very similar to those of anaesthetic leprosy. The ob- jective and subjective symptoms in the progress of these diseases are so different as to render the diagnosis be- tween them certain. Prognosis. — The prognosis of the disease is, to a cer- tain extent, favorable, but depends largely on the degree SCLERODERMA. 325 of development, particularly if it has not yet become atrophic. In this latter condition the lesions are lasting; but in its earlier stage, and especially when there is only moderate hypertrophic change in the connective tissue, there is a tendency to spontaneous disappearance. Its course of development, when mainly hypertrophic, is quite short, as compared with the period elapsed dur- ing the atrophic stage, which is usually slow and chronic, extending over several years. Etiology. — The cause of this disease is yet to be de- termined. From what is known concerning the func- tional disturbances and trophic changes that occur in the development of its lesions, and their appearances in the hypertrophic and atrophic stages, the disease is thought to be due to some disorder of the nervous system, and probably of tropho-neurotic nature. Its occurrence has been noted mostly in females, and is at times attended with symptoms of more or less nervous debility. Sclero- derma, in some essential respects, resembles morphoea, and inferentially is very likely of a similar origin. Indeed, some view morphcea as merely a localized form of scleroderma. Treatment. — In the treatment of this disease, locally, some mild stimulant may be applied, as a mercurial preparation, and electricity to promote resolution. Phosphorated oil inunctions are beneficial. The patient should be well-fed, and have a daily allowance of either cod-liver or chaulmoogra oil. Phosphorus is the principal internal remedy. Scleroderma. Scleroderma is a chronic circumscribed affection of the skin, appearing on almost any part of the body, having I been observed on the face, neck, upper and lower 326 SKIN DISEASES. extremities and elsewhere. It commences with slowly- forming infiltration, apparently permeating the entire thickness of the skin, with slight elevation of the affected area. The color is slightly heightened, with a brownish red tint. At the same time the integument becomes matted to the underlying connective tissue and fasciae, and so tightly bound down to them that no motion of the skin over them is possible, resembling scleriasis in this respect. This condition remains for a varying period, with constant tendency to spread, usually in the form of a band. Thus, when it commences on one of the lower extremities, for instance, it slowly progresses upward, involving a breadth of integument equally perhaps one- fourth or one- third of the circumference of the limb. After a time the other limb, or one of the arms, may become involved. As the disease progresses, however, the parts first involved undergo a change. The infiltra- tion subsides, and gradually reveals the fact that the normal connective tissue of the skin has in part dis- appeared. In other words, marked atrophy is manifest. The skin, however, has not loosened its hold on the underlying tissues, and still remains as firmly bound down to them as ever. The affection is accompanied with very little pain or other local inconvenience, except so far as it interferes with the free action of the joints and muscles. The diagnosis of scleroderma is not difificult, as the hide-bound condition above described is met with in but one other affection, namely, scleriasis. The history of the invasion and the course of the affection should be sufficient to enable it to be distinguished from Morphoea. The prognosis of scleroderma varies. In some cases it may continue for many years without apparently com- promising the general health, while in others its progress SCLERIASIS. 327 may be more rapid, and possibly be the exciting cause of visceral troubles that ultimately prove fatal. Treatment. — There are no drugs known to the old school which, given internally or applied externally, influence the progress of the disease in the slightest degree. Frictions, massage, and the constant galvanic current, however, will sometimes result in very marked improve- ment in the condition of the affected parts. Antini. crud.^ Alumina, Berberis, Causticuin, Mer- curius, Pulsatilla, Rhus tox., and Sulphu?' may often be of service. Scleriasis. Scleriasisis an acute affection of the skin, characterized by the sudden development of a curious scleroid condition over an extensive surface. In a few days the greater part of the integument of the chest, abdomen, or back ma3^ without change of color or any inflammatory symp- toms, become rigid and firmly bound down to the tissues beneath. It appears to have absolutely lOvSt its elasticity, and to be so firmly attached that it is as impossible to raise or pinch it up in folds as it would be to pinch up paint or varnish from a board. This condition ma}^ exist in varying extent and of varying degrees of severity for several weeks, when a gradual return to the normal may ensue. The prognosis is good, as the cases usually recover. The etiology is obscure, but the affection is probably of rheumatic origin. Treatment. — Little need be done in the way of special treatment, but proper attention should be given to the correction of any marked impairment of the general health. Turkish baths and massage, with or without 328 SKIN DISEASES. electricity, appear to shorten the course of the affection. As internal remedies Hydrocotyle, Phos. , and Stillingia may be thought of. Sclerema Neonatorum. This is an affection of the skin met with in new-born infants, in which the greater part of the integument may become rapidly involved in a process which results in a generahzed hide-bound condition, which interferes with motion of the limbs, and even restricts the action of the thoracic muscles. A fatal termination is usually to be looked for in a few days. The nature of the disease is obscure — in fact, its exact etiolog}^ is unknown; but its general features point to a close relationship to the affection described as scleriasis, as met with in adults — the better prognosis in this latter disease being due to the greater resisting powers of the adult. Treatment, other than sustaining, appears to be of lit- tle avail. Keloid. Keloid is characterized by the growth upon the skin of one or more rounded or oval, flat, smooth-surfaced tumors of varying size, from the margins of which irreg- ular projections are frequently met with. The development and progress of the affection is chronic, and is attended with but little pain or other in- convenience. The color of the skin is in some cases little changed, while in others it becomes paler and even com- pletely blanched, like that of ordinary scar tissue. ,The affection is said to arise spontaneously, and at other times at the site of some traumatism or wound of the skin; and the terms true and false keloid have KELOID. 329 been applied to these two forms, which are to be distin- guished only by their etiolog3^ Vidal reports the case of a 53 year old man in whom a keloid, nine centimetres long, three centimetres wide and one centimetre high, developed spontaneously in the sternal region. He did not have syphilis and no discov- erable cause could be found. At first it increased in size, but slowly; since 1878, however, it grew more rapidly and became painful. A second keloid has lately developed in the flexure of the right elbow, also without visible cause. We know, however, that keloid may arise from even the minutest wounding of the skin, as from the prick of a pin or lancet point. Amicus reports the case of a young nervous woman who, from childhood, suffered from nervous symptoms. One year before coming under his observation she was attacked with a symmetrical eruption on the trunk and lower extremities, showing 318 keloids, the size of millet seeds. The lymphatics were normal; the urine showed nothing wrong. During her sojourn in the hospital she had several convulsions, retention of urine, etc. These so-called keloids were small pinkish elevations on the skin, which might be mistaken for sarcomata. No trauma preceded the trouble. Mr. Hutchinson mentions some rare forms of keloid, in which he details several interesting cases, with the fol- lowing conclusions: 1. That with keloid, as with other skin diseases, we must not expect too close a conformity to the type form. 2. That for clinical convenience, we may recognize ^, several varieties of keloid, the prognosis as to sponta- ,neous disappearance and proneness to return after ex- 1 cision differing much in each. 22 330 SKIN DISEASES. 3. That the first and most typical is that in which keloid begins in very small, perhaps forgotten, scars, and slowly spreads far beyond their limits into sound skin. In most cases, the extension and duration are indefinite; and the hardness, glossiness, abruptness of outline, etc. , are always well marked. The proneness to recur very quick! 3^ after excision is very great in these. 4. That in the second group, in which keloid growth begins in the middle of large scars, such as those of burns, it is seldom so well characterized. It often does not extend beyond the scar, and often, especially in young persons, soon begins to soften again, and to grad- ually disappear. 5. That in a third form the keloid growth is deeper, never produces the glossy, superficial, elevated, and spurred patches which occur in the others. These cases are very slow, and show but little tendency to spontan- neous disappearance. They do not develop in connection with large scars, but rather with inflammatory damage to the skin. They are less prone than the others to recur after excision. 6. That although definite scars almost invariably pre- cede the formation of keloid, yet that there are allied conditions which result rather from inflammation after injury, than from anything which is demonstrable as cicatrix. 7. That the cases of multiple keloid prove either that there is in some persons a remarkable tendency to the disease, or that primary patches have the power of in- fecting the blood and producing others. 8. That there is little or no clinical proof of tendency on the part of keloid to pass into cancer. The etiology of keloid is unknown, and we can only say that some individuals possess a certain peculiarity or FIBROMA. 331 idiosyncracy that leads to the development of this curious affection. Treatment. — Excision, cauterization, potential caus- tics, whether alkaline or acid, when of suflSicient power to rapidly destroy the tumor, are almost invariably fol- lowed by relapse and often in an aggravated form. Re- lief sometimes follows scarifications followed by the application of acetic acid. The operation should be per- formed a number of times, according to the size, etc., of the tumor. In cases of excessive keloidal growth, ex- cision may be employed as a means of temporary relief. Several cases are recorded where electricity has been employed with excellent results. Fluoric acid is the principal internal remedy, and the next is Graphites. Nitric acid and Sabina are occasionally indicated. Dr. Neatly reports a number of cases as cured by the persistent use of Silicea for a few months. Fibroma. This name is applied to tumors of varied size and form, which take their origin from the dermal or sub-dermal tissues, which are single or multiple, and vary in size from a small nodule to a tumor of many pounds' weight. These tumors may be sessile or pedunculated. The affection is chronic, taking years for its complete development, but the growths are usually painless, and give little or no inconvenience, except such as may arise from their size or particular location. The causes of fibroma are unknown, but they are of perhaps more frequent occurrence in mulattoes than in either the pure white or black races. Diagnosis. — Fibromata are to be distinguished from sarcomata and neuromata, and this may be readily done 332 SKIN DISEASES. when we remember that the former are of more rapid growth, and exhibit changes in the color and texture of the skin, which in fibroma are unaffected. Neuromata are usually painful. The diagnosis must be made in the early stage from sebaceous cysts; in the case of cysts, the origin from a flat gland, the central aperture or en- trance to it, and the fatty contents which can be squeezed out, determine the nature of the disease. The hard con- tractile sessile outgrowths of keloid could not well be mistaken for the lax, flabby, pedunculated tumors of fibroma, which have the aspect of normal integument. Treatment. — Piffard says: ''Excision is the only practicable method of treatment, and this is to be recom- mended only when the tumors are few in number, or when their situation demands it. ' ' Fox says the treatment is simple: '' When small, fibromata may be removed. In elderly men they are sometimes small, flat, and numerous — especially about the back, over the shoulders, and on the chest. I have never had the least trouble in getting rid of them all by the use of acid nitrate of mercury caustic to the smaller, and the joint use of that remedy and the ligature to the larger ones. I generally, after applying the acid, give an oxide of zinc paste to be used, to prevent too much irritation." The Arsenzte of calcarea and Lycopodium are the princi- pal internal remedies. There is yet another form of fibrous hypertrophy, in which greater laxity of tissue is observed. It is called — Dermatolysis. In this affection the skin hangs in loose folds. Its fibro-cellular element is greatly increased. The affection really includes all pendulous conditions, from obesity, . ELEPHANTIASIS. 333 parturition, the state of skin in lax and enlarged mammse, and the like. In the uncomplicated form of disease, the hypertrophic growth arranges itself in layers like the folds of a tippet; there is little vascularity; the sensibility of the past is diminished. Elephantiasis. This affection is characterized by great hypertrophy of the integument of either the leg or scrotum in men, or leg or labia in women, or both locations may be involved at the same time. It occurs frequently in tropical coun- tries, but rarely in northern climes. In the development of this disease general symptoms precede the local ones, and the first indications are usually a sharp, febrile attack, in no way distinguishable at the beginning from an ordinary severe paludal fever. In a few days, however, pain in the groin, with swelling of the lymphatics, is noticed, and this in turn is followed by more or less oedema of the foot and leg. After the subsi- dence of the febrile attack the oedema of the limb abates, but does not as a rule wholly subside. After a varying and uncertain interval a second febrile attack occurs, with re- newed sw^elling of the limb, which but partially subsides, leaving the part still a little larger than before. These at- tacks succeed each other irregularly several years, until finally the leg or other part affected may attain an enor- mous size. Elephantiasis is unquestionably due to obstruction of the lymphatic circulation; and this in turn has been most conclusively proved in many cases to be due to the presence of a minute worm, the filaria sanguinis, which lodges and excites inflammation in the lymphatic glands and produces occlusion of the vessels. The febrile attacks, which occur with a certain periodicity, may be 334 SKIN DISEASES. due to the development of fresh broods oi filaria. This parasite, however, is not met with in the higher latitudes, in which cases of the disease are sometimes encountered; and hence these latter need some other reasonable ex- planation, which we regret to say is not forthcoming. It is supposed by some that the mosquito plays an im- portant part in the development and transportation of the undeveloped filarise. Elephantiasis is always a grave disease, and may last a life time. Treatment. — A milk diet is the best for the elephan- tiasis patient, and if it is a possible thing a change of climate should be made. I can not recommend Esmarch's bandage, neither amputation, as I have never seen any benefit from either expedient. Relief, and occasionally beneficial results, come from the use of hamamelis or chaulmoogra oil dressings. Myristica sebifera is the main internal remedy. Hy- drocotyle Asiatica^ has been recommended, as have also Anacardium orientale and Elceis guineensis. Milium. This name is given to an affection characterized by the appearance of minute white or pearly papules. These little papules are usually clustered about the eyes, sometimes on the upper and the lower lids, and often on tbe cheeks just below the eyes. They cor- respond to sebaceous glands, of which the orifices have in some manner become occluded, thus allowing an accu- mulation of sebum. They are much more frequently met with in women than in men. Treatment. — Milia are readily removed by dividing the thin skin that retains them with a sharp curved MAMMILLITIS MALIGNA. 335 needle ground flat on the curve. A little pressure is exerted, and the tiny white sebous concretion rolls out. The Calcium iod. is the principal remed}^ and the next Staphysagria. Tabaciim may be thought of. Mammillitis Maligna. Under this designation we embrace the peculiar and rare disease of the nipple and areola, commonly known as "'Paget's disease of the nipple." Dr. James Paget was the first to describe this disease, and he states that he had seen some fifteen cases, all oc- curring in women between the ages of forty and sixty. The affection commences as a red, almost raw inflamma- tory condition, confined to the mammilla and surround- ing areola; the surface being somewhat granular, and looking not unlike an ordinary eczema rubrum from which the epithelium had exfoliated, and accompanied with a very similar exudation, with some tingling, burn- ing, and itching. In other words, it presented the ordi- nary appearances of a common eczema, except that, when taken between the fingers, there was a firmness of the tissues, approaching the condition of induration, that is never met with in eczema proper. The chief peculiarities of this disease, however, are the facts that, first, it is exceedingly rebellious to treatment, obstinately refusing to heal under the simple measures that would suffice in ordinary eczema; and, second, that the disease in question proves to be a forerunner of car- cinoma. It is on this fact that the real importance of the disease depends, as in the beginning it gives rise to very little local or other inconvenience. Treatment. — If the diagnosis is firmly established, extirpation, either by the knife or caustic, is the only 336 SKIN DISEASES. means of treatment that promises any success, as sooth- ing remedies do not check its progress, while those of a stimulating nature simply aggravate the lesion. I am unable to recommend any homoeopathic remedy as having had any influence upon the disease. Kali mur. and Silicea might be tried, given in alternation. Ainhum. This disease consists of spontaneous amputation of the little toes, with hypertrophy of the amputated part. The name means " to saw." The disease is said to exist amongst the Africans. A small semi-circular furrow first appears in the digito- plantar fold, which gradually increases, without pain or inflammation, the toe enlarging, and getting loose and in the way. If the toe is cut off, the wound left heals very speedily. The cause is unknown. The general health does not suffer. The disease is symmetrical. The am- putated toe shows fatty change of the tissues, enlarge- ment of the areolar spaces of some of the bones of the phalanges, the bone tissue between the middle and proximal phalanges being replaced by fibrous tissue, the separation of the toe taking place at the proximal, inter-phalangeal joint, and not the metatarsal phalangeal joint; the cartilage and articular end of the middle phalanx being removed and replaced by fibrous tissue^ which looks like an ordinary cicatrix. Nsevus. These spots are congenital; and they are not only hardly ever amenable to surgical treatment, but have in many cases been rendered much worse by such inju- dicious treatment. Some remarkable nsevi reproduce upon the skin of the child while yet unborn the vivid N^vus. 337 impression made upon the mind of the mother. An- other and more profound influence of the same kind, or one exerted in an earlier stage of pregnane}^, results in actual deformities and monstrosities. NcBvi materni may be arranged in three distinct classes, in the order of their gravity. 1. Moles, the most common of all, whose character and harmlessness are well known, and which are gener- ally attributed to some alteration in the structure of the rete raucosum. 2. Venous Aneurisms — Anastomosis of Venous CapiU laries. — These form a dark-red circumscribed stain, which generally appears on one side of the face, and is sometimes of considerable extent. These " marks," which appear to be simple dilatations of the sub-cuticular capillary vessels, may increase in extent till puberty, and then remain stationary. 3. A?ieurisms and Dilatations of the Arterial Capil- laries — These form the most important of the naevi; they are apt to enlarge in after-life, especially when stimulated by external irritation, and they may give rise to danger- ous hemorrhage if improperl}^ meddled with. They form slightly elevated spots, with well-defined margin and a granular surface, which consists of an erectile vascular tissue. These granulated tumors, raised above the skin, may in fact be constituted of venous or of arterial vessels. In the former case they may be of a dark-blue or livid color; in the latter, of a brighter red. Treatment. — Mr. Thomas reports three cases treated b}^ collodion. The nsevi were covered, together with the surrounding skin, with collodion, which was repeatedly applied. Improvement was so marked as to do away with the necessity for operative interference. Dr. Mayor publishes an interesting case of a nsevus of 338 SKIN DISEASES. the cutaneo-subcutaneous variety, on the back, in a girl aged ten months, where he successfully tried electrolysis. The number of sittings was two, and the duration of each about two minutes. On examination of the patient, nearly four years later, not a trace of the naevus was detected. Dr. Marshall, from an experience of many years, recommends the electrolytic treatment of naevi as superior to every other. After criticising the methods in vogue, he claims for electrolysis: That it gives no after-pain; that it is free from danger; that there is no bleeding; that the resulting scar is white and shows no tendency to contract — a point not to be forgotten since nsevi are so common about the head and face. This method is slow, the disappearance being gradual. One or more needles are used according to the size of the growth, and they are moved about to attack the various portions without withdrawing them. It is well, at first, to work well away from the surface to avoid destroying the same. The scars left by the negative needles are apt to be brown and disfiguring and hence the positive pole is to be preferred, being slower in its action, less apt to cause sloughing or to be followed by bleeding after withdrawal of the needle, A rheophore attached to the negative pole completes the circuit, a second puncture being thus avoided. As re- gards the number of cells, ten are usually sufiicient, although in deep nsevi as many as twenty have been used. A change in color to a dusky hue is the indica- tion to stop the current. To withdraw the needle it should be first rotated and the orifice can be painted with collodion. The following remedies should be carefully studied, in order to find the simile in each case: This being found, it should be given sufficiently high and at long intervals, in N^vus. 339 order to remove as rapidly as possible from the system the morbid condition which sustains these irregularities of the circulation, and to enable nature to remedy the deficiency in structural organization from which perhaps they originally sprung. If the arterial capillaries are involved: Bellad. will be indicated by red radii extending from the centre. Calc. carb. — In leucophlegmatic temperaments. Lycopod. — In hypertrophied capillary tumors, both venous and arterial. If the venous capillaries are hivolved : Carbo veg. — Particularly when the slightest irritation causes free hemorrhage. Phos. — Small wounds bleed much; this may be either venous or arterial. Dr. Wilkinson reports a case of naevus on left labium majus, little girl aged six weeks, cured by application of thuja 6>, thrice daily for six weeks. CHAPTER XIV. NEW FORMATIONS, OR NEOPLASMATA. Neoplasmata are essentially characterized by the for- mation of new kinds of tissue in the skin. Neoplasms are observed in many different diseases of the skin, and under a variety of circumstances, but those diseases only are included in this chapter in which a neoplasm forms the entire disease. The new tissue in neoplasms has been regarded as originating in, and therefore an hyper- trophy of, already existing elements; but it is certainly not a pure hypertrophy, and it is new in regard to its characters and behavior. On this account it is impossi- ble to include the neoplasmata in any but a special group. Lupus. There are three principal forms of this disease — the superficial variety, commonly spoken of as lupus erythe- matosus ; the deeper, or lupus vulgaris ; and the deeply destructive form, or lupus exedens. These three varieties present certain features in com- mon, and their color is peculiar. It is neither the frank red of an active congestion nor the brownish ham-color of syphilis, but rather the vinous color that derives its hue from chronic venous congestion; mingled with a certain amount of red. The lesions are few in number; often but a single lesion may be present, but quite fre- quently we may find two or three — rarely more. Their course is chronic, years being devoted to their develop- LUPUS ERYTHEMATOSUS. 341 ment. They almost always leave scars, even in the absence of ulceration. The local symptoms are insignifi- cant, as there is rarely either pain or itching, at most a slight burning sensation, to which the patient becomes habituated and ceases to notice. In the patient's family history, pulmonary phthisis is an almost constant feature. Several years ago Bazin and Hardy gave the name of scrofidides to these affections, recognizing at that time their dependence on the general constitutional condition that predisposes to tuberculosis. Quite recently, the bacillus tuberculosis has been found to be a constant ac- companiment of the lesions, thus demonstrating the soundness of the opinions advanced by the eminent der- matologists above mentioned. Lupus Erythematosus. In this variety the lesion commences as a reddish macule, barely elevated above the level of the surround- ing skin. As it slowly but gradually increases in size, the elevation slightly increases, and small, closely ad- herent scales form upon the surface. The extension is peripheral, and after many months, or perhaps years, may attain the size of a coin. When it has reached a diameter of, say, one-half to three-quarters of an inch, the central and older portions begin to lose their infiltrated character, sink to the level of and even beneath the level of the skin, at the same time losing their color. This continues until we find a white depressed scar, sur- rounded by a still infiltrated raised reddened ring. Dur- ing the progress of the lesion as described, other similar ones may have appeared on neighboring or on distant parts; but, as a rule, their number is limited. When two patches have appeared in close proximity, the}^ may join by mutual peripheral extension. In this way the 342 SKIN DISEASES. greater portion of one side, or even both sides, of the face may become involved by the disease. Such ex- tensive invasion, however, is the result of years, as cases are met with in which the lesions have been gradually extending in this manner for twenty years or more, the older portions of the lesion undergoing the retrogressive changes we have noticed. The favorite seat of all varieties of lupus is the face, although other parts may be attacked as well, and even to the exclusion of the face. Epithelioma may develop upon the site of a long- existing erythematous lupus, or in the neighborhood of lupous lesions. Lupus Vulgaris. L. vulgaris is characterized by the development of tubercles within or projecting to a greater or less degree above the surface of the skin. It rarely appears as an isolated tubercle, but more frequently in groups of six or a dozen tubercles, quite close to, but not touching one another, little bands of apparently healthy skin inter- vening, thus forming a patch. As the disease progresses, however, the tubercles may unite by mutual extension and the entire patch present a lupous character. There may be one or more of these patches. The tubercles themselves are soft, sometimes almost jelly-like, in appearance and consistence. The extension of the lesions is slow, years intervening before the patches attain any notable size. Just as in the erythematous variety, the lesions of lupus vulgaris may undergo resolution, leaving a depressed cicatrix, or else they may ulcerate superficially. The ulcerative action is exceedingly slow, and appears to involve only the upper portion of the derm — more rarely , LUPUS EXEDENS. 343 its entire thickness. The exudation from the surface of the ulcer is exceedingly scanty, and forms a crust adhering somewhat closely to the sore. The scars that result are of a reticulate character, not unlike those produced by a severe burn, and naturally cause more or less disfigurement. Lupus vulgaris, after ulceration takes place, may be succeeded by epithelioma at the margins of the ulcer. Lupus Exedens. This form of lupus was recognized by all the older writers; but those of recent times seem disposed to deny it a place in nosology, or declare that the cases described under this name were not lupus at all, but were epithe- liomata. This is not in accord with Dr. Piffard's observations, and he describes in this place a variety of lupus characterized by the development of usually a single good-sized soft tubercle. This slowly increases in size, until after a lapse of years, perhaps, ulceration sets in, which extends both in width and depth, involving the tissues beneath the skin. The margins of the ulcer are uneven, ragged, and burrowed under. The edges, however, are soft, not presenting any hardness or indura- tion. After an indefinite period, however, at one or more points on the periphery of the ulcer hard nodules may and usually do develop, and which can easily recognize as unmistakable epithelioma. This epitheliomatous pro- cess may extend until the greater part of the ulcer is involved. The only contention concerning the nature of this disease is whether it is a true epithelioma from the beginning, or whether it is an epithelioma ingrafted on a lupous basis. Whatever may be the true pathology of the disease, the practical outcome is the same, and this is 344 SKIN DISEASES. usually a fatal termination, unless the lesions be early vigorously dealt with. Lupus may occur in the throat, and may make its appearance at any time of life. It occurs in men oftener than in women. It may occur in any constitution but seems to prefer the lymphatic temperament. Inheritance has nothing to do with it. Sometimes the mucous membrane assumes a purplish color, swells up and becomes granular and one or two of the granulations develop so much as to reach the size of a pea, or even that of a hazel-nut. Occasionally, the tubercles become prominent in the throat previous to alteration in the mucous membrane, and without differing from its normal color. They may be either superficial or deep. Their surface is smooth and brilliant, but if several of them become intimately united they appear as a single mass, rounded, cloven, and anfractuous. When the tubercles develop exuberantly in the larynx, breathing becomes embarrassed, and even stridulous. There is no alteration in the sensitiveness of the affected parts. Finally, the tubercles soften and become ulcerated. This melting down does not take place in a complete manner. In some cases, only the surface of the tumor becomes fissured or excavated as a margin to simple excoriations. In others, the destructive process attacks a greater or smaller portion of the tubercle in its entire depth, producing ulcers which dip out of sight in the midst of the tissues. The cure of these cases is difficult and is followed by indelible scars. In some cases, the ulcers are developed in a slow but fatal manner; in others, they spread with astonishing rapidity; while in some others, they stop in the beginning, but how far their ravages may extend it is impossible to predict. Instead of appearing in its usual idiopathic form, LUPUS EXEDENS. 345 lupus, at times, develops subsequent to other skin lesions, for instance, a traumatism. In such cases it affects one or more localities, but always where formerly an injury, ulceration or scar has been. If the disease attacks the fingers it can completely de- stroy thern, but never the nails or the matrix. As the finger is shortened by the disease the nail maintains its position at the end of the stump, and may finally reach a position over the head of the metacarpal bone, where it remains in apparently as healthy a condition as in its nor- mal condition. The family history of the great majority of patients suffering from lupus reveals the important fact that phthisis pulmonaris is met among the near relations to a surprising extent, and we are forced to the conclusion that the same constitutional condition that predisposes one subject to the invasion of tuberculosis of the lungs predisposes another to tuberculosis of the skin; but the exact role played by the tubercle bacillus is no more known to us in the one case than in the other. The diagnosis of lupus is in general easy. When we consider the location of the disease, the color of the lesions, their slow development, the absence of sub- jective symptoms, the presence of citatrices in cases of long standing, and the repeated relapses after even vigor- ous attempts at treatment, we ought not to be often led astray. A question may sometimes arise as to whether certain tubercles or ulcerations are lupous or syphilitic. The length of time they have existed will usuall}^ settle this, when we remember that syphilitic lesions may reach a degree of development in a few weeks that might hardl}^ be accomplished b}^ lupus in years. The single tubercle of lupus exedens is to be distinguished from sarcoma and epithelioma. In sarcoma the development 23 346 SKIN DISEASES. of the lesion is much more rapid, while in epithelioma, the tubercle is hard, but in lupus exedens it is soft. In no disease of the skin is the prognosis more de- pendent on the character of the treatment. In early cases it is absolutely good if sufficiently vigorous treat- ment be instituted, while lack of appreciation or lack of vigor on the part of the physician is responsible for most of the extensive and long-standing cases that we meet with. Treatment. — Lupus erythematosus may sometimes be cured by the induction of an artificial eruption produced by the action of irritants. This method, however, is not to be commended. It is much better to destroy it with an active caustic, provided the extent of the eruption does not contra-indicate this method. When the lesion is quite small, excision may be practiced; or thorough scraping with the dermal curette, followed by nitric acid, or the actual cautery. lyUpus vulgaris demands the same treatment as the other form. In lupus exedens thorough removal with the knife of the diseased portions, including a portion of the surrounding apparently healthy tissue, is the better plan. Dr. Mackay reports two cases of lupus healed after a few weeks of treatment by a twenty per cent, ointment of resorcin, applied after scarification. The application of resorcin was attended with but comparatively little pain. Sulphurous acid, in the form of a lotion, or an oil, or in the gaseous state, has been employed as a remedial agent in lupus. The gaseous form may readily be ob- tained by burning in a jar, and allowing the fumes free contact with the surface to be treated. This can only be used upon parts removed from the respiratory organs. As a rule, two applications daily, each for about twenty LUPUS EXEDENS. 347 minutes, will be found best. The lotion is best obtained by the use of the pharmacopoeical preparation of the acid, diluted in strengths of one in two, or one in three. This can be applied to any part of the face without pro- ducing disagreeable effects. The oil is preferred by some, and is prepared b}' dissolving the anhydrous acid in cas- tor or olive oil. Satisfactory results frequently follow this method of treatment. Alveloz has latel}' been recommended as a local appli- cation for lupus and cancer. Cases have been reported where brilliant cures were effected by the use of the drug. I have had no opportunity of testing its virtues. The application of ice will frequently relieve the severe pain that is sometimes the accompaniment of lupus; some authors claim curative effects from the use of ice. Arsenicum alb. and Hydrocotyle, are the main internal remedies. Others ma}^ be indicated as follows: Aurum miir. — When starting from the nasal mucous membrane; a discharge from the nares very offensive; absorptiori of the bones of the nose; melancholia. Cishis. — Lupus on the face; worse from cold air. Graphites. — Lupus on the nose; obstruction of the nares; dry, cracked skin; every injury tends to ulcera- tion. Guarana. — Lupus of an ochre-red color, yellow spots on the temples. Hepar. — Lupus on the elbows; ulcers with burning or stinging edges; nodosities on the head sore to the touch; swelling of the upper lip. Hydrastis. — Ulcers on the legs; exfoliation of the skin; purulent discharge from the nostrils; faint, sinking feeling at the stomach. Kali bichrom. — Ulcers painful to the touch; worse in 348 SKIN DISEASES. cold weather; ulceration of the nasal septum; loss of appetite; all the secretions are tenacious and stringy. Lycopod. — In recent cases; hunger with constant feeling of satiety; arms and fingers go to sleep easily; purulent discharge from the ears; weakness of memory; melan- cholia. Nitric ac. — Lupus on the nodules of the ears; offensive purulent discharge from the ears; dry, scaly skin; affec- tions of the bones and glands; in dark complexions. Oleum jec. ass. — A valuable remedy. Staphysagria. — Ulcers on the alse of the nose; weary pains in the limbs as if bruised; teeth turn black and decay; in scrofulous subjects. Epithelioma. Epithelioma, or epithelial cancer of the skin, is character- ized by the appearance of a hard tubercle or nodule, slowly increasing in size until ulceration sets in, which ulceration may extend both laterally and deeply and destroy all tissues with which it comes in contact. As its name implies, it is an outgrowth from the epithelial tissues, in which a more or less extensive and exuberant proliferation of epithelial cells occurs. The typical epithelioma may be said to take its origin in the Malpighian layer, the cells of which increase in number and seek accommodation in the deeper layers of the skin. As they increase, however, some of them, from the pressure of the neighboring connective tissue, are forced to occupy a smaller space than they would if permitted to multiply freely in all directions. As a result of this compression, small rounded bodies are formed, in which the cells assume a stratified arrangement, constituting the epithelial cell-nests well-known to every microscopical observer. Coincident with this extension of the disease ii EPITHELIOMA. 349 inward there is a greater or less projection outward, forming a distinct sessile tubercle, or a more flattened growth. Primary cancer of the skin is a rare condition, while ■epithelioma, involving both cutaneous and mucous sur- faces — as ordinary cancer of the lip — is sufiiciently com- mon. Cancer of the skin, however, w^hich has developed secondarily to some pre-existing morbid growth, is the variety most frequently found in practice. Epithelioma is distinctly the product of irritation — not an acute and transient irritation, even if frequently re- peated, but rather one that is hardly, if at all, appreciable to the senses, and which is persistent and active through a lengthened period. Thus we may find that a purely innocent and benign growth, like a simple wart, may after a lapse of years become the seat of an epithelioma, which would not otherwise have appeared. A localized seborrhoeic condition, which of itself implies an irritation of the epithelial lining of the glands, may, and not infre- quently does, become the starting point of cancer. Lupus offers an inviting field for the development of the disease; and in general it may be said that an ulcerating lupus, if left to itself, will almost invariably in time be- come supplanted by epithelioma. Sarcoma more rarely is followed by epithelioma, and this rarity may be ex- plained by the fact that sarcoma usually runs its course and has destroyed the patient before the cancerous af- fection has had time to develop — the irritation produced "by the sarcoma being more active than that w^hich ordi- narily leads to the occurrence of the other disease. Epithelioma is met wdth clinically in two distinct forms, in one of which the cutaneous involvement is more superficial than in the other. In the superficial variety, ■which is less frequently met with than the other, the 350 SKIN DISEASES. patient's attention is first attracted to a little crust — usually on some part of the face. This he picks off, and gives little further attention to the matter. A new crust forms, and this is in turn picked off, and reveals, per- haps, a slightly excoriated surface. He consults a phy- sician, who, failing to recognize the gravity of the condi- tion, prescribes some salve or other, or lightly touches the part with caustic. The lesion extends, and perhaps rarely reaches the hands of a surgeon until it has ad- vanced to the stage of frank ulceration. We now find a sharp-cut ulcer, extending through the entire thickness of the skin, but not involving the subcutaneous tissues. This ulceration advances at its borders, or sometimes in one direction only, while reparative changes may some- times occur in the other, much after the manner of some cases of lupus. The progress of the ulceration is exceed- ingly tardy, and years may elapse before the ulcer has attained any considerable size, and, when it does, we will sometimes find that cicatricial tissue now occupies a por- tion of the territory that had been the early seat of the cancerous lesion. The other, or tuberous form of epithelioma, will be recognized at the beginning as a hard tubercle, occupy- ing the seat of what may have been previously the situa- tion of a wart, mole, etc. This tubercle increases in size^ and the tissues beneath it are palpably involved in the morbid process. The skin surrounding the tubercle is also involved to a certain, or, rather, uncertain extent, as is evident to sight and touch. Later, ulceration ap- pears, and the margins of the ulcer are everted and hard. As the ulcer spreads laterally, so also does it become deeper, and the process continuing unchecked leads in time to a fatal termination. The diagnosis of epithelioma, when actually existing. EPITHELIOMA. 351 is surrounded with very few difi&culties as the induration of the tissues is hardly to be met with in any other chronic cutaneous lesion; but the physician should be prepared as well to recognize conditions which will probably become epitheliomatous in time. It is this failure to diagnosticate an impending epithelioma that leads more frequently than it should to inefficient treatment and the sacrifice of lives that might otherwise have been saved. The face is the most frequent seat of purely cutaneous epitheliomata; and, if a physician can not make up his mind as to whether a certain hard tubercle or a chronic ulceration is cancerous or not, his plain duty is to take his patient to some one who can. The prognosis of cutaneous epithelioma is good, provided the lesion is seen in its early stages, and its locality permits of suitable and efficient local treatment. On the other hand, it is distinctly dad if the disease has gained much headway or involves an extensive surface. The treatment of epithelioma will depend, firstly, on W'hether the particular lesion in question is, or is not, in a curable condition. This is in realitj^ the most serious question that the surgeon has to determine, and to its solution he should bring his best judgment, based on his knowledge and experience. If he decides that it is incurable, any operation would be a barbarity, and suggestive of charlantry; but if there is a good prospect for the thorough removal of the neoplasm, no time should be lost in carrying it into effect. The removal of epitheliomata may be effected in two ways. One of these is with the knife, and, when this is practicable, it is the best way; and there is but one rule to follow — cut widely and cut deeply. If for any reason the knife is impracticable, the diseased tissues may be destroyed by a sufficiently active chemical agent; and 352 SKIN DISEASES. experience has shown that arsenic properly used is probably the most efficient means at our command. Now, there are two ways of using arsenic; one is to use it strong enough to destroy the cancer; and the other is to use a weaker preparation and destroy your patient by arsenical poisoning. The stronger the arsenial preparation the greater its local action; while the weaker it is, the less is its topical action, and the greater the probability of systemic absorption. Take anhydrous chloride of zinc and mix it with an equal weight of water — to this add sufficient arsenic to make a moderately stiff paste. This should be applied to the diseased parts in a reasonably thick layer with a little absorbent cotton as a top dressing. To this treatment there is one objection, namely, the severe pain that the arsenic will cause, which can only be mitigated by the free use of morphine. If the lesion be of moderate size, and the application thorough, the falling slough will, in a week or two, reveal a healthy ulcer, which only requires a little time for complete healing. If the case has progressed beyond the period when a cure may reasonably be expected, the prudent surgeon will seek only to mitigate the patient's sufferings until death brings its release. Resorin grammes 30. Vaseline, " 100, applied daily, has cured some cases that were diagnosed as epithelioma. The parts were first cleansed with borax water. Aristol has been successfully used as a topical applica- tion. Its advantages over arsenic are its painlessness, and rapidity of action. Thuja is the principal internal remedy. Other remedies are: Sepia ^ Ars. alb. (malignant form), Con- il SARCOMA. 353 durango. Lapis alba. Nitric acid.: A roundish ulcer, bluish-red and nodulated; bleeds upon slightest touch; burning pain which becomes almost unbearable, when eating or drinking, when touched by cold or warm food. Hoang nan. — Attacking especially the mucous surfaces. Petroleu7?i. — Nodules on hands, wrists, arms, feet and legs; worse about wrists or wherever the dress is tight (palms and soles being free), less on face, neck and parts to which oily matters find access. Pimples itching on angle between scrotum and thigh, scabs in fold of left wing of nose. Sarcoma. The word literally means a fleshy tumor, and embraces in its scope a varity of new growths, which present certain common features, but which differ, however, among themselves in many essential particulars, both as to form and constitution. In general, it may be stated that a sarcoma is a tumor composed in the main, of cellular tissues, the cells them- selves being either round or fusiform, and partaking of the characters of embryonic rather than fully organized adult tissue. The new growth is usually exceedingly vascular, being permeated with large vessels, some of which are doubtless extensions from pre-existing vessels of the neighboring parts, while others are doubtless first and independently formed in the new growth itself, and connect themselves later with the older vessels. In some instances there is a considerable deposit of pigmentary particles, probably derived from the blood coloring matter throughout the growth. These histological changes give rise to three types of tumor — namely, the round-cell sarcoma, in which the round cells greatly predominate over the fusiform; the spindle-cell sarcoma. 354 SKIN DISEASES. in which these cells make up the greater part of the growth; and, thirdly, the melano or pigment-sarcoma, which may resemble either of the addition of the foregoing with the addition of the pigmentary deposit. As a rule, neither of these types is met with in its purity, the majority of sarcomata being of a mixed type, with one or the other greatly predominating. The earliest noticeable lesion of sarcoma may be a macule or a tubercle. The macule may develop into a tubercle, or, on the other hand, may vSpread laterally in the skin, forming a patch or blotch one, two, or more inches in diameter. These patches are heightened in color, the hue being a bluish-brown, are hardly at all elevated, and differ in consistence but little from the surrounding integument. In fact, they appear to be patches of chronic congestion rather than infiltration. The evolution of the macules is tardy, and a year or more ma}^ be occupied before they attain any considerable size. It is possible that these macules may exist singly, but they are usually multiple. These macules may undergo com- plete resolution, and leave little trace of their previous ex- istence. Under these circumstances the propriety of classing them as a variety or lesion of sarcoma might be seriously questioned were it not for the fact that they not infrequently become the starting-point of typical sar- comatous growths. After the macule has attained a cer- tain size, an elevation at one point occurs, developing into a tubercle and ultimately into a tumor. The primary tubercle of sarcoma may develop at the site of some long-standing innocent growth, as a mole, etc., or may take its origin in apparently normal skin. The former is the more usual course in persons advanced in years, while the latter is commonly the case in children and young persons. SARCOMA. 355 The progress of sarcoma is usually rapid, and a tubercle in a few weeks may deserve the title of tumor, and after the lapse of some months may attain the size of a child's head or even larger. The sarcomatous tubercles and tumors present one character which is in striking contrast with carcinomatous growth. I allude to their consistency. Sarcomata are soft, sometimes of almost jelly-like consistence, w^hile car- cinomata are hard. After sarcomata have attained a certain size, they usually soften in the more central and older portions, and break down, forming a fungoid ulcer, from the base and edges of w^hich secondary sarcomata may spring. Occa- sionally the margin of the ulcer becomes epitheliomatous. No age is exempt from the development of sarcoma, but it is decidedl}^ more frequent before the age of fifteen and after forty-five than during the intermediate period. When w^e compare the three most important tumor types — namely, carcinoma, fibroma, and sarcoma — we are struck with their peculiarities and contrasts. Carcin- oma is especialh^ prone to occur late in life; it is a malignant growth, composed of tissue elements w^hich are little viable, and do not form permanent tissue, but ulti- mateh^ break down with ulceration. Fibroma, on the other hand, prefers the middle period of life, is benign, and is composed of viable and permanent tissue; while sarcoma, as we have seen, prefers the extremes of life, and is malignant, its elements not going to the formation of permanent tissue. Sarcoma may be characterized by the development of either single or multiple tumors. When single and not interfered with they may attain a considerable size. When multiple the tumors vary in size from that of a pea to that of a hen's egg. 356 SKIN DISEASES. Hemorrhages accompany advanced cancerous disease, but they are insignificant compared with those which may occur in sarcoma. The extreme vascularity of the new growth and^ the unsubstantial character of the ves- sel's walls are sufficient to account for this pronounced hemorrhagic feature, which is met with not only in old and advanced tumors, but even in those that are small and have had but a few weeks' growth. Sarcomata may appear on any portion of the integu- ment, and exhibit little preference for any particular location, and after they have existed for some time are liable to develop on the mucous membranes, and also in- vade the viscera. The general health and vigor may be apparently un- impaired during the early periods of the existence of sarcoma; but as the disease advances, these gradually fail, but without, however, the development oi a cachexia^ as marked as in the latter stages of cancer. The prognosis of sarcoma varies. In single small tumors of recent appearance it is good, as they can be easily removed; and when the operation is properly per- formed they do not as a rule return. When sarcoma be- comes generalized the prognosis is unfavorable, and this is specially the case when complicated with melanosis. Large sarcomatous tumors are usually fatal. Treatment. — Beyond attention to the general health, there need be little expected from internal treatment, although there are undoubted cases of sarcoma on record in which the homoeopathic remedy exerted a favorable in- fluence and apparently effected a cure. In small and young single sarcomata mechanical re- moval should be effected just as soon as a diagnosis is established, care being taken to remove a considerable portion of the apparently healthy skin, and the location CARCINOMA. 357 of the tumor will permit. Special provision should be made against hemorrhage, which, from the large number and size of vessels entering the tumor, may be excessive. In very large sarcomata, in which an ultimate fatal termination is to be anticipated, removal is hardly to be recommended, except as a palliative measure, looking only to temporary relief. In these cases removal by means of a loop of platinum ware heated by electricity is to be preferred to the knife, on the score of safety from hemorrhage. Carcinoma. The carcinomatous family of malignant tumors con- tain the tumors which the term cancer, as understood at the present day, is properly applied. A carcinoma is a tumor made up of a typical epithelial new formation-cells, of epithelial origin, but imperfect embryonic cells. Structurally it consists of cavernous, fibrous stroma, in the interspaces or alveoli of which are found the epithe- lial cells suspended in a serous fluid. The cells are not separated by any visible intercellular substance. Even the blood vessels run in the fibrous stroma and not be- tween the cells. The development of cancer from epithelium has been clearly shown in certain localities where morbid processes are taking place. Some years ago, Paget called atten- tion to the point that a certain eczema of the nipple is often the precursor of cancer. In cases of this kind, it has been showm that the proliferation of cells which is active over the denuded portions is continued down into the milk ducts until these ducts have become filled and ex- panded by the over-accumulation of imperfectly formed cells. At the same time, the connective tissue surround- ing the duct takes on an increased vascularity from the 358 SKIN DISEASES. irritation, and is infiltrated with small cells resembling leucocytes. There is no direct connection between the cells of the duct and those found in the connective tissues outside. The latter are not migrating epithelial cells, but appear as the product of inflammation. As the ducts become filled and their walls distended, they give way, and the epithelial cells infiltrate into the surrounding tissues where they proliferate and become centres of disease. It is believed by some pathologists that the entire growth is not due to the proliferation of epithelium, al- though originating in this way. Endothelial cells, con- nective tissue cells, and indifferent corpuscles in the pres- ence of, or by contact with, a growing carcinoma, it is claimed, become infected and transformed into cells simi- lar to those of the tumor itself. While this may be true, the progress of carcinoma in its extension to the lymphatic glands does not support this theory, for instead of in- fecting and transforming the gland as a whole, the mode of invasion is between and around the lymph corpuscles, they being affected only by the pressure of the rapidly growing masses. As the cells increase and distend the con- nective-tissue spaces the fibrous tissues are pressed back and welded together, and the stroma of the cancer makes its appearance. The stroma is not real cancerous tissue, but the natural tissue of the part is sometimes increased by unnatural activity of the surrounding tissue. The blood-vessels of the stroma, like the fibrous tissue, in- crease in size, so that the stroma becomes much more vascular than the original fibrous tissue. Scheurlen claims to have obtained by cultivation from the juice of cancer of the breast in sterilized plural fluid, colonies of bacilli and spores, the bacilli being from, i 3m. to 2.5m. in length. By inoculating six dogs, in the CARCINOMA. 359 posterior mammary glands, with an emulsion of these cultures he has demonstrated the appearance of cancerous tumors. Finally, he has found the spores, if not the bacilli in question, in all the preparations of cancer stained by Gram's method. His conclusions are as follows: i. There exist constantlj^ in cancerous tumors bacilli which may be isolated. 2. The spores of these bacilli are found in all microscopic preparations of cancerous tissue. 3. Inoculation of animals with pure cultures of these bacilli determines the development of cancerous tumors. 4. There is a relation of cause and effect between these bacilli and cancer. The female sex, on the whole, is much more exposed to cancer than the male, on account of the greater liability of the female organs of generation. The breast alone probably furnishes as many cases of carcinoma as all other portions of the body. Carcinoma is essentially a disease of old age. It is so rare before thirty years that the age is often the most important consideration in the early diagnosis between benign and malignant growths. After thirty years of age it becomes more frequent, but it is not until the acme of life is reached and the organs begin their natural retro- gression, that cancer becomes common. At, and after the climacteric in women, and at a somewhat later period in men, the cancer is most active. So well recognized is this fact that a tumor appearing at this time of life is always regarded with suspicion. Certain localities are attacked much earlier than others. In early adult life it is found most frequently in the testicle and labia; from thirty-five to fifty, in the breast, uterus, the tongue, and the penis; from fifty to sixty-five years, on the lip and oesophagus. It is a noticeable fact that the organs in 360 SKIN DISEASES. which natural degeneracy of function takes place are the organs most frequently attacked. The carcinoma is a tumor of rapid growth. It never remains idle, and, with the exception to be noted, never decreases in size. In the manner of its extension, locally, it resembles sarcoma. The carcinoma is liable to many changes, but one of the most common features is the tendency to ulceration shown by the growth. The reproduction of cancer in an associated lymphatic gland is of such frequent occurrence that it is looked upon as one of the most certain signs of carcinoma. The glands affected are usually those having a direct ana- tomical connection with the affected part. Thus the axillary glands follow infection of the breast; the lym- phatics in the groin, carcinoma of the testicle; and the submaxillary or sublingual glands, infection of the tongue or lip. There seems to be no limit to the number of glands involved. From one to fifty have been found enlarged, varying all the way from the size of a pea to that of a walnut. The lungs, liver, etc., may become infected through metastatic deposits, carried thence by the blood. The chief forms of carcinoma are the schirrus, en- cephaloma, colloma,and melanoma. The schirrus is characterized by its firm, hard, dense feel, having a similarity, in this respect, to normal cartilage. It is most frequent of all the forms, and has been observed and recognized from the earliest times. The e?icephaloma is a soft tumor, and is the most malignant of all tumors. It occurs at an earlier age than the other forms of cancer, being almost the only one which is found before the age of puberty. To the touch, the tumor presents a peculiar soft feel, giving way under CARCINOMA. 361 pressure, and returning to its shape again, as if filled with fluid. It varies in volume from the smallest kernel to a tumor of the size of an adult's head. The collorna is so called because it consists, in large part, of a clear, viscid, gelatine-like substance. The melayiotic cancer, is apparently an encephaloid cancer which has been changed in appearance by the deposition of a black pigment in the elements composing the growth. A noted peculiarity of melanosis of the integument is its pronounced tendency to form in or tinder a pigmentary mole. The diagnosis of the different forms of carcinoma, when located in some external part, is usually a matter of no great difficulty. The schirrus is generally found in the breast. It is a solitary tumor, and rarely appears before the forty-fifth year of age. In feel it is firm, hard, dense, resembling cartilage. It grows slowly, and never attains large size. From its start it is accompanied by sharp, shooting, lancinating pains, which are distinctly localized. It early contracts adhesions to the integument and deeper tissues. If in the breast, the nipple is retracted. The superficial veins are but slightly enlarged. Ulceration occurs early, and the ulcer has an abrupt, steep edge, and a firm hard base. The lymphatics are invaded at, or soon after, the beginning of ulceration. The diagnostic symptoms of schirrus are clear-cut and cannot be mistaken. The encephaloma may occur at any age and in almost any portion of the body. It is soft, lobulated, usually solitary. It grows rapidly, and often acquires a very large size. Pain is absent or slight until the advent of ulceration, when it becomes severe, but does not assume the lancinating character of the schirrus. The sub- cutaneous veins are always enlarged. Ulceration is early 24 362 SKIN DISEASES. and the ulcer is foul, with thin edges, and is often covered with a fungous, friable mass. The lymphatics are early involved. The colloid cancer is rare, and its characteristics are not pronounced. It is tardy in its growth, of uniform con- sistency, free from pain, and often attains an immense bulk. It is usually found in the peritoneal cavity; when superficial, it may be confounded with a fibrous or carti- laginous tumor or sarcoma. It is distinguished from fibroma by its more rapid growth, its large size, and its constitutional tendency; from chondroma by its elasticity and less firm feel, as well as by its more rapid progress; from sarcoma by its more uniform growth and compara- tively slow progress. The 7nelanotic cancer can only be distinguished by the peculiarity of its color and its frequent origin from pig- mentary moles. From the facts given in the diagnosis this may be deduced; a tumor appearing late in life, which grows rapidly, is attended with pain, infiltration of the surrounding tissues, and adhesions to the integument and tissues beneath, shows a marked tendency to ulcera- tion and to infection of the lymphatic glands, and decay of the vital forces, is a cancer or malignant tumor. The prognosis in carcinoma is exceedingly unfavorable/ the natural progress in every case being toward the de- struction of life. The prognosis, as to course and dura- tion of the disease, varies much in the different forms and in the different parts of the system affected. Scirrhous cancer is one of the most regular in its course, its average duration, when uninterrupted by operation, being about three years. The encephaloma is more rapid in its course, the aver- age duration of life being less than two years, even in parts whose formations are . not essential to life. Carci- I CARCINOMA. 363 noma of the tongue, the interior of the month, the oesophagus, and the penis are very rapid in progress, being usuall}' fatal in from twelve to eighteen months. Carcinoma of the lip, the face, and the rectum are slower and more amenable to treatment. Treatment. — The treatment of cancer has always been extremely unsatisfactory. Various remedies have from time to time been heralded as cures, but after thorough trial have in every instance been discarded. Among these are: Chian turpentine; Resorcin; Inter- parenchymatous injections of ozone- water; Chromic acid; Cundurango bark, etc. Galvanism has been highly recommended, as has also the inoculation of the cancer with erysipelas. Occasionally, cures of cancer by the administration of homoeopathic remedies have been recorded, but the cases are so few, and the possibilities of error in diagnosis so many, that the value of these remedies in the treatment of this disease cannot but be called into question. There are many tumors, the result of acute or chronic inflam- matory action, which resemble very closely some of the forms of cancer. Many of these are amenable to the properly selected remedy, and it is cases of this character that have been cured by the remedy recorded. That no remedy has been discovered which is absolutely specific to the disease there can be no reason to doubt, but that remedies are of no value in the treatment of the disease cannot be so positively asserted. Whatever doubts may arise as to the value of remedies in overcoming the dis- ease when once aroused, there can be none as to service rendered by remedies in retarding the development of the disease and in relieving many of the accompanying symp- toms. At the close of this article will be found the remedies employed in the treatment of cancer. 364 SKIN DISEASES. While remedies are of value in relieving many of the attendant symptoms of cancer, and are often curative in ulcerations and indurations resembling cancer, at the present day surgery offers the only possibility of a radical cure. In certain forms of cancer in which involvement of the lymphatics does not occur until late in the prog- ress of the disease, the possibility of cure following an operation is always greater than in those in which lym- phatic involvement is early noticed. Epitheliomas of the lower lip are quite amenable to treatment, the thorough removal of the tumor before the submaxillary gland becomes involved being, in many in- stances, followed by cure. Even in the more rapid and malignant scirrhous and encephaloid tumor, thorough removal gives a percentage of cures sufficiently large to encourage the belief that early and radical measures will succeed in materially reducing the mortality of the dis- ease. The removal of the disease, if it does not succeed in effecting a cure, is still a great benefit to the patient. A careful study of the statistics shows that the average duration of life is increased twelve months in cases oper- ated upon over those in which the disease proceeds un- molested by surgical measures. The increase in life in some cases is several years. Even if this hope cannot be entertained, an operation is often justifiable on the ground that it will avert the suffering attendant upon the regular progress of the disease. The relief which fol- lows an operation is sometimes remarkable. Freed of the local pain and offensive discharge, the patient will become cheerful, sleep, eat, and even gain in flesh. In those cases in which an operation is not advisable, much relief from pain and offensive odor may be ob- tained by the use of certain applications. The best of ij CARCINOMA. 365 these is hydrochlorate of Cocaine. Painting the ulcerated surface with a two-to- four per cent, solution affords instant relief. When the discharge is profuse and offensive, the ulcer should be washed frequently with a strong solution of carbolic acid. Hyposulphite of soda may be used when other disinfectants fail. The surface of the ulcer is washed with a saturated solution added to an equal quantity of water, and lint steeped in the solution is laid upon it. The distressing night-sweats of the later stages of the disease may be controlled or improved by the use of aromatic sulphuric acid or aromatic vinegar. At this time also the use of morphine to allay pain and to secure sleep is permissible. It is best given by hypodermic in- jection. Therapeutical indications: Acetic acid. — Cancer of stomach, ulcerative gnawing pain at one spot in stomach with agony and depression, preventing sleep; severe burning pain in stomach and abdo- men, vomiting of yellow, j^eastlike matter, of blood; eyes sunken and surrounded by a dark circle; face pale and w^axen; tongue pale and flabby. Apis met. — Is indicated in cancer of the breast, in which the induration has followed an old case of mastitis^ and in which the pain is of a burning, stinging character. The characteristic urinary symptoms of the drug are the best indications for its use. Arsen. alb. — Foul, destructive, easily bleeding, and cancerous ulcers, with burning and corrosive pains in the interior of the affected parts; terrible darting and lanci- nating pains through them; burning discharges, which may be thick or thin, brown or black, extremely offen- sive; worse after midnight. Aurum. — The womb is prolapsed and indurated; pain like that of a bruise, with shooting and drawing, and the 366 SKIN DISEASES. mind constantly dwells on suicide. Cancer of the palate and nasal bones, or of the nose; pus greenish, ichorous, and putrid; cancer of stomach in last stage, when there are only few subjective symptoms. Bellad. — Scirrhous indurations; cancerous ulcers, burn- ing when touched; black crust of blood in the bottom of the ulcer; pus scanty. Pains come and go suddenly. Carbo mi. — Cachexia fully developed. Scirrhous can- cer on the forehead; sudden and short aching from col- loid cancer in the pit of the stomach, on taking a deep inspiration, clawing and griping in stomach, violent pressing in loins, small of back and thighs during menses, with chilliness and yawning; weak empty feel- ing in the pit of the stomach; it checks the putrid taste, the waterbrash, and contracting, spasmodic burning; scirrhous mammae with dirty bluish loose, skin or red spots on skin, burning and drawing towards axilla; ax- illary glands indurated. Causticum. — Patient cannot bear the pressure of the clothes on the stomach; the lightest food or even the smallest quantity causes a violent lancinating pain in the stomach; scirrhus of the lips, with itching and soreness, which when ulcerated has a violent burning pain; pus bloody, or greenish, or corroding, or thin, watery, and yellow. Chelidoiimm. — Old, spreading, putrid, carcinomatous ulcers; the pain in the stomach is of a gnawing or digging character; nausea, with sensation of heat in the stomach; burning in stomach. Calcarea phos. — Cancer in scrofulous constitutions. Calcarea fluor . — Knots, kernels, hardened glands in the female breast. Swelling on the jaw bone which is hard. Chimaphila. — Tumors of the mammae, enlargements of lymphatic glands. CARCINOMA. 367 Clematis. — For softened scirrhous uteri, with corrosive leucorrhcea and lancinating pains. Conium. — Bleeding of the ulcers, with a secretion of fetid ichor; a portion becomes gangrenous; concealed •cancer of bone; cancerous swelling and induration of glands; cancer of the lips; spreading cancerous ulcers in the face; contractive spasmodic pains in the stomach; cancer and cancerous ulcers after contusion; burning stitches; stinging in the affected parts. Cundurango . — Is onl}^ eflScacious in open cancer and cancerous ulcers, where it effectually moderates the -severit}^ of the pains. It does not act on scirrhous and in- durated parts. Femim phos. — An excellent alternate remedy for ex- cessive pain in cancer. Eucalyptus. — One of the best remedies for destroying the fetid odor of cancerous discharges, used internally and locally. Galium. — Epithelioma, when the disease is slow in its progress, and where there are nodular deposits near the surface. Graphites. — Hot and painful vagina; swelling of the lymphatic vessels and mucous follicles; the neck of the uterus is hard and swollen, with tuberculous 7iodes and cauliflower excrescences; great weight in the abdomen on rising, with fainting sort of weakness and aggravations of the pains, delaying menses, with aggravation of the pains shortly before and at the appearance of the menses; discharge of black, lumpy, fetid blood; stitches shooting through the abdomen as far as the thighs; buryiing and stitching pains; constipation; livid complexion; sad and anxious mood. Frequently useful in connection with ovarian diseases. Hepar. — Corrosive pain in a cancerous ulcer, bleeding 368 SKIN DISEASES. at the slightest touch; yellow skin and complexion; erup- tions around the mouth, lips and chin, which are con- verted into cancerous ulcers, rapidly spreading; pressure and dull aching pain in the stomach after moderate eating; cancerous ulcer of the mammae, with stinging burning in the edges; pus, copious or scanty, smells like old cheese.. Hydrastis. — Recommended for all sorts of cancer, but it will only act as a regulator for the faulty nutrition^ and thus exerts a favorable influence in soft or encepha loid cancer. Iodide of Arsenic. — Swollen gland in the left axilla, size of a hen's ^%%, hard, and exuding a fluid which forms a hard, brown crust. The tumor is painful and sensitive to the touch; breast of the same side enlarged, indurated and very sore. Yellow, bloody, and irritating leucorrhoea, with swelling of the labia. lodium. — Uterine hemorrhage after every stool, with cutting in the abdomen, and pains in the loins and small of the back; great weakness during the menses, particu- larly in going upstairs; long-lasting uterine hemorrhage;: dwindling and falling away of the mammse; aggravated from externa] warmth; complete prostration of strength and general emaciation; violent vomiting, renewed by eating; pulsations in the pit of the stomach. Kali phos. — Cancer, pain, offensive discharge and dis- coloration. Kali sulph. — Epithelioma. Cancer on the skin near a mucous lining, with discharge of thin, yellow, serous^ mattery secretions. Kreosotum. — Shooting stitches in the vagina, burning and swelling of the external and internal labia; profuse discharge of dark coagulated blood, or of a pungent bloody ichor, preceded by pain in the back; aggravation of the pains at night; fainting on rising from the bed; CARCINOMA. 369 she alwa3^s feels chill}^ at the menstrual period; complex- ion livid; disposition sad, irritable; cauliflower excres- cences; wretched complexion, great debility, sleepless- ness. Tightness of the pit of the stomach, cannot bear the weight of her clothing; painful hard place on the left side of her stomach. Lachesis. — Melanosis, colloid, and encephaloid cancer; violent burning, gangrenous spots; cancer of the breast, with lancinating pains; the pit of the stomach very sensi- tive to touch; uterine cancer developing itself at the climacteric, or as a consequence of the change of life; the pains increase rapidly, until relieved by a profuse dis- charge of blood; violent pains, as if a knife were thrust through the abdomen, which has to be relieved from all pressure. Lapis albus. — Cancer as long as it has not opened, based on scrofulosis. Lycopod. — Swelling of the upper lip, with a large ulcer on the Vermillion border of the lower one; vomiting of food, bile, coagulated blood, and pus; tension in the hy- pochondria as from a loop; great emaciation and internal debility. Mercurius. — Cancerous ulcers, with a severe shooting and lancinating pain, not relieved by either hot or cold applications; spreading ulcers, spongy, readily bleeding, and extremely painful; unequal elevations and depres- sions in the floor of the ulcer; swelling of the w^bole or only the tip of the nose, accompanied by pain and inflam- mation, followed by cancer; pus thin, ichorous, and acrid. Mezereum. — Scirrhus ventriculi with burning, corrod- ing pains; internal surface of the gastric mucous mem- brane feels raw, with sensation as if food remained for a 370 SKIN DISEASES. long time undigested in the stomach, causing pressure and blood vomiting; hypochondriasis. Murex. — Carcinoma uteri, with great depression of mind; pain in uterus as if wounded by a cutting instru- ment; lancinating, throbbing pains in uterus; acrid dis- charge, causing pudenda and thighs to swell and become raw, burning and itching; faintness and an "all-gone" feeling in epigastrium ; deep hypochondriasis. Natru7n carb. — Induration of neck of womb, os uteri out of shape; pressing in hypogastrium towards genital organs, as if everything would come out; headache in sun and from mental labor; great nervousness and anxiety. Nitric acid. — Pain and swelling of the submaxillary gland, with induration, ultimately becoming scirrhous; burning sensation in the stomach; mercurio-syphilitic taint; urine very offensive; aggravated after midnight; in uterine cancer sympathetic affection of the inguinal glands; violent cramp-like pains, as if the abdomen would burst, with constant eructations; violent pressing, as if everything would come out of the vulva, with pain from the back down the thighs. Nux vom. — Ulcers with pale red, elevated edges; a painful, small, scirrhous tumor on the forehead; vomit- ing of sonr-smelling mucus and dark clotted blood. Nupha?'. — Several cases of cancer have been reported as cured by the use of this drug. Its use is empirical, and comes to us from the Indians. Phosphorus. — Cutting pains through the abdomen, sometimes with vomiting, painful to the touch, and when walking; belching up of large quantities of wind after dinner; frequent and profuse hemorrhages, pouring out freely, and then ceasing for some hours or days. RODENT ULCER. 371 Phytolacca. — Scirrhus, especially mammae; cancer of lips and cancerous, ill conditioned ulcers of the face. Sepia. — Suspicious tubercle on lip of a cartilaginous appearance, sometimes bleeding and having a scirrhous appearance, with a broad base; epithelial cancer of lip, with burning pain and a pricking as from a splinter of wood; complexion yellow and earthy; cancer of rectum; indurations, ulcerations, and congestion of the os and cervix uteri; cutting pains in abdomen and a pressure on uterus downward, as if everything would fall out; sinking sensation at pit of stomach. Silicea. — Painful dryness of the nose; scirrhous indura- tion of the upper lip and face; continuous nausea and vomiting, especially when drinking; sensitiveness of the pit of the stomach; melancholy; in uterine cancer dis- charge of blood between the regular periods, with repeated paroxysms of ic}^ coldness over the whole body; fetid, brownish, purulent, ichorous leucorrhoea. Staph. — Scurfy and burning painful lips with pain in the submaxillary glands, with or without swelling. Syphilis and mercurialization. Thuja. — Sycosis; cauliflower excrescences; medullary and fungoid cancers. Zincum — Pewter-like hue of the face; scirrhous tumors in different parts of the body. Rodent Ulcer. Rodent ulcer has been called cancerous ulcer of the face, cancroid ulcer, ulcus exedens, noli 7ne tangere. A. patient has a small tubercle upon the face, covered by a smooth skin; he may call it a wart, and it may remain on the face unaltered for years, and then, when the patient gets old, it may begin to ulcerate. The ulcer spreads 372 SKIN DISEASES. slowly, but constantly, and if it be left alone it may destroy the whole of the cheek, the bones of the face, and ultimately the patient's life; but it may take some years to run this course. The disease is entirely local. It does not affect the lymphatic glands, nor do similar tumors appear on other parts of the body. The disease usually attacks some part near the eyelids; it is of slow progress; there is little pain. The disease has been described as commenc- ing as a *' pimple," " a blind boil," "a small hard pale tubercle," etc.; which tends to scab after a small central crack makes its appearance. There is, in fact, a small pimple followed by a minute ulcer. The disease extends gradually in all directions, but very slowly. When an ulcer forms, the edge is indurated and raised, but not un- dermined and everted; and there is no infiltration of the surrounding healthy structures. The surface of the ulcer is dry, clean, glossy, and does not give exit to any foul secretion; it is irregular in form, more or less oval, however. The disease differs clinically from the ordinary progress of cancer by its greater slowness, the little pain and hemorrhage, the absence both of any attempt at the for- mation of a fungoid growth, and of fetor. The glands, moreover, are never affected. The advances of the de- posit and ulceration are unequal, hence the eaten-out or rodent appearance. The ulceration advances in extent, and in depth. The growth is always in one mass, not in distinct centers. Rodent ulcer then occurs on the face, has an indurated edge, a tendency to spread without respect to kind of tissue, is of slow progress, painless, is not related to any cachexia, never causes enlargement of glands, and microscopically presents characters that betoken it as the RODENT ULCER. 3 73 least expressed form of the cancerous cachexia. It is most common between fifty and sixty, and it does not occur before thirty; generally it has its seat about the eyelids, and occurs in either sex equally, and it never at- tacks the lower lip. The treatment is simple and satisfactory. Experience teaches that extirpation by the knife is the most success- ful mode of treatment. One case is reported where the application of lactic acid resulted in the speedy cure of a rodent ulcer. The following homoeopathic remedies may be com- pared: Arsenicum, Belladon7ia, Cicuta, Hepar, Hydro- cotyle, Hydrastis, Mercurius, Nitric acid, Silicea, Sta- phisagria, Sulphur, Uranium. CHAPTER XV. CUTANEOUS HEMORRHAGES. General Remarks. Blood may be effused into the skin under a variety of circumstances. The occurrence may take place as an idiopathic condition spontaneously ; or secondarily in con- nection with other diseases of the skin. The blood-ves- sels may be ruptured, and so permit the escape of blood, or the blood globules may escape bodily through the actual vessel walls. The usual cause of rupture is trau- matic injury. The hemorrhagic spots receive different names according to their size and shape. When they are small, in the form of red points, they are Q^Vi^d. petechics ; when larger, and more or less linear, vibices; when large in the form of bruises, ecchymosis; and when the blood collects in the form of a distinct tumor, hcBmatomata. The seco7idary forms of cutaneous hemorrhage occur in connection with typhus, measles, scarlatina, and variola, the early eruptions of which may severally be more or less hemorrhagic, the hypersemia being accompanied by actual hemorrhage into the skin. The eruption of sev- eral of the ordinary inflammatory diseases of the skin also are sometimes complicated by a certain amount of effusion of blood. Other conditions under which cuta- neous hemorrhages arise are altered states of the blood current, such as impurifications by bile products, stasis of the capillaries produced in connection with kidney and heart disease, etc. PURPURA. 375 It is only to hemorrhage occurring as a primary and independent disease that the term purpura is applied, and this we will now describe. Purpura. Purpura is an affection of the skin characterized by the sudden appearance of reddish macules of varying size and on various parts of the body. In a short time they be- come purplish, the color not being removable by pressure. After they have existed a few days they undergo changes in color similar to those which follow a bruise. The eruption ma}^ appear in either sex, at any age, and in almost any condition of general health; in those who are greatly enfeebled as w^ell as in those in an ap- parentl}^ robust condition. The eruption may cover the greater part of the surface, but more frequently is confined to the lower extremities. A single purpuric outbreak may be the beginning and end of the trouble, or, as frequently happens, fresh crops may appear at regular or irregular intervals for a considerable period. The affection has been noticed in connection wnth suppressed menstruation, apparently taking the place of the natural flow. The foregoing features characterize purpura simplex, which, as a rule, is not a serious affection. Sometimes, however, the hemorrhages are not confined to the cutaneous tissues, but may take place internally as well, and serious loss of blood may result from the rupture of superficial capillaries in the various mucous membranes, and especially those of the gastro-intestinal tract. This form is termed purpura hemorrhagica. The etiology of purpura is absolutely unknown. It has no connection, however, with the congenital anomaly 376 SKIN DISEASES. known as hemophilia, nor with the acquired condition known as scorbutus, or scurvy. Diagnosis. — The name should be confined to the sim- ple affection we have described, and should not be used in connection with any other distinct disease that hap- pens to be complicated with minute hemorrhagic effu- sions. Scurvy should never be mistaken for purpura, or vice versa. In the former disease the limbs are swollen and tense, and the hemorrhages form diffuse patches rather than macules. The gums also are swollen, and ready to bleed at the slightest provocation. Purpuric blotches are likewise met with in speliosis rheumatica; but the pro- nounced arthritic symptoms serve as a mark of distinction. Petrone found single, small, ovoid micrococci in the blood of a young man who was suffering from purpura hemorrhagica rheumatica febriHs. Some of his blood was subcutaneously injected into a rabbit. After two days numerous hemorrhagic spots appeared in the skin of one ear. By this experiment Petrone thinks he has demonstrated the infectious nature of the disease. Treatment. — Piffard says that one drug stands pre- eminent and alone as an efficient agent in the treatment of purpura, and this is ergot. He advises the use hypo- dermically of ergotine, or drachm doses of the fluid ex- tract given internally two or three times a day. He also advises against the use of iron, quinine, and similar drugs of the tonic class. The diet should consist of the most nutritious articles. Malt preparations are useful foods. Outdoor exercise is very beneficial. Locally, hamamelis is one of the best remedies, and when there is much hemorrhage, ice treat- ment may be resorted to. PURPURA. 377 Simple purpura responds best to Ars. aid., and the hemorrhagic form to Sulph. acid. Other remedies may- be indicated as follows: Arnica. — Yellow, blue and reddish-blue spots; in ly- ing-in women. Baptisia. — Livid spots all over the body and limbs, of the size of a three-cent piece; great languor; desire to lie down; tired, bruised, sick feeling all over the body. Berberis. — Petechise on the right shoulder or left humerus, back of the head and wrist. Bruised pain with stiffness and lameness in small of back; renal or vesical complications. Chloral. — Its continued use internally has caused pur- pura hemorrhagica, preceded by a bright red blush, ery- thematous in aspect, but permanent under pressure, fol- lowed in two days by deep red spots, mixed with mottled livid patches. The buccal mucous membrane becomes red, raw, ulcerated, and blistered, breath fetid, pulse 120 and feeble. A desquamation ensued, but with bed-sores in some places. In other cases it caused petechise, vibices, and ecchymoses. Cocoa. — Dark spots like ecchymoses under the skin, about the size of a pin's head, on the fingers. Erigeron. — When apparently well-indicated remedies fail. Ha7namelis. — Hemorrhagic purpura; profuse epistaxis; passive, venous hemorrhages; great lassitude and weari- ness; in old people. Lachesis. — Simple purpura; blackish-blue spots; great physical and mental exhaustion; climacteric troubles. Mercurius. — Bluish-red spots, darker on the margin and lighter in the centre. Other symptoms of Merc. present. 25 378 SKIN DISEASES. Phosphorus. — Petechial spots on the skin; bluish-red spots on the legs; purple-like exanthem over the whole body. Rhus tox. — Simple purpura; dark brown spots on in- side of ankles; rheumatism of joints worse during rest; swollen ankles after sitting too long. Terebinth. — Hemorrhagic purpura; intestinal hemor- rhages; hematuria. Verat. vir. — Simple purpura; galvanic- like shocks in the limbs; rapid pulse; slow respiration; in plethoric in- dividuals. CHAPTER XVI. Pruritus. Pruritus is characterized by the occurrence of itching; in fact, pruritus is itching. It may co-exist with, or be entirely unaccornpanied by, organic change in the skin; and a knowledge of the conditions under which it occurs is essential. Pruritus occurs in the course of most inflammations of the skin; in connection with rheumatic manifestations; the circulation of morbid elements, as bile, urinary ex- creta; elevations of temperature, senile decay of the skin, gastro-intestinal disturbance, nervous diseases, Bright's disease, genito-urinary and uterine derangements, seden- tary habits, and stimulating diet; it is also occasioned by local causes; about the rectum by ascarides and piles, and over the body in various parts by parasites (animal or vegetable). When pruritus is spoken of in the abstract, itching, as constituting the primar}^ and sole disease pres- ent, is signified, and the nervous character of the itching is frequently shown by its sudden appearance, its almost as sudden disappearance, and often its marked tendency to periodicity. Pruritus may be general or local, and it is very gener- ally followed by secondary changes in the skin. When general it is due to the causes of more general operation, mentioned above. When pruritus occurs, of course in most cases the -patient scratches more or less violently for the relief of 380 SKIN DISEASES. the itching, and this induces certain special diseased con- ditions. In fact, the phenomena of a scratched skin are produced, or what is termed a '' pruriginous eruption.''' In certain cases pruritus exists in the first place as ap- parently the sole disease, and in which scratching is practiced, and eruptions follow. These conditions we will now discuss. Pruritus Senilis. — In old people whose skin begins to exhibit atrophous changes the sensibility of the skin is much disordered and more or less associated pruritus occurs. The practitioner is consulted for this pruritus, and at first there is nothing else to be observed in the skin but laxity and thinness of the integuments, with perhaps plugging up of a certain number of the follicles by the exuviae shed from the sebaceous glands. The pruritus is the evil from which the patient desires to be rid. It is increased by heat, cold, the warmth of the bed, by digestion, and other things. These cases may be re- lieved by the use of alkaline baths, free oiling of the sur- face, or some local anodyne application. Besnier advises in these cases that the patient bathe in a solution contain- ing to each litre a solution of carbolic acid lo.oo to 500 grammes of acet. aromat. This should be followed by dusting the affected parts with amylum, 90; bismuth salicyl., 20.0. After awhile the scratching practiced to relieve the ir- ritation induces the development of distinct eruptive phenomena. A certain amount of hypersemia occurs, and this is followed by the formation of lymph papules, which, being scratched, become pruriginous — that is to say, the apices are torn, a little blood oozes out and dries on these apices as a dark speck. These changes are followed by more or less infiltration of certain parts, by the inter- mingling of excoriations made by the nails with the pru- PRURITUS. 381 riginous rash, and in some instances by ecthymatous pus- tules or urticaria. The pruritus is often intense, and takes the form of a stinging, creeping, or burning sensa- tion. The pruritus is the primar}^ as it is occasionally the sole condition. The disease may be, of course, more or less general, or more marked in one place than an- other. The cure of pruritus senilis is, too, effected by emollient and vapour baths, and anodjmes, locall}^ applied. The following formulae are often of benefit: 1^. Sodii Hyposulphit, dr. j. Acid Carbol., dr. ss. Glycerini, oz. j. Lislerine, oz. iij. M. Sig. : Use as a lotion. Or, Or, Or, Or, 1^. Ammon. sulpho-ichthyolat, 5jj- Aquae rosge, Glycerini, aa 3ss. M. Sig.: Use as a lotion. fl. Opium, gr. viij. Creasote, gtt. x. I^ard, 5Jj. M. Sig.: Use locally. 9^. Tincture of myrrh, gtt. xxx. Oxide of zinc, gr. xx. Cold cream, 5J. M. Sig.: Use locally. 9^. Carbonate of soda, 3ss. Conium juice, ^j. Elder flower water, §j. M. Sig. : Use locally. 382 SKIN DISEASES. The above formulae, and many others, may be used in any of the forms of pruritus. Under the varieties men- tioned below, some other means of affording relief will be noticed. Pruritus Ani. — Itching about the anus arises from a variety of causes. It is a common consequence of piles, as carides, tinea circinata, the friction of the parts in stout people (intertrigo), gout, and uterine disorder. It occurs from the latter by reflex action. It is often very troublesome. The result of scratching is to give rise to the development of papulae, and, it maj^ be, considerable inflammatory thickening. The practitioner must of course discover any local cause for the disease, and take care to negative its opera- tion. The same local applications recommended for the preceding will be useful. In addition I would advise the following: 9^. Oil of bitter almonds, ^ij. Cyanide of potassium, gr. x. Galen's cerate, ^ij. M. Sig. : Apply locally. This must be used with great caution. Pruritus PrcEputii. — Is merely itching about the glans, connected with an abnormal secretion from the follicles of that part. The remedy is free washing with soap and water and the application of an oxide of zinc powder or lotion, as follows: ^. Oxide of zinc, 5ij- Glycerine, 5ij- Lead-water, 3iss. lyime-water, §vj to viij. M. Sig.: Apply locally. Pruritus Piideyidi, or itching about the genital parts, is common in women, and arises from a variety of causes PRURITUS. 383 — eczema, intertrigo, the presence of vegetable fungi, ovarian and uterine irritation, hemorrhoids, and varicosity of veins of the genital parts. In those cases in which there appears no structural change relief is to be obtained by the locally applied anodynes, care being taken to treat any uterine or ovarian disease appropriately. For the relief of the itching the following means may be .used: The cure of the complaint in any of its above forms can only be accomplished by the administration of the properly indicated homoeopathic remedy, hints of which will be found at the close of this article. In many cases, relief will be demanded for the excessive itching, and in such cases it is admissible to make use of one or more of the following: 1^. Hyposulphite of soda, 5j. Glycerine, ^j. Water, giij. M. Sig. : Use locally. Peppermint water is one of our best local applications in the above-mentioned forms of pruritus. Patients can easily make their own lotion, as required for use, by putting a teaspoonful of borax into a pint bottle of hot water, and adding to it five drops of oleum menthae peperitse, and shaking well; the parts affected to be freely bathed with a soft sponge. If cracks, or sores, or eczema, or rawness be present this lotion will be too severe. Olive oil, with five grains of iodoform to the ounce, is better. A sitz bath of cold water is often beneficial. Galvanism, as a remed}^ in pruritus vulvae et ani, is a valuable adjuvant. A current from six elements with the anode applied to the vulva and the cathode to the af- fected portions of the integument. The sittings should last about ten minutes. 384 SKIN DISEASES. Therapeutic Hints: Itching as if from ants: I^ach., Phos., Puis., Secale. Bitings: Berb., Bry., Chin., Colch., I^ach., Led., Magn. acet., Merc, Nux vom., Oleand., Puis. Burning: Agar., Arg. n., Ars., Bry., Calad., Caps.» Cic, Kupliorb., Hep,, Ign., Merc, Nux vom., Ran., Rhus, Sabad., Spig., Staph., Sulph., Verat., VioL od. As if from congelation: Agar. Corrosive itching: Rhus ven. Crawling: Arg. n., Ars., Dulc, Magn. c, Sil., Spig., Staph. Creeping: Sil. Dull: Hepar. As if electric sparks: Phell. As if from fleas: Arg. n., Lyco. , Magn. acet., Merc, Mezer., Oleand., Puis., Sil., Spong., Staph., Tabac, Teucr., Thuja, Zinc Gnawing: Agn., Ars., Cocc, Dig., Euphorb., Magn. aust., Oleand., Plat., Puis., Rhod., Ruta. Intolerable: Merc, Sil. Itch-like: Amb., Merc, Verat. Jerking: Staph. Itching as of lice: Arg. n., Canth., Magn. m., Plat., Zinc As from mosquito-bites: Rhus ven. As of nettles: Colch., Lupul. Painful: Alum., Ammon., Baryt., Cham., Cocc, Lupul., Nitr. Pinching: Mosch. Pleasant: Merc. Prickling: Cin., Plat., Zinc. Stinging: Agn., Arg., Arn., Asaf., Bry., Con., Cycl., Dros., Graph., Ign., Led., Magn. acet., Merc, PRURITUS. 385 Oleand., Puis.. Ran. sc, Rhus, Ruta, Sabina, Spig., Spoiig., Squill., Stan., Staph., Thuja, Ver., Viol. tr. Tearing: Bell., Bry. Tickling: Agar., Calc. c, Euphorb., Merc, Plat., Puis., Ruta. Titillating: Bell., Chel., Chin., Plat., Puis., Rhod., Sabad., Squilla. Violent: Agar., Dros., Ipec, Lach. Voluptuous: Anac, Merc, Sulph. Wandering: Cham., Graph., Kali c, Magn. m., Mez., Rhus v.. Staph., Zinc Of wounds: Chin., Tart. emet. Location. Anus: Alum., Ambra, Amm. c, Anac, Calc. c> Carbo veg., Caust., Kali c, Lyco., Nux vom., Phos., Sabad., Sep., Sil., Spig., Sulph. nates, between the: Alum,, Con., Seneg. perinaeum: Agn., Alum., Ars., Carbo veg., Ign., Mur. ac, Nux vom., Plumb., Tarax. Sexual parts: Ambra, Amm. c, Berb., Calc c, Cann., Canth., Carbo veg., Caust., Cocc, Coff., Raph., Con., Hep., Ign., Kali c, Kreas., lyyco., Magn. acet., Magn. m., Merc, Natr. m., Nitr. ac, Nux vom., Petr. , Puis., Rhus, Sep., Sil., Sulph., Thuja. fraenulum: Cann., Caust., Hep., Merc. glans: Merc, Natr. c, Natr. m., Nitr. ac, Nux vom., Sep., Thuja. testicles: Merc. scrotum: Berb., Carbo veg., Caust., Cocc, Graph., Lyco., Nitr. ac, Nux vom., Petr. clitoris: Sulph. penis: Nitr. ac. 386 SKIN DISEASES. mons veneris: Kali c. labia: Amm. c, Calc. c, Carbo veg., Con., Graph., Kalic, Merc, Natr. m., Nitr. ac, Sil., Staph., Sulph. vagina: Canth., Con., Kreas., Sulph. prepuce: Cann., Carbo veg., Lyco., Magn. acet., Nitr. ac, Nux vom., Puis. CHAPTER XVII. Chromatogenous Diseases, or Alteration In the Pigmentation of the Skin. Pigmentary discolorations may be divided into three main groups — (i) primary and idiopathic, (2) secondary or symptomatic, and (3) congenital. The primary or idiopathic pigmentations result from the application of irritants, which set up hyperaemia in some cases and in others not — as after the action of heat — or friction, or irritants, such as mustard plasters, or the pressure on a part, as by dresses, mechanical restraints, the friction of straps, and the following of certain handi- crafts by which certain parts of the body are exposed to the sun or specially rubbed, as in masons. Scratching also will be followed in some cases by discoloration — this is seen in phtheiriasis particularly. Secondary or symptomatic staiiiings are those which follow in the wake of other diseases, or are due to dis- turbance of organs at a distance from the seat of discolor- ation that do not, in other words, constitute the essential disease, but are secondary to, or form only a part of, the essential diseases present in any given case. There are three groups of secondary pigmentations: i. Those which follow in the wake of and occur in the same seat as cer- tain skin eruptions; 2. Pigmentations occurring in con- nection with certain cachexias, the latter being associated with definite organic diseases of important internal or- gans; 3. Physiological pigmentations connected with uterine functional changes. 388 SKIN DISEASES. As regards congenital pigmentations^ I need only say these are seen in moles and pigmentary nsevi. Those cases in which the pigmentation of the skin is at fault as the sole existing disease may be divided into two classes — those in which the pigment is deficient in quantity (Leucoderma, or Vitiligo), and those in which it is in excess (Melanoderma). These may be congenital or acquired, general or local. The seat of change is the rete mucosum. Vitiligo. Vitiligo, or leucoderma, is an affection characterized by circumscribed patches of skin, from which the pigment has disappeared to a greater or less extent. At the be- ginning the patches will be quite limited in extent, and affect by preference the face, neck, hands, and genitals. As a rule, however, triey increase for a certain length of time, and neighboring patches coalesce. The borders of the spots are usually somewhat hyperpigmented, as if the pigment which had been removed from the centre had been simply deposited at the edges. This feature, how- ever, is not always met with. The course of vitiligo varies. With some individuals it reaches a certain degree of development, and then re- mains stationary for years; in others, it progresses in- definitely, and this so particularly when it affects the negro. In perhaps the majority of cases there is a return of the natural pigment after the lapse of a few years, while in others the affection appears, lasts a few months and disappears, only to be followed by one or several re- currences. It may be absent during the hot months, and return during the cold ones. The causes of vitiligo are unknown. It occurs in both Vitiligo, MELANODERMA. 389 sexes with apparently the same frequenc}^ and usually without being preceded by any acute disease, or general failure of health. In fact, the majority of patients will complain of nothing except the uusightliness of the af- fection, which may pursue its course uncomplicated by trouble that can be attributed to it. There is no reason for believing that it ever shortens life. When we con- sider the permanency and progressive nature of some cases, we are utterly at a loss to account for this curious affection. Treatment. — The old school acknowledge their in- capacity to do anything in this affection. Our school is but little better off. Locally, the pigmentation around the patch may be lessened by the use of strong acetic acid. Galvanism ma}^ prove serviceable. Internall}* the Sulphide of Arseni- cum will be oftenest used with benefit. Natrum c., Nitr. ac., Su7?tbul din6. the Phosphide of Zi?ic may be studied. Melanoderma. This term of course means excess of pigment resulting in dark discoloration s, but the altered tint of skin may be blue, yellowish, or black; hence the terms cyanoderma, xanthoderma, and melasma. Melasma^ or that condition in which the discoloration of skin is black in color, is general or partial. The latter is generally called melasma. It may be a physi- ological condition, as seen in the staining around the nipple andthelinea alba in pregnancy; this condition may be excessive. The varieties of melasma are lentigo and ephelis. Lentigo is known as freckles. The seat of the pig- ment deposit is the rete mucosum; it is often congenital, ^ and of varying extent and distribution; generally, how- 390 SKIN DISEASES. ever, it consists of round yellowish spots, the size of split peas and less, not only on the parts exposed to the light, but also those covered by the dress. Lentigo oc- curs in those with fair skins, and particularly red-haired folk. There is no desquamation, no itching, and no heat of any kind in connection with freckles, which often disappear after puberty. Freckles do not depend upon seasonal change. Lentigo may sometimes be made to disappear by an application of citric acid night and morning. One writer reports the application of emulsion of almonds, night and morning, to be the most satisfactory treatment, and advises its continuance until a slight amount of des- quamation takes place. Another writer recommends the application of oleate of copper for the removal of freckles. Care should be exercised that a pure sample of the drug is obtained. ^. Cupric. Oleat., ^j. Petrolei, ^xvj. M. Sig. : Appl> twice a day. The internal remedies are: Ferrum mag. — Spots resembling summer freckles on back of hands and fingers. Kali carb. — Freckles on the face. Lycopod. — Freckles on the left side of the face and across the nose. Nitric acid. — Freckles on the chest; dark freckles. Petroleum. — Freckles on the arms. Phosphorus. — Freckles on the lower limbs. Sepia. — Freckles on the cheeks. Sulphur. — Freckles on the nose. EPHELIS, OR SUNBURN. 391 Ephelis, or Sunburn. In this particular variet}^ of discoloration the pigment deposit is excited b}^ the sun's raj^s. Sunburn consists of little dots the size of pins' heads, which appear upon the parts of the body exposed to the influence of the sun, and are seen mostly in lymphatic subjects with delicate skins. Temporary benefit accrues from the use of local applications strong enough to cause exfoliation of the corneal cells. A one per cent, solution of mercuric bichloride and a ten per cent, solution of calcium chlo- ride are the lotions most commonly used. Ver. alb. , Robinia and Kali carb. are useful internal remedies. Bufo is indicated when the face tans quickly. Melasmic discoloration likewise occurs as the result of the action of local irritants — excessive scratching, strong lights, blisters Pigmentary Ncsvi. — These consist of collections of pig- ment in the rete and corium, and a certain amount of hypertrophy of the papilla at times. They may be fur- nished with hairs. Moles are of this nature. Xanthoderma. — In this disease the pigmentary dis- coloration is yellowish. It is characteristic of certain races, and is due to some special condition of the color- ing matter of the skin, molecular or chemical. Cyanoderma, or blue discoloration, is different from colored sweat. It is a curiosity, if not, at least in the greater number of instances, a hoax. CHAPTER XVIII. PARASITIC DISEASES. The parasites are of two kinds, animal and vegetable. The principal animal parasites are the Acarus scabiei, or itch mite; the Pedicuhis, or louse; the Cimex lectu- lariuSy or bedbug; the Ptilex irritans, or flea; and the Pulex penetrans, or chigoe. The bite of the Cimex lectularius causes a hypersemic papule with a small red spot in the centre. That of the flea produces a little circular erythematous spot, which exhibits a dark speck in the centre, that marks the wound made by the insect. The chigoe attacks the feet and hands, entering the skin beneath the nails or betwixt the toes, or upon some portion of the extremities, either by a channel made for itself, or by the ducts of the skin; its tracks can sometimes be traced as an elongated brown spot. The application of a lotion of glycerine and water, of each 5jj, and tincture of calendula 5j will be found very useful in allaying the irritation in the case of the first two. The treatment of chigoe disease consists in dilating the original channel of entrance, and carefully removing the chigoe bodily; after which apply an ointment composed of lard and salt. Certain caterpillars, if they get upon the skin, may ex- cite urticaria also. Children of lymphatic temperament who are not kept clean, are poorly nourished, or insufficiently clothed, and PHTHEIRIASIS. 393 live in rooms badly ventilated, are particularly liable to vegetable parasitic diseases; and unless measures are adopted to remove the exciting causes and predisposing conditions treatment is unsatisfactory and relapses are frequent. The patients should be isolated whenever practicable. The varieties are: Tinea favosa, or favus; tinea ton- surans; tinea circinata; tinea versicolor; and onychia parasitica, Phtheiriasis. Phtheiriasis is the name applied to the affections pro- duced by the invasion of the there well known varieties of pediculus — namely, the head-louse, body-louse, and pubic or crab louse. The nature and appearance of these insects are so well known that we need not describe them. The first of these infest the scalp; the second confines itself to the non-hairy portions of the surface; and the third prefer the pubic region, but may be met with wherever the hairs are short, but avoiding the scalp. Phtheiriasis Capitis. This affection occurs most frequently in children, more rarely in women, and almost never in men. The insect {pediculus capitis) finds its most congenial abiding-place in the hair of children, where it lays its eggs, and at- taches them by a kind of cement to the shafts of the hair. The eggs take but a few days to hatch, and in a short time the parts may become pretty thickly settled. They derive their nourishment from the skin, and by their presence produce considerable itching and lead to a corresponding amount of scratching. In children predis- 26 394 SKIN DISEASES. posed to eczema they not infrequently lead to the devel- opment of this affection. The diagnosis is, of course, readily made, as inspec- tion of the scalp will quickly reveal the presence of the insects and their ova, if at all abundant. In doubtful cases the fine- tooth comb will soon settle the question. The treatment, of course, involves the removal of the insects and their ova, usually called " nits." In children, clipping the hair as close as possible, or perhaps shaving it, is, of course, the quickest way of relieving the patient of these pests. When this is not practicable, the scalp should be thoroughly washed with tincture of staphisa- gria, or with ordinary kerosene oil. A few applications will kill the living insects, but do not appear to destroy the vitality of the ova. These should be removed as far as possible with the fine-tooth comb. Many, however, will still remain, and the best way to get rid of them will be to go over the scalp carefully and clip the shafts of all the hairs to which they are attached. The head should be washed for a week or ten days, for fear some of the eggs may have escaped detection. It is almost needless to say that soap and water, freely used, are essential ad- juvants to the means just mentioned. The following is a very excellent application: 9? 01. Staphisagrise, ^j. 01. Ivimonis, dr. j. 01. Amygdalse, ^iv. M. Sig. : Apply to the aflfected parts daily. Phtheiriasis Corporis. This affection is very rarely met with in young persons, and is found most frequently in middle and advanced life, and especially in the feeble and ill-fed, and among PHTHEIRIASIS PUBIS. 395 the frequenters of prisons and cheap lodgings. Though sometimes met with in women, nine- tenths of the cases are among men. Th.Q pediadus coj'pojHs diOQS not lodge upon the body, but infests and breeds among the folds of the under-gar- ments, from which hiding places it sallies forth to seek its nourishment from the skin. This it pierces with the sucker, and continues to feed until gorged with blood. These insects excite at times a liveh^ and most annojnng itching, and lead to vigorous scratching. In cases that have lasted for any length of time, the skin gradually <3arkens, even to the color of a mulatto. Diagnosis. — After a little experience a case of phthei- riasis will, in most cases, be recognized at a glance, and should alwaj^s be proved by a careful search for the in- sects. Strip the patient, if possible, and then examine not his skin, but his shirt, and, as a rule, you will find the pediculi, if present, without dijB&culty. Treatment. — Soap, water, and clean clothes are all that are necessary. The old clothes should be destroyed, or thoroughly disinfected by boiling or baking. Phtheiriasis Pubis. ThQ pediculus pubis affects a preference for the pubic region of both sexes, but is not confined to this locality; but in women may also be met with in the axillary region and in the eyebrows, and in men among the chest hairs and in the baard and whiskers. It rarely gives rise to as much irritation as the other varieties of pediculus, and its presence is often discovered accidentally. The insect attaches its eggs to the hairs like the pediculus capitis, and adheres to them itself or to the skin in the most tenacious manner by the aid of its crab-like claws. 396 SKIN DISEASES. The diagnosis is to be made by the discovery of the insect, but, having been found in its favorite seat, thor- ough examination of all other parts of the body liable to be infested should not be omitted. The treatment of this affection involves the employ- ment of some anti-parasitic application, and the one most in vogue is the common ** blue ointment." When, hov^^-^ ever, the patient will consent to it, shaving of the affected • parts is to be preferred. The affection is most frequently contracted during sexual intercourse, but may be de- rived from wearing infected clothing, or sleeping in an infected bed. The patient's under-clothes and bed-clothes should be boiled or baked, in order to destroy the insects and their eggs. Psorospermosis. Psorospermosis may be defined as a condition of the skin of varied lesion, but characterized by the presence of " psorosperms." The psorosperm is a living animal parasite, which infests the human skin as well as the bodies of some of the lower animals, and consists of a roundish or oval cell, containing one or more neuclei; the nucleus occupying but a small portion of the cell, the plasmic portion of which is extremely transparent and structureless. Much doubt exists among dermatologists as to the nature of this affection; and but little is known positively concerning it. Scabies. Scabies is a contagious affection of the skin character- . ized by the development of vesicles, pustules, and other t lesions on the skin, and caused by the presence of an animal parasite, known as the Acarus scabiei. Scabies. SCABIES. 397 The affection usually commences by the appearance of small, non-umbilicated vesicles on the hands and between the fingers, accompanied with severe itching. The itch- ing leads to scratching, and as a consequence transfer of the affection to other parts of the body with which the Tiands are brought in contact. Very earl 3^ in the disease, then, we will find it appearing on the penis, on the breasts in women, and on the feet in children. From these parts it may spread over the greater part of the surface, more profoundly on the anterior than posterior parts and avoid- ing the face and scalp. The vesicles above mentioned may be termed the primary lesions of the disease, but are usually followed in a few days by others secondary to the irritation pro- duced by the insect, and to the effects of the finger nails. These new lesions may be papular or pus.tular in character, and may even assume distinctly eczematous characters, or develop into a true eczema in those predis- posed to this affection. On the penis the lesions are usually papular. None of these features are absolutely pathognomonic. There is, however, a lesion which is met with in no other disease, and which when found renders the diagnosis absolute. This is a fine, grayish line fre- quently terminating in a vesicle, and found between the fingers more frequently than elsewhere. It is called the 4icarian burrow. When an impregnated female acarus finds lodgment on the skin, she immediately seeks a place in which to deposit her eggs. This she accom- plishes by boring beneath the epidermis and laying an €gg» and then advancing in a straight or slightly curved line for several days until ovulation is complete. She then dies, and her decomposing remains give rise to a vesicle or pustule. When the eggs hatch, the young find their way to the surface, and as soon as they assume the 398 SKIN DISEASES. adult form copulate, and the impregnated females com- mence to burrow as did their mother before them, A sharp needle-point, if guided by a sharper eye, will sometimes extract the acarus from her nest. The male acarus never burrows, and is very rarely detected. Etiology. — Scabies is one of the few diseases of which we can say that we absolutely know the cause; and yet there is no chapter in medical history more interesting than that which concerns the etiology of this affection. The acarus is exceedingly minute, and when first hatched has but six legs. It soon assumes its adult form,, however, with eight legs; and the sexes are easil}^ distin- guished by the fact that in the female the four posterior legs are furnished with projecting hairs, while in the male two of these legs terminate in suckers instead of hairs. Diagnosis. — The diagnosis of scabies should not in most cases be difiicult. The early vesicles on the hands are either to be found, or the patient may tell you that the affection commenced with small ''watery pimples." Next, examine the penis, and you will rarely miss find- ing papules on the glans or papules or vesicles on the cutaneous surface. Rather good-sized isolated pustules about the wrists are commonly present, and in women you usually find an eczematous eruption around the nipple. If on inquiry you find that one or the other of the patient's associates is suffering from a similar trouble, and that he has slept with him or worn his clothes, you may be fully confident of the diagnosis. The mere presence or the intensity of the itching can not be relied on to establish the nature of the disease, as in several other affections intense pruritus is a marked feature; and this is notably the case in phtheiriasis, pro- duced by the pediculus corporis, or body louse. The J. SCABIES. 399 papules or other lesions on the penis should not be mis- taken for lesions of venereal origin. To briefly sum up, then, the diagnostic points are: 1. A history of contagion. 2. The development of minute papulo- vesicles or ves- icles, spreading on contiguous portions of the skin or on parts habitually handled by the patient (never in patches but in rather a scattered manner). 3. Itching, worse at night and becoming progressively worse as larger areas become invaded by the itch-mite. 4. Sites of predilection shown by the disease. They are the webs of the fingers, the front of the wrists, the anterior edges of the axillae, the mamma, the penis, the abdomen and groins, the toes and feet. Flexor surfaces are more involved than extensor. 5. That the face remains free from the disease, except in the case of infants at the breast. 6. That it has taken about three weeks for the disease to involve the whole surface. 7. That old cases show all the lesions that can possibly be produced by disease of the skin, expressed by the term multiformity of lesions. 8. Incidentally — numerous scratch-marks. 9. The itch-mite and its canaliculi. Treatment — However distressing the present symp- toms, the patient may be confidently assured of speedy relief. This may be most promptly brought about by adopting the following somewhat vigorous treatment: Put the patient into a warm bath and let him soak for fifteen or twenty minutes. Then let him be rubbed thor- oughly all over with soft soap, assisted with a flesh- brush. Every part of the body from the neck down should receive a thorough application of the soft-soap and water and brush, in order to break over the burrows 400 SKIN DISEASES. of the insects. The soap is then washed off and the sur- face rubbed dry. Then rub the entire surface with alka- line sulphur ointment to each ounce of which a drachm of iodide of potassium has been added. After a thorough inunction the patient should go to bed and stay there until the following morning. When morning comes a warm bath should be given to remove the oint- ment, and the patient should put on new under-clothes. The under-clothes and bedding that have been in use should be thoroughly disinfected by boiling or baking, in order to destroy any wandering acari. This treatment is effective but harsh, and for a day or two the patient's skin will be far from comfortable, and the eczematous and other secondary lesions will be greatly aggravated. Emollient treatment, therefore, will in almost every in- stance be needed for a few days longer, and the use of the oxide of zinc ointment is as good as any. One of the following B's is, I think, far preferable, and less annoying to the patient: ^ Beta naphtholi, Balsam Peru, da gm. x Sapon. kalini viridis, Cretse albae pulveris, da gm. xx Vasogen. Sulph (3 per cent.) spiss. gm. x L. M. f. unguentum. Twenty-four hours' covering of the affected parts is sufficient in most cases Or, P^ Sapon. med., 100. 01. petrae., Alcotiol, dd 50. Cerae alb., 40. M, Sig. : Soap the whole body with this three or four times daily and the itch-mite will be destroyed. SCABIES. 401 Another, which has proved very efficacious in destroy- ing the acarus scabiei, is: ^ Naphthol, 15. Lard, 100. Green soap, 50. Prepared chalk, 10. M. ft. Unguent. For obstinate cases the following is excellent: ^ Pelroleum, 50 parts. White wax, 40 parts. Alcohol, 50 parts. Soap, 100 parts. M. Sig. : Apply locally. Remedies indicated: Arsen. alb. — Inveterate cases; eruption in the bends of the knees; pustular eruption, burning and itching; better from external warmth. Carbo veg. — Eruption dry and fine, almost over the whole body, worst on extremities; itching worse after un- dressing; dyspeptic symptoms, belching of wind and passing flatus; after abuse of mercurial salves. Caiisticum. — After abuse of sulphur or mercury; yel- lowish color of face; warts on the face; involuntary urina- tion when coughing, sneezing, or walking; sensitive to cold air. Croton tig. — Itching and painful burning, with redness of skin; formation of vesicles and pustules; desiccation, desquamation, and falling off of the pustules. Hepar. — Fat, pustular, and crusty itch; also after pre- vious use of mercury. Lobelia. — Pricking itching of the skin all over the body. Lycopodium. — Humid suppurating eruption, full of deep fissures; itching violently, when becoming warm through the day. 402 SKIN DISEASES. Mercurius. — Fat itch, especially in the bends of the elbows, if some of the vesicles become pustular; itching all over, worse at night when warm in bed; sleepless at night from the itching; diarrhoea. Psorinum. — Inveterate cases, with symptoms of tuber- culosis; also, in recent cases, with eruptions in the bend of the elbows and around the wrists; repeated outbreak of single pustules after the main eruption seems all gone. Sepia. — After previous abuse of sulphur; itching worse evenings, especially in females. Sulphur, — Mai7i remedy; voluptuous tingling, itching with burning and soreness after scratching; worse in warm bed; disposition to excoriation; glandi&lar swellings. Sulph. ac. — When itchiness of skin and single pustules appear every spring; after imperfectly cured itch. VEGETABLE PARASITIC DISEASES. Favus. Favus is a parasitic disease of the skin caused by a minute vegetable fungus. This disease may affect any portion of the body where there are hairs; but it pre^fers the scalp, especially the scalps of children. The fungus on which the disease de- pends is called Ackorioji Schonlemii, and falling on a con- genial soil, gains access to the hair follicles, where it spreads and multiplies. In a short time it is perceived on the surface as a whitish speck, and later forms a very light-yellow umbilicated crust, the centre of which is per- forated by a hair. A number of contiguous cups may coalesce, forming a crusty patch. The fungus, by its development and increase, presses on the follicular con- tents, and interferes with the nutrition of the hairs, and FAYUS. 403 in time insures their destruction and permanent disap- pearance. Favus of the scalp usually makes its first ap- pearance in childhood. Spontaneous cure rarel}', if ever, occurs; and the affection lasts indefinitely — that is, as long as there is a hair follicle left for the achorion to lodge in. In this way the affection may be prolonged for twenty years or more. The most striking features of a long-standing case are the sparseness of the hairs over the affected area, the appearance presented being entirely different from that of any of the commoner forms of alopecia. The peculiar crusts may be present to aid the diagnosis, but not infrequently they are entirely absent from the surface, -as various ointments, or even plenty of soap and water, are sufficient to prevent their develop- ment on the surface to an extent to prevent them to be visible to the naked eye. The progress of the affection is extremely slow, and, when not checked by efficient treatment, may last for twent}^ years or more. Favus on the body — that is, on the trunk or extemities — first exhibits its presence by a small erythematous, patch like a commencing ringworm; this spreads until it has a diameter of an inch or more, when the character- istic crusts appear. Etiology. — The disease is due to a vegetable parasite, and is communicable from one to another. This disease is not infrequent in the common domestic mouse, from which animal it is sometimes conve3^ed to the household cat, who in turn transmits it to the children of the family. Diagnosis. — In most cases the diagnosis is easy. If the affection is in full efflorescence, it can hardly be mis- taken for anything else, as there is no other disease that presents the characteristic umbilicated, light yellow, and 404 SKIN DISEASES. dry crusts. lu an advanced case the peculiar alopecia, marked by the presence of a few, scattered, lusterless hairs, distinguishes it from every other form of baldness. In doubtful cases the microscope will reveal the parasite, which consists of minute spores and mycelium. Treatment. — The treatment of favus of the general surface is exceedingly simple. All that is necessary is to pick off the crusts and make a few applications of tincture of iodine, or other efficient parasiticide, to the affected patches. When, however, the affection is located on the scalp, it is very difficult to cure. The primary indication is to destroy the parasite. As this fungus flourishes in the lowest depths of the hair follicles, ordinary applications made to the surface are not sufficient. It is necessary to attack the parasite in its stronghold, and this can only be done by first extracting the hairs. These should be re- moved by properly constructed epilation forceps. After epilation a solution of corrosive sublimate, two grains to the ounce, should be rubbed in. This should be repeated daily until a considerable degree of irritation is produced. The artificial irritation should be sufficient to produce ex- foliation of the epithelial lining of the follicle. If the affected surface is at all extensive, it is hardly practicable to epilate and mercurialize the whole of it at a single sitting; it should be done in sections. This treatment should be continued with as much regularity and thor- oughness as circumstances will permit. In a few weeks the disease will appear to be cured; but in general this appearance is delusive, and treatment should not be re- laxed simply because the disease is no longer visible on the surface. In all cases the patients should be kept under observation for several months after active treat- ment has been suspended. FAVTTS. 405 Of internal remedies the following may be mentioned: Agaricus. — Favus with biting itching in the scalp; crusts sometimes spread to other parts of the body ; sen- sation as if ice-cold needles were piercing the skin. Arsenicum alb. — The scalp is found perfectly dry and rough, covered with dry scales and scabs, extending sometimes even over the forehead, face, and ears. Arsenicum iod. — Scalp dry and rough, and covered with dry scales and scabs; extend to forehead, face and ears; intense itching and burning. Bromine, — Malignant scald head, oozing profusely; discharge dirty looking, offensive smelling; when the skin is dry, extreme tenderness of the scalp; crawling beneath the skin of the occiput. Calcarea carb. — Scabs are thick, and cover a quantity of thick pus; the scabs are large, even one-half of the entire scalp being covered with a single scab; eruption spreading to the face; burning and itching; glandular swellings on the neck. Clematis. — Eruption on occiput, extending down the neck, moist, sore, with crawling and stinging itching; often drying up in scales; itching worse when getting warm in bed, and but temporary relief by scratching. Cornus circinata. — Dry or moist eruption; scrofulosis, with dry spasmodic cough, or tedious chronic cough, with mucous expectoration. Dulcamara. — In scrofulous children when the crusts are thick and the hair falls out; bleeding after scratching; glandular swellings in the neighborhood of the eruption. Graphites. — Exudation of clear, glutinous fluid form- ing moist scabs; secretion from scratching; falling out of hair; skin dry and inclined to crack; tendency to ulcera- tion. 406 SKIN DISEASES. Jacea. — Thick incrustations, pouring out a large quan- tity of thick yellow fluid, which agglutinates the hair. Kali carb. — Exudation of moisture after scratching; sensitiveness to cold; frequent urination, especially at night; dryness and falling out of the hair, in old over- treated cases. Lappa major. — Scalp covered with a grayish- white crust, and most of the hair disappeared; eruption spread- ing overhead, face, and neck; moist foul-smelling eruption on the head of children; swelling and suppuration of the axillary glands; boils all over the body. Lycopodium. — Eruption beginning on the back of the head; when there are several spots, and when the crusts are fetid, thick and bleed easily. Hunger, but a small quantity of food fills him up. Mezereiim. — Head covered with a thick leathery crust, under which pus collects and mats the hair; dry eruption on the head, with intolerable itching, as if the head were in an ant's nest. White, scaly, peeling off eruption on the scalp, extending over forehead and temples. Oleander. — Biting itching on the scalp, as if from ver- min; worse back part of head and behind ears; better when first scratching it, followed by burning and soreness; worse evenings when undressing; humid, scaly, biting, itching eruption, especially on the back part of head. Phosphoriis. — May be used when the follicles appear to have been destroyed, and the scalp left smooth and shining. Psorinum. — Moist, suppurating, fetid eruption, or dry eruption; hair dry, lusterless, tangles easily; averse to having head uncovered; wears a fur cap even in hottest weather. Staphisagria. — Yellow, moist, offensive scales; falling out of the hair; humid, itching, fetid eruption on occiput, TRICOPHYTOSIS. 407 sides of the head, and behmd ears; scratching changes the place of itching, but increases the oozing. Sulphur. — May be necessary to help along the action of the indicated drug. Ustilago. — When there is great moisture, with matting and falling of the hair. Vinca minor. — Offensive, moist eruption, with brownish crust; abundance of lice on the head; hair matted to- gether; the hair falls out in single spots and white hairs grow there. Viola tricolor. — Thick crusts; hair becomes matted; urine smells like cat's urine. Swelling of the cervical glands; intolerable itching at night. Tricophytosis. Tricophytosis is an affection of the skin, due to the de- velopment of a minute fungus known by the name of the Tricophyton tonsurans. The disease itself bears the com- mon name of "ringworm." There are four principal varieties of the affection, which present appearances dif- fering somewhat from each other, due to differences of location. These are tricophytosis capitis, barbce, corporis^ and genisto-fevioralis. Tricophytosis Capitis. This variety is almost wholly confined to childhood and youth — very rarely, if ever, appearing in adult life. The symptom that usually first attracts attention is a small, scaly, patch on the scalp, perhaps half an inch in diameter, from which the hair appears to have fallen. On closer examination, however, it is found that, instead of the hairs having fallen, they are broken off a line or two from the surface. If an attempt be made to extract a few of these short stumps with forceps, it will be found 408 SKIN DISEASES. that many of them do not come out by the roots, but break off in the follicle, leaving the lower extremity of the root in situ. This fragility of the hairs is a marked feature of the disease, and brings it into contrast with favus, in which affection the hair-shafts are not notably weakened. If one of the extracted hair-stumps be examined under the microscope, it will be found infiltrated throughout its entire extent with the minute spores of the tricophyton. This fungus, when it takes lodgment on the scalp, gains access to the hair-follicles, into which it descends until it reaches the bottom. Here it increases and invades the root, and travels up the shaft toward the surface. It produces dissociation of the fibres, and thereby weakens the hair. After the surface is reached, there is no out- side pressure to counteract the pressure from within the shaft, and the latter gives way and breaks off. The original patch extends centrifugally, and new ones form, so that after a few weeks or months there may be a pretty complete involvement of a considerable portion of the scalp. In scrofulous subjects, or those prone to suppurative action, the irritation of the fungus may cause the forma- tion of little collections of pus on the substance of the scalp, which, opening on the surface, give a honey- combed appearance to the lesion, to which the older writers assigned the name of kerion. When left to nature, the affection persists indefinitely, apparently as long as the hairs and hair-follicles afford sufficient pabulum for the fungus. The ultimate ter- mination is baldness. The circular patches on the scalp may spread beyond the line of the hair and down upon the adjacent uncovered skin; and in the form of tricho- phytosis corporis may appear on other parts of the body. TRICOPHYTOSIS BARB^. 409 Tricophytosis Barbae. This variety is confined to adult males, and appears on the bearded portions of the face and neck. At its first appearance we usually find a small, red, and very slightly raised spot. In a few days this develops into a distinct ring, with elevated margin, gradually increasing in size, and new spots and rings appearing. Accompanying I these lesions we may have pustules, tubercles, and some- I times considerable infiltration of the integument — in fact, I something not unlike the kerion of children. If shaving I be practiced, the irritation is increased. The hairs some- i times break and sometimes fall out, and, if examined i microscopically, will be found infiltrated with the fungus. Tricophytosis Corporis. This is the ordinary ringworm of the body, and is too I familiar to need any special description. Appearing at I first as a small red spot, it soon assumes the annular form, ii bounded by a slightly reddened and raised periphery. ' The center of the patch is apparently healthy, or, at j most, slightly reddened. When two neighboring rings extend until they meet, the elevated margins which are i in contact melt away, and we may have a figure eight, Ij or some similar form. II This form of tricophytosis rarely gives rise to much in- i convenience by itself, except in tropical countries, when ! this fungus is found to flourish with a vigor not met with ; in cooler regions. Tricophytosis Genito-Femoralis. i| This is not a very uncommon variety of ringworm, and is almost wholly confined to adult males. The usual loca- 27 410 SKIN DISEASES. tion is at the tipper and inner aspect of the thigh and contiguous parts. It generally involves a portion of the scrotum as well as the thigh. The diagnosis of t. capitis is usually easy, as the broken-off hair-stumps are characteristic. T. barbcs, when seen early, and before marked inflammatory action has changed the aspect of the part, ought to be recognized without difficulty, but later in the course of the disease it might be mistaken for eczema barbae, or so-called non- parasitic sycosis. Ringworm of the body is recognizable under almost any condition that can be imagined, and tricophytosis genito-femoralis equally so, unless obscured by a co-existing eczema. Under all circumstances, how- ever, the microscope may be relied on to settle the diagnosis. Etiology. — Trichophytosis is due to a vegetable para- site, and is propagated from one to another by contact. Ringworm of the head is usually contracted by the care- less habit among children of wearing each other's head- gear, and in public institutions by the common use of brushes and combs, towels, etc. In nursing infants the trouble is sometimes conveyed to the breasts of their mothers. Ringworm of the beard is perhaps more frequently con- tracted at barber shops than elsewhere, from the use of contaminated utensils, and may be passed in turn to the lips or cheeks of young women. Tricophytosis is met with in the rat, cat, dog, cow, horse, and perhaps in other animals, and may be con- veyed by them to man. Cavalrymen, who are accus- tomed to practice their exercises on bare-back horses, sometimes contract the genito- femoral variety. Treatment. — The cure of t. capitis is by no means easy. Methods of treatment innumerable have been and TRICOPHYTOSIS GENITO-FEMORALIS. 411 are being proposed; but none are simpler or more effect- ive than the treatment originally proposed by Bazin fort}^ years ago. This consists in thorough epilation, combined with applications of a solution of bichloride. If the parasite is destroyed, the affection ceases; hence the first object is to secure destruction of the tricophytoji. The spores, how- ever, are deeply buried in the hair-follicle, and are not easily reached by lethal applications while the hairs are still i7i situ. The first thing to be done, then, is to re- move them as thoroughly as possible with the aid of a properly constructed epilation forceps. Attack the affected spot or spots with forceps, extract- ing every hair-stump possible. Many will break off; but do not leave a single one visible above the surface. Then thoroughly wash with a bichloride lotion, of the strength of one to three grains to the ounce. Apply this daily, unless it produces too much reaction, in which case dilute it, or omit for a few days. At the end of a week, again, with forceps in hand, repeat the epilation, as many of the broken hairs will have appeared above the surface. Ex- tract as many of them as possible, and continue this treat- ment as long as necessary, which may perhaps be six weeks or six months, according to the extent of the dis- ease, or the intelligence and care with which the treat- ment is carried out, remembering that patience and bi- chloride will succeed in the end. The following makes a good application: 9^. CarboHc acid. Chloral, Tincture Iodine, aa ^jjj. M. Sig. : Apply once a day with a brush. Three or four times for ringworm. Ringworm of the beard demands and will respond to the same treatment. 412 SKIN DISEASES. Ringworm of the non-hairy parts is a very readily curable affection. Sulphur ointment, any form of mer- curial ointment, tincture of iodine, or chrysarobin dis- solved in traumaticin. A few applications of either of these will prompty remove the trouble. Ringworm of the crotch may be treated in a similar manner, without epilation — an excellent application be- ing a solution of six or seven grains of chrysarobin in an ounce of traumaticin. Internal remedies: Sepia and Tellurium are adapted to the ringworm variety, as occurring on either body or scalp. See remedies under " Favus." Chromophytosis. Chromophytosis is a parasitic affection characterized by the appearance of yellowish-brown spots on the skin. The discolored spots are in the beginning small and ir- regularly scattered over the invaded surface. They are very slightly, if at all, elevated, and are covered with minute, barely perceptible scales. The affection is usually con- fined to the trunk and upper extremities, almost never appearing on the lower limbs. Its favorite seat is the chest and back; but it may spread to the neck and down upon the abdomen, and upon the arm between the shoulder and elbow. The macules may be very numer- ous, and many of them not larger than a pea; or they may coalesce by mutual extension, and form patches of considerable size. The progress of the affection is slow; and it is not un- common to meet with cases in which the lesions have ex- isted for several years. It is sometimes met with in the strong and hearty, but most commonly in those who are enfeebled by chronic disease, and is especially frequent in ONYCHOMYCOSIS. 413 those who are suffering from phth;sis or syphilis. It was, in fact, at one time classed as a symptom of phthisis. This was, of course, before the true nature of the disease had been ascertained. It is usually more noticeable in winter than in summer, a fact explainable by the lighter clothing and more frequent ablutions in warm than in cold weather. Itching is sometimes present, but is rarely severe enough to seriously incommode the patient. Etiology. — Chromophytosis is caused by the develop- ment of a minute fungus, called the microsporon andonini among the superficial epidermic cells. Being of a para- sitic nature, it is presumably contagious. Treatment. — This affection is easily cured, provided proper treatment is instituted and persisted in. The one prominent indication is to destroy the superficial epithelial cells, and bring about their exfohation, bringing with them the parasite. The list of agents that will ac- complish this is a long one; but those found most gen- erally useful are lotions of bichloride, tincture of iodine, sulphur ointment, and chrysarobin. If seven or eight grains of the latter be added to an ounce of traumaticin, and painted upon the spots for several days in succession, the epidermis will soon desquamate. For the treatment to be effectual, it is necessary that every spot, no matter how minute, should receive the selected application. This is rarely done the first time, and the case should be inspected weekly by the physician, and the applications made by him so far as practicable. It must not be forgotten that the under clothes need disinfection or destruction; otherwise the affection is very liable to recur. Onychomycosis. This term is used to designate disease of the nails due to the attack upon them of vegetable parasites. The name of the fungus is the achorion. 414 SKIN DISEASES. Speaking generally, the effect of the attack of the fun- gus upon the nail is to thicken it, to render it brittle, to break it up into layers, and to make it opaque, or it may be yellowish. The seat of the fungus growth is shown in some cases in the early stage by yellowish specks im- bedded in the nail, and the fungus oftentimes attacks in the first place the side or the part near the root of the nail, giving rise to a certain amount, it may be, of inflam- mation and discomfort. This condition of nail has been produced in those who have attended to children's heads affected with ringworm, in one or more nails, and as an independent state of dis- ease or preceded by tinea circinata of the fingers or back of the hand, which has spread to the nail, and in that way infected it. The diagnosis is made by paying attention to the co- existence of parasitic disease, and by the microscopical examination. It must not be forgotten that the nails are rendered opaque, thick, and brittle in connection with psoriasis, pityriasis rubra, lichen ruber, and the like; but in parasitic cases the evidence of the connection between the nail and the general disease and the origination of the former from the latter is usually clear. The treatment is, in the majority of cases, very satis- factory, but in order that a successful result may be at- tained speedily it is necessary that the parasiticide should be made to reach the deeper parts of the nail, and that the nail structure should be kept soaked in the parasiti- cide lotion. Scrape off some of the loose laminae of the nails, then apply every second or third day some strong acetic acid to the seat of the change, the whole nail area if necessary, taking care not to make the matrix too tender; and then keep the nail or nails soaked in a solu- tion of hyposulphite of soda (gss to gvj of water). INGROWING TOE-NAILS. 415 Perseverance with the lotion will certainly cure the dis- ease. There are a few diseases of the nails that can hardly be classified, yet are of sufi&cient importance to demand a passing notice; and we know of no more suitable place than the present one to take them up. The first of which we will make mention is that very uncomfortable condi- tion known as: Ingrcwing Toe-Nails. This affection is too well known to need any descrip- tion, and we will simply giv^e two methods of treatment that have been very successfully used in our practice. The first is known as the liquor ferri sesquichlor. treat- ment, and the method of using, as follows: After disinfecting the wound with corrosive mercury apply a few drops of the liquor ferri sesquichlor. , after lifting the nail somewhat. Allow this to dry. On the second and third days, the same process is repeated. Then with delicate forceps try to remove the hard crust that has formed. The slight bleeding that ensues is im- mediately stopped by a fresh application of the liquor. In a few days more the same process of ablation is again practiced. After a few applications, thus carried out, the nail rots so that it can be removed with the aid of the ■scissors or a dull knife without causing any pain To prevent relapses, it is well to insert fine layers of cork under the edges of the new nail as it grows forward. The second plan of treatment is preferable in some •cases. After cleaning the diseased nail in a soap-bath and having dried it thoroughly, the whole nail is smooth- ly enveloped with tin-foil. A thin strip of tin-foil is pressed in on the side where the nail has grown in, or tries to grow in. These strips are kept in their place by 416 SKIN DISEASES. a thin layer of 5^ellow wax, so that in all places where the nail touches the flesh some tin-foil lies between them. Tin-foil acts not only mechanically, but the constant con- tact of these moist and granulating spots with the me- tallic foil dries up the affected places in a few weeks and causes a more healthy state in the morbid nail. It is a great gain for laboring people that they are thus able to follow their usual avocations, and it is only necessary to renew the dressing three times during the first two weeks. The feet must not be bathed during that time, but may be cleansed with dry wheat bran. Paronychia. Paronychia is an inflammation, situated around and be- neath the nail, terminating in suppuration. It attacks mostly the thumb and fingers, and makes its appearance as a dusky-red, extremely painful border, either completely or partially surrounding the nail. In a few days the pain becomes throbbing in character and pus forms, attended at times by more or less constitutional disturbance. Treatment. — Locally, thepithof the common bullrusk has been used with good results. Natrum sulph. is the principal internal remedy. Paronychia may sometimes be aborted by the following simple treatment: Take a handful of fresh wood-ashes; pour upon it a quarter of a litre of boiling water, so as to get a strong lye. As soon as the patient feels the char- acteristic pains of the paronychia, with hammering and throbbing, the hand should be put in the hot lye, after which it is covered with compresses soaked in the solu- tion. It maj^ be necessary to repeat the procedure once or twice. PARONYCHIA. 417 A very annoying condition, especially when occurring in young women, is "red hands." An excellent oint- ment for this condition is the following: J^. Lanolin, loo grms. Paraffin, liquid, 25 grms. VanilHn, o.oi grms. 01. rosse, gtt. j. M. Sig. : Apply a thin coating of this ointment to the hands at bed time. CHAPTER XIX. DISORDERS OF THE GLANDS. There are two sets of organs to deal with here — the sweat glands and the sebaceous glands. I. Diseases of the Sweat Glands. The deviations from health may be functional or struct- ural; the former include all those cases in which the sweat varies in amount and kind, but in which there is no change in the actual tissue of the glands or follicles themselves; the latter, those in which the sweat follicles are likewivSe congested, obliterated, inflamed, enlarged, or otherwise structurally altered. The disorders may be arranged thus: A. Disorders of Function and B. Structural Disorders. A. Functional Diseases of the Sweat Glands. Hypkridrosis is the term applied to excessive sweating. It is, however, not very often an independent form of dis- ease. It occurs in connection with general febrile dis- turbances, as in pneumonia, phthisis, rheumatism — ap- pearing to be "critical" in some cases. It may, how- ever, occur as a purely local disease, and then the excessive secretion of sweat takes place from the face, the hands, the feet, or the armpits, and it is very annoying. A similar state of things is natural to some persons. The sweat may be very offensive. Hyperidrosis may give rise to eczema and intertrigo, as about the feet frequently. In some cases hyperidrosis, that is, a freer secretion of FUNCTIONAL DISEASES. 419 sweat than usual, may be conjoined with or followed by more or less congestion of the follicles, and then the morbid states known as miliaria and lichen tropicus re- sult. If the sweat fails to escape it may collect under the cuticle, forming sweat vesicles. This is sudamina. Probably the most annoying form of this affection is that where the feet are the parts attacked. Various means have been used with varying success. Dr. Ar- mingaud recommends a hypodermic injection of Pilocar- pine in cases of fetid foot-sweat. Chromic acid has been used with excellent results. Frequently, one application of a five per cent, solution of chromic acid suffices. The solution should be applied with cotton-wool to the soles of the feet and between the toes. If there are wounds on the feet, they had better be healed before applying the chromic acid. Therapeutical indications: Bar. carb. — Fetid foot-sweat, with callosities on the soles which are painful on w^alking; soles feel bruised at night, keeping one awake, after rising and walking. Calc. carb. — Foot-sweat which makes the feet sore; feet feel cold and damp, as if she had wet stockings; burning in the soles. Canthar. — Temporary cold sweat on feet; smells like urine. Carbo veg. — Foot-sweat excoriating toes; toes red, swollen; stinging, as if frosted; tip of toes ulcerated. Graphites. — Profuse foot-sweat, not fetid as in Sepia or Silic. , but the most moderate walking causes soreness be- tween the toes, so that the parts become raw; spreading blisters on the toes, thick and crippled toe-nails. Helleborus. — Humid, painless vesicles between the toes. ■ lodum. — Acrid, corrosive foot-sweat; edematous swell- ing of the feet. 420 SKIN DISEASES. Kali carb. — Profuse fetid foot- sweat; swelling and red- ness of the soles; chilblains; stitches in the painful and sensitive corns. Lac. ac. — Profuse foot- sweat, but not fetid. Lycopod. — Profuse and fetid foot- sweat, with burning in the soles; one foot hot, the other cold, or both cold and sweaty; swelling of the soles; they pain when walking; fissures on the heel. Mur. ac. — Cold sweat on the feet, evening in bed; swelling, redness and burning of tips of toes; chilblains. Nitr. ac. — Foul-smelling /^